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Objective: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program., Methods: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05., Results: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]., Conclusion: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.

Objective: To compare in-hospital complication rates for diabetic and nondiabetic patients admitted from the emergency department (ED) for possible myocardial ischemia., Methods: This was a prospective, observational study of consecutive consenting patients presenting to a suburban university hospital ED during study hours with typical and atypical symptoms consistent with cardiac ischemia. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Inpatient records were reviewed by trained data abstractors to ascertain hospital course and occurrence of complications. Final discharge diagnosis of acute myocardial infarction (AMI) was assigned by World Health Organization criteria. Categorical and continuous data were analyzed by chi-square and t-tests, respectively. All tests were two-tailed with alpha set at 0.05., Results: There were 1,543 patients enrolled who did not have complications at initial presentation; 283 were diabetic. The rule-in rate for AMI was 13.8% for nondiabetic patients and 17.7% for diabetic patients (p = 0.09). Times to presentation were similar for nondiabetic vs diabetic patients [248 minutes (95% CI = 231 to 266) vs 235 minutes (95% CI = 202 to 269); p = 0.32]. Nondiabetic patients tended to be younger [56.6 years (95% CI = 55.8 to 57.4) vs 61.6 years (95% CI = 60.2 to 63.1); p = 0.001] and were less likely to be female (34.3% vs 48.1%; p = 0.001). The two groups had similar prevalences for initial electrocardiograms diagnostic for AMI (5.5% vs 7.4%; p = 0.21). There was no significant difference between nondiabetic and diabetic patients for the occurrence of the following complications after admission to the hospital: congestive heart failure (1.3% vs 1.1%, p = 0.77); nonsustained ventricular tachycardia (VT) (1.3% vs 1.2%, p = 0.93); sustained VT (1.2% vs 1.1%, p = 0.85); supraventricular tachycardia (1.7% vs 3.2%, p = 0.12); bradydysrhythmias (1.9% vs 1.1%, p = 0.33); hypotension necessitating the use of pressors (0.9% vs 1.1%, p = 0.76); cardiopulmonary resuscitation (0.2% vs 0.7%, p = 0.10); and death (0.3% vs 0.7%, p = 0.34). One or more complications occurred with similar frequencies for patients in the two groups (6.3% vs 5.7%; p = 0.70)., Conclusions: No statistically significant difference was found in the postadmission complication rates for initially stable diabetic vs nondiabetic patients admitted for possible myocardial ischemia. Based on these results, the presence or absence of diabetes as a comorbid condition does not indicate a need to alter admitting decisions with respect to risk for inpatient complications.

Objective: To determine the incidence of clinically significant intracranial injury in the anticoagulated patient suffering minor head trauma without loss of consciousness (LOC) or acute neurologic abnormality., Methods: A retrospective chart review was performed based on a computerized search of electronic patient records from six community hospital EDs, one of which is a trauma center. Patients taking warfarin who sustained minor head trauma without LOC having no acute neurologic abnormalities treated from January 1994 to January 1996 were identified using a search of electronic ED records. Charts were reviewed for mechanism of injury, physical examination findings of head injury, and concomitant injury. Prothrombin time and head CT results were recorded if obtained. For those patients not receiving a head CT on ED evaluation, telephone follow-up was performed to determine outcome., Results: There were 65 patients meeting inclusion criteria. Thirty-eight patients had prothrombin times obtained, with ranges from 12.0 sec to 30.7 sec. There was no intracranial injury found in any of the 39 patients having a head CT. Additionally, follow-up on the 26 patients who did not undergo CT scanning revealed no evidence of complications related to their head injuries., Conclusions: The incidence of clinically significant intracranial injury is extremely low in the anticoagulated patient suffering minor blunt head trauma without LOC or acute neurologic abnormality. CT scanning may not be necessary in these patients. Larger prospective studies are needed to confirm these findings.