Droperidol undermining gastroparesis symptoms (DRUGS) in the emergency department.

BACKGROUND/PURPOSE: Gastroparesis is a syndrome of delayed gastric emptying without obstruction. There are high rates of Emergency Department (ED) visits due to gastroparesis, and this chronic disease is difficult to treat which often leads to hospital admissions. This study aimed to evaluate the impact droperidol administration has on opioid therapy, symptom relief, co-administration of antiemetic and prokinetic medications, disposition, cost, and length of stay (LOS) of patients presenting to the ED. RESULTS: A total of 431 patients were identified and 233 met the inclusion criteria. Droperidol administration reduced the number of patients requiring opioid therapy (108/233 [46%] vs 139/233 [60%], P-value 0.0040), reduced patient-reported pain scales by 4 points, and reduced antiemetic therapy requirement (140/233 [60%] vs 169/233 [73%], P-value 0.0045). No differences were found in terms of ED LOS (Median 6 h [IQR 4-8] vs 5 h [IQR 4-9], P-value 0.3638), hospital LOS (Median 6 h [IQR 4-30 vs 7 h [IQR 4-40], P-value 0.8888), hospital admission rates (67/233 [29%] vs 71/233 [31%], P-value 0.6101), ED cost to the facility (Median $1462 [IQR $1114 - $1986] vs $1481 [IQR $1034 - $2235], P-value 0.0943), or hospital cost (Median $4412 [IQR $2359 - $9826] vs $4672 [IQR $2075 - $9911], P-value 0.3136). CONCLUSION: In patients with gastroparesis presenting to the ED, droperidol reduced opioid use, improved pain control, and decreased antiemetic use without any differences in MME per dose, length of stay, hospital admission rate, or cost.

Evaluation of lung ultrasound to detect volume overload in children undergoing dialysis.

BACKGROUND: Lung ultrasound is a well-established technique to assess extravascular lung water, a proxy for volume status, in the adult population. Despite its utility, the data are limited supporting the use of ultrasound to evaluate fluid volume status among pediatric patients. Our study uses a simplified ultrasound protocol to evaluate changes in extravascular lung water, represented by b-lines, among pediatric patients undergoing hemodialysis. METHODS: This prospective single-center study included children from birth to 18 years of age. The number of b-lines per ml/kg of fluid removed was compared prior to, at the midpoint, and following termination of dialysis. An 8-zone protocol was utilized, and b-lines were correlated to hemoconcentration measured by the CRIT-LINE® hematocrit. RESULTS: Six patients with a total of 26 hemodialysis sessions were included in this study. The b-line measurements post-dialysis were 2.27 (p < 0.001; 94%CI -3.31, -1.22) lower relative to pre-dialysis. The number of b-lines was reduced by 1.69 (p < 0.001; -2.58, -0.80) between pre-dialysis and at the midpoint of dialysis and by 0.58 (p = 0.001; -0.90, -0.24) between the midpoint of dialysis and post-dialysis. A 1 mL/kg fluid loss correlated to a decrease in the original b-lines by 0.079. An inverse relationship (r = -0.54; 95% CI: -0.72, -0.34; p < 0.001) was noted between the b-lines and the patients' hematocrit levels. CONCLUSIONS: A simplified 8-zone ultrasound protocol can assess fluid volume change in real time and correlates with hematocrit levels obtained throughout dialysis. This provides a valuable method for monitoring fluid status in volume overloaded patient populations. A higher resolution version of the Graphical abstract is available as Supplementary information.

Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema.

OBJECTIVES: The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation. METHODS: Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set. RESULTS: A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set. CONCLUSIONS: A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.

A REVIEW OF LAWSUITS RELATED TO POINT-OF-CARE EMERGENCY ULTRASOUND APPLICATIONS.

