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Computed tomography (CT) is the diagnostic standard in Emergency Department evaluation of suspected renal colic but delivers substantial radiation. We determined the frequency of CT scan in suspected renal colic, diagnosis and outcome, and cumulative CT scans per patient. A retrospective chart review with waiver of informed consent was conducted. A total of 356 patient encounters were reviewed from January to October 2003. Mean age was 39 years. Seventy-four percent included a CT scan, with 38% normal, 58% showing urolithiasis, and 1% showing emergent etiologies. Six percent of patients undergoing CT were admitted for urolithiasis, and 6% had a urologic procedure within 7 days. Sixteen percent of patients did not have a CT scan, and 79% underwent two or more CT scans. Emergency Department patients presenting with symptoms suggesting renal colic are likely to undergo CT on multiple occasions. Radiation exposures from repeated CT scans are substantial, and a clinical decision rule for this scenario is needed.

The disparities in health care and health outcomes between the majority population and cultural and racial minorities in the United States are a problem that likely is influenced by the lack of culturally competent care. Emergency medicine and other primary-care specialties remain on the front lines of this struggle because of the nature of their open-door practice. To provide culturally appropriate care, health care providers must recognize the factors impeding cultural awareness, seek to understand the biases and traditions in medical education potentially fueling this phenomenon, and create a health care community that is open to individuals' otherness, thus leading to better communication of ideas and information between patients and their health care providers. This article highlights the rationale for and current problems in teaching cultural competency and examines several different models implemented to teach and promote cultural competency along the continuum of emergency medicine learners. However, the literature addressing the true efficacy of such programs in leading to long-lasting change and improvement in minority patients' clinical outcomes remains insufficient.

Background The effect of resident work-hour restriction on patient outcome remains controversial. Methods Demographic data, mechanism of injury, length of hospital stay length of intensive care unit (ICU) stay, ventilator days, mortality, and complication data were prospectively collected for 11 months before and 11 months after institution of a rotating night-float system. Seven attending surgeons reviewed all complications and categorized each as preventable, potentially preventable, or nonpreventable. Results Both study periods were comparable with respect to demographic data, mean Injury Severity Score, mechanism of injury, and admissions. Limitation of resident work hours had no effect on length of hospital or ICU stay, ventilator days, or mortality. Work-hour restrictions did not increase or decrease the total number of complications nor did it alter the distribution of those determined to be preventable or potentially preventable. Conclusions Resident work-hour restrictions were not associated with significant improvement or deterioration in patient outcome.

n o s i f p c i b t t p w t m c r a f r s w a r s d t c q w s s s i f t u besity is a complex, multifactorial chronic disease involving nvironmental (social and cultural), genetic, physiologic, metbolic, behavioral, and psychological components. Responsible or greater than 300,000 deaths per year, it is second only to obacco abuse as the leading cause of preventable death in the nited States. Approximately 127 million adults in the United tates are overweight (BMI 25), 60 million are obese (BMI 30), and 9 million are severely obese (BMI 40). The verall prevalence of obesity has geometrically increased from 2.8% in 1962 to 30.5% in 2000. Although the prevalence of verweight is higher in men (67%) than women (62%), obesity nd severe obesity are more prevalent in women (34% vs 27.7% nd 6.3% vs 3.1%, respectively). The comorbidities of obesity re numerous and affect nearly every organ system: cardiovasular (eg, essential hypertension, coronary artery disease, left entricular hypertrophy), central nervous system (eg, stroke, diopathic intracranial hypertension), gastrointestinal (eg, choecystitis, cholelithiasis, fatty liver infiltration), respiratory (eg, bstructive sleep apnea, obesity hypoventilation syndrome, sthma), psychologic (eg, social stigmatization, depression), orhopedic (eg, osteoarthritis), metabolic (eg, insulin resistance, iabetes mellitus, dyslipidemia), reproductive (eg, anovulation, arly puberty), cutaneous (eg, intertrigo, hirsutism), and exremities (eg, varicosities, edema). In addition, obese patients re at an increased risk for complications at the time of surgery nd postoperatively, including myocardial infarction, deep veous thrombosis, pulmonary embolism, pneumonia, and ound infections. The concept for a surgical procedure to treat obesity was eveloped from the results of cancer and ulcer procedures. Paients that had large portions of their stomachs or small intesines removed were observed to experience significant postoprative weight loss. In the mid-1950s, Linnear et al started reating artificial malabsorbtion syndromes. They used intesti

The present study prospectively evaluated adjunctive antiplatelet therapy in patients without insulin-requiring diabetes during elective coronary stenting. Three hundred patients were randomized to one of three treatment groups: clopidogrel pretreatment, adjunctive abciximab, or control. Stenting was successful in 98% and no deaths occurred. Thirty-day and 1-year major adverse coronary events (MACEs) was similar in all groups. A subgroup of 109 patients undergoing single-vessel stenting of type A/B1 lesions with short guidewire times had no postprocedure myocardial infarction or 30-day MACE. We conclude that patients with these characteristics may safely undergo elective coronary stenting without adjunctive antiplatelet therapy.

