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1.
Pediatr Emerg Care ; 40(9): e186-e194, 2024 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-38713835

RESUMEN

OBJECTIVE: It is unclear which pediatric emergency departments (PEDs) have a point-of-care ultrasound (POCUS) credentialing process or if this process is consistent per expert guidelines. Our objective was to describe formalized POCUS credentialing processes across PEDs that are active in the pediatric emergency medicine POCUS (P2) Network. METHODS: A survey was developed from nationally recommended credentialing guidelines. This anonymous survey was sent out to the P2 Network comprising more than 230 members involved in pediatric POCUS. The survey was analyzed using descriptive analysis with counts and percentages. RESULTS: A total of 36 PEDs responded to the survey. All departments had a faculty member in charge of maintaining the credentialing process, and all faculty members had POCUS education available; 88.6% of education was scheduled didactics or bedside teaching. There were 80.6% of PEDs that had a process for internally credentialing faculty. Some PEDs offered protected education for POCUS, however, 44.8% had <50% of their faculty credentialed. There were 4 PEDs that offered incentives for completion of POCUS credentialing including salary bonuses; only 1 offered shift buy down as incentive. That PED had 100% of its faculty credentialed. All PEDs performed quality assurance on POCUS scans done in the ED, most done weekly. Billing for scans occurred in 26 PEDs. Skin/soft tissue and focused assessment with sonography for trauma were the 2 most common applications credentialed. CONCLUSIONS: Among PEDs surveyed, there was a lack of standardization of POCUS resources and components of credentialing. Incentives may be beneficial in improving credentialing faculty and standardizing the credentialing process.


Asunto(s)
Habilitación Profesional , Servicio de Urgencia en Hospital , Sistemas de Atención de Punto , Ultrasonografía , Humanos , Sistemas de Atención de Punto/normas , Ultrasonografía/normas , Encuestas y Cuestionarios , Pediatría/normas , Niño
2.
Facial Plast Surg ; 40(2): 158-167, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37734402

RESUMEN

Follicular unit excision (FUE) has risen to the forefront as the world's most popular hair transplant procedure. However, most writing on this subject has catered to the advanced practitioner. The goal of this article will be to focus on safe planning and decision making along with key technical steps that will guide the beginner surgeon to harvest a graft safely and to harvest the donor area in a uniform way to avoid overharvesting. Topics covered in this article also include instrumentation and decision making between FUE versus linear strip excision.


Asunto(s)
Alopecia , Folículo Piloso , Humanos , Folículo Piloso/trasplante , Alopecia/cirugía , Recolección de Tejidos y Órganos , Trasplante de Piel , Trasplante Autólogo/métodos
3.
Ann Emerg Med ; 82(3): e97-e105, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37596031

RESUMEN

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.


Asunto(s)
Trastornos de la Conducta Infantil , Urgencias Médicas , Trastornos Mentales , Humanos , Masculino , Femenino , Niño , Adolescente , Trastornos Mentales/terapia , Servicios Médicos de Urgencia , Trastornos de la Conducta Infantil/terapia , Personal de Salud , Servicios de Salud Mental
4.
J Emerg Med ; 65(5): e427-e431, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-37722950

RESUMEN

BACKGROUND: Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy. OBJECTIVE: The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS. METHODS: We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis. RESULTS: From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0. CONCLUSIONS: Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.

5.
Pediatr Emerg Care ; 38(2): e1014-e1018, 2022 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-34787985

RESUMEN

ABSTRACT: Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.


Asunto(s)
Servicios Médicos de Urgencia , Medicina de Emergencia , Medicina de Urgencia Pediátrica , Niño , Humanos , Sistemas de Atención de Punto , Ultrasonografía
6.
Pediatr Emerg Care ; 38(9): 442-447, 2022 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-36040465

RESUMEN

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.


Asunto(s)
Intususcepción , Sistemas de Atención de Punto , Niño , Servicio de Urgencia en Hospital , Humanos , Intususcepción/diagnóstico por imagen , Estudios Prospectivos , Reproducibilidad de los Resultados , Ultrasonografía/métodos
7.
Ann Emerg Med ; 78(5): 606-615, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-34226072

RESUMEN

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.


