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Introduction: Mushroom toxicity is an important etiology of acute liver injury in a patient with gastrointestinal symptoms. Case Report: We present the case of a male patient presenting to the emergency department (ED) with gastrointestinal distress who was placed under ED observation for elevated liver function tests. During his hospital course, it was revealed he had consumed wild mushrooms believed to be Amanita phalloides. Conclusion: While mushroom ingestion and subsequent toxicity are rare, a high index of suspicion in foraging hobbyists is essential to arriving at the correct diagnosis and directing the patient to the appropriate management.

Abstract Background As cancer therapies have improved, spinal metastases are increasingly common. Resulting complications have a significant impact on patient's quality of life. Optimal methods of surveillance and avoidance of neurologic deficits are understudied. This study compares the clinical course of patients who initially presented to the emergency department (ED) versus a multidisciplinary spine oncology clinic and who underwent stereotactic body radiation therapy (SBRT) secondary to progression/presentation of metastatic spine disease. Methods We performed a retrospective analysis of a prospectively maintained database of adult oncologic patients who underwent spinal SBRT at a single hospital from 2010 to 2021. Descriptive statistics and survival analyses were performed. Results We identified 498 spinal radiographic treatment sites in 390 patients. Of these patients, 118 (30.3%) presented to the ED. Patients presenting to the ED compared to the clinic had significantly more severe spinal compression (52.5% vs. 11.7%; p

Background: Patients with hip fractures frequently present to the emergency department (ED). Traditional methods of pain control often include the use of opioid pain medication. Fascia iliaca nerve blocks offer an alternative method to acute pain management in the ED for hip fractures. At the time of this publication, there are no readily available, cost-effective gelatin models of the surrounding fascia iliaca anatomy. Objectives: The objective was to design an accurate and cost-effective model to simulate fascia iliaca nerve block models for training emergency medicine clinicians. Discussion: A gelatin model was created to simulate the anatomy of the inguinal region in order to perform a fascia iliaca block. This fascia iliaca nerve block model aided in training of residents and attendings to become familiar with the anatomy and techniques necessary to perform this nerve block. Clinicians were able to practice ultrasound guided in-plane approach into the fascia iliaca space where they could then hydrodissect and distill anesthetic. Each model could be used several times allowing trainees multiple attempts. Conclusion: A method to create a fascia iliaca nerve block model using readily available supplies was designed to aid training of emergency medicine clinicians. We hope to improve the technique and clinician comfort-level when performing the fascia iliaca nerve block using this model.

T cells from narcolepsy patients were recently reported to recognize hypocretin, a wakefulness-promoting neurohormone, suggesting autoimmune origin of the disease. Here the authors show that hypocretin-specific T cells expand both in healthy controls and in narcolepsy patients, and identify preliminary features that may distinguish them.

Abstract Study objective With increasing prevalence of extended‐spectrum beta‐lactamase‐producing enterobacteriaceae (ESBLE), more reliable identification of predictors for ESBLE urinary tract infection (UTI) in the emergency department (ED) is needed. Our objective was to evaluate risk factors and their predictive ability for ED patients with ESBLE UTI. Methods This was a retrospective case‐control study at an urban academic medical center. Microbiology reports identified adult ED patients with positive urine cultures from 2015–2018. Inclusion criteria were diagnosis of UTI with monomicrobial enterobacteriaceae culture growth. Exclusions were cultures with carbapenemase‐resistant enterobacteriaceae or urinary colonization. Collected variables included demographics, comorbidities, and recent medical history. Patient disposition, urine culture susceptibilities, presence of ESBLE, empiric antibiotics, and therapy modifications were collected. Patients were stratified based on ESBLE status and analyzed via descriptive statistics. The data were divided into 2 parts: the first used to identify possible predictors of ESBLE UTI and the second used to validate an additive scoring system. Results Of 466 patients, 16.3% had ESBLE urine culture growth and 83.7% did not; 39.5% of ESBLE patients required antibiotic therapy modification, as compared to 6.4% of ESBLE negative patients (odds ratio [OR] 9.5; confidence interval [CI] 8.9–10.1). Independent predictors of ESBLE UTI were IV antibiotics within 1 year (OR 5.4; CI 2.1–12.8), surgery within 90 days (OR 6.4; CI 1.5–27.8), and current refractory UTI (OR 8.5; CI 2.0–36.6). Conclusion Independent predictors of ESBLE UTI in emergency department patients included IV antibiotics within 1 year, surgery within 90 days, and current refractory UTI.

