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MicroRNAs (miRNAs) have recently emerged as an important new class of cellular regulators that control various cellular processes and are implicated in human diseases, including cancer. Here, we show that loss of let-7 function enhances lung tumor formation in vivo, strongly supporting the hypothesis that let-7 is a tumor suppressor. Moreover, we report that exogenous delivery of let-7 to established tumors in mouse models of non-small-cell lung cancer (NSCLC) significantly reduces the tumor burden. These results demonstrate the therapeutic potential of let-7 in NSCLC and point to miRNA replacement therapy as a promising approach in cancer treatment.

Background: Emergency departments (EDs) are traditionally designed to provide rapid evaluation and stabilization and are neither staffed nor equipped to provide prolonged care. Longer ED length of stay (LOS) may compromise quality of care and contribute to delays in the emergency evaluation of other patients. Objectives: The objective was to determine whether ED LOS increased between 2001 and 2005 and whether trends varied by patient and hospital factors. Methods: This was a retrospective analysis of a nationally representative sample of 138,569 adult ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2001 to 2005. ED LOS was measured from registration to discharge. Results: Median ED LOS increased 3.5% per year from 132 minutes in 2001 to 154 minutes in 2005 (p-value for trend

We read with interest the letter from Dr Bouzas-Mosquera about our published article.1 We appreciate both his comments and the opportunity to respond. We used a subjective assessment of the pretest probability of acute coronary syndrome (ACS) by the emergency department (ED) caregiver because it incorporates into a single metric all of the data available to decision makers before imaging. Its limitation is that it is too insensitive to use to discharge ED patients directly home without further testing for ACS. It was used because no well established, universally accepted, and validated risk score exists that can be applied to undifferentiated ED populations with chest pain. …

Objectives Cardiac multidetector computed tomography (CMCT) has potential to be used as a screening test for patients with acute chest pain, but several tools are already used to risk-stratify this population. Risk models exist that stratify need for intensive care (Goldman), short-term prognosis (Thrombolysis in Myocardial Infarction, TIMI), and 1-year events (Sanchis). We applied these cardiovascular risk models to candidates for CMCT and assessed sensitivity for prediction of in-hospital acute coronary syndrome (ACS). We hypothesized that none of the models would achieve a sensitivity of 90% or greater, thereby justifying use of CMCT in patients with acute chest pain. Methods We analyzed TIMI, Goldman, and Sanchis in 148 consecutive patients with chest pain, nondiagnostic electrocardiogram, and negative initial cardiac biomarkers who previously met inclusion and exclusion criteria for the Rule-Out Myocardial Infarction Using Coronary Artery Tomography Study. ACS was adjudicated, and risk scores were categorized based on established criteria. Risk score agreement was assessed with weighted κ statistics. Results Overall, 17 (11%) of 148 patients had ACS. For all risk models, sensitivity was poor (range, 35%-53%), and 95% confidence intervals did not cross above 77%. Agreement to risk-classify patients was poor to moderate (weighted κ range, 0.18-0.43). Patients categorized as "low risk" had nonzero rates of ACS using all 3 scoring models (range, 8%-9%). Conclusions Available risk scores had poor sensitivity to detect ACS in patients with acute chest pain. Because of the small number of patients in this data set, these findings require confirmation in larger studies.

E m b d p e e w T i u a d t o s l r. Emily Brown: Today’s case is that of a 10-year-old remenarchal girl, accompanied by her parents, who resented to the Emergency Department (ED) with a hief complaint of intermittent abdominal pain for the ast 7 days. The pain was primarily located in the lower bdomen. There was no increase in the pain after ingesion of food. The patient also complained of nausea and on-bilious and non-bloody vomiting, approximately wice per day. The patient’s parents reported that the ymptoms developed suddenly 7 days ago, persisted for days, then spontaneously remitted. She was asymptomtic for the following 2 days and was able to resume ormal summertime activities. However, 2 days before resentation, the abdominal pain recurred and has peristed since that time. Although the patient denied dysria, she reported difficulty urinating over the past week. he stated “I feel like I really have to push to get it out.” he patient described bloating and said that her pants had ot been fitting well over the past week. The patient enied fevers, chills, sick contacts, or recent travel. She enied melena, diarrhea, or constipation. The last bowel ovement was the day before presentation and was ormal. The past medical history was unremarkable and imunizations were up to date. The patient was not taking ny medications and had no known drug allergies. She ives with her parents and younger brother in the suburbs f Boston and is active in summer sports. Dr. David Peak: The differential diagnosis of abominal pain in a female can be broad. How did you use he initial history to narrow your differential? Dr. E. Brown: The most important factor in narrowng the differential was the intermittent nature of her ymptoms. Several life-threatening disease processes, w

