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The physical layout of the emergency department affects the way in which patients and providers move within the space and can cause substantial changes in workflow and, therefore, affect communication patterns between providers. There is no 1 ED design that enables the best patient care, and quantitative studies looking at ED design are limited. The goal of this study was to examine how different ED designs, centralized and decentralized, are associated with communication patterns among health care professionals. A task performance, direct observation time study was used. By developing a novel tablet-based digital mapping tool using a cloud-based mapping platform (ArcGIS), data on provider actions and interactions were collected and mapped to a precise location within the emergency department throughout an entire nursing shift. The difference in the duration of nurse-physician interactions between the 2 ED designs was statistically significant. Within the centralized design, nurse-physician interactions totaled 14 minutes and 38 seconds compared with 30 minutes and 11 seconds in the decentralized design (t = 2.31, P = 0.02). More conversations between nurses and physicians occurred inside the patient's room in the decentralized design. Our findings suggest that the ED design affects communication patterns among health care providers and that the design has the potential to affect the quality of patient care. [ABSTRACT FROM AUTHOR]

Little is known about the bovine milk proteome or whether it can be affected by diet. The objective of this study was to determine if the dietary rumen degradable protein (RDP):rumen undegradable protein (RUP) ratio could alter the bovine milk proteome. Six Holstein cows (parity: 2.5 ± 0.8) in mid lactation were blocked by days in milk (80 ± 43 d in milk) and milk yield (57.5 ± 6.0 kg) and randomly assigned to treatment groups. The experiment was conducted as a double-crossover design consisting of three 21-d periods. Within each period, treatment groups received diets with either (1) a high RDP:RUP ratio (RDP treatment: 62.4:37.6% of crude protein) or (2) a low RDP:RUP ratio (RUP treatment: 51.3:48.7% of crude protein). Both diets were isonitrogenous and isoenergetic (crude protein: 18.5%, net energy for lactation: 1.8 Mcal/kg of dry matter). To confirm N and energy status of cows, dry matter intake was determined daily, rumen fluid samples were collected for volatile fatty acid analysis, blood samples were collected for plasma glucose, β-hydroxybutyrate, urea nitrogen, and fatty acid analysis, and total 24-h urine and fecal samples were collected for N analysis. Milk samples were collected to determine the general milk composition and the protein profile. Milk samples collected for high-abundance protein analysis were subjected to HPLC analysis to determine the content of α-casein, β-casein, and κ-casein, as well as α-lactalbumin and β-lactoglobulin. Samples collected for low-abundance protein analysis were fractionated, enriched using ProteoMiner treatment, and separated using sodium dodecyl sulfate-PAGE. After excision and digestion, the peptides were analyzed using liquid chromatography (LC) tandem mass spectrometry (MS/MS). The LC-MS/MS data were analyzed using PROC GLIMMIX of SAS (version 9.4, SAS Institute Inc., Cary, NC) and adjusted using the MULTTEST procedure. All other parameters were analyzed using PROC MIXED of SAS. No treatment differences were observed in dry matter intake, milk yield, general milk composition, plasma parameters, or rumen volatile fatty acid concentrations, indicating no shift in total energy or protein available. Milk urea N and plasma urea N concentrations were higher in the RDP group, indicating some shift in N partitioning due to diet. A total of 595 milk proteins were identified, with 83% of these proteins known to be involved in cellular processes. Although none of the low-abundance proteins identified by LC-MS/MS were affected by diet, feeding a diet high in RUP decreased β-casein, κ-casein, and total milk casein concentration. Further investigations of the interactions between diet and the milk protein profile are needed to manipulate the milk proteome using diet. [ABSTRACT FROM AUTHOR]