Mutations in the DEPDC5 gene can cause epilepsy, including forms with and without brain malformations. The goal of this study was to investigate the contribution of DEPDC5 gene dosage to the underlying neuropathology of DEPDC5-related epilepsies. We generated induced pluripotent stem cells (iPSCs) from epilepsy patients harboring heterozygous loss of function mutations in DEPDC5. Patient iPSCs displayed increases in both phosphorylation of ribosomal protein S6 and proliferation rate, consistent with elevated mTORC1 activation. In line with these findings, we observed increased soma size in patient iPSC-derived cortical neurons that was rescued with rapamycin treatment. These data indicate that human cells heterozygous for DEPDC5 loss-of-function mutations are haploinsufficient for control of mTORC1 signaling. Our findings suggest that human pathology differs from mouse models of DEPDC5-related epilepsies, which do not show consistent phenotypic differences in heterozygous neurons, and support the need for human-based models to affirm and augment the findings from animal models of DEPDC5-related epilepsy.

Alternating hemiplegia of childhood (AHC) is a rare neurodevelopmental disease caused by heterozygous de novo missense mutations in the ATP1A3 gene that encodes the neuronal specific α3 subunit of the Na,K-ATPase (NKA) pump. Mechanisms underlying patient episodes including environmental triggers remain poorly understood, and there are no empirically proven treatments for AHC. In this study, we generated patient-specific induced pluripotent stem cells (iPSCs) and isogenic controls for the E815K ATP1A3 mutation that causes the most phenotypically severe form of AHC. Using an in vitro iPSC-derived cortical neuron disease model, we found elevated levels of ATP1A3 mRNA in AHC lines compared to controls, without significant perturbations in protein expression. Microelectrode array analyses demonstrated that in cortical neuronal cultures, ATP1A3+/E815K iPSC-derived neurons displayed less overall activity than neurons differentiated from isogenic mutation-corrected and unrelated control cell lines. However, induction of cellular stress by elevated temperature revealed a hyperactivity phenotype following heat stress in ATP1A3+/E815K neurons compared to control lines. Treatment with flunarizine, a drug commonly used to prevent AHC episodes, did not impact this stress-triggered phenotype. These findings support the use of iPSC-derived neuronal cultures for studying complex neurodevelopmental conditions such as AHC and provide a platform for mechanistic discovery in a human disease model.

Mutations in ATP1A3 encoding the catalytic subunit of the Na/K-ATPase expressed in mammalian neurons cause alternating hemiplegia of childhood (AHC) as well as an expanding spectrum of other neurodevelopmental syndromes and neurological phenotypes. Most AHC cases are explained by de novo heterozygous ATP1A3 mutations, but the fundamental molecular and cellular consequences of these mutations in human neurons are not known. In this study, we investigated the electrophysiological properties of neurons generated from AHC patient-specific induced pluripotent stem cells (iPSCs) to ascertain functional disturbances underlying this neurological disease. Fibroblasts derived from two subjects with AHC, a male and a female, both heterozygous for the common ATP1A3 mutation G947R, were reprogrammed to iPSCs. Neuronal differentiation of iPSCs was initiated by neurogenin-2 (NGN2) induction followed by co-culture with mouse glial cells to promote maturation of cortical excitatory neurons. Whole-cell current clamp recording demonstrated that, compared with control iPSC-derived neurons, neurons differentiated from AHC iPSCs exhibited a significantly lower level of ouabain-sensitive outward current (‘pump current’). This finding correlated with significantly depolarized potassium equilibrium potential and depolarized resting membrane potential in AHC neurons compared with control neurons. In this cellular model, we also observed a lower evoked action potential firing frequency when neurons were held at their resting potential. However, evoked action potential firing frequencies were not different between AHC and control neurons when the membrane potential was clamped to −80 mV. Impaired neuronal excitability could be explained by lower voltage-gated sodium channel availability at the depolarized membrane potential observed in AHC neurons. Our findings provide direct evidence of impaired neuronal Na/K-ATPase ion transport activity in human AHC neurons and demonstrate the potential impact of this genetic defect on cellular excitability.

