The Chest Pain Choice trial: a pilot randomized trial of a decision aid for patients with chest pain in the emergency department

Background: Chest pain is a common presenting complaint in the emergency department (ED). Despite the frequency with which clinicians evaluate patients with chest pain, accurately determining the risk of acute coronary syndrome (ACS) and sharing risk information with patients is challenging. The aims of this study are (1) to develop a decision aid (CHEST PAIN CHOICE) that communicates the short-term risk of ACS and (2) to evaluate the impact of the decision aid on patient participation in decision-making and resource use. Methods/Design: This is a protocol for a parallel, 2-arm randomized trial to compare an intervention group receiving CHEST PAIN CHOICE to a control group receiving usual ED care. Adults presenting to the Saint Mary's Hospital ED in Rochester, MN USA with a primary complaint of chest pain who are being considered for admission for prolonged ED observation in a specialized unit and urgent cardiac stress testing will be eligible for enrollment. We will measure the effect of CHEST PAIN CHOICE on six outcomes: (1) patient knowledge regarding their short-term risk for ACS and the risks of radiation exposure; (2) quality of the decision making process; (3) patient and clinician acceptability and satisfaction with the decision aid; (4) the proportion of patients who decided to undergo observation unit admission and urgent cardiac stress testing; (5) economic costs and healthcare utilization; and (6) the rate of delayed or missed ACS. To capture these outcomes, we will administer patient and clinician surveys after each visit, obtain video recordings of the clinical encounters, and conduct 30-day phone follow-up. Discussion: This pilot randomized trial will develop and evaluate a decision aid for use in ED chest pain patients at low risk for ACS and provide a preliminary estimate of its effect on patient participation in decision-making and resource use

Salmonella Urinary Tract Infection Heralding Thoracic Mycotic Aneurysm: Case Report as Medical Apology

We report a case as a patient apology as a means of teaching other physicians about a unique presentation of a rare disease. Salmonella species are unusually isolated organisms in urine. In the case described, appreciation for the rarity of Salmonella species in the urine facilitated recognition of a serious disseminated Salmonella infection. Physicians should consider disseminated Salmonella infection, as was found in a patient with an aortic mycotic aneurysm, after isolation of Salmonella in urine despite an initially benign clinical presentation

Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List

Introduction: Several factors influence the final placement of a medical student candidate on anemergency medicine (EM) residency program’s rank order list, including EM grade, standardized letterof recommendation, medical school class rank, and US Medical License Examination (USMLE) scores.We sought to determine the correlation of these parameters with a candidate’s final rank on a residencyprogram’s rank order list.Methods: We used a retrospective cohort design to examine 129 candidate packets from an EMresidency program. Class ranks were assessed according to the instructions provided by the students’medical schools. EM grades were scored from 1 (honors) to 5 (fail). Global assessments noted on the standardized letter of recommendation (SLOR) were scored from 1 (outstanding) to 4 (good). USMLEscores were reported as the candidate’s 3-digit scores. Spearman’s rank correlation coefficient wasused to analyze data.Results: Electronic Residency Application Service packets for 127/129 (98.4%) candidates wereexamined. The following parameters correlated positively with a candidate’s final placement on therank order list: EM grade, q¼0.379, P , 0.001; global assessment, q¼0.332, P , 0.001; and classrank, q¼0.234, P¼0.035. We found a negative correlation between final placement on the rank orderlist with both USMLE step 1 scores, q¼0.253, P¼0.006; and USMLE step 2 scores, q¼0.348, P¼0.004.Conclusion: Higher scores on EM rotations, medical school class ranks, and SLOR globalassessments correlated with higher placements on a rank order list, whereas candidates with higherUSMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that otherfactors may influence a candidate’s final ranking. [West J Emerg Med. 2012;13(6):458–462.

Salmonella Urinary Tract Infection Heralding Thoracic Mycotic Aneurysm: Case Report as Medical Apology

We report a case as a patient apology as a means of teaching other physicians about a unique presentation of a rare disease. Salmonella species are unusually isolated organisms in urine. In the case described, appreciation for the rarity of Salmonella species in the urine facilitated recognition of a serious disseminated Salmonella infection. Physicians should consider disseminated Salmonella infection, as was found in a patient with an aortic mycotic aneurysm, after isolation of Salmonella in urine despite an initially benign clinical presentation

Factors Affecting Candidate Placement on an Emergency Medicine Residency Program's Rank Order List

INTRODUCTION: Several factors influence the final placement of a medical student candidate on an emergency medicine (EM) residency program’s rank order list, including EM grade, standardized letter of recommendation, medical school class rank, and US Medical License Examination (USMLE) scores. We sought to determine the correlation of these parameters with a candidate’s final rank on a residency program’s rank order list. METHODS: We used a retrospective cohort design to examine 129 candidate packets from an EM residency program. Class ranks were assessed according to the instructions provided by the students’ medical schools. EM grades were scored from 1 (honors) to 5 (fail). Global assessments noted on the standardized letter of recommendation (SLOR) were scored from 1 (outstanding) to 4 (good). USMLE scores were reported as the candidate’s 3-digit scores. Spearman’s rank correlation coefficient was used to analyze data. RESULTS: Electronic Residency Application Service packets for 127/129 (98.4%) candidates were examined. The following parameters correlated positively with a candidate’s final placement on the rank order list: EM grade, ρ = 0.379, P < 0.001; global assessment, ρ = 0.332, P < 0.001; and class rank, ρ = 0.234, P = 0.035. We found a negative correlation between final placement on the rank order list with both USMLE step 1 scores, ρ = −0.253, P=0.006; and USMLE step 2 scores, ρ = −0.348, P = 0.004. CONCLUSION: Higher scores on EM rotations, medical school class ranks, and SLOR global assessments correlated with higher placements on a rank order list, whereas candidates with higher USMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that other factors may influence a candidate’s final ranking

Headache in Pregnancy: An Approach to Emergency Department Evaluation and Management

Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy [West J Emerg Med. 2015;16(2):291–301.