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Background-D-dimer has been reported to be elevated in acute aortic dissection. Potential use as a "rule-out" marker has been suggested, but concerns remain given that it is elevated in other acute chest diseases, including pulmonary embolism and ischemic heart disease. We evaluated the diagnostic performance of D-dimer testing in a study population of patients with suspected aortic dissection. Methods and Results-In this prospective multicenter study, 220 patients with initial suspicion of having acute aortic dissection were enrolled, of whom 87 were diagnosed with acute aortic dissection and 133 with other final diagnoses, including myocardial infarction, angina, pulmonary embolism, and other uncertain diagnoses. D-dimer was markedly elevated in patients with acute aortic dissection. Analysis according to control disease, type of dissection, and time course showed that the widely used cutoff level of 500 ng/mL for ruling out pulmonary embolism also can reliably rule out aortic dissection, with a negative likelihood ratio of 0.07 throughout the first 24 hours. Conclusion-D-dimer levels may be useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.

Background The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. Methods and Results A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3 hours. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. Conclusions The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.

A complete understanding of the anatomy, pathophysiology, and presenting signs and symptoms of appendicitis, combined with a thorough history and physical examination, will be the most important factors in allowing the practicing emergency physician to make the correct diagnosis of acute appendicitis. For patients in which the diagnosis is less clear or for patients in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) additional diagnostic testing, usually US or CT, and early surgical consultation are recommended.

knowledge, the first to determine the prevalence of acute aortic dissection in patients suspected of having this disease. Our earlier study showed a prevalence of 25%, 1 and the described study was Ϸ40%. 2 Because our conditions were limited to tertiary centers that see and treat aortic dissection routinely and thus likely have increased awareness to this disease, we noted that these figures are most likely higher than those that will be seen in the community setting. Thus, we described likelihood ratios rather than predictive values because the latter is affected by prevalence. Dr Hugli's second issue concerns clinical spectrum. Our study and its findings were based on patients with suspected acute aortic dissection and not chest pain in general; thus, caution is needed in the generalization of our findings beyond the tested parameters of patients with acute aortic dissection presenting to mainly tertiary centers. Furthermore, on the topic of selection and verification bias, results of D-dimer measurements were not made available to the treating physician; therefore, this bias was not applicable to the present study. We disagree with the reasoning that examination of consecutive cases may have caused selection bias but rather assert that this allowed a more unbiased selection process. Although our present findings are limited to the described conditions, we believe that D-dimer is useful at present and that our findings, as an initial step, will help make possible the actual clinical use of D-dimer for acute aortic dissection and provide a diagnostic algorithm to optimize the use of imaging tests in these settings. We expect our findings to serve as a "working hypothesis" to be tested in more general settings such as in patients presenting with chest pain in general and in extension to the community setting (eg, nontertiary centers, healthcare systems) and further in studies that address usefulness of diagnostic strategies that incorporate both biochemical and imaging tests. We envision that a clinical algorithm will be developed that assigns patients to clinical risk groups that will help distinguish between high-risk patients who go directly to imaging and moderate-risk groups and identify lower-risk groups in which D-dimer may emerge as a rule-out screening measure.

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.ACADEMIC EMERGENCY MEDICINE 2014;21:574-598 © 2014 by the Society for Academic Emergency Medicine E mergency medicine (EM) is the only medical specialty that has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, "The Model of the Clinical Practice of Emergency Medicine" (EM Model), was developed through the collaboration of six organizations: the American Board of Emergency Medicine (ABEM-the administrative organization for the project), the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents' Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department (ED) visits and several expert panels.1 The resulting product was first published in 2001 2 and has successfully served as the common source document for all EM organizations. One of its strengths is incorporating the reality that EM is a specialty driven by symptoms, not diagnoses, requiring simultaneous therapeutic and diagnostic interventions.The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of EM, to consider alterations to the EM Model suggested by the collaborating organizations, and to recommend changes to the six sponsoring organizations.The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. The initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005.3,4 Subsequently, a task force met every 2 years to review the EM Model THE EM MODELThe EM Model is a three-dimensional descri...

The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.

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