A Pilot Study Evaluating LV Diastolic Function with M-Mode Measurement of Mitral Valve Movement in the Parasternal Long Axis View.

This pilot study aimed to develop a new, reliable, and easy-to-use method for the evaluation of diastolic function through the M-mode measurement of mitral valve (MV) movement in the parasternal long axis (PSLA), similar to E-point septal separation (EPSS) used for systolic function estimation. Thirty healthy volunteers from a tertiary emergency department (ED) underwent M-mode measurements of the MV anterior leaflet in the PSLA view. EPSS, A-point septal separation (APSS), A-point opening length (APOL), and E-point opening length (EPOL) were measured in the PSLA view, along with the E and A velocities and e' velocity in the apical four-chamber view. Correlation analyses were performed to assess the relationship between M-mode and Doppler measurements, and the measurement time was evaluated. No significant correlations were found between M-mode and Doppler measurements in the study. However, M-mode measurements exhibited high reproducibility and faster acquisition, and the EPOL value consistently exceeded the APOL value, resembling the E and A pattern. These findings suggest that visually assessing the M-mode pattern on the MV anterior leaflet in the PSLA view may be a practical approach to estimating diastolic function in the ED. Further investigations with a larger and more diverse patient population are needed to validate these findings.

Online Learning versus Hands-On Learning of Basic Ocular Ultrasound Skills: A Randomized Controlled Non-Inferiority Trial.

Background and objectives: Ocular ultrasound is a core application of point-of-care ultrasound (POCUS) to assist physicians in promptly identifying various ocular diseases at the bedside; however, hands-on POCUS training is challenging during a pandemic. Materials and Methods: A randomized controlled non-inferiority trial was conducted in an academic emergency department from October 2020 to April 2021. Thirty-two participants were randomly assigned to one of two groups. Group H (hands-on learning group) participated individually in a hands-on session with a standardized patient for 30 min, whereas Group O (online learning group) learned training materials and video clips for 20 min. They scanned four eyeballs of two standardized patients sequentially following the ocular POCUS scan protocol. Repeated POCUS scans were performed 2 weeks later to assess skill maintenance. Both groups completed the pre- and post-surveys and knowledge tests. Two emergency medicine faculty members blindly evaluated the data and assigned a score of 0−25. The primary endpoint was the initial total score of scan quality evaluated using non-inferiority analysis (generalized estimating equation). The secondary endpoints were total scores for scan quality after 2 weeks, scan time, and knowledge test scores. Results: The least squares means of the total scores were 21.7 (0.35) for Group O and 21.3 (0.25) for Group H, and the lower bound of the 95% confidence interval (CI) was greater than the non-inferiority margin of minus 2 (95% CI: −0.48−1.17). The second scan scores were not significantly different from those of the first scan. The groups did not differ in scanning time or knowledge test results; however, Group H showed higher subjective satisfaction with the training method (p < 0.001). Conclusion: This study showed that basic online ocular ultrasound education was not inferior to hands-on education, suggesting that it could be a useful educational approach in the pandemic era.

Timeliness of Single-Patch 12-Lead Electrocardiography for Patients with Chest Pain at the Emergency Department.

A 12-lead ECG is used in emergency departments to diagnose and treat patients with chest discomfort. Performing ECGs at the proper time has been found to increase treatment outcomes. A timer on a wearable ECG ensures proper recording. We compared the timing accuracy of single-patch 12-lead ECG to conventional ECG, expecting the former to be more accurate. Adult patients with chest pain but not in shock were randomized into two groups: SP-ECG and C-ECG. The final analysis included 33 of the 36 recruited patients. The key result was the time taken to record the ECG in both groups. The two groups' average ages were 63.7 and 58.1 years. The SP-ECG group was 87.5 percent timely, while the C-ECG group was 47.0 percent (P.74). At the second follow-up, it was 75.0 percent and 35.2%. Continuous ECG without interfering with other exams is feasible in complex ER circumstances. But the accuracy of single-patch ECG has not been verified. The device also had some minor difficulties. The use of SP-ECG may help alleviate overcrowding or staffing issues in EDs, although more research is required.

