Disseminated Tuberculosis with Cutaneous Findings in an Immunocompetent Patient: A Case Report.

BACKGROUND: Tuberculosis (TB) is one of the leading causes of infectious disease, and emergency medicine providers are often the first physicians to encounter patients with untreated or undiagnosed disease. CASE REPORT: We present the case of a 30-year old man with disseminated TB with multiple musculoskeletal and subcutaneous tubercular abscesses. The diagnosis was suspected in the Emergency Department, but his inpatient treatment was complicated by various social issues. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights uncommon examination findings of TB and illustrates the importance of considering this disease when treating patients who present with atypical manifestations of it.

Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review.

BACKGROUND: Patients presenting to the emergency department (ED) with psychiatric complaints often require medical screening to evaluate for a medical cause of their symptoms. OBJECTIVE: We sought to evaluate the existing literature on the medical screening of psychiatric patients and establish recommendations for ideal screening practices in Western-style EDs. METHODS: PubMed, PsycINFO, and ClinicalTrials.gov were searched for clinical studies examining the medical screening of adult psychiatric patients in the ED or inappropriate referrals to psychiatry. Articles were graded using the Effective Public Health Practice Project (EPHPP) grading tool and sorted into topics. A 3-level grading algorithm used by other emergency medicine organizations was used to evaluate the strength of the evidence for each recommendation. RESULTS: Sixty articles met the inclusion and exclusion criteria. Most published literature on medical screening consisted of nonrandomized studies with a high risk of bias. Some screening procedures, such as history and physical examination, were extensively recommended. Other screening procedures received mixed recommendations. CONCLUSIONS: Based on available literature, physician experts developed 7 recommendations. For a patient with known psychiatric disease presenting with symptom exacerbation, medical screening should include a full medical and psychiatric history, a targeted physical examination, and a mental status examination. Urine toxicology screening and nonurine drug screen laboratory testing should not be routinely performed. Additional screening tests may be valuable for patients with new-onset psychiatric symptoms who are ≥65 years of age, are immunosuppressed, or have concomitant medical disease. However, additional studies on this topic with more rigorous methodology must be conducted to establish definitive guidelines.

The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis.

The diagnostic accuracy of emergency department (ED) ocular ultrasonography may be sufficient for diagnosing retinal detachment. We systematically reviewed the literature to determine the diagnostic accuracy of ED ocular ultrasonography for the diagnosis of retinal detachment. This review conformed to the recommendations from the Meta-analysis of Observational Studies in Epidemiology statement. An experienced medical librarian searched the following databases from their inception, without language restrictions: Ovid MEDLINE, PubMed, EMBASE, the Cochrane Library, Emergency Medical Abstracts, and Google Scholar. Content experts were contacted and bibliographies of relevant studies were reviewed to identify additional references. Evidence quality was independently assessed by 2 investigators using the revised Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Discrepancies were resolved by consensus or adjudication by a third reviewer. Diagnostic test characteristics were summarized and reported with 95% confidence intervals. Of 7,771 unique citations identified, 78 were selected for full-text review, resulting in 4 trials assessed for quality. Agreement between authors' QUADAS-2 scoring was good (κ=0.63). Three trials were deemed to have a low risk of bias. They enrolled ED-based patients (N=201) and evaluated clinician-performed bedside ocular ultrasonography, using either a 7.5- or 10-MHz linear-array probe. Two trials included patients who had retinal detachment from trauma. The prevalence of retinal detachment ranged from 15% to 38%. Sensitivity and specificity ranged from 97% to 100% and 83% to 100%, respectively. The results of the bedside ocular ultrasonography were compared with the reference standard of an ophthalmologic evaluation; one trial also included orbital computed tomography findings suggestive of retinal detachment. Bedside ocular ultrasonography has a high degree of accuracy in identifying retinal detachment, according to 3 small prospective investigations. Larger prospective validation of these findings would be valuable.

Cerebral oximetry with cerebral blood volume index in detecting pediatric stroke in a pediatric ED.

