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Background Streptococcus pneumoniae is a causative agent of community-acquired pneumonia (CAP). The 13-valent pneumococcal conjugate vaccine (PCV13) has significantly decreased the burden of PCV13-serotype pneumococcal disease; however, disease from nonvaccine serotypes remains substantial. A recent study documented the persistence of PCV13 serotypes among US adults hospitalized with radiographically confirmed CAP. The current analysis used a recently developed urinary antigen detection (UAD) assay (UAD2) to extend these results to additional serotypes included in an investigational PCV20 vaccine. Methods This prospective study enrolled adults aged ≥18 years hospitalized with radiographically confirmed CAP between October 2013 and September 2016. Presence of S pneumoniae was determined by blood and respiratory sample culture, BinaxNOW urine testing, and UAD. In addition to Quellung on cultured isolates when available, serotypes were identified from urine specimens using UAD1 for PCV13 serotypes and UAD2 for 7 PCV20-unique serotypes (8, 10A, 11A, 12F, 15B, 22F, and 33F) and 4 additional serotypes (2, 9N, 17F, and 20). Results Among 12 055 subjects with radiographically confirmed CAP, 1482 were positive for S pneumoniae. PCV13- and PCV20-unique serotypes were associated with 37.7% (n = 559) and 27.0% (n = 400) of cases, respectively; 288 subjects were exclusively diagnosed as positive for S pneumoniae by UAD2. Demographic and clinical disease characteristics were similar between subjects with CAP caused by PCV13 and PCV20-unique serotypes. Conclusions The current analysis using UAD2 identified a sizeable proportion of hospitalized adult CAP associated with PCV20-unique serotypes. PCV20 may therefore address the burden of CAP caused by the additional serotypes present in the vaccine., A novel urinary antigen detection assay substantially increased detection of non-pneumococcal conjugate vaccine 13 (PCV13) serotypes included in an investigational PCV20 among US adults with community-acquired pneumonia (CAP). PCV20 may address the burden of CAP due to the additional serotypes.

Background and Purpose: Early detection of large vessel occlusion (LVO) stroke optimizes endovascular therapy and improves outcomes. Clinical stroke severity scales used for LVO identification have variable accuracy. We investigated a portable LVO-detection device (PLD), using electroencephalography and somatosensory-evoked potentials, to identify LVO stroke. Methods: We obtained PLD data in suspected patients with stroke enrolled prospectively via a convenience sample in 8 emergency departments within 24 hours of symptom onset. LVO discriminative signals were integrated into a binary classifier. The National Institutes of Health Stroke Scale was documented, and 4 prehospital stroke scales were retrospectively calculated. We compared PLD and scale performance to diagnostic neuroimaging. Results: Of 109 patients, there were 25 LVO (23%), 38 non-LVO ischemic (35%), 14 hemorrhages (13%), and 32 stroke mimics (29%). The PLD had higher sensitivity (80% [95% CI, 74–85]) and similar specificity (80% [95% CI, 77–83]) to all prehospital scales at their predetermined high probability LVO thresholds. The PLD had high discrimination for LVO ( C -statistic=0.88). Conclusions: The PLD identifies LVO with superior accuracy compared with prehospital stroke scales in emergency department suspected stroke. Future studies need to validate the PLD’s potential as an LVO triage aid in prehospital undifferentiated stroke populations.

A vulvar hematoma is a hemorrhagic fluid collection in the female external genitalia. The majority occur as an obstetrical complication, especially during labor. Non-obstetrical vulvar hematomas are usually the result of trauma, with coitus being the most common etiology.We present the case of a 25-year-old woman with significant vaginal pain and swelling after vigorous sexual intercourse. She exhibited tenderness and swelling of the left labia majora and minora. The differential diagnosis included bleeding, abscess, and deep venous thrombosis. Laboratory studies were normal and computed tomography of the pelvis indicated the swelling was most likely due to blood. The patient was taken to the operating room, and approximately 150 cubic centimeters of clot was evacuated. The patient had an uneventful recovery and was discharged home the next day.This case illustrates the unique presentation and challenges in making the diagnosis of vulvar hematoma.

