The influence of meteorological factors on the occurrence of trauma and motor vehicle collisions in Tokyo.

BACKGROUND: Previous studies have suggested a possible association between meteorological factors and the occurrence of trauma, but with conflicting results. This study investigated the relation of the occurrence of trauma with meteorological factors, including barometric pressure, ambient temperature, relative humidity and rainfall. METHODS: Hourly data were collected on traumatic injuries through ambulance transport records of the Tokyo Fire Department from 1 January to 31 December 2005. Hourly meteorological data for Tokyo were also collected from the Japan Meteorological Agency during the same period. A time-series analysis was performed using an autoregressive integrated moving average (ARIMA) model to control for autocorrelations in time-series data. RESULTS: Of a total of 643,849 patients who were transported to hospitals by ambulance, there were 226,339 trauma patients, including 94,916 patients from motor vehicle collisions (42% of all trauma patients). Based on the ARIMA model, higher temperature (p<0.001), greater rainfall (p<0.05) and holidays (p<0.001) were significantly associated with the occurrence of trauma. These factors were also significantly associated with the occurrence of motor vehicle collisions. Barometric pressure and humidity were not associated with the occurrence of trauma. CONCLUSIONS: This population-based study shows that, in addition to high temperature, rainfall and holidays are associated with the occurrence of trauma including motor vehicle collisions.

Managing ankle injuries in the emergency department.

We review the anatomy and physiology of the ankle joint with attention to the structures most likely to be injured. We discuss the epidemiology of ankle injuries and their physical and radiographic evaluation, including the Ottawa Ankle Rules. Treatment, consultation, and pitfalls are followed by more specific discussions of tendonitis, Achilles tendon injury, tendonous subluxations, tarsal tunnel syndrome, sonovial impingement, and injury to the os trigonum. The references provide a guide for further reading.

Disability and dementia in the emergency department.

The elderly consume medical services in an amount disproportionate to their number. Disability and dementia are commonly underdiagnosed and misunderstood in any emergency department setting. Educating emergency physicians regarding the evaluation of dementia, disability, and abuse is crucial to appropriate management and optimal outcome of these clinical problems.

Depression and aging too often do mix.

Depression in elderly persons is prevalent, often undiagnosed, and usually untreated. Because there is no reliable diagnostic test, careful clinical evaluation is essential. With aggressive antidepressant treatment, the overall long-term outcome in elderly patients is optimistic. In this article, Dr Birrer discusses the scope of the problem, important diagnostic considerations, and the current recommended treatments in this population.

Lyme carditis: a rare presentation in an unexpected setting.

A case is reported of a 27-year-old man who presented to an inner city trauma center after he had experienced several seizure-like episodes. He was diagnosed with Lyme carditis and required 6 weeks of treatment with intravenous ceftriaxone for complete resolution of his symptoms. The case is discussed along with a review of the literature.

Accessing the scientific literature. The reality of virtual scholarship.

The age-honored practice of plowing through the Index Medicus in a good medical library to meander through citations for treasured finds is an anachronism. Today, clinicians have the astonishing capacity to bring to bear existing knowledge almost effortlessly. Virtual scholarship makes available up-to-date medical citations and their abstracts. There can be access around the clock on any topic in the office, at the bedside, or from home. Computerized searches of the medical literature promote directed continuing education and may enhance clinical care of patients.

Prevention and care of diabetic foot ulcers.

The foot is frequently overlooked in the management of diabetic patients. Failure to control diabetic foot ulcers at an early stage can lead to life-threatening infection or amputation. Preventive care should emphasize patient education, glycemic control, careful daily foot hygiene and appropriate footwear. Early management of a diabetic foot ulcer should include culture-directed antibiotic therapy when there is evidence of infection, moist dressings and adjustment of footwear or casting to avoid pressure on the wound site. All patients with foot ulcers should be evaluated for evidence of foot ischemia. Surgical intervention to debride infected tissue and bone or to revascularize ischemic tissue can aid in ulcer healing. Serious infection or severe ischemia, unfortunately, often necessitates amputation.

Obese children should be screened for hypercholesterolemia.

