Jeanne L. Jacoby

Stevens-Johnson syndrome after treatment with azithromycin: an uncommon culprit

Azithromycin is a commonly prescribed antibiotic but is not considered a common etiologic agent for Stevens-Johnson syndrome (SJS). SJS is a dermatologic emergency that occurs within a spectrum of severity and can result in severe morbidity and mortality.

Troponin leak associated with drug-induced methemoglobinemia☆☆☆★

Drug-induced methemoglobinemia is a well-described entity but has not been previously associated with elevated troponins in the absence of cardiac symptoms. We report a case of a patient presenting to the emergency department (ED) with complaints related to an exacerbation of her long-standing cystitis. A low pulse oximetry reading prompted an evaluation, revealing a troponin leak, which peaked at 10 hours. Her methemoglobin level was found to be elevated at 11.4%, but a preexisting anemia apparently prevented the clinical recognition of cyanosis. The methemoglobinemia was determined to be secondary to her ingestion of phenazopyridine and trimethoprim-sulfa methoxizole. Although phenazopyridine and sulfa agents have long been known to cause methemoglobinemia, our patient exhibited an asymptomatic troponin leak that has not been previously reported as a complication of drug-induced methemoglobinemia. Clinicians should be aware of this potential association.

Pain Perception in Latino vs. Caucasian and Male vs. Female Patients: Is There Really a Difference?

Introduction Pain is a common emergency department (ED) complaint. It is important to understand the differences in pain perception among different ethnic and demographic populations. Methods We applied a standardized painful stimulus to Caucasian and Latino adult patients to determine whether the level of pain reported differed depending on ethnicity (N=100; 50 Caucasian [C], 50 Latino [L] patients) and gender (N=100; 59 female, 41 male). Patients had an initial pain score of 0 or 1. A blood pressure cuff was inflated 20 mm HG above the patient’s systolic blood pressure and held for three minutes. Pain scores, using both a 10-cm visual analog scale (VAS) and a five-point Likert scale, were taken at the point of maximal stimulus (2 minutes 50 seconds after inflation), and at one- and two-minute intervals post deflation. Results There was a statistically significant difference between the Likert scale scores of Caucasian and Latino patients at 2min 50sec (mean rank: 4.35 [C] vs. 5.75 [L], p<0.01), but not on the VAS (mean value: 2.94 [C] vs. 3.46 [L], p=0.255). Women had a higher perception of pain than males at 2min 50sec on the VAS (mean value: 3.86 [F] vs. 2.24 [M], p<0.0001), and the Likert scale (mean rank: 5.63 [F] vs. 4.21 [M], p<0.01). Conclusion Latinos and women report greater pain with a standardized pain stimulus as compared to Caucasians and men.

Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED

Objective We sought to evaluate the effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex. Methods This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow‐up and asked to self‐report interim falling. Results Data from 192 subjects were analyzed. At baseline, 71.4% (n = 137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n = 148) scored below average on the Chair test. There were no differences by patient sex. By the six‐month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non‐significant higher prevalence of falls compared to males (29.7% versus 22.2%, p = 0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%–82.5%), a specificity of 28.4% (95% CI: 21.1%–36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%–34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%–83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%–88.7%), a specificity of 23.4% (95% CI: 16.7%–31.3%), a PP value 27.0% (95% CI: 20.1%–34.9%) and a NP value of 75.0% (95% CI: 59.7%–86.8%). No significant differences were observed between sexes. Conclusions There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting.

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

Introduction This study investigated factors that influence emergency medicine (EM) patients’ decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties. Methods A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants’ responses. Results A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient’s gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285–2.389}], ID [OR:3.281, 95% CI{2.293–4.695}], and OB/GYN [OR:2.408, 95% CI{1.741–3.330}]). EM’s rankings of “how well the research was explained” and whether “the knowledge learned would benefit others” as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated “risk of unknown side effects” as their strongest barrier. Regardless of the patients’ race, “time commitment” was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218–2.136}], ID [OR:1.340, 95% CI{1.006–1.784}], or OB/GYN [OR:1.901, 95% CI{1.431–2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked “having all material provided in my own language” as the most helpful resource. Conclusion There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient’s own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.

Impact of Race Versus Education and Race Versus Income on Patients’ Motivation to Participate in Clinical Trials

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients’ education and income. A self-administered survey asked outpatients to rank potential influential factors on a “0” to “4” significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < 

Left ventricular perforation with catheter decompression: Case report and review of complications

30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.

