Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial

ObjectivesTo investigate the cost effectiveness of intravenous ketorolac compared with intravenous morphine in relieving pain after blunt limb injury in an accident and emergency department.DesignDouble blind, randomised, controlled study and cost consequences analysis.SettingEmergency department of a university hospital in the New Territories of Hong Kong.Participants148 adult patients with painful isolated limb injuries (limb injuries without other injuries).ResultsNo difference was found in the median time taken to achieve pain relief at rest between the group receiving ketorolac and the group receiving morphine, but with movement the median reduction in pain score in the ketorolac group was 1.09 per hour (95% confidence interval 1.05 to 2.02) compared with 0.87 (0.84 to 1.06) in the morphine group (P=0.003). The odds of experiencing adverse events was 144.2 (41.5 to 501.6) times more likely with morphine than with ketorolac. The median time from the initial delivery of analgesia to the participant leaving the department was 20 (4.0 to 39.0) minutes shorter in the ketorolac group than in the morphine group (P=0.02). The mean cost per person was $HK44 (£4; $5.6) in the ketorolac group and $HK229 in the morphine group (P<0.0001). The median score for patients'' satisfaction was 6.0 for ketorolac and 5.0 for morphine (P<0.0001).ConclusionIntravenous ketorolac is a more cost effective analgesic than intravenous morphine in the management of isolated limb injury in an emergency department in Hong Kong, and its use may be considered as the dominant strategy.     

Association Between Hypoglycemia And Fall-Related Fractures And Health Care Utilization In Older Veterans With Type 2 Diabetes

Objective: To examine the association between hypoglycemia and fall-related outcomes in older patients with type 2 diabetes mellitus (T2DM).Methods: This retrospective cohort study used electronic medical records of T2DM patients (≥65 years) from the Veterans Integrated Service Network 16 (VISN 16) data warehouse (01/01/2004-06/30/2010). Patients in nonhypoglycemia group (non-HG) were 1:1 randomly matched with patients in hypoglycemia group (HG) by age (±5 years), sex, race, and medical center location. Fall-related events (i.e., fractures and head injuries) were identified, with a fall being the external cause within ±2 days. McNemar tests and generalized estimating equation (GEE) models were used to compare fall-related events in the 1-year outcome period after the index date (i.e., date of first hypoglycemic episode). We also examined fall-related healthcare utilization.Results: A total of 4,215 patients in each group were studied, with the mean age of 76.5 years (SD: 5.85). The mean Charlson comorbidity index (CCI) scores were 5.73 (SD: 2.95) in the HG and 4.34 (SD: 2.40) in the non-HG. The HG had significantly higher rates of fall-related events than non-HG, 27 (0.64%) versus 1 (0.02%) and 89 (2.11%) versus 21 (0.50%) events within 30 days and 1 year, respectively. GEE models confirmed the elevated risk of fall-related events after controlling for sociodemographic and clinical characteristics, comorbidities, and medication use (adjusted odds ratio [aOR]: 2.70; 95% confidence interval [CI]: 1.64–4.47). The HG patients were more likely to have emergency department (ED) visits, hospital admissions, and long-term care placement compared to their counterparts.Conclusion: Hypoglycemia is associated with worse fall-related outcomes among the elderly veterans.Abbreviations:aOR = adjusted odds ratioCCI = Charlson comorbidity indexCI = confidence intervalED = emergency departmentGEE = generalized estimating equationHG = hypoglycemia groupICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical ModificationMI = myocardial infarction T2DM = type 2 diabetes mellitusVHA = Veterans Health Affairs     

Injury patterns in cyclists attending an accident and emergency department: a comparison of helmet wearers and non-wearers.

