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Maxine Inocencio Jeannine Childs Mikaela L. Chilstrom Kristin Berona 《The Journal of emergency medicine》2017,52(6):e217-e220
Background
Delayed recognition of tension pneumothorax can lead to a mortality of 31% to 91%. However, the classic physical examination findings of tracheal deviation and distended neck veins are poorly sensitive in the diagnosis of tension pneumothorax. Point-of-care ultrasound is accurate in identifying the presence of pneumothorax, but sonographic findings of tension pneumothorax are less well described.Case Report
We report the case of a 21-year-old man with sudden-onset left-sided chest pain. He was clinically stable without hypoxia or hypotension, and the initial chest x-ray study showed a large pneumothorax without mediastinal shift. While the patient was awaiting tube thoracostomy, a point-of-care ultrasound demonstrated findings of mediastinal shift and a dilated inferior vena cava (IVC) concerning for tension physiology, even though the patient remained hemodynamically stable.Why Should an Emergency Physician Be Aware of This?
This case demonstrates a unique clinical scenario of ultrasound evidence of tension physiology in a clinically stable patient. Although this patient was well appearing without hypotension, respiratory distress, tracheal deviation, or distended neck veins, point-of-care ultrasound revealed mediastinal shift and a plethoric IVC. Given that the classic clinical signs of tension pneumothorax are not uniformly present, this case shows how point-of-care ultrasound may diagnose tension pneumothorax before clinical decompensation. 相似文献3.
Pyong Wha Choi 《The Journal of emergency medicine》2017,52(4):e117-e122
Background
Although colonoscopy is generally a safe procedure, lethal complications can occur. Colonoscopic perforation is one of the most serious complications, and it can present with various clinical symptoms and signs. Aggravating abdominal pain and free air on simple radiography are representative clinical manifestations of colonoscopic perforation. However, unusual symptoms and signs, such as dyspnea and subcutaneous emphysema, which are less likely to be related with complicating colonoscopy, may obscure correct clinical diagnosis. We present two cases of pneumomediastinum, pneumothorax, and subcutaneous emphysema caused by colonoscopic perforation.Case Report
A 75-year-old woman and a 65-year-old man presented with dyspnea, and facial swelling and abdominal pain, respectively. In the first case, symptoms occurred during polypectomy, whereas they occurred after polypectomy in the second case. Chest radiograph and computed tomography scans revealed pneumomediastinum, pneumothorax, and subcutaneous emphysema in the neck. During both operations, an ascending colonic subserosa filled with air bubbles was observed, and laparoscopic right hemicolectomy was performed in the first case. In the second case, after mobilization of the right colon, retroperitoneal colonic perforation was identified and primary repair was performed. The postoperative course was uneventful.Why Should an Emergency Physician be Aware of This?
These cases show the unusual clinical manifestations of colonoscopic perforation, which depend on the mechanism of perforation. Awareness of these less typical manifestations is crucial for prompt diagnosis and management for an emergency physician. 相似文献4.
Background
Ideally, high-stakes examinations assess 1 dimension of medical knowledge to produce precise estimates of a candidate’s performance. It has not been reported whether the American Board of Physical Medicine and Rehabilitation Part 1 Certification Examination (ABPMR-CE-1) is unidimensional or not.Objective
To examine the ABPMR-CE-1 to measure how many dimensions it assesses.Design
Retrospective observational study.Setting
We assessed examination results from the 2015 ABPMR-CE-1.Participants
A total of 489 deidentified candidates taking the 2015 ABPMR-CE-1.Methods
A 1-parameter Item Response Theory (IRT) measurement model was utilized. A Principal Components Analysis (PCA) of standardized residual correlations was used to detect multidimensionality.Main Outcome Measure
Number of primary dimensions reflected in the 325 test questions.Results
The results of the dimensionality analysis indicated that the ABPMR-CE-1 examination is highly unidimensional from a psychometric perspective. Expert content review of the substantive content of small contrasting clusters of questions provided additional assurance of the unidimensional nature of the examination.Conclusions
The ABPMR-CE-1 appears indeed to measure a single construct, which suggests a sound structure of the examination. It closely approximates the assumption of statistical unidimensionality.Level of Evidence
Not applicable. 相似文献5.
