provider type and sex on empir”>1918 Correspondence / American Journal of Emergency Medicine 36 (2018) 1895–1921

admission systolic blood pressure b 90 mm Hg (OR 5.788, P b 0.001) and independently predicted massive APE after covariate adjust- ment (OR 2.454, P = 0.03) [5]. Therefore, syncope is not only one of the signs of APE (occurring in ~12% of the cases), it may indicate a high-risk APE, and so missing the diagnosis can theoretically lead to a grave outcome if anticoagulation is not timely given. While the multiple studies investigating the prognostic value of syncope in APE do not re- port increased in-hospital mortality, this could possibly be explained by physicians beginning anticoagulation therapy immediately upon di- agnosis, thereby preventing early deaths/complications. In the Costantino Study, at 90 days follow up, APE was identified in b1% of pa- tients with syncope at index presentation, however, there are no further details regarding their clinical profile at 90days (e.g. oxygen require- ments, right ventricular dysfunction…etc.). Additionally, there was no reporting of mortality at 90 days.

Untreated APE carries risk of death from effect of original event as well as recurrent thromboembolism. So, what should we do? We agree with avoiding routine imaging to rule out APE in Patients with syncope but to rather approach this scenario on a case by case basis to avoid both extremes mainly to prevent hazards of radiation, contrast al- lergy/nephropathy, over diagnosis and over treatment, and at the same time to avoid a False sense of security that may lead to missing a case of high-risk APE, especially in subjects presenting with syncope without a clear alternative diagnosis, continued hemodynamic instability and sus- picious patients’ history.

Hesham R. Omar

Internal Medicine Department, Mercy Medical Center, Clinton, IA, USA

Corresponding author.

E-mail address: [email protected] (H.R. Omar).

Mehdi Mirsaeidi

Division of Pulmonary, Critical Care, Sleep and Allergy, University of Miami,

Miller School of Medical, FL, USA Section of Pulmonary, Department of Medicine, Miami VA Medical Center,

Miami, FL, USA

Devanand Mangar

Tampa General Hospital, FGTBA and TEAMHealth, Tampa, FL, USA

Enrico M. Camporesi

University of South Florida, FGTBA and TEAMHealth, Tampa, FL, USA

11 February 2018

https://doi.org/10.1016/j.ajem.2018.02.037

References

1. Prandoni P, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med 2016;375(16):1524-31.
2. Verma AA, et al. Pulmonary embolism and deep venous thrombosis in patients hospi- talized with syncope: a multicenter cross-sectional study in Toronto, Ontario, Canada. JAMA Intern Med 2017;177(7):1046-8.
3. Costantino G, et al. Prevalence of pulmonary embolism in patients with syncope. JAMA Intern Med; 2018.
4. Oqab Z, Ganshorn H, Sheldon R. Prevalence of pulmonary embolism in patients pre- senting with syncope. A systematic review and meta-analysis. Am J Emerg Med 2017. https://doi.org/10.1016/j.ajem.2017.09.015.
5. Omar HR, et al. Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism. Am J Emerg Med 2018;36(2):297-300.

   Effect of provider type and sex on empiric treatment of STD infections in Adolescent patients

   Teens and young adults have the highest rates of sexually trans- mitted infections (STIs) of any age group [1]. Emergency depart- ments (EDs) are a key point of access to care for many of these patients. When adolescents present with symptoms suggestive of an STI, the Centers for Disease Control and Prevention (CDC) recom- mends Routine testing for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT), liberal antibiotic treatment, and close outpatient follow-up [1]. Previous studies have shown the CDC’s suggestions are not always put into action, and there are no specific guidelines for ED providers [2-5]. The unpredictable diagnostic and treatment patterns of practitioners can lead to underrecognized GC and CT in- fections, delay in treatment for patients, and lingering consequences of the STI infection itself. This study sought to quantify the frequency of these missed GC and CT cervical infections in adolescent females tested in the ED, to describe and compare the characteristics of those treated and not treated during their initial presentation, and to characterize the influence of ED provider type and gender on the empiric treatment of STIs.

   We conducted a retrospective cohort analysis over a period of

   28 months in three academic medical centers, including one children’s hospital. The study included female ED patients ages 12-19 who were tested for GC/CT. Specimens were collected using cervical swabs and diagnoses made using Polymerase chain reaction assays. The turnaround time for study results was approximately 24 h among participating hospitals. Exclusion criteria included patients with a repeat infection involving the same pathogen, sexual assault victims, and patients that left against medical advice or refused treatment. The cohort was divided into groups based on PCR result (STI+ or -) and treatment status (em- pirically treated in the ED or not). Groups were compared on the basis of presenting signs and symptoms and final discharge diagno- ses. Descriptive statistics (mean, SD) and frequency tables were used to describe clinical findings and demographic characteristics. Overall sensitivity of empiric treatment for suspected GC/CT was determined. Accuracy of empiric treatment (% of treated patients found to be STI+) was compared based on provider type (attending/ resident/and midlevel provider) and gender. Groups were compared using 2-tailed unpaired t-tests and Wilcoxon rank sum tests for contin- uous and ordinal data, while nominal data were analyzed by x² test or 2- tailed Fisher’s exact test.

