Treatment of Skin Abscesses: A Review of Wound Packing and Post-Procedural Antibiotics.

OBJECTIVE: Skin abscesses can be a significant source of morbidity and are frequently encountered by physicians across the country. Incision and drainage (I&D) remains the standard of care; however, significant variability exists in the treatment of abscesses after I&D. Some recent evidence has suggested that routinely performed treatment modalities may not be beneficial. We examine the available evidence investigating if I&D alone is sufficient as the sole management for the treatment of uncomplicated abscesses, specifically focusing on wound packing and post-procedural antibiotics. METHODS: We reviewed available literature for any published observational or randomized control trials on the treatment of abscesses via packing and antibiotics. Only recent manuscripts published in the English language and in the past 10 years (2004 through 2014) were included due to the emergence of methicillin-resistant Staphylococcus aureus (MRSA) as one of the leading causative organism of soft tissue infections in the past decade. RESULTS: Three randomized control trials (RCT) and one observational study investigated wound packing versus no packing following I&D. None of the studies demonstrated a difference in treatment failure rates, recurrence rates, or need for secondary interventions in non-packed wounds; however, packing groups had more pain. Six studies investigated the post-procedural use of antibiotics. The RCTs failed to show decreases in treatment failure rates with antibiotics, but two studies demonstrated a short-term decrease in new lesion formation. The observational studies demonstrated mixed results regarding rates of treatment cure with appropriate antibiotic selection, specifically in patients with positive wound cultures for MRSA. DISCUSSION: Regardless of supplemental post-procedural treatment, all studies demonstrate high rates of clinical cure following I&D. While the number of studies is small, there is data to support the elimination of abscess packing and routine avoidance of antibiotics post-I&D in an immunocompetent patient; however, antibiotics should be considered in the presence of high risk features. Due to limited studies and conflicting data, we are unable to make a recommendation in support or opposition of adjunctive post-procedural packing and antibiotics in an immunocompromised patient.

Return-to-play: a primary care physician's guide to management.

BACKGROUND: In the primary care clinic, allowing young athletes to return to play following injuries and illnesses can be a challenging balancing act between promoting speed of recovery while still allowing for full recovery and prevention of future injuries or complications. METHODS: A literature review of relevant return-to-play articles was performed for musculoskeletal injuries, concussions, and infectious mononucleosis. RESULTS: We identified several evidence-based approaches to allowing athletes to return to activity following injuries and illnesses. The majority of return-to-play recommendations found were expert opinion-based. DISCUSSION: Evidence does exist for primary care providers to assist in guiding their athletic patients back to activity, but it is limited in quantity and quality. The decision to return-to-play is complex, and is best individualized for the patient. Existing guidelines can assist in management; however, only as an adjunct to the clinical decision of a well-informed physician practicing patient-centered medical care.

Anti-Hu Positive Antibodies and Small Cell Carcinoma: A Single Center Review.

INTRODUCTION: Small cell lung cancer (SCLC), having properties of neuroendocrine cells, accounts for a small (15 percent) but significant percent of all newly diagnosed lung cancers and is distinguished from non-small cell lung cancer by its rapid doubling time, high growth fraction and the early development of widespread metastases. Therefore, investigation into early diagnosis and treatment is crucial. One sequela of SCLC is a paraneoplastic neurological syndrome usually mediated by a high titer of anti-Hu antibodies, a disease which can present in several variations of paraneoplastic encephalomyelitis. The presence of anti-Hu antibodies in patient serum, even at a low titer, may serve as a diagnostic marker for SCLC and as a model for antibody-based early cancer detection. Furthermore, anti-Hu titers may eventually function as a prognostic indicator and trending titers may be a way to monitor treatment of SCLC and associated paraneoplastic syndromes. METHODS: In this retrospective chart review from a single hospital, we review all patients who had positive anti-Hu antibodies and discuss level of titers at diagnosis, outcomes, and length of survival. RESULTS: We describe three cases of positive anti-Hu antibodies and document their diagnosis of SCLC and outcomes. CONCLUSIONS: Anti-Hu antibodies can be used as a diagnostic tool for aiding in the diagnosis of SCLC. Anti-Hu antibodies may be able to be followed as a marker of progression of the disease.

Sports concussion management: a review of the evidence.

BACKGROUND: Concussions, a subset of mild traumatic brain injuries (TBI), are common sports-related conditions. Public controversy has aided to the awareness of these head injuries, creating increased concern about their diagnosis and appropriate management. Recent guidelines have brought a change in the way concussions are managed. METHODS: We reviewed recent literature on recognizing and managing concussions and other mild, uncomplicated TBI. While randomized controlled studies and well-designed observational trials were preferred, due to the paucity of methodologically sound evidence, relevant systematic reviews, retrospective reviews and observational trials were also included. RESULTS: Evidenced-base management of concussions, specifically with cognitive and physical rest, is sparse, and the majority of the evidence that does exist is poor. We identified several studies that may contradict the recent guidelines that full physical and cognitive rest is the most beneficial management strategy. DISCUSSION: Recent guidelines in post-concussion management and return-to-play are valuable tools to the primary care physician. However, they have not been validated and are not the result of large scale trials showing demonstrable benefit. While the guidelines are useful tools for returning athletes to full activity following an injury, post-concussion management should be individualized based on each patient assessment, symptoms, and response to care.