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would increase the ED discharge rate and shorten ED length of stay for admitted patients. Methods: We performed a before and after study assessing the disposition of all patients > 35 years old who all patients presenting with chest pain or tightness to 2 hospitals who received a troponin in the ED. Prior to transition to the Roche 5 th generation troponin T (hsTnT), we conducted 2 town halls, in-services with EM, cardiology, emergency medicine and distributed a slide set to all providers. Expert physician advice was also made available to facilitate decisionmaking on an as needed basis. We used a 0-and 2-hour sampling strategy (unless the first value was <6 ng/L) and used cut-points of 19 and 53ng/L to define "ruled out" or "consistent with AMI." Indeterminate values were to be repeated every 2 hours, with rules for delta values provided to the treating care team. Data were collected for 1 year prior to and 2 months after transition to hsTnT. Our main outcome was disposition decision from the ED. Secondary outcome was time from presentation to admission/observation decision (out of concern that more discharges might result in longer ED stays). We present comparisons with 95% confidence intervals (CI) and standard statistical testing. Results: There were 5,234 presentations from 4,295 patients during the preperiod, and 831 presentations from 769 patients in the after period that met study criteria. They were similar with respect to age groups (73.8% versus 75.6% ages 36-64 respectively, p¼0.27), and race (39% white versus 41% white, p¼0.29), but the pre period had fewer males (51% male versus 54 % male, p¼0.02). Compared to the pre-period, after hsTnT conversion, the discharge rate increased (58.7% [55.3-62.2%] v 45.2% [43.8-46.6%] ; p<0.001) without a change in the median time to disposition decision for admitted/obs patients (199.75 min [192.2-207.7] v 199.1 min [177.1-221.8 ]; p¼0.96). Conclusions: The transition hsTnT resulted in an increased number of patients being discharged without increasing the time to admission/obs decision.

Testicular pain has a wide differential and the nonspecific presentation should be triaged rapidly for urgent diagnosis and treatment. Scrotal pyoceles are uncommon collections of purulent fluid between the visceral and parietal tunica vaginalis, usually secondary to acute epididymo-orchitis, intra-abdominal infection, or trauma. Epididymitis and epididymo-orchitis are generally secondary to sexually transmitted infections or urinary tract pathogens. Epidymo-orchitis can compromise the testicular blood supply, leading to a microinfarction and rupture through the tunica albuginea; inflammatory and infectious material then translocate into the tunica vaginalis leading to the formation of a pyocele. Ultrasonography is the preferred method of diagnostic imaging, which can show a classic “falling snow” sign, loculations, or gas. The treatment for a scrotal pyocele is pain control, fluid resuscitation, broad-spectrum antibiotics, and early urology/general surgery consultation. In such cases, Fournier gangrene (FG) should be clinically ruled out and the presence of signs of Fournier gangrene should be met with an urgent surgical consult.

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