A unique case of bradycardia recognized by wearable technology as first presentation of complete heart block

Wearable technology has advanced significantly, and the proposed health benefits have been widely touted. Most of the discussion has been surrounding the identification and diagnosis of asymptomatic atrial fibrillation. However, the heart monitoring functions of the wearable technology can also identify other abnormalities as well. We present the first case of wearable technology identified bradycardia diagnosed as the primary presentation of complete heart block. Wearable technology has advanced significantly, but still poses questions regarding its use in screening for rare conditions. One remaining challenge is balancing the desire to screen for rare asymptomatic conditions without overburdening emergency departments with patients responding to alarms on their devices.     

Delusional parasitosis as presenting symptom of occipital lobe cerebrovascular accident

Delusional parasitosis manifests as a fixed, false belief that an individual is infested by living organisms. Primary delusional parasitosis is a psychiatric disorder with the delusion as an isolated manifestation, whereas secondary delusional parasitosis is a delusion occurring secondary to a psychiatric disorder, substance use, or medical illness. A 62-year-old woman with no psychiatric history presented to the Emergency Department with two to three months of “whole body itching” and seeing small insects crawling on her skin and in her hair. Exam of her skin and scalp was notable for no appreciable lesions, rashes, excoriations, or insects. Her neurologic exam was notable for full visual fields, and no localizing deficits. A non-contrast head CT demonstrated a nonspecific heterogeneous low-attenuation lesion within the medial right occipital lobe, and a follow up MRI confirmed a right posterior cerebral artery distribution subacute infarction. She was admitted for two days, and ultimately was discharged on aspirin and atorvastatin for secondary prevention. An emergency physician should remain vigilant in his/her assessment of patients with seemingly psychiatric symptoms, in particular elderly patients with no known psychiatric illnesses. Neuroimaging should be amongst studies considered in the evaluation of elderly patients presenting with new onset psychiatric complaints.     

Assessing a Novel Method of Calculation of the Cobb Angle for Scoliosis: Interexaminer Reliability and Student Satisfaction

ObjectiveThe objectives of this pilot study were to compare the interexaminer reliability of 2 different methods of Cobb angle measurement and to determine whether the participants considered 1 of the 2 methods easier to learn, understand, and apply.MethodsEntry-level anatomy students who have familiarity with vertebral column anatomy but have not had previous radiology training were instructed on how to measure a Cobb angle. Each student measured 2 curves (thoracic and lumbar) on a single radiograph, first with the traditional method of Cobb angle measurement and second with a novel method of Cobb angle measurement using a digital level.ResultsThe variance of measurements decreased by using the novel method from thoracic to lumbar measurements and for the moderate and severe scoliosis films. All decreases in variance were statistically significant except for the lumbar measurement variance for the severe scoliosis film. The novel method of Cobb angle measurement with these same participants showed interexaminer reliability. More than 78% of naive participants considered the proposed method easier to learn, understand, and apply when compared with the traditional method.ConclusionIn this group of naive students, there was improved interrater reliability, greater satisfaction, and reduced measurement variances in some cases, with a novel method using a digital level to measure the Cobb angle compared with the traditional method of measurement.     

Cost analysis of the History,ECG, Age,Risk factors,and initial Troponin (HEART) Pathway randomized control trial

Introduction

The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported.

Cardiology consultation reduces provocative testing rates in an ED observation unit

Background

In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model).

Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management

Objective

The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos.

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure

Objectives

The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both.

Clinical manifestations and risk factors of community-onset Acinetobacter species pneumonia in Japan; case control study in a single institute in Japan

To clarify the etiology, patients' characteristics and risk factors for community-onset AP (Acinetobacter species pneumonia), we conducted this case-control study. We reviewed all patients with community-onset AP at our institute from 2010 until 2018. We defined non-AP group as a control. The patients with non-Acinetobacter spp. pneumonia (non-AP) were randomly selected during the study period without clinical information based on medical records' list among patients with community-onset pneumonia. The age (±2 years) and sex were matched to the patients with community-onset AP, and the ratio was AP:non-AP group = 1:3. Patients' characteristics, clinical outcomes, pathogens isolated and drug susceptibility were evaluated by comparing AP and non-AP group.The mean age of community-onset AP group was 79 years. They were 8 males and 5 females. The 30-day and in-hospital mortality rates of community-onset AP were 23% (v.s. 3%, p = 0.049) and 31% (v.s. 5%, p = 0.029) respectively, which are higher than the control group. Heavy alcohol consumption (23% v.v. 0%, p = 0.023), higher Charlson Comorbidity index (3.2 v.s. 2.0, p = 0.046) and lobar pneumonia by chest radiology (50% v.s. 23%, p = 0.071) were seen more frequently in community-onset AP than in the control group.In conclusion, community-onset AP shows poor outcomes despite the appropriate antibiotic therapy. Heavy alcohol history might be a risk factor of AP. Patients with community-onset AP could have more comorbidity and poor general conditions than the control group.     

Intensive In-Hospital Rehabilitation After Hip Fracture Surgery and Activities of Daily Living in Patients With Dementia: Retrospective Analysis of a Nationwide Inpatient Database

ObjectivesTo examine the effects of earlier, more frequent, and larger daily amounts of postoperative rehabilitation on activities of daily living (ADL) after hip fracture surgery in patients with dementia.DesignRetrospective cohort study.SettingA total of 1053 acute-care hospitals.ParticipantsPatients aged ≥65 years with dementia at admission underwent hip fracture surgery and received postoperative rehabilitation from April 1, 2014 to March 31, 2016 (N=43,206).InterventionsThree rehabilitation variables as key independent variables: (1) the interval from surgery to starting rehabilitation (days); (2) the frequency of postoperative rehabilitation (days per week); and (3) the average daily units of postoperative rehabilitation (minutes per daily rehabilitation).Main Outcome MeasureADLs based on the Barthel Index (BI) at discharge from acute-care hospitals.ResultsIn the multivariable linear regression analysis, delayed rehabilitation was significantly associated with a lower BI at discharge (for each day of the interval increase, BI at discharge was 0.38 lower; 95% confidence interval [CI], 0.21-0.54), and a significant increase in the BI at discharge was observed in patients who underwent more frequent rehabilitation (BI [95% CI] was 2.62 [0.99-4.25], 5.83 [4.28-7.38], 7.56 [5.95-9.16], and 9.16 [7.34-10.97] higher for frequencies of 3.1-4.0, 4.1-5.0, 5.1-6.0, and >6.0 days per week, respectively) and larger daily amounts of rehabilitation (4.37 [3.69-5.06] and 6.60 [5.63-7.57] higher for 40-59 and ≥60 minutes per day, respectively).ConclusionsThese results suggest that earlier, more frequent, and larger daily amounts of postoperative rehabilitation in acute-care hospitals are independently associated with better recovery in ADL at discharge from acute-care hospitals after hip fracture surgery in patients with dementia.