By William Zhu, MD

Centered in the midwestern U.S. and in 30+ states across the country, over 3,000 people have experienced unusually persistent bouts of diarrhea from the parasite cyclospora, according to data collected from the CDC and various state health departments as of July 13th 2026. 

Cyclospora cayetanesis is a coccidian protozoa whose hosts are humans. Transmission occurs when contaminated food or water is consumed usually in the form of raw produce.  Incubation period is around 1-2 weeks making source identification difficult. When a outbreak is detected, there are more infected than reported.

Symptoms are watery, sometimes explosive diarrhea, fatigue and myalgias. These symptoms may persist for weeks with a waxing-waning course. 

Diagnosis requires stool PCR as stool ova parasite tests yield a high false negative rate due intermittent fecal shedding. If in doubt consult infectious disease. Keep other causes of diarrhea like C. Diff, Campylobacter Jejuni and E. Coli on the differential.

Treatment is supportive with correction of fluid loss and electrolyte derangements.  Isolation not required as freshly excreted oocytes and not infectious for over a week. In healthy individuals the infection is typically self limiting.

Preferred antimicrobial agent is trimethoprim-sulfamethoxazole at 160mg TMP+800mg SMX BID for 7-10 days with most individuals experiencing symptom improvement and resolution around 2 days on therapy. Consider prolonged therapy for individuals with immunocompromise. For patients with sulfa allergies ciprofloxacin 500mg BID for 7 days then 3 times a week for 2 weeks is acceptable.

Prevention is centered on washing fresh produce, but cooking all fruits and veggies is the only definitive way to avoid infection as the parasite is resistant to municipal chlorination and conventional washing. Washing produce with soap is not recommended.

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Author: Matthew Jackson, MD

The Ket-Mid Study (1) is a recent RCT out of a tertiary center in a largely rural region of Egypt that evaluated combined ketamine (2 mg/kg) and midazolam (0.2 mg/kg) (ket-mid) to midazolam plus placebo (pla-mid) as the first line seizure abortive therapy. Children in the ket-mid group achieved 76% termination at 5 minutes compared to 21% of those in the pla-mid group (p<0.001). Adverse outcomes were rare, though the pla-mid group did have more hypotension.

Notably, the population included differed from that typically seen in the US. These kids were seizing for a long time, with a median seizure duration before IV meds of 34 minutes, and the benefit of ketamine on subgroup analysis seemed to shrink for those that were treated in less than 30 minutes. CNS infections were also much more common, accounting for the underlying pathology in 11% of cases. Important exclusion criteria also included trauma, inborn errors of metabolism, underlying CNS malignancy, and others not always known to EMS or ED clinicians at the time therapy begins.

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Pseudo-Brugada pattern in hyperkalemia

Category: ECG

By: Chuck Siegel

Keywords: Brugada sign, hyperkalemia, ECG, arrhythmia

Hyperkalemia can produce a variety of ECG changes, including well-known changes such as peaked t-waves, QRS widening, PR-interval prolongation, loss of the p-waves, and the sine wave morphology. One change not as commonly seen is coved ST-elevation in V1-V3 that mimics the ECG changes associated with Brugada sign. Unlike Brugada syndrome, these ECG changes are transient and resolve upon treatment of the hyperkalemia.

The mechanism of these ECG findings relate to the elevated extracellular potassium’s inactivating effect on sodium channels, similar to the sodium channelopathy found in Brugada syndrome. The mean serum potassium concentration of reported cases is often above 6.5 mEq/L. Importantly, hyperkalemia-induced Brugada pattern has not been associated with sudden cardiac death or ventricular arrhythmias.

An example of a hyperkalemia-induced pseudo Brugada pattern in a patient with a K of 7.2 mEq/L (A) as well as that same patient’s ECG following treatment of their hyperkalemia (B).

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By Bobbi-Jo Lowie, MD

Assistant Professor 

Emergency Medicine

University of Maryland School of Medicine

Since April of 2024 there have been 36 confirmed cases of avian influenza A across the United States. Avian influenza, primarily caused by influenza viruses that infect birds, can pose significant health risks to both animals and humans. The most notable strains include H5N1 and H7N9, with H5N1 being particularly alarming due to its high mortality rate among infected humans. The virus primarily spreads from birds to humans through direct contact with infected birds, their droppings, or contaminated environments. Although there have been recorded cases of human-to-human transmission, this usually occurs only in close-contact situations.

