Septic pulmonary embolism arising from a small temporal boil in a patient with diabetes mellitus type 2: A rare case report.

Septic pulmonary embolism (SPE) can originate from unusual sources like small boils, warranting consideration of diverse etiologies in respiratory distress. Prompt diagnosis, tailored antibiotics, and vigilant complication management optimize outcomes. Early recognition and treatment of minor infections, especially in diabetes are crucial.

Maximal Tizanidine withdrawal managed with dexmedetomidine: a vital intervention.

Tizanidine withdrawal is a rare and complex phenomenon characterized by a surge in adrenergic activity upon abrupt discontinuation of the drug. We present a unique case of a 41-year-old male with multiple comorbidities who self-administered an exceptionally high daily dose of Tizanidine, leading to severe withdrawal symptoms. This case report highlights the challenges in managing such cases. The patient, with a history of myofascial pain syndrome, hypertension, anxiety, and depression, experienced distressing symptoms, including tachycardia, rebound hypertension, neuropsychiatric manifestations, and involuntary muscle movements. Unlike previous cases, our patient required the addition of dexmedetomidine in conjunction with benzodiazepines for symptom management. Reintroduction of Tizanidine, carefully controlled and tapered, led to stabilization of hemodynamics and cessation of involuntary movements. This case underscores the importance of individualized treatment and vigilant monitoring when dealing with Tizanidine withdrawal, particularly at elevated daily doses.

Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging.

BACKGROUND: Pleural effusion is a fluid buildup in the pleural space that mostly result from congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism. The diagnosis of this condition can be challenging as it presents symptoms that may overlap with other conditions; therefore, imaging diagnostic tools such as chest x-ray/radiograph (CXR), point-of-care ultrasound (POCUS), and computed tomography (CT) have been employed to make an accurate diagnosis. Although POCUS has high diagnostic accuracy, it is yet to be considered a first-line diagnostic tool as most physicians use radiography. Therefore, the current meta-analysis was designed to compare POCUS to chest radiography. METHODS: n extended search for studies related to our topic was done on five electronic databases, including PubMed, Medline, Embase, Scopus, and Google Scholar. A quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was performed on all eligible articles obtained from the databases. Moreover, the diagnostic accuracy of POCUS and CXR was performed using STATA 16 software. RESULTS: Our search yielded 1642 articles, of which only 18 were eligible for inclusion and analysis. The pooled analysis showed that POCUS had a higher diagnostic accuracy compared to CXR (94.54% (95% CI 91.74-97.34) vs. 67.68% (95% CI 58.29-77.08) and 97.88% (95% CI 95.77-99.99) vs. 85.30% (95% CI 80.06-90.54) sensitivity and specificity, respectively). A subgroup analysis based on the position of patients during examinations showed that POCUS carried out in supine and upright positions had higher specificity than other POCUS positions (99%). In comparison, lateral decubitus CXR had higher sensitivity (96%) and specificity (99%) than the other CXR positions. Further subgroup analyses demonstrated that CXR had higher specificity in studies that included more than 100 patients (92.74% (95% CI 85.41-100). Moreover, CXR tends to have a higher diagnostic accuracy when other CXR positions are used as reference tests (93.38% (95% CI 86.30-100) and 98.51% (95% CI 94.65-100) sensitivity and specificity, respectively). CONCLUSION: POCUS as an imaging modality has higher diagnostic accuracy than CXR in detecting pleural effusion. Moreover, the accuracy is still high even when performed by physicians with less POCUS training. Therefore, we suggest it is considered a first-line imaging tool for diagnosing pleural effusion at the patients' bedside.

The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review.

BACKGROUND: Cardiac arrest in hospital and out-of-hospital settings is associated with high mortality rates. Therefore, a bedside test that can predict resuscitation outcomes of cardiac arrest patients is of great value. Point-of-care ultrasound (POCUS) has the potential to be used as an effective diagnostic and prognostic tool during cardiac arrest, particularly in observing the presence or absence of cardiac activity. However, it is highly susceptible to "self-fulfilling prophecy" and is associated with prolonged cardiopulmonary resuscitation (CPR), which negatively impacts the survival rates of cardiac arrest patients. As a result, the current systematic review was created to assess the role of POCUS in predicting the clinical outcomes associated with out-of-hospital and in-hospital cardiac arrests. METHODS: The search for scientific articles related to our study was done either through an electronic database search (i.e., PubMed, Medline, ScienceDirect, Embase, and Google Scholar) or manually going through the reference list of the relevant articles. A quality appraisal was also carried out with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2), and the prognostic test performance (sensitivity and sensitivity) was tabulated. RESULTS: The search criteria yielded 3984 articles related to our topic, of which only 22 were eligible for inclusion. After reviewing the literature, we noticed a wide variation in the definition of cardiac activity, and the statistical heterogeneity was high; therefore, we could not carry out meta-analyses. The tabulated clinical outcomes based on initial cardiac rhythm and definitions of cardiac activity showed highly inconsistent results. CONCLUSION: POCUS has the potential to provide valuable information on the management of cardiac arrest patients; however, it should not be used as the sole predictor for the termination of resuscitation efforts.

