Abstract Purpose of Review We will review select aspects of clinical presentation, epidemiology, initial diagnostic testing, prophylaxis and treatment of important fungal infections. Both superficial and invasive mycoses will be discussed. Recent Findings Multiple new diagnostic tests for fungal infections, including serology-based, molecular-based, and next generation sequencing tools, are emerging. Novel treatments include both testing new molecules and repurposing old pharmaceuticals for antifungal activity. Awareness is increasing of the importance of timely diagnosis and aggressive treatment of fungal ocular disease. Recent papers highlight the association between severe viral diseases, including COVID-19, and invasive fungal infections and the potential for sexual spread of certain kinds of dermatophytoses. Summary The growing burden of fungal infections, along with the emergence of novel pathogens and resistance to existing antifungal agents, make it important for clinicians to stay informed of new approaches in prophylaxis, diagnosis and management of fungal disease.

FigureA 62-year-old man presents with a history of right-sided weakness, lasting probably less than five to seven minutes. He isn't sure, but his wife remembers that he had slurred, incomprehensible speech for at least a couple of minutes. They drove to the ED, and because he feels fine now, they wonder whether they should have come. He has a history of diabetes and of high blood pressure, both of which are reasonably well controlled. The emergency physician decides to get a head CT, which is normal. His bedside blood glucose is 102 mg/dl. You hear no carotid bruits, and refer him to his primary care doctor for follow-up. Three weeks later and two days after the couple return from a Caribbean cruise, he suffers a dense stroke. During his hospitalization, he is noted to be in atrial fibrillation. A lawsuit is filed against the emergency physician. One plaintiff's expert faults the EP for not obtaining an EKG and starting warfarin therapy. Another plaintiff expert faults him for discharging the patient at all, for not obtaining an EKG, and for not starting heparin therapy as a bridge to warfarin therapy. Both are willing to attest to a degree of medical certainty that this man would be functioning normally had he received competent emergency care. At deposition, the EP does not recognize the gentleman. He is unable to speak or walk, and cannot be deposed. The wife shoots daggers at the EP during the whole affair. In my past two articles, I have reviewed some difficulties in diagnosing transient ischemic attack (TIA) and in defining the entity. Considering that the incidence of TIA in the general population is approximately 68 per 100,000 population (Stroke 1998;29:2109), or between 200,000 and 500,000 TIAs annually in the United States (N Engl J Med 2002;347:1687), TIAs are something the EP deals with routinely. These figures have been amplified by a recent article demonstrating that there have been approximately 2,969,000 visits to emergency departments in the United States for TIA over a 10-year period ending 2001: three visits per 1000 or 0.3 percent of all ED visits. (Acad Emerg Med 2006;13[6]:666.) The traditional definition — the abrupt onset of a neurologic deficit lasting less than 24 hours and caused by a focal vascular lesion — is antiquated, as we have seen. Studies using magnetic resonance imaging show that 50 percent of patients meeting the traditional definition of TIA have actually had infarctions. (Cerebrovasc Dis 2005;19:362.) Of those with an index TIA, the risk of stroke within 48 hours approximates four percent to five percent. (Stroke 2003;34:e138 and 2005;36:720.) How Much Work-up in the ED? This question has a number of different answers, depending on the technology available and the timeliness of follow-up. In a recent review, 53 percent of TIA patients arrived between 8 a.m. and 4 p.m., an unusual excess of daytime visits. (Acad Emerg Med 2006;13[6]:666.) This figure is striking in that it may indicate that patients may not take symptoms seriously if they resolve quickly; after all, they didn't come in during off hours. EPs may not take the symptoms so seriously either. Once in the ED, head CT was obtained in 56 percent of patients and MRI in fewer than five percent of TIA patients. This is in spite of the fact that the American Heart Association recommends that head CT be performed on all these patients. (Stroke 1999;30:2502.) This also doesn't take into account that MRI with diffusion-weighted imaging is our best test to distinguish stroke from TIA. Of course, the lack of MRIs ordered is mitigated by the fact