Refractory Hypoglycemia Due to Sulfonylurea Contamination of Illicit Opioid Medications.

Illicit drug supply adulteration can heighten the risk for adverse health outcomes. Sulfonylurea medications are widely used in the treatment of diabetes mellitus (DM). Unintentional or intentional overdose of sulfonylureas can cause refractory hypoglycemia. This case report describes a 62-year-old male patient who presented to the emergency department (ED) after being found on the ground with signs of mild trauma. He was noted to be persistently hypoglycemic despite boluses of intravenous dextrose, a dextrose infusion, and oral nutrition. The patient did report purchase and oral ingestion of pills sold as oxycodone and that the pill shape and color were different from his usual supply. The patient was empirically treated with octreotide resulting in normalization of his serum glucose. Testing demonstrated a serum glipizide concentration six times the reporting range. This case represents unintentional sulfonylurea exposure in the setting of non-prescribed oxycodone use, resulting in hypoglycemia refractory to intravenous dextrose and oral nutrition. Octreotide is an additional potential treatment for this condition. As in this case, ingestion of street drugs may present a potential source of sulfonylurea exposure. Opioid contamination with sulfonylureas has not been widely reported in the literature and knowledge about this potential exposure is important for the prompt recognition and treatment of these patients by emergency physicians.

Radioactive contamination in feral dogs in the Chernobyl exclusion zone: Population body-burden survey and implications for human radiation exposure.

This report describes a two-year effort to survey the internal 137Cs and external ß-emitter contamination present in the feral dog population near the Chernobyl nuclear power plant (ChNPP) site, and to understand the potential for human radiation exposure from this contamination. This work was performed as an integral part of the radiation safety and control procedures of an animal welfare oriented trap-neuter-release (TNR) program. The measurement program focused on external contamination surveys using handheld ß-sensitive probes, and internal contamination studies using a simple whole-body counter. Internal 137Cs burden was measured non-invasively during post-surgical observation and recovery. External ß contamination surveys performed during intake showed that 21/288 animals had significant, removable external contamination, though not enough to pose a large hazard for incidental contact. Measurements with the whole-body counter indicated internal 137Cs body burdens ranging from undetectable (minimum detection level ∼100 Bq/kg in 2017, ∼30 Bq/kg in 2018) to approximately 30,000 Bq/kg. A total of 33 animals had 137Cs body-burdens above 1 kBq/kg, though none posed an external exposure hazard. The large variation in the 137Cs concentration in these animals is not well-understood, could be due to prey selection, access to human food scraps, or extended residence in highly contaminated areas. The small minority of animals with external contamination may pose a contamination risk allowing exposures in excess of regulatory standards.

Faculty support bundle for simulation education.

BACKGROUND: Postgraduate training programmes rely on faculty to meet core educational needs, including simulation. Time is arguably the most valuable resource for academic physicians, which presents a challenge for recruiting faculty to provide extra-clinical teaching. To increase faculty engagement in simulation-based education (SBE), we first identified barriers to participation. Next, we sought to overcome barriers using a self-determination theory (SDT) framework to increase motivation using strategies that addressed faculty autonomy, competence and relatedness. METHODS: Faculty from a single department of emergency medicine were surveyed about factors influencing participation in SBE. Responses were grouped into themes and used to develop the intervention-a faculty support bundle-to overcome common barriers and promote participation. Supports focused on course materials, organisational consistency and peer recognition. Faculty participation in SBE pre- and post-implementation of the support bundle was analysed via chi-squared analysis. Faculty who delivered SBE were resurveyed after the implementation phase to explore how the support bundle affected their experience. RESULTS: Initial survey response was 41%. Reported barriers to participation in SBE included scheduling issues, preparation time, competing responsibilities, lack of confidence with simulation and lack of interest. Twenty-four faculty participated in SBE during the pre-implementation phase, compared to 39 post implementation (p = 0.03). DISCUSSION: The faculty support bundle increases faculty participation in SBE. Strategies focused on internal motivators identified using an SDT framework. In contrast to traditional external motivators, these were no cost interventions. Those seeking to increase faculty participation in SBE should consider implementing similar strategies.

