Photodiagnostic services in the UK and Republic of Ireland: a British Photodermatology Group Workshop Report.

BACKGROUND: Photodiagnostic investigations are essential for the accurate diagnosis of abnormal cutaneous photosensitivity and provide important information for the management of patients with photodermatoses (cutaneous photosensitivity disorders). Although photodiagnosis has been undertaken since the early 1970s, specialist services in the United Kingdom (UK) and Republic of Ireland are limited and there is no formal guidance on diagnostic approach. Indeed, there is a limited literature in this area of methodology and diagnostic practice. OBJECTIVES: The primary objective was to undertake a British Photodermatology Group Workshop to review the role and activities of specialist centres in the UK and Republic of Ireland in order to ascertain whether there were consensus practices. Secondary objectives were to identify key priorities for service, training and research. METHODS: An initial detailed survey review of current activities was undertaken prior to the Workshop and data from this survey were used to inform discussion at the Workshop, which was attended by key photodermatology experts from the UK and Republic of Ireland. RESULTS/CONCLUSIONS: We have undertaken a detailed review of current Photodiagnostic Services in the UK and Republic of Ireland and report on our findings from the 12 centres and we have identified key areas of consensus practice. This is an important step in the process of standardising and optimising procedures and protocols and defining minimum clinical standards for photodiagnostic investigations, which are of such diagnostic importance in Dermatology.

Unpredicted late-, new-onset thrombocytopenia and hypofibrinogenemia in Fab antivenom-treated rattlesnake envenomation.

The use of Fab antivenom (Crotalidae Polyvalent Immune Fab (Ovine) (CroFab); Boston Scientific) against North American Crotalidae envenomation is associated with the development of late- (≥4 days post-envenomation), new-onset of hematological abnormalities. Although attempts have been made to identify predictive indicators during the acute phase of an envenomation, of patients who are not at-risk of late-, new-onset of hematological abnormalities, there has been at least one prior report of a patient who developed thrombocytopenia that was unpredicted by current indicators. We add three cases of unpredicted, late-, new-onset of hematological abnormalities in patients with Fab-treated rattlesnake bite.

Comparison of F(ab')2 and Fab antivenoms in rattlesnake envenomation: First year's post-marketing experience with F(ab')2 in New Mexico.

Two antivenoms are available for rattlesnake envenomations in the U.S., Fab (CroFab®, BTG, UK), and F(ab')2 (Anavip®, Bioclon, Mexico) antivenom (AV) with F(ab')2AV released in October 2018. The F(ab')2AV Phase 3 comparative clinical trial demonstrated similar efficacy in treating venom-caused hematologic toxicity, similar rates of Types I and III hypersensitivity reactions, and a lower rate of recurrent hematological effects than FabAV. We hypothesized that a post-marketing, comparative study of effectiveness and rates of hypersensitivity reactions in treating rattlesnake envenomations in New Mexico would demonstrate similar outcomes. Patients eligible for the study presented to a New Mexico healthcare facility between May and October 2019 and were known/suspected to have a rattlesnake bite. Exclusion criteria for antivenom comparison were those with a dry bite, lost to follow-up, or late presentation. All cases were included for patient/bite demographics, initial local control, hematological control, number of maintenance/control doses, development of persistent, recurrent or late-, new-onset hematologic effects, and hypersensitivity reactions. We used Fisher's exact tests for analysis and 0.05 cutoff to determine significance. There were 54 rattlesnake-bitten patients in New Mexico with 17 excluded for comparison of antivenom because of dry bites, loss to follow-up, and one case of late presentation. Thirty-seven patients remained for comparative analysis between F(ab')2AV (n = 11) and FabAV (n = 26). There were no significant demographic differences between F(ab')2 and Fab-treated patients. No patient had a Type I hypersensitivity reaction. No rescue doses were given. The rate of recurrent, persistent or late-, new-onset of hematologic effects was 0% with F(ab')2AV and 29% with FabAV. No patient was readmitted. No patient had bleeding complications. Type III hypersensitivity reactions were similar between F(ab')2AV (36%) and FabAV (25%). The results of our study are consistent with the Phase 3 clinical comparative trial and indicate no significant differences in safety or effectiveness between FabAV and F(ab')2AV. F(ab')2AV offers the advantages of not requiring maintenance doses and may have a lower rate of late hematologic effects in treating rattlesnake envenomations.

