Emergency Department Computed Tomography Use for Non-traumatic Abdominal Pain: Minimal Variability.

INTRODUCTION: Variability in the use of computed tomography (CT) between providers in the emergency department (ED) suggests that CT is ordered on a provider rather than a patient level. We aimed to evaluate the variability of CT ordering practices for non-traumatic abdominal pain (NTAP) across physicians in the ED using patient-visit and physician-level factors. METHODS: We conducted a retrospective study among 6,409 ED visits for NTAP from January 1 to December 31, 2012, at a large, urban, academic, tertiary-care hospital. We used a two-level hierarchical logistic regression model to estimate inter-physician variation. Intraclass correlation coefficient (ICC) was calculated. RESULTS: The hierarchical logistic regression analyses showed that patient-visit factors including younger age, arrival mode by ambulance, prior CT, >79 ED arrivals in the previous four hours, and ultrasound had statistically significant negative associations with physician CT ordering, while surgical team admission and white blood count (WBC) >12.5 K/millimeter cubed (mm3) had statistically significant positive associations with physician CT ordering. With physician-level factors, only physicians with >21 years experience after medical school graduation showed statistical significance negatively associated with physician CT ordering. Our data demonstrated increased CT ordering from the mean in only one out of 43 providers (2.3%), which indicated limited variation across physicians to order CT. After adjusting for patient-visit and physician-level factors, the calculated ICC was 1.46%. CONCLUSION: We found minimal physician variability in CT ordering practices for NTAP. Patient-visit factors such as age, arrival mode, admission team, prior CT, ED arrivals in previous four hours, ultrasound, and WBC count were found to largely influence CT ordering practices.

Unsuspected Clenbuterol Toxicity in a Patient Using Intramuscular Testosterone.

Clenbuterol is a beta-agonist that has been abused by fitness-oriented individuals for muscle growth and weight loss. We report a case of a 46-year-old man who presented tachycardic, hypokalemic, and hyperglycemic after injecting testosterone obtained from Brazil. He developed refractory hypotension and was started on an esmolol infusion for suspected beta-agonist toxicity. Laboratory analysis showed a detectable clenbuterol serum concentration. Analysis of an unopened ampule contained boldenone undecylenate, clenbuterol, and vitamin E. This case illustrates a novel exposure that caused beta-agonist toxicity and was treated successfully with rapid-onset beta blocker.