Alloplastic Facial Implants.

As the face ages, there is thinning of the epidermis, volume loss and rearrangement of the soft tissues, and malabsorption of the skeletal framework. It is essential to have a thorough understanding of the aging process for successful facial augmentation and rejuvenation. Alloplastic implants can be used to provide a long-lasting solution for augmentation of skeletal deficiencies, restoration of facial irregularities, and rejuvenation of the face. In this study, we describe the ideal implant characteristics along with the advantages and disadvantages of various implant materials. We also present techniques in nasal and premaxillary augmentation, midface augmentation, mandibular augmentation, and lip augmentation. Additionally, computer-aided design and manufacturing as well as bioprinting are emerging technologies with growing applications in facial plastic and reconstructive surgery. We discuss their role in the creation of patient-specific custom implants. The overall goal of facial rejuvenation is to address multiple aspects of the facial aging process including deficiencies in the skin, soft tissues, and skeletal framework. The use of alloplastic implants alone or synergistically with additional surgical procedures can restore a wide range of anatomical deficits that occur with age.

Repeat CT Performed Within One Month of CT Conducted in the Emergency Department for Abdominal Pain: A Secondary Analysis of Data From a Prospective Multicenter Study.

OBJECTIVE: The purpose of this study is to determine both the frequency of repeat CT performed within 1 month after a patient visits the emergency department (ED) and undergoes CT evaluation for abdominal pain and the frequency of worsened or new CT-based diagnoses. SUBJECTS AND METHODS: Secondary analysis was performed on data collected during a prospective multicenter study. The parent study included patients who underwent CT in the ED for abdominal pain between 2012 and 2014, and these patients constituted the study group of the present analysis. The proportion of patients who underwent (in any setting) repeat abdominal CT within 1 month of the index CT examination was calculated. For each of these patients, results of the index and repeat CT scans were compared by an independent panel and categorized as follows: no change (group 1); same process, improved (group 2); same process, worse (group 3); or different process (group 4). The proportion of patients in groups 1 and 2 versus groups 3 and 4 was calculated, and patient and ED physician characteristics were compared. RESULTS: The parent study included 544 patients (246 of whom were men [45%]; mean patient age, 49.4 years). Of those 544 patients, 53 (10%; 95% CI, 7.5-13%) underwent repeat abdominal CT. Patients' CT comparisons were categorized as follows: group 1 for 43% of patients (23/53), group 2 for 26% (14/53), group 3 for 15% (8/53), and group 4 for 15% (8/53). New or worse findings were present in 30% of patients (16/53) (95% CI, 19-44%). When patients with findings in groups 1 and 2 were compared to patients with findings in groups 3 and 4, no significant difference was noted in patient age (p = 0.25) or sex (p = 0.76), the number of days between scans (p = 0.98), and the diagnostic confidence of the ED physician after the index CT scan was obtained (p = 0.33). CONCLUSION: Short-term, repeat abdominal CT was performed for 10% of patients who underwent CT in the ED for abdominal pain, and it yielded new or worse findings for 30% of those patients.

Embolization of a contraceptive implant into the pulmonary vasculature in an adolescent female.

Nexplanon is a long-acting 4cm radio-opaque rod shaped contraceptive device implanted in the subdermal layer of the inner, upper arm. Complications from implantation are uncommon and mostly local and minor, including infection at the implantation site with resulting cellulitis or abscess, hematoma, abnormal scar formation, or local damage to nerves and blood vessels. Intravascular insertion is estimated to be at 1.3 per million Nexplanon implants, and migration and embolization is a rare complication of this device. We present a case report of a 16year old female who presented to the pediatric emergency department with subjective dyspnea and an embolized contraceptive device within a subsegmental branch of the left lower lobe pulmonary artery. After discussion with consultants, interventional radiology was able to successful retrieve the device without complication.

Unusual Complications From Babesia Infection: Splenic Infarction and Splenic Rupture in Two Separate Patients.

BACKGROUND: Babesiosis is a zoonotic parasitic infection transmitted by the tick, Ixodes scapularis. Splenic infarct and rupture are infrequent complications of Babesia parasitemia, and have not been previously reported in the emergency medicine literature. CASE REPORT: We present two separate cases seen within 1 month at our institution: a case of splenic rupture and another case of splenic infarction due to Babesia parasitemia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Babesia infection in humans is increasingly prevalent in both the United States and worldwide, and clinical manifestations can range from subclinical to fulminant infections. An unusual but potentially fatal complication of babesiosis is splenic infarctions and rupture. Due to the endemicity of this parasite, a careful history and level of suspicion will enable the emergency physician to consider and test for babesiosis in patients with splenic injuries and without obvious traditional risk factors.

Role of CT in the Diagnosis of Nonspecific Abdominal Pain: A Multicenter Analysis.

