Stercoral Colitis: An Unexpected Presentation in a Young Adolescent.

Stercoral colitis is an uncommon inflammatory condition primarily affecting individuals with chronic constipation, immobilization, and advanced age, occasionally manifesting in pediatric patients. It arises from the accumulation of impacted fecal matter, leading to colonic distension and subsequent fecaloma formation, culminating in pressure necrosis and perforation. Mortality rates can exceed 60% in vulnerable populations due to complications such as colonic perforation and ischemia. Presented is the case of a 14-year-old female with stercoral colitis, initially presenting with diarrhea, abdominal pain, and metabolic acidosis. Despite improvement followed by a sudden deterioration, diagnostic challenges persisted, highlighting the complexity of diagnosing this condition, especially in pediatric cases. Key diagnostic criteria include vague abdominal symptoms, leukocytosis, and elevated inflammatory markers, alongside potential metabolic derangements. Imaging modalities, such as abdominal CT scans, aid in diagnosis, delineating features like colonic distension and wall thickening. Treatment strategies encompass aggressive bowel disimpaction, with endoscopic or surgical interventions reserved for refractory cases or perforations. Recognition of stercoral colitis is crucial for timely intervention, given its significant morbidity and mortality. Although typically associated with elderly or bedbound patients, the condition can also affect younger individuals, emphasizing the importance of considering it in the differential diagnosis, particularly in cases of chronic constipation. Integration of diagnostic imaging techniques facilitates accurate diagnosis, guiding appropriate therapeutic interventions and potentially mitigating adverse outcomes.

Angioedema: A Possible Complication of Amlodipine Use.

Angioedema is a documented but uncommon adverse effect of dihydropyridine calcium channel blockers such as amlodipine. We present the case of a 38-year-old man who presented to the emergency department (ED) with severe swelling of his upper lip that had begun earlier in the day. His medical history was notable for hypertension treated with amlodipine; his only other medication was a multivitamin. The patient denied any known drug allergies, new foods, insect bites, recent travel, or sick contacts. Physical examination showed hypertension and massive edema isolated to the upper lip; it was otherwise unremarkable. Laboratory results showed no abnormalities aside from a slight normocytic anemia. The patient was diagnosed with angioedema, with amlodipine suspected as the cause. Amlodipine was discontinued and treatment was initiated with IV glucocorticoids and diphenhydramine. The swelling improved steadily over the next 36 hours and the patient was discharged on hospital day 3.

A novel simulation model for tube thoracostomy.

Objective: Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine. Methods: This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues. Results: The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt. Conclusions: We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.

Benign Presentation Following Massive Deutetrabenazine Overdose.

Deutetrabenazine (DTBZ) (Austedo®) is a novel vesicular monoamine transporter 2 (VMAT2) inhibitor, which acts by blocking dopamine release and other monoamines from neuronal vesicles. Although this drug is considered the first-line treatment for tardive dyskinesia (TD), VMAT2 inhibition has also been shown to improve patients' symptoms with Huntington's disease-induced chorea. We present the case of a 59-year-old woman with a history of TD, who presented to the emergency department following massive DTBZ ingestion. The relative paucity of other overdose symptoms further supports the manufacturer's claims of a low side effect profile for this drug in overdose. Although DTBZ demonstrates an excellent safety profile, emergency physicians should be aware of the potential side effect of DTBZ overdose, in addition to other known side effects of this novel drug.

An Unusual Case Presentation of Emphysematous Cystitis.

Emphysematous cystitis (EC) is a rare infection characterized by gas formation in the bladder wall. We present an unusual case of emphysematous cystitis of a 37-year-old female patient with pneumaturia, vomiting, nausea and abdominal pain. EC was diagnosed on a computed tomography (CT) scan which demonstrated abnormal bladder wall thickening that contained air. Urinalysis was positive for hematuria, bacteria and an elevated leukocyte esterase which further supported the diagnosis. This patient's atypical symptoms and lack of other risk factors that are commonly seen in patients with EC highlight the need for vigilance when assessing for EC.

Remdesivir for the Treatment of COVID-19: A Systematic Review of the Literature.