Background— Cardiac magnetic resonance (CMR) imaging permits early triage of patients presenting to the emergency department with acute chest pain but has been limited by the inability to differentiate new from old myocardial infarction. Our objective was to evaluate a CMR protocol that includes T2-weighted imaging and assessment of left ventricular wall thickness in detecting patients with acute coronary syndrome in the emergency department. Methods and Results— In this prospective cohort observational study, we enrolled patients presenting to the emergency department with acute chest pain, negative cardiac biomarkers, and no ECG changes indicative of acute ischemia. The CMR protocol consisted of T2-weighted imaging, first-pass perfusion, cine function, delayed-enhancement magnetic resonance imaging, and assessment of left ventricular wall thickness. The clinical outcome (acute coronary syndrome) was defined by review of clinical charts by a consensus panel that used American Heart Association/American College of Cardiology guidelines. Among 62 patients, 13 developed acute coronary syndrome during the index hospitalization. The mean CMR time was 32±8 minutes. The new CMR protocol (with the addition of T2-weighted and left ventricular wall thickness) increased the specificity, positive predictive value, and overall accuracy from 84% to 96%, 55% to 85%, and 84% to 93%, respectively, compared with the conventional CMR protocol (cine, perfusion, and delayed-enhancement magnetic resonance imaging). Moreover, in a logistic regression analysis that contained information on clinical risk assessment (c-statistic=0.695) and traditional cardiac risk factors (c-statistic=0.771), the new CMR protocol significantly improved the c-statistic to 0.958 ( P Conclusions— The present study indicates that a new CMR protocol improves the detection of patients with acute coronary syndrome in the emergency department and adds significant value over clinical assessment and traditional cardiac risk factors.

Q a a r. Pooja Agrawal: Today’s case is that of a 64-year-old oman who was brought in to the Emergency Department y Emergency Medical Services after an apparent suiide attempt. The patient was upset that her husband was till communicating with his ex-wife, who lived in their uilding. After being involved in a verbal altercation ith this woman, the patient stated that she wanted to ie, and subsequently ingested a handful of pills. After uestioning, it was determined that she had taken over 40 ills of 50 mg nortriptylene 2 h before presenting to the mergency Department. She denied ingesting anything lse. She was, at this point, asymptomatic. The past medical history was significant for depresion, hypertension, type 2 diabetes, and mild chronic bstructive pulmonary disease. She had no personal hisory of syncope or coronary disease. The family history as non-contributory; there was no history of sudden nexplained death. Medications included aspirin, chloriazepoxide, hydrochlorthiazide, lisinopril, metformin, someprazole, nortriptyline, tramadol, and simvastatin. here were no recent fevers, illnesses, or trauma. Vital signs were: temperature 36.4°C (97.5°F), heart ate 95 beats/min, blood pressure 160/72 mm Hg, respiatory rate 16 breaths/min, and oxygen saturation 95% on oom air. Initially, the patient appeared agitated and onfused, and subsequently became more somnolent ith shallow breathing. Physical examination revealed o evidence of head injury. Pupils were equal, round, and eactive to light. The neck was supple without meningeal igns. Heart sounds were rapid and regular with no urmurs, rubs, or gallops. The lungs were clear bilaterally o auscultation. The abdomen was soft, with no distenion, tenderness, or guarding. Extremities were warm and ry without rash or swelling. There were no track marks. a

*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Founders 114, Boston, MA 02114

MicroRNAs play important roles in animal development, cell differentiation, and metabolism and have been implicated in human cancer. The let-7 microRNA controls the timing of cell cycle exit and terminal differentiation in Caenorhabditis elegans and is poorly expressed or deleted in human lung tumors. Here, we show that let-7 is highly expressed in normal lung tissue, and that inhibiting let-7 function leads to increased cell division in A549 lung cancer cells. Overexpression of let-7 in cancer cell lines alters cell cycle progression and reduces cell division, providing evidence that let-7 functions as a tumor suppressor in lung cells. let-7 was previously shown to regulate the expression of the RAS lung cancer oncogenes, and our work now shows that multiple genes involved in cell cycle and cell division functions are also directly or indirectly repressed by let-7. This work reveals the let-7 microRNA to be a master regulator of cell proliferation pathways. [Cancer Res 2007;67(16):7713–22]

We thank Dr Hamon and colleagues1 for their interest in our work. We agree that our data demonstrate that both the absence of coronary artery plaque or stenosis on noninvasive coronary multidetector computed tomography (MDCT) angiography has high negative predictive value for the subsequent diagnosis of acute coronary syndrome. However, as …

