PEM Network Sep '12 Newsletter

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  • 1. September 2012 ENVIRONMENTAL EMERGENCIES From the Editors: From the Site Administrator: Do you remember the difference between a crotaline and an elapid snake? Neither do we. That’s why the focus of the fall edition of the PEMNetwork newsletter is environmental emergencies. Hot and cold, bites and stings, disasters and preparedness, you’ll find it all here. "Welcome to the exciting new face of the PEMNetwork. With new topic search-ability, active group forums, and more collaborative members than ever before, we continue to innovate and educate. We are looking forward to seeing you at the 2012 NCE where the PEMNetwork will hold an open meeting and present at the SOEM conferences.”  Contents: Bath Salts..........................2 Lyme Disease........................3 BASE Camp...........................4 Hurricane Preparedness............5-6 EKG Feature: Hypothermia............7 Heat Illness........................8 Board Review: Bites and Stings...9-10 Altitude Illness...................11 Image Feature: Worms!.............12 Notes from the Sub-site Editors....13 [1] - Angela Lumba, MD, FAAP Washington University School of Medicine, Head Site Administrator
  • 2. BATH SALTS Sing-Yi Feng, MD FAAP Assistant Professor of Pediatrics/Medical Toxicologist UT Southwestern Medical Center at Dallas   “Bath salts” were first reported as drug of abuse to the North Texas Poison Center in 2010. Since then, Poison Centers across the United States have reported increasing numbers of calls involving “bath salts”. These “bath salts” usually contain mephedrone and methylenedioxypyrovalerone (MDPV) and are insufflated or “snorted” much like cocaine. Mephedrone is a synthetic stimulant of the amphetamine and cathionine class. Methylenedioxypyrovalerone is also a synthetic stimulant with effects similar to amphetamines. Both drugs have been reported to cause agitation, euphoria, hypertension and tachycardia. These effects resemble methamphetamine and cocaine toxicity. Patients can also develop hyperthermia and ultimately rhabdomyolysis, end organ failure and possibly death from the use of “bath salts.” So far, one death in Florida in 2011 has been attributed to the use of bath salts. Bath salts are easily purchased on the Internet and at “head shops.” It is considered a designer drug because although mephedrone and MDPV have never been used for bath salts, they are labeled as such with the phrase “Not for Human Consumption” in order to bypass the Federal Analog Act. The Federal Analog Act of the United States Controlled Substance Act states that any chemical "substantially similar" to a controlled substance listed in Schedule I or II is to be treated as if it were also listed in those schedules, but only if intended for human consumption. Many states such as Florida have now made the substances contained in bath salts illegal to own and sell. Also, as of September 7, 2011, The United States Drug Enforcement Administration (DEA) used its emergency scheduling authority to temporarily control mephedrone. This was deemed necessary to protect the public from the supposed hazard posed by the drug. Except as authorized by law, this action will make possessing and selling mephedrone or the products that contain it illegal in the U.S. for at least one year while the DEA and the United States Department of Health and Human Services conduct further study. [2]
  • 3. LYME DISEASE lymphatics to bone, synovial tissue, CNS, heart, or skin. 25% of patients will have Matthew Thornton, MD common. Meningitis, cranial neuropathies, and carditis are more Yale University School of Medicine Lyme Disease is the most common vector-borne illness in the U.S. “Lyme arthritis” was first described in 1976, with multiple EM. Fever and myalgia are also LYME DISEASE serious complications. Heart block responsive to antibiotics is the most common manifestation of carditis. the discovery of the causative spirochete, Borrelia burgdorferi in 1981. Borrelia is Late disseminated disease causes “Lyme arthritis”, typically in the knee. transmitted by the Ixodid tick and occurs