Spaceflight Environment.

The safety and health of individuals who may be exposed to the spaceflight environment are first and foremost cared for through prevention. This environment, which encompasses microgravity, radiation, and alternobaric factors, can have physiologic impacts on every human system. Available medical care and resources in the spaceflight environment are currently limited by mass and volume constraints, with available medical resources thereby focusing on a patient's stabilization and evacuation. An understanding of the spaceflight environment and its possible effects is crucial for the treatment of individuals prior to, during, and after spaceflight.

57-Year-Old Male Veteran with Recurrent Fevers.

A 57-year-old male veteran presented to the emergency department for recurrent fevers for 10 days. The patient was febrile but had an overall benign physical exam. This interesting case explores the broad differential diagnosis and evaluation in a patient who presents with fever of unknown origin.

POCUS for Diastolic Dysfunction: A Review of the Literature.

Emergency and critical care physicians frequently encounter patients presenting with dyspnea and normal left ventricular systolic function who may benefit from early diastolic evaluation to determine acute patient management. The current American Society of Echocardiography Guidelines approach to diastolic evaluation is often impractical for point of care ultrasound (POCUS) evaluation, and few studies have evaluated the potential use of a simplified approach. This article reviews the literature on the use of a simplified diastolic evaluation to assist in determining acute patient management.

Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency.

Introduction With the rising opioid epidemic, there has been a push for multimodal pain management within the emergency department. Nerve blocks have been shown to be an effective pain management strategy for many conditions, with improved success when used with ultrasound. However, there is no generally accepted method for teaching residents how to perform nerve blocks. Materials and methods Seventeen residents from a single academic center were enrolled. The residents were surveyed pre-intervention regarding demographics, confidence, and use of nerve blocks. The residents then completed a mixed-model curriculum that included an electronic module (e-module) on three plane nerve blocks and a practice session. Three months later, residents were tested on their ability to independently perform the nerve blocks and resurveyed regarding confidence and use. Results Of the 56 residents in the program, 17 enrolled in the study; 16 participated in the first session, and nine participated in the second session. Each resident had < four ultrasound-guided nerve blocks prior to participation with a slight increase in the total number of nerve blocks after the sessions. Residents were able to perform, on average, 4.8 of seven tasks independently. Residents who completed the study reported feeling more confident in their ability to perform ultrasound-guided nerve blocks (p = 0.01) and to complete associated tasks (p < 0.01). Conclusion This educational model resulted in residents completing the majority of tasks independently with improved confidence in ultrasound-guided nerve blocks. There was only a slight increase in clinically performed blocks.

Ultrasound in Pregnancy.

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

Which Way Would You Slice It? Evaluation of 3 Educational Models for the Loop Drainage Technique.

Introduction: Emergency department visits for cutaneous abscesses are increasing. It is important for healthcare professionals to be proficient in identifying and treating abscesses. Loop drainage technique (LDT) is a newer technique which has been described in several articles but limited resources for teaching have been studied. The objective of this study was to compare 3 models for learning and teaching the LDT. Methods: This was a prospective survey study of a convenience sample of emergency medicine residents at a large urban academic center. Residents volunteered to participate during a scheduled cadaver and simulation session. After a self-directed review of the LDT, each participant performed ultrasound visualization and then the LDT on 3 simulated abscesses: a cadaveric model, a commercial abscess pad, and a homemade phantom. Participants completed pre- and post-simulation surveys. Results: Of 57 residents, 28 participated in the 1-day simulation. The majority (57.1%, p < 0.009) preferred the cadaver model for learning the LDT, and 78.6% reported it to have the most realistic physical examination for an abscess (p = 0.001). Prior to participation, 0% of residents felt proficient performing LDT. After participation, 46.4% of residents felt proficient and 78.6% reported intent to use in clinical practice (p < 0.001). Conclusions: Simulation is an effective educational tool for both learning new skills and improving procedural competency. Residents found cadavers provided the most realistic physical examination, and the majority preferred it for learning the LDT. However, cadavers are not always accessible, an important factor when considering various educational settings.

'Diagnosis of Boerhaave's Syndrome With Aid of Bedside Ultrasound.

