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Objective: Inhalant abuse has been a source of increasing concern because of its easy accessibility and affordability. Anecdotal reports have previously described ethyl chloride as a potential cause of altered mental state and neurologic symptoms. Its use has been thought to be found most often in adolescents and among men who have sex with men. Common acute symptoms include confusion, dizziness, headache, nausea, and fatigue. We describe two cases of adult patients who presented to one general hospital emergency department with ethyl chloride toxicity. The first presented with acute delirium; the second with a picture of chronic neurological symptomatology. It is important that clinicians become familiar with ethyl chloride intoxication because of its prevalence and potential to present with varying acute and chronic symptomatology.

Objective To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs). Methods The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission. Results During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission. Conclusions The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Mask wearing is now ubiquitous because of the COVID-19 pandemic and has given rise to medical device-related pressure injuries in persons at risk of skin breakdown. The ear has unique anatomy that is particularly susceptible to injury from pressure. In this time of mandatory personal protective equipment requirements in healthcare facilities, protection and assessment of skin in the vulnerable postauricular area are needed. This article presents a case report of a pressure injury on the ear, reviews the anatomy of the ear, and provides strategies for assessment and treatment of pressure injuries in this often overlooked anatomic region.

Objective: Drug overdose deaths have risen precipitously over the past two years in the United States. Polysubstance overdose with opiates and amphetamines have been of particular concern. Kratom (Mitragyna speciosa) is an unregulated widely available herb with both stimulant and opiate μ-receptor activity. Studies suggest that its use is quickly increasing. Case: We describe a patient who presented to a psychiatric hospital with a mixed toxic syndrome due to chronic kratom and prescribed SSRI use compounded by acute intake of methamphetamine. The patient displayed psychosis, tremulousness, myoclonus, and extreme anxiety. Her clinical picture was consistent with both serotonin syndrome and opiate withdrawal. Conclusion: We call attention to this case because polysubstance overdoses are common, and kratom is widely available. Complex toxic presentations that involve kratom are likely to be increasingly encountered.

To provide information about changes associated with aging skin and the implications for wound care practitioners.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Describe proposed biologic theories of aging and the biology of aging skin.2. Discuss the clinical consequences of aging skin and the implications for wound care practitioners.Aging is a complex phenomenon manifested by macromolecular damage, adverse changes to the genome, blunted immunologic function, alterations in body composition, and decreased adaptation to stress. Understanding the changes that skin undergoes with age is essential for wound care practitioners. Accordingly, this article will introduce the reader to theories of aging, the biologic changes associated with aging skin, and clinical considerations for the wound care practitioner, including the concepts of skin failure, Skin Changes At Life's End, and frailty.Aging is a complex phenomenon manifested by macromolecular damage, adverse changes to the genome, blunted immunologic function, alterations in body composition, and decreased adaptation to stress. Understanding the changes that skin undergoes with age is essential for wound care practitioners. Accordingly, this article will introduce the reader to theories of aging, the biologic changes associated with aging skin, and clinical considerations for the wound care practitioner, including the concepts of skin failure, Skin Changes At Life’s End, and frailty.

To synthesize the literature regarding skin injuries that are found in patients at the end of life and to clarify the terms used to describe these conditions.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After completing this continuing education activity, you should be better able to:1. Define the terms used to describe pressure injuries and skin changes at the end of life.2. Discuss the concept of skin failure as applied to end-of-life skin injuries and implications for practice.This article synthesizes the literature regarding the concepts of "terminal" skin injuries that are found in patients at the end of life, including Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, and skin failure. Also included is a discussion of avoidable and unavoidable pressure injuries as defined and differentiated by the Centers for MedicareMedicaid Services and the National Pressure Ulcer Advisory Panel. To help clarify the controversy among these terms, a unifying concept of "skin failure" that may occur with an acute illness, chronic illness, or as part of the dying process is proposed. This proposed concept of skin failure is etiologically different than a pressure injury, although pressure injury and skin failure can occur concomitantly. These proposed concepts require further research and validated diagnostic criteria. Consensus around appropriate terminology is essential to reduce confusion among stakeholders and ensure appropriate patient care.

