ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

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Schizophrenia, the most common psychotic disorder, affects 1 percent of the general population.  The symptoms begin in late adolescence or early 20s in men and 20s and early 30s in women.  The DSM-IV diagnostic criteria for schizophrenia includes:  at least 6 months of sufficiently deteriorated occupational, interpersonal and self-supportive functioning; two or more of the following positive symptoms: delusions, hallucinations, disorganized speech or behavior; or negative symptoms such as affective flattening, alogia or avolition during a 1 month period.  The symptoms can not be accounted for by the presence of a schizoaffective or major mood disorder, autism, or an organic condition.  Positive and negative symptoms vary in intensity over time.  Criminal behavior is not a characteristic of schizophrenia however, patients may commit violent acts due to their hallucinations, delusions, or impaired social skills.  The lifetime prevalence of suicide is 10 percent amongst schizophrenics.

    Multiple genetic and environmental factors are responsible for the symptoms seen in schizophrenia.  One factor is the dopamine theory in which increased dopaminergic neurotransmission causes psychosis.  By decreasing dopaminergic transmission via antipsychotic drugs, the distractibility seen in schizophrenia decreases and improves perceptual abilities.  The theory has several flaws.  First, symptoms are not fully alleviated by treatment.  Secondly, dopamine levels are within normal ranges before and after treatment.  Thirdly, dopamine and its role in the brain is more complex than acting as a simple switch for psychotic symptoms.  Inhibitory interneurons are also affected by a decrease in their number, in enzymes that synthesize the inhibitory neurotransmitter gamma-aminobutyric acid, in neuropeptides cholecystokinin and somatostatin, and in migration of neurons into the cortex from white matter.  There are also genetic findings such as greater concordance among monozygotic twins than dizygotic twins and the high incidence of schizophrenia among adopted children, whose biologic mothers have schizophrenia.  These findings point to a genetic component that accounts for 70 percent of the risk.  The environmental component accounts for the remaining 30 percent, that includes perinatal and childhood brain injury and psychosocial stressors.

    The pharmacologic approach to schizophrenia and its symptoms is centered on neurotransmitters that control the response of neurons to stimuli.  First generation antipsychotic agents such as haloperidol and chlorpromazine block dopamine D2 receptors.  Twenty percent of patients have complete remission of their symptoms, most patients have some response but with continuing symptoms.  Side effects include involuntary movement disorders arising from the extrapryamidal system.  Symptoms include dystonia, akathisia, bradykinesia and tremor.  Akathisia, a state of restlessness, is a major cause of noncompliance with the drug regimen.  It can be treated with propranolol.  Bradykinesia, slowed voluntary movements can be treated with benzotropine.  Tardive dyskinesia, a choreoathetotic movement disorder, develops in 30 percent of patients after several years of treatment.  Orofacial movements are common manifestations.  It slowly resolves after withdrawal of first generation drugs, although it may be irreversible.  When diagnosed early it is usually reversed with a change in medication.  Temperature dysregulation can lead to neuroleptic malignant syndrome, in which the patient’s temperature exceeds 104°F.  Dantrolene, bromocriptine, and rapid cooling can be used to treat the hyperthermia.  Prolonged QT interval is seen in several antipsychotics, in particular thioridazine. 

    Second generation antipsychotic agents block D2 dopamine receptors (like first generation drugs) however they are less tightly bound and the D2 dopamine receptor antagonism is not the sole therapeutic mechanism.  They include clozapine, risperidone, olanzapine, ziprasidone, quetiapine, ariprazole and amisulpride.  Their efficacy is equivalent or exceeds the first generation drugs particularly with respect to negative symptoms.  Side effects include weight gain, DM, hypercholesterolemia, hyperprolactinemia, and seizures.  Movement disorders, including tardive dyskinesia are decreased with the second generation drugs.  Clozapine was the first second generation drug to be used and it also blocks D1, D4 dopamine receptors and norepinephrine and serotonin receptors.  Agranulocytosis is a serious risk associated with clozapine and patients taking the drug must undergo frequent monitoring of leukocyte counts.  They are also at risk for myocarditis.  Agranulocytosis can lead to fevers, malaise and frequent infections in the schizophrenic patient.  For noncompliant patients there are depot injection preparations available.

    The primary mode of treatment of schizophrenia is pharmacologic.  Supportive psychosocial methods are useful in the long-term treatment of schizophrenia.  If the acutely psychotic schizophrenic is delirious, suicidal or homicidal and/or has no support, the patient needs to be hospitalized.
 
 

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