Emergency department observation units and the older patient.

An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.

Difficulties in diagnosing pulmonary embolism in the obese patient: a literature review.

Several of the signs and symptoms of pulmonary embolism, such as dyspnea, tachypnea, and tachycardia, are common in the obese population, so these patients are frequently suspected of having a pulmonary embolism. Establishing an accurate diagnosis in this situation is often difficult. We performed a review of the literature examining the difficulty of diagnosing pulmonary embolism in obese patients. Several factors compromise the ability of clinicians to accurately diagnose pulmonary embolism in obese patients. When patients weigh over 350 lbs (159 kg), thoracic imaging often cannot be performed because of the weight limitations of the scanning equipment. If equipment is available that can scan these patients, image quality is often poor. The literature that is available to guide the clinician in this difficult clinical scenario is sparse. Access to radiology equipment that can image morbidly obese patients is improving, but questions about image quality remain. Further research on both imaging and outcomes is needed.

Vocal cord dysfunction: beyond severe asthma.

BACKGROUND: Vocal cord dysfunction (VCD) is the abnormal adduction of the vocal cords during inspiration causing extrathoracic airway obstruction. VCD has been described as a confounder of severe asthma. The influence of VCD among less severe asthmatics has not been previously defined. METHODS: We retrospectively reviewed the medical records of 59 patients with pulmonologist-diagnosed asthma who were referred for videolaryngostroboscopy (VLS) testing from 2006 to 2007. RESULTS: A total of 44 patients had both asthma and VCD. 15 patients had asthma without concomitant VCD. Females were predominant in both groups. Overall, the majority of patients referred for VLS testing had mild-to-moderate asthma (78%) and 72% of these patients had VCD. Few patients from either group had "classic" VCD symptoms of stridor or hoarseness. Gastroesophageal reflux disease (GERD) and rhinitis were common in both groups. CONCLUSIONS: Vocal cord dysfunction occurs across the spectrum of asthma severity. There was a lack of previously described "classic" VCD symptoms among asthmatics. Symptoms were diverse and not easily distinguished from common symptoms of asthma, highlighting the need for a high index of suspicion for VCD in patients with asthma. Failure to consider and diagnose VCD may result in misleading assumptions about asthma control, and result in unnecessary adjustments of asthma medications. The high prevalence of GERD raises the question of the role of acid reflux in the pathogenesis of VCD in asthmatics.