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Background: Patients presenting to the emergency department with a possible barbeque brush bristle ingestion pose many challenges. A detailed history and oral examination is needed and the typical first line investigation involves flexible laryngoscopy for direct visualization of the bristle. Given the high rate of false negatives with laryngoscopy, further imaging may be required in patients with a high suspicion of bristle ingestion Case Reports: We report on two cases presenting to the emergency department with pain following ingestion of grilled food. In both cases imaging was required to identify and assist with the removal of the bristle. Why Should an Emergency Physician Be Aware of This? Emergency physicians should have a high index of suspicion for bristle ingestion in patients with acute onset of pain or a foreign body sensation after ingesting grilled meats. Patients may require imaging to identify bristles if physical examination and laryngoscopy is negative.

LIU, S., J. GOODMAN, R. NOLAN, S. LACOMBE, and S. G. THOMAS. Blood Pressure Responses to Acute and Chronic Exercise Are Related in Prehypertension. Med. Sci. Sports Exerc., Vol. 44, No. 9, pp. 1644–1652, 2012. Purpose: Aerobic exercise is recommended as a way to prevent hypertension. However, about 25% of individuals receive minimal antihypertensive benefits associated with chronic exercise training. Thus, we attempt to identify those ‘‘nonresponders’’ to chronic exercise on the basis of their blood pressure (BP) responses to acute exercise (single session). Our primary objective was to correlate the magnitude of BP decrease after acute exercise to the magnitude of BP reduction after chronic exercise. Our secondary objective was to examine the correlates of BP reduction after acute and chronic exercise. Methods: Seventeen prehypertensive (120 to 139/80 to 89 mm Hg) males and females (45–60 yr old) underwent acute exercise assessments before an 8-wk walking/jogging program (four times per week, 30 min per session, 65% maximum oxygen consumption). BP, hemodynamics, HR variability, and baroreflex sensitivity were assessed before and after acute exercise and chronic training. Results: BP was significantly reduced j7.2 T 1.2/j4.2 T 1.0 and j7.0 T 1.4/j5.2 T 1.2 mm Hg relative to baseline after acute (30 min at 65% maximum oxygen consumption) and chronic exercise, respectively (P G 0.01). The magnitude of change in systolic BP after acute exercise was strongly correlated with change in resting systolic BP after chronic training, r = 0.89, P G 0.01. A similar correlation was observed with diastolic BP, r = 0.75, P G 0.01. After acute exercise, significant reductions in total power (ms 2 ) and baroreflex sensitivity were observed in both sexes (P G 0.01). However, after chronic exercise, only men demonstrated a significant reduction in the low-frequency-to-high-frequency ratio (j36%), P G 0.01. Conclusions: The magnitude of the acute BPlowering with exercise may predict the extent of BP lowering after chronic training interventions in prehypertensive individuals.

Equicaloric bouts of interval (IE: 5 × 2:2 min at 85% and 40% maximal oxygen uptake) and steady state (SS: 21 min at 60% maximal oxygen uptake) exercise were performed by 13 older prehypertensive males on separate days, at equivalent times of day, to assess the influence of exercise mode on postexercise hypotension (PEH). Exercise conditions were compared with a control session. Cardiovascular measures were collected for 30 min prior to, and 60 min following exercise. PEH, as measured by mean postexercise systolic blood pressure (SBP) decrease (IE: –4 ± 6 mm Hg; SS: –3 ± 4 mm Hg; control: 4 ± 4 mm Hg), area under the SBP curve (IE: –240 ± 353 mm Hg·min; SS: –192 ± 244 mm Hg·min), and minimum SBP achieved (IE: –15 ± 7 mm Hg; SS: –13 ± 7 mm Hg), was equivalent after both conditions. Stroke volume was significantly reduced (IE: –14.6 ± 16.0 mL; SS: –10.1 ± 14.2 mL, control –1.7 ± 2.2 mL) and heart rate was significantly elevated (IE: 13 ± 8 beats·min–1; SS: 7.9 ± 8 beats·min–1; control: –2 ± 3 beats·min–1) postexercise after both conditions. Cardiac output and total peripheral resistance were nonsignificantly decreased and increased postexercise, respectively. Baroreflex sensitivity (BRS) was reduced following IE (p < 0.05) and heart rate variability (HRV) parameters were reduced after both conditions, with IE eliciting larger and longer reductions in some indices. The results from the current study indicate that older prehypertensive adults experience similar PEH following equicaloric bouts of IE and SS exercise despite larger alterations in HRV and BRS elicited by IE.

Background With the publication of the 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation, the Canadian Cardiovascular Society Atrial Fibrillation Guidelines Committee has introduced a new triage and management algorithm; the so-called “CCS Algorithm”. The CCS Algorithm is based upon expert opinion of the best available evidence; however, the CCS Algorithm has not yet been validated. Accordingly, the purpose of this study is to evaluate the performance of the CCS Algorithm in a cohort of real world patients. Methods We compared the CCS Algorithm with the European Society of Cardiology (ESC) Algorithm in 172 hospital inpatients who are at risk of stroke due to non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. Results The CCS Algorithm and the ESC Algorithm were concordant in 170/172 patients (99% of the time). There were two patients (1%) with vascular disease, but no other thromboembolic risk factors, which were classified as requiring oral anticoagulant therapy using the ESC Algorithm, but for whom ASA was recommended by the CCS Algorithm. Conclusions The CCS Algorithm appears to be unnecessarily complicated in so far as it does not appear to provide any additional discriminatory value above and beyond the use of the ESC Algorithm, and its use could result in under treatment of patients, specifically female patients with vascular disease, whose real risk of stroke has been understated by the Guidelines.

SummaryPatient’s values and preferences regarding the relative importance of preventing strokes and avoiding bleeding are now recognised to be of great importance in deciding on therapy for the prevention of stroke due to atrial fibrillation (SPAF). We used an iPad questionnaire to determine the minimal clinically important difference (Treatment Threshold) and the maximum number of major bleeding events that a patient would be willing to endure in order to prevent one stroke (Bleeding Ratio) for the initiation of antithrombotic therapy in 172 hospital in-patients with documented non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. Patients expressed strong opinions regarding SPAF. We found that 12% of patients were “medication averse” and were not willing to consider antithrombotic therapy; even if it was 100% effective in preventing strokes. Of those patients who were willing to consider antithrombotic therapy, 42% were identified as “risk averse” and 15% were “risk tolerant”. Patients required at least a 0.8% (NNT=125) annual absolute risk reduction and 15% relative risk reduction in the risk of stroke in order to agree to initiate antithrombotic therapy, and patients were willing to endure 4.4 major bleeds in order to prevent one stroke. In conclusion, there was a substantial amount of inter-patient variability, and often extreme differences in opinion regarding tolerance of bleeding risk in the context of stroke prevention in atrial fibrillation. These findings highlight the importance of considering patient preferences when deciding on SPAF therapy.