In 2004, 2009, and 2014, we examined the number of endowed faculty positions in academic departments of emergency medicine (ADEMs).We sought to survey ADEMs regarding the current number of endowed faculty positions and compare the results over time.A survey was emailed to the chairs of all ADEMs belonging to the Association of Academic Chairs of Emergency Medicine or identified by the Association of American Medical Colleges. We requested the following information: number of endowed chairs and professorship positions; the amount required to fund; the amount allowed to be spent annually; the date established; and the names of the positions.One hundred chairs responded out of a total of 109 ADEMs, for a response rate of 92%. Thirty-eight ADEMs (38%) reported having a total of 55 endowed chair positions. Twenty-six ADEMs (26%) reported having a total of 37 endowed professorships. The most common amount required to fund an endowed chair was $2 million to $2.5 million, and $1 million for an endowed professorship. The majority of ADEMs were allowed to spend 4-5% of the value of the endowment annually.Forty-six individual ADEMs (46%) reported having at least one endowed faculty position compared with only 30 in 2014 and only 19 in 2009. The total number of endowed faculty positions in ADEMs was 92 in the current study compared with 53 in 2014, 25 in 2009, and only 9 in 2004.

Awareness about food allergy and food-induced anaphylaxis (FIA) has increased dramatically over the past decade. It remains unclear, however, whether concordance with guidelines for FIA management has improved over time.Our objective was to describe changes in emergency department (ED) concordance with guidelines for FIA management.We analyzed data from 2 multicenter retrospective studies of patients with food-related acute allergic reactions seen in 1 of 17 EDs during 2 time periods: 1999 to 2001 and 2013 to 2015. Visits were identified similarly across years-for example, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.60, 995.61-995.69, 995.0, and 995.3. Anaphylaxis was defined as an acute allergic reaction with involvement of 2+ organ systems or hypotension. We compared concordance between time periods for 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for an epinephrine autoinjector (EAI), (3) referral to an allergist/immunologist, and (4) instructions to avoid offending allergen.We compared 290 patients with FIA during 1999 to 2001 and 459 during 2013 to 2015. Any treatment with epinephrine (pre-ED or in the ED) for patients with FIA increased over time (38% vs 56%; P.001). Prescriptions for EAI at discharge (24% vs 54%; P.001) and documentation for referral to an allergist/immunologist (14% vs 24%; P = .001) approximately doubled, whereas instructions to avoid the offending allergen did not change significantly (37% vs 43%; P = .08). Receipt of 3+ guideline recommendations remained low but almost quadrupled over the study interval (6% vs 23%; P.001).Over the nearly 15-year study interval, we observed clinically and statistically significant increases in ED concordance with epinephrine-related guidelines for FIA. Management gaps remain and interventions to standardize care still appear warranted.

Background Few studies have measured the burden of adult pneumococcal disease after the introduction of 13-valent pneumococcal conjugate vaccine (PCV13) into the US infant vaccination schedule. Further, most data regarding pneumococcal serotypes are derived from invasive pneumococcal disease (IPD), which represents only a fraction of all adult pneumococcal disease burden. Understanding which pneumococcal serotypes cause pneumonia in adults is critical for informing current immunization policy. The objective of this study was to measure the proportion of radiographically-confirmed (CXR+) community-acquired pneumonia (CAP) caused by PCV13 serotypes in hospitalized US adults. Methods This observational, prospective surveillance study recruited hospitalized adults aged ≥18 years from 21 acute care hospitals across 10 geographically-dispersed cities in the United States between October 2013 and September 2016. Clinical and demographic data were collected during hospitalization. Vital status was ascertained 30 days after enrollment. Pneumococcal serotypes were detected via culture from the respiratory tract and normally-sterile sites (including blood and pleural fluid). Additionally, a novel, Luminex-based serotype-specific urinary antigen detection (UAD) assay was used to detect serotypes included in PCV13. Results Of 15,572 enrolled participants, 12,055 eligible patients with CXR+CAP were included in the final analysis population. Mean age was 64.1 years and 52.7% were aged ≥65 years. Common comorbidities included chronic obstructive pulmonary disease (43.0%) and diabetes mellitus (28.6%). PCV13 serotypes were detected in 552/12,055 (4.6%) of all patients and 265/6347 (4.2%) of those aged ≥65 years. Among patients aged 18–64 years PCV13 serotypes were detected in 3.8–5.3% of patients depending on their risk status. Conclusions After implementation of a pneumococcal conjugate vaccination program in US children, and despite the herd protection observed in US adults, a persistent burden of PCV13-type CAP remains in this population.

