First EDition: Emergency Physicians’ Rates of Opioid Prescribing, more

Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239.

Tertiary Center Repeat Computed Tomography Scans Find Additional Injuries

MICHELE G. SULLIVAN

FRONTLINE MEDICAL NEWS

Imaging obtained at nontertiary trauma centers (NTCs) probably does not tell the whole story of a trauma patient’s injuries, according to a new retrospective study.

Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.

Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at an NTC, and then transferred to the Level 1 University of Oklahoma tertiary trauma center (TTC). The facility’s primary radiologist reviewed all of the initial computed tomography (CT) scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.

The team split imaging and interpretation disconnects into four categories:

• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.”
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up—the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”

During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.

The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%), and least common for chest injuries (32%).

An inadequate NTC work-up as judged by the TTC attending was the most common reason for obtaining new images (76%). Poor image quality was the next most common reason (31%).

Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.

Type B errors occurred in 15% of patients. Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.

“This study confirms that images are often repeated or completed after having images done at NTCs,” Dr Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”

Cutaneous Eruption Reported in Pregnant Woman With Locally Acquired Zika Virus

M. ALEXANDER OTTO

FRONTLINE MEDICAL NEWS

Zika presented in a young, pregnant Florida woman as erythematous follicular macules and papules on the trunk and arms, scattered tender pink papules on the palms, and a few petechiae on the hard palate, according to a report in the New England Journal of Medicine.

The report advises how Zika virus may present during pregnancy. “Medical providers on the front line should be aware of the constellation of symptoms in patients reporting travel to endemic areas, including areas in Southern Florida, where other non-travel-associated cases have been confirmed,” wrote investigators led by Lucy Chen, MD, of the University of Miami.

The 23-year-old woman presented on July 7, 2016 at 23 weeks and 3 days’ gestation with a 3-day history of fever, widespread pruritic rash, and sore throat, which were followed by myalgias and joint pain 2 days later. The cutaneous eruption was noted on physical examination; neither conjunctivitis nor lymphadenopathy was present. The patient and her partner said they had not traveled outside the United States for 2 years.

Zika virus RNA was detected in the woman’s urine and serum specimens with the use of reverse-transcriptase polymerase chain reaction and persisted for 2 weeks in urine samples and for 6 weeks in serum samples. On histopathology, skin lesions revealed a mild perivascular lymphocytic infiltration in the upper dermis, admixed with some neutrophils. Liver and renal functions were normal.

Fetal ultrasonography performed on the day of presentation showed an estimated fetal weight of 644 g (53rd percentile), an estimated head circumference of 221 mm (63rd percentile), and normal intracranial anatomy. Fevers and rash subsided after 3 days of supportive care. Screening for measles, varicella, rubella, syphilis, Epstein-Barr virus, influenza, hepatitis B, hepatitis C, mumps, and dengue was negative.

An initial immunoglobulin M test on July 7 was negative; seroconversion occurred 1 week after presentation and remained positive through delivery.

A full-term infant weighing 2,990 g was delivered vaginally. Neonatal ultrasonography and magnetic resonance imaging of the head showed a normal head size and intracranial anatomy, with no calcifications. Placental tissue was negative for Zika virus, and neonatal laboratory testing revealed no evidence of infection.

The case was confirmed by the Miami-Dade County Department of Health as the first non-travel-associated Zika infection in the United States.