Objectives: A prior single-center study clemonsfraled historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population. Methods: This is a prospective observational study of patients >= 65 years presenting after a fall to three EDs. Patients were eligible if they were al baseline mental status and were nor triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anlicoagulanls/anliplateler use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients. Results: 723 patients (median age 83, interquartile range 74-88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulationlantiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6-94) with a specificity of 38.8% (CI 35.1-42.7). The positive predictive value in this population was 10% (CI 7.5-13.3) with a negative predictive value of 97.3% (CI 94.4-98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed. Conclusion: In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC. (C) 2018 Published by Elsevier Inc.

OBJECTIVES:The objective was to prospectively validate and refine previously published criteria to determine the potential utility of chest x-ray (CXR) in the evaluation and management of patients presenting to the emergency department (ED) with nontraumatic chest pain (CP).METHODS:A prospective observational study was performed of patients presenting to three EDs in the United States with a chief complaint of nontraumatic CP. Previously defined high-risk history and examination elements were combined into a refined decision rule and these elements were recorded for each patient by the ED physician. CXR results were reviewed and analyzed to determine the presence of clinically significant findings including pneumonia, pleural effusion, pneumothorax, congestive heart failure, or the presence of a new mass. Odds ratios for each history and examination element were analyzed as well as sensitivity, specificity, and negative predictive value (NPV) of the rule overall.RESULTS:A total of 1,111 patients were enrolled and 1,089 CXRs were analyzed. There were 70 (6.4%) patients with clinically relevant findings on CXR. The refined decision rule had a sensitivity of 92.9% (confidence interval [CI] = 83.4%-97.3%) and specificity of 30.4% (CI = 27.6%-33.4%) to predict clinically relevant findings on CXR, with a NPV of 98.4% (CI = 96.1%-99.4%). Five CXRs with clinically significant findings would have been missed by application of the refined rule (three pneumonias and two pleural effusions). Applying these criteria as a CXR decision rule to this population would have reduced CXR utilization by 28.9%.CONCLUSIONS:This study validates previous research suggesting a low clinical yield for CXR in the setting of nontraumatic CP in the ED. This refined clinical decision rule has a favorable sensitivity and NPV in a patient population with low incidence of disease. Further validation is needed prior to use in practice.

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BACKGROUND:The Accreditation Council for Graduate Medical Education (ACGME) recently has mandated the formation of a clinical competency committee (CCC) to evaluate residents across the newly defined milestone continuum. The ACGME has been nonproscriptive of how these CCCs are to be structured in order to provide flexibility to the programs.OBJECTIVES:No best practices for the formation of CCCs currently exist. We seek to determine common structures of CCCs recently formed in the Council of Emergency Medicine Residency Directors (CORD) member programs and identify unique structures that have been developed.METHODS:In this descriptive study, an 18-question survey was distributed via the CORD listserv in the late fall of 2013. Each member program was asked questions about the structure of its CCC. These responses were analyzed with simple descriptive statistics.RESULTS:A total of 116 of the 160 programs responded, giving a 73% response rate. Of responders, most (71.6%) CCCs are chaired by the associate or assistant program director, while a small number (14.7%) are chaired by a core faculty member. Program directors (PDs) chair 12.1% of CCCs. Most CCCs are attended by the PD (85.3%) and selected core faculty members (78.5%), leaving the remaining committees attended by any core faculty. Voting members of the CCC consist of the residency leadership either with the PD (53.9%) or without the PD (36.5%) as a voting member. CCCs have an average attendance of 7.4 members with a range of three to 15 members. Of respondents, 53.1% of CCCs meet quarterly while 37% meet monthly. The majority of programs (76.4%) report a system to match residents with a faculty mentor or advisor. Of respondents, 36% include the resident's faculty mentor or advisor to discuss a particular resident. Milestone summaries (determination of level for each milestone) are the primary focus of discussion (93.8%), utilizing multiple sources of information.CONCLUSIONS:The substantial variability and diversity found in our CORD survey of CCC structure and function suggest that there are myriad strategies that residency programs can use to match individual program needs and resources to requirements of the ACGME. Identifying a single protocol for CCC structure and development may prove challenging.

A panel of physicians from the Society for Academic Emergency Medicine (SAEM) Graduate Medical Education (GME), Ethics, and Industry Relations Committees were asked by the SAEM Board of Directors to write a position paper on the relationship of emergency medicine (EM) GME with industry. Using multiple sources as references, the team derived a set of guidelines that all EM GME training programs can use when interacting with industry representatives. In addition, the team used a question-answer format to provide educators and residents with a practical approach to these interactions. The SAEM Board of Directors endorsed the guidelines in June 2009.

A case-based book organized by the top 10 common complaints of patients presenting to emergency departments. This approach allows the reader to learn the pathophysiology of the major diseases, and analyze each case in a way that more closely approximates the clinical practice of medicine; not knowing which organ system is damaged or compromised before examining the patient. The cases are based on real patients and the diseases are either common in emergency practice, or are dangerous diagnoses not to be missed. The case descriptions include questions regarding the patient's presentation and basic information about the disease, illustrating key elements from the history, physical, and when necessary ancillary studies that help lead to a diagnosis. Each chapter ends with a flow diagram showing how diseases of different organ systems can present with similar initial complaints. This book is an ideal resource for medical students, residents and trainees in emergency medicine.