Esophageal oxyhemoglobin saturation as a resuscitative metric in hemorrhagic shock.

Background: Mixed venous saturation (SvO2) is considered the gold standard to assess the adequacy of tissue oxygen delivery (DO2) in shock states. However, SvO2 monitoring is challenging as it requires an invasive catheter and frequent blood sampling. Non-invasive methods, including near-infrared spectroscopy, have demonstrated low sensitivity to tissue dysoxia. Methods: We fabricated a new device that uses resonance Raman spectroscopy (RRS) to quantify oxyhemoglobin saturation (ShbO2) in the esophagus (eShbO2), tongue (tShbO2), and liver (hShbO2). In two rat models of hemorrhagic shock, we quantified (1) The correlation of RRS-measured ShbO2 to SvO2 during progressive hemorrhage (n=20) and (2) The value of these metrics to predict near-term mortality in fixed, severe hemorrhage (mean blood pressure =25 mm Hg; n=18). Results: In model 1, eShbO2 (r=0.705, p<0.0001) and tShbO2 (r=0.724, p<0.0001) correlated well with SvO2 and with serum lactic acid (eShbO2-lactate r=0.708, p<0.0001; tShbO2-lactate r=0.830, p<0.0001). hShbO2 correlated poorly with both SvO2 and lactic acid. Using time-matched ShbO2-SvO2 pairs, the performance of ShbO2 to detect severe tissue hypoxia (SvO2<20%) was excellent (AUC 0.843 for eShbO2, 0.879 for tShbO2). In model 2, eShbO2 showed a maximized threshold of 40% with 83% of animals dying within 45 minutes of this cut-off, demonstrating accuracy as a monitoring device. This was similar for tShbO2, with a threshold of 50%, predicting death within 45 minutes in 76% of animals. ShbO2 showed superior sensitivity to invasive monitoring parameters, including MABP<30 mm Hg (sensitivity 59%), pulse pressure<15 mm Hg (sensitivity 50%), and heart rate>220 bpm (sensitivity 39%, p=0.004). Conclusions: eShbO2 represents a new paradigm to assess the adequacy of DO2 to a tissue. It constitutes a promising monitoring method to evaluate tissue oxygen saturation in real time and non-invasively, correlating with SvO2 and time to death. Level of evidence: Level III, therapeutic/care management.

Point-of-Care-Ultrasound Quality Assurance Data from Fellow-Performed Exams in a Pediatric Emergency Department: A Descriptive Study.

OBJECTIVES: Point-of-care-ultrasound (POCUS) is increasingly used by pediatric emergency medicine (PEM) fellows, but scant data exists on the accuracy of exam interpretations. Our goal was to determine whether agreement on exam interpretation between quality assurance (QA) faculty (reference standard) and PEM fellows varied by fellowship year or exam type. METHODS: Retrospective review of fellow-performed POCUS exams between January 2019 and June 2022. Negative binomial (NB) random effects regression was used to account for longitudinal measurement of individual fellow performance across 3 years. Fixed effects were exam type and fellowship year. To assess between- and within-user variability across time, a random intercept and slope were included for each fellow. RESULTS: Exactly 3032 exams, performed by 24 fellows, were included. Raw proportion agreement by fellowship year was high for all exam types (≥88%). From the NB model, there was no statistically significant effect of fellowship year on the mean count of agreement. The relative risk (RR) of agreement for exam types was greatest for cardiac vs other types. The standard deviations for the random intercept and random slope were 0.09 and 0.04, respectively, with a correlation of -0.94. CONCLUSIONS: PEM fellows generally interpret exams correctly, with little variation through fellowship, although those who began with more basic skills showed more progress over time. Fellowship year did not influence the likelihood of correct interpretation but there was variation across exam type, with the best agreement for cardiac exams. The extent to which disagreements between fellows and QA faculty represent clinically significant errors requires further study.

Deep venous thrombosis (DVT) diagnostics: gleaning insights from point-of-care ultrasound (PoCUS) techniques in emergencies: a systematic review and meta-analysis.

