1
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Rola P, Haycock K, Spiegel R. What every intensivist should know about the IVC. J Crit Care 2024; 80:154455. [PMID: 37945462 DOI: 10.1016/j.jcrc.2023.154455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 11/12/2023]
Abstract
Assessment of the IVC by point-of-care ultrasound in the context of resuscitation has been a controversial topic in the last decades. Most of the focus had been on its use as a surrogate marker for fluid responsiveness, with results being equivocal. We review its important anatomical aspects as well as the physiological rationale behind ultrasound assessment and propose a new way to do so, as well as explain its central role in the concept of fluid tolerance.
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Affiliation(s)
- Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, CEMTL, Montreal, Canada.
| | - Korbin Haycock
- Emergency Department, Riverside University Health Systems, Moreno Valley, CA, Loma Linda University Medical Center, Loma Linda CA, and Desert Regional Medical Center, Palm Springs, CA, United States of America
| | - Rory Spiegel
- Departments of Critical Care and Emergency Medicine, Medstar Washington Hospital Center, Washington, DC, United States of America
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2
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Talmud J, Spiegel R. Uncertainty in the Management of Uncertain Head Trauma: January 2024 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2024; 83:81-82. [PMID: 38105106 DOI: 10.1016/j.annemergmed.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- Jonathan Talmud
- Department of Emergency Medicine, ChristianaCare Hospital System, Newark, DE
| | - Rory Spiegel
- Departments of Emergency Medicine and Critical Care, Medstar Washington Hospital Center, Washington, DC
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3
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Argaiz ER, Romero-Gonzalez G, Rola P, Spiegel R, Haycock KH, Koratala A. Bedside Ultrasound in the Management of Cardiorenal Syndromes: An Updated Review. Cardiorenal Med 2023; 13:372-384. [PMID: 37980889 DOI: 10.1159/000534976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/17/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Cardiorenal syndromes constitute a spectrum of disorders involving heart and kidney dysfunction modulated by a complex interplay of neurohormonal, inflammatory, and hemodynamic derangements. The management of such patients often poses a diagnostic and therapeutic challenge to physicians owing to gaps in understanding of pathophysiology, paucity of objective bedside diagnostic tools, and individual biases. SUMMARY In this narrative review, we discuss the role of clinician who performed bedside ultrasound in the management of patients with cardiorenal syndromes. Novel sonographic applications such as venous excess ultrasound score (VExUS) are reviewed in addition to the lung and focused cardiac ultrasound. Further, underrecognized causes of heart failure such as high-flow arteriovenous fistula are discussed. KEY MESSAGE Bedside ultrasound allows a comprehensive hemodynamic characterization of cardiorenal syndromes.
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Affiliation(s)
- Eduardo R Argaiz
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico,
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico City, Mexico,
| | - Gregorio Romero-Gonzalez
- Nephrology Department, University Hospital Germans Trias i Pujol, Badalona, Spain
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Philippe Rola
- Intensive Care Unit, Hopital Santa Cabrini Ospedale CEMTL, Montreal, Québec, Canada
| | - Rory Spiegel
- Department of Critical Care, Georgetown University Medstar Washington Hospital Center, Washington, District of Columbia, USA
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, California, USA
- Department of Emergency Medicine, Riverside University Health System, Moreno Valley, California, USA
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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4
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Bhardwaj V, Rola P, Denault A, Vikneswaran G, Spiegel R. Femoral vein pulsatility: a simple tool for venous congestion assessment. Ultrasound J 2023; 15:24. [PMID: 37165284 PMCID: PMC10172460 DOI: 10.1186/s13089-023-00321-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 04/10/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Femoral vein Doppler (FVD) is simpler than the VExUS score which is a multimodal scoring system based on combination of IVC diameter, hepatic venous Doppler, portal vein pulsatility and renal vein Doppler, may be useful in assessing right ventricular overload and signs of venous congestion. There is limited data on the relationship between FVD and VExUS score. RESULTS Adult post-cardiac surgery patients were assessed for venous congestion using the VExUS score and FVD. Agreement between VExUS and FVD was studied using Kappa test, sensitivity, specificity, PPV and NPV for VExUS and FVD was calculated keeping CVP as gold standard. In total, 107 patients were enrolled, with a mean age of 55.67 ± 12.76. The accuracy of VExUS and FVD for detecting venous congestion was 80.37 (95% CI of 71.5 to 87.4) and 74.7 (95% CI of 65.4 to 82.6), respectively. The level of agreement between FVD and VExUS was moderate (Kappa value of 0.62, P < 0.001) while the agreement between FVD and CVP was weak (Kappa value of 0.49, P < 0.001). CONCLUSION FVD has good accuracy for detecting venous congestion and shows moderate agreement with VExUS grading. With potentially easier physical accessibility and a shorter learning curve for novices, it may be a simple and valuable tool for assessing venous congestion.
