Reliability and reproducibility of the venous excess ultrasound (VExUS) score, a multi-site prospective study: validating a novel ultrasound technique for comprehensive assessment of venous congestion.

Though the novel venous excess ultrasound (VExUS) score is increasingly used as a noninvasive means of venous congestion measurement, the inter-rater reliability (IRR), inter-user reproducibility (IUR), and utility of concurrent ECG have not been evaluated. We conducted a multicenter study of the IRR, IUR, and utility of ECG for VExUS interpretation between four attending physicians of diverse specialties, reporting the Kappa statistic (KS) and Intraclass Correlation Coefficient (ICC) for IRR and IUR for scans with and without ECG. Eighty-four paired VExUS exams from 42 patients, 60 of which had a concurrent ECG tracing, were interpreted. They showed substantial IRR, with a KS of 0.71 and ICC of 0.83 for the overall VExUS grade (p < 0.001), and IUR, with a KS 0.63 and ICC of 0.8. There was greater agreement among images with an ECG tracing. These results suggest that ECG-augmented VExUS may be a reliable and reproducible measure interpretable by clinicians with diverse backgrounds.

Management of Soft-tissue Defects of Hand in a Conflict Combat Zone: A Case Series.

Introduction: Managing soft-tissue defects of hand is a challenging problem for any surgical team, even more in a field hospital setting of a conflict combat zone, where resources are scarce and such cases due to blunt trauma, gunshot wound and deep tissue infections are common. Case Report: We present four different cases, all middle aged males, who sustained injuries due to crush, low velocity gun shot, and defects post-debridement of acute onset infections following abrasions. The first patient was managed with doubled pedicled abdominal flap, the second patient was managed with external fixation for fracture, and cross finger flap for the defect. The third and fourth patients had similar presentations of acute onset deep soft tissue and bony infection, out of which one was managed with full thickness skin graft from anterior abdominal wall and the other with bi-pedicled abdominal flap. All the patients had good functional outcomes with no functional restrictions at follow-up of 12 weeks. Conclusion: All the cases were performed in a challenging situation of a highly active combat field zone, with limited resources and lack of availability of a trained hand surgeon. An early soft-tissue coverage, as soon as possible, was crucial in saving the hand function and guaranteeing a speedy return to function in view of lack of a professional hand surgery team and specialized microsurgery equipment.

Splenogonadal Fusion - A Rare Anomaly.

Splenogonadal fusion (SGF) is a rare congenital anomaly. Less than 200 cases of SGF have been documented till date. We present a case of 14-year-old male patient with swelling in the left scrotum for 3 years. Left orchidectomy was done. Histopathology showed ectopic splenic tissue surrounding testicular parenchyma suggestive of SGF. This rare congenital malformation may occur due to the proximity of developing gonad and spleen, resulting in abnormal connection between them during gestation. SGF presents a diagnostic challenge preoperatively; however, recent imaging methods can aid with the diagnosis. SGF as a rare cause of testicular swelling should be kept in mind and evaluated to avoid unnecessary orchidectomy.

Ultrasound-Assessed Gastric Antral Area Correlates With Aspirated Tube Feed Volume in Enterally Fed Critically Ill Patients.

BACKGROUND: Enteral tube feed (ETF) intolerance occurs frequently in hospitalized patients and more so in critically ill patients. Most critical care nurses continue to assess gastric residual volume (GRV), especially among those with a history of ETF intolerance. We hypothesized that ultrasound assessment of GRV correlates directly with aspirated tube feed volume. METHODS: This was a prospective cohort study of a convenience sample of critically ill mechanically ventilated patients admitted to an intensive care unit receiving ETF. The gastric antrum was imaged using the aorta and inferior vena cava (IVC) as landmarks concurrently and simultaneously using a curvilinear probe in the midline. All ultrasound measurements were performed at 30 degrees head up, in the supine position, and prior to the assessment of GRV by nursing staff blinding the ultrasonographer to gastric volume aspirated. Gastric antral area was determined by assessing anteroposterior (AP) and craniocaudal (CC) diameters of the gastric antrum. RESULTS: Gastric cross-sectional area (CSA) using IVC as a landmark ( R2 = 0.92, P < .0001) and aorta as a landmark ( R2 = 0.86, P < .0001) correlated with aspirated volume. CC diameter of the stomach measured using the aorta as a landmark correlated with aspirated volume and increased linearly with increasing GRV ( R2 = 0.78, P < .0001). A CC diameter of <10 cm using the aorta as a landmark predicted a gastric volume of <500 mL. CONCLUSIONS: Ultrasound assessment provides accurate assessment of gastric volume in real-life settings, and the CC diameter of the gastric antrum provides a simple surrogate of GRV.

Pet Groomer's Lung: A novel occupation related hypersensitivity pneumonitis related to pyrethrin exposure in a pet groomer.

A 61-year-old man was evaluated for a 2 month history of cough and dyspnea without relevant exposures other than pyrethrin containing insecticidal sprays he used while grooming dogs almost daily. High Resolution Computed Tomography (HRCT) of the chest demonstrated a Non-Specific Interstitial Pneumonia (NSIP) pattern. Pulmonary function testing revealed an isolated mildly reduced diffusion capacity. Bronchoalveolar lavage (BAL) results confirmed the presence of foamy histiocytes, lymphocytes, and polymorphonuclear cells consistent with ongoing exposure. Open lung biopsy showed poorly formed granulomas and bronchiolitis. He was advised to avoid exposure to pyrethrin. While he declined to stop grooming dogs, on follow-up, his symptoms had improved with use of a P100 mask and better ventilation to protect himself when using the pet sprays. We conclude that sustained exposure to pyrethrin containing sprays in the pet grooming industry may be a risk factor for a novel occupation related hypersensitivity pneumonitis. ("Pet Groomer's Lung"). Am. J. Ind. Med. 60:141-145, 2017. © 2016 Wiley Periodicals, Inc.