BACKGROUND: The assessment of deep venous thrombosis (DVT) is clinically difficult diagnosis. The "gold standard test" for DVT diagnosis is venography; however, various point-of-care ultrasound (POCUS) protocols have been suggested for DVT evaluation in the emergency department. AIMS: This review evaluated the role of different POCUS protocols in diagnosing DVT in the emergency department. METHODS: A systematic review and meta-analysis was conducted based of PRISMA guideline and registered on PROSEPRO (CRD42023398871). An electronic database search in Embase, PubMed, ScienceDirect, and Google scholar and a manual search were performed to identify eligible studies till February 2023. Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was used to assess the risk of bias in included studies. Quantitative analysis was carried out using STATA 16 and Review Manager software (RevMan 5.4.1). Sensitivity, specificity of POCUS protocols for DVT diagnosis compared to reference standard test was calculated. RESULTS: Heterogeneity was identified between 26 included studies for review. The pooled sensitivity, specificity, PPV, and NPV for the 2-point POCUS protocol were 92.32% (95% CI: 87.58-97.06), 96.86% (95% CI: 95.09-98.64), 88.41% (95% CI: 82.24-94.58) and 97.25% (95% CI: 95.51-98.99), respectively. Similarly, the pooled sensitivity, specificity, PPV, and NPV for 3-point POCUS were 89.15% (95% CI: 83.24-95.07), 92.71% (95% CI: 89.59-95.83), 81.27% (95% CI: 73.79-88.75), and 95.47% (95% CI: 92.93-98). The data pooled for complete compression ultrasound, and whole-leg duplex ultrasound also resulted in a sensitivity and specificity of 100% (95% CI: 98.21-100) and 97.05% (95% CI: 92.25-100), respectively. On the other hand, the time from triage to DVT diagnosis was significantly shorter for emergency physician-performed POCUS than diagnostic tests performed by radiologists. CONCLUSION: The diagnostic performance of POCUS protocols performed by emergency physicians was excellent. Combined with the significant reduction in time to diagnosis. POCUS can be used as the first-line imaging tool for DVT diagnosis in the emergency department. We also recommended that attending emergency physicians with POCUS training are present during DVT diagnosis to improve diagnostic performance even though high diagnostic performance is observed even with the minimum training.

Accuracy of point-of-care capillary blood sugar measurements in critically ill patients: An observational study.

Background: Accurately monitoring blood glucose levels is vital for critically ill individuals. Point-of-care (POC) glucose meters are commonly used in local intensive care units (ICUs). This study aimed to assess the precision of POC glucose meter readings in critically ill individuals with specific evaluation in patients with and without shock against the reference standard of venous blood glucose measurements. Methods: An observational study was done on adult patients admitted in the ICU at a teaching institution. Capillary blood samples were collected from the patient's fingertip using lancet device with aseptic measures. The sample was analyzed using the GlucoCare Sense Glucometer (RMD Mediaids Limited, Taiwan). At the same time, 2 ml of blood was drawn from the patient's peripheral veins and analyzed by glucose oxidase-peroxidase method as reference. Results: POC glucose measurements averaged 140 ± 20.23 mg/dl, while laboratory values were recorded as 116.10 ± 17.13 mg/dl. The difference between the two methods was 24.34 ± 12.01 mg/dl. A strong correlation (r = 0.805) was found between capillary and laboratory blood glucose levels, indicating a significant association (P < 0.0001). Twenty-two (44%) patients were in shock during the study. The mean difference between laboratory and POC blood glucose levels was higher in patients with circulatory shock (36.82 ± 4.84 mg/dl) than those without shock (14.61 ± 4.49 mg/dl), P < 0.05. Conclusion: POC glucose meters may lead to underdetection of hypoglycemia in critically ill patients, as their values are higher than laboratory values. Moreover, the results showed that POC glucometers are inaccurate for monitoring glucose in hypotensive patients in shock. Standard venous glucose monitoring methods may be more appropriate for these patients.

Prevalence of Cryptococcal Antigenemia and Lateral Flow Assay Accuracy in Severely Immunosuppressed AIDS Patients.

This study aimed to estimate the prevalence of cryptococcal antigenemia detected by lateral flow assay (LFA) in AIDS patients and its accuracy in the diagnosis of cryptococcosis. Conducted at a university hospital in Brazil from March 2015 to July 2017, it included AIDS patients over 18 years old with a CD4+ count ≤ 200 cells/mm3. Cryptococcal antigen (CrAg) detection using LFA and latex agglutination (LA), along with blood and urine cultures, were performed. The reference standard was the identification of Cryptococcus spp. in clinical specimens through microbiological or histopathological examination. Among 230 patients, the prevalence of CrAg detected by LFA (CrAg LFA) was 13.0%. Factors associated with cryptococcal antigenemia included fever, vomiting, seizures, and a lack of antiretroviral therapy. The sensitivity and specificity of CrAg LFA were 83.9% and 98.0%, respectively. The positive predictive value (PPV) was 86.7%, the negative predictive value (NPV) was 97.5%, and overall accuracy was 96.1%. Cross-reactions were observed in patients with histoplasmosis and paracoccidioidmycosis, but not with aspergillosis or positive rheumatoid factor. The study concludes that the LFA is a useful tool for detecting cryptococcal antigenemia in severely immunocompromised AIDS patients due to its high NPV, specificity, and PPV.