Abstract Background The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency. Methods The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated. Results In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing “resuscitations,” the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year. Conclusions Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

Purpose: To develop statistical dose-volume histogram (DVH)–based metrics and a visualization method to quantify the comparison of treatment plans with historical experience and among different institutions. Methods and materials: The descriptive statistical summary (ie, median, first and third quartiles, and 95% confidence intervals) of volume-normalized DVH curve sets of past experiences was visualized through the creation of statistical DVH plots. Detailed distribution parameters were calculated and stored in JavaScript Object Notation files to facilitate management, including transfer and potential multi-institutional comparisons. In the treatment plan evaluation, structure DVH curves were scored against computed statistical DVHs and weighted experience scores (WESs). Individual, clinically used, DVH-based metrics were integrated into a generalized evaluation metric (GEM) as a priority-weighted sum of normalized incomplete gamma functions. Historical treatment plans for 351 patients with head and neck cancer, 104 with prostate cancer who were treated with conventional fractionation, and 94 with liver cancer who were treated with stereotactic body radiation therapy were analyzed to demonstrate the usage of statistical DVH, WES, and GEM in a plan evaluation. A shareable dashboard plugin was created to display statistical DVHs and integrate GEM and WES scores into a clinical plan evaluation within the treatment planning system. Benchmarking with normal tissue complication probability scores was carried out to compare the behavior of GEM and WES scores. Results: DVH curves from historical treatment plans were characterized and presented, with difficult-to-spare structures (ie, frequently compromised organs at risk) identified. Quantitative evaluations by GEM and/or WES compared favorably with the normal tissue complication probability Lyman-Kutcher-Burman model, transforming a set of discrete threshold-priority limits into a continuous model reflecting physician objectives and historical experience. Conclusions: Statistical DVH offers an easy-to-read, detailed, and comprehensive way to visualize the quantitative comparison with historical experiences and among institutions. WES and GEM metrics offer a flexible means of incorporating discrete threshold-prioritizations and historic context into a set of standardized scoring metrics. Together, they provide a practical approach for incorporating big data into clinical practice for treatment plan evaluations.

Introduction: Audience response systems (ARS) are increasingly popular; however, their contribution to education is not completely clear. Our study found that scores from review quizzes delivered by an ARS correlate with in-training exam (ITE) scores and are viewed positively by residents. This information may be useful in identifying poor performers early so that targeted educational interventions can be made. The objective was to determine if scores on review quizzes delivered by an ARS correlate with ITE scores and to obtain participant feedback on use of the ARS for ITE preparation. Methods: This was a prospective observational study of emergency medicine (EM) residents at six accredited EM residency programs. Subjects included residents who had taken previous ITEs. Subjects participated in bimonthly review sessions using an ARS. Twelve review quizzes were administered, each consisting of 10 multiple-choice questions. After the ITE, subjects completed an attitudinal survey consisting of six Likert-scale items and one “yes/no” item. We used a mixed linear model to analyze the data, accounting for prior 2012 ITE scores and nesting due to institution. Results: Among 192 participants, 135 (70.3%) completed the ITE in both 2012 and 2013; we analyzed their data for the first objective. Results from the mixed linear model indicate that the total mean score on the review quizzes was a significant [t(127) = 6.68; p < 0.001] predictor of the 2013 ITE after controlling for the 2012 ITE score. One hundred forty-six (76.0%) participants completed the attitudinal survey; 96% of respondents stated that they would like ARS to be used more often in resident education. Respondents felt the sessions aided in learning (mean 7.7/10), assisted in preparation for the ITE (mean 6.7/10), and helped identify content areas of weakness (mean 7.6/10). Conclusion: Our results suggest that scores from review quizzes delivered by an audience response system correlate with in-training exam scores and is viewed positively by residents. [West J Emerg Med. 2017;18(3)525-530.]

