The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients

BACKGROUND:Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients.The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes(such as acute pulmonary edema necessitating endotracheal intubation).We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefi t from volume resuscitation.DATA RESOURCES:We performed a search using PubMed,Scopus,and MEDLINE.The following search terms were used:fluid responsiveness,ultrasound,non-invasive,hemodynamic,fluid challenge,and passive leg raise.Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient’s cardiovascular ability to respond to intravenous fl uid administration using ultrasound.RESULTS:Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava,common carotid artery,subclavian vein,internal jugular vein,and femoral vein.Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients.CONCLUSION:Ultrasound in combination with passive leg raise is a non-invasive,costand time-effective modality that can be employed to assess volume status and response to fluid resuscitation.Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava,and internal jugular vein.A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.

Experimental Study of Assessment on Ventricular Activation Origin and Contraction Sequence by Doppler Tissue Imaging

To evaluate the possibility and accuracy of Doppler tissue image (DTI) on assessment of normal and abnormal ventricular activation and contraction sequence, 9 open chest canine hearts were analyzed by acceleration mode, M mode, and spectrum mode DTI. Our results showed that: (1) Acceleration mode DTI could show the origin of activation and conduction sequence on line; (2) M mode DTI revealed that the activation in mid interventricular septum was earlier than that in mid left ventricular posterior wall at sinus activation; (3) Spectrum DTI showed the ventricular endocardium was activated earlier than the ventricular epicardium in all segments at sinus rhythm. The earliest site of activation of the normal ventricular wall was at middle interventricular septum; the latest site was at basal posterior wall; the contraction sequence was different at the different walls; (4) During abnormal ventricular activation, mid left ventricular posterior wall was activated earliest in accordance with the pacing sites. Abnormal ventricular activation was slower than sinus activation, and the contraction sequence varied at different sites of ventricular wall. It is concluded that DTI can be used to localize the origin of normal or abnormal myocardial activation and to assess the contraction sequence conveniently, accurately and non invasively.

T-cell/histiocyte-rich large B-cell lymphoma in a child:A case report and review of literature

T-cell/histiocyte-rich large B-cell lymphoma is uncommon in children population. There were few cases reported in the literature with wide range clinical presentations including advanced stage, and more involvement of liver, spleen and bone marrow. Head and neck lymphadenopathy tends to present in younger children. We report a case of 10-year-old boy who initially presented intermittent fever, headaches and neck lymphadenopathy. Subsequently, he developed diffuse lymphadenopathy and hepatosplenomegaly. T-cell/histiocyte-rich large B-cell lymphoma was diagnosed on a cervical lymph node biopsy. Cervical lymphadenopathy in this age group is most commonly reactive or nonmalignant processes. Lymphoma is much less frequent; mainly are non-Hodgkin lymphomas. However, a subset of large B-cell lymphoma called T-cell/histiocyte-rich B-cell lymphoma is rare in children.

Patient care during interfacility transport:a narrative review of managing diverse disease states

BACKGROUND:When critically ill patients require specialized treatment that exceeds the capability of the index hospitals,patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care.Therefore,appropriate and efficient care for patients during the process of transport between two hospitals(interfacility transfer)is an essential part of patient care.While medical adverse events may occur during the interfacility transfer process,there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.METHODS:We conducted searches from the PubMed,Cumulative Index of Nursing and Allied Health(CINAHL),and Scopus databases up to June 2022.Two reviewers independently screened the titles and abstracts for eligibility.Studies that were not in the English language and did not involve critically ill patients were excluded.RESULTS:The search identified 75 articles,and we included 48 studies for our narrative review.Most studies were observational studies.CONCLUSION:The review provided the current evidence-based management of diverse disease states during the interfacility transfer process,such as proning positioning for respiratory failure,extracorporeal membrane oxygenation(ECMO),obstetric emergencies,and hypertensive emergencies(aortic dissection and spontaneous intracranial hemorrhage).

Effects of USPSTF guidelines on patterns of screening and treatment outcomes for prostate cancer

The updated United States Preventive Services Task Force(USPSTF) for prostate cancer in 2012 recommends against prostate-specific antigen(PSA) based screening for men of all ages. Prostate cancer is the second most common and second most deadly cancer in American men. PSA screening for prostate cancer has been present since 1994 leading to an over diagnosis and over treatment of low volume disease. There is an overall agreement of men towards the guidelines but even with the understanding of the USPSTF, these men tend to follow more personal beliefs that have been influenced by their knowledge of the disease process and physician influence. Physicians also followed the directions of the patients and opted not to change their current practice of PSA screening despite the new guidelines. Time, legal, and ethical issues were some of the barriers that physicians faced in tailoring their practice towards screening. The importance of informed consent is highlighted by both the patients and the physicians and clearly more effective when the patient was pre-informed of the disease processand prompted the physicians to initiate conversation of informed screening. Younger patients were inclined towards aggressive treatment and older patients opted towards watchful waiting both with emphasis on the importance of evidence-based information provided by the physician. Decision aids were useful in making informed decisions and could be used to educate patients on screening purposes and treatment options. However, even with well-created decision aids and physician influence, patients' own belief system played a major part in healthcare decision making in either screening or treatment for prostate cancer.

