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Thom C, Livingstone K, Ottenhoff J, Han D, Martindale J, Moak J. Comparison of transvaginal ultrasound utilization between radiology and point of care ultrasound in first trimester pregnancy. Am J Emerg Med 2024; 80:143-148. [PMID: 38604108 DOI: 10.1016/j.ajem.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/12/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Transvaginal (TVUS) and transabdominal ultrasound (TAUS) are both utilized in the evaluation of early pregnancy patients. While many practitioners using point of care ultrasound (POCUS) will generally not pursue TVUS in cases where an intrauterine pregnancy (IUP) is visualized on TAUS, this may not be true in Radiology performed ultrasound. OBJECTIVES To evaluate for differences in transvaginal ultrasound (TVUS) utilization between Radiology performed (RP) ultrasound and point of care ultrasound (POCUS) by Emergency Department (ED) physicians in early pregnancy patients. Secondarily, to assess length of stay (LOS) differences and the impact of specialized emergency ultrasound training on TVUS utilization. METHODS This was a retrospective study at a single academic ED. Study population was all ED patients who underwent first trimester ultrasound during the one year period of March 1, 2021 to February 28, 2022. Variables evaluated were chief complaint, gestational age, LOS, TAUS and TVUS utilization, ultrasound findings, and ultrasound specialty training of the ED physician. RESULTS There were 133 cases of POCUS ultrasound and 254 cases of RP ultrasound. All cases had TAUS imaging performed. Median LOS for patients when POCUS was utilized was 207 min (IQR 151-294) and 258 min (IQR 208-328) for those only using RP ultrasound, p ≤ 0.001. In the POCUS cohort, 38% (95% CI 30%-46%) received TVUS, while 94% received TVUS in the RP cohort (95% CI 90%-96%), p ≤ 0.001. Patients seen by ED faculty with ultrasound specialty training had TVUS 53% of the time (95% CI 41%-65%), while those seen by other ED faculty had TVUS 79% (95% CI 74%-83%) of the time, p = 0.035. CONCLUSION POCUS in early pregnancy is associated with a significant reduction in TVUS usage. We suspect that POCUS users elect not to pursue TVUS after an IUP is identified on TAUS, while technicians perform protocol-based TVUS irrespective of TAUS findings. Patients seen by ultrasound trained ED physicians are less likely to receive TVUS.
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Affiliation(s)
| | | | | | - David Han
- University of Virginia Health System, USA
| | | | - James Moak
- University of Virginia Health System, USA
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2
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Adhikari S, Leo M, Liu R, Johnston M, Keehbauch J, Barton M, Kendall J. The 2023 Core Content of advanced emergency medicine ultrasonography. J Am Coll Emerg Physicians Open 2023; 4:e13015. [PMID: 37564703 PMCID: PMC10411060 DOI: 10.1002/emp2.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.
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Affiliation(s)
- Srikar Adhikari
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Megan Leo
- Department of Emergency MedicineBoston Medical CenterBostonMassachussetsUSA
| | - Rachel Liu
- Department of Emergency MedicineYale UniversityNew HavenConnecticutUSA
| | - Mary Johnston
- American Board of Emergency MedicineEast LansingMichiganUSA
| | | | - Melissa Barton
- American Board of Emergency MedicineEast LansingMichiganUSA
| | - John Kendall
- Department of Emergency MedicineDenver Health Medical CenterDenverColoradoUSA
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3
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Poxon A, Clarfield L, Cherniak R, Page A, Po L. Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:21-26. [PMID: 36436806 DOI: 10.1016/j.jogc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.
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Affiliation(s)
- Amanda Poxon
- Temerty School of Medicine, University of Toronto, Toronto, ON.
| | - Lauren Clarfield
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Rebecca Cherniak
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Andrea Page
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; DAN Women and Babies Program at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Leslie Po
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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Çelik A, Yazıcı MM, Oktay M. The impact of high-frequency linear transducer on the accuracy of pelvic ultrasound in early pregnancy pelvic pain and bleeding. Am J Emerg Med 2022; 61:105-110. [DOI: 10.1016/j.ajem.2022.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 10/31/2022] Open
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Derr C, Shteyman A, Jackson SA, Lu Y, Campbell T, De Lucia A, Merritt R, Lupez K, Elkes J, Hansen A, Jelic T, DeRespino A, Grant A. Determination of Endovaginal Ultrasound Proficiency and Learning Curve Among Emergency Medicine Trainees. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1741-1752. [PMID: 34698417 DOI: 10.1002/jum.15857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations. METHODS This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident. RESULTS A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy. CONCLUSIONS There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.
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Affiliation(s)
- Charlotte Derr
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Alan Shteyman
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Saundra A Jackson
- Department of Emergency Medicine, Emergency Resources Group, Jacksonville, FL, USA
| | - Yuanyuan Lu
- Study Design and Data Analysis Center, University of South Florida Morsani College of Medicine, Knoxville, TN, USA
| | | | - Anthony De Lucia
- Department of Emergency Medicine, C.W. Bill Young Department of Veterans Affairs Medical Center, Bay Pines, FL, USA
| | - Raymond Merritt
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Tufts Medical Center, Boston, MA, USA
| | - Johnathon Elkes
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Allyson Hansen
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allison DeRespino
- Department of Emergency Medicine, James A. Haley Veterans Hospital, Tampa, FL, USA
| | - Ashley Grant
- Department of Emergency Medicine, Florida State University College of Medicine, Sarasota Memorial Hospital, Sarasota, FL, USA
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Cohen A, Shi D, Keraney E, Stankard B, Nelson M. Ultrasound in the Emergency Department Identifies Ectopic Pregnancy Post Hysterectomy: A Case Report. Clin Pract Cases Emerg Med 2022; 6:129-132. [PMID: 35701342 PMCID: PMC9197750 DOI: 10.5811/cpcem.2022.2.54929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/10/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Ruptured ectopic pregnancy is one of the leading causes of maternal death. Point-of-care ultrasound (POCUS) has been shown to be highly sensitive for excluding ectopic pregnancy. Ectopic pregnancy after a hysterectomy is a rare but life-threatening occurrence. We present a case where POCUS helped to diagnose a post-hysterectomy ectopic pregnancy. Case report A 36-year-old female with a prior surgical history of hysterectomy without oophorectomy presented to the emergency department with lower abdominal pain. A POCUS revealed free fluid in the right upper quadrant with an unremarkable gallbladder. Subsequently, the pelvic POCUS noted free fluid as well as a heterogeneous structure in the right adnexa. The clinician ordered a serum beta human chorionic gonadotropin level, which was 173.2 international units per milliliter (lU/mL) (negative: < 5m IU/ml). Transvaginal ultrasound revealed a right adnexal echogenic structure with surrounding vascularity and moderate, complex free fluid suggestive of hemorrhage. Given the concern for possible ectopic pregnancy, obstetrics took the patient to the operating room where a right tubal ectopic pregnancy was confirmed. Conclusion A ruptured ectopic pregnancy is a life-threatening condition that requires rapid diagnosis. Ectopic pregnancy post hysterectomy is an uncommon occurrence infrequently considered in the differential diagnosis of lower abdominal pain, leading to considerable delays in diagnosis. Although uncommon, emergency clinicians must consider this diagnosis in female patients with lower abdominal pain.