Study Objectives: Hypotension is a common side effect of propofol, but there are no reliable methods to determine which patients are at risk for significant propofol-induced hypotension (PIH). Ultrasound has been used to estimate volume status by visualization of inferior vena cava (IVC) collapse. This study explores whether IVC assessment by ultrasound can assist in predicting which patients may experience significant hypotension.Methods: This was a prospective observational study conducted in the operating suite of an urban community hospital. A convenience sample of consenting adults planned to receive propofol for induction of anesthesia during scheduled surgical procedures were enrolled. Bedside ultrasound was used to measure maximum (IVCmax) and minimum (IVCmin) IVC diameters. IVC-CI was calculated as [(IVCmax-IVCmin)/IVCmax × 100%]. The primary outcome was significant hypotension defined as systolic blood pressure (BP) below 90mmHg and/or administration of a vasopressor to increase BP during surgery.Results: The study sample comprised 40 patients who met inclusion criteria. Mean age was 55years, (95%CI, 49-60) with 53% female. 55% of patients had significant hypotension after propofol administration. 76% of patients with IVC-CI≥50% had significant hypotension compared to 39% with IVC-CI<50%, P=.02. IVC-CI≥50% had a specificity of 77.27% (95%CI, 64.29%-90.26%) and sensitivity of 66.67% (95%CI, 52.06%-81.28%) in predicting PIH. The odds ratio for PIH in patients with IVC-CI≥50% was 6.9 (95%CI, 1.7-27.5).Conclusion: Patients with IVC-CI≥50% were more likely to develop significant hypotension from propofol. IVC ultrasound may be a useful tool to predict which patients are at increased risk for PIH. [ABSTRACT FROM AUTHOR]

Study Objective: We sought to identify findings on bedside renal ultrasound that predicted need for hospitalization in patients with suspected nephrolithiasis.Methods: A convenience sample of patients with suspected nephrolithiasis was prospectively enrolled and underwent bedside ultrasound of the kidneys and bladder to determine the presence and degree of hydronephrosis and ureteral jets. Sonologists were blinded to any other laboratory and imaging data. Patients were followed up at 30 days by phone call and review of medical records.Results: Seventy-seven patients with suspected renal colic were included in the analysis. Thirteen patients were admitted. Reasons for admission included intractable pain, infection, or emergent urologic intervention. All 13 patients requiring admission had hydronephrosis present on initial bedside ultrasound. Patients with moderate hydronephrosis had a higher admission rate (36%) than those with mild hydronephrosis (24%), P<.01. Of patients without hydronephrosis, none required admission within 30 days. The sensitivity and specificity of hydronephrosis for predicting subsequent hospitalization were 100% and 44%, respectively. Loss of the ipsilateral ureteral jet was not significantly associated with subsequent hospital admission and did not improve the predictive value when used in combination with the degree of hydronephrosis.Conclusions: No patients with suspected renal colic and absence of hydronephrosis on bedside ultrasound required admission within 30 days. Ureteral jet evaluation did not help in prediction of 30-day outcomes and may not be useful in the emergency department management of renal colic. [ABSTRACT FROM AUTHOR]

Study objective Two-point compression ultrasonography focuses on the evaluation of common femoral and popliteal veins for complete compressibility. The presence of isolated thrombi in proximal veins other than the common femoral and popliteal veins should prompt modification of 2-point compression technique. The objective of this study is to determine the prevalence and distribution of deep venous thrombi isolated to lower-extremity veins other than the common femoral and popliteal veins in emergency department (ED) patients with clinically suspected deep venous thrombosis. Methods This was a retrospective study of all adult ED patients who received a lower-extremity venous duplex ultrasonographic examination for evaluation of deep venous thrombosis during a 6-year period. The ultrasonographic protocol included B-mode, color-flow, and spectral Doppler scanning of the common femoral, femoral, deep femoral, popliteal, and calf veins. Results Deep venous thrombosis was detected in 362 of 2,451 patients (14.7%; 95% confidence interval [CI] 13.3% to 16.1%). Thrombus confined to the common femoral vein alone was found in 5 of 362 cases (1.4%; 95% CI 0.2% to 2.6%). Isolated femoral vein thrombus was identified in 20 of 362 patients (5.5%; 95% CI 3.2% to 7.9%). Isolated deep femoral vein thrombus was found in 3 of 362 cases (0.8%; 95% CI –0.1% to 1.8%). Thrombus in the popliteal vein alone was identified in 53 of 362 cases (14.6%; 95% CI 11% to 18.2%). Conclusion In our study, 6.3% of ED patients with suspected deep venous thrombosis had isolated thrombi in proximal veins other than common femoral and popliteal veins. Our study results support the addition of femoral and deep femoral vein evaluation to standard compression ultrasonography of the common femoral and popliteal vein, assuming that this does not have a deleterious effect on specificity. [ABSTRACT FROM AUTHOR]