Objective To study the epidemiology and characteristics of wounds related to malignancy in a large, academically affiliated postacute/long-term care (PALTC) facility. Design Retrospective case series of 1 year of wound care consultations. Inclusion criteria included a cancer diagnosis with wounds related to malignancy or complications from cancer-related debility and/or treatment. Setting Academically affiliated 514-bed PALTC facility. Participants Of 190 consults, 27 residents (14.2%) met the inclusion criteria. Of these, 20 (74.1%) were female, and 7 (25.9%) were male. The average age of residents with a cancer diagnosis and wounds was 69.5 years (range, 48.1-86.7 years), and 25 (92.6%) were on the postacute service. Results The most common reasons for consultation included pressure injuries (44.4%), surgical wounds (21.4%), and malignant wounds (14.8%). Seventy-six percent of pressure injuries were present on admission. Breast (29.6%), gastrointestinal (25.9%), and gynecologic (11.1%) malignancies were most common. Of the studied residents, 14 (51.9%) had metastases, and 13 (92.9%) had pressure injuries. Conclusions These findings begin to fill a gap in understanding the spectrum of wounds in PALTC residents with cancer and reinforce the importance of the wound care skill set, including pressure injury prevention. Quality cancer care for older adults must anticipate severe skin complications not only from the tumor and its treatment, but also from the sequelae of immobility, immune compromise, malnutrition, and skin failure. The close association of metastatic disease with pressure injury raises issues of unavoidability and casts new doubt upon the use of pressure injuries for quality measurement.

The purpose of this learning activity is to provide information about the effects of oral medications on wound healing.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Identify oral medications that aid in wound healing.2. Recognize oral medications that interfere with wound healing.Given the accelerated medical discoveries of recent decades, there is a surprising lack of oral medications that directly improve wound healing. Of the oral medications available, most target ancillary aspects of wound care such as pain management, infection mitigation, and nutrition. This article describes oral pharmacologic agents intended to build new tissue and aid in wound healing, as well as an introduction to oral medications that interfere with wound healing. This review will not discuss the pharmacology of pain management or treatment of infection, nor will it address nutritional supplements.

This article reports the findings of the Unavoidable Pressure Ulcer Committee (of the VCU Pressure Ulcer Summit) that was tasked with addressing key issues associated with pressure injuries that are unavoidable or unpreventable. Our goals were (1) to clarify nomenclature and descriptions surrounding "terminal ulceration," (2) to describe the medical complications and comorbid conditions that can lead to skin failure and/or terminal ulceration, (3) to describe the variable possible causes of unavoidable pressure injuries, and (4) to present clinical cases to exemplify pressure injuries considered to be unavoidable.

BackgroundNumerous studies shown that structural hippocampal alterations are present in subjects at high risk of developing psychosis or schizophrenia. These findings indicate that in a subset of patients undergoing first-psychosis episode (FPE), hippocampal volume alterations are accompanied by associated cognitive and neuropsychological deficits. The combination of psychological deficits and neuroanatomical alterations, in turn, appears to increase treatment complexity and worsen clinical outcomes.ObjectiveWe aim to determine whether cognitive and neuropsychological functioning deficits precede or follow hippocampal alterations during early onset psychosis.MethodsThis cross-sectional study describes 3 case-studies of adolescent subjects, ages 16–17, admitted at the child and adolescent inpatient psychiatric unit in lieu of first psychotic episode. We conducted detailed structured clinical psychiatric interviews, anatomical-structural magnetic resonance imaging (MRI), sleep-deprived electroencephalogram (EEG) recordings, laboratory testing, and a comprehensive battery of psychological testing to better understand their clinical pictures.ResultsPsychological testing in each patient demonstrated the presence of low to borderline intellectual functioning coupled with neuropsychological deficits in different psychiatric domains. Interestingly, these changes coincided with structural MRI alterations in the hippocampal area.ConclusionsOur case report adds to the armamentarium of literature signifying that radiologically detectable alterations of the hippocampus may occur either concomitantly or closely following the development of early cognitive deficits in patients with FPE.

Background Hair cortisol analysis is increasingly being appreciated and applied in both research and medicine, aiding endocrinologists with diagnosis. Content We provide an overview of hair cortisol research in general and an update on methodological considerations including the incorporation of cortisol into hair, hair growth rates, and sampling procedures, mincing vs. grinding of samples during preparation for extraction, various extraction protocols, and quantification techniques. We compare the clinical utility and application of hair cortisol with traditional methods of measurement while acknowledging the limitations of analysis including variations in hair growth parameters. We explore the value of hair cortisol in cases of Cushing syndrome (particularly Cyclical Cushing), Adrenal insufficiency (including Addison's disease), therapy monitoring, cardiovascular disease, stress, and mental illness. Summary Hair cortisol provides a unique objective biomarker for the analysis of endogenous cortisol levels for not only clinical diagnostic purposes but also in research. The use of hair cortisol has great potential for advancing patient care.

