Approach to the Hypoglycemic Patient.

Hypoglycemia is commonly encountered in the emergency department. Patients can present with a myriad of symptoms and its presentation can mimic other more serious diagnoses. Despite the relative ease of its management, clinicians often miss the diagnosis or mismanage it even when discovered. Glucose is an important energy source for the brain and failing to recognize hypoglycemia or mismanaging it can lead to permanent neurologic disability or death. Although it is important to replenish glucose in a rapid fashion, it is equally important to discover and manage the underlying etiology to prevent further episodes of hypoglycemia.

Diagnosis and Management of Adrenal Insufficiency and Adrenal Crisis in the Emergency Department.

BACKGROUND: Adrenal insufficiency can result in significant patient morbidity and mortality, but due to the range of symptoms and variable clinical course and etiologies, it can be a challenging condition to diagnose and manage. OBJECTIVE: This narrative review will discuss the evaluation of an adult patient at risk for a new diagnosis of adrenal insufficiency and the management of a patient with known or suspected adrenal insufficiency. DISCUSSION: A new presentation of adrenal insufficiency can range from nonspecific, minor symptoms including fatigue, to a life-threatening adrenal crisis with hemodynamic instability. Due to the variety of signs and symptoms, the diagnosis is often missed. Those with known adrenal insufficiency are at risk for adrenal crisis, which may occur due to a variety of triggers. Initial evaluation includes assessment for the underlying etiology or concomitant condition, laboratory analysis, and imaging, when clinically indicated. Although not necessary for evaluation in the emergency department setting, the diagnosis is confirmed by specific testing such as the cosyntropin stimulation test. The mainstay of treatment in adrenal crisis is hydrocortisone, intravenous fluid, glucose repletion, and treatment of the underlying acute trigger. CONCLUSIONS: Emergency clinicians must be prepared to recognize, evaluate, and manage those with known or suspected adrenal insufficiency or adrenal crisis.

Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State.

BACKGROUND: Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations. OBJECTIVE: This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state. DISCUSSION: Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit. CONCLUSIONS: Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Decompensated hypothyroidism: A review for the emergency clinician.

BACKGROUND: Decompensated hypothyroidism, formerly known as myxedema coma, is an endocrine emergency that commonly presents with altered mental status, as well as hypothermia and depressed vital signs. The condition is often caused by an inciting event, which may lead to significant delays in the diagnosis and management of this disease. Although the incidence is low, this disease is associated with significant morbidity and mortality. Therefore, it is important for emergency clinicians to be aware of this condition. OBJECTIVE: This narrative review evaluates the emergency medicine diagnosis and management of adult patients with decompensated hypothyroidism. DISCUSSION: Decompensated hypothyroidism is a severe hypothyroid state associated with multiple organ failure. The diagnosis can be challenging due to similarities with more common diseases and lack of consideration of the diagnosis. Many patients may present with altered sensorium or depressed vital signs. Clinicians should obtain a thyroid stimulating hormone and free thyroxine level when considering the diagnosis. Management involves resuscitation, early steroid supplementation, thyroid hormone replacement, and treatment of the inciting event. CONCLUSIONS: Decompensated hypothyroidism should be considered in the evaluation of patients with altered sensorium and depressed vital signs so as to not miss this critical diagnosis.

Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is a hyperglycemic emergency that presents commonly to the emergency department. Severe DKA has the potential for significant morbidity and mortality if not recognized early and treated appropriately. It is incumbent on the emergency clinician to be vigilant in the management of these critically ill patients. OBJECTIVE: This narrative review evaluates the emergency medicine management of the adult patient with severe DKA. DISCUSSION: DKA is a condition found most commonly in patients with insulin-dependent diabetes, often due to nonadherence with diabetic medications or an inciting event, such as infection or ischemia. The severity of DKA is classified based on the level of acidosis present rather than absolute glucose level. The management of severe DKA involves assessing and treating the inciting event, fluid hydration, insulin, and potassium repletion. Close monitoring is necessary to prevent the complications that can occur. CONCLUSIONS: DKA is a medical condition that has the potential for significant morbidity and mortality if not recognized and managed appropriately.

Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries.

Many orthopedic injuries can have hidden risks that result in increased liability for the emergency medicine practitioner. It is imperative that emergency medicine practitioners consider the diagnoses of compartment syndrome, high-pressure injury, spinal epidural abscess, and tendon lacerations in the right patient. Consideration of the diagnosis and prompt referrals can help to minimize the complications these patients often develop.

The Approach to the Patient with Hematuria.

Hematuria is common; whether gross or microscopic, it is incumbent on emergency providers to consider life-threatening and benign processes when evaluating these patients. Most workup is driven by a focused history and physical, including laboratory studies and diagnostic imaging. The cause originates in the genitourinary tract and, as long as the patient remains stable, they can be discharged with close outpatient follow-up. The importance of this cannot be stressed enough because hematuria, especially in the elderly, frequently signals the presence of urologic malignancy. In addition, the workup occasionally yields a nongenitourinary tract cause, and these patients often require emergent management.

Comparison of Plasma-Lyte A and Sodium Chloride 0.9% for Fluid Resuscitation of Patients With Diabetic Ketoacidosis.

Purpose: The aim of this study was to compare Plasma-Lyte A (PL) and sodium chloride 0.9% (NS) in regard to time to resolution of diabetic ketoacidosis (DKA) when one fluid was used predominantly over the other for resuscitation. Methods: We performed a retrospective analysis of the records of patients treated for DKA at a large, academic medical center between July 1, 2013, and July 1, 2015. Patients were placed into the PL or NS group based on the predominant fluid they received during fluid resuscitation. Serum biochemistry variables were categorized as follows: initial, 2 to 4 hours, 4 to 6 hours, 6 to 12 hours, and 12 to 24 hours. The primary outcome was mean time to resolution of DKA. Results: Eighty-four patients were included in the study. The primary outcome of mean time to resolution of DKA was similar between the PL (19.74 hours) and NS (18.05 hours) groups (P = .5080). Patients treated with PL had a significantly greater rise in pH within the 4- to 6-hour and 6- to 12-hour periods. The chloride level was significantly higher and the anion gap was significantly lower for the NS group in the 6- to 12-hour period. Conclusion: These data suggest that the use of PL for fluid resuscitation in DKA may confer certain advantages over NS.

Does the Concept of the "Flipped Classroom" Extend to the Emergency Medicine Clinical Clerkship?

INTRODUCTION: Linking educational objectives and clinical learning during clerkships can be difficult. Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences, some of which may not be relevant to recommended educational objectives. Students can be directed to standardize their clinical experiences, and this improves performance on examinations. We hypothesized that applying a "flipped classroom" model to the clinical clerkship would improve performance on multiple-choice testing when compared to standard learning. METHODS: Students at two institutions were randomized to complete two of four selected EM clerkship topics in a "flipped fashion," and two others in a standard fashion. For flipped topics, students were directed to complete chief complaint-based asynchronous modules prior to a shift, during which they were directed to focus on the chief complaint. For the other two topics, modules were to be performed at the students' discretion, and shifts would not have a theme. At the end of the four-week clerkship, a 40-question multiple-choice examination was administered with 10 questions per topic. We compared performance on flipped topics with those performed in standard fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and willingness of preceptors to allow a chief-complaint focus. RESULTS: Sixty-nine students participated; examination scores for 56 were available for analysis. For the primary outcome, no difference was seen between the flipped method and standard (p=0.494.) A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly (3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol. CONCLUSION: Preparation for a clinical shift with pre-assigned, web-based learning modules followed by an attempt at chief-complaint-focused learning during a shift did not result in improvements in performance on a multiple-choice assessment of knowledge; however, one third of participants did not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned learning as well as clinical experiences, and consider alternate measures of knowledge.

Overtreatment of gonorrhea and chlamydial infections in 2 inner-city emergency departments.