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Affiliation(s)
- Allison Cohen
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Dorothy Shi
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Evan Keraney
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Brendon Stankard
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Matthew Nelson
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
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7
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External validation of the POP score for predicting obstetric and gynecological diseases in the emergency department. Am J Emerg Med 2021; 51:348-353. [PMID: 34808457 DOI: 10.1016/j.ajem.2021.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The POP score was developed as an easy screening tool for predicting obstetrics and gynecological (OBGYN) diseases in the emergency department (ED), and consists of three predictors, each representing one point: past history of OBGYN diseases, no fever or digestive symptoms, and peritoneal irritation signs). However, its external validity has not yet been evaluated. We aimed to perform the external validation of the POP score. METHODS This is a multi-center, retrospective cohort study using ED data of three tertiary care hospitals in Japan between Jan 2017 and October 2020. Young adult women aged 16-49 years with abdominal pain were included in the analysis. The probability of OBGYN diseases was calculated using a logistic regression model of the POP score. Predictions were compared with observations to evaluate the calibration of the model. Further, the diagnostic ability (sensitivity, specificity, and likelihood ratio) of the POP score was evaluated. RESULTS Of 66,599 ED visits, 1026 young adult women (median age [interquartile range]: 31 [23-41] years) were included for the analysis. The c-statistic was 0.645 [95% confidence interval (CI): 0.603-0.687]. The predicted probabilities of OBGYN diseases was generally well-calibrated to the observations. When the cut-off was set between 2 and 3 points for the ruling in of OBGYN diseases, the positive likelihood ratio was 9.72 [95% CI: 3.33-28.4]. When the cut-off was set between 0 and 1 points for ruling out of OBGYN diseases, negative likelihood ratio was 0.181 [95% CI: 0.059-0.558]. CONCLUSIONS Using ED data of three tertiary care hospitals, we externally validated the POP score for prediction of OBGYN diseases in the ED. The POP score likely has clinical value for screening OBGYN diseases in young adult women with abdominal pain in the ED.
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8
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Urquhart S, Barnes M, Flannigan M. Comparing Time to Diagnosis and Treatment of Patients with Ruptured Ectopic Pregnancy Based on Type of Ultrasound Performed: A Retrospective Inquiry. J Emerg Med 2021; 62:200-206. [PMID: 34538680 DOI: 10.1016/j.jemermed.2021.07.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hemorrhage from ruptured ectopic pregnancy is the leading cause of first trimester mortality in North America. OBJECTIVES Our objective was to compare patients with a ruptured ectopic pregnancy who had an emergency department (ED) point-of-care ultrasound (PoCUS) with those who received a radiology department-performed ultrasound (RADUS). Four time intervals were measured: ED arrival to ultrasound interpretation, obstetric consultation, operating room (OR) arrival, and ultrasound interpretation to OR arrival. METHODS This was a retrospective cohort study of patients with ruptured ectopic pregnancy seen between February 2012 and September 2018 at an urban tertiary care hospital. Patients who received an ultrasound in the ED, went directly to the OR, and had confirmed rupture were included. RESULTS Of 262 patients diagnosed with ectopic pregnancy during the study period, 36 (14%) were ruptured and 32 were enrolled. Comparing times between PoCUS (n = 10) and RADUS (n = 22) groups, the mean time from ED arrival to ultrasound interpretation was 15 vs. 138 min (difference 123, 95% confidence interval [CI] 88-158), from ED arrival to obstetric consultation was 35 vs. 150 min (difference 115, 95% CI 59-171), from ED arrival to OR arrival was 160 vs. 381 min (difference 222, 95% CI 124-320), and from ultrasound interpretation to OR arrival was 145 vs. 243 min (difference 98, 95% CI 12-184). CONCLUSION ED patients with a ruptured ectopic pregnancy who received a PoCUS first had shorter times to diagnosis, obstetric consultation, and OR arrival compared with those who received RADUS.
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Affiliation(s)
- Sara Urquhart
- Michigan State University College of Human Medicine, Grand Rapids, Michigan.
| | - Mariah Barnes
- Department of Emergency Medicine, Spectrum Health, Grand Rapids, Michigan
| | - Matthew Flannigan
- Department of Emergency Medicine, Spectrum Health, Grand Rapids, Michigan
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9
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Diagnostic Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine. Emerg Med Clin North Am 2021; 39:509-527. [PMID: 34215400 DOI: 10.1016/j.emc.2021.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Point-of-care ultrasound has become an essential part of pediatric emergency medicine training and practice. It can have significant clinical benefits, including improving diagnostic accuracy and decreasing length of stay, and does not require radiation exposure for patients. In this review, we summarize the current diagnostic point-of-care ultrasound applications in pediatric emergency medicine, their evidence, and techniques.