To describe and test a model that compares the accuracy of data gathered prospectively versus retrospectively among adult emergency department patients admitted with chest pain.The authors developed a model of information flow from subject to medical record to the clinical study case report form, based on a literature review. To test this model, a bidirectional (prospective and retrospective) study was conducted, enrolling all eligible adult patients who were admitted with a chief complaint of chest pain. The authors interviewed patients in the emergency department to determine their chest pain history and established a prospective database; this was considered the criterion standard. Then, patient medical records were reviewed to determine the accuracy and completeness of the information available through a retrospective medical record review.The model described applies the concepts of reliability and validity to information passed on by the study subject, the clinician, and the medical record abstractor. This study was comprised of 104 subjects, of which 63% were men and the median age was 63 years. Subjects were uncertain of responses for 0-8% of questions and responded differently upon reinterview for subsets of questions 0-30% of the time. The sensitivity of the medical record for risk factors for coronary artery disease was 0.77 to 0.93. Among the 88 subjects (85%) who indicated that their chest pain was substernal or left chest, the medical record described this location in 44%. Timing of the chest pain was the most difficult item to accurately capture from the medical record.Information obtained retrospectively from the abstraction of medical records is measurably less accurate than information obtained prospectively from research subjects. For certain items, more than half of the information is not available. This loss of information is related to the data types included in the study and by the assumptions that a researcher performing a retrospective study makes about implied versus explicitly stated responses. A model of information flow that incorporates the concepts of reliability and validity can be used to measure some of the loss of information that occurs at each step along the way from subject to clinician to medical record abstractor.

Background: To determine, among patients who present to the emergency department with symptoms suggestive of acute coronary syndrome (ACS), predictors of short-term revascularization. Methods: A prospective descriptive trial was performed. Potential predictors for revascularization were measured by means of a questionnaire of providers, serum for cardiac biomarkers, and an initial ECG. The primary outcome of revascularization (coronary bypass graft or percutaneous intervention) was determined through a medical record review. Potential predictors of revascularization were entered into a family of logistic regressions. Results: 341 eligible subjects were enrolled, of whom 14% underwent revascularization. The predictors of revascularization included ST elevation on initial ECG (odds ratio 12.0), and an elevation in troponin I (odds ratio 8.9), CKMB (odds ratio 6.8), or myoglobin (odds ratio 4.7) on admission. When all three biomarkers competed in the same model, troponin I appeared to be the strongest predictor of short-term revascularization. Conclusion: In a single site study, among emergency department patients with symptoms suggestive of ACS, ST elevation on initial ECG and an elevation in troponin I, CK-MB, and myoglobin upon presentation all predicted short -term revascularization. Among the three biomarkers, elevation in troponin I was the strongest predictor. Abbreviated Abstract. We conducted a prospective descriptive trial to identify predictors of short-term revascularization among 341 emergency department patients who presented with symptoms suggestive of ACS. Fourteen percent of the study population received revascularization. Predictors of revascularization included ST elevation on initial ECG (odds ratio 12.0.), and an elevation in troponin I (odds ratio 8.9), CKMB (odds ratio 6.8), or myoglobin (odds ratio 4.7) on admission. When all three biomarkers competed in the same model, troponin I appeared to be the strongest predictor of short-term revascularization.

OBJECTIVES To measure agreement between formal and medical record criteria for the diagnosis of acute coronary syndrome (ACS) among patients undergoing an emergency department evaluation for potential acute coronary symptoms. METHODS Cases of ACS were determined by both formal (World Health Organization 1984 criteria for acute myocardial infarction [AMI], Braunwald criteria for unstable angina pectoris [UAP]) and medical record criteria. In the latter, a diagnosis was made if providers indicated AMI or UAP anywhere in the medical record. All information included in formal criteria was available to clinicians establishing the medical record diagnosis. The two criteria for diagnosis were compared, and a kappa value was recorded. Two blinded observers adjudicated discordant cases, with a kappa value recorded. Disagreements between these two coinvestigators were resolved by a Delphi technique. RESULTS A total of 375 eligible subjects were enrolled, of whom 65 (17%; 45 AMI, 20 UAP) had ACS by both sets of criteria. Formal and medical record criteria disagreed in 32 subjects. This represented 9% (95% confidence interval = 6% to 12%) of the overall study population but 33% (95% confidence interval = 23% to 43%) of subjects with possible ACS. Coinvestigators acting as judges and blinded to each other's determinations agreed that 25 of these subjects had ACS and three did not; they disagreed on four subjects (kappa = 0.54). Among these four subjects, a Delphi consensus technique determined that two subjects had AMI and two had no ACS. CONCLUSIONS In a single-site study, among subjects who have possible ACS as determined by either or both formal and medical record criteria, these two sets of criteria disagree in almost one third of cases. Among discordant cases, even two expert judges frequently disagreed on the final diagnosis. A modified Delphi technique to address these disagreements is described.

