Ultrasound-guided rhomboid intercostal block (RIB) for acute scapula fracture in the emergency department

INTRODUCTION

Proper pain in acute scapular fractures can be challenging to achieve due to their anatomy and location. While the current mainstay of treatment relies on opioids, the Rhomboid Intercostal Block (RIB) has been utilized for anesthesia to effectively treat pain for scapular fractures. However, it has not yet been utilized in the emergency department (ED).

CASE REPORT

In this case report, we present the first documented use of RIB to treat pain safely and effectively in a 69-year-old male with a scapula fracture following a ground-level fall in the ED. The RIB was performed under ultrasound guidance, providing precise localization and administration of the nerve block.

CONCLUSION

The RIB demonstrated successful pain management in the ED. Although hopeful, further research is needed to understand limitations, potential side effects, length of pain control, and overall clinical outcomes of the RIB in the ED.

Clavipectoral plane block performed in the emergency department for analgesia after clavicular fractures

Clavicle fractures are common injuries in the Emergency Department (ED). Adequate pain control with oral or intravenous medications is the central aspect of treatment. The ultrasound-guided clavipectoral plane block (CPB), previously described in anesthesia literature, offers complete analgesia of the clavicle with a low adverse effect profile. In this case series, we describe the first reported utilization of the CPB for analgesia for acute clavicular fractures in the ED. We performed the CPB for distal and midshaft clavicular fractures on patients who suffered from a variety of traumatic accidents including bicycle accidents, motorcycle accidents, and motor vehicle accidents. All patients experienced significant reductions in their reported pain without any reported complications. Given the need to provide patients with appropriate pain control in the ED, the CPB offers an effective, simple method for providing analgesia without known significant risks, including without the risks associated with high-dose systemic analgesia.

Trauma-Informed Care for Acute Care Settings: A Novel Simulation Training for Medical Students

Introduction

Physicians often care for patients who have experienced traumatic events including abuse, discrimination, and violence. Trauma-informed care (TIC) is a framework that recognizes the prevalence of trauma, promotes patient empowerment, and minimizes retraumatization. There are limited education curricula on how to apply TIC to acute care settings, with simulation-based training presenting a novel educational tool for this aim.

Methods

Students participated in a didactic on TIC principles and its applications in acute care settings. Learners participated in three simulation cases where they performed physical exams and gathered history on patients with urgent medical needs related to intimate partner violence, transgender health, and health care discrimination. Debriefing followed each simulation.

Results

Seventeen medical students participated across four sessions. The sessions were evaluated with pre- and postparticipation surveys, including Likert scales and free-response questions. After participation, individuals' self-assessed confidence improved across multiple domains, including identifying situations for trauma screenings, inquiring about trauma, and responding as a bystander. Learners also felt more familiar with TIC-specific history taking and physical exam skills. Finally, simulation was perceived as a beneficial educational tool. All findings were statistically significant (p ≤ .01).

Discussion

Our simulation-based training enabled students to practice conversations and interventions related to trauma. This novel training represents a feasible and effective means for teaching TIC for acute care settings, including in the emergency department and in-patient settings. Development and evaluation were supported by the Society for Academic Emergency Medicine.

Trauma-informed care (TIC) best practices for improving patient care in the emergency department

A patient's current or previous experience of trauma may have an impact on their health and affect their ability to engage in health care. Every year, millions of patients who have experienced physically or emotionally traumatic experiences present to emergency departments (ED) for care. Often, the experience of being in the ED itself can exacerbate patient distress and invoke physiological dysregulation. The physiological reactions that lead to fight, flight, or freeze responses can make providing care to these patients complex and can even lead to harmful encounters for providers. There is a need to improve the care provided to the vast number of patients in the ED and create a safer environment for patients and healthcare workers. One solution to this complex challenge is understanding and integrating trauma-informed care (TIC) into emergency services. The federal Substance Abuse and Mental Health Service Administration's (SAMHSA) six guiding principles of TIC offer a universal precaution framework that ensures quality care for all patients, providers, and staff in EDs. While there is growing evidence that TIC quantitatively and qualitatively improves ED care, there is a lack of practical, emergency medicine-specific guidance on how to best operationalize TIC. In this article, using a case example, we outline how emergency medicine providers can integrate TIC into their practice.

