Comparing cost of F(.ab')2AV vs FabAV in the treatment of copperhead envenomation-One center's experience.

The definitive treatment of North American crotalid snakebites is antivenin. In 2000, an FabAV antivenom (CroFab®) was introduced and in 2022, F(ab')2AV (Anavip®) was approved for treatment of copperhead bites. Our center that sees primarily copperhead snake bites added the recently approved treatment as a second option for the 2022 snake bite season. This brief report we describe our initial experience with the two antivenins via retrospective chart review: the cost, charge, laboratory differences, response to therapy, complications and duration of hospitalization of admitted patients with copperhead envenomation. Using three independent reviewers in this IRB exempt report we found 31 patients with copperhead bites (7 exclusions) leaving 19 adults and 7 children for analysis. We found there was no difference in age, sex, presence of lab abnormalities, total vials administered, or length of stay. There was significant differences in hospital costs and charges to the patient. Future research should include multi-center experiences comparing the two antivenins.

Predicting opioid use disorder in patients with chronic pain who present to the emergency department.

BACKGROUND: Emergency department (ED) patients with chronic pain challenge providers to make quick and accurate assessments without an in-depth pain management consultation. Emergency physicians need reliable means to determine which patients may receive opioid therapy without exacerbating opioid use disorder (OUD). METHODS: Eighty-nine ED patients with a chief complaint of chronic pain were enrolled. Researchers administered questionnaires and reviewed medical and state prescription monitoring database information. Participants were classified as either OUD or non-OUD. Statistical analysis included a bivariate analysis comparing differences between groups and multivariate logistic regression evaluating ORs. RESULTS: The 45 participants categorised as OUD had a higher proportion of documented or reported psychiatric diagnoses (p=0.049), preference of opioid treatment (p=0.005), current oxycodone prescription (p=0.043), borrowed pain medicine (p=0.004) and non-authorised dose increase (p<0.001). The state prescription monitoring database revealed the OUD group to have an increased number of opioid prescriptions (p=0.005) and pills (p=0.010). Participants who borrowed pain medicine and engaged in non-authorised dose increase were 5.2 (p=0.025, 95% CI 1.24 to 21.9) and 6.1 times (p=0.001, 95% CI 1.55 to 24.1) more likely to have OUD, respectively. LIMITATIONS: Major limitations of our study include a small sample size, self-reported measures and convenience sample which may introduce selection bias. CONCLUSION: Patients with chronic pain with OUD have distinguishable characteristics. Emergency physicians should consider such evidence-based variables prior to opioid therapy to ameliorate the opioid crisis and limit implicit bias.

Sports-Related Concussions in Children: Differences in Care and Expectations When Seen in an Emergency Department Versus a Sports Medicine Clinic.

OBJECTIVES: Patient and parent expectations can potentially influence management of care. We compared expectations in the diagnosis of concussion between patients who presented to a pediatric emergency department (ED) and those who presented to a sports medicine clinic, and if there was a difference in computed tomography (CT) scans performed. METHODS: Head-injured athletes aged 8 to 18 years presenting to a pediatric ED and a sports medicine clinic were enrolled. Both groups completed questionnaires on their understanding of concussion and expectations of care. Charts were then reviewed. RESULTS: Forty patients were enrolled in the study: 23 from a pediatric ED and 17 from a sports medicine clinic. Forty-one percent of athletes received a head CT in the pediatric ED versus 12% of those in the clinic population with no abnormal findings (P = 0.04). Forty-one percent of athletes and 48% of parents in the pediatric ED setting reported that a CT was "necessary" to diagnose concussion versus 18% in both groups from the clinic (P = 0.12, P = 0.07). Athletes presenting to the clinic were more likely to have been evaluated by an athletic trainer after the injury than those presenting to the pediatric ED (80% vs 23%, P = 0.004). CONCLUSIONS: Patients and parents who presented to a pediatric ED for sports-related head injury had a trend toward higher expectations of a CT scan being necessary to diagnose concussion and did have a higher rate of CT scans performed. Education of athletes and parents engaging in organized sports may be worthwhile to assist in setting expectations in diagnosis of concussion.

Artificial neural networks: Predicting head CT findings in elderly patients presenting with minor head injury after a fall.