An Educational Intervention Allows for Greater Prehospital Recognition of Acute Stroke.

Thoracostomy tube placement is one of the more common procedures performed in the Emergency Department, most commonly for treatment of pneumothorax or hemothorax but occasionally for drainage of empyema or pleural effusion. Thoracostomy may be a life-saving procedure with a wide range of complication rates reported, ranging from 19.4-37%, most commonly extrathoracic placement. Most recent meta-analyses showed a relatively stable complication rate of 19% over the past three decades with the vast majority being benign in nature. We present a case with the rare complication of thoracostomy in which of a small-caliber thoracostomy tube was placed in the left ventricle. Although thoracotomy was performed to remove the catheter, the patient remained virtually asymptomatic and had an uneventful course.

Retropharyngeal air and pneumomediastinum: a rare complication of influenza A and asthma in an adult

We performed a study to determine whether a brief educational intervention directed at pre-hospital providers would increase the identification of stroke victims in the pre-hospital setting. The purpose of this IRB approved, before-and-after research project was to determine whether the implementation of Advanced Stroke Life Support Class (ASLS) [1] training for pre-hospital providers would lead to improved field identification of stroke. In June 2014 we presented a didactic and scenario-based 8 h class teaching the Miami Emergency Neurologic Deficit, (MEND) exam [2] as part of the ASLS class which emphasizes the pre-hospital recognition and management of acute stroke to the 25 full-time and 15 part-time paramedics at a local ambulance service with approximately 16,000,911 calls/year. The receiving hospital is a 900-bed suburban teaching hospital with a yearly census of 80,000 and is a JCAHO approved comprehensive Stroke Center. The course consists of lectures, hands on instruction, and small group stations, which included standardized patients mimicking specific stroke syndromes. At each station, the participants were required to complete a patient assessment, identify the stroke syndrome (left brain, right brain, brainstem, cerebellum