Basic life support knowledge among healthcare providers in Afghanistan: a cross-sectional study of current competencies and areas for improvement

Basic life support (BLS) is a type of emergency care provided by healthcare workers and public safety professionals to individuals experiencing cardiac arrest, respiratory distress, or other cardiopulmonary emergencies. Despite having a high burden of cardiovascular disease and trauma from conflict in Afghanistan, little is known about the level of BLS knowledge Afghani healthcare workers have. A cross-sectional study was conducted in Kabul, Afghanistan, to assess healthcare workers' training and knowledge of BLS. The study, which took place from March to June 2022 across multiple public and private hospitals, was approved by the institutional ethics committee of Ariana Medical Complex. The sample size was calculated using a nonprobability convenience sampling method, and the study population consisted of healthcare workers actively working in a health center who were willing to complete a questionnaire. The results of the study showed that most participants (71.3%) were in the 21-30-year-old age range, and a third (32.3%) were doctors. 95.3% of participants had poor knowledge of BLS, with a mean score of 4.47±1.58 out of 13. Additionally, it was evident from questionnaire responses that providers are not adequately performing BLS. These findings suggest that further work, including regular BLS courses, is necessary to improve the knowledge and practice of BLS by healthcare workers in Afghanistan.

Feasibility of a novel ultra-low-cost bubble CPAP (bCPAP) System for neonatal respiratory support at Muhimbili National Hospital, Tanzania

OBJECTIVE

Continuous Positive Airway Pressure (CPAP) is recommended in the treatment of respiratory distress syndrome of premature newborns, however there are significant barriers to its implementation in low-resource settings. The objective of this study was to evaluate the feasibility of use and integration of Vayu bCPAP Systems into the newborn unit at Muhimbili National Hospital in Tanzania.

STUDY DESIGN

A prospective qualitative study was conducted from April 6 to October 6 2021. Demographic and clinical characteristics of patients treated with Vayu bCPAP Systems were collected and analyzed. Healthcare workers were interviewed until thematic saturation. Interviews were transcribed, coded, and analyzed using a framework analysis.

RESULTS

370 patients were treated with Vayu bCPAP Systems during the study period. Mean birth weight was 1522 g (500-3800), mean duration of bCPAP treatment was 7.2 days (<1-39 d), and survival to wean was 81.4%. Twenty-four healthcare workers were interviewed and perceived Vayu bCPAP Systems as having become essential for treating neonatal respiratory distress at MNH. Key reasons were that Vayu bCPAP Systems improve patient outcomes, are easy to use, and more patients are now able to receive quality care. Barriers to integration included durability of oxygen tubing material and training.

CONCLUSIONS

It was feasible to implement and integrate Vayu bCPAP Systems into the care of neonates at Muhimbili National Hospital.

Ultrasound-Guided Erector Spinae Plane Block in Emergency Department for Abdominal Malignancy Pain: A Case Report

INTRODUCTION

Severe breakthrough pain is a common occurrence in patients with cancer and is responsible for thousands of emergency department (ED) visits each year. While opioids are the current mainstay of treatment, they have multiple limitations including inadequate control for a quarter of patients with cancer. The ultrasound-guided erector spinae plane block (ESPB) has been used in the ED to effectively treat pain for pathologies such as acute pancreatitis, since it provides somatic and visceral analgesia.

CASE REPORT

In this case report we describe the use of an ESPB to treat breakthrough pain safely and effectively in a 54-year-old female with a history of metastatic colon cancer.