The Impact of Anonymity in Emergency Medicine Morbidity and Mortality Conferences: Findings from a National Survey of Resident Physicians.

INTRODUCTION: Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. METHODS: We conducted a national survey at 33 emergency medicine residency programs evaluating residents' perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified. RESULTS: There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity's impact on punitive response to error, the ability to learn from cases, and professional responsibility. CONCLUSION: Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.

Emergency Medicine Morbidity and Mortality Conference and Culture of Safety: The Resident Perspective.

OBJECTIVE: Morbidity and mortality conference (M&M) is common in emergency medicine (EM) and an Accreditation Council for Graduate Medical Education (ACGME) requirement. We aimed to characterize the prevalence of elements of EM M&M conferences that foster a strong culture of safety. METHODS: Emergency medicine residents at 33 programs across the United States were surveyed using questions adapted from a previously tested survey of EM program directors and the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety Survey. RESULTS: The survey response rate was 80.3% (1,002/1,248). A total of 60.3% (601/997) of residents had not submitted a case of theirs to M&M in the past year. A total of 7.6% (73/954) reported that issues raised at M&M always led to change while 88.3% (842/954) reported that they sometimes did and 4.1% (39/954) reported that they never did. A total of 56.2% (536/954) responded that changes made due to M&M were reported back to the residents. Of residents who had cases presented at M&M, 24.2% (130/538) responded that there was regular debriefing, 65.2% (351/538) responded that there was not, and 10.6% (57/578) were unsure. A total of 10.2% (101/988) of respondents agreed that M&M was punitive, 17.4% were neutral (172/988), and 72.4% (715/988) disagreed. A total of 18.0% (178/987) of residents agreed that they felt pressure to order unnecessary tests because of M&M, 22.3% (220/987) were neutral, and 59.6% (589/987) disagreed. A total of 87.4% (862/986) felt that M&M was a valuable educational didactic session, and 78.3% (766/978) believed that M&M contributes to a culture of safety in their institution. CONCLUSIONS: While most residents believe that M&M is a valuable didactic session and contributes to institutional culture of safety, there are opportunities to improve by communicating changes made in response to M&M, debriefing residents who have had cases presented, and taking steps to make M&M not feel punitive to some residents.

Ovarian and tubal torsion: imaging findings on US, CT, and MRI.

Accurate diagnosis of adnexal torsion is often challenging, as clinical presentation is nonspecific and the differential for pelvic pain is broad. However, prompt diagnosis and treatment is critical to good clinical outcomes and preservation of the ovary and/or fallopian tube. Ultrasound (US) imaging is most frequently used to assess torsion. However, as computed tomography (CT) utilization in the emergency setting has increased, there are times when CT is the initial imaging test. Additionally, the nonspecific clinical presentation may initially be interpreted as gastrointestinal in etiology, where CT is the preferred exam. For these reasons, it is imperative to know the findings of adnexal torsion on CT as well as US. Magnetic resonance imaging (MRI) is helpful in cases where the diagnosis remains unclear and is particularly helpful in the young or pregnant patient with equivocal sonographic findings, as it provides excellent soft tissue contrast without ionizing radiation. This article will illustrate the findings of surgically confirmed ovarian and fallopian tube torsion on US, CT, and MRI, including those in the pregnant patient. Ovarian enlargement, adnexal mass, twisting of the vascular pedicle, edematous and heterogeneous appearance of the ovary, peripheral ovarian follicles, free fluid, uterine deviation towards the side of torsion, adnexal fat stranding, tubal dilatation, and decreased adnexal enhancement will be reviewed. Familiarity with the range of imaging findings across multiple modalities is key to improving the likelihood of timely diagnosis and therefore improved clinical outcomes.

Is preoperative diagnosis possible? A clinical and radiological review of lymphoepithelial cysts of the pancreas.

