Volume 113, Issue 9

Context: Hypertension is a common incidental finding in the emergency department (ED). However, the authors noticed a segment of patients who present to the ED specifically because their blood pressure is found to be elevated outside of the hospital. Emergency medicine physicians are often unsure of the level of intervention that is required for these patients. Objective: To determine if these patients have serious outcomes (ie, final diagnosis of myocardial infarction, angina, coronary syndrome, congestive heart failure, pulmonary edema, hypertensive encephalopathy, malignant hypertension, stroke, transient ischemic attack, subarachnoid hemorrhage, loss of vision, kidney failure, or aortic dissection) within 7 days of the initial ED visit. Methods: The authors retrospectively reviewed ED medical records from 2008 with a chief complaint of high blood pressure or hypertension in the physician or nursing notes. Age, sex, blood pressure, history of hypertension, associated symptoms, tests, medications, admission or discharge information, final diagnoses, and return visits within 7 days were recorded. Results: Of the 316 medical records that were reviewed, 149 met the study criteria and were included in analysis. Patient age range was 19 to 94 years (mean, 59.8 years; median, 61 years). Sixty patients (40%) were men and 89 (60%) were women. Of the 149 patients, 121 (81%) had a previous diagnosis of hypertension and 28 (19%) did not. Five patients (3%) had a normal initial blood pressure in the ED. Sixteen patients (11%) did not undergo diagnostic tests, and 77 patients (52%) received medication in the ED. Twenty-six patients (17%) were admitted to the hospital, and 123 (83%) were discharged or eloped. Four patients (2.7%; 95% confidence interval, 0.7-6.7) had a serious outcome noted within 7 days of initial presentation to the ED. Conclusion: Among patients presenting to the ED with a chief complaint of hypertension or high blood pressure and no serious associated complaint, the risk of serious outcome within 7 days is low.

Context: Osteoarthritic knee pain is very common, as are leg length discrepancies (LLDs). The relationship between LLDs and osteoarthritic knee pain is not well understood. Objective: To confirm a clinical impression that osteoarthritic knee pain is more common in the short (ie, superior-presenting) leg, as measured by supine physical examination of 3 bony landmarks: the medial malleoli, the anterior superior iliac spines, and the iliac crests. The secondary objective was to measure the relative positions of the 3 bony landmarks to better understand functional contributions to LLD. Methods: A prospective single-occasion observational design was used. Patients who reported osteoarthritic knee pain during an office visit were recruited, and data were collected on 3 bony landmarks and which knee was usually most painful. Results: Of the 32 participants who were recruited, 28 were women and 4 were men. Of the 17 participants who reported having right knee pain, 10 had a short right leg and 7 had a short left leg. Of the 15 participants who reported having left knee pain, 13 had a short left leg, 1 had a short right leg, and 1 had equal leg lengths. Knee pain was most severe in the short leg for 23 of 32 participants (71.9%). The most common pattern was for both iliac crests to be equal and the short leg to be concordant with a superior anterior superior iliac spine, which occurred in 23 of 32 participants (71.9%). In the present study population, the magnitude of LLD ranged from 0 to 2.1 cm. Conclusion: Osteoarthritic knee pain was more common in the apparent short leg. More sophisticated studies, including investigations into the role of pelvic torsion in knee pain, as well as investigations for interoperator reliability and validity, are needed to build on the findings reported in this observational study.

Fibromyalgia is a common chronic syndrome defined by core symptoms of widespread pain, fatigue, and sleep disturbance. Other common symptoms include cognitive difficulty, headache, paresthesia, and morning stiffness. Fibromyalgia is increasingly understood as 1 of several disorders that are referred to as central sensitivity syndromes; these disorders share underlying causes and clinical features. Tender points are often detected in patients with fibromyalgia and were formerly required for diagnosis. Newly proposed criteria, however, rely on patients' reports of widespread pain and other somatic symptoms to establish the diagnosis of fibromyalgia. The management of fibromyalgia requires a multidimensional approach including patient education, cognitive behavioral therapy, exercise, and pharmacologic therapy. The present review provides an update on these various aspects of treating a patient with fibromyalgia.

Context: Counterstrain is 1 osteopathic manipulative treatment technique taught to osteopathic medical students, but teaching all 300 counterstrain tender points is not feasible at most colleges of osteopathic medicine (COMs) because of time limitations. Objective: To identify high-yield tender points in osteopathic medical students for teaching and to assess for correlations between tender points and demographic information, weight, and history of pain or trauma. Methods: First- and second-year osteopathic medical students at 5 COMs were surveyed regarding the presence and absence of tender points found on themselves by fellow students. Demographic information, weight, and history of pain and trauma data were collected. The McNemar test was used to compare the frequency of positive tender points between the right and left sides. Multiple logistic regression models were fit to the data to determine if participant characteristics were related to having 1 or more positive tender points in a tender point group. Wilcoxon signed rank tests were used to compare the percentage of positive anterior vs posterior tender points. Multiple logistic regression models were used to test for differences between COMs after accounting for differences in participant characteristics. Results: Frequency of 78 tender point groups was obtained. Forty tender point groups (51%) were positive for the presence of 1 or more tender points by 50% or more of the participants. Positive tender points were more common on the right side for 23 groups (all P <.001). Female participants were more likely to have tender points for 22 groups (all P <.001). The 20- to 25-year-olds had more tender points for 6 groups (all P ≤.03). Tender points were more common in participants with a history of pain for 29 groups (all P <.001) and with a history of trauma for 4 groups (all P ≤.05). Anterior tender points were more common for cervical, thoracic, rib, and lumbar body regions ( P <.001). Differences were found between COMs for all tender point groups ( P ≤.02). Conclusion: Nearly half of the tender point groups surveyed were reported positive by 50% or more of participants, and high-yield tender points were found in each body region. Ultimately, these results may guide counterstrain curricula for COMs.

The 2012-2013 influenza epidemic arrived approximately 4 weeks early, augmented by an unusual variant type-A (“swine flu”) strain that caused greater-than-normal illness and a lack of efficacy in vaccination against it. Tens of thousands of people die of influenza or related complications during a nonepidemic influenza season. Osteopathic medicine can substantially help to address the complications that result from influenza. For example, during the deadly 1918-1919 Spanish influenza pandemic, osteopaths reduced patient mortality and morbidity by using lymphatic treatment techniques. Use of osteopathic manipulative treatment with vaccination, antiviral therapy, and chemoprophylaxis has potential to save lives and reduce complications. The present article describes the role of osteopathic manipulative treatment in the management of influenza and highlights current issues surrounding the use of antiviral therapy.

Mucormycosis is an opportunistic fungal infection with a high mortality rate. Although mucormycosis is relatively rare, recent studies suggest that the incidence is on the rise as a result of increased use of chemotherapy and steroids. The authors present an unusual case of invasive mucormycosis in a hospitalized patient with AIDS who was receiving short-term, high-dose steroids and who had associated steroid-induced diabetes. The patient was otherwise healthy, with no underlying risk factors such as neutropenia or intravenous drug use. The patient developed acute onset of proptosis, vision loss, and invasive Mucor in the left maxillary sinus that extended along the optic nerve intracranially. Despite aggressive treatment, the patient died. Physicians should be aware of steroid-induced diabetes as a risk factor for invasive fungal infections such as mucormycosis.