Extracorporeal Life-support for Out-of-hospital Cardiac Arrest: A Nationwide Multicenter Study.

BACKGROUND: Despite potential clinical roles of extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) compared to that of conventional cardiopulmonary resuscitation (CCPR), use of ECLS for OHCA is not strongly endorsed by current clinical guidelines. OBJECTIVE: The purpose of this study is to investigate the clinical roles of extracorporeal life support (ECLS) compared with that of conventional cardiopulmonary resuscitation (CCPR) for out-of-hospital cardiac arrest (OHCA) patients. METHODS: The outcomes of OHCA between 2015 and 2020, enrolled in the Korean Cardiac Arrest Research Consortium (KoCARC), a multicenter OHCA patient registry including 65 participating hospitals throughout the Republic of Korea (ClinicalTrials.gov, number NCT03222999). Differences in clinical features were adjusted by matching the propensity for ECLS. The primary outcome was 30-day neurologically favorable survival with cerebral performance category of 1 or 2. Restricted mean survival time (RMST) was used to compare outcomes between groups. RESULTS: Of 12,006 patients included, ECLS was applied to 272 patients (2.2%). The frequency of neurologically favorable survival was higher in the ECLS group than the CCPR group (RMST difference, 5.5 days [95% CI, 4.1-7.0 days], P < 0.001). In propensity score-matched 271 pairs, the clinical outcome of ECLS and CCPR did not differ to a statistically significant extent (RMST difference, 0.4 days [95% CI -1.6 to 2.5 days], P = 0.67). Subgroup analyses revealed that the clinical roles of ECLS was evident in patients with nonshockable rhythm or CPR time ≥20 min (RMST difference, 2.7 days [95% CI 0.5-4.8 days], P = 0.015), but not in patients without these features (RMST difference, -3.7 days [95% CI -7.6 to 0.2 days], P = 0.07). CONCLUSIONS: In this real-world data analysis, ECLS compared to CCPR did not result in better overall clinical outcomes of OHCA. The clinical efficacy of ECLS may be limited to a subgroup of high-risk patients.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis.

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions-expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.

Impact of Personal Protective Equipment on Out-of-Hospital Cardiac Arrest Resuscitation in Coronavirus Pandemic.

Background and Objectives: This retrospective study evaluated the clinical impact of enhanced personal protective equipment (PPE) on the clinical outcomes in patients with out-of-hospital cardiac arrest. Moreover, by focusing on the use of a powered air-purifying respirator (PAPR), we investigated the medical personnel's perceptions of wearing PAPR during cardiopulmonary resuscitation. Materials and Methods: According to the arrival time at the emergency department, the patients were categorized into a conventional PPE group (1 August 2019 to 20 January 2020) and an enhanced PPE group (21 January 2020, to 31 August 2020). The primary outcomes of this analysis were the return of spontaneous circulation (ROSC) rate. Additionally, subjective perception of the medical staff regarding the effect of wearing enhanced PPE during cardiopulmonary resuscitation (CPR) was evaluated by conducting a survey. Results: This study included 130 out-of-hospital cardiac arrest (OHCA) patients, with 73 and 57 patients in the conventional and enhanced PPE groups, respectively. The median time intervals to first intubation and to report the first arterial blood gas analysis results were longer in the enhanced PPE group than in the conventional PPE group (3 min vs. 2 min; p = 0.020 and 8 min vs. 3 min; p < 0.001, respectively). However, there were no significant differences in the ROSC rate (odds ratio (OR) = 0.79, 95% confidence interval (CI): 0.38-1.67; p = 0.542) and 1 month survival (OR 0.38, 95% CI: 0.07-2.10; p = 0.266) between the two groups. In total, 67 emergent department (ED) professionals responded to the questionnaire. Although a significant number of respondents experienced inconveniences with PAPR use, they agreed that PAPR was necessary during the CPR procedure for protection and reduction of infection transmission. Conclusion: The use of enhanced PPE, including PAPR, affected the performance of CPR to some extent but did not alter patient outcomes. PAPR use during the resuscitation of OHCA patients might positively impact the psychological stability of the medical staff.