BACKGROUND: Despite pediatric stroke awareness and pediatric stroke activation systems, recognition and imaging delays along with activation inconsistency still occur. Reliable objective pediatric stroke detection tools are needed to improve detection and activations. Regional cerebral oxygen saturation (rcso2) with cerebral blood volume index (CBVI) can detect abnormal cerebral physiology. OBJECTIVE: To determine cerebral oximetry in detecting strokes in stroke alert and overall stroke patients. METHOD: Left rcso2, right rcso2, and rcso2 side differences for stroke, location, and types were analyzed. RESULTS: Compared with stroke alert (n = 25) and overall strokes (n = 52), rcso2 and CBVI were less than those in nonstrokes (n = 133; P < .0001). Rcso2 side differences in stroke alert and overall strokes were greater than in nonstrokes (P < .0001). Lower rcso2 and CBVI correlated with both groups' stroke location, left (P < .0001) and right rcso2 (P = .004). Rcso2 differences greater than 10 had a 100% positive predictive value for stroke. Both groups' rcso2 and CBVI side differences were consistent for stroke location and type (P < .0001). For both groups, left rcso2 and CBVI were greater than those of the right (P < .0001). Hemorrhagic strokes had lower bilateral rcso2 and CBVI than did ischemic strokes (P < .001). CONCLUSIONS: Cerebral oximetry and CBVI detected abnormal cerebral physiology, stroke location, and type (hemorrhagic or ischemic). Rcso2 side differences greater than 10 or rcso2 readings less than 50% had a 100% positive predictive value for stroke. Cerebral oximetry has shown potential as a detection tool for stroke location and type in a pediatric stroke alert and nonalert stroke patients. Using cerebral oximetry by the nonneurologist, we found that the patient's rcso2 side difference greater than 10 or one or both sides having less than 50% rcso2 readings suggests abnormal hemispheric pathology and expedites the patient's diagnosis, neuroresuscitation, and radiologic imaging.

Are plain radiographs sufficient to exclude cervical spine injuries in low-risk adults?

BACKGROUND: The routine use of clinical decision rules and three-view plain radiography to clear the cervical spine in blunt trauma patients has been recently called into question. CLINICAL QUESTION: In low-risk adult blunt trauma patients, can plain radiographs adequately exclude cervical spine injury when clinical prediction rules cannot? EVIDENCE REVIEW: Four observational studies investigating the performance of plain radiographs in detecting cervical spine injury in low-risk adult blunt trauma patients were reviewed. CONCLUSION: The consistently poor performance of plain radiographs to rule out cervical spine injury in adult blunt trauma victims is concerning. Large, rigorously performed prospective trials focusing on low- or low/moderate-risk patients will be needed to truly define the utility of plain radiographs of the cervical spine in blunt trauma.

Streptococcal necrotizing myositis: a case report and clinical review.

BACKGROUND: Streptococcal necrotizing myositis, also known as gangrenous myositis, is a very rare and severe soft tissue infection that predominately involves skeletal muscle and, eventually, superficial fascia and surrounding tissues. The presentation is often nonspecific until the rapidly progressing clinical course becomes apparent. A high morbidity and mortality rate has been reported in the small number of cases since 1900. Despite several attempts to better define the different entities causing necrotizing myositis, no single definitive causal relationship has been defined. OBJECTIVES: A review of the literature is presented here to help clinicians distinguish those with necrotizing myositis from those with nonnecrotizing myositis when the clinician is at all confronted with the suspicion for such an infection. CASE REPORT: The case presented is that of a 48-year-old woman who had streptococcal necrotizing myositis. She died roughly 72 h after admission. After the patient's death, the clinical team sought consent for autopsy. Hospital staff made contact with family, and information was obtained from the family that the onset of the patient's symptoms was allegedly temporally related to her acquisition of a new tattoo on the right back, where the tattoo process allegedly included injection of cremated ashes of a pet dog. CONCLUSION: A high level of suspicion for necrotizing myositis must be maintained for a patient with unexplained severe muscle pain and soft tissue swelling accompanied by systemic inflammatory response syndrome.

Nitrates for acute heart failure syndromes.

