Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure.

INTRODUCTION: The identification of diastolic heart failure (DHF) is important for determining the prognosis of congestive heart failure patients. This study attempted to determine the accuracy of emergency physicians who performed bedside echocardiography (BECH) in patients with diastolic dysfunction. METHODS: Three attending emergency physicians underwent 3 h of didactic and 3 h of hands-on training taught by a cardiology specialist for the echocardiographic diagnostic criteria of DHF. Between February and April 2010, the emergency physicians performed BECH for patients presenting with dyspnoea, and echocardiographic views were recorded. Our gold standard for the diagnosis of diastolic dysfunction was the cardiologists' echocardiography report. Results were compared with χ(2) testing. RESULTS: Of the 69 enrolled patients, 51 were diagnosed as having diastolic dysfunction by emergency physicians. The sensitivity of BECH was 89% (77-95) and specificity was 80% (51-95) with 95% CI. The accuracy of the emergency physicians' echocardiographic diagnosis was 87%. CONCLUSION: BECH performed by emergency physicians may serve as an objective, rapid, non-invasive tool in the assessment of patients presenting with dyspnoea in ED.

Paramedic-performed Focused Assessment with Sonography in Trauma (FAST) in the emergency department.

BACKGROUND: Our objective was to evaluate the accuracy of paramedic-performed Focused Assessment with Sonography in Trauma (PFAST) for detection of free fluid in patients admitted to the Emergency Department (ED) following trauma. METHODS: After four hours of didactic and four hours of hands-on training, four paramedics prospectively evaluated trauma patients. Our gold standard was the official radiologist reports of ultrasonography and computerized abdominal tomography (CAT). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were calculated and analyzed using SPSS 15.0 with ?2 testing. RESULTS: One hundred and twenty-seven patients were evaluated by the paramedics. Fourteen patients had positive free fluid in the abdomen. Of these, 11 were corroborated by radiology reports and CAT (true positives), and three were found to be negative (false positives). In 113 cases, PFAST was negative for free fluid. Of these, 111 were determined not to have free fluid (true negatives), whereas free fluid was detected by CAT in 2 (false negatives). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were 84.62, 97.37, 32.15, 0.16, and 203.50, respectively. CONCLUSION: Our study shows that paramedics can perform FAST in hospital Eds with a high degree of accuracy.

The role of cobalt-albumin binding analysis in the diagnosis of experimental abdominal compartment syndrome in rabbits.

BACKGROUND: The purpose of our study was to examine the role of cobalt-albumin binding assay (CABA) for the early diagnosis of abdominal compartment syndrome (ACS). METHODS: Twenty-four anesthetized and ventilated rabbits were randomly assigned to four groups as 1 to 4, with each group comprised of six animals. Intraabdominal hypertension of 25 mmHg was induced for 15, 30, 45, and 60 minutes by insufflation in the four groups, respectively. Five ml of blood was drawn from each animal before the animals were sacrificed. A CABA test was performed on the samples and results were compared with pathologic diagnosis of intestinal samples shown as a score of damage severity values. RESULTS: Ischemia-modified albumin (IMA) in Group 4 was significantly higher than in Group 1 and Group 2 (0.65 ± 0.16, 0.60 ± 0.25 and 0.61 ± 0.14, respectively; p < 0.05). However, there was no significant difference between the IMA of Group 3 and Group 4. Score of damage severity values reached statistically significant levels in Group 4 compared with Group 1 and Group 2 (p < 0.004 and 0.006, respectively) and in Group 3 compared with Group 1 (p < 0.004). There was also a statistically significant difference between Groups 1 and 2 (p < 0.004). CONCLUSION: CABA plays an important role in the early diagnosis of ACS at the beginning of intestinal ischemia.

The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident.

PURPOSE: To compare the accuracy of diagnosing appendicitis between emergency medicine residents using the Alvarado score and general surgery residents using ultrasonography and their clinical provision. METHODS: A total of 358 patients (192 men and 166 women) were admitted to the emergency service with suspected appendicitis. Each patient was evaluated by an emergency medicine resident and then by a general surgeon independently. Age, sex, operational data, diagnosis, and the Alvarado scores were measured. RESULTS: The sensitivity and specificity of the Alvarado score were 95.4% (95% confidence interval 91-99%) and 45.7% (95% confidence interval 37.4-54%), respectively. There was a significant difference between the sexes in the predictive values of a positive test (P=0.045) and a negative test (P=0.02). There was no statistical difference between the emergency medicine residents and general surgery residents in terms of positive and negative predicitive values (P>0.05 each). CONCLUSION: There was no statistical difference between the emergency medicine residents using the Alvarado score and the general surgery residents in terms of suspecting the diagnosis of appendicitis.