Although large volumes of information are entered into our electronic health care records, radiation oncology information systems and treatment planning systems on a daily basis, the goal of extracting and using this big data has been slow to emerge. Development of strategies to meet this goal is aided by examining issues with a data farming instead of a data mining conceptualization. Using this model, a vision of key data elements, clinical process changes, technology issues and solutions, and role for professional societies is presented. With a better view of technology, process and standardization factors, definition and prioritization of efforts can be more effectively directed.

Introduction: The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. Objective: To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. Methods: We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. Results: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient= -0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p

Groundwater management is conducted in spatial aquifers where well pumping results in localized cones of depression. This is in contrast to the single-cell aquifer used in most economic analyses that assumes groundwater depletion occurs uniformly over a study area. We address two aspects of the optimal management of groundwater: a spatially explicit representation of the aquifer and the potential of on-farm reservoirs to recharge the underlying aquifer. A spatial-dynamic model of the optimal control of groundwater use and on-farm reservoir adoption is developed. Results suggest that a single-cell aquifer overestimates groundwater use and farm net returns over thirty years.

History of present illness: A 28-year-old male presents to emergency department with a chief complaint of dysuria over the past seven days associated with a new penile lesion over the same period. He reports sexual activity with “many men and women” without condom use. His review of system is otherwise negative. Significant findings: Physical examination revealed a non-tender, erythematous lesion on the glans penis, two similar adjacent satellite lesions, as well as tender inguinal lymphadenopathy. No penile discharge was noted. Discussion: Syphilis is a sexually transmitted disease caused by Treponema pallidum. The early stage of the infection consists of three phases – primary syphilis, secondary syphilis and early latent syphilis. The late stage occurs amongst untreated patients, leading to asymptomatic chronic latent disease.2 The feared complication of latent disease is progression to tertiary syphilis, which may occur decades later and includes major cutaneous, musculoskeletal, cardiovascular, and neurological complications.1 Primary syphilis infection manifests as a chancre, a localized, typically painless skin lesion at the site of inoculation. The classic lesion forms a 1-2-centimeter ulcer with a raised, indurated margin commonly with associated moderate regional lymphadenopathy. Chancres are self-limited and heal within six weeks without treatment.2,5 Diagnosis can be made with nontreponemal tests (which are nonspecific) and treponemal tests (which are more complex and expensive, but specific). Nontreponemal tests include the rapid plasma regain (RPR) and venereal disease research laboratory (VDRL). The treponemal test of choice is the fluorescent treponemal antibody absorption (FTA-ABS). Darkfield microscopy in combination with direct fluorescent antibody testing can be used to identify the organism.1,5 The preferred treatment for early syphilis is a single dose of 2.4 million units of intramuscular penicillin G.1,3,4 Our patient was given this treatment, along with empiric coverage for gonorrhea and chlamydia co-infection with ceftriaxone and azithromycin. His RPR and FTA testing was positive, as was his chlamydia DNA PCR.

History of present illness: A 28-year-old male presented to the emergency department with a chief complaint of two weeks of headache, chills, and numbness in his hands. He reported removing a tick from his upper back approximately two weeks ago, but did not know how long the tick had been embedded. His review of symptoms was otherwise unremarkable. Significant findings: On physical examination, an 8-cm non-raised, erythematous lesion with central clearing was noted on the right posterior thorax. A small scab was located at the center of the lesion with no evidence of retained tick. No other rashes were present. Discussion: Lyme disease is a tick-borne illness caused primarily by the spirochete Borrelia burgdorferi. Ticks must be attached for a minimum of 48 hours in order to transmit the spirochete.1 Erythema migrans (EM) is the most common clinical manifestation of Lyme disease. EM is characterized by a slowly-expanding erythematous rash at the site of the tick bite, typically appearing between 7 and 14 days following tick attachment. Rashes range from 5cm to 30cm and may develop central clearing.2 EM must be differentiated from initial erythema at the site of the bite due to a reaction to tick saliva. The differential includes southern tick-associated rash illness, erythema multiforme, cellulitis, contact dermatitis, and tinea corporis. The presence of erythema migrans has a sensitivity of 69% and a specificity of 98% for Lyme disease.3 Serological testing is not indicated in patients with EM, as only about 30% will be seropositive at presentation.4 Treatment of early Lyme disease consists of doxycycline preferentially, or amoxicillin, or cefuroxime for 14 days.6 Recurrence of erythema migrans after a full course of antibiotics is most likely due to re-infection rather than relapse.7 Prognosis is excellent with antibiotic treatment; however, those in endemic areas are at high risk for re-infection.8

