A Case Report of Unilateral Orolingual Angioedema Secondary to Alteplase Administration.

Emergency physicians should be aware of adverse drug reactions prior to administering medication. Alteplase, or tissue plasminogen activator (tPA), is a common medication in the emergency department, whether it is being used for a stroke or pulmonary embolus. Angioedema can be caused by almost any medication. tPA administration can cause an atypical form of angioedema. The following case was one of unilateral orolingual angioedema associated with tPA administration in the emergency department in a stroke patient. The mechanism of tPA-induced angioedema is poorly understood. Angioedema can be treated with stopping the infusion of medication, Benadryl® (Johnson & Johnson Consumer, Inc., Fort Washington, PA), histamine antagonists, steroids, and epinephrine. Angioedema is a life-threatening event in certain situations, and emergency medicine providers would do well knowing how to approach these cases.

Real-time monitoring of calcification process by Sporosarcina pasteurii biofilm.

Sporosarcina pasteurii is known to produce calcite or biocement in the presence of urea and Ca(2+). Herein, we report the use of novel ultramicrosensors such as pH, Ca(2+), and redox sensors, along with a scanning electrochemical microscope (SECM), to monitor a real-time, bacteria-mediated urea hydrolysis process and subsequent changes in morphology due to CaCO3 precipitation. We report that the surface pH of a live biofilm changed rapidly from 7.4 to 9.2 within 2 min, whereas similar fast depletion (10 min) of Ca(2+) was observed from 85 mM to 10 mM in the presence of a high urea (10 g L(-1)) brine solution at 23 °C. Both the pH and the Ca(2+) concentration profiles were extended up to 600 µm from the biofilm surface, whereas the bulk chemical composition of the brine solution remained constant over the entire 4 h of SECM experiments. In addition, we observed a change in biofilm surface morphology and an increase in overall biofilm height of 50 µm after 4 h of precipitation. Electron microscopy confirmed the changes in surface morphology and formation of CaCO3 crystals. Development of the Ca(2+) profile took 10 min, whereas that of the pH profile took 2 min. This finding indicates that the initial urea hydrolysis process is fast and limited by urease or number of bacteria, whereas later CaCO3 formation and growth of crystals is a slow chemical process. The ultramicrosensors and approaches employed here are capable of accurately characterizing bioremediation on temporal and spatial scales pertinent to the microbial communities and the processes they mediate.

Emergency physician perceptions of shared decision-making.

OBJECTIVES: Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated. METHODS: As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM. RESULTS: A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose." CONCLUSIONS: Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.