A pilot retrospective study of a physician-directed and genomics-based model for precision lifestyle medicine.

Precision lifestyle medicine is a relatively new field in primary care, based on the hypothesis that genetic predispositions influence an individual's response to specific interventions such as diet, exercise, and prescription medications. Despite the increase in commercially available genomic testing, few studies have investigated effects of a physician-directed program to optimize chronic disease using genomics-based precision medicine. We performed an pilot, observational cohort study to evaluate effects of the Wild Health program, a physician and health coach service offering genomics-based lifestyle and medical interventions, on biomarkers indicative of chronic disease. 871 patients underwent genomic testing, biomarker testing, and ongoing health coaching after initial medical consultation by a physician. Improvements in several clinically relevant out-of-range biomarkers at baseline were identified in a large proportion of patients treated through lifestyle intervention without the use of prescription medication. Notably, normalization of several biomarkers associated with chronic disease occurred in 47.5% (hemoglobin A1c [HbA1c]), 33.3% (low density lipoprotein particle number [LDL-P]), and 33.2% (C-reactive protein [CRP]). However, due to the inherent limitations of our observational study design and use of retrospective data, ongoing work will be crucial for continuing to shed light on the effectiveness of physician-led, genomics-based lifestyle coaching programs. Future studies would benefit from implementing a randomized controlled study design, tracking specific interventions, and evaluating physiological data, such as BMI.

Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs.

BACKGROUND: Focused cardiac ultrasound (FOCUS) is insensitive for pulmonary embolism (PE). Theoretically, when a clot is large enough to cause vital sign abnormalities, it is more likely to show signs of right ventricular dysfunction on FOCUS, although this has not been well quantified. A rapid bedside test that could quickly and reliably exclude PE in patients with abnormal vital signs could be of high utility in emergency department (ED) patients. We hypothesized that in patients with tachycardia or hypotension, the sensitivity of FOCUS for PE would increase substantially. METHODS: We performed a prospective observational multicenter cohort study involving a convenience sample of patients from six urban academic EDs. Patients suspected to have PE with tachycardia (heart rate [HR] ≥ 100 beats/min) or hypotension (systolic blood pressure [sBP] < 90 mm Hg) underwent FOCUS before computed tomography angiography (CTA). FOCUS included assessment for right ventricular dilation, McConnell's sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion. If any of these were abnormal, FOCUS was considered positive, while if all were normal, FOCUS was considered negative. We a priori planned a subgroup analysis of all patients with a HR ≥ 110 beats/min (regardless of their sBP). We then determined the diagnostic test characteristics of FOCUS for PE in the entire patient population and in the predefined subgroup, based on CTA as the criterion standard. Inter-rater reliability of FOCUS was determined by blinded review of images by an emergency physician with fellowship training in ultrasound. RESULTS: A total of 143 subjects were assessed for enrollment and 136 were enrolled; four were excluded because they were non-English-speaking and three because of inability to obtain any FOCUS windows. The mean (±SD) age of enrolled subjects was 56 (±7) years, mean (±SD) HR was 114 (±12) beats/min, and 37 (27.2%) subjects were diagnosed with PE on CTA. In all subjects, FOCUS was 92% (95% confidence interval [CI] = 78% to 98%) sensitive and 64% specific (95% CI = 53% to 73%) for PE. In the subgroup of 98 subjects with a HR ≥ 110 beats/min, FOCUS was 100% sensitive (95% CI = 88% to 100%) and 63% specific (95% CI = 51% to 74%) for PE. There was substantial interobserver agreement for FOCUS (κ = 1.0, 95% CI = 0.31 to 1.0). CONCLUSIONS: A negative FOCUS examination may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 beats/min. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients with suspected PE and abnormal vital signs.

Diagnosing centrally located pulmonary embolisms in the emergency department using point-of-care ultrasound.