BACKGROUND: Previous investigators have assessed United States Case Law to evaluate the medicolegal risk surrounding point-of-care ultrasound applications. These studies have suggested that nonperformance is the primary source of an allegation of medical malpractice. OBJECTIVES: The objective of this study is to update the literature regarding medical malpractice cases involving ultrasound applications that could be used at the point of care, and assess the risk conveyed to advanced practice providers and by application of emerging applications of ultrasound. METHODS: Authors reviewed the Westlaw database for medical malpractice cases involving point-of-care ultrasound applications between December 2012 and January 2021. Cases were included if there was an allegation of misconduct by an emergency provider and if an ultrasound included in the American College of Emergency Physicians investigators core, extended, emerging, or adjunct applications was discussed to any degree. Investigators independently reviewed the cases for inclusion. Authors abstracted the case information, type of ultrasound performed, and the specific allegation of misconduct. RESULTS: Nineteen cases met inclusion criteria. Seven cases involved core applications of emergency ultrasound and 13 involved extended, emerging, or adjunct applications. One case was included in both categories as it included elements of both core and extended applications. The most common primary allegation was failure to perform an ultrasound. No cases clearly alleged misinterpretation of a point-of-care ultrasound. CONCLUSION: As previous studies have suggested, nonperformance of ultrasound seems to convey the greatest medicolegal risk. Extended, emerging, or adjunct applications of ultrasound may convey a slightly higher risk.

Ultrasound-Assisted Diagnosis of Embolic Cerebrovascular Accident From Left Atrial Myxoma in the Emergency Department.

BACKGROUND: Acute-onset, unilateral weakness is an alarming presentation due to the possibility of a cerebrovascular accident. When considering cerebrovascular accidents in patients younger than 35 years, emergency physicians should evaluate embolic sources. CASE REPORT: A 28-year-old man with no reported past medical history presented to the Emergency Department with a complaint of acute-onset left-sided hemiparesis and facial droop that started a day prior to arrival. He was stable, had unilateral weakness, hyperreflexia, and slightly slurred speech. He reported no sensory deficits. A computed tomography scan of the head demonstrated areas of ischemia. Patient demographics suggested an embolic source, so point-of-care-ultrasound (POCUS) was performed by emergency practitioners, leading to the discovery of a large, mobile, left atrial mass. After admission and confirmatory imaging, the mass was surgically removed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In young, otherwise healthy individuals, heart masses should be considered as a cause of unexplained stroke-like symptoms. POCUS can identify these masses and expedite care.

Adaptive Cycling.

Adaptive athletes have globally embraced the sport of adaptive cycling, and participation is expanding rapidly on local, national, and international levels. With a diverse array of events supporting adaptive cyclist participation, there is a need to create more awareness about the history and classes of adaptive cycling, adaptive cycle technology, and injuries and medical concerns specific to this group of adaptive athletes. This communication aims to review the major aspects of adaptive cycling, from the technological aspects of both the cycles and adaptations of the athlete to injuries and medical concerns specific to adaptive cyclists.

Cerebral Venous Thrombosis: An Uncommon Cause of Papilledema on Bedside Ocular Ultrasound.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare, difficult-to-diagnose form of venous thromboembolic disease and is considered a type of stroke. Its presentation is highly variable and may be easily confused for more common and less debilitating or life-threatening diagnoses such as migraine, seizure, or idiopathic intracranial hypertension. CASE REPORT: A 25-year-old woman presented with a complaint of bifrontal throbbing headache and blurry vision. A bedside ultrasound of the orbit suggested increased intracranial pressure. A subsequent computed tomography venogram demonstrated a left transverse sinus thrombosis. The patient was started on enoxaparin and admitted for bridging to warfarin and evaluation for hypercoagulable state. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CVT is a rare form of stroke that carries a high rate of mortality and morbidity and masquerades as more common and benign diagnoses. Emergency department bedside ultrasound of the orbit may make the diagnosis of CVT more attainable by identifying patients with increased intracranial pressure.

Ultrasound-Assisted Diagnosis of Optic Neuritis in the Emergency Department: A Case Report.

