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ARTICLES IN PRESS
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Articles In Press
Articles In Press
Brief Research Report (Limit 1500 words)
Enroller Experience and Parental Familiarity of Disease Influence Participation in a Pediatric Trial
Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children.
Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller.
Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation.
Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.
Images in Emergency Medicine (Limit 500 words)
Evolving Paralysis after Motor Vehicle Collision
An 85-year-old male presented to the emergency department after a motor vehicle collision and developed progressive neurological deficits. CT imaging demonstrated epidural thickening from C2-C7, and MRI was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome.
Cases of traumatic spinal epidural hematomas are rarely seen in the emergency department. These are part of a small subset of operative neurological emergencies that benefit from urgent operative intervention.
A Strange Twist
Case presentation. A 16-year-old female presented to the emergency department with a four-day history of right lower quadrant abdominal pain for several hours. The patient was afebrile and physical examination was notable for isolated tenderness in the right lower quadrant. Ultrasound and computed tomography demonstrated an adnexal cystic structure. Pelvic magnetic resonance imaging was ordered to better characterize the pathology. Discussion. Isolated fallopian tube torsion is an uncommon entity requiring prompt surgical intervention. Recognition and appropriate management are essential.
Nail gun injury of the trachea and spinal cord
A 26-year-old man was impaled by a nail after a nail gun accident. He was fully conscious with weakness and loss of sensation in the extremities. Cervical computed tomography showed a 9-cm long nail penetrating the spinal cord. The nail was removed 6 hours after the incident. The neurological deficits gradually improved, and at the 3-month follow-up, the patient had completely recovered from muscle weakness.
The present case showed a favorable neurological course, which was be attributable to the fact that the cervical spinal cord injury did not involve the corticospinal tracts and anterior horn.
Omental Prolapse Through Vaginal Cuff Dehiscence
A 31-year old female with a history of laparoscopic assisted vaginal hysterectomy presented by ambulance to the emergency department with acute onset of abdominal pain and a vaginal protrusion which occurred while straining to pass a bowel movement. Physical examination was notable for a flat but slightly tender abdomen, normal bowel sounds, scant vaginal bleeding, and a 15cm long, blood-tinged mass protruding from the vagina. A brief and unsuccessful attempt at reduction was made by the emergency physician. Obstetrics and Gynecology was consulted, and the patient was taken to the operating
Omental prolapse through vaginal cuff dehiscence. Following vaginal hysterectomy, the vaginal cuff is closed surgically1. Occasionally, this site can dehisce, allowing abdominal contents to enter the vagina or protrude through the vaginal canal. Vaginal cuff dehiscence is estimated to have a rate of 0.39%. It is more commonly seen after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy, (0.28%)2.
Risk factors include trauma from sexual intercourse, repetitive Valsalva maneuvers, smoking, malnutrition, anemia, diabetes, immunosuppression, and corticosteroid use2. Cases typically present as vaginal spotting or post-coital bleeding, and occasionally pelvic pressure or protrusion2. Most cases occur within weeks to months after the procedure, but some can present years later. Patients are at risk for infection due to exposure of peritoneal contents to vaginal and skin flora. Management includes administration of broad-spectrum antibiotics. Partial dehiscence can be managed with rest, but large dehiscence is usually managed surgically.
This case highlights the importance of the pelvic exam in patients with vaginal bleeding and abdominal pain, and care should be taken to not mistake protruding omental tissue for prolapsed vaginal mucosa.
1. Binz NM, et al. Complications of Gynecologic Procedures. Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.
2. Clarke-Pearson D, & Geller E. Complications of Hysterectomy. Obstetrics & Gynecology, 121 (3), 654-673; 2013.
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Articles in Press
Once articles have been accepted for publication but have not yet been assigned to an issue, we place them here.
Case Report (Limit 1750 words)
Pheochromocytoma: A Diagnosis Made More Difficult in the COVID-19 Era
Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other more common pathologies. Identification in the Emergency Department is inherently difficult. In the COVID-19 pandemic physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases, like pheochromocytoma, less likely to be recognized.
We report a case of pheochromocytoma discovered in the emergency department in a patient who presented with fatigue, tachycardia, and diaphoresis. The differential included pulmonary embolism, cardiomyopathy, congestive heart failure and infectious causes. A broad workup was begun including serology, electrocardiogram, Computed Tomography Angiogram (CTA), and COVID-19 testing. This patient was evaluated in the winter of 2020, the local height of the COVID-19 pandemic, and was found to be positive. A tiny retroperitoneal tumor was reported on CTA as “incidental” in the setting of multifocal pneumonia from COVID-19 infection. But further history taking discovered many years of intermittent symptoms and suggested that the tumor may be more contributory to the patient’s presentation. Subsequent MRI and surgical pathology confirmed the pheochromocytoma.
This case presentation highlights the importance of careful history taking, keeping a broad differential, and examining incidental findings in the context of the patient’s presentation.
Case Report: Pancreatitis, with a Normal Serum Lipase, as a Rare Post-Esophagogastroduodenoscopy Complication
Pancreatitis after Esophagogastroduodenoscopy (EGD) is not a common occurrence, particularly in the setting of a normal serum lipase. The lack of commonality may delay diagnosis and treatment in some patients presenting to the emergency department with abdominal pain after an otherwise uncomplicated procedure. This case report serves to bring awareness to this potential procedural complication and the possibility of pancreatitis with a normal serum lipase.
Takotsubo cardiomyopathy following traumatic hand amputation
Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease. We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point of care ultrasound (POCUS) associated with traumatic hand amputation. The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition ten days later. Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.
Hypotension unresponsive to fluid resuscitation: A Case Report
Introduction: Iron deficiency anemia is commonly seen in the emergency department, and the cause can be complex and variable. Chronic lice infestation as the etiology of severe iron deficiency anemia has not been well studied and is mostly limited to case reports.
Case Report: We present a case of a female without known medical history who presented to the emergency department for generalized weakness and was found to have severe anemia in the setting of chronic lice infestation. This patient’s hypotension was initially unresponsive to fluid resuscitation which allowed for consideration of other etiologies of this patient’s presentation and an unusual case of severe anemia.
Conclusion: Severe and chronic pediculosis can cause chronic blood loss and be an unusual and rare cause of iron deficiency anemia. In the setting of anemia and hypotension unresponsive to fluid resuscitation, consideration should be given to early PRBC transfusion and subsequent investigation of causes of severe anemia.
Occipital Lobe Status Epilepticus; A Rare Stroke Mimic with Novel Imaging Findings: A Case Report
This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of partial status epilepticus of the occipital lobe. Her initial brain computerized axial tomographic (CT) perfusion scan and magnetic resonance imaging (MRI) revealed novel findings associated with this diagnosis.
A 70-year-old female presented to our ED with left visual field hemianopsia, dyskinesia, dysmetria and facial droop. Her initial diagnosis was left posterior fossa circulation cerebrovascular accident. However, her neuroimaging indicated hypervascularity of the left occipital lobe without evidence of infarct or structural lesion. A cerebral angiogram excluded arterio-venous malformation. Subsequently, an electroencephalogram showed left occipital lobe status epilepticus.
Hemianopsia is a rare presentation of partial status epilepticus mimicking stroke. Hypervascularity seen on advanced neuroimaging may have suggested this diagnosis on initial ED evaluation.