that this test is not available in most EDs. It is less understandable that electrocardiograms were only performed on 73 percent of TIA patients acutely. This is a low-tech test, available uniformly, and recommended by the American Heart Association (Stroke 1999;30:2502) and the National Stroke Association (Stroke 1999;30:1991) to be performed on all TIA patients. Atrial fibrillation is a major etiology for TIA, and treatment with heparin is recommended for new TIA patients due to atrial fibrillation. Back to Basics What else should be done universally? It doesn't make sense to perform expensive testing on inpatients or outpatients when there is no emergency treatment dependent on the test results. Antiplatelet agents are recommended by the AHA and the National Stroke Association. This may include aspirin or, if aspirin is contraindicated or has failed, ticlopidine or clopidogrel. Increasing the dose of aspirin has not been shown effective. The decision to use antiplatelet agents should be made in concert with the primary care physician or neurologist who will assume care for the patient after the emergency visit. In a recent 10-year review of TIA cases in the U.S., only 42 percent of TIA patients received any medications at all. No randomized, controlled study has ever shown the benefits of hospitalization for TIA. (Ann Emerg Med 2004;43:592.) This statement may not justify patient discharge, however. The major downside to not working up patients promptly in the hospital is the risk of missing occlusive carotid artery disease. The effectiveness of carotid endarterectomy is a function of the degree of stenosis and of the time delay that occurs between the TIA and surgery. (Lancet 2004;363(9413):915.) Carotid ultrasonography is noninvasive, with a sensitivity of 93% for high-grade stenosis and a specificity of 89% using cerebral angiography as the gold standard. (Mayo Clin Proc 1994;69:1027.) Echocardiography is noninvasive and may pick up left ventricular or atrial thrombus. Transesophageal echo may diagnose patent foramen ovale, aortic arch plaque, or atrial septal aneurysm, but is a more expensive and invasive test. I could find no literature that suggests that hospitalization is mandatory to accomplish ultrasound studies. Risk Stratification Can we risk-stratify which TIA patients with negative CT are at high risk of stroke? One review listed four groups possibly at high risk that might warrant immediate admission for further evaluation and treatment: ▪ “Aspirin failure” TIA. ▪ Possible cardioembolic stroke (i.e., atrial fibrillation). ▪ “Crescendo” transient ischemic attack: more than three ischemic events within 72 hours, with increased severity and frequency of symptoms. ▪ Patients with motor or speech deficits of more than 10 minutes, those 60 or older, or those with diabetes are at higher risk for early stroke. Clinical risk stratification models for TIA have been developed based on how many of these five findings were present. (Ann Emerg Med 2004;43:592.) The Bottom Line It appears there are approximately 10,000 to 25,000 patients who sustain strokes within 48 hours of an index TIA. With admission rates at only 54 percent for TIA, it is clear that EPs are discharging thousands of people from emergency departments who have really sustained strokes. Thousands more have sustained TIAs and will have a stroke within days of discharge from the emergency department, without a work-up meeting standards established by national groups. If there is a standard of care for TIA as defined by the American Heart Association or the National Stroke Association, then a lot of emergency physicians out there are not adhering to it. TIAs represent another entity in which standard of care may not be so standard. If the concept of acute ischemic cerebrovascular syndrome becomes accepted, then TIA will be seen within the spectrum of stroke, similarly to DVT and pulmonary embolus. If this is so, then expect that patients with TIA in the foreseeable future will be confined routinely in the hospital or observation bed pending rule-out for carotid artery disease or treatable cardiac etiology. The Bottom Line on Stroke Approximately 10,000 to 25,000 patients sustain strokes within 48 hours of an index TIA. ▪ Admission rates are at only 54 percent for TIA, meaning that EPs are discharging thousands of people from emergency departments who have sustained strokes. Thousands more have sustained TIAs and will have a stroke within days of discharge from the emergency department. ▪ Emergency physicians are not adhering to a standard of care for TIA as defined by the American Heart Association or the National Stroke Association.

