Katherine L. Boyle

Vertebral Artery Anatomy : A Review of Two Hundred Fifty Magnetic Resonance Imaging Scans

Study Design. The aim of this study is to characterize the anatomy of vertebral arteries using magnetic resonance imaging scans of 250 consecutive patients. Objectives. To document the prevalence of midline vertebral artery (VA) migration in a subgroup of patients presenting with neck pain, radiculopathy, or myelopathy and to identify the course of the VA through the TFs. Summary of Background Data. Knowledge of VA anomalies and their respective prevalence may help surgeons decrease the incidence of iatrogenic injury to this artery. Methods. In this retrospective review of 281 consecutive patients, who had an magnetic resonance imaging for axial neck pain, radiculopathy, or myelopathy, anatomic measurements were obtained from C2 to C7. Results. The observed VA anomalies can be classified into following 3 main groups: (1) intraforaminal anomalies-midline migration, (2) extraforaminal anomalies, and (3) arterial anomalies. Midline migration of the VA was identified in 7.6% (19/250) of patients. The etiology can be degenerative or traumatic. It is important to note that the pattern of medial migration was clockwise rotation from caudal to cephalad and was present in all of our patients with anomalous arteries. Additionally, at C6, only 92% (460/500) of VAs were located within their respective transverse foramens and hypoplastic VAs were identified in 10% (25/250) of patients. Conclusion. Anomalies that must be considered before surgery include interforamenal anomalies, extraforamenal anomalies, and arterial anomalies. The intraforaminal anomalies involve midline migration, which places the VA at direct risk during corpectomy. Extraforaminal anomalies are related to VAs entering the transverse foramen at a level other than C6, which can increase the risk of injury during the anterior approach to the cervical spine. Arterial anomalies can be fenestrated, hypoplastic, or absent. These raise concern with the ability to maintain cerebral perfusion in the setting of damage to one of the VAs with the presence of contralateral arterial abnormality.

Nasopharyngeal Necrosis After Chronic Opioid (Oxycodone/Acetaminophen) Insufflation

Nasopharyngeal necrosis resulting from narcotic insufflation is a recognized phenomenon, but cocaine use is more commonly associated with this pathology than opioid abuse. Physical exam findings associated with severe tissue destruction are not routinely seen on physical examination or available in the medical literature. We present a case of chronic oxycodone/acetaminophen insufflation and images of a defect in the soft palate.

Acute Amnestic Syndrome Associated with Fentanyl Overdose

Fentanyl Overdose and Acute Amnestic Syndrome A syndrome of severe amnesia and medial temporal changes on magnetic resonance imaging after drug overdose has been reported with increasing frequency. Four additional cases are now reported in patients from Massachusetts who tested positive for fentanyl.

Drugs and Medical Devices: Adverse Events and the Impact on Women’s Health

A large number of medications and medical devices removed from the market by the US Food and Drug Administration over the past 4 decades specifically posed greater health risks to women. This article reviews the historical background of sex and gender in clinical research policy and describes several approved drugs and devices targeted for use in women that have caused major morbidity and mortality. The intended population for the medications and devices, population affected, approval process, and the basic and legal actions taken against the medication/drug company are also discussed. It is recognized that women are still at risk for harm from unsafe medications and devices, and continued improvements in legislation that promotes inclusion of sex and gender into the design and analysis of research will improve safety for both men and women.

Oxymorphone Insufflation Associated with Acute Sensorineural Hearing Loss: Case Files of the University of Massachusetts Medical Toxicology Fellowship

A37-year-oldmale was found supine andminimally responsive in his mother’s basement. Emergency medical services reported miotic pupils, bradypnea, and depressed mental status that improved significantly after administration of naloxone 1 mg intramuscularly. In the emergency department, the patient had stable vital signs and normal mental status. He reported having consumed alcohol earlier, then snorting crushed Opana® (oxymorphone: Endo Pharmaceuticals Inc; Chadds Ford, PA, USA) shortly before being found unresponsive. The patient purchased the oxymorphone on the Internet and was unsure if he used the immediateor the extended-release formulation. In the emergency department, the patient felt well, except for acute subjective bilateral hearing loss described as feeling like he was “in a tunnel.” He denied any associated trauma, headaches, changes in vision, tinnitus, or ataxia. His physical examwas unremarkable except for subjective bilateral hearing loss observed by both the patient and the examiners. No formal audiologic testing was performed. What Is the Differential Diagnosis of Sensorineural Hearing Loss?