BACKGROUND: Current drug therapy for acute heart failure syndromes (AHFS) consists mainly of diuretics supplemented by vasodilators or inotropes. Nitrates have been used as vasodilators in AHFS for many years and have been shown to improve some aspects of AHFS in some small studies. The aim of this review was to determine the clinical efficacy and safety of nitrate vasodilators in AHFS. OBJECTIVES: To quantify the effect of different nitrate preparations (isosorbide dinitrate and nitroglycerin) and the effect of route of administration of nitrates on clinical outcome, and to evaluate the safety and tolerability of nitrates in the management of AHFS. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to July week 2 2011) and EMBASE (1980 to week 28 2011). We searched the Current Controlled Trials MetaRegister of Clinical Trials (compiled by Current Science) (July 2011). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction. SELECTION CRITERIA: Randomised controlled trials comparing nitrates (isosorbide dinitrate and nitroglycerin) with alternative interventions (frusemide and morphine, frusemide alone, hydralazine, prenalterol, intravenous nesiritide and placebo) in the management of AHFS in adults aged 18 and over. DATA COLLECTION AND ANALYSIS: Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using the Cochrane Collaboration tool for assessing risk of bias. MAIN RESULTS: Four studies (634 participants) met the inclusion criteria. Two of the included studies included only patients with AHFS following acute myocardial infarction (AMI); one study excluded patients with overt AMI; and one study included participants with AHFS with and without acute coronary syndromes.Based on a single study, there was no significant difference in the rapidity of symptom relief between intravenous nitroglycerin/N-acetylcysteine and intravenous frusemide/morphine after 30 minutes (fixed-effect MD -0.30, 95% CI -0.65 to 0.05), 60 minutes (fixed-effect MD -0.20, 95% CI -0.65 to 0.25), three hours (fixed-effect MD 0.20, 95% CI -0.27 to 0.67) and 24 hours (fixed-effect MD 0.00, 95% CI -0.31 to 0.31). There is no evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following outcome measures: requirement for mechanical ventilation, systolic blood pressure (SBP) change after three hours and 24 hours, diastolic blood pressure (DBP) change after 30, 60 and 90 minutes, heart rate change at 30 minutes, 60 minutes, three hours and 24 hours, pulmonary artery occlusion pressure (PAOP) change after three hours and 18 hours, cardiac output (CO) change at 90 minutes and three hours and progression to myocardial infarction. There is a significantly higher incidence of adverse events after three hours with nitroglycerin compared with placebo (odds ratio 2.29, 95% CI 1.26 to 4.16) based on a single study. There was no consistent evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following secondary outcome measures: SBP change after 30 and 60 minutes, heart rate change after 90 minutes, and PAOP change after 90 minutes. None of the included studies reported healthcare costs as an outcome measure. There were no data reported by any of the studies relating to the acceptability of the treatment to the patients (patient satisfaction scores).Overall there was a paucity of relevant quality data in the included studies. Assessment of overall risk of bias in these studies was limited as three of the studies did not give sufficient detail to allow assessment of potential risk of bias. AUTHORS' CONCLUSIONS: There appears to be no significant difference between nitrate vasodilator therapy and alternative interventions in the treatment of AHFS, with regard to symptom relief and haemodynamic variables. Nitrates may be associated with a lower incidence of adverse effects after three hours compared with placebo. However, there is a lack of data to draw any firm conclusions concerning the use of nitrates in AHFS because current evidence is based on few low-quality studies.

Improvement in Resident Scholarly Output with Implementation of a Scholarly Activity Guideline and Point System.

Introduction: Ensuring high-quality scholarly output by graduate medical trainees can be a challenge. Within many specialties, including emergency medicine (EM), it is unclear what constitutes appropriate resident scholarly activity. We hypothesized that the quantity and quality of scholarly activity would improve with a clearer guideline, including a point system for eligible scholarly activities. Methods: A resident Scholarly Activity Guideline was implemented for EM residents in a university setting. The guideline consists of a point system in which point values, ranging from 1-10, are assigned to various types of scholarly activities. Residents must earn at least 10 points and present their work to meet their scholarly graduation requirement. We tracked scholarly activities for graduates from the classes of 2014-2020, with the guideline being implemented for the class of 2016. In a blind analysis, we compared median total points per resident, mean counts of the Boyer model of scholarship components per resident, and mean counts of significant scholarly output per resident before vs after the guideline was implemented. Significant scholarly output was defined as an implemented protocol, a research project with data collection and analysis, a research abstract presentation, or an oral abstract presentation. Results: Among 64 residents analyzed, 48 residents used the guideline. We found that median points per resident increased after the guideline was implemented (median, interquartile range: before 7 [7], after 11 [10, 13], P = 0.002). Post-guideline scholarly activities were found to represent more of Boyer's components of scholarship [mean before 0.81 [SD 0.40], mean after 1.52 [SD 0.71], mean difference 0.71, 95% confidence interval [CI] 0.332 ± 1.09, P < 0.001. There was no difference in the mean significant scholarly output per resident (mean before 1.38 [SD 1.02], mean after 1.02 [SD 1.00], mean difference 0.35, 95% CI 0.93 ± 0.23, P = 0.23). Conclusion: Implementation of a Scholarly Activity Guideline point system significantly increased the quantity and, by one of two measures, increased the quality of scholarly output in our program. Our point-based guideline successfully incorporated traditional and modern forms of scholarship that can be tailored to resident interests.