Synovial osteochondromatosis of the temporomandibular joint: A case report

BACKGROUND Synovial osteochondromatosis is a rare but benign condition that can result in significant impairment of joint functionality.This case report documents an uncommon presentation of this disorder occurring within the temporomandibular joint,causing the patient significant pain,trismus,and difficulty with daily activities such as eating and speaking.A review of the literature including disease mechanisms and previously documented cases is included to provide comprehensive background for clinical decision-making.CASE SUMMARY A 48-year-old male patient presented with a 3-mo history of trismus,crepitus with jaw movement and significant pain while chewing.Physical examination revealed a firm mass and tenderness to palpation at the right temporomandibular joint.Further workup revealed a bilobed mass extending into the joint space as well as significant bony erosion of the glenoid fossa.The patient underwent mass excision with joint reconstruction and pathology revealed synovial osteochondromatosis.The patient reported significant improvement in his symptoms postoperatively.CONCLUSION This report outlines the investigative approach and treatment course of synovial osteochondromatosis.The positive outcome following surgical intervention in this case emphasizes the importance of interdisciplinary collaboration and the potential for improvement in quality of life of this patient population.

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers

BACKGROUND:Traumatic cardiac arrest(TCA)is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system.Although there have been advances in treatment modalities,survival rates for TCA patients remain low.This narrative literature review critically examines the indications and eff ectiveness of current therapeutic approaches in treating TCA.METHODS:We performed a literature search in the PubMed and Scopus databases for studies published before December 31,2022.The search was refi ned by combining search terms,examining relevant study references,and restricting publications to the English language.Following the search,943 articles were retrieved,and two independent reviewers conducted a screening process.RESULTS:A review of various studies on pre-and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm.There were conflicting results regarding other prognostic factors,such as witnessed arrest,bystander cardiopulmonary resuscitation(CPR),and the use of prehospital or in-hospital epinephrine.Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma.Resuscitative endovascular balloon occlusion of the aorta(REBOA)provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock.When implemented in the setting of aortic occlusion,emergency thoracotomy and REBOA resulted in comparable mortality rates.Veno-venous extracorporeal life support(V-V ECLS)and veno-arterial extracorporeal life support(V-A ECLS)are viable options for treating respiratory failure and cardiogenic shock,respectively.In the context of traumatic injuries,V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.CONCLUSION:TCA remains a signifi cant challenge for emergency medical services due to its high morbidity and mortality rates.Pre-and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures.Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment effi cacy and ameliorate survival outcomes.

Interactions between hepatic iron and lipid metabolism with possible relevance to steatohepatitis

The liver is an important site for iron and lipid metabolism and the main site for the interactions between these two metabolic pathways. Although conflicting results have been obtained, most studies support the hypothesis that iron plays a role in hepatic lipogenesis. Iron is an integral part of some enzymes and transporters involved in lipid metabolism and, as such, may exert a direct effect on hepatic lipid load, intrahepatic metabolic pathways and hepatic lipid secretion. On the other hand, iron in its ferrous form may indirectly affect lipid metabolism through its ability to induce oxidative stress and inflammation, a hypothesis which is currently the focus of much research in the field of nonalcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH). The present review will first discuss how iron might directly interact with the metabolism of hepatic lipids and then consider a new perspective on the way in which iron may have a role in the two hit hypothesis for the progression of NAFLD via ferroportinand the iron regulatory molecule hepcidin. The review concludes that iron has important interactions with lipid metabolism in the liver that can impact on the development of NAFLD/NASH. More defined studies are required to improve our understanding of these effects.

The SHP-2 tyrosine phosphatase:Signaling mechanisms and biological functions

Cellular biological activities are tightly controlled by intracellular signaling processes initiated by extracellular signals. Protein tyrosine phosphatases, which remove phosphate groups from phosphorylated signaling molecules, play equally important tyrosine roles as protein tyrosine kinases in signal transduction. SHP-2, a cytoplajsmic SH2 domain containing protein tyrosine phosphatase, is involved in the signaling pathways of a variety of growth factors and cytokines. Recent studies have clearly demonstrated that this phosphatase plays an important role in transducing signal relay from the cell surface to the nucleus, and is a critical intracellular regulator in mediating cell proliferation and differentiation.

