Syringe Administration of Epinephrine by Emergency Medical Technicians for Anaphylaxis

Objective: In recent years, the costs of epinephrine autoinjectors (EAIs) in the United States have risen substantially. King County Emergency Medical Services implemented the “Check and Inject” program to replace EAIs by teaching emergency medical technicians (EMTs) to manually aspirate epinephrine from a single-use 1 mg/mL epinephrine vial using a needle and syringe followed by prehospital intramuscular administration of the correct adult or pediatric dose of epinephrine for anaphylaxis or serious allergic reaction. Treatment was guided by an EMT protocol that required a trigger and symptoms. We sought to determine if the “Check and Inject” program was safely implemented by EMTs treating presumed prehospital anaphylaxis or serious allergic reaction. Methods: We conducted a prospective investigation of all cases treated as part of the “Check and Inject” program from July 2014 through December 2016 in suburban King County, Washington, and January 2016 through December 2016 within the city of Seattle. All cases were prospectively collected using a custom quality improvement data form completed by the first responding EMTs. Two physicians completed a structured review of each EMS medical record to determine if the EMTs followed the Check and Inject protocol and determine if epinephrine was clinically-indicated based on physician review. Results: Of the 411 cases eligible for analysis, EMTs followed the protocol appropriately in 367 (89.3%) cases. In the remaining 44 (10.7%) cases, the EMS incident report form failed to document either a clear inciting allergic trigger or an appropriate symptom from the protocol list. Physician review determined that epinephrine was clinically indicated in 36 of the 44 cases. Among the remaining 8 cases (1.9%) that did not meet protocol criteria and were not clinically-indicated based on physician review, none had a documented adverse reaction to the epinephrine. Conclusion: We observed that EMTs successfully implemented the manual “Check and Inject” program for severe allergic reactions and anaphylaxis in a manner that typically agreed with physician review and without any overt identified safety issues.     

Connexin 43 in astrocytes contributes to motor neuron toxicity in amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive loss of motor neurons in the CNS. Astrocytes play a critical role in disease progression of ALS. Astrocytes are interconnected through a family of gap junction proteins known as connexins (Cx). Cx43 is a major astrocyte connexin conducting crucial homeostatic functions in the CNS. Under pathological conditions, connexin expression and functions are altered. Here we report that an abnormal increase in Cx43 expression serves as one of the mechanisms for astrocyte‐mediated toxicity in ALS. We observed a progressive increase in Cx43 expression in the SOD1^G93A mouse model of ALS during the disease course. Notably, this increase in Cx43 was also detected in the motor cortex and spinal cord of ALS patients. Astrocytes isolated from SOD1^G93A mice as well as human induced pluripotent stem cell (iPSC)‐derived astrocytes showed an increase in Cx43 protein, which was found to be an endogenous phenomenon independent of neuronal co‐culture. Increased Cx43 expression led to important functional consequences when tested in SOD1^G93A astrocytes when compared to control astrocytes over‐expressing wild‐type SOD1 (SOD1^WT). We observed SOD1^G93A astrocytes exhibited enhanced gap junction coupling, increased hemichannel‐mediated activity, and elevated intracellular calcium levels. Finally, we tested the impact of increased expression of Cx43 on MN survival and observed that use of both a pan Cx43 blocker and Cx43 hemichannel blocker conferred neuroprotection to MNs cultured with SOD1^G93A astrocytes. These novel findings show a previously unrecognized role of Cx43 in ALS‐related motor neuron loss. GLIA 2016;64:1154–1169     

Phenytoin,Levetiracetam, and Pregabalin in the Acute Management of Refractory Status Epilepticus in Patients with Brain Tumors

Background  

There were nearly 700,000 patients in the United States in 2010 living with brain tumor diagnoses. The incidence of seizures in this population is as high as 70% and is historically difficult to control. Approximately 30–40% of brain tumors patients who present with status epilepticus (SE) will not respond to typical therapy consisting of benzodiazepines and phenytoin (PHT), resulting in patients with refractory status epilepticus (RSE). RSE is usually treated with anesthetic doses of propofol or midazolam infusions. This therapy can have significant risk, particularly in patients with cancer.     