OBJECTIVES: To construct an artificial neural network (ANN) model that can predict the presence of acute CT findings with both high sensitivity and high specificity when applied to the population of patients≥age 65years who have incurred minor head injury after a fall. METHODS: An ANN was created in the Python programming language using a population of 514 patients ≥ age 65 years presenting to the ED with minor head injury after a fall. The patient dataset was divided into three parts: 60% for "training", 20% for "cross validation", and 20% for "testing". Sensitivity, specificity, positive and negative predictive values, and accuracy were determined by comparing the model's predictions to the actual correct answers for each patient. RESULTS: On the "cross validation" data, the model attained a sensitivity ("recall") of 100.00%, specificity of 78.95%, PPV ("precision") of 78.95%, NPV of 100.00%, and accuracy of 88.24% in detecting the presence of positive head CTs. On the "test" data, the model attained a sensitivity of 97.78%, specificity of 89.47%, PPV of 88.00%, NPV of 98.08%, and accuracy of 93.14% in detecting the presence of positive head CTs. CONCLUSIONS: ANNs show great potential for predicting CT findings in the population of patients ≥ 65 years of age presenting with minor head injury after a fall. As a good first step, the ANN showed comparable sensitivity, predictive values, and accuracy, with a much higher specificity than the existing decision rules in clinical usage for predicting head CTs with acute intracranial findings.

PI3K mediated activation of GSK-3ß reduces at-level primary afferent growth responses associated with excitotoxic spinal cord injury dysesthesias.

BACKGROUND: Neuropathic pain and sensory abnormalities are a debilitating secondary consequence of spinal cord injury (SCI). Maladaptive structural plasticity is gaining recognition for its role in contributing to the development of post SCI pain syndromes. We previously demonstrated that excitotoxic induced SCI dysesthesias are associated with enhanced dorsal root ganglia (DRG) neuronal outgrowth. Although glycogen synthase kinase-3ß (GSK-3ß) is a known intracellular regulator neuronal growth, the potential contribution to primary afferent growth responses following SCI are undefined. We hypothesized that SCI triggers inhibition of GSK-3ß signaling resulting in enhanced DRG growth responses, and that PI3K mediated activation of GSK-3ß can prevent this growth and the development of at-level pain syndromes. RESULTS: Excitotoxic SCI using intraspinal quisqualic acid (QUIS) resulted in inhibition of GSK-3ß in the superficial spinal cord dorsal horn and adjacent DRG. Double immunofluorescent staining showed that GSK-3ß(P) was expressed in DRG neurons, especially small nociceptive, CGRP and IB4-positive neurons. Intrathecal administration of a potent PI3-kinase inhibitor (LY294002), a known GSK-3ß activator, significantly decreased GSK-3ß(P) expression levels in the dorsal horn. QUIS injection resulted in early (3 days) and sustained (14 days) DRG neurite outgrowth of small and subsequently large fibers that was reduced with short term (3 days) administration of LY294002. Furthermore, LY294002 treatment initiated on the date of injury, prevented the development of overgrooming, a spontaneous at-level pain related dysesthesia. CONCLUSIONS: QUIS induced SCI resulted in inhibition of GSK-3ß in primary afferents and enhanced at-level DRG intrinsic growth (neurite elongation and initiation). Early PI3K mediated activation of GSK-3ß attenuated QUIS-induced DRG neurite outgrowth and prevented the development of at-level dysesthesias.

Long-term efficacy of pressure immobilization bandages in a porcine model of coral snake envenomation.

BACKGROUND: Pressure immobilization bandages delay mortality for 8 hours after coral snake envenomation, but long-term efficacy has not been established. OBJECTIVE: The objective of this study is to determine the long-term efficacy of pressure immobilization bandages after coral snake envenomation in the absence of antivenom therapy. METHODS: A randomized, observational pilot study was conducted. Ten pigs (17.3-25.6 kg) were sedated, intubated for 5 hours, and injected subcutaneously with 10 mg of lyophilized Micrurus fulvius venom resuspended in water. Pigs were randomly assigned to a control group (no treatment) or a treatment group (compression bandage and splint) approximately 1 minute after envenomation. Bandage pressure was not controlled. Pigs were monitored daily for 21 days for signs of respiratory depression, decreased oxygen saturations, and paralysis. In case of respiratory depression, pigs were humanely euthanized and time to death recorded. Statistical analysis was performed with Fisher exact test, Mann-Whitney U test, and Kaplan-Meier survival curve as appropriate. RESULTS: Median survival time of control animals was 307 minutes compared with 1172 minutes in treated animals (P = .10). Sixty percent of pigs in the treatment group survived to 24 hours vs 0% of control pigs (P = .08). Two of the treatment pigs survived to the end point of 21 days but showed necrosis of the distal lower extremity. CONCLUSIONS: Long-term survival after coral snake envenomation is possible in the absence of antivenom with the use of pressure immobilization bandages. The applied pressure of the bandage is critical to allowing survival without necrosis. Future studies should be designed to accurately monitor the pressures applied.

