An additional physician significantly reduced the length of stay of medical emergency department outpatients.

In the present study, we assessed the incidence of adverse events and influenza-like symptoms in a working population in Switzerland that was vaccinated against influenza. A total of 12,582 individuals of working age (<65 years old) were offered a free influenza vaccine of their choice (injectable or intranasal vaccine) in October and November 2000. Of these individuals, 1600 were vaccinated against influenza. Ninety-seven percent of the vaccine recipients chose the intranasal vaccine, and 3% chose the injectable influenza vaccine. The incidence of influenza-like symptoms and side effects was 13% and 36%, respectively. Individuals who chose the intranasal vaccine were more likely to report side effects (OR, 3.23; 95% CI, 1.29-8.08). Facial paralysis was observed in 11 patients and was the most severe adverse event associated with the intranasal influenza vaccine. As a result of these adverse events, the intranasal vaccine was removed from the market in the fall of 2001.

OBJECTIVE:To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain. DESIGN:Prospective observational study. SETTING:General medical outpatient clinic in a university teaching hospital. PARTICIPANTS:One hundred ninety new, consecutive patients with a mean age of 44 years (SD ‫؍‬ 14 years, range 30-58 years) with a main complaint of abdominal or chest pain. MEASUREMENTS AND MAIN RESULTS:The preliminary diagnosis, established on the basis of patient history and physical examination, was compared with a final diagnosis, obtained after workup at completion of the chart. A nonorganic cause was established in 66 (59%) of 112 patients with abdominal pain and in 65 (83%) of 78 with chest pain. The preliminary diagnosis of "nonorganic" versus "organic" causes was correct in 79% of patients with abdominal pain and in 88% of patients with chest pain. An "undoubted" preliminary diagnosis predicted a correct assessment in all patients with abdominal pain and in all but one patient with chest pain. Overall, only 4 patients (3%) were initially incorrectly diagnosed as having a nonorganic cause of pain rather than an organic cause. In addition, final nonorganic diagnosis ( n ‫؍‬ 131) was compared with long-term follow-up by obtaining information from patients and, if necessary, from treating physicians. Follow-up information, obtained for 71% of these patients after a mean of 29 months (range 18-56 months) identified three other patients that had been misdiagnosed as having abdominal pain of nonorganic causes. Compared with follow-up, the diagnostic accuracy for nonorganic abdominal and chest pain at chart completion was 93% and 98%, respectively. CONCLUSIONS:A preliminary diagnosis of nonorganic versus organic abdominal or chest pain based on patient history and physical examination proved remarkably reliable. Accuracy was almost complete in patients with an "undoubted" preliminary diagnosis, suggesting that watchful waiting can be recommended in such cases. bdominal and chest pain are among the most frequent main complaints of patients in ambulatory care.

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Gaze evoked amaurosis in dysthyroid orbitopathyEDITOR,-Gaze evoked amaurosis is an uncommon symptom usually associated with intraconal masses such as cavernous haemangioma 1 or optic nerve sheath meningioma.2 3 Patients describe transient loss of vision in eccentric positions of gaze with full recovery of vision on returning to the primary position. The cases previously published have all been unilateral. We describe a case of bilateral gaze evoked amaurosis in a patient with dysthyroid orbitopathy. CASE REPORTA 62 year old smoker gave a 12 month history of transient bilateral loss of vision on upgaze associated with supraorbital discomfort. His hobby was flying radio controlled model aeroplanes but after crashing two of these during amaurotic episodes he presented to an ophthalmologist. Two years previously he had required admission for cardiac failure associated with thyrotoxicosis but after treatment with iodine-131 and carbimazole his thyroid status had been stabilised.Ophthalmic examination revealed symmetrical axial proptosis (26 mm), restriction of upgaze, and lid signs consistent with dysthyroid orbitopathy. In primary position the corrected distance acuities were 6/6 in both eyes with 17/17 Ishihara colour plates seen and full visual fields. On upgaze the distance acuities were reduced to less than 6/60 with none of the Ishihara colour plates seen. The intraocular pressures (IOP) increased from 20 mm Hg (both eyes) in primary position to 30 mm Hg (right eye) and 31 mm Hg (left eye) in elevation. Pupil examination using infrared pupillography showed 0.20 mm dilatation of both pupils and 15% reduction in light reflex amplitude on upgaze compared with the primary position. The disc and fundal appearances were normal and did not change with direction of gaze. On general examination the patient had pretibial myxoedema but appeared clinically euthyroid.The pattern VEP in both eyes was normal in the primary position but reduced in amplitude on upgaze (Fig 1A). Fluorescein angiography showed normal perfusion of the optic disc and retina both in primary position and in upgaze. Orbital computed tomography revealed moderate enlargement and oedema in all extraocular muscles; no tumour or other mass lesion was present (Fig 2). The patient was treated with oral steroids (prednisolone 40 mg/day). One month later there was symptomatic improvement, 2-3 mm less proptosis, and the distance acuities had improved to 6/36 (right eye) and 6/60 (left eye) on upgaze. There was no change in the IOP rise associated with elevation of the eyes. The pupils dilated less on upgaze (0.05 mm) and there was less attenuation of the light reflex amplitude (5%) compared with before treatment. The pattern VEP showed improvement on upgaze (Fig 1B) compared with before treatment. The steroid dose was tapered oV over the next 6 months with no relapse of his symptoms. The patient has now returned to his hobby of flying model aeroplanes. COMMENTThe visual loss in this patient was transient, reversible, and related to the position of the globe in ...