J Emerg Med
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Chest pain is a common presentation to the emergency department (ED), though the majority of patients are not diagnosed with acute coronary syndrome (ACS). Many patients are admitted to the hospital due to fear of ACS. ⋯ With nonischemic ECG and negative cardiac biomarker, the risk of ACS approaches < 1%. Use of stress test and CCTA for risk stratification of low-risk chest pain patients is controversial. These tests may allow prognostication but do not predict ACS risk beyond ECG and troponin. CCTA may be useful for intermediate-risk patients, though further studies are required.
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Joint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider. ⋯ Emergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.
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Multicenter Study Clinical Trial
Safety and Efficacy of the "Easy Internal Jugular (IJ)": An Approach to Difficult Intravenous Access.
The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in the internal jugular vein using ultrasound guidance. This technique is used in patients who do not have suitable peripheral or external jugular venous access. The efficacy and safety of this procedure are unknown. ⋯ The Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.
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Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED. ⋯ Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED.
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Case Reports
Delayed Antitoxin Treatment of Two Adult Patients with Botulism after Cosmetic Injection of Botulinum Type A Toxin.
Injection of botulinum toxin type A for cosmetic purposes is common. It is believed to be safe, but adverse reactions have been reported, including dysphagia, generalized paralysis, respiratory depression, and death caused by focal injection of the toxin. Early administration of antitoxin in patients with adverse reactions is the mainstay of management, but the time window for its clinical efficacy is not well defined. ⋯ Two female adult patients with clinical botulism after botulinum toxin type A injection are described. Both patients had received intramuscular injection of botulinum toxin type A in their calves at beauty shops for cosmetic reasons. They developed clinical botulism about 3 days postinjection. They presented late to the emergency department. Monovalent type A botulinum antitoxin was administered 7 and 9 days from symptom onset, respectively. Both patients showed clinical improvement after the antitoxin treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may present to the emergency department with systemic effects of botulinum toxin type A after cosmetic injection. Clinical efficacy of botulinum antitoxin treatment was observed in two patients who were given the drug 7 and 9 days after the occurrence of symptoms of botulism after cosmetic injection of botulinum toxin type A. It may be worthwhile to commence antitoxin treatment even if patients present late.