This article reviews approaches to the evaluation and treatment of patients with mammalian bites presenting to the Emergency Department with an emphasis on infectious complication prevention and management. Recent studies questioned the wisdom of leaving all bite wounds open, while reinforcing extreme caution with primary closure of wounds in areas of the body where infection development is likelier and more consequential. Nuances have also emerged as far as prophylactic antibiotics are concerned. Once an initial trauma assessment and stabilization have been completed in the patient with an animal bite, attention is drawn to management of the wound. Initial evaluation includes a careful history and physical, supplemented by radiographic evaluation as indicated. Especially after attacks by large dogs, or if the patient is a small child, advanced imaging such as a CT scan may be necessary to evaluate the full extent of the injuries. All but the most superficial wounds should be copiously irrigated with either tap water or a virucidal solution, such as povidone-iodine if rabies or other viral exposure is a concern. Gaping wounds, or wounds in cosmetically sensitive areas, can be closed primarily if the presentation is not delayed and no host factors for increased infection risk, such as poorly controlled diabetes, are identified. Complex wounds, especially those on the hands and face, often require the involvement of plastic surgery, and on occasion admission to the operating room for proper management. Antibiotic prophylaxis is almost universally indicated in hand or foot wounds or after bites from cats. Tetanus vaccination status should be ascertained and updated as indicated. Different viruses can be transmitted after mammalian bites, ranging from zoonotic rabies and Herpes B virus to human-borne hepatitis and HIV viruses. Often, this exposure necessitates chemoprophylaxis, which may be lifesaving. Patients and their families may need education on behavioral modifications and precautions to prevent future injuries from animal attacks. Finally, socioeconomic determinants of health must be considered, such as concerns for a patient’s ability to adhere to treatment plans, wound care, and follow-up.

The recent COVID-19 pandemic has caused over 800,000 deaths in the USA as of this writing. Remarkable, several effective vaccines have been developed within 1 year of the occurrence of the pandemic’s outbreak in the USA. Although the vaccine has proven to be remarkably effective in preventing hospitalization and death, the number of unvaccinated persons in the USA who are eligible for the vaccine remains over 35%. Unvaccinated persons pose a risk for vaccine mutation and prolongation of the pandemic, with its attendant quarantines and societal shutdowns. The ability of clinicians to address this problem remains unclear in a population suspicious of science and of the health care community.

Adult respiratory distress syndrome is a life-threatening complication from severe COVID-19 infection resulting in severe hypoxic respiratory failure. Strategies at improving oxygenation have evolved over the course of the pandemic. Although non-invasive respiratory support reduces the need for intubation, a significant number of patients with COVID-19 progress to invasive mechanical ventilation. Once intubated, a lung protective ventilation strategy should be employed that limits tidal volumes to 6 ml/kg of predicted body weight and employs sufficient positive end-expiratory pressure to maximize oxygen delivery while minimizing the fraction of inspired oxygen. Intermittent prone positioning is effective at improving survival, and there is a growing body of evidence that it can be safely performed in spontaneously breathing patients to reduce the need for invasive mechanical ventilation. Inhaled pulmonary vasodilators have not been shown to improve survival or cost-effectiveness in COVID-19 and should be used selectively. Finally, the best outcomes are likely achieved at centers with experience at severe ARDS management and protocols for escalation of care.

The aim of this review is to discuss the management of febrile children and evaluate current and potential markers to screen for serious bacterial infection (SBI). Procalcitionin (PCT) and C-reactive protein (CRP) seem to be the most useful; however, newer markers such as presepsin, neutrophil CD64, and secretory phospholipase A2 (sPLA2) have shown to be promising. A confirmed viral infection lowers the risk of a concomitant SBI and may reduce the need for further invasive studies. The approach and workup of a febrile infant still remain challenging. Biomarkers and viral testing serve as useful adjuncts in guiding clinical decision making but should not be used as definitive tools to rule out a SBI in children.