OBJECTIVE: The objective of our study was to determine whether specific patient and physician factors-known before CT-are associated with a diagnosis of nonspecific abdominal pain (NSAP) after CT in the emergency department (ED). MATERIALS AND METHODS: We analyzed data originally collected in a prospective multicenter study. In the parent study, we identified ED patients referred to CT for evaluation of abdominal pain. We surveyed their physicians before and after CT to identify changes in leading diagnoses, diagnostic confidence, and admission decisions. In the current study, we conducted a multiple regression analysis to identify whether the following were associated with a post-CT diagnosis of NSAP: patient age; patient sex; physicians' years of experience; physicians' pre-CT diagnostic confidence; and physicians' pre-CT admission decision if CT had not been available. We analyzed patients with and those without a pre-CT diagnosis of NSAP separately. For the sensitivity analysis, we excluded patients with different physicians before and after CT. RESULTS: In total, 544 patients were included: 10% (52/544) with a pre-CT diagnosis of NSAP and 90% (492/544) with a pre-CT diagnosis other than NSAP. The leading diagnoses changed after CT in a large proportion of patients with a pre-CT diagnosis of NSAP (38%, 20/52). In regression analysis, we found that physicians' pre-CT diagnostic confidence was inversely associated with a post-CT diagnosis of NSAP in patients with a pre-CT diagnosis other than NSAP (p = 0.0001). No other associations were significant in both primary and sensitivity analyses. CONCLUSION: With the exception of physicians' pre-CT diagnostic confidence, the factors evaluated were not associated with a post-CT diagnosis of NSAP.

Insights into the Functional Anatomy Behind the PREEMPT Injection Paradigm: Guidance on Achieving Optimal Outcomes.

OBJECTIVE: To provide clinically relevant insights on the identification of the muscles and techniques involved in the safe and effective use of onabotulinumtoxinA for chronic migraine prophylaxis. BACKGROUND: Although guidance on the use of onabotulinumtoxinA for chronic migraine is available, based on the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program, clinical experience has shown that insufficient understanding of the anatomy and function of the head and neck muscles may lead to undesirable outcomes and suboptimal efficacy. DESIGN/METHODS: Each muscle involved in the standardized PREEMPT injection paradigm is reviewed with a thorough description of each muscle's anatomy (ie, muscle description and location, innervation, vascular supply) and function. Key insights based on clinical experience are also provided to help improve outcomes. RESULTS: The identification of the muscles in the PREEMPT injection paradigm should be based on each patient's unique anatomy and injections should be administered using the advised techniques. A thorough examination of the patient prior to treatment is also critical to determine if any preexisting conditions may increase the risk for unwanted outcomes and appropriate expectations should be communicated. CONCLUSIONS: Thorough knowledge of the functional anatomy of the muscles involved in the standardized PREEMPT injection paradigm is critical to achieve the efficacy and safety observed in clinical trials. In addition, it is important to assess a patient's baseline condition to anticipate the risk for unwanted outcomes that may result from treatment.

RSV in adult ED patients: Do emergency providers consider RSV as an admission diagnosis?

BACKGROUND: Respiratory Syncytial Virus (RSV) has been recognized for over half a century as a cause of morbidity in infants and children. Over the past 20years, data has emerged linking RSV as a cause of illness in adults resulting in 177,000 annual hospitalizations and up to 14,000 deaths among older adults. OBJECTIVE: Characterize clinical variables in a cohort of adult RSV patients. We hypothesize that emergency physicians do not routinely consider RSV in the differential diagnosis (DDx) of influenza like illness. METHODS: Observational study of all adult inpatients, age≥19, with a positive RSV swab ordered within 48h of their hospital visit, including their emergency department (ED) visit, and who initially presented to a university affiliated urban 100,000 annual visit emergency department from 2007 to 2014. A data collection form was created, and a single trained clinical research assistant abstracted demographic, clinical variables. ED providers were given credit for RSV DDx if an RSV swab was ordered as part of the diagnostic ED workup. RESULTS: 295 consecutive inpatients (mean age=66.5years, range, 19-97, 53% male) were RSV positive during the 7-year study period. 207 cases (70%) were age≥60. 76 (26%) had fever, 86 (29%) had O2sat <92% and 145 (49%) had wheezing. 279 patients required admission, 30 needed ICU stay and overall mortality was 12 patients (4%). Age≥60 was associated with overall mortality (p=0.09). There were 106 (36%) immunocompromised patients (23% transplant, 40% cancer, 33% steroid use) in the cohort. A diagnosis of RSV was considered in the ED in 105 (36%) of patients. Being immunocompromised, having COPD/asthma, O2sat <92, or wheezing did not alert the ED provider to order an RSV test. CONCLUSION: Adults can harbor RSV as this can lead to significant mobility and mortality, especially in individuals who are over the age of 60. RSV is not being considered in the DDx diagnosis, and this was especially surprising in the transplant/immunocompromised subgroups. Given antiviral treatment options, educational efforts should be undertaken to raise awareness of RSV in adults.

CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making.

PURPOSE: To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings. MATERIALS AND METHODS: This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics. RESULTS: Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P < .0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P < .0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics. CONCLUSION: Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.

Solid Midfacial Implants: When Fillers Are Not Enough.