Background: For patients with early intrauterine pregnancy (IUP), the sonographic signs of the gestation may be below the resolution of transabdominal ultrasound (TAU); however, it may be identified by transvaginal ultrasound (TVU). We sought to determine how often TVU performed in the emergency department (ED) reveals a viable IUP after a nondiagnostic ED TAU and the impact of ED TVU on patient length of stay (LOS).Methods: This was a retrospective cohort study of women presenting to our ED with complications of early pregnancy from January 1, 2007 to February 28, 2009 in a single urban adult ED. Abstractors recorded clinical and imaging data in a database. Patient imaging modality and results were recorded and compared with respect to ultrasound (US) findings and LOS.Results: Of 2429 subjects identified, 795 required TVU as part of their care. Emergency department TVU was performed in 528 patients, and 267 went to radiology (RAD). Emergency department TVU identified a viable IUP in 261 patients (49.6%). Patients having initial ED US had shorter LOS than patients with initial RAD US (median 4.0 vs 6.0 hours; P < .001). Emergency department LOS was shorter for women who had ED TVU performed compared with those sent for RAD TVU regardless of the findings of the US (median 4.9 vs 6.7 hours; P < .001). There was no increased LOS for patients who needed further RAD US after an indeterminate ED TVU (7.0 vs 7.1 hours; P = .43). There was no difference in LOS for those who had a viable IUP confirmed on ED TAU vs ED (median 3.1 vs 3.2 hours, respectively; P < .32).Conclusion: When an ED TVU was performed, a viable IUP was detected 49.6% of the time. Emergency department LOS was significantly shorter for women who received ED TVU after indeterminate ED TAU compared with those sent to RAD for TVU, with more marked time savings among those with live IUP diagnosed on ED TVU. For patients who do not receive a definitive diagnosis of IUP on ED TVU, this approach does not result in increased LOS. [ABSTRACT FROM AUTHOR]

Mixed phase, hydrogenated amorphous and nanocrystalline silicon thin films grown by co-deposition (nanocrystals and amorphous material deposited sequentially in the same vacuum system) demonstrate pronounced quantum confinement effects. Based on photoluminescence measurements of co-deposited samples, we find evidence that the optical gap of nanocrystals embedded in hydrogenated amorphous silicon is increased to energies exceeding bulk crystalline silicon values -- at least as high as 1.35 eV. The broad spectrum of emission of the nanocrystals is attributed to the size distribution and local fluctuations in matrix hydrogenation. The temperature dependence of this PL suggests that these nanocrystals possess fewer defects than those grown by conventional plasma enhanced chemical vapor deposition methods. Interactions between electronic states in nanocrystals and localized states in amorphous silicon matrix tissues are discussed in terms of their role in determining the strength of the quantum confinement potential. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective was to determine risk factors associated with difficult venous access (DVA) in the emergency department (ED). METHODS: This was a prospective, observational study conducted in the ED of an urban tertiary care hospital. Adult patients undergoing intravenous (IV) placement were consecutively enrolled during periods of block enrollment. The primary outcome was DVA, defined as 3 or more IV attempts or use of a method of rescue vascular access to establish IV access. Univariate and multivariate analyses for factors predicting DVA were performed using logistic regression. RESULTS: A total of 743 patients were enrolled, of which 88 (11.8%) met the criteria for DVA. In the adjusted analysis, only 3 medical conditions were significantly associated with DVA: diabetes (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.8), sickle cell disease (OR 3.8, 95% CI 1.5-9.5), and history of IV drug abuse (OR 2.5, 95% CI 1.1-5.7). Notably, age, body mass index, and dialysis were not. Of patients who reported a history of requiring multiple IV attempts in the past for IV access, 14% met criteria for DVA on this visit (OR 7.7 95% CI 3-18). Of the patients who reported a history of IV insertion into the external jugular, ultrasound-guided IV placement, or a central venous catheter for IV access, 26% had DVA on this visit (OR 16.7, 95% CI 6.8-41). CONCLUSIONS: Nearly 1 of every 9 to 10 adults in an urban ED had DVA. Diabetes, IV drug abuse, and sickle cell disease were found to be significantly associated with DVA. [ABSTRACT FROM AUTHOR]

