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Studies have suggested that an age-adjusted D-dimer (AADD) could improve specificity while maintaining sensitivity for the diagnosis of pulmonary embolism (PE). Most laboratories and published data report D-dimer in fibrinogen equivalent units, but some laboratory assays report using D-dimer units (DDU). However, only two small studies have examined AADD with a DDU-based assay. Our study aims to assess the sensitivity and specificity of AADD cutoffs, compared to the conventional cutoffs, in a large cohort of patients who underwent D-dimer testing using a DDU-based assay, for suspected PE. We included 1831 patients who presented to the emergency department and underwent a diagnostic workup that included a D-dimer test followed by computed tomography pulmonary angiography (CTA). The laboratory utilized the HemosIL D-Dimer HS reagent, reporting D-dimer values in DDU (ng/mL). We retrospectively adjusted D-dimer levels for patients using the formula: age (years) x 5 ng/mL. This adjustment created a comparison group to evaluate the test characteristics of the AADD cutoff compared to the conventional cutoff. The conventional D-dimer cutoff of 230 ng/mL had a sensitivity of 97.4 % (95 % Confidence Interval [CI]: 95.3–99.4 %), specificity of 7.3 % (CI: 6.0–8.6 %), positive predictive value (PPV) of 13 % (CI: 11.4–14.6 %), and negative predictive value (NPV) of 95.1 % (CI: 91.3–98.9 %). The AADD cutoff had a sensitivity of 96.1 % (CI: 93.5–98.6 %), specificity of 16.6 % (CI: 14.8–18.4 %), PPV of 14.1 % (CI: 12.3–15.8 %), and NPV of 96.7 % (CI: 94.6–98.8 %). In this study using a DDU-based assay, the specificity of the AADD cutoff was greater while the sensitivity was similar to that of the unadjusted cutoff, with no statistically significant difference observed. •Few studies have validated Age-adjusted D-Dimer (AADD) in D-Dimer unit based assays.•AADD sensitivity was 96.1 % (CI: 93.5-98.6 %) vs 97.4 % (CI: 95.3-99.4 %) for conventional.•AADD increased specificity to 16.6% (CI: 14.8-18.4 %) from 7.3% (CI: 6.0-8.6 %).•Applying AADD cutoffs could have reduced unnecessary imaging by 8.3%.

11% of new cancer diagnoses occur in the emergency department. Historically, these diagnoses disproportionately affect underserved patient populations and are associated with poor outcomes. This is an observational study of the Rapid Assessment Service (RAS) program, which aims to provide timely outpatient follow-up and facilitate a diagnosis for patients discharged from the emergency department with suspected malignancies. We performed a retrospective chart review of 176 patients who were discharged from the emergency department with RAS clinic follow up between February 2020 and March 2022. We manually chart reviewed 176 records in order to determine the average time to RAS clinic appointment, average time to diagnosis, and the final diagnosis based on biopsy. 163 of 176 patients (93%) discharged to RAS received reliable follow-up care. 62 of the 176 patients (35%) followed up in the RAS clinic with a mean of 4.6 days. 46 of the 62 patients (74%) who followed up in the RAS clinic were ultimately diagnosed with a new cancer, with a mean time to diagnosis of 13.5 days. The leading new cancer diagnoses included: lung, ovarian, hematologic, head and neck, and renal cancers. Creating a Rapid Assessment Service facilitated an expedited oncologic work-up and diagnosis in an outpatient setting.

Rapid diagnosis of volume overload in patients with suspected congestive heart failure (CHF) is necessary for the timely administration of therapeutic agents. We sought to use the measurement of respiratory variation of inferior vena cava (IVC) diameter as a diagnostic tool for identification of CHF in patients presenting with acute dyspnea. The IVC was measured sonographically during a complete respiratory cycle of 46 patients meeting study criteria. Percentage of respiratory variation of IVC diameter was compared to the diagnosis of CHF or alternative diagnosis. Respiratory variation of IVC was smaller in patients with CHF (9.6%) than without CHF (46%) and showed good diagnostic accuracy with area under the receiver operating characteristic curve of 0.96. Receiver operating characteristic curve analysis showed optimum cutoff of 15% variation or less of IVC diameter with 92% sensitivity and 84% specificity for the diagnosis of CHF. Inferior vena cava ultrasound is a rapid, reliable means for identification of CHF in the acutely dyspneic patient.

