Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage.

INTRODUCTION: Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary. METHODS: We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure. RESULTS: A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93). CONCLUSION: This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.

Effects of phosphatidylinositol diphosphate on phospholipid asymmetry in the human erythrocyte membrane.

While phospholipid asymmetry has been well characterized in red blood cells (RBCs), controversy exists as to what role PIP2 plays in cation-induced phosphatidylserine (PS) exposure. We report that PIP2 can redistribute intracellular cations and thereby lead to a loss of phospholipid asymmetry. Flow cytometry was employed to monitor intracellular cation levels by using the fluorophore Fluo-3 and exposure of PS on the outer surface of the RBC bilayer by using fluorescently labeled annexin V. The addition of PIP2 to RBCs led to a concentration-dependent increase in cytosolic cations and PS exposure. IF RBCs were preincubated with 25 microM neomycin sulfate, an inhibitor of phosphoinositide metabolism, PIP2-induced PS exposure decreased dramatically. If the RBC buffer system contained 2.5 mM EGTA, PS exposure also decreased significantly, suggesting a competition between intracellular Fluo-3 and extracellular EGTA. Together, these data indicate that (1) PS exposure was found in RBCs that exhibited an increased cytosolic cation concentration available for the fluorophore. Fluo-3, (2) both the level of intracellular cations and the movement of PS from the inner to the outer monolayer were affected by the level of PIP2 in the bilayer, (3) the cleavage of PIP2 by a phosphoinositide-specific phospholipase lead to the redistribution of intracellular cations and to an increase in the amount of PS exposed on the outer leaflet of the bilayer, and (4) a transient channel could be formed during the interaction of PIP2 with the RBC membrane which would then allow the transbilayer movement of phospholipids and cations.

An unusual complication of radial head fractures.

Radial head fractures are a fairly common injury secondary to falls on the outstretched forearm. Specific combinations of injuries involving radial head fractures and triceps tendon avulsion have been reported. Compartment syndromes secondary to distal forearm fractures are common; however fracture of the radial head rarely results in an acute compartment syndrome. A patient is reported with the combination of radial head fracture and triceps tendon avulsion complicated by the acute development of a compartment syndrome.

Parenteral lorazepam versus parenteral haloperidol for the control of psychotic disruptive behavior.

In a double-blind, prospective study, 2 mg of intramuscular lorazepam and 5 mg of intramuscular haloperidol were equally effective in controlling aggression, agitation, and assaultive behavior. Although lorazepam and haloperidol produced an equivalent mean decrease in aggression, significantly more subjects who received lorazepam had a greater decrease in aggression ratings than haloperidol recipients; this effect was independent of sedation. Lorazepam produced significantly fewer extrapyramidal symptoms. These data support the current clinical practice of using lorazepam (alone, or in combination with a neuroleptic) for control of acute aggressive and assaultive behavior.

Pneumocephalus from a frontal-ethmoid neurilemoma.

A 68-year-old man had memory lapse, character change, and unsteady gait. Skull films disclosed a spontaneous pneumocephalus with air in both ventricles. A dense, bony lesion in the right ethmoid area was thought to be an osteoma, a not infrequent cause of dural erosion. The bony lesion, however, proved to be an osteoid reaction around a primary neurilemoma. Neurilemomas arising in the paranasal sinuses are uncommon tumors and, to the best of our knowledge, this is the first reported case of a patient with a neurilemoma who had pneumocephalus. The lesion was excised through a Lynch approach, and the patient has remained free of tumor for the past two years.

Alternative to the back ward: the quarterway house.

The Quarterway House was founded in December 1978 to deinstitutionalize and provide rehabilitation services to a small group of long-term, seriously ill inpatients of the Massachusetts Mental Health Center. The purposes of the residential program are to provide a less institutional therapeutic environment and to develop a psychosocial treatment program that might enable some patients to move toward more independent settings in the community. In a randomized experimental study, with center inpatients as the control group, the effectiveness of the program was assessed by multiple outcome measures before the program began and at one year. Although neither group moved rapidly to more independent community living, Quarterway House patients showed improvement in general functioning and socialization-survival skills and decreased medication and seclusion. They did not show a decline in psychotic symptoms, obstreperousness, or antisocial behavior. Over-all, the findings suggest the program may prove useful for the long-term rehabilitation of severely ill patients.