History of present illness: A 77-year-old female presented to the emergency department after being found down at home, last seen normal 7 ½ hours prior to arrival. Patient had a history of hypertension, congestive heart failure, atrial fibrillation and breast cancer status post chemotherapy/radiation and lumpectomy. Physical exam showed right gaze preference, left facial droop and tongue deviation and flaccid left hemiplegia. Significant findings: A non-contrast computed tomography (CT) scan showed a hyperdensity along the right middle cerebral artery (MCA) consistent with acute thrombus. The red arrow highlights the hyperdensity in the annotated image. Discussion: The dense MCA sign can serve as an important tool in the diagnosis of acute stroke. It typically appears before other signs of infarct are apparent on CT imaging, and identifies an intracranial large artery occlusion and corresponding infarct, in the correct clinical setting.1 Calcifications in the same area of the brain could be mistaken for an MCA sign, but this sign carries a high specificity (95%) and lower sensitivity (52%) for arterial obstruction in ischemic stroke.2 Early identification allows for a wider array of treatment options for a patient with an ischemic stroke, including intra-venous or intra-arterial thrombolysis and mechanical thrombectomy. This patient was subsequently taken for mechanical thrombectomy. Mechanical thrombectomy was chosen for this patient because the resources were available, and recent clinical trials have shown that newer types of mechanical thrombectomy have a positive functional outcome in patients with an ischemic stroke from an intracranial large artery occlusion, as compared to intravenous tissue plasminogen activator (tPa) alone.3,4,5,6 In facilities lacking the capability for mechanical thrombectomy, treatment considerations include rapid transfer to a facility with capability, or proceeding with intravenous tPa. After intervention, this patient had residual left sided deficits and dysarthria that were improved from presentation. She had an uncomplicated hospital course and was discharged to acute rehabilitation.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

History of present illness: A 58-year-old female presented to the emergency department reporting six days of progressive, atraumatic left eye vision loss. Her symptoms started with the appearance of dark spots and “spider webs,” and then progressed to darkening of vision in her left eye. She reports mild pain since yesterday. Her review of symptoms was otherwise negative. Ocular physical examination revealed normal external appearance, intact extraocular movements, and visual acuities of 20/25 OD and light/dark sensitivity OS. Fluorescein uptake was negative and slit lamp exam was unremarkable. Significant findings: Bedside ocular ultrasound revealed a serpentine, hyperechoic membrane that appeared tethered to the optic disc posteriorly with hyperechoic material underneath. These findings are consistent with retinal detachment (RD) and associated retinal hemorrhage. Discussion: The retina is a layer of organized neurons that line the posterior portion of the posterior chamber of the eye. RD occurs when this layer separates from the underlying epithelium, resulting in ischemia and progressive photoreceptor degeneration, with potentially rapid and permanent vision loss if left untreated.1 Risk factors include advanced age, male sex (60%), race (Asians and Jews), and myopia and lattice degeneration.2 Bedside ultrasound (US) performed by emergency physicians provides a valuable tool that has been used by ophthalmologists for decades to evaluate intraocular disease.1,3 Findings on bedside ultrasound consistent with RD include a hyperechoic membrane floating in the posterior chamber. RD usuallyremain tethered to the optic disc posteriorly and do not cross midline, a feature distinguishing them from posterior vitreous detachments. Associated retinal hemorrhage, seen as hyperechoic material under the retinal flap, can often be seen.1,2 US can also distinguish between “mac-on” and “mac-off” detachments. If the retina is still attached to the macula (mac-on), central vision is preserved and emergent repair is essential before progression to a mac-off RD.2 In a prospective observational study, emergency physicians achieved 97% sensitivity, and 92% specificity in diagnosing this pathology on bedside US. Optic disc edema and vitreous hemorrhage accounted for the false positives.2 Emergent ophthalmology consultation was obtained for our patient who saw the patient the same day for vitrectomy. Topics: Retinal detachment, retinal hemorrhage, bedside ultrasound, POCUS

