Prospective Validation and Refinement of a Decision Rule to Obtain Chest X-ray in Patients With Nontraumatic Chest Pain in the Emergency Department.

OBJECTIVES: The objective was to prospectively validate and refine previously published criteria to determine the potential utility of chest x-ray (CXR) in the evaluation and management of patients presenting to the emergency department (ED) with nontraumatic chest pain (CP). METHODS: A prospective observational study was performed of patients presenting to three EDs in the United States with a chief complaint of nontraumatic CP. Previously defined high-risk history and examination elements were combined into a refined decision rule and these elements were recorded for each patient by the ED physician. CXR results were reviewed and analyzed to determine the presence of clinically significant findings including pneumonia, pleural effusion, pneumothorax, congestive heart failure, or the presence of a new mass. Odds ratios for each history and examination element were analyzed as well as sensitivity, specificity, and negative predictive value (NPV) of the rule overall. RESULTS: A total of 1,111 patients were enrolled and 1,089 CXRs were analyzed. There were 70 (6.4%) patients with clinically relevant findings on CXR. The refined decision rule had a sensitivity of 92.9% (confidence interval [CI] = 83.4%-97.3%) and specificity of 30.4% (CI = 27.6%-33.4%) to predict clinically relevant findings on CXR, with a NPV of 98.4% (CI = 96.1%-99.4%). Five CXRs with clinically significant findings would have been missed by application of the refined rule (three pneumonias and two pleural effusions). Applying these criteria as a CXR decision rule to this population would have reduced CXR utilization by 28.9%. CONCLUSIONS: This study validates previous research suggesting a low clinical yield for CXR in the setting of nontraumatic CP in the ED. This refined clinical decision rule has a favorable sensitivity and NPV in a patient population with low incidence of disease. Further validation is needed prior to use in practice.

Aerodigestive tract burn from ingestion of microwaved food.

Aerodigestive tract burns represent a rare but potentially devastating injury pattern throughout the world. Although the majority of these injuries do not require intervention, these burns have the potential for poor outcomes. Traditionally this disease has been caused by superheated gases found in explosions or fire-related injury. However, as technology advances, it brings novel methods for injury that require physician awareness of potential hazards. We describe a case of laryngeal and esophageal thermal burn caused by a microwave heated food bolus.

Mid-level Providers Working in a Low-acuity Area are More Productive than in a High-acuity Area.

INTRODUCTION: Mid-level providers (MLP) are extensively used in staffing emergency departments (ED). We sought to compare the productivity of MLPs staffing a low-acuity and high-acuity area of a community ED. METHODS: This is a retrospective review of MLP productivity at a single center 42,000-volume community ED from July 2009 to September 2010. MLPs staffed day shifts (8AM-6PM or 10AM-10PM) in high- and low-acuity sections of the ED. We used two-tailed T-test to compare patients/hour, relative value units (RVUs)/hour, and RVUs/patient between the 2 MLP groups. RESULTS: We included 49 low-acuity and 55 high-acuity shifts in this study. During the study period, MLPs staffing low-acuity shifts treated a mean of 2.7 patients/hour (confidence interval [CI] +/- 0.23), while those staffing high-acuity shifts treated a mean of 1.56 patients/hour (CI +/- 0.14, p<0.0001). MLPs staffing low-acuity shifts generated a mean of 4.45 RVUs/hour (CI +/- 0.34) compared to 3.19 RVUs/hour (CI +/- 0.29) for those staffing high-acuity shifts (p<0.0001). MLPs staffing low-acuity shifts generated a mean of 1.68 RVUs/patient (CI +/- 0.06) while those staffing high-acuity shifts generated a mean RVUs/patient of 2.05 (CI +/- 0.09, p<0.0001). CONCLUSION: MLPs staffing a low-acuity area treated more patients/hour and generated more RVUs/hour than when staffing a high-acuity area.

Bladder diverticulitis: a case report.

Bladder diverticulum, an outpouching of the mucosa through the muscular wall of the bladder, is a multifactorial disease process that can be either acquired or congenital. Although small diverticuli are usually asymptomatic, a large diverticulum may result in hematuria, urinary tract infection, acute abdomen due to its rupture, acute urinary retention, or neoplasm formation. We describe the case of an elderly gentleman who presented to the emergency department with abdominal pain and was ultimately diagnosed with bladder diverticulitis, a disease not previously described in the literature.

Hyposmia following laryngectomy: experimental model.

Hyposmia following laryngectomy is a well-known clinical observation, yet the causes have been controversial for many years. In an attempt to resolve this issue, an animal model was constructed. Eighteen dogs were divided into three equal groups: control dogs, dogs that underwent tracheostomy, and dogs that underwent tracheostomy and denervation of the larynx, simulating total laryngectomy. Four to 6 months following these operations, biopsies from olfactory mucosa were taken. The results showed marked changes in the olfactory mucosa of the two test groups: cystic degeneration of secretory glands in the olfactory mucosa of the first group and involution of the olfactory mucosa, substituted by dense connective tissue and "ballooning" of olfactory nerve fibres in the second group. These findings suggest that the changes in olfactory mucosa are not only caused by a loss of nasal airway but also the existence of a neurologic connecting network between the vagus nerve and the olfactory cortex.