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10
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Stone BS, Muruganandan KM, Tonelli MM, Dugas JN, Verriet IE, Pare JR. Impact of point-of-care ultrasound on treatment time for ectopic pregnancy. Am J Emerg Med 2021; 49:226-232. [PMID: 34146921 DOI: 10.1016/j.ajem.2021.05.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/13/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is useful in the evaluation of early pregnancy by confirming intrauterine pregnancy and recognizing hemorrhage from ectopic pregnancy. We sought to determine whether transabdominal POCUS by itself or in conjunction with consultative radiology ultrasound (RADUS), reduces Emergency Department (ED) treatment time for patients with ectopic pregnancy requiring operative care, when compared to RADUS alone. A secondary objective was to determine whether the incorporation of POCUS reduces time to operative care for patients with ruptured ectopic pregnancy specifically, when compared to RADUS alone. METHODS We performed a retrospective review of patients admitted for operative management of ectopic pregnancy. We excluded patients with known ectopic pregnancy and/or imaging prior to arriving to the treatment area, found not to have an ectopic pregnancy, or did not undergo operative care. Descriptive statistics, classical and nonparametric statistical analysis, and linear regression were performed. RESULTS There were 220 patients admitted with ectopic pregnancy, 111 met exclusion criteria, yielding 109 for analysis. Of 109, 36 received POCUS (23/36 also had RADUS), while 73 received RADUS only. Among the POCUS group 31/36 (86%) were classified as ruptured versus 47/73 (64%) in the RADUS group. The average ED treatment time in the POCUS group for all admitted ectopic pregnancies was 157.9 min (standard deviation [SD] 101.3) versus 206.3 min (SD 76.6) in the RADUS group (p = 0.0141). The median time to operating room (OR) for ruptured ectopic pregnancies was 203.0 min (interquartile range [IQR] 159.0) in the POCUS group versus 293.0 min (IQR 139.0) in the RADUS group (p = 0.0002). Regression analysis of the primary outcome was limited by multiple interactions and sample size. When controlling for race, positive shock index and ED visit time, POCUS was found to be associated with a significantly shorter time to OR among ruptured ectopic pregnancies compared to RADUS (p = 0.0052). CONCLUSION Compared to RADUS alone, incorporation of POCUS was associated with significantly faster ED treatment time for all ectopic pregnancies and significantly faster time to OR for ruptured ectopic pregnancies, even when combined with RADUS. When controlling for clinical differences, time to OR was still faster for patients who underwent POCUS. The integration of POCUS should be considered to expedite care for patients with ectopic pregnancy requiring operative care.
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Affiliation(s)
- Bethsabee S Stone
- Pediatric Emergency Department, Boston Medical Center, Boston University School of Medicine, 1 Boston Medical Center Place, Boston, MA 02118, United States of America.
| | - Krithika M Muruganandan
- Emergency Department, Boston Medical Center, Boston University School of Medicine, 1 Boston Medical Center Place, Boston, MA 02118, United States of America
| | - Melinda M Tonelli
- Emergency Department, Boston Medical Center, Boston University School of Medicine, 1 Boston Medical Center Place, Boston, MA 02118, United States of America
| | - Julianne N Dugas
- Emergency Department, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States of America
| | - Ivy E Verriet
- Pediatric Emergency Department, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States of America
| | - Joseph R Pare
- Emergency Department, Boston Medical Center, Boston University School of Medicine, 1 Boston Medical Center Place, Boston, MA 02118, United States of America
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11
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Moake MM, Price AB, Titus MO, Barnes RM. Point-of-Care Ultrasound Facilitates Management of Ruptured Ectopic Pregnancy. Pediatr Emerg Care 2021; 37:282-285. [PMID: 33903289 DOI: 10.1097/pec.0000000000002375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Abdominal pain in the pregnant adolescent presents a diagnostic dilemma with potential life-threatening etiologies. We present a case where point-of-care ultrasound was used to facilitate diagnosis and expedite lifesaving management of a ruptured ectopic pregnancy. We further review the technique and literature for first-trimester transabdominal point-of-care ultrasound.
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Affiliation(s)
| | | | | | - Ryan M Barnes
- Emergency Medicine, Medical University of South Carolina, Charleston, SC
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12
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Urquhart S, Stevens K, Barnes M, Flannigan M. Point of Care Ultrasound First: An Opportunity to Improve Efficiency for Uncomplicated Pregnancy in the Emergency Department. POCUS JOURNAL 2021; 6:42-44. [PMID: 36895504 PMCID: PMC9979936 DOI: 10.24908/pocus.v6i1.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction: Research suggests emergency providers using point-of-care ultrasound (POCUS) to confirm an uncomplicated intrauterine pregnancy (IUP) can decrease emergency department (ED) length of stay (LOS) compared to a radiology department ultrasound (RADUS). The objective of this study was to compare the time to diagnosis and LOS between POCUS and RADUS patients. Methods: This was a retrospective study at one urban medical center. A standardized tool was used to abstract data from a random sample of pregnant patients diagnosed with uncomplicated IUP between January 2016 and December 2017 at a single tertiary care medical center. Microsoft Excel 2010 software was used to measure time intervals, prepare descriptive statistics, and perform Mann-Whitney U tests to compare differences. Results: A random sample of 836 (36%) of the 2,346 emergency department patients diagnosed with an IUP between 8-20 weeks' gestation during the study period was evaluated for inclusion. Three hundred sixty-six met inclusion criteria and were included in the final analysis. Patients were divided into 2 groups based on which type of ultrasound scan they received first: POCUS (n=165) and RADUS (n=201). Patients who received POCUS were found to have an IUP identified in an average of 48 minutes (95% CI, 43 to 53), while the RADUS group's mean time to diagnosis was 120 minutes (95% CI 113 to 127) with a difference of 72 minutes (95% CI, 63 to 80; p<0.001). The mean LOS for patients who received POCUS was 132 minutes (95% CI, 122 to 142), while that of the RADUS group was 177 minutes (95% CI 170 to 184) with a difference of 45 minutes (95% CI 32 to 56; p<0.001). The study is limited by its single-center, retrospective design and by lack of blinding of data abstractors. Conclusion: Pregnant emergency department patients diagnosed with an uncomplicated IUP between 8-weeks and 20-weeks' gestation had statistically significant reduction in time to diagnosis and disposition from the ED if assessed with POCUS as compared to RADUS.
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Affiliation(s)
- Sara Urquhart
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
| | - Kendall Stevens
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
| | - Mariah Barnes
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
| | - Matthew Flannigan
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
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Kodaira Y, Pisani L, Boyle S, Olumide S, Orsi M, Adeniji AO, Pisani E, Zanette M, Putoto G, Koroma MM. Reliability of ultrasound findings acquired with handheld apparatuses to inform urgent obstetric diagnosis in a high-volume resource-limited setting. Int J Gynaecol Obstet 2020; 153:280-286. [PMID: 33159814 DOI: 10.1002/ijgo.13475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 08/03/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate the reliability of obstetric handheld smartphone-based point-of-care ultrasound (POCUS) in a resource-limited high-volume setting. METHODS A single-center prospective observational study among women requiring urgent diagnosis and admitted to a maternity referral hospital in Sierra Leone from March to April 2019. Pre-specified ultrasound findings were obtained with a handheld POCUS device; a comprehensive ultrasound examination was then performed by an experienced operator using conventional full-feature apparatus. Agreement was assessed by diagnostic accuracy and Cohen κ-statistics. RESULTS Overall, there were 307 participants. The mean aggregated diagnostic accuracy was 95.5% (κ-statistic, 0.90; 95% confidence interval [CI], 0.89-0.93; P < 0.001). Highest accuracy was reported for detecting free fluid collection in the abdominal cavity (100%; κ-statistic, 1.00; 95% CI, 1.00-1.00; P < 0.001). Ultrasound findings obtained with the handheld device for intrauterine pregnancy, fetal heartbeat, cephalic presentation, multifetal pregnancy, and assessment of gestational age based on bi-parietal diameter were highly reliable (agreement, >90%; κ-statistic, >0.80). Detection of low-lying placenta or placenta previa was the least reliable (κ-statistic, 0.53; 95% CI, 0.13-0.93; P < 0.001). CONCLUSION Handheld POCUS findings were found to be reliable for detecting pre-specified urgent obstetric findings in a high-volume resource-limited referral hospital.