w s t t r. Calvin Brown: Today’s case is that of a 17-year-old outh who presented to the Emergency Department (ED) ith complaints of abdominal pain and difficulty breathng after sustaining knife stab wounds to the anterior bdominal and lower chest regions. The patient was ssaulted by an unknown assailant and reportedly had bdominal contents protruding through his abdominal all. The patient was found by Emergency Medical ervices (EMS) personnel to be awake, alert, and in bvious discomfort. Vital signs at the scene were: blood ressure 140/78 mm Hg, pulse 115 beats/min, and resirations 30 breaths/min. The patient was transported by MS without incident. Upon arrival in the ED the patient as combative and had one episode of blood-tinged mesis. The past medical history was significant only for sthma. The patient did not take any medications or have ny medication allergies. Is there any other information ou would like to know about the history? Dr. Alex Manini: Was there any further information bout the scene? Was there a lot of blood seen or was a eapon found? Dr. C. Brown: There was minimal blood loss at the cene and although the weapon was not found, the paient estimated a blade length of 5 inches. The initial vital igns in the ED were: blood pressure of 138/80 mm Hg, eart rate 120 beats/min, respiratory rate 32 breaths/min, nd oxygen saturation 91% on room air. The primary urvey revealed a patent airway and symmetric breath

a b m H T m T a v r r. Morris Rivera: Today’s case is that of a 50-year-old an who presented to the emergency department (ED) ith a complaint of chest pain. He was running the oston marathon when at the 10-mile mark he began to evelop discomfort in his chest and shoulders with acompanying dyspnea. His symptoms improved with oderation of exertion, allowing him to finish the race ver a considerably longer period of time than in previus attempts. After crossing the finish line he presented o the first aid booth, where he was given oxygen and valuated by emergency medical services (EMS). hortly after his arrival there the patient reported resoution of his symptoms. The EMS providers noted a middle-aged man who ppeared diaphoretic and in moderate respiratory disress, with a systolic blood pressure of 70 mm Hg and an lectrocardiogram (EKG) notable for ST segment elevaions in leads V1–V5. He was given aspirin and transorted to the ED. At the time of arrival in the ED, the patient reported o further chest pain, which he had characterized as a ightness, limited in duration to the latter half of the arathon. The patient reported excellent baseline exerise tolerance, running approximately 10 miles every ther day. Past medical history was significant for hyertension and hypothyroidism, for which he took lisinpril and levothyroxine. The patient recalled being told y his primary care physician of having an “abnormal” KG.

Introduction: Although proper analgesia provision for patients in the in hospital acute setting has received recent attention, little discussion has been done of prehospital pain relief. This study was conducted to evaluate the safety of fentanyl administration during air medical transport of adult trauma patients. Setting: Urban air medical transport program using a flight nurse/paramedic crew operating with patient care protocols and off-line medical control. Methods: Flight records for trauma patients transported directly from the scene receiving fentanyl were analyzed retrospectively. Study parameters were obtained for the times just preceding and after fentanyl administration. A t test (α = 0.05) comparison between before and after fentanyl administration was performed for the following study parameters: systolic blood pressure, heart rate, oxygen saturation, respiratory rate, and Glasgow coma score in non-intubated patients. Flight records were also reviewed for any administration of naloxone or subjective notation of complications possibly attributable to fentanyl. Results: Fentanyl was administered 154 times to 99 patients. No patient received in-flight naloxone, and no fentanyl-related complications were noted on flight record review. Conclusion: Administration of fentanyl for in-flight trauma analgesia in adults seems safe. Further study should investigate efficacy of in-flight fentanyl administration and determine whether prehospital opiate administration impairs emergency department evaluation of trauma patients.

c t t t t r. David Brown: Today’s case is that of a 70-year-old oman who presented to the Emergency Department ED) with chest pain. She was awakened from sleep at :30 a.m. on the day before admission with chest and pigastric burning that was severe and associated with ausea, diaphoresis, and mild dyspnea. The symptoms ersisted for 90 min and then resolved. She went back to leep until later that morning when she awoke again with hest burning. These symptoms disappeared after 15–20 in and recurred several more times that day. When she woke the next morning and the symptoms of chest and pigastric burning recurred and persisted for 90 min, she ame to the ED. There was no further dyspnea, nausea, r diaphoresis. There was no radiation of the pain, which as non-pleuritic. There was no dizziness or palpitaions. There was no back pain or lower abdominal pain. he had no known history of cardiovascular or gastroinestinal disease. Her past medical history was notable for ype II diabetes mellitus and hypertension. There was no amily history of coronary artery disease. She was a ormer smoker who quit 5 years ago; she used only ccasional alcohol. Her medications were glyburide and isinopril. She had no drug allergies. Are there any quesions regarding the history? Dr. Nathan Mick: In retrospect, over the past several eeks had the patient noted any exertional dyspnea, hest or epigastric pain? Dr. Brown: She could not recall any prior similar

