Comparison of CT head interpretation between emergency physicians and neuroradiologists.

Cranial computed tomography (CT) of the head is widely used in the emergency department 24 h a day. We compared the accuracy of CT head interpretation between staff emergency physicians (EPs) and neuroradiologists. We conducted a health records review of patients who required head CT in the emergency department. Two independent reviewers rated disagreement as clinically normal, significant, or clinically insignificant findings using published definition criteria. We calculated concordance and prepared descriptive and kappa statistics with 95% confidence intervals using SAS 9.1 software. We included 442 for this study. CT heads were classified as: normal or nonacute 81.5% (360 cases), insignificant 3.8% (17 cases), and significant 14.7% (65 cases). The weighted kappa for agreement was 0.83 (95% confidence interval 0.76-0.90). None of these patients had adverse outcomes related to EP misinterpretation of the CT head. In conclusion, clinically important findings on CT head are not commonly missed by our EPs and patients rarely have inappropriate disposition.

Predictors of positive chest radiography in non-traumatic chest pain in the emergency department.

OBJECTIVES: To determine predictors associated with positive chest x-ray finding in patients presenting with non-traumatic chest pain in the Emergency Department (ED). METHODS: Health records, including the final radiology reports of all patients who presented with non-traumatic chest pain and had a chest x-ray performed in an urban Canadian tertiary care ED over four consecutive months were reviewed. Demographic and clinical variables were also extracted. Chest x-ray findings were categorized as normal (either normal or no significant change from previous x-rays) or abnormal. Descriptive statistics were used to describe the data. Multivariable logistic regression was used to determine the association between various predictors and chest x-ray finding (positive/negative). RESULTS: The 330 study patients had the following characteristics: mean age 58±20 years; female 41% (n=134). Patients' chief complaints were only chest pain 75% (n=248), chest pain with shortness of breath 12% (n=41), chest pain with palpitation 4% (n=14), chest pain with other complaints 9% (n=28). Chest x-rays were reported as normal or no acute changes in 81% (n=266) of patients, and abnormal in 19% (n=64) of patients. The most common abnormal chest x-ray diagnoses were congestive heart failure (n=28; 8%) and pneumonia (n=17; 5%). Those with abnormal chest x-ray findings were significantly older (71 versus 55 years; p<0.001), had chest pain with shortness of breath (36% versus 11%; p<0.001), had significant past medical history (39% versus 14%; p<0.001), and were also tachypnoic (31% versus 12%; p<0.001). CONCLUSION: This study found that patients with non-traumatic chest pain are likely to have a normal chest x-ray if they were young, not tachypnoeic or short of breath, and had no significant past medical history. A larger study is required to confirm these findings.

Do beta-blockers reduce short-term mortality following acute myocardial infarction? A systematic review and meta-analysis.

OBJECTIVE: Acute myocardial infarction (AMI) remains a major cause of death and beta-blockers are known to reduce long-term mortality in post-AMI patients. We sought to determine whether patients receiving beta-blockers acutely (within 72 h) following AMI had a lower mortality rate at 6 weeks than patients receiving placebo. METHODS: We conducted a systematic review of randomized controlled clinical trials that assessed 6-week mortality and compared beta-blockers with placebo in patients randomized within the first 72 hours following AMI. We searched these databases: MEDLINE (1966-2006), EMBASE (1980-2007), Cochrane Central Register of Controlled Trials, Health Star (1966-2007), Cochrane Database for Systematic Reviews, ACP Journal Club (1991-2007), Database of Abstracts of Reviews of Effect (< 1st quarter 2007) and Conference Papers Index (1984-2007). Two blinded reviewers extracted the data and rated study quality using the Jadad score and the adequacy of allocation concealment score, which was adopted by the Cochrane group. We calculated pooled odds ratios (ORs) using a random effect model and performed sensitivity analyses to explore the stability of the overall treatment effect. RESULTS: We included 18 studies (13 were rated high-quality) with 74 643 enrolled participants and had 5095 deaths. Compared with placebo, adding beta-blockers to other interventions within 72 hours after AMI did not result in a statistically significant reduction in 6-week mortality (OR 0.95, 95% confidence interval [CI] 0.90-1.01). When restricted to high quality studies, the OR for 6-week mortality reduction was 0.96 (95% CI 0.91-1.02). We found similar results including studies that enrolled patients within 24 hours after AMI. However, a subgroup analysis that excluded high-risk patients with Killip class III and above showed that beta-blockers resulted in a significant reduction in short-term mortality (OR 0.93, 95% CI 0.88-0.99). CONCLUSION: Acute intervention with beta-blockers does not result in a statistically significant short-term survival benefit following AMI but may be beneficial for low-risk (Killip class I) patients.