Lymphoepithelial cysts of the pancreas are rare lesions found mainly in middle-aged men. They are usually benign and have no clear natural history except one study linking their occurrence with HIV infection. Nevertheless, they often cause enormous psychological stress to patients as they tend to mimic pancreatic neoplasms which are known to carry poor prognosis. The authors have therefore assessed the published literature from PubMed in order to determine whether lymphoepithelial cysts can be diagnosed preoperatively using novel imaging techniques. Based on our findings, it is evident that three-dimensional computed tomography scans, in-phase and out-of phase magnetic resonance imaging studies, and endosonography have enabled better characterization of pancreatic lymphoepithelial cysts than a decade ago. Endoscopic ultrasound-guided fine needle aspiration has also added considerably to the promise of preoperative diagnosis. Thus, the authors can affirm that despite surgical excision of the cyst with pathological examination being the gold standard for diagnosis, it is possible that a combination of the modern imaging techniques and/or minimally-invasive approach can enable patients avoid unnecessary surgery in the future.

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation.

INTRODUCTION: High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulation's ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data. METHODS: Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity. RESULTS: 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5+/-1.3 min (mean+/-SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8+/-0.5 min, and completed endotracheal intubations at 11.3+/-4.0 min. CPR was performed within 3.1+/-2.3 min; arrhythmia recognition occurred by 4.9+/-2.1 min, defibrillation at 6.8+/-2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9+/-2.3 min (p<0.01) and 2.1+/-4.1 min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies. CONCLUSION: On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulation's role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

High-fidelity medical simulation as an assessment tool for radiology residents' acute contrast reaction management skills.

PURPOSE: The aims of this study were to use medical simulation as an assessment tool for the evaluation of radiology residents' compliance with contrast reaction treatment protocols and to gauge their perceptions of the simulation experience. METHODS: A prospective, observational study of postgraduate year 2 and 3 radiology residents' management of simulated life-threatening contrast reactions was designed. After standard didactic teaching on departmental contrast reaction protocols, residents participated individually in high-fidelity medical simulations of acute contrast reactions. Residents' performance of predetermined critical actions was recorded. Presimulation and postsimulation multiple-choice testing evaluated residents' knowledge of departmental protocols. Each resident completed 5-point, Likert-type surveys assessing comfort level while managing contrast reactions and perceptions of the simulation experience. RESULTS: Residents performed a mean of 13 of 20 critical actions (range, 10-16). The average presimulation multiple-choice testing score was 56%, whereas the average postsimulation score was 92% (P = .0003). Subjects' average ratings of comfort level in managing in-hospital contrast reactions before and after study intervention were 3.47 and 4.07, respectively (P = .03). Average ratings for comfort level in the outpatient setting were 3.08 before and 3.69 after the study (P = .69). All residents strongly agreed that the simulation was a valuable educational experience, while 85% strongly agreed that it improved their skills in managing acute contrast reactions. CONCLUSION: Standard didactic instruction may provide insufficient training and reinforcement of acute contrast reaction management skills. Medical simulation may provide a valuable means of assessing residents' skills and comfort levels in managing severe contrast reactions.

Does 16-detector computed tomography improve detection of non-traumatic subarachnoid hemorrhage in the Emergency Department?

The diagnosis of subarachnoid hemorrhage remains difficult to establish, yet the sensitivity of increasingly available 16-detector computed tomography (CT) has not been evaluated. The objective of this study was to estimate the sensitivity of 16-detector CT for the diagnosis of non-traumatic subarachnoid hemorrhage in the Emergency Department (ED). A retrospective review was performed in an academic tertiary care hospital. Patients presenting to the ED from September 2003 through December 2004 with symptoms suggestive of subarachnoid hemorrhage and having a final diagnosis of non-traumatic subarachnoid hemorrhage were eligible for study. Diagnosis was established by positive 16-detector CT examination of the brain, or spinal fluid analysis. Patient demographics and results of CT, angiogram, and spinal fluid analysis were reviewed. Sensitivity of 16-detector CT was calculated by comparing CT results and cerebral angiogram results. Refined Wilson Simple Asymptotic 95% confidence intervals were calculated. Sixty-one consecutive patients met the study criteria and had a final diagnosis of non-traumatic subarachnoid hemorrhage. One of these patients did not have subarachnoid hemorrhage identified by 16-detector CT, but had a positive lumbar puncture and an aneurysm confirmed on cerebral angiography. Sensitivity of 16-detector CT for subarachnoid hemorrhage was 97% (95% confidence interval 84-100%). Sixteen-detector CT did not improve detection of non-traumatic subarachnoid hemorrhage when compared with studies using single-detector CT. If there is high clinical suspicion for non-traumatic subarachnoid hemorrhage and non-contrast 16-detector CT scan is negative, further evaluation is suggested.