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Affiliation(s)
- Yuichi Kodaira
- Department of Obstetrics and Gynecology, Funabashi Central Hospital, Funabashi, Japan.,Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Sonia Boyle
- Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - Salawu Olumide
- Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - Michele Orsi
- Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | | | - Enzo Pisani
- Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy.,Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - Marianna Zanette
- Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy.,Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - Giovanni Putoto
- Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy
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Pek JH, Simpson WL, Owen J, Nelson B. Live Twin Ectopic Pregnancy. J Emerg Med 2020; 59:e77-e79. [PMID: 32451187 DOI: 10.1016/j.jemermed.2020.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York
| | - William L Simpson
- Department of Radiology, The Mount Sinai Hospital, New York, New York
| | - Jane Owen
- Department of Obstetrics and Gynecology, The Mount Sinai Hospital, New York, New York
| | - Bret Nelson
- Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York
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15
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Services for emergency department patients experiencing early pregnancy complications: A survey of Ontario hospitals. CAN J EMERG MED 2019; 21:653-658. [DOI: 10.1017/cem.2019.344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectivesWomen experiencing complications of early pregnancy frequently seek care in the emergency department (ED), because most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals.MethodsThe emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology.ResultsRespondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported that they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications, including pregnancy of unknown location and threatened abortion. Respondents also stated that a radiologist-interpreted ultrasound was available to only 22 (34.9%) of hospital sites for 24 hours, 7 days per week for women with early pregnancy complications.ConclusionsThe results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.
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Beals T, Naraghi L, Grossestreuer A, Schafer J, Balk D, Hoffmann B. Point of care ultrasound is associated with decreased ED length of stay for symptomatic early pregnancy. Am J Emerg Med 2019; 37:1165-1168. [PMID: 30948256 DOI: 10.1016/j.ajem.2019.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Emergency physicians (EP) can accurately rule out ectopic pregnancy with pelvic point of care ultrasound (PPOCUS). Multiple studies have suggested that PPOCUS may decrease length of stay (LOS) for emergency department (ED) patients presenting with early symptomatic pregnancy compared to comprehensive ultrasound (CUS). This systematic review and meta-analysis examines the association between the use of PPOCUS vs CUS and ED LOS. METHODS A systematic review of the literature was performed. Patients with symptomatic early pregnancy receiving EP-performed PPOCUS were compared to patients receiving CUS without PPOCUS. Keywords and search terms were generated for PPOCUS, ED LOS and CUS. Two independent reviewers screened abstracts for inclusion. A third reviewer was used when conflicts arose to gain consensus. Formal bias assessment was performed on included studies. Meta-analysis was carried out, pooling the mean differences between studies using a random-effects model. RESULTS 2980 initial articles were screened, 32 articles underwent detailed review, 8 underwent bias assessment, and 6 were included in the final meta-analysis. There were 836 patients in the study group and 1514 in the control group. All studies showed a decreased LOS in the PPOCUS group with a mean decrease of 73.8 min (95% CI 49.1, 98.6). Two studies not included in the meta-analysis also showed significantly decreased LOS with PPOCUS. CONCLUSION Use of PPOCUS in the evaluation of patients with symptomatic early pregnancy is associated with decreased LOS in patients ultimately diagnosed with intrauterine pregnancy. This review suggests that this finding is generalizable to a variety of practice settings.
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Affiliation(s)
- Tyler Beals
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Leily Naraghi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Anne Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Jesse Schafer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Dan Balk
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Beatrice Hoffmann
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
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17
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Panebianco N, Shofer F, O'Conor K, Wihbey T, Mulugeta L, Baston CM, Suzuki E, Alghamdi A, Dean A. Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1965-1975. [PMID: 29380893 DOI: 10.1002/jum.14546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/10/2017] [Accepted: 11/04/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Emergency department (ED) transvaginal ultrasound (US) is underused in clinical practice. This study assessed pregnant women's perceptions of ED transvaginal US in terms of pain, embarrassment, anxiety, and willingness to receive the procedure. Secondary variables include physicians' perceptions of patients' experiences. METHODS Women undergoing US examinations for complications of first-trimester pregnancy were prospectively surveyed before any US and after ED and/or radiology transvaginal US. Patients' and physicians' assessments of pain, embarrassment, and anxiety were measured with visual analog scales (0-100). RESULTS A total of 398 women were enrolled. In the pre-US survey, the median anxiety score was 14 (interquartile range, 3-51), and 96% of patients were willing to have an ED transvaginal US if necessary. Of those who had ED transvaginal US, 96% would agree to have another examination. Patients reported minimal pain/embarrassment, and there was no difference if performed in the ED versus radiology (median pain, 11.5 versus 13; P = .433; median embarrassment, 7 versus 4; P = .345). Of the 48 who had both ED and radiology transvaginal US, 85% thought the ED transvaginal US was worthwhile. Physicians accurately assessed patient's embarrassment and pain (mean differences, 3.5 and -1.9, respectively; P > .25 for both); however, they overestimated them relative to the pelvic examination (mean difference for embarrassment, 12.8; P < .0001; pain, 8.0; P = .01). CONCLUSIONS Pregnant ED patients report low levels of anxiety, pain, and embarrassment, and after ED transvaginal US, 96% would agree to have the examination again. There is no difference in pain/embarrassment between ED and radiology transvaginal US. Emergency department physicians accurately assessed patients' pain and embarrassment with ED transvaginal US but overestimated them compared to the pelvic examination.
