J Emerg Med
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Observational Study
Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study.
Evaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays. ⋯ In our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.
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Acute proximal hamstring ruptures can be a diagnostic challenge in the emergency department. The revealing sign of large posterior thigh ecchymosis is typically not yet present; the physical examination is limited due to pain, radiographs can be unremarkable, and definitive testing with magnetic resonance imaging is not practical. These avulsions are often misdiagnosed as hamstring strains and treated conservatively. The diagnosis is made after failed treatment, often months after the injury. Surgical repair at that time can be technically challenging and higher risk due to tendon retraction and adhesion of the tendon stump to the sciatic nerve. ⋯ The first case illustrates an example of how delay in diagnosis can occur in both emergency medicine and outpatient primary care settings. It also shows complications and morbidity potential for patients who warrant and do not receive timely surgical repair. The second case illustrates physical examination findings obtainable during the acute setting, and the use of point-of-care ultrasound (POCUS) in facilitating an expedited diagnosis and treatment plan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Timely diagnosis of hamstring rupture is paramount to optimize patient outcomes for this serious injury. The best results are obtained with surgical repair within 3-6 weeks of injury. POCUS evaluation can aid significantly in the timely diagnosis of this injury. If the POCUS examination raises clinical concern for a proximal hamstring rupture, this may allow for earlier diagnosis and definitive treatment of proximal hamstring rupture.
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Multicenter Study
HEART Score and Stress Test Emergency Department Bayesian Decision Scheme: Results from the Acute Care Diagnostic Collaboration.
Accurate identification of patients at risk of major adverse cardiac events (MACE) places a substantial burden on emergency physicians (EPs). Bayesian nomogram for risk stratification in low- to intermediate-risk cardiovascular patients has not been investigated previously. ⋯ This Bayesian analysis demonstrated slight superiority of stress ECHO over ETT in low- and intermediate-risk patients in ruling out MACE.
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The emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease. ⋯ The ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.
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Herpes simplex virus (HSV) infection represents significant morbidity and mortality in the neonatal period. Although clear guidelines exist on the evaluation and management of the otherwise well-appearing febrile neonate pertaining to occult serious bacterial infections, there is no standardized approach regarding when to initiate testing and treatment for HSV infection. It is vital we establish a unified guideline based on available clinical research to aid in our decision to evaluate and initiate therapy for this disease. ⋯ Neonatal HSV infection carries significant morbidity and mortality if left untreated. High-quality clinical evidence on when to evaluate and treat for possible HSV infection is lacking. Based on available research, HSV infection in the febrile neonate should be strongly considered if age is < 21 days, or if presenting with concerning clinical features. If testing is performed, empiric treatment with high-dose acyclovir should be initiated. Additional research is needed to further clarify which cases mandate evaluation and treatment for HSV, and to better define treatment protocols.