UMEM Educational Pearls - By Jon Mark Hirshon

The current number of influenza cases in the Southern Hemisphere is substantially higher than normal.  For example, in Australia the number of influenza cases this year are twice the next highest year. 

Have you gotten your flu shot yet?

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The blue-ringed octopus (genus Hapalochlaena) is normally found in the Great Barrier Reef and other coastal waters and tide pools around Australia and other Western Pacific islands. Though not an aggressive animal, when it does bite, such as stepped upon, it can inject tetrodotoxin along with a number of other toxic compounds.

 

Tetrodotoxin can cause paralysis, leading to respiratory failure and death, though the blockage of voltage-gated fast sodium channel conduction, blocking peripheral nerve conduction. Treatment is supportive, as the venom usually wears off within 4 to 10 hours.

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Category: International EM

Title: Top Natural Disasters By Death Toll

Keywords: Floods, earthquakes, hurricanes, natural disasters (PubMed Search)

Posted: 9/6/2017 by Jon Mark Hirshon, MD, MPH (Updated: 10/18/2019)
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With the recent destruction by Hurricane Harvey and the impending impact of Hurricane Irma, it is important to recognize the historical death toll from natural disasters. While the list can vary, here is a top ten list from the library of the National Oceanic and Atmospheric Administration:

Rank

Event

Location

Date

Death Toll (Estimate)

1

1931 Yellow River flood

Yellow River, China

Summer 1931

850,000-4,000,000

2

1887 Yellow River flood

Yellow River, China

September-October 1887

900,000-2,000,000

3

1970 Bhola cyclone

Ganges Delta, East Pakistan

November 13, 1970

500,000- 1,000,000

4

1201 Earthquake

Eastern Mediterranean

1201

1,000,000

5

1938 Yellow River flood

Yellow River, China

June 9th, 1938

500,000 - 900,000

6

Shaanxi Earthquake

Shaanxi Province, China

January 23, 1556

830,000

7

2004 Indian Ocean earthquake/tsunami

Indian Ocean

December 26, 2004

225,000-275,000

8

1881 Haiphong Cyclone

Haiphong, Vietnam

1881

300,000

9

1642 Kaifeng Flood

Kaifeng, Henan Province, China

1642

300,000

10

Tangshan Earthquake

Tangshan, China

July 28, 1976

242,000*

* Official Government figure. Estimated death toll as high as 655,000.

 

 

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Category: International EM

Title: Which patients with suicidal ideation are safe to discharge?

Keywords: suicide, clinical policies, risk-assessment tools (PubMed Search)

Posted: 8/11/2017 by Jon Mark Hirshon, MD, MPH (Emailed: 8/16/2017) (Updated: 8/16/2017)
Click here to contact Jon Mark Hirshon, MD, MPH

Takeaways

In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.) 

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Category: International EM

Title: Should you order labs on that routine psychiatric patient?

Keywords: Mental health, routine laboratory test, acute psychiatric patient (PubMed Search)

Posted: 8/2/2017 by Jon Mark Hirshon, MD, MPH
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Patients with psychiatric disorders are found globally, with a recent global burden of disease estimate that mental illness accounted for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years.

 

The American College of Emergency Physicians just published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”

 

One question they sought to answer was “In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?”

 

Their assessment was: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.” This was a Level C recommendation, based upon the quality of the research.

 

Bottom Line: Current literature does not support routinely ordering laboratory testing on patients with acute psychiatric symptoms. However, the quality of the evidence was not strong and local clinical context should be considered.

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Category: International EM

Title: In the Time of Cholera

Keywords: Cholera, conflict, children (PubMed Search)

Posted: 7/5/2017 by Jon Mark Hirshon, MD, MPH (Updated: 10/18/2019)
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Cholera is an acute diarrheal disease that can kill within hours if left untreated.

Rising cholera, diarrhea and malnutrition is a deadly combination in war torn countries, such as Yemen, South Sudan, Somalia and Sudan, especially for children.

Yemen currently has the worst outbreak globally, with over 260,000 suspected cases and over 1,600 deaths. In Yemen:

o   Half the suspected cases are children

o   A quarter of the deaths are among children

 

Bottom Line:

Cholera remains a major cause of morbidity and mortality globally, especially in areas of conflict.

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Takeaways

A patient presents with altered mental status for unclear reasons- could it be anticholinergic syndrome? 

 

There are many medications (e.g. Beers Criteria, see pearl from March 5, 2017) and plants (e.g.: certain mushrooms) that can cause this life-threatening toxidrome.

 

The quick mnemonic for anticholinergic poisoning is:

·      Hot as a hare (hyperthermia)

·      Red as a beet (flushed)

·      Cry as a bone (decreased secretions)

·      Blind as a bat (mydriasis)

·      Mad as a hatter (delirium)

·      Full as a flask (urinary retention)

 

Bottom line: Keep anticholinergic syndrome within your differential for a patient with altered mental status without a clear cause.  