Prognostic implication of elevated cardiac troponin I in patients visiting emergency department without diagnosis of coronary artery disease.

OBJECTIVES: Elevated cardiac troponin is not uncommon in patients visiting emergency department (ED) even without coronary artery disease, but its prognostic implication is not well understood in such patients. METHODS: In this retrospective single-center registry, we investigated clinical outcome of patients visiting ED without documented coronary artery disease. Patients were categorized according to the maximal value of Siemens ADVIA Centaur TnI-Ultra assay (TnI) within 24 h after visit. Primary endpoint was 180-day all-cause death that included cardiac and non-cardiac death. RESULTS: A total of 35,205 patients with median age 61 years and male gender 54.7% were included. Below the lowest level of detection (LOD) (≤0.006 ng/mL), between LOD and assay-specific <99th percentile (0.007-0.039 ng/mL), below median of ≥99th percentile (0.040-0.149 ng/mL), and above median of ≥99th percentile (≥0.150 ng/mL) TnI were found in 18,502 (52.6%), 11,338 (32.2%), 3,029 (8.6%), and 2,336 (6.6%) patients. In the 180-day follow-up period, 4,341 (12.3%) all-cause death including 694 (2.0%) cardiovascular death and 3,647 (10.4%) non-cardiovascular death developed. The risks of all-cause, cardiovascular, and non-cardiovascular death increased across higher TnI strata (hazard ratio [HR]=1.3 to 2.4; 2.0 to 9.3; 1.3 to 1.7; p<0.001, all). Analyses of multivariate models showed consistent results. CONCLUSIONS: In patients visiting ED, elevated TnI was associated with higher risk of 180-day cardiovascular and non-cardiovascular death. Patients with elevated TnI may need additional evaluation or careful follow-up even without primary diagnosis of coronary artery disease.

Cardiac troponin I predicts clinical outcome of patients with cancer at emergency department.

BACKGROUND: The prognostic ability of cardiac troponin I (TnI) has been demonstrated in general populations and among cardiovascular disease patients, but it has not been evaluated in cancer patients. HYPOTHESIS: This study assumes to have the prognostic ability of cardiac troponin in cancer patients visiting the emergency department. METHODS: Cancer patients visiting the emergency department were enrolled in this retrospective cohort study. Patients with previously known coronary artery disease or clinically indicated coronary angiography were not included. The maximal value from Siemens ADVIA Centaur troponin I Ultra assay within 24 hours was assessed. The primary endpoint was 180-day all-cause death, including cardiovascular and noncardiovascular death. RESULTS: A total of 9135 cancer patients (mean age: 63 years, male gender: 60%) were enrolled. Lowest (0.006 ng/mL), assay-specific <99th % (0.007-0.039 ng/mL), below median ≥ 99th % (0.040-0.129 ng/mL), and above median ≥ 99th % (≥0.130 ng/mL) TnI were found in 4487 (49.1%), 3158 (34.6%), 852 (9.3%), and 638 (7.0%) patients, respectively. There was 3192 (34.9%) all-cause deaths including 137 (1.5%) cardiovascular and 3047 (33.4%) noncardiovascular deaths in the 180-day follow-up period. The risks of all-cause, cardiovascular, and noncardiovascular death increased across higher TnI strata (hazard ratio [HR] = 1.3-2.9; 2.1-9.3; 1.3-1.8; P < .001, all). These findings were consistent within clinical subgroups including solid and hematologic cancers. CONCLUSIONS: Cancer patients visiting the emergency department with elevated troponin I were at increased risk of 180-day death. Cancer patients with elevated TnI may need additional evaluation or careful follow-up even without cardiovascular disease diagnosis.

Triple rule-out computed tomography for risk stratification of patients with acute chest pain.

AIMS: Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain. METHODS: We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings. RESULTS: TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons). CONCLUSION: Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores.