The Americans With Disabilities Act, Reasonable Accommodations, and Medical Education.

The number of students with a disability matriculating into institutions of medical education, including physician assistant programs, is increasing. Educational institutions must develop procedures with regard to the Americans with Disabilities Act (ADA) including the provision of reasonable accommodations to provide equal opportunities for all. These procedures must be compliant with federal and state laws while protecting academic integrity, maintaining technical standards, and successfully navigating the institutional and individual faculty barriers. Knowledge of the ADA and the ADA Amendments Act of 2008 as well as some familiarity with the legal precedent regarding these laws will facilitate planning and decision-making for students with disabilities. This is imperative for educating not just those with specific disabilities but also the evolving learners of today. Such knowledge, coupled with the continued prioritization of technical standards and student outcomes, will assist in the curricular development of the future.

A man with a productive cough.

The clinical presentation of active tuberculosis is nonspecific. This article describes a patient whose chronic cough was eventually diagnosed as reactivation tuberculosis.

Physician Assistant Management of Pediatric Patients in a General Community Emergency Department: A Real-World Analysis.

PURPOSE: Multiple studies have documented the nonclinical characteristics of physician assistant (PA) practices in the emergency department (ED). This study examines the clinical care PAs provide to younger pediatric patients in a general community ED. METHODS: The electronic medical record database of an urban community general ED was queried to identify pediatric patients aged 6 years or younger. This age group was selected because it was considered to be representative of physiologic and pathologic conditions unique to children. The 72-hour recidivism rates were used as an objective outcome measure to compare the care provided by PAs with the care of attending emergency physicians (EPs). Three different treatment groups were defined for the analysis: EPs alone, PAs alone, and PAs with consults from EPs (PA & EP). RESULTS: A total of 10,369 children aged 6 years or younger were seen during a 24-month study period. The mean (SD) age of the patients was 2.2 (0.2) years, with 2909 (28%) aged 1 year or younger. A total of 807 (7.8%) patients returned within 72 hours of their initial ED visit with 57 (0.55%) subsequently admitted. Recidivism rates for the 3 clinical groups were as follows: PA (6.8%), EP (8.0%), and PA & EP (9.3%) (P < 0.03). Patients admitted to the hospital on their return visits for the 3 clinical groups were as follows: PA (0.4%), EP (0.6%), and PA & EP (0.7%) (P = 0.2). CONCLUSIONS: Based on the outcome measure of 72-hour recidivism, PA management of pediatric patients 6 years or younger is similar to that of attending EPs.

A young woman with numbness in her feet.

This article describes a young, otherwise healthy woman who presented to the ED with numbness in her feet and was discharged. Twenty-four hours later, she returned because of difficulty walking; in 48 hours she could not walk without assistance. Although Guillain-Barré syndrome was suspected initially, the patient's weakness, sensory loss, and autonomic dysfunction eventually were diagnosed as transverse myelitis, a myelopathy often associated with infectious or autoimmune diseases. The article describes the presentation, diagnostic evaluation and criteria, treatment, and prognosis of transverse myelitis.

Recognizing postural orthostatic tachycardia syndrome.

This article describes the pathophysiology, clinical presentation, differential diagnosis, diagnosis, and management of postural orthostatic tachycardia syndrome (POTS), a potentially debilitating autonomic disorder that can have many causes and presentations. POTS can be mistaken for panic disorder, inappropriate sinus tachycardia, and chronic fatigue syndrome. Clinician suspicion for the syndrome is key to prompt patient diagnosis and treatment.

Management of pediatric skin abscesses in pediatric, general academic and community emergency departments.

OBJECTIVES: To compare the evaluation and management of pediatric cutaneous abscess patients at three different emergency department (ED) settings. METHOD: We conducted a retrospective cohort study at two academic pediatric hospital EDs, a general academic ED and a community ED in 2007, with random sampling of 100 patients at the three academic EDs and inclusion of 92 patients from the community ED. Eligible patients were ≤18 years who had a cutaneous abscess. We recorded demographics, predisposing conditions, physical exam findings, incision and drainage procedures, therapeutics and final disposition. Laboratory data were reviewed for culture results and antimicrobial sensitivities. For subjects managed as outpatients from the ED, we determined where patients were instructed to follow up and, using electronic medical records, ascertained the proportion of patients who returned to the ED for further management. RESULT: Of 392 subjects, 59% were female and the median age was 7.7 years. Children at academic sites had larger abscesses compared to community patients, (3.5 versus 2.5 cm, p=0.02). Abscess incision and drainage occurred in 225 (57%) children, with the lowest rate at the academic pediatric hospital EDs (51%) despite the relatively larger abscess size. Procedural sedation and the collection of wound cultures were more frequent at the academic pediatric hospital and the general academic EDs. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence did not differ among sites; however, practitioners at the academic pediatric hospital EDs (92%) and the general academic ED (86%) were more likely to initiate empiric MRSA antibiotic therapy than the community site (71%), (p<0.0001). At discharge, children who received care at the community ED were more likely to be given a prescription for a narcotic (23%) and told to return to the ED for ongoing wound care (65%). Of all sites, the community ED also had the highest percentage of follow-up visits (37%). CONCLUSION: Abscess management varied among the three settings, with more conservative antibiotic selection and greater implementation of procedural sedation at academic centers and higher prescription rates for narcotics, self-referrals for ongoing care and patient follow-up visits at the community ED.