Acute Traumatic Subdural Hematoma in the Elderly and Associated Factors that May Influence Chronicity.

Traumatic acute subdural hematomas (TASDH) is by far the most common traumatic brain injury in adult patients with blunt trauma, who presented to the Emergency Department (ED). One of the serious sequale of TASDH is the development of Chronic Subdural Hematomas (CSD) with associated deterioration in mental status and convulsion.1,2 Studies to identify the risk factors that favors development of chronicity of TASDH are few and inconclusive. As seen in our prior initial study, there were few factors which were common in those who developed chronicity of their TASDH, and we elected to expand our pool of patients to include those admitted between the years of 2015 and 2021 with ATSDH and identify the common factors associated with development of CSD.

Can Time to Treatment Reduce In-Hospital Mortality and Morbidity Among Surgical and Nonsurgical Elderly Patients With Sepsis.

Sepsis mortality remains high and efforts to reduce it are continuing. We collected data from our patients presented to the emergency department (ED) with sepsis and performed a retrospective analysis of 1079 patients seen in the ED with sepsis during 2018 and 2020, before and after implementation of the new CDC protocol. Statistical analysis was performed using Student's t-test and chi square test as well as Cox regression analysis. The patients were divided into pre-protocol (group 1) and post-protocol (group 2). A total of 1079 patients were included in the study. The mean age was 65 + 16.86 years, divided equally between gender (male 49%, female 51%). Patients with certain comorbidities showed statistically significant survival rate in the protocol group. The current protocol for sepsis when implemented will improve patients' survival, in both surgical and medical patients and significantly in those with comorbid conditions.

Impact of osteopathic manipulative techniques on the management of dizziness caused by neuro-otologic disorders: systematic review and meta-analysis.

CONTEXT: Osteopathic manipulative treatment (OMT) has been utilized by osteopathic clinicians as primary or adjunctive management for dizziness caused by neuro-otologic disorders. To our knowledge, no current systematic reviews provide pooled estimates that evaluate the impact of OMT on dizziness. OBJECTIVES: We aimed to systematically evaluate the effectiveness and safety of OMT and analogous techniques in the treatment of dizziness. METHODS: We performed a literature search in CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database (AMED), EMCare, Physiotherapy Evidence Database (PEDro), PubMed, PsycINFO, Osteopathic Medicine Digital Library (OSTMED.DR), and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2021 for randomized controlled trials (RCTs) and prospective or retrospective observational studies of adult patients experiencing dizziness from neuro-otological disorders. Eligible studies compared the effectiveness of OMT or OMT analogous techniques with a comparator intervention, such as a sham manipulation, a different manual technique, standard of care, or a nonpharmacological intervention like exercise or behavioral therapy. Assessed outcomes included disability associated with dizziness, dizziness severity, dizziness frequency, risk of fall, improvement in quality of life (QOL), and return to work (RTW). Assessed harm outcomes included all-cause dropout (ACD) rates, dropouts due to inefficacy, and adverse events. The meta-analysis was based on the similarities between the OMT or OMT analogous technique and the comparator interventions. The risk of bias (ROB) was assessed utilizing a modified version of the Cochrane Risk of Bias Tool for RCTs and the Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) for observational studies. The quality of evidence was determined utilizing the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: There were 3,375 studies identified and screened, and the full text of 47 of them were reviewed. Among those, 12 (11 RCTs, 1 observational study, n=367 participants) met the inclusion criteria for data extraction. Moderate-quality evidence showed that articular OMT techniques were associated with decreases (all p<0.01) in disability associated with dizziness (n=141, mean difference [MD]=-11, 95% confidence interval [CI]=-16.2 to -5.9), dizziness severity (n=158, MD=-1.6, 95% CI=-2.4 to -0.7), and dizziness frequency (n=136, MD=-0.6, 95% CI=-1.1 to -0.2). Low-quality evidence showed that articular OMT was not associated with ACD rates (odds ratio [OR]=2.2, 95% CI=0.5 to 10.2, p=0.31). When data were pooled for any type of OMT technique, findings were similar; however, disability associated with dizziness and ACD rates had high heterogeneity (I2=59 and 46%). No studies met all of the criteria for ROB. CONCLUSIONS: The current review found moderate-quality evidence that treatment with articular OMT techniques was significantly associated with decreased disability associated with dizziness, dizziness severity, and dizziness frequency. However, our findings should be interpreted cautiously because of the high ROB and small sample sizes in the eligible studies.

Effect of Implementation of an Early Treatment of Sepsis Protocol on Surgical Outcomes.

Sepsis outcomes remain high regarding mortality and morbidity, despite efforts to reduce them. We retrospectively evaluated a protocol in the first 6 months of implementation to measure outcomes. Retrospective data collection and analysis was performed of 200 consecutive patients seen in the ED during the first 4 months of 2020 after implementation of the sepsis protocol (group 1) and compared to another 200 consecutive patients during the same time frame in 2019 before the sepsis protocol (group 2). The collected parameters included age, gender, race, length of stay comorbid conditions, mortality, and therapy received. Statistical significance was determined at a p-value ≤.05. Mean age and gender of the groups were similar, 64 vs 66 years for group 1 and 2, respectively. Each group was 45% male. Mean length of stay were 8.9 and 8.6 days in group 1 and 2, respectively. Group 1 had a mortality rate of 13% vs 18% in group 2 (p = .21). Comorbid conditions including cardiovascular disease, diabetes, renal failure, and COPD were analyzed regarding mortality that influenced outcomes using Cox regression analysis. COPD and diabetic patient mortality were significantly lower in the protocol group. Surgical patients had a survival rate of 92.4%. Therefore, the current protocol for sepsis management did improve mortality. Further studies with a larger number of patients are in progress.

Dermatologic and Ophthalmologic Treatment of Erythema Multiforme Major: A Case Report.

Erythema multiforme major (EMM) is a rare type IV cytotoxic reaction targeting keratinocytes of the mucosal surfaces and the dermis. Dusky, targetoid lesions with central clearing are classically present, which may become blistered and rupture. The disease is usually self-limited and managed with supportive care and treatment of the underlying condition. The most common triggering factors are adverse reactions to medications, herpes simplex virus (HSV), and Mycoplasma pneumoniae. Rapid recognition of EMM is essential to avoid long-term complications. This case presents a 39-year-old male with a unique history of recent non-steroidal anti-inflammatory drug (NSAID) use, past infection with HSV-1, and an acute Mycoplasma pneumoniae infection. The patient developed painful lesions on the skin, oral mucosa, ocular surfaces, and urethra. The painful lesions caused complications with feeding and voiding. Initially, the triggering event was unclear. Supportive care was started. NSAIDs were discontinued and similarly-structured drugs were avoided. Treatments targeting Mycoplasma pneumoniae and HSV-1 were initiated while lab results were pending. Once the results returned, the treatment regimen of corticosteroids for inflammation, acyclovir for HSV-1, and azithromycin for Mycoplasma pneumoniae was continued. Vaseline was applied to open lesions. The patient was also treated with mouthwash consisting of aluminum (Al) hydroxide/magnesium (Mg) hydroxide/simethicone (400 mg/400 mg/40 mg). Topical 2% lidocaine gel with applicator was used to assist with urinary discomfort during voiding. Fentanyl was used for pain control. The patient successfully recovered and was discharged to follow-up with ophthalmology. Long-term sequelae including trichiasis, symblepharon, and punctal stenosis were noted during follow-up appointments.