Initial Multiple Sclerosis Diagnosis in the Emergency Department

Multiple sclerosis is a chronic autoimmune disease consisting of inflammation, demyelination and loss of axon integrity in the central nervous system. Like many autoimmune diseases, its severity, initial presentation and symptomatology vary. MS is typically onset in young adults between twenty to forty years old, and has been found two-three times more likely in women than in men. As a chronic illness, like many others, it can present in the emergency department as an undifferentiated neurologic complaint. This is a case report of new onset multiple sclerosis in the emergency department, outlining the importance of a broad set of differential diagnoses and benefit of MRI availability for evaluation of entirety of spinal cord in cases such as these

Brief Review: Kano Model in Healthcare

Here we discuss the use of the Kano Model in the hypothetical example of a re-design of resident conference experience. Kano appreciated that there were a number of attributes to quality. These are discussed in this brief review

Case Report: COVID Arm (COVID Vaccine Arm)

We report the case of a 38-year-old male physician who was vaccinated with the Pfizer vaccine. He experienced arm pain and swelling on the vaccinated arm as well as systemic symptoms, including fever, chills, headache and weakness. The systemic symptoms improved after the use of oral prednisone. A review of the literature on the COVID vaccine is presented

Brief Review: Low Frequency Event Charts (G-Charts) in Healthcare

The ability to determine if a change in a system is actually an improvement—or worsening in function—is one of the essential desiderata of quality improvement efforts. There are many ways to look at the issue. A special problem occurs when the event being studied is low frequency by nature. By way of example, patient falls in a given hospital or division of a hospital may occur in a way that is low frequency—yet each event is important. Process engineering has developed an approach to low frequency events. Part of this approach may involve specialized charts that look at the “time-between-events”—as known as geometric or “G charts”. Time between events charts (G charts) are a form of statistical process control analysis with a special niche for the analysis of low frequency events that occur over time. G-charts have been used in a variety of healthcare applications. Many current statistical software packages have G chart capability

Wernicke’s Encephalopathy Secondary to Hyperemesis Gravidarum

Wernicke’s encephalopathy (WE) is a neurological disorder secondary to thiamine deficiency that is precipitated by administration of glucose-containing fluids prior to thiamine supplementation. Though WE is typically diagnosed among alcoholics (12.5%), the prevalence among nonalcoholics can vary from 0.04-0.13%. Around 30-40% of patients with underlying thiamine deficiency will only experience one of the symptoms from the typical triad, with the complete triad (encephalopathy, oculomotor dysfunction/nystagmus, and ataxia) only evident among 5-16% of the population. Among the non-alcoholic patient population presenting with WE, a history of vomiting is more frequent. While nausea affects around 80% of pregnant women, an extreme form of the same affects only 0.5 to 3%, however can lead to severe nutritional deficiency. Pregnant women have an increased demand for thiamine and among patients with underlying hyperemesis gravidarum, thiamine (vitamin B1) rapidly depletes. Thiamine is an essential cofactor with regard to carbohydrate metabolism and in cells with high metabolic requirements and inadequate stores, neuronal damage can occur. WE remains a clinical diagnosis and thus difficult to observe in patient presenting with a low index of suspicion

Case Report: Use of Bedside Handheld Ultrasound to Diagnose Finger Dislocation

Here we present the case of a 37-year-old male with a finger injury in which finger dislocation was suspected clinically. A bedside pocket ultrasound was performed using a water submersion technique, which identified a posterior dislocated right 2nd digit at the PIP joint. This finding was confirmed with an x-ray. This case report demonstrates that ultrasonography can be utilized to correctly identify finger dislocation. Although larger studies need to be performed to validate the accuracy of this imaging technique, the implications may improve care of the patient. It would also be particularly beneficial for this technique to be applied to the pediatric population as it may reduce unnecessary radiation. In conclusion, ultrasonography can be successfully utilized to correctly diagnose finger dislocations

Case Report: Unintentional Edible THC Ingestion (Gummi Worms) in a Child

We report the case of a 4 year male who presented to the ED with what his mother described as unusual fatigue and sleepiness. The mother related that family and friends had some to her house for a holiday gathering and that one of the guests had an accessible and open handbag that contained gummi worm THC. The guest observed the child eating the gummi worms and immediately notified the patient’s mother. Poison control was contacted. The child was observed for 6 hours and left the ED in good condition without any specific treatment needed. Awareness of the potential of unintentional edible cannabis in the pediatric population is important

Handheld Bedside POCUS in the Evaluation of Neck Swelling: A Case of Ludwig\u27s Angina

Ludwig\u27s angina is a rare and life threatening cellulitic infection, first described by German physician, Wilhelm Frederick Von Ludwig in 1836, as a gangrenous infection of the soft tissue floor of the mouth and neck. The potential to spread rapidly to contiguous tissues surrounding the upper airways, notably the glottis, resulted in Ludwig\u27s angina carrying a high mortality rate near 50% in the pre- antibiotic era. It necessitates rapid detection and management to assure respiratory compromise does not occur. This case study is novel as it illustrates handheld bedside POCUS utilization in diagnosing Ludwig’s Angina

Case report: Octreotide Associated Hyperkalemia

78-year-old female with past medical history of acromegaly status post pituitary adenoma status post resection presents to the emergency department with abdominal pain. ED workup was not significant for any acute intra-abdominal abnormalities; however, incidental finding of hyperkalemia was pertinent to the visit. Patient was treated in the ED for her condition but her potassium levels remained elevated despite repeated saline infusions. Patient was ultimately admitted to the hospital where it was discovered that she had recently been switched from octreotide injections to an oral somatostatin analogue Mycapssa. We believe that this patient’s hyperkalemia was caused by octreotide-induced insulin suppression and resultant impaired cellular potassium uptake. Although octreotide has a wide variety of medical applications it can/should be used with caution as complications arising from elevated potassium can be potentially dangerous

Understanding engagement and disengagement from pro-environmental behaviour: The role of neutralization and affirmation techniques in maintaining persistence in and desistance from car use

Despite mounting evidence that car use is a prime culprit of global warming, our love affair with the car persists. General awareness of the environmental consequences of car usage is high but fails to correspond to moderated car use. This paper contributes to an understanding of how university students’ environmental beliefs affect decisions to engage in continued car use (persistence) and/or to discontinue or reduce car use (desistance). The aim of the research presented here was to explore the range of neutralizations and counterneutralizations (affirmations) employed by students and to examine the ways in which they are used to justify and maintain either persistence or desistance in car use. The research consisted of six focus group sessions with thirty-four UK-based Higher Education students. Analysis of the study’s data highlights the range of neutralizations and counter-neutralizations employed by students in social settings. The article discusses the usefulness of neutralization theory in accounting for actual and/or intended nonenvironmentally friendly behaviour such as car use. In addition, the study’s findings are discussed in relation to prior research and to potential implications for public policy interventions which favour moderating car usage