History of present illness: An 88-year-old female was found lying prone and unresponsive outside of her home with an unknown downtime. She was intubated in the field by medics and brought to the emergency department (ED). In the ED, she had a core temperature of 78 degrees Fahrenheit (°F) with a heart rate of 21 beats per minute. Active rewarming and resuscitation were started and serial electrocardiograms (ECGs) were performed; two hours later, her core temperature had increased to 86°F. Significant findings: The initial ECG shows a junctional rhythm with Osborn waves (or J point elevations/J waves) in the lateral precordial leads, as well as the limb leads (Image 1). The second ECG, 49 minutes later, shows an improving ventricular rate and Osborn wave height decrease of approximately 50% (Image 2). Discussion: Differentiating between mild, moderate and severe hypothermia can help guide resuscitation efforts in these patients. Patients with mild hypothermia have core temperatures between 90-95°F and present with shivering, tachypnea, and tachycardia. Those with moderate hypothermia have core temperatures between 82-90°F and present with muscle rigidity, altered mental status, bradycardia and hypoventilation. Severe hypothermia is defined as a core temperature below 82°F. These patients are often comatose, hypotensive, and apneic.1 Patients with primary hypothermia and cardiac stability who have been treated with active external and minimally invasive rewarming techniques have a rate of neurologically intact survival of approximately 100%.2 For patients with primary hypothermia and cardiac instability or cardiac arrest, extracorporeal membrane oxygenation (ECMO) may be the best treatment option. The rate of neurologically intact survival for patients with cardiac arrest treated with extracorporeal rewarming is approximately 50%. If ECMO or cardiopulmonary bypass is not available and transport to a facility with these capabilities is not possible, circulation should be supported with CPR while the patient is rewarmed with an alternative internal rewarming technique. Topics: EKG, Osborn wave, J wave, ECG, cardiology, environmental, hypothermia, ECMO

History of present illness: A 56-year-old male, with a history of hypertension, diabetes, and dyslipidemia, presented with chest pain, fever, and abdominal pain associated with diarrhea, one day post colonoscopy, for which an electrocardiogram (ECG) was done. On further review of history, the patient reported a syncopal episode 2 monthprior. Additionally, he reports a brother who died of sudden cardiac death (SCD) at the age 50. Significant findings: ECG shows an incomplete right bundle branch block (blue arrow) with coved ST segment elevation and an inverted T wave in V1 (red arrow) and ST segment elevation in V2 (black arrow). Discussion: Brugada syndrome is a rare autosomal dominant disease with mutations in the cardiac sodium channel. It is highly associated with ventricular fibrillation and sudden cardiac death (SCD) in predominately middle-aged males.1 The diagnosis is based on a particular ECG pattern described by the Brugada brothers in 1992.2 There are 3 types of Brugada patterns. Our patient’s ECG was consistent with type 1, which is diagnostic and is characterized by a coved ST segment elevation greater than 2mm followed by a negative T wave in the precordial leads.3 Other types include type 2, which shows a saddle-back ST segment elevation with a J-wave greater than 2mm followed by a positive or biphasic T wave, and type 3, which shows ST elevation less than 2 mm in either coved or saddle-back type T wave.4 Patients with Brugada syndrome often present with syncope, non-sustained ventricular tachycardia, atrial fibrillation, or SCD, with a family history of similar episodes. The presence of fever, alcohol intake, sodium channel blockers, cocaine use, and electrolyte imbalances can significantly increase the incidence of arrhythmia.1 The risk of cardiac events in patients with type 1 Brugada and syncope is 1.9% per year and 7.7% per year in those with aborted SCD.3 An implantable cardiac defibrillator (ICD) is the main treatment for symptomatic patients. Those who are asymptomatic or those with type 2 or 3 morphology should undergo further genetic testing and risk stratification for ICD placement.1 Our patient had a negative cardiac catheterization but with his ECG pattern along with his history of syncope and family history of SCD, he was diagnosed with type 1 Brugada syndrome and received an ICD. Topics: EKG, ECG, cardiology, Brugada, arrhythmia

