The effect of temperature on the longevity of cercariae of Trichobilharzia spp. under laboratory conditions.

General EcologyCercarial dermatitis, or swimmer’s itch, is a common inflammatory allergic reaction to the accidental attempted penetration of the human epidermis by the cercarial stage of avian schistosomes, most commonly of the genus Trichobilharzia. Longevity of cercariae of Trichobilharzia spp. was determined at the summer lake temperatures of 18.5°, 23.5°, and 28.5° C. Cercarial longevity was found to be negatively effected by high temperatures (28.5° C) but no significant difference was found between the two lower temperatures. Fifty percent (50 %) mortality occurred at 40, 44, and 18 hours for 18.5°, 23.5°, and 28.5° C, respectively. Because snails shed cercariae every morning, it is highly likely that high concentrations of swimmer’s itch-causing cercariae are always present in the water. Increased mortality is likely due to a behavioral change caused by the high temperatures, where cercariae swim in bursts of rapid, sporadic shivering.http://deepblue.lib.umich.edu/bitstream/2027.42/64872/1/Shtull-Leber_Eytan_2009.pd

The effect of temperature on the longevity of Trichobilharzia ocellata cercariae in laboratory conditions.

General EcologyOur experiment investigated the effect of temperature on the longevity of Trichobilharzia ocellata cercariae. Since cercariae emerge from their intermediate snail host in search of their definitive avian hosts, cercarial longevity affects trematode transmission success, which in turn influences abundance and distribution of host populations. Recently emerged cercariae were placed in three temperature intervals, 18.5°C, 23.5°C, and 28.5°C, representing low, intermediate, and high temperatures of Douglas Lake, Michigan; cercariae were counted in time intervals until death. Cercariae in high temperatures experienced significantly lower survivorship than low and intermediate temperatures. Cercariae in the 28.5°C temperature setting lived to a maximum of approximately 45 hours post-emergence, while cercariae in the 23.5°C and 18.5°C temperature settings lived approximately 70 hours post-emergence (at maximum). Observed trends were consistent with results from pervious studies.http://deepblue.lib.umich.edu/bitstream/2027.42/64873/1/Liebert_Jamie_2009.pd

Patient Preferences for Diagnostic Testing in the Emergency Department: A Crossâ sectional Study

BackgroundDiagnostic testing is common during emergency department (ED) visits. Little is understood about patient preferences for such testing. We hypothesized that a patient’s willingness to undergo diagnostic testing is influenced by the potential benefit, risk, and personal cost.MethodsWe conducted a cross sectional survey among ED patients for diagnostic testing in two hypothetical scenarios: chest pain (CP) and mild traumatic brain injury (mTBI). Each scenario defined specific risks, benefits, and costs of testing. The odds of a participant desiring diagnostic testing were calculated using a series of nested multivariable logistic regression models.ResultsParticipants opted for diagnostic testing 68.2% of the time, including 69.7% of CP and 66.7% of all mTBI scenarios. In the CP scenario, 81% of participants desired free testing versus 59% when it was associated with a $100 copay (difference = 22$100 copayment (difference = 17%, 95% CI = 11% to 24%). Benefit and risk had mixed effects across the scenarios. In fully adjusted models, the association between cost and desire for testing persisted in the CP (odds ratio [OR] = 0.33, 95% CI = 0.23 to 0.47) and adult mTBI (OR = 0.47, 95% CI = 0.33 to 0.67) scenarios.ConclusionsIn this EDâ based study, patient preferences for diagnostic testing differed significantly across levels of risk, benefit, and cost of diagnostic testing. Cost was the strongest and most consistent factor associated with decreased desire for testing.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144652/1/acem13404.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144652/2/acem13404_am.pd

Rethinking the Brain Death Controversy: A History of Scientific Advancement and the Redefinition of Death in Jewish Law

Honors (Bachelor's)Hebrew and Jewish Cultural Studies (HJCS)Near Eastern StudiesLaw SchoolUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/77671/1/eytansht.pd

Pre-hospital midazolam for benzodiazepine-treated seizures before and after the Rapid Anticonvulsant Medication Prior to Arrival Trial: A national observational cohort study.

