Anthrax in injecting drug users: the need for increased vigilance in the clinic

The emergence of a previously unrecognized route of Bacillus anthracis infection over the last few years has led to concern: sporadic anthrax outbreaks among heroin users in northern Europe have demonstrated the severe pathology associated with the newly described ‘injectional anthrax’. With a high case fatality rate and non-specific early symptoms, this is a novel clinical manifestation of an old disease. Lack of awareness of this syndrome among emergency room clinicians can lead to a delayed diagnosis among heroin users; indeed, for many health workers in developed countries, where infection by B. anthracis is rare, this may be the first time they have encountered anthrax infections. As the putative route of contamination of the heroin supply is potentially ongoing, it is important that clinicians and public health workers remain vigilant for early signs of injectional anthrax.     

Venous thromboembolism: reducing the risk

This article demonstrates how services provided in minor injury units (MIUs) and emergency departments (EDs) can be improved by the implementation of routine thromboprophylaxis by subcutaneous injections of low molecular weight heparin for patients whose lower limbs are immobilised by plaster casts. The author offers evidence of the need for such a change in practice from a literature review and a case study, and describes how it can be achieved in five steps. She also outlines a protocol for routine thromboprophylaxis in MIUs and EDs.     

Venous air embolism from central venous catheterization: a need for increased physician awareness.

OBJECTIVES: To report a series of patients with clinically diagnosed venous air embolism (VAE) and major sequelae as a complication of the use of central venous catheters (CVCs), to survey health care professionals' practices regarding CVCs, and to implement an educational intervention for optimizing approaches to CVC insertion and removal. SETTING: Tertiary care, university-based 806-bed medical center. INTERVENTIONS: We surveyed 140 physicians and 53 critical care nurses to appraise their awareness of the proper management and complications of CVCs. We then designed, delivered, and measured the effects of a multidisciplinary educational intervention given to 106 incoming house officers. MEASUREMENTS AND MAIN RESULTS: Although most physicians (127, 91%) chose the Trendelenburg position for CVC insertion, only 42 physicians (30%) reported concern for VAE. On CVC removal, only 36 physicians (26%) cited concern for VAE. Some physicians (13, 9%) reported elevating the head of the bed during CVC removal, possibly increasing the risk of VAE. Awareness of VAE or its prevention did not correlate with the level of physician training, experience, or specialty. After the educational intervention, concern for and awareness of proper methods of prevention of VAE improved (p < .001). At 6-month follow-up, reported use of the Trendelenburg position continued, but concern cited for VAE had returned to baseline. CONCLUSIONS: There is inadequate awareness of VAE as a complication of CVC use. Focused instruction can improve appreciation of this potentially fatal complication and knowledge of its prevention, but the effect declines rapidly. To achieve a more sustained improvement, a more intensive, hands-on, periodic educational program will likely be necessary, as well as reinforcement through enhanced supervision of CVC insertion and removal practices.     

Venous thromboembolism: prevention & treatment

Venous thromboembolism still threatens the lives of hundreds of thousands of people in the United States--and some of them are your patients. Here's how to put the latest research and technology to good use in the fight against thromboembolic disease.     

Venous thromboembolism: implications for gene-based diagnosis and technology development

Venous thromboembolism is an hypercoagulable state that frequently reflects a complex interplay between inherited, acquired and environmental factors. The overall incidence of venous thromboembolism, which increases with age, is approximately 1:1000 in the US and Western Europe. In addition to known risk factors such as pregnancy and cancer, genetic variants can also increase the venous thromboembolism risk. Once such genetic variant, FV Leiden is characterized by single-point mutation and has been found in approximately 20% of idiopathic venous thromboembolism cases. The discovery of FV Leiden unleashed an increased interest in the genetics of venous thromboembolism as well as other cardiovascular diseases. Because FV Leiden was not only defined by only one common single nucleotide polymorphism but was also widely prevalent, impetus for the development of novel mutation detection methodologies and platforms for DNA analysis in both the clinical and research laboratory was greatly accelerated. An overview of this technology and its relationship to the genetics of venous thromboembolism is reviewed.     

