Left Ventricular Ejection Fraction Assessment by Emergency Physician-Performed Bedside Echocardiography: A Prospective Comparative Evaluation of Multiple Modalities.

BACKGROUND: Although there is some support for visual estimation (VE) as an accurate method to estimate left ventricular ejection fraction (LVEF), it is also scrutinized for its subjectivity. Therefore, more objective assessments, such as fractional shortening (FS) or e-point septal separation (EPSS), may be useful in estimating LVEF among patients in the emergency department (ED). OBJECTIVE: Our aim was to compare the real-world accuracy of VE, FS, and EPSS using a sample of point-of-care cardiac ultrasound transthoracic echocardiography (POC-TTE) images acquired by emergency physicians (EPs) with the gold standard of Simpson's method of discs, as measured by comprehensive cardiology-performed echocardiography. METHODS: We conducted a single-site prospective observational study comparing VE, FS, and EPSS to assess LVEF. Adult patients in the ED receiving both POC-TTE and comprehensive cardiology TTE were included. EPs acquired POC-TTE images and videos that were then interpreted by 2 blinded EPs who were fellowship-trained in emergency ultrasound. EPs estimated LVEF using VE, FS, and EPSS. The primary outcome was accuracy. RESULTS: Between April and May 2018, 125 patients were enrolled and 113 were included in the final analysis. EP1 and EP2 had a κ of 0.94 (95% confidence interval [CI] 0.87-1.00) and 0.97 (95% CI 0.91-1.00), respectively, for VE compared with gold standard, a κ of 0.40 (95% CI 0.23-0.57) and 0.38 (95% CI 0.18-0.57), respectively, for EPSS compared with gold standard, and a κ of 0.70 (95% CI 0.54-0.85) and 0.66 (95% CI 0.50-0.81), respectively, for FS compared with gold standard. Sensitivity of severe dysfunction was moderate to high in VE (EP1 85% and EP2 93%), poor to moderate in FS (EP1 73% and EP2 50%), and poor in EPSS (EP1 11% and EP2 18%). CONCLUSIONS: Using a real-world sample of POC-TTE images, the quantitative measurements of EPSS and FS demonstrated poor accuracy in estimating LVEF, even among experienced sonographers. These methods should not be used to determine cardiac function in the ED. VE by experienced physicians demonstrated reliable accuracy for estimating LVEF compared with the gold standard of cardiology-performed TTE.

The importance of improving the quality of emergency surgery for a regional quality collaborative.

INTRODUCTION: Within a large, statewide collaborative, significant improvement in surgical quality has been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative, variations in outcomes among hospitals, and variations in adherence to evidence-based process measures. Overall, these data will form a basis for a broad-based quality improvement initiative within Michigan. METHODS: We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (N = 190,826) within 34 hospitals participating in the Michigan Surgical Quality Collaborative from 2005 to 2010. Adjusted hospital-specific outcomes were calculated using a stepwise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities and case complexity. Hospitals were also compared on the basis of their adherence to evidence-based process measures [measures at the patient level for each case-Surgical Care Improvement Project (SCIP)-1 and SCIP-2 compliance]. RESULTS: Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within Michigan Surgical Quality Collaborative hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was a wide variation in compliance with SCIP-1 and SCIP-2 measures and overall compliance (42.0%) was markedly lower than that for elective colon surgery (81.7%). CONCLUSIONS: Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

Single Versus Double Tourniquet Technique for Ultrasound-Guided Venous Catheter Placement.