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Affiliation(s)
- V Bhardwaj
- Critical Care, Narayana Health City, Bangalore, India.
| | - P Rola
- ICU Chief of Service, Santa Cabrini Hospital, Montreal, Canada
| | - A Denault
- Department of Anesthesiology, Monteal Heart Institute, Montreal, Canada
| | - G Vikneswaran
- Clinical Research, Narayana Health City, Bangalore, India
| | - R Spiegel
- Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC, USA
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5
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Affiliation(s)
- Ryan P Radecki
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Rory Spiegel
- Department of Emergency Medicine and the Department of Critical Care, MEDStar Washington Hospital, Washington, DC
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6
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Tavazzi G, Spiegel R, Rola P, Price S, Corradi F, Hockstein M. Multi-organ Evaluation of Perfusion and Congestion Using Ultrasound in Patients with Shock. Eur Heart J Acute Cardiovasc Care 2023; 12:344-352. [PMID: 36928914 DOI: 10.1093/ehjacc/zuad025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
There is increasing evidence on the role of ultrasound in the evaluation of multi-organ hypoperfusion and congestion in patients with cardiocirculatory shock both to identify the underlying pathophysiological mechanism, to drive and monitor the treatment. The cardiac and lung ultrasound are included as integrated multiparametric approach to the very early phase of patients with hemodynamic instability/ cardiogenic shock. Splanchnic ultrasound has been mainly applied in heart failure and predominant circulatory failure. Although poorly validated in the critically ill, many ultrasound parameters have a strong physiological background to support their use in the acute setting either those that apply for heart/lung and for splanchnic organ evaluation. This review summarizes the ultrasonographic parameters that have shown evidence in literature in the diagnostic/therapeutic pathway to define the congestion/perfusion profile of the organs that are involved in the pathophysiological cascade of cardiocirculatory shock.
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Affiliation(s)
- Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Intensive Care Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Rory Spiegel
- Department of Emergency Medicine, Department of Critical Care Medicine, Georgetown.,University School of Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010
| | - Philippe Rola
- Department of Adult Intensive Care, Royal Brompton Hospital, London, UK
| | - Susanna Price
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Corradi
- Santa Cabrini Hospital Ospedale, CEMTL, 5655 Rue Saint-Zotique E, Montreal, Quebec H1T 1P7
| | - Maxwell Hockstein
- Department of Emergency Medicine, Department of Critical Care Medicine, Georgetown.,University School of Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010
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7
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Breed R, Mazer-Amirshahi M, Spiegel R. Delayed QT Prolongation: Derivation of a Novel Risk Factor for Adverse Cardiovascular Events From Acute Drug Overdose: January 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 81:104-105. [PMID: 36543482 DOI: 10.1016/j.annemergmed.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Rebecca Breed
- Department of Emergency Medicine MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC
| | - Rory Spiegel
- Department of Emergency Medicine MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC
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Spiegel R, Hockstein M, Waters J, Goyal M. The Survival of the Surviving Sepsis Campaign. Med Clin North Am 2022; 106:1109-1117. [PMID: 36280336 DOI: 10.1016/j.mcna.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Even well-intentioned policies have great potential to cause harm. This statement is vividly illustrated by the influential, yet controversial, Surviving Sepsis Campaign guidelines and subsequent CMS benchmarks. Despite low-quality evidence, tendentious industry ties, and rebuke from the Infectious Disease Society of America (IDSA), these benchmarks continue to eschew therapy driven by clinician expertise and individual patient needs in favor of mandating an arbitrary, one-size-fits-all approach that suspends clinical judgment and promotes indiscriminate use of treatments that have the potential to cause great harm.