Injectable lidocaine provides similar analgesia compared to transdermal lidocaine/tetracaine patch for the incision and drainage of skin abscesses: a randomized, controlled trial.

BACKGROUND: Local anesthesia used for incision and drainage of abscesses is known to be painful. STUDY OBJECTIVE: We studied the analgesia provided by a lidocaine/tetracaine patch compared to injectable lidocaine during incision and drainage (I&D) of skin abscesses. METHODS: This was a prospective, double-blind, randomized, controlled trial carried out in the Emergency Department (ED) of an adult tertiary referral center. Adult patients with a skin abscess in need of I&D were randomized to one of two groups. One group received a lidocaine/tetracaine patch and injectable normal saline for anesthesia. The second group received a placebo patch and injectable 1% lidocaine. A visual analog pain scale was used to record the patient's pain level prior to treatment, during the procedure, and after I&D. RESULTS: There were 20 patients enrolled in the study, including 12 randomized to the lidocaine/tetracaine patch and 8 to the injectable lidocaine. Pain scores preprocedure were similar in the two groups. Pain scores during I&D and postprocedure were compared between groups using a paired t-test. Patients receiving injectable lidocaine experienced pain that was similar (50.1 ± 5.9 mm; 95% confidence interval [CI] 45.2-55.1) to those receiving the transdermal lidocaine/tetracaine patch (60.1 mm ± 11.0; 95% CI = 55.2-68.1), p = 0.04, with a power of 80% to detect a difference of 20 mm at p ≤ 0.05; although this was statistically significant, it was not clinically significant. There was also no statistical difference between the two groups in the postprocedure pain scores (p = 0.65). CONCLUSION: Local injection of lidocaine provided clinically similar analgesia compared to the lidocaine/tetracaine patch during I&D of skin abscesses in the ED. Pain at presentation and after the procedure was similar in both groups. Emergency physicians should continue to use a local injected anesthetic for I&D of skin abscesses until a less painful alternative is identified.

Location of the appendix in the gravid patient.

BACKGROUND: Several studies have attempted to support or dispel the teaching of appendix movement away from the right lower quadrant (RLQ) during pregnancy with contradictory results. OBJECTIVE: This study investigated the location of the appendix in the gravid patient in an emergency department (ED) setting using computed tomography (CT). METHODS: This was a retrospective chart review of consecutive gravid patients presenting to the ED for trauma who required abdominal CT. The patient population was obtained using the Vidant Medical Center Trauma Registry from January 1, 2000 to December 31, 2006. The abdomen was divided into nine regions using the mid-clavicular lines, superior anterior iliac spine, and umbilicus. A single Board-certified radiologist determined the region location of the appendix. RESULTS: Forty-five patients were identified and 35 were studied. Ten patients were excluded due to appendix not identified, unknown gestational age, or inability to review the CT study. In 21 of 22 third-trimester pregnancies, the appendix was not found in the right lower region (RLR), which corresponded to the RLQ. All 11 patients in the second trimester did not have the appendix in the RLR. Two patients were identified in the first trimester and neither appendix was found in the RLR. CONCLUSIONS: The appendix in the gravid patient was not found in the RLR with increasing frequency as pregnancy progressed.

Emergency Medical Service Transport Time in Rural Farm and Non-Farm Pediatric Trauma.