History of present illness: 70-year-old male with a history ventricular arrhythmia, AICD (automated implantable cardioverter defibrillator), coronary artery disease and cardiac stents presented to the Emergency Department after three AICD discharges with dyspnea but no chest pain. During triage, he was found to have an irregular radial pulse and was placed on a cardiac monitor. Significant findings: The patient was found to be in a polymorphic ventricular tachycardia; he was alert, awake and asymptomatic. A rhythm strip showed a wide complex tachycardia with the QRS complex varying in amplitude around the isoelectric line consistent with Torsades de Pointes. Discussion: Torsades de Pointes (TdP) is a specific type of polymorphic ventricular tachycardia. The arrhythmia’s characteristic morphology consists of the QRS complex “twisting” around the isoelectric line with gradual variation of the amplitude, reflecting its literal translation of “twisting of the points.”1 This arrhythmia occurs in the context of prolonged QT. The most common form of acquired QT prolongation is medication induced. Common causes include antiarrhythmics, antipsychotics, antiemetics, and antibiotics.2 Patient specific risk factors include female sex, bradycardia, hypokalemia, hypomagnesemia, hypocalcemia, hypothermia and heart disease.3 In the setting of prolonged QT, the repolarization phase is extended. TdP is initiated when a PVC (premature ventricular contraction) occurs during this repolarization, known as an ‘R on T’ phenomenon. TdP is often asymptomatic and self-limited. The danger in TdP is its potential to deteriorate into ventricular fibrillation. A mainstay of management of TdP is prevention of risk factors when possible.4 Unstable patients should be treated with synchronized cardioversion. Magnesium sulfate should be administered in all cases of TdP.1 If a patient is not responsive to magnesium, consider isoproterenol, amiodarone, and overdrive pacing. Since this patient was asymptomatic, he was given 2gm of magnesium sulfate and placed on an amiodarone infusion, after which Tdp terminated with a resulting sinus rhythm. AICD interrogation showed multiple episodes of ventricular fibrillation. The patient was admitted for further management and to determine why his AICD was not functioning properly. Topics: EKG, ECG, cardiology, ventricular tachycardia, arrhythmia, Torsades de Pointes

History of present illness: A 55-year-old male presented to the emergency department with a chief complaint of right arm pain. Five days prior to arrival, he attempted to lift himself up on his van and experienced what he described as a “rubber band snapping” in his right arm. He reported severe pain at the time that persisted but lessened in severity. Additionally, he reported increasing bruising over the proximal right arm. He had no history of prior right arm or shoulder injury. Significant findings: Physical exam was significant for ecchymosis and mild swelling of the right bicep. When the right arm was flexed at the elbow, a prominent mass was visible and palpable over the right bicep. Right upper extremity strength was 4/5 with flexion at the elbow. Discussion: The biceps brachii muscle is comprised of a long and short head, which share a common attachment at the bicipital tuberosity on the radius. The short head originates from the coracoid process of the scapula and the long head originates from the supraglenoid tubercle.1 Biceps tendon rupture has been found to occur at a rate of 0.53/100,000 over five years, and is three times more likely to occur in men than women.2 Risk factors for biceps tendon rupture include male sex, old age, increased body mass index, smoking, and pre-existing shoulder pathology.3,4 Diagnosis of biceps tendon rupture is typically a clinical diagnosis utilizing inspection and palpation as well as special testing such as the Speed’s and/or Yergason’s tests. Ultrasound may be used to aid in diagnosis; in full-thickness tears, ultrasound was found to have a sensitivity of 88% and a specificity of 98%. However, in partial thickness tears ultrasound has a sensitivity of 27% and a specificity of 100%.5 Often considered the gold standard in diagnosis, MRI has been found to have a sensitivity of only 67% and specificity of 98% in detecting complete tears6. Treatment initially consists of rest, ice, compression, and a short course of non-steroidal anti-inflammatory drugs. Follow up with an orthopedic surgeon is recommended in two to four weeks to determine operative versus non-operative management.7

