Screening for QT Prolongation in the Emergency Department: Is There a Better “Rule of Thumb?”

Introduction: Identification of QT prolongation in the emergency department (ED) is critical for appropriate monitoring, disposition, and treatment of patients at risk for torsades de pointes (TdP). Unfortunately, identifying prolonged QT is not straightforward. Computer algorithms are unreliable in identifying prolonged QT. Manual QT-interval assessment methods, including QT correction formulas and the QT nomogram, are time-consuming and are not ideal screening tools in the ED. Many emergency clinicians rely on the “rule of thumb” or “Half the RR” rule (Half-RR) as an initial screening method, but prior studies have shown that the Half-RR rule performs poorly as compared to other QT assessment methods. We sought to characterize the problems associated with the Half-RR rule and find a modified screening tool to more safely assess the QT interval of ED patients for prolonged QT.Methods: We created graphs comparing the prediction of the Half-RR rule to other common QT assessment methods for a spectrum of QT and heart rate pairs. We then proposed various modifications to the Half-RR rule and assessed these modifications to find an improved “rule of thumb.”Results: When compared to other methods of QT correction, the Half-RR rule appears to be more conservative at normal and elevated heart rates, making it a safe initial screening tool. However, in bradycardia, the Half-RR rule is not sufficiently sensitive in identifying prolonged QT. Adding a fixed QT cutoff of 485 milliseconds (ms) increases the sensitivity of the rule in bradycardia, creating a safer initial screening tool.Conclusion: For a rapid and more sensitive screening evaluation of the QT interval on electrocardiograms in the ED, we propose combining use of the Half-RR rule at normal and elevated heart rates with a fixed uncorrected QT cutoff of 485 ms in bradycardia

Multilevel MDA-Lite Paris Traceroute

Since its introduction in 2006-2007, Paris Traceroute and its Multipath Detection Algorithm (MDA) have been used to conduct well over a billion IP level multipath route traces from platforms such as M-Lab. Unfortunately, the MDA requires a large number of packets in order to trace an entire topology of load balanced paths between a source and a destination, which makes it undesirable for platforms that otherwise deploy Paris Traceroute, such as RIPE Atlas. In this paper we present a major update to the Paris Traceroute tool. Our contributions are: (1) MDA-Lite, an alternative to the MDA that significantly cuts overhead while maintaining a low failure probability; (2) Fakeroute, a simulator that enables validation of a multipath route tracing tool's adherence to its claimed failure probability bounds; (3) multilevel multipath route tracing, with, for the first time, a Traceroute tool that provides a router-level view of multipath routes; and (4) surveys at both the IP and router levels of multipath routing in the Internet, showing, among other things, that load balancing topologies have increased in size well beyond what has been previously reported as recently as 2016. The data and the software underlying these results are publicly available.Comment: Preprint. To appear in Proc. ACM Internet Measurement Conference 201