Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care.

Background and Objectives: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients' characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient's clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Materials and Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients' management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusion: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

Erratum to: Inter-device reproducibility of retrobulbar blood flow velocity measurements in healthy subjects using color Doppler imaging.

[This corrects the article DOI: 10.1007/s40477-016-0194-5.].

Inter-device reproducibility of retrobulbar blood flow velocity measurements in healthy subjects using color Doppler imaging.

PURPOSE: To evaluate the inter-device reproducibility of retrobulbar blood flow measurements obtained by two commercially available CDI (color Doppler imaging) devices. METHODS: The right eyes of 10 healthy volunteers were investigated. Four examiners, namely two ophthalmologists and two radiologists, performed CDI examination of the ophthalmic artery, central retinal artery and temporal short posterior ciliary arteries using both CDI devices: ESAOTE MYLAB™ and SIEMENS ANTARES STELLAR PLUS™. The peak systolic velocity (PSV), the end-diastolic velocity (EDV) and the resulting resistivity index (RI) were averaged for 3 cardiac cycles. To evaluate the reproducibility between both device measurements, the Lin's concordance correlation coefficient (CCC) was used. CCC can be expressed as the product of Pearson's r (the measure of precision) and C_b (the measure of accuracy). RESULTS: Results show that the inter-device reproducibility for CDI measurements is not acceptable since a poor degree of overall concordance (0.15 0.71) but overall precision low (0.18< Pearson's r <0.47). Ophthalmologists and radiologists obtained similar results. CONCLUSIONS: To evaluate the causal role of blood flow abnormalities in glaucoma, CDI analysis using different devices seems unreliable. CDI inter-device reproducibility seems unrelated to medical speciality of the examiners. However, to improve present results, the use of similar probes and standardized CDI instrument settings as well as a CDI images analysis by a single grader, might possibly improve the inter-device reproducibility when testing the retrobulbar blood flow velocity.

Reproducibility of retrobulbar blood flow velocity measurements in normal subjects using two different CDI devices.

PURPOSE: This study was done to evaluate the intra- and inter-operator reproducibility of colour Doppler imaging (CDI) in assessing blood flow velocity in the ophthalmic (OA), central retinal (CRA) and short posterior ciliary arteries (SPCA) in healthy subjects. MATERIALS AND METHODS: The right eye of two groups of eight healthy volunteers was examined. Two radiologists and two ophthalmologists, divided into pairs, measured peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistivity index (RI) of each vessel using a different CDI device for each group. The concordance between two measurements was evaluated with Lin's concordance correlation coefficient (CCC). RESULTS: Globally, very good degrees of intra-operator concordance were obtained for the PSV (0.859 cm/s), EDV (0.834 cm/s) and RI (0.859) of the OA. There was moderate concordance for PSV (0.574 cm/s) and EDV (0.594 cm/s) and good concordance for RI (0.694) for the CRA. Good degrees of concordance were obtained for the SPCA measurements. However, inter-operator concordance was found globally poor. CONCLUSIONS: These data show that CDI measurements in retrobulbar vessels are operator dependent. To increase the intra-operator and inter-operator concordance, rules should be adopted for timing of the examination and positioning of the probe to minimise the pressure applied on the eye.