Radial Artery Pseudoaneurysm From a Squirrel Bite.

Radial artery pseudoaneurysm is a rarelimb-threatening complication that occurs from vascular procedures and direct trauma. We present a rare case of a 74-year-old female who presented to the emergency department with a squirrel bite to her right wrist. Although initially benign-appearing, computed tomography angiography of the right upper extremity showed a pseudoaneurysm at the distal radial artery. The patient was successfully treated with careful compression and rapid resolution was confirmed with an arterial right upper extremity ultrasound that visualized a formed thrombus. Emergency providers should have a high index of suspicion for radial artery pseudoaneurysms in the setting of animal bites to the wrist.

Spontaneous Liver Rupture in the Setting of Autoimmune Disease and Periportal Edema.

Spontaneous liver rupture is a rare and life-threatening occurrence associated with high morbidity and mortality. We report a rare case of an elderly patient with a significant history of autoimmune disease who initially presented with cholestatic symptomatology that subsequently resulted in spontaneous liver rupture and hemorrhagic shock. An initial CT scan prior to the rupture showed periportal edema. In a patient with unexplained abdominal pain and imaging findings of periportal edema, emergency providers should have a lower threshold for suspecting the development of liver rupture or other hepatic pathologies. In the case of a potential liver rupture, admission for observation and early resuscitation can prove key to successful treatment.

Difficult Intravenous Access Requiring Ultrasound in the Emergency Department: Associations With Delays in Care and Areas for Quality Improvement.

Background Patients with difficult intravenous access (DIVA) requiring ultrasound-guided intravenous (USGIV) access have been associated with delays in treatment, imaging, and disposition in academic emergency department (ED) patient populations. Our objective in this study was to characterize differences in time to intravenous access, imaging, and disposition between patients with DIVA versus those without DIVA requiring USGIV access in a community ED while also assessing for DIVA-associated comorbidities. Methods A cross-sectional, observational analysis was performed on admitted ED patients evaluated from September 2 to September 31, 2022, at a community ED. Patients with DIVA were defined as patients with two failed attempts at traditional intravenous placement. These patients require USGIV placement per institutional protocol. Patients younger than 18 years of age, trauma admissions, repeated visits from the same patient, patients with missing data, and direct hospital admissions were excluded. Continuous variables were recorded with medians and included ED throughput measures of time to vascular access, contrast CT imaging, and disposition. Differences in median times between DIVA patients versus non-DIVA patients were assessed with the Mann-Whitney U-test. Categorical data involving comorbidities were reported as percentages, and differences in proportions between DIVA versus non-DIVA patients were assessed via chi-square tests. Multivariate logistic regression analysis evaluated for correlations between DIVA and times to access, contrast CT imaging, disposition, and significant covariates while adjusting for demographic information. Results A total of 1250 patients were included in this investigation (5.8% associated with DIVA requiring USGIV access). The median age of all subjects was 69 (interquartile range = 58, 79) with no significant difference between the DIVA and non-DIVA groups. Patients with DIVA were more likely to be female in comparison to patients without DIVA (65.3% and 51.2%, respectively, p < 0.05). Patients with a history of end-stage renal disease (ESRD) (p < 0.001), intravenous drug use (IVDU) (p < 0.001), and venous thromboembolism (p < 0.05) had statistically significant associations with DIVA. On regression analysis, patients with DIVA were more likely to have a history of ESRD with an odds ratio (OR) of 3.56 (95% confidence interval (CI): 1.62-7.81) and a history of IVDU with an OR of 14.29 (95% CI: 5.17-39.54). Patients with DIVA were associated with statistically significant greater median times to vascular access, contrast CT imaging, and disposition (p < 0.001 for time to access and disposition and p < 0.01 for time to contrast CT imaging). Conclusion In this study, DIVA cases requiring USGIV access were positively associated with significantly longer times to access, contrast CT imaging, and disposition compared to patients without DIVA at our community ED. Comorbidities such as IVDU and ESRD had statistically significant associations with DIVA requiring USGIV access.

Implementation of a Resident-Designed Procedure Cart in a Busy Emergency Department.

The authors present a description of the procedure cart they designed for their Emergency Department. This project was in response to the inefficiencies in having to gather supplies from various locations to get set up. A complete description including each of the drawer contents is provided to allow others to easily replicate a tool that saved the authors much time and frustration in daily practice.

