An Unusual Case of Neonatal High-Output Heart Failure: Infantile Hepatic Hemangioma.

BACKGROUND: Infantile hepatic hemangioma (IHH) is a rare but life-threatening disorder that must be considered in the newborn presenting with high-output heart failure (HF). IHH is a tumor comprised of large vascular beds, which require a significant increase in blood flow as the lesion grows. This, in turn, creates an undue burden on the cardiovascular system, leading to high-output HF and potentially, respiratory distress. Recent changes have been made in the classification of certain hepatic hemangiomas and their treatments. CASE REPORT: A 10-day-old girl presented to the Emergency Department with increased respiratory effort and an episode of apnea and cyanosis. A chest x-ray study was obtained and showed cardiomegaly and pulmonary edema concerning for HF. The patient was promptly admitted to the pediatric intensive care unit, where advanced imaging was obtained revealing findings consistent with IHH. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: HF in an infant is a critical condition often requiring prompt intervention and rapid diagnosis of the correct etiology to save a life. IHH is an example of an extrathoracic etiology of pediatric HF that has undergone recent changes in terminology and diagnosis. Increased awareness among emergency physicians of this disease process and its treatments can lead to expeditious diagnosis and treatment of this potentially life-threatening illness.

Novel Internal Medicine Residency Ultrasound Curriculum Led by Critical Care and Emergency Medicine Staff.

INTRODUCTION: Point-of-care ultrasound (POCUS) is an integral aspect of critical care and emergency medicine curriculums throughout the country, but it has been slow to integrate into internal medicine residency programs. POCUS has many benefits for internal medicine providers, guiding diagnostic decisions and aiding in procedures. Additionally, POCUS is a convenient and portable resource specifically for internal medicine providers in the military when practicing in deployed or critical care settings. Critical care and emergency medicine clinicians are excellent resources to lead these courses. We sought to develop a new POCUS curriculum for internal medicine residents within the Naval Medical Center Portsmouth Internal Medicine Residency program with the support of emergency medicine and critical care medicine staff to lead and oversee the training. The project's aim was to increase internal medicine resident confidence with POCUS by 20% and proficiency with POCUS as evidenced by pretest and posttest analysis by 10%. MATERIALS AND METHODS: The program consisted of a 2-day, 9-hour, introductory course, combining lecture with hands-on scanning taught by emergency medicine physicians who had completed emergency ultrasound fellowship-level training. This was followed by a longitudinal component of hands-on scanning throughout the academic year built into the residents' schedules. Emergency and critical care medicine ultrasound staff reviewed all studies for quality assurance (QA). The residents were given both precourse and post-course knowledge tests and confidence surveys, which utilized a 5-point Likert scale. The knowledge assessments were analyzed with a paired t-test, and the Likert scale data were analyzed using the Wilcoxon signed-rank test. The Naval Medical Center Portsmouth Institutional Review Board deemed this project nonhuman subjects' research. RESULTS: Twenty participants were enrolled, with 10 (50%) of those enrolled completing all course requirements. The average precourse knowledge assessment score was 76.60%, and postcourse assessment score was 80.95% (+4.35%, P = .33). The confidence survey scores were initially 73.33% and improved to 77.67% (+4.34%, P = .74). CONCLUSIONS: A curriculum comprised of a 9-hour workshop followed by a longitudinal hands-on experience can provide improvement in internal medicine resident POCUS knowledge and confidence. This model emphasizes the benefit of emergency and critical care cooperation for ultrasound training and provides an emphasis on medicine-relevant scans and longitudinal training.

Evacuation of Non-ST Elevation Myocardial Infarction in West Africa: 19 Hours of Lessons Learned in Prolonged Casualty Care and En Route Care.