In humans, avian influenza can present with symptoms ranging from mild respiratory illness to severe pneumonia. Patients may experience fever, cough, sore throat, muscle aches, and in severe cases, gastrointestinal symptoms. Those that have more moderate or severe illness may develop shortness of breath, altered mental status, or seizures. Complications include acute respiratory failure, pulmonary hemorrhage among others, with respiratory failure being the most common cause of death in this patient population.

Diagnosing avian influenza involves a combination of clinical presentation, travel history, and exposure to birds and confirmation through PCR testing of upper respiratory tract samples like a nasopharyngeal swab.

 Treatment for avian influenza focuses on antiviral medications such as oseltamivir which is most effective when administered early in the course of the illness but still administered after 48 hours of illness. Supportive care is essential for managing severe cases, especially those that progress to acute respiratory distress syndrome.

Author:

Gabriella Miller (She/Her)

Clinical Instructor

Department of Emergency Medicine

University of Maryland School of Medicine

Doxycycline PEP for the prevention of bacterial STIs.

The CDC now recommends “doxy PEP” for high-risk individuals. Doxycycline post-exposure prophylaxis (doxy PEP) is a prescription for patients to self-administer 200 mg doxycycline by mouth within 72 hours after anal, oral, or vaginal sex to prevent the transmission of chlamydia, gonorrhea, and syphilis. The CDC defines “high-risk” as men who have sex with men (MSM) and transgender women (TGW) who have been diagnosed with a bacterial STI within the past 12 months. They summarize the findings of the French IPERGAY and ANRS DOXYVAC studies, as well as the US DoxyPEP study, which all show promising reductions in risk ratios or hazard ratios of decreasing bacterial STI transmission on high-risk populations, including those who are taking PrEP for HIV. No significant adverse events related to doxy PEP have been reported.

Conclusion:

Counsel patients at high risk for bacterial STIs regarding the prescription of doxy-PEP for patient self-administration within 72 hours after sex.

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Title: Basics of Sleep Physiology and Architecture

By: Youssef Annous, MD

Sleep is integral for physical and mental health and performance. Sleep is extremely well conserved among species. All mammals need sleep to survive.1 A single sleep cycle typically lasts anywhere between 90 and 120 minutes and is broken down into two phases2:

Non-Rapid Eye Movement sleep

Stage 1 (Light Sleep)

This is the lightest form of sleep and the easiest to wake up from. During this stage, it is normal to experience muscle twitching and the sensation of drifting in and out of consciousness. This stage lasts approximately 5 minutes in the beginning of sleep and comprises around 5% of total sleep duration.2

Stage 2 (Light Sleep)

During this stage, you are likely to begin experiencing decrease in body temperature, heart rate (HR), blood pressure (BP) and respiratory rate (RR). Electroencephalography (EEG) during this phase of sleep would show sleep spindles and K complexes.2 These findings have been linked to memory consolidation.3

Stage 3 (Deep Sleep)

This is the deepest stage of sleep. During this phase, body temperature, HR, BP, and RR are at their lowest. This is the most restorative stage of sleep. It is essential for immune health, cardiovascular health, tissue repair, bone growth, and muscle recovery.2 It is also when growth hormone (GH) is at its highest. Physiological (e.g. illness) or psychological (e.g. anxiety) stressors can negatively impact this stage. We experience less deep sleep as we age.4

Rapid Eye Movement (REM) sleep

This stage of sleep is characterized by rapid eye movement, abundance of dreaming and heightened brain activity. During REM, there is total body paralysis with exception of ocular and respiratory muscles. It is theorized that your body is paralyzed during this stage to protect you from dream enactment. You experience more REM the longer you sleep. REM has been shown to be essential for memory consolidation, cognitive function, mood regulation and for coping with stress. This stage is particularly compromised by sedatives including but not limited to alcohol, benzodiazepines, and tetrahydro-cannabinoid (THC). Several studies in animals and humans showed that even modest REM sleep deprivation can result in increased mortality. 2,5,6

All sleep stages are extremely essential. Be careful of self-medicating with sleep aids such benzodiazepines or alcohol as this can be detrimental for your health. In later UMEM pearls, we will discuss protocols, supplements and behavioral ways to improve each stage of sleep for better mental and physical health.

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