Intrathecal neuropeptide Y reduces behavioral and molecular markers of inflammatory or neuropathic pain

Our previous work indicates that the intrathecal administration of neuropeptide Y (NPY) acts at its cognate receptors to reduce behavioral signs of nociception in several models of inflammatory pain, including the formalin test. The present study extends these findings to a rat model of peripheral neuropathic pain, and then evaluates the hypothesis that NPY inhibits inflammation- and nerve injury-induced activation of spinal nociceptive transmission. Here we show that NPY dose-dependently reduced behavioral signs of mechanical and cold hypersensitivity in the spared nerve injury (SNI) model. Intrathecal administration of either a Y1 (BIBO3304) or a Y2 (BIIE0246) receptor antagonist dose-dependently reversed the anti-allodynic actions of NPY. To monitor the effects of NPY on the stimulus-induced activation of spinal nociresponsive neurons, we quantified protein expression of the immediate-early gene c-fos in lamina I-VI of the L4-L5 dorsal horn, with special attention to the mediolateral pattern of Fos immunohistochemical staining after SNI. Either tactile stimulation of the hindpaw ipsilateral to nerve injury, or intraplantar injection of noxious formalin, increased the number of Fos-like immunoreactive profiles. Tactile stimulation evoked a mediolateral pattern of Fos expression corresponding to the innervation territory of the uninjured (sural) nerve. We found that intrathecal NPY reduced both formalin- and SNI-induced Fos expression. NPY inhibition of SNI-induced Fos expression was localized to the sural (uninjured) innervation territory, and could be blocked by intrathecal BIBO3304 and BIIE0246. We conclude that NPY acts at spinal Y1 and Y2 receptors to reduce spinal neuron activity and behavioral signs of inflammatory or neuropathic pain.

Tonic status epilepticus: an unusual presentation of unresponsiveness

We report an unusual cause of unresponsiveness in a 73-year-old woman seen in the emergency department. Extensive evaluation, including an emergency EEG that demonstrated rhythmic, high-voltage spike-and-wave discharges characteristic of convulsive activity, confirmed the diagnosis of generalized tonic status epilepticus. The patient's persistent subclinical seizures terminated after the IV administration of diazepam. Varying presentations of generalized tonic status epilepticus have been described in the neurology literature, with EEG confirmation of this diagnosis. Review of the emergency medicine literature does not describe a similar presentation of altered mental status in the adult population. This case illustrates one necessary role for ED EEG in the identification of occult status epilepticus causing altered mental status.

Objectives to direct the training of emergency medicine residents on off-service rotations: pulmonary

This article outlines the objectives for a resident rotation in pulmonary diseases. It is part of a continuing series on the goals and objectives to direct Emergency Medicine resident training on off-service rotations. Pulmonary disease accounts for a high percentage of presenting complaints and potentially life-threatening disease in the emergency department. Because of the frequency of respiratory disease in Emergency Medicine, many Emergency Medicine residencies offer individual off-service rotations in Pulmonary Medicine. The objectives of this article are viewed as a one-month component of an Internal Medicine Rotation in the first year of training. These objectives are designed to help focus the resident's reading and study during a pulmonary off-service rotation.

Lights and siren: a review of emergency vehicle warning systems

Emergency medical services providers routinely respond to emergencies using lights and siren. This practice is not without risk of collision. Audible and visual warning devices and vehicle markings are integral to efficient negotiation of traffic and reduction of collision risk. An understanding of warning system characteristics is necessary to implement appropriate guidelines for prehospital transportation systems. The pertinent literature on emergency vehicle warning systems is reviewed, with emphasis on potential health hazards associated with these techniques. Important findings inferred from the literature are 1) red flashing lights alone may not be as effective as other color combinations, 2) there are no data to support a seizure risk with strobe lights, 3) lime-yellow is probably superior to traditional emergency vehicle colors, 4) the siren is an extremely limited warning device, and 5) exposure to siren noise can cause hearing loss. Emergency physicians must ensure that emergency medical services transportation systems consider the pertinent literature on emergency vehicle warning systems.

Objectives to direct the training of emergency medicine residents on off-service rotations: ophthalmology

This is the ninth article in a continuing series for emergency medicine education. Ophthalmology is the topic. Since ophthalmologic problems are common in the emergency department and have obvious importance in clinical care, the time spent on an ophthalmology rotation can be very valuable in emergency medicine training. This experience is often limited to a 2-week rotation. Therefore, clear goals and objectives take on a greater significance for the resident-in-training.

Objectives to direct the training of emergency medicine residents on off-service rotations: critical care medicine, Part 2

This article is the second of two parts outlining the objectives for resident rotations in intensive care units. It is part of a larger continuing series on the goals and objectives to direct the training of emergency medicine residents on off-service rotations. The critical care unit allows the resident an opportunity to provide continuing care for critically ill patients, many of whom enter the health care system through the emergency department. Critical care medicine is a natural continuum of emergency medicine, and provides the resident with the ability to follow the natural progression of seriously ill patients, as well as build confidence and experience in caring for the critically ill and injured. These objectives are designed to help focus the resident's reading and study during the rotation.

Hiccups (singultus): review and approach to management

Hiccups are a common, and fortunately usually transient, benign malady. Occasionally, however, hiccups fail to resolve spontaneously, resulting in patient fatigue and incapacitation and the need for the affected individual to seek medical care for resolution of the problem. The approach to the management of these patients consists of the identification and treatment of serious underlying causes of the episode as well as therapeutic interventions to achieve hiccup resolution.