CONCLUSION

The ESPB may have utility in addressing well documented disparities in pain treatment in the ED, but additional research is needed to understand side effects, duration of pain control, and clinical outcomes of the ESPB.

Addressing the humanitarian crisis in Afghanistan through $10 billion Afghani assets: what are the challenges and opportunities at hand?

Background

The current humanitarian crisis in Afghanistan started after the US and international allies’ withdrawal. This has put the country in a dire situation as the globalized infrastructure supporting Afghanistan came to halt. Moreover, 10 billion USD of Afghanistan’s assets were frozen by the U.S and other international organizations after the Taliban takeover. This further exacerbated the humanitarian crisis and quickened the economic collapse in Afghanistan. These assets should be freed to support the people of Afghanistan.

Main body

In order to address this situation, international oversight is needed to allow these funds to be returned and used by the Central Bank of Afghanistan without misappropriation by the Taliban. We suggest a number of short term interventions and long term considerations to improve the situation in Afghanistan with the $10 billion in frozen assets. In the short term, economic stability and the hunger crisis should be addressed by funding international organizations such as the World Food Program and national Afghani NGOs. In the long term funds should be used to build back the economy, build healthcare infrastructure, and support the development of women and children.

Conclusion

At this juncture, the world and international organizations have a moral and ethical responsibility to ensure the 10 billion in funds go to the owners, the people of Afghanistan. With oversight and fund distribution to the right partners, progress can be made by providing support in security, healthcare, education and food resources. This calls for action to deliver $10 billion of assets to the Afghan people in a transparent manner, avoiding further tension and disasters in the country.

The Role of NRF2/KEAP1 Pathway in Glioblastoma: Pharmacological Implications

Glioblastoma multiforme (GBM) grade IV glioma is the most frequent and deadly intracranial cancer. This tumor is determined by unrestrained progression, uncontroled angiogenesis, high infiltration and weak response to treatment, which is chiefly because of abnormal signaling pathways in the tumor. A member related to the Cap 'n' collar family of keypart-leucine zipper transcription agents-the transcription factor NF-E2-related factor 2 (Nrf2)-regulates adaptive protection answers by organized upregulation of many genes that produce the cytoprotective factors. In reply to cellular pressures types such as stresses, Nrf2 escapes Kelch-like ECH-related protein 1 (Keap1)-facilitated suppression, moves from the cytoplasm towards the nucleus and performs upregulation of gene expression of antioxidant responsive element (ARE). Nrf2 function is related tocontrolling many types of diseases in the human specially GBM tumor.Thus, we will review the epigeneticalregulatory actions on the Nrf2/Keap1 signaling pathway and potential therapeutic options in GBM by aiming the stimulation of Nrf2.

Trauma-informed Care Interventions in Emergency Medicine: A Systematic Review

Introduction

Trauma exposure is a highly prevalent experience for patients and clinicians in emergency medicine (EM). Trauma-informed care (TIC) is an effective framework to mitigate the negative health impacts of trauma. This systematic review synthesizes the range of TIC interventions in EM, with a focus on patient and clinician outcomes, and identifies gaps in the current research on implementing TIC.

Methods

The study was registered with PROSPERO (CRD42020205182). We systematically searched peer-reviewed journals and abstracts in the PubMed, EMBASE (Elsevier), PsycINFO (EBSCO), Social Services Abstract (ProQuest), and CINAHL (EBSCO) databases from 1990 onward on August 12, 2020. We analyzed studies describing explicit TIC interventions in the ED setting using inductive qualitative content analysis to identify recurrent themes and identify unique trauma-informed interventions in each study. Studies not explicitly citing TIC were excluded. Studies were assessed for bias using the Newcastle-Ottawa criteria and Critical Appraisal Skills Programme (CASP) Checklist.

