Longitudinal Ultrasound-Guided Injection Curriculum for Physical Medicine and Rehabilitation Residents.

ABSTRACT: Physiatrists are increasingly using musculoskeletal ultrasound for both diagnostic and therapeutic purposes. However, a standardized longitudinal curriculum for instructing physical medicine and rehabilitation residents in performing ultrasound-guided interventional procedures has yet to be established. The purpose of this study is to develop and assess the effectiveness of a longitudinal curriculum in training residents to perform common ultrasound-guided musculoskeletal injections using fresh-frozen cadaveric specimens. The course included six weekly hands-on educational sessions, divided by anatomical region, integrated into an established anatomy and physical examination curriculum. After completion of the curriculum, residents reported improved comfort and confidence and displayed improved competence in performing these injections. Other physiatry residency programs should consider implementing longitudinal, hands-on cadaveric training courses to better prepare trainees to perform ultrasound-guided injections as part of their future clinical practice.

Pulmonary embolism prevalence among emergency department cohorts: A systematic review and meta-analysis by country of study.

Essentials The threshold to test for pulmonary embolism (PE) might be lower in North America than Europe. We compared the PE prevalence and positive yield of imaging in Europe and North America. More patients tested in Europe are diagnosed with PE, and imaging is more often positive. Our systematic review supports the hypothesis of overtesting for PE in North America. ABSTRACT: Background There is an impression that North American emergency department (ED) patients tested for pulmonary embolism (PE) differ from European ones. Objectives We compared the PE prevalence, frequency of use, and positive yield of imaging among ED patients tested for PE in Europe and North America. Methods We searched for studies reporting consecutive ED patients tested for PE. Two authors screened full texts, performed risk of bias assessment, and data extraction. We conducted a meta-analysis of proportions for each outcome and a multiple meta-regression. Results From 3109 publications, 44 were included in the systematic review. The prevalence of PE in Europe was 23% (95% confidence interval [CI], 21-26) and in North America 8% (95% CI, 6-9). The adjusted mean difference (aMD) in the prevalence of PE in the European compared with North American studies, was 15% (95% CI, 10-20). Computed tomography pulmonary angiography (CTPA) was used in 60% (95% CI, 52%-68) of European and 38% (95% CI, 24-51) of North American patients tested for PE (aMD, 23% [95% CI, 7-39]). The CTPA diagnostic yield was 29% (95% CI, 26-32) in Europe and 13% (95% CI, 9-17) in North America (aMD, 15% [95% CI, 8-21]). Conclusion Compared with North America, European ED studies have a higher prevalence of PE and diagnostic yield from CTPA, despite a higher frequency of CTPA use among patients tested for PE. This supports the hypothesis that those tested for PE in North American EDs have a lower risk of PE compared with Europe.

Test-retest reliability of near-fibre jiggle in the ulnar intrinsic hand muscles.

OBJECTIVE: Near-fibre (NF) jiggle is one method of measuring the shape variability of motor unit potentials (MUPs) from successive firings during voluntary contractions. MUP shape variability has been associated with neuromuscular stability and health. The purpose of this study was to analyze the test-retest reliability of NF jiggle in the ulnar nerve innervated intrinsic hand muscles of healthy subjects. METHODS: Twenty healthy adult were tested (Mean age = 23.2 ±â€¯1.9; 8 females). Measurements of NF jiggle were assessed with a standard concentric needle during mild-moderate contractions from the first dorsal interosseous (FDI), the abductor digiti minimi (ADM), and the forth dorsal interosseous (4DI) muscles. Test-retest reliability were evaluated using intraclass-correlation coefficient (ICC). RESULTS: NF jiggle showed good test-retest reliability in the FDI, ADM and 4DI muscles with ICC values of 0.86, 0.85, and 0.87, respectively. The SEM for the FDI, ADM, and 4DI were 1.9%, 2.1%, and 2.5%. Finally, the MDC of the FDI, ADM and 4DI were 4.4%, 5.0%, and 7.1%. CONCLUSION: To date, this is the first investigation to explore NF jiggle in the intrinsic hand muscles. NF Jiggle demonstrates good test-retest reliability coefficients and with low measurement error.

Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the ED.

BACKGROUND: Diagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific. OBJECTIVE: We compared the efficacy and safety of using age-adjusted D-dimer interpretation, clinical probability-adjusted D-dimer interpretation and standard D-dimer approach to exclude PE in ED patients. DESIGN/METHODS: We performed a health records review at two emergency departments over a two-year period. We reviewed all cases where patients had a D-dimer ordered to test for PE or underwent CT or VQ scanning for PE. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. We applied the three D-dimer approaches to the low and moderate probability patients. The primary outcome was exclusion of PE with each rule. Secondary objective was to estimate the negative predictive value (NPV) for each rule. RESULTS: 1163 emergency patients were tested for PE and 1075 patients were eligible for inclusion in our analysis. PE was excluded in 70.4% (95% CI 67.6-73.0%), 80.3% (95% CI 77.9-82.6%) and 68.9%; (95% CI 65.7-71.3%) with the age-adjusted, clinical probability-adjusted and standard D-dimer approach. The NPVs were 99.7% (95% CI 99.0-99.9%), 99.1% (95% CI 98.3-99.5%) and 100% (95% CI 99.4-100.0%) respectively. CONCLUSION: The clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value.

Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies.

Guidelines advise performing a computed tomography head scan for all anticoagulated head injured patients, but the risk of intracranial haemorrhage (ICH) after a minor head injury is unclear. We conducted a systematic review and meta-analysis to determine the incidence of ICH in anticoagulated patients presenting with a minor head injury and a Glasgow Coma Score (GCS) of 15. We followed Meta-Analyses and Systematic Reviews of Observational Studies guidelines. We included all prospective studies recruiting consecutive anticoagulated emergency patients presenting with a head injury. Anticoagulation included vitamin-K antagonists (warfarin, fluindione), direct oral anticoagulants (apixaban, rivaroxaban, dabigatran and edoxaban) and low molecular weight heparin. A total of five studies (including 4080 anticoagulated patients with a GCS of 15) were included in the analysis. The majority of patients took vitamin K antagonists (98·3%). There was significant heterogeneity between studies with regards to mechanism of injury and methods. The random effects pooled incidence of ICH was 8·9% (95% confidence interval 5·0-13·8%). In conclusion, around 9% of patients on vitamin K antagonists with a minor head injury develop ICH. There is little data on the risk of traumatic intracranial bleeding in patients who have a GSC 15 post-head injury and are prescribed a direct oral anticoagulant.