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Managing Skin Abscesses in the MRSA Era

Managing Skin Abscesses in the MRSA Era

Abscesses are one of the most common skin conditions encountered by general practitioners and emergency physicians, and the incidence of these infections has increased in recent years. In addition, MRSA infections have become one of the most common causes of skin abscesses. “Community-associated MRSA (CA-MRSA) has also been shown to cause severe infections in non-immuno-compromised hosts,” explains David A. Talan, MD, FACEP, FIDSA. “We’re still unsure as to why CA-MRSA appears to be more virulent than other healthcare–associated strains and methicillin-susceptible Staphylo-coccus aureus. Unfortunately, the management of skin abscesses is highly variable throughout the country.” In a review article published in the New England Journal of Medicine, Dr. Talan and Adam J. Singer, MD, described helpful approaches to managing common skin abscesses that generally involve the extremities and trunk. “When possible, our recommendations were based on randomized trials,” Dr. Talan says. “However, many recommendations are based on small observational studies or expert opinion. While there may be some disagreement, the approaches we advise have been both workable and useful in our practice.” Diagnosis Skin abscesses typically appear as a swollen, red, tender, and fluctuant mass, often with surrounding cellulitis. The diagnosis of skin abscesses based on physical exams is often straightforward and proven correct by incision and drainage. Ultrasonography may be helpful for cases in which the abscess is deep, complex, or obscured by extensive cellulitis. It may also be helpful for patients treated for cellulitis in which initial antibiotic treatment fails and to ensure the adequacy of drainage. Needle aspiration is an alternative approach to diagnosing and treating abscesses. Treatments “Standard incision and drainage is the mainstay of...
Substance Use Disorders Among Emergency Physicians

Substance Use Disorders Among Emergency Physicians

The prevalence of substance use disorders among physicians ranges between 10% and 14%, a rate that is similar to that of the general population. “Research has shown that several specialties have a higher-than-expected rate of these disorders, most notably anesthesiology, emergency medicine, and psychiatry,” says John S. Rose, MD. Despite the reported higher rates of substance use disorders and participation in Physician Health Programs (PHPs) among these specialties, few studies have focused specifically on the prognosis and recovery of emergency physicians (EPs) in PHPs. Important New Data There are little data on whether EPs who receive treatment by PHPs have similar outcomes with these programs as other physicians. To address this research gap, Dr. Rose and colleagues conducted a study using data from 16 state PHPs that followed participants with substance use disorders for 5 or more years. Published in the Western Journal of Emergency Medicine, the study compared outcomes of EPs with other practitioners who were enrolled in state PHPs. “Research has been limited regarding whether EPs perform as well as other physicians after treatment from PHPs,” Dr. Rose says. “We wanted to determine if there were any characteristics for EPs that were significantly different from those of other physicians.” For the study, investigators reviewed data on 904 physicians with a diagnosis of substance use disorders between 1995 and 2001. They compared 56 EPs with 724 other physicians and assessed rates of relapse, successful completion of monitoring, and return to clinical practice within 5 years. Overall, EPs had a higher-than-expected rate of substance use disorders. “EPs were almost three times as likely to be enrolled in a PHP...
A Closer Look at MI Among Younger Women

A Closer Look at MI Among Younger Women

Over time, the frequency of myocardial infarction (MI) in the United States has been declining overall as improvements have been made with regard to medical therapy for coronary artery disease. Although there has been a decline in the rate of ST-elevation MI (STEMI) in those aged 55 and older, the rate has remained steady in patients younger than 55 and among younger women. “Studies have shown that it’s harder to recognize the signs of MI in women,” says Luke Kim, MD, FACC, FSCAI. “Previous analyses indicate that women tend to receive less aggressive treatment than men.” Analyzing Disparities In a study presented at the Society for Cardiovascular Angiography and Interventions 2014 Scientific Sessions, Dr. Kim and colleagues analyzed data on about 13,000 women and more than 42,000 men aged 55 and younger who were hospitalized with an acute MI from 2007 to 2011 using the Nationwide Inpatient Sample database. The authors looked at temporal trends in MI as well as adverse in-hospital outcomes to compare findings by gender. The researchers observed a slight decline in the number of MIs among younger women between 2007 and 2009 but little change after that. Women had more preexisting health problems than men, including diabetes, hypertension, kidney disease, peripheral vascular disease, congestive heart failure, and obesity. Women were also more likely than men to have non-STEMIs. The study by Dr. Kim and colleagues also revealed that there were disparities in the treatment of MI. “Women who suffered an MI were far less likely than men to be treated with PCI or CABG surgery,” explains Dr. Kim. “They were also more likely to face...
Updated Guidelines for Valvular Heart Disease

Updated Guidelines for Valvular Heart Disease

According to recent estimates, just less than 3% of Americans have moderate-to-severe valvular heart disease (VHD), a condition that increases in prevalence with age. The disease affects between 4% and 9% of those aged 65 to 75 and 12% to 13% of those aged 75 and older. Many of these patients require surgical or interventional procedures, but even with these treatments, the overall survival rates associated with VHD are lower than expected. The risk of adverse outcomes due to VHD is high because of limited options for restoring normal valve function and because of failures to intervene at the optimal time point in the disease course. A Welcome Update In 2008, the American College of Cardiology (ACC) and American Heart Association (AHA) released an updated guideline for diagnosing and managing adult patients with VHD. In 2014, the ACC/AHA updated these guidelines in an effort to facilitate access to concise, relevant information at the point of care when clinical knowledge is needed the most. “In the past 5 years, we have accumulated new evidence and a better understanding of earlier research surrounding VHD,” explains Paul Sorajja, MD, FACC, FAHA, FSCAI, who was a member of the ACC/AHA writing group that developed the most recent guideline update. “Our goal was to provide clinicians with concise, evidence-based recommendations and the supporting documentation to encourage their use.” Restructured Definitions The 2014 guidelines include restructured definitions of VHD severity into four classifications—at risk, progressive, asymptomatic severe, and symptomatic severe (Table 1). “These categories were created to help clinicians determine the optimal timing of interventions,” Dr. Sorajja says. The stages consider the degree of valve...
Clinical Questions at the Point of Care

Clinical Questions at the Point of Care

Since the 1980s, studies have shown that clinicians frequently raise questions during patient encounters in all healthcare settings. These studies have suggested that although questions arise frequently, they often go unanswered. “Unanswered questions should be seen as an opportunity to improve outcomes by filling gaps in medical knowledge,” says Guilherme Del Fiol, MD, PhD. He adds that understanding clinicians’ questions is essential to guiding the design of interventions that aim to provide the right information at the right time. According to Dr. Del Fiol, there are challenges associated with maintaining current knowledge in medicine. “Several factors can come into play,” he says. “Science is continuing to expand medical knowledge, but this can make it increasingly complex to appropriately deliver healthcare. In addition, the aging population continues to grow, a phenomenon that further complicates how easily clinicians can address more difficult questions at the point of care.” No systematic reviews have been available on the clinical questions raised by clinicians in the context of patient care and decision making. A Systematic Review on Clinical Questions Dr. Del Fiol and colleagues recently conducted a systematic review of the literature on clinicians’ questions. Published in JAMA Internal Medicine, the research focused on the need for general medical knowledge that could be obtained from books, journals, specialists, and online resources. The systematic review took into account the frequency by which clinicians raised clinical questions, how often these questions were pursued and how often answers were successfully found, and the types of questions that were typically asked. They also sought to determine overriding themes and the potential effects of information seeking on clinicians’ decision...
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