OBJECTIVES--To study circumstances of bicycle accidents and nature of injuries sustained and to determine effect of safety helmets on pattern of injuries. DESIGN--Prospective study of patients with cycle related injuries. SETTING--Accident and emergency department of teaching hospital. SUBJECTS--1040 patients with complete data presenting to the department in one year with cycle related injuries, of whom 114 had worn cycle helmets when accident occurred. MAIN OUTCOME MEASURES--Type of accident and nature and distribution of injuries among patients with and without safety helmets. RESULTS--There were no significant differences between the two groups with respect to type of accident or nature and distribution of injuries other than those to the head. Head injury was sustained by 4/114 (4%) of helmet wearers compared with 100/928 (11%) of non-wearers (P = 0.023). Significantly more children wore helmets (50/309 (16%)) than did adults (64/731 (9%)) (P < 0.001). The incidence of head injuries sustained in accidents involving motor vehicles (52/288 (18%)) was significantly higher than in those not involving motor vehicles (52/754 (7%)) (chi 2 = 28.9, P < 0.0001). Multiple logistic regression analysis of probability of sustaining a head injury showed that only two variables were significant: helmet use and involvement of a motor vehicle. Mutually adjusted odds ratios showed a risk factor of 2.95 (95% confidence interval 1.95 to 4.47, P < 0.0001) for accidents involving a motor vehicle and a protective factor of 3.25 (1.17 to 9.06, P = 0.024) for wearing a helmet. CONCLUSION--The findings suggest an increased risk of sustaining head injury in a bicycle accident when a motor vehicle is involved and confirm protective effect of helmet wearing for any bicycle accident.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Immediate health effects of an urban wildfire.

To document the immediate health effects of the urban wildfire that swept through parts of Alameda County, California, on October 20 and 21, 1991, we conducted a retrospective review of emergency department and coroner''s records. Nine hospitals (6 local and 3 outlying) were surveyed for the week beginning October 20, 1991. Coroner''s reports were reviewed for 25 identified fire-related deaths. A total of 241 fire-related emergency encounters, including 44 inpatient admissions, were recorded for 227 persons. Nearly a fourth of emergency department patients were seen for work-related injuries, more than half of which occurred among professional firefighters. Smoke-related disorders constituted more than half of all emergency department cases; of these, 61% had documented bronchospasm. Major trauma and burns contributed 1% and 4% of principal diagnoses, respectively; these were exceeded in number by corneal abrasions (13%), other medical problems (8%), and minor trauma (7%), among other diagnoses. All coroner''s cases involved extensive burns, many with documented smoke inhalation injury. While the Oakland-Berkeley fire storm resulted in a high case-fatality ratio among major burn cases (25/31), those who survived the initial fire storm did well clinically. Among emergency department patients, medical (particularly smoke-related) disorders outnumbered traumatic presentations by a ratio of more than 2 to 1.     

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial

Objective To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community.Design Cluster randomised controlled trial involving 56 clusters. Weeks were randomised to the paramedic practitioner service being active (intervention) or inactive (control) when the standard 999 service was available.Setting A large urban area in England.Participants 3018 patients aged over 60 who called the emergency services (n=1549 intervention, n=1469 control).Main outcome measures Emergency department attendance or hospital admission between 0 and 28 days; interval from time of call to time of discharge; patients'' satisfaction with the service received.Results Overall, patients in the intervention group were less likely to attend an emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95% confidence interval for difference −60 minutes to −25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (relative risk 1.16, 1.09 to 1.23). There was no significant difference in 28 day mortality (0.87, 0.63 to 1.21).Conclusions Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.Trial registration ISRCTN27796329.     

Review of traumatic injuries in regional federal penitentiaries.

The incidence of major injuries in inmates of Canadian prisons has steadily increased in recent years. The medical records of the emergency department serving virtually all prisoners at federal penitentiaries in the Kingston, Ont. area were reviewed for cases of traumatic injury. In the 30-month period ending Mar. 1, 1984 there were 353 visits to the emergency department, of which 140 were for accidental injuries and 213 for injuries resulting from violence. Of the injuries caused by violence 75 (35%) were self-inflicted and 138 (65%) were inflicted by others. Of the 75 inmates with self-inflicted injuries 17 required admission to hospital, and 12 of these underwent surgery. Of the 138 inmates injured by others 50 were admitted to hospital, and 6 of these were transferred to the neurosurgical or cardiothoracic department at Kingston General Hospital; 31 of the 50 underwent surgery, and 4 died in hospital as a result of their injuries.     