We discuss and review new antimicrobials for treatment of bacterial, viral, fungal, and parasitic infections with indications, contraindications, and side effects for each. We will also review new information and indications on older agents that are relevant to clinical practice. Many of them may be unfamiliar to Emergency Physicians given their newness and at times hospital restrictions on their use. We also review some new promising agents that are not yet in the clinical pipeline. As new antibiotics become available for clinicians to use, new information becomes available with respect to the drugs’ indications, efficacy, pathogen resistance, drug-drug interactions, and side effects. This article provides Emergency Department clinicians with a useful summary with new information on antibiotic use and recent research into agents which may become available.

Ticks are the most important vectors of human diseases after mosquitoes. Emergency physicians throughout the USA can be expected to encounter Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, and other disorders based upon geographic location. The number of identifiable disorders transmitted by these arthropods has increased in recent years. Severe fever with thrombocytopenia syndrome has only been described within the past decade, and the new millennium has seen over 10 new species of rickettsial disease discovered. Ticks transmit more pathogenic species than any other group of blood-feeding arthropods. This review provides an update on the diagnosis and management of the diseases most likely to be encountered in clinical practice.

The goal of this review was to determine the current treatment and prevention recommendations for Clostridium difficile infections (CDI) and their efficacy. We elucidate new treatment and prevention strategies that are in development, and define populations that are at greatest risk of CDI. New practice guidelines recommend vancomycin or fidaxomicin as first-line treatment for CDI with oral metronidazole only being used in cases of non-severe CDI when vancomycin and fidaxomicin are not available. Metronidazole is recommended in an IV formulation in conjunction with oral vancomycin in fulminant CDI. Recurrent CDI (rCDI) may be treated with vancomycin, fidaxomicin, or fecal microbiota transplant (FMT). Recent studies show fidaxomicin and fecal microbiota transplantation to be the most effective in decreasing the risk of rCDI. Prevention of CDI is primarily through judicious use of antibiotics and strategies aimed at minimizing the spread of C. difficile spores in hospitals. New preventative options are being studied including an oral beta-lactamase that may decrease the risk of developing CDI after beta-lactam use and a potential vaccine against toxins A and B produced by C. difficile. rCDI continues to be a significant problem particularly in older populations. New treatment guidelines may provide increased protection of recurrence as new medications and treatment modalities are more often utilized. Adjunctive treatments currently being studied may provide additional protection against recurrence but prevention against initial (iCDI) is still of great importance.

This article aims to review recent literature regarding the risks of disease exposure to pre-hospital providers and the patients they serve, as well as the challenges they face in minimizing transmission and exposure. Many studies continue to show poor compliance with consistent universal precautions, as well as proper hand hygiene. Vaccination rates are suboptimal despite attempts to encourage compliance. With the spread of multi-drug resistant organisms, new techniques of decontamination need to be investigated. There remains a general lack of information and studies regarding the risks of disease exposure and transmission to EMS providers despite the significance hazards their profession can pose. However, there remains a continued theme throughout the majority of EMS and pre-hospital studies, demonstrating that hand washing and consistent use of personal protective equipment remains a persistent, preventable means of disease exposure and transmission.

A high percentage of patients present to the emergency department for management of painful conditions. It is in society’s interest to provide pain relief without contributing to the ongoing opioid crisis. Acupuncture is an ancient therapy dating from more than 4000 years. It has not historically been shown in rigorous duplicated studies to be effective in the management of acutely painful conditions. More recent literature has shown its promise in the treatment of a variety of defined and common complaints. Nonopioid treatment options for management of moderate to severe acute pain in the emergency department are limited. Recent reports and comparative studies utilizing acupuncture show promise for the emergency care of acute painful conditions.