OBJECTIVES: Pediatric farm injuries tend to be more severe and have poorer outcomes compared to injuries sustained in non-farm settings. Timely emergency medical service (EMS) response and transport to definitive care is crucial for optimizing outcomes for trauma patients. We aimed to determine if pediatric farm injuries were associated with longer EMS response and transport times compared to pediatric non-farm injuries in rural communities. METHODS: The 2021 National EMS Information System (NEMSIS) database was used to identify rural EMS activations where injured pediatric patients who were transported to a hospital. Median transport times for farm and non-farm injuries, as well as other components of prehospital time and use of air EMS transport, were compared between injuries on farms and injuries in non-farm rural settings. RESULTS: The analytic sample included 22,248 rural EMS activations for pediatric injuries, of which 156 (1%) were for pediatric farm injuries. For non-farm and farm injuries, the median transport times were 20 minutes and 28 minutes, respectively. Median total prehospital time was 50 minutes compared to 62 minutes, and 9.8% of patients with non-farm injuries versus 20.5% of those with farm injuries were transported to a hospital by air EMS units. After multivariable adjustment, farm vs. non-farm injury location was associated with a 4 minute increase in EMS transport time, but no difference in initial EMS response time, EMS time on scene, or use of air EMS units. CONCLUSION: Among children sustaining an injury that resulted in rural EMS activation, farm injuries were associated with prolonged transport time compared to non-farm injuries, which may contribute to worse in-hospital outcomes described to pediatric farm injuries in prior research.

Naltrexone prevents delayed encephalopathy in rats poisoned with the sarin analogue diisopropylflurophosphate.

BACKGROUND: Acute poisoning with organophosphate compounds can cause chronic neuropsychological disabilities not prevented by standard antidotes of atropine and pralidoxime. We determine the efficacy of naltrexone in preventing delayed encephalopathy after poisoning with the sarin analogue diisofluorophosphate (DFP) in rats. METHODS: A randomized controlled experiment was conducted. Rats were randomly assigned to receive a single intraperitoneal (IP) injection of 5 mg/kg DFP (n = 12) or vehicle control (isopropyl alcohol, n = 5). Rats were observed for cholinesterase toxicity and treated with IP atropine (2 mg/kg) and pralidoxime (25 mg/kg) as needed. After resolution of acute toxicity, rats injected with DFP were again randomized to receive daily injections of naltrexone (5 mg/kg per day) or saline (vehicle control). Control animals also received daily injections of saline. For 4 weeks after acute poisoning, rats underwent neurologic testing with the Morris Water Maze for assessment of spatial learning and reference memory. Comparisons on each test day were made across groups using analysis of variance followed by Fisher's least significant difference. Comparisons of changes in performance between first and last test day within each group were made using a paired t test. Significance was determined at P < .05. RESULTS: All rats receiving DFP developed toxicity requiring rescue. Spatial learning was significantly worse in the DFP-only group compared with the naltrexone-treated and control groups at day 10 (P = .0078), day 13 (P = .01), day 24 (P = .034), and day 31 (P = .03). No significant differences in reference memory were detected at any time point. CONCLUSION: Naltrexone protected against impairment of spatial learning from acute poisoning with DFP in rats.

Retrospective chart review of substance abuse in patients with psychiatric emergencies in an emerging urban county.

Objectives: Substance abuse is common in patients with psychiatric emergencies. To further understand the connection between substance abuse and psychiatric disorders, a retrospective chart review was done that included positive drug screens among patients with psychiatric emergencies and to determine whether there was an association between substances used and the psychiatric diagnosis. Methods: A retrospective chart review of patients seen in an emergency department with psychiatric emergencies was conducted. The review comprised 1000 charts with diagnoses of anxiety, depression, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, alcohol abuse, or schizoaffective disorder. Data collected included patient demographics, tobacco abuse, chief complaint, arrival mode, voluntary versus involuntary status, suicide attempt on presentation, psychiatric diagnoses, urine drug screen, and ethanol results. Chi-square statistical analysis was conducted to examine the relationship between substances of abuse and psychiatric diagnoses. Results: Approximately 58% of patients with a history of psychiatric illness had a positive urine drug screen. Of 245 patients with schizoaffective disorder, 69 (28%) were positive for tetrahydrocannabinol (THC) and 48 (20%) were positive for cocaine. Of 225 patients with depression, 59 (29%) were positive for THC and 33 (15%) were positive for cocaine. Cannabis was the most commonly reported substance used among patients with depression, schizophrenia, anxiety, schizoaffective disorder, and bipolar disorder, and ethanol was most common in patients with ADHD. No significant correlations were found between psychiatric diagnosis and positive drug screens. A statistically significant secondary end point was found that White people using cannabinoids were more likely to attempt suicide than were African American people (P = 0.02). Conclusions: Positive drug screens were common among patients presenting to an ED with psychiatric emergencies. Cannabis was the most commonly reported substance used among patients independent of diagnosis. Ethanol was the most common in patients with ADHD. Urine drug screens are unlikely to provide insights into relationships between specific substance use and psychiatric emergencies.

