A Clinician's Guide to the Implementation of Point-of-Care Ultrasound (POCUS) in the Outpatient Practice.

Point-of-care ultrasound (POCUS) is a valuable clinical tool used at the patient bedside to rapidly assess a wide variety of symptoms and problems which would otherwise take hours or even days. Though it has become the standard of care in Emergency Medicine and is becoming so in hospital internal medicine, less uptake has been appreciated in the outpatient setting despite reported interest from clinicians practicing there. A number of common barriers have been cited to explain this gap in use, which usually include access to equipment, mentorship, and time. In this review we present a proposed framework for clinicians who have an interest in implementing POCUS in their outpatient practice which we hope can mitigate some of these barriers and provide a more streamlined pathway to their desired goals.

Perioperative cardiac risk reduction in non cardiac surgery.

For patients undergoing nonemergent noncardiac surgery, care must be taken to identify patients at increased risk of major adverse cardiovascular events, as these remain a significant source of perioperative morbidity and mortality. Identification of at-risk patients requires careful attention to risk factors including assessment of functional status, medical comorbidities, and a medication assessment. After identification, to minimize perioperative cardiac risk, care should be taken through a combination of appropriate medication management, close monitoring for cardiovascular ischemic events, and optimization of pre-existing medical conditions. There are multiple society guidelines that aim to mitigate risk of cardiovascular morbidity and mortality in patients undergoing nonemergent noncardiac surgery. However, the rapid evolution of medical literature often creates gaps between the existing evidence and best practice recommendations. In this review, we aim to reconcile the recommendations made in the guidelines from the major cardiovascular and anesthesiology societies from the USA, Canada, and Europe, and to provide updated recommendations based on new evidence.

Oil Red O Staining of Pulmonary Macrophages in Bronchoalveolar Lavage Specimens Is Not Specific for Vaping-Associated Lung Injury.

OBJECTIVES: Oil Red O (ORO) positivity in bronchoalveolar lavage (BAL) fluid macrophages in the setting of e-cigarette, or vaping, product use-associated acute lung injury (EVALI) has been frequently requested by clinicians based on rare reports and subsequent US Centers for Disease Control and Prevention guidelines. The aim of this study was to determine the specificity of ORO staining in BAL specimens with disease states other than EVALI. METHODS: Consecutive BAL specimens (October-December 2019) were stained with ORO. The lipid-laden macrophage index (LLMI) was calculated for each case. RESULTS: We studied BAL samples from 50 patients. Indications for BAL were surveillance bronchoscopy for lung transplantation (27/50), suspected infection (12/50), sarcoidosis/suspected sarcoidosis (3/50), nodules or ground-glass opacities (3/50), hemoptysis (2/50), asthma or eosinophilic pneumonia (2/50), and idiopathic pulmonary fibrosis (1/50). ORO staining was seen in BAL fluid macrophages in 45 of 50 cases (focal in 18, moderate in 23, diffuse in 4); LLMI ranged from 0 to 218. Using a threshold of LLMI of 85 or higher as positive, ORO was positive in 7 of 50 (14%) cases (range, 85-218). CONCLUSIONS: ORO staining in BAL fluid macrophages is not specific for EVALI. Even when an LLMI of 85 or higher is used as a threshold for positivity, ORO positivity occurs in a significant subset of non-vaping-related cases.