Do all patients with shoulder dislocations need prereduction x-rays?

OBJECTIVE: Some would advocate against routine use of prereduction x-rays for shoulder dislocations. Our objective was to examine the percent of dislocations that also had fractures as a function of age to determine whether there are some decades of life with a sufficiently low risk of fracture to avoid routine prereduction x-rays. METHODS: This was a retrospective cohort study in 19 New Jersey and New York emergency departments. We used The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes to identify patients with shoulder dislocations and, among these, those who also had fractures. A priori, we chose to group the patients by decade of life. For patients with dislocations in each age group, we calculated the percent that also had fractures. RESULTS: Of the total 5,408,837 visits in the database, there were 7209 patients with dislocations, of which 465 (6.5%) had fractures. We found the lowest percent of fractures in the 2nd and 3rd decades of life (0.7% [95% confidence interval, 0.3%-1.2%] and 0.8% [0.4%-1.3%]). In the 4th and 5th decades of life, the percents were 2.6% (1.7%-3.5%) and 4.6% (3.2-6.0%), respectively, and they steadily increased to 19% or greater in the 8th to 10th decades of life. Omitting the prereduction x-rays for patients in the 2nd and 3rd decades of life would reduce the total number of prereduction x-rays by 40%. CONCLUSION: In the second and third decades of life, less than 1% of patients with shoulder dislocations also had fractures. Because these patients have a sufficiently low risk of fracture, routine prereduction x-rays may not be necessary for them.

Emergency department visits for concern regarding anthrax--New Jersey, 2001.

INTRODUCTION: In October of 2001, after letters processed in Trenton, New Jersey, resulted in multiple cases of anthrax, emergency departments (EDs) in New Jersey experienced an increase in visits from patients concerned about possible exposure to agents of biologic terrorism. Information about the effect of an actual biologic terrorism attack on the emergency department population might be useful in the design of biosurveillance systems, particularly with regard to their performance during the mitigation phase that occurs after an attack. In addition, such information might help identify issues that arise regarding the public health response in the ED setting. OBJECTIVES: The objectives of this report were to identify and characterize ED visits, by patients concerned with exposure to biologic terrorism agents, in selected New Jersey hospitals after the anthrax attack in fall 2001. METHODS: A retrospective cohort design was used in this study. The setting was 15 New Jersey EDs within a 55-mile radius of Trenton. Participants were consecutive patients evaluated by ED physicians for the following four periods in 2001: 1 month before September 11; 1 month after September 11; 1 month after October 11; and for the second month after October 11. Percentages of visits were calculated with a concern for exposure (CE) visits by using International Classification of Diseases, Ninth Revision (ICD-9) descriptors: Feared Complaint-No Diagnosis (ICD-9 code v65.6) and Screening for Infectious Disease (ICD-9 code v75.9) for all hospitals and for Trenton versus non-Trenton hospitals as a percentage of ED visits. Charts were reviewed by using a structured data form. RESULTS: A total of 225,403 ED visits occurred during the 4 months, of which 698 were CE visits. The percentages of CE visits for the four periods were 0.06%, 0.06%, 0.92%, and 0.10%, respectively. For the peak third period, the percentage was increased for the two Trenton hospitals, 1.81%, versus 0.82% for the 13 non-Trenton hospitals. This report is a summary of the 508 visits associated with concern for anthrax exposure during the peak third period: 47% reported exposure to powder, 13% were postal workers, 4% received chest radiographs, 65% had a nasal swab for anthrax, 13% had ED decontamination, and 32% received antibiotics. CONCLUSION: An increase in CE visits occurred during the 1-month period after October 11, 2001. During the peak month, a higher increase occurred in Trenton EDs. Considering the substantial variation in diagnostic evaluation and treatment, readily available guidelines are needed.