Arthritis resolves in 1-2 weeks, but even untreated cases will eventually resolve. primarily in New England, New York, the mid-Atlantic Coast, Wisconsin, and Recurrences are not uncommon. Minnesota. Animal studies have shown that Serologic testing is an adjunct to clinical diagnosis in disseminated disease. infected ticks must feed for 36-72 hours in ELISA for IgM and IgG may be sent, and if positive, followed by confirmatory Western order for transmission to occur, such that the risk of transmission from a known tick Blot. False-positive ELISA is extremely bite is only 1-2%. Lyme Disease is divided into 3 common. Treatment of Lyme disease is a bit chronological stages, all with different tricky, with regimens differing based on disease stage and manifestations. Tick presentations and distinct pathology, though there may be some degree of bite prophylaxis is not recommended, overlap. These stages are 1) Early localized, 2) Early disseminated, and 3) even in Lyme endemic regions, unless the tick has been attached for >36 hours and Late disseminated. the patient is able to take doxycycline. Early localized disease is treated with oral Early localized disease occurs 1-55 days after a bite, involving the classic doxycycline, amoxicillin, or cefuroxime for erythema chronicum migrans (EM) rash at the site of the bite, and may also include 14-21 days. Doxycycline has the advantage of being active against possible flu-like symptoms. A characteristic rash coexisting ehrlichiosis. Disseminated disease causing multiple EM or an isolated and possible tick exposure are all that is required for diagnosis and treatment. nerve palsy requires a longer treatment of Early disseminated disease occurs 3-10 weeks after a bite when the 21-28 days. Meningitis/encephalitis and symptomatic carditis with heart block spirochetes spread via blood or require IV therapy with ceftriaxone, as does persistent or recurrent arthritis. 1. Steere AC. Lyme disease. N Engl J Med 2001; 345:115. 2. Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis 2000; 31:533. 3. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of Incidence of Lyme (per 100,000 pop.) America. Clin Infect Dis 2006; 43:1089. 4. Centers for Disease Control and Prevention: Lyme Disease.  Accessed 7/3/12. [3] Manifestations Erythema migrans rash (top)is caused by local spread of spirochetes. It is nonpruritic and nonpainful and lasts 1-2 weeks. Bells palsy (middle) in early disseminated disease. Lyme arthritis (above) is a late manifestation.
  • 4. BASE CAMP BASE Camp: A Multi-Institutional Teamwork and Procedural Skills Simulation Training Conference for Pediatric Emergency Medicine Fellows Kevin Ching, MD For more information, see: In order to provide similar experiences for PEM fellows, BASE Camp assembled a Weill-Cornell Medical Center collaborative group of expert PEM faculty In the fast-paced practice of emergency from 10 universities to develop an intensive two-day multidisciplinary training medicine, fellows must develop critical skills and behaviors swiftly. From day one, program. Using state-of-the-art simulation technology, BASE Camp provides new PEM fellows are expected to develop an fellows with an opportunity to begin ability to lead a team under crisis conditions, while possessing the technical developing hands-on experience and proficiency to perform a staggering number proficiency in crucial teamwork and of complex procedural skills. Yet, with only procedural domains. Before arriving at BASE Camp, fellows a 4-month pediatric residency requirement are provided online an interactive prefor acute care, there is no guarantee that conference introduction and overview of graduating residents have been teamwork concepts, emergency trauma adequately prepared for this challenge. procedural skills, the approach to a difficult The probability is high that a new fellow pediatric airway, and advanced airway has never had the opportunity to insert a techniques to establish a cognitive chest tube or manage an infant in framework for the 2-day course. In the cardiopulmonary arrest. In addition to course, fellows are challenged to technical competency, fellows must collaborate