BACKGROUND: Boerhaave's syndrome is characterized by transmural rupture of the distal esophagus in the setting of increased intraluminal pressures combined with negative intrathoracic pressure. It is a rare condition with high mortality (20-50% mortality rate). CASE REPORT: This is a case of a 47-year-old man who appeared acutely ill, presenting with shortness of breath, chest and abdominal pain, and diagnosed with Boerhaave's syndrome with the assistance of bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIANS BE AWARE OF THIS?: Emergency physicians must have a heightened suspicion of this diagnosis in patients presenting with chest and abdominal pain and can use bedside ultrasound skills to aid with diagnosis.

Two pulmonary emboli in a psych pod.

BACKGROUND: A female patient known to have schizoaffective disorder self-presented to an emergency department in a state of acute agitation and paranoia shortly after a 35-day inpatient stay at a psychiatric facility. CASE REPORT: The patient exhibited no signs or complaints of dyspnea or hypoxia, but later collapsed and became hypoxic after sleeping comfortably with sedation for 12 h in the psychiatric unit. She was intubated and a computed tomography angiogram revealed bilateral lobar pulmonary emboli and right heart strain. CONCLUSION: Psychiatric hospitalizations, medications, diagnoses and relevant sequelae increase venous thromboembolism risk more than many realize.

36-year-old Male with Syncope.

CASE PRESENTATION: A 36-year-old incarcerated male presented to the emergency department (ED) after an episode concerning for syncope. The patient had nystagmus and ataxia on initial examination. DISCUSSION: There is a broad differential diagnosis for syncope, and for patients presenting to the ED we tend to focus on cardiogenic and neurologic causes. This case takes the reader through the differential diagnosis and systemic work-up of a patient presenting to the ED with syncope.

Soy isoflavones and their metabolites modulate cytokine-induced natural killer cell function.

Soybeans are a rich source of isoflavones that have been linked with anti-inflammatory processes and various health benefits. However, specific mechanisms whereby soy bioactives impact immune cell subsets are unclear. Isoflavones, such as genistein and daidzein, are metabolized by microbes to bioactive metabolites as O-desmethylangolensin (O-DMA) and equol, whose presence has been linked to health benefits. We examined how soy isoflavones and metabolites impact natural killer (NK) cell signaling and function. We observe no impact of isoflavones on viability of healthy donor peripheral blood mononuclear cells (PBMCs) or NK cells, even at high (25 µM) concentrations. However, pre-treatment of PBMCs with physiologically-relevant concentrations of genistein (p = 0.0023) and equol (p = 0.006) decreases interleukin (IL)-12/IL-18-induced interferon-gamma (IFN-γ) production versus controls. Detailed cellular analyses indicate genistein and equol decrease IL-12/IL-18-induced IFN-γ production by human NK cell subsets, but do not consistently alter cytotoxicity. At the level of signal transduction, genistein decreases IL-12/IL-18-induced total phosphorylated tyrosine, and phosphorylation MAPK pathway components. Further, genistein limits IL-12/IL-18-mediated upregulation of IL-18Rα expression on NK cells (p = 0.0109). Finally, in vivo studies revealed that C57BL/6 mice fed a soy-enriched diet produce less plasma IFN-γ following administration of IL-12/IL-18 versus control-fed animals (p < 0.0001). This study provides insight into how dietary soy modulates NK cell functions.

Pediatric ADHD Medication Exposures Reported to US Poison Control Centers.

: media-1vid110.1542/5754332180001PEDS-VA_2017-3872Video Abstract OBJECTIVES: To describe the characteristics and trends of exposures to attention-deficit/hyperactivity disorder (ADHD) medications among individuals 0 to 19 years old reported to US poison control centers. METHODS: National Poison Data System data from 2000 through 2014 were retrospectively analyzed to examine pediatric ADHD medication exposures. RESULTS: From 2000 through 2014, there were 156 365 exposures reported to US poison control centers related to ADHD medications. The overall rate of reported exposures increased 71.2% from 2000 to 2011, followed by a 6.2% decrease from 2011 to 2014. Three-fourths (76.0%) of exposures involved children ≤12 years old. Methylphenidate and amphetamine medications accounted for 46.2% and 44.5% of exposures, respectively. The most common reason for exposure was therapeutic error (41.6%). Intentional medication exposures (including suspected suicide and medication abuse and/or misuse) were reported most often among adolescents (13-19 years old), accounting for 50.2% of exposures in this age group. Overall, the majority of exposed individuals (60.4%) did not receive health care facility treatment; however, 6.2% were admitted to a hospital for medical treatment, and there were 3 deaths. The increasing number and rate of reported ADHD medication exposures during the study period is consistent with increasing trends in ADHD diagnosis and medication prescribing. Exposures associated with suspected suicide or medication abuse and/or misuse among adolescents are of particular concern. CONCLUSIONS: Unintentional and intentional pediatric exposures to ADHD medications are an increasing problem in the United States, affecting children of all ages.

