Emergency department point-of-care ultrasonography improves time to pericardiocentesis for clinically significant effusions.

OBJECTIVE: Our objective was to determine the utility of point-of-care ultrasound (POCUS) to identify and guide treatment of tamponade or clinically significant pericardial effusions in the emergency department (ED). METHODS: This was a retrospective cohort study of non-trauma patients who were diagnosed with large pericardial effusions or tamponade by the ED physician using POCUS. The control group was composed of those patients later diagnosed on the medical wards or incidentally in the ED by other means such as a computed tomography. The following data were abstracted from the patient's file: demographics, medical background, electrocardiogram results, chest radiograph readings, echocardiogram results, and patient outcomes. RESULTS: There were 18 patients in the POCUS arm and 55 in the control group. The POCUS arm had a decreased time to pericardiocentesis (11.3 vs. 70.2 hours, P=0.055) as well as a shorter length of stay (5.1 vs. 7.0 days, P=0.222). A decreased volume of pericardial fluid was drained (661 vs. 826 mL, P=0.139) in the group diagnosed by POCUS. CONCLUSION: This study suggests that POCUS may effectively identify pericardial effusions and guide appropriate treatment, leading to a decreased time to pericardiocentesis and decreased length of hospital stay. Pericardial tamponade or a large pericardial effusion should be considered in all patients presenting to the ED with clinical, radiographic, or electrocardiographic signs of cardiovascular compromise.

The effect of administrative cessation of the use of ipratropium bromide in the treatment of acute asthma attacks in the emergency department.

BACKGROUND: The anticholinergic agent ipratropium bromide has demonstrated effectiveness in the treatment of severe asthma exacerbations. METHODS: We conducted a retrospective quasi-experiment to investigate the clinical consequences on acute asthma patients of the administrative removal of ipratropium bromide from an emergency department (ED) of a large tertiary hospital. We compared the combined negative outcome (hospitalization, length of stay in the ED, hospital readmission within 48 hours or 7 days, intubation, and death) of acute asthma patients, treated in the 12 months preceding (n = 394; Period A) and the 12 months following (n = 334; Period B) the policy change. Multiple imputations based on sequentially improved regressions were performed for missing data on measures of severity. RESULTS: Administration of steroid medications increased from 49.8% to 61.4%; p = .002 from Period A to Period B. There was no statistically significant difference in combined negative outcome between Periods A and B (41.1% and 42.9%, respectively). CONCLUSIONS: An administrative decision to stop the purchase of ipratropium bromide in an ED was followed by an increased use of steroids; adverse consequences did not increase in acute asthmatic patients. In the absence of ipratropium bromide in the ED, steroids may thus serve as an appropriate substitute, an observation that calls for a randomized controlled clinical trial.

Acute myocarditis: noninvasive evaluation with cardiac MRI and transthoracic echocardiography.

OBJECTIVE: The diagnosis of acute myocarditis is challenging. Nonspecific clinical presentation and an overlap with the diagnosis of acute myocardial infarction present a diagnostic dilemma. The purpose of this article is to describe the role of cardiac MRI and transthoracic echocardiography (TTE) in the diagnosis of acute myocarditis. MATERIALS AND METHODS: Thirty-two sequential patients (all male; average age, 33 years) with clinically suspected myocarditis were included. All patients underwent cardiac MRI with sequences dedicated for the evaluation of myocardial delayed enhancement and TTE for the evaluation of wall motion abnormalities (WMAs). Nine patients were excluded because of diagnosis of acute myocardial infarction (n=2) or inadequate cardiac MRI technique (n=7). Retrospective analysis of the images of the remaining 23 patients was performed. RESULTS: An epicardial pattern of abnormal patchy myocardial delayed enhancement was seen on cardiac MRI in 21 of 23 (91%) patients. WMAs were seen on TTE in eight of 23 (35%) patients. Regional rather than global involvement was seen mainly in the inferolateral segments, with a predominance in the midventricular portion. CONCLUSION: Cardiac MRI might have a greater impact than TTE in confirming the presence of acute myocarditis and evaluating the extent of myocardial involvement. Cardiac MRI provides noninvasive imaging that may obviate invasive procedures such as coronary catheter angiography or endomyocardial biopsy.

The effects of external counter pulsation therapy on circulating endothelial progenitor cells in patients with angina pectoris.

