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ACADEMIC EMERGENCY MEDICINE 2012; 19:361-364 © 2012 by the Society for Academic Emergency Medicine Abstract Background: No single confirmatory device can accurately distinguish between endotracheal, endobronchial, and esophageal intubation. Bedside ultrasound (US) shows promising potential for endotracheal tube (ETT) verification. Image acquisition depends on the approach used and the experience of the sonographer. Air within the trachea remains a challenge for interpretation of US images. Insufflation of the ETT cuff with saline helps overcome this difficulty and allows easy visualization of the cuff. This novel approach has not been studied in ETT verification among novice sonographers. Objectives: The objective was to evaluate the accuracy of novice sonographers in identifying proper ETT location and depth using US visualization of a saline-filled cuff. Methods: Eight pediatric emergency medicine (PEM) fellows without prior training in airway bedside US participated in this prospective pilot study. Baseline US knowledge was assessed using a pretraining questionnaire. Fellows received a 20-minute didactic training session focused on airway US, followed by a 30-minute practice session. Using a linear US probe placed at the suprasternal notch, fellows identified the saline-filled cuff of an ETT in both the trachea and the esophagus. Following training, the ETT was placed in either the esophagus or the trachea of the cadaver model by the principal investigator. ETT depth (adequacy) was confirmed by chest radiograph. Each PEM fellow, blinded to the placement of the ETT, used bedside US to determine ETT location and depth. If placement was determined to be tracheal, the fellow was asked to comment on adequacy of tube placement. Adequate placement was defined as complete visualization of the ETT cuff within the trachea at the suprasternal notch. This was used as a surrogate for correct depth. This study sequence was repeated five times for each trainee, following varying placement of the ETT in the trachea or esophagus. Results: The PEM fellows displayed limited baseline knowledge of US prior to receiving the training module (average score of 50% on pretest questionnaire). None had any prior airway bedside US experience. Following training, PEM fellows correctly identified ETT location in 39 of 40 scans, with a sensitivity of 96% (23 of 24) for identifying tracheal location. The tube depth was correctly identified in 22 of 23 scans identified as tracheal intubations. Conclusions: PEM fellows, lacking formal airway bedside US training, were able to identify the location and depth of a saline-filled ETT above or at the suprasternal notch in an adult cadaver model following a 50-minute teaching module. Filling the ETT cuff with saline allowed novice sonographers to accurately visualize the ETT within the trachea. [ABSTRACT FROM AUTHOR] more...

Background: There has been concern that a disproportionate use of some health services exists among races. Whether this applies to patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) has not been determined. Objective: To assess if there is a racial disparity in the application of diagnostic tests for PE or DVT, or in reaching a diagnosis or using medical facilities. Design: A study of cross-sectional samples of hospitalizations during 21 years using data from the National Hospital Discharge Survey. Setting: Noninstitutional hospitals in 50 states and the District of Columbia from January 1, 1979, through December 31, 1999. Patients: The National Hospital Discharge Survey abstracts demographic and medical information from the medical records of inpatients. For 1979 through 1999, the number of patients sampled ranged annually from 181 000 to 307 000. Measurements: The number of sampled patients with DVT and with PE and the number of diagnostic tests performed were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. A multistage estimation procedure gave an estimate of values for the entire United States. Results: The age-adjusted rates of diagnosis of PE and of DVT per 100 000 population were not lower in blacks than in whites. Rates of use of radioisotopic lung scans, venous ultrasonography of the lower extremities, and contrast venography were comparable between races. The durations of hospitalization for patients with a primary discharge diagnosis of PE and of DVT were also comparable. Conclusions: There is nothing to suggest that diagnostic tests are being withheld, and there is no evidence of a failure to reach a diagnosis in blacks with thromboembolic disease. [ABSTRACT FROM AUTHOR] more...

