Atypical presentations of dengue disease in the elderly visiting the ED

Objective

The objective was to compare the clinical characteristics of elderly and young adult patients with dengue in the emergency department (ED).

Methods

Demographic characteristics, clinical presentation, disease severity, laboratory characteristics, and outcomes were analyzed prospectively as a case-control study.

Results

Of the 193 adults with serologically confirmed dengue disease in 2007, 31 (16.1%) were elderly patients (aged ≥ 65) and 162 were young adults (aged < 65). More dengue hemorrhagic fever (12.9% vs 2.5%, P = .02), a longer ED stay (13.3 vs 8.6 hours, P = .004), a longer hospital stay (7.4 vs 3.4 days, P < .001), a higher Simplified Acute Physiology Score II in the ED (29.7 vs 17.4, P < .001), and a higher rate of at least 1 comorbidity (61.8 vs 22.8%, P < .001) were found in the elderly. However, the length of the intensive care unit stay (elderly 0.7 vs young adults 0.3 day, P = .47) and the 14-day mortality rate (0% vs 0.6%, P = 1.00) were similar. Of note, in terms of clinical presentations of dengue in the ED, there were more elderly patients with isolated fever (41.9% vs 17.9%, P = .003) and fewer with typical presentation (41.9% vs 75.9%, P = < .001) than there were young adults.

Conclusions

The present study found a higher number of atypical presentations, a longer hospitalization, and a higher degree of clinical illness in elderly patients with dengue.     

Locally Acquired West Nile Encephalitis

Background

West Nile virus (WNV) has spread rapidly across the United States since 1999, causing epidemics of neurologic illnesses including meningitis, encephalitis, and acute flaccid paralysis. West Nile encephalitis can be fatal; recovery can be incomplete; and constitutional and neurological symptoms can persist for months to years.

Objectives

To raise awareness of an important epidemiologic cause of febrile illness with neurologic involvement in the United States.

Case Report

We report the case of a 46-year-old woman who presented with fever, altered mental status, and maculopapular rash, who was diagnosed with locally acquired WNV encephalitis.

Conclusion

Infection with WNV should be considered in patients presenting to emergency departments with fever and neurologic symptoms. Recommended evaluation includes serologic testing of cerebrospinal fluid and serum.     

Bacterial blood cultures in children with sickle cell disease

Background

Children with sickle cell disease (SCD) are considered at risk for bacteremia, especially when they present to the emergency department (ED) with fever.

Objective

We aimed to determine the incidence of bacteremia in children with SCD presenting with or without fever to a pediatric ED.

Methods

A retrospective chart review of 692 pediatric ED visits of children with SCD during a 2-year period was conducted.

Results

Seven blood cultures (6 homozygous and 1 heterozygous) had bacterial growth (1.3%; 95% confidence interval, 0.5-2.1), 3 of which were among febrile children (1.7%; 95% confidence interval, 0-3.6). All identified microorganisms are part of the normal skin or oral flora and could represent contamination. None of the patients had growth of the Streptococcus pneumoniae species.

Conclusion

A very low rate of bacterial growth and no S pneumoniae were found. The absence of S pneumoniae in our cohort can be associated with the addition of the 7-valent pneumococcal conjugate vaccine.     

