RESUMO
OBJECTIVE: To determine headache diagnosis and treatment patterns in the outpatient setting, focusing on documentation of the International Classification of Headache Disorders (ICHD) criteria. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort data were collected from electronic medical records of adults aged 18-35 who presented to resident-staffed family medicine outpatient clinics in the Midwest, USA, for a new or worsening headache between 2015 and 2016. Diagnosis codes were used to summarize the overall nature and prevalence of headaches. A random subset of 30 patients each for migraine headache (MGH) with and without aura and tension-type headache (TTH) were reviewed to determine how many of the five possible ICHD criteria were documented. Demographics/clinical characteristics, ICHD criteria, number and type of medications, and healthcare utilization (imaging, primary and emergency department care) through one year following the initial visit were summarized and compared across headache types. RESULTS: There were 716 unique patients during the study period (414 MGH, 227 unspecified headaches, 75 TTH, or others). Complete ICHD criteria were documented for two patients in total. There was partial documentation (e.g., one to four of the possible five) for 30% of TTH, 63% of MGH without aura, and 77% of MGH with aura (p<0.05). Across headache types, patients were prescribed an average of 2.3 to 3.3 medications over one year, with MGH patients generally trying more medications (up to eight for those with aura and up to 12 for those without). Abortive or rescue medications were prescribed to nearly all patients; prophylactics were prescribed for 50% of MGH with aura, 66.7% of MGH without aura, and 53.3%. Non-pharmacologic interventions were less prescribed: 33.3% of TTH patients and 3.3% of MGH types combined (p<0.05). Healthcare utilization was highest for MGH with aura (ED visits) and without aura (clinic visits) patients compared to TTH (p<0.001). CONCLUSION: Headache-related documentation is often incomplete, which may limit interpretation and associations between diagnoses, prescribing patterns, and healthcare utilization. Future studies should evaluate the use of electronic medical records (EMR)-based templates to improve documentation, and additional detailed studies are needed in the local setting to determine whether treatment, including the use of non-pharmacologic and prophylactic methods of treatment, is optimal.
RESUMO
Erysipelothrix rhusiopathiae, a pleomorphic gram-positive bacillus, is found widely in nature or as a commensal pathogen. It infects domestic animals such as swine, which may be the major reservoir of the organism. E. rhusiopathiae is primarily an occupational illness; 89% of the cases are linked to high-risk epidemiological situations. Humans that are infected by this bacillus typically present with one or a combination of the following symptoms: localized skin lesion (erysipeloid), diffuse cutaneous eruptions with systemic symptoms, or bacteremia, which is often followed by endocarditis. We report a case of E. rhusiopathiae bacteremia that was present without severe clinical illness such as endocarditis, arthritis, or skin lesions. The patient was a 64-year-old male with a complicated past medical history including subclinical alcoholic liver disease. Penicillin-G therapy completely resolved the patients bacteremia. The case presented has exceptional clinical merit due to 2 key factors: the patient does not fit the occupational demographic typically affected by this bacterium, and the patient presented with subclinical septicemia, which has a high correlation with fatal endocarditis. This case brings a new prospective to E. rhusiopathiae bacteremia.