Asunto(s)
Medicina de Emergencia/normas , Intususcepción/diagnóstico por imagen , Pruebas en el Punto de Atención/normas , Ultrasonografía/normas , Niño , Preescolar , Competencia Clínica , Femenino , Humanos , Lactante , Intususcepción/terapia , Masculino , Estudios Prospectivos
8.
Appl Opt ; 60(16): 4502-4510, 2021 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-34143003

RESUMEN

Previous work demonstrated a good fit to the degree of polarization (DOP) of luminescence measurements on {110} facets of InP using a simple dependence of DOP of luminescence on strain: ${-}{K_e} ({e_1} - {e_3})$, where ${K_e}$ is a positive calibration constant, and ${e_1}$ and ${e_3}$ are normal components of strain in the plane of the facet and along $\langle 1\bar 10\rangle$ and $\langle 001\rangle$ directions [Appl. Opt.43, 1811 (2004)APOPAI0003-693510.1364/AO.43.001811]. Recent analytic modeling, which by necessity to be analytic must make simplifying assumptions, has suggested that unless the measurements are along crystallographic axes, the dependence of the DOP of luminescence on strain is more complicated: ${-}{K_e} (1.315 {e_1} - 0.7987 {e_3})$ for measurements from an InP facet, with a similar "excess" ${e_1}$ for GaAs [Appl. Opt.59, 5506 (2020)APOPAI0003-693510.1364/AO.394624]. In this work, we fit finite element simulations (FEM) to DOP measurements of the photoluminescence from facets of InP bars with ${\{111\} _B}$ v-grooves that have been placed in a cylindrical bending moment. We find that the more complicated dependence of DOP on strain, as derived by the analytic model, fits the data better than the previously assumed simple dependence. This finding thus corroborates the analytical model and should have an impact on understanding the strain-dependent operation of optoelectronic devices.

9.
Pediatr Emerg Care ; 37(12): 632-636, 2021 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-34772878

RESUMEN

ABSTRACT: Point-of-care ultrasound (POCUS) has been described as a useful tool for identification of coronavirus disease 2019 (COVID-19) in adults and children. Although several case reports describe POCUS findings in children with COVID-19, to our knowledge, there have been no published multicenter case series describing the large heterogeneity in lung POCUS findings in pediatric COVID-19. This series includes 7 symptomatic patients with COVID-19 who had a lung POCUS performed at 6 institutions by pediatric emergency attendings and fellows. The findings were variable, ranging from no findings to the appearance of B-lines, pleural abnormalities, consolidations, and a pleural effusion. Further studies are needed to improve our understanding, characterization, and prognostic correlation of POCUS findings in this novel disease in children.


Asunto(s)
COVID-19 , Adulto , Niño , Humanos , Pulmón/diagnóstico por imagen , Sistemas de Atención de Punto , SARS-CoV-2 , Ultrasonografía
10.
Nature ; 515(7528): 577-81, 2014 Nov 27.
Artículo en Inglés | MEDLINE | ID: mdl-25428507

RESUMEN

The immune system influences the fate of developing cancers by not only functioning as a tumour promoter that facilitates cellular transformation, promotes tumour growth and sculpts tumour cell immunogenicity, but also as an extrinsic tumour suppressor that either destroys developing tumours or restrains their expansion. Yet, clinically apparent cancers still arise in immunocompetent individuals in part as a consequence of cancer-induced immunosuppression. In many individuals, immunosuppression is mediated by cytotoxic T-lymphocyte associated antigen-4 (CTLA-4) and programmed death-1 (PD-1), two immunomodulatory receptors expressed on T cells. Monoclonal-antibody-based therapies targeting CTLA-4 and/or PD-1 (checkpoint blockade) have yielded significant clinical benefits-including durable responses--to patients with different malignancies. However, little is known about the identity of the tumour antigens that function as the targets of T cells activated by checkpoint blockade immunotherapy and whether these antigens can be used to generate vaccines that are highly tumour-specific. Here we use genomics and bioinformatics approaches to identify tumour-specific mutant proteins as a major class of T-cell rejection antigens following anti-PD-1 and/or anti-CTLA-4 therapy of mice bearing progressively growing sarcomas, and we show that therapeutic synthetic long-peptide vaccines incorporating these mutant epitopes induce tumour rejection comparably to checkpoint blockade immunotherapy. Although mutant tumour-antigen-specific T cells are present in progressively growing tumours, they are reactivated following treatment with anti-PD-1 and/or anti-CTLA-4 and display some overlapping but mostly treatment-specific transcriptional profiles, rendering them capable of mediating tumour rejection. These results reveal that tumour-specific mutant antigens are not only important targets of checkpoint blockade therapy, but they can also be used to develop personalized cancer-specific vaccines and to probe the mechanistic underpinnings of different checkpoint blockade treatments.


Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Antígenos de Neoplasias/genética , Antígenos de Neoplasias/inmunología , Linfocitos T CD8-positivos/inmunología , Vacunas contra el Cáncer/uso terapéutico , Puntos de Control del Ciclo Celular/inmunología , Inmunoterapia , Sarcoma/terapia , Animales , Epítopos/genética , Masculino , Ratones , Sarcoma/inmunología , Vacunas Sintéticas/uso terapéutico
11.
J Emerg Med ; 58(3): 457-463, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31843323

RESUMEN

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES: We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS: POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS: In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS: We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.


Asunto(s)
Medicina de Emergencia , Sistemas de Atención de Punto , Piel/diagnóstico por imagen , Ultrasonografía , Niño , Servicio de Urgencia en Hospital , Docentes , Humanos , Reproducibilidad de los Resultados
12.
Facial Plast Surg ; 35(3): 278-285, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31189202

RESUMEN

Fat grafting is a safe, effective method for facial rejuvenation if used to restore lost facial volume, but it is not as a method to correct cutaneous deformities and rhytids, or to counteract gravitational effects. The most significant postoperative complication is weight gain that can make a face look overinflated. Accordingly, it is important to select a safe and appropriate candidate. This article outlines who is a suitable prospect for fat grafting and juxtaposes the two methods of facial volume restoration: fat grafting versus injectable fillers. Then a detailed exposition of the operative technique is outlined, including anesthesia, harvesting, processing, and injection. Finally, this article concludes with a description of the postoperative course and the management of potential complications.


Asunto(s)
Tejido Adiposo , Cara , Rejuvenecimiento
13.
Nature ; 490(7421): 502-7, 2012 Oct 25.
Artículo en Inglés | MEDLINE | ID: mdl-22992524

RESUMEN

The AP1 transcription factor Batf3 is required for homeostatic development of CD8α(+) classical dendritic cells that prime CD8 T-cell responses against intracellular pathogens. Here we identify an alternative, Batf3-independent pathway in mice for CD8α(+) dendritic cell development operating during infection with intracellular pathogens and mediated by the cytokines interleukin (IL)-12 and interferon-γ. This alternative pathway results from molecular compensation for Batf3 provided by the related AP1 factors Batf, which also functions in T and B cells, and Batf2 induced by cytokines in response to infection. Reciprocally, physiological compensation between Batf and Batf3 also occurs in T cells for expression of IL-10 and CTLA4. Compensation among BATF factors is based on the shared capacity of their leucine zipper domains to interact with non-AP1 factors such as IRF4 and IRF8 to mediate cooperative gene activation. Conceivably, manipulating this alternative pathway of dendritic cell development could be of value in augmenting immune responses to vaccines.


Asunto(s)
Factores de Transcripción con Cremalleras de Leucina de Carácter Básico/metabolismo , Células Dendríticas/citología , Células Dendríticas/metabolismo , Factores Reguladores del Interferón/metabolismo , Animales , Presentación de Antígeno , Antígenos CD/metabolismo , Factores de Transcripción con Cremalleras de Leucina de Carácter Básico/química , Factores de Transcripción con Cremalleras de Leucina de Carácter Básico/deficiencia , Factores de Transcripción con Cremalleras de Leucina de Carácter Básico/genética , Linfocitos T CD4-Positivos/citología , Linfocitos T CD4-Positivos/inmunología , Antígenos CD8/inmunología , Antígenos CD8/metabolismo , Antígeno CTLA-4/metabolismo , Diferenciación Celular , Línea Celular Tumoral , Linaje de la Célula , Células Dendríticas/inmunología , Femenino , Fibrosarcoma/inmunología , Fibrosarcoma/metabolismo , Fibrosarcoma/patología , Regulación de la Expresión Génica , Cadenas alfa de Integrinas/metabolismo , Factores Reguladores del Interferón/deficiencia , Factores Reguladores del Interferón/genética , Interleucina-10/metabolismo , Interleucina-12/inmunología , Interleucina-12/metabolismo , Leucina Zippers , Masculino , Ratones , Ratones Endogámicos C57BL , Trasplante de Neoplasias , Proteína Oncogénica p65(gag-jun)/metabolismo , Unión Proteica , Estructura Terciaria de Proteína , Proteínas Represoras/deficiencia , Proteínas Represoras/genética , Linfocitos T Colaboradores-Inductores/citología , Linfocitos T Colaboradores-Inductores/inmunología , Linfocitos T Colaboradores-Inductores/metabolismo , Toxoplasma/inmunología
14.
J Emerg Med ; 55(1): 51-63, 2018 07.
Artículo en Inglés | MEDLINE | ID: mdl-29805070