Pharmacologic prophylaxis for acute mountain sickness: a systematic shortcut review.

STUDY OBJECTIVE: Multiple studies have explored pharmacologic interventions to prevent acute mountain sickness. A systematic review of this subject published in 2000 found that both acetazolamide and dexamethasone were effective. Since 2000, a number of other agents have been reported to be beneficial. This EBEM review evaluates the most current evidence on this topic. METHODS: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, SPORTDiscus, Emergency Medical Abstracts, and ClinicalTrials.gov from 2000 to July 2011. Only randomized placebo-controlled trials with an N greater than or equal to 50 and systematic reviews were reviewed. Standard criteria for assessing trial quality were independently assessed by 2 authors. RESULTS: Seven hundred eighty-six citations were retrieved, of which 105 were reviewed in their entirety. Eleven randomized controlled trials and 1 systematic review appeared to meet inclusion criteria; however, 4 randomized controlled trials were excluded for high risk of bias. The remaining 7 randomized controlled trials investigated antioxidants, magnesium, sumatriptan, gabapentin, acetazolamide, and Ginkgo biloba. No trials studying dexamethasone met our criteria. Acetazolamide was associated with a reduction in acute mountain sickness symptoms, with a number needed to treat ranging from 8 to 3 among 3 trials and at doses ranging from 250 to 750 mg daily. Sumatriptan showed benefit in 1 trial (number needed to treat=4), as did gabapentin (number needed to treat=6). Antioxidants, magnesium, and G biloba were not efficacious. Reported adverse events included somnolence with gabapentin and paresthesias with acetazolamide. The systematic review affirmed our results but did not capture trials studying antioxidants, magnesium, sumatriptan, or gabapentin. CONCLUSION: Acetazolamide is effective for the prevention of acute mountain sickness but may be associated with paresthesias. Sumatriptan and gabapentin are beneficial but require further study.

Evidence-based emergency medicine: clinical synopsis. What is the appropriate antibiotic course for the treatment of urinary tract infections in children?

DATA SOURCES: The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966 to 2005, and EMBASE from 1988 to 2005, without language restriction. STUDY SELECTION: Randomized and quasi-randomized controlled trials comparing short-term (2 to 4 days) with standard (7 to 14 days) oral antibiotic therapy in children aged 3 months to 18 years, with culture-proven urinary tract infections. DATA EXTRACTION AND SYNTHESIS: Two authors independently assessed study quality and extracted data from included trials. A random-effects model was used to analyze data. Only randomized controlled trials were included; only 2 clearly described allocation concealment, whereas none of the trials defined appropriate blinding or used an intention-to-treat analysis.

Implementation of a health-literate patient decision aid for chest pain in the emergency department.

OBJECTIVE: The aim of this study was to investigate the implementation of a new health-literacy-tested patient decision aid for chest pain in Emergency Department (ED) patients. Outcomes included disposition, knowledge, decisional conflict and satisfaction prior to discharge. Patient health literacy was explored as a factor that may explain disparities in sub-group analysis of all outcomes. METHODS: A health-literacy adapted tool was deployed using a pre/post intervention design. Patients enrolled during the intervention period were given the adapted chest pain decision aid that was used in conversation with their emergency medicine physician to decide on their course of action prior to being discharged. RESULTS: A total of 169 participants were surveyed and used in the final analysis. Patients in the usual care group were 2.6 times more likely to be admitted for chest pain than patients in the intervention group. Knowledge scores were higher in the intervention group, while no significant differences were observed in decisional conflict and patient satisfaction, or by patient health literacy level. CONCLUSION AND PRACTICE IMPLICATIONS: Using the adapted chest pain decision tool in emergency medicine may improve knowledge and reduce admissions, while addressing known barriers to understanding related to patient health literacy.