Maintenance of Department of Defense(DoD) weapon systems, conducting battlefield training exercises as well as meeting military construction and/or demolition schedules, invariably generate fugitive air emissions, many of which are visible. Although there is no codified federal method for quantifying fugitive emissions opacity, many state and local air regulatory agencies have instituted enforceable fugitive emission opacity standards at DoD facilities. The current study focused on comparing the performance of the digital opacity compliance system (DOCS) with U.S. Environment Protection Agency Method 9 (Method 9) certified human observers in quantifying the visible opacity associated with fugitive emissions produced using a commercial fog generator. By systematically repositioning both DOCS cameras and Method 9-certified observers during field testing, differences in method performance as a function of observational locations were documented. At both the 30- and 300-ft off-set distances, opacity levels reported by the DOCS technology and Method 9-certified smoke readers were found to be statistically different at the 99% confidence level. Alternatively, at the 90- and 150-ft off-set distances, results suggested that there was an insignificant difference at the 99% confidence level between the two methods. Comparing the magnitude of the each method's standard deviation suggested that, at the 30-ft off-set distance, the DOCS technology was consistently more precise than Method 9-certified readers regardless of the observer's downwind distance. However, at the 90, 150, and 300-ft off-set distances, method precision seemed to vary as a function of both off-set and downwind distance. The primary factor affecting the consistency in opacity measurements appeared to be the impact of ground-level air turbulence on fog plume dispersion and transport. Field observations demonstrated that localized wind shear played a critical and decisive role in how and to what extent fugitive emissions opacity could be determined, regardless of the method selected. [ABSTRACT FROM AUTHOR] more...

Background & Aims: Lugol's chromoendoscopy (LCE)-based detection of esophageal squamous cell neoplasia (ESCN) is limited by low specificity. High-resolution microendoscopy (HRME) was shown to improve specificity and reduce unnecessary biopsies when used by academic endoscopists. In this international randomized controlled trial, we determined the clinical impact, efficiency, and performance of HRME in true global health contexts with a range of providers., Methods: Individuals undergoing screening or surveillance for ESCN by expert and novice endoscopists were enrolled in China and the United States from diverse clinical settings. Participants were randomized to LCE (standard of care) or LCE + HRME (experimental). The primary outcomes were the efficiency and clinical impact of LCE vs LCE + HRME using gold-standard consensus pathology., Results: Among 916 consented participants, 859 (93.8%) were recruited in China and 36 (3.9%) in the United States; 21 (2.3%) were excluded due to incomplete procedure or data. In the screening arm, 217 participants were randomized to LCE and 204 to LCE + HRME; in the surveillance arm, 236 were randomized to LCE and 238 to LCE + HRME. HRME increased efficiency in screening: diagnostic yield (neoplastic/total biopsies) improved from 20.0% (95% confidence interval [CI], 12.7-29.2) to 51.7% (95% CI, 32.5-70.6) with 65.2% (95% CI, 54.6-74.9) of biopsies potentially saved and 59.7% (95% CI, 47.5-71.1) of participants potentially spared any biopsy. Six participants (0.7%) had neoplasia missed by the endoscopist on HRME (false negatives); of these, 3 were moderate or high-grade dysplasia missed by novices., Conclusions: A low-cost microendoscope improves the efficiency and clinical impact of ESCN screening and surveillance when combined with LCE. HRME may spare unnecessary biopsies, leading to cost savings in underserved global settings where the disease is prevalent. (ClinicalTrials.gov, Number NCT02029937)., (Published by Elsevier Inc.) more...

Purpose: We present final 5-year outcomes of the multicenter randomized sham-controlled trial of a water vapor therapy (Rezūm™) for treatment of moderate to severe lower urinary tract symptoms due to benign prostatic hyperplasia., Materials and Methods: A total of 197 subjects > 50 years of age with International Prostate Symptom Score ≥13, maximum flow rate ≤15 ml/second and prostate volume 30 to 80 cc were randomized and followed for 5 years. From the control arm of 61 subjects, a subset of 53 subjects requalified and after 3 months received treatment as part of the crossover group and were also followed for 5 years. The total number of vapor treatments to each lobe of the prostate was determined by length of prostatic urethra and included middle lobe treatment per physician discretion., Results: Significant improvement of lower urinary tract symptoms was observed at < 3 months post-thermal therapy, remaining durable through 5 years in the treatment group (International Prostate Symptom Score reduced 48%, quality of life increased 45%, maximum flow rate improved 44%, Benign Prostatic Hyperplasia Impact Index decreased 48%). Surgical re-treatment rate was 4.4% with no reports of device or procedure related sexual dysfunction or sustained de novo erectile dysfunction. Results within the crossover group were similar through 5 years., Conclusions: Minimally invasive treatment with water vapor thermal therapy provides significant and durable symptom relief as well as flow rate improvements through 5 years, with low surgical re-treatment rates and without impacting sexual function. It is a versatile therapy, providing successful treatment to obstructive lateral and middle lobes. more...

