Utility of Point-of-Care Ultrasound in the Diagnosis of Idiopathic Intracranial Hypertension in the Emergency Department.

BACKGROUND: Emergency physicians are frequently required to identify and triage patients with increased intracranial pressure (ICP). Idiopathic intracranial hypertension (IIH) is a possible cause that must be considered. Its prognosis depends on prompt recognition and treatment, and progression of the disease can lead to permanent vision loss and considerable morbidity. Point-of-care ultrasound can rapidly identify elevated ICP. Measurements of the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) can act as surrogates for ICP. CASE SERIES: We describe five cases in which ultrasound was used to identify increased ICP and aid clinical decision-making. In several of the cases, ultrasound was used to confirm a suspicion for IIH and initiate therapy while awaiting the results of a more time-consuming and technically challenging test, such as lumbar puncture or optical coherence tomography. One of the patients was pregnant, and sonographic evidence of elevated ICP helped avoid exposing the patient to unnecessary radiation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a quick and versatile tool for screening patients with neurologic symptoms, and when integrated into the proper clinical context, can reduce the use of more invasive tests. It can be particularly useful in patients with pathology that may not show abnormalities on computed tomography scan or in whom lumbar puncture is technically difficult, making patients at risk for IIH well-suited to examination by ultrasound. We use a cutoff of 5 mm for ONSD and 0.6 mm for ODE, though there are no universally agreed on cutoff values.

Comparison of four model for end-stage liver disease-based prognostic systems for cirrhosis.

Serum sodium (Na) has been suggested for incorporation into the Model for End-Stage Liver Disease (MELD) to enhance its prognostic ability for patients with cirrhosis. Three Na-containing models--the Model for End-Stage Liver Disease with the incorporation of serum sodium (MELD-Na), the integrated Model for End-Stage Liver Disease (iMELD), and the Model for End-Stage Liver Disease to sodium (MESO) index--were independently proposed for this purpose. This study investigated the accuracy of these 4 MELD-based models for outcome prediction. The c-statistic equivalent to the area under the receiver operating characteristic curve (AUC), used to predict 3- and 6-month mortality, was calculated and compared in 825 patients with cirrhosis. The MELD score tended to be lower with increasing Na level. At 3 months of enrollment, the iMELD had the highest AUC (0.807) and was followed by the MELD-Na (0.801), MESO (0.784), and MELD (0.773); the difference between the MESO and MELD was statistically significant (P = 0.013). At 6 months, the iMELD still had the highest AUC (0.797) and was followed by the MELD-Na (0.778), MESO (0.747), and MELD (0.735); all comparisons showed significant differences between each other (all P < 0.01), with the exception of iMELD and MELD-Na (P = 0.18). With the most discriminative cutoffs, the specificity and negative predictive value were 70%-85% and 89%-97%, respectively, at 3 and 6 months for the 4 models. Patients with spontaneous bacterial peritonitis (SBP) consistently had significantly higher MELD-derived scores in all 4 models compared to patients without SBP (all P < 0.01). Patients with hepatic encephalopathy also had higher scores in all 4 models, although the statistical significance was established only for the iMELD (41.0 +/- 11.5 versus 37.6 +/- 9.1, P = 0.037). In conclusion, the incorporation of Na into the MELD may enhance prognostic accuracy. Both the iMELD and MELD-Na are better prognostic models for outcome prediction in patients with cirrhosis. Patients with SBP have a higher MELD-derived score. Future studies are warranted to define the optimal MELD-based prognostic model for cirrhosis.

Validation of the HCC-MELD for dropout probability in patients with small hepatocellular carcinoma undergoing locoregional therapy.

BACKGROUND: The model for end-stage liver disease (MELD) is used in prioritizing cirrhotic patients awaiting liver transplantation. Patients with small hepatocellular carcinoma (HCC) are eligible candidates. An HCC-MELD equation was recently proposed to predict the dropout rate of HCC patients on the waiting list. This study aimed to validate the accuracy of this equation. METHODS: We investigated 390 patients with small HCC who were candidates for liver transplantation and underwent locoregional therapy. RESULTS: The estimated probability of dropout according to the equation was 8.2% for T1 stage and 13.5% for T2 stage HCC (p < 0.0001). The actual disease progression rate at three months was 2.1% for T1 and 3.0% for T2 stage HCC. At six months, the progression rate was 5.3% for T1 stage and 6.8% for T2 stage. The area under receiver operating characteristic curve of the HCC-MELD equation was 0.81 at three months and 0.80 at six months. Patients undergoing radiofrequency ablation (RFA) had significantly lower dropout rates compared with other treatment groups according to the equation (p = 0.0007). The actual tumor progression rate was also the lowest for the RFA group at both three and six months. CONCLUSION: The HCC-MELD equation is a feasible predictive model for patients with small HCC undergoing locoregional therapy.

Is the corrected-creatinine model for end-stage liver disease a feasible strategy to adjust gender difference in organ allocation for liver transplantation?

BACKGROUND: The Model for End-stage Liver Disease (MELD) scoring system is used for organ allocation in liver transplantation. Female cirrhotic patients have lower glomerular filtration rates (GFR) than males for the same creatinine (Cr) level. Correcting the Cr in females for the same GFR as in males shows that females have lower MELD scores and therefore a lower priority for liver transplantation; however, there has been no outcome data that justifies this modification. METHODS: We investigated 472 cirrhotic patients, comparing the mortality rate between males and females in relation to MELD and corrected-Cr MELD. RESULTS: Compared to females, male patients had a higher MELD (14.5+/-5.5 vs. 13.8+/-5.7) and significantly higher GFR (61.7+/-21.4 vs. 54.7+/-25.6 mlLmin/1.73 m, P=0.0002) because their Cr value was higher (1.4+/-0.4 vs. 1.3+/-0.5 mg/dL, P=0.0002). The corrected-Cr MELD score in females was higher (15.7+/-6.3) compared to the MELD in their original counterpart (P<0.0001) and the males (P=0.060). Female and male patients had a similar 3-month mortality rate (6.7% vs. 6.3%) and MELD (21.9+/-8.6 vs. 21.7+/-8.9) among deceased patients. At 6 months, female patients tended to have a lower mortality (12.5% vs. 14.7%) and a lower MELD (18.9+/-7.7 vs. 19.4+/-8.5) in deceased patients. However, at 9 and 12 months, females had a consistently higher mortality (25% vs. 21.2% and 37.5% vs. 31.3%, respectively) but lower MELD scores than males by 0.3-1 point. CONCLUSIONS: Using corrected-Cr MELD, which would prioritize female patients for liver transplantation, may only be justified in predicting intermediate-term (9- and 12-month), but not short-term (3- and 6-month) mortality.

Incidence and descriptive epidemiology of injuries to college ultimate players.

CONTEXT: The burden of injuries to college ultimate players has never been fully described. OBJECTIVE: To quantify the injury rate in ultimate players and describe the diagnoses, anatomic locations, and mechanisms of injuries. DESIGN: Descriptive epidemiology study. SETTING: College ultimate teams in the United States during the 2012 season. MAIN OUTCOME MEASURE(S): Initial injury rate per 1000 athlete-exposures. RESULTS: The initial injury rate in college ultimate players was 12.64 per 1000 athlete-exposures; the rate did not differ between men and women (P = .5). Bivariate analysis indicated that injuries occurred twice as often during games as during practices, men were more likely than women to be injured when laying out for the disc, and men were more likely to incur strains and sprains than women. CONCLUSIONS: Injury patterns to college ultimate players were similar to those for athletes in other National Collegiate Athletic Association sports. This is the first study to systematically describe injuries to ultimate players.