Background Changes in emergency department (ED) concordance with guidelines for the management of stinging insect-induced anaphylaxis (SIIA) are not known. Objective To describe temporal changes in ED concordance with guidelines for the management of SIIAs. Methods We analyzed data from 2 multicenter retrospective studies of patients with stinging insect-related acute allergic reactions seen in 1 of 14 North American EDs during 2 periods: 1999 through 2001 and 2013 through 2015. Visits were identified similarly across studies (eg, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 989.5, 995.0, and 995.3). Anaphylaxis was defined as an acute allergic reaction with involvement of at least 2 organ systems or hypotension. We compared concordance between periods with 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for epinephrine auto-injector, (3) referral to an allergist/immunologist, and (4) instructions to avoid the offending allergen. Results We compared 182 patients with SIIA during 1999 to 2001 with 204 during 2013 to 2015. Any treatment with epinephrine (before arrival to the ED or in the ED) increased over time (30% vs 49%; P P P = .002), and instructions to avoid the offending allergen did not change (23% vs 24%; P = .94). Receipt of at least 3 guideline recommendations increased over time; however, the comparison was not statistically significant (10% vs 16%; P = .15). Conclusion During the nearly 15-year study interval, we observed increased ED concordance with epinephrine-related guideline recommendations for the management of SIIA. Reasons for the decrease in allergy/immunology referrals merit further study.

Background In 2013, milestone ratings became a reporting requirement for emergency medicine (EM) residency programs. Programs rate each resident in the fall and spring on 23 milestone subcompetencies. Objective This study examined the incidence of straight line scoring (SLS) for EM Milestone ratings, defined as a resident being assessed the same score across the milestone subcompetencies. Methods This descriptive analysis measured the frequencies of SLS for all Accreditation Council for Graduate Medical Education (ACGME)–accredited EM programs during the 2015–2016 academic year. Outcomes were the frequency of SLS in the fall and spring milestone assessments, changes in the number of SLS reports, and reporting trends. Chi-square analysis compared nominal variables. Results There were 6257 residents in the fall and 6588 in the spring. Milestone scores were reported for 6173 EM residents in the fall (99% of 6257) and spring (94% of 6588). In the fall, 93% (5753 residents) did not receive SLS ratings and 420 (7%) did, with no significant difference compared with the spring (5776 [94%] versus 397 [6%]). Subgroup analysis showed higher SLS results for residents' first ratings (183 of 2136 versus 237 of 4220, P < .0001) and for their final ratings (200 of 2019 versus 197 of 4354, P < .0001). Twenty percent of programs submitted 10% or more SLS ratings, and a small percentage submitted more than 50% of ratings as SLS. Conclusions Most programs did not submit SLS ratings. Because of the statistical improbability of SLS, any SLS ratings reduce the validity assertions of the milestone assessments.

Author(s): Weingart, Gregory S.; Glueckert, Lindsey; Cachaper, Girlyn A.; Zimbro, Kathie S.; Maduro, Ralitsa S.; Counselman, Francis | Abstract: Introduction: Since hoverboards became available in 2015, 2.5 million have been sold in theUS. An increasing number of injuries related to their use have been reported, with limited data onassociated injury patterns. We describe a case series of emergency department (ED) visits forhoverboard-related injuries.Methods: We performed a retrospective chart review on patients presenting to 10 EDs insoutheastern Virginia from December 24, 2015, through June 30, 2016. We used a free-textsearch feature of the electronic medical record to identify patients documented to have the word“hoverboard” in the record. We reported descriptive statistics for patient demographics, types ofinjuries, body injury location, documented helmet use, injury severity score (ISS), length of stay inthe ED, and ED charges.Results: We identified 83 patients in our study. The average age was 26 years old ( 18 months to 78years). Of these patients, 53% were adults; the majority were female (61.4%) and African American(56.6%). The primary cause of injury was falls (91%), with an average ISS of 5.4 (0-10). The majorityof injuries were contusions (37.3%) and fractures (36.1%). Pediatric patients tended to have morefractures than adults (46.2% vs 27.3%). Though 20% of patients had head injuries, only one patientreported using a helmet. The mean and median ED charges were $2,292.00 (SD $1,363.64) and$1,808.00, respectively. Head injuries resulted in a significantly higher cost when compared to otherinjuries; median cost was $2,846.00.Conclusion: While the overall ISS was low, more pediatric patients suffered fractures comparedto adults. Documented helmet use was low, yet 20% of our population had head injuries.Further investigation into proper protective gear and training is warranted.

