Stereotactic radiosurgical targets with a distinct connectivity profile predict improvement in tremor after treatment. Such connectomic fingerprints show promise for developing patient-specific biomarkers to guide therapy with stereotactic radiosurgical thalamotomy. BACKGROUND AND PURPOSE: Given the increased use of stereotactic radiosurgical thalamotomy and other ablative therapies for tremor, new biomarkers are needed to improve outcomes. Using resting-state fMRI and MR tractography, we hypothesized that a “connectome fingerprint” can predict tremor outcomes and potentially serve as a targeting biomarker for stereotactic radiosurgical thalamotomy. MATERIALS AND METHODS: We evaluated 27 patients who underwent unilateral stereotactic radiosurgical thalamotomy for essential tremor or tremor-predominant Parkinson disease. Percentage postoperative improvement in the contralateral limb Fahn‐Tolosa‐Marin Clinical Tremor Rating Scale (TRS) was the primary end point. Connectome-style resting-state fMRI and MR tractography were performed before stereotactic radiosurgery. Using the final lesion volume as a seed, “connectivity fingerprints” representing ideal connectivity maps were generated as whole-brain R-maps using a voxelwise nonparametric Spearman correlation. A leave-one-out cross-validation was performed using the generated R-maps. RESULTS: The mean improvement in the contralateral tremor score was 55.1% (SD, 38.9%) at a mean follow-up of 10.0 (SD, 5.0) months. Structural connectivity correlated with contralateral TRS improvement (r = 0.52; P  = .006) and explained 27.0% of the variance in outcome. Functional connectivity correlated with contralateral TRS improvement (r = 0.50; P  = .008) and explained 25.0% of the variance in outcome. Nodes most correlated with tremor improvement corresponded to areas of known network dysfunction in tremor, including the cerebello-thalamo-cortical pathway and the primary and extrastriate visual cortices. CONCLUSIONS: Stereotactic radiosurgical targets with a distinct connectivity profile predict improvement in tremor after treatment. Such connectomic fingerprints show promise for developing patient-specific biomarkers to guide therapy with stereotactic radiosurgical thalamotomy.

Objectives: A prior single-center study clemonsfraled historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population. Methods: This is a prospective observational study of patients >= 65 years presenting after a fall to three EDs. Patients were eligible if they were al baseline mental status and were nor triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anlicoagulanls/anliplateler use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients. Results: 723 patients (median age 83, interquartile range 74-88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulationlantiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6-94) with a specificity of 38.8% (CI 35.1-42.7). The positive predictive value in this population was 10% (CI 7.5-13.3) with a negative predictive value of 97.3% (CI 94.4-98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed. Conclusion: In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC. (C) 2018 Published by Elsevier Inc.

BACKGROUND:Military hospitals in Iraq and Afghanistan treated children with traumatic injuries during the recent conflicts. Diagnostic imaging is an integral component of trauma management; however, few published data exist on its use in the wartime pediatric population.OBJECTIVE:The authors describe the emergency department (ED) utilization of radiology resources for pediatric trauma patients in Iraq and Afghanistan.MATERIALS AND METHODS:We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients admitted to military fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We retrieved ED data on ultrasound (US), radiographic and computed tomography (CT) studies.RESULTS:During the study period, there were 3,439 pediatric encounters, which represented 8.0% of all military hospital trauma admissions. ED providers obtained a total of 12,376 imaging studies on 2,920 (84.9%) children. Of the 12,376 imaging studies, 1,341 (10.8%) were US, 4,868 (39.3%) were radiographic and 6,167 (49.8%) were CT exams. Most children undergoing radiographic evaluation were boys (77.8%) and located in Afghanistan (70.4%), and they sustained penetrating injuries (68.0%). Children who underwent imaging had higher composite injury severity scores in comparison to those who did not undergo imaging (10 versus 9).CONCLUSION:Military health care providers frequently utilized radiographic studies in the evaluation of pediatric trauma casualties in Iraq and Afghanistan. Deployed military hospitals that treat children would benefit from dedicated pediatric-specific imaging training and protocols.

Objective: Cricothyrotomy is a complex procedure with a high rate of complications including failure to cannulate and injury to adjacent anatomy. The Control-Cric (TM) System and QuickTrach II (TM) represent two novel devices designed to optimize success and minimize complications with this procedure. This study compares these two devices against a standard open surgical technique. Methods: We conducted a randomized crossover study of United States Army combat medics using a synthetic cadaver model. Participants performed a surgical cricothyrotomy using the standard open surgical technique, Control-Cric (TM) System, and QuickTrach II (TM) device in a random order. The primary outcome was time to successful cannulation. The secondary outcome was first-attempt success. We also surveyed participants after performing the procedures as to their preferences. Results: Of 70 enrolled subjects, 65 completed all study procedures. Of those that successfully cannulated, the mean times to cannulation were comparable for all three methods: standard 51.0 s (95% CI 45.2-56.8), QuickTrach II (TM) 39.8 s (95% CI 31.4-48.2) and the Cric-Control (TM) 53.6 (95% CI 45.7-61.4). Cannulation failure rates were not significantly different: standard 6.2%, QuickTrach II (TM) 13.9%, Cric-Control (TM) 18.5% (p = 0.106). First pass success rates were also similar (93.4%, 91.1%, 88.7%, respectively, p=0.670). Of respondents completing the post-study survey, a majority (52.3%) preferred the QuickTrach II (TM) device. Conclusions: We identified no significant differences between the three cricothyrotomy techniques with regards to time to successful cannulation or first-pass success. Published by Elsevier Inc.