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Affiliation(s)
- Nova Panebianco
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Frances Shofer
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Katie O'Conor
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Tristan Wihbey
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Lakeisha Mulugeta
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Cameron M Baston
- the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Evan Suzuki
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Adel Alghamdi
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Anthony Dean
- Department of Emergency Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
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18
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A Review of the Management of Loss of Pregnancy in the Emergency Department. J Emerg Nurs 2018; 44:146-155. [DOI: 10.1016/j.jen.2017.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 10/29/2017] [Accepted: 11/04/2017] [Indexed: 12/30/2022]
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Stachura M, Landes M, Aklilu F, Venugopal R, Hunchak C, Berman S, Maskalyk J, Sarrazin J, Kebede T, Azazh A. Evaluation of a point-of-care ultrasound scan list in a resource-limited emergency centre in Addis Ababa Ethiopia. Afr J Emerg Med 2017; 7:118-123. [PMID: 30456122 PMCID: PMC6234161 DOI: 10.1016/j.afjem.2017.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/03/2017] [Accepted: 04/21/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Emergency centres (EC) in low- and middle-income countries often have limited diagnostic imaging capabilities. Point-of-care ultrasound (POCUS) is used in high-income countries to diagnose and guide treatment of life-threatening conditions. This study aims to identify high impact POCUS scans most relevant to practice in an Ethiopian EC. METHODS A prospective observational study where patients presenting to Tikur Anbessa Specialized Hospital EC in Addis Ababa were eligible for inclusion. Physicians referred patients with a clinical indication for POCUS from a pre-determined 15-scan list. Scans were performed and interpreted, at the bedside, by qualified emergency physicians with POCUS training. RESULTS A convenience sample of 118 patients with clinical indications for POCUS was enrolled. The mean age was 35 years and 42% were female. In total, 338 scans were performed for 145 indications in 118 patients. The most common scans performed were pericardial (n = 78; 23%), abdominal free fluid (n = 73; 22%), pleural effusion/haemothorax (n = 51; 15%), inferior vena cava (n = 43; 13%), pneumothorax (n = 38; 11%), and global cardiac activity (n = 25; 7%). One hundred and twelve (95%) POCUS scans provided clinically useful information. In 53 (45%) patients, ultrasound findings changed patient management plans by altering the working diagnosis (n = 32; 27%), resulting in a new treatment intervention (n = 28; 24%), resulting in a procedure/surgical intervention (n = 17; 14%) leading to consultation with a specialist (n = 16; 14%), and/or changing a disposition decision (n = 9; 8%). DISCUSSION In this urban, low-resource, academic EC in Ethiopia, POCUS provided clinically relevant information for patient management, particularly for polytrauma, undifferentiated shock and undifferentiated dyspnea. Results have subsequently been used to develop a locally relevant emergency department ultrasound curriculum for Ethiopia's first emergency medicine residency program.
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Affiliation(s)
- Maja Stachura
- Lion’s Gate Hospital, North Vancouver, BC, Canada
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
| | - Megan Landes
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
- University Health Network, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Fasika Aklilu
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- The Scarborough Hospital, Scarborough, ON, Canada
| | - Raghu Venugopal
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
- University Health Network, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cheryl Hunchak
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz-Reisman Emergency Medicine Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Sara Berman
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
- University Health Network, Toronto, ON, Canada
| | - James Maskalyk
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, Canada
- St. Michaels Hospital, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Josee Sarrazin
- Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | | | - Aklilu Azazh
- Addis Ababa University, Addis Ababa, Ethiopia
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine, University of Toronto, Canada
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Allen B, Carrol LV, Hughes DR, Hemingway J, Duszak R, Rosenkrantz AB. Downstream Imaging Utilization After Emergency Department Ultrasound Interpreted by Radiologists Versus Nonradiologists: A Medicare Claims–Based Study. J Am Coll Radiol 2017; 14:475-481. [DOI: 10.1016/j.jacr.2016.12.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 12/16/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
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21
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Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2017; 69:241-250.e20. [DOI: 10.1016/j.annemergmed.2016.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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Wilson SP, Connolly K, Lahham S, Subeh M, Fischetti C, Chiem A, Aspen A, Anderson C, Fox JC. Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay. World J Emerg Med 2016; 7:178-82. [PMID: 27547276 DOI: 10.5847/wjem.j.1920-8642.2016.03.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS). METHODS This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment. RESULTS We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01). CONCLUSION In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.
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Affiliation(s)
- Sean P Wilson
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - Kiah Connolly
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - Shadi Lahham
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - Mohammad Subeh
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - Chanel Fischetti
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - Alan Chiem
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California 90095, USA
| | - Ariel Aspen
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - Craig Anderson
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
| | - John C Fox
- Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA
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Hall JW, Denne N, Minardi JJ, Williams D, Balcik BJ. Check the Head: Emergency Ultrasound Diagnosis of Fetal Anencephaly. West J Emerg Med 2016; 17:460-3. [PMID: 27429697 PMCID: PMC4944803 DOI: 10.5811/westjem.2016.5.30326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/04/2016] [Accepted: 05/11/2016] [Indexed: 11/20/2022] Open
Abstract
Background Early pregnancy complaints in emergency medicine are common. Emergency physicians (EP) increasingly employ ultrasound (US) in the evaluation of these complaints. As a result, it is likely that rare and important diagnoses will be encountered. We report a case of fetal anencephaly diagnosed by bedside emergency US in a patient presenting with first-trimester vaginal bleeding. Case Report A 33-year-old patient at 10 weeks gestation presented with vaginal bleeding. After initial history and physical examination, a bedside US was performed. The EP noted the abnormal appearance of the fetal cranium and anencephaly was suspected. This finding was confirmed by a consultative high-resolution fetal US. Making the diagnosis at the point of care allowed earlier detection and more comprehensive maternal counseling about pregnancy options. This particular patient underwent elective abortion which was able to be performed at an earlier gestation, thus decreasing maternal risk. If this diagnosis would not have been recognized by the EP at the point of care, it may not have been diagnosed until the second trimester, and lower-risk maternal options would not have been available.
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Affiliation(s)
- John W Hall
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - Nicolas Denne
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - Joseph J Minardi
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - Debra Williams
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - B J Balcik
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
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Marin JR, Lewiss RE. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med 2016; 65:472-8. [PMID: 25805037 DOI: 10.1016/j.annemergmed.2015.01.028] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 01/10/2023]
Abstract
Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.
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Chiem AT, Soucy Z, Dinh VA, Chilstrom M, Gharahbaghian L, Shah V, Medak A, Nagdev A, Jang T, Stark E, Hussain A, Lobo V, Pera A, Fox JC. Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:221-233. [PMID: 26764278 DOI: 10.7863/ultra.15.05006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/26/2015] [Indexed: 06/05/2023]
Abstract
Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.