in teams, often as leaders, in develop team leadership and crisis varied resuscitations. Fellows are given management skills, neither of which are ample opportunities to learn, practice, and likely to fully develop in residency. apply advanced airway maneuvers, like The ACGME requires that fellows “learn the skills necessary to prioritize and the use of an intubating-LMA in a child with a retropharyngeal abscess, or the video simultaneously manage the emergency laryngoscope in an adolescent with care of multiple patients,” and that “they laryngeal edema in anaphylaxis. must have supervised experiences using their technical/procedural and resuscitation Emergency trauma procedural skills like cricothyroidotomy, chest tube competency skills.” Such skills have traditionally been acquired through “trial by thoracostomy, and pericardiocentesis are fire” in the emergency department—with all practiced first on advanced trauma simulators, then human cadavers and the risks related to such practice. animal tracheas, before applying these skills together as teams during a largeBASE Camp: Basic Training for scale multi-casualty trauma simulation. Pediatric Emergency Medicine Last year, BASE Camp hosted its 2nd Fellows was developed to offer a highannual conference, training 24 first-year impact, immersive, and standardized PEM fellows from 13 fellowships across 8 learning solution that would level the Northeastern states. Preliminary data has playing field for incoming fellows and shown that even among this population of prepare them for the challenges of an EM highly motivated learners, the opportunities fellowship. BASE camp brings together to acquire experience as team leaders in a new first-year PEM fellows to collectively resuscitation or inserting a chest tube are introduce, review, and provide limited. As BASE Camp looks forward to opportunities to practice teamwork introducing new educational strategies for behaviors and critical emergency its 3rd year this Fall, the hope is not only to procedural skills. The first PEM “boot provide experiences that foster complex camp” of its kind in the Northeast, the thought and decision making within a inspiration for BASE Camp grew out of a teamwork domain, but to provide practice pediatric critical care program inspired by in rare but critical emergency procedural Nishizaki at the Childrenʼs Hospital of skills. Philadelphia. [4]
  • 5. HURRICANE PREPAREDNESS Daniel Park, MD Medical University of South Carolina The 2012 hurricane season runs from June 1 through November 30. This • Learn about your community’s emergency plans, warning signals, year’s season is marked by the 20th evacuation routes, and locations of anniversary of Hurricane Andrew, the catastrophic category 5 hurricane that emergency shelters • Inform local authorities about any barreled through South Florida on August 24, 1992. Andrew caused an special needs. For children with special health care needs it is estimated 20-40 million dollars in important to complete a health care damage and killed at least 60 people. For those living in hurricane prone areas, summary, including names/contact information for the child’s medical care knowledge of hurricane readiness and evacuation procedures is not only providers. A two-week supply of medications, equipment, supplies, and prudent but essential. The Centers for foods for special diets is also Disease Control and the American Academy of Pediatrics have outlined recommended. • Locate and secure important specific steps for hurricane readiness that will arm the prescient citizen with documents • Stock your home with emergency the knowledge to protect one’s family supplies. At minimum, this should and vulnerable members of the community. include a 3-5 day supply of water (5 gallons/person) and non-perishable Emergency care places the ABCs paramount during an initial evaluation of food, first aid kit, battery-powered radio, flashlights, batteries, sleeping any patient. Similarly, hurricane bags/blankets, water-purifying preparedness carries its own critical reflexive moves: 1) Taking the first steps, supplies (chlorine, iodine tablets, etc.), baby food/supplies, toiletries, and