Myalgia as a Symptom of Envenomation by the Eastern Coral Snake, Micrurus Fulvius: A Case Report.

We present the case of a patient who developed myalgia as the primary symptom of envenomation by the eastern coral snake, Micrurus fulvius. The patient was evaluated and treated in the emergency department. Physical examination did not demonstrate any neuromuscular abnormalities. On consultation with the poison control center, the patient's myalgia was determined to be an effect of envenomation, and 5 vials of North American coral snake antivenin were administered. The patient was admitted to the intensive care unit where his symptoms resolved. He was discharged the following day after remaining asymptomatic for 24 h.

Viper-induced Consumptive Coagulopathy from a Decapitated Eastern Diamondback Rattlesnake.

We present the case of a patient who presented with viper-induced consumptive coagulopathy after a bite on the thumb from a decapitated eastern diamondback rattlesnake. The patient was evaluated and treated in the Emergency Department and was admitted to the intensive care unit.

A geographical workforce analysis of hand therapy services in relation to US population characteristics.

INTRODUCTION: A paucity of work force planning literature exists for hand therapy services. PURPOSE: This descriptive study aimed to map the geographical distribution of US Certified Hand Therapists (CHTs) and describe characteristics of US populations living in respective CHT workplace Zip Code Tabulation Areas (ZCTAs). METHODS: A de-identified Zip Code list of all active CHTs through April 2016 from the Hand Therapy Certification Commission, included 5572 CHTs with US ZCTAs. The CHT ZCTAs were matched with population parameters "rurality", "poverty" and "race and ethnicity" from the 2010 US Census and 2014 American Community Survey. RESULTS: The 5,572 CHTs practice ZCTAs mostly overlapped with high density US population areas, covering just 9% of the total number of 33,120 US ZCTAs. The population in CHT ZCTAs was 1) urban in nature, 2) with lower poverty rates than ZCTAs without CHTs, and 3) mostly reflecting US race and ethnicity population distribution. Only 3.7% of CHTs worked in large concentrations of 11 to 26 CHTs per ZCTA near or in urban centers. Most CHTs, 67%, worked in one to three CHTs per ZCTA concentrations, contributing to a larger geographic spread of CHT locations than expected. DISCUSSION AND CONCLUSION: This study provides a foundational snap shot of the distribution, the potential availability, of the 2016 CHT workforce in the context of US population characteristics. It may serve as baseline for supply and demand studies and interventions to grow the CHT profession and optimize the distribution of CHTs to better meet population needs.

Life in a landfill slum, children's health, and the Millennium Development Goals.

People living in slums can be considered left behind with regard to national successes in achieving Millennium Development Goals (MDGs). The objective of this study was to evaluate the living and working conditions of waste pickers and their children in a landfill slum located in the largest city in eastern Indonesia. A total of 113 people from the landfill slum and 1184 people from the general population participated in face-to-face interviews. Municipal solid waste (MSW) was analyzed for metals, metalloids and fecal indicator bacteria. Ambient air quality including particulate matter was measured in the landfill. Households in the landfill slum were 5.73 (p=0.04) times more likely to be below the international poverty line (MDG 1: Poverty) and 15.6 times (p<0.01) more likely to have no one in the household possessing a primary education (MDG 2: Universal Education), and 107 times (p<0.01) more likely not to have improved sanitation facilities (MDG 7: Environmental Sustainability) when compared to the general population. Diarrhea is one of the leading causes of death in children under five in Indonesia. Young children living in the landfill slum were 2.87 times (p=0.02) more likely to develop diarrhea than their general population counterparts. Other survey results and environmental measurements suggest that landfill slum children have additional adverse health effects (e.g. infections and poisoning). Poverty underlies several MDG issues that directly or indirectly affect child health. Therefore, eradicating extreme poverty will continue to be the most critical challenge for the MDGs beyond 2015.

Childhood acute respiratory infections and household environment in an Eastern Indonesian urban setting.

