Necrotizing Fasciitis Masquerading as Stroke: A Diagnostic Dilemma.

Necrotizing fasciitis (NF) poses a diagnostic challenge due to its rarity and similarity in presentation with other critical conditions. We report a case of a 79-year-old male who initially presented with altered mental status and stroke-like symptoms; he was ultimately diagnosed with abdominal wall NF spreading to the lower extremity. Despite a history of cecal mass perforation noted in prior imaging, the patient had been discharged from an outside emergency room on antibiotics, highlighting a missed opportunity for early intervention. Subsequent deterioration led to sepsis, organ failure, and ultimately, the detection of NF. Prompt recognition of subtle skin changes and laboratory abnormalities, along with a detailed physical examination, is essential for a timely and accurate diagnosis. Surgical debridement, coupled with broad-spectrum antibiotics, remains the cornerstone of treatment. Delays in surgical management significantly increase mortality, emphasizing the importance of prompt diagnosis and intervention. This case underscores the necessity for heightened awareness among healthcare providers to recognize NF promptly, especially when its clinical presentation overlaps with other critical conditions. Multidisciplinary collaboration and continued education are imperative to improve outcomes and prevent delays in the diagnosis and treatment of NF.

A 30 YEAR (1991-2020) RETROSPECTIVE MORTALITY REVIEW OF GIRAFFIDS (GIRAFFA SPP. AND OKAPIA JOHNSTONI) IN MANAGED CARE.

Identifying common causes of mortality in zoo giraffe (Giraffa spp.) and okapi (Okapia johnstoni) provides an opportunity to help improve welfare and population management for these endangered species. Mortality reports from 1,024 giraffe and 95 okapi in zoos were compiled from the Species 360 Zoological Information Management Software (ZIMS) utilizing the Morbidity & Mortality Analysis tool. Thirty years of mortality reports (1991-2020) were evaluated to help identify trends and evaluate the impacts, if any, of changes over time in husbandry and management practices. The most common causes of death for giraffe from 1991 to 2015 were neonatal issues (234/845, 27.7%), trauma (213/845, 25.2%), noninfectious disease (190/845, 22.5%), and infectious disease (188/845, 22.2%). In comparison, the most common causes of mortality for giraffe from 2016 to 2020, were noninfectious disease (78/179, 43.6%), trauma (39/179, 21.8%), neonatal issues (39/179, 21.8%), and infectious disease (17/179, 9.5%). The most common cause of death for okapi from 1991 to 2015 were neonatal issues (29/64, 45.3%), infectious disease (13/64, 20.3%), noninfectious disease (11/64, 17.2%), and trauma (10/64, 15.6%). In comparison, the most common cause of death for okapi from 2016 to 2020 was noninfectious disease (15/31, 48.4%), neonatal issues (8/31, 25.8%), and infectious disease (5/31, 16.1%). The results suggest that zoo giraffids have had a relative decrease in mortality from infectious diseases in recent years, whereas death from noninfectious causes has increased significantly. Trauma-related giraffe mortalities and neonatal mortality in both giraffe and okapi, although decreasing in prevalence between time periods, continue to be important causes of death in zoos. This is the first descriptive mortality review for the Giraffidae family and provides data on potential giraffe and okapi health issues that zoos could proactively address.

Can Pre-Hospital Medical Management Predict In-Hospital Mortality in Trauma?

The current literature demonstrates an association between both size and presence of TBI and its effects on mortality; however, it does not readily address the morbidity and associated functional outcomes of those who survive. We hypothesize that the likelihood of discharge to home decreases with advancement of age in the presence of TBI. This is a single-center study of trauma registry data, inclusive years July 1, 2016, to October 31, 2021. The inclusion criteria was based upon age (≥40 years), and ICD10 diagnosis of a TBI. Disposition to home without services was the dependent variable. 2031 patients were included in the analysis. We hypothesized correctly that the likelihood of discharge to home decreases (by 6%) with advancement of age (per year) in the presence of intracranial hemorrhage.

Traumatic Brain Injury Under Triage Risk: A Rural Trauma System Experience.

BACKGROUND: The process of interfacility transfer may cause a delay in the necessary medical treatment, which could lead to poor outcomes and increased mortality rates. The ACS-COT considers an acceptable under triage rate of <5%. The aim of this research was to identify the likelihood of under triage among transferred-in traumatic brain injury (TBI) patients. METHODS: This is a single-center study of Trauma Registry data, from July 1, 2016, to October 31, 2021. The inclusion criteria were based upon age (≥40 years), ICD10 diagnosis of TBI, and interfacility transfer. Under triage using the Cribari matrix method was the dependent variable. A logistic regression was performed to identify additional predictor variables on the likelihood that an adult TBI trauma patient experienced under triage. RESULTS: 878 patients were included in the analysis; 168 (19%) experienced an under triage. The logistic regression model was statistically significant (N = 837, P < .01). In addition, several significant increases in odds for under triage were identified, which included increasing injury severity score (ISS; OR 1.40, P < .01), increasing AIS head region (OR 6.19, P < .01), and personality disorders (OR 3.61, P = .02). In addition, a reduction in odds in TBI adult trauma under triage is the comorbidity of anticoagulant therapy (OR .25, P < .01). CONCLUSIONS: The likelihood of under triage in the adult TBI trauma population is associated with increasing AIS head injuries and increasing ISS and among those with mental health comorbidities. This evidence and additional protective factors, such as patients on anticoagulant therapy, may aid in education and outreach efforts to reduce under triage among the regional referring centers.