Background: Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED. Methods: This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results. Results: One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92). Conclusion: In this study, US was 100% specific for the dx of ADHF. [ABSTRACT FROM AUTHOR]

Abstract: Study objective: Patients in the third trimester of pregnancy presenting to the emergency department (ED) with hypotension are routinely placed in the left lateral tilt (LLT) position to relieve inferior vena cava (IVC) compression from the gravid uterus thereby increasing venous return. However, the relationship between patient position and proximal intrahepatic IVC filling has never assessed directly. This study set out to determine the effect of LLT position on intrahepatic IVC diameter in third trimester patients under real-time visualization with ultrasound. Methods: This prospective observational study on the labor and delivery floor of a large urban academic teaching hospital enrolled patients between 30 and 42 weeks estimated gestational age from August 2011 to March 2012. Patients were placed in three different positions: supine, LLT, and right lateral tilt (RLT). After the patient was in each position for at least 3min, IVC ultrasound using the intercostal window was performed by one of three study sonologists. Maternal and fetal hemodynamics were also monitored and recorded in each position. Results: A total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26cm (95% confidence interval [CI] 1.13–1.55) in LLT compared to 1.13cm (95% CI 0.89–1.41) in supine, p =0.01. When comparing each individual patient''s LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10–48%) larger. Six patients had the largest maximum IVC measurement in the supine position. No patients experienced any hemodynamic instability or distress during the study. Conclusion: IVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients. [Copyright &y& Elsevier]

Retained foreign objects account for as much as 2% of soft tissue injuries sustained in the wilderness. Subcutaneously embedded fragments are often missed during the initial medical evaluation and may result in morbidity secondary to delayed removal. Although the utility of ultrasonography in the emergency department for the detection of retained objects is established, the potential use of point-of-care ultrasound to aid with foreign body removal in the field has not been well described. We present 2 case reports that demonstrate the value of ultrasonography in detecting and successfully removing foreign bodies sustained in the wilderness, and outline a procedural technique that minimizes morbidity and uses equipment available in wilderness medical field kits. We propose that with the advent of portable and handheld ultrasound units, foreign body removal in the field has become feasible and may decrease the morbidity of soft tissue injuries, particularly in austere and wilderness environments with limited access to immediate medical care. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Ultrasound-guided peripheral intravenous catheters (USGPIVs) have been observed to have poor durability. The current study sets out to determine whether vessel characteristics (depth, diameter, and location) predict USGPIV longevity. Methods: A secondary analysis was performed on a prospectively gathered database of patients who underwent USGPIV placement in an urban, tertiary care emergency department. All patients in the database had a 20-gauge, 48-mm-long catheter placed under ultrasound guidance. The time and reason for USGPIV removal were extracted by retrospective chart review. A Kaplan-Meier survival analysis was performed. Results: After 48 hours from USGPIV placement, 32% (48/151) had failed prematurely, 24% (36/151) had been removed for routine reasons, and 44% (67/151) remained in working condition yielding a survival probability of 0.63 (95% confidence interval [CI], 0.53-0.70). Survival probability was perfect (1.00) when placed in shallow vessels (<0.4 cm), moderate (0.62; 95% CI, 0.51-0.71) for intermediate vessels (0.40-1.19 cm), and poor (0.29; 95% CI, 0.11-0.51) for deep vessels (≥1.2 cm); P < .0001. Intravenous survival probability was higher when placed in the antecubital fossa or forearm locations (0.83; 95% CI, 0.69-0.91) and lower in the brachial region (0.50; 95% CI, 0.38-0.61); P = .0002. The impact of vessel depth and location was significant after 3 hours and 18 hours, respectively. Vessel diameter did not affect USGPIV longevity. Conclusion: Cannulation of deep and proximal vessels is associated with poor USGPIV survival. Careful selection of target vessels may help improve success of USGPIV placement and durability. [ABSTRACT FROM AUTHOR]

