Ultrasound training for emergency physicians--a prospective study.

OBJECTIVES: Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course. METHODS: In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered. RESULTS: In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4). CONCLUSIONS: Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.

Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder vs intravenous pyelography in the evaluation of suspected ureteral colic.

OBJECTIVE: To determine the role of bedside renal ultrasonography (US) and plain radiography of the kidneys, ureters, and bladder (KUB) as the initial investigative modality for those patients presenting to the ED with unilateral flank pain and hematuria. The hypothesis was that the renal US + KUB may obviate the need for emergent i.v. pyelography (i.v.P) in a majority of patients. METHODS: Prospective study over an 8-month period of all consecutive adult patients between the ages of 18 and 65 years presenting with unilateral flank pain and hematuria to the ED at LAC + USC Medical Center. Patients received KUB followed by a 500-mL bolus of normal saline. Bedside US was then performed by emergency physicians (EPs). Hydronephrosis of the kidney was graded as mild, moderate, or severe. All patients then underwent i.v.P. The results of the bedside US + KUB were then compared with those of i.v.P (the criterion standard). RESULTS: Of a total of 139 eligible patients, 108 were enrolled. The combination of US and KUB correctly identified pathology consistent with nephroureterolithiasis with a sensitivity of 97.1% (95% CI = 93.1-100%) when compared with i.v.P. The KUB + US results were falsely positive in 16 patients, resulting in a specificity of 58.9% (95% CI = 43.5-74.3%). The positive predictive value of the combined modality was 80.7%, the negative predictive value was 92.0%, and the overall accuracy was 83.3%. CONCLUSION: The bedside US + KUB has a high sensitivity and can be performed rapidly at the bedside by the EP when compared with i.v.P. This combined modality is an effective screening tool in the initial evaluation of ureteral colic.

Medial collateral ligament replacement with a partially absorbable tissue scaffold.

The medial collateral ligaments and medial capsular structures of canines were resected and replaced with a carbon fiber-polylactic acid polymer tissue scaffold or allowed simply to "scar-in." After 4, 8, 12, and 26 weeks in vivo, the stability of the knees was quantitatively evaluated and the mechanical properties of the regrown structures determined. Histological sections of the regrown structures were examined after 26 weeks in vivo. At all time periods, the knees receiving tissue scaffold ligaments were significantly more stable than those knees allowed to stabilize with scar tissue. Initial strength, rapid ingrowth, and benign tissue reaction suggest this new composite material may be useful in the treatment of joint instability.

Soft tissue attachment of a filamentous carbon-absorbable polymer tendon and ligament replacement.

Soft tissue structures can be replaced by a filamentous carbon-polylactic acid polymer tissue scaffold. A successful replacement requires a secure bond between the synthetic material and living soft tissue. This attachment has been investigated in a rabbit model. In 23 male, white New Zealand rabbits, the proximal third of the Achilles tendon of the hind leg was resected. Seventeen of these rabbits received composite tendon implants; six received no implants and served as shams. In all cases, the contralateral limb served as a unoperated control. Biological fixation of the synthetic material to the tendinous and myotendinous tissues of the rabbit gastrocnemius system was achieved. This occurred by ingrowth of soft tissue into the 7 mu carbon fiber network. This bond developed rapidly and was mechanically secure under physiologic loading conditions. The anastomoses' strengths were tested in tension over a 12-week period and compared to the breaking strengths of their contralateral, unoperated gastrocnemius systems and the sham systems. After four weeks, the systems with implants had strengths equivalent to those of the unoperated systems. Sham systems were significantly weaker throughout the test period. Histologically, the ingrowth process was associated with little inflammatory response. The ingrown tissue was found to be highly cellular with collagen oriented longitudinally to the tendon. After 12 weeks, the volume of collagenous tissue making up the regrown tendon section appeared nearly normal. Secure biological fixation of the carbon-polylactic acid scaffold to soft tissues may allow it application in repair or replacement of tendon or ligament deficits.

Neglected children: mothers' report of child behavior problems and observed verbal behavior.

This laboratory investigation assessed situational differences in observed maternal verbal behavior and the report of child behavior problems between groups of low-income Caucasian mothers and their neglected, behavior problem, or nonproblem children. Relative to controls, the interactions of neglect mothers were most negative and controlling during child-directed play. Behavior-problem mothers were most negative and as controlling as neglect mothers during parent-directed play. Both groups reported more difficult child behavior than controls. The results indicate the importance of considering situational variability and mode of analysis (i.e., frequency and/or percentage) when behavior differences between groups are being determined.

Scoliosis in fetal alcohol syndrome: a case report.

This ease study examines scoliosis as a result of Fetal Alcohol Syndrome (FAS). The authors suggest that the frequent occurrence of this disorder warrants a larger evaluation of scoliosis and other musculo-skeletal anomalies in Fetal Alcohol Syndrome.

Treating overweight children through parental training and contingency contracting.

Fifteen overweight girls aged 5 to 11 yr were randomly assigned to one of two weight-reduction treatments: response-cost plus reinforcement, response-cost only, or a no-treatment control group. In the response-cost plus reinforcement group, parents contracted to facilitate their child's weight loss by carrying out reinforcement and stimulus control techniques, completing weekly charts and graphs, and encouraging their child to exercise. The response-cost only group parents did not contract to reinforce their child's performance. The response-cost program applied to both experimental groups was conducted in weekly meetings in which parents lost previously deposited sums of money. Twenty-five per cent was deducted for missing the weekly meeting, 25% for failing to fill out charts and graphs, and 50% if their child failed to meet her specified weekly weight-loss goal. At the end of the 12-week treatment period, both experimental groups had lost significantly more weight than the control group. After an eight-week, no-contact follow-up, some of the lost weight was regained. The response-cost plus reinforcement group was still significantly below the controls. The response-cost group just missed significance. A 31-week, no-contact follow-up failed to show a treatment effect, but did show a trend towards slower weight gain by the response-cost plus reinforcement group.