Correlation of Physical Exam Findings with Fever in Patients with Skin and Soft Tissue Infections.

INTRODUCTION: The objectives of this study were to determine the prevalence of fever in adult ED patients with skin and soft tissue infections (SSTI) and to determine which, if any, physical exam, radiograph and laboratory test findings were associated with fever. METHODS: We conducted a prospective, observational study at an urban county trauma center of adults who presented to the ED for evaluation of suspected SSTI. ED providers measured area of erythema and induration using a tape measure, and completed data sheets indicating comorbid conditions and the presence or absence of physical exam findings. Fever was defined as any recorded temperature ≥ 38°C during the first six hours of ED evaluation. RESULTS: Of the 734 patients enrolled, 96 (13.1%) had fever. Physical and laboratory exam findings associated with the presence of a fever in multivariable logistic regression were the area of erythema, particularly the largest quartile of area of erythema, 144 - 5,000 cm2, (odd ratio [OR] = 2.9; 95% confidence interval [CI] [1.6 - 5.2]) and leukocytosis (OR = 4.4, 95% CI [2.7 - 7.0]). Bullae, necrosis, streaks, adenopathy, and bone involvement on imaging were not associated with fever. CONCLUSION: Fever is uncommon in patients presenting to the ED for evaluation of suspected SSTI. Area of erythema and leukocytosis were associated with fever and should be considered in future decision rules for the evaluation and treatment of SSTI.

Study of medical students' malpractice fear and defensive medicine: a "hidden curriculum?".

INTRODUCTION: Defensive medicine is a medical practice in which health care providers' primary intent is to avoid criticism and lawsuits, rather than providing for patients' medical needs. The purpose of this study was to characterize medical students' exposure to defensive medicine during medical school rotations. METHODS: We performed a cross-sectional survey study of medical students at the beginning of their third year. We gave students Likert scale questionnaires, and their responses were tabulated as a percent with 95% confidence interval (CI). RESULTS: Of the 124 eligible third-year students, 102 (82%) responded. Most stated they rarely worried about being sued (85.3% [95% CI=77.1% to 90.9%]). A majority felt that faculty were concerned about malpractice (55.9% [95% CI=46.2% to 65.1%]), and a smaller percentage stated that faculty taught defensive medicine (32.4% [95% CI=24.1% to 41.9%]). Many students believed their satisfaction would be decreased by MC and lawsuits (51.0% [95% CI=41.4% to 60.5%]). Some believed their choice of medical specialty would be influenced by MC (21.6% [95% CI=14.7% to 30.5%]), and a modest number felt their enjoyment of learning medicine was lessened by MC (23.5% [95% CI=16.4% to 32.6%]). Finally, a minority of students worried about practicing and learning procedures because of MC (16.7% [95% CI=10.7% to 25.1%]). CONCLUSION: Although third-year medical students have little concern about being sued, they are exposed to malpractice concerns and taught considerable defensive medicine from faculty. Most students believe that fear of lawsuits will decrease their future enjoyment of medicine. However, less than a quarter of students felt their specialty choice would be influenced by malpractice worries and that malpractice concerns lessened their enjoyment of learning medicine. [West J Emerg Med. 2014;15(3):293-298.].

NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma.

IMPORTANCE: Chest radiography (chest x-ray [CXR] and chest computed tomography [CT]) is the most common imaging in blunt trauma evaluation. Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation. OBJECTIVE To validate our previously derived decision instrument (NEXUS Chest) for identification of blunt trauma patients with very low risk of thoracic injury seen on chest imaging (TICI). We hypothesized that NEXUS Chest would have high sensitivity (>98%) for the prediction of TICI and TICI with major clinical significance. DESIGN, SETTING, AND PARTICIPANTS: From December 2009 to January 2012, we enrolled blunt trauma patients older than 14 years who received chest radiography in this prospective, observational, diagnostic decision instrument study at 9 US level I trauma centers. Prior to viewing radiographic results, physicians recorded the presence or absence of the NEXUS Chest 7 clinical criteria (age >60 years, rapid deceleration mechanism, chest pain, intoxication, abnormal alertness/mental status, distracting painful injury, and tenderness to chest wall palpation). MAIN OUTCOMES AND MEASURES: Thoracic injury seen on chest imaging was defined as pneumothorax, hemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion or laceration seen on radiographs. An expert panel generated an a priori classification of clinically major, minor, and insignificant TICIs according to associated management changes. RESULTS: Of 9905 enrolled patients, 43.1% had a single CXR, 42.0% had CXR and chest CT, 6.7% had CXR and abdominal CT (without chest CT), 5.5% had multiple CXRs without CT, and 2.6% had chest CT alone in the emergency department. The most common trauma mechanisms were motorized vehicle crash (43.9%), fall (27.5%), pedestrian struck by motorized vehicle (10.7%), bicycle crash (6.3%), and struck by blunt object, fists, or kicked (5.8%). Thoracic injury seen on chest imaging was seen in 1478 (14.9%) patients with 363 (24.6%) of these having major clinical significance, 1079 (73.0%) minor clinical significance, and 36 (2.4%) no clinical significance. NEXUS Chest had a sensitivity of 98.8% (95% CI, 98.1%-99.3%), a negative predictive value of 98.5% (95% CI, 97.6%.6-99.1%), and a specificity of 13.3% (95% CI, 12.6%-14.1%) for TICI. The sensitivity and negative predictive value for TICI with clinically major injury were 99.7% (95% CI, 98.2%-100.0%) and 99.9% (95% CI, 99.4%-100.0%), respectively. CONCLUSIONS AND RELEVANCE: We have validated the NEXUS Chest decision instrument, which may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.