We provide an overview of new chemotherapy agents for the treatment of bacterial, viral, fungal, and parasitic infections with indications, contraindications, and side effects for each. Some of them have been restricted for use only by subspecialists, possibly limiting emergency physicians’ comfort with prescribing these medications. We also review some new and promising agents that have not been approved by the Food and Drug Administration as of this writing.

Purpose of Review Relief of pain and discomfort is a critical component of the mission of every health care provider to reduce suffering. Pain management is of paramount importance in the provision of care at every level. This is an era of increasing patient expectations of care, yet also there exists an ongoing scourge of opiate abuse. Recent Findings ED visits for opioid overdoses rose 30% in all parts of the USA from July 2016 through September 2017. Deaths from narcotic overdose in the USA now exceed those from motor vehicle crashes. The concept of an “opiate-free” emergency department has been posited. Summary The emergency practitioner is presented with clinical and political challenges which did not exist in the past. This article elucidates current pharmacologic options regarding analgesia in the emergency setting, with some possible future options.

The safety and feasibility of active surveillance in comorbid patients with renal masses ≥4.0 cm is uncertain. The aim of this study is to describe our institutional experience with the observation of large renal masses.One hundred patients were identified with renal masses ≥ 4.0 cm that were followed on observation for at least 6 months without surgical intervention between 1994 and 2016. Linear regression was conducted to determine predictors for renal mass growth and competing risk methods were used to estimate the probability of progression in the setting of death from other causes.Median age at diagnosis was 73 years and 73% of patients had a Charlson Comorbidity index ≥ 4. At presentation, the median mass size was 4.9 cm. The median growth rate was 0.4 cm/y and there were no significant predictors of growth. Surveillance was discontinued in 34 patients who underwent delayed intervention. Median follow up for metastasis-free survivors was 4 years. In total, 10 patients developed metastatic disease, 3 died from kidney cancer and 30 patients died from other causes. The 5-year probability of other cause mortality was 22% (95% CI: 14%–32%) compared to 6% (95% CI: 2%–13%) for metastatic progression of kidney cancer.In highly comorbid patients, the observation of large renal masses has low likelihood for metastatic progression relative to the risk of nonkidney cancer related death. This data supports the use of surveillance as an acceptable strategy for highly selected patients with competing risks from other serious illnesses.

Clinicians in every setting have been charged with relief of pain as part of their mission as providers. Pain relief has been listed as one of the drivers of patient satisfaction and, in many settings, of reimbursement. Manyhealth care practitioners equate aggressive pain relief with administration of narcotic analgesia. Given the scourge ofnarcotic addiction, and evidence that many patients started on narcotic analgesics in the emergency setting will still betaking narcotics one year later, and may die from narcotic addiction or overdose, the possibility of providing pain reliefwithout the use of narcotics has attained some urgency.

Patient satisfaction has become an increasingly important metric of quality of care and of the patient experience. It has also become an important driver of reimbursement for provider services. Components of patient satisfaction include provision of timely care, keeping the patient and their families apprised of the progress of their diagnostic work-up and treatment, cleanliness of the environment, responsiveness of the treatment team, as well as relief of pain and discomfort. In an era of increasing patient expectations of care, as well as the recent epidemic of opiate abuse, the emergency provider is presented with clinical challenges which did not exist until recently.

