Chad E. Branecki

Peripheral nerve induces macrophage neurotrophic activities: regulation of neuronal process outgrowth, intracellular signaling and synaptic function

Rat cortical neurons cultured in conditioned media from human monocyte-derived macrophages (MDM) show increased neuronal protein synthesis, neurite outgrowth, mitogen-activating protein kinase activity, and synaptic function. Neurotrophic properties of human MDM-conditioned media are significantly enhanced by human peripheral nerve and to a more limited extent by CD40 ligand pre-stimulation. Such positive effects of MDM secretions on neuronal function parallel the secretion of brain-derived neurotrophic factor (BDNF). MDM activation cues may serve to balance toxic activities produced during neurodegenerative diseases and thus, under certain circumstances, mitigate neuronal degeneration.

Evaluation of a Novel Handoff Communication Strategy for Patients Admitted from the Emergency Department

Introduction Miscommunication during inter-unit handoffs between emergency and internal medicine physicians may jeopardize patient safety. Our goal was to evaluate the impact of a structured communication strategy on the quality of admission handoffs. Methods We conducted a mixed-methods, pre-test/post-test study at a 560-bed academic health center with 60,000 emergency department (ED) patient visits per year. Admission-handoff best practices were integrated into a modified SBAR format, resulting in the Situation, Background, Assessment, Responsibilities & Risk, Discussion & Disposition, Read-back & Record (SBAR-DR) model. Physician handoff conversations were recorded and transcribed for the 60 days before (n=110) and 60 days after (n=110) introduction of the SBAR-DR strategy. Transcriptions were scored by two blinded physicians using a 16-item scoring instrument. The primary outcome was the composite handoff quality score. We assessed physician perceptions via a post-intervention survey. Results The composite quality score improved in the post-intervention phase (7.57 + 2.42 vs. 8.45 + 2.51, p=.0085). Three of the 16 individual scoring elements also improved, including time for questions (70.6% vs. 82.7%, p=.0344) and confirmation of disposition plan (41.8% vs. 62.7%, p=.0019). The majority of emergency and internal medicine physicians felt that the SBAR-DR model had a positive impact on patient safety and handoff efficiency. Conclusion Implementation of the SBAR-DR strategy resulted in improved verbal handoff quality. Agreement upon a clear disposition plan was the most improved element, which is of great importance in delineating responsibility of care and streamlining ED throughput. Future efforts should focus on nurturing broader physician buy-in to facilitate institution-wide implementation.

Milk-alkali-induced pancreatitis in a chronically hypocalcemic patient with DiGeorge syndrome.

BACKGROUND Pancreatitis is a common diagnosis in the emergency department (ED), and milk-alkali syndrome (MAS) is an uncommon etiology for pancreatitis. MAS is caused by increased calcium and alkali ingestion, causing hypercalcemia accompanied by metabolic alkalosis and renal failure. Once considered rare, MAS is an increasingly common cause of hypercalcemia. Awareness of the resurgence of this syndrome is important for emergency physicians when recalling the causes of renal failure and pancreatitis. We present a case of pancreatitis and acute renal failure (ARF) in a chronically hypocalcemic DiGeorge syndrome patient, resulting from hypercalcemia secondary to excessive ingestion of calcium carbonate tablets. CASE REPORT A patient with DiGeorge syndrome and chronic abdominal pain due to gastroesophageal reflux disease (GERD) presented to our ED for severe abdominal pain. He reported nausea and vomiting, as well as epigastric pain that seemed worse than his typical pain. Laboratory evaluation revealed pancreatitis and ARF, although the patient had no prior history of these conditions. Upon further questioning, his mother divulged that the patient had been taking large quantities of calcium carbonate tablets for his worsening GERD symptoms. The patient was admitted to the intensive care unit where his pancreatitis and ARF eventually resolved as his calcium levels returned to his baseline. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MAS is a relatively uncommon diagnosis, but can lead to serious sequelae such as pancreatitis and ARF. Questioning the patient about calcium ingestion is an important facet to the diagnosis and work-up of pancreatitis and ARF. Recognition of this etiology can improve patient outcomes and prevent recurrences.

A description of teaching methods using an on-site instructor versus a distant site instructor to train laryngoscopy to medical students in Hanoi, Vietnam, from Omaha, Nebraska, by video communication.

This study demonstrated a method to train medical students at Hanoi Medical School in airway management from Omaha, Nebraska, using tele-mentoring techniques. Correct placement of the endotracheal tube was documented by tele-broncoscopy following intubation. This technology may increase medical training capabilities in remote or developing areas of the world. Medical care delivery could be performed using this technology by tele-mentoring a lesser trained medical provider at a distant site enabling them to accomplish complex medical tasks.

Use of transatlantic telebroncoscopy to confirm proper endotracheal tube placement during a simulated chemical, biological, radiological or nuclear or explosive (CBRNE) event

Airway management is a cornerstone of medical support in the event of a chemical, biological, radiological, nuclear, or explosive event (CBRNE). Challenges are presented due to: the potential of having a large number of patients needing immediate treatment, lack of medical providers skilled in complex airway management tasks such as intubation, tactile and movement challenges caused by providers wearing protective gear and copious airway secretions in the event of a nerve agent exposure. These difficulties may increase the chance of emergency providers placing the endotracheal tube in an improper location during intubation. This study utilized telebronchoscopy to confirm proper endotracheal tube placement by anesthesia providers located at a transcontinental site. The results of this paper show that tele-video laryngoscopy and telebronchoscopy may be useful tools for emergency personnel providing airway management in the event of a CBRNE situation.

Comparison of Airtraq optical laryngoscope and Storz video laryngoscope in a cadaver model.

BACKGROUND Airway management in the emergency department is a critical intervention that requires both standard techniques and rescue techniques to ensure a high rate of success. Recently, video laryngoscope (VL) systems have become increasingly common in many large urban EDs, but these systems may exceed the budgets of smaller rural EDs and EMS services and the Airtraq optical laryngoscope (OL) may provide an effective, low-cost alternative. We hypothesized that laryngeal view and time to endothracheal tube placement for OL and VL intubations would not be significantly different. METHODS This was a prospective, crossover trial. SETTING University-based emergency medicine residency program procedure laboratory utilizing lightly embalmed cadavers. SUBJECTS PGY1-3 emergency medicine residents. The study subjects performed timed endotracheal intubations alternately using the OL and VL. The subjects then rated the Cormack-Lehane laryngeal view for each device. STATISTICAL ANALYSIS Mean time to intubation and the mean laryngeal view score were calculated with 95% confidence intervals and statistical significance was determined by Students t test. RESULTS Fourteen subjects completed the study. The average laryngeal view achieved with the OL vs. the VL was not significantly different, with Cormack-Lehane grade of 1.14 vs. 1.07, respectively. Time to endotracheal intubation, however, was significantly different (P<0.001) with the average time to intubation for the OL 25.49 seconds (95% CI: 17.95-33.03) and the VL 13.41 seconds (10.27-16.55). CONCLUSION The Airtraq OL and the Storz VL yielded similar laryngeal views in the lightly embalmed cadaver model. Time to endotracheal tube placement, however, was less for the VL.