The aging process results in volumetric changes on multiple levels of the face including the skin, soft tissue, and underlying facial skeleton. Malar and mandibular augmentation with facial fillers and alloplastic implants are two treatment options used to achieve the goal of volume enhancement. Noninvasive modalities have become increasingly popular due to the availability of office-based options that require a limited understanding of facial aesthetics, a basic grasp of the mechanisms behind the aging process, and no level of surgical expertise or training. It is important, however, to understand the limitations and appropriate use of each technique, surgical and nonsurgical, either as a sole modality or in conjunction with each other to attain optimal aesthetic results. Although minimally invasive soft-tissue augmentation procedures such as fillers offer midface treatment options, alloplastic implants provide a stable support platform or scaffolding for skeletal and soft-tissue augmentation that fillers alone cannot often provide. A multilevel understanding of facial aesthetics must include the facial skeletal architecture and foundation that it provides for proper soft-tissue draping and contour. Alloplastic implants remain the standard for skeletal augmentation and remain the mainstay when fillers are not sufficient for midface augmentation.

African tick-bite fever in a returning traveler.

BACKGROUND: African tick bite fever (ATBF) is an emerging infection endemic to sub-Saharan Africa and increasingly noted in travelers to the region. CASE REPORT: We present a case of ATBF in a 63-year-old man who presented with complaints of a rash and fever to the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rickettsial diseases are increasingly common and are seen on every continent except Antarctica. Many factors are contributing to their prevalence, and they have become the second most common cause of fever behind malaria in the traveler returning from Africa. Due to the global distribution of rickettsial diseases, as well as increasing international travel, emergency physicians might encounter ill and febrile travelers. A careful travel history and examination will enable the emergency physician to consider spotted fever group rickettsial diseases in their differential diagnosis for single and multiple eschars.

Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial.

BACKGROUND: Community-associated methicillin-resistant S. aureus (CA-MRSA) is the most common organism isolated from purulent skin infections. Antibiotics are usually not beneficial for skin abscess, and national guidelines do not recommend CA-MRSA coverage for cellulitis, except purulent cellulitis, which is uncommon. Despite this, antibiotics targeting CA-MRSA are prescribed commonly and increasingly for skin infections, perhaps due, in part, to lack of experimental evidence among cellulitis patients. We test the hypothesis that antibiotics targeting CA-MRSA are beneficial in the treatment of cellulitis. METHODS: We performed a randomized, multicenter, double-blind, placebo-controlled trial from 2007 to 2011. We enrolled patients with cellulitis, no abscesses, symptoms for <1 week, and no diabetes, immunosuppression, peripheral vascular disease, or hospitalization (clinicaltrials.gov NCT00676130). All participants received cephalexin. Additionally, each was randomized to trimethoprim-sulfamethoxazole or placebo. We provided 14 days of antibiotics and instructed participants to continue therapy for ≥1 week, then stop 3 days after they felt the infection to be cured. Our main outcome measure was the risk difference for treatment success, determined in person at 2 weeks, with telephone and medical record confirmation at 1 month. RESULTS: We enrolled 153 participants, and 146 had outcome data for intent-to-treat analysis. Median age was 29, range 3-74. Of intervention participants, 62/73 (85%) were cured versus 60/73 controls (82%), a risk difference of 2.7% (95% confidence interval, -9.3% to 15%; P = .66). No covariates predicted treatment response, including nasal MRSA colonization and purulence at enrollment. CONCLUSIONS: Among patients diagnosed with cellulitis without abscess, the addition of trimethoprim-sulfamethoxazole to cephalexin did not improve outcomes overall or by subgroup. CLINICAL TRIALS REGISTRATION: NCT00676130.

Epidural bupivacaine administration after infiltration of liposomal bupivacaine for transversalis fascia plane block: A case report.

Extended-release liposomal bupivacaine is frequently used in surgical infiltration for postoperative pain control. The manufacturer recommends against subsequent local anesthetics within 96 hours. We administered epidural bupivacaine one day after local liposomal bupivacaine infiltration for staged hemipelvectomy without symptoms of LAST. Further pharmacokinetic and clinical safety studies are needed.

The Calm Before the Storm: Using In Situ Simulation to Evaluate for Preparedness of an Alternative Care Hospital During the COVID-19 Pandemic.

OBJECTIVES: Coronavirus disease (COVID-19) has been identified as an acute respiratory illness leading to severe acute respiratory distress syndrome. As the disease spread, demands on health care systems increased, specifically the need to expand hospital capacity. Alternative care hospitals (ACHs) have been used to mitigate these issues; however, establishing an ACH has many challenges. The goal of this session was to perform systems testing, using a simulation-based evaluation to identify areas in need of improvement. METHODS: Four simulation cases were designed to depict common and high acuity situations encountered in the ACH, using a high technology simulator and standardized patient. A multidisciplinary observer group was given debriefing forms listing the objectives, critical actions, and specific areas to focus their attention. These forms were compiled for data collection. RESULTS: Logistical, operational, and patient safety issues were identified during the simulation and compiled into a simulation event report. Proposed solutions and protocol changes were made in response to the identified issues. CONCLUSION: Simulation was successfully used for systems testing, supporting efforts to maximize patient care and provider safety in a rapidly developed ACH. The simulation event report identified operational deficiencies and safety concerns directly resulting in equipment modifications and protocol changes.