Study Objectives: The American College of Radiology lists oral contrast as an institution-specific option in the evaluation of right lower quadrant pain. Previous literature indicates that an accurate assessment for appendicitis can be made by CT using IV contrast alone, with significant time savings from withholding oral contrast. Before 2010, the protocol for CT use in the evaluation of possible appendicitis or undifferentiated abdominal pain routinely included oral contrast. The purpose of this study was to determine the incidence of repeat CT scans with oral contrast for the purpose of arriving at a final disposition in patients undergoing evaluation for abdominal pain. This analysis was also to determine if the general surgery service was willing and able to make accurate clinical determinations to operate without the use of oral contrast.Methods: Consecutive abdominal CTs for nontraumatic abdominal pain were evaluated retrospectively over a 7-month period from January through July 2010. CT scans performed for evaluation of trauma were eliminated, as were cases in patients with known previous appendectomy or in cases in which appendicitis was not a consideration. Follow-up was by chart review over the ensuing 30 days for complications or need for surgery, which was not detected after the initial CT scan. The study was conducted at a teaching hospital, level I trauma center with an annual ED census of 99,000 visits.Results: A total of 311 CT scans met the study criteria. No cases of appendicitis were missed. Two patients were operated on based upon inflammatory findings in the right lower quadrant, one with typhlitis, the second with possible inflammatory bowel disease versus typhlitis. In each case, the diagnosis was made by CT, but the surgery service chose to operate based on clinical findings. Sixteen (5.14%; 95% CI, 3.2%-8.2%) cases of acute appendicitis were accurately identified. A normal appendix was visualized in 125 (40.2 %; 95% CI, 34.9-45.7) patients. No patients (0%; 95% CI, 0%-1.2%) required a repeat CT scan with oral contrast as part of the workup. On 30-day follow-up by chart review, no (0%; 95% CI, 0%-1.2%) significant surgical problems were identified, and no cases of missed appendicitis were identified.Conclusions: Abdominal CT scan without the use of oral contrast is accurate to allow for appropriate decision making by emergency physicians and general surgeons. In our series, no patients required repeat scanning. Further assessment by larger studies is appropriate.

ImageIncreased disclosure of injuries to patients will likely boost the number of lawsuits filed and payouts made. This is not to say that enhanced transparency is not a good thing; it just may be an expensive thing. Disclosure flies in the face of the traditional “deny and defend” policy of stonewalling against potential or real litigants. The Studdert article I reviewed last month concluded that forecasts of reduced litigation and cost were unlikely from transparency of adverse outcomes to patients. (Health Aff 2007; 26[1]:215.) Health care providers historically have not been trained how to disclose bad news, perhaps were embarrassed about what happened, and certainly have been fearful of litigation. The prudent insurer typically would recommend that things be kept secret, argue fault at every turn, and fight every step of the way to make litigation chronologically long, expensive, and as slow as possible. (J Health Life Sci Law 2009;2[2]:125.) These attitudes, by the way, are about as far as possible from the Institute of Medicine's utopian view of a health care system that is safe, efficient, patient-centered, timely, efficient, and equitable. (Health Aff 2004;23[4]:11.) Back to Ethics Patients increasingly expect to be apprised of care that has gone wrong. It would be difficult to argue otherwise from a moral perspective. The National Quality Forum, in fact, has listed standards of disclosure of unanticipated outcomes as part of its safe standards. (www.qualityforum.org/publications/reports/safe_practices_2009.asp.) And it is undoubtedly true that many lawsuits are filed in part by victims trying to find out the truth. There certainly seems to be a growing consensus among physicians that disclosing errors to patients is important. (Arch Intern Med 2005; 165[16]:1819; New Engl J Med 2007; 356[26]:2713.) Disclosing, taking responsibility, apologizing, and preventing recurrences have become hot topics, and are increasingly mandated and accepted within the health care community. Risk managers, however, may operate independently of an institution's quality infrastructure and leaders, and may be loath to apologize for an error. Pennsylvania passed a law in 2002 requiring hospitals to notify patients within seven days after a “serious event.” This communication is prohibited as evidence of liability for the disclosed event. (Arch Intern Med 2005;165[16]:1819.) Many other states have adopted so-called “apology laws,” which protect specific information such as apologies, but do not protect accompanying specific information about what caused the injury or who was at fault. Apparently, only Pennsylvania specifies sanctions for noncompliance. Why Patients Sue If poor communication constituted the major reason that patients decided to sue, then disclosure certainly would decrease the amount of litigation. Patients may very well simply want the truth or for mistakes to be corrected so the next patient does not experience a bad outcome. Many patients never would have found out about their injury if not for disclosure. It strains credulity to think that monetary compensation doesn't enter into the equation somewhere for plaintiffs. Interestingly, there is a case in the private sector that tends to support the concept that disclosure may be cost-effective, in addition to the obvious ethical considerations. COPIC Insurance, a liability insurer in Colorado, developed a program in 2000 to facilitate communication about injuries. Patients were provided with up to $30,000 in compensation for “costs.” Because no fault was listed and patients did not waive their right to sue, the payments under this program were not considered reportable to the National Practitioner Data Bank. Payments averaged approximately $5400 each, and seven of the approximately 750 patients paid went on to litigate their cases, and only two resulted in tort compensation. The low average payment per incident suggests that money alone is not the main driver for these suits. It is noteworthy that exclusion criteria for the program included clear negligence, attorney involvement, death, or complaint to the state board. (CMAJ 2006;175[8]:889.) It seems likely to me that those egregious cases excluded by the program should have generated significant payments. While there is evidence from the Lexington (KY) VA Medical Center and the University of Michigan Health System that the cost of litigation declined significantly in the five-year period following implementation of an open-disclosure program, I remain skeptical about the cause and effect. Historical controls are difficult to evaluate; litigation may have decreased over time for a variety of reasons. It seems difficult to extrapolate a VA experience to a broader spectrum of health care. The Colorado experience is intriguing if it is borne out that transparency is not necessarily expensive. I will talk more about the University of Michigan experience next month. Disclosure of harmful events is a concept that is here to stay. It is difficult to argue ethically against it. Issues of patient satisfaction and the rates of ensuing litigation have not been elucidated. Transparency will entail training and simulation for clinicians who will be doing more of this is the future, until systems are in place to drive down the medical error rate.Dr. Glauser: is an assistant professor of medicine at Case Western Reserve University and attending staff faculty in emergency medicine at the Cleveland Clinic Foundation in Cleveland.