BACKGROUND: Optic neuritis is a common cause of subacute unilateral vision loss, occurring in 1-5 per 100,000 persons per year. It is more common in Caucasians, women, and those from countries with northern latitudes. Those aged 20-49 years are at greatest risk. The condition arises due to inflammation of the optic nerve. Inflammation may occur due to systemic inflammatory disorders, most commonly multiple sclerosis. CASE REPORT: A 21-year-old African-American male presented to our emergency department with a complaint of painful unilateral vision loss. On examination he was found to have a relative afferent pupillary defect and red desaturation. A bedside ultrasound suggested pseudopapilledema suggestive of optic neuritis. He was admitted to Neurology for confirmation of and treatment for optic neuritis. Magnetic resonance imaging confirmed optic neuritis. The patient was treated with i.v. steroids and discharged after improvement in visual function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Optic neuritis is a clinical diagnosis. The subtle historical components and examination findings make it a diagnostic challenge for the busy emergency physician. Early diagnosis may improve visual outcomes. Discovery of pseudopapilledema on bedside ultrasound may be seen in optic neuritis, and is another finding that emergency physicians may assess for in patient presenting with unilateral vision loss.

Emergency Department Diagnosis of Septic Pulmonary Embolism due to Infectious Endocarditis Using Bedside Ultrasound.

BACKGROUND: Septic pulmonary embolism (SPE) is a rare disorder caused by metastasis of infectious thrombi to the lungs. Most commonly, this occurs as a result of infectious endocarditis. This clinical entity may easily be confused for more common and less mortal diagnoses such as pneumonia, bronchitis, or pulmonary embolism. CASE REPORT: A 47-year-old woman presented in respiratory distress with a complaint of cough productive of rusty sputum, shortness of breath, and pleuritic chest pain. A bedside ultrasound suggested endocarditis and SPE. She was resuscitated and admitted to the hospital for surgical source control and continued i.v. antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SPE is a rare disorder that may be easily missed but carries a high mortality rate. Additionally, the presence of the embolic phenomena makes the diagnosis of infectious endocarditis more attainable in the emergency department (ED). To our knowledge, this case is the first in which ED bedside ultrasound was used to make the diagnosis of SPE due to infectious endocarditis.

Adolescent Pitcher Recovery from Partial Ulnar Collateral Ligament Tear after Platelet-Rich Plasma.

Platelet-rich plasma (PRP), as a regenerative treatment for partial ulnar collateral ligament (UCL) tears, is validated to lead to faster clinical recovery and return to play in adult athletes. However, studies examining such a role of PRP in younger pediatric and adolescent athletes are scarce. A 14-year-old adolescent throwing athlete, a right-handed pitcher, presented with chronic right medial elbow pain discovered to be secondary to a partial UCL tear, as identified on both ultrasound and magnetic resonance imaging. A single ultrasound-guided injection of PRP to the pathologic site of the partial UCL tear, in concert with our standardized rehabilitation protocol for throwing athletes after UCL injuries, enabled the boy to heal and return to throwing at full pitching distance without pain and without complications. This emphasizes the utility of PRP as a regenerative treatment option in an adolescent throwing athlete.

Acute Hypotonia in an Infant.

BACKGROUND: Acute flaccid myelitis (AFM) is increasing in incidence in the United States and presenting to emergency departments (EDs) across the country. This clinical entity presents as acute paralysis, with magnetic resonance imaging changes in the gray matter only in children younger than 21 years of age. The etiology is unknown, although preceding viral illnesses are common. There are no consensus guidelines regarding treatment. CASE REPORT: A 4-month-old girl presented with decreased bilateral arm movement. The history consisted of a recent upper respiratory illness and abrupt decline in movement. She was found to have truncal and peripheral hypotonia, while maintaining her airway. Magnetic resonance imaging found gray matter hyperintensity at C2-C6, with no white matter changes. The patient was positive for enterovirus. Intravenous steroids and intravenous immunoglobulin were given, with slight improvement prior to discharge to an inpatient rehabilitation center. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: AFM was largely nonexistent in the United States after implementation of the polio vaccine, but the incidence has recently increased. Pediatric patients are now presenting to EDs with acute hypotonia, and emergency physicians must recognize how to differentiate this emerging diagnosis from other causes of acute flaccid paralysis. The clinical course of AFM does not seem to change acutely, in stark contrast to disease entities like botulism, which can change in hours. Patients with AFM do not need aggressive ED diagnostic evaluation, but rather transfer to a pediatric hospital for further care. Therefore, discerning the etiology of pediatric hypotonia with history and physical examination alone is important.

