Right Ventricular Flow Dynamics in Dilated Right Ventricles: Energy Loss Estimation Based on Blood Speckle Tracking Echocardiography—A Pilot Study in Children

Using blood speckle tracking (BST) based on high-frame-rate echocardiography (HFRE), we compared right ventricle (RV) flow dynamics in children with atrial septal defects (ASDs) and repaired tetralogy of Fallot (rTOF). Fifty-seven children with rTOF with severe pulmonary insufficiency (PI) (n = 21), large ASDs (n = 11) and healthy controls (CTL, n = 25) were included. Using a flow phantom, we studied the effects of imaging plane and smoothing parameters on 2-D energy loss (EL). RV diastolic EL was similar in ASD and rTOF, but both were greater than in CTL. Locations of high EL were similar in all groups in systole, occurring in the RV outflow tract and around the tricuspid valve leaflets in early diastole. An additional apical early diastolic area of EL was noted in rTOF, corresponding to colliding tricuspid inflow and PI. The flow phantom revealed that EL varied with imaging plane and smoothing settings but that the EL trend was preserved if kept consistent.     

A Novel Protocol for Contact Isolation for Multidrug-Resistant Organisms in Children on Inpatient Rehabilitation and Effects on Functional Outcomes: A Noninferiority Study

Background

The incidence of contact isolation for multidrug-resistant organisms is increasing in acute hospitals and inpatient rehabilitation units alike. There is limited evidence on the effect of contact isolation on functional outcomes during inpatient rehabilitation.

Cardiorespiratory Fitness and the Risk of Serious Ventricular Arrhythmias: A Prospective Cohort Study

Cardiorespiratory fitness (CRF) is an established risk factor for cardiovascular disease outcomes. However, the relationship of CRF with risk of ventricular arrhythmias (VAs) is unknown. We aimed to assess the prospective association of CRF with the risk of serious VAs. Cardiorespiratory fitness, as measured by maximal oxygen uptake, was assessed using a respiratory gas exchange analyzer in 2299 middle-aged men in the Kuopio Ischemic Heart Disease prospective cohort. We corrected for within-person variability in CRF levels using data from repeated measurements 11 years apart. During median follow-up of 25.3 years (interquartile range, 18.7-27.2 years), 73 serious VAs were recorded. The age-adjusted regression dilution ratio of CRF was 0.58 (95% CI, 0.53-0.64). In analysis adjusted for age, the hazard ratio (HR) for serious VAs per 1-SD increase in CRF was 0.64 (95% CI, 0.49-0.84). The association persisted on additional adjustment for body mass index, systolic blood pressure, history of hypertension, prevalent coronary heart disease, smoking, history of diabetes, cholesterol level, alcohol consumption, and physical activity (HR, 0.67; 95% CI, 0.51-0.88). The corresponding adjusted HRs (95% CIs) were 0.29 (0.14-0.59) and 0.32 (0.15-0.65), respectively, comparing the top vs bottom tertiles. The associations were stronger on correction for regression dilution bias, remained consistent on exclusion of men with a history of coronary heart disease, and did not vary importantly in several relevant clinical subgroups. Cardiorespiratory fitness is inversely associated with future risk of serious VAs, independently of several cardiovascular disease risk factors. Further research is needed to assess the causal relevance of these findings.     

The Diagnosis of Concussion in Pediatric Emergency Departments: A Prospective Multicenter Study

Background

The accurate identification of children with a concussion by emergency physicians is important to initiate appropriate anticipatory guidance and management.