an 2) Preparing to evacuate, and 3) Completing your family disaster plan. emergency kit for the car with food, flares, booster cables, maps, tools, a Taking the first steps first aid kit, fire extinguisher, etc. If you are under a hurricane watch or Preparing to evacuate warning, the CDC advises the following: If the forecast calls for a hurricane, expect the need to evacuate and [5] Mass flooding prompts helicopter rescues after Hurricane Katrina (top, center); Hurricane Victim holds a meal package administered by U.S. Army (above). Specific steps to ensure food and water safety during hurricanes, power outages, and floods can be found at
  • 6. prepare for it. When a hurricane watch is issued you should: • Living and learning spaces (including homes, schools, and day-care facilities) are free from physical • Never ignore an evacuation order • Fill up your car’s gas tank/arrange for transport • Fill up clean water containers and environmental hazards to children • Spaces where children play should be clear of debris and free from environmental hazards to children • Prepare an emergency kit for your car • Cover windows and doors with plywood or boards to reduce risk of flying glass Completing your family disaster plan It is important to meet with your family before a disaster occurs to discuss the importance of preparation. • Place pets and livestock in safe areas. Often, animals are prohibited from emergency shelters. If developmentally appropriate, discuss with children what to do if the family is separated. Practicing the disaster • Fill sinks and bathtubs with water for washing plan is both a practical and essential exercise not only for hurricanes, but for any emergency. If ordered to evacuate: Sources: • Take only essential items with you • Make sure the car’s emergency kit is ready • Follow designated evacuation routes • Stay indoors until authorities declare the storm over; 1. AAP Children and Disasters: Disaster preparedness to meet children’s needs. Retrieved June 30, 2012, from disasters/hurricanes-storms.cfm 2. AAP: Clinician Recommendations Regarding Return of Children to Areas Impacted by Flooding and/or Hurricanes. Retrieved June 30, if possible take shelter in a windowless, interior room or 2012, from closet. Stay away from all windows and exterior doors. ReturnofChildren.pdf 3. CDC Emergency Preparedness and Response. Retrieved June After the storm has passed, the American Academy of Pediatrics recommends the following before children are 30, 2012, from 4. Food Facts from the U.S. Food and Drug Administration: What returned to areas impacted by flooding and/or hurricanes: Consumers Need to Know About Food and Water Safety During • Basic utilities and public services should be reliably re-established Hurricanes, Power Outages, and Floods. Retrieved June 30, 2012, from [6]
  • 7. BABY, IT’S COLD OUTSIDE! J-waves J-waves were noted on the EKG (above), with resolution on the repeat EKG (right) after rewarming. EKG FEATURE: Rahul Kaila, MD University of Minnesota Amplatz Children's Hospital This is a case of 14 y/o male who had altered mental status and was found to be hypothermic with a temperature of 91 F on the street. His EKG showed Osborne or J wave ( marked in the EKG ) which is the upward deflection at the junction of QRS and ST representing distortion in the earliest phase of repolarization. J waves are usually observed in people suffering from hypothermia with a temperature of less than 32 C though they may also occur in people with high blood levels of calcium, brain injury, vasoplastic angina. [7]