The effects on sports performance of technologic advances in sports prostheses and wheelchairs.

The field of medicine continues to advance as new technologies emerge. These technological advancements include the science of sports prostheses and wheelchairs, in which there have been significant advancements over the past decades. The world of adaptive sports continues to expand, largely due to a combination of the increase in awareness, inclusion, and technology. As participation in sports for people with impairments increases, there has been an associated demand for new, innovative adaptive sporting equipment designs that help accommodate the physical deficits of the individual. Controversy has risen as persons with disabilities advance their skills with adaptive sports equipment to compete with individuals without disabilities. The controversy leads to the question: is the adaptive equipment allowing athletes with disability to regain the lost function from their baseline or does it allow them to exceed prior ability level? This narrative review provides information regarding the performance effects of advances in technology and biomechanics of adaptive sports equipment to help answer these questions.

Golf in the Paralympic Games.

ABSTRACT: The Paralympic Games offer exciting opportunities for athletes with an impairment to compete at the highest level with other athletes from around the globe, fostering international goodwill, inclusivity, and diversity. Golf returned to the Olympic Games in 2016; despite a significant growth in popularity for persons with physical and mental impairments, it has not been a Paralympic Games sport. The inaugural US Adaptive Open may provide a model for future Paralympic Games golf competitions.

Special Populations in Orthobiologics: Athletic, Elderly, and Pediatrics Populations.

This section is devoted to a review of the literature regarding the usage of orthobiologics in the special populations of elite athletes, the elderly, and pediatrics. The prospect of these regenerative options is encouraging to help provide alternative options that may enhance recovery and healing of acute and degenerative pathologic conditions. The goal is to provide the readers an overview of the existing literature highlighting areas with growing research and others that are still lacking.

The association between severe maternal morbidity and mortality and race/ethnicity with community type in Maryland.

BACKGROUND: Severe maternal morbidity and mortality are increasing in the United States with continued healthcare disparities among Non-Hispanic Black women. However, there is sparse data on the disparities of severe maternal morbidity and mortality by race/ethnicity as it relates to community type. OBJECTIVE: To determine whether residing in rural communities increases the racial/ethnic disparities in severe maternal morbidity and mortality. DESIGN: This study is a cross-sectional analysis of women admitted for delivery from 2015 to 2020. A total of 204,140 adults who self-identified as women, were admitted for delivery, who resided in Maryland, and were between the ages 15 and 54 were included in our analysis. Community type was defined as either rural or urban. METHODS: A multivariable logistic regression, which included an interaction term between race/ethnicity and community type, was used to assess the effect of community type on the relationship between race/ethnicity and severe maternal morbidity and mortality. Data were obtained from the Maryland Health Service Cost Review Commission database. The primary outcome was a composite, binary variable of severe maternal morbidity and mortality. Exposures of interest were residence in either rural or urban counties in Maryland and race/ethnicity. RESULTS: Our study found that after adjusting for confounders, odds of severe maternal morbidity and mortality were 65% higher in Non-Hispanic Black women (odds ratio 1.65, 95% confidence interval: 1.46-1.88, p < 0.001) and 54% higher in Non-Hispanic Asian women (odds ratio 1.54, 95% confidence interval: 1.24-1.90, p < 0.001) compared to Non-Hispanic White women. The interaction term used to determine whether community type modified the relationship between race/ethnicity and severe maternal morbidity and mortality was not statistically significant for any race/ethnicity (Non-Hispanic Black women, p = 0.60; Non-Hispanic Asian women, p = 0.91; Hispanic women, p = 0.15; Other/Unknown race/ethnicity, p = 0.54). CONCLUSION: Although our study confirmed the known disparities in maternal outcomes by race/ethnicity, we found that residing in rural communities did not increase racial/ethnic disparities.