RESUMEN

BACKGROUND: Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic. OBJECTIVE: Our aim was to provide emergency physicians with an overview of PR procedural sedation medications in pediatric patients. METHODS: We performed a PubMed literature search of relevant keywords limited to studies of human subjects published in English between January 1, 1990 and December 31, 2017. We excluded case reports, general review articles, editorial/opinion pieces, correspondence, and abstracts. Two of the authors then conducted a structured review of the selected studies. RESULTS: A total of 315 PubMed citations meeting the search criteria were found. Twenty-eight articles were included for final detailed review. Only 4 of the 28 included studies were conducted in the emergency department setting. A total of 9 different medications have been studied for PR procedural sedation. Sedation effectiveness ranged from 40% to 98%. No life-threatening complications were reported in any of the included clinical trials. Hypoxia was found to occur in up to 10% of those receiving PR sedation. CONCLUSIONS: Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed.


Asunto(s)
Administración Rectal , Sedación Consciente/normas , Hipnóticos y Sedantes/administración & dosificación , Hidrato de Cloral/administración & dosificación , Hidrato de Cloral/uso terapéutico , Sedación Consciente/métodos , Diazepam/administración & dosificación , Diazepam/uso terapéutico , Servicio de Urgencia en Hospital/organización & administración , Humanos , Hipnóticos y Sedantes/uso terapéutico , Ketamina/administración & dosificación , Ketamina/uso terapéutico , Metohexital/administración & dosificación , Metohexital/uso terapéutico , Midazolam/administración & dosificación , Midazolam/uso terapéutico , Pediatría/métodos , Pediatría/tendencias
15.
J Emerg Med ; 54(2): 215-220, 2018 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-29089155

RESUMEN

BACKGROUND: This review provides practicing emergency physicians updated information regarding point-of-care ultrasound (POCUS) imaging of patients with suspected urolithiasis. METHODS: A PubMed literature search was conducted for articles published between January 1, 1996 and May 31, 2017 and limited to human clinical trials written in English with relevant keywords. High-quality studies identified then underwent a structured review. Recommendations herein are made based on the literature review. RESULTS: Two hundred seventy-two abstracts fulfilling the search criteria were screened and 10 appropriate articles were rigorously reviewed in detail. There were 8 prospective studies and 2 retrospective studies. Only 1 of them was a multi-institutional randomized trial. POCUS performed in the emergency department (ED) is moderately sensitive and specific in making the diagnosis of urolithiasis in symptomatic patients. Suspected urolithiasis patients evaluated initially with ED POCUS have complication rates compatible with those evaluated initially with computed tomography. CONCLUSIONS: POCUS has moderate accuracy in making the diagnosis of urolithiasis. Nevertheless, it may be safely used as a first line of imaging in ED patients with suspected symptomatic urolithiaisis.


Asunto(s)
Ultrasonografía/métodos , Urolitiasis/diagnóstico , Servicio de Urgencia en Hospital/organización & administración , Humanos , Sistemas de Atención de Punto , Tomografía Computarizada por Rayos X/métodos , Tomografía Computarizada por Rayos X/normas , Ultrasonografía/normas , Urolitiasis/terapia
16.
J Emerg Med ; 55(5): 693-701, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30170835

RESUMEN

BACKGROUND: Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches. OBJECTIVE: To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting. METHODS: Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7-10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians. RESULTS: In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty. CONCLUSIONS: Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.


Asunto(s)
Servicio de Urgencia en Hospital , Infecciones de los Tejidos Blandos/diagnóstico por imagen , Infecciones de los Tejidos Blandos/terapia , Ultrasonografía/métodos , Adolescente , Niño , Preescolar , Diagnóstico Diferencial , Femenino , Humanos , Lactante , Masculino , Examen Físico , Sistemas de Atención de Punto , Estudios Prospectivos
17.
Pediatr Emerg Care ; 34(2): 145-148, 2018 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-29346232

RESUMEN

The presentation of a pediatric patient to the emergency department for a malfunctioning or dislodged gastrostomy tube (G-tube) is not uncommon. As such, these tubes are often replaced at the bedside. Improper placement can result in a number of complications, including perforation, fistula tract formation, peritonitis, and sepsis. The current criterion standard method to confirm proper G-tube placement is contrast-enhanced radiography. However, point-of-care ultrasound may be an alternative method to guide and confirm pediatric G-tube replacement in the emergency department. We report a series of cases on this novel point-of-care ultrasound application.


