Point-of-care ultrasound assessment of the abdominal aorta by physician assistant students: a pilot study.

OBJECTIVE: Point-of-care ultrasound (POCUS) decreases time to diagnosis and improves mortality of those diagnosed with abdominal aortic aneurysms and dissections. While medical students have demonstrated an ability to obtain adequate POCUS images of the abdominal aorta (AA), physician assistant (PA) student studies are lacking. This pilot study aims to evaluate the ability of PA students to acquire AA POCUS images. METHODS: PA students, instructors, and models voluntarily participated. Student participants received online material to review several weeks before the study. During the study, students performed 4 precepted practice scans of the AA, and their fifth scan was recorded for review by three ultrasound fellowship trained Emergency Medicine physicians. Images were graded on proper identification and measurement of the AA, as well as interpretability of images. RESULTS: A total of 20 PA students participated. Ninety-five percent were able to obtain interpretable transverse images of the distal aorta and longitudinal views of the aorta, and 65% were able to obtain interpretable transverse images of the proximal and mid aorta. CONCLUSIONS: In the most rigorous evaluation of student-obtained AA POCUS images to date, we found that PA students were able to obtain adequate AA images. PA students were able to image the distal and longitudinal aorta in the transverse plane where the majority of AAAs are found to a very high degree. Results demonstrate PA students' ability to learn POCUS and encourage PA education to take steps to incorporate POCUS education and development of competency standards for PA graduates.

How should we treat patients who wake up with a stroke? A review of recent advances in management of acute ischemic stroke.

Acute ischemic strokes account for 85% of all strokes and are the fifth leading cause of mortality in the United States. About one in five of all ischemic strokes occur during sleep and are not noticed until the patient wakes up with neurological deficits. There is growing evidence to support that a significantly higher number of stroke patients could benefit from more aggressive care, especially those patients who wake up with strokes. There is increasing research to support a physiologically-based approach based on advanced imaging rather than simply a time-based determination of whether or not a patient would benefit from reperfusion. Advanced imaging such as CT-Perfusion and MR DWI-FLAIR can be used to establish the age of the lesion and determine the extent of the brain tissue that is salvageable. If physicians could identify those patients with wake-up strokes that are candidates for intervention, there may be opportunity to treat 3 million more people, reducing long term disability and healthcare expenditures. Patients who are in the window for IV rtPA should receive it as soon as possible as well as be evaluated for mechanical thrombectomy. For those who are out of the window for IV rtPA, consider further imaging such as CTP and MR brain for diffusion-weighted sequences to evaluate for potential endovascular intervention. If a large vessel occlusion is present and imaging demonstrates a small infarct core and a large area of salvageable tissue, mechanical thrombectomy may be beneficial for the best possible functional outcome.

Hydroceles-Not Just For Men.

BACKGROUND: Hydroceles develop in females through the canal of Nuck. This canal is formed when the processes vaginalis fails to obliterate during development. The canal of Nuck can lead to the formation of not only hydroceles, but hernias as well. Although physicians typically think of hydroceles occurring in males, on rare occasions, they do occur in females because of this defect. They are often mistaken for incarcerated hernias, making ultrasound an excellent tool to distinguish between them and guide further treatment. CASE REPORT: We report a rare case of a 46-year-old female with the chief complaint of a painful groin mass. A diagnosis of a hydrocele was made by point of care ultrasonography in the emergency department after being misdiagnosed by computed tomography scan on two previous occasions. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point of care ultrasound (POCUS) is a valuable tool for emergency physicians and can lead to quick diagnoses and appropriate management of the patient. Using ultrasound in conjunction with other imaging modalities can improve diagnostic accuracy. POCUS is portable and a powerful tool for immediate answers, and continues to prove its utility for clinical decision making.

Design of a randomized, placebo-controlled study evaluating efficacy and safety of a cancer preventative vaccine in dogs.

Preventative anti-cancer vaccination strategies have long been hampered by the challenge of targeting the diverse array of potential tumor antigens, with successes to date limited to cancers with viral etiologies. Identification and vaccination against frameshift neoantigens conserved across multiple species and tumor histologies is a potential cancer preventative strategy currently being investigated. Companion dogs spontaneously develop cancers at a similar incidence to those in people and are a complementary comparative patient population for the development of novel anti-cancer therapeutics. In addition to an intact immune system with tumors that arise in an autochthonous tumor microenvironment, dogs also have a shorter lifespan and temporally compressed tumor natural history as compared to humans, which allows for more rapid evaluation of safety, immunogenicity, and efficacy of cancer vaccination strategies. Here we describe the study protocol for the Vaccination Against Canine Cancer Study (VACCS), the largest interventional cancer clinical trial conducted in companion dogs to date. In addition to safety and immunogenicity, the primary endpoint of VACCS is the cumulative incidence (CI) of dogs developing malignant neoplasia of any type at the end of the study period. Secondary endpoints include changes in incidence of specific tumor types, survival times following neoplasia diagnosis, and all-cause mortality.

Case Report: Not Your Typical Kidney Stone.