In March 2020, the World Health Organization declared the spread of SARS-CoV-2 a global pandemic. To date, coronavirus disease-2019 (COVID-19) has spread to over 200 countries, leading to over 1.6 million cases and over 99,000 deaths. Given that there is neither a vaccine nor proven treatment for COVID-19, there is currently an urgent need for effective pharmacotherapy. To address the need for an effective treatment of SARS-CoV-2 during the worldwide pandemic, this systematic review of intravenous (IV) remdesivir was performed. Remdesivir, an anti-viral prodrug originally developed to treat Ebola virus disease, has shown broad spectrum activity against the Coronavirus family. A recent case report reported improvement of clinical symptoms with remdesivir in a patient with COVID-19. After conducting a systematic search of 18 clinical trial registries and three large scientific databases, we identified 86 potentially eligible items. Following removal of duplicates (n = 21), eligible studies were reviewed independently by two authors. After the first round of screening, inter-rater agreement was 98.5% (κ = 0.925). After the second round of full-text screening, inter-rater agreement was 100%. A total of seven ongoing and recruiting clinical trials of remdesivir (100-200 milligrams, intravenous [IV]) were included. We identified the following primary outcomes: patients discharged (n = 2); time to clinical status improvement (n = 2); improved O2 saturation (n = 2); body temperature normalization (n = 2); and clinical status (n = 1). Secondary outcomes in all identified studies included documentation of adverse events. Phase 3 trials are expected to be completed between April 2020-2023. Therefore, despite supportive data from in vitro and in vivo studies, the clinical effectiveness of IV remdesivir for treatment of COVID-19 and potential side effects remain incompletely defined in the human population.

Multi-Institutional Survey of Fourth Year Students' Self Assessed Milestone Based Skill Proficiency and Faculty Expectation During an Emergency Medicine Clerk-ship: Implications For Curriculum Development.

This article was migrated. The article was marked as recommended. Introduction: Emergency medicine milestones suggest skill performance expectations for graduating medical students. The objective of this study is to examine differences between student's perceived proficiency and faculty expectations relative to Level 1 EM milestones, identifying opportunities for curriculum development. Methods: Using ACGME milestone language, the authors developed a survey that measures student perceived skill proficiency with 22 skills, which was administered to fourth year medical students at 6 institutions. Similar surveys were sent to faculty to determine their expectations of students' skill proficiency. Differences between student and faculty responses were calculated. Results: There were 608 student and 114 faculty responses. There was a statistically significant difference between mean student and faculty responses for 13 of the 22 skills. For 10 of these skills, students rated their own skill proficiency higher than faculty expectations. For 3 of the skills, faculty rated their expectations higher than students' perceived proficiency. Conclusions: For pharmacology skills, student ratings were low, indicating an area to focus curriculum development. Items where student ratings are higher than faculty may be a result of overconfidence or a lack of understanding by faculty of students' abilities. Formal assessment of skills in these areas would help clarify the reason and direct faculty and curriculum development.

A randomized comparison trial of case-based learning versus human patient simulation in medical student education.

OBJECTIVES: Human patient simulation (HPS), utilizing computerized, physiologically responding mannequins, has become the latest innovation in medical education. However, no substantive outcome data exist validating the advantage of HPS. The objective of this study was to evaluate the efficacy of simulation training as compared with case-based learning (CBL) among fourth-year medical students as measured by observable behavioral actions. METHODS: A chest pain curriculum was presented during a one-month mandatory emergency medicine clerkship in 2005. Each month, students were randomized to participate in either the CBL-based or the HPS-based module. All students participated in the same end-of-clerkship chest pain objective structured clinical examination that measured 43 behaviors. Three subscales were computed: history taking, acute coronary syndrome evaluation and management, and cardiac arrest management. Mean total and subscale scores were compared across groups using a multivariate analysis of variance, with significance assessed from Hotelling's T2 statistic. RESULTS: Students were randomly assigned to CBL (n = 52) or HPS (n = 50) groups. The groups were well balanced after random assignment, with no differences in mean age (26.7 years; range, 22-44 years), gender (male, 52.0%), or emergency medicine preference for specialty training (28.4%). Self-ratings of learning styles were similar overall: 54.9% were visual learners, 7.8% auditory learners, and 37.3% kinetic learners. Results of the multivariate analysis of variance indicated no significant effect (Hotelling's T2 [3,98] = 0.053; p = 0.164) of education modality (CBL or HPS) on any subscale or total score difference in performance. CONCLUSIONS: HPS training offers no advantage to CBL as measured by medical student performance on a chest pain objective structured clinical examination.