Screening only those with a positive family history misses many children with hypercholesterolemia. This study investigated whether sensitivity improved by adding obesity as a criterion when screening children for cholesterol. During a two-year period screenings were conducted on 506 inner-city subjects aged 5-19. Demographic, clinical, and dietary information was also recorded. Mean age of participants was 11 +/- 4 years; 52 percent were female, 53 percent black, 39 percent Hispanic, and 8 percent other. Mean cholesterol level was 4.14 mmol/l (160 mg/dl). In multivariate analysis obesity was an independent risk factor for hypercholesterolemia, F = 13.14, p < 0.001. The sensitivity of obesity as a screening tool for hypercholesterolemia was better than that for positive family history (42 vs. 24 percent, respectively). Combining the two improved the sensitivity to 49 percent. The authors recommend expanding the indications for screening children to include obesity, in addition to positive family history of hypercholesterolemia or premature cardiovascular disease.

Orbital emphysema: how common, how significant?

STUDY OBJECTIVE: To describe the natural history of orbital emphysema and its management in the emergency setting. DESIGN: Retrospective medical record review. SETTING: Inner-city integrated hospital system (four divisions) including one Level I trauma center. PARTICIPANTS: All cases of orbital floor fracture and orbital emphysema from January 1, 1988, to December 31, 1993. RESULTS: The average patient was aged 33 years, and the male-to-female ratio was 7 to 1. Trauma was the underlying etiology in all patients. Seventy-four percent of patients required hospitalization, and 43% developed significant complications. Eighty-three percent were managed with antibiotics. Orbital emphysema was identified on conventional radiographs in 65% of cases. CONCLUSION: Identification of orbital emphysema in the ED should prompt a careful search for associated injury. Consultation should be sought in the presence of orbital or ocular injury. Antibiotic prophylaxis is not necessary for clean wounds.

Immediate Diagnosis of Ankle Trauma.

In brief Traumatic Injuries to the ankle vary greatly in severity, from minor contusions to displaced intra-articular fractures. A systematic approach to their evaluation can lead to more accurate diagnoses and help simplify treatment options. Primary care physicians can successfully manage most sports-related ankle trauma, but knowing when to obtain orthopedic consultation is equally important.

Body smuggling of illicit drugs: two cases requiring surgical intervention.

The smuggling of illicit drugs by concealing them within the human body has become a widespread practice. Those individuals who transport packaged drugs are commonly known as "body packers" or "mules". "Body stuffers," on the other hand, are individuals who emergently place the contraband in a body orifice when they sense apprehension is imminent. In the latter instance, the drugs are not well packaged for transportation by human "consumption," hence the high risk for leakage. These individuals require prompt surgical attention under two circumstances: when they are found to suffer from drug overdosage caused by inadvertent leakage or when obstruction in the body is caused by the drug-laden bags. Two such cases are reported. The first patient presented with acute drug overdose and required an emergency laparotomy. The second patient presented with pyloric obstruction and was treated by endoscopic removal of the bag. One must be aware that these patients are walking time bombs, carrying drugs that may be well packed but have the potential to deliver a lethal dose without warning. Knowledge of the type of drug and type of packaging are essential in managing these patients. The overall plan should be close observation, careful monitoring, conservative therapy, and expectant rapid surgical intervention as needed.

Self-mutilation: three cases and a review of the literature.

The self-mutilating patient is an unusual psychiatric presentation in the emergency department (ED). Nonetheless, serious underlying psychiatric pathology and drug abuse are important background risk factors. A careful stepwise approach in the ED is essential, although the prognosis, follow-up, and eventual rehabilitation are poor.

Vaginal bleeding secondary to an aborting uterine leiomyoma.

The authors present the case of a young woman who presented to the emergency department with vaginal bleeding and an "aborting" uterine leiomyoma. Although well described in the gynecologic literature, this phenomenon is not commonly seen in the emergency department, nor is it well described in the emergency medicine literature. The case highlights the importance of a thorough pelvic examination in all women presenting with a complaint of vaginal bleeding, and in addition it describes an atypical presentation for uterine leiomyomas.