Implementation of a rapid chest pain protocol in the emergency department: A quality improvement project.

PURPOSE: The purpose of this quality improvement (QI) project is to compare the effectiveness of a rapid 90-min chest pain screening and evaluation protocol to a 120-min screening and evaluation protocol in determining patient readiness for hospital admission or discharge home. DATA SOURCES: The existing chest pain protocol utilized in the emergency department (ED) was revised based on a review of current research changing initial screening and reevaluation times from 120 to 90 min. A prospective comparative study of patients presenting to the ED with chest pain was performed comparing the existing chest pain protocol of 120 min (standard care) with a rapid screening evaluation protocol of 90 min. A total of 128 patients presenting to an ED in Texas with chest pain comprised the sample for this study. CONCLUSIONS: There was a significant difference in the number of minutes between the groups for readiness for disposition. The average time from chest pain evaluation to readiness for disposition home, observation, or admission decreased from an average of 191 min in the standard care group to an average of 118 min in the rapid screening group. IMPLICATIONS FOR PRACTICE: Use of the rapid screening and evaluation protocol decreased the time to disposition by an average of 73 min, which enhanced ED flow without influencing disposition and patient safety.

Sertoli-Leydig cell tumor with unique nail findings in a post-menopausal woman: a case report and literature review.

BACKGROUND: Sertoli-Leydig cell tumor (SLCT) is a rare sex-cord tumor that usually occurs unilaterally and accounts for < 0.5% of all ovarian tumors. SLCT is uncommon in post-menopausal women, with the average age of diagnosis being 25 years. CASE: We present a case of a 63-year-old post-menopausal woman presenting with progressive hirsutism, and male-pattern baldness. Unusual nail changes were also observed. METHODS: Hormonal profile of the patient revealed increased testosterone and estradiol levels, and a 3.5 cm left ovarian mass. The patient was evaluated and was not found to be anemic or iron-deficient. Intraoperative frozen section assessment during laparoscopic exploration revealed SLCT, which was confirmed subsequently by histopathological and immunohistochemical (IHC) examination. Nail bed tissues were collected from normal females and evaluated by IHC for the presence of androgen receptors (AR). RESULTS: The patient had an excellent postoperative course and all her testosterone-related manifestations were reversed within one year of surgery. Following surgery, the patient's unique nail abnormalities also resolved gradually. The IHC evaluation also confirmed the presence of AR in nail bed tissues of females. CONCLUSION: SLCT, albeit rare, should be considered in post-menopausal women presenting with virilization and elevated androgen levels. Unusual nail signs may develop in response to increased androgen levels in these patients.

Adenomatous hyperplasia of the gallbladder.

Adenomatous hyperplasia of the gallbladder is an uncommon condition, particularly in men. A literature search yields minimal information on this entity, thus suggesting the infrequency of its occurrence. Adenomyomatosis is an entity that closely resembles adenomatous hyperplasia but has hypertrophy of the muscular layer and extensive Rokitansky-Aschoff sinuses. We report the finding of adenomatous hyperplasia in a middle-aged male in the setting of symptomatic cholelithiasis.

Metastatic pleomorphic carcinoma of lung presenting as abdominal pain.

Pleomorphic carcinoma of lung is a rare subtype that has a propensity to metastasize to the small bowel. This rarely encountered tumor may present a diagnostic challenge to pathologists and result in delay that could impact clinical decisions. Lung cancer can metastasize to any organ in the body; however, clinical manifestations of metastasis to the small bowel are a relatively rare event. Because they are so rare, small-bowel metastases are usually seen only at autopsy. Clinical presentation of small-bowel metastasis of lung cancer may represent a terminal event if not recognized and surgically resolved. Prompt surgical intervention may significantly extend the life of the patient.

Primary renal non-Hodgkins lymphoma presenting with acute renal failure.

Primary renal lymphoma (PRL) has been reported in medical literature. Its occurrence is rare and controversial, the kidney being an extranodal organ. We report a case of primary renal lymphoma presenting with acute-on-chronic renal failure and unilateral involvement of the left kidney without obstruction and with minimal peripheral organ involvement. Definitive diagnosis was made from histologic examination of the mass postoperatively. Renal function became stabilized after the removal of the tumor.

A positive antibody screen--an encounter with the Augustine antibody.

An antibody screen is performed on the blood of patients who may require blood transfusion. If an antibody is detected, it must be identified to avoid transfusing the patient with blood that contains the corresponding antigen. Antibody screens are also performed as part of a prenatal profile to detect antibodies that may cause hemolytic disease of the newborn. In this article we report the detection of a unique antibody to an antigen of high incidence, the anti-Augustine antibody. We describe problems that may occur when this antibody is encountered, including its identification and obtaining suitable transfusion products for the patient. A brief historical review of the clinical significance of this antibody is included in the article.