Femoral neck stress fractures.

Femoral neck stress fractures are unusual but not rare athletic injuries. In one large series they accounted for 5% of all stress fractures. Early recognition of the signs and symptoms of this injury is important, as objective findings are often delayed. The potential problems from this fracture are serious. The aetiology includes repeated force above a certain load without internal bone response time. Loss of shock absorption due to muscle fatigue and limitation of ankle motion by boots or splints may also play a role. The diagnosis is based on the finding of groin pain and radiographic testing, which often requires plain films and bone scintigraphy. Regular radiographic findings present in stages progressing from a normal film through sclerosis to a disruption of the cortex and displacement. Bone scintigraphy may be positive 2 or more weeks before plain film changes are present. Classification schemes follow the radiographic changes. A classification system and treatment plan may be based on 3 categories of these fractures--compression side, tension side and displaced femoral neck fracture. Treatment ranges from rest with early symptoms to surgical stabilisation for any widening of cortical cracks and/or displaced fractures. Prompt diagnosis and carefully supervised treatment is the key to preventing displacement. Prolonged disability secondary to pain, nonunion or avascular necrosis is associated with displacement of the femoral neck stress fracture.

Guns and knives in New Mexico: patterns of penetrating trauma, 1978-1993.

OBJECTIVE: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data. METHODS: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978-1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults. RESULTS: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased. CONCLUSIONS: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.

Repeat ambulance use by pediatric patients.

OBJECTIVE: To compare pediatric patients transported by ambulance on more than one occasion (repeat) with those transported only once. METHODS: The authors analyzed pediatric (patient < 21 years old) transports for 1992-1995 by the ambulance service that provides 99% of transports for a non-innercity metropolitan area. Repeat transports were compared with single transports with regard to patient age, gender, chief complaint, and payment source. RESULTS: There were 17,448 transports involving 15,168 patients. Nearly half (49.0%) of the repeat transports involved patients in the oldest age category, 17 to 20.9 years, contrasted with 38.0% of single transports (p < 0.00001). Females comprised 51.4% of the repeat transports and 48.5% of the single transports (p = 0.0008). Traumatic complaints accounted for one-third (33.0%) of the repeat transports and half (51.1%) of the single transports (p < 0.0001). Chief complaints of the patients with repeat transports were more likely to be seizure, assault, abdominal pain, and respiratory problems, and less likely to be falls and motor vehicle-related complaints, than chief complaints of the patients with single transports (p < 0.0001). More than one-third (39.0%) of the repeat transports were funded by Medicaid, in contrast with 19.8% of the single transports (p < 0.0001). CONCLUSIONS: Compared with single transports, repeat transports were more likely to involve patients more than 16 years of age, female, and with a chief complaint of seizure, assault, abdominal pain, or respiratory distress, and more likely to be funded by public insurance (Medicaid). Repeat pediatric transports warrant further investigation. This information may be useful in designing interventions targeted at reducing emergencies and hence ambulance use.

Relationships between ambulance transports for alcohol intoxication and assault.

OBJECTIVE: To evaluate the association between ambulance transports for assault and those for alcohol intoxication. METHODS: A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault. RESULTS: Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001). CONCLUSIONS: Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.

Disturbing trends: the epidemiology of pediatric emergency medical services use.

OBJECTIVE: To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints. METHODS: An out-of-hospital database for the primary transporting service in an urban area was analyzed for patients 0-20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed. RESULTS: There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0-11-year-olds (4.2%); 11-16-year-olds (17.5%); and 17-20-year-olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group. CONCLUSIONS: A substantial proportion of pediatric emergency medical services transports are for high-risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.

Femoral neck stress fractures.

