The effect of potassium supplementation and concomitant medications on potassium homeostasis for hospitalized patients.

PURPOSE: Hospitalized patients receive potassium (K+) supplementation for hypokalemia, with clinicians often estimating a rise in serum K+ levels of 0.1 mEq/L per 10 mEq delivered. However, there is limited evidence to support this expectation. Patients also concomitantly take medications that may alter K+ levels, and it is not known to what degree these may impact interventions to correct K+ levels via supplementation. The objective of this study was to identify the impact of oral and/or intravenous K+ supplementation on serum K+ levels, including the influence of selected concomitant medications, in adult hospitalized patients. METHODS: A single-center, retrospective descriptive study of adult hospitalized patients receiving K+ supplementation at a tertiary hospital between 2021 and 2022 was conducted. Patients were included if they received at least one dose of potassium chloride while admitted to the general medicine ward. The primary outcome was the daily median change in serum K+, normalized per 10 mEq of supplementation administered. The secondary outcome was the impact of selected concomitant medication use on supplement-induced changes in serum K+. RESULTS: A total of 800 patients and 1,291 daily episodes of K+ supplementation were evaluated. The sample was approximately 53% women, was 78% white, and had a median age of 68 years. The overall daily median change in serum K+ level was 0.05 mEq/L per 10 mEq of supplementation delivered. Patients received a median of 40 mEq of supplementation per day, primarily via the oral route (80.6%). Among the concomitant medications assessed, loop diuretics significantly dampened the impact of K+ supplementation. CONCLUSION: Supplementation of K+ in non-critically ill hospitalized patients is variable and dependent on concomitant medication use.

Xylazine poisoning: a systematic review.

PURPOSE: Xylazine is an alpha-2-adrenergic agonist used for its sedative and analgesic properties in veterinary medicine. While not approved by the Food and Drug Administration for use in humans, anecdotal evidence suggests that exposures in humans is on the rise. We sought to systematically review and synthesize the evidence on xylazine exposure in humans focusing on the clinical presentation, management, and outcomes. METHODS: We conducted a systematic review of the literature including PubMed, Embase, and Scopus from their inception to September 9, 2021. We searched abstracts from selected emergency medicine and toxicology conferences from 2011 through 2021. We included clinical reports of xylazine exposure in humans. We excluded animal studies, in vitro studies, laboratory studies, or articles in a language other than English. From each included article, we extracted subjective and objective data that focused on clinical presentation, management, and outcomes of patients exposed to xylazine. RESULTS: We evaluated a total of 1409 records, rendering a final set of 17 articles and 2 abstracts meeting inclusion criteria. We identified a total of 98 patients amongst reports ranging from 1979 to 2020 and across nine countries. The most common types of xylazine exposures reported were unintentional exposure and intentional misuse/abuse. Common symptoms on presentation included hypotension, bradycardia, drowsiness, lethargy, while apnea with intubation and death were less frequently reported. CONCLUSION: Human exposure to xylazine appears to be a rising concern within the prehospital and emergency medicine setting. Although a standardized treatment algorithm cannot be recommended at this time, further research is needed to improve the care of patients exposed to xylazine.

Case-Based Questions for Teaching Emergency Medicine Pharmacotherapy.

Audience: This pharmacotherapy curriculum is designed for emergency medicine residents of all postgraduate years and could also be given to rotating medical students during clerkships. Length of Curriculum: Curriculum is to run monthly for an 18-month general curriculum cycle. Introduction: Pharmacotherapy is a critical part of day-to-day practice of Emergency Medicine (EM). The purpose of this innovation is to give this subject specific dedicated instruction time. We introduced a dedicated pharmacotherapy curriculum as part of our conference time through a series of case-based question sets that mirrored our educational blocks. Educational Goals: Our goals were to teach residents clinical applications of EM pharmacotherapy including drug selection and consideration of alternatives, interactions, and adverse effects, as well as to prepare them for pharmacotherapy questions on board examinations. Educational Methods: The educational strategies used in this curriculum include: case-based vignettes, multiple choice assessments, and guided review explanation and discussion. Questions and explanations are written by resident physicians using a variety of textbooks and online resources and are then reviewed, edited, and expanded upon by attending physicians and an EM pharmacist. Research Methods: This curriculum was implemented in the University of Pittsburgh Emergency Medicine residency program. Curriculum is ongoing and initial data covers a 4-month pilot period. Survey questionnaires were given before and after, using the 7-point Likert scale (1 strongly agree to 7 strongly disagree) for self-assessed knowledge and satisfaction with the curriculum. Primary measure was resident agreement with the statement, "I am confident in overall knowledge of EM pharmacotherapy." We also surveyed readiness for independent practice, knowledge appropriate for training level, board exam preparedness, and satisfaction with curriculum. Results: On the whole residents did feel their pharmacology knowledge improved. Our primary marker was response to a survey question, "I am confident in my overall knowledge of EM pharmacotherapy." In our sample of 30 residents, this question received a pretest score of 3.7 on a 7-point Likert scale (1 strongly agree, 7 strongly disagree). On post intervention surveys this score had improved to 2.6 (p = .00008). In general, residents appreciated this change in curriculum structure. Resident assessment of their improvement during the curriculum was 2.1, aligning with "agree." Satisfaction also improved from a 3.8 on initial survey to a 3.1, with statistical significance (p =.023). Discussion: We had success in our primary outcome of self-assessed resident learning as above. Satisfaction also improved. Residents assessed self-improvement in knowledge relative to year of training, clinical practice ability, and independent practice ability by statistically significant amounts. In addition, the assessments provided the residency clinical competency committee with objective knowledge of pharmacotherapy-based topics. We feel this easy to implement and effective curriculum would be generalizable across programs looking to add options for teaching EM pharmacotherapy, or to other programs looking to add a formal instruction and evaluation component to traditionally informal curriculum. Topics: Emergency Medicine, education, pharmacotherapy, case based, questions, milestones.

Contribuiçöes da Escola Francesa de Psicánalise / Contributions of the French School of Psychoanalysis

O presente trabalho descreve um panorama geral das correntes psicanalíticas da atualidade, particularmente do movimento psicanalítico na França. Após mencionar brevemente as diversas instituiçöes psicanalíticas francesas e seus principais autores, o artigo detem-se mais demoradamente em Lacan e sua Escola Estruturalista