Objectives The American Board of Emergency Medicine (ABEM) has introduced a new testing format for the oral certification examination (OCE): the enhanced oral or "eOral" format. The purpose of this study was to perform initial validity analyses of the eOral format. The two hypotheses were: 1) the case content in the eOral format was sufficiently similar to clinical practice and 2) the eOral case materials were sufficiently similar to clinical practice. The eOral and traditional formats were compared for these characteristics. Methods This was a prospective survey study. The survey was administered as a voluntary postexamination activity at the end of the 2015 spring (April 25-27) and fall (October 10-13) ABEM OCEs. The survey is a routine part of the ABEM oral examination experience. For 2015, two additional questions were added to gauge the similarity of the eOral format to clinical practice. Validity was defined by content and substantive elements within Messick's model of construct validity as well as portions of Kane's validity model. Results Of the 1,746 physicians who took the oral examination, 1,380 physicians (79.0%) completed all or part of the study survey questions. The majority of respondents agreed the patient presentations in the cases were similar (strongly agreed or agreed) to cases seen in clinical practice, in both the traditional cases (95.1%) and the eOral cases (90.1%). Likewise, the majority of respondents answered that the case materials (e.g., laboratory, radiographs) were similar (strongly agreed or agreed) to what they encounter in clinical practice, both in the traditional format (85.8%) and in the eOral cases (93.7%). Conclusions Most emergency physicians reported that the types of cases tested in the traditional and eOral formats were similar to cases encountered in clinical practice. In addition, most physicians found the case materials to be similar to what is seen in clinical practice. This study provides early validity evidence for the eOral format.

We present the case of a 75-year-old man with vague symptoms and hypotension found to be in electrical storm secondary to sustained ventricular tachycardia. The patient did not respond to intravenous amiodarone, magnesium, lidocaine, or four cardioversion attempts. This case illustrates the challenges in managing patients with electrical storm presenting to the emergency department.

Background: Copperhead snakes (Agkistrodon contortrix) are considered as the least toxic of the North American pit vipers. The reported incidence of coagulopathy from copperhead envenomation is variable, possibly secondary to regional variation in subspecies and venom potency. Coagulation studies are often obtained when evaluating for the coagulopathic effects of copperhead venom, but the clinical utility of these indices is unclear. The aim of this study was to determine the prevalence of hematologic toxicity due to copperhead envenomation in hospitalized patients.Methods: This was a multi-center retrospective chart review study using electronic hospital data between January 1, 2006 and December 31, 2016 evaluating prevalence of coagulopathy following copperhead envenomation. Patients presenting to one of three major academic tertiary care centers in Virginia with suspected copperhead envenomation were identified using medical billing codes. The primary outcome was to summarize the prevalence of hematologic toxicity including thrombocytopenia, elevated prothrombin or partial thromboplastin times, or hypofibrinogenemia.Results: There were 244 cases used for final analysis. Hematologic toxicity occurred in 14% (95% CI 10-18%) of patients. Specific indices included thrombocytopenia in 1.2% (95% CI 0.4-3.6%), hypofibrinogenemia in 0.7% (95% CI 0.0-3.8%), elevated PT in 10.0% (95% CI 6.8-14.5%), and aPTT in 3.9% (95% CI 2.1-7.2%) of patients. There was no clinically significant bleeding reported in any case.Conclusions: Subtle hematologic abnormalities due to copperhead envenomation in patients treated in the Commonwealth of Virginia were relatively common, but do not appear to be clinically significant in this study population.

OBJECTIVE As part of the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program, ABEM-certified physicians are required to pass the Continuous Certification (ConCert) examination at least every 10 years. With the 2015 ConCert examination, ABEM sought to better understand emergency physicians' perceptions of the benefits of preparing for and taking the examination and the career benefits of staying ABEM-certified. METHODS This was a prospective survey study. A voluntary postexamination survey was administered at the end of the 2015 ABEM ConCert examination (September 21-26, 2015). Physicians were asked about the benefits of preparing for the examination and maintaining ABEM certification. Examination performance was compared to perceptions of learning and career benefits. RESULTS Of the 2,601 on-time test takers, 2,511 respondents participated (96.5% participation rate). The majority of participants (92.0%) identified a benefit to preparing for the ConCert examination, which included reinforced medical knowledge (73.9%), increased knowledge (66.8%), and making them a better clinician (39.4%). The majority of respondents (90.8%) identified a career benefit of maintaining ABEM certification, which included more employment options (73.8%), more positively viewed by other physicians (56.8%), and better financial outcomes (29.8%). There was a statistically significant association between the perception of knowledge reinforcement and examination performance (p < 0.001). There was also a statistically significant association between the perception that staying certified created more career opportunities and examination performance (p < 0.001). CONCLUSIONS Most emergency physicians identified benefits of preparing for and taking the ABEM ConCert examination, which included reinforcing or adding medical knowledge and making them better clinicians. Most physicians also found career benefits to remaining ABEM-certified, which included greater employment choices, higher financial compensation, and higher esteem from other physicians. The belief that preparing for and taking the examination reinforced medical knowledge was associated with better examination performance.