Knowledge Retention From Emergency Medicine Simulation-Based Learning Curriculum for Pre-clinical Medical Students.

Introduction Traditional medical school curricula rely on textbook-based learning during the first two years, often limiting students' clinical exposure. Simulation-based learning (SBL) provides an opportunity for students to gain clinical exposure and competency with common procedures as well as to gain knowledge related to common clinical topics. Retention of factual knowledge is a current topic of discussion as medical learners often have difficulty with long-term retention. The aim of this study was to assess if students would learn, retain, and enjoy emergency medicine (EM)-focused SBL. Materials and methods We developed an EM-focused SBL curriculum consisting of four main educational events: suturing, medical stabilization, mass casualty triage, and point-of-care ultrasound (POCUS). Participants were first- and second-year healthcare students enrolled in a traditional, preclinical curriculum, who completed pre- and post-event quizzes consisting of multiple-choice questions on topics covered during the SBL scenario. We compared pre- and post-event quiz scores using a one-way paired t-test. Quizzes were readministered up to 100 days after each SBL event to test knowledge retention, and scores were compared across time by repeated-measures analysis of variance (RMANOVA). Results For suture (n=22), mass casualty (n=20), and ultrasound simulations (n=17), post-event mean quiz scores increased significantly in comparison to mean quiz scores from before the event (p≤0.05). Medical stabilization simulation post-event scores were increased but did not reach statistical significance. Data collected at 45, 74, and 94 days following the suture lab as well as 29 and 49 days after the medical evacuation event, and 20 days after the mass casualty event showed no statistical decrease in quiz means suggesting retention of knowledge among learners. Subjective assessments of participant satisfaction demonstrated an enjoyment of the events. Discussion EM-focused SBL events offered enjoyable learning opportunities for students to effectively obtain and possibly retain clinical knowledge. Conclusion SBL has the potential to improve student retention of clinical knowledge during the preclinical years and, therefore, should be further explored and implemented as a core pillar of medical education as opposed to its current state as a learning adjunct.

Morphine Resistance in Spinal Cord Injury-Related Neuropathic Pain in Rats is Associated With Alterations in Dopamine and Dopamine-Related Metabolomics.

Opioids are not universally effective for treating neuropathic pain following spinal cord injury (SCI), a finding that we previously demonstrated in a rat model of SCI. The aim of this study was to determine analgesic response of morphine-responsive and nonresponsive SCI rats to adjunct treatment with dopamine modulators and to establish if the animal groups expressed distinct metabolomic profiles. Thermal thresholds were tested in female Long Evans rats (N = 45) prior to contusion SCI, after SCI and following injection of morphine, morphine combined with dopamine modulators, or dopamine modulators alone. Spinal cord and striatum samples were processed for metabolomics and targeted mass spectrometry. Morphine provided analgesia in 1 of 3 of SCI animals. All animals showed improved analgesia with morphine + pramipexole (D3 receptor agonist). Only morphine nonresponsive animals showed improved analgesia with the addition of SCH 39166 (D1 receptor antagonist). Metabolomic analysis identified 3 distinct clusters related to the tyrosine pathway that corresponded to uninjured, SCI morphine-responsive and SCI morphine-nonresponsive groups. Mass spectrometry showed matching differences in dopamine levels in striatum and spinal cord between these groups. The data suggest an overall benefit of the D3 receptor system in improving analgesia, and an association between morphine responsiveness and metabolomic changes in the tyrosine/dopamine pathways in striatum and spinal cord. PERSPECTIVE: Spinal cord injury (SCI) leads to opioid-resistant neuropathic pain that is associated with changes in dopamine metabolomics in the spinal cord and striatum of rats. We present evidence that adjuvant targeting of the dopamine system may be a novel pain treatment approach to overcome opioid desensitization and tolerance after SCI.

Can clinical prediction rules used in acute pediatric ankle and midfoot injuries be applied to an adult population?

