Emergency department headache admissions in an acute care hospital:why do they occur and what can we do about it?

<p><b>INTRODUCTION</b>Many patients present to the Emergency Department (ED) complaining of headache and a significant proportion of these visits would result in hospital admissions. This study analyses the demographics, presentation, work-up, reasons for admission, diagnoses and outcomes of patients admitted with the chief complaint of headache--to identify possible ways of reducing such admissions.</p><p><b>MATERIALS AND METHODS</b>A retrospective analysis was done of the electronic medical records/discharge summaries of all adult patients admitted during a 1-year period from January to December 2006 with the diagnosis of primary headaches or secondary headaches not related to trauma, intracranial infection, inflammation, mass lesion, raised intracranial pressure or a serious systemic illness from the ED of the National University Hospital of Singapore.</p><p><b>RESULTS</b>One thousand two hundred and seventy-six patients presented to the adult ED with primary headaches or secondary headaches not related to serious conditions in 2006. This represented 2% of the ED attendances in the period. Two hundred and twenty-three patients were admitted for various reasons--diagnostic uncertainty: 110 (49%), pain control: 73 (33%), social/patient request: 60 (27%) and others: 4 (2%). Sixty-six per cent of the patients had either computed tomography (CT) or magnetic resonance (MR) head imaging. Eighteen patients (8%) were eventually diagnosed with a "potentially serious" diagnosis (intracranial haemorrhage, brain metastasis, stroke, meningitis, cerebral inflammation, cysticercosis, cervical osteomyelitis, hydrocephalus, seizure and malignant hypertension).</p><p><b>CONCLUSION</b>Specific strategies addressing the various reasons for admission including physician training, use of evaluation protocols, imaging to exclude secondary pathology, a longer duration of treatment and evaluation in the ED, effective pain control and patient education may help reduce headache admissions.</p>

POEMS syndrome--a case for more aggressive treatment

<p><b>INTRODUCTION</b>Patients with POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal or M-protein and skin changes) syndrome exhibit a wide range of clinical manifestations and are often seen by a variety of specialists prior to diagnosis.</p><p><b>CLINICAL PICTURE</b>We describe a case of POEMS syndrome that first presented with significant neuropathy but progressed to develop further manifestations of the condition, including marked gastrointestinal symptoms.</p><p><b>TREATMENT</b>The patient was commenced on localised radiotherapy and chemotherapy in addition to immunomodulatory therapy for the neuropathy.</p><p><b>CONCLUSION</b>We highlight several learning points that may benefit physicians from varied specialties. This case is also unique for its marked gastrointestinal manifestation. To our knowledge, this is the second reported case in the literature with this feature.</p>