BACKGROUND: Infections with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are the most commonly reported sexually transmitted diseases in the United States. OBJECTIVES: The primary objective of this study was to estimate the incidence of overtreatment of GC and CT infections in the emergency department (ED). The secondary objective was to determine if there are clinical variables that predict infection with GC and CT. METHODS: A retrospective medical record review was performed at 2 inner-city hospitals. Records were obtained from the evaluation of female patients who presented to the ED between January 1, 2012, and December 31, 2012, who were tested for GC and CT infection. A standardized form was used to extract specific information from each medical record. RESULTS: Data were extracted from 538 medical records. Of the 522 ED visits, 32 (6%) yielded test results positive for either GC or CT, including 3 that were positive for both. Treatment was administered to 101 patients (19%) and declined by an additional 9 (2%). Of those receiving antibiotics, 87 of 101 (0.86; 95% confidence interval, 0.77-0.92) had negative test results. Of those not offered antibiotics, 17 of 412 (0.04; 95% confidence interval, 0.02-0.07) had positive test results. The overtreatment proportion was similar at hospitals (55/66 [0.83] and 32/35 [0.91], respectively). Of clinical variables that were considered, only age less than 19 years was statistically associated with a positive test result for GC and CT. CONCLUSION: The rate of overtreatment for GC and CT was 86%. The practice of empirical treatment should be reconsidered.

The changing face of diabetes in America.

So much has changed in the field of diabetes diagnosis and management in the United States. Unhealthy lifestyle choices have hastened an epidemic of childhood obesity, causing a paradigm shift in how childhood diabetes is conceptualized. Once thought a consequence of obesity, sedentary lifestyle, and genetics, diabetes with onset in adults has been found to have a variant with autoimmunity. As the lines among adult-onset, child-onset, and type 1 and type 2 diabetes mellitus become more blurred, best practices in management and prevention become more complicated. This article highlights key points regarding 2 variants, juvenile-onset type 2 diabetes mellitus and latent autoimmune diabetes of adults.

Current diagnosis and treatment of hyperglycemic emergencies.

Diabetic ketoacidosis and hyperosmolar hyperglycemic state are the most feared complications of uncontrolled diabetes seen in emergency medicine. The treatment of both conditions must be tailored to individual patients and relies on aggressive fluid resuscitation, insulin replacement, and electrolyte management. Emergency medicine providers must address the underlying causes and monitor for complications of therapy. Improved understanding of the underlying pathophysiology and application of evidence-based guidelines have significantly improved prognosis and decreased mortality. The purpose of this article is to review the diagnosis, presentation, and emergency department management of diabetic ketoacidosis and hyperosmolar hyperglycemic state with an emphasis on current management and treatment guidelines.

Methicillin-resistant Staphylococcus aureus carriage in hospitalized chronic hemodialysis patients and its predisposing factors.

There has been a paucity of literature on methicillin-resistant Staphylococcus aureus (MRSA) colonization in chronic hemodialysis patients who required admission. The purpose of this study is to determine the MRSA carriage rate in hospitalized chronic hemodialysis patients, to identify the risk factors, and assess the consequences of MRSA colonization. This was a retrospective study of hospitalized chronic hemodialysis patients at Khoo Teck Puat Hospital from July 1, 2010 to June 30, 2011. MRSA screening was done on the day of admission using culture method with MRSA select (Bio-Rad)™. The patients were divided into two groups: MRSA carriers and noncarriers. Demographic data, medical, and laboratory information was obtained via electronic medical record system. Outcome measures were infection rates during current hospitalization episode, frequency of hospitalization, and cumulative hospitalization days per year. Prevalence rate of MRSA colonization in hospitalized chronic hemodialysis patients was 15.1%, compared to all admitted patients (5.8%). Diabetes mellitus, Malay ethnicity, shorter hemodialysis duration and use of tunneled hemodialysis catheters were associated with MRSA colonization (P < 0.05). Relative risk of infection during the episode of admission among MRSA carriers was 3.2-fold compared to noncarriers. MRSA colonization rates tend to be higher in patients on hemodialysis for less than 3 years and it correlates with longer hospitalization after adjustment for other variables (P < 0.05). Patients on chronic hemodialysis requiring admission have higher rates of MRSA colonization. The risk factors of MRSA carriers and the correlation of MRSA rates to longer hospitalization suggest its nosocomial origin in this group of patients.