Fractioned Dose Regimen of Sunitinib for Patients with Gastrointestinal Stromal Tumor: A Pharmacokinetic and Treatment Efficacy Study

AIM: Sunitinib has shown benefit in patients with imatinib (IM)–resistant gastrointestinal stromal tumor (GIST). However, its advantages are somewhat diminished because of associated toxicities. Herein, we clarify the efficacy and safety of fractioned dose regimen of sunitinib by a pharmacokinetic and efficacy study. MATERIALS AND METHODS: Between 2001 and March 2013, a total of 214 patients with metastatic GIST was treated at Chang Gung Memorial Hospital. Among them, 55 (11.6%) patients who received sunitinib were investigated. One group of patients was administered with standard dose of once-daily sunitinib (standard dose group) and the other group was administered with standard total daily dose of sunitinib in fractioned doses (fractioned dose group). RESULTS: Thirty-two male and 23 female patients with a median age of 55 years received sunitinib. The median duration of sunitinib administration was 9.2 months. The clinical benefit was 65.2%. The mean peak blood level of sunitinib in patients with fractioned doses was significantly lower than that in those with once-daily dose (83.4 vs 50.1 ng/ml, P = .01). The rates of adverse effects of hand-foot syndrome, mucositis, and yellow skin were significantly decreased by fractioned doses of sunitinib. However, the progression-free and overall survival did not differ between patients with different treatment regimens. CONCLUSION: The fractioned dose regimen of sunitinib appears to be a safe and effective treatment for patients with IM-resistant/intolerant GISTs. Significantly decreased toxicity of this regimen could be explained by significantly lower peak sunitinib blood level. However, the treatment efficacy is not reduced by this regimen.     

Risk of infection following a visit to the emergency department: a cohort study

Background:

The risk of infection following a visit to the emergency department is unknown. We explored this risk among elderly residents of long-term care facilities.

Methods:

We compared the rates of new respiratory and gastrointestinal infections among elderly residents aged 65 years and older of 22 long-term care facilities. We used standardized surveillance definitions. For each resident who visited the emergency department during the study period, we randomly selected two residents who did not visit the emergency department and matched them by facility unit, age and sex. We calculated the rates and proportions of new infections, and we used conditional logistic regression to adjust for potential confounding variables.

Results:

In total, we included 1269 residents of long-term care facilities, including 424 who visited the emergency department during the study. The baseline characteristics of residents who did or did not visit the emergency department were similar, except for underlying health status (visited the emergency department: mean Charlson Comorbidity Index 6.1, standard deviation [SD] 2.5; did not visit the emergency department: mean Charlson Comorbidity index 5.5, SD 2.7; p < 0.001) and the proportion who had visitors (visited the emergency department: 46.9%; did not visit the emergency department: 39.2%; p = 0.01). Overall, 21 (5.0%) residents who visited the emergency department and 17 (2.0%) who did not visit the emergency department acquired new infections. The incidence of new infections was 8.3/1000 patient-days among those who visited the emergency department and 3.4/1000 patient-days among those who did not visit the emergency department. The adjusted odds ratio for the risk of infection following a visit to the emergency department was 3.9 (95% confidence interval 1.4–10.8).

Interpretation:

A visit to the emergency department was associated with more than a threefold increased risk of acute infection among elderly people. Additional precautions should be considered for residents following a visit to the emergency department.Infections associated with health care are an important health risk. A recent survey by the World Health Organization reported that 8.7% of patients in hospital developed such infections.^1,2 The third leading cause of death in the United States is health care–associated deaths, with over 100 000 people dying from infections associated with health care each year.³ In Canada, a point-prevalence survey found that 11.6% of adults in hospital experience a health care–associated infection.⁴Little attention has been paid to infections acquired in other health care settings. Visiting an emergency department has been identified as a risk for disease during outbreaks of measles^5,6 and SARS,^7,8 but little is known about the potential risk of endemic infection from exposure in this setting. A visit to the emergency department differs from a stay in hospital: exposure and duration of contact with other patients is shorter, but the number and density of patients with acute illness with whom there could be contact is higher.Elderly residents of long-term care facilities are likely to be at the greatest risk of morbidity and mortality from communicable diseases acquired in the emergency department. When residents are transferred to the emergency department for assessment, they are likely to have longer stays and to be cared for in multibed observation areas and corridors.⁹ If they acquire an infection while in the emergency department, these residents may be the source of an outbreak upon return to their facility; this can lead to increases in workload and costs. A Canadian study estimated the cost of an influenza outbreak to be over $6000 per 30-day period, with an estimated incidence of death of 0.75/100 residents during the same period.¹⁰ In this study, we explored the risk of acute respiratory and gastrointestinal infection associated with a visit to the emergency department among elderly residents of long-term care facilities.     

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.     

Open Access to Diabetes Center from the Emergency Department Reduces Hospitalizations in the Susequent Year

Objective: Patients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures.Methods: We conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures.Results: Compared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by $5,461 compared with controls.Conclusion: Eliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year.Abbreviations:ARR = arrivedED = emergency departmentEDRP = emergency department diabetes rapid-referral ProgramHbA1c = hemoglobin A1cNS = no show     

ISS与APACHEⅡ评分对急诊多发伤患者伤情评估的价值分析

目的:探讨损伤严重程度计分法(Injuryseverityscore,ISS)和慢性健康评分(Acute physiology and chronic health evaluation scoreⅡ,APACHEⅡ)评分对急诊多发伤患者伤情评估的应用价值。方法:将我院自2016年6月至2019年6月急诊收治的多发伤患者85例作为研究对象,分别使用ISS和APACHEⅡ评分,追踪患者住院期间的伤情严重程度和预后情况。结果:急诊多发伤患者入院时ISS评分和APACHEⅡ评分越高,患者ICU收住率和死亡率越高,患者预后越差(P0.05);死亡的急诊多发伤患者ISS评分和APACHE-Ⅱ评分均明显高于存活组(P0.05)。ISS评分预测急诊多发伤患者死亡的灵敏度为87.06%,特异性为85.88%,APACHE-Ⅱ评分预测急诊多发伤患者死亡的灵敏度和特异性分别为88.24%和87.06%,差异无统计学意义(P0.05),两者联合预测急诊多发伤患者死亡的灵敏度为95.29%,特异性为94.12%,均优于单独预测(P0.05)。结论:ISS评分和APACHE-Ⅱ评分能够较为准确的评估急诊多发伤患者的病情严重程度,对患者预后具有较好的预测价值,两者结合使用的应用价值更高。     

Bicycle spoke injuries in the lower extremity

This study reports the authors' 5-year experience with treating lower extremity injuries in bicycle passengers caused by the spokes. This patient group was selected from 716 lower extremity injuries that received treatment at our outpatient plastic surgery clinic. A total of 26 patients were treated during the study. Patients ranged from 2 to 19 years old, with a mean age of 5.6 years. The authors treated more female passengers (62 percent) than male passengers. The right foot (52 percent) was involved more often than was the left. Most patients were injured in the afternoon, from 2 to 7 PM (62 percent), and between May and October (77 percent). The rear wheel (89 percent) injured the majority of patients. The Achilles tendon was the most common site of injury (63 percent). The typical types of wounds observed included the following: type I, laceration with partial avulsion of skin and subcutaneous tissue (41 percent) and laceration forming a distally based flap (33 percent); type II, abrasions with ecchymoses and friction burn from the shearing effect of the spokes creating a partial- to full-thickness skin defect (26 percent). Of the type I injuries, full-thickness skin lacerations (33 percent) were closed primarily. Partial-thickness skin lacerations, abrasions, ecchymoses, and skin defects (67 percent) were treated conservatively with wound irrigation and dressing. The wound healing time for type I injuries was 29 days; for type II injuries, it was 27 days. These healing times were prolonged compared with healing by first intention. No significant difference was found in healing time when comparing both types of injury. Four patients required hospitalization. No patient required skin grafting. No fractures were noted because these patients were selected from the outpatient plastic surgery clinic and did not include patients from the emergency room. Since the first report of bicycle spoke injuries a half-century ago, prevention has not improved.     

