Failure of Real-time Passive Notification about Radiation Exposure to Influence Physician Ordering Behavior.

Objectives  To determine whether real-time passive notification of patient radiation exposure via a computerized physician order entry system would alter the number of computed tomography scans ordered by physicians in the Emergency Department (ED) setting. Methods  When a practitioner ordered a computed tomography scan, a passive notification was immediately and prominently displayed via the computerized physician order entry system. The notification stated the following: the amount of estimated radiation in millisieverts (mSv), the equivalent number of single-view chest radiographs, and equivalent days of average environmental background radiation to which a patient during a specific computed tomography scan would be exposed. The primary outcome was changed in the number of computed tomography scans ordered when comparing data collected before and after the addition of the notification. Results  Before the dosimetry notification ("intervention") was instituted, 1,747 computed tomography scans were performed on patients during 11,709 Emergency Department visits (14.9% computed tomography scan rate). After the intervention had been instituted, 1,827 computed tomography scans were performed on patients during 11,582 Emergency Department patient visits (15.8% computed tomography scan rate). No statistically significant difference was found for all chief complaints combined (p = 0.17), or for any individual chief complaint, between the number of computed tomography scans performed on Emergency Department patients before versus after the intervention. Conclusions  Passive real-time notification of patient radiation exposure displayed in a computerized physician order entry system at the time of computed tomography scan ordering in the Emergency Department did not significantly change the number of ordered scans.

Randomized controlled trial of prophylactic antibiotics for dog bites with refined cost model.

OBJECTIVE: The aim of this study was to determine the rate of infection at which it is cost-effective to treat dog bite wounds with antibiotics. METHODS: Our study was composed of two parts. First we performed a randomized, double-blind controlled trial (RCT) to compare the infection rates of dog bite wounds in patients given amoxicillin-clavulanic acid versus placebo. Subjects were immunocompetent patients presenting to the emergency department (ED) with dog bite wounds less than 12 hours old without suspected neurovascular, tendon, joint or bone injury, and who had structured follow-up after two weeks. Second, we developed a cost model with sensitivity analysis to determine thresholds for treatment. RESULTS: In the RCT, primary outcomes were obtained in 94 patients with dog bites. The overall wound infection rate at two weeks was 2% [95% CI 0 to 7%]. Two of 46 patients (4%) receiving no antibiotics developed infections, while none of the 48 patients (0%) receiving prophylactic antibiotics developed an infection (absolute reduction 4% [95% CI -1.0 to 4.5%]). Using a sensitivity analysis across a rate of infections from 0-10%, our cost model determined that prophylactic antibiotics were cost effective if the risk of wound infection was greater than 5% and antibiotics could decrease that risk by greater than 3%. CONCLUSION: Our wound infection rate was lower than older studies and more in line with current estimates. Assuming that prophylactic antibiotics could provide an absolute risk reduction (ARR) of 3%, it would not be cost effective to treat wounds with an infection rate of less than 3% and unlikely that the ARR would be achievable unless the baseline rate was greater than 5%, suggesting that only wounds with greater than 5% risk of infection should be treated. Future work should focus on identifying wounds at high-risk of infection that would benefit from antibiotic prophylaxis.

The violent or agitated patient.

Violent and agitated patients are high risk because they may pose a physical threat to the staff, may harm themselves, and may have dangerous comorbidities and illness that are causing the violence. The emergency physician must quickly control these behaviors, and thoroughly identify and treat their etiology, while simultaneously protecting the patients' rights and reducing the risks of injury to themselves, other patients, and medical staff. This article highlights potentially high-risk situations and describes corresponding mitigation tactics.

Celiac disease symptoms in a female collegiate tennis player: a case report.

OBJECTIVE: To present the case of a collegiate tennis player with celiac disease symptoms. BACKGROUND: Celiac disease is a common intestinal disorder that is often confused with other conditions. It causes severe intestinal damage manifested by several uncomfortable signs and symptoms. Failure by the sports medicine staff to recognize symptoms consistent with celiac disease and treat them appropriately can have deleterious consequences for the athlete. DIFFERENTIAL DIAGNOSIS: Irritable bowel syndrome, Crohn disease, Addison disease, lupus erythematosus, juvenile rheumatoid arthritis, lactose intolerance, herpes zoster, psychogenic disorder (depression), fibromyalgia, complex regional pain syndrome, hyperthyroidism, anemia, type I diabetes. TREATMENT: The athlete underwent a series of blood and allergen tests to confirm or refute a diagnosis of celiac disease. When celiac disease was suspected, dietary modifications were made to eliminate all wheat-based and gluten-based products from the athlete's diet. UNIQUENESS: The athlete was able to fully compete in a competitive National Collegiate Athletic Association Division I tennis program while experiencing the debilitating effects associated with celiac disease. The immediacy of symptom onset was notable because the athlete had no history of similar complaints. CONCLUSIONS: Celiac disease is a potentially life-threatening condition that affects more people than reported. A properly educated sports medicine staff can help to identify symptoms consistent with celiac disease early, so damage to the intestine is minimized. Prompt recognition and appropriate management allow the athlete to adjust the diet accordingly, compete at a high-caliber level, and enjoy a healthier quality of life.

Hepatocyte nuclear factor 4alpha controls the development of a hepatic epithelium and liver morphogenesis.

Although advances have been made in understanding cell differentiation, only rudimentary knowledge exists concerning how differentiated cells form tissues and organs. We studied liver organogenesis because the cell and tissue architecture of this organ is well defined. Approximately 60% of the adult liver consists of hepatocytes that are arranged as single-cell anastomosing plates extending from the portal region of the liver lobule toward the central vein. The basal surface of the hepatocytes is separated from adjacent sinusoidal endothelial cells by the space of Disse, where the exchange of substances between serum and hepatocytes takes place. The hepatocyte's apical surface forms bile canaliculi that transport bile to the hepatic ducts. Proper liver architecture is crucial for hepatic function and is commonly disrupted in disease states, including cirrhosis and hepatitis. Here we report that hepatocyte nuclear factor 4alpha (Hnf4alpha) is essential for morphological and functional differentiation of hepatocytes, accumulation of hepatic glycogen stores and generation of a hepatic epithelium. We show that Hnf4alpha is a dominant regulator of the epithelial phenotype because its ectopic expression in fibroblasts induces a mesenchymal-to-epithelial transition. Most importantly, the morphogenetic parameters controlled by Hnf4alpha in hepatocytes are essential for normal liver architecture, including the organization of the sinusoidal endothelium.