Just over 100 years ago, an article was published describing a plan to treat decubitus ulcers that can shed light upon medical progress and current practices. Key prevention and treatment elements included a dedicated ward, staff continuity, frequent position changes and special surfaces, cleanliness, disinfectants, and dressing changes. The necessity of resource allocation and interdisciplinary collaboration was acknowledged. This article sheds light on not only how much we have learned, but also how far we have to go.

Skin failure is an emerging concept that clarifies trends in clinical practice. Its recognition provides common nomenclature, opens research directions, and questions assumptions regarding pressure ulcers as a quality measure. Adoption of the term is a step toward uniform terminology in compliance with a value based payment system.

The Centers for Medicare and Medicaid Services has released the new Resident Assessment Instrument version 3.0, which went into effect October 1, 2010. The intention of the revised Resident Assessment Instrument is to improve health-related quality of life and care planning, and incorporate evolving standards of terminology, assessment, and technology. To reach this goal, Section M: Skin Conditions has been greatly expanded and will alter the process of pressure ulcer assessment in all long-term care facilities across America. Details of this assessment instrument include upgraded criteria for risk factors, staging, identification, tracking, and evolution of pressure ulcers. The medical director can and should assume a leadership role in education and collaboration with primary care physicians and wound clinicians to accommodate changes in revised Section M. Integrating the medical director into the facility's wound care program will improve the quality of care for residents of long-term care facilities.

BackgroundOn October 29th, 2012, Hurricane Sandy caused a storm surge interrupting electricity with disruption to Manhattan’s (New York, USA) health care infrastructure. Beth Israel Medical Center (BIMC) was the only fully functioning major hospital in lower Manhattan during and after Hurricane Sandy. The impact on emergency department (ED) and hospital use by geriatric patients in lower Manhattan was studied.MethodsThe trends of ED visits and hospitalizations in the immediate post-Sandy phase (IPS) during the actual blackout (October 29 through November 4, 2012), and the extended post-Sandy phase (EPS), when neighboring hospitals were still incapacitated (November 5, 2012 through February 10, 2013), were analyzed with baseline. The analysis was broken down by age groups (18-64, 65-79, and 80+ years old) and included the reasons for ED visits and admissions.ResultsDuring the IPS, there was a significant increase in geriatric visits (from 11% to 16.5% in the 65-79 age group, and from 6.5% to 13% in the 80+ age group) as well as in hospitalizations (from 22.7% to 25.2% in the 65-79 age group, and from 17.6% to 33.8% in the 80+ age group). However, these proportions returned to baseline during the EPS. The proportions of the categories “dialysis,” “respiratory device,” “social,” and “syncope” in geriatric patients in ED visits were significantly higher than younger patients. The increases of the categories “medication,” “dialysis,” “respiratory device,” and “social” represented two-thirds of absolute increase in both ED visits and admissions for the 65-79 age group, and half of the absolute increase in ED visits for the 80+ age group. The categories “social” and “respiratory device” peaked one day after the disaster, “dialysis” peaked two days after, and “medication” peaked three days after in ED visit analysis.ConclusionsThere was a disproportionate increase in ED visits and hospitalizations in the geriatric population compared with the younger population during the IPS. The primary factor of the disproportionate impact on the geriatric population appears to be from indirect effects of the hurricane, mainly due to the subsequent power outages, such as “dialysis,” “respiratory device,” and “social.” Further investigation by chart review may provide more insights to better aid with future disaster preparedness.GotandaH, FogelJ, HuskG, LevineJM, PetersonM, BaumlinK, HabbousheJ. Hurricane Sandy: impact on emergency department and hospital utilization by older adults in Lower Manhattan, New York (USA). Prehosp Disaster Med. 2015;30(5):496–502.