Background: Platelet aspirin resistance is reported to be as high as 45%. The prevalence of emergency department (ED) platelet aspirin resistance in suspected acute coronary syndrome (ACS) is not described. Our purpose was to determine the prevalence of platelet aspirin resistance.Methods: We determined platelet aspirin resistance in a convenience sample of ED suspected ACS patients. Eligible patients had longer than 10 minutes of chest pain or an ischemic equivalent. Two hours after receiving 325 mg of aspirin, blood was assessed for platelet function (Accumetrics, San Diego, CA). Definitions are as follows: aspirin resistance, at least 550 aspirin reaction units; positive troponin T, greater than 0.1 ng/mL; significant coronary lesion, at least 70% stenosis. The composite end point was prospectively defined as a 30-day revisit, positive cardiac catheterization, or hospital length of stay (LOS) longer than 3 days.Results: Of 200 patients, 50.5% were male, 50.0% were black, troponin T was positive in 7.5%, cardiac catheterization was done in 10.5%, and 33.3% had a significant stenosis. Final diagnoses were noncardiac in 83.4%, stable angina in 8.0%, and unstable angina in 8.5%. Overall, 6.5% were resistant to aspirin; and high-risk patients trended to more aspirin resistance than non high-risk patients (23.1% [3] vs 9.1% [17]; P value 95% confidence interval [Cl], -0.0929 to 0.373). One-month follow-up found ED revisits in 12.5% of aspirin-resistant vs 4.9% of non aspirin-resistant patients (95% CI, -0.114 to 0.182) and rehospitalization in 12.5% of resistant patients vs 4.3% of nonresistant patients (P value 95% CI, -0.108 to 0.187). Although LOS was similar at index admission, if rehospitalized, LOS was 6.5 for aspirin-resistant patients vs 3.2 days in nonresistant patients (P<.0001).Conclusion: This first report of platelet aspirin resistance in patients presenting to the ED with suggested ACS finds that it is present in 6.5% of patients. (C) 2010 Elsevier Inc. All rights reserved.