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Affiliation(s)
- Rory Spiegel
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA; Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA.
| | - Max Hockstein
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA; Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA
| | - Jessica Waters
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA
| | - Munish Goyal
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA
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9
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Ingham M, Blay JY, Baird J, D'Silva D, O'Keefe K, Kong R, Spiegel R, Wahba M, Weetall M. 1528TiP A phase II/III study evaluating the efficacy and safety of unesbulin in advanced leiomyosarcoma (SUNRISELMS). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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10
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Bhat RG, Nguyen MV, Blue O, Thai HT, Cacciapuoti M, Harvey H, Spiegel R. High sensitivity troponin - Six hours is the magic number. Am J Emerg Med 2022; 61:52-55. [PMID: 36041277 DOI: 10.1016/j.ajem.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND High sensitivity troponin assays have become widespread for emergency department evaluation of acute chest pain. We assessed if a high sensitivity troponin under the 99th percentile upper reference limit drawn at 6 h or greater from symptom onset could safely rule out acute coronary syndrome in patients who did not meet the rapid rule-out strategy. METHODS We conducted a multicenter retrospective study examining emergency department patients with chest pain who did not meet rapid-rule out criteria and were admitted for further evaluation. Among these admitted patients, we assessed the rate of clinically relevant adverse cardiac events (death, cardiac or respiratory arrest, STEMI, or life-threatening arrhythmia) and NSTEMI in patients with high sensitivity troponin less than the 99th percentile value obtained after at least 6 h of chest pain. RESULTS Out of 1187 patients admitted, we found 30 clinically relevant adverse cardiac events, all of which occurred in patients admitted for another compelling reason or ischemic ECG. 36 patients had an NSTEMI, of which 33 were identified with high sensitivity troponin greater than 99th percentile upper reference limit within 6 h of chest pain onset. This left 0 clinically relevant adverse cardiac events and 3 NSTEMI among the 429 patients with high sensitivity troponin less than the 99th percentile at 6 h and nonischemic ECG and no other compelling reason for admission. CONCLUSION This study assessed patients with chest pain with high sensitivity troponin values between 3 ng/L and the 99th percentile upper reference limit after 6 h of chest pain and found that they have a low rate of clinically relevant adverse cardiac events and NSTEMI.
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Affiliation(s)
- Rahul G Bhat
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America
| | - Michael V Nguyen
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America.
| | - Omoyemen Blue
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America
| | - Huyen-Trang Thai
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America
| | - Maria Cacciapuoti
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America; Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, DC, United States of America
| | - Hayley Harvey
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America
| | - Rory Spiegel
- Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America
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11
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Amirahmadi R, Sullivan S, Britton N, Siegel A, Spiegel R, Miceli J, Duong V, Sholander JT, Fontaine MJ, McCurdy MT. Lowering platelet count threshold to 10,000/µL for peripherally inserted central catheter placement safely conserves blood products. Ann Hematol 2022; 101:2045-2052. [PMID: 35763062 DOI: 10.1007/s00277-022-04891-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 06/05/2022] [Indexed: 11/26/2022]
Abstract
Despite the low risk of peripherally inserted central catheter (PICC) insertion-related bleeding, the practice of administering prophylactic platelets varies greatly. Limiting unnecessary blood product transfusions reduces transfusion-related adverse events, financial cost, and delays in care. We assessed the impact of lowering prophylactic platelet administration threshold on blood product utilization patterns and bleeding events. This quasi-experimental study was conducted in an urban academic tertiary medical center. The study population included patients with platelet counts ≥ 10,000/µL and < 50,000/µL undergoing PICC placement in 2018 and 2019 when the minimum platelet thresholds were 50,000/µL and 10,000/µL, respectively. The primary outcome was blood product utilization and the secondary outcome was PICC insertion-related bleeding complications. Thirty-five patients using the 10,000/µL (10 K) platelet threshold and 46 patients using the 50,000/µL (50 K) platelet threshold were enrolled. The 50 K group received more platelets before PICC insertion (0.870 ± 0.885 and 0.143 ± 0.430 pools of platelets-per-person, p < 0.001). No patients experienced clinically significant bleeding. Immediately following PICC insertion, minor bleeding occurred in five patients (two [4.3%] and three [8.6%] in the 50 K and 10 K groups, respectively). Bleeding rates between the two cohorts did not differ (p = 0.647). Lowering the minimum platelet threshold from 50,000/µL to 10,000/µL resulted in less prophylactic platelet and total blood product administration with no appreciable difference in PICC insertion-related bleeding.
