Early detection of myocardial infarction with reference to baseline levels during health: impact on biological variation of high-sensitivity cardiac troponin.

A 78-year-old male was seen in the emergency department (ED) with chest pain. Fifteen months earlier, he had presented to the ED with shoulder and elbow pain. High-sensitivity cardiac troponin I (hs-cTnI) testing was conducted at that time, which produced normal results of 10 and 13 ng/L (cutoff <48 ng/L). During the current admission, his electrocardiogram was unremarkable, with a borderline prolonged PR interval noted. The patient's hs-cTnI results were 25, 47, and 254 ng/L at 0, 1, and 7 hours, respectively. He was diagnosed with demand ischemia and admitted to the hospital. The detection of acute myocardial infarction in this case was made during the first sample collection (t = 0), despite the fact that this result was well within the normal range.

Implementation and analysis of a multifaceted intervention for alcohol use disorder from a single academic urban emergency department.

BACKGROUND: From 2006 to 2014, alcohol-related visits to the emergency department (ED) increased by 76% in the United States, highlighting the need for improved ED-driven interventions addressing alcohol use disorder (AUD). Naltrexone is an FDA-approved medication for AUD shown to decrease craving and self-administration of alcohol. While oral naltrexone and extended-release naltrexone have been long utilized in primary care and inpatient hospital settings, the use of naltrexone in the ED is limited. METHODS: This study implemented and analyzed a multifaceted intervention regarding ED naltrexone prescribing at a large safety net, academic, urban hospital. A baseline assessment of preintervention conditions and perspectives on naltrexone prescribing was conducted through a chart review and standardized interviews with ED providers, respectively. The interview results guided design of interventions that addressed identified barriers. These included provider education, prescribing aids, and zero-cost naltrexone tablets supplied by the ED pharmacy to patients upon discharge. RESULTS: Between September 1, 2019, and August 31, 2020, of 753 unique patients who had a primary diagnosis or chief complaint containing the word "alcohol," only five (0.66%) were prescribed naltrexone. ED providers identified lack of training regarding naltrexone, lack of a prescribing protocol, and limited patient and provider education materials as barriers to prescribing naltrexone. Following the intervention, among 278 eligible patients, 11 oral naltrexone prescriptions were written (3.96%) between April 13, 2021, and August 1, 2021. This represents a sixfold increase over the preintervention period. CONCLUSIONS: An intervention to increase ED oral naltrexone prescriptions for AUD was successfully implemented, addressing lack of provider education, lack of prescribing resources, and patient barriers to accessing prescribed medications. Longer-term follow-up is needed to assess the efficacy and sustainability of these interventions. Nevertheless, ED clinicians are well positioned to initiate naltrexone prescriptions for patients presenting with AUD.

The Development, Implementation, and Evolution of an Emergency Medicine Ultrasound-guided Regional Anesthesia Curriculum.

Introduction: Despite the inclusion of both diagnostic and procedural ultrasound and regional nerve blocks in the original Model of the Clinical Practice of Emergency Medicine (EM), there is no recommended standardized approach to the incorporation of ultrasound-guided regional anesthesia (UGRA) education in EM training. Methods: We developed and implemented a structured curriculum for both EM residents and faculty to learn UGRA in a four-hour workshop. Each Regional Anesthesia Anatomy and Ultrasound Workshop was four hours in length and followed the same format. Focusing on common UGRA blocks, each workshop began with an anatomist-led cadaveric review of the relevant neuromusculoskeletal anatomy followed by a hands-on ultrasound scanning practice for the blocks led by an ultrasound fellowship-trained EM faculty member, fellow, or a postgraduate year (PGY)-4 resident who had previously participated in the workshop. Learners identified the relevant anatomy on point-of-care ultrasound and reviewed how to conduct the blocks. Learners were invited to complete an evaluation of the workshop with Likert-scale and open-ended questions. Results: In the 2020 academic year, six regional anesthesia anatomy and ultrasound workshops occurred for EM faculty (two sessions, N = 24) and EM residents (four sessions, N = 40, including a total of five PGY4s, 10 PGY3s, 12 PGY2s, and 13 PGY1s). Workshops were universally well-received by both faculty and residents. Survey results found that 100.0% of all responding participants indicated that they were "very satisfied" with the session. All were likely to recommend this session to a colleague and 95.08% of participants believed the session should become a required component of the EM curriculum. Conclusion: The use of UGRA is increasing, and and it critical in EM. An interdisciplinary approach in collaboration with anatomists on an interactive, nerve block workshop incorporating both gross anatomy review and hands-on scanning was shown to be well-received and desired by both EM faculty and residents.