 

Note: An earlier version of this pearl incorrectly listed organophospahtes, which cause cholingeric toxicity.

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Post-partum hemorrhage results in approximately 100,000 deaths annually and is the leading cause of maternal death globally.

In a just published study in the Lancet, among approximately 20,000 women from 21 countries enrolled in the WOMAN study, death due to bleeding was significantly reduced in women given tranexamic acid (1.5%) compared to those in the placebo group (1.9%) {RR 0.81, 95% CI 0.65–1.00; p=0.045)}. This was especially true in women given tranexamic acid with 3 hours of giving birth (1·2%) vs in the placebo group (1·7%) {RR 0.69, 95% CI 0.52–0.91; p=0·008)}.

Bottom line:

The authors’ interpretation “Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”

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Currently, Nigeria is having the worst outbreak of bacterial meningitis in almost 10 years, involving 23 states, 13,420 suspected cases, and 1,069 deaths, as of May 9.

 

Bacterial meningitis outbreaks frequently occur in West Africa.  The area most frequently struck by epidemics of bacterial meningitis is in the sub-Saharan region of Africa. This includes 26 countries and over 400 million people. Epidemics most often occur in the dry season  from December-June. Neisseria meningitides serogroup A historically accounts for approximately 90% of the cases.

 

The U.S. Centers for Disease Control and Prevention recommends quadrivalent vaccines (protects against four serogroups A, C, W, and Y) for individuals traveling or living in countries in which meningococcal disease is hyperendemic or epidemic.

 

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Category: International EM

Title: Reduced Shigella Susceptibility to Ciprofloxacin

Keywords: CDC, Shigella, antibiotic, health advisory (PubMed Search)

Posted: 4/19/2017 by Jon Mark Hirshon, MD, MPH (Updated: 10/18/2019)
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Takeaways

The Centers for Disease Control and Prevention (CDC) just released an official health advisory through the Health Alert Network entitled: “CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin”

 

Concerning treatment, one key point is:

Do not routinely prescribe antibiotic therapy for Shigella infection. Instead, reserve antibiotic therapy for patients for whom it is clinically indicated or when public health officials advise treatment in an outbreak setting.

o   Shigellosis is generally a self-limited infection lasting 5-7 days.

o   Unnecessary treatment with antibiotics promotes resistance.

o   Treatment can shorten the duration of some illnesses, though typically only by 1-2 days

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Category: International EM

Title: Falls in the elderly

Keywords: Falls, elderly (PubMed Search)

Posted: 3/29/2017 by Jon Mark Hirshon, MD, MPH (Updated: 10/18/2019)
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·       Falls are the second leading cause of accidental or unintentional injury deaths worldwide.

·       Each year an estimated 424 000 individuals die from falls globally of which over 80% are in low- and middle-income countries.

·       Adults older than 65 suffer the greatest number of fatal falls.

·       37.3 million falls that are severe enough to require medical attention, occur each year.

·       Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.

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Category: International EM

Title: New Antibiotics Desperately Needed

Keywords: Antibiotic resistance, bacterial pathogens (PubMed Search)

Posted: 3/15/2017 by Jon Mark Hirshon, MD, MPH
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The World Health Organization (WHO) recently published their first ever list of antibiotic-resistant "priority pathogens".  These 12 families of bacterial pathogens have the potential to be a significant threat to human health.

 

These bacteria are divided in critical, high and medium priority pathogens. 

 

The critical pathogens requiring R & D for new antibiotics are:

 

1.     Acinetobacter baumannii, carbapenem-resistant

2.     Pseudomonas aeruginosa, carbapenem-resistant

3.     Enterobacteriaceae, carbapenem-resistant, ESBL-producing

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Emergency department crowding is an almost universal problem. Whether it is called "access block" (Austalia) or "boarding" (United States), it is seen everywhere.

 

The American College of Emergency Physicians (ACEP) states that "a “boarded patient” is defined as a patient who remains in the emergency department after the patient has been admitted to the facility, but has not been transferred to an inpatient unit."

 

It should be clear that the primary cause of overcrowding is boarding: the practice of holding patients in the emergency department after they have been admitted to the hospital, because no inpatient beds are available. This practice has been shown to have an adverse impact on patients, with longer delays causing greater morbidity and mortality.

