Pediatric emergency medicine point-of-care ultrasound: summary of the evidence.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed how to and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines

The Right Stuff: biodegradable alternatives to plastic mulch

This project was a continuation of work started by Mark Ingman after he was bothered by the amount of plastic sheeting used in agriculture in China. He was determined to develop an alternative to this environmentally destructive use of plastic by farmers. The plastic “mulch” is used to prevent weeds and maintain soil moisture, but after a season of use the plastic is either thrown into a landfill or burned. Needless to say this creates a lot of unnecessary waste. Mark came back to the United States and put together a team to develop an alternative to the plastic mulch using wool and flax shive waste. The shive waste is an agricultural byproduct. It is composed of biomass available after processing the plant for fibers, oil and seeds. The project was sponsored by the EPA and given a P3 Phase 2 Grant after all initial work. Dr. Skip Rochefort was asked to consult to help develop the product further. He suggested using sodium alginate, a common food additive, to bind the flax shive into a sheet form. Sodium alginate is biodegradable and fit within the sustainability needs of the project. I was tasked with taking Dr. Rochefort's idea and turning it into the final mulch sheet product. The goal of the project was to make this sheet retain moisture and prevent weeds like other mulches but biodegrade over time. At the end of the season, this product would be tilled into the soil as a soil amendment

Genome-Wide Gene Expression Analysis in Cancer Cells Reveals 3D Growth to Affect ECM and Processes Associated with Cell Adhesion but Not DNA Repair

Cell morphology determines cell behavior, signal transduction, protein-protein interaction, and responsiveness to external stimuli. In cancer, these functions profoundly contribute to resistance mechanisms to radio- and chemotherapy. With regard to this aspect, this study compared the genome wide gene expression in exponentially growing cell lines from different tumor entities, lung carcinoma and squamous cell carcinoma, under more physiological three-dimensional (3D) versus monolayer cell culture conditions. Whole genome cDNA microarray analysis was accomplished using the Affymetrix HG U133 Plus 2.0 gene chip. Significance analysis of microarray (SAM) and t-test analysis revealed significant changes in gene expression profiles of 3D relative to 2D cell culture conditions. These changes affected the extracellular matrix and were mainly associated with biological processes like tissue development, cell adhesion, immune system and defense response in contrast to terms related to DNA repair, which lacked significant alterations. Selected genes were verified by semi-quantitative RT-PCR and Western blotting. Additionally, we show that 3D growth mediates a significant increase in tumor cell radio- and chemoresistance relative to 2D. Our findings show significant gene expression differences between 3D and 2D cell culture systems and indicate that cellular responsiveness to external stress such as ionizing radiation and chemotherapeutics is essentially influenced by differential expression of genes involved in the regulation of integrin signaling, cell shape and cell-cell contact

International consensus conference recommendations on ultrasound education for undergraduate medical students

Objectives: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students. Methods: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting. Results: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care. Conclusions: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice

Icterus and abdominal pain: an unexpected, rare sonographic finding in a Peruvian Emergency Department

Abstract Background The use of point-of-care ultrasound (POCUS) has become increasingly important in resource-limited settings. It can rapidly diagnose both tropical infectious diseases and more common pathology at the bedside. In these practice settings, POCUS can have a significant impact on management strategies and patient care. Ultrasonography has been the gold standard for the diagnosis and staging of Echinococcus disease. However, even in the “classic” clinical scenario and setting, the clinician must maintain a broad differential diagnosis. Point-of-care ultrasound can be helpful in performing the rapid diagnosis and therefore direct appropriate treatment strategies based on the results. Case presentation We present a case of a 27-year-old woman presenting to an emergency department in Peru with jaundice and abdominal pain. Initially given the region of her origin, the working diagnosis was an Echinococcus cyst. However, when POCUS was performed, the findings were not consistent with hydatid disease. Ultimately, surgical pathology revealed a choledochal cyst, a rare finding in adulthood. Conclusions This case initially appears as a “classic” finding of Echinococcus disease. It is important for the clinician sonographer to appreciate the features consistent with Echinococcus cysts and distinguish from those features that are more consistent with other pathology

Change in Intraocular Pressure During Point-of-Care Ultrasound

Introduction: Point-of-care ocular ultrasound (US) is a valuable tool for the evaluation of traumaticocular injuries. Conventionally, any maneuver that may increase intraocular pressure (IOP) isrelatively contraindicated in the setting of globe rupture. Some authors have cautioned against theuse of US in these scenarios because of a theoretical concern that an US examination may causeor exacerbate the extrusion of intraocular contents. This study set out to investigate whether ocularUS affects IOP. The secondary objective was to validate the intraocular pressure measurementsobtained with the Diaton® as compared with standard applanation techniques (the Tono-Pen®).Methods: We enrolled a convenience sample of healthy adult volunteers. We obtained thebaseline IOP for each patient by using a transpalpebral tonometer. Ocular US was then performedon each subject using a high-frequency linear array transducer, and a second IOP was obtainedduring the US examination. A third IOP measurement was obtained following the completionof the US examination. To validate transpalpebral measurement, a subset of subjects alsounderwent traditional transcorneal applanation tonometry prior to the US examination as a baselinemeasurement. In a subset of 10 patients, we obtained baseline pre-ultrasound IOP measurementswith the Diaton® and Tono-Pen®, and then compared them.Results: The study included 40 subjects. IOP values during ocular US examination were slightlygreater than baseline (average +1.8mmHg, p=0.01). Post-US examination IOP values were notsignificantly different than baseline (average -0.15mmHg, p=0.42). In a subset of 10 subjects, IOPvalues were not significantly different between transpalpebral and transcorneal tonometry (average+0.03mmHg, p=0.07).Conclusion: In healthy volunteer subjects, point-of-care ocular US causes a small and transientincrease in IOP. We also showed no difference between the Diaton® and Tono-Pen® methodsof IOP measurement. Overall, the resulting change in IOP with US transducer placement isconsiderably less than the mean diurnal variation in healthy subjects, or pressure generated byphysical examination, and is therefore unlikely to be clinically significant. However, it is important totake caution when performing ocular ultrasound, since it is unclear what the change in IOP would bein patients with ocular trauma. [West J Emerg Med. 2015;16(2):263–268.

Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement

Introduction: Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.Methods: This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigatorusing first the low-frequency (5–1 MHz) followed by the high-frequency (10–5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation ofTT placement.Results: Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10–5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.Conclusion: Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10–5 MHz) linear transducer. [West J Emerg Med. 2012;13(4):305–311.

Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement

Introduction: Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.Methods: This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigatorusing first the low-frequency (5–1 MHz) followed by the high-frequency (10–5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation ofTT placement.Results: Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10–5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.Conclusion: Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10–5 MHz) linear transducer. [West J Emerg Med. 2012;13(4):305–311.]