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Affiliation(s)
- Roxana Amirahmadi
- Department of Internal Medicine, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Scott Sullivan
- Department of Critical Care Medicine, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Noel Britton
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ariel Siegel
- Department of Internal Medicine, New York University Langone Health, New York, NY, USA
| | - Rory Spiegel
- Departments of Critical Care and Emergency Medicine, Washington Hospital Center, Washington, DC, USA
| | | | - Vu Duong
- University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Sheth J, Spiegel R. Epistaxis, TX-Yah or TX-Nah? Ann Emerg Med 2021; 78:455-456. [PMID: 34420559 DOI: 10.1016/j.annemergmed.2021.07.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Waters J, Spiegel R, Hockstein M. Helmets Save Lives, or At Least Ventilator-Free Days: August 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:310-312. [PMID: 34325865 PMCID: PMC8313428 DOI: 10.1016/j.annemergmed.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Jessica Waters
- Department of Emergency Medicine, MedStar Washington Hospital Center
| | - Rory Spiegel
- Department of Emergency Medicine, MedStar Washington Hospital Center
| | - Max Hockstein
- Department of Emergency Medicine, MedStar Washington Hospital Center
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14
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Rola P, Miralles-Aguiar F, Argaiz E, Beaubien-Souligny W, Haycock K, Karimov T, Dinh VA, Spiegel R. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. Ultrasound J 2021; 13:32. [PMID: 34146184 PMCID: PMC8214649 DOI: 10.1186/s13089-021-00232-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/09/2021] [Indexed: 11/10/2022] Open
Abstract
The importance of functional right ventricular failure and resultant splanchnic venous congestion has long been under-appreciated and is difficult to assess by traditional physical examination and standard diagnostic imaging. The recent development of the venous excess ultrasound score (VExUS) and growth of point-of-care ultrasound in the last decade has made for a potentially very useful clinical tool. We review the rationale for its use in several pathologies and illustrate with several clinical cases where VExUS was pivotal in clinical management.
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Affiliation(s)
- Philippe Rola
- ICU Chief of Service, Santa Cabrini Hospital, Montreal, QC, Canada.
| | | | - Eduardo Argaiz
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador, Zubiran, Tlalpan, Mexico City, Mexico
| | | | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health Systems Medical Center, Moreno Valley, CA, USA
| | - Timur Karimov
- Intensive Care, Hôpital Honoré Mercier, Ste-Hyacinthe, QC, Canada
| | - Vi Am Dinh
- Department of Emergency Medicine and Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Rory Spiegel
- Department of Critical Care, Georgetown University Medstar Washington Hospital Center, Washington, DC, USA
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15
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Spiegel R, Teeter W, Sullivan S, Tupchong K, Mohammed N, Sutherland M, Leibner E, Rola P, Galvagno SM, Murthi SB. The use of venous Doppler to predict adverse kidney events in a general ICU cohort. Crit Care 2020; 24:615. [PMID: 33076961 PMCID: PMC7574322 DOI: 10.1186/s13054-020-03330-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/06/2020] [Indexed: 12/20/2022]
Abstract