Background We aimed to compare the diagnostic accuracy of the Alere Triage Cardio3 Tropinin I (TnI) assay (Alere, Inc., USA) and the PathFast cTnI-II (Mitsubishi Chemical Medience Corporation, Japan) against the central laboratory assay Singulex Erenna TnI assay (Singulex, USA). Methods Using the Markers in the Diagnosis of Acute Coronary Syndromes (MIDAS) study population, we evaluated the ability of three different assays to identify patients with acute myocardial infarction (AMI). The MIDAS dataset, described elsewhere, is a prospective multicenter dataset of emergency department (ED) patients with suspected acute coronary syndrome (ACS) and a planned objective myocardial perfusion evaluation. Myocardial infarction (MI) was diagnosed by central adjudication. Results The C-statistic with 95% confidence intervals (CI) for diagnosing MI by using a common population (n=241) was 0.95 (0.91-0.99), 0.95 (0.91-0.99), and 0.93 (0.89-0.97) for the Triage, Singulex, and PathFast assays, respectively. Of samples with detectable troponin, the absolute values had high Pearson (R(P)) and Spearman (R(S)) correlations and were R(P)=0.94 and R(S)=0.94 for Triage vs Singulex, R(P)=0.93 and R(S)=0.85 for Triage vs PathFast, and R(P)=0.89 and R(S)=0.73 for PathFast vs Singulex. Conclusions In a single comparative population of ED patients with suspected ACS, the Triage Cardio3 TnI, PathFast, and Singulex TnI assays provided similar diagnostic performance for MI.

Objectives To maintain certification by the American Board of Emergency Medicine (ABEM), physicians are required to pass the Continuous Certification (ConCert) examination at least every 10 years. On the 2014 ConCert postexamination survey, ABEM sought to understand the manner in which ABEM diplomates prepared for the test and to identify associations between test preparation approaches and performance on the ConCert examination. Methods This was a cross-sectional survey study. The survey was administered at the end of the 2014 ConCert examination. Analyses included chi-square and linear regression to determine the association of preparation methods with performance. Results Of the 2,431 on-time test-takers, 2,338 (96.2%) were included. The most commonly used study approach was the review of written materials designed for test preparation (1,585; 67.8%), followed by an online training course (1,006; 43.0%). There were 758 (32.4%) physicians who took a single onsite board review course, while 41 (1.8%) took two or more onsite courses. Most physicians (1,611; 68.9%) spent over 35 hours preparing for the ConCert examination. The study method that was most associated with favorable test scores was the review of written materials designed for test preparation (p < 0.001). Attending an onsite preparation course was associated with poorer performance (p < 0.001). There was a significant association between no additional preparation and failing the examination (chi-square with Yates correction; p = 0.001). Conclusions A substantial majority (97.8%) of physicians taking the 2014 ABEM ConCert examination prepared for it. The majority of physicians used written materials specifically designed for test preparation. Reviewing written materials designed for test preparation was associated with the highest performance.

Background The American Board of Emergency Medicine (ABEM) convened a summit of stakeholders in Emergency Medicine (EM) to critically review the ABEM Maintenance of Certification (MOC) Program. Objective The newly introduced American Board of Medical Specialties (ABMS) 2015 MOC Standards require that the ABMS Member Boards, including ABEM, “engage in continual quality monitoring and improvement of its Program for MOC …” ABEM sought to have the EM community participate in the quality improvement process. Discussion A review of the ABMS philosophy of MOC and requirements for MOC were presented, followed by an exposition of the ABEM MOC Program. Roundtable discussions included strengths of the program and opportunities for improvement; defining, teaching, and assessing professionalism; identifying and filling competency gaps; and enhancing relevancy and adding value to the ABEM MOC Program. Conclusions Several suggestions to improve the ABEM MOC Program were discussed. ABEM will consider these recommendations when developing its next revision of the ABEM MOC Program.