Lung Ultrasound Findings in Patients Hospitalized With COVID-19.

OBJECTIVES: Lung ultrasound (LUS) can accurately diagnose several pulmonary diseases, including pneumothorax, effusion, and pneumonia. LUS may be useful in the diagnosis and management of COVID-19. METHODS: This study was conducted at two United States hospitals from 3/21/2020 to 6/01/2020. Our inclusion criteria included hospitalized adults with COVID-19 (based on symptomatology and a confirmatory RT-PCR for SARS-CoV-2) who received a LUS. Providers used a 12-zone LUS scanning protocol. The images were interpreted by the researchers based on a pre-developed consensus document. Patients were stratified by clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset) and time from symptom onset to their scan. RESULTS: N = 22 patients (N = 36 scans) were included. Eleven (50%) patients experienced clinical deterioration. Among N = 36 scans, only 3 (8%) were classified as normal. The remaining scans demonstrated B-lines (89%), consolidations (56%), pleural thickening (47%), and pleural effusion (11%). Scans from patients with clinical deterioration demonstrated higher percentages of bilateral consolidations (50 versus 15%; P = .033), anterior consolidations (47 versus 11%; P = .047), lateral consolidations (71 versus 29%; P = .030), pleural thickening (69 versus 30%; P = .045), but not B-lines (100 versus 80%; P = .11). Abnormal findings had similar prevalences between scans collected 0-6 days and 14-28 days from symptom onset. DISCUSSION: Certain LUS findings may be common in hospitalized COVID-19 patients, especially for those that experience clinical deterioration. These findings may occur anytime throughout the first 28 days of illness. Future efforts should investigate the predictive utility of these findings on clinical outcomes.

Point-of-Care Ultrasound Predicts Clinical Outcomes in Patients With COVID-19.

OBJECTIVES: Point-of-care ultrasound (POCUS) detects the pulmonary manifestations of COVID-19 and may predict patient outcomes. METHODS: We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID-19. Inclusion criteria included adult patients hospitalized for COVID-19 who received lung POCUS with a 12-zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage. RESULTS: N = 160 patients were included. Among critically ill patients, B-lines (94 vs 76%; P < .01) and consolidations (70 vs 46%; P < .01) were more common. For scans collected within 24 hours of admission (N = 101 patients), early B-lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71-14.30]; P < .01) or consolidations (OR 2.49 [95% CI: 1.35-4.86]; P < .01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01-4.70]; P = .047). Patients with a normal scan within 24 hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09-0.75]; P < .01) or supplemental oxygen (OR 0.26 [95% CI: 0.11-0.61]; P < .01). Ultrasound findings did not dynamically change over a 28-day scanning window after symptom onset. CONCLUSIONS: Lung POCUS findings detected within 24 hours of admission may provide expedient risk stratification for important COVID-19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24 hours of admission appears protective. POCUS findings appeared stable over a 28-day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.

Virtual anatomy and point-of-care ultrasonography integration pilot for medical students.

Despite its significant clinical use, there is no standardized point-of-care ultrasonography (POCUS) curriculum in undergraduate medical education. As Covid-19 abruptly mandated the use of virtual education, instructors were challenged to incorporate and improve POCUS education within these new constraints. It was hypothesized that integrating POCUS into anatomy via brief video lessons and a subsequent interactive virtual lesson would lead to an objective understanding of POCUS concepts, improved understanding of the corresponding anatomy, and subjective improvement of student confidence with POCUS. A cross-sectional descriptive study assessed first-year medical students' perspectives and performance before and after the interventions (n = 161). The intervention was split into two parts: (1) three optional 10-minute POCUS videos that reinforced anatomy concepts taught in the laboratory sessions, and (2) a subsequent two-hour interactive virtual session reviewing POCUS and anatomy concepts. Students completed a knowledge and confidence assessment tool before and after the interactive session. Survey responses (n = 51) indicated that 94% of students felt the optional videos improved their understanding of POCUS and were educationally valuable. One half of medical students (50%) indicated that the demonstrations improved their anatomy understanding. Initial self-reported confidence was low after the optional video lessons, despite an average score of 58% on the knowledge assessment (n = 130). However, confidence increased significantly along with an increase in score performance to 80% after the interactive session (n = 39, P < 0.01). Results suggest that the virtual integration pilot enhanced student learning of both anatomy and POCUS.