Comparison between transthoracic echocardiography and transoesophageal echocardiography in the diagnosis of acute aortic dissection from an emergency perspective. A systematic review and meta-analysis.

Background: Acute aortic dissection (AAD) is a life-threatening medical condition with high early fatality. Therefore, a prompt and precise diagnosis, which can be achieved through invasive and non-invasive techniques is vital. Echocardiography, unlike MRI and CT, is accessible in emergency units and bedside-compatible. The recommended echocardiographic techniques for AAD are transthoracic and transoesophageal echocardiography (TTE and TOE). Therefore, our review compares their diagnostic roles in AAD. Methods: Studies relevant to our topic were attained through a database search and manual scrutiny of references lists of articles obtained from the electronic databases. The Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) has been used for quality assessment. All quantitative analyses were performed using either STATA 16 or Comprehensive Meta-Analyst software. Results: The search strategy yielded 1,798 articles, of which only 11 were eligible for inclusion. Our subgroup analysis showed that conventional TTE had a sensitivity and specificity of 85.35% and 84.51% for the diagnosis of Stanford type A AAD and was 45.89% sensitive and 87.05% specific for the diagnosis of type B AAD. However, the subgroup analysis shows that contrast-enhancement of TTE results in a sensitivity and specificity of 93.30% and 97.60% for diagnosis of type A AAD, and 83.60% and 94.50% for diagnosis of type B AAD, respectively. On the other hand, conventional TOE was 93.64% sensitive and 95.50% specific for the diagnosis of type A AAD, 99.80% sensitive and 99.87% specific for the diagnosis of type B AAD. Moreover, our analyses show that TTE has pooled false negative and positive rates of 28.6% and 18.6%, while TOE has shown false negative and positive rates of 2.4% and 4.3%, respectively. Conclusion: TOE is the more favorable diagnostic tool for AAD diagnosis than TTE. However, it cannot be used as a stand-alone diagnostic tool since misdiagnosis cases are being reported. Contrast-enhanced TTE can also diagnose AAD since it provides similar results to conventional TOE.

An integrative comparative study between ultrasound-guided regional anesthesia versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: A systematic review and meta-analysis.

Background: Emergency physicians play a major role in managing patients with hip fractures. The most commonly used pain management option is parenteral opioids. However, parenteral opioids are subjected to several adverse effects. New pain management techniques such as regional anesthesia are used as alternatives to parenteral opioids. Anatomical landmarks were used to administer regional anesthesia; however, ultrasound guidance has shown promising results with regional anesthesia. Objective: of the Review: The present study compares the efficacy of ultrasound-guided regional anesthesia (USGRA) to parenteral opioids in analgesia of hip fractures patients. Methods: A literature search for original and relevant articles carried out through six electronic databases, yielded 710 articles which were then assessed using the eligibility criteria resulting in 8 studies eligible for inclusion. Results: A Meta-analysis of the seven studies showed that ultrasound-guided femoral nerve block was more effective than parenteral opioids in relieving pain. Similarly, meta-analysis of data from two studies shows that US-guided FICB significantly reduced pain scores than parenteral opioids. A subgroup analysis of adverse events showed no significant difference in nausea/vomiting and respiratory complications. However, a subgroup analysis on hypotension showed that the incidence of hypotension was significantly lower in USGRA than parenteral opioids. The present study also revealed that patients in the USGRA group required less frequent rescue analgesia than the patients in the parenteral opioids group. Conclusion: Results of the present study show that USGRA is superior to parenteral opioids in reducing pain and the need for rescue analgesia in patients with hip fractures.

Acceptability and Feasibility of Mini Clinical Evaluation Exercise (Mini-CEX) in the Busy Emergency Department.