Introduction: Airway compromise is the second leading cause of preventable death on the battlefield among US military casualties. Airway management is an important component of pediatric trauma care. Yet, intubation is a challenging skill with which many prehospital providers have limited pediatric experience. We compare mortality among pediatric trauma patients undergoing intubation in the prehospital setting versus a fixed-facility emergency department. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric encounters in Iraq and Afghanistan from January 2007 to January 2016. We compared outcomes of pediatric subjects undergoing intubation in the prehospital setting versus the emergency department (ED) setting. Results: During this period, there were 3439 pediatric encounters (8.0% of DODTR encounters during this time). Of those, 802 (23.3%) underwent intubation (prehospital=211, ED=591). Compared to patients undergoing ED intubation, patients undergoing prehospital intubation had higher median composite injury severity scores (17 versus 16) and lower survival rates (66.8% versus 79.9%, p < 0.001). On univariable logistic regression analysis, prehospital intubation increasedmortality odds (OR 1.97, 95% CI 1.39-2.79). After adjusting for confounders, the association between prehospital intubation and death remained significant (OR 2.03, 95% CI 1.35-3.06). Conclusions: Pediatric trauma subjects intubated in the prehospital setting had worse outcomes than those intubated in the ED. This finding persisted after controlling for measurable confounders. Published by Elsevier Inc.

Background: Type II diabetes mellitus (DM) is an increasingly prevalent cause of morbidity and mortality among U.S. adults, with increasing prevalence in emergency department (ED) visits. Multiple medications, such as exenatide, a glucagon-like peptide-1 agonist, have been developed in the past decade to combat this growing problem. This medication is well documented to cause gastrointestinal upset and skin nodules at the injection site. However, currently no documented cases exist regarding manipulation of injection nodules causing increased absorption or reports demonstrating an increase in adverse drug reactions. Case Report: We report an interesting case of an adult male patient who likely experienced increased systemic absorption of exenatide by manipulating an injection nodule, which ultimately resulted in nausea, retching, diarrhea, and a tachycardic heart rate of 130-140 beats/min. These symptoms are known side effects of exenatide. Why Should an Emergency Physician Be Aware of This?: Given the high frequency of DM patients presenting to the ED, emergency physicians should be familiar with diabetic maintenance medications and their adverse reactions. Treating these side effects and properly educating patients can alleviate discomfort, prevent future adverse reactions, and decrease return visits to the ED. (C) 2018 Elsevier Inc. All rights reserved.

Background: The management of patients with impaled unexploded devices is rare in the civilian setting. However, as the lines of the traditional battlefield are blurred by modern warfare and terrorist activity, emergency providers should be familiar with facility protocols, plans, and contact information of their local resources for unexploded devices. Case Report: A 44-year-old male sustained a close-proximity blast injury to his lower extremities while manipulating a mortar-type firework. He presented to the regional trauma center with an open, comminuted distal femur fracture and radiographic evidence of a potential explosive device in his thigh. His management was coordinated with the local Explosive Ordinance Disposal and the fire department. Why Should an Emergency Physician Be Aware of This?: Explosive devices pose a grave threat when encountered. Familiarization with protocols to manage these patients can mitigate disaster. Emergency providers should expect and be prepared to coordinate care for these patients. (C) 2017 Elsevier Inc. All rights reserved.

Background Myasthenia gravis (MG) is an uncommon autoimmune disorder affecting the neuromuscular junction and manifesting as muscle weakness. A multitude of stressors can exacerbate MG. When symptoms are exacerbated, muscle weakness can be severe enough to result in respiratory failure, a condition known as myasthenic crisis (MC). Objective This review discusses risk factors, diagnosis, management, and iatrogenic avoidance of MC. Discussion MC can affect any age, ethnicity, or sex and can be precipitated with any stressor, infection being the most common. MC is a clinical diagnosis defined by respiratory failure caused by exacerbation of MG. Muscle weakness can involve any voluntary muscle. MC can be differentiated from other neuromuscular junction diseases by the presence of normal reflexes, normal sensation, lack of autonomic symptoms, lack of fasciculations, and worsening weakness with repetitive motion. Treatment should target the inciting event and airway support. All acetylcholinesterase inhibitors should be avoided in crisis, including edrophonium testing and corticosteroids initially. Respiratory support can begin with noninvasive positive-pressure ventilation, as this has been successful even in patients with bulbar weakness. If intubation is necessary, consider avoiding paralytics or use a reduced dose of nondepolarizing agents. Conclusions MC should be in the differential of any patient with muscular weakness and respiratory compromise. Emergency department management of MC should focus on ruling out infection and respiratory support. Strong consideration should be given to beginning with noninvasive positive-pressure ventilation for ventilatory support. Corticosteroids, depolarizing paralytics, and acetylcholinesterase inhibitors should be avoided in patients with MC in the emergency department.

A prior study suggested that signs of head trauma and loss of consciousness (LOC) may determine intracranial injury (ICI) in low risk elderly fall patients. We sought to assess whether these factors adequately predict ICI in this population.

We examined triage nurses' assessment of patients' language proficiency compared to patients' self-reported proficiency and the impact of language discordance on door-to-room time and patient satisfaction. This was a prospective study of emergency department walk-in patients. Patients completed a survey in which they identified their language proficiency. On a Likert scale, patients ranked how well they felt they were understood and how satisfied they were with the triage process. Nurses completed surveys identifying the patient's primary language and how well they felt they understood the patient. Door-to-room times were obtained from medical records. 163 patients were enrolled. 66% of patients identified themselves as having good English proficiency, while 34% of patients had limited English proficiency. Nurses misclassified 27% of self-identified Spanish-speaking patients as being English proficient. Spanish-speakers felt less satisfied with triage than English-speakers (p < 0.01). There were no differences in door-to-room time. Triage nurses overestimate patient language skills. Spanish-speaking patients feel less satisfied with triage than English-speakers.