Fifty-four femoral neck stress fractures were studied prospectively to evaluate treatment methods. Fifty-four fractures in 49 patients were identified in a 4 year prospective study that included 1,049 stress fractures of all types. From our evaluation of treatment methods, a modification of existing classification systems was developed based on radiographic findings and treatment. Differences from earlier studies were noted in racial diversity, in nonprogression of tension-side fractures, and in return to function.

Farm-related injury mortality in New Mexico, 1980-91.

To compare the epidemiology of farm with non-farm occupational injury deaths, we reviewed state medical examiner data for all occupational injury deaths in New Mexico from 1980 to 1991. We identified 53 farm-related injury deaths for a rate of 21.3 per 100,000 worker-years. Farm workers were four times more likely than non-farm workers to die from occupational injury. American Indians had the highest farm injury death rate. Farm decedents were older than non-farm decedents (t498 = 6.29, p < 0.0001). Half of the farm decedents were 50 years of age or older; one-third were 60 years of age or older. Crush injuries accounted for half of all farm injury deaths including 18 of 23 motor vehicle deaths, half of these involving a tractor rollover. One in six farm injury deaths were from electrocution: one in five involved alcohol. Our study indicates that New Mexico has high farm-related injury mortality related to tractor use, alcohol intoxication, farm animals, and exposure to electricity. American Indians and older males are especially susceptible to these factors.

One-week survey of pain intensity on admission to and discharge from the emergency department: a pilot study.

The purpose of this pilot study was to determine the incidence and severity of pain intensity in patients 4 years of age and older presenting to the noncritical ward of the emergency department (ED). All patients presenting to the ED of two university hospitals (one general, one pediatric) who were triaged to the noncritical ward during 12 h/day for 1 week were asked to report their pain intensity on admission and again asked just prior to discharge home. The chromatic analogue scale with a range of 0-10 was used as the measure of pain intensity. Pain reports were obtained from half of all patients (58% of adults, 47% of children) admitted during the study week. Approximately one-third (29% of adults and 31% of children) reported no pain on admission, but half of both age groups (52% of adults, 48% of children) reported pain 4/10 or higher. On discharge, one-third of both groups reported pain 4/10 or higher. Eleven percent of both adults and children reported pain 1.5/10 or higher on discharge than on admission. Adult patients with musculoskeletal complaints had the highest pain intensities (mean score admission-discharge, 5.6-4.7/10; other categories, <5). For children, neurological complaints, exclusively headaches, were highest (mean score admission-discharge, 4.8-5.2/10; other categories, <5). Children accompanied by their mothers alone had poorer pain improvement (no change) than children accompanied by their fathers alone or both parents (score improvement of 1). It thus appears that pain is a problem for the majority of patients presenting to the ED. An important percentage of patients leave the ED with more pain than when they arrived. Further investigation is warranted to determine factors predicting poor pain resolution during an ED visit.

Moving targets: bicycle-related injuries and helmet use among university students.

We conducted a cross-sectional study to evaluate bicycling habits and helmet use in a sample of university students in a southwestern state university. Thirty-one of 100 students in our sample owned bicycle helmets; of these, 17 (54.8%) wore helmets during most (more than three fourths) of their bicycle trips. Almost half of the students reported that more than 25% of their bicycling was done in heavy traffic but they rarely used bicycle trails. Sixty-five students in the sample had sustained at least one minor injury during the previous 5 years, and 18 had been hospitalized as a result of bicycle-related injuries. We found no substantial differences between male and female subjects in bicycle-related hospitalizations, although male subjects were more likely to sustain minor injuries than were females. Helmet ownership was most strongly associated with previous injury experience, especially hospitalization resulting from bicycling injuries (OR = 3.6; 95% CI = 1.3, 10.1). We also observed an association between helmet ownership and possession of insurance coverage for bicycling injuries (OR = 3.0; 95% CI = 1.2, 7.6). Ethnicity was a factor in helmet ownership--helmets were owned by 26 of 69 (37.7%) of non-Hispanic whites, in contrast to 1 of 24 (4.2%) of all other ethnic groups combined. Our survey data suggest that perceived risk is an important factor in bicyclists' use of safety helmets.

Guns, alcohol, and intimate partner violence: the epidemiology of female suicide in New Mexico.