Seth M. Grubb Jonathan I. Stuart Hillary M. Harper 《The American journal of emergency medicine》2017,35(11):1787.e1-1787.e3
Background
Undifferentiated abdominal pain is a common condition encountered in the emergency department. While a patient's age, risk factors, and comorbidities often aid in risk stratification and guide emergency department evaluation, atypical presentations of serious disease may still occur suddenly in young otherwise healthy patients.Case report
In this vignette we discuss a case of spontaneous, atraumatic renal rupture with large retroperitoneal hemorrhage (Wunderlich's Syndrome) in a 22 year old male.Discussion
Emergency physicians regularly encounter uncommon causes of abdominal pain. Wunderlich's syndrome is rare but proper understanding of the disease process will aid in decision making and improve disposition and outcomes for patients. Likely presentations and risk factors for atraumatic renal rupture will be discussed as well as ED management and definitive treatment options. 相似文献6.
Alexander J. Bajorek Chloe Slocum Richard Goldstein Jacqueline Mix Paulette Niewczyk Colleen M. Ryan Carla Tierney Hendricks Ross Zafonte Jeffrey C. Schneider 《PM & R》2017,9(1):1-7
Background
A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied.Objective
To assess how cognitive function affects rehabilitation outcomes in the burn injury population.Design
Retrospective study.Setting
Inpatient rehabilitation facilities in the United States.Participants
A total of 5347 adults admitted to an IRF with burn injury between 2002 and 2011.Methods or Interventions
Multivariable regression was used to model rehabilitation outcome measures, using the cognitive domain of the Functional Independence Measure (FIM) instrument as the independent variable and controlling for demographic, medical, and facility covariates.Main Outcome Measurements
FIM total gain, readmission to an acute care setting at any time during inpatient rehabilitation, readmission to an acute care setting in the first 3 days of IRF admission, rate of discharge to the community setting, and length of stay efficiency.Results
Cognitive FIM total at admission was a significant predictor of FIM total gain, length of stay efficiency, and acute readmission at 3 days (P < .05). Cognitive FIM total scores did not have an impact on acute care readmission rate or discharge to the community setting.Conclusions
Cognitive status may be an important predictor of rehabilitation outcomes in the burn injury population. Future work is needed to further examine the impact of specific cognitive interventions on rehabilitation outcomes in this population.Level of Evidence
II 相似文献7.
Background
Pulmonary embolism (PE) affects >600,000 patients per year in the United States. Evaluation includes clinical decision rules, laboratory tests, and several imaging modalities. The diagnosis of PE has risen in recent years, particularly subsegmental PE (SSPE). Controversy exists concerning the diagnosis and treatment of these lesions.Objective
We sought to provide emergency physicians with a review of the controversies surrounding PE testing and the diagnosis and treatment of SSPE.Discussion
With the rise of computed tomography (CT) testing for PE, diagnosis has increased. Providers often omit risk stratification in favor of D-dimer or imaging, which does not have literature support. The detection of PE has risen by 80%, and this increased testing is associated with several risks, including contrast reaction, nephropathy, and increased radiation. SSPE diagnosis has risen with improved imaging technology, but the literature shows low interobserver agreement with diagnosis of true SSPE. Studies disagree on the clinical significance and dangers of this PE subset. The American College of Chest Physicians 2016 guidelines recommend withholding anticoagulation for SSPE with low risk for recurrent thrombus and no concurrent deep vein thrombosis. Patients at high risk for recurrent venous thromboembolism or with deep vein thrombosis warrant anticoagulation. The provider is ultimately responsible for appropriate evaluation with risk stratification and selective testing.Conclusions
SSPE presents a quandary, because the literature differs in showing harm despite increased diagnosis. American College of Chest Physicians guidelines for the treatment of SSPE take into account the patient, the imaging, and other imaging modalities. Providers should use risk stratification with shared decision-making in the evaluation and treatment of SSPE. 相似文献8.
