Evaluation of High Altitude Interstitial Pulmonary Edema in Healthy Participants Using Rapid 4-View Lung Ultrasound Protocol During Staged Ascent to Everest Base Camp.

INTRODUCTION: Prior research identified possible interstitial pulmonary fluid, concerning for early high altitude pulmonary edema (HAPE), in a large percentage of trekkers above 3000 m using a comprehensive 28-view pulmonary ultrasound protocol. These trekkers had no clinical symptoms of HAPE despite these ultrasound findings. The more common 4-view lung ultrasound protocol (LUP) is accurate in rapidly detecting interstitial edema during resource-rich care. The objective of this study was to evaluate whether the 4-view LUP detects interstitial fluid in trekkers ascending to Everest Base Camp. METHODS: Serial 4-view LUP was performed on 15 healthy trekkers during a 9-d ascent from Kathmandu to Everest Base Camp. Ascent protocols complied with Wilderness Medical Society guidelines for staged ascent. A 4-view LUP was performed in accordance with the published 2012 international consensus protocols on lung ultrasound. Symptom assessment and 4-view LUP were obtained at 6 waypoints along the staged ascent. A 4-view LUP was positive for interstitial edema if ≥3 B-lines were detected in 2 ultrasound windows. RESULTS: A single participant had evidence of interstitial lung fluid at 5380 m as defined by the 4-view LUP. There was no evidence of interstitial fluid in any participant below 5380 m. One participant was evacuated for acute altitude sickness at 4000 m but showed no preceding sonographic evidence of interstitial fluid. CONCLUSIONS: In this small study, sonographic detection of interstitial fluid, suggestive of early HAPE, was not identified by the 4-view LUP protocol.

Evaluation of Gender Differences in Ultrasound Milestone Evaluations During Emergency Medicine Residency Training: A Multicenter Study.

OBJECTIVES: Prior literature has demonstrated incongruities among faculty evaluation of male and female residents' procedural competency during residency training. There are no known studies investigating gender differences in the assessment of procedural skills among emergency medicine (EM) residents, such as those required by ultrasound. The objective of this study was to determine if there are significant gender differences in ultrasound milestone evaluations during EM residency training. METHODS: We used a stratified, random cluster sample of Accreditation Council for Graduate Medical Education (ACGME) EM residency programs to conduct a longitudinal, retrospective cohort analysis of resident ultrasound milestone evaluation data. Milestone evaluation data were collected from a total of 16 ACGME-accredited EM residency programs representing a 4-year period. We stratified milestone data by resident gender, date of evaluation, resident postgraduate year, and cohort (residents with the same starting date). RESULTS: A total of 2,554 ultrasound milestone evaluations were collected from 1,187 EM residents (750 men [62.8%] and 444 women [37.1%]) by 104 faculty members during the study period. There was no significant overall difference in mean milestone score between female and male residents [mean difference = 0.01 (95% confidence interval {CI} = -0.04 to 0.05)]. There were no significant differences between female and male residents' mean milestone scores at the first (baseline) PGY1 evaluation (mean difference = -0.04 [95% CI = -0.09 to 0.003)] or at the final evaluation during PGY3 (mean difference = 0.02 [95% CI = -0.03 to 0.06)]. CONCLUSIONS: Despite prior studies suggesting gender bias in the evaluation of procedural competency during residency training, our study indicates that there were no significant gender-related differences in the ultrasound milestone evaluations among EM residents within training programs throughout the United States.

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial.

Importance: The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown. Objective: To determine if the FAST examination during initial evaluation of injured children improves clinical care. Design, Setting, and Participants: A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center. Interventions: Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone. Main Outcomes and Measures: Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges. Results: Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291). Conclusions and Relevance: Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting. Trial Registration: clinicaltrials.gov Identifier: NCT01540318.

Creation of a High-fidelity, Low-cost Pediatric Skull Fracture Ultrasound Phantom.