Under-triage of Elderly Trauma Patients With Comorbid Conditions.

This study aims at identifying the under-triage patients to improve the quality of care among those transferred into a level I trauma system. This is a single-center study of Trauma Registry data, inclusive years, from July 1, 2016 to January 31, 2021. Patients were grouped based upon under-triage, over-triage, and OK triage. The under-triage group was more likely to be older, partially activated, blunt, fall trauma patients with a higher GCS, higher ISS, and significant injuries found to the head/neck who experienced a longer length of stay at the referring facility and higher morbidity outcomes with diagnosed comorbidities of dementia and hypertension. There are distinct differences in under and over-triage groups within this trauma system, which gives insight into future education and outreach among interfacility transfers.

Presentation, Clinical Pathology Abnormalities, and Identification of Gastrointestinal Parasites in Camels (Camelus bactrianus and Camelus dromedarius) Presenting to Two North American Veterinary Teaching Hospitals. A Retrospective Study: 1980-2020.

Old World Camelids (OWC) represent two species (Camelus bactrianus and Camelus dromedarius) with increasing numbers in North America. Gastrointestinal (GI) parasitism is a major cause of clinical disease in camelids and leads to significant economic impacts. Literature reporting on clinical parasitism of camels is localized to India, Africa, and the Middle East, with limited information available on OWCs in North America. Objectives of this study were to report on clinical presentation and diagnostic findings in Camelus bactrianus and Camelus dromedarius with GI parasitism and provide a comparative analysis between geographic regions. Medical records of OWCs presenting to two veterinary teaching hospitals (of the University of Tennessee and University of Wisconsin) were evaluated. Thirty-one camels including 11 Bactrians and six dromedaries (14 species not recorded) were included for the clinical component of this study, reporting on signalment, presenting complaint, and clinical pathology. Anorexia, weight loss, and diarrhea were the most common presenting complaint. Clinical pathology findings included eosinophilia, hypoproteinemia, and hyponatremia. For the second component of this study, a total of 77 fecal parasite examination results were evaluated for parasite identification and regional variation. Trichuris, Capillaria, Strongyloides, Nematodirus, Dictyocaulus, Moniezia, and protozoan parasites (Eimeria, Cryptosporidium, Giardia) were recorded. Strongyle-type eggs predominated, followed by Trichuris and Eimeria spp. There was a statistically significant variation in prevalence of coccidia between the two regions, with fecal examinations from Tennessee more likely to contain Eimeria (P = 0.0193). Clinicians treating camels in North America should recognize anorexia, weight loss, and diarrhea combined with clinical pathologic changes of hypoproteinemia, eosinophilia and hyponatremia as possible indications of GI parasitism. Clinicians should also consider the potential for regional variation to exist for GI parasites of camels in different areas of North America.

Quantification of Cognitive Dysfunction in Dizzy Patients Using the Neuropsychological Vertigo Inventory.

OBJECTIVE: Currently available patient reported outcomes questionnaires for dizzy patients give limited insight into the cognitive dysfunction patients often report. Using the newly developed English version of the neuropsychological vertigo inventory (NVI), we aimed to quantify the cognitive impairment of dizzy patients. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary neurotology clinic. PATIENTS: Adults with vestibular diagnoses seen between June 2018 and October 2018. Patients with neurologic disorders affecting cognition were excluded. INTERVENTIONS: None. MAIN OUTCOME MEASURE: NVI score. Secondary measures: dizziness handicap inventory (DHI) score, cognitive failure questionnaire (CFQ) score, 20-item short form health survey scores (SF20). RESULTS: Of 67 subjects, 13 had BPPV, 11 had Menière's disease (MD), and 20 had vestibular migraine (VM). VM patients were significantly younger (43.5 versus 61.1 yrs, p = 0.016), and had significantly higher NVI (67.5 versus 51.0, p = 0.040) scores than BPPV patients. MD patients had significantly higher CFQ scores (44.8 versus 23.4, p = 0.015) than BPPV patients. NVI scores were similar between MD (67.3) and VM (67.5) patients (p = 1.000). DHI scores were similar for all patients (p = 0.102). NVI scores were highly correlated to CFQ scores (r = 0.864, p < 0.001). CONCLUSIONS: VM patients have levels of cognitive dysfunction similar to MD patients, but greater than BPPV patients. A lack of difference in DHI scores among these patients reflects its limitation in assessing the cognitive domain.