Risk Factors Predicting Cellulitis Diagnosis in a Prospective Cohort Undergoing Dermatology Consultation in the Emergency Department.

Cellulitis is an infection of the skin and skin-associated structures with many clinical mimickers known collectively as pseudocellulitis. Dermatology or infectious disease consultation is considered the gold standard for diagnosis. We evaluated a prospective cohort of adult patients presenting to the emergency department (ED) with concern for lower extremity cellulitis who received dermatology consultation with conferral of a final diagnosis. Possible risk factors independently associated with cellulitis diagnosis (P<.1) were included in a logistic regression model for prediction of cellulitis diagnosis. Factors having odds ratios with a confidence interval excluding 1 were identified as significant independent predictors. The study identified factors that should be considered in evaluation of patients with suspected uncomplicated lower extremity cellulitis.

Thoracic trauma in polo: two cases and a review of the literature.

BACKGROUND: The traditional sport of polo has been played for centuries and has been deemed one of the most dangerous sports due to its high speed and the uncertainty of what might happen as directions change and contact occurs between horses and riders as well as with balls and mallets. Despite its longevity, there is very little in the medical literature about the sport of polo. OBJECTIVES: Two cases of thoracic trauma after falls from horses while playing polo are presented. Both falls resulted in similar injury patterns to the riders. A discussion follows that reviews the medical literature on equestrian injuries in general and polo injuries in particular. DISCUSSION: Both cases show a similar injury pattern of clavicle fracture, multiple rib fractures, and lung injury (pulmonary contusion and pneumothorax). Literature review reveals severe injury including head and spinal trauma to be disproportionately represented in the equestrian sports. CONCLUSION: Emergency physicians should look for significant injuries when evaluating victims of polo accidents, as the forces generated can be quite high. Protective equipment, although potentially helpful, has not been studied and may not prevent these high-velocity injuries.

Intervention to decrease leaving without treatment among intoxicated emergency department patients.

OBJECTIVE: Approximately 15% of the >4000 patients presenting each year to our emergency department (ED) with a chief complaint or discharge diagnosis related to alcohol were leaving without treatment (LWT). If they are not clinically sober at the time of departure, these patients are at risk for falls or other injury. Our goal was to create an intervention to decrease this rate of early departure. METHODS: A stakeholder group identified the reasons why intoxicated patients were leaving without treatment, concluding that the primary reason patients left was there was no process in place for evaluating and caring for these patients who potentially had impaired decision-making capacity. The group created a worksheet for the triage nurse to identify and manage patients presenting with intoxication and impaired decision-making or ambulation, with protocols to keep the patient in a supervised area. We performed a before and after analysis, evaluating 12 months before and 12 months after the protocol was initiated, with the primary outcome being the rate of intoxicated patients who left without treatment. We also measured the recidivism rate (the rate of return to the ED within 24 h after departure) and the ED length of stay (LOS). RESULTS: After the intervention was initiated, the percentage of intoxicated patients who left without treatment decreased from 15.0% to 7.4% LWT (p < 0.001). Among patients who stayed until discharge during the intervention period, the 24-hour recidivism was 9.4%, compared to 22.6% for those who left without treatment (p < 0.001). This difference in recidivism rates for each group was the same before and after the intervention, but fewer patients left without treatment after. For those patients with alcohol-related visits, the ED LOS was statistically significantly longer in the intervention phase, by a mean of 42 min for all patients (p < 0.001), as well as by a mean of 24 min for those who stayed to be dispositioned (p = 0.031). CONCLUSION: Providing a standardized process for caring for acutely intoxicated patients leads to fewer patients leaving the ED before discharge. Patients who stay to the completion of treatment have a lower recidivism rate within 24 h after leaving than those in the leaving without treatment category.

Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial.

Importance: Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost. Objective: To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis. Design, Setting, and Participants: This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups. Interventions: Dermatology consultation within 24 hours of hospitalization. Main Outcomes and Measures: Length of hospital stay and duration of intravenous antibiotic treatment. Results: Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines. Conclusions and Relevance: Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment. Trial Registration: clinicaltrials.gov Identifier: NCT01706913.

