Gen Vaughan and the Maternal Gift Economy

C’est une discussion de l’auteure qui a rencontré Genevieve Vaughan et appris de ses écrits que l’économie du don maternel offrait une alternative viable à notre économie de marché capitaliste dominante. Elle ajoute que la philosophie de Vaughan a fortement marqué sa vie et son travail. La philosophie de Vaughan a résonné dans sa vie de recherchiste féministe qui toute sa vie a voulu remettre les femmes dans l’Histoire, là ou elles et leurs actions furent invisibles ou même sérieusement absentes pendant des millénaires

Using MRI of the Optic Nerve Sheath to Detect Elevated Intracranial Pressure

The current gold standard for the diagnosis of elevated intracranial pressure (ICP) remains invasive monitoring. Given that invasive monitoring is not always available or clinically feasible, there is growing interest in non-invasive methods of assessing ICP using diagnostic modalities such as ultrasound or magnetic resonance imaging (MRI). Increased ICP is transmitted through the cerebrospinal fluid surrounding the optic nerve, causing distention of the optic nerve sheath diameter (ONSD). In this issue of Critical Care, Geeraerts and colleagues describe a non-invasive method of diagnosing elevated ICP using MRI to measure the ONSD. They report a positive correlation between measurements of the ONSD on MRI and invasive ICP measurements. If the findings of this study can be replicated in larger populations, this technique may be a useful non-invasive screening test for elevated ICP in select populations

Using lung ultrasound to differentiate patients in acute dyspnea in the prehospital emergency setting

The diagnosis and treatment of dyspnea in the emergency department and in the prehospital setting is a challenge faced by the emergency physician and other prehospital care providers. While the use of lung ultrasound as a diagnostic tool in dyspneic patients has been well researched, there has been limited evaluation of its use in the prehospital setting. In the previous issue of Critical Care, Prosen and colleagues study the accuracy of lung ultrasound compared with both N-terminal pro-brain natriuretic peptide and the clinical examination for differentiating between acute decompensated congestive heart failure and chronic obstructive pulmonary disease exacerbations for patients in the prehospital setting. Their article adds to the growing body of evidence demonstrating the diagnostic efficacy of lung ultrasound in differentiating between these two disease processes in the acutely dyspneic patient

Myeloperoxidase to Risk Stratify Emergency Department Patients with Chest Pain

Previous studies suggest that serum myeloperoxidase (MPO) is a potentially useful biomarker to risk stratify troponin-negative patients with suspected myocardial ischemia. We hypothesized that the relationship between initial serum MPO levels would correlate with 30-day adverse cardiac outcomes for low risk emergency department (ED) patients with suspected myocardial ischemia. This prospective cohort study enrolled ED patients with chest pain or suspected myocardial ischemia, non-diagnostic ECG, and initially negative cardiac troponin I. We defined 30-day adverse cardiac events as death, myocardial infarction, or coronary revascularization. We calculated summary statistics, standard deviation (SD), odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC). We enrolled 159 patients who had a mean age of 55 ± 13, were 56% female, of whom 5.2% suffered at least one adverse cardiac event. MPO test characteristics were poor, with an ROC area of only 0.47 (CI 0.23-0.71). MPO levels were not associated with adverse events (OR 0.99, CI 0.98-1.01, p=0.62). The optimal ROC cutpoint to predict adverse cardiac events had poor sensitivity and specificity (57% and 52%, respectively). Mean MPO concentrations in the event group did not differ from the non-event group. In this limited cohort of low risk ED patients with chest pain, we were unable to demonstrate utility of MPO for risk stratification. If confirmed in larger studies, these findings may call into question the routine use of MPO for low-risk chest pain

Bedside ultrasound and the assessment of renal colic: a review

ABSTRACT Renal colic is a common emergency department (ED) presentation. The use of CT in the diagnosis of renal colic has increased over the past two decades and is now the most common imaging modality used in many institutions. However, with growing concerns about cumulative radiation exposure, increasing healthcare costs and patient flow in EDs, alternative approaches may need to be considered. Point-of-care ultrasound may offer a radiation-free, rapid and cost-effective alternative. The authors reviewed the literature and synthesised some of the data comparing point-of-care ultrasound with CT scanning as well as some of the evidence for how it might be incorporated into a renal colic management strategy. It is concluded that there is enough evidence to define a rational algorithm for renal colic management. A prospectively validated algorithm would greatly assist primary care and emergency practitioners while reducing costs and radiation dose