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Affiliation(s)
- Alan T Chiem
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.).
| | - Zachary Soucy
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Vi Am Dinh
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Mikaela Chilstrom
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Laleh Gharahbaghian
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Virag Shah
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Anthony Medak
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Arun Nagdev
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Timothy Jang
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Elena Stark
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Aliasgher Hussain
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Viveta Lobo
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - Abraham Pera
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
| | - J Christian Fox
- Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.)
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Cox C, MacDonald S, Henneberry R, Atkinson PR. My patient has abdominal and flank pain: Identifying renal causes. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2015; 23:242-50. [PMID: 27433264 DOI: 10.1177/1742271x15601617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/14/2015] [Indexed: 12/18/2022]
Abstract
Acute flank and abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound (PoCUS), emergency physicians have an added tool to help identify renal problems as a cause of a patient's pain. PoCUS for hydronephrosis has a sensitivity of 72-83.3% and a varying specificity, similar to radiology-performed ultrasonography. In addition to assessment for hydronephrosis, PoCUS can help emergency physicians to exclude other serious causes of flank and abdominal pain such as the presence of an abdominal aortic aneurysm, or free fluid in the intraperitoneal space, which could represent hemorrhage. Use of PoCUS for the assessment of flank pain has resulted in more rapid diagnosis, decreased use of computed tomography, and shorter emergency department length of stay.
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Affiliation(s)
- Christopher Cox
- Dalhousie University-Emergency Medicine, Halifax, Nova Scotia, Canada
| | - Scott MacDonald
- Dalhousie University-Emergency Medicine, Halifax, Nova Scotia, Canada
| | - Ryan Henneberry
- Dalhousie University-Emergency Medicine, Halifax, Nova Scotia, Canada
| | - Paul R Atkinson
- Dalhousie University-Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
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Popowski T, Huchon C, Fathallah K, Falissard B, Dumont A, Fauconnier A. Impact of accreditation training for residents on sonographic quality in gynecologic emergencies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:829-835. [PMID: 25911716 DOI: 10.7863/ultra.34.5.829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the impact of an educational intervention based on an original accreditation training program on the quality of emergency sonography performed by obstetrics and gynecology (Ob/Gyn) residents. METHODS We conducted a prospective before-after study on residents who performed bedside standardized sonographic examinations as first-line investigations in patients seen at our gynecologic emergency department. In both periods, the residents followed a 1-hour class taught by a board-certified Ob/Gyn sonography expert (opinion leader) and received a written standardized imaging protocol. An accreditation training process was implemented for the new residents at the beginning of the second period: 5 complete sonographic examinations were required for each resident, and facilitated feedback from the opinion leader was performed using a dedicated sonographic quality score. During both periods, all consecutive sonograms were collected and stored. The primary outcome was the sonographic quality score. A mixed model for repeated measures was used to compare scores in both periods from 20 consecutive sonographic examinations performed by 5 residents who were different in each period. RESULTS The mixed model analysis showed an increase in quality scores in the post-accreditation training compared to the pre-accreditation training period (estimated coefficient ± SD, 4.13 ± 0.51; t = 8.16). The sonographic examination order also had a significant effect in both periods (estimated coefficient ± SD, 0.11 ± 0.03; t = 3.99). CONCLUSIONS An accreditation training process including facilitated feedback from a local opinion leader improved the quality of sonographic examinations performed by Ob/Gyn residents in women presenting to a gynecologic emergency department.
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Affiliation(s)
- Thomas Popowski
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France (T.P., C.H., K.F., A.F.); University Versailles Saint-Quentin-en-Yvelines, Versailles, France (T.P., C.H., K.F., A.F.); Research Unit EA 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles Saint-Quentin, Montigny-le-Bretonneux, France (T.P., C.H., A.D., A.F.); Institut National de la Santé et de la Recherche Médicale Unité 669, University Paris-Sud and University Paris-Descartes, Paris, France (B.F.); and Unité Mixte de Recherche 216, Institut de Recherche Pour le Développement Paris Descartes, Université Paris Descartes, Paris, France (A.D.)
| | - Cyrille Huchon
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France (T.P., C.H., K.F., A.F.); University Versailles Saint-Quentin-en-Yvelines, Versailles, France (T.P., C.H., K.F., A.F.); Research Unit EA 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles Saint-Quentin, Montigny-le-Bretonneux, France (T.P., C.H., A.D., A.F.); Institut National de la Santé et de la Recherche Médicale Unité 669, University Paris-Sud and University Paris-Descartes, Paris, France (B.F.); and Unité Mixte de Recherche 216, Institut de Recherche Pour le Développement Paris Descartes, Université Paris Descartes, Paris, France (A.D.)
| | - Khadija Fathallah
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France (T.P., C.H., K.F., A.F.); University Versailles Saint-Quentin-en-Yvelines, Versailles, France (T.P., C.H., K.F., A.F.); Research Unit EA 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles Saint-Quentin, Montigny-le-Bretonneux, France (T.P., C.H., A.D., A.F.); Institut National de la Santé et de la Recherche Médicale Unité 669, University Paris-Sud and University Paris-Descartes, Paris, France (B.F.); and Unité Mixte de Recherche 216, Institut de Recherche Pour le Développement Paris Descartes, Université Paris Descartes, Paris, France (A.D.)
| | - Bruno Falissard
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France (T.P., C.H., K.F., A.F.); University Versailles Saint-Quentin-en-Yvelines, Versailles, France (T.P., C.H., K.F., A.F.); Research Unit EA 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles Saint-Quentin, Montigny-le-Bretonneux, France (T.P., C.H., A.D., A.F.); Institut National de la Santé et de la Recherche Médicale Unité 669, University Paris-Sud and University Paris-Descartes, Paris, France (B.F.); and Unité Mixte de Recherche 216, Institut de Recherche Pour le Développement Paris Descartes, Université Paris Descartes, Paris, France (A.D.)
| | - Alexandre Dumont
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France (T.P., C.H., K.F., A.F.); University Versailles Saint-Quentin-en-Yvelines, Versailles, France (T.P., C.H., K.F., A.F.); Research Unit EA 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles Saint-Quentin, Montigny-le-Bretonneux, France (T.P., C.H., A.D., A.F.); Institut National de la Santé et de la Recherche Médicale Unité 669, University Paris-Sud and University Paris-Descartes, Paris, France (B.F.); and Unité Mixte de Recherche 216, Institut de Recherche Pour le Développement Paris Descartes, Université Paris Descartes, Paris, France (A.D.)
| | - Arnaud Fauconnier
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France (T.P., C.H., K.F., A.F.); University Versailles Saint-Quentin-en-Yvelines, Versailles, France (T.P., C.H., K.F., A.F.); Research Unit EA 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles Saint-Quentin, Montigny-le-Bretonneux, France (T.P., C.H., A.D., A.F.); Institut National de la Santé et de la Recherche Médicale Unité 669, University Paris-Sud and University Paris-Descartes, Paris, France (B.F.); and Unité Mixte de Recherche 216, Institut de Recherche Pour le Développement Paris Descartes, Université Paris Descartes, Paris, France (A.D.)
