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Computed Tomography Coronary Angiography for Rapid Disposition of Low- risk Emergency Department Patients with Chest Pain Syndromes

Citation: Hollander JE, Litt HI, Chase M, et al. Acad Emerg Med. 2007;14(2):112-116.
Key point: CT coronary angiography may safely allow rapid dis- charge of patients with negative studies.
Patients with recent normal cardiac catheterization are at low risk for complications of ischemic chest pain. Computed tomography coronary angiography has high correlation with cardiac catheterization for detection of coronary stenosis. Therefore, the investigators’ emergency department incorporated CT coronary angiography into the evaluation of low-risk patients with chest pain.

Low-risk chest pain patients (Thrombolysis in Myocardial Infarction [TIMI] score of 2 or less) without acute ischemia on an electrocardiogram had CT coronary angiography performed in the ED. If the CT coronary angiography was negative, the patient was discharged home. The main outcomes were death and myocardial infarction within 30 days of ED discharge, as determined by telephone follow up and record review.

Of the 54 patients evaluated, after CT coronary angiography, 46 patients (85%) were immediately released from the ED, and none had cardiovascular complications within 30 days. Eight patients were admitted after CT coronary angiography: one had >70% stenosis, five patients had 50% to 69% stenosis, and two had 0–49% stenosis. Three patients had further noninvasive testing; one had reversible ischemia, and catheterization confirmed the results of CT coronary angiography. All patients were followed for 30 days, and none had an adverse event dur- ing index hospitalization or at 30-day follow up.

When used in the clinical setting for the evaluation of ED patients with low-risk chest pain, CT coronary angiography may safely allow rapid discharge of patients with negative studies.

MDCT in Early Triage of Patients with Acute Chest Pain

Citation: Hoffmann U, Pena AJ, Moselewski F, et al. Am J Roentgenol.  2006;187(5):1240-1247
URL: Key point: MDCT detection of coronary stenoses can greatly decrease unnecessary hospital admissions.
Current risk stratification of patients with acute chest pain but normal initial cardiac enzymes and nondiagnostic ECG is inefficient.

The authors sought to determine whether con- trast-enhanced multidetector computed tomography (MDCT)- based detection of stenosis is feasible and improves early and accurate triage of patients with acute chest pain.
The authors studied 40 patients (53% men; mean age, 57 ± 13 years) with chest pain who were awaiting hospital admission to rule out an acute coronary syndrome despite the absence of diagnostic ECG changes and normal cardiac enzymes on ED presentation. Patients underwent contrast-enhanced MDCT before hospital admission.

All five patients (12.5%) with ACS (one with non-ST elevation myocardial infarction, four with unstable angina pectoris) had at least one significant coronary stenosis on MDCT (sensitivity, 100%). ACS was ruled out in 35 patients (87.5%). Significant coronary stenosis was excluded in 26 of the 35 patients without ACS by MDCT (specificity, 74%), potentially saving 70% of unnecessary hospital admissions.

MDCT-based detection of significant coronary stenoses has tremendous potential to decrease the number of unnecessary hospital admissions, without reducing appropriate admission rates, in patients with chest pain who have nondiagnostic ECG  results  and normal  cardiac  enzymes.


Atypical Clinical Features of Pediatric Appendicitis

Citation: Becker T, Kharbanda A, Bachur R. Acad Emerg Med. 2006;14:124-129.
Key point: Forty-four percent of patients with proven appendicitis had six or more atypical characteristics.
The diagnosis of appendicitis remains challenging in children. Delays in diagnosis or misdiagnosis have important medical and legal implications. The typical, or classic, presentation of pediatric appendicitis has been modeled after adult disease; however, many children present atypically with subtle findings or unusual signs.

Children and adolescents with suspected appendicitis were enrolled over 20 consecutive months. Pediatric emergency physicians completed standardized data collection forms on eli- gible patients.

Seven hundred fifty-five patients were enrolled. The median age was 11.9 years; 36% of patients were diagnosed with appendicitis.

The most common atypical features included:

  • absence of pyrexia (83%)
  • absence of Rovsing’s sign (68%)
  • normal or increased bowel sounds (64%)
  • absence of rebound pain (52%)
  • lack of migration of pain (50%)
  • lack of guarding (47%)
  • abrupt onset of pain (45%)
  • lack of anorexia (40%)
  • absence of maximal pain in the right lower quadrant (32%)
  • absence of percussive tenderness (31%).

Forty-four percent of patients with proven appendicitis had six or more atypical characteristics. The median number of atyp- ical features for patients with proven appendicitis was five.

The greatest negative predictors, on the basis of likelihood ratios, were as follows:

  • white blood cell count (WBC) of <10,000 per cubic mil- limeter (likelihood ratios [LR], 18)
  • absolute neutrophil count (ANC) of <7,500 per cubic mil- limeter (LR, 35)
  • lack of percussive tenderness (LR, 50)
  • lack of guarding (LR, 63)
  • no nausea or emesis (LR, 65).

Two  atypical features are the strongest negative predictors   of appendicitis in children: WBC of <10,000 per cubic millimeter  and an ANC of <7,500  per cubic  millimeter.

Update on Helicobacter pylori Treatment

Citation: Ables AZ, Simon I, Melton ER. Am Fam Physician. 2007;75:351-358
Key point: A “test-and-treat” strategy is recommended for most patients  with undifferentiated dyspepsia.
One half of the world’s population has Helicobacter pylori infec- tion. Although it is unclear whether eradication of H pylori improves symptoms in patients with nonulcer dyspepsia, there is strong evidence that eradication of this bacterium improves healing and reduces the risk of recurrence or rebleeding in patients with duodenal or gastric ulcer.

A “test-and-treat” strategy is recommended for most patients with undifferentiated dyspepsia. With this approach, patients undergo a noninvasive test for H pylori infection and, if positive, are treated with eradication therapy. This strategy reduces the need for antisecretory medications as well as the number of endoscopies. The urea breath test or stool antigen test is rec- ommended.

Until recently, the recommended duration of therapy for H pylori eradication was 10 to 14 days. Shorter courses of treatment (i.e., one to five days) have demonstrated eradication rates of 89% to 95% with the potential for greater patient  compliance. A one day treatment course consists of bismuth subsalicylate, amoxicillin, and metronidazole, all given four times with  a one-time dose of lansoprazole. In children with documented H pylori infection, however, all regimens should continue to be prescribed for seven to 14 days until short-course treatment is studied  and its effectiveness  has been established

Abstracts in Urgent Care: April, 2007