Femoral Nerve Blocks versus Standard Pain Control for Hip Fractures: A Retrospective Comparative Analysis.

Introduction: Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control, which reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures. Methods: This retrospective study included adult patients presenting to the emergency department (ED) with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period were randomly selected to represent the control group. The primary outcome was pre-operative opioid requirement, assessed by morphine milligram equivalents (MME). Results: During the study period, 90 patients were identified in each treatment group. Mean pre-operative MME was 10.3 (95% confidence interval [CI]: 7.4-13.2 MME) for the intervention group and 14.0 (95% CI: 10.2-17.8) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from ED triage to hospital discharge (7.2 days, 95% CI: 6.2-8.0 days) than patients who received standard care (8.6 days, 95% CI: 7.2-10.0 days). Still, this difference was not statistically significant (P=0.09). Conclusions: Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.

A Timeline of Onychomycosis Therapy and Future Directions.

Onychomycosis was first described in the mid-1800's, and early treatment regimens involved applying corrosive substances and nail plate avulsion. It was not until the mid-1900's that more specific antifungal agents were utilized. Initially, only oral drugs were used, with ciclopirox 8% solution later approved in 1999. Presently, terbinafine, itraconazole, and fluconazole (off-label) are used for systemic onychomycosis therapy in the US, and topicals include ciclopirox, efinaconazole and tavaborole. Devices, topicals with new mechanisms of action, and oral medications with potentially better efficacy are now being explored for treatment of onychomycosis.

Retrospective Case Series on Risk Factors, Diagnosis and Treatment of Pseudomonas aeruginosa Nail Infections.

BACKGROUND: Pseudomonas aeruginosa is the most common pathogen causing bacterial nail infections, producing a classic blue-green pigment, known as chloronychia. Clinical examination and dermoscopic findings, as well as diagnosis and treatment, have not been well characterized. OBJECTIVE: The aim was to characterize the clinical and dermoscopic findings of P. aeruginosa infection of the nails and assess treatment efficacy. METHODS: This is a retrospective study of patients with P. aeruginosa nail infection diagnosed between January 27, 2017 and May 28, 2019. Demographics, history, clinical and dermoscopic findings, diagnostics tests, and treatment were documented and analyzed. RESULTS: Twenty-six patients with P. aeruginosa nail infections were analyzed, with 21 patients completing treatment, two lost to follow-up, and three still undergoing treatment. Clinical examination findings were notable for onycholysis in 76.9% of patients. Green discoloration was seen in 38.5% of patients and green-brown discoloration in 30.8%. A majority of the patients had only one nail involved (73.1%). Dermoscopic findings were significant for greenish pigmentation in 37.5% of patients and 88.9% of cases presenting with a fading border. Wound cultures of nail plates were more sensitive (40%) than dermatopathology (16.7%), but the difference was not statistically significant (p value = 0.1596). All patients were treated with ophthalmic 0.3% gentamicin topical solution nightly for a 3-month period and those who completed therapy had complete resolution of their infection. LIMITATIONS: The limitations of the study were the retrospective design and the small cohort size. CONCLUSION: Clinical examination findings of onycholysis coupled with a green or green-brown discoloration involving one or more digits and dermoscopic findings of greenish discoloration with a fading border are consistent with a diagnosis of Pseudomonas nail infection. Gentamicin topical solution is an effective, inexpensive, easy-to-use treatment for this condition. Larger randomized clinical trials are necessary to compare efficacy with other therapeutic options.

Review of onychocryptosis: epidemiology, pathogenesis, risk factors, diagnosis and treatment.

Ingrown toenail, or onychocryptosis, is a highly prevalent nail condition that occurs when the nail edge grows into the periungual dermis. It most frequently affects the hallux and has a biphasic presentation, being most common in the second and fifth decades. It is often painful and may be debilitating in severe cases. Risk factors include trauma, weight changes, poor nail-cutting technique, and hyperhidrosis. Both conservative and surgical treatments have been described, and choice of therapy is dependent on patient co-morbidities, severity, and associated symptoms. This review covers the epidemiology, risks factors, pathogenesis, evaluation, and staging of ingrown toenails, as well as, treatment options. Although there is an unmet need for clinical trials comparing therapies, current recommendations are to treat conservatively and then proceed to surgical therapies if symptoms persist.

Denial of Illness in a Patient with Infiltrative Basal Cell Carcinoma.

A 73-year-old Caucasian man presented with a pink, pearly papule anterior to his right ear. He was a well-educated, retired stockbroker. Biopsy revealed an infiltrating basal cell carcinoma (BCC). The dermatologist repeatedly attempted to contact the patient encouraging treatment. After ignoring calls and letters, he was lost to contact with dermatology for 10 years. In the interim, the patient presented to the emergency room after discovering maggots in his ear. He subsequently consulted a head and neck surgeon but refused the recommended surgical excision. Although still operable, by this time the patient had developed significant erosion (Figure 1), nerve damage with loss of taste, facial muscle control, and hearing loss. One year after surgical consultation, he returned to dermatology due to ear discharge and pain while chewing. Multiple clinicians urged him to reconsider surgery. The patient stated that he had avoided treatment for the previous 10 years, because he had felt "stronger than the cancer." He had been convinced that cancer "can't hurt me." Despite this, he conceded that denying treatments earlier was "probably the worst decision of my life." By then the cancer was inoperable and required chemotherapy. The patient again refused treatment and later expired.

Clinical pearl: benzethonium chloride for habit-tic nail deformity.

Treatment of habit-tic nail deformity is challenging, as it often requires both patient awareness and behavioral changes that may be long-standing. Many treatment options have been suggested, but limitations include inadequate supporting evidence and potential adverse effects. Herein, we describe the use of benzethonium chloride as a safe and effective treatment of habit-tic nail deformity.

Clinical pearl: kinesiology tape for onychocryptosis.

Onychocryptosis, or ingrown toenail, is characterized by penetration of the periungual skin by the nail plate. One conservative treatment is taping, but frequent detachment is a notable shortcoming. We describe use of kinesiology tape to overcome this limitation for effective treatment of onychocryptosis.

Cervical lymphadenopathy from PRP treatment with microneedling therapy.

BACKGROUND: Platelet-rich plasma is highly enriched plasma that contains a large concentration of platelets that secrete various growth factors and is used in a wide variety of surgical and cosmetic procedures, including hair regrowth and skin rejuvenation. METHODS: Microneedling therapy is being combined with platelet-rich plasma to potentiate patient's cosmetic effects. While microneedling therapy and platelet-rich plasma therapy have been around for years and are growing in popularity internationally, there are limited data regarding complications when they are used in conjunction. RESULTS: We present a case in which a patient presented with acute, painful lymphadenopathy shortly after undergoing the combination treatment of a microneedling pen with platelet-rich plasma therapy. CONCLUSION: Individuals should know of the potential adverse effect of microneedling pen therapy used in conjunction with platelet-rich plasma therapy, and it should be included in patient consent forms and doctor-patient education.