Background Ultrasound-guided regional anesthesia (UGRA) is increasingly used by emergency physicians to provide safe and effective pain relief for patients. However, one of the factors limiting its widespread use is the lack of realistic models available for learners to train on. There are currently no inexpensive nerve block models available that are injectable and that closely mimic nerves, fascial planes, muscles, and other landmarks. Our aim is to create inexpensive, injectable nerve block models that can be used as effective medical training tools for UGRA. Methods By using a lean cut of pork such as pork loin, yarn soaked in ultrasound gel to simulate peripheral nerves, and drinking straws filled with gel to represent vascular structures, we created various nerve block models. Meat glue applied between sections of meat appears hyperechoic under ultrasound, thereby mimicking fascial planes and has the added benefit of helping to secure the components of the model together. Using these elements, we were able to create realistic peripheral nerve, fascia iliaca compartment, serratus anterior plane, and interscalene brachial plexus models. Results One of the necessary skills in performing UGRA involves placing the needle tip along a fascial plane and visualizing hydrodissection of this plane with the local anesthetic. When meat glue (transglutaminase) is applied between layers of meat such as pork loin, the meat binds together and creates a hyperechoic line that mimics a fascial plane. When meat glue is applied to two apposing fascial layers naturally occurring on the meat, the fascial plane can be injected, and fluid can be seen hydrodissecting in this space. We created several nerve block models using meat glue and other components to mimic normal landmarks. Conclusions We have developed inexpensive and easily reproducible models that create the realistic appearance of tissues, nerves, and fascial planes under ultrasound. They can also accurately simulate hydrodissection of fluid in fascial planes. We hope these nerve block models will allow for the education in UGRA to be more widespread and accessible to learners from all specialties.

Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses. This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p < 0.05 denoting statistical significance. Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p < 0.001). This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

The study protocol was approved by the Institutional Review Board of Maimonides Medical Center.2.2 Selection of participants Eligible study subjects were adult patients with a chief complaint of chest pain, shortness of breath, or syncope who had a CE ordered and performed that day. Exclusion criteria included patients who were pregnant, had atrial fibrillation at the time of FOCUS, known mitral valve repair or replacement (MVR), severe mitral annular calcification (MAC), heart rate over 100 beats per minute, time lapse between FOCUS and CE of over 8 h, and the presence of ventricular assist devices. EPs obtained an apical four chamber view and recorded the following measurements on a standardized data collection sheet: mitral inflow velocities E and A, septal TDI velocities e’ and a’, lateral TDI velocities e’ and a’, largest horizontal diameter of left atrium (LA), septal E/e’, lateral E/e’, EP assessment as to the presence or absence of DD, and EP grading of DD into mild, moderate, or severe categories. The secondary outcome was the agreement between FOCUS and CE in determining the grading of DD using the weighted kappa statistic.2.5 Sample size calculation Based on the calculated kappa of 0.64 in a prior study by Unlüer et al., a minimum of 165 patients would be needed in order to achieve 80% power to detect a difference between kappa = 0.5 and kappa = 0.64, with alpha = 0.05 [8].2.6 Data collection procedure All data were saved in password protected storage that could only be accessed by study investigators and research personnel.2.7 Statistical methods The study data was entered into and analyzed using Microsoft Excel (Microsoft Excel 2010; Microsoft Corporation, Seattle, WA) and SPSS statistical

To compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB). A multicenter, prospective, randomized, clinical trial. The study was conducted in the emergency departments of 3 academic hospitals located in New York City. Patients aged ≥60 years presenting to the emergency department with hip fracture. A subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours. Seventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P < .0001) at 2 hours and from 6.23 to 3.87 (P < .0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P < .0001) at 2 hours and from 6.62 to 3.46 (P < .0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38). Ultrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.

It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality. We designed a prospective observational study of children <18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdominal aorta and right lower quadrant (RLQ) structures (psoas muscle and iliac vessels) pre- and post-ORC administration. Images were compared independently by two blinded emergency US-certified physician-assessors for quality, specifically to determine whether ORC obscured the anatomical structures in question. A total of 17 subjects were enrolled, and each subject had two POCUS studies of the abdomen, one pre- and one post-ORC administration looking to visualize the anatomy of the RLQ and abdominal aorta in both studies. Statistical analysis showed no significant differences in mean values of POCUS image quality scoring by two blinded US-trained physician-assessors for either RLQ structures or abdominal aorta when performed pre- and post-administration of ORC. Early ORC administration in children with abdominal pain does not adversely affect image quality of a subsequently performed abdominal US. Patients who may require abdominal CT to determine the etiology of abdominal pain can receive early administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.

Delayed cardiac tamponade (DCT) is a rare and life-threatening complication of catheter ablation performed as a treatment of atrial fibrillation, with few cases described in the medical literature. We present the case of a 57year-old man presenting with DCT 61days following a catheter ablation procedure. To the best of our knowledge, this is the most delayed case of cardiac tamponade (CT) following catheter ablation described in the literature. We also discuss the importance of point of care ultrasound (POCUS) in the diagnosis and treatment of CT. Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental status, often without chest pain. Common risk factors for CT include cancer, renal failure, pericarditis, cardiac surgery, myocardial rupture, trauma, and retrograde aortic dissection. In addition, although rare, both catheter ablation and use of anticoagulation carry risks of developing CT. A worldwide survey of medical centers performing catheter ablation found CT as a complication in less than 2% of cases [1]. Some proposed mechanisms of DCT include small pericardial hemorrhages following post-procedural anticoagulation or rupture of the sealed ablation-induced left atrial wall [2]. Clinical examination and electrocardiography may be helpful. However, the criterion standard for diagnosing CT is echocardiography [3].

Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non-diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2hour post-ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2h. Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.