Background In 2004 and 2009, we examined the number of endowed faculty positions in academic departments of Emergency Medicine (ADEMs). Objective We sought to survey ADEMs regarding the number of endowed faculty positions and compare the results to the 2004 and 2009 studies. Methods A survey was e-mailed to the chairs of all ADEMs belonging to the Association of Academic Chairs of Emergency Medicine. We requested information on the following: the number of endowed chair and professorship positions; the amount required to fund; the amount allowed to be spent annually; the date established; and the source of funding. Results Eighty-nine chairs responded (100% response rate). Nineteen chairs reported 1 endowed chair position. One chair reported 2 such positions, and 2 chairs reported 3 positions. One chair reported 4 positions. In total, 23 ADEMs (25.8%) reported 31 endowed chair positions. For endowed professorships, 8 chairs reported 1 professorship each. Four chairs replied that they had 2 positions each and 2 chairs reported 3 positions each. A total of 14 ADEMS (15.7%) reported having 22 endowed professorships. The most common amount required to fund an endowed chair position was $2 million, and $1 million for an endowed professorship. The majority of ADEMs were allowed to spend 4% to 5% of the value of the endowment annually. Conclusion Thirty ADEMs (33.7%) currently have an endowed position, compared to only 19 (26%) 5 years ago. Emergency Medicine now has a total of 53 endowed positions, compared to only 25 such positions in 2009 and just 9 endowed positions in 2004.

We present the case of a 56-year-old man with a history of type 2 diabetes mellitus who presented to the emergency department in diabetic ketoacidosis (DKA) with only a slightly elevated serum glucose. The patient was taking empagliflozin (Jardiance®), a sodium-glucose cotransporter-2 inhibitor. There are increasing reports of this unusual complication in patients taking this class of medication. Emergency physicians need to be aware of this complication, as the euglycemia and history of type 2 diabetes mellitus can make the correct diagnosis of DKA challenging.

Impaired functional status is associated with risk of elder mistreatment. Screening for functional impairment in elderly patients admitted to emergency departments could be performed to identify patients at risk for elder mistreatment who might benefit from further evaluation. This study utilized a modified Identification of Seniors at Risk (ISAR) screening tool to identify the proportion of elderly at risk for mistreatment due to functional difficulties presenting to two emergency departments in southeastern Virginia, one urban, the other rural. Of a 180-patient cohort (90 per site), 82 screened positive (46%), ISAR > 2 (range 0–6), indicating nearly half of all patients enrolled are at risk for mistreatment. Patients presenting to the urban emergency departments were potentially more at risk than their rural counterparts (p