INTRODUCTION: Peripheral, ultrasound-guided intravenous (IV) access occurs frequently in the emergency department, but certain populations present unique challenges for successfully completing this procedure. Prior research has demonstrated decreased compressibility under double tourniquet technique (DT) compared with single tourniquet (ST). We hypothesized that catheters inserted under DT method would have a higher first-stick success rate compared with those inserted under ST method. METHODS: We randomized 100 patients with a history of difficult IV access, as defined by past ultrasound IV, prior emergency visit with two or more attempts required for vascular access, history of IV drug abuse, history of end stage renal disease on hemodialysis or obesity, to ultrasound-guided IV placement under either DT or ST method. We measured the vein characteristics measured under ultrasound, and recorded the number of attempts and location of attempts at vascular access. RESULTS: Of an initial 100 patients enrolled, we analyzed a total of 99 with 48 placed under ST and 51 placed under DT. Attending physicians inserted 41.7% of ST and 41.2% of DT, with non-attending inserters (including residents, nurses, and technicians) inserted the remainder. First-stick success rate was observed at 64.3% in ST and 66.7% in DT (p=0.93). Attendings had an overall higher first-stick success rate (95.1%) compared to non-attending inserters (65.5%) (p=<0.001). The average vein depth measured in ST was 0.73 centimeters (cm) compared with 0.87 cm in DT (p=0.02). CONCLUSION: DT technique did not produce a measureable increase in first-stick success rate compared to ST, including after adjusting for level of training of inserter. However, a significant difference in average vein depth between the study arms may have limited the reliability of our overall results. Future studies controlling for this variable may be required to more accurately compare these two techniques.

Operative Hysteroscopy Intravascular Absorption Syndrome Causing Hyponatremia with Associated Cerebral and Pulmonary Edema.

Operative hysteroscopy intravascular absorption syndrome is an iatrogenic syndrome caused by absorption of hypo-osmolar distension medium during hysteroscopy, which can lead to rapid hyponatremia with resulting cerebral and pulmonary edema. We present a case of a 47-year-old female who underwent hysteroscopic myomectomy at an outpatient ambulatory surgical center who was brought to the emergency department with dyspnea, hypoxia, and altered mental status. Workup showed hyponatremia with cerebral edema on computed tomography of the head and pulmonary edema on chest radiograph. The patient improved after resuscitation with intravenous saline and supplemental oxygen, and she was discharged home the next day.

Bilateral Posterior Native Hip Dislocations after Fall from Standing.

We present a case of bilateral posterior native hip dislocations after a fall from standing. This exceedingly rare diagnosis is classically associated with younger patients whose bones are strong enough to dislocate rather than fracture in the setting of a high-momentum collision. We present an unusual case of an 88-year-old male with native hips who sustained a low-energy collision after falling from standing and was found to have bilateral posterior hip dislocations without associated pelvis or femur fractures.

EEG biomarkers of target engagement, therapeutic effect, and disease process.

Studies suggest that abnormalities in glutamate and GABA signaling contribute to deficits in schizophrenia and related conditions and that these neurochemical abnormalities produce changes in electroencephalographic (EEG) indices, including event-related potentials and event-related power within specific frequency ranges. Furthermore, clinical studies suggest that a subset of EEG biomarkers is associated with symptoms. This review addresses the relationship between EEG and behavior in preclinical models of N-methyl-d-aspartate (NMDA)-receptor hypofunction, as well as how these models can be used to screen therapies. Data from schizophrenia patients are juxtaposed with data from animal models, and EEG and behavioral data from mice with disruption of NMDA receptors in excitatory and/or inhibitory neurons are then compared to the pattern observed in schizophrenia. Also discussed are results following exposure to potential therapeutic agents, including GABAB agonists. Furthermore, evidence demonstrates that elevated resting gamma power is associated with deficits in social interactions. Consistent with elevated baseline noise, excitatory neurons from transgenic mice show increased intrinsic excitability in in vitro-slice patch-clamp studies across model systems. GABAB receptor agonists reduce this excitability, improve gamma-band responses, and reverse behavioral deficits in mice. Data suggest that baseline gamma power is associated with social function and GABAB agonists may be useful for schizophrenia. Translational EEG biomarkers reflect target engagement and can contribute to the design of more efficient drug trials, likely accelerating the development of new therapeutics for central nervous system disorders.