Background Changes in Doppler flow patterns of hepatic veins (HV), portal vein (PV) and intra-renal veins (RV) reflect right atrial pressure and venous congestion; the feasibility of obtaining these assessments and the clinical relevance of the findings is unknown in a general ICU population. This study compares the morphology of HV, PV and RV waveform abnormalities in prediction of major adverse kidney events at 30 days (MAKE30) in critically ill patients. Study design and methods We conducted a prospective observational study enrolling adult patients within 24 h of admission to the ICU. Patients underwent an ultrasound evaluation of the HV, PV and RV. We compared the rate of MAKE-30 events in patients with and without venous flow abnormalities in the hepatic, portal and intra-renal veins. The HV was considered abnormal if S to D wave reversal was present. The PV was considered abnormal if the portal pulsatility index (PPI) was greater than 30%. We also examined PPI as a continuous variable to assess whether small changes in portal vein flow was a clinically important marker of venous congestion. Results From January 2019 to June 2019, we enrolled 114 patients. HV abnormalities demonstrate an odds ratio of 4.0 (95% CI 1.4–11.2). PV as a dichotomous outcome is associated with an increased odds ratio of MAKE-30 but fails to reach statistical significance (OR 2.3 95% CI 0.87–5.96), but when examined as a continuous variable it demonstrates an odds ratio of 1.03 (95% CI 1.00–1.06). RV Doppler flow abnormalities are not associated with an increase in the rate of MAKE-30 Interpretation Obtaining hepatic, portal and renal venous Doppler assessments in critically ill ICU patients are feasible. Abnormalities in hepatic and portal venous Doppler are associated with an increase in MAKE-30. Further research is needed to determine if venous Doppler assessments can be useful measures in assessing right-sided venous congestion in critically ill patients.
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Affiliation(s)
- Rory Spiegel
- Department of Critical Care, Georgetown University Medstar Washington Hospital Center, Washington, DC, USA.,Department of Emergency Medicine, Georgetown University Medstar Washington Hospital Center, Washington, DC, USA
| | - William Teeter
- Department of Emergency Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA. .,Program in Trauma and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Scott Sullivan
- The U.S. Army Command and General Staff College, Leavenworth, KS, USA
| | - Keegan Tupchong
- Division of Critical Care, Department of Emergency Medicine, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Division of Critical Care, Department of Medicine, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Nabeel Mohammed
- Department of Surgical Critical Care, Medstar Washington Hospital Center, Washington, DC, USA
| | - Mark Sutherland
- Department of Critical Care and Emergency Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Evan Leibner
- Critical Care Medicine, Department of Emergency Medicine Mount, Sinai Hospital, New York, NY, USA
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, Canada
| | - Samuel M Galvagno
- Department of Anesthesiology, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah B Murthi
- Program in Trauma and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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16
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Radecki RP, Spiegel R. The Good, the Bad, and Evaluation for Pulmonary Embolism. Ann Emerg Med 2020; 76:367-368. [DOI: 10.1016/j.annemergmed.2020.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Abstract
Intravenous (IV) fluids are among the most common interventions performed in the emergency department. They are at times lifesaving, but if used recklessly can be harmful. Given their ubiquity, it is important to understand the history, physiology, and current strategies that govern the use of IV fluids during the resuscitation of the critically ill.
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Affiliation(s)
- David Gordon
- Department of Medicine, University of Maryland Medical Center, 110 South Paca Pratt Street, Baltimore, MD 21201, USA
| | - Rory Spiegel
- Attending Emergency Medicine, Georgetown University Hospital, Washington Hospital Center, Faculty Critical Care, 110 Irving Street, East Building Room 3124, Washington, DC 20010, USA.
