Methamphetamine Poisoning After "Plugging" Intentional Recreational Rectal Use.

BACKGROUND: Methamphetamine is a commonly used illicit substance. The route of administration is usually parenteral, oral ingestion, or snorting. A less common route of administration is placing in the rectum. CASE REPORT: A 28-year-old man presented to the emergency department with acute methamphetamine toxicity within 30 min after intentional rectal administration of methamphetamine for recreational purposes. The patient had hypertension, tachycardia, drug-induced psychosis, elevated creatine kinase, and required rapid sequence intubation and admission to the intensive care unit. Our patient had no clinical evidence of bowel ischemia or injury at the time of discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rectal administration of methamphetamine is known as "plugging," "booty bumping," "keestering," and "butt whacking." The rectal administration of methamphetamine has the increased risk of severe acute methamphetamine toxicity, as rectal administration bypasses first-pass metabolism, allowing for a more acute onset and higher bioavailability of methamphetamine compared with oral administration. There is the potential for mesenteric ischemia and bowel injury after rectal methamphetamine. Close clinical monitoring for bowel and rectal ischemia or injury are recommended, in addition to management of the sympathomimetic toxidrome.

Ultrasound-Guided Fascia Iliaca Compartment Block Simulation Training in an Emergency Medicine Residency Program.

Introduction Geriatric hip fractures present a difficult challenge in the emergency department (ED) to achieve adequate analgesia. Opioid-sparing ultrasound-guided fascia iliaca compartment blocks (UFIB) have been shown to be both safe and effective in treating pain from hip fractures. In this study, we investigated the teachability of UFIB to emergency medicine (EM) residents using simulation models and also assessed if UFIB training increases its utility in the ED. Methods We created a UFIB model to simulate the procedure in a controlled environment. Sixteen residents from Loma Linda Emergency Medicine Residency participated in a pre-workshop survey and hands-on UFIB workshop. Comfort level in performing UFIB and confidence level in needle finding skills during UFIB were analyzed, plotted, and represented graphically. Results Comfort level in performing UFIB increased by approximately 50% (p < 0.01). Success rates also increased by 460% (p<0.05) after the workshop. However, the UFIB continued to be underutilized as 44% of respondents expressed that there is a "lack of time" to perform UFIB during their shifts. Conclusion A single one-hour workshop increased comfort level in performing UFIB and helped residents successfully achieve better pain control in patients with hip fractures. However, residents continued to refrain from using UFIB because it is too time-consuming.

Ultrasound-Guided Percutaneous Cryoneurolysis for Post-Thoracotomy Pain Syndrome: A Case Report.

Post-thoracotomy pain syndrome (PTPS) is a post-operative thoracotomy complication that is difficult to treat. We describe the first-time use of ultrasound-guided percutaneous cryoneurolysis of the intercostal nerves to successfully treat PTPS refractory to conventional medications and interventions. We report a case of a 40-year-old male with two years of severe PTPS sustained after undergoing a thoracotomy. Treatment with intercostal cryoneurolysis resulted in an immediate 75% improvement in pain for six weeks followed by sustained 50% pain relief for eight weeks. This highlights the potential of this intervention as a radiation-free, safe, and efficacious therapy for chronic PTPS.

Lasmiditan for the acute treatment of migraine.

Migraine is a leading cause of morbidity and disability worldwide. Triptans were the first migraine-specific drug class developed and have proven efficacy in treatment of this neurological disease. They are however contraindicated in patients with cardiovascular disease and possibly others, owning to their vasoconstrictive properties. This review will focus on lasmiditan, which has been called the first 'ditan' and 'neurally acting anti-migraine agent', designed to selectively agonize the serotonin 5-HT1F receptor subtype, providing anti-migraine effects without concomitant vasoconstriction. To date, lasmiditan has proven safe and effective for the acute treatment of migraine in two Phase II and four Phase III trials. Post hoc analysis revealed that the majority of treatment-emergent adverse events were CNS-related, mild-to-moderate in severity and self-limiting. The US FDA label recommends that patients not drive or operate machinery until at least 8 h after taking each dose of lasmiditan.

Lay abstract Migraine is a leading cause of pain and disability worldwide. Triptans (e.g., sumatriptan) were the first migraine-specific drug class developed and have proven to be effective treatments. Triptans are however contraindicated in patients with heart disease and possibly in some subsets of migraine, due to vasoconstriction concerns. This review will focus on lasmiditan, the first 5-HT_1F receptor agonist or 'ditan'. It does not carry vasoconstrictive concerns and is safe to use in patients who cannot take triptans. To date, lasmiditan has proven safe and effective for the acute treatment of migraine in multiple medical studies. Data from these studies indicates that the most common adverse effects from lasmiditan were dizziness, tingling and sleepiness. These symptoms were generally mild-to-moderate in severity and self-limiting. The US FDA label recommends that patients not drive or operate machinery until at least 8 h after taking each dose of lasmiditan.

Vascular Neurologists as Directors of Stroke Centers in the United States.

BACKGROUND AND PURPOSE: Hospital certification as primary and comprehensive stroke center is associated with improvement in care. We aimed to characterize the leadership at stroke centers nationwide to determine the proportion led by vascular neurologists, a board-recognized subspecialty focusing on stroke care. METHODS: We identified hospitals in the United States holding primary and comprehensive stroke center designation as of September 2013. We contacted each hospital to identify the medical director and used data from relevant medical boards to determine specialization. Sex and date of medical school graduation were obtained from an online physician database. RESULTS: Of the 1167 primary and 50 comprehensive stroke center hospitals certified by the Joint Commission (n=1114), Det Norske Veritas (n=68), and Healthcare Facilities Accreditation Program (n=35), we identified the director in 940 (77%). Leadership was most often by a neurologist (n=745; 79%) followed by physicians in emergency medicine (n=58; 6%) and internal medicine (n=17; 2%). Vascular neurologists (n=319) led about one-third of stroke centers. Directors were mostly men (n=764; 81%), with a median number of years after medical school graduation of 25 (interquartile range, 18-34). Comprehensive stroke centers were more likely than primary stroke centers to have leadership by vascular neurologist (77%, n=37 versus 32%, n=282; P<0.001). CONCLUSIONS: Vascular neurologist led about one-third of stroke centers. There is opportunity for vascular neurologists to increase their role in stroke center directorship.