Objectives The initial step in certification by the American Board of Emergency Medicine (ABEM) requires passing a multiple-choice-question qualifying examination. The qualifying examination is typically taken in the first year after residency training. This study was undertaken to determine if a delay in taking the qualifying examination is associated with poorer performance. The authors also examined the relationship between in-training examination scores and qualifying examination scores. Methods This was a pooled time-series cross-section study. Primary measurements were initial qualifying examination scores, the timing of the qualifying examination, and in-training examination scores. The three groups, based on qualifying examination timing, were immediate, 1-year delay, and ≥2-year delay. In-training examination scores were analyzed to determine the relationship between intrinsic ability, examination timing, and qualifying examination scores. For analysis, a generic pooled ordinary least-squares dummy variable model with robust standard errors was used. A pre hoc level of significance was determined to be α < 0.01. Results There were 16,353 qualifying examination test administrations between 2000 and 2012. In-training examination scores were positively correlated with qualifying examination scores (p < 0.001). The group pass rates were 98.9% immediate, 95.6% 1-year delay, and 86.6% ≥2-year delay. After controlling for in-training examination scores, delay taking the qualifying examination of 1 year was associated with a decrease in score of –0.6 (p = 0.003). A delay in taking the qualifying examination ≥2 years was associated with a decrease in score of –2.5 points (p < 0.001). Conclusions After accounting for innate ability using in-training examination scores, delay taking the qualifying examination was associated with poorer performance. This effect was more pronounced if the delay was ≥2 years. Resumen Objetivos El paso inicial en la certificacion por la American Board of Emergency Medicine (ABEM) requiere aprobar un examen de cualificacion (EC) de preguntas de eleccion multiple. El EC se realiza habitualmente en el primer ano tras la formacion de la residencia. Este estudio se llevo a cabo para determinar si un retraso en la realizacion del EC esta asociado con un peor rendimiento. Tambien se examino la relacion entre las puntuaciones del examen durante la formacion (EDF) y las puntuaciones del EC. Metodologia Estudio transversal de series temporales sumatorias. Las mediciones principales fueron las puntuaciones iniciales del EC, el momento del EC y las puntuaciones del EDF. Los tres grupos, basados en el momento del EC fueron: inmediato, un ano de retraso y 2 o mas anos de retraso. Se analizaron las puntuaciones del EDF para determinar la relacion entre la capacidad intrinseca, el tiempo del examen y las puntuaciones del EC. Para el analisis, se utilizo un modelo variable de minimos cuadrados ordinarios sumatorio generico con errores estandar robustos. Se determino un nivel de significacion pre hoc de α < 0,01. Resultados Hubo 16.353 EC entre el 2000 y el 2012. Las puntuaciones del EDF se correlacionaron positivamente con las puntuaciones del EC (p < 0,001). La proporcion de aprobados de cada grupo fue: 98,9% para el grupo inmediato, 95,6% para 1 ano de retraso y 86,6% para 2 o mas anos de retraso. Tras ajustar por las puntuaciones de EDF, el retraso del EC un ano se asocio con un descenso en la puntuacion de -0,6 (p = 0,003). Un retraso de realizacion del EC de 2 o mas anos se asocio con descenso en la puntacion de -2,5 puntos (p < 0,001). Conclusiones Tras tener en cuenta las capacidades innatas mediante las puntuaciones del EDF, el retrasar la realizacion del EC se asocio con un peor rendimiento. Este efecto fue mas pronunciado si el retraso fue ≥ a 2 anos.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residency programs and the residents in them. We present the 2014 annual report on the status of US emergency medicine training programs.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents in those programs. We present the 2013 annual report on the status of US emergency medicine training programs.

The Model of the Clinical Practice of Emergency Medicine (the EM Model) is a three-dimensional representation of the clinical practice of emergency medicine. It is a product of successful collaboration involving the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), the Emergency Medicine Residents' Association (EMRA), the Council of Emergency Medicine Residency Directors (CORD), the Residency Review Committee for Emergency Medicine (RRC-EM), and the American Academy of Emergency Medicine (AAEM). In 2017, the most recent update and revision of the EM Model will be published. This document will represent the culmination of nearly 40 years of evolution, from a simple listing of presenting patient complaints, clinical symptoms, and disease states into a three-dimensional representation of the clinical practice of emergency medicine. These dimensions include conditions and components, physician tasks, and patient acuity. In addition, over the years, two other documents have been developed, the Knowledge, Skills, and Abilities (KSAs) and the Emergency Medicine Milestones. Both serve as related and complementary educational and assessment tools. This article will review the development of the EM Model from its inception in 1979 to today.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2016 annual report on the status of US emergency medicine training programs.

A negative urine pregnancy test in the emergency department traditionally excludes the diagnosis of pregnancy. We report a rare case of ruptured ectopic pregnancy in a patient with a negative urine pregnancy test but with a serum beta-human chorionic gonadotropin (β-hCG) of 10 mIU/mL. The patient developed hemoperitoneum and required laparoscopy by Obstetrics and Gynecology (OB/Gyn). This case highlights the fallibility of the urine pregnancy test in diagnosing early pregnancy.

The 2011 Model of the Clinical Practice of Emergency Medicine. ACADEMIC EMERGENCY MEDICINE 2012; 19:000–000 © 2012 by the Society for Academic Emergency Medicine