 

ACEP has created resources to help address this issue, including an emergency medicine practice paper on high impact solutions. See: file:///Users/jhirshon/Downloads/EMPC_Crowding%20IP_092016%20(1).pdf

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Category: International EM

Title: Congenital Zika Syndrome

Keywords: Zika, arbovirus, pregnancy, congenital (PubMed Search)

Posted: 2/15/2017 by Jon Mark Hirshon, MD, MPH (Updated: 10/18/2019)
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Congenital infection with the Zika virus is associated with 5 types of birth defects

·      These are rarely or never seen with other infections during pregnancy

 

·      These defects are:

1.     Severe microcephaly (small head size) resulting in a partially collapsed skull

2.     Decreased brain tissue with brain damage

3.     Damage to the back of the eye with a specific pattern of scarring and increased pigment

4.     Limited range of joint motion, such as clubfoot

5.     Too much muscle tone restricting body movement soon after birth 

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Category: International EM

Title: Opioids- A Major Killer

Keywords: Opioids, overdose, injury, death (PubMed Search)

Posted: 1/18/2017 by Jon Mark Hirshon, MD, MPH
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·       Opioid deaths, such as from heroin and prescription opioids, are a major problem globally

·       In the U.S., since 1999 overdose deaths from prescription opioids have quadrupled.

o   Almost half of opioid deaths involve a prescription opioid

·       The most common drugs related to prescription opioid deaths are:

o   Methadone

o   Oxycodone

o   Hydrocodone

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Category: International EM

Title: Vitamin B12 Deficiency: Part 2

Keywords: B12 deficiency, ataxia, dementia, pernicious anemia (PubMed Search)

Posted: 1/4/2017 by Jon Mark Hirshon, MD, MPH
Click here to contact Jon Mark Hirshon, MD, MPH

Vitamin B12 deficiency can cause significant disease, including severe neurologic problems. However, patient presentations can vary greatly.

Signs and symptoms can include:

  • Constitutional symptoms: fatigue, lack of energy, lightheadedness, loss of appetite
  • Gastrointestinal problems: diarrhea or constipation
  • Cardiovascular: shortness of breath, dyspnea on exertion, tachycardia, CHF
  • Oral lesions: swollen, red tongue (glossitis) or bleeding gums
  • Problems concentrating

Prolonged B12 deficiency can lead to significant neurologic complications, frequently related to the spinal cord, and can include:

  • Mild impairment to dementia
  • Depression, psychosis
  • Loss of balance, limb weakness, ataxia
  • Peripheral neuropathy (numbness and tingling of hands and feet)

Vitamin B12 deficiency, including pernicious anemia, is typically seen in malnourished individuals. Globally, it is widespread in those who live in poverty.

In the U.S., we often consider it in individuals who are chronic alcoholics. However, it can be seen in others, including:

  • Bariatric patients after certain weight-loss surgeries
  • Conditions causing problems with food digestion, including Crohn’s disease, celiac disease, or fish tapeworm (Diphyllobothrium latum) infection
  • Individuals on certain medications for a prolonged time, including proton pump inhibitors, histamine 2 receptor blockers and metformin
  • Inadequate dietary intake or genetic intrinsic factor deficiency

Category: International EM

Title: Zika Update: It's Here to Stay!

Keywords: Zika, WHO, Public Health Emergency (PubMed Search)

Posted: 11/29/2016 by Jon Mark Hirshon, MD, MPH (Emailed: 11/30/2016) (Updated: 11/30/2016)
Click here to contact Jon Mark Hirshon, MD, MPH

Takeaways

The World Health Organization announced on November 18th, 2016 that the Zika virus and associated consequences will no longer Public Health Emergency of International Concern. This changes the originally recommendation in February 2016.

 

However, Zika remains a “significant enduring public health challenge requiring intense action”. The consequences of the disease remains significant, especially for pregnant women and infants.

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Category: International EM

Title: FASH exam (part 2)

Keywords: Infectious Disease, ultrasound, HIV, TB (PubMed Search)

Posted: 9/29/2016 by Jon Mark Hirshon, MD, MPH (Emailed: 11/3/2016) (Updated: 11/3/2016)
Click here to contact Jon Mark Hirshon, MD, MPH

Takeaways

As noted in a previous post, the FASH exam is the Focused Assessment with Sonography for HIV/TB. Below are typical ultrasound images of a positive FASH exam.

 

Peri-aortic lymph nodes- Multiple enlarged nodes, 97.1% specific for TB

 

Splenic lesions – multiple ‘punched out’ lesions

 

The effusions often have fibrous stranding

 

Submitted by Dr. Laura Diegelmann

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Category: International EM

Title: Focused Assessment with Sonography for HIV/TB (FASH- Part 1)

Keywords: Infectious disease, ultrasound, HIV, TB (PubMed Search)

Posted: 9/29/2016 by Jon Mark Hirshon, MD, MPH (Emailed: 10/5/2016) (Updated: 10/5/2016)
Click here to contact Jon Mark Hirshon, MD, MPH

Takeaways

What is the FASH Exam?

  • Focused Assessment with Sonography for HIV/TB
  • A new exam suitable for rapid identification of extrapulmonary TB

 

Submitted by Dr. Laura Diegelmann

 

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