   During the study period, 1303 adolescent females were evaluat- ed for STIs by 81 different ED providers. A total of 121 patients (9.3%) had a positive PCR test for GC and/or CT; 40 (33.1%) did not receive empiric treatment in the ED. Sensitivity of providers’ ability to predict a positive test result based on their decision to treat empirically was found to be 66.9% (95% CI: 58.5 to 75.3%). No signif- icant differences were found between provider types and gender. Overall, 412 adolescents were treated empirically in the ED; 331 (80.3%) had subsequent negative PCR studies for GC and/or CT. Factors such as age, ethnic background, IUD use, previous STI, or known STI exposure were not associated with treatment in the ED. Treated patients were more likely to complain of an abnormal vaginal discharge (p b 0.01) or urinary symptoms (p b 0.01). Untreated patients were more likely to have a discharge diagnosis of nonspecific abdominal or pelvic pain, pregnancy related issues, or abnormal Vaginal bleeding. On ED discharge 68.9% of the patients empirically treated were given home-going instructions on STI; 23% were given instructions on safe sex practices. Of the 40 adolescent patients with an STI who left untreated in the ED, 15 (37.5%) were lost to follow-up.

   Correspondence / American Journal of Emergency Medicine 36 (2018) 1895–1921 1919

   In our study population, one-third of adolescent females found to have either GC or CT were not treated in the ED. This falls within the scope of a previous review which found that anywhere from 27.4- 86.0% of females who were infected with CT, GC, or both were not treat- ed in the ED [6]. The sensitivity of providers’ ability to predict a positive test result based on decision to treat empirically was 67%. This too is comparable to a previous study which found provider judgement for empiric treatment for an STI had a sensitivity of 67.6% [5]. While Wiest et al. found that provider type (physician vs. midlevel provider) significantly influenced treatment [2], we found no significant differ- ences in treatment accuracy of patients based on provider type or gen- der. Of all patients empirically treated, 80% turned out to be negative for GC/CT and thus would be considered over-treated. This was higher than previous studies in which 25% and 45% of patients that tested negative for an STI were treated empirically [2,4]. Future research should empha- size point-of-contact testing, better mechanisms for contact and follow- up after ED discharge, and improved treatment policies.

   Erica Tavares, MD¹

   Michigan State University College of Human Medicine, Department of

   Emergency Medicine, United States Department of Emergency Medicine, Spectrum Health Hospitals,

   United States

   Lindsey Ouellette, MPH²

   Michigan State University College of Human Medicine, Department of

   Emergency Medicine, United States

   Junwen Law, MD¹ Timothy Joseph, MD¹ Jennifer Zhan, MD¹ Christopher Ardary, MD¹

   Michigan State University College of Human Medicine, Department of

   Emergency Medicine, United States Department of Emergency Medicine, Spectrum Health Hospitals,

   United States

   Adam Nicholson, MD¹

   Department of Emergency Medicine, Helen DeVos Children’s Hospital,

   United States

   Jeffrey Jones, MD?

   Michigan State University College of Human Medicine, Department of

   Emergency Medicine, United States Department of Emergency Medicine, Spectrum Health Hospitals,

   United States

   ?Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids,

   MI 49503, United States.

   E-mail address: [email protected] (J. Jones).

   https://doi.org/10.1016/j.ajem.2018.03.003

   References

   Workowski KA, Bolan GA. Centers for disease control and prevention. Sexually trans- mittED diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(3):1-137.

6. Wiest DR, Spear SJ, Bartfield JM. Empiric treatment of gonorrhea and chlamydia in the ED. Am J Emerg Med 2001;19(4):274-5.
7. Anaene M, Soyemi K, Caskey R. Factors associated with the over-treatment and under-treatment of gonorrhea and chlamydia in adolescents presenting to a public hospital emergency department. Int J Infect Dis 2016;53:34-8.
8. Krivochenitser R, Bicker E, Whalen D, Norman C, Jones JS. Adolescent patients with sexually transmitted infections: who gets lost to follow-up? J Emerg Med 2014; 47(5):507-12.
9. Breslin K, Tuchman L, Hayes KL, et al. Sensitivity and specificity of empiric treatment for sexually transmitted infections in a pediatric emergency department. J Pediatr 2017;189:48-53.
10. Jenkins WD, Zahnd W, Kovach R, Kissinger P. Chlamydia and gonorrhea screening in United States emergency departments. J Emerg Med 2013;44(2):558-67.

    Medical toxicology education in US emergency medicine residencies

    Medical toxicology (TOX), a core content area of the American Board of Emergency Medicine [1] and an American Board of Medical Special- ties (ABMS) recognized subspecialty of Emergency Medicine (EM), Pediatrics, and Preventive Medicine [2] focuses on the “diagnosis, man- agement, and prevention of poisoning and other adverse effects due to medications, occupational and environmental toxicants and biological agents” [3] The importance of TOX training has long been recognized. In 1983, the American College of Emergency Physicians declared that “Emergency physicians should be qualified to render toxicologic care, and that they should be prepared by training and by facility organiza- tions to fulfill this function.” [4] There is limited literature describing US-emergency medicine (EM)-resident TOX education and training. We sought to describe this education through a survey of EM-residency- program directors.

    Program and assistant program directors of the 164 Accreditation Council for Graduate Medical Education (ACGME)- approved US-EM- residency programs in the 2015-2016 academic year were asked to describe TOX-curriculum; the duration and nature of the rotation (mandatory/elective, activities), location of the rotation (b1 h. drive from home institution), the number of full-time -board-certified/eligible TOX faculty affiliated with the program, the number of TOX lectures given to residents each year outside of a TOX rotation, and the number of graduates pursuing TOX fellowship in the preceding 5 years. Re- sponses were anonymous with the exception of program identification to prevent duplication of responses. For non-respondents, the residency website was queried whether a mandatory or elective rotation was part of the curriculum, the duration of the rotation, and the number of board-certified/eligible-full-time TOX faculty affiliated with the residency program. Information was obtained for all 164 ACGME-approved-EM- residency programs.

    ¹ 15 Michigan St NE Suite 701, Grand Rapids, MI 49503, United States.

    

    ² 15 Michigan St NE 736, Grand Rapids, MI 49503, United States.

    Fig. 1. Toxicology rotations offered in EM residencies.