Effect of wavefront corrugations on fringe motion in an astronomical interferometer with spatial filters.

Numerical simulations of atmospheric turbulence and adaptive optics (AO) wavefront correction are performed to investigate the time scale for fringe motion in optical interferometers with spatial filters. These simulations focus especially on partial AO correction, where only a finite number of Zernike modes are compensated. The fringe motion is found to depend strongly on both the aperture diameter and the level of AO correction used. In all the simulations the coherence time scale for interference fringes is found to decrease dramatically when the Strehl ratio provided by the AO correction is < or = 30%. For AO systems that give perfect compensation of a limited number of Zernike modes, the aperture size that gives the optimum signal for fringe phase tracking is calculated. For AO systems that provide noisy compensation of Zernike modes (but are perfectly piston neutral), the noise properties of the AO system determine the coherence time scale of the fringes when the Strehl ratio is < or = 30%.

Myocardial preconditioning factors evoke mesenteric ischemic tolerance via opioid receptors and K(ATP) channels.

We have shown that a reverse-phase concentrate generated from the effluent of preconditioned (PC) rabbit hearts evokes a cardioprotective effect in virgin acceptor hearts. With the use of a model of sustained (1 h) simulated ischemia in isolated, spontaneously contracting rabbit jejunum, our current aims were to 1) determine whether protective factor(s) released from PC hearts can improve ischemic tolerance in noncardiac tissue; and 2) obtain preliminary insight into the mediator(s) involved in triggering and eliciting this remote protection. Recovery of contractile force following reoxygenation (our index of ischemic tolerance) was enhanced in jejunal segments pretreated with concentrate generated from PC hearts (33 +/- 3% of baseline, P < 0.01) versus segments that received no concentrate (21 +/- 2%) and segments treated with concentrate from normoxic hearts (16 +/- 3%; P < 0.01). Protection achieved with PC concentrate was attenuated by coadministration of naloxone or glibenclamide, thereby implicating the involvement of opioids and ATP-sensitive potassium channels. Moreover, evaluation of purified subfractions of the crude PC concentrate identified a specific bioactive fraction that may participate in triggering the improved jejunal ischemic tolerance.

Delta opiates increase ischemic tolerance in isolated rabbit jejunum.

UNLABELLED: Mammalian hibernation is mediated by humoral agonists of the delta opioid receptor (DOR). Moreover, transfer of either humoral or synthetic DOR agonists to non-hibernators reportedly induces a state of improved myocardial ischemic tolerance. OBJECTIVE: To determine whether the DOR agonist D-Ala 2, D-Leu 5, enkephalin (DADLE) similarly elicits protection in noncardiac-i.e., mesenteric-tissue. METHODS: In Protocols 1 and 2, the authors developed and characterized an in vitro model of mesenteric ischemia/reperfusion in isolated rabbit jejunum by documenting the effect of increasing ischemic duration (0 to 120 minutes) and the relative importance of glucose and/or oxygen deprivation on the evolution of jejunal injury. In Protocol 3, jejunal segments were randomized to receive either no treatment (controls) or 15 minutes of pretreatment with 1 microM DADLE, followed by 60 minutes of simulated ischemia and 30 minutes of reperfusion. Jejunal injury was quantified by repeated, time-matched assessment of peak contractile force evoked by 1 microM acetylcholine (all protocols) and delineation of tissue necrosis (Protocol 1). RESULTS: Development of significant jejunal injury required combined oxygen/glucose deprivation. Moreover, there was a direct relationship between ischemic duration and tissue injury, and a significant inverse correlation between reperfusion contractile force (% of baseline) and the extent of smooth muscle necrosis (r(2) = 0.87; p < 0.01). Most notably, mesenteric ischemia/reperfusion injury was attenuated by DADLE: reperfusion contractile force was 47 +/- 5% versus 36 +/- 5% in DADLE-treated versus control segments (p < 0.01). CONCLUSIONS: Treatment with the delta opioid agonist DADLE increases ischemic tolerance of isolated rabbit jejunum.