This pilot study evaluated the potential effect of household environmental factors such as income, maternal characteristics, and indoor air pollution on children's respiratory status in an Eastern Indonesian community. Household data were collected from cross-sectional (n = 461 participants) and preliminary childhood case-control surveys (pneumonia cases = 31 diagnosed within three months at a local health clinic; controls = 30). Particulate matter (PM2.5 and PM10) was measured in living rooms, kitchens, children's bedrooms, and outside areas in close proximity once during the case-control household interviews (55 homes) and once per hour from 6 a.m. to midnight in 11 homes. The household survey showed that children were 1.98 times (p = 0.02) more likely to have coughing symptoms indicating respiratory infection, if mothers were not the primary caregivers. More children exhibited coughing if they were not exclusively breastfed (OR = 2.18; p = 0.06) or there was a possibility that their mothers were exposed to environmental tobacco smoke during pregnancy (OR = 2.05; p = 0.08). This study suggests that household incomes and mother's education have an indirect effect on childhood pneumonia and respiratory illness. The concentrations of PM2.5 and PM10 ranged from 0.5 to 35.7 µg/m3 and 7.7 to 575.7 µg/m3, respectively, based on grab samples. PM was significantly different between the case and control groups (p < 0.01). The study also suggests that ambient air may dilute indoor pollution, but also introduces pollution into the home from the community environment. Effective intervention programs need to be developed that consider multiple direct and indirect risk factors to protect children.

Estimating medically fragile population in storm surge zones: a geographic information system application.

OBJECTIVE: To develop a simple, cost-effective method for determining the size and geographic distribution of medically fragile (MF) individuals at risk from tropical storm surges for use by emergency management planners. DESIGN: The study used Geographic Information System (GIS) spatially referenced layers based on secondary data sources from both state and federal levels. SETTING: The study setting included the eastern North Carolina coastal counties that would be affected by tropical storm surges. SUBJECTS: The initial MF population was extrapolated from national estimates for five conditions and then applied to US Census block population. These conditions included insulin dependent diabetes, chronic obstructive pulmonary disease, congestive heart failure, end stage renal disease, and patients receiving long-term oxygen treatment. MAIN OUTCOMES: The main outcome of this study was a series of local and regional maps that portrayed the geographic distribution and estimated counts of potentially at-risk MF population from a tropical storm surge scenario. CONCLUSIONS: Maps depicting the geographic distribution and potential numbers of MF individuals are important information for planning and preparedness in emergency management and potentially engaging the public.

Physical and physiological consequences of passive intra-oral shimming.

Imaging the human orbitofrontal cortex (OFC) with fMRI is problematic due to the proximity of this region to the air-filled sinuses, which causes susceptibility artifacts. Placing a strongly diamagnetic material into the mouth ('mouthshim') of a human volunteer can significantly reduce the artifacts in this region. Using the same combined olfactory and visual fMRI paradigm, we compared brain activation and static B0 field maps of participants being scanned both with and without the 'mouthshim'. Results demonstrate that the device improves the B0 field homogeneity within OFC, resulting in significantly stronger BOLD activation in this region. However, the device also caused both increased head motion and reduced activation in insular cortices due to more frequent swallowing and tactile stimulation of the tongue. The 'mouthshim' should only, therefore, be used where sensitivity in OFC regions is paramount.

Perturbation method for magnetic field calculations of nonconductive objects.

Inhomogeneous magnetic fields produce artifacts in MR images including signal dropout and spatial distortion. A novel perturbative method for calculating the magnetic field to first order (error is second order) within and around nonconducting objects is presented. The perturbation parameter is the susceptibility difference between the object and its surroundings (for example, approximately 10 ppm in the case of brain tissue and air). This method is advantageous as it is sufficiently accurate for most purposes, can be implemented as a simple convolution with a voxel-based object model, and is linear. Furthermore, the method is simple to use and can quickly calculate the field for any orientation of an object using a set of precalculated basis images.

Distinct portions of anterior cingulate cortex and medial prefrontal cortex are activated by reward processing in separable phases of decision-making cognition.

BACKGROUND: Choosing between actions associated with uncertain rewards and punishments is mediated by neural circuitry encompassing the orbitofrontal cortex, anterior cingulate cortex (ACC), and striatum; however, the precise conditions under which these different components are activated during decision-making cognition remain uncertain. METHODS: Fourteen healthy volunteers completed an event-based functional magnetic resonance imaging protocol to investigate blood-oxygenation-level-dependent (BOLD) responses during independently modeled phases of choice cognition. In the "decision phase," participants decided which of two simultaneous visually presented gambles they wished to play for monetary reward. The gambles differed in their magnitude of gains, magnitude of losses, and the probabilities with which these outcomes were delivered. In the "outcome phase," the result of each choice was indicated on the visual display. RESULTS: In the decision phase, choices involving large gains were associated with increased BOLD responses in the pregenual ACC, paracingulate, and right posterior orbitolateral cortex compared with choices involving small gains. In the outcome phase, good outcomes were associated with increased BOLD responses in the posterior orbitomedial cortex, subcallosal ACC, and ventral striatum compared with negative outcomes. There was only limited overlap between reward-related activity in ACC and orbitofrontal cortex during the decision and outcome phases. CONCLUSIONS: Neural activity within the medial and lateral orbitofrontal cortex, pregenual ACC, and striatum mediate distinct representations of reward-related information that are deployed at different stages during a decision-making episode.

