Antibiotic prophylaxis for oral lacerations: our emergency department's experience.

BACKGROUND: The purpose of this study was to examine the emergency physician (EP) practice of prescribing prophylactic antibiotics for patients with oral lacerations. A secondary outcome measure was the infection rate of those who were or were not prescribed antibiotics. METHODS: The study was a retrospective chart review of 323 patients who presented to a large urban emergency department (ED) between January 1, 2012 and December 31, 2012 with an oral laceration. RESULTS: Of the 323 charts reviewed, topical and/or systemic antibiotics were prescribed in the ED to 62 % (199/323) of patients. Of those patients, 38 % (75/199) received only topical antibiotics, 34 % (68/199) received only systemic antibiotics, and 28 % (56/199) were prescribed topical and systemic antibiotics. Thirty-eight percent (124/323) of patients received no antibiotics. Eighteen percent (58/323) of patients returned for follow-up with an infection rate of 10 % (6/58). There was a statistical difference in rates of infection between patients who received antibiotics and who did not receive antibiotics and a statistical difference in rates of infection between patients with complex lacerations who received and did not receive antibiotic. CONCLUSIONS: This study shows that there is a considerable amount of practice variance in prescribing prophylactic antibiotics for oral lacerations among EPs in our ED. Due to the poor follow-up rate, an accurate infection rate could not be determined. In the future, adequately powered randomized controlled studies may provide compelling data for or against the necessity for prophylactic antibiotic use for oral lacerations.

Usefulness of the Mortality in Severe Sepsis in the Emergency Department score in an urban tertiary care hospital.

BACKGROUND: The Mortality in Severe Sepsis in the Emergency Department (MISSED) score is a newly proposed scoring system. The goal of this study is to determine if the MISSED score is generalizable to an urban tertiary care hospital. METHODS: This is a retrospective chart review conducted from July 2012 to June 2014. Inclusion criteria consisted of adult emergency department (ED) patients with severe sepsis, defined as lactate level 4mmol/L or greater. Demographics, lactate, international normalized ratio (INR), albumin, intensive care unit admission, and ED intubation were analyzed using χ(2) test, t test, and logistic regression. The MISSED score was calculated using the variables albumin 27g/L or less, INR 1.3 or greater, and age 65years or older and analyzed using the area under the curve. The primary outcome was inhospital mortality. RESULTS: A total of 182 patients met inclusion criteria, and mortality was 32%. Patients in the mortality group had older age (58.1±17.2 vs 62.7±14.7; P=.07), higher lactate (5.9±2.7 vs 7.3±3.1; P<.01), lower albumin (34.3±8.3 vs 25.6±7.1; P<.0001), higher INR (1.4±0.6 vs 2.4±1.9; P<.0001), ED intubation (21% vs 56%; P<.0001), and intensive care unit admission (41% vs 78%; P<.0001). The regression model found that albumin of 27g/L or less (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.05-3.36), INR 1.3 or greater (OR, 8.3; 95% CI, 3.35-20.51), and ED intubation (OR, 5.6; 95% CI, 2.56-12.35) predicted mortality. The area under the curve for the MISSED score was 0.78 (95% CI, 0.73-0.85). CONCLUSION: The MISSED score is useful for predicting mortality in ED patients with severe sepsis.

Do state medical board applications violate the americans with disabilities act?

PURPOSE: To determine whether medical licensing board application questions about the mental or physical health or substance use history of the applicant violate the Americans with Disabilities Act (ADA) of 1990. METHOD: Content analysis of 51 allopathic licensing applications (50 states and District of Columbia) was performed at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in 2005. Questions referencing physical or mental health or substance use were identified by a team of physicians and reviewed and categorized based on the ADA and appropriate case law by legal counsel. RESULTS: Of the 51 applications reviewed, 49 (96%) contained questions pertaining to the physical or mental health or substance use history of the applicant. Thirty-four of the 49 (69%) state medical licensing applications contained at least one "likely impermissible" or "impermissible" item based on the ADA and appropriate case law. CONCLUSIONS: Most state medical licensing applications contain questions that ask about the physical or mental health and substance use of physician applicants. Many licensing applications appear to be in violation of the ADA, even 19 years after enactment of the regulation. These questions do not elicit responses by which professional competence can be judged. The presence of these questions on licensing applications may cause physicians to avoid or delay treatment of personal illness.

