ABSTRACTS

but this s tudy provides some ECG criteria that, when pres- ent, can be relied on as indicators of acute or prior myocar- dial infarction in the setting of LBBB.]

Gregory C Cover, MD -

embolism, fat, femur fracture

Fat e m b o l i s m in p a t i e n t s w i t h an i so la ted f r a c t u r e of t h e femora l sha f t Ten Duis H J, Nijsten MWN, Klasen H J, et at J Trauma 28:383-390 Mar 1988

The fat embol ism syndrome consists of a complex in- cluding respiratory distress, cerebral disturbances, and pe- t ech iae af ter one or m o r e long bone f rac tures , bu t consistent risk factors remain unclear. One hundred seven- ty-two consecutive patients (age range, 16 to 65 years) with isolated fracture of the femoral shaft were studied prospec- tively with individuals having moderate and severe accom- panying injuries excluded. Two main groups were distin- guished: those who had a closed fracture and were initially treated conservat ively (nondecompressed group) and pa- tients who had an open or closed fracture but were sur- gically decompressed within 24 hours (decompressed group). C l i n i c a l fat e m b o l i s m deve loped on ly in the non- decompressed group, with an incidence of 4%. This group also showed significantly higher temperatures, decreased pulse rates, progressive hemoglobin decrease, and fracture location more proximal (P < .025) than the other patients in the nondecompressed group. It was concluded that tem- perature elevations to levels of 38.5 C or more within the first 24 hours after injury combined with a fracture of the femoral shaft just proximal to the isthmus seem to have some predictive value for the development of fat embolism.

Cynthia Elliott, MD

publication, academic promotion

A c a d e m i c p r o m o t i o n at a m e d i c a l schoo l Batshaw ML, Plotnick LP, Petty BG, et al N Engl J Med 318:741-747 Mar 1988

A retrospective study of promotions at Johns Hopkins University School of Medicine over a five-year period was conducted to assess promotion likelihood based on career orientation (clinician-teacher vs researcher) and publication record. Promotion of candidates to the rank of associate pro- fessor was approved 93% of the time and to professor 79% of the time. There was no significant difference in promo- tion probabilities between career-orientation groups unless clinician-teacher resignations were considered. In this case, overall promotion rate of clinician-teachers declined from

94% to 70% (P = .001). This is of interest as 28% of those who did resign prior to consideration for promotion feared they would not be promoted. The mean age at time of pro- motion to associate professor was 39 years and to professor, 45 years. Faculty promoted to associate professor had pro- duced an average of 23 total publications in peer review journals with an average of ten as first author, and an aver- age of 11 total articles in the three years prior to promotion consideration. The totals of first author and recent publica- tion numbers were approximately twice as high in these three categories for promoted faculty as for nonpromoted faculty. It was concluded that career choice did not affect timing or probability of academic promotion at this institu- tion, but publ icat ion records of p romoted versus non- promoted facul ty were dis t inct ively different. /Editor's n o t e : It is clear that at this institution the clinician-teach- ers mus t have a significant number of publications in order to be promoted. Therefore, the challenge for emergency medicine faculty in academic institutions is to achieve this goal while providing clinical care and teaching on line, in some instances 24 hours per day, often with very l imited numbers. It is a formidable, but not impossible, challenge that mus t be me t for long-term survival of the specialty,]

Michael Hunt, MD

chest pain, compliance

Pat ien ts w i t h a c u t e c h e s t pain w h o leave e m e r g e n c y d e p a r t m e n t s a g a i n s t m e d i c a l a d v i c e Lee TH, Short LW, Brand DA, et al J Gen Intern Med 3:21-24 Jan/Feb 1988

A study of 107 emergency department patients from three university and four communi ty hospitals who signed out against medical advice (AMA) in the course of being evalu- ated for acute chest pain was performed. Clinical data, in- cluding history, physical examination, and ECG, were re- ceived by the physic ian as part of a s tandard protocol . Nonadmitted patients were considered,to have left AMA when the note of the evaluating physician described dis- charge AMA. When the 107 patients were compared with those in the control groups of patients and discharged pa- tients, statistically significant differences were found for many clinical choice characteristics and for the likelihood of death w i th in 72 hours of presentation to the ED. Com- pared with 321 matched control patients who were admit- ted, patients leaving AMA were significantly younger; were less likely to describe pain as pressure, to be diaphoretic, to have prior history of angina or myocardial infarction; or to have evidence of ischemia or infarction not known to be present on previous ECGs. Compared with patients who were discharged, patients who left AMA were more likely to be male, to present within four hours after onset of pain, to describe pain as pressure, and to have prior history of

178/1256 Annals of Emergency Medicine 17:11 November 1988