Myeloperoxidase (MPO) is proposed for risk stratification in patients with suspected acute coronary syndromes (ACSs). We determined if MPO has diagnostic value in patients being evaluated for ACS.MIDAS was an 18-center prospective study enrolling suspected ACS emergency department patients who presented8 hours after symptom onset and in whom serial cardiac markers and objective cardiac perfusion testing were planned. Blinded MPO (Biosite, Inc, San Diego, CA) and troponin I (Triage Cardio 3; Biosite, Inc) were drawn at arrival, and Troponin I (TnI) was measured at 90, 180, and 360 minutes. Final diagnoses were adjudicated by the local investigator blinded to study assay.Of 1,018 patients, 54% were male, 26% black, with a mean age of 58 ± 13 years. Diagnoses were ACS in 288 (23%) and noncardiac chest pain (NCCP) in 788 (77%). Of patients with ACS, 94 (9.2%) had a myocardial infarction (MI) at presentation (69 non-ST-elevation MI, 25 ST-elevation MI), and 136 had unstable angina. Using a cutpoint of 210 ng/mL to provide 90% specificity, MPO had a sensitivity of 0.18; negative predictive value, 0.69; positive predictive value, 0.47; negative likelihood ratio, 0.91; and a positive likelihood ratio of 1.83 to differentiate ACS and NCCP. Because of the large overlap of quartiles, MPO was not clinically useful to predict serial TnI changes. The C statistics ± 95% CI for MPO differentiating ACS from NCCP and for AMI versus NCCP were 0.629 ± 0.04 and 0.666 ± 0.06, respectively.Myeloperoxidase has insufficient accuracy for decision making in patients with suspected ACS.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency training programs and the residents in those programs. We present the 2011 annual report on the status of US emergency medicine training programs.

A 38-year-old man with a history of schizophrenia presented with pain and swelling of his testicles, with the right side worse than the left. Physical examination was remarkable for a very firm, large, right-sided scrotal mass. Testicular ultrasound was suspicious for neoplasm or abscess. On the pelvic computed tomography (CT) scan, which was obtained as part of a metastatic cancer work-up, two metallic foreign bodies were identified in the pelvis. On further questioning, the patient admitted to ingesting the nails 2 days prior, in a suicide attempt. We review the evaluation of unilateral scrotal pain and swelling, and incidental foreign body ingestion.

A 2-year-old boy was brought to the Emergency Department (ED) with a complaint of 3-week history of increasing lethargy, weight loss, intermittent low grade fever, and right-sided tremor. A non-contrast computed tomography (CT) scan of the head, ordered by the patient's pediatrician, was interpreted as abnormal and the patient was referred to the ED for further evaluation. Physical examination was remarkable for somnolence requiring tactile stimulation to arouse the patient. Neurologic examination revealed right-sided choreoathetosis and unsteady gait. A contrast CT scan of the head demonstrated multiple ring-enhancing lesions throughout the brain and mild to moderate third and lateral ventricular enlargement. In view of the positive purified protein derivative test, chest X-ray study, and gastric aspirates positive for tuberculosis, a diagnosis of intracranial tuberculomas was made. The epidemiology, clinical presentation, diagnostic evaluation, and management of intracranial tuberculomas are reviewed.

Objective This study was conducted to determine if emergency medicine (EM) physicians recognize emergency department (ED) patients with asymptomatic elevated blood pressure (AEBP) by diagnosis, treatment, or referral. The study also evaluated whether differences exist in identification of AEBP based on patient age, sex, race, or insurance status. Methods A retrospective chart review of all adult patients presenting to a tertiary care teaching hospital ED between April 1, 2004, and June 30, 2004, was performed. Patients were included if documented blood pressure(s) were 140/90 mm Hg or higher. Exclusion criteria included age younger than 18 years or older than 89 years, history of hypertension, admission, condition clearly defined by a hypertensive state, or blood pressure lower than 140/90 mm Hg. Results A total of 9805 charts were reviewed; 1574 (16%) patients met inclusion criteria. The average age of our study patient was 38 ± 14 years; 51% were women and 71.8% were African American. Only 112 patients with AEBP (7%) received attention for their elevated blood pressure (ie, diagnosis, treatment, medication prescription, and/or referral). There was no statistically significant difference between patients identified with AEBP and those not recognized by ED physicians by patient age, sex, race, or insurance status. Conclusions Emergency department physicians recognize, treat, and/or refer only a small percentage of ED patients with AEBP. No difference in identification, treatment, or referral exists based on patient age, sex, race, or insurance status.

A 19-year-old woman, 8 days postpartum, presented to the Emergency Department (ED) with a chief complaint of headache, decreased vision, and agitation. Past medical history was unremarkable. Physical examination was remarkable only for dry mucous membranes, decreased visual acuity, and trace pedal edema bilaterally. While in the ED, the patient experienced a generalized tonic-clonic seizure. Computed tomography (CT) scan of the head was suspicious for venous infarction. Magnetic resonance imaging (MRI) and MR venography revealed sagittal sinus and left transverse sinus thrombosis. The risk factors, clinical presentation, diagnostic evaluation, and management of cerebral venous thrombosis are reviewed.