Utilization of an intra-oral diamagnetic passive shim in functional MRI of the inferior frontal cortex.

Due to the presence of gross magnetic susceptibility artifacts, functional MRI (fMRI) has proved problematic in studies of the human inferior frontal cortex (IFC). There is a strong desire, therefore, to employ techniques that mitigate susceptibility artifacts in the IFC while preserving the imaging parameters of an fMRI study. It has been shown that the use of a single, strongly diamagnetic, intra-oral passive shim significantly improves the homogeneity of the static magnetic field (B(0)) and, as a result, alleviates the susceptibility artifacts within the IFC. In this study, practical issues regarding the use of an intra-oral passive shim are examined. We investigated B(0) instabilities within the IFC resulting from subject head motion in order to calculate the effects of an intra-oral passive shim on the temporal variance of an EPI time series. These studies show that the addition of an intra-oral passive shim improves both B(0) homogeneity and signal stability, and increases sensitivity to functional activation.

Protocol to determine the optimal intraoral passive shim for minimisation of susceptibility artifact in human inferior frontal cortex.

At higher static magnetic field (B(0)) strengths (>/=3 T), the study of human inferior frontal cortex (IFC) when utilising a variety of MRI techniques is severely hampered by the presence of susceptibility artifacts. This is particularly the case for blood oxygenation level-dependent functional MRI, where large signal voids are generally encountered in the frontal lobes. A previous study described an approach to artifact correction involving a mouth insert consisting of a prototype diamagnetic passive shim [Magn. Reson. Med. 48 (2002), 906]. Here we extend that method by investigating the effect of five different intraoral passive shims on B(0) homogeneity and echoplanar imaging susceptibility artifacts within the brain, and particularly the IFC, of six subjects. The optimal passive shim is shown to be subject- and study-specific, providing an average reduction in mean absolute B(0) offset within the IFC of 57%, along with a concomitant reduction in echoplanar susceptibility artifact. All subjects were at ease while wearing the intraoral shims. A 4-min in vivo protocol to determine the optimal passive shim from the available set, utilising intrinsic structural and B(0) subject data, is described and shown to be accurate and reliable.

Optimization of static field homogeneity in human brain using diamagnetic passive shims.

These preliminary studies demonstrate that static field inhomogeneity in the human inferior frontal cortex (IFC) is significantly diminished through placement of a small amount of strongly diamagnetic material in the roof of the mouth. As a result, susceptibility-related image artifacts in this region, as observed in blood oxygen level dependent (BOLD) functional MRI (fMRI), are considerably decreased without compromising the spatial or temporal resolution of the study. Simulations of the static field utilizing perturbation theory are shown, which support the experimental results. The limitations and possible future developments of the technique are described. The application of diamagnetic passive shimming on other regions of the brain is also discussed. Routine use of the proposed method within fMRI studies is practicable through subject-specific optimization of the technique utilizing the simulation algorithm.

Fast, fully automated global and local magnetic field optimization for fMRI of the human brain.

The aim of this novel technique is to allow researchers, particularly those operating at high static magnetic field strengths on fMRI applications, to tailor the static magnetic field within the brain. The optimum solution for their experimental needs is reached, utilizing the full potential of the active shims at their disposal. The method for shimming human brain, which incorporates automatic brain segmentation to remove nonbrain tissue from the optimization routine, is presented and validated. The technique is fast, robust, and accurate, achieving the global minimum to a static field homogeneity function of the in vivo brain. Both global and specified local regions of the brain can be selected on which to optimize the shims without requiring skilled intervention. The effectiveness of the automated local shim is demonstrated in an olfactory fMRI study where significant activations in the orbitofrontal cortex were very clear when the above method was employed.