The American journal of emergency medicine
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Randomized Controlled Trial Comparative Study
Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial.
Hyperglycemia is commonly encountered in the ED; the importance of glucose reduction in patients well enough to be discharged is unknown. ⋯ In the intention-to-treat analysis, ED length of stay and 7-day outcomes were not significantly different whether moderate or loose glycemic control was pursued. However, the length of stay for those with discharge glucose <350 mg/dL was approximately 29 min longer. ED glycemic control did not appear to be associated negative short-term outcomes. Glucose reduction in well-appearing ED patients may consume time and resources without conferring short- or long-term benefits.
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Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED. ⋯ Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.
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Case Reports
Anomalous left anterior descending artery diagnosed on pulmonary artery computed tomography.
Typically, the left anterior descending artery (LAD) and left circumflex artery (LCX) arise from the left main coronary artery. However, uncommon coronary anomalies may be found in clinical practice. This case presents with a rare finding where the LAD originates from the right coronary artery (RCA) separately from the LCX and takes an interarterial pathway to reach its perfusion territory. ⋯ However, it is important to realize the different pathways of coronary artery anomalies because those with the inter-arterial subtype, such as our patient, may result in sudden cardiac death. All cases of clinically suspected inter-arterial coronary artery anomalies are recommended to undergo imaging studies to help visualize anatomic features as a guide for further management. This case represents the first reported diagnosis of this type of anomalous coronary artery on CTPA.
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The Sequential Organ Failure Assessment (SOFA) and modified SOFA (mSOFA) are risk stratification systems which incorporate respiratory, coagulatory, liver, cardiovascular, renal, and neurologic systems to quantify the overall severity of acute disorder in the intensive care unit. ⋯ The SOFA and mSOFA scores demonstrated fair discrimination and good calibration in predicting in-hospital mortality when applied to ED. However, further external validation studies are needed before their use in routine clinical care.
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Hiccups are usually benign, while myocardial infarction (MI) has the potential for morbidity and mortality. Here, we report 3 cases of MI, with hiccups being the only symptom on presentation to the emergency department. Attention should be given to patients who present with hiccups and multiple risk factors for acute coronary syndrome, especially those with factors predisposing them to atypical presentations, such as diabetes mellitus, and old age.