ACEP NowACEP Now https://www.acepnow.com Fri, 17 Jan 2020 19:50:59 +0000 en-US hourly 1 https://wordpress.org/?v=5.3.2 Toxicology Q&A Answer: Morning Glory https://www.acepnow.com/article/toxicology-qa-answer-morning-glory/ https://www.acepnow.com/article/toxicology-qa-answer-morning-glory/#respond Wed, 08 Jan 2020 05:11:05 +0000 https://www.acepnow.com/?post_type=article&p=22630 See Question Answer: Morning glory. Morning glory is often referred to by its variety—including Heavenly Blue, Pearly...

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PHOTO: Jason Hack (Oleander Photography)

See Question

Answer: Morning glory.

Ipomoea tricolor, violacea, and others

Ipomoea tricolor, violacea, and others. PHOTO: Jason Hack (Oleander Photography)

Morning glory is often referred to by its variety—including Heavenly Blue, Pearly Gates, Flying Saucers, Blue Star, Summer Skies, and Wedding Bells. This hardy annual climbing vine has single-colored funnel-shaped flowers spaced along its course, with deep green heart-shaped leaves. It blooms in early summer until the first frost.

“Morning” references that the flowers roll themselves closed every evening and unfurl in the morning.

The seeds of many species of morning glory contain a naturally occurring tryptamine, lysergic acid amide (LSA), which is chemically similar to LSD and has similar effects. Seeds are used for their strong psychedelic or hallucinogenic mental effects.

Often, the seeds are crushed and swallowed or made into teas to induce intentional intoxication.

Common names: Heavenly Blue, Flying Saucers, Blue Star

Common names: Heavenly Blue, Flying Saucers, Blue Star
PHOTO: Jason Hack (Oleander Photography)

Apart from the desired hallucinogenic effects, patients often exhibit dilated pupils, increased heart rate, nausea, vomiting, diarrhea, numbness of the limbs, and muscle spasms.

Culturally, the hallucinogenic effects have been ceremonially used by the Aztec people in various rituals, and they referred to the plant as “Rivea corymbose” or “ololiuqui.”

Other South American cultures have used the seeds to diagnose illnesses and foretell various future events.

Interesting Facts

  • The Victorian language of flowers uses the morning glory blossom to represent “love in vain.”
  • Although morning glory seeds for sale are often coated with methylmercury (an antifungal) to stop abuse, many online retailers will sell them in bulk specifically as “untreated.” Online comment sections are an interesting read for these items.
  • There is some evidence that the LSA alkaloid present in morning glory seeds may originate in fungi that grew with the seeds, which became symbiotically entwined with the plant life cycle.

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Toxicology Q&A Question: What Is This Psychedelic Bloom? https://www.acepnow.com/article/toxicology-qa-question-what-is-this-psychedelic-bloom/ https://www.acepnow.com/article/toxicology-qa-question-what-is-this-psychedelic-bloom/#respond Wed, 08 Jan 2020 05:11:03 +0000 https://www.acepnow.com/?post_type=article&p=22552 Question: What flower with varietal names including Heavenly Blue, Flying Saucers, and Blue Star might have felt...

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PHOTO: Jason Hack (Oleander Photography)

Question: What flower with varietal names including Heavenly Blue, Flying Saucers, and Blue Star might have felt at home in a Beatles song?

Click here for the answer

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By the Numbers: the DEA-X Waiver https://www.acepnow.com/article/by-the-numbers-the-dea-x-waiver/ https://www.acepnow.com/article/by-the-numbers-the-dea-x-waiver/#respond Tue, 07 Jan 2020 16:38:44 +0000 https://www.acepnow.com/?post_type=article&p=22567 102,570 Total number of physicians with a DEA-X waiver in the United States (source) 80% reduction in...

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  • 102,570 Total number of physicians with a DEA-X waiver in the United States (source)
  • 80% reduction in opioid overdose deaths when frontline physicians in France had access to buprenorphine for patients with opioid addiction (source)
  • 26% of all ACEP Councillors surveyed at ACEP19 had obtained an X waiver
  • 10% of all patients with opioid use disorder are currently able to access evidence-based treatment
  • Emergency medicine ranks #6 as a specialty in terms of overall number of physicians with a DEA-X waiver (source)
  • 2 states have a Get Waivered campaign (source)
  • 1 decision you make could be the difference between life and death for patients with opioid addiction
  • Get Waivered today.