What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?

BACKGROUND: Computed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant. STUDY OBJECTIVES: This study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel. METHODS: Patients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance. RESULTS: Of 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries-primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT. CONCLUSION: Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management.

Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments.

BACKGROUND: Although they infrequently lead to management changing diagnoses, chest x-rays (CXRs) are the most commonly ordered imaging study in blunt trauma evaluation. OBJECTIVES: To determine: 1) the reasons physicians order chest X-ray studies (CXRs) in blunt trauma assessments; 2) what injuries they expect CXRs to reveal; and 3) whether physicians can accurately predict low likelihood of injury on CXR. METHODS: At a Level I Trauma Center, we asked resident and attending physicians treating adult blunt trauma patients: 1) the primary reason(s) for getting CXRs; 2) what, if any, significant intrathoracic injuries (SITI) they expected CXRs to reveal; and 3) the likelihood of these injuries. An expert panel defined SITI as two or more rib fractures, sternal fracture, pulmonary contusion, pneumothorax, hemothorax, or aortic injury on official CXR readings. RESULTS: There were 484 patient encounters analyzed--65% of participating physicians were residents and 35% were attendings; 16 (3.3%) patients had SITI. The most common reasons for ordering CXRs were: "enough concern for significant injury" (62.9%) and belief that CXR is a "standard part of trauma work-up" (24.8%). Residents were more likely than attendings to cite "standard trauma work-up" (mean difference = 13.5%, p = 0.003). When physicians estimated a < 10% likelihood of SITI on CXR, 2.1% (95% confidence interval [CI] 1.0-4.1%) of patients had SITI; when they predicted a 10-25% likelihood, 5.7% (95% CI 1.2-15.7%) had SITI; and when they predicted a > 25% likelihood, 9.1% (95% CI 3.0-20.0%) had SITI. CONCLUSIONS: Physicians order CXRs in blunt trauma patients because they expect to find injuries and believe that CXRs are part of a "standard" work-up. Providers commonly do not expect CXRs to reveal SITI. When providers estimated low likelihood of SITI, the rate of SITI was very low.

Derivation of a decision instrument for selective chest radiography in blunt trauma.

BACKGROUND: To derive a decision instrument (DI) that identifies patients who have virtually no risk of significant intrathoracic injury (SITI) visible on chest radiography and, therefore, no need for chest imaging. METHODS: This is a prospective observational study. At three Level 1 trauma centers, physicians caring for blunt trauma patients aged >14 years were asked to record the presence or absence of 12 clinical criteria before viewing chest imaging results. SITI was defined as pneumothorax, hemothorax, aortic/great vessel injury, two or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion on official radiograph readings. The κ (interrater reliability) and screening performance of individual criteria were determined. By using recursive partitioning, the most highly sensitive combination of criteria for SITI was derived. RESULTS: Of the 2,628 subjects enrolled, 271 (10.3%) were diagnosed with a total of 462 SITIs, with rib fractures (73%), pneumothorax (38%), and pulmonary contusion (29%) as the most common injuries. Chest pain and chest wall tenderness had the highest sensitivity for SITI (65%). The DI of chest pain, distracting injury, chest wall tenderness, intoxication, age >60 years, rapid deceleration, and altered alertness/mental status had the following screening performance: sensitivity 99.3% (95% confidence interval [CI], 97.4-99.8), specificity 14.0% (95% CI, 12.6-15.4), negative predictive value 99.4% (95% CI, 97.8-99.8), and positive predictive value 11.7% (95% CI, 10.5-13.1). All seven criteria in the DI met the predetermined cut off for acceptable κ (range, 0.51-0.81). CONCLUSIONS: We derived a DI consisting of seven clinical criteria that can identify SITI in blunt trauma patients with extremely high sensitivity. If validated, this instrument will allow for safe, selective chest imaging with potential resource savings.

A pilot study to develop a prediction instrument for endocarditis in injection drug users admitted with fever.

