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Background: A single serum creatinine measurement cannot distinguish acute kidney injury from chronic kidney disease or prerenal azotemia. Objective: To test the sensitivity and specificity of a single measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL) and other urinary proteins to detect acute kidney injury in a spectrum of patients. Design: Prospective cohort study. Setting: Emergency department of Columbia University Medical Center, New York, New York. Participants: 635 patients admitted to the hospital with acute kidney injury, prerenal azotemia, chronic kidney disease, or normal kidney function. Measurements: Diagnosis of acute kidney injury was based on the RIFLE (risk, injury, failure, loss, and end-stage) criteria and assigned by researchers who were blinded to experimental measurements. Urinary NGAL was measured by immunoblot, N-acetyl-[beta]-D-glucosaminidase (NAG) by enzyme measurement, [[alpha].sub.1]-microglobulin and [[alpha].sub.1]-acid glycoprotein by immunonephelometry, and serum creatinine by Jaffe kinetic reaction. Experimental measurements were not available to treating physicians. Results: Patients with acute kidney injury had a significantly elevated mean urinary NGAL level compared with the other kidney function groups (416 [micro]g/g creatinine [SD, 387]; P = 0.001). At a cutoff value of 130 [micro]g/g creatinine, sensitivity and specificity of NGAL for detecting acute injury were 0.900 (95% CI, 0.73 to 0.98) and 0.995 (CI, 0.990 to 1.00), respectively, and positive and negative likelihood ratios were 181.5 (CI, 58.33 to 564.71) and 0.10 (CI, 0.03 to 0.29); these values were superior to those for NAG, [[alpha].sub.1]-microglobulin, [[alpha].sub.1]-acid glycoprotein, fractional excretion of sodium, and serum creatinine. In multiple logistic regression, urinary NGAL level was highly predictive of clinical outcomes, including nephrology consultation, dialysis, and admission to the intensive care unit (odds ratio, 24.71 [CI, 7.69 to 79.42]). Limitations: All patients came from a single center. Few kidney biopsies were performed. Conclusion: A single measurement of urinary NGAL helps to distinguish acute injury from normal function, prerenal azotemia, and chronic kidney disease and predicts poor inpatient outcomes.

Your review of Layered Voice Analysis from VLLC of Washington ['Can you handle the truth?, GCN, Sept. 1, Page 1] is astonishingly defective. This $16,000 product screws around with systems […]

Objective. In the United States, per-capita opioid dispensing has increased concurrently with analgesic-related mortality and morbidity since the 1990s. To deter diversion and abuse of controlled substances, most states have implemented electronic prescription drug monitoring programs (PDMPs). We evaluated the impact of state PDMPs on opioid dispensing.Methods. We acquired data on opioids dispensed in a given quarter of the year for each state and the District of Columbia from 1999 to 2008 from the Automation of Reports and Consolidated Orders System and converted them to morphine milligram equivalents (MMEs). We used multivariable linear regression modeling with generalized estimating equations to assess the effect of state PDMPs on per-capita dispensing of MMEs.Results. The annual MMEs dispensed per capita increased progressively until 2007 before stabilizing. Adjusting for temporal trends and demographic characteristics, implementation of state PDMPs was associated with a 3% decrease in MMEs dispensed per capita (p=0.68). The impact of PDMPs on MMEs dispensed per capita varied markedly by state, from a 66% decrease in Colorado to a 61% increase in Connecticut.Conclusions. Implementation of state PDMPs up to 2008 did not show a significant impact on per-capita opioids dispensed. To control the diversion and abuse of prescription drugs, state PDMPs may need to improve their usability, implement requirements for committee oversight of the PDMP, and increase data sharing with neighboring states.