BACKGROUND:Implementation of evidence-based treatment for pre-hospital status epilepticus can improve outcomes. We hypothesized that publication of a pivotal pre-hospital clinical trial (RAMPART), demonstrating superiority of intramuscular midazolam over intravenous lorazepam, altered the national utilization rates of midazolam for pre-hospital benzodiazepine-treated seizures, while upholding its safety and efficacy outside the trial setting. METHODS AND FINDINGS:This is a retrospective, observational cohort study of pre-hospital patient encounters throughout the United States in the National Emergency Medicine Services Information System database, from January 2010 through December 2014. We compared the rates and odds of midazolam use as first-line treatment among all adult and pediatric benzodiazepine-treated seizures before and after RAMPART publication (February 2012). Secondary analyses were conducted for rates of airway interventions and rescue therapy, as proxies for safety and efficacy of seizure termination. 156,539 benzodiazepine-treated seizures were identified. Midazolam use increased from 26.1% in January 2010 to 61.7% in December 2014 (difference +35.6%, 95% CI, 32.7%-38.4%). The annual rate of midazolam adoption increased significantly from 5.9% per year to 8.9% per year after the publication of RAMPART (difference +3.0% per year; 95%CI, 1.6%-4.5% per year; adjusted OR 1.24; 95%CI, 1.17-1.32). Overall frequency of rescue therapy and airway interventions changed little after the publication of RAMPART. CONCLUSIONS:These data are consistent with effective, ongoing, but incomplete clinical translation of the RAMPART results. The effects of the trial, however, cannot be isolated. The study was limited by broad inclusion of all benzodiazepine-treated seizures as well as a lack of information on route of drug of administration. The safety and effectiveness of midazolam for benzodiazepine-treated seizures in prehospital clinical practice appear consistent with trial data, which should encourage continuing increases in utilization

Dysphagia Alone as a Unique Presentation of Wound Botulism in the Emergency Department: A Case Report

Introduction: Wound botulism is a rare and potentially fatal infectious disease, often seen in patients who abuse injection drugs. It classically presents with dysfunction of bilateral cranial nerves followed by proximal and distal motor weakness, which can progress to respiratory failure.Case Report: We report a case of a 31-year-old female who presented to the emergency department for the fifth time with an eight-day history of isolated dysphagia without any other neurologic symptoms. She reported a history of injection drug abuse via “skin popping,” was admitted to the hospital, and ultimately diagnosed with wound botulism.Conclusion: This case exemplifies the diagnostic pitfalls of rare diseases such as wound botulism and provides insight regarding the diagnosis and treatment of this entity. This case also highlights the unique medical and social challenges emergency physicians face while trying to reliably evaluate patients who abuse controlled substances

Post-hoc sensitivity analysis of effect of shifts in benzodiazepine use during diazepam shortage on rates of midazolam adoption.

<p>Post hoc piecewise linear regression with discontinuous indicator variable for the month in which a critical diazepam shortage was reached. The national diazepam shortage began in August 2011 and in December 2011 became widespread and critical enough to warrant an update to the announcement on <a href="http://ASHP.org" target="_blank">ASHP.org</a> that called for use of alternative medications (E. Fox, written communication, May 2016). This call to use alternative benzodiazepines corresponded to the likely depletion of the field inventory of diazepam, which has a typical shelf-life of 2–4 months [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0173539#pone.0173539.ref006" target="_blank">6</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0173539#pone.0173539.ref007" target="_blank">7</a>]. The resolutions of a prior and the above diazepam shortages, in June 2011 and October 2013, respectively, did not appear to be as impactful on the data (models not shown). This is not surprising as the 2011 shortage affected all Hospira formulations, while in 2013 at least one presentation of diazepam was made available (E. Fox, written communication, May 2016), dampening the impact of the resolution of that shortage. Furthermore, the rolling lorazepam shortage was not modeled, as it was likely buffered by the existence of multiple drug suppliers. The 7.1% decline in diazepam utilization at the start of the shortage was associated with a 6.3% rise in midazolam utilization and a 0.8% rise in lorazepam utilization. After taking into account the sudden shifts in benzodiazepine use that occurred at the time of the shortage, the annual rate of midazolam adoption increased significantly, from 2.9% per year in 2010–2011 to 7.9% per year in 2012–2014 (difference +5.0% per year; 95%CI, 3.0%-7.0% per year). There was no significant change in the annual rate of change in diazepam use after the shortage, which was decreasing at 3.4% per year in 2010–2011, and at 4.5% per year between 2012 and 2014 (difference -1.1% per year; 95%CI, -3.3% to 1.2% per year).</p

Inclusion of eligible patient care events for primary analysis.

<p>*Race, ethnicity, and service level all had high levels of missingness and were therefore excluded from the regression models in order to maximize the number of events analyzed. Race was missing for 27,770 events, ethnicity for 43,164 events, and service level for 66,683 events.</p

Characteristics of EMS encounters involving benzodiazepine-treated seizures in the NEMSIS database, 2010–2014.

<p>Characteristics of EMS encounters involving benzodiazepine-treated seizures in the NEMSIS database, 2010–2014.</p