Kitty Litter Dermatitis from-Bromo-2-Nitropropane-1,3-Diol.

70-year-old white man presented with a 6-week history of an acute pruritic eruption in the axillary vaults, inguinal folds, and central lumbar area. Due to the severity of the pruritus, the patient was evaluated in the emergency department. He was treated with intramuscular triamcinolone, oral fluconazole, clobetasol cream, and miconazole powder, which provided only minimal relief. The patient had presented with brightly erythematous patches in the axillary vaults and inguinal folds with numerous erythematous, scaly, coalescing papules and plaques agminated on the lumbar region (Figure). Due to persistence, despite topical corticosteroids, an allergic contact dermatitis was suspected so patch-testing using the T.R.U.E. Test (SMARTPractice Denmark ApS, Hillerod, Denmark) epicutaneous system was conducted. Results were positive for 5-chloro-2-methyl-4-isothazolinone (panel 2.1, #17), budesonide (panel 3.1, #30), and 2-bromo-2-nitropropane-1,3-diol, also known as bronopol (panel 3.1, #36). The patient's topical medications were adjusted based on these results, and he was advised to avoid any products containing these contactants.

Identification of a Human Trafficking Victim: A Simulation.

Audience: This case was designed for emergency medicine interns and residents. Introduction: Human trafficking is unfortunately an ever-growing and wide-reaching problem in the United States as well as the rest of the world. The International Labor Organization estimates 49.6 million people were affected by this modern-day slavery worldwide in 2021.1,2 The emergency department represents an opportunity to identify and provide aid to victims of human trafficking. Studies have shown that 63.3% of survivors interacted with the emergency department during their time of exploitation; however, most of these patients are not identified as human trafficking victims and opportunities for intervention are missed.3,4. Educational Objectives: By the end of this simulation, participants will be able to: (1) Identify signs of human trafficking. (2) Demonstrate the ability to perform a primary and secondary assessment of a patient when there is concern for human trafficking. (3) Demonstrate the ability to appropriately separate an at-risk patient from a potential trafficker. (4) Identify resources and a reliable course of action to permanently remove the patient from the harmful situation. Educational Methods: A hybrid teaching model was employed that included both a lecture and a standardized patient simulation session followed by a structured debriefing session. Research Methods: A simulation with a standardized participant was implemented at an urban academic emergency department with a three-year EM residency program. Participants were evaluated with a survey prior to and after the simulation, where they responded to questions regarding human trafficking patients on a scale of 1 to 5, where 5 represented the greatest level of agreement. Nineteen emergency medicine interns and residents participated in this project. Results: Prior to simulation training, and after the lecture, residents were surveyed on their confidence in identifying and treating patients who are affected by trafficking, their level of previous training in this topic, and whether they considered trafficking an important issue in emergency medicine. When asked if human trafficking is an important issue faced by the emergency department, 15 of the 19 of residents who completed the survey rated the importance a 5/5 on a Likert scale ranging from 1-not important to 5. Residents were also asked if they had received prior training in human trafficking on a scale of never (1) to often (5). Eight residents responded with either never or close to never. Two months after the simulation, the residents were again sent an optional survey. Ten residents responded. All who participated in the simulation now rated themselves a 4/5 on a scale from not confident to very confident. Of those who did not attend the simulation, the median value was a 3/5. Out of the residents who attended the simulation training, every resident rated the experience 5 out of 5 in terms of usefulness. One hundred percent of residents would recommend simulation training on human trafficking to other emergency medicine residents. Discussion: This was an effective educational initiative because this education model allowed the residents to feel more comfortable identifying individuals affected by human trafficking, and all the residents who responded to the survey stated that they would recommend the use of simulation to others for education on human trafficking. Topics: High-fidelity simulation, human trafficking identification, human trafficking response.

More Than Skin Deep: An Unusual Case of a Migrating Pacemaker Lead.