OBJECTIVE: The study objective was to investigate the combined accuracy of right heart strain on focused cardiac ultrasound (FOCUS) and deep vein thrombosis (DVT) on compression ultrasound (CUS) for identification of centrally located pulmonary embolism (PE) diagnosed on computed tomography pulmonary angiography (CTPA). METHODS: This was a prospective observational study using a convenience sample of patients undergoing CTPA in the emergency department (ED) for evaluation of PE. Patients received a FOCUS looking for right heart strain (McConnell's sign, septal flattening, right ventricular enlargement or tricuspid annular plane systolic ejection (TAPSE) <17mm) and a CUS looking for DVT. Ultrasounds were interpreted by both the investigator performing the ultrasound and the principal investigator independently. RESULTS: There were 199 patients enrolled in the study, with 46/199 (23.1%) positive for a PE. Of these, 20/46 (43.5%) PE's were located centrally. Of those with a PE, 20/46 (43.5%) had an associated DVT identified on bedside ultrasound. Among patients with a proximal PE, 18/20 (90.0%) had evidence of right heart strain and the combination of lower extremity CUS and FOCUS was 100% sensitive. Diagnostic accuracy of ultrasound was much lower for peripherally located PEs. CONCLUSIONS: Emergency physician-performed bedside ultrasound may be sufficient to exclude the presence of centrally located PE, as the sensitivity in this study was 100%. Additionally, several patients with PE may qualify for early anticoagulation when DVT is identified, and further research in indicated to determine whether these patients ultimately require CTPA given identical treatment algorithms in the absence of RV strain or biomarker elevation.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience.

INTRODUCTION: Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. METHODS: This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. RESULTS: All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. CONCLUSION: POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

A Comparison of Web-Based with Traditional Classroom-Based Training of Lung Ultrasound for the Exclusion of Pneumothorax.

BACKGROUND: Lung ultrasound (LUS) is a well-established method that can exclude pneumothorax by demonstration of pleural sliding and the associated ultrasound artifacts. The positive diagnosis of pneumothorax is more difficult to obtain and relies on detection of the edge of a pneumothorax, called the "lung point." Yet, anesthesiologists are not widely taught these techniques, even though their patients are susceptible to pneumothorax either through trauma or as a result of central line placement or regional anesthesia techniques performed near the thorax. In anticipation of an increased training demand for LUS, efficient and scalable teaching methods should be developed. In this study, we compared the improvement in LUS skills after either Web-based or classroom-based training. We hypothesized that Web-based training would not be inferior to "traditional" classroom-based training beyond a noninferiority limit of 10% and that both would be superior to no training. Furthermore, we hypothesized that this short training session would lead to LUS skills that are similar to those of ultrasound-trained emergency medicine (EM) physicians. METHODS: After a pretest, anesthesiologists from 4 academic teaching hospitals were randomized to Web-based (group Web), classroom-based (group class), or no training (group control) and then completed a posttest. Groups Web and class returned for a retention test 4 weeks later. All 3 tests were similar, testing both practical and theoretical knowledge. EM physicians (group EM) performed the pretest only. Teaching for group class consisted of a standardized PowerPoint lecture conforming to the Consensus Conference on LUS followed by hands-on training. Group Web received a narrated video of the same PowerPoint presentation, followed by an online demonstration of LUS that also instructs the viewer to perform an LUS on himself using a clinically available ultrasound machine and submit smartphone snapshots of the resulting images as part of a portfolio system. Group Web received no other hands-on training. RESULTS: Groups Web, class, control, and EM contained 59, 59, 20, and 42 subjects. After training, overall test results of groups Web and class improved by a mean of 42.9% (±18.1% SD) and 39.2% (±19.2% SD), whereas the score of group control did not improve significantly. The test improvement of group Web was not inferior to group class. The posttest scores of groups Web and class were not significantly different from group EM. In comparison with the posttests, the retention test scores did not change significantly in either group. CONCLUSIONS: When training anesthesiologists to perform LUS for the exclusion of pneumothorax, we found that Web-based training was not inferior to traditional classroom-based training and was effective, leading to test scores that were similar to a group of clinicians experienced in LUS.

Emergency department patients with small bowel obstruction: What is the anticipated clinical course?

