A Guide to Point of Care Ultrasound Evaluation of Pneumonia

A patient presenting with fever, hypoxia, productive cough, and leukocytosis can be diagnosed with pneumonia without any imaging findings. However, we often rely on X-ray and computed tomography (CT) imaging to support the clinical diagnosis. Ultrasound is an effective imaging modality for identifying pneumonia without delay and radiation risks.1,2 A meta-analysis by Ye et al. in 2015 found that ultrasound diagnosis of pneumonia had a pooled sensitivity of 0.95 and a pooled specificity of 0.9, which is superior to X-ray imaging which had a pooled sensitivity of 0.77 and a similar pooled specificity of 0.9.3 This study used CT imaging as a gold standard for comparison

A Guide to Point of Care Ultrasound Lung and IVC Examination of a Volume Overloaded Patient

A patient presents with dyspnea, hypoxia, and lower extremity edema. Their history is notable for recent high salt intake and non-compliance with diuretics, and their lungs have rales bilaterally. Clinically, we can diagnose a heart failure exacerbation with pulmonary edema. However, we often rely on X-ray and computed tomography (CT) imaging to support the clinical diagnosis and explore the etiology of the hypoxia and dyspnea to narrow the differential. Ultrasound is an effective modality for identifying pulmonary edema and pleural effusions while at the same time ruling out other etiologies such as pneumonia and pneumothorax. With bedside point of care ultrasound (POCUS), there is no radiation risk and no delay in obtaining imaging. A systematic review and meta-analysis study by Maw et al. published in 2019 found that lung ultrasound diagnosis of pulmonary edema in the setting of clinical suspicion for acute decompensated heart failure had a pooled sensitivity of 0.88 and specificity of 0.9, which is superior to X-ray imaging which demonstrated a pooled sensitivity of 0.73 and a pooled specificity of 0.9.

A Guide to Point of Care Ultrasound Examination of a Pericardial Effusion

A patient presents with pleuritic chest pain, dyspnea, and a recent viral illness. They have no prior cardiac or pulmonary history. Their X-ray on admission demonstrates no pulmonary findings and an enlarged cardiac silhouette, and their EKG is low voltage with electrical alternans. Ultrasound is an effective modality for identifying pericardial effusion and cardiac tamponade while at the same time evaluating for other causes, such as heart failure. Often patients with symptomatic pericardial ef fusion present with non-specific symptoms. While a “formal” transthoracic echocardiogram remains the gold standard for diagnosis, a bedside point of care ultrasound (POCUS) cardiac evaluation can significantly decrease the time to diagnosis and trigger an order for an urgent “formal” echocardiogram.1 A retrospective study by Hanson and Chan in 2021 found that POCUS led to an expedited average time to diagnosis of 5.9 hours compared to \u3e12 hours with other imaging. Those with a symptomatic pericardial effusion identified by POCUS had a significantly decreased time to treatment; time to pericardiocentesis of 28.1 hours compared to \u3e 48 hours with other diagnostic modalities.

A Guide to Point of Care Ultrasound Examination of Acute Decompensated Heart Failure

A patient presents with dyspnea on exertion, orthopnea, and lower extremity edema. They have a prior history of coronary artery disease and reported episodes of chest pain three months ago. They did not seek medical evaluation at the time and have had no chest pain recently. In this setting, there is a high clinical suspicion of heart failure with concern for ischemic heart disease. The gold standard for diagnosis of heart failure is a formal transthoracic echocardiogram. Bedside point of care ultrasound (POCUS) is a tool that can provide essential information without delay in diagnosis

A Case of Signet Ring Cell Colon Carcinoma Initially Presenting As Acute Diverticulitis

This is a unique case of a female with an acute bout of diverticulitis who six weeks later on follow up colonoscopy, was found to have signet ring cell colon carcinoma. The purpose is to deliver awareness of this rare type of colon malignancy, emphasize the continued need for screening colonoscopy, and to provide the reader with a distinct and thought provoking spin on the conventional diagnosis of diverticulitis

Am I getting an accurate picture: a tool to assess clinical handover in remote settings?

BACKGROUND: Good clinical handover is critical to safe medical care. Little research has investigated handover in rural settings. In a remote setting where nurses and medical students give telephone handover to an aeromedical retrieval service, we developed a tool by which the receiving clinician might assess the handover; and investigated factors impacting on the reliability and validity of that assessment. METHODS: Researchers consulted with clinicians to develop an assessment tool, based on the ISBAR handover framework, combining validity evidence and the existing literature. The tool was applied 'live' by receiving clinicians and from recorded handovers by academic assessors. The tool's performance was analysed using generalisability theory. Receiving clinicians and assessors provided feedback. RESULTS: Reliability for assessing a call was good (G = 0.73 with 4 assessments). The scale had a single factor structure with good internal consistency (Cronbach's alpha = 0.8). The group mean for the global score for nurses and students was 2.30 (SD 0.85) out of a maximum 3.0, with no difference between these sub-groups. CONCLUSIONS: We have developed and evaluated a tool to assess high-stakes handover in a remote setting. It showed good reliability and was easy for working clinicians to use. Further investigation and use is warranted beyond this setting

Integrated transcriptomic and proteomic analysis of the global response of Wolbachia to doxycycline-induced stress

The bacterium Wolbachia (order Rickettsiales), representing perhaps the most abundant vertically transmitted microbe worldwide, infects arthropods and filarial nematodes. In arthropods, Wolbachia can induce reproductive alterations and interfere with the transmission of several arthropod-borne pathogens. In addition, Wolbachia is an obligate mutualist of the filarial parasites that cause lymphatic filariasis and onchocerciasis in the tropics. Targeting Wolbachia with tetracycline antibiotics leads to sterilisation and ultimately death of adult filariae. However, several weeks of treatment are required, restricting the implementation of this control strategy. To date, the response of Wolbachia to stress has not been investigated, and almost nothing is known about global regulation of gene expression in this organism. We exposed an arthropod Wolbachia strain to doxycycline in vitro, and analysed differential expression by directional RNA-seq and label-free, quantitative proteomics. We found that Wolbachia responded not only by modulating expression of the translation machinery, but also by upregulating nucleotide synthesis and energy metabolism, while downregulating outer membrane proteins. Moreover, Wolbachia increased the expression of a key component of the twin-arginine translocase (tatA) and a phosphate ABC transporter ATPase (PstB); the latter is associated with decreased susceptibility to antimicrobials in free-living bacteria. Finally, the downregulation of 6S RNA during translational inhibition suggests that this small RNA is involved in growth rate control. Despite its highly reduced genome, Wolbachia shows a surprising ability to regulate gene expression during exposure to a potent stressor. Our findings have general relevance for the chemotherapy of obligate intracellular bacteria and the mechanistic basis of persistence in the Rickettsiales

Signal transduction in a covalent post-assembly modification cascade

Natural reaction cascades control the movement of biomolecules between cellular compartments. Inspired by these systems, we report a synthetic reaction cascade employing post-assembly modification reactions to direct the partitioning of supramolecular complexes between phases. The system is composed of a self-assembled tetrazine-edged FeII8L12 cube and a maleimide-functionalized FeII4L6 tetrahedron. Norbornadiene (NBD) functions as the stimulus that triggers the cascade, beginning with the inverse-electron-demand Diels–Alder reaction of NBD with the tetrazine moieties of the cube. This reaction generates cyclopentadiene as a transient by-product, acting as a relay signal that subsequently undergoes a Diels–Alder reaction with the maleimide-functionalized tetrahedron. Cyclooctyne can selectively inhibit the cascade by outcompeting NBD as the initial trigger. Initiating the cascade with 2-octadecyl NBD leads to selective alkylation of the tetrahedron upon cascade completion. The increased lipophilicity of the C18-tagged tetrahedron drives this complex into a non-polar phase, allowing its isolation from the initially inseparable mixture of complexes

A psycho-Geoinformatics approach for investigating older adults’ driving behaviours and underlying cognitive mechanisms

Introduction: Safe driving constantly challenges the driver’s ability to respond to the dynamic traffic scene under space and time constraints. It is of particular importance for older drivers to perform sufficient visual and motor actions with effective coordination due to the fact of age-related cognitive decline. However, few studies have been able to integrate drivers’ visual-motor behaviours with environmental information in a spatial-temporal context and link to the cognitive conditions of individual drivers. Little is known about the mechanisms that underpin the deterioration in visual-motor coordination of older drivers. Development: Based on a review of driving-related cognitive decline in older adults and the context of driver-vehicle-environment interactions, this paper established a conceptual framework to identify the parameters of driver’s visual and motor behaviour, and reveal the cognitive process from visual search to vehicle control in driving. The framework led to a psycho-geoinformatics approach to measure older drivers’ driving behaviours and investigate the underlying cognitive mechanisms. The proposed data collection protocol and the analysis and assessments depicted the psycho-geoinformatics approach on obtaining quantified variables and the key means of analysis, as well as outcome measures. Conclusions: Recordings of the driver and their interactions with the vehicle and environment at a detailed scale give a closer assessment of the driver’s behaviours. Using geoinformatics tools in driving behaviours assessment opens a new era of research with many possible analytical options, which do not have to rely on human observations. Instead, it receives clear indicators of the individual drivers’ interactions with the vehicle and the traffic environment. This approach should make it possible to identify lower-performing older drivers and problematic visual and motor behaviours, and the cognitive predictors of risky driving behaviours. A better targeted regulation and tailored intervention programs for older can be developed by further research

Investigation of hospital discharge cases and SARS-CoV-2 introduction into Lothian care homes

Background The first epidemic wave of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Scotland resulted in high case numbers and mortality in care homes. In Lothian, over one-third of care homes reported an outbreak, while there was limited testing of hospital patients discharged to care homes. Aim To investigate patients discharged from hospitals as a source of SARS-CoV-2 introduction into care homes during the first epidemic wave. Methods A clinical review was performed for all patients discharges from hospitals to care homes from 1st March 2020 to 31st May 2020. Episodes were ruled out based on coronavirus disease 2019 (COVID-19) test history, clinical assessment at discharge, whole-genome sequencing (WGS) data and an infectious period of 14 days. Clinical samples were processed for WGS, and consensus genomes generated were used for analysis using Cluster Investigation and Virus Epidemiological Tool software. Patient timelines were obtained using electronic hospital records. Findings In total, 787 patients discharged from hospitals to care homes were identified. Of these, 776 (99%) were ruled out for subsequent introduction of SARS-CoV-2 into care homes. However, for 10 episodes, the results were inconclusive as there was low genomic diversity in consensus genomes or no sequencing data were available. Only one discharge episode had a genomic, time and location link to positive cases during hospital admission, leading to 10 positive cases in their care home. Conclusion The majority of patients discharged from hospitals were ruled out for introduction of SARS-CoV-2 into care homes, highlighting the importance of screening all new admissions when faced with a novel emerging virus and no available vaccine