Trauma casualty care has historically been the cornerstone of special operations military medical training. A recent case of myocardial infarction at a remote base of operations in Africa highlights the importance of foundational medical knowledge and training. A 54-year-old government contractor supporting operations in the AFRICOM area of responsibility (AOR) presented to the Role 1 medic with substernal chest pain with onset during exercise. Abnormal rhythm strips concerning for ischemia were obtained from his monitors. A MEDEVAC to a Role 2 facility was arranged and executed. At the Role 2 a non-ST-elevation myocardial infarction (NSTEMI) was diagnosed. The patient was emergently evacuated on a lengthy flight to a civilian Role 4 treatment facility for definitive care. He was found to have a 99% occlusion of the left anterior descending (LAD) coronary artery, as well as a 75% occlusion of the posterior coronary artery and a chronic 100% occlusion of the circumflex artery. The LAD and posterior arteries were stented, and the patient made a favorable recovery. This case highlights the importance of preparedness for medical emergencies and care of medically critical patients in remote and austere locations.

Determining Intraosseous Needle Placement Using Point-of-Care Ultrasound in a Swine (Sus scrofa) Model.

OBJECTIVE: Intraosseous (IO) access is critical in resuscitation, providing rapid access when peripheral vascular attempts fail. Unfortunately, misplacement commonly occurs, leading to possible fluid extravasation and tissue necrosis. Current research exploring the utility of bedside ultrasound in confirming IO line placement is limited by small sample sizes of skeletally immature subjects or geriatric cadaveric models. The objective of this study was to investigate the potential value of ultrasound confirming IO needle placement in a live tissue model with bone densities approximated to the young adult medical or trauma patient. MATERIALS AND METHODS: In this randomized, blinded prospective study, IO devices were placed into the bilateral humeri of 36 sedated adult swine (N = 72) with bone densities approximating that of a 20-39-year-old adult. Of the 72 lines, 53 were randomized to the IO space ("correct") and 19 into the subcutaneous tissue ("incorrect"). Four emergency physicians with variable ultrasound experience and blinded to needle location independently assessed correct or incorrect needle placements based on the presence of an intramedullary "flare" on color power Doppler (CPD) during a saline flush. Participants adjusted the ultrasound beam trajectory and recorded assessments up to three times, totaling 204 separate observations. RESULTS: Overall, sensitivity for placement confirmation was 72% (95% CI: 64%-79%). Specificity was 79% (95% CI: 66%-89%). First assessment and final assessment results were similar. More experienced sonographers demonstrated greater success in identifying inaccurate placements with a specificity of 86% (95% CI: 63%-96%). CONCLUSION: Within the context of this study, point-of-care ultrasound with CPD did not reliably confirm IO line placement. However, more accurate assessments of functional and malpositioned catheters were noted in sonographers with greater than 4 years of experience. Future study into experienced sonographers' use of CPD to confirm IO catheter placement is needed.

Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm.

INTRODUCTION: Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objectives of the study is to use current evidence and recommendations to (1) propose a diagnostic algorithm for IC-DVT when definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVT treatment. DISCUSSION: The Figure combines D-dimer testing with serial CUS or a single deferred FLUS for the diagnosis of IC-DVT. Such an algorithm has the potential to safely direct the management of suspected IC-DVT when definitive testing is unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated and awaiting further evidence. CONCLUSION: When IC-DVT is not ruled out in the ED, the suggested algorithm, although not prospectively validated by a controlled study, offers an approach to diagnosis that is consistent with current data and recommendations. When IC-DVT is diagnosed, current references suggest that a decision between anticoagulation and continued follow-up outpatient testing can be based on shared decision-making. The risks of proximal progression and life-threatening embolization should be balanced against the generally more benign natural history of such thrombi, and an individual patient's risk factors for both thrombus propagation and complications of anticoagulation.

Intravitreal triamcinolone for choroidal neovascularization in ocular histoplasmosis syndrome.

PURPOSE: To report the effects of intravitreal triamcinolone acetonide injections for subfoveal and juxtafoveal choroidal neovascularization (CNV) in ocular histoplasmosis syndrome. METHODS: In a retrospective analysis, the proportion of eyes that gained >or=5 or lost >or=5 and >or=15 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters, best-corrected visual acuity using ETDRS letter score (VA), greatest linear dimension (GLD), and treatment side effects were assessed. RESULTS: Ten patients (five subfoveal, five juxtafoveal CNV; median follow-up: 17 months; range, 6-41 months) were evaluated. Thirty percent gained >or=5 letters, 20% lost 5 to 14 letters, and 50% maintained stable VA. Overall, mean VA and GLD remained stable. Side effects were transient intraocular pressure elevation and mild cataract development. CONCLUSIONS: Intravitreal triamcinolone acetonide for CNV resulting from OHS was found to be relatively safe and showed good visual outcome for both subfoveal and juxtafoveal CNV. Further studies are warranted to evaluate this treatment.