BACKGROUND: Emergency physicians (EPs) often care for patients with acute small bowel obstruction. While some patients require exploratory laparotomy, others are managed successfully with supportive care. We aimed to determine features that predict the need for operative management in emergency department (ED) patients with small bowel obstruction (SBO). METHODS: We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period. We evaluated demographic characters (prior SBO, prior abdominal surgery, active malignancy) and clinical findings (leukocytosis and lactic acid) to determine features associated with the need for urgent operative intervention. RESULTS: Patients with a prior SBO were less likely to undergo operative intervention [20.3% (42/207)] compared to those without a prior SBO [35.2% (57/162)]. Abnormal bloodwork was not associated with need for operative intervention. 68% of patients with CT scan findings of both an SBO and a hernia, however, were operatively managed. CONCLUSIONS: Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization. Abnormal bloodwork was not associated with operative intervention. The CT finding of a hernia, however, predicted the need for operative intervention, while other findings (ascites, duodenal thickening) did not. Further research would be helpful to construct a prediction rule, which could help community EPs determine which patients may benefit from expedited transfer for operative management, and which patients could be safely managed conservatively as an initial treatment strategy.

Evaluation of the Aortic Arch from the Suprasternal Notch View Using Focused Cardiac Ultrasound.

BACKGROUND: The suprasternal notch view (SSNV) is an additional echocardiographic view not routinely used by emergency physicians (EPs) performing focused cardiac ultrasound (FOCUS). OBJECTIVE: This pilot study determined the ease and self-perceived accuracy of the SSNV as performed by EPs. Additionally, we assessed the accuracy of FOCUS including the SSNV in thoracic aortic measurements compared to chest CT angiography (CTA). METHODS: This was a prospective, observational, pilot study of adult patients undergoing chest CTA. Thoracic aortic measurements were recorded at the sinus of Valsalva, sinotubular junction, and ascending aorta at its widest diameter in the parasternal long axis (PSL) view and SSNV. EPs rated ease of acquisition and self-perceived accuracy of thoracic aorta measurements. Two blinded radiologists performed thoracic aortic CTA measurements at predefined locations corresponding to the ultrasound measurements. RESULTS: Of the 79 patients (median age 57 years) enrolled, the SSNV was obtained in 97% of cases. EPs rated the ease of obtaining the SSNV as "easy" in 64.5% of cases and "very difficult" in 7.6% of cases. The mean difference between ultrasound (FOCUS plus SSNV) and CTA measurements were 1.2 mm (95% limits of agreement -2.9 to 5.3) at the sinus of Valsalva, 1.0 mm (95% limits of agreement -5.5 to 3.6 mm) at the sinotubular junction, 0.8 mm (95% limits of agreement -6.2 to 4.6 mm) at the proximal ascending aorta, and 0.6 mm (95% limits of agreement -2.8 to 4.0) at the aortic arch. CONCLUSIONS: Our findings suggest that the SSNV is an easily attainable and accurate view of the thoracic aorta that can be obtained by EPs in the majority of ED patients.

Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department.

Small bowel obstruction (SBO) is a common cause of acute abdominal pain presenting to the emergency department (ED). Although the literature is limited, point-of-care ultrasonography (POCUS) has been found to have superior diagnostic accuracy for SBO compared to plain radiography; however, it is rarely used in North America for this. We present the case of a middle-aged man who presented with abdominal pain where POCUS by the emergency physician early in the hospital course expedited the diagnosis of SBO and led to earlier surgical consultation. The application of POCUS for SBO is easily learned and applied in the ED. POCUS for SBO may obviate the need for plain radiography and expedite patient care.

Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study.

BACKGROUND: Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED. METHODS: We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared. RESULTS: The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%. CONCLUSIONS: The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED. TRIAL REGISTRY: Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.

Positive FAST without hemoperitoneum due to fluid resuscitation in blunt trauma.

BACKGROUND: The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. OBJECTIVES: To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. CASE REPORT: We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. CONCLUSION: This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination.

Double-lung point sign in traumatic pneumothorax.

Lung ultrasound has emerged as a rapid and accurate screening tool for pneumothorax. The lung point sign, a sonographic representation of the point on the chest wall where the pleural layers re-adhere, is 100% specific to confirm the diagnosis. Double lung point sign for a single pneumothorax is extremely unusual and has only been reported twice in the literature. A 49-year-old woman was transported to the emergency department (ED) intubated and sedated with severe head injury. She remained hemodynamically stable without respiratory compromise throughout her ED course. Chest computed tomography was notable for an anterior left pneumothorax with underlying pulmonary contusion. Bedside ultrasound of this region revealed a double lung point sign. Our case report is the first to confirm association of the double lung point sign with a single pneumothorax on corresponding computed tomographic imaging.

Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain.

OBJECTIVE: We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain. METHODS: This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics. RESULTS: Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred. CONCLUSIONS: Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.