Over the past decade, point-of-care ultrasound has become a common tool used for both procedures and diagnosis. Developing high-fidelity phantoms is critical for training in new and novel point-of-care ultrasound applications. Detecting skull fractures on ultrasound imaging in the younger-than-2-year-old patient is an emerging area of point-of-care ultrasound research. Identifying a skull fracture on ultrasound imaging in this age group requires knowledge of the appearance and location of sutures to distinguish them from fractures. There are currently no commercially available pediatric skull fracture models. We outline a novel approach to building a cost-effective, simple, high-fidelity pediatric skull fracture phantom to meet a unique training requirement.

Ultrasound equipment for the pediatric emergency department: a review.

Ultrasound is gaining momentum for use in the pediatric emergency department. It is important to understand the fundamentals of ultrasound equipment as it relates to pediatric emergency medicine.

Vaginal vault dehiscence after hysterectomy.

STUDY OBJECTIVE: The purpose of our study was to evaluate factors predisposing vault dehiscence after hysterectomy and its manifestation. DESIGN: Case series and review of the literature (Canadian Task Force classification II-3). SETTING: Multicenter study. PATIENTS: Retrospective analysis of 16 unpublished cases of vaginal vault dehiscence after total laparoscopic hysterectomy from physicians who participated in the exchange on the topic of vaginal vault dehiscence at the American Association of Gynecologic Laparoscopists Endo Exchange List (group A) and review of 38 reported cases in the literature (group B). INTERVENTIONS: The participating physicians were asked to complete a detailed questionnaire related to vault dehiscence. In addition, we performed literature search using the keywords "vault dehiscence," "vaginal vault dehiscence," "vault prolapse," and "hysterectomy," and conducted the search in MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews. MEASUREMENTS AND MAIN RESULTS: We estimated risk factors and characteristic features for vaginal vault dehiscence. The incidence of vault dehiscence was higher after laparoscopic hysterectomy (1.14%) than after abdominal hysterectomy (0.10%, p <.0001, OR 11.5) and after vaginal hysterectomy (0.14%, p <.001, OR 8.3). The time interval between hysterectomy and occurrence of vault dehiscence in the laparoscopic group (8.4 +/- 1.2 weeks) was significantly shorter than in the abdominal hysterectomy (112.7 +/- 75.1 weeks, p = .01) and in vaginal hysterectomy (136.5 +/- 32.2 weeks, p <.0001) groups, respectively. It appears that sexual intercourse was the main triggering event for vault dehiscence (58.8%). Vaginal bleeding (50%) and vaginal evisceration (48.1%) were the main symptoms. CONCLUSION: Our data suggest that vaginal vault dehiscence is rare but may occur more often after laparoscopic hysterectomy than after other hysterectomy approaches. Whether it is related to the technique of laparoscopic suturing is unclear. Other risk factors such as early resumption of regular activities and sexual intercourse may play a role.

TVT erosion secondary to a twist in tape.

Mesh erosions through vaginal mucosa as well as the urethra following TVT procedures have been reported but are rare. We report a case of a 50-year-old woman who was found to have mesh erosion through vaginal mucosa 8 weeks after her TVT procedure, apparently secondary to a twist in the tape. Excision of approximately 5 mm of tape encompassing the twist was accomplished without difficulty, and allowed for complete healing of the vaginal mucosa and resolution of the patient's pain and irritative voiding symptoms.

PelviSoft BioMesh augmentation of rectocele repair: the initial clinical experience in 35 patients.

Graft materials have been utilized in the repair of posterior vaginal wall defects to enhance anatomical and functional results, and to improve long-term outcomes. We report on our initial series of 35 patients treated with porcine dermal acellular collagen matrix BioMesh (PelviSoft BioMesh, CR Bard, Cranston, R.I., USA), which has alleviated problems with early postoperative vaginal mucosal dehiscence and delayed healing experienced with the use of other graft materials in the posterior vaginal wall.