Megan Sutter Laiene Olabarrieta Landa Amilkar Calderón Chagualá Helmer Chacón Peralta Gina Vergara Torres Paul B. Perrin Juan Carlos Arango-Lasprilla 《PM & R》2017,9(1):8-14
Background
Stroke is a primary cause of death and disability in upper-middle–income countries such as Colombia. Given the lack of comprehensive rehabilitation for stroke patients in Colombia, there is a need to assess longitudinal mental health problems poststroke in this region.Objective
To compare the course of mental health in stroke patients to healthy controls over the first year poststroke in Ibague, Colombia.Design
Cross-sectional study.Setting
The Psychological Attention Center of Antonio Nariño University in Ibague, Colombia.Participants
Stroke patients (n = 50) and age- and gender-matched healthy controls (n = 50).Methods
Patients and controls completed self-report Spanish versions of demographic information, injury-related characteristics, and mental health questionnairesMain Outcome Measurements
Outcomes assessed included mental health (depression, anxiety, and stress) at 3, 6, and 12 months poststroke.Results
Hierarchical linear models suggested that stroke patients had worse depression and anxiety over time than controls (P < .001). Among patients, depression and anxiety decreased over time (P < .001), whereas stress increased over time (P < .01). The findings suggest that although anxiety and depression improved over time in stroke patients, their mental health remained significantly lower than that of controls.Conclusions
This is the first study to examine the course of mental health over the first year poststroke in Latin America, specifically in Ibague, Colombia. Despite the improvements in anxiety and depression over the first year poststroke, patient anxiety and depression were still worse in comparison to those in healthy controls. The current findings indicate a need for rehabilitation services in Colombia, especially targeting mental health issues.Level of Evidence
I 相似文献9.
Introduction
Osteopathic Manipulative Treatment (OMT) is effective in improving function, movement and restoring pain conditions. Despite clinical results, the mechanisms of how OMT achieves its' effects remain unclear. The fascial system is described as a tensional network that envelops the human body. Direct or indirect manipulations of the fascial system are a distinctive part of OMT.Objective
This review describes the biological effects of direct and indirect manipulation of the fascial system.Material and methods
Literature search was performed in February 2016 in the electronic databases: Cochrane, Medline, Scopus, Ostmed, Pedro and authors' publications relative to Fascia Research Congress Website.Results
Manipulation of the fascial system seems to interfere with some cellular processes providing various pro-inflammatory and anti-inflammatory cells and molecules.Discussion
Despite growing research in the osteopathic field, biological effects of direct or indirect manipulation of the fascial system are not conclusive.Conclusion
To elevate manual medicine as a primary intervention in clinical settings, it's necessary to clarify how OMT modalities work in order to underpin their clinical efficacies. 相似文献10.
Naciye Sinem Gezer Pınar Balcı Kemal Çağlar Tuna Işıl Başara Akın Mustafa Mahmut Barış Neşe Çolak Oray 《The American journal of emergency medicine》2017,35(4):623-627
Background
Chest radiography is the initial choice for thoracic imaging. However, the wide availability of computed tomography (CT) has led to a substantial increase in its use in the emergency department (ED). We evaluated the utility of chest CT after a chest X-ray in patients presenting to the ED with non-traumatic thoracic emergencies, and determined if the diagnosis and management decision changed after CT.Methods
The study enrolled 500 consecutive patients with both chest X-rays and CT who presented to the ED with non-traumatic complaints. Chest X-rays and CT images obtained within 12 h before any definitive treatment were randomly evaluated in consensus by two radiologists blinded to the clinical information.Results
The chest X-ray and CT image findings were concordant in 49.2% of the 500 patients and this concordance was negatively correlated with patient age. Leading diagnosis and management decisions based on the chest radiograph changed after CT in 35.4% of the study group and this finding was also correlated with age. In 55% of 205 patients, pneumonic infiltrations were undiagnosed with radiography. Pulmonary edema was the most specific (93.3%) and sensitive (85.4%) radiography finding. Posteroanterior chest radiographs taken in the upright position had higher concordance with CT than anteroposterior (AP) radiographs taken in the supine position.Conclusions
Chest CT may be an appropriate imaging choice in patients presenting to the ED for non-traumatic reasons, particularly for elderly patients and when the radiograph is taken with the AP technique in a supine position. 相似文献11.
Background
Insect venom anaphylaxis is a potentially life-threatening disorder. Transient coagulopathy in insect venom anaphylaxis is a rare phenomenon.Case Report
A 41-year-old man presented to the Emergency Department (ED) with hypotension after a run in a park. History and examination revealed signs of anaphylactic shock. A deranged coagulation profile with a normal platelet count led to the diagnosis of wasp sting anaphylaxis.Why Should an Emergency Physician Be Aware of This?
Transient deranged coagulation profile with a normal platelet count may arise from insect venom anaphylaxis. This specific finding may aid the emergency physician in making a diagnosis of anaphylactic shock in an otherwise healthy patient presenting with shock with no apparent cause. 相似文献12.
Background
There is a growing interest in the use of biologic agents such as platelet-rich plasma and mesenchymal stem/stromal cells to treat musculoskeletal injuries, including meniscal tears. Although previous research has documented the role of diagnostic ultrasound to evaluate meniscal tears, sonographically guided (SG) techniques to specifically deliver therapeutic agents into the meniscus have not been described.Objective
To describe and validate SG injection techniques for the body and posterior horn of the medial and lateral meniscus.Design
Prospective, cadaveric laboratory investigation.Setting
Academic institution procedural skills laboratory.Subjects
Five unenbalmed cadaveric knee-ankle-foot specimens from 5 donors (3 female and 2 male) ages 33-92 years (mean age 74 years) with body mass indices of 21.1-32.4 kg/m2 (mean 24.1 kg/m2).Methods
A single, experienced operator completed SG injections into the bodies and posterior horns of the medial and lateral menisci of 5 unenbalmed cadaveric knees using colored latex and a 22-gauge, 38-mm needle. After injection, coinvestigators dissected each specimen to assess latex distribution within the menisci and identify injury to intra-articular and periarticular structures.Main Outcome Measures
Latex location within the target region of meniscus (accurate/inaccurate), and iatrogenic injury to “at risk” intra- and periarticular structures (present/absent).Results
Seventeen of 20 injections were accurate. Two of 3 inaccurate injections infiltrated the posterior horn of the medial meniscus instead of the targeted meniscal body. One inaccurate lateral meniscus injection did not contain latex despite sonographically accurate needle placement. No specimen exhibited injury to regional neurovascular structures or intra-articular hyaline cartilage.Conclusions
SG meniscus injections are feasible and can accurately and safely deliver injectates such as regenerative agents into bodies and posterior horns of the medial and lateral menisci. The role of SG intrameniscal injections in the treatment of patients with degenerative and traumatic meniscal disorders warrants further exploration.Level of Evidence
Not applicable. 相似文献13.
Acute Promyelocytic Leukemia Presenting as Focal Neurologic Findings and Deteriorating Mental Status
Background
Acute promyelocytic leukemia (APL) is a rare but particularly malignant form of acute leukemia that is characterized by a rapid progression to fatal hemorrhage. Survival rates of patients with APL have increased with the introduction of all-trans retinoic acid (ATRA), but early deaths caused by hemorrhage still persist.Case Report
A man with undiagnosed APL presenting with focal neurologic findings and deteriorating altered mental status caused by an intracranial hemorrhage is discussed.Why Should An Emergency Physician Be Aware of This?
It is important to consider APL when diagnosing etiologies for intracranial hemorrhage. In addition to standard care, early administration of ATRA is recommended upon clinical suspicion of the disease. 相似文献14.
Alexander Beyer Beejal Ganti Allen Majkrzak Nik Theyyunni 《The Journal of emergency medicine》2017,52(4):e123-e127
Background
Oral tyrosine kinase inhibitors (TKIs) are becoming increasingly common in oncology practice due to ease of administration and patient preference. This class of medications is relatively unknown to emergency physicians.Case Report
Here we present a case of electrical storm (ES) thought to be associated with ibrutinib, a TKI. The ES was unabated despite antidysrhythmic therapy and electrical cardioversion, and was treated with supportive care, which eventually included the use of extracorporeal membrane oxygenation. This patient had no risk factors or apparent causes of recurrent ventricular tachycardia.Why Should an Emergency Physician Be Aware of This?
ES has not previously been described with ibrutinib, but may be associated with off-target effects of the drug. 相似文献15.
Mary P. Henman 《The Journal of emergency medicine》2017,52(1):117-120
Background
A suicidal person with a do-not-resuscitate (DNR) order presents an ethical dilemma to the emergency physician. Many believe that suicide is an irrational action, and therefore, all suicide attempts must be treated. Others believe a DNR order should be respected even in the setting of a suicide attempt.Case Report
An elderly woman with a known terminal illness presented to the emergency department after a suspected suicide attempt. She had a DNR order during her previous hospitalization. The emergency physician felt obligated to intubate the woman despite his recognition that she was terminally ill.Discussion
Reasons to both honor and not honor a DNR order after a suicide attempt are reviewed.Conclusion
Not all patients who attempt suicide are necessarily incapable of making a rational decision about their health care. In some cases it may be appropriate to withhold resuscitation attempts in suicidal patients who have a preexisting DNR order. Institutional policies are needed to provide guidance in this situation. 相似文献16.