An end-product market survey on biotoxins in commercial wild harvest shellfish (Plebidonax deltoides, Katelysia spp., Anadara granosa, Notocallista kingii) during three harvest seasons (2015⁻2017) from the coast of New South Wales, Australia found 99.38% of samples were within regulatory limits. Diarrhetic shellfish toxins (DSTs) were present in 34.27% of 321 samples but only in pipis (P. deltoides), with two samples above the regulatory limit. Comparison of these market survey data to samples (phytoplankton in water and biotoxins in shellfish tissue) collected during the same period at wild harvest beaches demonstrated that, while elevated concentrations of Dinophysis were detected, a lag in detecting bloom events on two occasions meant that wild harvest shellfish with DSTs above the regulatory limit entered the marketplace. Concurrently, data (phytoplankton and biotoxin) from Sydney rock oyster (Saccostrea glomerata) harvest areas in estuaries adjacent to wild harvest beaches impacted by DSTs frequently showed elevated Dinophysis concentrations, but DSTs were not detected in oyster samples. These results highlighted a need for distinct management strategies for different shellfish species, particularly during Dinophysis bloom events. DSTs above the regulatory limit in pipis sampled from the marketplace suggested there is merit in looking at options to strengthen the current wild harvest biotoxin management strategies.

An irrigated agricultural landscape experiencing groundwater overdraft generates economic returns and a suite of ecosystem services (in particular, groundwater supply, greenhouse gases reduction, and surface water quality). Alternative land cover choices indicate tradeoffs among the value of ecosystem services created and the economic returns. These tradeoffs are explored using efficiency frontiers that determine the least value in ecosystem services that must be given up to generate additional economic returns. Agricultural producers may switch to irrigation with surface water using on-farm reservoirs and tail water recovery systems in response to groundwater overdraft, and this has consequences for the bundle of ecosystem service values and economic returns achievable from the landscape. Planning that accounts for both ecosystem service value and economic returns can achieve more value for society, as does the adoption of reservoirs though lowering the costs of irrigation, increasing groundwater levels, and reducing fuel combustion and associated GHG emissions from groundwater pumping. Sensitivity analyses of per unit value of ecosystem services, crop prices, and the groundwater and water purification model parameters indicate tradeoff among ecosystems service values, such as the use of a high-end social cost of carbon ultimately lowers groundwater supply and water purification value by more than 15%.

We describe an agent-based model purposed for social learning, which was developed by stakeholders, with the technical assistance of professional modelers, to facilitate stakeholder involvement in modeling issues related to the development of an adaptive environmental management plan for the Texas Gulf Coast (USA) estuaries. Stakeholders developed the model during six workshops that spanned a three-year period, and used the model to simulate the population dynamics (recruitment, growth, movement, and mortality) of blue crabs ( Callinectes sapidus ) in the Aransas and Copano Bays in response to various freshwater inflow and harvest scenarios. Results of scenarios representing normal, low, and high harvest levels indicated little effect on blue crab abundances, but harvests increased ≈75 % when harvest level was doubled and decreased ≈50 % harvest level was halved. These results failed to confirm the perceptions of stakeholders. However, upon more thorough consideration of the scientific bases for the quantitative representation (by the modelers) of the processes they wanted to include in the model, most stakeholders realized their initial perceptions were inconsistent with current data-based knowledge.•The agent-based model is described using the ODD protocol.•The brief model user's guide is provided.•The model calibration, verification, and technical evaluation are described., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)