Background: Intravenous fluid (IVF) administration for the prevention of contrast-induced nephropathy (CIN) is considered standard of care, but the effect of IVF therapy on longer-term outcomes after radiocontrast dye administration is not well known., Methods and Results: We studied 4367 patients undergoing coronary and peripheral angiography and intervention at a veterans' administration medical center. 2653 patients (61%) received IVF prior to the procedure and 1714 (39%) did not. Of the 4367 subjects 1962 (45%) had repeat creatinine values at 72 h and 3100 (70%) had repeat creatinine values at 3 months. CIN at 72 h occurred in 68 (6.7%) patients in the IVF group and in 87 patients (9.8%) in the group receiving no IVF (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.94-0.99; p = 0.004). At 3 months, renal dysfunction was seen in 224 (11.5%) patients of the IVF group versus 152 (13.1%) of the group receiving no IVF (OR 0.98, CI 0.96-1.01; p = 0.18). In adjusted analyses using a propensity score, IVF therapy was associated with a significant reduction in CIN occurrence at 72 h (OR = 0.97, (95% CI 0.94-0.99, p = 0.01) but was not associated with a change in the incidence of renal dysfunction at 3 months (OR 0.98, 95% CI 0.96-1.01. p = 0.18)., Conclusion: In this cohort of US veterans, IVF administration was associated with a decreased incidence of CIN at 72 h but was not associated with a decreased incidence of renal dysfunction at 3 months., (Published by Elsevier Inc.) more...

Background: Advances in clinical research methods have led to prospective randomized controlled (level 1) clinical studies evaluating diagnostic modalities resulting in a paradigm shift in the literature for diagnosing deep vein thrombosis (DVT) and pulmonary embolism (PE). To assess whether these advances correlate with clinical practice, we analyzed 21-year trends in diagnostic testing for patients with venous thromboembolism., Methods: We used discharge data from the National Hospital Discharge Survey (1979-1999) to determine DVT and PE cases annually. Procedure fields were screened to determine patients who had DVT or PE or who underwent venography, arteriography of the pulmonary arteries, pulmonary scintigraphy, or DVT ultrasonic scanning. Searching EMBASE, MEDLINE, and the American Thoracic Society guidelines, a literature-based time line of level 1 studies was derived and juxtaposed against trends and procedure use., Results: Improved diagnostic tests resulted in diagnostic changes in patients with suspected venous thromboembolism. These observed changes correlated over time in subsequent years with level 1 studies. Diagnostic DVT approaches showed an initial marked increased use of venography followed by a rapid decline that coincided with increased use of Doppler ultrasonography. Diagnostic approaches to PE were characterized by initial marked increases in lung scanning followed by a rapid decline as use of ultrasonography considerably increased and pulmonary angiography modestly increased., Conclusions: Diagnostic approaches to DVT and PE have changed markedly during the past 2 decades, in temporal harmony with the evolving literature. Change in clinical practice occurs over years, and long-term follow-up is required to capture this change. more...

Ventilated sanders are commonly used during aircraft surface abrasion but there is limited data on their effectiveness in reducing worker exposures. This study compared two handheld ventilated sander brands, DCM and Dynabrade, in a laboratory glovebox. Both sanders collect particulates by drawing air through holes in the sanding pads; the dust subsequently passes into a vacuum collection system. Aluminum panels coated with aircraft epoxy primer and polyurethane paint were abraded and inhalable dust concentrations were measured inside the glovebox with IOM samplers. The results indicate that both sanders effectively control inhalable dust, with the DCM sander reducing mass concentrations by 93 percent, and the Dynabrade by 98 percent, when the ventilation system is used. The Dynabrade unit, however, was more aggressive and produced over four times as much dust per unit time as the DCM unit. In spite of this, the Dynabrade sander adequately collected this additional dust. Varying abrasive grit size did not significantly affect dust generation, although the differences between the grit sizes used (180 and 240 grit) were not great and may have influenced the results. more...