Plasma levels of N-terminal peptide of pro-atrial natriuretic peptides in myoskeletal injuries

To determine whether concentrations of the N-terminal peptide of pro-atrial natriuretic peptide (proANP) and of alpha atrial natriuretic peptide 1-28 (aANP) releases are affected by myoskeletal injuries, samples from 24 patients with muscle injuries were therefore collected within 48 h of injury. The mean age of patients was 65; range: 17-90 years. These were compared with 18 non-injured subjects with a mean age of 40; range: 17-80 years. A specific enzyme immunoassay (EIA) method suitable for the determination of proANP and aANP was used. aANP required plasma extraction and no extraction was needed for proANP determination.ProANP level was significantly higher in patients on admission and this level was maintained 24 h after admission (p < 0.05) compared to controls. However, aANP 1-28 level remained statistically unchanged in the patients samples. The level of proANP was over 10 times greater than the levels obtained with aANP. N-terminal peptide of proANP may be a supplementary tool in the study of early phase of myoskeletal injuries in human.     

8. Blessures au hockey majeur: 3 ans d'étude

In a major junior hockey team there were 238 injuries in 257 games during the three seasons of 1973-76 (mean number of injuries per game, 0.926). Incapacity from these injuries resulted in a loss of 345 practices and 299 games (mean number per injury, 1.45 and 1.26, respectively). The site of the game, whether at home or out of town, and the period in which the injury occurred did not seem to be important. Risk of injury seemed to be greatest in the defensive zone. Forwards were the most often injured, their injuries accounting for 45.8% of the total; defensive players were next most often hurt (31.9%). The age of the injured players ranged from 16 to 19 years, those 19 years old predominating (42.0%).There were 91 injuries of the lower limb (38.2% of the total), the knee being the site most frequently injured (31 injuries; 34.1% of the 91), and 74 injuries of the upper limb, the shoulder being the site most frequently injured (25 injuries; 33.8% of the 74). The main causes of injury were a blow by the puck (frequency, 21.0%), a check (18.5%), a blow by a stick (14.7%) and a fight (13.4%).     

Safety and Efficacy of Glucostabilizer in the Management of Diabetic Ketoacidosis

Objective: To evaluate the safety and efficacy of GlucoStabilizer software intravenous insulin (IV) dosing in comparison to American Diabetes Association protocol-directed provider-guided insulin dose adjustment (PGIA).Methods: GlucoStabilizer calculates the dose of IV insulin required to reach a prescribed target glucose range. GlucoStabilizer has not been fully studied in DKA. This retrospective study compared outcomes in patients with DKA before and after the implementation of GlucoStabilizer. Insulin doses were administered based on GlucoStabilizer calculations or PGIA. The analysis evaluated before-after changes in the amount of insulin used, time to target, hypoglycemia or hypokalemia events, and the time to DKA resolution.Results: We studied 77 patients with insulin doses calculated by GlucoStabilizer and 69 patients with PGIA dosing. GlucoStabilizer was superior to PGIA. Patients treated with GlucoStabilizer-calculated doses did not experience hypoglycemia (N = 0 versus N = 10; P<.001). The 10 unique PGIA patients had a total of 18 episodes with 17 between 55 to 69 mg/dL; 1 <54 mg/dL, and no episodes <40 mg/dL. The GlucoStabilizer group required less insulin to reach DKA resolution (59.2 versus 101.2 units; P<.001). Time to glycemic target and DKA resolution were similar (6.7 versus 4.6 hours; P = .132) and (9.8 versus 9.9 hours; P = .803), respectively. No difference in the incidence of hypokalemia was seen (N = 9 versus N = 11; P = .48).Conclusion: This study demonstrates the Gluco Stabilizer settings that can be successfully used in the management of DKA with the avoidance of hypoglycemia. Patients treated with GlucoStabilizer-calculated doses experienced no hypoglycemia and required less insulin as compared to those managed with PGIA.Abbreviations: ADA = American Diabetes Association; DKA = diabetic ketoacidosis; ED = emergency department; eGMS = electronic glycemic management systems; ICU = intensive care unit; IV = intravenous; PGIA = protocol-directed provider-guided insulin dose adjustment     

