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Bismuth subsalicylate (BSS) is the active ingredient in over-the-counter antacid and antidiarrheal medications. Coagulopathy in the setting of acetylsalicylic acid toxicity is well documented but not in setting of bismuth subsalicylate overuse. We present a case report of coagulopathy from BSS poisoning in a patient with underlying cirrhosis. The patient’s high prothrombin time suggests inhibition of vitamin K-dependent coagulation factors. The patient had decreased factor V activity, which is responsible for converting prothrombin to thrombin. Patients with cirrhosis often have hypoprothrombinemia which may be exacerbated by salicylate-induced coagulopathy. Given the widespread use of BSS products, physicians should recognize coagulopathy as a possible manifestation of toxicity especially in patients with underlying liver disease. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13181-019-00709-y) contains supplementary material, which is available to authorized users.

Introduction Emergency medicine (EM) physicians serve at the frontline of disasters in our communities. The 2016 Model of Clinical Practice according to the American Board of EM identifies disaster management as an integral task of EM physicians. We described a low-cost and feasible tabletop exercise to implement such training for EM residents. Methods The exercise took place during 2 hours of resident didactic time. A lecture introduced the incident command system (ICS) and triage concepts, followed by a tabletop scenario with a map of a disaster scene or emergency department. Facilitators presented situational prompts of tasks for residents to address during the exercise. These exposed residents to challenges in disaster scenarios, such as surge and limited resources. The exercise concluded with a debrief and short lecture reviewing scenario-specific topics and challenges. Residents completed an online pre- and postexercise assessment, evaluating knowledge and perceptions of disaster scenario management. Results Eighteen residents participated in this exercise. The response rates to the pre- and postsurvey were 76% and 72% respectively. Using a Mann Whitney U test, no statistically significant difference was demonstrated on the medical knowledge component of the survey. There was, however, a statistically significant increase in perceived confidence of the residents' ability to manage disaster incidents. Discussion We developed a simple exercise that is an easily adaptable and practical option for introduction to disaster preparedness training. These concepts are difficult to teach and assess among learners, however it remains an important component of education for EM physicians-in-training.

The opioid epidemic has significantly evolved over the last three decades. The initiation and continuation of prescription opioids for pain control were one of the primary contributors, across different medical settings. The emergency department (ED) is typically the first place patients go to for management of acute pain, and often where opioid naïve patients first become exposed to opioids. In 2018, the ED of University Hospital located in Newark, NJ implemented a pain guideline to ensure that patients are not unnecessarily exposed to opioids. The goal of our study was to determine whether provider adherence was successful in reducing opioid administration.We conducted a retrospective review of pharmacy records of patients treated for pain in the ED within the time frame January 1, 2017 and December 31, 2019. We analyzed the change in our practice by comparing the amount of opioid and non-opioid medications administered and the number of patients administered each type, as well as the change in our utilization of specific medications. The t-test or the χThere were decreases in the mean number of opioid doses administered in 2017 (1273) compared to 2019 (498; p = 0.027). There was an increase in non-opioid analgesics administered, (mean 2017: 1817, mean 2019: 2432.5, p = 0.018). There was also an increase in the proportion of patients given non-opioid analgesics (mean 2017: 22%, mean 2019: 28%, p0.0001). There were increases in administrations of acetaminophen (40% to 52%) and ibuprofen (30% to 35.1%), and decreases in administrations of hydromorphone (2.5% to 0.03%), morphine (11.5% to 5.6%), oxycodone (10.6% to 5.3%), and tramadol (5.7% to 1.9%) (all p0.0001).A guideline that emphasizes the use of non-opioid analgesics first line treatment for acute pain can be effective for reducing opioid administration in the ED. Through the use of our guideline, we reduced the number of patients who have received opioid analgesics and, at the same time, increased non-opioid analgesic administration. Future studies should explore readmission rates, duration of pain relief in patients managed with non-opioid versus opioid analgesics, and perception of relief through the use of satisfaction scores.