BACKGROUND: Almost every patient who comes to an emergency department (ED) with the chief complaint of ankle or foot pain will receive a radiograph, but less than 15% will have a finding positive for ankle or midfoot fracture. In an effort to reduce the number of radiographs performed, clinicians have attempted to derive a set of maximally sensitive clinical prediction rules. Dayan et al (Acad Emerg Med. 2004;11(7):736-745) in 2004 derived a set of such rules for children. These rules have not yet been evaluated in the adult population. OBJECTIVE: The objective of this study is to apply the existing clinical prediction rules used to identify children with fractures after twisting injuries of the ankle to a population that includes adults. METHODS: This was a prospective observational study using convenience sampling. Patients older than 2 years presenting to the ED or associated urgent care center with the chief complaint of an ankle or foot injury were considered eligible for enrollment into the study. After informed consent was obtained, 11 physical examination variables were assessed. Radiographs were obtained and reported, and the radiograph results were noted on the patient's data sheet. Based on the radiograph results, sensitivity and specificity of each of the physical examination variables were analyzed. RESULTS: Sixty-eight patients were eligible, and 29 patients were enrolled after exclusion criteria were applied (median age, 34 years). Three patients were diagnosed with a malleolar zone fracture, and 2 patients were diagnosed with a midfoot zone fracture. Five indicators were found to be 100% sensitive for ankle fracture, and 2 indicators were 100% sensitive for midfoot fracture. CONCLUSIONS: The same indicators found to be predictive of high risk for fracture in a population of pediatric patients were found to be predictive in a population including adults.

A localizing circumferential compression device increases survival after coral snake envenomation to the torso of an animal model.

BACKGROUND: Pressure immobilization bandages have been shown to delay onset of systemic toxicity after Eastern coral snake (Micrurus fulvius) envenomation to the distal extremity. OBJECTIVES: To assess the efficacy of a novel compression device in delaying onset of systemic toxicity after truncal envenomations with Eastern coral snake (Micrurus fulvius) venom in a porcine model. METHODS: With University approval, nine juvenile pigs (11 kg to 22 kg) were sedated, anesthetized, and intubated but not paralyzed to ensure continuous spontaneous respirations in a university animal laboratory. Each animal was injected subcutaneously with 10 mg of M. fulvius venom in a pre-selected area of the trunk. After 1 min, six animals had the application of a novel, localizing circumferential compression (LoCC) device applied to the bite site (treatment group) and three animals had no treatment (control group). The device was composed of a rigid polymer clay form molded into a hollow fusiform shape with an internal dimension of 8 × 5 × 3 cm and an elastic belt wrapped around the animal securing the device in place. Vital signs were recorded at 30-min intervals. End points included a respiratory rate below 3 breaths/min, oxygen saturation < 80%, or survival to 8 h. Survival to 8 h was analyzed using Fisher's exact test, with p < 0.05 indicating significance. Survival analysis was performed using the Mantel-Cox test to assess time to death with outcomes represented in a Kaplan-Meier Cumulative survival plot. RESULTS: Five of the six pigs in the treatment group survived 8 h (293-480 min). None of the control pigs survived to 8 h (Fisher's exact p = 0.04), with mean time of respiratory failure 322 min (272-382 min). Survival analysis showed a significant delay in time to event in the treatment group compared to the control group (p = 0.04). CONCLUSIONS: The LoCC device used in this study delayed the onset of systemic toxicity and significantly increased survival time after artificial truncal envenomation by Eastern coral snake venom.

Neuroscience Near-Peer-Led Flipped Classroom Improves Student Confidence With Clinical Application of Content and Test-Taking Skills.

Introduction: The ability to apply knowledge gained in neuroscience coursework to a clinical scenario is found to be difficult by many medical students. Neuroscience is both important for future clinical practice and an area frequently tested on USMLE Step 1 examinations. Methods: Second-year medical students created a peer-led flipped classroom to help first-year students practice applying medical neuroscience course information to clinical situations and demonstrate how that information might be tested in board-style questions. The second-year students designed a series of board-style questions that included explanations for both the correct and incorrect answers. We divided the first-year students (n = 80) into small groups during the flipped classroom sessions, where they were led by second-year medical students in discussion about the questions and clinical situations. Results: Students reported agreement that the session addressed gaps in their knowledge and provided them with useful critical thinking skills for approaching board-style questions (83% and 81% agreed or strongly agreed, respectively). Discussion: The flipped classroom improved student confidence in both applying neuroscience concepts to clinical scenarios and to board-style vignette questions.