  • 8. The major outcome determinant in heat stroke is duration of hyperpyrexia. HEAT-RELATED ILLNESS Amanda Greuter, MD Childrens Medical Center of Dallas Heat illness is defined as “the inability to maintain normal body temperature because of excess heat hyperthermia (38-40*C), and incoordination. Heat stroke is a life- production or decreased heat transfer to the environment.” Heat stroke threatening emergency, defined as severe hyperthermia (>40*C), occurs when the excess body temperature results in cellular injury, with severe CNS dysfunction. Patients with heat stroke present and is a common cause of morbidity with hot, dry, ashen skin and can have and mortality among athletes, with mortality rates of nearly 10%. significant end-organ involvement. Profound peripheral vasodilation and Acclimatization, or lack thereof, thermal damage to the myocardium can play a significant role in the risk for leads to decreased cardiac output and heat illness. With prolonged exposure, shock. Acute tubular necrosis leading cardiac output due to massive peripheral vasodilation and a stressed, dysfunctional myocardium (resulting from thermal damage). Patients do not often require aggressive volume resuscitation as they are not typically severely dehydrated. Inotropic sweating rates increase, promoting effective cooling as well as triggering to renal failure, rhabdomyolysis, hepatic failure, and DIC are common increased aldosterone secretion (and thus decreased sodium losses). Un- manifestations. The major outcome determinant in heat stroke victims is acclimatized people are prone to the duration of hyperpyrexia. significantly greater salt losses and less effective sweating. Management of heat cramps and heat exhaustion involve simple, Heat illness can progress from mild to severe depending on a variety practical measures of removal from heat, rest, and oral or IV fluid and salt of factors, including acclimatization replacement. Management of heat and conditioning. Heat cramps are a relatively minor condition occurring in stroke involves immediate, active cooling to a temperature of 38.5*C. References: Council on Sports Medicine and Fitness well-acclimatized and conditioned patients. Severe muscle cramps This may be achieved by ice packs to the neck, groin, and axilla, submersion Stress and Exercising Children and Adolescents. occur upon relaxation, contact with in ice water, cooling blankets, cold, or passive extension of a flexed convection cooling with fans and mist, limb. This occurs after inadequate salt cooled IV fluids, and lavage (gastric, replacement causes electrolyte depletion. Heat exhaustion occurs primarily bladder, peritoneal, thoracic) if necessary. Ice water submersion is support (specifically dobutamine, which increases contractility while maintaining peripheral vasodilation and thus cooling) should be considered early, with a goal to maintain UOP>1mL/kg/hr. Chemistries, creatine kinase, coags, and urine should be used to assess for end-organ involvement. and Council on School Health. Climatic Heat Pediatrics. 2011;128(3):e741-7. Ewald MB, Baum CR. Environmental Emergencies. In Fleisher GR and Ludwig S 6th Edition Textbook of Pediatric Emergency Medicine (783-6, 791-4). 2010. Philadelphia: Lippincott Williams and Wilkins. McLaren C, Null J, Quinn J. Heat Stress most effective, but may be impractical, From Enclosed Vehicles: Moderate Ambient in un-acclimatized patients who have either inadequate fluid or salt with evaporative cooling the most effective next choice. Sedation and Temperatures Cause Significant Temperature replacement. It is characterized by profuse sweating, fatigue, weakness, paralysis may be used to decrease metabolic heat production. Heat thirst, headache, vomiting, mild stroke patients often have insufficient [8] Rise in Enclosed Vehicles. Pediatrics. 2005; 116:e109-112. Smith JE. Cooling Methods Used in the Treatment of Exertional Heat Illness. British J. of Sports Med. 2005;39:503-7.
  • 9. Snakes, Spiders, and Scorpions BOARD REVIEW: BITES AND STINGS Questions used with permission by Jennifer Pai, MD, editor of Pediatric Emergency Medicine Practice. For full text and more review topics, visit 1. Which of the following crotaline snakes causes significant neurological toxicity with or with- out local b. Crotaline snake: triangular head, elliptical pupils c. Brown recluse spider: red hourglass -shaped mark tissue damage and hemotoxicity? on ventral abdomen a.Cottonmouth snake b.Eastern Diamondback Rattlesnake d.Black widow spider: violin-shaped mark on dorsal thorax c. Mojave Rattlesnake d.Copperhead snake 6. Which of the following statements regarding Centruroides exilicauda scorpion stings is correct? 