Purpose To provide information about a secondary analysis of pressure ulcer data regarding incidence, avoidability, and level of harm. Target audience This continuing activity is intended for physicians and nurses with an interest in skin and wound care. Objectives After participating in this educational activity, the participant should be better able to:1. Summarize the data provided in the Office of Inspector General (OIG) study regarding incidence of pressure ulcers (PrUs) found in hospitals and skilled nursing facilities (SNFs).2. Identify the classification systems used that designate levels of harm to patients and the avoidability of PrUs. Objective To investigate in greater detail the government data on pressure ulcer (PrU) incidence, avoidability, and level of harm. Design The authors performed a secondary analysis of PrU data published in 2 studies by the Office of Inspector General (OIG) on adverse events in hospitals and skilled nursing facilities (SNFs). Setting Acute care hospitals and Medicare-certified SNFs across the United States. Patients The hospital sample included 780 Medicare beneficiaries randomly selected from 999,645 discharges during October 2008. The SNF population included 653 Medicare beneficiaries randomly selected from 100,771 patients whose stay began within 1 day of hospital discharge, who had a length of stay of 35 days or less, and whose stay ended in August 2011. Main outcome measures Pressure ulcer incidence with stage, location, avoidability, and level of harm using the Modified National Coordinating Council for Medication Errors Reporting and Prevention Index. Main results The PrU incidence in hospitals was 2.9%, and the incidence in SNFs was 3.4%. Most PrUs were Stages I and II, with 78.3% in hospitals and 54.5% in SNFs. The avoidability of PrUs was similar in both locations, with 39.1% unavoidable in hospitals and 40.9% unavoidable in SNFs. All hospital-acquired PrUs and 90.9% of SNF-acquired PrUs were designated level E on the National Coordinating Council for Medication Errors Reporting and Prevention Index, indicating a temporary harm event. Conclusions The OIG studies captured few Stage III PrUs and no Stage IV PrUs, and they underestimate the level of harm generated from PrUs in hospitals and SNFs. The studies offer a structured algorithm for avoidability determination, but lack measures of reliability and validity. Nonetheless, the high rate of unavoidable ulcers leads to questions on the reliability of PrUs as a quality indicator. There are several weaknesses in OIG methodology with regard to PrUs; however, its structured algorithm can be viewed as a starting point for future studies of PrU avoidability.

Randomized controlled trials of case management in primary care have been infrequent and contradictory. The aim of this study was to determine if a clinic-based ambulatory case management intervention, Primary Intensive Care (PIC), would reduce hospital utilization and total cost and/or improve health outcomes among primary care patients with a recent history of high use of inpatient services. Current patients withor =2 hospital admissions per year in the 12-18 months prior to recruitment in an urban primary care clinic were enrolled in a randomized clinical trial. Patients were randomized to the PIC intervention or usual care. PIC patients underwent a comprehensive multidisciplinary assessment with the result being a team-generated plan. The PIC team nurse practitioner served as case manager for the 12 months of follow-up and provided services designed to implement the care plan for those in the experimental group. Health care use, function, and a medication adherence scale were measured at baseline and at 12 months. There were no significant differences when either comparing the number of admissions pre and post enrollment within groups or the followup results post intervention between groups. A similar result was noted for the number of emergency department visits. The number of clinic visits increased in the intervention group by 1.5 visits per year which was statistically significant when compared to the control group. Overall functional status, health outcomes, and the Mental Health Functional Status subscore did not change significantly in either group during the study. We were unable to detect a difference in hospital use or functional status, mental health function, or medication adherence among patients who require frequent hospital admissions using our intervention.

Jean-Martin Charcot was a towering figure in the French medical community in the 19th century. Among the diseases he studied was the decubitus, or pressure ulcer, as it is commonly called today. He did not believe that pressure or local irritation were causative factors for the decubitus but rather subscribed to the "neurotrophic theory," which held that damage to the central nervous system led directly to its occurrence. Charcot observed that many patients who developed eschar of the sacrum and buttocks died soon afterwards, and referred to this lesion as the decubitus ominosus, implying that its occurrence heralded impending death. His description of the evolving decubitus is extraordinarily detailed and accurate and includes complications that are seldom seen today, such as gangrenous metastases to the lung and invasion of the spinal cord. Charcot's therapeutic nihilism is largely a product of the limited medical technology of his day. The importance of risk factor assessment and timely intervention for persons at risk is now understood. In addition, it is recognized that not all pressure ulcers are unavoidable and that many ulcers, particularly those in early stages, can be reversed. Comparing Charcot's view of the decubitus with our own, insight is provided into the way medicine is practiced today.