Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Comparative Study
Disagreement between emergency physician and inpatient physician diagnosis of infection in older adults admitted from the emergency department.
Older adults with infection are at increased risk of misdiagnosis while they are patients in the emergency department (ED) due to the common presence of nonspecific signs and symptoms. The primary objective was to determine the proportion of admitted older adult patients thought by the emergency physician (EP) to be infected, as compared with the diagnostic impression of inpatient physicians. The secondary objective was to determine the agreement between EP and inpatient physician diagnosis of specific infection types. ⋯ In older patients admitted from the ED, the provisional ED diagnosis and the inpatient diagnosis of an acute infection often disagree. In this sample, 18% of older ED patients diagnosed with infection during an ED stay were not diagnosed as infected by the inpatient physician. Regarding infection types, EPs were poor at diagnosing bacteremia and overdiagnosed pulmonary infections. EP diagnosis of skin and soft tissue infection generally agreed with the inpatient physician. There was also disagreement regarding presence of UTI, but the true nature of this difference is unclear from the data obtained in this study.
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The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases. ⋯ The clinical practice guideline performed well in a general teaching hospital. Rates of negative appendectomy and missed appendicitis were low and 58% of patients were managed without a CT scan.
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Randomized Controlled Trial
The effect of weight-based volume loading on the inferior vena cava in fasting subjects: a prospective randomized double-blinded trial.
Inferior vena cava ultrasound (IVC-US) assessment has been proposed as a noninvasive method of assessing volume status. Current literature is divided on its ability to do so. The primary objective was to compare IVC-US changes in healthy fasting subjects randomized to either 10 or 30 mL/kg of intravenous (IV) fluid administration versus a control group that received only 2 mL/kg. ⋯ Overall, there were statistically significant differences in mean IVC-US measurements before and after fluid loading, but not between groups. Fasting asymptomatic subjects had a wide intersubject variation in both baseline IVC-US measurements and fluid-related changes. The degree of IVC-US change in association with graded acute volume loading was not predictably proportional between our subjects.
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Reflection is a cognitive process in which new information and experiences are integrated into existing knowledge structures and mental models, resulting in meaningful learning. Reflection often occurs after an experience is over, promoting professional development and lifelong learning. However, a reflective emergency physician (EP) is also able to apply reflection in real time: self-monitoring, coping with the unexpected, and quickly thinking on his or her feet to solve complicated, unique, and challenging clinical problems. ⋯ Evidence demonstrating the value of teaching reflection is emerging that substantiates longstanding educational theories. While a few educators have started to explore the use of reflection for emergency medicine (EM) learners, the potential for broader application exists. This review summarizes the literature regarding reflection in medical education and provides a basic primer for teaching reflection.
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The objective was to determine the association of four clinical risk scores and coronary plaque burden as detected by computed tomography (CT) with the outcome of acute coronary syndrome (ACS) in patients with acute chest pain. The hypothesis was that the combination of risk scores and plaque burden improved the discriminatory capacity for the diagnosis of ACS. ⋯ Risk scores (Goldman, Sanchis, TIMI) have modest discriminatory capacity and coronary plaque burden has good discriminatory capacity for the diagnosis of ACS in patients with acute chest pain. The combined information of risk scores and plaque burden significantly improves the discriminatory capacity for the diagnosis of ACS.