2. Which of the following is a common finding following a. Local pain and paresthesias are decreased by black widow spider envenomation? percussion over the affected area a. Severe local tissue damage at the site of the bite b.Muscle pain and cramping b.Young children are least severely affected c. Severe cases include fasciculations, uncontrolled c. Respiratory failure muscle movements, and cranial nerve dysfunction d.Thrombocytopenia 7. Which of the following is the best treatment modality 3. What is one of the most common toxicities following brown recluse spider envenomation? for dermatonecrosis caused by brown recluse spider envenomations? a.Dermatonecrosis b.Neuromuscular weakness c.Respiratory failure a. Good local wound care, analgesia, and tetanus prophylaxis b.Hyperbaric oxygen therapy c.Electric shock therapy d. Dapsone or colchicine 4. What is the most appropriate treatment for rapidly progressing local tissue swelling and hemotoxicity following crotaline envenomation? a. Fasciotomy b.Corticosteroids c.Constrictive tourniquet of affected extremity 8. Which of the following are important aspects for treatment for coral snake envenomation? a. Careful monitoring and support of respiratory function d.CroFab® antivenom administration b. Repeated monitoring of coagulation profiles c. Careful monitoring of the site of envenomation for severe tissue damage 5. Which toxic species and matching distinguishing physical characteristic is correct? a. Eastern coral snake: red on black on yellow bands see p. 9 for answers and discussion [9]
  • 10. Bites and Stings Answers 1. c. While local tissue damage is venomous snake bites in the U.S. They are identified by their triangular head, elliptical pupils, and fangs. the most common complication of most crotaline bites, the venom of Eastern Coral Snake has red on yellow on black bands but is easily the Mojave Rattlesnake contains a potent neurotoxin, with clinical confused with the nonvenomous King Snake, leading to the saying, presentation similar to coral snake “red on yellow, kill a fellow; red on (elapid) envenomation. black, venom lack”. The black widow spider is characterized by a 2. b. Black widow spider venom lacks cytotoxic agents, so there is red hourglass-shaped mark on its abdomen, while the brown recluse little to no local tissue injury. has a violin-shaped mark on its Instead, the venom decreases acetylcholine reuptake, resulting in BITES & STINGS thorax. severe muscle cramps, abdominal pain and muscle spasm. Symptoms can be managed with opioids and 6. c. The neurotoxins of C. exilicauda scorpions cause sympathetic and parasympathetic benzodiazepines. overstimulation, which may be mistaken for seizure activity. 3. a. Brown recluse venom contains many cytotoxic digestive Catacholamine release may result in enzymes, thus the hallmark of bites is local tissue necrosis ranging from mild to extensive. myocardial damage and dysrhythmias as well. 7. a. Tetanus status should be addressed in all bites and stings. reverse pathology at the site of Rest and elevation to decrease venom spread, analgesics, and envenomation, does halt progression of local toxicity, systemic antihistimines for pruritis are typically the only necessary care. Steroids, dysfunction, and coagulopathy. Repeat dosing may be needed in antibiotics, dapsone, and hyperbaric 4. d. Antivenom, while not able to severe cases. CroFab® is a fragmented antibody which is less antigenic than previous formulations, with lower risk of serum sickness. Fasciotomy, steroids, and oxygen have been reported but not shown to be effective. 8. b. Coral snake venom produces systemic neurotoxicity, tourniquettes are not recommended, which may be delayed up to 18 hours after envenomation. as these treatments may worsen outcomes. Envenomation can lead to loss of muscle strength and paralysis, thus, patients with a history of an elapid 5. b. Crotaline snakes, or pit vipers, account for 99% of bite should be observed in the hospital for neurologic abnormalities. [10] Stay Away from these Bad Boys! Pictured above are a water moccasin (top), scorpion, and diamondback rattlesnake. Both snakes are of the crotaline CME Reviews >3 class. years old are downloadable for free.