The patient is a 66-year-old male, with a history of kidney stones, who presents to the emergency department complaining of dull, right-sided flank pain radiating to the right testicle that began one hour prior to arrival. The patient had a computed tomography (CT) of the abdomen and pelvis without contrast, which demonstrated a right renal calculus with forniceal rupture. This case represents a rare complication of a typical Emergency Department complaint; therefore, clinicians should be aware of its clinical relevance. Topics: Flank pain, forniceal rupture, renal colic, CT scan.

Henoch-Schönlein Purpura in the Adult, a Case Report.

This case report describes a dermatologic finding that is not typical in the adult population, but may be medically significant. A 39-year-old female patient with a past medical history that was negative for autoimmune disorders, vasculitides, or chronic infectious disease presented to our emergency department for evaluation of a painful rash on the bilateral lower extremities. She complained of two days of worsening raised, erythematous, pruritic and painful patches around both ankles, some of which had opened to become weeping sores. There was surrounding edema of both extremities. She denied any systemic symptoms. Online literature, primarily UpToDate was reviewed, and it was suspected that her rash may have been Henoch-Schönlein Purpura (HSP), given her lack of other medical history and a visual appearance that seemed consistent with the condition. To evaluate for renal involvement and systemic inflammation, labs were drawn and were grossly unremarkable except for a mild elevation in her C-reactive protein with a level of 37.6 mg/L. She was treated with intravenous (IV) hydration and IV ketorolac, with resultant symptomatic improvement. Since she did not have any apparent systemic involvement, she was discharged to follow up with rheumatology, with a recommendation to take over the counter non-steroidal anti-inflammatory drugs (NSAIDs). The patient was ultimately seen by rheumatology several months later, and a biopsy of the lesions demonstrated what appeared to be Henoch-Schönlein Purpura given her clinical presentation. Henoch-Schönlein Purpura can occur in adults, however rare, requiring close follow-up since in the adult population, it may result in renal failure and need for dialysis. Topics: Rash, Henoch-Schönlein purpura, dermatology, nephrology, rheumatology, vasculitis.

Bilateral Common Iliac Artery Aneurysm, a Case Report.

Patient is a 72-year-old male who presented with abdominal pain and hypertension. Through bedside point-of-care ultrasound (POCUS), patient was found to have markedly enlarged bilateral iliac artery aneurysms with signs of impending rupture, which was confirmed on computed tomography (CT) angiogram of the abdomen/pelvis. Patient was immediately taken to the operating room for emergent repair of aneurysm, and was discharged from the hospital the next day. Point-of-care ultrasound is critical in diagnosis and guiding treatment in patients in the emergency department and should be considered in those with undifferentiated abdominal pain. Topics: Abdominal pain, iliac artery aneurysm, point-of-care ultrasound.

Microparticle-based lung delivery of INH decreases INH metabolism and targets alveolar macrophages.

Microparticles prepared by the precipitation with a compressed antisolvent (PCA) process were evaluated for their potential in targeting an ionizable prodrug of isoniazid (INH), isoniazid methanesulfonate (INHMS), for sustained delivery of INH to alveolar macrophages (AMs). The charged prodrug was ion-paired with two different hydrophobic cations (tetrapentylammonium (TPA)- and tetraheptylammonium (THA)-bromide), and loaded separately into the poly(l-lactide) (PLA) microparticles. The drug/polymer particles were spherical in shape and between 1 and 3 mum in diameter. The choice of hydrophobic cations did not affect drug incorporation efficiencies or the release kinetics of INH from the microparticles. Using a sensitive liquid chromatographic tandem mass spectrometric (LC-MS/MS) assay developed for INH, high level of INH was detected in NR8383, a rat AM cell line, following exposure of these cells to drug-loaded microparticles. To confirm the microparticles can target AMs in vivo, we compared the INH levels in lavaged bronchoalveolar macrophages by LC-MS/MS after the Sprague-Dawley rats were administered either INHMS in PLA microparticles by intra-tracheal instillation or INH solution by gavage or intra-tracheal instillation. As expected, only microparticles provided sustained and targeted delivery of INH to AMs. Most importantly, this method of delivery led to substantial reduction in the blood levels of acetylisoniazid (AcINH), a major and potential toxic metabolite of INH.

In vitro and in vivo evaluation of the effects of PLA microparticle crystallinity on cellular response.

Previous research suggests that crystallinity of poly(L-lactide) P(L)LA microparticles can influence surface free energy, which in turn might influence biocompatibility. This work studies the cellular response to P(L)LA microparticles of different crystallinity both in vitro and in vivo. Following incubation with P(L)LA microparticles, the in vitro production of reactive oxygen intermediates (ROI) was measured as a marker of cellular response. In both fluorescence and chemiluminescence experiments to measure ROI, a small effect of microparticle crystallinity on NR8383 AM response was observed. Microparticles of higher crystallinity elicited a smaller inflammatory response compared to lower crystallinity particles. Compared to the elevated inflammatory response induced by zymosan, the response to all P(L)LA microparticles tested was practically negligible. Results from in vivo experiments further supported conclusions that P(L)LA microparticles elicit minimal inflammatory response. Following acute exposure to P(L)LA microparticles in guinea-pig lungs, the inflammatory response was not significantly different from the response observed when sterile saline was administered. In contrast to the in vitro experiments, there were not apparent differences in cellular responses to microparticles of different crystallinity.