Enhanced bioavailability of lycopene when consumed as cis-isomers from tangerine compared to red tomato juice, a randomized, cross-over clinical trial.

SCOPE: Tangerine tomatoes (Solanum lycopersicum) are rich in tetra-cis-lycopene resulting from natural variation in carotenoid isomerase. Our objective was to compare the bioavailability of lycopene from tangerine to red tomato juice, and elucidate physical deposition forms of these isomers in tomatoes by light and electron microscopy. METHODS AND RESULTS: Following a randomized cross-over design, subjects (n = 11, 6 M/5 F) consumed two meals delivering 10 mg lycopene from tangerine (94% cis) or red tomato juice (10% cis). Blood was sampled over 12 h and triglyceride-rich lipoprotein fractions of plasma were isolated and analyzed using HPLC-DAD-MS/MS. Lycopene was crystalline in red tomato chromoplasts and globular in tangerine tomatoes. With tangerine tomato juice we observed a marked 8.5-fold increase in lycopene bioavailability compared to red tomato juice (p < 0.001). Fractional absorption was 47.70 ± 8.81% from tangerine and 4.98 ± 1.92% from red tomato juices. Large heterogeneity was observed among subjects. CONCLUSION: Lycopene is markedly more bioavailable from tangerine than from red tomato juice, consistent with a predominance of cis-lycopene isomers and presence in chromoplasts in a lipid dissolved globular state. These results justify using tangerine tomatoes as a lycopene source in studies examining the potential health benefits of lycopene-rich foods.

Bioactive compounds or metabolites from black raspberries modulate T lymphocyte proliferation, myeloid cell differentiation and Jak/STAT signaling.

Bioactive phytochemicals from natural products, such as black raspberries (BRB; Rubus occidentalis), have direct anticancer properties on malignant cells in culture and in xenograft models. BRB components inhibit cancer progression in more complex rodent carcinogenesis models. Although mechanistic targets for BRB phytochemicals in cancer cells are beginning to emerge, the potential role in modulating host immune processes impacting cancer have not been systematically examined. We hypothesized that BRB contain compounds capable of eliciting potent immunomodulatory properties that impact cellular mediators relevant to chronic inflammation and tumor progression. We studied both an ethanol extract from black raspberries (BRB-E) containing a diverse mixture of phytochemicals and two abundant phytochemical metabolites of BRB produced upon ingestion (Cyanidin-3-Rutinoside, C3R; Quercitin-3-Rutinoside, Q3R). BRB-E inhibited proliferation, and viability of CD3/CD28 activated human CD4(+) and CD8(+) T lymphocytes. BRB-E also limited in vitro expansion of myeloid-derived suppressor cells (MDSC) and their suppressive capacity. Pre-treatment of immune cells with BRB-E attenuated IL-6-mediated phosphorylation of signal transducer and activator of transcription-3 (STAT3) and IL-2-induced STAT5 phosphorylation. In contrast, pre-treatment of immune cells with the C3R and Q3R metabolites inhibited MDSC expansion, IL-6-mediated STAT3 signaling, but not IL-2-induced STAT5 phosphorylation and were less potent inhibitors of T cell viability. Together these data indicate that BRB extracts and their physiologically relevant metabolites contain phytochemicals that affect immune processes relevant to carcinogenesis and immunotherapy. Furthermore, specific BRB components and their metabolites may be a source of lead compounds for drug development that exhibits targeted immunological outcomes or inhibition of specific STAT-regulated signaling pathways.