To report a case of laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy (AEP). Video abstract. Academic center. A 40-year-old G5P3013 woman at approximately 7 weeks gestation who was referred to our emergency room due to abnormally rising β-human chorionic gonadotropin (hCG) levels. Transvaginal ultrasonography revealed a cystic structure measuring 2.8 × 1.6 × 1.9 cm in the posterior cul-de-sac distinct from the cervix. The mass was noted to have peripheral hypervascularity and a thickened wall. A small amount of free fluid was noted adjacent to the mass. Laparoscopic excision of a primary posterior cul-de-sac AEP and evacuation of hemoperitoneum. The patient's baseline β-hCG and hematocrit (HCT) was 6810.7 mIU/mL and 42.4%, respectively. Diagnostic laparoscopy revealed normal uterus, normal right ovary, normal left ovary with a corpus luteal cyst and normal bilateral fallopian tubes without dilatation or hemorrhage. The AEP was noted in the right posterior cul-de-sac and was dissected from the underlying peritoneum. The left lateral aspect of the AEP extended into the posterior vaginal wall. The patient was admitted for overnight observation and her post-operative HCT was 35.1%. AEPs are extremely rare and account for 1% of all ectopic pregnancies. Approximately 90% of AEPs require surgical management. Historically, AEPs were treated with laparotomy given the high risk of hemorrhage and hemodynamic instability. However, as exemplified by the current case, laparoscopy is a safe and feasible option for the surgical management of AEPs. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVES: This study aimed to evaluate emergency medical physician's knowledge of the charges for the entirety of medical care provided to patients they treated and discharged from the emergency department (ED). METHODS: The study was administered in an academic ED. Patients were eligible for the study if they were discharged from the ED by the attending who first evaluated them. Following patient discharge from the ED, the attending physician and resident were asked to estimate the total billed to the patient (all charges billed to patient before adjustments for insurance provider or coverage status were applied). The median error of the physician's estimate was compared to their years of experience. RESULTS: Physicians underestimated actual total charges 93% (127/136) of the time. The median estimate was 36% (IQR 23%-54%) of the actual final ED charge, representing a median underestimation of $1268 (IQR $766-$2347). There was no correlation between degree of error and postgraduate years of the physician. CONCLUSION: This study demonstrated a significant underestimation of a patient's total charges by emergency medical physicians. There was no correlation in years of experience and ability to accurately estimate charges. While all physicians tended to underestimate charges, physicians tended to have good inter-rater agreement. [ABSTRACT FROM AUTHOR]

Background: Autism Spectrum Disorder (ASD) can result in a child having restrictive or repetitive behavior, particularly when observing dietary intake. The purpose of the study was to identify the relationship between mealtime behavior, feelings about mealtime, and parental/caregiver dietary intake. Methods: A cross sectional study was conducted, recruiting parents/caregivers (n = 27) of children living with ASD who attended a community outreach program in the Midwest. Data collection included completion of a one-time survey, which included 21 items focused on meal time behavior, feelings about meal time behavior, weight change, and parental/caregiver dietaiy intake. Results: Disruptive behavior, parental mealtime actions, child's selection or refusal, and limited variety were associated with parental/caregiver dietary intake behaviors. Mealtime difficulty correlated with frequency of eating out (r = .429, p = .025) and failing to eat 2 serving or more of fruit per day (r = .391, p = .044). Negative feelings about mealtime were associated with skipping breakfast (r = .415, p = .032). Parental/caregiver mean body mass index (BMI) increased significantly (p <.001) since child's diagnosis; intake of savory snacks (r = -.487, p = .012) and sweets (r = -.445, p = .023) was associated with weight gain. Conclusion: Future studies are warranted to explore the impact of ASD within the family unit overtime. Family centered approaches to address mealtime behavior, mealtime actions, and managing feelings about mealtime are needed. Programs should focus on managing disruptive behavior, increasing parental confidence about mealtimes, and positive parental modeling behaviors. [ABSTRACT FROM AUTHOR]

Background: The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care.Objectives: This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic.Discussion: The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings.Conclusion: Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19. [ABSTRACT FROM AUTHOR]