The role of proprotein convertase subtillisin/kexin type 9 in placental salvage and lipid metabolism in women with preeclampsia.

INTRODUCTION: Preeclampsia is associated with decreased maternal low-density lipoprotein cholesterol (LDL-c), which is essential for fetal growth. The underlying mechanisms for decreased LDL-c in preeclampsia remain unknown. Proprotein convertase subtillisin/kexin type 9 (PCSK9) regulates serum LDL-c via LDL receptor (LDL-R) degradation. We describe the possible role of PCSK9 in lipid metabolism in all compartments of the parturient (maternal blood, placental tissue, and fetal blood) in pregnancies with and without preeclampsia. METHODS: This is an observational study examining PCSK9 levels in maternal sera, umbilical cord blood, and PCSK9 protein content in placental tissue in three different locations (maternal placental interface, fetal placental interface, and umbilical cord) in women with and without preeclampsia at >23 weeks gestation. RESULTS: 68 parturients with preeclampsia and 55 without preeclampsia were enrolled. Maternal serum LDL-c (116.6 ± 48.9 mg/dL vs 146.1 ± 47.1 mg/dL, p = 0.0045) and PCSK9 (83 [61.8127.6] ng/mL vs 105.3 [83.5142.9] ng/mL, p = 0.011) were also reduced in the preeclamptics versus controls. There were no differences in PCSK9 protein content between preeclamptics and controls at comparative placental interfaces. However, PCSK9 protein content increased between the preeclampsia maternal placental interface (1.87 ± 0.62) and the preeclampsia umbilical cord (2.67 ± 1.08, p = 0.0243). DISCUSSION: PCSK9 levels are lower in maternal sera in preeclampsia when compared to controls. Placental PCSK9 protein content in preeclampsia increases from the maternal interface to the umbilical cord; however, this is not seen in controls. This suggests a potential compensatory mechanism for PCSK9 which allows for higher circulating fetal LDL-c levels in preeclampsia.

Instituting a Curriculum for Cardio-Obstetrics Subspecialty Fellowship Training.

Maternal mortality is rising in the United States, and cardiovascular disease is the leading cause. Adverse pregnancy outcomes such as preeclampsia and gestational diabetes heighten the risk of cardiovascular complications during pregnancy and the peripartum period and are associated with long-term cardiovascular risks. The field of cardio-obstetrics is a subspecialty within adult cardiology that focuses on the management of women with or at high risk for heart disease who are considering pregnancy or have become pregnant. There is growing recognition of the need for more specialists with dedicated expertise in cardio-obstetrics to improve the cardiovascular care of this high-risk patient population. Current recommendations for cardiovascular fellowship training programs accredited by the Accreditation Council for Graduate Medical Education involve establishing core competency in the knowledge of managing heart disease in pregnancy. However, little granular detail is available of what such training should entail, which can lead to knowledge gaps. Additionally, dedicated advanced subspecialty training in this area is not commonly offered. Multidisciplinary collaborative teams have been shown to improve outcomes in cardiac patients during pregnancy, and cardiovascular fellows-in-training interested in cardio-obstetrics should have the opportunity to participate in and contribute to a pregnancy heart team. In this document, we describe a proposed specialized cardio-obstetrics training pathway that could serve to adequately prepare trainees to competently and comprehensively care for women with cardiovascular disease before, during, and after pregnancy.

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care.

Purpose of Review: The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings: A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary: Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.