Results

We identified a total of 1,372 studies and abstracts, with 10 meeting inclusion criteria for final analysis. Themes within TIC interventions that emerged included educational interventions, collaborations with allied health professionals and community organizations, and patient and clinician safety interventions. Educational interventions included lectures, online modules, and standardized patient exercises. Collaborations with community organizations focused on addressing social determinants of health. All interventions suggested a positive impact from TIC on either clinicians or patients, but outcomes data remain limited.

Conclusion

Trauma-informed care is a nascent field in EM with limited operationalization of TIC approaches. Future studies with patient and clinician outcomes analyzing universal TIC precautions and systems-level interventions are needed.

Development of an Offline, Open-Source, Electronic Health Record System for Refugee Care

While electronic health records (EHRs) have been shown to be effective in improving patient care in low-resource settings, there are still barriers to implementing them, including adaptability, usability, and sustainability. Taking a user-centered design process we developed the Hikma Health EHR for low resourced clinics caring for displaced populations. This EHR was built using React Native and Typescript that sync to a Python backend repository which is deployed on Google Cloud SQL. To date the Hikma Health EHR has been deployed for 26,000 patients. The positive impacts of the system reported by clinician users are 3-fold: (1) improved continuity of care; (2) improved visualization of clinical data; and (3) improved efficiency, resulting in a higher volume of patients being treated. While further development is needed, our open-source model will allow any organization to modify this system to meet their clinical and administrative needs.

A free, open-source, offline digital health system for refugee care (Preprint)

Background

Objective

Methods

Results

Conclusions

Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review

Background

Continuous positive airway pressure (CPAP) is the gold standard of care in providing non-invasive positive pressure support to neonates in respiratory distress in high-resource settings. While safety has been demonstrated in low-resource settings, there is a lack of knowledge on the barriers and facilitators to proper implementation.

Objective

To identify and describe the barriers, facilitators, and priorities for future implementation of CPAP for neonates and infants in low-resource settings.

Methods

A systematic search (database inception to March 6, 2020) was performed on MEDLINE, Embase, Web of Science, CINAHL, Global Health, and the WHO Global Index Medicus using PRISMA-ScR guidelines. Original research articles pertaining to implementation of CPAP devices in low-resource settings, provider or parent perspectives and experiences with CPAP, cost-benefit analyses, and cost-effectiveness studies were included. Inductive content analysis was conducted.

Findings

1385 article were screened and 54 studies across 19 countries met inclusion criteria. Six major themes emerged: device attributes, patient experiences, parent experiences, provider experiences, barriers, and facilitators. Nasal trauma was the most commonly reported complication. Barriers included unreliable electricity and lack of bioengineering support. Facilitators included training, mentorship and empowerment of healthcare providers. Device design, supply chain infrastructure, and training models were imperative to the adoption and sustainability of CPAP.

Conclusion

Sustainable implementation of CPAP in low resource settings requires easy-to-use devices, ready access to consumables, and holistic, user-driven training. Further research is necessary on standardizing metrics, interventions that support optimal provider performance, and conditions needed for successful long-term health system integration.

Rethinking the Principle of Justice for Marginalized Populations During COVID-19

In the face of limited resources during the COVID-19 pandemic response, public health experts and ethicists have sought to apply guiding principles in determining how those resources, including vaccines, should be allocated.

Reduction of COVID-19 Incidence and Nonpharmacologic Interventions: Analysis Using a US County-Level Policy Data Set

BACKGROUND

Worldwide, nonpharmacologic interventions (NPIs) have been the main tool used to mitigate the COVID-19 pandemic. This includes social distancing measures (closing businesses, closing schools, and quarantining symptomatic persons) and contact tracing (tracking and following exposed individuals). While preliminary research across the globe has shown these policies to be effective, there is currently a lack of information on the effectiveness of NPIs in the United States.

OBJECTIVE

The purpose of this study was to create a granular NPI data set at the county level and then analyze the relationship between NPI policies and changes in reported COVID-19 cases.