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Abstract
Emergency physicians have used point-of-care ultrasonography since the 1990 s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.
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Polena V, Huchon C, Varas Ramos C, Rouzier R, Dumont A, Fauconnier A. Non-invasive tools for the diagnosis of potentially life-threatening gynaecological emergencies: a systematic review. PLoS One 2015; 10:e0114189. [PMID: 25723401 PMCID: PMC4344336 DOI: 10.1371/journal.pone.0114189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/05/2014] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To identify non-invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy. METHODS MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 × 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility ≥ 95% and LR-≤ 0.25, or Specificity ≥ 90% and LR+ ≥ 4. RESULTS We identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure<110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration <10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs. CONCLUSION This systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.
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Affiliation(s)
- Viola Polena
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France
| | - Cyrille Huchon
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France; Department of Gynaecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, 78103, Poissy, France
| | - Catalina Varas Ramos
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France
| | - Roman Rouzier
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, 35 rue Dailly, 92210, Saint-Cloud, France
| | - Alexandre Dumont
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France; Institut de Recherche pour le Développement, UMR 216, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Arnaud Fauconnier
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France; Department of Gynaecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, 78103, Poissy, France
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National specialty trends in billable diagnostic ultrasound in the ED: analysis of Medicare claims data. Am J Emerg Med 2014; 32:1470-5. [DOI: 10.1016/j.ajem.2014.09.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/28/2014] [Accepted: 09/01/2014] [Indexed: 11/23/2022] Open
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Chiem AT, Chan CHY, Ibrahim DY, Anderson CL, Wu DS, Gilani CJ, Mancia ZJ, Fox JC. Pelvic ultrasonography and length of stay in the ED: an observational study. Am J Emerg Med 2014; 32:1464-9. [DOI: 10.1016/j.ajem.2014.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 08/29/2014] [Accepted: 09/01/2014] [Indexed: 11/16/2022] Open
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Evaluation of waiting times and sonographic findings in patients with first trimester vaginal bleeding at the university hospital of the west indies. Can emergency department ultrasound make a difference? W INDIAN MED J 2014; 63:247-51. [PMID: 25314282 DOI: 10.7727/wimj.2013.230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/26/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pregnant female patients with vaginal bleeding in the first trimester are seen commonly in the Emergency Department (ED) at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. The protocol for the management of these patients requires that they have a sonographic evaluation performed for the purpose of localizing the pregnancy where possible, to assist with determining the risk for an ectopic pregnancy. The ultrasound examinations are performed in the radiology department. OBJECTIVE This retrospective study was conducted to evaluate how long patients wait for a pelvic ultrasound. We also sought to establish how many patients had ultrasound findings that would have allowed safe discharge home. METHODS The records of 150 patients seen in the six-month period from January 1 to July 30, 2008 were examined. Data were extracted pertaining to age, time to see an emergency room doctor, time taken for ultrasound examination to be obtained from the radiology department and the ultrasound findings. RESULT Fifty-four per cent presented to the Emergency Department with a complaint of vaginal bleeding and abdominal pain, 29% with bleeding only, 16% with abdominal pain only and one with syncope. One hundred and sixteen of the patients enrolled had an ultrasound performed at UHWI. The average waiting time for an ultrasound was 3.8 ± 2.5 hours. The majority (66/116) of the patients had an intrauterine pregnancy (IUP) demonstrated on ultrasound. Twenty-nine had no IUP, free fluid or adnexal mass. These 95 patients would likely have been discharged home. Ten patients had an adnexal mass with or without free fluid, and ten had free fluid only on ultrasound. One patient was found to have a definite ectopic pregnancy. These 21 patients would have been referred for evaluation by the obstetrician on call for further management. CONCLUSION The majority of patients had sonographic findings that would have allowed safe and timely discharge from the Emergency Department had ultrasound been available at the point of care.
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Clinical factors affecting the accuracy of ultrasonography in symptomatic first-trimester pregnancy. Obstet Gynecol 2014; 117:299-306. [PMID: 21252743 DOI: 10.1097/aog.0b013e3182050ed0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate factors associated with accuracy of initial ultrasonography in patients with symptomatic first-trimester pregnancy. METHODS Ultrasound diagnosis in the emergency department was compared with an ultimate clinical diagnosis in women in need of a gynecologic consult. The sensitivity, specificity, positive predictive values, and accuracy of the initial ultrasound impression were calculated and stratified by criteria of diagnosis, serum human chorionic gonadotropin (hCG) levels, pain, and bleeding. RESULTS Eighteen hundred eighty women were evaluated. Overall accuracy of initial ultrasound diagnosis was 78%. A probable ultrasound diagnosis of ectopic pregnancy (adnexal mass without the presence of a yolk sac or embryo) resulted in a higher sensitivity (42.1% compared with 13.2%: P<.001) but a lower positive predictive value (82.7% compared with 98%: P<.01) compared with a definite diagnosis. A probable ultrasound diagnosis of intrauterine pregnancy (double decidual sign without yolk sac or embryo) resulted in a higher sensitivity (36.0% compared with 4.0%; P<.001) and lower positive predictive value (58.8% compared with 87.0%; P>.001) compared with a definite diagnosis. The sensitivity (34.3% compared with 75.9%; P<.01) and positive predictive value (80.4% compared with 91.5%; P=.02) were lower for diagnosis of ectopic pregnancy when serum hCG level was less than 2,000 milli-international units/mL. Ultrasonography was less accurate when bleeding was the chief complaint (72.7% compared with 84.8% P<.006) but not substantially altered by pain as a chief complaint (78.0 compared with 77.8% P>.99). CONCLUSION A substantial number of misdiagnoses can occur when initial ultrasound diagnosis of intrauterine pregnancy or ectopic pregnancy is made without evidence of a yolk sac or embryo, when hCG values are low, or when a patient has significant bleeding. LEVEL OF EVIDENCE II.