Injuries of the tarsometatarsal joints: treatment and outcome

Between January 2005 and May 2009, a total of 26 patients, 21 males and 5 females, were admitted for treatment of Lisfranc lesion. All patients were radiologically evaluated and classified according to the criteria proposed by Myerson: 5 (19.2%) patients had a type A injury, 2 patients (7.7%) presented with a type B1 injury, 17 (65.4%) sustained the most common type B2 injury and 1 (3.8%) patient suffered from a type C1 and C2 injury. Taking radiological and clinical findings in account, fifteen patients were elected for operative treatment and eleven patients were treated conservatively. According to type of fracture we established three groups; in group I metatarsal fracture was found in fourteen (53.9%) patients, group II with phalangeal fracture in three (11.5%) cases, whereas in group III nine (34.6%) patients sustained combined metatarsal, navicular and, most commonly, a cuneiform fracture. Using the American Orthopedic Foot and Ankle Society (AOFAS) midfoot scoring scale and SF-36 questionnaire, the functional outcome was assessed. The mean value for age distribution was 42.7 +/- 13.2 years and the mean follow up was 27.9 +/- 12.4 months. A p value < 0.005 was regarded as statistically significant for the analysis of the results. We found by means of SF 36 questionnaire a statistically significant difference in the role limitation due to existence of pain (p = 0.04) and poor general health (p = 0.013) in the group of patients that sustained combined foot fracture. The purpose of this study is to assess the treatment of Lisfranc injuries in our patients, according to SF36 and AOFAS criteria, clinical outcome was evaluated. In the group I the mean AOFAS score was 74.0 +/- 9.1 and in the group II it reached 72.0 +/- 5.2 signifying fair outcome! Poor outcome was present in the group III with mean AOFAS score 67.1 +/- 9.0. All unstable injuries require surgery. Clinical outcome is highly dependent on the restoration of normal anatomic alignment.     

Retrospective case evaluation of gender differences in sports injuries in a Japanese sports medicine clinic

Background: Although both gender- and sports-specific injuries exist among athletes, gender differences in the types of injuries caused by sports activities, except for anterior cruciate ligament (ACL) injury and anterior knee pain, are not well established.Objective: An observational study with a retrospective case-series design was conducted to investigate gender-specific differences in the types of injuries sustained while engaging in sports activities common to both males and females.Methods: We analyzed injuries sustained during sports activities including basketball, volleyball, tennis, skiing, track and field, and swimming, using data on age, sex, sports activities, activity levels, and sports injuries that had been computerized at our sports medicine (orthopedics) clinic. Inclusion criteria were sports activities that had a record of >100 injuries in total and athletes aged <50 years who were engaging in only 1 sports activity. We determined the absolute number of patients in each category and their percentage (proportion) of our cohort. The proportions of common injuries caused by sports activities were investigated, and gender-specific differences in the types of common injuries caused by sports activities were clarified. The Fisher exact test was used to determine the significance (P < 0.01) of the gender-specific differences in the types of sports injuries.Results: According to our database, during the 14-year period between October 1992 and December 2006, a total of 2989 athletes (1624 males and 1365 females) aged <50 years who engaged in 1 of the 6 sports activities described consulted our sports medicine clinic. The most common sports injuries were ACL injury (14.3%) and knee pain (13.7%), followed by ankle sprain (9.4%), lumbar disc disease (7.0%), meniscus injury (5.1%), stress fracture (2.9%), low back pain (2.5%), patellar tendinitis (2.1%), injury of the medial collateral ligament of the knee (2.0%), lumbar spondylolysis (1.7%), and muscle strain (1.5%). Among these 11 types of sports injuries, a significantly higher proportion of females who engaged in basketball (24.4% vs 10.5%), volleyball (20.5% vs 4.5%), or skiing (41.4% vs 26.5%) presented with an ACL injury, compared with their male counterparts (all, P < 0.001). There was also a significantly higher proportion of females than of males among the track and field athletes who presented with stress fractures (18.7% vs 3.9%; P < 0.001).Conclusion: The findings of this retrospective study suggest that there are gender-specific differences in the types of injuries sustained during sports activities.     

