Triple rule-out coronary CT angiography evaluation of low-to-moderate risk ACS patients presenting to the ED provided a noncoronary diagnosis that explained the presenting complaint in 11% of patients, suggested the presence of significant moderate-to-severe coronary disease in 11% (22 of 197) of patients, and precluded additional diagnostic cardiac testing in the majority of patients with no adverse outcomes at 30-day follow-up.

Patients did not estimate the risk of development of cancer from their imaging examinations as high and were more concerned about having their condition diagnosed with CT than about the risk of future cancer. Knowledge and attitudes differed by age, race, education, insurance status, and pain level but not by sex, body mass index, or perceived seriousness of condition.

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Objectives: The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients.Methods: This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders.Results: A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (±standard deviation [SD]) age was 50 (±16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. Conclusions:The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.ACADEMIC EMERGENCY MEDICINE 2009; 16:921-927 ª

The overall effective radiation dose for triple rule-out coronary CTA was reduced by more than 50% with ECG-based tube current modulation without loss of image quality. Tube current modulation should be used for triple rule-out coronary CTA examinations whenever possible.

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Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR = 1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.

Abstract. Objectives:To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. Methods: This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. Results: A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty-three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). Conclusions: Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.