Where There's Smoke, There's Fire: A Case Report of Turbulent Blood Flow in Lower Extremity Point-of-care Ultrasound in COVID-19.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) may predispose patients to increased risk of venous thromboembolism (VTE) due to various pathophysiological mechanisms, including but not limited to endothelial injury, inflammation, cytokine-mediated microvascular damage, and reactive thrombocytosis. A high risk of vessel thrombosis correlates with disease severity, making early identification and treatment of prime consideration.Although identification of a deep venous thrombosis (DVT) or pulmonary embolism warrants immediate treatment with anticoagulation, trying to predict which COVID-19 patients may be at increased risk for developing these pathologies is challenging. CASE REPORTS: We present two cases of patients with COVID-19 who had ultrasonographic findings of turbulent blood flow within the deep venous system, without clear evidence of acute proximal DVT, who were subsequently found to have significant VTE. CONCLUSION: Point-of-care lower extremity ultrasound has become one of the core applications used by emergency physicians. Typically we perform compression ultrasound for DVT evaluation. This novel finding of turbulent blood flow, or "smoke," within the deep venous system, may serve as a marker of increased risk of clot development and could be an indication to consider early anticoagulation.

Ultrasound Identification of Retrobulbar Hematomas by Emergency Physicians in a Cadaveric Model.

INTRODUCTION: Retrobulbar hemorrhage (RBH) is a rare complication of facial trauma that can lead to dangerous orbital compartment pressures and must be rapidly recognized to prevent permanent vision loss. Point-of-care ultrasound (POCUS) offers a rapid modality for evaluating a wide variety of ocular pathologies, and prior case reports demonstrate the ability of clinicians to recognize RBH using ultrasound. This study aimed to assess the ability of clinicians at various stages of training to identify a RBH using POCUS in a cadaveric model. Clinicians also were assessed for self-reported comfort using ultrasound for ocular pathology before and after the study. METHODS: Participants included 17 physicians who evaluated 10 eyes (from five cadavers) that were independently randomized to have either a modeled RBH or no hemorrhage. Participants' final diagnosis of each eye was recorded (RBH present or not), and participants also completed pre- and post-activity surveys. RESULTS: The overall sensitivity and specificity to correctly diagnose retrobulbar fluid was 87% and 88%, respectively. Sensitivity and specificity were higher after excluding clinicians in their early phase of training. Additionally, self-reported comfort level with ocular ultrasound was significantly improved by this activity. CONCLUSION: Emergency physicians at a variety of training levels can correctly identify a cadaveric model of retrobulbar hemorrhage. Use of this cadaveric model can improve exposure of clinicians to the appearance of a rare but vision-threatening ocular pathology such as RBH.

Development of Nanofibrous Ocular Insert for Retinal Delivery of Fluocinolone Acetonide.

PURPOSE: Topical formulations are less effective in treating retinal inflammatory diseases due to poor avaliability of drug at target tissues. Nanofibers due to their unique structural features show great promise for drug delivery to retinal segment following topical application. AIM: The aim of the present study was to design preservative free controlled release ocular drug delivery system for improved drug availability at the target site with higher patient compliance. MATERIALS AND METHODS: The fluocinolone acetonide-loaded PCL nanofibers were prepared by electrospinning technique. Optimized formulation was chosen on the basis of outcome of inclusive in-vitro characterization, SEM, FTIR, XRD, in-vitro release, isotonicity, sterility, and biodegradibility. The relative efficacy of optimized formulation was investigated in rabbits against its marketed counter part. RESULTS: The prepared fibers were sterile, smooth, non-woven and they showed extended drug release behavior. Ocular and plasma kinetics showed therapeutic levels at the target site while minimizing systemic distribution. CONCLUSIONS: Preclinical results established that PCL nanofibers serve as a promising drug carrier for retinal segment.

A prospective feasibility trial of a novel intravascular catheter system with retractable coiled tip guidewire placed in difficult intravascular access (DIVA) patients in the Emergency Department.

The primary study objective was to evaluate insertion success rates. Secondary objectives included patient satisfaction, procedure time, complication rates, completion of therapy and dwell time of the novel AccuCath® 2.25″ Blood Control (BC) Catheter System (FDA approved) placed in difficult-access patients. This was a single-arm feasibility trial evaluating the AccuCath® 2.25″ BC Catheter System in a convenience sample of DIVA patients defined as at least two failed initial attempts or a history of difficult access plus the inability to directly visualize or palpate a target vein. All enrolled patients were 18 years of age or older. A total of 120 patients were enrolled. These patients had an average of 3.7 and median of 3 prior attempts at vascular access prior to AccuCath placement. Successful access was gained in 100% of the patients, 77% on the first attempt and all within three attempts; 88.5% of patients completed therapy, with the remaining 12.5% experiencing minor complications that required discontinuation of the catheter. The average patient satisfaction score on a 5-point Likert scale was highly positive at 4.6. Preliminary results show that the AccuCath® 2.25″ BC Catheter System has excellent success rates in gaining vascular access in an extremely difficult patient population. The device did not lead to any significant complications. Patients were also very satisfied with the procedure.