*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, ‡Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and §Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Eric S. Nadel, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115

m h p b w e e ( s t r. Peter Pang: Today’s case is that of a 54-year-old oman who presented to the Emergency Department ED) in respiratory distress. Paramedics were called for hortness of breath and weakness. At the scene the paient complained of worsening shortness of breath hroughout the day, increasing significantly over the past our, and generalized weakness over the past week. ccording to the paramedics, the patient denied chest, ack, or abdominal pain. There were no fevers, chills, ausea, vomiting or diarrhea. The past medical history ncluded depression and a pulmonary embolism (PE). ital signs in the field were: blood pressure 104/60 mm g, heart rate 70 beats per minute (bpm), and respiratory ate 24 breaths per minute. During transport, the patient ecame increasingly short of breath and lethargic. Upon rrival in the ED, the patient deteriorated rapidly. She ad clear lungs, a slow regular heart rate, soft abdomen, nd bilateral lower extremity edema. The patient was ethargic, minimally responsive to verbal stimuli, and oving all four extremities. During transport from the aramedics’ gurney to the hospital stretcher, the patient’s espiratory effort ceased, and no pulses were palpable. Dr. Eric Nadel: Are there any questions about the nitial presentation? Dr. Emily Senecal: You mentioned the past medical istory included pulmonary embolism and depression. as the patient taking any medications? Were any pill ottles found in the house? Was there any family mem

Recurrence of persistent pulmonary hypertension of the newborn (PPHN) after successful extracorporeal membrane oxygenation (ECMO) therapy has been reported.1,2 Payne1 treated the recurrence of PPHN with conventional therapy, and two of his three patients recovered. De La Cruz2 reported using a second course of ECMO to treat a recurrence of pulmonary hypertension and respiratory failure of other origins in three patients. Two of the three infants survived. As of January 13, 1993, there were a total of 47 infants reported to the Extracorporeal Life Support Organization (ELSO) who had undergone a second course of ECMO.3 The two most common diagnoses among these infants were congenital diaphragrnatic hernia and PPHN.

Dr. Nathan Mick: Today’s case is that of a 6-month-old female presenting with decreased responsiveness. The patient was well until that morning when she was difficult to arouse from sleep. The patient’s mother noted that during the past week the child had begun to sleep through the night without waking. At 7:00 that morning when she went in to awaken the child and couldn’t, she assumed the child was “tired” and allowed her to remain sleeping. One hour later, she again had difficulty waking her daughter and called her pediatrician who urged her to have her daughter evaluated in the Emergency Department (ED). The mother reported that her daughter was an only child with no recent sick contacts and that the house contained no prescription medications. The child’s past medical history was notable for a normal term labor and vaginal delivery. There had been no significant illnesses. She was breast fed until 3 months of age and then transitioned to formula. The patient was cared for by her maternal grandmother during the daytime as her parents both worked outside the home. She had met normal developmental milestones to date. She was on no prescription medications, had no allergies, and was up to date on all immunizations including the pneumococcal vaccine. The patient lived with her mother and father, who had been married 5 years. Dr. Eric Nadel: Are there any questions about the initial history? Dr. Jessica Peters: Was there any history of trauma? Dr. Nathan Mick: The mother denied any history of trauma in the preceding week. The child was able to crawl but not walk and there were no stairs or other “high risk” areas in the home. The child’s initial vital signs were: pulse 140 beats/ minute, respiratory rate 30 breaths/minute, oxygen saturation 99%, temperature 37°C, and blood pressure 96/50 mm Hg. The physical examination revealed a well-developed, well-nourished 6-month-old lying quietly on a gurney. The skin examination revealed no petechiae or ecchymoses. The head and neck examinations revealed no signs of otitis media, trauma, nuchal rigidity, or pharyngitis. The pupils were normal, round and reactive. There was no respiratory distress and breath sounds were clear. The heart and abdominal examinations were normal. The child was listless with open eyes and very little movement of the extremities. She did not respond negatively to separation from her mother and did not respond to venipuncture and vascular access. Dr. Eric Nadel: Are there any questions regarding the physical examination? Dr. Todd Thomsen: Perhaps the most ominous finding on examination is the lack of response to “stimulation” via needle stick. Was this child protecting her airway? Dr. Nathan Mick: The child was handling her secretions without difficulty and was ventilating normally with a normal oxygen saturation, so immediate airway