A resonance sonorheometry guided dose reduction of plasma transfusion in repetitive hip surgery in a patient with a severe factor XI deficiency: a case report.

Factor XI deficiency is a rare disorder with an unpredictable bleeding tendency. Here, we report the successful use of the sonic estimation of elasticity via resonance sonorheometry for guiding the management of haemostasis in a patient with a severe factor XI deficiency in repeated revision hip surgeries. Regardless of an administration of fresh frozen plasma, a significant haemorrhage occurred at the first of three hip surgeries. The repeat application of fresh frozen plasma normalised the prolonged activated partial thromboplastin time and the resonance sonorheometry clot time values; the factor XI activity increased to a sufficient level. No significant bleeding occurred in the second and third hip surgery. Using a resonance sonorheometry guided approach in haemostasis management has the potential to improve safety for patients with factor XI deficiency undergoing surgery by ensuring sufficient clotting and preventing side effects.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) cannula malposition identified with point-of-care ultrasound.

BACKGROUND: Point-of-care ultrasound (POCUS) has become a mainstay in the evaluation of critically ill patients in the intensive care unit (ICU). ECMO patients are susceptible to complications during prolonged ICU stay, including cannula malposition, which has deleterious consequences. Although the literature surrounding utility of ultrasound on ECMO patients is expansive, direct comparison between radiographic imaging versus ultrasound for identification of cannula malposition is lacking. CASE PRESENTATION: The authors identified four patients with cannula malposition discovered through POCUS that was missed on routine radiographic imaging. Identification and correction of malposition changed their ECMO course. CONCLUSION: This case series is the first in literature demonstrating that ultrasound may be superior to radiographic images for ECMO cannula malposition. Further investigation into this subject is warranted.

eviQ Cancer Treatments Online: Providing evidence-based information to improve cancer patient outcomes.

AIM: To understand the current usage of eviQ Cancer Treatments Online (www.eviQ.org.au), an Australian, open-access website providing evidence-based and consensus-driven cancer treatment protocols and information, and the extent to which it is meeting its intended outcomes and providing value to its users. METHODS: A mixed-method evaluation was conducted in 2020-2022 which included a review of key program documentation and website usage data, and delivery of a focused online survey to its users. RESULTS: In 2022, 329 clinicians representing all Australian states and territories contributed to eviQ content development and review. eviQ content continues to grow with a 15.2% increase in total content from 2019 to 2022.  eviQ website users continue to grow with 90,000 total monthly users in 2022, representing a 166% increase from 2018. The proportion of international users compared to Australian users continues to grow with 57% of total users in Australia and 43% international in 2022. Of 466 survey responses, the most cited reason for eviQ use was for information on side effects/toxicity (67%). Ninety-three percent (93%) of respondents either agreed or strongly agreed that eviQ contributed to both health professionals providing the best evidence-based treatment and care and improving the standardization of treatment and care provided. CONCLUSION:  eviQ is embedded in Australian clinical practice, highly valued, and relied upon by users. Users agree that eviQ has a positive impact on patients by supporting the delivery of evidence-based treatment and that eviQ contributed to patients' improved health outcomes and quality of life. eviQ's increasing international usage should be explored.

The role of viscoelastic hemostatic assays for postpartum hemorrhage management and bedside intrapartum care.