Aortic dissection associated with blunt chest trauma diagnosed by elevated D-dimer.

INTRODUCTION: Similar to spontaneous aortic dissection, traumatic aortic dissection is diagnosed with a careful history and physical exam, chest radiograph, and ultimately, dedicated aortic imaging. The diagnosis of spontaneous aortic dissection may be aided by using the serum D-dimer test. The use of D-dimer for diagnosing aortic injury in the setting of blunt trauma has not previously been reported. PRESENTATION OF CASE: We present a case of aortic dissection in a 61-year-old male diagnosed when the patient presented with chest pain after blunt chest trauma. DISCUSSION: The patient had no known history or risk factors for aortic disease. None of the classic findings were present by history, physical examination or chest radiograph and the diagnosis was made as the result of an elevated D-dimer. We discuss how the D-dimer test fortuitously led to the diagnosis in this case, and the implications. CONCLUSION: D-dimer could be helpful in diagnosing aortic injuries in low-risk chest trauma patients.

No Difference in Adverse Events Between Surgically Treated Reduced and Unreduced Distal Radius Fractures.

OBJECTIVES: To determine if closed reduction is worthwhile for the subset of patients who choose operative treatment before attempted reduction of their distal radius fracture. We hypothesize that there are no differences in (1) adverse events and (2) subsequent surgeries between patients treated with manipulative reduction compared with those that were splinted without reduction. DESIGN: Retrospective cohort study. SETTING: Three affiliated urban hospitals in a single city in the United States. PATIENTS/PARTICIPANTS: One thousand five hundred eleven consecutive adult patients who underwent open reduction and internal fixation of their distal radius fracture between January 1, 2007, and December 31, 2012, of whom 102 (7%) were not reduced before surgery. INTERVENTION: Manipulative reduction compared with splinting without reduction. MAIN OUTCOME MEASUREMENTS: Adverse events were defined as any infections, hematomas treated operatively, disproportionate finger stiffness, (transient) neuropathology after surgery, delayed carpal tunnel release, malunion, reoperation for loss of alignment, hardware removal, and tendon ruptures within 1 year after surgery. Outcome measures were grouped to determine the overall adverse event rate and subsequent surgery rate. RESULTS: We found no difference in specific adverse events between unreduced and reduced fractures. After adjusting for possible confounding variables by logistic regression, we found no difference in overall rates of adverse events (adjusted odds ratio unreduced fractures 1.2, 95% confidence interval 0.67-2.0) and subsequent surgeries (adjusted odds ratio unreduced fractures 0.65, 95% confidence interval 0.23-1.8). CONCLUSIONS: Leaving the fracture unreduced before surgery was not associated with increased adverse events or subsequent surgeries. For patients who make an informed decision to undergo operative treatment for their closed neurovascular intact displaced distal radius fracture, manipulative reduction may not be helpful.

National athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes.

OBJECTIVE: To present recommendations for the prevention, detection, and comprehensive management of disordered eating (DE) in athletes. BACKGROUND: Athletes with DE rarely self-report their symptoms. They tend to deny the condition and are often resistant to referral and treatment. Thus, screenings and interventions must be handled skillfully by knowledgeable professionals to obtain desired outcomes. Certified athletic trainers have the capacity and responsibility to play active roles as integral members of the health care team. Their frequent daily interactions with athletes help to facilitate the level of medical surveillance necessary for early detection, timely referrals, treatment follow-through, and compliance. RECOMMENDATIONS: These recommendations are intended to provide certified athletic trainers and others participating in the health maintenance and performance enhancement of athletes with specific knowledge and problem-solving skills to better prevent, detect, and manage DE. The individual biological, psychological, sociocultural, and familial factors for each athlete with DE result in widely different responses to intervention strategies, challenging the best that athletics programs have to offer in terms of resources and expertise. The complexity, time intensiveness, and expense of managing DE necessitate an interdisciplinary approach representing medicine, nutrition, mental health, athletic training, and athletics administration in order to facilitate early detection and treatment, make it easier for symptomatic athletes to ask for help, enhance the potential for full recovery, and satisfy medicolegal requirements. Of equal importance is establishing educational initiatives for preventing DE.