Pacemakers are commonly utilized in clinical practice and are generally well tolerated; therefore, clinicians may not be exposed to potential complications associated with pacemakers. This case report aims to illustrate the clinical presentation of a pacemaker lead migration, an uncommon potential complication. We present an 83-year-old male with a past medical history of complete atrioventricular block managed with a permanent pacemaker who presented with an open wound on his right chest. He had capped, abandoned right-sided leads from a previous pacemaker. At presentation, there was blood-tinged, yellow drainage and visible erosion of his electrodes. Computed tomography showed the right ventricular pacing lead perforating the right ventricle. Pacemaker lead migration outside of the chest wall is rare. Perforations may present asymptomatically or strikingly with effusions, pneumothoraces, hemothoraces, or cardiac tamponade. Management options include lead repositioning or extraction.

A Case of a Carotid Cavernous Fistula.

CASE PRESENTATION: A 73-year-old male presented to the emergency department complaining of pain in his right eye for four weeks. He denied any trauma, and the pain was accompanied by ptosis, proptosis, swelling, redness, blurred vision, and a frontal headache. On examination, conjunctival arterialization was also appreciated. Magnetic resonance imaging and angiography showed evidence of a carotid cavernous fistula for which the patient underwent successful transvenous coiling and embolization. DISCUSSION: Carotid cavernous fistulas are classified as higher flow, direct fistulas or lower flow, indirect fistulas; the latter is more insidious in onset. Classic symptoms include conjunctival arterialization, proptosis, ptosis, palpebral edema, ocular palsy, vibratory sensation, elevated intraocular pressure without pupillary or visual acuity deficits, and headache. The treatment of choice is transvenous embolization.

Ultrasound Measurement of Carotid Intima-Media Thickness and Plaques in Predicting Coronary Artery Disease.

Ultrasound measurement of carotid intima-media thickness (CIMT) and plaque thickness (PT) may be an additional tool for risk stratification of patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). The aim of this study was to evaluate the correlation of CIMT and PT with coronary artery disease (CAD) in risk stratification tests.This prospective observational study was conducted in an academic tertiary care ED. Carotid ultrasound measurements were obtained for emergency patients with suspected ACS. Carotid measurements included PT, mean CIMT and maximum CIMT. The correlations between carotid ultrasound and the results of coronary catheter angiography (CA), coronary computed tomography angiography (CCTA) and stress tests were identified. The convenience sample included 58 patients comprising 39 men and 19 women with a mean age of 60 ± 12 y. Twenty-two percent (13/58) of patients were positive for CAD, as indicated by results of the cardiac risk stratification tests. Presence of plaque correlated with CCTA findings, with a high specificity (92.8%) for a positive test. Max CIMT predicted abnormal CCTA (area under the curve [AUC] = 0.93, 95% confidence interval: 0.80-1). The correlations with stress test (0.78, 0.46-1) and CA (0.55, 0.28-0.82) were weaker. Presence of carotid plaque correlated significantly with findings of CAD on all risk stratification tests, but especially with CCTA. Carotid ultrasound could have a role in risk stratification in the ED, though more research is needed.

Interferon-alpha as a mediator of polyinosinic:polycytidylic acid-induced type 1 diabetes.

A number of studies and clinical case reports have implicated interferon (IFN)-alpha as a potential mediator of type 1 diabetes pathogenesis. Administration of polyinosinic:polycytidylic acid (poly I:C), a mimic of viral double-stranded RNA, induces diabetes in C57BL/6 mice expressing the B7.1 costimulatory molecule in islets. We investigated the potential role of IFN-alpha in this disease model. The quantitative correlation between IFN-alpha levels and time to diabetes, diabetes prevention with anti-IFN-alpha antibody, and ability of IFN-alpha itself to induce diabetes are consistent with the hypothesis that poly I:C in this model acts by induction of IFN-alpha in a genetically susceptible host. Numerous recent studies highlight the importance of the innate immune system and toll receptors in determining adaptive immune responses, and we speculate that for type 1 diabetes, viral and other environmental factors may act through induction of IFNs.