OBJECTIVES: External counter pulsation therapy (ECPT) offers symptomatic relief and improves ischemia in patients with refractory angina pectoris. We aimed to determine the effects of ECPT on circulating endothelial progenitor cells (EPCs). METHODS: We prospectively studied 25 patients with angina pectoris treated with ECPT (n = 15) or receiving standard care (n = 10). The number of EPCs positive for CD34 and kinase insert domain receptor (KDR) was determined by flow cytometry and the number of colony-forming units (CFUs) was assessed in a 7-day culture, before ECPT and after 9 weeks. RESULTS: ECPT improved anginal score from a median of 3.0 to 2.0 (p < 0.001). Concomitantly, ECPT increased EPC number from a median of 10.2 to 17.8/10(5) mononuclear cells (p < 0.05), and CFUs from 3.5 to 11.0 (p = 0.01). Flow-mediated dilatation was improved by ECPT from 7.4 to 12.2% (p < 0.001) and correlated with EPC-CFUs (r = 0.461, p = 0.027). The levels of asymmetric dimethylarginine were reduced by ECPT from 0.70 to 0.60 micromol/l (p < 0.01). In contrast, the same parameters did not change in the control group, before and after follow-up. CONCLUSIONS: The present pilot study shows, for the first time, that ECPT is associated with increased number and colony-forming capacity of circulating EPCs.

Urine leukotriene B4 in familial Mediterranean fever and other forms of right lower abdominal pain.

BACKGROUND: Acute right lower abdominal pain may present a diagnostic dilemma. Leukotrienes have been found to be elevated in familial Mediterranean fever (FMF), a disease manifesting with recurrent episodes of "acute abdomen." OBJECTIVES: To determine whether urine leukotriene B4 (LTB4) may differentiate between an FMF attack and some other forms of acute right lower abdominal pain. METHODS: The LTB4 level was determined, using a commercial enzyme-linked immunosorbent assay (ELISA), in urine samples obtained from 36 patients with acute (< 24 hours) right lower abdominal pain presenting to the emergency department, and from 18 healthy volunteers. RESULTS: Compared with the healthy control subjects, LTB4 was significantly higher in those who had FMF (12 patients, p < 0.03). In other forms of acute right lower abdominal pain, including appendicitis (eight patients), urologic disorders (eight patients), and nonspecific abdominal pain (eight patients), intermediate levels of LTB4 were observed, not significantly different from those of either FMF patients or healthy control subjects. CONCLUSIONS: In the samples tested, urine LTB4 levels were not instrumental in differentiating FMF from other acute right lower abdominal pain.

Acute pulmonary edema in the emergency department: clinical and echocardiographic survey in an aged population.

BACKGROUND: This study is aimed at better defining the prevalence of left ventricular dysfunction, atrial fibrillation, and mitral regurgitation in aged patients with cardiogenic acute pulmonary edema. METHODS: One hundred and twenty-three consecutive patients with acute pulmonary edema (APE) arriving at the emergency department of a peripheral hospital who underwent Doppler echocardiography within 36 hours of admission were reviewed retrospectively. RESULTS: Left ventricular ejection fraction (LVEF) was normal or near normal (ie, LVEF > or = 40%) in 41.4% (n = 51 patients), and depressed in 58.5% (n = 72). Significant valvular dysfunction was present in 37.4%; mitral regurgitation was the most frequent (22.8%; n = 28). We found a significant positive correlation between systolic blood pressure (SBP) and LVEF (P = 0.003). Within the group of patients presenting with lower SBP (< or = 140 mm Hg), as blood pressure diminished, LVEF also diminished significantly (P = 0.008). In a logistic regression analysis, male sex and SBP of less than 120 mm Hg were found to be the strongest predictors for LVEF < or = 40%, conferring a 2.68- and 2.73-fold risk, respectively (95%CI, 1.19 to -6.00; P = 0.016 and 95%CI, 0.956-7.80; P = 0.061, respectively) compared with female sex and higher SBP groups. CONCLUSIONS: This study emphasizes that emergency departments should have clear-cut policies for diagnosing and treating acute coronary syndromes and tachyarrhythmias, as being potential treatable causes of APE. Once stabilized, patients should be examined for treatable valvular causes. A further study, of acute echocardiography done upon arrival to the emergency department in patients with APE is warranted.