Dopamine D1 or D3 receptor modulators prevent morphine tolerance and reduce opioid withdrawal symptoms.

The long-term treatment of chronic pain by opioids is limited by tolerance and risk of addiction/dependence. Previously, we have shown that combination treatment of morphine with a dopamine D1 or D3 receptor modulator restored morphine analgesia in morphine-resistant neuropathic pain and decreased morphine's reward potential in an acute setting. Here, we investigated whether such adjunct therapy with a dopamine D1 receptor preferring antagonist (SCH 39166) or a dopamine D3 receptor preferring agonist (pramipexole) could prevent morphine tolerance and reduce withdrawal symptoms. Initially, tolerance to the combination of morphine + pramipexole was assessed in mice. Mice receiving intraperitoneal injections of morphine showed reduced thermal thresholds on Day 7 whereas those receiving morphine + pramipexole maintained analgesia at Day 7. Next, tolerance and withdrawal to both combinations were tested over 14 days in rats. Rats were assigned one of four drug conditions, (1) saline, 2) morphine, 3) morphine + SCH 39166, 4) morphine + pramipexole), for chronic administration via osmotic pumps. Chronic administration of morphine over 14 days resulted in a significant reduction of morphine analgesia. However, analgesia was maintained when morphine was administered with either the dopamine D1 receptor preferring antagonist or the D3 receptor preferring agonist. Withdrawal symptoms peaked at 48 h and were decreased in rats receiving either combination compared to morphine alone. The data suggests that adjunct therapy with dopamine D1 or D3 receptor preferring modulators prevents morphine tolerance and reduces the duration of morphine withdrawal symptoms, and thus this combination has potential for long-term pain management therapy.

Hyper-use of the ED.

OBJECTIVES: This study aims to describe the population that averages one or more emergency department (ED) visits per month and compare them to the general ED population to determine if there are associated characteristics. METHODS: A retrospective cohort study conducted in a teaching hospital between January 1, 2001, and December 31, 2004, identified all patients with more than 35 visits. This hyper-user (HU) cohort (n = 49) was compared to a randomly selected group of non-HU patients (n = 50) on the following measures: age, sex, insurance coverage, primary medical doctor (PMD), dwelling location, chief complaint, comorbidities, and disposition. RESULTS: The HU group was significantly older (mean, 49.45 years) than the non-HU group (37.32 years) with a P < .0001. There was no difference between the groups in sex, insurance coverage, PMD, dwelling location, and disposition. A univariant logistical regression found that previous cardiovascular, genitourinary, or psychiatric disease were predictors of hyper-use. CONCLUSIONS: The HU group is older and more likely to have a history of cardiovascular, genitourinary, and psychiatric disease but is similar to the non-HU group in other measured parameters. The HU group appears to have equal access to a PMD and is not more likely to be admitted to the hospital than the non-HU group.

Dopamine D1 and D3 receptor modulators restore morphine analgesia and prevent opioid preference in a model of neuropathic pain.

A secondary consequence of spinal cord injury (SCI) is debilitating chronic neuropathic pain, which is commonly morphine resistant and inadequately managed by current treatment options. Consequently, new pain management therapies are desperately needed. We previously reported that dopamine D3 receptor (D3R) dysfunction was associated with opioid resistance and increases in D1 receptor (D1R) protein expression in the spinal cord. Here, we demonstrate that in a model of SCI neuropathic pain, adjuvant therapy with a D3R agonist (pramipexole) or D1R antagonist (SCH 39166) can restore the analgesic effects of morphine and reduce reward potential. Prior to surgery thermal and mechanical thresholds were tested in three groups of female rats (naïve, sham, SCI). After surgery, testing was repeated under the following drug conditions: 1) saline, 2) morphine, 3) pramipexole, 4) SCH 39166, 5) morphine + pramipexole, and 6) morphine + SCH 39166. Reward potential of morphine and both combinations was assessed using conditioned place preference. Following SCI, morphine + pramipexole and morphine + SCH 39166 significantly increased both thermal and mechanical thresholds. Morphine alone induced conditioned place preference, but when combined with either the D3R agonist or D1R antagonist preference was not induced. The data suggest that adjunct therapy with receptor-specific dopamine modulators can restore morphine analgesia and decrease reward potential and thus, represents a new target for pain management therapy after SCI.