A Small-Molecule Dengue Virus Entry Inhibitor

The incidence of dengue fever epidemics has increased dramatically over the last few decades. However, no vaccine or antiviral therapies are available. Therefore, the need for safe and effective antiviral drugs has become imperative. The entry of dengue virus into a host cell is mediated by its major envelope (E) protein. The crystal structure of the E protein reveals a hydrophobic pocket that is presumably important for low-pH-mediated membrane fusion. High-throughput docking with this hydrophobic pocket was performed, and hits were evaluated in cell-based assays. Compound 6 was identified as one of the inhibitors and had an average 50% effective concentration of 119 nM against dengue virus serotype 2 in a human cell line. Mechanism-of-action studies demonstrated that compound 6 acts at an early stage during dengue virus infection. It arrests dengue virus in vesicles that colocalize with endocytosed dextran and inhibits NS3 expression. The inhibitors described in this report can serve as molecular probes for the study of the entry of flavivirus into host cells.Dengue is a mosquito-borne viral disease that has become a major public health concern worldwide in recent years. Annually, 100 million cases of dengue fever and 500,000 cases of dengue hemorrhagic fever occur, particularly in tropical Asia, Latin America, and the Caribbean (5, 22). At present, dengue is endemic in 112 countries around the world (23). However, there is no vaccine or treatment other than vector control and supportive medical care. The development of safe and effective therapeutics is therefore urgently needed.The etiological agents involved are four serotypes of dengue virus (dengue virus serotype 1 [DENV-1], DENV-2, DENV-3, and DENV-4), which belong to the genus Flavivirus in the family Flaviviridae. Besides dengue virus, many flaviviruses are important human pathogens, including West Nile virus (WNV), yellow fever virus (YFV), Japanese encephalitis virus (JEV), and tick-borne encephalitis virus. The dengue viral genome is a single-stranded, positive-sense RNA of about 11 kb in length and contains both 5′ and 3′ untranslated regions. The genomic RNA encodes a single polyprotein that is co- and posttranslationally processed by both viral and cellular proteases into three structural proteins, the capsid (C), premembrane (prM), and envelope (E) proteins, and seven nonstructural proteins, the NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5 proteins (21).Infection by dengue virus is initiated by fusion between the viral membrane and the host membrane. The fusion process is mediated by the dengue virus E protein in a pH-dependent manner (36). The dengue virus E protein consists of three domains: central domain I, extended fingerlike domain II, and immunoglobulin-like domain III (24-26, 41). A similar three-domain organization is found in the E proteins of tick-borne encephalitis virus (31) and WNV (15, 28) and the E1 protein of Semliki Forest virus (19). All these E proteins represent a distinct class (class II) of viral fusion proteins that is different from the class I fusion proteins represented by gp120/gp41 of human immunodeficiency virus (HIV) and the hemagglutinin of influenza virus (7, 10, 34). The recently determined crystal structure of the dengue virus E protein reveals a hydrophobic pocket occupied by a detergent molecule (β-N-octylglucoside [β-OG]) lying at a hinge region between domains I and II of the E protein, which is important for the low-pH-triggered conformational rearrangement required for fusion (25). The available structural data open up a new avenue for identifying antiviral agents active against early steps of dengue virus infection (30).Inhibition of enveloped viruses at the stage of viral entry provides a route for therapeutic intervention, as evidenced by the peptidic HIV entry inhibitor enfuviritide (T-20) (16, 35). Other peptides have demonstrated activity against retroviruses in vitro (6, 32) and paramyxoviruses (17, 39, 40). Hrobowski and coworkers have identified peptide inhibitors of dengue virus and WNV infectivity using a physiochemical algorithm (12). Peptidic antivirals, however, suffer from poor absorption from the gastrointestinal tract, necessitating intravenous delivery and high manufacturing costs, making it impractical to treat most vulnerable patients with dengue. We therefore explored the development of nonpeptidic small molecules to inhibit dengue virus entry. We hypothesized that the in silico docking of small-molecule libraries active against the dengue E protein''s hydrophobic pocket could be successfully applied to the identification of inhibitors of dengue virus entry. This high-throughput docking (HTD) effort led to the identification of small molecules that were able to inhibit the replication of dengue virus in a cellular assay. The initial hits were further evaluated and optimized to identify compound 6 as a lead. Mechanism-of-action studies indicate that compound 6 blocks dengue virus replication at an early stage of the viral life cycle.     

A 6-Year-Old Girl with Fever,Rash, and Increased Intracranial Pressure

Background

Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes.

Objective

Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF.

Methods

We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection.

Conclusions

We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.     

Frequency and Cost of Claims by Injury Type From a State Workers' Compensation Fund From 1998 Through 2008

Objective

To determine which work-related injuries are the most frequent and costly.

Design

Secondary analysis of workers' compensation claims data.

Setting

Data were provided by a large, Maryland workers' compensation insurer from 1998 through 2008.

Participants

Not applicable.

Interventions

None.

Main Outcomes Measures

For 45 injury types, the number of claims and compensation amount was calculated for total compensation and for medical and indemnity compensation separately.

Results

Back and knee injuries were the most frequently occurring single injury types, whereas heart attack and occupational disease were the most expensive in terms of mean compensation. When taking into account both the frequency and cost of injury (mean cost × number occurrences), back, knee, and shoulder injuries were the most expensive single injury types.