OBJECTIVE: Seeking to evaluate the feasibility of a prediction instrument for endocarditis in febrile injection drug users (IDUs), we determined (1) the frequency percentage of IDUs admitted with fever diagnosed with endocarditis and (2) whether individual or combinations of emergency department (ED) clinical criteria (patient history, physical examination findings, and laboratory tests) are associated with endocarditis in IDUs admitted to rule out endocarditis. METHODS: The ED and inpatient charts of all IDUs with a diagnosis of rule out endocarditis admitted at 3 urban hospitals in 2006 were reviewed. Screening performance of individual criteria was determined, and the most sensitive combination of criteria was derived by classification tree analysis. RESULTS: Of 236 IDUs admitted with fever, 20 (8.5%) were diagnosed with endocarditis. Lack of skin infection, tachycardia, hyponatremia, pneumonia on chest radiograph, history of endocarditis, thrombocytopenia, and heart murmur had the best screening performance. The classification tree-derived best criteria combination of tachycardia, lack of skin infection, and cardiac murmur had a sensitivity of 100% (95% confidence interval, 84%-100%) and negative predictive value of 100% (95% confidence interval, 88%-100%). CONCLUSIONS: Using ED clinical criteria, a multicenter prospective study to develop an instrument for endocarditis prediction in febrile IDUs is feasible, with an estimated target enrollment of 588 patients.

Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department.

STUDY OBJECTIVES: We determine whether homeless persons present to the emergency department (ED) for food, shelter, and safety and whether the availability of alternative sites for provision of these needs might decrease their ED presentations. METHODS: In July to August 2006 and February to March 2007, adult homeless and control (not homeless) patients, who self-presented (nonambulance) to an urban county ED, were interviewed with a structured instrument. RESULTS: One hundred ninety-one homeless and 63 control subjects were enrolled. Homeless persons spent a mean (standard deviation [SD]) of 3.5 (3.0) nights/week sleeping without shelter and ate a mean (SD) of 2.1 (1.1) meals per day; 51% stated they had been assaulted on the street. On an analog scale, in which 0=no problem and 10=worst possible problem in their daily lives, the mean (SD) homeless subject responses for hunger, lack of shelter, and safety were 4.8 (3.7), 6.1 (4.2), and 5.1 (4.0), respectively. More homeless (29% [55/189]) than not homeless (10% [6/63]) persons replied that hunger, safety concerns, and lack of shelter were reasons they came to the ED (Delta=20%; 95% confidence interval 10% to 29%). If offered a place that would provide food, shelter, and safety at all times, 24% of homeless subjects stated they would not have come to the ED. CONCLUSION: Homeless persons commonly come to the ED for food, shelter, and safety. Provision of these subsistence needs at all times at another site may decrease their ED presentations.

A prospective study of primary surrogate decision makers' knowledge of intensive care.

OBJECTIVES: We sought to determine 1) primary surrogate decision makers' knowledge of their family members' intensive care and resuscitation status; 2) whether characteristics such as low education level and lack of English language fluency were associated with poor knowledge of intensive care; 3) surrogates' ratings of intensive care unit team communication; and 4) barriers to communication. DESIGN: Prospective study. SETTING: Medical intensive care units of a county hospital located in an urban area. SUBJECTS: Primary surrogate decision makers of all adults admitted >48 hrs from August 2005 to April 2006, enrolled sequentially. INTERVENTIONS: Using a structured instrument consisting of visual analog scales, Likert-type questions, and an objective assessment of knowledge of family member's current intensive care, we interviewed primary surrogate decision makers after they had at least one bedside patient visit. MEASUREMENTS AND MAIN RESULTS: Of eligible primary surrogate decision makers, 81 were enrolled; 96% had spoken to hospital staff. On a scale in which 0 indicated the worst possible communication and 10 indicated the best possible communication, primary surrogate decision makers' mean (SD) ratings were 8.6 (2.3) for nurses and 7.8 (2.8) for doctors. Forty-seven percent of primary surrogate decision makers met the predetermined criteria for good understanding with no significant difference between college-educated (44%) and non-college-educated (50%) primary surrogate decision makers; more non-English-speaking primary surrogate decision makers (63%), however, had poor understanding than English speakers (40%) (mean difference in proportions 23%, 95% confidence interval 1% to 46%). Seventy-three percent (95% confidence interval 61-82) of primary surrogate decision makers correctly identified their family members' resuscitation orders (do-not-resuscitate, limited resuscitation, or full code). The primary reasons cited for poor communication/understanding were as follows: not given enough time (21%), explanations too complicated (16%), and too emotionally upset (5%). CONCLUSIONS: Although most primary surrogate decision makers reported good understanding and excellent staff communication, almost half had poor understanding on objective testing; non-English speakers were more likely to have poor understanding.