Minocycline Toxicity: Case Files of the University of Massachusetts Medical Toxicology Fellowship

Keywords Minocycline .Tetracycline .Blueskinpigmentation .BlackbonediseaseCase PresentationA 61-year-old man was brought to the emergency department(ED) for shortness of breath, fatigue, frequent falls, and bluishdiscoloration of his skin. The primary care physician trans-ferred the patient due to concern for cyanosis. On presentationto the ED, the patient was oriented but appeared fatigued. Thepatient was afebrile and had the following vital signs: bloodpressure 161/88 mmHg, pulse 71/min, respiratory rate 16/min,and oxygen saturation 100 % on room air by fingertip pulseoximetry. On physical exam, pupils were 4 mm and reactivebilaterally, extraocular movements were intact, and there wasno nystagmus. Anicteric sclerae were notable for blue pigmen-tation (Fig. 1). Heart sounds were regular, without murmurs,rubs, or gallops. Lung sounds were clear to auscultation bilat-erally. Other thanataxia, the neurological exam was unremark-able. The skin had a generalized bluish tinge, especially on thearms,withdarkerpigmentationonthecheeks(Figs. 2,3and4).There was acne on the back and facial rosacea. Bluish discol-oration was also noted under the proximal nail beds (Fig. 5).When questioned about the skin discoloration, the patient andhisfamilymembersdescribedaninsidiousonset.Photographsof the patient from years ago confirmed that this was notcongenital. Medical history included acne, orthostatichypotension, and Parkinsons disease, for which a deep brainstimulator had been surgically implanted. A comprehensivemedication list was not immediately available; however, thepatientdeniedanyrecentmedicationadditionsoradjustments.The patientwasunemployed, denied anyrecent travel, andnoother members of his household were complaining of fatigueor similar blue skin discoloration.What is the Differential Diagnosis of these SkinChanges?When developing a differential diagnosis (see Table 1) forbluish skin discoloration, one must determine if the patienthas cyanosis. A significant toxicologic cause of blue skinappearance from cyanosis is methemoglobinemia. A carefulhistory may help differentiate between acquired versus con-genital methemoglobinemia. Recent exposure to dapsone,benzocaine, lidocaine, nitrates, or aniline dye raises suspi-cion foracquired methemoglobinemia. Sulfhemoglobinemiashould be considered in patients with a positive methemo-globin reading on co-oximetry, but who do not respond tomethylene blue treatment. Oxidizing agents that may causemethemoglobinemia can also produce sulfhemoglobinemiain the presence of sulfur compounds, such as sulfonamidederivatives, hydrogen sulfide, or gastrointestinal sources [1].Causes of noncyanotic skin discoloration are extensive.Metal deposition (e.g., silver, gold, bismuth) causes blueskin pigmentation. Chronic or improper exposure to silvercan result in a silvery blue or gray skin discoloration knownas argyria. Argyria is caused by silver deposition in the skin,specifically within fibroblasts, macrophages, and in the ex-tracellular matrix. These skin changes are often most signif-icant in sun-exposed areas [2]. Similarly, chrysiasis refers to

Oxycodone overdose in the pediatric population: case files of the University of Massachusetts Medical Toxicology Fellowship.

A 7-year-old female, status post recent tonsillectomy, presented to the emergency department (ED) after an unintentional Roxicet® (oxycodone-acetaminophen coformulation) overdose. The patient weighed 19 kg and was prescribed 1.5 mL of Roxicet® 5/325 mg per 5 mL to take as needed for pain. Her mother misunderstood the dosing instructions and gave the patient 1.5 teaspoons (7.5 mL) of the medication, and immediately brought her to the ED. On arrival, the patient was non-toxic-appearing with normal mental status, physical exam, and vital signs. She complained of a stomachache and nausea, but denied any vomiting or diarrhea. Her medical history was significant for tonsillectomy 3 days previously and a remote herniorrhaphy. Her only prescription or over-the-counter medication was Roxicet® as needed for pain.

Reduction of opioid prescribing through the sharing of individual physician opioid prescribing practices

Background: Drug overdoses are the most common cause of accidental death in the United States, with the majority being attributed to opioids. High per capita opioid prescribing is correlated with higher rates of opioid abuse and death. We aimed to determine the impact of sharing individual prescribing data on the rates of opioid prescriptions written for patients discharged from the emergency department (ED). Methods: This was a pre‐post intervention at a single community ED. We compared opioid prescriptions written on patient discharge before and after an intervention consisting of sharing individual and comparison prescribing data. Clinicians at or over one standard deviation above the mean were notified via standard template electronic communication. Results: For each period, we reported the median number of monthly prescriptions written by each clinician, accounting for the total number of patient discharges. The pre‐intervention median was 12.5 prescriptions per 100 patient discharges (IQR 10–19) compared to 9 (IQR 6–11) in the post‐intervention period (p < 0.001). This represents a 28% reduction in the overall rate of opioid prescriptions written per patient discharged. Using interrupted time series analysis for monthly rates, this was associated with a reduction in opioid prescriptions, showing a decrease of almost 9 prescriptions for every 100 discharges over the 6 months of the study (p = 0.032). Conclusion: Our study demonstrates the sharing of individual opioid prescribing data was associated with a reduction in opioid prescribing at a single institution.

Pediatric Poisonings in a Rural Ugandan Emergency Department

Objective This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents. Methods This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed. Results From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%). Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison. Conclusions Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.