Bedside assessment of central venous pressure by sonographic measurement of right ventricular outflow-tract fractional shortening.

OBJECTIVES: We aimed to assess the suitability of right ventricular outflow tract (RVOT) fractional shortening for estimating low central venous pressure (CVP). To the best of our knowledge, there have been no similar studies in the English language literature. METHODS: In this cross-sectional study, the emergency physicians measured the RVOT fractional shortening on parasternal short-axis view. A receiver operating characteristic curve analysis was conducted to identify the threshold that maximized the sensitivity and specificity for discriminating normal and low CVPs by the RVOT fractional shortening value. The sensitivity, specificity, and the positive and the negative likelihood ratios of RVOT fractional shortening to truly estimate CVP were calculated. RESULTS: Fifty-eight consecutive patients had invasive CVP monitoring. Nine patients with high CVP and eight for other reasons were excluded. Forty-one patients were enrolled in the study, of whom 21 were in low CVP group and 20 were in normal CVP group. RVOT diastolic diameters, RVOT systolic diameters, and RVOT fractional shortening were lower in low CVP group and this difference was statistically significant (P<0.001). The cutoff value for RVOT fractional shortening to differentiate the low and normal CVPs using the highest sensitivity and specificity was 26.44%. Area under the receiver operating characteristic curve was 0.933 (0.810-0.987) with a P value of less than 0.001. The sensitivity and specificity of RVOT fractional shortening to truly estimate CVP were 95 (75-99) and 80% (58-94), respectively. CONCLUSION: In the hands of emergency physicians, a RVOT fractional shortening measurement is a good predictor of low CVP.

Do we routinely need cranial computed tomography for mild head injuries in Turkey?

The objectives of this study were to determine the role of clinical parameters in detecting intracranial injury and to find out whether cranial computed tomography (CT) is routinely needed for mild head injury (MHI) in Turkey. This retrospective study was conducted by reviewing the records of patients with MHI who underwent cranial CT in our emergency department. We carried out multiple logistic regression analysis, and odds ratios with 95% confidence intervals were calculated by using SPSS 15.0. This study included 923 patients. Positive cranial CT findings were determined in 17 patients (1.8%) and six of them (0.6%) underwent surgery. Statistically significant correlations were found among headache, presence of clinical findings of skull fracture, focal neurological deficit and positive cranial CT findings. Although the incidence of the intracranial lesions, especially those requiring surgery, is low in MHI, the liberal use of CT scanning in MHI seems to be justified in countries such as Turkey.

Role of bombesin and cholecystokinin receptors in gastric injury induced by hemorrhagic shock in the rat.

Bombesin has been shown to have trophic effects on the gastrointestinal tissue. Bombesin has direct mitogenic effects besides stimulating release of gastric hormones. The aim of this study was to investigate the effect of bombesin in hemorrhagic shock-induced stress ulcers in rats, and the role of cholecystokinin (CCK) receptors in this activity. Hemorrhagic shock was created by withdrawing 3 ml blood/200 g b.w. of rats. At the end of the 1-hour hypovolemic shock period, histological analysis, gastric ulcer index, gastric myeloperoxidase activity and gastric protein oxidation levels were determined. When given before the hemorrhage, subcutaneous bombesin (10 microg/kg) reduced macroscopically gastric ulcer index (p < 0.05). Blockade of CCK-A receptors with intraperitoneal MK-329 (1 mg/kg) did not reverse bombesin-induced gastroprotection. Blockade of CCK-B receptors with intraperitoneal L-365,260 (25 mg/kg) reversed bombesin-induced gastroprotection. Blockade of the two receptors resulted in no gastroprotection at all. It is concluded that bombesin treatment attenuated hemorrhagic shock-induced stress ulcers in rats via CCK receptors.