Dr. Azita. G. Hamedani: Today’s case is that of a 67-year-old man who was transferred to our facility from an outside hospital for further evaluation of headache and visual change. The patient had no prior headache history and had been in his usual state of good health until 2 weeks prior to presentation when he developed sudden onset of a sharp, right-sided headache. He initially rated the headache as an 8 out of 10, and stated it was his “worst headache.” The headache subsequently lessened in intensity without any specific intervention. Dr. Eric S. Nadel: At this point, what diagnoses are most concerning? Dr. Hamedani: Sudden onset of “worst headache” is very concerning for a subarachnoid hemorrhage. More than 10% of neurologically intact patients with the “worst headache” are subsequently found to have subarachnoid hemorrhages (1). Furthermore, at least 20% of patients with subarachnoid hemorrhages have an unusually severe “sentinel headache” in the days to weeks prior to their index hemorrhage (2). Also concerning is the diagnosis of temporal arteritis, as patients classically develop headaches and associated visual changes. Partial or complete permanent unilateral visual loss occurs in 20% of patients, and often is an early manifestation of the disease. Left untreated, the contralateral eye is often involved within the subsequent 2 weeks (3). Dr. David F. M. Brown: As you mentioned, the headache started 2 weeks ago. Did the patient seek any interim medical care? Dr. Hamedani: Several days after the onset of his headache, the patient saw his primary care physician (PCP). An outpatient computed tomography (CT) scan of the head was completed, and read as negative for intracranial pathology. After several more days, the patient noted his right-sided headache now to be associated with right eye aching. He denied any visual changes at this point. Because of his continued headache, the patient revisited his PCP. This time an outpatient magnetic resonance imaging (MRI) of the head was ordered. Soon after the completion of this study, the patient developed diplopia. His wife, a nurse, also noted new right-sided ptosis. The PCP was re-contacted, and the patient was advised to go to the nearest available Emergency Department (ED). As the Emergency Physicians learned, the preliminary read on the patients’ head MRI from earlier that day was negative for any intracranial pathology. Results of laboratory work done at the outside ED, including an erythrocyte sedimentation rate (ESR), were normal. At this point, the patient was transferred to our hospital for further evaluation of his new-onset ptosis and diplopia. Dr. Michelle Finkel: What further information do we have about this patient’s diplopia? Were there any other cranial nerve deficits? Dr. Hamedani: Upon arrival at our ED, the patient no

Dr. Martin Lucenti: Today’s case is that of a 46-yearold man with a history of aortic insufficiency, who was in his usual state of health when he developed shortness of breath while playing golf. He had associated mild chest discomfort, which he described as heaviness, and a sensation that his heart was racing. Shortly after the onset of these symptoms he developed a cough with bloody sputum. He became more short of breath and was brought to a community hospital by his friends. Vital signs upon presentation to the outside hospital were: temperature 36.4°C (97.6°F), blood pressure 198/68 mm Hg, heart rate 119 beats per minute, respiratory rate 25 breaths per minute, and oxygen saturation 90% on room air. The patient was described as mildly diaphoretic, sitting upright, and working hard to breath. The lung examination revealed bilateral crackles, and the heart was tachycardic with a question of a heart murmur. The patient was placed on a cardiac monitor, supplemental oxygen was administered, and an intravenous line was placed. Laboratory data showed a white blood cell count of 11.4 k/mm, hematocrit 42%, platelet count 331 k/mm, sodium 140 mmol/L, potassium 4.7 mmol/L, chloride 107 mmol/L, carbon dioxide 22.9 mmol/L, BUN 22 mg/dL, creatinine 1.0 ng/dL, and glucose 120 mg/dL. The electrocardiogram was interpreted as sinus tachycardia with left ventricular hypertrophy. The chest X-ray study showed bilateral infiltrates and cardiomegaly. The patient was given ceftriaxone 1 gram i.v., azithromycin 500 mg orally, and vancomycin 1 gram i.v. due to a concern for possible pneumonia. The patient developed worsened hypoxia at the community hospital and he was transferred to our Emergency Department (ED) for further evaluation. Dr. Eric Nadel: Are there any questions about the prehospital course? Dr. Nathan Mick: Was there consideration of etiologies other than pneumonia, including cardiac etiologies such as myocardial infarction or congestive heart failure (CHF)? Dr. Lucenti: It is unclear whether other etiologies were considered. There was no treatment administered for ischemic heart disease or CHF. Upon arrival in our ED, the patient was diaphoretic and in moderate respiratory distress, sitting upright, and speaking in 2–3 word phrases. He complained of palpitations but denied chest pain, abdominal pain, nausea and vomiting. The patient’s past medical history was significant for severe aortic insufficiency. He had an echocardiogram 1 year prior to presentation that showed a bicuspid aortic valve with moderate aortic insufficiency, normal right-sided heart function, left ventricular hypertrophy, and an ejection fraction of 65%. The patient also had a history of gastroesophageal reflux and hypercholesterolemia. The patient was taking nifedipine, omepra

OBJECTIVES To describe the non-traumatic clinical settings in which abdominal computed tomography (CT) is used and to determine its diagnostic utility. METHODS A retrospective descriptive study of consecutive non-traumatic adult patients who underwent abdominal CT in a university hospital emergency department (ED). Radiology reports and patient charts were reviewed. The indication for each CT was determined by two reviewers. Indications were described as specific (e.g. "rule-out" appendicitis) or non-specific (e.g. abdominal pain). CT results were classified as positive, negative (normal or no new information) or indeterminate (technical limitations). For those with specific indications, positive results were further subdivided into supportive (of the clinical suspicion) or non-supportive (abnormal but suggesting an alternative diagnosis). The clinical course and results of subsequent diagnostic procedures were used to confirm CT results for admitted patients. Incidental CT findings were recorded. RESULTS 177 patients were entered; mean age was 58 years; 48% were men. The most frequent indications ("rule-outs") were aortic disorders (23%), abscess (16%), and diverticulitis (14%). In patients with specific indications (n=160), 44% of the CT results supported the indication, 13% suggested an alternative diagnosis (non-supportive), 41% were negative, and 3% were indeterminate. In admitted patients (n=129), CT findings were contradicted in 6%. CONCLUSIONS Adult ED patients undergo abdominal CT for a variety of non-traumatic indications. Findings in less than half support the pre-test clinical suspicion and an alternative previously unsuspected diagnosis is suggested in 13%. Follow-up is inconsistent with CT results in a small but significant number of cases.

Once the diagnosis of deep venous thrombosis (DVT) has been established the focus shifts to management of the disease. The goals of acute treatment of DVT are several: arrest growth of the thrombus, dissolve or remove the thrombus, and prevent embolizations of the thrombus. Although these goals have remained constant, the initial management of DVT has undergone a series of evolutions during the past decade, affecting both acute treatment and disposition decisions. As this article discusses, emergency medicine is at the cutting edge of these changes.

Dr. David Brown: Today’s case is that of a 19-yearold man who presented to the Emergency Department complaining of palpitations. He was at a party when he became aware of his heart pounding. There was no chest pain, dyspnea, or syncope. He felt lightheaded but denied vertigo, visual changes, or focal weakness or numbness. He had no significant past medical history and had never felt palpitations before. He did not receive regular medical care. He smoked a pack of cigarettes daily and frequently used marijuana, alcohol, and cocaine. He denied any drug use, however, on the evening of presentation. Are there any questions about the history? Dr. Laura Bontempo: Did the patient have any fever or other recent illness? Dr. Eric Legome: Was he taking any medications? Dr. Brown: He reported several days of congestion and sore throat without any fever or cough. He was taking no medications except for an unidentified overthe-counter cold medicine preparation. Dr. J. Tobias Nagurney: If this is a dysrhythmia, there may be underlying familial heart disease. Was there any family history of cardiac problems, specifically dysrhythmias, syncope, or sudden death? Dr. Brown: The patient reported no family history of cardiovascular disease or sudden death. On physical examination, he was an anxious young man with the odor of alcohol on his breath. Vital signs revealed a temperature of 37.2°C (97.9°F), blood pressure of 118/70 mm Hg, pulse of 160 beats/min, respirations of 16 breaths/ min, and an oxygen saturation of 100% on room air. The head was atraumatic. The pupils were 5 mm bilaterally and reactive to light. The oropharynx was clear. The neck examination revealed equal carotid pulses and no jugular venous distention or thyromegaly. The chest was clear to auscultation. The left ventricular apical impulse was nondisplaced. The heart sounds were crisp with a tachycardic S1 and S2. There were no murmurs or gallops. The abdomen was flat, soft, and nontender; there were no masses, organomegaly, or bruits. Bowel sounds were present. Rectal examination revealed no masses and brown stool that was negative for occult blood. The extremities had full pulses with no cyanosis or edema. The skin was warm and dry without rashes. Neurologic examination revealed an anxious man with rapid speech and an otherwise clear mental status. Strength and sensation were normal; gait was not tested. Are there any questions about the physical examination? Dr. Theodore Benzer: Were there any track marks on the skin to suggest injection drug use? Dr. Brown: There were no needle marks on the skin noted. Are there any thoughts regarding the initial presentation or management of this patient? Dr. Eric Nadel: This is a stable tachycardia in a young man with a history of drug use who is also taking cold medicine that likely contains a sympathomimetic agent. His pupils are somewhat dilated and he is anxious and speaking rapidly. I am most concerned with a dysrhythmia because of cocaine or sympathomimetic drug intoxication. While you were performing your initial history and physical examination, the patient was undoubtedly placed on a cardiac monitor. What did this show? Dr. Brown: The monitor showed a wide complex