Bedside ultrasound and the assessment of renal colic: a review

ABSTRACT Renal colic is a common emergency department (ED) presentation. The use of CT in the diagnosis of renal colic has increased over the past two decades and is now the most common imaging modality used in many institutions. However, with growing concerns about cumulative radiation exposure, increasing healthcare costs and patient flow in EDs, alternative approaches may need to be considered. Point-of-care ultrasound may offer a radiation-free, rapid and cost-effective alternative. The authors reviewed the literature and synthesised some of the data comparing point-of-care ultrasound with CT scanning as well as some of the evidence for how it might be incorporated into a renal colic management strategy. It is concluded that there is enough evidence to define a rational algorithm for renal colic management. A prospectively validated algorithm would greatly assist primary care and emergency practitioners while reducing costs and radiation dose

Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda

Background: Over the last decade, the diffusion of ultrasound technology to nontraditional users has been rapid and far-reaching. Much research and effort has been focused on developing an ultrasound curriculum and training and practice guidelines for these users. The potential for this diagnostic tool is not limited to the developed world and in many respects ultrasound is adaptable to limited resource international settings. However, needs-based curriculum development, training guidelines, impact on resource utilization, and sustainability are not well studied in the developing world setting. Aims: We review one method of introducing applicable curriculum, training local providers, and sustaining a comprehensive ultrasound program. Methods: Two rural Rwandan hospitals affiliated with a US nongovernmental organization participated in a pilot ultrasound training program. Prior to introduction of ultrasound, local physicians completed a survey to determine the perceived importance of various ultrasound scan types. Hospital records were also reviewed to determine disease and presenting complaint prevalence as part of an initial needs assessment and to define our curriculum. We hypothesized certain studies would be more utilized and have a greater impact given available treatment resources. Results: We review here the choice of curriculum, the training plan, helpful equipment specifications, and implementation of ongoing measures of quality assessment and sustainability. Our 9-week lecture and practice-based ultrasound curriculum included obstetrics, abdominal, renal, hepatobiliary, cardiac, pleural, vascular, and procedural ultrasound. Conclusions: While ultrasound as a diagnostic modality for resource-poor parts of the world has generated interest for years, recent advances in technology have brought ultrasound again to the forefront as a sustainable and high impact technology for resource-poor developing world nations. From our experience in rural Rwanda, we conclude that ultrasound remains helpful in patient care and the diagnostic impact is enhanced by choosing the correct applications to implement. We also conclude that ultrasound is a teachable skill, with a several week intensive training period involving hands-on practice skills and plans for long-term learning and have begun a second phase of evaluating knowledge retention for this introductory program

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.post-print2.282 K

Design and rationale of the B-lines lung ultrasound guided emergency department management of acute heart failure (BLUSHED-AHF) pilot trial

Background Medical treatment for acute heart failure (AHF) has not changed substantially over the last four decades. Emergency department (ED)-based evidence for treatment is limited. Outcomes remain poor, with a 25% mortality or re-admission rate within 30 days post discharge. Targeting pulmonary congestion, which can be objectively assessed using lung ultrasound (LUS), may be associated with improved outcomes. Methods BLUSHED-AHF is a multicenter, randomized, pilot trial designed to test whether a strategy of care that utilizes a LUS-driven treatment protocol outperforms usual care for reducing pulmonary congestion in the ED. We will randomize 130 ED patients with AHF across five sites to, a) a structured treatment strategy guided by LUS vs. b) a structured treatment strategy guided by usual care. LUS-guided care will continue until there are ≤15 B-lines on LUS or 6h post enrollment. The primary outcome is the proportion of patients with B-lines ≤ 15 at the conclusion of 6 h of management. Patients will continue to undergo serial LUS exams during hospitalization, to better understand the time course of pulmonary congestion. Follow up will occur through 90 days, exploring days-alive-and-out-of-hospital between the two arms. The study is registered on ClinicalTrials.gov (NCT03136198). Conclusion If successful, this pilot study will inform future, larger trial design on LUS driven therapy aimed at guiding treatment and improving outcomes in patients with AHF