    Compiled by Alister Martin, MD, instructor in emergency medicine, Massachusetts General Hospital, Boston

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    Reader Suggests We Take a Team Approach to Compartment Syndrome https://www.acepnow.com/article/reader-suggests-we-take-a-team-approach-to-compartment-syndrome/ https://www.acepnow.com/article/reader-suggests-we-take-a-team-approach-to-compartment-syndrome/#respond Sat, 21 Dec 2019 00:05:04 +0000 https://www.acepnow.com/?post_type=article&p=22557 I read the October ACEP Now article “Spot and Treat Compartment Syndrome” by Dr. Long and Dr....

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    I read the October ACEP Now article “Spot and Treat Compartment Syndrome” by Dr. Long and Dr. Koyfman with interest. I found the article to have a number of very good points, including the inaccuracy of the history and physical examination. As someone who has been actively involved in this topic for many years, I have several observations.

    The article implies that obtaining the intracompartmental pressure is expected when entertaining the diagnosis and that it has a great sensitivity and specificity. The test characteristics of pressure measurement are probably excellent in the hands of someone who uses the technique frequently and acts upon those results. I would propose that person is not an emergency physician.

    The problems with the emergency physician measuring the intracompartmental pressure are several.

    1. You must measure the pressure in each compartment. There are four compartments in the leg, two in the forearm, and nine (!) in the foot. Being sure that you have measured the pressure in each compartment and using the measurement tool properly are not a given. Then, what would you do with the result? I can’t imagine any surgeon will operate based solely on your measurements or say-so. They will insist on their own evaluation and/or measurements as the authors suggest in the article. Seemingly, this is a redundant and painful procedure for the patient. I have performed pressure measurements several times with an orthopedist, and they are not as straightforward as: Just do it.
    2. There will surely be an emergency physician who will avoid (consciously or subconsciously) entertaining the diagnosis if it requires an infrequently used and somewhat cumbersome procedure. Suggesting that intracompartmental pressure is an integral part of the diagnostic workup paints an imprecise and perhaps unnecessarily tortuous path for the emergency physician to make the diagnosis of compartment syndrome.
    3. Lastly, fasciotomy is the definitive treatment for compartment syndrome. This is a procedure that no emergency physician should be performing (or has delineated in their staff privileges to perform) regardless of the pressure results (except under the rarest of circumstances). The surgeon will be charged with acting based on their own evaluation that may or may not include pressure measurements.

    Emergency physician intracompartmental pressure monitoring has a number of shortcomings. Consequently, let’s not make the process of diagnosing compartment syndrome more onerous than it really is by suggesting that the emergency physician should be performing a procedure that should be more appropriately performed by the person who will be the interventionist. Keep it simple.

    So, how should emergency physicians handle cases where they are concerned about compartment syndrome? Call the surgeon and discuss the case.

    Jim Webley, MD, FACEP
    Pontiac, Michigan

    The Authors Respond

    We thank Dr. Webley for his insightful comments on the article. He brings to light several important considerations, including the need for early orthopedic involvement if compartment syndrome is suspected. Measurement of a compartment pressure is not necessary prior to orthopedic surgeon consultation. If the compartment pressure is assessed, the clinician obtaining the measurement must be familiar with the anatomy due to the differing compartments dependent on the specific location.

    We also agree that fasciotomy is a difficult procedure, and most emergency clinicians are not trained to perform it. However, as Dr. Stuart Swadron says, “we need to know what we need to know, and one step further.” While rare, there are circumstances where an emergency clinician may need to perform this procedure, such as in an austere military setting with no surgical backup.

    As Dr. Webley discusses, the key to diagnosis is clinical suspicion in the ED, as failure to consider the condition is why we often miss it. A patient with severe pain, recurrent need for analgesia, or objective evidence of neurovascular compromise warrants emergent discussion with the surgeon. Keep in mind that severe pain, which may be out of proportion to the exam or increase with passive stretch of the compartment, is often the only finding in acute compartment syndrome.

