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Mehta P, Thoppil J, Koyfman A, Long B. High risk and low prevalence diseases: Flexor tenosynovitis. Am J Emerg Med 2024; 77:132-138. [PMID: 38147700 DOI: 10.1016/j.ajem.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 12/28/2023] Open
Abstract
INTRODUCTION Flexor tenosynovitis (FTS) is a deep space infection of an upper extremity digit which carries a high rate of morbidity. OBJECTIVE This review highlights the pearls and pitfalls of FTS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION FTS typically occurs after direct penetrating trauma to the volar aspect of an upper extremity digit. Development of a deep space infection that quickly propagates through the flexor tendon sheath of a digit can result in serious structural damage to the hand and place the patient at risk for significant morbidity such as finger amputation or even result in death. Signs of FTS include symmetrical swelling of the affected finger, the affected finger being held in a flexed position, pain on any attempt of passive finger extension, and tenderness along the course of flexor tendon sheath, known as the Kanavel signs. Systemic symptoms such as fevers and chills may occur. Recognition of these signs and symptoms is paramount in diagnosis of FTS, as laboratory and imaging assessment is not typically diagnostic. ED management involves intravenous antibiotics and emergent surgical specialist consultation. CONCLUSION An understanding of the presentation and risk factors for development of FTS can assist emergency clinicians in diagnosing and managing this disease in an expedited fashion.
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Affiliation(s)
- Prayag Mehta
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Joby Thoppil
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Thoppil J, Mehta P, Bartels B, Sharma D, Farrar JD. Impact of norepinephrine on immunity and oxidative metabolism in sepsis. Front Immunol 2023; 14:1271098. [PMID: 38022663 PMCID: PMC10662053 DOI: 10.3389/fimmu.2023.1271098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Sepsis is a major health problem in the United States (US), constituting a leading contributor to mortality among critically ill patients. Despite advances in treatment the underlying pathophysiology of sepsis remains elusive. Reactive oxygen species (ROS) have a significant role in antimicrobial host defense and inflammation and its dysregulation leads to maladaptive responses because of excessive inflammation. There is growing evidence for crosstalk between the central nervous system and the immune system in response to infection. The hypothalamic-pituitary and adrenal axis and the sympathetic nervous system are the two major pathways that mediate this interaction. Epinephrine (Epi) and norepinephrine (NE), respectively are the effectors of these interactions. Upon stimulation, NE is released from sympathetic nerve terminals locally within lymphoid organs and activate adrenoreceptors expressed on immune cells. Similarly, epinephrine secreted from the adrenal gland which is released systemically also exerts influence on immune cells. However, understanding the specific impact of neuroimmunity is still in its infancy. In this review, we focus on the sympathetic nervous system, specifically the role the neurotransmitter norepinephrine has on immune cells. Norepinephrine has been shown to modulate immune cell responses leading to increased anti-inflammatory and blunting of pro-inflammatory effects. Furthermore, there is evidence to suggest that norepinephrine is involved in regulating oxidative metabolism in immune cells. This review attempts to summarize the known effects of norepinephrine on immune cell response and oxidative metabolism in response to infection.
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Affiliation(s)
- Joby Thoppil
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States
| | - Prayag Mehta
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States
| | - Brett Bartels
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States
| | - Drashya Sharma
- Department of Immunology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - J. David Farrar
- Department of Immunology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
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Thoppil J, Kraut L, Montgomery C, Castillo W, Silverman R, Gupta S, Davis F. A retrospective analysis of gender among patients admitted to a clinical decision unit at risk for acute coronary syndrome. World J Emerg Med 2023; 14:133-137. [PMID: 36911051 PMCID: PMC9999137 DOI: 10.5847/wjem.j.1920-8642.2023.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Joby Thoppil
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Texas 75002, USA
| | - Lauren Kraut
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Texas 75002, USA
| | - Collin Montgomery
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
| | - Wilfrido Castillo
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
| | - Robert Silverman
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
| | - Sanjey Gupta
- Department of Emergency Medicine, South Shore Hospital, Bay Shore NY 11706, USA
| | - Frederick Davis
- Department of Emergency Medicine, Long Island Jewish Medical Center, Queens NY 11040, USA
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Howarth K, Thoppil J, Salazar GA. Emergency department management of cellulitis and other skin and soft-tissue infections. Emerg Med Pract 2022; 24:1-24. [PMID: 35467810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
Cellulitis and other skin and soft-tissue infections (SSTIs) are common presentations in the emergency department. This review describes the varied etiologies and patient presentations of the more common SSTIs: cellulitis, abscesses, and necrotizing soft-tissue infections. A discussion of the common diagnoses masquerading as SSTIs is presented, as well as a stepwise approach to avoiding misdiagnosis. Diagnostic studies are also evaluated, including discussions on ultrasound, computed tomography, and clinical decision rules. This review also provides an evidence-based analysis of the controversies in management of abscesses, including the commonly utilized techniques of incision and drainage, irrigation, packing, and concurrent antibiotic therapy.