Major depression and immunity in alcohol-dependent persons.

UNLABELLED: Altered immunity has been associated with both alcoholism and major depression (MD). We investigated the contribution of MD, as well as alcoholism, to in vitro measures of immunity in inner-city alcohol-dependent (SCID-DSM-III-R) persons and community nonabusers, all otherwise in good health. METHODS: Alcohol-dependent persons at an ambulatory alcohol treatment center who did not abuse other substances were studied along with the comparison sample (total n=122). Enumerative and functional immune measures included leukocyte and lymphocyte subsets, mitogen response, natural killer cell activity (NKCA), and granulocytic phagocytosis. RESULTS: Controlling for alcohol dependence, age, gender, racial background, and medical status, MD was associated with decreased phytohemagglutinin (PHA) responses (p<.03), possibly decreased NKCA (p<.08), and increased circulating monocytes (p<.04). Controlling for MD, age, gender, racial background, and medical status, alcohol dependence was associated with decreased circulating B lymphocytes (p<.02), possibly decreased CD56+ (NK) cells (p<.06), and increased monocytes (p<.04). Responses to concanavalin A and pokeweed mitogen, granulocyte functions, and the composition of other leukocyte and lymphocyte subsets showed no evidence of being associated with MD or with alcoholism (p>.1). Secondary analyses exploring factors such as recent alcohol use, cigarette use, and nutrition suggested that these factors accounted for the altered lymphocyte subsets associated with alcoholism and the possibly decreased NKCA with MD. They did not account for the association of MD with increased monocytes and decreased PHA. DISCUSSION: MD-associated immune changes in alcoholics are modest and consistent with those seen in MD without alcoholism. Some MD- and many alcoholism-associated immune effects appear related to factors such as cigarette use and recent alcohol exposure.

A preliminary study of the effect of external qigong on lymphoma growth in mice.

OBJECTIVE: To examine the effectiveness of external qigong on the in vivo growth of transplantable murine lymphoma cells in mice. BACKGROUND: Qigong is a traditional Chinese health practice that is believed by many to have special preventive and healing power. Underlying the system is the belief in the existence of a subtle energy (qi), which circulates throughout the body, and when strengthened or balanced, can improve health and ward off or slow the progress of disease. To date, much of the literature showing the effects of qi are presented in the non-Western literature, and as such are viewed with considerable skepticism. In an attempt to demonstrate qi in a controlled setting, the effect of external qigong emission from a qigong healer on the in vivo growth of transplantable murine lymphoma cells in mice was explored in two pilot studies. METHODS: In study 1, 30 SJL/J mice were injected intravenously with lymphoma cells that localize and exhibit aggressive growth in the lymphoid tissues of untreated syngeneic recipients. These tumor-injected mice were divided into 3 groups: (1). qigong treatment (administered by a qigong healer); (2). sham treatment; and (3). no-treatment control. The sham group received the same number of treatments from a person without training in qigong, who imitated the motions of the qigong healer. The control group received no treatment at all. In study 1, the mice were sacrificed on the 9th or 11th days after tumor-cell injection, and in study 2, the mice were sacrificed on the 10th and 13th days. Tumor growth in lymph nodes (LN) was estimated by LN weight expressed as a percentage of total body weight. RESULTS: In study 1, LNs from mice in the qigong-treated group were significantly smaller than LN from mice in either the control group or in the sham treatment group (p < 0.05), suggesting that there was less tumor growth in the qigong-treated mice. In study 2, using the same design as study 1, the same pattern of difference found in study 1 emerged: LN ratio from mice in the qigong-treated group was smaller than that in either the control group or in the sham group. However, these results did not reach statistical significance, partially as a result of larger variances in all groups in this study. CONCLUSIONS: These preliminary results, while still inconclusive, suggest that qigong treatment from one particular qigong practitioner might influence the growth of lymphoma cells negatively. Further studies with different practitioners, more repeated trials, and/or different tumor models are needed to further investigate the effects of external qigong on tumor growth in mice.