Conclusions

Successful prevention and management of back, knee, and shoulder injuries could lead to a substantial reduction in the burden associated with work-related injuries.     

Exploring experiences of physical activity among people with Alzheimer's disease and their spouse carers: a qualitative study

Objectives

To improve understanding about the barriers and facilitators to physical activity for people with Alzheimer's disease and their spouse carers, and to consider the development of activity interventions that would be acceptable, sustainable and feasible for both groups.

Design

A qualitative approach, using semi-structured interviews, facilitated exploration of physical activity in a small group of people with Alzheimer's disease and their spouse carers.

Setting

Participants were recruited from one memory clinic in South West England.

Participants

Potential participants were identified by clinical psychologists at the memory clinic and were given information about participating in the research. Five people with Alzheimer's disease and their spouse carers were subsequently recruited for semi-structured interviews, which took place at the memory clinic. Interviews were audio-recorded and transcribed verbatim.

Main outcome measures

Qualitative data were analysed using thematic analysis. Three major themes have been presented.

Results

The findings illustrate the complex interplay between the overarching themes ‘self’, ‘others’ and ‘couple’ that affect physical activity for both people with Alzheimer's disease and their spouse carers, and which are linked to the progression of dementia.

Conclusions

An individually tailored approach for couples, which values the role of the carer and accounts for the progressive and changing nature of dementia, should be a guiding principle for intervention design.     

Primary sternal osteomyelitis with bacteremia and distal seeding

Background

Primary sternal osteomyelitis is a rare disease, whereas secondary sternal osteomyelitis is relatively well known as a complication in post-sternotomy patients.

Objective

Describe a case of primary Staphylococcus aureus sternal osteomyelitis in an immunocompetent man and its diagnostic challenges, treatment, and complications.

Case Report

A 46-year-old man presented with prolonged sternal pain and swelling, fatigue, and fever. He is diagnosed with primary sternal osteomyelitis with concurrent bacteremia and complicated by local and distant abscess formation. The diagnosis was aided by computed tomography, and treatment consisted of incision and drainage and long-term antibiotics.

Conclusion

Primary sternal osteomyelitis is uncommon and often difficult to diagnose. Complications include abscess formation and distal seeding. Diagnosis can be aided by a detailed history and radiography, and treatment may consist of a prolonged course of antibiotics and incision and drainage.     

Preliminary Investigation of an Electromyography-Controlled Video Game as a Home Program for Persons in the Chronic Phase of Stroke Recovery

Objective

To investigate the preliminary effectiveness of surface electromyography (sEMG) biofeedback delivered via interaction with a commercial computer game to improve motor control in chronic stroke survivors.

Design

Single-blinded, 1-group, repeated-measures design: A1, A2, B, A3 (A, assessment; B, intervention).

Setting

Laboratory and participants' homes.

Participants

A convenience sample of persons (N=9) between 40 and 75 years of age with moderate to severe upper extremity motor impairment and at least 6 months poststroke completed the study.

Intervention

The electromyography-controlled video game system targeted the wrist muscle activation with the goal of increasing selective muscle activation. Participants received several laboratory training sessions with the system and then were instructed to use the system at home for 45 minutes, 5 times per week for the following 4 weeks.

Main Outcome Measures

Primary outcome measures included duration of system use, sEMG during home play, and pre/post sEMG measures during active wrist motion. Secondary outcomes included kinematic analysis of movement and functional outcomes, including the Wolf Motor Function Test and the Chedoke Arm and Hand Activity Inventory-9.

Results

One third of participants completed or exceeded the recommended amount of system use. Statistically significant changes were observed on both game play and pre/post sEMG outcomes. Limited carryover, however, was observed on kinematic or functional outcomes.

Conclusions

This preliminary investigation indicates that use of the electromyography-controlled video game impacts muscle activation. Limited changes in kinematic and activity level outcomes, however, suggest that the intervention may benefit from the inclusion of a functional activity component.     

The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED

Background

The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use.

Objective

The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries.

Design/Methods

Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetron's effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnoses of head injury who did not receive a head CT and were discharged.

Results

A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses.

Conclusion

Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.     