Does ablation of supraventricular tachycardia in children with a structurally normal heart improve quality of life?

INTRODUCTION: Ablation has become first-line therapy for managing many pediatric patients with atrioventicular accessory pathway or atrioventricular nodal-mediated supraventricular tachycardia (SVT). Studies to date have all focused on elimination of the SVT substrate; yet, there are no studies to document whether this results in improved quality of life (QoL) scores. OBJECTIVE: The objective of this study was to evaluate whether a successful catheter ablation improved QoL scores in pediatric patients. PATIENT AND METHODS: Pediatric patients between the age of 5 and 18 years with structurally normal hearts and re-entry SVT that were referred to the electrophysiology laboratory between October 2004 and June 2006 at the Children's Healthcare of Atlanta were eligible to be enrolled in the study. The Pediatric Quality of Life Inventory cardiac model questionnaire was administered to patients prior to and 6 months following catheter ablation. Areas evaluated were physical, emotional, social, school, and psychosocial function. The paired t-test was used to test the difference between pre- and post-time points for the study groups. P value <.05 was considered significant. RESULTS: Forty-three patients consented to initial enrollment and returned the initial questionnaires. Seven patients did not have ablations performed during the electrophysiology study and therefore were excluded from further analysis. Complete pre- and post-ablation data were available for 27 patients. Comparing pre-ablation data with post-ablation data, there was significant improvement in all measured areas following successful elimination of tachycardia substrate. Patients reported lowest social and physical functioning scores pre-ablation. The greatest reported improvement post-ablation was in physical functioning. CONCLUSION: Successful elimination of SVT substrate results in improved pediatric QoL scores as reported by patients.

A comparison of heparin management strategies in infants undergoing cardiopulmonary bypass.

BACKGROUND: Recent investigations in adult patients have suggested that a heparin concentration-based anticoagulation protocol for heparin administration during cardiopulmonary bypass (CPB) significantly reduced hemostatic activation when compared with standard weight-based heparin doses. Reductions in hemostatic activation during CPB could be particularly beneficial in pediatric patients in whom CPB-related coagulation issues are complex and influenced by many variables. However, information regarding heparin levels during CPB and their correlation to hemostatic activation is lacking in children. In this investigation, we compared a patient-specific heparin concentration-based heparin management protocol with a standard weight-based protocol in infants <6-mo-of-age. The efficacy of these two protocols was assessed by comparisons of heparin concentration, levels of biochemical markers of hemostatic activation, and clinical outcome. METHODS: Twenty-five infants <6-mo-old scheduled for primary, elective repair of a congenital heart defect were enrolled in this study. Patients were randomized to receive either 400 U/kg of heparin (control group) or a patient-specific heparin dose calculated by the Hepcon Hemostasis Management System Plus (Hepcon HMS; Medtronic, Minneapolis, MN; intervention group). Heparin concentrations were compared between the two groups at predetermined intervals. Blood samples for biochemical markers of hemostatic activation were collected before and after CPB, and measurements of clinical outcome were recorded. RESULTS: Infants in the intervention group received a larger total heparin dose than infants in the control group. Heparin concentrations after the initial heparin dose and 30 min into CPB were similar between groups; however, at the start of rewarming and at the termination of CPB, infants in the intervention group had significantly higher heparin concentrations than infants in the control group. Infants in the intervention group also generated less F1.2 and consumed less factor VIII than infants in the control group. Clinically, however, infants in the intervention group received one more donor exposure from the administration of blood products post-CPB. CONCLUSION: A heparin concentration-based heparin management protocol in infants <6-mo-old resulted in higher, more constant heparin concentrations during CPB than a standard weight-based protocol. Furthermore, higher heparin concentrations were associated with greater suppression of hemostatic activation, as measured by less generation of thrombin and less consumption of factor VIII. Our findings demonstrate that use of a patient-specific heparin concentration-based protocol for heparin administration during CPB in infants may attenuate hemostatic activation. However, further research is needed to determine if this protocol has clinically beneficial hemostatic effects.