Suicide is among the leading causes of death in the United States, and in women the second leading cause of injury death overall. Previous studies have suggested links between intimate partner violence and suicide in women. We examined female suicide deaths to identify and describe associated risk factors. We reviewed all reports from the New Mexico Office of the Medical Investigator for female suicide deaths occurring in New Mexico from 1990 to 1994. Information abstracted included demographics, mechanism of death, presence of alcohol/drugs, clinical depression, intimate partner violence, health problems, and other variables. Annual rates were calculated based on the 1990 census. The New Mexico female suicide death rate was 8.2/100,000 persons per year (n = 313), nearly twice the U.S. rate of 4.5/100,000. Non-Hispanic whites were overrepresented compared to Hispanics and American Indians. Decedents ranged in age from 14 to 93 years (median = 43 years). Firearms accounted for 45.7% of the suicide deaths, followed by ingested poisons (29.1%), hanging (10.5%), other (7.7%), and inhaled poisons (7.0%). Intimate partner violence was documented in 5.1% of female suicide deaths; in an additional 22.1% of cases, a male intimate partner fought with or separated from the decedent immediately preceding the suicide. Nearly two-thirds (65.5%) of the decedents had alcohol or drugs present in their blood at autopsy. Among decedents who had alcohol present (34.5%), blood alcohol levels were far higher among American Indians compared to Hispanics and non-Hispanic Whites (p = .01). Interpersonal conflict was documented in over 25% of cases, indicating that studies of the mortality of intimate partner violence should include victims of both suicide and homicide deaths to fully characterize the mortality patterns of intimate partner violence.

Arthroscopy. When and where to use it.

When clinical examination and noninvasive techniques have not provided the diagnosis for intraarticular problems, arthroscopy of certain joints may be useful. The instruments and techniques of the 1980s have made diagnosis and operative treatment with arthroscopy possible for a variety of intraarticular lesions. The advantages of minimally invasive surgery that can often be done on an outpatient basis make this an ideal technique for many patients. Clinical findings may be confirmed or treated by arthroscopy with minimal discomfort, reduced costs, and shortened recovery period.

Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi.

Cancer of the oesophagus is the 6th most common cancer in Malawi. Nationwide only three hospitals are able to perform oesophagectomies, and there is no radiotherapy or chemotherapy available. Owing to late presentation of the patients (sometimes in combination with co-morbidities such as HIV/AIDS or tuberculosis) the vast majority of patients are not suitable for surgery. Self-expanding metal stents (SEMS) of the oesophagus provide a suitable palliative option to improve the quality of life for patients. This project took a nationwide approach, raising funds for both technical equipment and training of endoscopists and nursing staff throughout Malawi.

Clinical and economic impact of contaminated blood cultures within the hospital setting.

Blood cultures have an important role in the diagnosis of serious infections, although contamination of blood cultures (i.e. false-positive blood cultures) is a common problem within the hospital setting. The objective of the present investigation was to determine the impact of the false-positive blood culture results on the following outcomes: length of stay, hotel costs, antimicrobial costs, and costs of laboratory and radiological investigation. A retrospective case-control study design was used in which 142 false-positive blood culture cases were matched with suitable controls (patients for whom cultures were reported as true negatives). The matching criteria included age, comorbidity score and month of admission to the hospital. The research covered a 13-month period (July 2007 to July 2008). The findings indicated that differences in means, between cases and controls, for the length of hospital stay and the total costs were 5.4 days [95% CI (confidence interval): 2.8-8.1 days; P<0.001] and £5,001.5 [$7,502.2; 95% CI: £3,283.9 ($4,925.8) to £6,719.1 ($10,078.6); P<0.001], respectively. Consequently, and considering that 254 false-positive blood cultures had occurred in the study site hospital over a one-year period, patients with false-positive blood cultures added 1372 extra hospital days and incurred detrimental additional hospital costs of £1,270,381 ($1,905,572) per year. The findings therefore demonstrate that false-positive blood cultures have a significant impact on increasing hospital length of stay, laboratory and pharmacy costs. These findings highlight the need to intervene to raise the standard of blood-culture-taking technique, thus improving both the quality of patient care and resource use.