Clinical treatment pathways are useful to ensure that evidence-based medicine is consistently applied in hospital systems and have been shown to improve patient outcomes. Such pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care. In 2011, we published the Columbia University Medical CenterNew York Presbyterian Hospital – Clinical Pathways for Acute Coronary Syndromes and Chest Pain. This algorithm includes primary percutaneous coronary intervention for all patients with ST-segment elevation myocardial infarction and an early invasive approach for patients with non–ST-segment elevation myocardial infarction. Since our last chest pain algorithm update, the novel antiplatelet agent ticagrelor has been introduced in the United States, resulting in an important revision of our acute coronary syndrome clinical pathways. Herein, we present our updated chest pain algorithm and provide rationale for the changes that we have made to our protocol.

In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which includes primary percutaneous intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2008, there have been changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. In particular, recent data on the novel antiplatelet agent prasugrel, dosing of clopidogrel after PCI, and interactions with clopidogrel and other medicines and substrates, which can lead to decreased platelet response to clopidogrel, have led us to update our ACS clinical pathway. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI, and provide rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care.

In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2003, there have been numerous changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.

Objectives:Significant variation in emergency department (ED) patient arrival rates necessitates the adjustment of staffing patterns to optimize the timely care of patients. This study evaluated the effectiveness of a queueing model in identifying provider staffing patterns to reduce the fraction of patients who leave without being seen.

In acute ST elevation myocardial infarction (STEMI), rapid reperfusion of the infarcted artery improves cardiovascular outcomes; however, many hospitals have difficulty achieving recommended times. We hypothesized that a Rapid-Response Alphanumeric Paging Design (RAPiD) would reduce door-to-balloon time for primary percutaneous coronary intervention (PCI) in STEMI.

Objectives:During a widespread North American blackout in August 2003, the authors identified a cluster of patients presenting to their northern Manhattan emergency department (ED) with complaints related to medical device failure. The characteristics of this group with respect to presenting complaint, type of device failure, time spent in the ED, and disposition are described in an effort to better understand the resource needs of this population. Methods:This was a retrospective chart review for all patients evaluated in an urban teaching ED during a 24‐hour period spanning the duration of regional power failure. Charts for patients presenting with medical device failure as part of their triage complaint were abstracted. Results:Twenty‐three of 255 patients coming to the ED during the 24‐hour period presented with medical device failure. Nineteen of the device failures were due to nonfunctioning oxygen conservers, three to ventilator failure, and two to airway suction device failure (one patient had two devices fail). Thirteen of these patients were admitted to the hospital and accounted for 22% of all admissions during the study interval. Discharged patients spent a mean of 15.1 hours (range: 3.8–24.4 hours) in the ED. Conclusions:Patients using electrical medical devices seek care in the ED when power failure occurs, and they require significant ED and hospital resources. Effective disaster planning should anticipate the needs of this population.

Several letters to the editor are presented in response to articles in previous issues including an article comparing the late U.S. President John F. Kennedy with U.S. President George W. Bush from the July 2, 2007 issue, the article about communal dining by Lisa McLaughlin in the June 25, 2007 issue, and the essay "Demoting the Dog," by Lisa Cullen in the July 2, 2007 issue.

Objective:To assess the efficacy of soft cervical collars in the early management of whiplash‐injury‐related pain.

Perioperative errors potentially can lead to the failure of endosseous implants. Such errors are easily avoidable when appropriate attention is given to the regional anatomy and the application of sound surgical principles. Obeying the tenets of good surgical technique (inherent in all surgical operations) should not be difficult for the oral and maxillofacial surgeon. Errors made preoperatively, postoperatively, and in the restorative stages of implant reconstruction can lead to case failure. Intraoperative surgical misadventures that interfere with osseointegration or implant alignment are critical factors that determine treatment outcome.

Several letters to the editor are presented in response to articles in previous issues including an article comparing the late U.S. President John F. Kennedy with U.S. President George W. Bush from the July 2, 2007 issue, the article about communal dining by Lisa McLaughlin in the June 25, 2007 issue, and the essay "Demoting the Dog," by Lisa Cullen in the July 2, 2007 issue.

A team from the dental school at the Medical College of Virginia/Virginia Commonwealth University notes that removing multiple intraoral sutures in heart patients can pose certain risks in “Suture Removal-Induced Bacteremia: A Possible Endocarditis Risk.”