When the Secondary Survey is Primary: Knife Blade in the Spine

We report a case of massive pneumomediastinum, small apical pneumothoraces, and retropharyngeal emphysema in an adult female patient with both influenza A and asthma. Pneumomediastinum occurs because of a rapid increase of pressure within the alveoli, secondary to forceful coughing or bronchospasm. This pressure increase causes the alveoli to rupture, releasing air into the lung parenchyma andmediastinum. Although pneumomediastinum is usually a benign entity, in some cases, it can progress to subcutaneous emphysema and, as in this case, retropharyngeal emphysema leading to airway compromise. Pneumomediastinum has been previously reported in the pediatric literature in asthmatic patients with influenza; but it has only very rarely been reported as a cause of airway obstruction in adults, and there are no reports in the literature of retropharyngeal emphysema as a result of influenza. This case report highlights the importance of considering chest radiography and computed tomography in asthmatic patients or those with influenza who have suspected extra-alveolar air. A 27-year-old woman presented to our suburban emergency department complaining of shortness of breath, neck fullness, and right-sided chest pain worsening over the past 2 days. The patient is a known asthmatic who was poorly controlled on her home regimen of an albuterol metered-dose inhaler. She was seen the day before at an urgent care facility and given a diagnosis of community-acquired pneumonia and was started on a steroid taper, albuterol nebulizers, and clarithromycin. On initial presentation in the emergency department, shewas noted to be in severe respiratory distress, using accessory muscles, and sitting in the tripod position. She said that she could not lie flat and that the neck swelling made it impossible to cough. Initial vital signs were as follows: temperature, 97.8°F; heart rate, 110 beats per minute; blood pressure, 130/86 mm Hg; respiratory rate, 32; and pulse oximetry, 99% on room air. On physical examination, she was found to have diffuse wheezing in all lung fields with palpable crepitus of the neck. Laboratory test were positive for a low CO2 level of 22 mm/L, and a swab was positive for influenza A. Chest radiograph (Fig. 1) revealed atelectasis of the right middle and lower lobes with significant pneumomediastinum. The patient ☆ The authors have no outside support information, conflicts, or financial interest to disclose; and this work has not been presented elsewhere. ☆ MN, AR, and JJ researched the case; MN and JJ drafted themanuscript; and all authors contributed substantially to its revision. JJ takes responsibility for the paper as a whole. 0735-6757/© 2015 Elsevier Inc. All rights reserved. Please cite this article as: Niehaus M, et al, Retropharyngeal air and pneum adult, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.06.0 was admitted to the intensive care unit, and computed tomographic (CT) scans of the chest (Fig. 2) and neck (Fig. 3) were performed that demonstrated extensive pneumomediastinum extending into the soft tissues of the neck and anterior superior chest wall soft tissues. There was opacification of the right bronchus intermedius and resulting atelectasis of the right lower and middle lobes, consistent with mucous plugging; two small apical pneumothoraces were also noted. Gas in the retropharynx appeared to cause some degree of pharyngeal airway effacement. During her hospital stay, she was treated with antibiotics and oseltamivir in addition to nebulized albuterol and ipratropium, intravenous prednisone, and supplemental oxygen therapy. Shedid not require chest tube placement or bronchoscopy. By the time of discharge on day 6, her pneumothoraces had resolved; and chest radiograph showed only a small residual amount of subcutaneous emphysema. Pneumomediastinum, or the presence of air in the mediastinum, is an uncommon clinical finding that has a reported incidence between 1 in 45,000 and 1 in 25,000, with young men accounting for up to 76% of cases [1]. Hamman first described pneumomediastinum in 1939 when he identified subcutaneous emphysema in a postpartum patient. Pneumomediastinum is caused by a rapid increase in alveolar pressure, causing alveolar rupture and the release of air into the tissues either with or without an associated pneumothorax. This pressure increase can be caused by the Valsalva maneuver or forceful coughing in the presence of bronchospasm. In addition, alveolar rupture can occur in the presence of lung disease when alveoli spontaneously rupture. In the case of our patient, the presence of both bronchospasm and intrinsic lung disease coupled with influenza likely led to an increase in intrapulmonary pressure that precipitated alveolar rupture and subsequent pneumomediastinum. Case reports have identified other causes including trauma, crackcocaine use, central line placement, bronchoscopy, endoscopy, and colonoscopy [2]. Pneumomediastinum caused by influenza has only rarely been described in adults. One Chinese article describes 2 adult cases resulting from H7N9 infection [3]. There are several case reports cited in the pediatric literature associated with the 2009 H1N1 influenza pandemic. In these cases, the only inciting events were forceful coughing and coexistent influenza infection, which is known to cause diffuse alveolar inflammation [4–6]. The overall incidence of spontaneous pneumomediastinum in children is unknown but in thosewith asthma, it is estimated that the incidence is 3 per 1000 children [5]. Pneumomediastinum leading to retropharyngeal air is even rarer. Retropharyngeal air has previously been cited as a rare complication of dental procedures [7–9]. Chen et al [10] report spontaneous pneumomediastinum presenting as a sore throat due to omediastinum: a rare complication of influenza A and asthma in an 20 Fig. 1. Initial chest radiograph demonstrating pneumomediastinum and subcutaneous emphysema. Fig. 3. Lateral neck CT demonstrating retropharyngeal air. 2 M. Niehaus et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx retropharyngeal air. However, this complication has not previously been described in adults or children as a result of influenza. Unlike pneumomediastinum, which is usually benign and self-limited, retropharyngeal air is not necessarily a benign condition even in those cases not associated with esophageal injury and infection. Skogvoll et al [11] describe a case of a 21⁄2-year-old child with acute obstructive airway disease secondary to adenovirus that led to respiratory failure secondary to retropharyngeal air obstructing the airway. Cohn et al [12] describe a case of retropharyngeal air accumulation as a complication of pneumomediastinum, requiring intubation in an asthmatic 13year-old adolescent. This case of an adult asthmatic with influenza presenting in respiratory distress secondary to massive pneumomediastinum and retropharyngeal emphysema demonstrates a rare complication of a combination of 2 not-so-uncommon conditions. Fig. 2. Chest CT demonstrating pneumomediastinum and small bilateral pneumothoraces. Please cite this article as: Niehaus M, et al, Retropharyngeal air and pneum adult, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.06.0 Matthew Niehaus DO Allison Rusgo, MPH, PA-C Kevin Roth DO Jeanne L. Jacoby MD* Department of Emergency Medicine, Lehigh Valley Health Network 1240 S Cedar Crest Blvd, Allentown, PA 18103 *Corresponding author. Emergency Medicine Research 1240 S Cedar Crest Blvd, Suite #212, Allentown, PA 18103 Tel.: +1 610 402 7262/7666; fax: +1 610 402 7160 E-mail address: Jeanne_L.Jacoby@lvhn.org http://dx.doi.org/10.1016/j.ajem.2015.06.020