    Brit Long, MD, FACEP; and
    Alex Koyfman, MD, FACEP, FAAEM

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    New ACEP Member Benefit Offers Legal Assistance, Free Counseling https://www.acepnow.com/article/new-acep-member-benefit-offers-free-counseling-legal-assistance/ https://www.acepnow.com/article/new-acep-member-benefit-offers-free-counseling-legal-assistance/#respond Sat, 21 Dec 2019 00:03:09 +0000 https://www.acepnow.com/?post_type=article&p=22543 ACEP’s new Wellness & Assistance Program was launched during ACEP19 in Denver. It offers ACEP members exclusive...

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    ACEP’s new Wellness & Assistance Program was launched during ACEP19 in Denver. It offers ACEP members exclusive access to three free counseling or wellness sessions. Support is available 24-7, and you can conduct your sessions over the phone, face to face, via text message, or through an online chat service—whatever works best for you. The service also offers 30-minute consultations for individual legal/financial matters for a small annual fee. Learn more about this new benefit.

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    Congratulations to the ACEP Section Award Winners https://www.acepnow.com/article/congratulations-to-the-acep-section-award-winners/ https://www.acepnow.com/article/congratulations-to-the-acep-section-award-winners/#respond Sat, 21 Dec 2019 00:03:09 +0000 https://www.acepnow.com/?post_type=article&p=22547 Every year, ACEP recognizes its membership sections that excel with the Service to Section, Service to College,...

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    Every year, ACEP recognizes its membership sections that excel with the Service to Section, Service to College, Promoting Section Membership, and Outstanding Newsletter Awards. Congratulations to 2019 section award winners:

    • Service to Section: Social Emergency Medicine Section
    • Service to College: Young Physicians Section
    • Promoting Section Membership: American Association of Women Emergency Physicians (AAWEP), Careers in EM
    • Outstanding Newsletter: Young Physicians Section

    Learn more about the section awards. 

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    FDA Drug Shortage Task Force Releases Long-Awaited Report https://www.acepnow.com/article/fda-drug-shortage-task-force-releases-long-awaited-report/ https://www.acepnow.com/article/fda-drug-shortage-task-force-releases-long-awaited-report/#respond Sat, 21 Dec 2019 00:03:09 +0000 https://www.acepnow.com/?post_type=article&p=22545 The U.S. Food and Drug Administration (FDA) recently released its long-awaited Drug Shortages Task Force report, “Drug...

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    The U.S. Food and Drug Administration (FDA) recently released its long-awaited Drug Shortages Task Force report, “Drug Shortages: Root Causes and Potential Solutions.” ACEP has been involved in this effort from the beginning, including calling for the creation of this task force, urging the FDA to find solutions to the drug shortage crisis, and working with congressional partners. In its report, the task force identifies three root causes of drug shortages: 1) lack of incentives to produce less profitable drugs; 2) the market’s failure to recognize or reward manufacturers for mature quality management systems; and 3) logistical and regulatory challenges that make it difficult for the market to recover after a disruption.

    The report also provides three potential solutions: 1) create a shared understanding of the impact of drug shortages and the contracting practices that may contribute to them; 2) create a rating system to incentivize drug manufacturers to invest in achieving quality management system maturity; and 3) promote sustainable private sector contracts. The report includes several ACEP priorities, including the need to enhance transparency to ensure adequate competition in the marketplace and better supply chain monitoring and response so as to guarantee the availability of lifesaving emergency medications.

    ACEP President William Jaquis, MD, FACEP, had a call with the nominee for FDA commissioner, Stephen Hahn, MD, FASTRO, on Nov. 15 to discuss the report and the impact drug shortages have had on emergency medicine. ACEP will continue to work alongside Congress and the FDA on this issue. Stay apprised of our progress.

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    CMS Releases Final 2020 Medicare Physician Fee Schedule https://www.acepnow.com/article/cms-releases-final-2020-medicare-physician-fee-schedule/ https://www.acepnow.com/article/cms-releases-final-2020-medicare-physician-fee-schedule/#respond Sat, 21 Dec 2019 00:03:09 +0000 https://www.acepnow.com/?post_type=article&p=22539 Recently, the Centers for Medicare and Medicaid Services (CMS) released its final 2020 Medicare Physician Fee Schedule...