METHODS

Using a standardized crowdsourcing methodology, we collected time-series data on 7 key NPIs for 1320 US counties.

RESULTS

This open-source data set is the largest and most comprehensive collection of county NPI policy data and meets the need for higher-resolution COVID-19 policy data. Our analysis revealed a wide variation in county-level policies both within and among states (P<.001). We identified a correlation between workplace closures and lower growth rates of COVID-19 cases (P=.004). We found weak correlations between shelter-in-place enforcement and measures of Democratic local voter proportion (R=0.21) and elected leadership (R=0.22).

CONCLUSIONS

This study is the first large-scale NPI analysis at the county level demonstrating a correlation between NPIs and decreased rates of COVID-19. Future work using this data set will explore the relationship between county-level policies and COVID-19 transmission to optimize real-time policy formulation.

Prevalence of Emergency Department Social Risk and Social Needs

Introduction

Social risks, or adverse social conditions associated with poor health, are prevalent in emergency department (ED) patients, but little is known about how the prevalence of social risk compares to a patient’s reported social need, which incorporates patient preference for intervention. The goal of this study was to describe the relationship between social risk and social need, and identify factors associated with differential responses to social risk and social need questions.

Methods

We conducted a cross-sectional study with 48 hours of time-shift sampling in a large urban ED. Consenting patients completed a demographic questionnaire and assessments of social risk and social need. We applied descriptive statistics to the prevalence of social risk and social need, and multivariable logistic regression to assess factors associated with social risk, social need, or both.

Results

Of the 269 participants, 100 (37%) reported social risk, 83 (31%) reported social need, and 169 (63%) reported neither social risk nor social need. Although social risk and social need were significantly associated (p < 0.01), they incompletely overlapped. Over 50% in each category screened positive in more than one domain (eg, housing instability, food insecurity). In multivariable models, those with higher education (adjusted odds ratio [aOR] 0.44 [95% confidence interval {CI}, 0.24–0.80]) and private insurance (aOR 0.50 [95% CI, 0.29–0.88]) were less likely to report social risk compared to those with lower education and state/public insurance, respectively. Spanish-speakers (aOR 4.07 [95% CI, 1.17–14.10]) and non-Hispanic Black patients (aOR 5.00 [95% CI, 1.91–13.12]) were more likely to report social need, while those with private insurance were less likely to report social need (private vs state/public: aOR 0.13 [95% CI, 0.07–0.26]).

Conclusion

Approximately one-third of patients in a large, urban ED screened positive for at least one social risk or social need, with over half in each category reporting risk/need across multiple domains. Different demographic variables were associated with social risk vs social need, suggesting that individuals with social risks differ from those with social needs, and that screening programs should consider including both assessments.

Error analysis of the rapid lifetime determination method for double-exponential decays and new windowing schemes

The rapid lifetime determination method (RLD) is a mathematical technique for extremely rapid evaluations of lifetimes in exponential decays. It has been applied in luminescence microscopy and single-molecule lifetime evaluation. To date, the primary application has been in single-exponential evaluations. We present extensions of the method to double exponentials. Using Monte Carlo simulations, we assess the performance of both the double-exponential decay with known lifetimes and the double-exponential decay with unknown preexponential factors and lifetimes. Precision is evaluated as a function of the noise level (Poisson statistics), the ratios of the lifetimes, the ratios of their preexponential factors, and the fitting window. Optimum measurement conditions are determined. RLD is shown to work well over a wide range of practical experimental conditions. If the lifetimes are known, the preexponential factors can be determined with good precision even at low total counts (10(4)). With unknown preexponential factors and lifetimes, precisions decrease but are still acceptable. A new gating scheme (overlapped gating) is shown to offer improved precision for the case of a single-exponential decay. Theoretical predictions are tested against actual experimental data from a laser-based lifetime instrument.

