Phlegmasia Cerulea Dolens: A New Perspective on Management.

This is a case of phlegmasia cerulea dolens (PCD) with unexpected but complete resolution of symptoms with short-term administration of heparin products, despite falling into category IIb according to the Rutherford limb ischemia scale, which regularly requires aggressive surgical intervention. We present a case of a 58-year-old Hispanic female with a past medical history of gastritis who arrived at the emergency room (ER) with acute onset severe pain on the left leg associated with discoloration of the leg. The patient was quickly diagnosed with PCD affecting the left lower extremity, which quickly resolved after administration of heparin infusion for one hour, despite the degree of limb ischemia. There is no consensus for the treatment of this condition. The most interesting feature of this case is the prompt resolution of symptoms with short-term administration of anticoagulation with total resolution without the need for thrombolysis or thrombectomy. This may suggest that prompt pharmacologic treatment in patients eligible for anticoagulation may successfully restore venous flow negating the need for further intervention.

The impact of an emergency medicine clinical pharmacist on nursing satisfaction.

BACKGROUND: In the United States, emergency medicine clinical pharmacists have become more common over the last several decades. Despite being a vital component of the emergency department interdisciplinary team, there is very limited information published regarding the direct impact emergency medicine clinical pharmacists have on other emergency department-based professions. OBJECTIVE: To determine if the addition of an emergency medicine clinical pharmacist improves nursing satisfaction with pharmacy services. SETTING: The study was conducted at a 422-bed urban teaching hospital consisting of approximately 60 emergency medicine nurses. METHODS: This was a prospective study that evaluated nursing satisfaction prior to the initiation of an emergency medicine clinical pharmacist and one year after implementation. The survey consisted of 29 questions and was designed to assess three areas of pharmacy: general pharmacy, pharmacy information technology, and emergency medicine clinical pharmacy services. For the majority of questions, a 5-point Likert scale ranging from 1 representing strongly disagree to 5 representing strongly agree was utilized. Responses for the 5 point Likert scale were further tabulated into either positive or negative responses. All emergency department nurses employed during the study period (September 2015 and 2016) were eligible to participate anonymously. MAIN OUTCOME MEASURE: The main outcome assessed was the difference in satisfaction scores between study periods. RESULTS: A total of 52 surveys were returned over the course of the study (22 [36.7%] in the pre-intervention group versus 30 [50%] in the post-intervention group). All general pharmacy questions were improved at one year with timely resolution of pharmacy related issues, medication procurement, and satisfaction with pharmacy services achieving statistical significance. Pharmacy information technology questions were significantly improved with respect to satisfaction with the automated medication dispensing system inventory, prevention and resolution of medication stock outs, and ease of medication removal compared to baseline. The perceived impact of emergency medicine clinical pharmacy services in the pre-intervention group was validated after the one-year implementation period. CONCLUSION: An emergency medicine clinical pharmacist increases nursing satisfaction with central pharmacy and pharmacy technology services and was able to maintain the nurses' perceived expected role of the clinical pharmacist.

Land cover impacts on storm flow suspended solid and nutrient concentrations in southwest Ohio streams.

Impacts between urban and agricultural land cover on storm flow water quality are poorly understood for the Eastern Corn Belt Ecoregion in SW Ohio. Storm flow water samples were collected from May 2017 to October 2017 across seven SW Ohio watersheds which ranged in urban land cover from 6% to 92% and in agricultural land cover from 4% to 70%. Two watersheds contained water resource recovery facilities (WRRFs). Percent agricultural land cover in a watershed and storm magnitude were primary explanatory variables for total suspended solid and total phosphorus concentrations. Total nitrogen, nitrate, and phosphate concentrations were primarily explained by the presence of WRRFs and percent agricultural land cover. Increased dissolved nutrient concentrations in watersheds with WRRFs indicate that WRRFs in the study area are ineffectively removing nitrate and phosphate from effluent. Results suggest that to improve water quality during storm flows, additional management efforts need to be focused on agricultural watersheds and WRRFs. PRACTITIONER POINTS: Storm flow water quality in the study area is significantly affected by land cover, WRRF Q, and storm Q. TSS and TP concentrations are best explained by percent of agricultural land cover in a watershed and magnitude of storms. TN, NO3 -N, and PO 4 3 -P concentrations are best explained by WRRF Q, followed by the percent agricultural land cover. This study shows that agricultural land cover and WRRFs play a significant role in water quality degradation in SW Ohio.