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    Recently, the Centers for Medicare and Medicaid Services (CMS) released its final 2020 Medicare Physician Fee Schedule rule, which includes changes that will affect Medicare physician payments and the Merit-based Incentive Payment System starting Jan. 1, 2020.

    CMS finalized an increase in these payments in line with the American Medical Association Relative Value Scale Update Committee recommendation for 2020. However, CMS also finalized a proposal to increase the office and outpatient evaluation and management (E/M) services rate in 2021. Medicare requires that overall changes to Medicare physician payments be budget-neutral, so this adjustment to the office and outpatient E/M codes is likely to reduce reimbursement to emergency medicine. So while emergency physician services will be more appropriately valued in 2020, payments for these same services may be significantly reduced the following year. Fortunately, CMS is leaving the door open to re-evaluate this policy in next year’s regulation, and ACEP will be working hard to ensure that these payment reductions do not become a reality in 2021.

    ACEP has broken down the rule on the Regs & Eggs blog, emphasizing seven key policies that apply to emergency medicine and ACEP’s stance on each policy. View the blog. Want to subscribe to Regs & Eggs to stay abreast of the regulatory updates affecting emergency medicine? Sign up to receive email updates at www.acep.org/regsandeggs. 

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    New “FAINT” Score May Work for Syncope Risk Stratification, but Needs Validation https://www.acepnow.com/article/new-faint-score-may-work-for-syncope-risk-stratification-but-needs-validation/ https://www.acepnow.com/article/new-faint-score-may-work-for-syncope-risk-stratification-but-needs-validation/#comments Sat, 21 Dec 2019 00:03:09 +0000 https://www.acepnow.com/?post_type=article&p=22532 The Case A 62-year-old female with a history of anemia and hypertension presents following an episode of...

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    The Case

    A 62-year-old female with a history of anemia and hypertension presents following an episode of syncope that morning while making her coffee. She felt light-headed. As she reached for the wall, the room “went dark.” The next thing she remembers is waking up on the floor. She denies headache, chest pain, shortness of breath, or palpitations. She has been feeling well recently and eating and drinking

    as usual. She has been taking her antihypertensives as prescribed. She is now back to her neurological baseline but feels fatigued.

    In the emergency department, she appears tired but well. Her vital signs and physical exam are unremarkable. She has no signs of head trauma, no cardiac murmurs, and no signs of heart failure. Her initial ECG is normal. Bloodwork has been sent to the lab. What is the utility of cardiac biomarkers in this patient? What will her ultimate ED disposition be if her workup is unremarkable?

    The Tricky Problem of Syncope

    In many ways, syncope management is a microcosm of emergency medicine. The differential diagnosis is broad, and the etiology is typically benign but rarely can also be serious or life-threatening. Safe medical decision-making requires a mixture of diagnostic acumen and risk stratification. Which patients can be safely discharged from the emergency department? Which require a stay in the observation unit or hospital? This question has vexed emergency clinicians for years.

    Over the last 20 years, researchers have attempted to identify risk factors for adverse events after syncope. The usual suspects emerged: advanced age, history of heart disease, abnormal vital signs, abnormal ECG.

    More recently, researchers have attempted to create simple, objective risk scores to help clinicians deliver sensible care to syncope patients—care that matches their risk profile.

    The San Francisco Syncope Rule gained early acceptance but has gradually faded away after attempts to validate the score were unsuccessful.

    Developing a New Metric

    We wanted to know if we could improve clinical outcomes and reduce low-yield admissions by developing a more accurate and reliable syncope risk score. So with funding from the National Institutes of Health, we conducted a five-year multicenter study to enroll a large enough sample size. We included patients ages 60 years and older with an ED complaint of syncope or near syncope. We excluded patients with other causes of loss of consciousness (eg, concussion, hypoglycemia, seizure) and those with a serious diagnosis identified in the emergency department (eg, myocardial infarction, pulmonary embolism, gastrointestinal bleed).

