The American journal of emergency medicine
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Chest imaging plays a prominent role in blunt trauma patient evaluation, but indiscriminate imaging is expensive, may delay care, and unnecessarily exposes patients to potentially harmful ionizing radiation. To improve diagnostic chest imaging utilization, we conducted 3 prospective multicenter studies over 12years to derive and validate decision instruments (DIs) to guide the use of chest x-ray (CXR) and chest computed tomography (CT). The first DI, NEXUS Chest x-ray, consists of seven criteria (Age >60years; rapid deceleration mechanism; chest pain; intoxication; altered mental status; distracting painful injury; and chest wall tenderness) and exhibits a sensitivity of 99.0% (95% confidence interval [CI] 98.2-99.4%) and a specificity of 13.3% (95% CI, 12.6%-14.0%) for detecting clinically significant injuries. ⋯ Designed primarily to focus on detecting major injuries, the NEXUS Chest CT-Major DI consists of six criteria (abnormal CXR; distracting injury; chest wall tenderness; sternal tenderness; thoracic spine tenderness; and scapular tenderness) and exhibits higher specificity (37.9%; 95% CI 35.8-40.1%). Designed to reliability detect both major and minor injuries (sensitivity 95.4%; 95% CI 93.6-96.9%) with resulting lower specificity (25.5%; 95% CI 23.5-27.5%), the NEXUS CT-All rule consists of seven elements (the six NEXUS CT-Major criteria plus rapid deceleration mechanism). The purpose of this review is to synthesize the three DIs into a novel, cohesive summary algorithm with practical implementation recommendations to guide selective chest imaging in adult blunt trauma patients.
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Randomized Controlled Trial
Does gender bias in cardiac stress testing still exist? A videographic analysis nested in a randomized controlled trial.
Despite a high prevalence of coronary heart disease in both genders, studies show a gender disparity in evaluation whereby women are less likely than men to undergo timely or comprehensive cardiac investigation. Using videographic analysis, we sought to quantify gender differences in provider recommendations and patient evaluations. ⋯ Despite a lower pretest probability of acute coronary syndrome in women, we did not observe any significant gender disparity in how patients were managed and evaluated. When the patients' and providers' gender matched, the provider involved them less in the decision making process, and the information provided was less helpful than when the genders did not match.
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Multicenter Study Observational Study
Etiologies and delirium rates of elderly ED patients with acutely altered mental status: a multicenter prospective study.
Altered mental status (AMS) is a challenging diagnosis in older patients and has a large range of etiologies. The aim of this study was to investigate the nature of such etiologies for physicians to be better aware of AMS backgrounds and hence improve outcomes and mortality rates. ⋯ The most common causes of AMS were infection and neurological diseases. Delirium was associated with AMS in nearly half the patients. Moreover, the rates of hospitalization and mortality remained high.
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Observational Study
Diagnostic accuracy of fibrinogen to differentiate appendicitis from nonspecific abdominal pain in children.
The aim of this study was to assess the diagnostic accuracy of the biomarker fibrinogen (FB), along with the more traditional markers white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP), to discriminate appendicitis from nonspecific abdominal pain (NSAP) in children. ⋯ WBC and ANC are useful inflammatory markers to discriminate appendicitis from NSAP. FB and CRP are not very useful to discriminate appendicitis from NSAP, but they discriminate properly complicated from uncomplicated appendicitis and NSAP, with a similar diagnostic accuracy. In a child with suspected appendicitis, a plasma FB level (prothrombin time-derived method) >520 mg/dL is associated to an increased likelihood of complicated appendicitis.
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A triage cardiology program, in which cardiologists provide consultation to the Emergency Department (ED), may safely reduce admissions. For patients with chest pain, the HEART Pathway may obviate the need for cardiology involvement, unless there is a difference between ED and cardiology assessments. Therefore, in a cohort concurrently evaluated by both specialties, we analyzed discordance between ED and cardiology HEART scores. ⋯ There is substantial discordance in HEART scores between ED physicians and cardiologists. A triage cardiology system may help refine risk stratification of patients presenting to the ED with chest pain, even when the HEART Pathway tool is used.