Background
Pediatric foreign-body ingestions are commonly managed by emergency physicians. Risk assessment and specific intervention are dependent on the nature and location of the foreign body. Radiographic evaluation is usually necessary to help define the clinical situation.Case Report
We present an interesting case of presumed ingestion of several disk batteries by a toddler with an unexpected outcome, reviewing aspects of this clinical problem and highlighting potential pitfalls in medical decision making.Why Should an Emergency Physician Be Aware of This?
Pediatric foreign-body ingestions are commonly managed in the emergency department, and timely and accurate intervention is dependent on correct defining and localization of the foreign body. This case illustrates potential pitfalls in this evaluation. 相似文献17.
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J. Megan Sions Peter C. Coyle Teonette O. Velasco James M. Elliott Gregory E. Hicks 《Archives of physical medicine and rehabilitation》2017,98(1):51-57
Objective
To determine whether multifidi size, intramuscular fat, or both, are associated with self-reported and performance-based physical function in older adults with and without chronic low back pain (LBP).Design
Case-control study.Setting
Individuals participated in a standardized evaluation in a clinical laboratory and underwent magnetic resonance imaging (MRI) of the lumbar spine at a nearby facility.Participants
A volunteer sample of community-dwelling older adults (N=106), aged 60 to 85 years, with (n=57) and without (n=49) chronic LBP were included in this secondary data analysis.Intervention
Average right-left L5 multifidi relative (ie, total) cross-sectional area (CSA), muscle-fat infiltration index (MFI) (ie, a measure of intramuscular fat), and relative muscle CSA (rmCSA) (ie, total CSA minus intramuscular fat CSA) were determined from MRIs. Linear regression modeling was performed with physical function measures as the dependent variables. Age, sex, and body mass index were entered as covariates. The main effects of L5 multifidi MFI and rmCSA, as well as their interaction with group assignment, were compared as independent variables.Main Outcome Measures
Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning subscale, timed Up and Go, gait speed, and fast stair descent performance.Results
Interaction terms between L5 multifidi MFI and group assignment were found to be significant contributors to the variance explained in all physical function measures (P≤.012). Neither the main effect nor the interaction with group assignment for L5 multifidi rmCSA significantly contributed to the variance explained in any of the physical function measures (P>.012).Conclusions
Among older adults with chronic LBP of at least moderate intensity, L5 multifidi muscle composition, but not size, may help to explain physical function. 相似文献19.
Hillary R. Bogner Heather F. de Vries McClintock Jibby E. Kurichi Pui L. Kwong Dawei Xie Sean Hennessy Joel E. Streim Margaret G. Stineman 《Archives of physical medicine and rehabilitation》2017,98(1):1-10
Objective
To examine how patient satisfaction with care coordination and quality and access to medical care influence functional improvement or deterioration (activity limitation stage transitions), institutionalization, or death among older adults.Design
National representative sample with 2-year follow-up.Setting
Medicare Current Beneficiary Survey from calendar years 2001 to 2008.Participants
Community-dwelling adults (N=23,470) aged ≥65 years followed for 2 years.Interventions
Not applicable.Main Outcome Measures
A multinomial logistic regression model taking into account the complex survey design was used to examine the association between patient satisfaction with care coordination and quality and patient satisfaction with access to medical care and activities of daily living (ADL) stage transitions, institutionalization, or death after 2 years, adjusting for baseline socioeconomics and health-related characteristics.Results
Out of 23,470 Medicare beneficiaries, 14,979 (63.8% weighted) remained stable in ADL stage, 2508 (10.7% weighted) improved, 3210 (13.3% weighted) deteriorated, 582 (2.5% weighted) were institutionalized, and 2281 (9.7% weighted) died. Beneficiaries who were in the top quartile of satisfaction with care coordination and quality were less likely to be institutionalized (adjusted relative risk ratio [RRR], .68; 95% confidence interval [CI], .54–.86). Beneficiaries who were in the top quartile of satisfaction with access to medical care were less likely to functionally deteriorate (adjusted RRR, .87; 95% CI, .79–.97), be institutionalized (adjusted RRR, .72; 95% CI, .56–.92), or die (adjusted RRR, .86; 95% CI, .75–.98).Conclusions
Knowledge of patient satisfaction with medical care and risk of functional deterioration may be helpful for monitoring and addressing disability-related health care disparities and the effect of ongoing policy changes among Medicare beneficiaries. 相似文献20.
S. Jun Son Hyunsoo Kim Matthew K. Seeley J. Ty Hopkins 《Archives of physical medicine and rehabilitation》2017,98(1):25-35