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Abstract
There has been an increase in the availability and use of bedside ultrasonography in the acute care setting. The approach to the female patient with a pelvic complaint (including pelvic pain, vaginal bleeding, vaginal bleeding in pregnancy, or vaginal discharge) has been transformed by the use of bedside ultrasonography. Providers familiar with the transabdominal and transvaginal (endocavitary) ultrasonographic examination can obtain more accurate information faster, thereby improving time to consultation or discharge and achieving an increase in patient satisfaction. This article reviews the use of ultrasonography for evaluation of obstetric and gynecologic complaints in the acute care setting.
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Pitfalls in emergency department focused bedside sonography of first trimester pregnancy. Emerg Med Int 2013; 2013:982318. [PMID: 23997954 PMCID: PMC3753733 DOI: 10.1155/2013/982318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/18/2013] [Indexed: 12/27/2022] Open
Abstract
Background. Bedside sonography performed by emergency physicians is frequently utilized for real-time clinical decision-making in the emergency department (ED) setting. This includes the sonographic evaluation of pain or bleeding in the first trimester of pregnancy. The detection of intrauterine pregnancy (IUP) or life-threatening conditions, including ectopic pregnancy, is critical. Objectives. This paper will review several important pearls and avoidable pitfalls of this diagnostic modality by brief presentation of illustrative cases followed by discussion of key principles. Case Reports. Three patients evaluated in the ED for bleeding or pain occurring during the first trimester of pregnancy will be presented. Conclusions. When conducting emergency bedside ultrasound for the evaluation of first trimester pregnancy, it is important to avoid common pitfalls that can place your patient at risk.
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Ma STC, Yeung AC, Chan PKS, Graham CA. Transvaginal ultrasound probe contamination by the human papillomavirus in the emergency department. Emerg Med J 2012; 30:472-5. [PMID: 22761513 DOI: 10.1136/emermed-2012-201407] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine if human papillomavirus (HPV) DNA can be detected on the transvaginal sonography (TVS) probe in the emergency department (ED) and whether the current barrier method plus disinfection can prevent HPV contamination of the TVS probe. METHODS This was a two-part cross-sectional study. In the first part, surveillance samples were taken from the TVS probe for HPV DNA detection daily for 2 months. In the second part, patients presenting with early pregnancy complications were identified in the ED and high vaginal swabs were taken for HPV DNA testing. Several probe swabs were taken to identify if contamination was possible in cases where the procedure was done on an HPV carrier. RESULTS A total of 120 surveillance samples were obtained, nine of which (7.5%) tested positive for HPV DNA. In the second part, 76 women were recruited, of whom 14 (18.4%) were HPV carriers. After the procedure and disinfection of the probe, three out of the 14 probe samples (21%) were HPV DNA positive. CONCLUSIONS HPV is commonly encountered in the ED and contamination of the TVS probe with HPV is possible. Although it is difficult to prove the viability and infectivity of the virus, vigilant infection control measures should be maintained.
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Crilly J, Wendt K, Beatson N. A structure and process evaluation of an Early Pregnancy Assessment Clinic (EPAC) in one Australian Emergency Department: Part 1. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.aenj.2012.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prospective outcomes of pregnant ED patients with documented fetal cardiac activity on ultrasound. Am J Emerg Med 2012; 30:472-5. [DOI: 10.1016/j.ajem.2010.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 12/14/2010] [Accepted: 12/15/2010] [Indexed: 11/17/2022] Open
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Dawson M, Mallin M. Emergency department ultrasound: a resident's perspective. Acad Emerg Med 2011; 18:307-8. [PMID: 21401794 DOI: 10.1111/j.1553-2712.2010.00974.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Matthew Dawson
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
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Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med 2011; 58:12-20. [PMID: 21310509 DOI: 10.1016/j.annemergmed.2010.12.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 10/26/2010] [Accepted: 11/15/2010] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE We seek to assess the performance of the β human chorionic gonadotropin (β-hCG) "discriminatory zone" when using bedside pelvic ultrasonography in the evaluation of symptomatic pregnant emergency department (ED) patients. METHODS This was a cross-sectional study of bedside pelvic ultrasonography performed on consecutive pregnant patients in the first trimester who presented to the ED with abdominal pain or vaginal bleeding. Patients received pelvic ultrasonography, serum β-hCG testing, and blinded formal radiologic ultrasonography. All patients were followed for 8 weeks to determine outcomes. The sensitivity and specificity of a discriminatory β-hCG level of 3,000 mIU/mL for the diagnosis of ectopic pregnancy were calculated for patients without an intrauterine pregnancy visualized by bedside ultrasonography. RESULTS Thirty-six faculty physicians performed bedside pelvic ultrasonography on 256 patients. There were 161 cases with a confirmed visualizable intrauterine pregnancy and 29 ectopic pregnancies. Bedside ultrasonography identified 115 intrauterine pregnancies. The range of β-hCG for cases of confirmed visualizable intrauterine pregnancy with a nondiagnostic bedside ultrasonography was 15 mIU/mL to 123,368 mIU/mL (median 6,633; interquartile range 1,551 to 32,699). For patients with nondiagnostic bedside ultrasonography, using a discriminatory β-hCG level of 3,000 mIU/mL to further assess for ectopic pregnancy showed sensitivity of 35% (95% confidence interval [CI] 18% to 54%) and specificity of 58% (95% CI 48% to 67%). Finally, the overall sensitivity of bedside pelvic ultrasonography for the detection of intrauterine pregnancy was 71% (95% CI 63% to 78%), and the specificity was 99% (95% CI 94% to 100%). CONCLUSION When bedside pelvic ultrasonography does not demonstrate an intrauterine pregnancy, serum β-hCG level is not helpful in differentiating intrauterine from ectopic pregnancy in symptomatic ED patients.
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Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G, Goldstein R, Kohn MA. Emergency Physician Ultrasonography for Evaluating Patients at Risk for Ectopic Pregnancy: A Meta-Analysis. Ann Emerg Med 2010; 56:674-83. [DOI: 10.1016/j.annemergmed.2010.06.563] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 06/03/2010] [Accepted: 06/28/2010] [Indexed: 12/27/2022]
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An early pregnancy assessment clinic combined with emergency physician ultrasound reduces admissions. Emerg Med Australas 2010; 22:194. [DOI: 10.1111/j.1742-6723.2010.01278.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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