Asunto(s)
Remoción de Dispositivos/métodos , Nutrición Enteral/métodos , Gastrostomía/métodos , Sistemas de Atención de Punto , Ultrasonografía Intervencional/métodos , Niño , Preescolar , Remoción de Dispositivos/efectos adversos , Servicio de Urgencia en Hospital , Nutrición Enteral/efectos adversos , Falla de Equipo , Femenino , Gastrostomía/efectos adversos , Humanos , Masculino , Reoperación
18.
Facial Plast Surg ; 34(2): 173-177, 2018 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-29631288

RESUMEN

Periorbital aging is mainly a product of volume loss, which can be addressed with fillers and/or fat grafting. This stands in contrast to the lower face where a lifting procedure can be the principal method to improve moderate-to-significant aging. New models to explain these concepts of periorbital rejuvenation to both the surgeon and the prospective patient are outlined herein, namely, three facial halos (around the eyes, around the perimeter of the face, and around the mouth) and asymmetric triangles around the eyes. Specific techniques for fillers and fat grafting are also covered separately in detail in this article.


Asunto(s)
Tejido Adiposo/trasplante , Rellenos Dérmicos/uso terapéutico , Párpados/cirugía , Envejecimiento de la Piel/fisiología , Adulto , Estética , Femenino , Humanos , Persona de Mediana Edad , Rejuvenecimiento/fisiología , Cirugía Plástica/métodos , Trasplante de Tejidos/métodos , Trasplante Autólogo
19.
J Emerg Med ; 52(2): 255-261, 2017 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-27863833

RESUMEN

BACKGROUND: Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality. However, precisely defining the optimal treatment for individual patients early after AIS onset remains elusive. There has recently been a surge in published studies documenting the effectiveness of mechanical intra-arterial thrombectomy for treatment of a subset of patients with AIS. This therapy has been proposed and studied for the small (<1.2%) subgroup of patients with ischemic strokes who have "large vessel" strokes or strokes that fail to improve after the administration of tissue plasminogen activator (t-PA). The current rapid systematic review provides practicing emergency physicians updated information regarding mechanical thrombectomy as a treatment option for carefully selected AIS patients. METHODS: A PubMed literature search was conducted from January 1996 to June 2016 and limited to human clinical trials written in English with relevant keywords. High-quality randomized controlled studies identified then underwent a structured review. RESULTS: In total, 179 papers fulfilling the search criteria were screened and 8 appropriate articles were rigorously reviewed in detail and recommendations given on the effectiveness and indication of mechanical intra-arterial thrombectomy for the treatment of AIS. CONCLUSIONS: Mechanical intra-arterial thrombectomy reduces long-term disability in a properly selected subset of patients who have an AIS caused by large vessel occlusion. Many of these patients will have failed to improve after intravenous administration of t-PA, and mortality is not increased when combined with t-PA. Careful screening criteria should be in place to identify the limited subset of patients to whom this therapy is delivered to derive optimal treatment benefits.


Asunto(s)
Trombolisis Mecánica/métodos , Trombolisis Mecánica/normas , Accidente Cerebrovascular/terapia , Trombectomía/métodos , Fibrinolíticos/farmacología , Fibrinolíticos/uso terapéutico , Humanos , Activadores Plasminogénicos/farmacología , Activadores Plasminogénicos/uso terapéutico
20.
J Emerg Med ; 51(2): 203-14, 2016 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-26972018

RESUMEN

BACKGROUND: Multiple case reports of using intravenous fat emulsion (IFE) as an antidote for human poisoning from various xenobiotics have been published over the last decade. Given the rapidly evolving field, emergency physicians may be uncertain about the indications, timing, and dose for IFE treatment. METHODS: A PubMed literature search was conducted from January 1996 to November 2015 and limited to human studies written in English and articles with relevant keywords. Guideline statements and nonsystematic reviews were excluded. Studies identified then underwent a structured review of their results. RESULTS: There were 986 papers fulfilling the search criteria screened, and 85 appropriate articles were rigorously reviewed in detail. Recommendations were given on indications, timing, and dose of IFE. Most of these were based on case reports and anecdotal experience. DISCUSSION: In critically ill patients with refractory shock or cardiac arrest after a suspected overdose of local anesthetics or selected xenobiotics, IFE may be considered as a potentially beneficial adjunctive treatment. Despite an abundance of reports on the use of IFE on xenobiotics poisoning, the quality of evidence is suboptimal and fraught with reporting bias. CONCLUSIONS: IFE may be an effective antidote in poisonings from various xenobiotics. However, further research is needed to determine its optimal circumstances, timing, and dose of use.


Asunto(s)
Antídotos/uso terapéutico , Emulsiones Grasas Intravenosas/uso terapéutico , Intoxicación/terapia , Enfermedad Crítica , Servicio de Urgencia en Hospital , Humanos
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