The development of a dental diagnostic terminology.

There is no commonly accepted standardized terminology for oral diagnoses. The purpose of this article is to report the development of a standardized dental diagnostic terminology by a work group of dental faculty members. The work group developed guiding principles for decision making and adhered to principles of terminology development. The members used an iterative process to develop a terminology incorporating concepts represented in the Toronto/University of California, San Francisco/Creighton University and International Classification of Diseases (ICD)-9/10 codes and periodontal and endodontic diagnoses. Domain experts were consulted to develop a final list of diagnostic terms. A structure was developed, consisting of thirteen categories, seventy-eight subcategories, and 1,158 diagnostic terms, hierarchically organized and mappable to other terminologies and ontologies. Use of this standardized diagnostic terminology will reinforce the diagnosis-treatment link and will facilitate clinical research, quality assurance, and patient communication. Future work will focus on implementation and approaches to enhance the validity and reliability of diagnostic term utilization.

Consortium for oral health-related informatics: improving dental research, education, and treatment.

Advances in informatics, particularly the implementation of electronic health records (EHR), in dentistry have facilitated the exchange of information. The majority of dental schools in North America use the same EHR system, providing an unprecedented opportunity to integrate these data into a repository that can be used for oral health education and research. In 2007, fourteen dental schools formed the Consortium for Oral Health-Related Informatics (COHRI). Since its inception, COHRI has established structural and operational processes, governance and bylaws, and a number of work groups organized in two divisions: one focused on research (data standardization, integration, and analysis), and one focused on education (performance evaluations, virtual standardized patients, and objective structured clinical examinations). To date, COHRI (which now includes twenty dental schools) has been successful in developing a data repository, pilot-testing data integration, and sharing EHR enhancements among the group. This consortium has collaborated on standardizing medical and dental histories, developing diagnostic terminology, and promoting the utilization of informatics in dental education. The consortium is in the process of assembling the largest oral health database ever created. This will be an invaluable resource for research and provide a foundation for evidence-based dentistry for years to come.

A comparison of salivary pH in sympatric wild lemurs (Lemur catta and Propithecus verreauxi) at Beza Mahafaly Special Reserve, Madagascar.

Chemical deterioration of teeth is common among modern humans, and has been suggested for some extinct primates. Dental erosion caused by acidic foods may also obscure microwear signals of mechanical food properties. Ring-tailed lemurs at the Beza Mahafaly Special Reserve (BMSR), Madagascar, display frequent severe tooth wear and subsequent tooth loss. In contrast, sympatric Verreaux's sifaka display far less tooth wear and infrequent tooth loss, despite both species regularly consuming acidic tamarind fruit. We investigated the potential impact of dietary acidity on tooth wear, collecting data on salivary pH from both species, as well as salivary pH from ring-tailed lemurs at Tsimanampesotse National Park, Madagascar. We also collected salivary pH data from ring-tailed lemurs at the Indianapolis Zoo, none of which had eaten for at least 12 hr before data collection. Mean salivary pH for the BMSR ring-tailed lemurs (8.098, n=41, SD=0.550) was significantly more alkaline than Verreaux's sifaka (7.481, n=26, SD=0.458). The mean salivary pH of BMSR (8.098) and Tsimanampesotse (8.080, n=25, SD=0.746) ring-tailed lemurs did not differ significantly. Salivary pH for the Indianapolis Zoo sample (8.125, n=16, SD=0.289) did not differ significantly from either the BMSR or Tsimanampesotse ring-tailed lemurs, but was significantly more alkaline than the BMSR Verreaux's sifaka sample. Regardless of the time between feeding and collection of pH data (from several minutes to nearly 1 hr), salivary pH for each wild lemur was above the "critical" pH of 5.5, below which enamel demineralization occurs. Thus, the high pH of lemur saliva suggests a strong buffering capacity, indicating the impact of acidic foods on dental wear is short-lived, likely having a limited effect. However, tannins in tamarind fruit may increase friction between teeth, thereby increasing attrition and wear in lemurs. These data also suggest that salivary pH varies between lemur species, corresponding to broad dietary categories.