We reviewed reports from 321 consecutive emergency department (ED) noncontrast, helical “renal stone” abdominal CT scans obtained at a single medical center between April 1996 to June 1997 for incidental findings. Incidental findings were common (45% of scans), and approximately half were rated of “moderate” or “serious” concern by 2 independent reviewers (kappa = 0.72). ED records indicated that only 21% of incidental findings were documented, and only 11 (18%) of cases with findings of “moderate/severe” concern had evidence of follow-up on hospital chart review. Although work-up of these 11 cases did not yield any serious diagnoses, many potentially serious incidental findings without follow-up remain worrisome. (Am J Emerg Med 2001;19:479-481. Copyright © 2001 by W.B. Saunders Company)

This article investigates the use of bedside abdominal ultrasonography (BAU) performed by emergency physicians (EPs) to screen patients for cholelithiasis and cholecystitis. In this prospective study EPs performed BAU on 116 patients. Agreement between BAU and formal abdominal ultrasound (FUS) performed in the radiology department for detecting cholelithiasis and cholecystitis was determined using Kappa statistics. Test characteristics of BAU for detecting cholelithiasis and acute cholecystitis were calculated. Agreement between BAU and FUS was 0.71 for cholelithiasis and 0.46 for acute cholecystitis. Test characteristics of BAU for cholelithiasis were sensitivity 92%, specificity 78%, positive predictive value (PPV) 86%, negative predictive value (NPV) 88%. Test characteristics of BAU for acute cholecystitis compared with clinical follow-up were sensitivity 91%, specificity 66%, PPV 70%, NPV 90%. BAU may be used to exclude cholelithiasis and is sensitive for cholecystitis. However, when EPs with limited experience identify cholecystitis a confirmatory test is warranted before cholecystectomy.

Dr. Mark Sagarin: Today’s case is that of a 56-year-old man with alcoholism who presented with tremor and confusion. He reported feeling poorly for 1 week with subjective fever, cough productive of yellow sputum, decreased appetite, and decreased urine output. The past medical history was notable for a transient ischemic attack 1-year previously, alcohol abuse, and smoking. He took no medications regularly and had no drug allergies. He consumed approximately five quarts of beer and one package of cigarettes each day. He was homeless. He denied drug use or unprotected sexual activity. Dr. David Brown: Are there any questions about the patient’s initial presentation? Dr. Ted Benzer: Could he tell you when his last drink was, and was there any recent history of trauma? Dr. Sagarin: His last alcoholic beverage was 2 to 3 days previously, and he thought it was possible he had fallen and had struck his head but could not say definitively. Dr. Stephen Thomas: Did he arrive in the Emergency Department (ED) by ambulance? If so, can you describe his prehospital course? Dr. Sagarin: He was found seated on a park bench, slightly confused, by a bystander who activated 911. Prehospital providers found him alert but tremulous. Prehospital vital signs were: systolic blood pressure 140 mmHg, heart rate 115 beats/min, respiratory rate 20 breaths/min, oxygen saturation 93% on room air. Paramedics administered oxygen by 100% facemask, which increased his saturation to 99%. Blood sugar was 100 mg/dL. One 18-gauge intravenous (i.v.) line was established and thiamine 100 mg i.v. was administered. He was transported rapidly to the ED. On physical examination, he was alert but slightly confused. Vital signs were: temperature 40.3°C, blood pressure 133/81 mmHg, heart rate 120 beats/min, respiratory rate 20 breaths/min, oxygen saturation 93% on room air. Skin examination was normal. Cranial examination revealed no deformities or scalp lacerations. Tympanic membranes were obscured by impacted cerumen. Nasopharyngeal, midface, and mandibular examinations were unremarkable. Oral mucous membranes were dry. There was a small amount of dried blood on the anterior tongue and lower incisors. There was poor dentition but no dental injury. The neck was supple without jugular venous distension. There were no carotid bruits, enlarged nodes, or thyromegaly. Lung auscultation revealed diffuse crackles in the right lung field. Cardiac examination revealed a rapid, regular rhythm with no murmurs, rubs, or gallops. The abdomen was soft, nontender, nondistended, with no rebound, guarding, or masses. The rectum was nontender with soft heme-negative stool in the vault. Prostate examination was normal. Extremity examination revealed no cyanosis, clubbing or edema, and 21 pulses throughout. The patient was anxious, alert, and oriented to name, hospital, and season. He could not recall the date or United States president’s name. He had a slight resting tremor. His strength was 5/5 throughout

*Harvard Affiliated Emergency Medicine Residency, Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; †Department of Emergency Medicine, Massachusetts General Hospital; and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114