Needle Embolization: Suspecting Needle Migration in Intravenous Drug Abusers.

BACKGROUND: Thirteen million people inject drugs globally, making intravenous drug abuse a substantial concern worldwide. While intravenous drug users occasionally report the breaking of a needle into the skin or subcutaneous tissue, central needle migration remains a rare but potentially devastating complication. CASE REPORT: A 27-year-old man with a history of intravenous drug abuse presented to the emergency department with the sudden onset of left-sided neck pain, chills, and subjective fever with a history of needle breaking in his left neck 3 weeks earlier while using heroin. A computed tomography scan of his chest revealed a needle lodged in the right ventricle with associated mediastinitis and mass effect on the left brachiocephalic vein, and a left internal jugular thrombus. Broad-spectrum antibiotics were initiated. This patient was managed nonsurgically for several reasons and was discharged on hospital day 12 with oral antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intravenous drug abusers commonly use cervical veins when their peripheral vasculature has become sclerosed. This puts intravenous drug users at increased risk for intravascular embolization. Due to varied symptomology-chest pain, dyspnea, fever, or asymptomatic-and timelines-days, weeks, or months-after reported needle fragmentation, this remains a complex and likely underdiagnosed condition. Case reports describe serious complications of intracardiac needle embolization, such as cardiac perforation, constrictive pericarditis, septic endocarditis, dysrhythmias, granulomas, venous thrombosis, empyema, acute or delayed spontaneous pneumothorax, osteomyelitis, and valvular damage. In this complicated patient population, clinicians should consider needle retention and relocation in patients who report needle breaking or in those who present with chest pain, dyspnea, or fever among other complaints.

Acute Kidney Injury After Computed Tomography: A Meta-analysis.

STUDY OBJECTIVE: Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta-analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast-enhanced CT versus noncontrast CT. METHODS: We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast. RESULTS: The database search returned 14,691 articles, inclusive of duplicates. Twenty-six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta-analysis demonstrated that, compared with noncontrast CT, contrast-enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all-cause mortality (OR 1.0; 95% CI 0.73 to 1.36). CONCLUSION: We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.

A survey of academic emergency medicine department chairs on hiring new attending physicians.

BACKGROUND: For graduating emergency medicine (EM) residents, little information exists as to what attributes department chairs are seeking in hiring new attendings. STUDY OBJECTIVES: To determine which qualities academic EM department chairs are looking for when hiring a new physician directly out of residency or fellowship. METHODS: An anonymous 15-item Web-based survey was sent to the department chairs of all accredited civilian EM residency programs in March of 2011. The questions assessed the desirability of different candidate attributes and the difficulty in recruiting EM-trained physicians. Respondents were also asked to give the current number of available job openings. RESULTS: Fifty-five percent of eligible department chairs responded. On a 5-point scale, the most important parts of a candidate's application were the interview (4.8 ± 0.4), another employee's recommendation (4.7 ± 0.5), and the program director's recommendation (4.5 ± 0.7). The single most important attribute possessed by a candidate was identified as "Ability to work in a team," with 58% of respondents listing it as their top choice. Advanced training in ultrasound was listed as the most sought-after fellowship by 55% of the chairs. Overall, department chairs did not have a difficult time in recruiting EM-trained physicians, with 56% of respondents stating that they had no current job openings. CONCLUSION: How a physician relates to others was consistently rated as the most important part of the candidate's application. However, finding a job in academic EM is difficult, with graduates having limited job prospects.

Abnormal urine color.

A change in urine color can be distressing for patients and physicians alike. Many of the causes of abnormal urine color are benign effects of medications and foods; however, a change in urine color may be a sign of an underlying pathological condition. The good news is that in many cases the diagnosis can be determined from a thorough history and urinalysis. This article presents many of the conditions physicians may encounter and will help them form a narrow differential diagnosis and treatment plan.

Case Report: Mass Casualty Lightning Strike at Ranger Training Camp.

BACKGROUND: Although lightning strikes are a rare occurrence, their significance cannot be ignored given military operations in the field during all types of weather. With proper medical management, patients with lightning injuries can return to duty. METHODS: Information for this case report comes from eyewitness account at the 6th Ranger Training Battalion and from review of physician documentation from the 96th Medical Group, Eglin Air Force Base, Florida. RESULTS: A lightning strike injured 44 Ranger School participants during a training exercise on August 12, 2015, at Camp Rudder, Florida. These patients were triaged in the field and transported to emergency department of Eglin Air Force Base. Of the 44 casualties, 20 were admitted. All were returned to duty the following day. One patient had cardiac arrest. This patient, along with two others, was admitted to the intensive care unit. Seventeen other patients were admitted for observation for rhabdomyolysis and/or cardiac arrhythmias. One patient was admitted with suspected acute kidney injury indicated by an elevated creatinine. All patients, including those admitted to the intensive care unit, were released on the day following the lightning strike without restrictions and were allowed to return to duty with increased medical monitoring. DISCUSSION: This case report highlights the need for proper triage and recognition of lightning strike injury, coordination of care between field operations and emergency department personnel, and close follow-up for patients presenting with lightning injury. Symptoms, physical exam, and laboratory findings from rigorous training can be difficult to distinguish from those resulting from lightning injury. Secondary injuries resulting from blunt trauma from falls may have been prevented by the use of the lightning strike posture. Further analysis of procedures and standard operating protocols to mitigate risk during thunderstorms may be required to prevent lightning's effects on large groups of military personnel.