Viscoelastic hemostatic assays are point-of-care devices that assess coagulation and fibrinolysis in whole blood samples. These technologies provide numeric and visual information of clot initiation, clot strength, and clot lysis under low-shear conditions, and have been used in a variety of clinical settings and subpopulations, including trauma, cardiac surgery, and obstetrics. Emerging data indicate that these devices are useful for detecting important coagulation defects during major postpartum hemorrhage (especially low plasma fibrinogen concentration [hypofibrinogenemia]) and informing clinical decision-making for blood product use. Data from observational studies suggest that, compared with traditional formulaic approaches to transfusion management, targeted or goal-directed transfusion approaches using data from viscoelastic hemostatic assays are associated with reduced hemorrhage-related morbidity and lower blood product requirement. Viscoelastic hemostatic assays can also be used to identify and treat coagulation defects in patients with inherited or acquired coagulation disorders, such as factor XI deficiency or immune-mediated thrombocytopenia, and to assess hemostatic profiles of patients prescribed anticoagulant medications to mitigate the risk of epidural hematoma after neuraxial anesthesia and postpartum hemorrhage after delivery.

Rapid point-of-care test for diagnosis of peritonitis in peritoneal dialysis patients.

BACKGROUND: Periplex® is a rapid point-of-care test based on the detection of interleukin-6 (IL-6) or matrix metalloproteinase-8 (MMP-8) to diagnose peritonitis in peritoneal dialysis (PD) patients. METHODS: This single-centre study was conducted in Singapore General Hospital from 2019 to 2022. The study recruited PD patients suspected of having peritonitis. Periplex was performed at the presentation and recovery of peritonitis. Primary outcomes were sensitivity and specificity of Periplex at presentation. The positive and negative predictive values of tests were also performed. RESULTS: A total of 120 patients were included in the study. The mean age was 60.9 ± 14.9 years, 53% were male, 79% were Chinese and 47.5% had diabetes mellitus. Periplex was positive in all patients with peritonitis (n = 114); sensitivity of 100%; 95% confidence interval (CI): 100-100%. Periplex was falsely positive in three patients with non-infective eosinophilic peritonitis, resulting in a low specificity of 50%; 95% CI: 41.1-59.0%. Periplex had a positive predictive value of 97.4% and a negative predictive value of 100%. During recovery from peritonitis, Periplex had high specificity (93.6%) and negative predictive value (98.7%) to indicate the resolution of infection. MMP-8 was more sensitive than IL-6 in detecting peritonitis. Periplex was positive in all patients with peritonitis regardless of the types of PD solutions used. CONCLUSIONS: Periplex had high sensitivity, and positive and negative predictive values in the diagnosis of peritonitis can be considered as a screening tool for peritonitis. Given its high specificity and negative predictive value, it may also be used to document the resolution of peritonitis.

Point-of-care ultrasound to diagnose acute cholecystitis in the emergency department: A scoping review.

Introduction/Purpose: Ultrasound is the first-line imaging modality for suspected acute cholecystitis. This can be radiology-performed ultrasound or point-of-care ultrasound (POCUS). POCUS can potentially streamline patient assessment in the emergency department (ED). The primary objective was to evaluate the literature for the diagnostic accuracy of POCUS performed for acute cholecystitis in the ED. Secondary objectives were to assess the effect of POCUS operator training on diagnostic accuracy for acute cholecystitis, utility of POCUS measurement of the common bile duct and POCUS impact on resource utilisation. Methods: A systematic scoping review of articles was conducted using Medline, Embase, CENTRAL and CINAHL. Original studies of adults with POCUS performed for the diagnosis of acute cholecystitis in the ED were included. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR). Results: A total of 1090 publications were identified. Forty-six met the eligibility criteria. Studies were thematically grouped into categories according to specified objectives. Point-of-care ultrasound was of acceptable but variable accuracy, contributed to by the absence of a consistent reference standard and uniform training requirements. It may positively impact ED resource utilisation through reduced ED length of stay and radiology-performed imaging, whilst improving patient experience. Conclusion: This review highlights the heterogeneity of existing research, emphasising the need for standardisation of training and reference standards in order to precisely define the utility of POCUS for acute cholecystitis in the ED and its benefits on ED resource utilisation.

Consensus on relevant point-of-care ultrasound skills in General Practice: a two-round French Delphi study.

