Echocardiographic diagnosis and clinical implications of wide-open tricuspid regurgitation for evaluating right ventricular dysfunction in the emergency department.

The tricuspid regurgitation pressure gradient (TRPG) reflects the difference in pressure between the right ventricle and right atrium (ΔPRV-RA). Its estimation by echocardiography correlates well with that obtained using right-heart catheterization. An elevated TRPG is an important marker for identifying right ventricular dysfunction in both the acute and chronic settings. However, in the "wide-open" variant of TR, the TRPG counterintuitively falls. Failure to recognize this potential pitfall and underlying pathophysiology can cause underestimation of the severity of right ventricular dysfunction. This could lead to erroneous fluid tolerance assessments, and potentially harmful resuscitative and airway management strategies. In this manuscript, we illustrate the pathophysiology and potential pitfall of wide-open TR through a series of cases in which emergency physicians made the diagnosis using cardiac point-of-care ultrasound. To our knowledge, this clinical series is the first to demonstrate recognition of the paradoxically-low TRPG of wide-open TR, which guided appropriate management of critically ill patients in the emergency department.

Urban housing prices within a core urban agglomeration in China.

To address the imbalanced development in China, this study focuses on housing prices in China's large urban areas, referred to as "agglomerations" which is distinct from the label of "tier 1" versus "tier 2" (and three and four) that is used to categorize cities in China which have been the focus of previous research. It primarily uses a dummy variable approach to analyze whether, in China, housing prices in cities within a core urban agglomeration increase faster than those in a non-core urban agglomeration. This study also makes technical contributions in using altitude and other appropriate instrumental variables to address endogeneity issues, which is useful in studying Chinese cities. Our results show that housing prices are found to grow more rapidly in cities in the Pearl River Delta urban agglomeration, at a statistically significant level, than in other regions studied. Therefore, polarization in the core urban agglomeration is now much severer than we expect. Using housing prices as an indicator, this study reveals a sharpened trend of imbalanced development in Chinese cities. In addition to its empirical findings, this study also discusses some policies that policymakers can make on coordinating economic growth and stabilizing housing prices.

Opioid crisis at the Jersey Shore-special report.

The USA is experiencing an epidemic of drug overdoses and deaths with a 200% increase in overdose deaths involving opioids including heroin. Legislation since 2013 has created paths to reduce opioid overdose deaths and since, basic life support (BLS) and police agencies have been administering naloxone to patients with suspected opioid overdoses as part of standard treatment protocols. Charts were reviewed from 1 January 2016 to 15 April 2016 on the de-identified electronic medical records of patients in a two-county system comprising the 'Jersey Shore' who received naloxone to determine the number of naloxone administrations and heroin overdoses. Additionally, narratives were examined for evidence of heroin use. Of the 312 patients, 213 received a first dose of naloxone by a family member or bystander, police, or by BLS; 99 received a first dose by a paramedic (ALS). About 233 were initially unresponsive or had altered mental status that improved after naloxone administration. About210 (67.3%) charts illustrated obvious opioid use. Of the note, 282 patients arrived to an emergency department alive. About 30 patients were pronounced dead. From 1 February 2016 to 31 March 2016, the number of opioid overdoses increased and the subsequent use of naloxone has increased by 176%.