BACKGROUND: Mini Clinical Evaluation Exercise (Mini-CEX) has been adapted to different specialties in clinical practice but with very little evidence documented about its use for residency training in the emergency department (ED). This study aims to assess its acceptability and feasibility as a formative tool in the busy emergency department. MATERIALS AND METHODS: Both the faculty members and the emergency medicine residents were sent a validated questionnaire using Google forms, and the results were analyzed using simple statistical tools. RESULTS: Forty-nine residents and 58 faculty participated in the survey. The study was carried out over a period of 4 months. The resident's completion rate was 96% (49 out of 51), while faculty completion rate was 96% (58 out of 60). The time for Mini-CEX completion ranged from 10 to 20 minutes. Most of the residents were satisfied with Mini-CEX as an assessment tool. Twelve residents expressed their concern regarding available time during busy clinical shifts. Most of the faculty agreed with the benefits of using Mini-CEX as a formative assessment tool. Several of them commented that they need "protected time" and "more training" to use this tool to provide maximum benefit to the residents. CONCLUSION: Despite busy nature of ED, Mini-CEX has been identified as an acceptable learning tool for residents in emergency medicine. Based on the faculty's feedback and comments, several faculty development workshops were conducted to improve faculty skills in carrying assessments by using Mini-CEX, and protected time is provided to some faculty members to carry out these formative assessments for the benefit of the residents.

Current Use, Perceived Barriers, and Learning Preference of Point of Care Ultrasound (POCUS) in the Emergency Medicine in Qatar - A Mixed Design.

INTRODUCTION: Point of care ultrasound (POCUS) has been a part of emergency medicine (EM) training for almost two decades. EM training program has a very broad and rigorous POCUS curricula which, in several cases, does not translate to routine application in clinical settings. This study therefore sought to compare the indications, utilization, barriers, and preferred POCUS educational method in a large Middle Eastern academic EM. METHODOLOGY: A validated questionnaire was emailed to 50 EM faculties between April and May 2019. Volunteer faculty members partook in a semi-structured interview to better understand the indications, current use, barriers, and preferred learning method. Responses were anonymous, and data were analyzed with descriptive statistics. RESULTS: This was a mixed design study. 30/50 (60%) of faculty responded to the survey, with a mean age of 39.2 years and a mean number of years in practice, 13.1. 55% (n=28) completed POCUS training in less than five years, while 45% completed more than five years ago and 5% never completed it. Forty percent of EM physicians were trained in Africa, while 55% were qualified in Asia and 5% completed their training in Europe. The indications and frequently performed procedures were consistent with the previous research. The common barrier reported was lack of time, lack of credentialing, lack of quality assurance, and national guidelines. The majority of the faculty preferred a blended learning approach for POCUS. CONCLUSION: POCUS perceived barriers to its full use include time constraints, lack of national guidelines, and credentialing (awarding POCUS qualifications) of the faculty. Blended learning appears to be the preferred approach towards acquiring the knowledge and skills of POCUS.

Modified Balance Error Scoring System (M-BESS) test scores in athletes wearing protective equipment and cleats.

BACKGROUND: Balance testing is an important part of the initial concussion assessment. There is no research on the differences in Modified Balance Error Scoring System (M-BESS) scores when tested in real world as compared to control conditions. OBJECTIVE: To assess the difference in M-BESS scores in athletes wearing their protective equipment and cleats on different surfaces as compared to control conditions. METHODS: This cross-sectional study examined university North American football and soccer athletes. Three observers independently rated athletes performing the M-BESS test in three different conditions: (1) wearing shorts and T-shirt in bare feet on firm surface (control); (2) wearing athletic equipment with cleats on FieldTurf; and (3) wearing athletic equipment with cleats on firm surface. Mean M-BESS scores were compared between conditions. RESULTS: 60 participants were recruited: 39 from football (all males) and 21 from soccer (11 males and 10 females). Average age was 21.1 years (SD=1.8). Mean M-BESS scores were significantly lower (p<0.001) for cleats on FieldTurf (mean=26.3; SD=2.0) and for cleats on firm surface (mean=26.6; SD=2.1) as compared to the control condition (mean=28.4; SD=1.5). Females had lower scores than males for cleats on FieldTurf condition (24.9 (SD=1.9) vs 27.3 (SD=1.6), p=0.005). Players who had taping or bracing on their ankles/feet had lower scores when tested with cleats on firm surface condition (24.6 (SD=1.7) vs 26.9 (SD=2.0), p=0.002). CONCLUSIONS: Total M-BESS scores for athletes wearing protective equipment and cleats standing on FieldTurf or a firm surface are around two points lower than M-BESS scores performed on the same athletes under control conditions.