Spontaneous Thyroid Nodule Hemorrhage in the Emergency Department

Objective: Spontaneous thyroid gland hemorrhage is a rare event. The present retrospective study considered its clinical impact and management in a referral center.Methods: Clinical records of adult patients accessed in the last 10 years (2009–2018) in the Emergency Department of Policlinico Gemelli IRCCS were reviewed to study patients with spontaneous thyroid nodule hemorrhage. All demographic and radiologic or surgical parameters were included, with special attention to the characteristics of thyroid disease and clinical management.Results: Among the 631,129 adults who were registered during the period considered, 59 consecutive patients were included in the study. The mean age was 48.3 ± 14.3 years, with a prevalence of females. The main symptoms were acute neck pain, dyspnea, and dysphagia. All patients underwent ultrasound evaluation; computed tomography scan was performed on only 3 patients, finding one case of active intranodular bleeding requiring urgent surgery. Six patients required hospitalization; the others were discharged and referred for ambulatory endocrinology follow-up. Among them, 7 patients underwent surgery in the next 6 months, with malignant disease found in 3 cases (5.1%).Conclusion: Intrathyroidal spontaneous hemorrhage is a rare event, occurring in multinodular as well as in single-nodule thyroid disease. Although the clinical course is mostly benign, this condition should be carefully evaluated as, in rare circumstances, active bleeding could induce airway obstruction with the need for emergency surgery. Patients should be referred to endocrinology ambulatory follow-up because bleeding could arise as the first sign of malignant lesions in some cases.Abbreviations: CT = computed tomography; ED = emergency department; FNA = fine-needle aspiration; US = ultrasound     

Epidemiology of Pediatric Ocular Trauma in the Chaoshan Region,China, 2001–2010

Background

Ocular trauma is the leading cause of monocular visual disability and noncongenital unilateral blindness in children. This study describes the epidemiology and medical care associated with nonfatal pediatric (≤17 years of age) eye injury-related hospitalization in the largest industrial base for plastic toy production in China.

Methods

A population-based retrospective study of patients hospitalized for ocular and orbital trauma in the ophthalmology departments of 3 major tertiary hospitals from 1st January 2001 to 31st December 2010 was performed.

Results

The study included 1035 injured eyes from 1018 patients over a 10-year period: 560 (54.1%) eyes exhibited open globe injuries, 402 (38.8%) eyes suffered closed globe injuries, 10 (1.0%) eyes suffered chemical injuries and 8 (0.8%) eyes exhibited thermal injuries, representing an average annual hospitalization rate of 0.37 per 10,000 (95% confidence interval [CI], 0.36–0.38) due to pediatric eye injury in the Chaoshan region. The mean patient age was 9.2±4.4 years with a male-to-female ratio of 3.3∶1 (P = 0.007). Children aged 6 to 11 years accounted for the highest percentage (40.8%, 416/1018) of hospitalization, 56.7% (236/416) of whom were hospitalized for open globe wounds. Injury occurred most frequently at home (73.1%). Open globe wounds cost the single most expensive financial burden (60.8%) of total charges with $998±702 mean charges per hospitalization.

Conclusions

Open globe wounds occurred at home are earmarked for the priorities to prevention strategies. Higher public awareness of protecting primary schoolchildren from home-related eye injuries should be strengthened urgently by legislation or regulation since the traditional industrial mode seems to remain the pattern for the foreseeable future. Further research that provide detailed information on the specific inciting agents of pediatric eye injuries are recommended for facilitating the development and targeting of appropriate injury prevention initiatives.