A case of idiopathic colonic varices.

Colonic varices, usually detected by means of colonoscopy, are extremely rare and typically indicative of portal hypertension or chronic hepatopathology. Even more rare are those cases with no underlying disease, or idiopathic colonic varices. The authors report a case of these unexplained varices found during colonoscopy of a 30-year-old man with a 10-year history of diarrhea and occasional bloody stool. A thorough workup was performed, revealing no underlying abnormalities for his varices. Additionally, the authors review the literature of this rare diagnosis. Physicians must rule out hepatic, vascular, and cardiac causes before classifying a case of varices as idiopathic.

A video study of drop instillation in both glaucoma and retina patients with visual impairment.

PURPOSE: To compare self-administration of drops in both visually impaired glaucoma subjects and retina subjects. DESIGN: Prospective, observational study. SETTING: Distinct glaucoma and retina practices. STUDY POPULATION: Subjects with glaucoma or retinal diseases with visual acuity of 20/60 or worse in 1 eye, significant field loss, or both. OBSERVATION PROCEDURES: Subjects were video recorded self-instilling a drop onto the worse eye. MAIN OUTCOME MEASURE: Proper instillation of eye drop onto ocular surface. RESULTS: We included 409 subjects (205 glaucoma, 204 retina). Differences between the groups included the following: glaucoma subjects included fewer females (P = .05), included fewer white persons (P < .005), had worse visual acuity (P < .005), had less self-reported arthritis (P < .05), were younger (P < .005), and had more previous exposure to drop use (P < .005). Glaucoma subjects had more bilateral impairment (60% vs 42%; P < .0005). Retina subjects instilled more drops (1.7 vs 1.4; P = .02) and more frequently touched the bottle to the eye (47% vs 33%; P = .003). Of subjects claiming not to miss the eye, nearly one third from each group (P = .32) actually missed. Approximately one third of each group could not get a drop onto the eye (30% retina vs 29% glaucoma; P = .91). Among subjects placing 1 drop onto the eye without touching the adnexae, there was a trend for glaucoma patients to perform better, although both groups did poorly (success, 39% glaucoma vs 31% retina; P = .09). CONCLUSIONS: Among visually impaired subjects, regardless of cause, drop administration was a problem. Both groups wasted drops, contaminated bottles, and had inaccurate perception of their abilities. This has implications for future therapeutic delivery systems.

Pharmacologic therapy for diabetic retinopathy.

Diabetic retinopathy remains one of the major causes of acquired blindness in developed nations. This is true despite the development of laser treatment, which can prevent blindness in the majority of those who develop macular oedema (ME) or proliferative diabetic retinopathy (PDR). ME is manifest by retinal vascular leakage and thickening of the retina. The hallmark of PDR is neovascularisation (NV)--abnormal angiogenesis that may ultimately cause severe vitreous cavity bleeding and/or retinal detachment. Pharmacologic therapy aimed specifically at preventing vascular leakage and NV would be a welcome addition to the armamentarium. PDR and ME could be prevented by improved metabolic control or by pharmacologically blunting the biochemical consequences of hyperglycaemia (e.g., with aldose reductase inhibitors, inhibitors of non-enzymatic glycation or by protein kinase C [PKC] inhibition). The angiogenesis in PDR could be treated via growth factor (e.g., vascular endothelial growth factor [VEGF], insulin like growth factor-1 [IGF-1]) blockade, integrin (e.g., alpha-v beta-3) blockade, extracellular matrix alteration (e.g., with steroid compounds) or interference with intracellular signal transduction pathways (e.g., PKC and mitogen activated protein kinase [MAPK] pathway proteins). Some of these antiangiogenic agents may also prove useful for treating or preventing ME. Numerous potentially useful antiangiogenic compounds are in development; two drugs are presently in clinical trials for treatment of the preproliferative stage of PDR, while two are in clinical trials for treatment of ME.