CONTEXT: Point-of-Care Ultrasound (POCUS) has become an important tool in the clinical practice of many specialties, but its use and impact in General Practice in France remains to be explored. OBJECTIVE: The objective of this study is to obtain a consensus among experienced French general practitioners on a list of relevant POCUS skills in General Practice in 4 anatomical regions. METHOD: We used a two-round Delphi method to obtain a consensus. An initial list of skills was drawn by conducting a literature review. To rate each skill, we used a nine-point Likert scale. An interactive meeting between experts took place between Delphi rounds. POCUS experts in General Practice were defined as general practitioners with theoretical training in ultrasound who regularly perform ultrasound, who have performed ultrasound for more than five years and/or are involved in providing ultrasound training. RESULTS: 11 French general practitioners screened 83 skills in 4 anatomical regions: abdominal, urogenital, vascular, gynecology and obstetrics. An agreement was obtained for 36 POCUS skills as to their appropriateness in General Practice. There were 17 skills with a strong appropriate agreement (100% of "7-9" ratings) and 19 skills with a relative agreement (100% of "5-9" ratings). CONCLUSION: These skills could serve as a basis for guidelines on the use and curriculum of POCUS in General Practice in France as well as in other countries with similar healthcare systems.

Innovations in dengue virus detection: An overview of conventional and electrochemical biosensor approaches.

Globally, people are in great threat due to the highly spreading of viral infectious diseases. Every year like 100-300 million cases of infections are found, and among them, above 80% are not recognized and irrelevant. Dengue virus (DENV) is an arbovirus infection that currently infects people most frequently. DENV encompasses four viral serotypes, and they each express comparable sign. From a mild febrile sickness to a potentially fatal dengue hemorrhagic fever, dengue can induce a variety of symptoms. Presently, the globe is being challenged by the untimely identification of dengue infection. Therefore, this review summarizes advances in the detection of dengue from conventional methods (nucleic acid-based, polymerase chain reaction-based, and serological approaches) to novel biosensors. This work illustrates an extensive study of the current designs and fabrication approaches involved in the formation of electrochemical biosensors for untimely identifications of dengue. Additionally, in electrochemical sensing of DENV, we skimmed through significances of biorecognition molecules like lectins, nucleic acid, and antibodies. The introduction of emerging techniques such as the CRISPR/Cas' system and their integration with biosensing platforms has also been summarized. Furthermore, the review revealed the importance of electrochemical approach compared with traditional diagnostic methods.

Impact of point-of-care clinical decision support on referrer behavior, imaging volume, patient radiation dose exposure, and sustainability.

OBJECTIVES: When referring patients to radiology, it is important that the most appropriate test is chosen to avoid inappropriate imaging that may lead to delayed diagnosis, unnecessary radiation dose, worse patient outcome, and poor patient experience. The current radiology appropriateness guidance standard at our institution is via access to a standalone web-based clinical decision support tool (CDST). A point-of-care (POC) CDST that incorporates guidance directly into the physician workflow was implemented within a subset of head and neck cancer specialist referrers. The purpose of this audit was to evaluate the imaging pathway, pre- and post-implementation to assess changes in referral behavior. METHODS: CT and MRI neck data were collected retrospectively to examine the relationship between imaging referrals pre- and post-POC CDST implementation. Effective radiation dose and estimated carbon emissions were also compared. RESULTS: There was an overall reduction in absolute advanced imaging volume by 8.2%, and a reduction in duplicate CT and MRI imaging by 61%, p < 0.0001. There was also a shift in ordering behavior in favor of MRI (OR [95% CI] = 1.50 [1.02-2.22], p = 0.049). These changes resulted in an effective radiation dose reduction of 0.27 mSv per patient, or 13 equivalent chest x-rays saved per patient, p < 0.0001. Additionally, the reduction in unnecessary duplicate imaging led to a 13.5% reduction in carbon emissions, p = 0.0002. CONCLUSIONS: Implementation of the POC CDST resulted in a significant impact on advanced imaging volume, saved effective dose, and reduction in carbon emissions. CRITICAL RELEVANCE STATEMENT: The implementation of a point-of-care clinical decision support tool may reduce multimodality ordering and advanced imaging volume, manifesting in reduced effective dose per patient and reduced estimated carbon emissions. Widespread utilization of the point-of-care clinical decision support tool has the potential to reduce imaging wait times. KEY POINTS: • Implementation of the point-of-care clinical decision support tool reduced the number of patients who simultaneously had a CT and MRI ordered for the same clinical indication compared to a standalone web-based clinical decision support tool. • The point-of-care clinical decision support tool reduced the absolute number of CT/MRI scans requested compared to the standalone web-based clinical decision support tool. • Utilization of the point-of-care clinical decision support tool led to a significant reduction in the effective dose per patient compared to the standalone web-based clinical decision support tool.

Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging.