  • 11. HIGH ALTITUDE ILLNESS Bogota, Colombia (above) 8,661 ft (2640m) above sea level. As a point of reference, the elevation of Denver, CO is 5280 ft (1609m). Lilia Reyes, MD NYU Medical Center Altitude illness is defined as the cerebral and pulmonary syndromes resulting from an ascent to high Treatment of AMS consists of halting further ascent until symptoms resolve, or descent to lower altitude if altitude, and represents a broad spectrum of pathology, symptoms are not improving. Acetazolamide can also be ranging from mild to life threatening. Hypobaric hypoxia used as treatment or as a preventative medication, acting results in a broad range of physiologic responses, including by causing a mild metabolic acidosis, increasing ventilatory increased sympathetic activity (with increased cardiac output), pulmonary vasoconstriction, and diuresis, rate and thus the PaO2. More serious altitude related illnesses include high with eventual increase in hematocrit to increase oxygen-carrying capacity. Three major factors influence the incidence and severity of altitude sickness; rate of ascent, altitude achieved, and length of stay. Acute Mountain Sickness (AMS) is the most common form of altitude sickness, occurring in approximately half of lowland- altitude cerebral edema (HACE) and high Children are at greater risk of AMS than adults due to increased susceptibility to hypoxia. altitude pulmonary edema (HAPE). HACE is the most severe form of altitude sickness in which hypoxia increases cerebral blood flow, resulting in edema and decreased integrity of the blood-brain barrier. It occurs in 1-2% of individuals who ascend without acclimatization and progresses from confusion living individuals who ascend to >14,000 ft. It presents (in order of prevalence) with headache, fatigue, and truncal ataxia to coma, with a 60% mortality rate among patients with coma. HAPE also occurs after shortness of breath, dizziness, anorexia, and nausea/ excessive hypoxia, with edema resulting from alveolar vomiting. AMS typically occurs 8-36 hours after arrival at altitudes above 8200 ft (2500m). Of note, children are at capillary membrane leak, increased ADH and resultant overload, and inflammatory cytokine release. Treatment of greater risk of AMS due to increased susceptibility to hypoxia and V/Q mismatch. Age less than 1 year, both consists of descent from altitude, oxygen, bed rest, and dexamethasone. Dexamethasone’s mechanism of prematurity, systemic disease, and respiratory infections action is unknown, but has been proven somewhat are all risk factors. effective in management of altitude illness. [11]
  • 12. FEATURE PHOTO: NAME THAT PARASITE Santi Mintegi Pediatric Emergency Department. Cruces University Hospital. Bilbao Professor of Pediatrics. University of the Basque Country “A fellow came one night some months ago to my office showing me what I send to you. She told me that boy's parents found it in the stools. Grandpa is a hunter.” Ascaris lumbricoides Ascariasis is a nematode (roundworm) and one of the most common human parasitic infections worldwide. Transmssion occurs via ingestion of contaminated water or food, or less commonly, contaminated soil. Its prevalence is greatest in tropical climates, with the majority of infections in Asia, Africa, and South America. Often, there are no symptoms with an A. lumbricoides infection. However, in the case of a particularly bad infection, symptoms may include bloody sputum, cough, fever, abdominal discomfort, or passing worms. Most diagnoses are made by identifying the appearance of the worm or eggs in feces. Due to the large quantity of eggs laid, physicians can diagnose using only one or two fecal smears. Infections can be treated with drugs called ascaricides. The treatment of choice is mebendazole. The drug functions by binding to tubulin in the worms' intestinal cells and body-wall muscles. [12]
  • 13. NOTES FROM OUR SUB-SITE EDITORS From the Fellowship Corner: Hello everyone, Over these past few weeks, we recommendation, and suggestions on what to include in your personal have been hard at work updating the statement. We have also included a fellowship subsection of so that it contains list of suggested questions to ask on your interview days along with some even more helpful information for the helpful tips on how to schedule upcoming PEM fellowship application interviews and even arrange your season. travel plans.  The Applicant's Corner has been updated to include the application  We look forward to hearing your suggestions on how we can continue timeline for the 2012 season. We have to improve the Applicant's Corner.  also included a variety of topics to help you through this application - Saranya Srinivasan, MD season. We have included general application tips, advice on how and Boston Combined Residency Program in Pediatrics From the Ultrasound Subsite: The PEM Fellows ultrasound subsite includes a list of ultrasound fellowships, cases and teaching points.  We welcome submissions for interesting cases and hope to see the subsite continue to grow. - Catherine Chung, MD Inova Fairfax Hospital for Children when to ask for letters of Editors: Purva Grover Michelle Alletag Angela Lumba Send Us Your Cases! We are currently accepting case reports, interesting photos, radiographic images, and EKGs for our winter newsletter. [13]