    After six years of hard work, and with the help of about a dozen collaborators, our syncope risk score, the aptly named “FAINT Score, was finally published in the Annals of Emergency Medicine.”1 In the end, we had enrolled more than 3,100 older adults with unexplained syncope or near syncope across 11 emergency departments in the United States. The primary outcome was death or serious cardiac event at 30 days.

    The FAINT Score consists of five variables (see Table 1). A FAINT Score of zero had a sensitivity of over 96 percent and specificity of 22 percent for predicting death or serious cardiac event at 30 days (see Table 1).

    Table 1: FAINT Score1

    (click for larger image) Table 1: FAINT Score1

    The negative predictive value of a FAINT Score of zero was over 99 percent, a promising finding that should satisfy those clinicians who believe that 1 percent is generally an acceptable miss rate for patients presenting with cardiovascular complaints. However, this risk score has not been externally validated and thus is not ready for clinical use in isolation.

    The FAINT Score now joins its Canadian cousin from Ottawa, the Canadian Syncope Risk Score. The latter has a greater number of variables (nine), some of which are subjective (ED diagnosis of cardiac syncope, for example), and is designed for use in patients ages 16 and older. Not surprisingly, both scores use the ECG and troponin as important predictive variables.

    Table 2: Estimated Risk of Serious Clinical Outcome at 30 Days1

    (click for larger image) Table 2: Estimated Risk of Serious Clinical Outcome at 30 Days1

    What’s next? Both scores are pending external validation to confirm that their test characteristics are, in fact, consistent with those in the initial derivation studies. Meanwhile, the formal external validation of the Canadian score is expected to be published soon.

    The validation of the FAINT Score is likely a few years away. Until then, we cannot formally endorse the use of it for widespread implementation. However, these scores are an exciting new development in the field of syncope risk stratification and may offer clinicians a useful tool to help determine which patients can be safely discharged directly from the emergency department. Ultimately, we believe these scores should be used in conjunction with, and not instead of, clinical gestalt, as is true for all clinical decision instruments. Consideration of other factors—such as the social circumstances, patient values, and preferences—is always warranted.

    Case Resolution

    Since the FAINT Score has not yet been externally validated, you cannot rely solely upon it. But its components may still be useful. You aptly order a high-sensitivity troponin and elevated N-terminal-prohormone BNP (NT-ProBNP), both of which come back normal. Calculating the patient’s FAINT Score to be zero, you believe that her risk of a serious cardiac event within 30 days is likely to be less than 1 percent. You return to the bedside and engage in shared decision-making with the patient. She understands that her risk is probably low but not zero. Although she lives alone, she agrees that discharge home with close outpatient follow-up this week is appropriate. The etiology of the syncope is never determined, but months later she is doing well, safely drinking coffee in her living room. 


    Dr. Probst is associate professor in the department of emergency medicine at Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai in New York City.

    Dr. Sun is Perelman Professor and Chair in the department of emergency medicine at the University of Pennsylvania in Philadelphia.

    Reference

    1. Probst MA, Gibson T, Weiss RE, et al. Risk stratification of older adults who present to the emergency department with syncope: the FAINT score [published online ahead of print Oct. 23, 2019]. Ann Emerg Med.

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    New JACEP Open Journal Is Now Accepting Submissions https://www.acepnow.com/article/new-jacep-open-journal-is-now-accepting-submissions/ https://www.acepnow.com/article/new-jacep-open-journal-is-now-accepting-submissions/#respond Sat, 21 Dec 2019 00:03:09 +0000 https://www.acepnow.com/?post_type=article&p=22549 ACEP’s new peer-reviewed, open-access journal is officially open for business! As a companion journal to Annals of Emergency...

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    JACEP OpenACEP’s new peer-reviewed, open-access journal is officially open for business! As a companion journal to Annals of Emergency Medicine, the focus of JACEP Open is to publish high-quality original peer-reviewed research, across the spectrum of basic and clinical research, in an open-access format to the worldwide community. JACEP Open will publish contributions in the form of original research, clinical reports, opinion, and educational information related to the practice, teaching, and research of emergency medicine. JACEP Open is welcoming submissions.

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