J Emerg Med
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Wernicke encephalopathy is an acute neurological emergency caused by thiamine (vitamin B1) deficiency. The syndrome is associated with a significant morbidity and mortality, and prompt recognition and treatment of the syndrome in the emergency department (ED) is essential to improving patient outcomes. Numerous factors and clinical settings have been identified that predispose a patient to thiamine deficiency and subsequent Wernicke encephalopathy. ⋯ We present the rare case of a 42-year-old man with a recent diagnosis of non-Hodgkin lymphoma who opted against chemotherapy in favor of a 60-day therapeutic water-only fast. On day 53 of his fast, the patient arrived to our ED in a coma and respiratory failure. Moments after the administration of thiamine, the patient's mental status and respiratory status improved significantly. Prior to admission and transport to the medical intensive care unit, the patient was awake, alert, and following basic commands. He was ultimately diagnosed with Wernicke encephalopathy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With the increasing incidence of patients choosing alternative medical therapies to treat a variety of diseases, numerous electrolyte, metabolic, and nutritional disorders are becoming increasingly more common in the ED setting. In some cases, patients may choose a therapeutic fast in an effort to combat a malignancy; the danger being that patients with cancers such as lymphoma are already at risk for thiamine deficiency as a result of the increased thiamine consumption associated with rapid cellular turnover. Wernicke encephalopathy is a life-threatening neurological emergency, and the emergency physician must be aware of the numerous predisposing factors to the condition, as early identification and treatment improves patient outcomes.
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Fewer than 150 cases of stercoral colitis have been reported in the literature. Stercoral colitis develops when feces impacts in the colon, resulting in increased luminal pressure, colon wall ulceration, and an inflammatory colitis. Patients are typically over the age of 60 years and have history of constipation. Mortality from colon perforation secondary to stercoral colitis is as high as 60%. ⋯ We present two male patients, ages 26 and 35 years old, with history of psychiatric illness who presented with constipation and abdominal pain, who were found to have stercoral colitis on computed tomography. One patient developed stercoral perforation of the colon requiring emergent laparotomy. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Stercoral colitis is a rare but potentially fatal etiology of abdominal pain that should be considered in young patients with history of constipation.
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Emergency Department Reliance (EDR: total emergency department [ED] visits/total ambulatory [outpatient + ED] visits) differentiates acute episodic ED users from those who may not have adequate access to outpatient care. ⋯ Compared to children, patients transitioning to adulthood relied more on the ED for their care. In addition, patients with high EDR incurred more days in the hospital and significantly higher health-care costs, highlighting the need to improve transition-related support, including better access to primary care and increased engagement with patients with SCD.
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Effective, appropriate, and safe opioid analgesia administration in the Emergency Department (ED) is a complex issue, with risks of both over- and underutilization of medications. ⋯ In preliminary analysis, MD/MLP status was significantly associated with likelihood of provider treatment of MSP with opioids. A follow-up study is warranted to confirm the results of this hypothesis-testing analysis and to inform efforts toward consistency in opioid therapy in the ED.