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18
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Rola P, Farkas J, Spiegel R, Kyle-Sidell C, Weingart S, Duggan L, Garrone M, Thomas A. Rethinking the early intubation paradigm of COVID-19: time to change gears? Clin Exp Emerg Med 2020; 7:78-80. [PMID: 32521584 PMCID: PMC7348679 DOI: 10.15441/ceem.20.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/29/2022] Open
Affiliation(s)
- Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, CIUSSS-CEMTL, Montreal, Canada
| | - Joshua Farkas
- Department of Critical Care, University of Vermont, Burlington, VT, USA
| | - Rory Spiegel
- Departments of Critical Care and Emergency Medicine, Washington Hospital Center, Georgetown University, Washington, DC, USA
| | | | - Scott Weingart
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Laura Duggan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - Marco Garrone
- Emergency Department, Mauriziano Ospedale, Torino, Italy
| | - Adam Thomas
- Adult Critical Care, University of British Columbia, Vancouver, Canada
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19
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Abstract
SummaryDevelopment of treatments for dementia is beset by special problems in defining the diagnosis, establishing efficacy criteria, and specifying the necessary duration of study. There is need for agreement among clinicians and scientists on diagnostic subgroups of dementia. Similarly, there is a need for harmonization of the regulatory guidelines in Europe, Japan, and the United States regarding the decision set of variables on which to base efficacy claims. The duration of trials must be based upon the intended claim: transient symptomatic benefit, maintained symptomatic benefit, or a therapeutic effect on disease progression. Claims other than transient benefit require long-term trials, suggested to be of at least six months in duration. Problems with long-term studies include slow patient accrual, high dropout rates, changing milieu, low return on investment, and lack of unanimity regarding regulatory requirements. Regulatory authorities must come to some accord, consonant with current clinical/scientific wisdom and consensus, regarding diagnosis, efficacy criteria, and feasible study duration, in order to attract continued sponsor investment in the development of antidementia treatments.
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20
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Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, Denault AY. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J 2020; 12:16. [PMID: 32270297 PMCID: PMC7142196 DOI: 10.1186/s13089-020-00163-w] [Citation(s) in RCA: 188] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/17/2020] [Indexed: 12/12/2022] Open
Abstract
Background Organ congestion is a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop several grading system prototypes using POCUS and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery. This is a post-hoc analysis of a single-center prospective study in 145 patients undergoing cardiac surgery for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed during the first 72 h after surgery. Five prototypes of venous excess ultrasound (VExUS) grading system combining multiple ultrasound markers were developed. Results The association between each score and AKI was assessed using time-dependant Cox models as well as conventional performance measures of diagnostic testing. A total of 706 ultrasound assessments were analyzed. We found that defining severe venous congestion as the presence of severe flow abnormalities in multiple Doppler patterns with a dilated IVC (≥ 2 cm) showed the strongest association with the development of subsequent AKI compared with other combinations (HR: 3.69 CI 1.65–8.24 p = 0.001). The association remained significant after adjustment for baseline risk of AKI and vasopressor/inotropic support (HR: 2.82 CI 1.21–6.55 p = 0.02). Furthermore, this severe VExUS grade offered a useful positive likelihood ratio (+LR: 6.37 CI 2.19–18.50) when detected at ICU admission, which outperformed central venous pressure measurements. Conclusions The combination of multiple POCUS markers may identify clinically significant venous congestion.
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Affiliation(s)
- William Beaubien-Souligny
- Department of Anesthesiology and Intensive Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada. .,Division of Nephrology, Centre Hospitalier de l'Université de Montreal, 1000, Rue St-Denis, Montreal, QC, H2X 0C1, Canada.
| | - Philippe Rola
- Division of Intensive Care, Santa Cabrini Hospital, Montreal, QC, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA, 92354, USA
| | - Josée Bouchard
- Division of Nephrology, Hôpital Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Rory Spiegel
- Departments of Critical Care and Emergency Medicine, Washington Hospital Center, Georgetown University, Washington, DC, USA
| | - André Y Denault
- Department of Anesthesiology and Intensive Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.,Division of Intensive Care, Centre Hospitalier de L'Université de Montreal, Montreal, QC, Canada
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21
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Abstract
The use of lactate as a marker of the severity of circulatory shock was popularized by Dr. Weil in the 1970's. Dr. Weil promoted the idea that blood lactate concentration increased in circulatory shock due to anaerobic metabolism following decreased oxygen delivery. This concept becomes entrenched with 1992 ACCP/SCCM consensus conference definition of sepsis. Since then, the central role of lactate in the definition and management of septic shock has only been expanded and become more ingrained. This review will discuss the wisdom of such an approach, an updated model describing the origins of hyperlactatemia in sepsis, and how such improvements in our knowledge of the underlying physiology should change our approach to resuscitation in patients presenting with septic shock.