Concurrent COVID-19 and Acute HIV: A Case Report and Diagnostic Review.

A 26-year-old male presented to the emergency department feeling unwell in February of 2021 with symptoms including diaphoresis, loose stools, and loss of taste sensation. Workup not only confirmed a diagnosis of COVID-19 but also revealed discordant HIV test results, with a reactive fourth-generation antigen/antibody test but a negative HIV-1/2 differentiation immunoassay. Subsequent HIV viral load testing obtained two days later ultimately established a diagnosis of acute HIV (AHI). Screening for HIV and other sexually transmitted infections decreased during the COVID-19 pandemic. It is critical that providers (1) continue recommended screening for HIV as an essential service; (2) consider acute HIV in the differential when evaluating patients with acute viral syndromes; (3) recognize that AHI can occur concurrently with other infections, including COVID-19; and (4) understand the differential diagnosis for discordant HIV test results and know when HIV viral load testing is needed to resolve such discordant results.

Interobserver Agreement of Lung Ultrasound Findings of COVID-19.

BACKGROUND: Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown. METHODS: This study was conducted between March and June 2020. Nine physicians (hospitalists: n = 4; emergency medicine: n = 5) from 3 medical centers independently evaluated n = 20 LUS scans (n = 180 independent observations) collected from patients with COVID-19, diagnosed via RT-PCR. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values (κ) were used to calculate IRR. RESULTS: There was substantial IRR on the following items: normal LUS scan (κ = 0.79 [95% CI: 0.72-0.87]), presence of B-lines (κ = 0.79 [95% CI: 0.72-0.87]), ≥3 B-lines observed (κ = 0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (κ = 0.57 [95% CI: 0.50-0.64]), subpleural consolidation (κ = 0.49 [95% CI: 0.42-0.56]), and presence of effusion (κ = 0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (κ = 0.23 [95% CI: 0.15-0.30]). DISCUSSION: Many LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.

Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients.

BACKGROUND: Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. METHOD: This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. RESULTS: 153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%). CONCLUSION: A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

Interdisciplinary approach to enhance trauma residents education of Extended-Focused Assessment for Sonography in Trauma in the emergency department.

BACKGROUND: Despite the utilization of point-of-care ultrasound (POCUS) by trauma surgeons, formal POCUS requirements do not exist for general surgery residents. We sought to evaluate surgery resident comfort with performing and interpreting of Extended-Focused Assessment for Sonography in Trauma (E-FAST) scans after a brief educational session. METHODS: A pre-survey, sent to PGY-2 and -3 surgical residents before their trauma rotation, evaluated comfort with eight components of the E-FAST. Residents were then required to watch a 15-min online video and attend a 1-h bedside training session moderated by emergency medicine ultrasound fellows during which residents practised E-FAST image acquisition and interpretation. After the rotation, residents completed a post-survey evaluating their comfort with the E-FAST. RESULTS: All 27 residents rotating on the trauma service during the 2017-2018 academic year were eligible and, therefore, approached by the study team. Twenty-one (77.78%) residents completed the pre-survey, training and post-survey. Initially, only 52% (13/25) of residents reported feeling confident in performing the E-FAST. After the session, all (100%) reported feeling confident in their training in E-FAST. Self-reported mean comfort with each of the eight components of the E-FAST showed a statistically significant (P < 0.01) increase from pre-post survey for all residents. Isolating only the residents who initially reported feeling confident in E-FAST still showed a statistically significant (P < 0.01) increase in mean comfort. CONCLUSION: A single POCUS training programme has been shown to improve surgical residents' comfort in performing and interpreting the E-FAST. This interdisciplinary approach can enhance collaboration and bridge gaps between emergency medicine and surgery residency programmes.