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Affiliation(s)
- Kyle Howarth
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Joby Thoppil
- Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gilberto A Salazar
- Associate Professor of Emergency Medicine; Department of Emergency Medicine; Section Director, EMS Education, University of Texas Southwestern Medical Center, Dallas, TX
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Pichlinski E, Hoff E, Epperson LC, Morley E, Cao JD, Thoppil J, Field S, Mehta P, Good D, Nijhawan A. Tetanus: A Rare Complication of Black Tar Heroin Use. Open Forum Infect Dis 2021; 9:ofab613. [PMID: 35146041 PMCID: PMC8826085 DOI: 10.1093/ofid/ofab613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/06/2021] [Indexed: 12/04/2022] Open
Abstract
Tetanus is associated with high morbidity and mortality, although this is rarely encountered in high-income countries. We present a case of tetanus in an unvaccinated patient secondary to black tar heroin use that highlights the importance of considering tetanus in appropriate clinical contexts, harm reduction interventions, and universal tetanus vaccination campaigns.
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Affiliation(s)
- Elisa Pichlinski
- Parkland Health and Hospital Systems, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emily Hoff
- Parkland Health and Hospital Systems, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lindsey Claire Epperson
- Parkland Health and Hospital Systems, Dallas, Texas, USA
- Department of Emergency Medicine, Division of Medical Toxicology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth Morley
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James Dazhe Cao
- Department of Emergency Medicine, Division of Medical Toxicology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joby Thoppil
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven Field
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Prayag Mehta
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Good
- Parkland Health and Hospital Systems, Dallas, Texas, USA
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ank Nijhawan
- Parkland Health and Hospital Systems, Dallas, Texas, USA
- Department of Internal Medicine, Division of Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Thoppil J, Montgomery C, Gupta S, Davis F. 95 Chest Pain and Sex: A Retrospective Analysis of Sex Differences in Patients Admitted to the Clinical Decision Unit With Concern for ACS. Ann Emerg Med 2018. [DOI: 10.1016/j.annemergmed.2018.08.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Thoppil J, Berman A, Kessler B, Sud P, Nogar J. Hand Compartment Syndrome Due to N-acetylcysteine Extravasation. Clin Pract Cases Emerg Med 2018; 1:377-379. [PMID: 29849372 PMCID: PMC5965219 DOI: 10.5811/cpcem.2017.9.35152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/07/2017] [Accepted: 09/22/2017] [Indexed: 11/11/2022] Open
Abstract
N-acetylcysteine (NAC) is the antidote for acetaminophen (APAP)-induced hepatotoxicity. Both intravenous (IV) and oral (PO) NAC formulations are available with equal efficacy. Adverse events from either preparation are rare. We describe a hand compartment syndrome after extravasation of NAC requiring emergent fasciotomy during phase three of treatment for suspected APAP toxicity. Extravasation injuries leading to compartment syndrome are rare. It is unclear whether IV NAC induced a direct tissue-toxic insult, or functioned as a space-occupying lesion to cause a compartment syndrome. Compartment syndrome from extravasation of NAC is possible. In cases where IV access is difficult, PO NAC is an alternative.
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Affiliation(s)
- Joby Thoppil
- Long Island Jewish Medical Center, Northwell Health, New Hyde Park, Department of Emergency Medicine, New Hyde Park, New York
| | - Adam Berman
- Long Island Jewish Medical Center, Northwell Health, New Hyde Park, Department of Emergency Medicine, New Hyde Park, New York
| | - Benjamin Kessler
- Staten Island University Hospital, Northwell Health, Department of Emergency Medicine, Staten Island, New York
| | - Payal Sud
- Long Island Jewish Medical Center, Northwell Health, New Hyde Park, Department of Emergency Medicine, New Hyde Park, New York
| | - Joshua Nogar
- Long Island Jewish Medical Center, Northwell Health, New Hyde Park, Department of Emergency Medicine, New Hyde Park, New York.,North Shore University Hospital, Northwell Health, Department of Emergency Medicine, Manhasset, New York
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