Patented antiinflammatory plant drug development from traditional medicine

Patents secured on antiinflammatory plant drugs derived from 38 plants are reviewed. An attempt has been made to compare the modern and traditional use of plant drugs and to establish the relevance of folk claims in developing modern drugs. The role of plant botanicals such as polysaccharides, terpenes, curcuminoids, alkaloids, etc. in alleviating inflammatory diseases including arthritis, rheumatism, acne skin allergy and ulcers is highlighted. Chemicals that alleviate swelling are derived from plants including grape, boswellia, turmeric, devil's claw and some essential oils such as clove, eucalyptus, rosemary, lavender, mint, myrrh, millefolia and pine have been patented and used as mixed formulations. Plants containing polysaccharides are the most potent in curing inflammatory diseases.     

A comparison of the Miller laryngoscope versus the prototype neonatal offset‐blade laryngoscope in a manikin

Laryngoscope blades used to intubate newborn babies are relatively bulky and frequently exert high pressure on the upper jaw. We tested a prototype neonatal offset‐blade laryngoscope (NOBL) developed to overcome these limitations. Our aims were to compare the pressure on the upper jaw exerted by a size 0 Miller laryngoscope and the NOBL on a neonatal manikin, as well as the time taken to intubate the trachea and the area of view of the larynx. Twenty healthcare professionals with more than five years of experience in neonatal intensive care took part; the findings were assessed using pressure‐sensitive film and photographs. High‐pressure indentation occurred in 17 (85%) attempts using the Miller versus 1 (5%) using the NOBL (p = 0.0001). The median (IQR [range]) pressure exerted with the Miller laryngoscope was 455 (350–526 [75–650]) kPa vs 80 (0–133 [0–195]) kPa with the NOBL (p < 0.0001). The area of pressure exerted with the Miller laryngoscope was 68 (32–82 [0–110]) mm² vs 8 (0–23 [0–40]) mm² with the NOBL (p < 0.0001). The time to intubate was 8.3 (7.3–10.1[4–19]) s for the Miller and 8.0 (5.6–9.6 [4–13.5]) s for the NOBL (p < 0.0001). The area of view blocked by the Miller laryngoscope was 38% of the oral orifice versus 12% with the NOBL. We conclude that the NOBL significantly reduced undesired pressure on the upper jaw during tracheal intubation and improved the view of the larynx compared with a conventional laryngoscope.     

Psychosocial care and its association with severe acute malnutrition

This cross-sectional study compared 120 children having severe acute malnutrition with 120 healthy children for exposure to 40 behaviors, by measuring psychosocial care based on Home Observation for Measurement of the Environment (HOME) inventory. The mean (SD) psychosocial care score of cases and controls significantly differed [18.2 (2.2) vs 23.5 (2.1); P<0.001]. A score of less than 14 was significantly associated with severe acute malnutrition (OR 23.2; 95% CI 8.2, 50).     

Modulation of asthma by endotoxin

Asthma is a common inflammatory disease triggered by both allergic and non‐allergic stimuli. The most common risk factor in the development of asthma is induction of IgE against indoor allergens and imbalance in the T‐helper type 1 (Th1) and Th2 with skewing towards Th2 response. Interplay of genetic and environmental factors is involved in induction and propagation of asthma. Endotoxin is a common environmental pollutant and elicits a Th1 response. The amount of endotoxin varies with several factors but of significant interest has been the role of pets. Endotoxin not only protects against the development of asthma but also enhances an already established inflammation. The difference of outcomes is likely not only due to the time and dose of exposure but also as we discuss the variable interaction of genes with environment. We focus on studies since 2001 that have explored the role of endotoxin in asthma and the gene–environment interactions of the endotoxin effect. Cite this as: V. Doreswamy andD. B. Peden, Clinical & Experimental Allergy, 2011 (41) 9–19.