Early diagnosis and critical management of wound botulism in the emergency department: a single center experience and literature review.

BACKGROUND: Clostridium botulinum remains a major threat to a select population of subcutaneous and intramuscular drug users. We conducted a retrospective study of patients who were diagnosed with wound botulism and their clinical presentations to the Emergency Department (ED). RESULTS: A total of 21 patients met the inclusion criteria and all had a confirmed history of heroin use disorder. Initial presentation to the ED included generalized weakness (n = 20, 95%), difficulty swallowing (n = 15, 71%), and speech/voice problems (n = 14, 79%). Sixteen patients (76%) also presented with visible skin wounds and fifteen (71%) required mechanical ventilation (MV). Patients who presented with dysphagia as well as dysarthria and/or dysphonia were more likely to require a percutaneous endoscopic gastrostomy (PEG) tube. Patients who required MV and PEG tubes were noted to have a longer hospital length of stay (LOS) due to the severity of the disease progression. CONCLUSIONS: Emergency physicians should remain vigilant about early recognition of wound botulism, especially in patients who inject drugs.

Gun Violence, mental health, and Connecticut physicians.

While there is a public perception that gun violence is associated with mental illness we present evidence that it is a complex public health problem which defies simple characterizations and solutions. Only a small percentage of individuals with mental illness are at risk for extreme violence and they account for only a small percentage of gun-related homicides. Individuals who are at risk for gun violence are difficult to identify and successfully treat. The incidence, and perhaps the demographics, of gun violence vary substantially from state to state. We make a case for Connecticut physicians to study gun violence at the state level. We recommend that Connecticut physicians promote and expand upon the American Academy of Pediatrics' recommendation for creating a "safe home environment. "We suggest that guns be secured in all homes in which there are children. In addition we suggest that guns be voluntarily removed from homes in which there are individuals with a history of violence, threats of violence, depression, drug and/or alcohol abuse, and individuals with major mental illnesses who are not cooperating with therapy.