Objectives to direct the training of emergency medicine residents on off-service rotations: critical care medicine, Part 1

This article is the first of two parts outlining the objectives for a resident rotating in the intensive care unit (ICU). It is part of a larger continuing series on the goals and objectives to direct the training of emergency medicine residents on off-service rotations. The critical care unit is a valuable rotation that allows the resident to see and care for critically ill patients, many of whom present initially to the emergency department. Critical care is a logical continuum for the sick and injured patient as he moves from the prehospital and emergency department (ED) settings to the ICU. These objectives are designed to focus the resident's reading and study during a critical care rotation.

Objectives to direct the training of emergency medicine residents on off-service rotations: electrocardiology

This is a continuing series of objectives to direct resident training in emergency medicine. Electrocardiography may not receive individual attention in many training programs. However, the importance, omnipresence, and medicolegal potential of electrocardiography in the practice of emergency medicine suggests its individual attention. Contents and specific learning objectives are presented to provide guidelines for resident mastery, following the format presented by preceding subjects.

Objectives to direct the training of emergency medicine residents on off-service rotation: otolaryngology

This is the sixth article in a continuing series on objectives for emergency medicine training; otolaryngological objectives will be presented. Otolaryngological skills and knowledge areas are frequently encountered in clinical practice. The Core Content in emergency medicine devotes an entire section to their listing. Off-service rotations provide some one-half of all rotational-based experience in emergency medicine training. Specific behaviorally based objectives for mastery of knowledge and skill areas provide guidance in a training rotation not directly under emergency medicine faculty supervision. References are suggested for additional and supportive information and reinforcement in skill and knowledge area mastery. These objectives are presented to aid in directing training of emergency medicine residents on an otolaryngological service.

Objectives to direct the training of emergency medicine residents on off-service rotations: emergency medical services

Emergency Medical Services are an area of special interest in emergency medicine. Many emergency physicians are called upon to direct, train, or manage emergency medical services. Residents training in emergency medicine have a need for a defined curriculum in emergency medical services. Residency training should provide a basic foundation in EMS including on- and off-line medical control, medicolegal aspects, communications, disaster management, and EMS history, structure, and function. The resident must gain experience through on-scene observation, EMT/Paramedic education, medical direction, and quality assurance activities. This paper is one in a continuing series of goals and objectives to direct resident training in off-service rotations. Specific resources, learning objectives, and experiences are suggested.

Objectives to direct the training of emergency medicine residents on off-service rotations: hand surgery

This is the fifth article in a continuing series on objectives to direct the training of emergency medicine residents. The emergency physician frequently must deal with hand injuries. Often these may appear innocuous; recognition of these injuries requires certain technical skills and a working knowledge of these entities. Specific objectives presented provide guidance for the didactic content as well as skill mastery for the resident experience.

Objectives to direct the training of emergency medicine residents on off-service rotations: dermatology

This is the fifth in a continuing series of objectives to direct resident training in emergency medicine. Approximately 50% of resident experience and training in emergency medicine takes place outside of the direct control and influence of full-time emergency medicine faculty. To gain some direction and control over these off-service rotations, objectives and references are offered here. Objectives for a dermatology rotation as well as contents and references are presented.

Nonsteroidal anti-inflammatory drugs and coma: a case report of fenoprofen overdose

We present the case of a 17-year-old girl who ingested 24 to 36 g fenoprofen as a suicidal gesture. She presented with coma, hypotension, metabolic acidosis, and respiratory depression within four hours of ingestion. The most common adverse effects of the nonsteroidal anti-inflammatory drugs occur in both therapeutic and toxic doses and include gastrointestinal upset, blood dyscrasias, and analgesic nephropathy. The propionic acid derivatives of nonsteroidal anti-inflammatory drugs, including fenoprofen and ibuprofen, are rarely associated with severe toxic effects. This is the first report of pure fenoprofen overdose presenting as coma and metabolic acidosis.

Objectives to direct the training of emergency medicine residents on off-service rotations: orthopedics

In this third article in a continuing series on objectives for emergency medicine training, orthopedic objectives are presented. Orthopedic complaints are common in emergency medicine. Direction in mastering evaluative, cognitive, and procedural skills are provided utilizing behaviorally based objectives and references. These objectives provide a structure for systematically learning the content of orthopedics through enlightened patient care, questioning of attending physicians and supervisors, and directed reading.

Objectives to direct the training of emergency medicine residents in off-service rotations: dental emergencies

Patients presenting for emergency care with complaints of dental origin are common. Rarely are dental topics systematically addressed during training rotations. In this second article in a continuing series on objectives for emergency medicine resident training, dental emergency objectives will be presented. Instructions for use of the references and objectives are provided. Cognitive and evaluative objectives are organized for mastery. A list of resources including references and audio visual materials are outlined. The objectives and reference materials presented provide a structure for the systematic study of dental emergencies in emergency medicine resident training.

Objectives to direct the training of emergency medicine residents on off-service rotations

Up to 50% of the 36 months of resident training in emergency medicine may be on off-service rotations. The experience on these rotations can lack educational content and opportunity pertinent to emergency medicine. The resident rarely has readily available and structured guidance to optimize training in terms of the anticipated needs of the specialty. In response to this problem, the authors have written curricula containing subject content listings, objectives, and supplied references for 16 off-service rotations. A plan for implementing the materials and an example from the obstetrics-gynecology rotation is given. After 12 months' experience, the authors have subjective responses from residents and off-service program directors that support the value of this information. Positive reports include: Residents having a better understanding of faculty expectations, improved "consistency of experience," residents appreciating the added attention, improved performance, and expanded reading efforts. One expressed concern is "too much to read." The project continues to evolve.