An Unusual Cause of Pelvic Pain and Fever: Periurethral Abscess from an Infected Urethral Diverticulum

Background

The evaluation of patients with pelvic pain is a common task for emergency physicians. Accurate diagnosis of the underlying cause of pelvic pain in women is often difficult given the diversity of pathology that can generate pelvic pain.

Objective

To report a rare but clinically significant cause of acute pelvic pain in women.

Case Report

We describe a rare case of a periurethral abscess secondary to an infected urethral diverticulum in a 41-year-old woman. She presented to our Emergency Department with pelvic pain, dysuria, and fever of 4 days duration.

Conclusion

Physical examination, imaging studies, and surgery aided in confirming the diagnosis of a periurethral abscess.     

Fever in non-neurological critically ill patients: A systematic review of observational studies

Purpose

There is no recommendation on how increased body temperature should be treated in non-neurological critically ill patients. To understand the epidemiology of fever and its association with mortality, we conducted a systematic review of the literature to search for data related to the association between fever and mortality.

Materials and Methods

We searched MEDLINE and PUBMED related articles and reference lists from January 1978 to July 2011 to select observational studies for assessment of the association of fever with mortality in non-neurological critically ill patients.

Results

We reviewed 1464 articles and found 9 relevant articles. We found that (1) there is no uniform definition of fever, (2) fever (37.5°C to >39.0°C) was not significantly associated with mortality (odds ratio, 1.22; P = .52), and (3) high fever (39.3°C to 39.5°C) was significantly associated with mortality (odds ratio, 2.95; P = .03). We also found that there has been no multicenter prospective observational study including important confounding factors, such as the use of antipyretic treatments, steroids, and extracorporeal circuits.

Conclusions

The limited evidence available suggests that the recommended definition of fever (38.3°C) might be too low to predict increased mortality. Because fever is common in the intensive care unit, there is an urgent need for more studies in this field.     

Factors Associated With Home Discharge Among Veterans With Stroke

Objective

To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs.

Design

Retrospective observational study.

Setting

Veterans Affairs facilities nationwide.

Participants

Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565).

Intervention

Not applicable.

Main Outcome Measure

Discharge location after hospitalization.

Results

There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11–1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03–.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50–.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63–.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07–1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76–.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77–.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78–.97), and serious nutritional compromise (OR=.49; 95% CI=.40–.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge.

Conclusions

We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.     

Determinants and costs of community nursing in patients with type 2 diabetes from a community-based observational study: The Fremantle Diabetes Study

Background

Despite widespread use, there is little information on the extent and impact of community nursing to patients with type 2 diabetes.

Objective

To determine the incidence, predictors and costs of community nursing provision to patients with type 2 diabetes in a large community-based representative study of diabetes in an urban Australian setting.

Design

Prospective observational study utilising data linkage.

Setting

Postcode defined region in Fremantle, Australia.

Participants

All patients with type 2 diabetes enrolled in the Fremantle Diabetes Study between 1993 and 1996.

Methods

Eligible patients were followed from July 1997, when home nursing data first became available, to death or census in November 2007. Home nursing data from the major community nursing service provider were linked with data from the Fremantle Diabetes Study. Cox and zero-inflated negative binomial (ZINB) regression modelling was used to identify predictors of incident home visits and visit frequency, respectively. Direct costs were estimated from the service provider's unit costs.

Results

During a mean ± SD 8.6 ± 2.9 years of follow-up, 27.8% of 825 patients (aged 65.2 ± 10.3 years at study entry; 51.2% male) received 21,878 home nursing visits (median frequency 31 [interquartile range 9–85] visits, range 1–1446 visits). In Cox and ZINB models, predictors of home nursing included older age, physical disability measures and macrovascular and microvascular complications. Insulin use was an important predictor of the frequency of visits whilst ethnic and economic factors predicted lower frequency. The estimated cost of home nursing, extrapolated nationally, adds 5% to the total Australian direct health care costs of diabetes.

Conclusions

Home nursing is frequently utilized in the management of type 2 diabetes with considerable individual variation in the use of this service. Given the associated costs, further research into how home nursing can best be employed is indicated.     