The need for increased vigilance in managing hyperglycaemia during acute coronary syndrome in the emergency department: An introduction to the evidence

Until recently, increased blood glucose levels in those with and without diabetes with critical illnesses were perceived to be adaptive and benign responses to physiological stress in the critical care environment. In a landmark study published in 2001, Van den Berghe and colleagues demonstrated stress hyperglycaemia was not beneficial for patients who were experiencing critical illness. Instead, they found it resulted in significant increases in mortality. Several clinical trials and meta-analyses have since reported early management of hyperglycaemia in acute coronary syndrome (ACS), and many other critical illnesses to be advantageous. Not all evidence supports tight glycaemic control however. In this paper, we examine possible mechanisms by which increased blood glucose may harm patients with ACS and explain how insulin may be protective. We introduce evidence for and against increased glucose control in the emergency department. Given the increased mortality and morbidity associated with high blood glucose in ACS, we recommend increased diligence in the management of hyperglycaemic patients with ACS upon presentation to emergency departments.     

Hypoglycemia in insulin-treated diabetes: a case for increased vigilance

Studies have shown that effective diabetes management can delay or prevent the micro- and macrovascular complications of diabetes. Achieving optimal glycemic control often requires treatment with intensive insulin management. However, with intensive insulin management comes the risk of severe hypoglycemia. Hypoglycemia requiring emergency medical assistance is as common in patients with longstanding insulin-treated type 2 diabetes mellitus as in patients with type 1 diabetes mellitus, and is associated with a significant economic and personal burden; untreated, severe hypoglycemia can result in morbidity and death. Key contributors to severe hypoglycemia are asymptomatic hypoglycemia and nocturnal hypoglycemia; both conditions inhibit patients' ability to recognize hypoglycemia when it is occurring and take appropriate action. As a result, many patients with types 1 and 2 diabetes mellitus are reluctant to follow and/or adjust their insulin regimens as needed because of fear of hypoglycemia, resulting in exposure to chronic hyperglycemia, oxidative stress, and long-term complications. Severe hypoglycemia can be prevented through vigilance in identifying patients at risk, utilizing appropriate medications and medication regimens, and effective glucose monitoring strategies and technologies. The purpose of this article is to review our current understanding of hypoglycemia and its impact on diabetes management, and to provide guidance to health care providers when assisting patients who utilize insulin therapy to do so safely and effectively.     

False-negative primary neonatal thyroid screening: the need for clinical vigilance and secondary screening

The screening of newborn babies for congenital hypothyroidism has changed the natural history of this abnormality. We describe here a case of a female patient with congenital hypothyroidism that was missed by primary neonatal thyroid screening (using thyroid-stimulating hormone) at two days of age; it was detected only after the development and persistence of jaundice during the first three weeks of life. A normal neonatal screening result does not preclude the development of hypothyroidism later in infancy. Clinical vigilance must be maintained by practitioners. A second screening between two and six weeks of age may be useful in order to detect the few cases missed at first screening.     

Venous thromboembolism: epidemiology, characteristics, and consequences

Venous thromboembolism (VTE) and its manifestations, including deep vein thrombosis (DVT) and pulmonary embolism (PE), pose a life-threatening health problem for thousands of people each year. The diagnosis of VTE is frequently missed, however, because few signs and symptoms are recognized. Symptoms of DVT may include pain, erythema, tenderness, and swelling of the affected limb, whereas PE often presents as sudden breathlessness with chest pain, or collapse with shock in the absence of other causes. Greater awareness of the epidemiology of VTE, the consequences of VTE, and the risk factors for VTE can help health care providers take appropriate preventive measures to reduce the incidence of VTE.     

Scrotal pain in the absence of torsion; need for vigilance

Epididymitis is a common presentation of acute testicular pain seen in the emergency department, the differential diagnosis being testicular torsion. The vast majority of young men with epididymitis have an infective aetiology and this settle with antibiotic treatment. The clinical course of a patient who presented with testicular pain is described. At ultrasonography, the patient was found to have the uncommon condition of testicular microlithiasis, a condition that has been linked to malignant disease. Emergency doctors should be aware of the potential consequences of returning scrotal pain consistent with epididymitis to the community on antibiotic treatment alone. All patients with probable epididymitis should have either a scrotal ultrasound or specialist follow up.     

Venous thromboembolism in the intensive care unit

Most ICU patients have a significant number of risk factors for VTE. The high incidence of DVT in the ICU population and the recognition of a high incidence of PE at autopsy confirm this. We have alluded to the difficulty of clinical diagnosis of VTE and the need for diagnostic investigations. We have reviewed currently available diagnostic investigations with regard to their sensitivity and specificity and their practicability in ICU patients, and have formulated recommended diagnostic algorithms (Figs. 4 and 5). The most important factor in the management of VTE is prevention. In the ICU, all patients are at high risk for VTE, and therefore, at a minimum should receive subcutaneous prophylactic heparin unless it is contraindicated. Alternative methods of prophylaxis are available, and should be considered for patients who have contraindications to heparin.     

Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.