Background: Xylazine is an alpha-2 adrenergic agonist commonly used as a large animal anesthetic. It is used as an adulterant in illicit opioids, and it is now well established that its synergistic effect with opioids increases lethality. The amount of xylazine adulterating illicit opioids is growing at an alarming rate, present in almost one-third of opioid overdose deaths reported in Philadelphia in 2019. Despite this, there are no reports considering the management of patients using xylazine chronically. In particular, there are no reported cases detailing the management of xylazine withdrawal or exploring the potential for ongoing treatment for those in recovery from xylazine use. Case Summary: We present the case of a 29 year old female with opioid use disorder and chronic xylazine use, admitted to the intensive care unit for treatment of chronic lower extremity wounds thought to be due to xylazine injection. Her xylazine withdrawal was managed with a combination of dexmedetomidine infusion, phenobarbital and tizanidine, later transitioned to clonidine. By hospital day 4 she was no longer experiencing withdrawal symptoms. She was transitioned from full-agonist opioids for pain to buprenorphine via a buprenorphine "micro-induction" and was ultimately discharged on buprenorphine, clonidine, and gabapentin on day 19 of admission. Clinical Significance: This case illustrates a potential treatment pathway that allows for safe and comfortable xylazine withdrawal in hospitalized patients. It also provides an introduction into several medical concerns affecting this patient population specifically, including xylazine-mediated soft tissue wounds.
(PDPH) declared a public health emergency due to hepatitis A in August 2019. 1 Our emergency department (ED) serves a population with many of the identified risk factors for hepatitis A transmission. This study examines the impact of an ED-based hepatitis A vaccination program, developed in partnership with the PDPH, on incidence of hepatitis A infection and hospital admission. Methods: We conducted a retrospective review of all ED visits in the 12-week period centered around the implementation of the ED-based hepatitis A vaccination program. All adult patients presenting to the ED were offered vaccination, with vaccines supplied free of charge by the PDPH. We compared the incidence of diagnosis and of hospital admission for treatment of hepatitis A before and after implementation of the program. Results: There were 10,033 total ED visits during the study period, with 5009 of them prior to the implementation of the vaccination program and 5024 after implementation. During the study period, 669 vaccines were administered. Before the vaccination program began, 73 patients were diagnosed with hepatitis A, of whom 67 were admitted. After implementation of the program, 38 patients were diagnosed with hepatitis A, of whom 31 were admitted. Conclusion: A partnership between an ED and the local public health department resulted in the vaccination of 669 patients in six weeks in the midst of an outbreak of a vaccine-preventable illness, with a corresponding drop in ED visits and hospital admission for acute hepatitis A.
INTRODUCTION: Determining accurate gestational age (GA) is an essential for decision making in obstetrics. Fetus folds around 12 weeks. We wanted to determine whether crown-rump length (CRL) or a composite biometric measurement (CBM) including head, abdominal and femur measurements, or a combination of CRL and CBM, provides a more accurate GA estimation between 12.0 weeks to 13.9 weeks gestation. METHODS: Fetal biometry data on singleton pregnancies was collected from a retrospective well-dated pregnancy cohort. All CRL images were reviewed for accuracy. GA by both CRL and CBM was compared to the certain GA using the Bland-Altman test to assess regression to the mean, limits of agreement, and bias. RESULTS: Included 1716 pregnancies revealed an average bias of +0.7 (-9.95 to 11.4) days with CRL; +3.37 (-3.82 to 10.6) with CBM between 12w0d-13w6d. GA is overestimated by both methods at 12 weeks. CRL underestimates GA after 13weeks, while CBM underestimates after 14weeks. The true GA estimation for 13.1-14.0 weeks is a combination of CRL (negative bias) and CBM (positive bias). Results were not altered by body mass index nor by fetal position of CRL measurement (midsagittal, coronal or prone). CONCLUSION: Given the larger bias of composite biometry dating, CRL-based dating is more accurate up to 13 weeks. The ACOG Committee Opinion number 611 (2014) should be modified to reflect measurement of CRL till 13w, but composite of CRL and CBM between 13w1d to 14 weeks. In addition, for pragmatic reasons, CRL measurement in any feasible plane should be acceptable.
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