Hyperhomocysteinemia (HHcy) is an independent risk factor for cardiovascular disease (CVD) which has been implicated in matochondrial (Mt) function impairment. In this study, we characterized Hcy metabolism in mouse tissues by using LC-ESI-MS/MS analysis, established tissue expression profiles for 84 nuclear-encoded Mt electron transport chain complex (nMt-ETC-Com) genes in 20 human and 19 mouse tissues by database mining, and modeled the effect of HHcy on Mt-ETC function. Hcy levels were high in mouse kidney/lung/spleen/liver (24–14 nmol/g tissue) but low in brain/heart (~5 nmol/g). S-adenosylhomocysteine (SAH) levels were high in the liver/kidney (59–33 nmol/g), moderate in lung/heart/brain (7–4 nmol/g) and low in spleen (1 nmol/g). S-adenosylmethionine (SAM) was comparable in all tissues (42–18 nmol/g). SAM/SAH ratio was as high as 25.6 in the spleen but much lower in the heart/lung/brain/kidney/liver (7–0.6). The nMt-ETC-Com genes were highly expressed in muscle/pituitary gland/heart/BM in humans and in lymph node/heart/pancreas/brain in mice. We identified 15 Hcy-suppressive nMt-ETC-Com genes whose mRNA levels were negatively correlated with tissue Hcy levels, including 11 complex-I, one complex-IV and two complex-V genes. Among the 11 Hcy-suppressive complex-I genes, 4 are complex-I core subunits. Based on the pattern of tissue expression of these genes, we classified tissues into three tiers (high/mid/low-Hcy responsive), and defined heart/eye/pancreas/brain/kidney/liver/testis/embryonic tissues as tier 1 (high-Hcy responsive) tissues in both human and mice. Furthermore, through extensive literature mining, we found that most of the Hcy-suppressive nMt-ETC-Com genes were suppressed in HHcy conditions and related with Mt complex assembly/activity impairment in human disease and experimental models. We hypothesize that HHcy inhibits Mt complex I gene expression leading to Mt dysfunction. Keywords: Database mining, Tissue expression profile, Homocysteine metabolism

Diabetes is common in Canada, and over the last decade, the incidence of diabetes has grown rapidly. The Canadian Diabetes Association (CDA) released the 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (CPGs) in April 2013. These internationally recognized guidelines provide recommendations on screening, prevention, diagnosis, education, and management of diabetes. This article summarizes four key messages in diabetes care, including diagnosis, glucose lowering, vascular protection, and organization of care. Information on how to access the CDA’s interactive online and mobile applications is also provided.

We hypothesized that exposure to synthetic glucocorticoid during rapid brain growth (d50–52, birth = 68 days) in fetal guinea pigs modifies hypothalamo-pituitary-adrenal (HPA) function after birth, and that this involves changes in central corticosteroid receptor regulation. On the basis of our previous studies, we proposed that this effect is sex-specific. Pregnant guinea pigs were treated with dexamethasone (1 mg/kg) or vehicle on d50–51 of gestation, and juvenile offspring were euthanized at rest or following isolation stress on postnatal day 18. Dexamethasone increased the length of gestation (1.5 days) and altered body and organ (brain, heart, adrenal) growth. Resting plasma cortisol concentrations were significantly elevated in young male, but not female guinea pigs exposed to dexamethasone as fetuses. In female offspring born to dexamethasone-treated mothers, cortisol responses to isolation stress were attenuated. In males, elevated basal cortisol levels were not increased further by isolation. In the brain, hippocampal glucocorticoid receptor (GR) mRNA levels were significantly lower (10–25%) in females exposed to dexamethasone in utero. In contrast, GR mRNA levels were elevated (10–20%) in males from this prenatal treatment group. Mineralocorticoid receptor mRNA in the limbic system and GR mRNA levels in the pars distalis were unaffected. Pro-opiomelanocortin mRNA was significantly lower (30%) in the male pars intermedia following dexamethasone exposure. In conclusion, prenatal glucocorticoid exposure affects growth and HPA function as well as limbic and hypothalamic GR expression in juvenile offspring, and these effects are highly sex-specific.

Heterotaxy syndrome with interruption of the inferior vena cava and direct hepatic vein inflow into the right atrium has important implications for cardiac surgery. We report a case causing pseudo Budd-Chiari syndrome after cardiopulmonary bypass.