Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice.

INTRODUCTION: Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F-TEE), so we trained and credentialed all of the physicians in our group. METHODS: We trained 52 EPs to perform and interpret F-TEEs using a 4-h simulator-based course. We kept a database of all F-TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics. RESULTS: Emergency physicians attempted 557 total F-TEE examinations (median = 10, interquartile range = 5-15) during the 42-month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F-TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%-96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%-95%). Indications for F-TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication. CONCLUSION: After initiating a mandatory group F-TEE training and credentialing program, we report the largest series to date of EP-performed resuscitative F-TEE. The majority of F-TEE examinations (75%) were performed by EPs without advanced US training beyond residency.

Effects of SiO2, SrO, MgO, and ZnO dopants in tricalcium phosphates on osteoblastic Runx2 expression.

Calcium phosphate materials share a compositional similarity to natural bone, which makes them excellent for use in orthopedic applications. Although these materials are osteoconductive, they lack strong osteoinductive capabilities and recent research has focused on the addition of biologics and pharmacologics with varying successes. In this study, trace elements that have been proven to play important roles in bone health and bone formation were incorporated into ß-tricalcium phosphate compacts in their oxide forms (SiO2, ZnO, SrO, and MgO). Cell material interactions were characterized using human fetal preosteoblastic cells. An MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide) assay was used to evaluate cellular proliferation. Cellular differentiation was evaluated using an enzymatic colorimetric alkaline phosphatase assay as well as immunohistochemistry for Runt-related transcription factor 2 (Runx2) expression. Results prove ZnO and MgO to be effective mitogenic factors and SiO2, ZnO, and SrO to be capable of inducing rapid cellular differentiation. MgO was found to have little effect on the modulation of osteoblastic differentiation, likely due to more aggressive inherent cellular regulation of Mg(2+). In addition to the results from the study, a signaling mechanism is proposed as to the action of the dopants for further consideration.