BACKGROUND: Pleural effusion is a fluid buildup in the pleural space that mostly result from congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism. The diagnosis of this condition can be challenging as it presents symptoms that may overlap with other conditions; therefore, imaging diagnostic tools such as chest x-ray/radiograph (CXR), point-of-care ultrasound (POCUS), and computed tomography (CT) have been employed to make an accurate diagnosis. Although POCUS has high diagnostic accuracy, it is yet to be considered a first-line diagnostic tool as most physicians use radiography. Therefore, the current meta-analysis was designed to compare POCUS to chest radiography. METHODS: n extended search for studies related to our topic was done on five electronic databases, including PubMed, Medline, Embase, Scopus, and Google Scholar. A quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was performed on all eligible articles obtained from the databases. Moreover, the diagnostic accuracy of POCUS and CXR was performed using STATA 16 software. RESULTS: Our search yielded 1642 articles, of which only 18 were eligible for inclusion and analysis. The pooled analysis showed that POCUS had a higher diagnostic accuracy compared to CXR (94.54% (95% CI 91.74-97.34) vs. 67.68% (95% CI 58.29-77.08) and 97.88% (95% CI 95.77-99.99) vs. 85.30% (95% CI 80.06-90.54) sensitivity and specificity, respectively). A subgroup analysis based on the position of patients during examinations showed that POCUS carried out in supine and upright positions had higher specificity than other POCUS positions (99%). In comparison, lateral decubitus CXR had higher sensitivity (96%) and specificity (99%) than the other CXR positions. Further subgroup analyses demonstrated that CXR had higher specificity in studies that included more than 100 patients (92.74% (95% CI 85.41-100). Moreover, CXR tends to have a higher diagnostic accuracy when other CXR positions are used as reference tests (93.38% (95% CI 86.30-100) and 98.51% (95% CI 94.65-100) sensitivity and specificity, respectively). CONCLUSION: POCUS as an imaging modality has higher diagnostic accuracy than CXR in detecting pleural effusion. Moreover, the accuracy is still high even when performed by physicians with less POCUS training. Therefore, we suggest it is considered a first-line imaging tool for diagnosing pleural effusion at the patients' bedside.

Wireless patient monitoring and Efficacy Safety Score in postoperative treatment at the ward: evaluation of time consumption and usability.

To evaluate objective time consumption and how nurses perceived introducing wireless patient monitoring (WPM) and a validated score on patient quality and safety, the Efficacy Safety Score (ESS), at a mixed surgery ward. After fulfilling a randomised controlled trial combining the ESS and WPM, we addressed time consumption and conducted a questionnaire survey among nurses who participated in the study. The questionnaire appraised the nurses' evaluation of introducing these tools for postoperative management. Of 28 invited nurses, 24 responded to the questionnaire, and 92% reported the ESS and WPM-systems to increase patient safety and quality of care. 67% felt the intervention took extra time, but objective workload measurements revealed reduced time to 1/3 using ESS and WPM compared to standard manual assessment. Improved confidence when using the systems was reported by 83% and improved working situation by 75%. In a test situation to measure time consumption, the ESS and pre-attached WPM-systems require less time than the conventional standard of care, and may allow for more frequent clinical monitoring at the post-surgical ward. The combination of the ESS and the WPM systems was perceived as positive by participating nurses and further clinical development and research is warranted.

A Case Report of Radial Artery Pseudoaneurysm After Repeated Radial Puncture for Arterial Blood Gas.

Arterial blood gas, with subsequent radial arterial puncture as a simple access point, comprises a ubiquitous medical procedure in the diagnostic workup of patients admitted to the emergency department with dyspnea. Despite being a relatively safe and technically straightforward procedure, due to its considerable use, it is of vital importance to be able to promptly recognize its potential complications. We present the case of a 96-year-old female patient admitted to the emergency department with dyspnea and cough who underwent left radial arterial puncture for arterial blood gas. A total of three puncture attempts were performed until arterial blood was collected. Roughly two weeks upon observation, the patient was readmitted to the emergency department after the insidious appearance of a painful swelling in the left wrist, with progressive worsening since hospital discharge. On physical examination, a painful erythematous pulsatile swelling in the left wrist's volar aspect was observed, and further point-of-care ultrasound evaluation documented a cysticlike collection, communicating with the radial artery's lumen, and suggesting the probable diagnosis of iatrogenic radial pseudoaneurysm. The patient was hospitalized and underwent surgical resection of radial pseudoaneurysm, with subsequent arterial repair. Although severe complications from arterial blood gas have a low incidence rate, prompt diagnosis and management are required. Therefore, point-of-care ultrasound, as an additional diagnostic tool, may play a role in minimizing the risk of procedural complications.