Acute Rheumatic Fever: Case Report and Review For Emergency Physicians

Background

Acute rheumatic fever (ARF), a consequence of group A streptococcal (GAS) pharyngitis, is characterized by nonsuppurative inflammatory lesions of the joints as well as subcutaneous and cardiac tissues. Although the overall incidence of ARF in the United States has declined in recent years, there have been reports of outbreaks in closed populations, as well as sporadic cases. Traditionally considered a disease of children, adults may also acquire the disease. Because of declining incidence and a presentation that may overlap with other conditions, ARF may not be considered in the differential diagnosis. Failure to recognize ARF may result in delayed diagnosis and recurrent disease.

Objective

This report is designed to assist emergency physicians in identifying components of the history and physical examination that are important to making a timely diagnosis of ARF.

Case Report

An otherwise healthy man presented to the emergency department (ED) with clinical findings consistent with ARF. Despite presentation to the ED on three occasions, during which he was treated for various conditions, it was not until the 3^rd encounter that the diagnosis of ARF was considered.

Conclusion

Failure to recognize ARF may result in repeated ED visits, delayed diagnosis, and prolonged patient discomfort. Recognition of the condition is important to prevent recurrent disease.     

Restraint Use in the Elderly Emergency Department Patient

Background

The elderly frequently suffer from altered mental status and other medical conditions requiring physical or chemical restraint for safety in the Emergency Department (ED).

Objective

This study examined outcomes of restrained elderly patients in the ED.

Methods

A 2-year retrospective study was conducted in an urban community teaching hospital ED. Included were patients ≥65 years of age who were physically restrained in the ED and hospitalized. Data collected included age, gender, restraint indications, restraint type, restraint duration, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay, and disposition.

Results

There were 83 patients in the study. Forty-seven (56.6%) were nursing home residents. Twenty-seven (32.5%) were admitted to the intensive care unit. Thirty-five (42.2%) received both chemical and physical restraint. The average number of patient medications on arrival to the ED was eight, and 3 patients were on a medication that could adversely interact with a chemical restraint medication. The mean inpatient length of stay was 7.2 days (SD 5.7 days). Ten patients expired, 14 were discharged home, and 59 were discharged to a nursing facility (8 with new behavioral medications). Of the 36 patients originally presenting to the ED from home, only 11 (30.6%) were discharged back to home. There were no significant differences in outcome between patients who received a combination of both chemical and physical restraints and patients who received physical restraint alone.

Conclusion

In this 2-year retrospective study, elderly patients placed in physical restraints in the ED had no recorded adverse outcomes. In addition, there were no adverse outcomes when they received both physical and chemical restraint. Elderly patients who were originally admitted from home and subsequently required physical restraint were unlikely to return home.     

People With Multiple Sclerosis Use Many Fall Prevention Strategies but Still Fall Frequently

Objective

To compare the use of fall prevention strategies by people with multiple sclerosis (MS) who do or do not fall.

Design

Prospective cohort. All assessments were completed between January 2011 and December 2011. Data used in this analysis were collected as part of an observational study that included baseline assessment followed by prospective counting of falls using fall calendars.

Setting

Veterans Affairs and university medical centers.

Participants

People with MS (N=58) of any subtype, aged 18 to 50 years, with Expanded Disability Status Scale score ≤6.0, recruited from MS clinics at the Portland VA Medical Center and Oregon Health and Science University and from the surrounding areas.

Interventions

Not applicable.

Main Outcome Measures

Measures included the occurrence of falls over 3 months and scores on the Fall Prevention Strategy Survey (FPSS) and the relations between fall prevention strategy use reported on the FPSS and falls.

Results

A total of 52 subjects completed the study. Of these, 33 (63%) subjects fell at least once in the 3-month period, and 19 (36%) subjects did not fall. The mean total FPSS score for the fallers was significantly higher than the nonfallers (mean ± SD, 8.1±6.4 vs 4.0±4.1; range, 0–20 vs 0–15; P=.007), and FPSS scores correlated with monthly fall rates (ρ=.49, P=.01). A higher proportion of fallers than nonfallers used the strategies of turning on lights at home, asking others for help, and talking to a health care professional about fall prevention. However, both groups rarely talked to a health care professional about fall prevention or asked a provider to check whether any medications might increase fall risk.

Conclusions

People with MS who fall use more fall prevention strategies than those who do not fall.