The purpose of this study was to determine if closure of the femoral artery access site using a percutaneous arterial suture device (Perclose, Menlo Park, CA) in patients undergoing coronary stenting can result in the same benefits as seen with radial artery access. A total of 218 consecutive patients underwent coronary stenting (109 femoral, 109 radial) by investigators experienced with each technique. The two groups were matched in terms of sex, age, clinical presentation (50% acute), number of vessels and lesions stented, and lesion morphology. The relative costs of the femoral and radial procedures were examined using a decision analytic model and sensitivity analysis. The suture device was not used in 20/109 patients (18%) for anatomic reasons and failed to obtain hemostasis in 9/89 patients (10%). One radial patient had an occluded radial artery postprocedure, but this was recanalized at follow-up a month later. Primary success, procedural complications, postprocedure length of stay, and the percentage of patients discharged the same day were the same in both groups. Because of the added time to deploy Perclose, total procedure time was significantly longer in the femoral group (57 ± 22 min femoral vs. 44 ± 22 min radial, P < 0.01). Access site complications occurred only in the femoral group. More patients were ambulatory the same day of the procedure in the radial group (95% radial vs. 56% femoral, P < 0.01). The cost of the radial approach was substantially less than the femoral approach because of lower supply costs and fewer access complications. The transradial approach is a dominant strategy for coronary stenting, offering better outcomes at lower cost. Cathet. Cardiovasc. Intervent. 49:150–156, 2000. © 2000 Wiley-Liss, Inc.

Objectives. The purpose of the present study was to compare the radial approach with the femoral approach for coronary stenting in patients with acute coronary syndromes.Background. Aggressive anticoagulation in patients with acute coronary syndromes increases the risk of femoral vascular complications. The transradial approach has the potential to significantly reduce the incidence of access site bleeding complications in this group of patients.Methods. One hundred forty-two patients with acute coronary syndromes undergoing coronary stenting were prospectively randomized to have their procedure performed from either the radial or femoral access site and the results compared.Results. Nine of 74 patients randomized to the radial group crossed over to the femoral group (6 negative Allen tests, 3 access failures). Patient demographics were the same in both groups. Primary success was identical: 96% radial, 96% femoral, ns. There were no procedural myocardial infarctions or deaths, and no patient was referred for emergency bypass surgery. There were no access site bleeding complications in the radial group as opposed to 3 (4%) in the femoral group, p < 0.01. Postprocedure length of stay, days (1.4 ± 0.2 radial vs. 2.3 ± 0.4 femoral, p < 0.01) as well as total hospital length of stay (3.0 ± 0.3 radial vs. 4.5 ± 0.5 femoral, p < 0.01) were significantly reduced in the radial group. Total hospital charge was also significantly lower in the radial group ($20,476 ± 811 radial versus $23,389 ± 1,180 femoral, p < 0.01).Conclusion. Coronary stenting from the radial approach is efficacious in patients with acute coronary syndromes. Access site bleeding complications are less, and early ambulation results in a shorter hospital length of stay. There was a 15% reduction in total hospital charge in the radial group.

To evaluate self-reports of prehospital providers' error frequency, disclosure, and reporting in their actual practice and in hypothetical scenarios.The authors surveyed a convenience sample of prehospital providers attending a statewide emergency medical services conference using a two-part instrument. Part 1 evaluated respondent demographics and actual practice patterns. Part 2 used hypothetic scenarios to assess error identification, disclosure, and reporting patterns. Descriptive statistics and Fisher's exact tests were used to characterize demographics and practice patterns. For hypothetical scenarios, the authors calculated mean responses with 95% confidence intervals (CIs) to assess error identification, anticipated disclosure, and reporting patterns.The response rate was 88% (372/425). Analysis was limited to 283 (75% of 372) respondents who were emergency medical technicians and had complete data. In the previous year, 157 (55%) providers identified no errors in practice, 100 (35%) reported one or two errors, and 26 (9%) identified more than two errors. In approximately half of cases, identified errors were reported to the receiving provider, or supervisor. In hypothetical cases, severe errors were identified 93% (95% CI 92-94) of the time, but the ability of providers to identify mild errors significantly varied. In all scenarios, respondents were much more likely to report errors to the receiving hospital, their supervisor, and their medical director than to patients.Prehospital providers demonstrate the capacity to identify, report, and, to a lesser extent, disclose errors in hypothetical scenarios but may not apply these skills uniformly in their own practices. Enhancing error management skills in prehospital clinical practice will require focused education and training.