Panic disorder and immunity: few effects on circulating lymphocytes, mitogen response, and NK cell activity.

Altered immune measures are commonly found in major depression (MD), however, less is known about the immune system in anxiety disorders. We examined quantitative and functional in vitro immune measures in patients with panic disorder (PD), which is often comorbid with MD. Fourteen otherwise healthy medication-free adults (ages 23-49; 11 female) meeting SCID-UP DSM-IIIR criteria for PD with agoraphobia and without current MD, were compared with 14 subjects free of PD, MD, or other major psychiatric disorders, matched by gender, age, and racial background. PD was associated with decreased percentage (p<.03) and total (p<.03) circulating CD19+ B lymphocytes, but no differences in other enumerative lymphocyte measures. Mitogen responses (Con A, PHA, PWM) did not differ except for possibly decreased PHA in PD (p<.06). NK cell activity did not differ between PD and control subjects. The few immune measure changes in PD contrast with those found in MD, providing further evidence for the specificity of immune changes in psychiatric disorders.

Immunity in adolescents with major depression.

OBJECTIVE: The association between major depression (MD) and altered immunity appears to be age-related, with differing immune changes found in prepubertal children, young adults, and older adults. There is limited information concerning immunity in adolescents with MD. METHOD: Thirty-six otherwise healthy medication-free adolescents (aged 14-20; 23 female) from a community sample, meeting Diagnostic Interview Schedule for Children DSM-III-R criteria for unipolar MD, were compared with 36 nondepressed adolescents matched by gender, age, and racial background. A battery of quantitative and functional immune measures was obtained. RESULTS: MD adolescents had increased (p < .05) circulating lymphocytes and lymphocyte subsets; however, altered distribution of lymphocyte subsets was found only for activated T (HLA-DR+) cells (p < .004) and, possibly, natural killer (NK) (CD56+) cells (p < .06), each showing lower percentages in the MD adolescents. Concanavalin A (but not phytohemagglutinin or pokeweed mitogen) mitogen response was lower in the MD adolescents (p < .02). NK cell activity was elevated at higher effector-target ratios (p < .001), an effect not associated with the number of circulating CD56+ (NK) cells. CONCLUSIONS: Depressed adolescents showed changes in immune measures that have been found to be altered in other MD groups, although the pattern of effects differs.

Immune measures in alcohol-dependent persons with minor health abnormalities.

Altered immunity is commonly associated with alcoholism. However, few studies have contrasted alcoholism per se with effects of the medical sequelae or comorbidities of alcoholism on the immune system. We previously found few differences in lymphocyte subsets, mitogen response, granulocytic phagocytosis, or natural killer cell activity when we compared healthy urban alcohol-dependent individuals with community control subjects. To begin to explore the role of medical factors, 11 alcohol-dependent persons derived from the same clinical population but showing mild medical abnormalities (AMMAs), primarily abnormal liver function test results, were compared with the previously described 44 alcohol-dependent persons without medical dysfunctions and 34 nonabusing community persons. The AMMAs had lower numbers of CD45RA + inducer-suppressor/naive cells (P <.02) and HLA-DR+-activated T cells (P <.04) compared with findings for nonabusers and higher percentages of circulating CD56 + natural killer cells (P <.03). Mitogen responses to concanavalin A, phytohemagglutinin, and pokeweed mitogen; natural killer cell activity; and granulocyte functions did not differ across groups. The AMMAs reported higher alcohol consumption than that reported by the other groups. The findings seem to indicate that mild medical conditions, or conditions linked to abnormal liver function test results, are associated with some of the immune alterations reported in alcohol-dependent persons. Immune changes, even among chronically alcohol-dependent persons, may occur along a continuum associated with total alcohol exposure and intercurrent physiologic abnormalities. Clinical studies may need to control for such mild abnormalities when investigating alcohol-immune relationships, and clinical interventions may be especially important for alcohol-dependent individuals who show early signs of compromised health.