Telemedicine in the emergency department in the era of COVID-19: front-line experiences from 2 institutions.

During the COVID-19 pandemic, one of the major changes that has occurred in emergency medicine is the evolution of telemedicine. With relaxation of regulatory and administrative barriers, the use of this already available technology has rapidly expanded. Telemedicine provides opportunity to markedly decrease personal protective equipment (PPE) and reduce healthcare worker exposures. Moreover, with the convenience and availability of access to medical care via telemedicine, a more fundamental change in healthcare delivery in the United States is likely. The implementation of telemedicine in the emergency department (ED) in particular has great potential to prevent the iatrogenic spread of COVID-19 and protect health care workers. Challenges to widespread adoption of telemedicine include privacy concerns, limitation of physical examination, and concerns of patient experience. In this clinical review, we discuss ED telemedicine applications, logistics, and challenges in the COVID-19 era as well as recent regulatory and legal changes. In addition, examples of telemedicine use are described from 2 institutions. Examples of future applications of telemedicine within the realm of emergency medicine are also discussed.

Erratum: This Article Corrects: "Just Missing the Mark: Discharging High-risk Atrial Fibrillation/Flutter without Thromboprophylaxis".

[This corrects the article on p. 361 in vol. 19, PMID: 29560066.].

Trigeminal Trophic Syndrome Leading to Orbital Cellulitis.

Trigeminal trophic syndrome is a rare condition that develops from trigeminal nerve damage causing dysesthesias that result in self-mutilation. Facial and nasal destruction develops from self-destructive behavior (repetitive picking or scratching) secondary to the altered skin sensation created by the damaged trigeminal nerve. Early recognition of this condition is crucial to the prevention of the detrimental complications of facial ulceration and nasal tissue necrosis that can lead to corneal ulcerations, full-thickness eyelid defect, and canthal lesions. This case demonstrates a previously unreported complication: orbital cellulitis.

A comparison of the image quality of full-time myocardial perfusion SPECT vs wide beam reconstruction half-time and half-dose SPECT.

OBJECTIVES: Wide Beam Reconstruction (WBR) (UltraSPECT, Ltd) uses resolution recovery and noise modeling to cope with decreased SPECT count statistics. Because WBR processing reconstructs half the usual SPECT count statistics, we postulate that image quality equivalent to a full-time acquisition can be achieved in either half the time or with half the radiopharmaceutical activity. METHODS: In 156 consecutive patients (pts) rest and 8-frame gated post-stress myocardial perfusion SPECT was performed following 333-444 and 1184-1480 MBq (9-12 and 32-40 mCi) Tc-99m sestamibi injections, respectively, with full-time (rest = 14 min; stress = 12.3 min) acquisitions processed with OSEM and also separate "half-time" acquisitions processed with WBR. A subsequent group of 160 consecutive pts matched in gender, weight, and chest circumference received "half-dose" rest and stress injections 214.6 ± 22.2 and 647.5 ± 92.5 MBq (5.8 ± 0.6 and 17.5 ± 2.5 mCi) with full-time SPECT acquisitions. Image quality (1 = poor to 5 = excellent) was judged by myocardial count density and uniformity, endocardial edge definition, perfusion defect delineation, right ventricular visualization, and background noise. RESULTS: Mean image quality for rest, stress, and post-stress gated images were 3.6 ± 0.7, 3.8 ± 0.7, and 3.9 ± 1.0, respectively, for "full-time OSEM; 3.7 ± 0.8, 4.0 ± 0.7, and 4.8 ± 0.4 for "half-time" WBR; and 4.3 ± 0.8, 4.6 ± 0.6, and 4.7 ± 0.6 for "half-dose" WBR. "Half-time" and "half-dose" WBR image quality were both superior to standard full-time OSEM (P's < .001). There was no significant difference between the summed stress and rest scores for "full-time" OSEM vs "half-time" WBR in 82 patients with perfusion defects. CONCLUSIONS: Both "half-time" and "half-dose" WBR provide myocardial perfusion SPECT quality superior to full-time OSEM, with an associated decrease in scan acquisition time and patient radiation exposure, respectively.

Determination of vitamin A (retinol) in infant and medical nutritional formulas with AOAC method 992.06 using a modified extraction procedure: single-laboratory validation.

The applicability of AOAC Official Method 992.06, vitamin A (retinol) in milk-based infant formula can be extended to specialty infant formulas, and medical and adult nutritional products with a few minor modifications to the sample preparation procedure. Currently, AOAC Official Method 992.06 is only applicable to milk-based infant formulas containing >500 IU vitamin A per reconstituted quart. When this method is used as written to test specialty infant formulas, vitamin A recoveries are low compared to results generated with alternate validated vitamin A methods. AOAC Method 992.06 vitamin A recoveries can be improved significantly in specialty infant formulas if the amount of potassium hydroxide used during the saponification step is doubled. With this one minor modification to the sample preparation procedure, AOAC Method 992.06 demonstrates acceptable precision and accuracy for the quantitation of vitamin A (retinol) in specialty infant formulas, milk- and soy-based infant formulas, and adult and medical nutritionals. Because increasing the amount of potassium hydroxide can cause emulsions to form, 2-4 mL aliquots of reagent alcohol may need to be added to some samples to separate the organic and aqueous layers during the extraction step. A single-laboratory validation of these modifications was completed. During validation, 15 different product matrixes were analyzed. The intermediate precision averaged 2.70% RSD, and spike recovery data averaged 96.3%.

Determination of trans vitamin K1 in infant and medical nutritional products using AOAC Method 999.15 with modified preparation and extraction procedures and C30 bonded phase chromatography: single-laboratory validation.

Modifications were made to AOAC Official Method 999.15 to extend its applicability to specialty infant formulas containing hydrolyzed proteins and free amino acids, and to medical and adult nutritional products. Minor changes to the sample preparation procedure and chromatographic separation improved vitamin K1 recoveries and reduced chromatographic interferences in these types of matrixes. Currently AOAC Method 999.15 is applicable only to the determination of total vitamin K1 (phylloquione) in infant formula and milk (fluid, ready-to-feed, and powdered) containing > 1 microg vitamin K1/100 g solids. AOAC Method 999.15 recoveries of vitamin K1 were improved by altering sample sizes, extraction solvents and amounts, and the reagent addition order and amount of water or aqueous solutions added. The chromatographic separation of vitamin K1 in medical nutritional products containing canola and marine oils was improved, and trans vitamin K1 was separated from the biologically inactive cis isomer in all products with a C30 3 microm column and a 100% methanol mobile phase. With these modifications to the extraction procedure and chromatographic separation, AOAC Method 999.15 demonstrated acceptable precision and accuracy for the quantitation of trans vitamin K1 in specialty infant formulas containing hydrolyzed proteins and free amino acids, and medical and adult nutritional products. A single-laboratory validation of these minor modifications was completed. Fourteen different product matrixes were analyzed during validation. The intermediate precision averaged 4.15% RSD (range 2.52-5.81% RSD), and recovery data averaged 100.1% (range 92.2-109%).

Determination of biotin by high-performance liquid chromatography in infant formula, medical nutritional products, and vitamin premixes.

A solid-phase extraction sample preparation procedure was developed for use with a high-performance liquid chromatography (HPLC) method for biotin analysis. The HPLC method used a reversed-phase C18 column; chromatography run time was 8.5 min. After eluting from the column, biotin went through postcolumn reaction to form a conjugate with streptavidin-fluorescein isothiocyanate, which was then detected by a fluorescence detector. This method was tested with infant formula, medical nutritional products, and vitamin premix samples.