Clinical Characteristics of Biopsy-Proven IgA Vasculitis in Children and Adults: A Retrospective Cohort Study

ObjectiveTo describe the differences in clinical characteristics and outcome between adult- and childhood-onset biopsy-proven IgA vasculitis (IgAV) in North America.Patients and MethodsPatients with IgAV diagnosed from January 1, 1997, through December 31, 2016, were retrospectively identified. Data were abstracted from direct medical record review. Kaplan-Meier methods were used to estimate survival rates.ResultsA total of 243 patients with IgAV were included (227 [93.4%] white, 141 [58.0%] male); 174 patients were adults (≥21 years), and 69 were younger than 21 years. Compared with patients younger than 21 years, adults at baseline more frequently had ulcerative skin lesions (19 [10.9%] vs 1 [1.4%]; P=.02) and nephrotic-range proteinuria (21 of 96 [21.9%] vs 1 of 38 [2.6%]; P=.007) but less commonly had abdominal pain (59 [33.9%] vs 42 [60.9%]; P<.001), ischemic gastrointestinal tract involvement (18 [10.3%] vs 14 [20.3%]; P=.04), and arthralgias (66 [37.9%] vs 42 [60.8%]; P<.001). During 389 person-years of follow-up, 29 deaths were observed. Five-year survival rates for patients aged younger than 21, 21 to 50, and 51 years or older were 100%, 94%, and 40%, respectively. In comparison to data from the United States life tables for whites, patients 51 years or older at diagnosis had a greater than 7-fold increased risk of mortality (standardized mortality, 7.60 [95% CI, 5.01-11.06]; P<.001).ConclusionIgA vasculitis in adults is associated with more severe skin/kidney involvement and poorer renal outcome. Among adults with IgAV, patients aged 51 years or older at diagnosis have significantly higher mortality (P<.001).     

2-D and 3-D Ultrasound for Tumor Volume Analysis: A Prospective Study

Ultrasound (US) allows real-time tumor assessment. We evaluated the volumetric limits of 2-D and 3-D US, compared with magnetic resonance imaging (MRI), with a prospective institutional review board–approved clinical evaluation of US-to-MRI volumetric correlation. US images of pre- and post-neoadjuvant breast cancers were obtained. Volume discrepancy was evaluated with the non-parametric Wilcoxon signed-rank test. Expected inter-observer variability <14% was evaluated as relative paired difference (RPD); clinical relevance was gauged with the volumetric standard error of the mean (SEM). For 42 patients, 133 of 170 US examinations were evaluable. For tumors ≤20 cm³, both highly correlated to MRI with RPD within inter-observer variability and Pearson's correlation up to 0.86 (0.80 before and 0.86 after neoadjuvant chemotherapy, respectively). Lesions 20–40 cm³ had US-to-MRI discrepancy within inter-observer variability for 2-D (RPD: 13%), but not 3-D (RPD: 27%) US (SEM: 1.47 cm³ for 2-D, SEM: 2.28 cm³ for 3-D), suggesting clinical utility. Tumors >40 cm³ correlated poorly. Tumor volumes ≤20 cm³ exhibited a good correlation to MRI. Studies of clinical applications are warranted.     

Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider

BackgroundHeart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted ventricular assist devices (VADs).ObjectiveThis review provides an evidence-based summary of the current data for the evaluation and management of implanted VAD complications in an emergency department context.DiscussionWith a prevalence of >5.8 million individuals and >550,000 new cases diagnosed each year, heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted VADs. As the prevalence of patients with VADs continues to grow, they will sporadically present to the emergency department, regardless of whether the facility is a designated VAD center. As a result, all emergency physicians must be familiar with the basic principles of VAD function, as well as the diagnosis and initial management of VAD-related complications. In this review, we address these topics, with a focus on contemporary third-generation continuous flow VADs. This review will help supplement the critical care skills of emergency physicians in managing this complex patient population.ConclusionsThe cornerstone of managing the unstable VAD patient is rapid initiation of high-quality supportive care and recognition of device-related complications, as well as the identification and use of specialist VAD teams and other resources for support. Emergency physicians must understand VADs so that they may optimally manage these complex patients.     

Echocardiographic Deformation Imaging for the Assessment of Left Ventricular Function: Clinical Implications and Perspectives— Update 2014

Echocardiographic deformation imaging is an emerging clinical method, which allows quantifying global and regional myocardial function. Its potential has been demonstrated in a large number of research settings, and it is now approaching routine clinical practice. This review provides an update on the recent developments in the field of deformation imaging and highlights current and potential future clinical applications of this promising technique.