Benjamin S. Heavrin

Ovarian Vein Thrombosis: A Rare Cause of Abdominal Pain Outside the Peripartum Period

Ovarian vein thrombosis (OVT) is a rare cause of abdominal pain that may mimic a surgical abdomen. The differential diagnosis of OVT includes acute appendicitis, endometritis, pelvic inflammatory disease, pyelonephritis, nephrolithiasis, tubo-ovarian abscess, and ovarian torsion. The complications of OVT, including sepsis and pulmonary embolism, are significant. Diagnosis relies on a careful examination of the radiographic findings. This diagnosis should be considered not only in postpartum patients but also in women with pelvic inflammatory disease, recent abdominal surgery, malignancy, or known hypercoagulable state. In this report we present a case of OVT in a 29-year-old woman presenting with 3 days of sharp left-sided abdominal pain, nausea, and vomiting after bilateral salpingectomy. We then discuss the epidemiology, pathophysiology, and clinical management of OVT.

An evaluation of statewide emergency department utilization following Tennessee medicaid disenrollment

OBJECTIVES During a series of reforms to the Tennessee Medicaid expansion program (TennCare) in 2005, approximately 171,000 adults were disenrolled from Medicaid. The objective of this study was to examine the statewide effect of such a disenrollment on Tennessee emergency department (ED) utilization. METHODS Administrative data on all ED visits in Tennessee from 2004 through 2006 were obtained from the State Emergency Department Database and State Inpatient Database under the Healthcare Utilization Project. Population statistics and uninsured estimates were obtained from the U.S. Census Bureau, and TennCare enrollment data were obtained from the State of Tennessee Department of TennCare. The proportion and rate of ED visits, assessed separately by payer type, were compared across a predisenrollment period from January 1, 2004, through July 31, 2005, and across a postdisenrollment period from August 1, 2005, through December 31, 2006. The proportion and rate of ED visits resulting in hospital admission, again assessed separately by payer type, were compared across the same disenrollment periods in a similar way. We fitted a series of linear models for the total number of ED visits and each proportion and rate, with various degrees of adjustment for seasonality and time trend. RESULTS The mean number of ED visits was 45,662 per week during the predisenrollment period and 44,463 per week during the postdisenrollment period (mean difference = -1,199; 95% confidence interval [CI] -1,722 to -676). By payer category, there was a decrease of 3,119 visits per week by TennCare beneficiaries and an increase of 2,203 per week by the uninsured. After disenrollment, the absolute proportion of ED visits by TennCare beneficiaries significantly decreased by 6.2% (95% CI = -6.6% to -5.8%), and the absolute proportion of uninsured ED visits increased by 5.3% (95% CI = 4.9% to 5.7%). The rate of ED visits by TennCare beneficiaries decreased by -0.091 ED visits/person/year (95% CI = -0.136 to -0.046) in the disenrollment period when controlling for time and seasonality. The rate of ED visits among the uninsured increased by 0.038 ED visits/person/year (95% CI = 0.011 to 0.065) in the postdisenrollment period when controlling for cubic time trend. The proportion of all TennCare ED visits that resulted in hospital admission did not change significantly between the two periods after adjusting for time trend and seasonality. The proportion of uninsured ED visits resulting in hospital admission, however, significantly increased after disenrollment by 2.0% (95% CI = 1.8% to 2.2%) and by 0.6% (95% CI = 0.0% to 1.2%) after adjusting for time and seasonality. CONCLUSIONS The TennCare disenrollment of 2005 was associated with a modest decrease in the number of total ED visits in Tennessee. However, the payer mix among the Tennessee ED population shifted abruptly. The increased rate of ED visits by Tennessees uninsured and the increased proportion of uninsured ED visits leading to hospital admission suggest an increased burden of illness in this highly vulnerable population.

Reply: BAG3 Protein in Advanced-Stage Heart Failure

We appreciate the interest of Dr. De Marco and colleagues in our report [(1)][1] and their interesting observations on the potential use of serum BAG3, possibly in combination with other tests, in monitoring progression of heart failure. We agree that a multiple biomarker approach may add unique

Tracheal Perforation After Thyroidectomy

A 55-year-old woman presented to our Emergency Department with progressively worsening neck swelling, dysphagia, and dyspnea after a coughing fit approximately 3 h before arrival. Her symptoms developed rapidly after the coughing fit. The neck swelling was painful and made breathing difficult. Of note, the patient had a total thyroidectomy for papillary thyroid carcinoma 4 weeks earlier. On examination, vital signs were as follows: temperature 37.2 C (99.0 F) orally, blood pressure 136/88 mm Hg, pulse 92 beats/min, respiratory rate 16 breaths/min, and SaO2 97% on room air. The patient looked uncomfortable but was able to speak normally. A homogeneous neck mass was noted. A picture of the

The National Report Card on the State of Emergency Medicine: Evaluating the Emergency Care Environment State by State 2009 Edition

Editor’s Note: You are reading the seventh installment of Annals of Emergency Medicine Journal Club. This bimonthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers—be they clinicians, academics, residents, or medical students—to critically appraise the literature. During a 2to 3-year cycle, we plan to ask questions that cover the main topics in research methodology and critical appraisal of the literature. To do this, we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue, but they are articles that serve the mission of covering the clinical epidemiology curriculum. Journal Club entries are published in 2 phases. In the first phase, a list of questions about the article is published in the issue in which the article appears. Questions are rated “novice,” ( ) “intermediate,” ( ) and “advanced” ( ) so that individuals planning a journal club can assign the right question to the right student. The answers to this journal club will be published in the June 2009 issue. US residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. International residency directors can gain access to the questions by going to http://www.emergencymedicine. ucla.edu/annalsjc/ and following the directions. Thus, if a program conducts its journal club within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by residents and medical students and discourage regurgitation of the published answers. It is our hope that the Journal Club will broaden Annals of Emergency Medicine’s appeal to residents and medical students. We are interested in receiving feedback about this