Effect of lateral versus supine wedged position on development of spinal blockade and hypotension

Aortocaval compression may not be completely prevented by the supine wedged or tilted positions. It is commonly believed, however, that the unmodified full lateral position after induction of spinal anaesthesia might allow excessive spread of the block. We therefore compared baseline arterial pressures in the supine wedged, sitting, tilted and full lateral positions in 40 women who were about to undergo elective caesarean section. They were then given spinal anaesthesia in the left lateral position and randomised to be turned to the right lateral or the supine wedged position, after which speed of onset and spread of blockade to cold sensation were measured every 2 min for 10 min and mean arterial pressure and ephedrine requirement were recorded every minute for 20 min. Baseline mean arterial pressure was 9 mmHg (95% CI 3 to 14) lower in the left lateral (measured in the upper arm) than in the sitting position; those in the supine wedged and tilted positions were intermediate. Following spinal anaesthesia, hypotension (defined as a reading </=80% of the baseline value in the same position) lasted 2.4 min longer (CI +0.6 to +4.1) in the supine wedged group, but there was no significant difference between the groups in maximum fall or ephedrine requirement. The upper level of block rose more rapidly in the supine wedged than in the lateral group and showed less variability. There is therefore no reason to fear the unmodified lateral group position, which may offer better protection against hypotension.

Improved streptococcal grouping antisera containing polyethylene glycol

Antisera to streptococcal groups A through G containing 4% polyethylene glycol 6000 were prepared and evaluated. Seventy strains of homologous and heterologous beta- and non-beta-hemolytic streptococci were included in the evaluation. Homologous reactions were determined against extracts prepared by four extraction methods: hot hydrochloric acid (Lancefield) extraction, autoclave extraction, hot formamide extraction, and nitrous acid extraction. Enhancement of the precipitin reaction in the presence of polyethylene glycol 6000 permitted a fourfold dilution of all antisera for use in the capillary precipitin test. At this dilution, the potency of the antisera exceeded requirements established for these reagents.

Congenital coronary aneurysms nine years following saphenous vein bypass graft surgery

A 34-year-old woman with two congenital coronary aneurysms received a saphenous vein bypass graft (SVBG) as treatment for a thrombosed right coronary artery aneurysm 9 years ago. The angiographic and surgical findings were reported at that time [1]. In 1979, she received a sequential SVBG to the left anterior descending and first diagonal coronary arteries following recurrence of angina and progressive occlusion of the left coronary artery aneurysm. She is believed to have the longest angiographically documented course following operation, and her case history is reported to aid in establishing the natural history of this unusual condition and its surgical management.

Cross-protective antigens of group A streptococci types 3 and 31 and types 46 and 51

Reciprocal cross-protective antigens have been demonstrated between types 3 and 31 cocci, and one-way cross-protective antigens have been demonstrated between types 46 and 51 cocci. The reciprocal cross-protective antigen of types 3 and 31 is distinct from the specific M protein of either type. In the one-way cross relationship, type 46 cocci contain both type 46 and type 51 M proteins and therefore stimulate protective antibodies against both types. Type 51 cultures contain only the homologous M antigen. These relationships were demonstrated by capillary precipitin tests, indirect bactericidal tests, and in agar-gel diffusion patterns. The practical significance of these relationships in the serological typing of group A streptococci is discussed along with their possible role in immunity to streptococcal infections in man.

Absorption of group A streptococcus anti-M typing sera with broken cells

Group A streptococcus anti-M typing sera that cannot be made specific by absorption with whole streptococcus cells have been absorbed with the soluble and insoluble fractions of ruptured heterologous cells. The technique has been used successfully for preparing specific anti-M sera against eight serotypes of group A streptococcus. The method involves breakage of the absorbing cells in the presence of the antiserum, and incubation of the mixture at 37 C for 1 hr, followed by 3 to 5 days of incubation at 4 C. The procedure is useful for preparing specific antiserum from certain lots of unabsorbed antiserum that otherwise would have to be discarded because of undesirable cross-reactivity.