Utilization of a gum elastic bougie to facilitate single lung intubation.

INTRODUCTION: Patients with severe pulmonary hemorrhage due to unilateral trauma or a bleeding cancer often present to the emergency department in acute respiratory distress. Although it is generally recommended to perform single lung intubation, most emergency department providers do not have access to or are not familiar with double-lumen endotracheal tubes, and blind insertion of an endotracheal tube to maximum depth does not ensure that the proper (nonhemorrhagic) lung is ventilated. Therefore, single lung intubation may be significantly delayed in these patients. The purpose of this study was to assess the accuracy of using a gum elastic bougie ("bougie") to facilitate single lung intubation. METHODS: We conducted a prospective, randomized, blinded pilot study assessing the accuracy of bougie-guided single lung intubation in a fresh human cadaveric model. Two investigators each inserted a bougie under video laryngoscope guidance. After passing the vocal cords, the intubator would be randomized to turn the bougie 90° clockwise (for right mainstem intubation) or 90° counterclockwise (for left mainstem intubation). The bougie was then advanced until resistance was met, and the endotracheal tube was subsequently advanced over the bougie. After intubation, a board-certified pulmonologist investigator who was blinded to the initial lung selection used a fiberoptic bronchoscope to confirm placement by assessing endotracheal tube location with respect to the carina. The primary outcome was the accuracy of correct lung placement. RESULTS: Two providers performed a total of 45 placements. There were 22 right mainstem and 23 left mainstem intubations. The overall accuracy was 100% (95% confidence interval, 90.2%-100%) for both right and left mainstem intubations. DISCUSSION: In our cadaveric model of mainstem intubation, bougie-guided single lung intubation was highly accurate for both left and right mainstem intubations. Future studies should assess the accuracy of this technique among different providers and bodies, as well as live patients.

Underutilization of evidence-based strategies in the diagnosis and treatment of venous thromboembolism among trainees.

BACKGROUND: The knowledge and attitude of trainees toward the use of prediction rules in the diagnosis of venous thromboembolism (VTE) is understudied. The extent of knowledge as far as imaging strategies in the setting of VTE and use of low molecular weight heparin (LMWH) among trainees is also understudied. METHODS: This was a cross-sectional study; between October, 2006 and March, 2008, surveys were distributed at grand rounds and national medicine board review courses. Respondents returning completed surveys included 43 medicine attendings, 139 residents, and 134 medical students Emergency physicians were called at work and 46 completed an abbreviated version of the survey. Attending and trainee responses were compared. RESULTS: Over 60% of students and 40% of residents did not use any prediction rules. Most attendings (>60%) did not use a prediction rule. Among attendings, 48% of emergency physicians and 30% of medicine attendings felt that prediction rules were too complex to use. Knowledge about imaging techniques and diagnostic protocols for VTE were worse for students than for residents. A substantial minority of all respondents (17% of students, 12% of residents and 13% of medicine attendings) would not use LMWH in the therapy of non-massive pulmonary embolism. In general, level of training did not translate into a greater proportion of correct responses to clinical scenarios or greater knowledge about imaging systems and strategies. CONCLUSION: Trainees do not use a structured approach to VTE diagnosis. LMWH therapy is underutilized by a large minority of trainees and attendings. A top-down approach is needed to revitalize evidence-based management of VTE.

Ethnic variations in quality of life and depressive symptoms among black Americans with acute decompensated heart failure.

BACKGROUND: Readmission rates for black Americans with heart failure are higher than for white Americans. Ethnic variations in quality of life (QOL) and depressive symptoms in black Americans with acute decompensated heart failure (ADHF) are understudied. OBJECTIVE: To assess the severity of depressive symptoms and their contribution to QOL in patients with ADHF receiving care at inner-city hospitals with high volumes of black patients. METHODS: Depressive symptoms and QOL measured using the Patient Health Questionnaire 9 (PHQ-9) and the Minnesota Living With Heart Failure Questionnaire (MLWHFQ), respectively, were assessed in 134 nonhemodialysis patients with ADHF cared for in neighborhoods of New York City with more than 80% black residents. Univariate and multivariate methods were used to assess the effect of ethnicity on QOL and the contribution of depressive symptoms to QOL. RESULTS: Significant depression (PHQ-9 > or = 10) was found in 45% of individuals; MLWHFQ scores for these patients were 61 +/- 20; 60% of patients were functionally impaired. Adjusted mean QOL scores were equivalent in the African American and Caribbean black groups. Depressive symptoms were equally severe in the 2 groups and explained an equivalent proportion (> 40%) of the variance in QOL in each group. CONCLUSIONS: Patients with ADHF cared for at centers with high volumes of black patients may have a high burden of depressive symptoms and a high prevalence of functional impairment because of depressive symptoms. Ethnicity among black Americans with ADHF does not predict QOL or severity of depressive symptoms.