Clinical Significance of Left Atrial Anatomic Abnormalities Identified by Cardiac Computed Tomography

Purpose: The clinical significance of newly identified left atrial anatomic abnormalities (LAAA)— accessory appendages, diverticula, septal pouches—by multidetector CT (MDCT) remains unclear. Similar anatomical outpouchings, i.e., the left atrial appendage, have been associated with cardioembolisms and arrhythmia. To test the hypothesis that LAAA are also associated with increased risk of these events, we performed a retrospective analysis to examine the association of LAAA in patients undergoing CT with embolic events and arrhythmia. Methods: 242 patients (mean age 56 SD 12 years, 41% female) were selected who had CT coronary angiography performed with 64-row MDCT between 2007 and 2012 if complete clinical history records were available. CT images were independently reviewed for the presence of LAAA. Association of cerebrovascular accident (CVA) or transient ischemic attack (TIA), atrial fibrillation, and palpitations to LAAA was calculated using odds ratios (OR) with 95% confidence interval (CI) and Fisher’s exact test. Results: After adjusting for age, sex, hypertension, dyslipidemia and diabetes via multiple logistic regression, patients with accessory appendages are more likely to have reported palpitations (OR: 1.80;CI: 1.03 - 3.16). Patients with diverticula and septal pouches are significantly older than those without these abnormalities (p = 0.01 and p = 0.02, respectively). Septal pouches are associated with diabetes (OR: 2.29;95%CI: 1.15 - 4.54). Conclusions: Accessory left atrial appendages are associated with palpitations. Patients with septal pouches and diverticula are significantly older than those patients without these anatomic abnormalities, suggesting age dependency of these findings. None of these anatomic abnormalities were associated with thromboembolic events after adjustment for potentially confounding comorbidities.

Detection of adrenal mass during an educational point-of-care ultrasound in the emergency department

Dear editor,Incidental adrenal mass is a common radiological finding that is mostly detected in abdominal computed tomography (CT) scans.^([1]) Though pheochromocytomas are a relatively rare chromaffin cell tumor,they are a"cannot miss"diagnosis,as they can be fatal.

Emergency department approach to monkeypox

BACKGROUND:Monkeypox(mpox) is a viral infection that is primarily endemic to countries in Africa,but large outbreaks outside of Africa have been historically rare.In June 2022,mpox began to spread across Europe and North America,causing the World Health Organization(WHO) to declare mpox a public health emergency of international concern.This article aims to review clinical presentation,diagnosis,and prevention and treatment strategies on mpox,providing the basic knowledge for prevention and control for emergency providers.METHODS:We conducted a review of the literature using PubMed and SCOPUS databases from their beginnings to the end of July 2023.The inclusion criteria were studies on adult patients focusing on emerging infections that described an approach to a public health emergency of international concern,systematic reviews,clinical guidelines,and retrospective studies.Studies that were not published in English were excluded.RESULTS:We included 50 studies in this review.The initial symptoms of mpox are non-specific:fever,malaise,myalgias,and sore throat.Rash,a common presentation of mpox,usually occurs 2–4 weeks after the prodrome,but the presence of lymphadenopathy may distinguish mpox from other infections from the Poxviridae family.Life-threatening complications such as pneumonia,sepsis,encephalitis,myocarditis,and death can occur.There are documented co-occurrences of human immunodeficiency virus(HIV) and other sexually transmitted infections that can worsen morbidity.CONCLUSION:The initial presentation of mpox is non-specific.The preferred treatment included tecovirimat in patients with severe illness or at high risk of developing severe disease and vaccination with two doses of JYNNEOS.However,careful history and physical examination can raise the clinicians’ suspicion and point toward a prompt diagnosis.There are diff erent modalities to prevent and treat mpox infection.

Hypertensive emergency versus preeclampsia in a patient with sickle cell disease:a case report

Sickle cell disease(SCD)is strongly associated with severe preeclampsia and has also been linked to poor pregnancy-related outcomes.Moreover,sickle cell nephropathy(SCN)is a common complication of SCD and results in chronic proteinuria.Pregnant patients with SCD who present to the emergency department(ED)with pulmonary edema,hypertension,and proteinuria may suffer from a hypertensive emergency with or without preeclampsia.Without prior lab work to determine whether a patient’s proteinuria or kidney dysfunction is new or at baseline,it may be impossible for the emergency physician to determine which diagnosis is more likely.Thus,amultidisciplinary approach which involves cardiology,nephrology,medicine and obstetrics consultations should be utilized to help direct treatment.We present the case of a 39-yearold patient with SCD,who was also 26 weeks pregnant,and presented to the ED with markedly elevated blood pressure and dyspnea.Although she was initially admitted to the obstetrics ward for blood pressure management given concern for preeclampsia,she was ultimately diagnosed with hypertensive emergency and sickle cell nephropathy.

Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia

BACKGROUND:The Pediatric Infectious Disease Society(PIDS)and Infectious Disease Society of America(IDSA)published an evidence-based guideline for the treatment of uncomplicated communityacquired pneumonia(CAP)in children,recommending aminopenicillins as the first-line therapy.Poor guideline compliance with 10%–50%of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported.A new clinical practice guideline(CPG)was implemented in our emergency department(ED)for uncomplicated CAP.The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre-and post-CPG implementation.METHODS:Prior to CPG-implementation,an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline.A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous(IV)antibiotics in the ED at Children’s National Health System pre-and post-CPG implementation.RESULTS:ED providers were aware of the PIDS/IDSA guideline recommendations,with 86.4%of survey responders selecting ampicillin as the initial antibiotic of choice.However,only 41.2%of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin(P<0.01).There was no statistically signifi cant increase in ampicillin prescribing post-CPG(P=0.40).CONCLUSIONS:Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP;however,this knowledge does not translate into clinical practice.Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.

Cervical instability in Klippel-Feil syndrome:case report and review of the literature

Background: The authors present a case of cervical myelopathy and radiculopathy in the setting of multiple Klippel-Feil syndrome abnormalities treated surgically with a single-level C3-C4 anterior cervical discectomy and fusion.We discuss the clinical presentation, radiographic findings, and various treatment options for cervical spine abnormalities in Klippel-Feil syndrome.Case Presentation: This 22-year-old female with Klippel-Feil syndrome presented with intermittent neck pain, left upper extremity weakness, and paresthesias.Preoperative MRI, CT, and X-rays of the cervical spine revealed anterolisthesis at C3/4 with unstable movement on flexion and extension imaging.In addition, there were multiple segmental fusion abnormalities including hemivertebrae and other congenital fusion abnormalities.A C3-C4 anterior cervical discectomy and fusion was performed with intervertebral disc spacer.Adequate decompression was achieved with postoperative resolution of the patient's symptoms and improvement in neurological exam.Conclusions: Single-level anterior cervical discectomy and fusion can be utilized for treatment of cervical myelopathy and radiculopathy in the setting of multiple congenital Klippel-Feil syndrome abnormalities.

ONECUT2 as a key mediator of androgen receptorindependent cell growth and neuroendocrine differentiation in castration-resistant prostate cancer

Despite androgen dependence in a majority of castration-resistant prostate cancers,some cancer cells are independent of androgen receptor(AR)function,a feature of heterogeneity in prostate cancer.One of the aggressive variants of prostate cancer that are AR independent is neuroendocrine prostate cancer(NEPC).This manuscript will focus on the new finding of human one cut domain family member 2(ONECUT2)transcription factor and its role in castration resistance,especially in NEPC.

Current laser therapy options for endoscopic treatment of upper tract urothelial carcinoma

Endoscopic management via retrograde ureteroscopic laser ablation of upper tract urothelial carcinoma(UTUC)has become the preferred treatment modality for low-risk tumors.The most popular ablative lasers over the past 15-20 years have been the holmium:yttrium-aluminum-garnet(Ho∶YAG)and neodymium(Nd∶YAG)lasers,but recently the thulium(Th∶YAG)laser has emerged as a potential alternative.This review compares the mechanism of action,physiological properties and effects,and oncologic outcomes of Ho∶YAG/Nd∶YAG lasers versus the Th∶YAG laser for UTUC treatment.Potential advantages of the Th∶YAG laser over existing technologies are outlined,followed by a discussion of emerging laser technologies in UTUC management.

Hypoxic Hepatitis: A Review and Clinical Update

Hypoxic hepatitis (HH),also known as ischemic hepatitis or shock liver,is characterized by a massive,rapid rise in serum aminotransferases resulting from reduced oxygen delivery to the liver.The most common predisposing condition is cardiac failure,followed by circulatory failure as occurs in septic shock and respiratory failure.HH does,however,occur in the absence of a documented hypotensive event or shock state in 50% of patients.In intensive care units,the incidence of HH is near 2.5%,but has been reported as high as 10% in some studies.The pathophysiology is multifactorial,but often involves hepatic congestion from right heart failure along with reduced hepatic blood flow,total body hypoxemia,reduced oxygen uptake by hepatocytes or reperfusion injury following ischemia.The diagnosis is primarily clinical,and typically does not require liver biopsy.The definitive treatment of HH involves correction of the underlying disease state,but successful management includes monitoring for the potential complications such as hypoglycemia,hyperglycemia,hyperammonemia and hepatopulmonary syndrome.Prognosis of HH remains poor,especially for cases in which there was a delay in diagnosis.The in-hospital mortality rate is >50%,and the most frequent cause of death is the predisposing condition and not the liver injury itself.