High enhancer, downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City.

BACKGROUND: Benzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular-a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use. METHODS: For qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18-32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18-29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use. RESULTS: Participants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use. CONCLUSION: Nonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.

Identification of subcutaneous myiasis using bedside emergency physician performed ultrasound.

BACKGROUND: Subcutaneous myiasis, a maggot infiltration of human tissue, is common in tropical countries. However, physicians in the United States may be unlikely to consider this etiology of dermatologic abnormalities even when a travel history suggests the diagnosis should be included in the differential. CASE REPORT: We report the case of a patient who returned from Sierra Leone with an infestation of a maggot of Cordylobia anthropophaga (tumbu fly) that was diagnosed and appropriately treated based on ultrasound findings. CONCLUSION: As international travel increases, clinicians should maintain a high level of suspicion for tumbu fly infestation in returned travelers from endemic areas. The increasing use of ultrasound in the Emergency Department for evaluation of skin and soft tissue infections may aid the physician in making the diagnosis of subcutaneous myiasis.

Rapid, needle-free delivery of lidocaine for reducing the pain of venipuncture among pediatric subjects.

OBJECTIVES: The purpose of this study was to determine the optimal configuration of an investigational, single-use, needle-free, drug system (ALGRX 3268) that delivers powdered lidocaine into the epidermis for the rapid production of local anesthesia among pediatric subjects undergoing venipuncture. METHODS: Children 3 to 18 years of age were randomly allocated to receive 1 of 3 treatments, ie, (1) placebo, (2) a system configured to deliver 0.25 mg of lidocaine, or (3) a system configured to deliver 0.5 mg of lidocaine, at the antecubital fossa 2 to 3 minutes before venipuncture. Three age groups were included, ie, 3 to 7 years, 8 to 12 years, and 13 to 18 years. Two sets of pain rating scales were used, the Faces Pain Scale-Revised for the youngest age stratum and a visual analog scale for the oldest age stratum. Children in the middle age stratum used both scales. RESULTS: One-hundred forty-four subjects completed the study. For all ages combined, there was a statistically significant and clinically meaningful reduction in pain scores for subjects who received 0.5 mg of lidocaine, compared with placebo. The reduction in pain after 0.25 mg of lidocaine did not achieve statistical significance. CONCLUSIONS: Both active configurations were safe and well tolerated by pediatric subjects undergoing venipuncture at the antecubital fossa. ALGRX 3268 at 0.5 mg, administered 2 to 3 minutes before venipuncture, produced significantly lower pain scores, compared with placebo.

The Effect of Urinary pH and Flow Rate on the Renal Elimination of Zopolrestat and Zopolrestat Glucuronide in Humans.

Zopolrestat is an aldose reductase inhibitor that may be useful in the treatment of diabetic complications by reducing flux through the polyol pathway. The plasma half-life of zopolrestat in man is approximately 30 h, and approximately 45% of an orally administered 1000-mg dose is eliminated in the urine as unchanged drug. Because active secretion accounts for much of the renal clearance for zopolrestat, a carboxylic acid with a pK(a) of 5.46, the effect of urinary pH and flow rate on renal clearance of drug was investigated in a series of studies. Renal clearance of zopolrestat following oral administration of 200 mg was determined in normal male volunteers under basal conditions and after treatment with NH(4)Cl and NaHCO(3) to alter urinary pH. Plasma concentrations of zopolrestat were similar under basal and NaHCO(3) treatment but were approximately twofold higher under NH(4)Cl treatment. However, the half-life of zopolrestat under NH(4)Cl treatment (29.5 h) was similar to the half-life of zopolrestat in untreated subjects. Renal clearance decreased by a factor of 2.54 for each unit decrease in urinary pH. In a second study, there was no effect of urine flow rate on renal clearance following an oral dose of 400 mg. Renal elimination of zopolrestat and zopolrestat glucuronide was also examined in volunteers with normal urine flow dosed at either 600 or 1000 mg/day. Whereas renal clearance of zopolrestat decreased with decreasing urinary pH, renal elimination of zopolrestat glucuronide was not affected by pH.