Applicability of portable retinal cameras and telemedicine as facilitating tools in screening diabetic retinopathy in the COVID-19 pandemic scenario / Aplicabilidade do retinógrafo portátil e telemedicina como ferramentas facilitadoras na triagem de retinopatia diabética no cenário de pandemia de COVID-19

ABSTRACT Purpose: Diabetes mellitus is a leading cause of impaired vision. The objective of this study was to evaluate the feasibility of use of portable retinograph and remote analysis of images along with a virtual questionnaire for screening for diabetic retinopathy in basic health units in the city of Ribeirão Preto/SP during the Covid-19 pandemic. Methods: Standard Covid-19 protocol was followed during the screening. Blood pressure and capillary blood glucose were measured. Demographic and social data were collected through a standardized online questionnaire via smartphone. After pupillary dilation, fundal images were obtained with portable retinographs by trained ophthalmology residents. Two standardized 45° images were acquired: one posterior segment and another nasal to the optic nerve. Diabetic retinopathy was classified according to the Early Treatment Diabetic Retinopathy Study. Results: A total of 350 patients (64% female; 45% aged 55-70 years; 55% Caucasian) were evaluated. For 40.5% of patients, the campaign was the first opportunity for retinal evaluation; 47.56% had diabetes mellitus for >10 years. On repeat analysis of images stored in a cloud-based repository by retinal specialist, a 7.8% difference was observed in the Early Treatment Diabetic Retinopathy Study diabetic retinopathy classification, compared to the screening findings. Mild diabetic retinopathy was observed in 12.23%, moderate diabetic retinopathy in 6.31%, and proliferative diabetic retinopathy in 2.58% patients. Macular edema was present in 4.58% patients. Diabetic retinopathy was not detected in 72.78% patients. Conclusion: Use of portable retinographs together with telemedicine can provide efficient alternative to traditional methods for screening and diagnosis of diabetic retinopathy.

RESUMO Objetivo: A diabetes mellitus é considerada uma epidemia global e causa de baixa visual em países em desenvolvimento. Este estudo foi realizado com o objetivo de avaliar a viabilidade do retinógrafo portátil e análise remota de imagens associada a questionário virtual para o rastreio de retinopatia diabética em Unidades Básicas de Saúde da cidade de Ribeirão Preto/SP durante a pandemia de Covid-19. Métodos: Trezentos e sessenta pacientes compareceram a campanha. O acolhimento foi realizado na Unidade Básica de Saúde pela equipe de enfermagem, respeitando medidas de prevenção do Covid-19 Os realizou-se aferição da pressão arterial e glicemia capilar seguida de dilatação. Dados demográficos e sociais foram coletados através de questionário on-line padronizado via smartphone e realizou-se a triagem da retinopatia diabética através da obtenção de imagens com retinógrafos portáteis realizados por residentes de oftalmologia previamente treinados, com a aquisição de 2 imagens padronizadas de 45º: uma do segmento posterior e outra nasal ao nervo óptico. Resultados: Trezentos e sessenta pacientes foram atendidos durante a campanha. Dez pacientes (1,02%) foram excluídos devido à opacidade de meios e impossibilidade de obtenção de imagens de fundo de olho. Foram avaliados 350 pacientes, 64% do sexo feminino, 45% entre 55 e 70 anos e 55% brancos. A Campanha foi a primeira avaliação de retina para 40,5% dos pacientes e 47,56% apresentavam diabetes mellitus há mais de 10 anos. Na análise comparativa da classificação da retinopatia diabética segundo Early Treatment Diabetic Retinopathy Study (triagem X Nuvem) observou-se uma diferença de 7,8% nos resultados. Retinopatia diabética leve foi observada em 12,23%, moderada em 6,31%, proliferativa em 2,58%; edema macular presente em 4,58% e ausência de retinopatia diabética em 72,78% dos pacientes. Conclusão: A utilização de retinógrafos portáteis juntamente a telemedicina, para o rastreamento da retinopatia diabética pode ser considerada uma alternativa eficiente para triagem e diagnóstico da retinopatia diabética dentro ou fora do cenário pandêmico, auxiliando na prevenção de perda visual pelo diabetes.