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Affiliation(s)
- Rory Spiegel
- Department of Critical Care and Department of Emergency Medicine, Georgetown University Medstar Washington Hospital Center, Washington, DC, USA
| | - David Gordon
- Department of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD, USA
| | - Paul E Marik
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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22
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Ju C, Spiegel R, Radecki R, Swaminathan AK. Rimegepant in the Treatment of Migraine Headache: The Importance of Comparator Treatments: November 2019 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2019; 74:721-723. [PMID: 31668246 DOI: 10.1016/j.annemergmed.2019.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Christine Ju
- Emergency Department, St. Joseph's University Medical Center, Paterson, NJ
| | - Rory Spiegel
- Departments of Emergency Medicine and Critical Care, MEDStar Washington Hospital, Washington, DC
| | - Ryan Radecki
- Department of Emergency Medicine, Northwest Permanente, Portland, OR
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23
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Spiegel R, Rothschild S, Kalla R. Supportive care to control nausea and dizziness in malignant tumours: A systematic review. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz434.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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24
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Marik PE, Farkas JD, Spiegel R, Weingart S. POINT: Should the Surviving Sepsis Campaign Guidelines Be Retired? Yes. Chest 2019; 155:12-14. [PMID: 30616719 DOI: 10.1016/j.chest.2018.10.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/29/2023] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington VT
| | - Rory Spiegel
- Department Emergency Medicine, Critical Care Fellow Division of Pulmonary Critical Care University of Maryland Medical Center, Baltimore, MD
| | - Scott Weingart
- Department Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
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25
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Marik PE, Farkas JD, Spiegel R, Weingart S. Rebuttal From Drs Marik, Farkas, Spiegel et al. Chest 2019; 155:17-18. [PMID: 30616721 DOI: 10.1016/j.chest.2018.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington VT
| | - Rory Spiegel
- Department Emergency Medicine, Critical Care Fellow Division of Pulmonary Critical Care University of Maryland Medical Center, Baltimore, MD
| | - Scott Weingart
- Department Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
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26
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Mirkin J, Radecki R, Spiegel R. In reply:. Ann Emerg Med 2019; 74:469. [DOI: 10.1016/j.annemergmed.2019.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Indexed: 11/29/2022]
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27
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Brown RM, Spiegel R. Antibiotic Prophylaxis in Patients with COPD. Am Fam Physician 2019; 99:Online. [PMID: 31150175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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28
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Leibner E, Spiegel R, Hsu CH, Wright B, Bassin BS, Gunnerson K, O’Connor J, Stein D, Weingart S, Greenwood JC, Rubinson L, Menaker J, Scalea TM. Anatomy of resuscitative care unit: expanding the borders of traditional intensive care units. Emerg Med J 2019; 36:364-368. [PMID: 30940715 PMCID: PMC6568315 DOI: 10.1136/emermed-2019-208455] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/17/2019] [Accepted: 03/21/2019] [Indexed: 11/03/2022]
Abstract
Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.
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Affiliation(s)
- Evan Leibner
- Institute of Critical Care Medicine, Mount Sinai Hospital, New York, New York, USA
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Mount Sinai Hospital, New York, New York
| | - Rory Spiegel
- Department of Emergency Medicine, The University of Maryland Medical Center, Baltimore, New York, USA
- Department of Pulmonary Critical Care, The University of Maryland Medical Center, Baltimore, New York, USA
| | - Cindy H Hsu
- Department of Emergency Medicine, Division of Emergency Critical Care, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, Division of Acute Care Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian Wright
- Departments of Neurosurgery, Stony Brook University School of Medicine, New York, USA
- Department of Emergency Medicine, Stony Brook University School of Medicine, New York, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, Division of Emergency Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - Kyle Gunnerson
- Department of Emergency Medicine, Division of Emergency Critical Care, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology/Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - James O’Connor
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Deborah Stein
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Scott Weingart
- Department of Emergency Medicine, Stony Brook University School of Medicine, New York, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lewis Rubinson
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jay Menaker
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas M Scalea
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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29
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Mirkin J, Radecki R, Spiegel R. Deriving Peace of Mind: In Search of a Fifth-Generation Troponin Testing Threshold to Safely Rule Out Acute Myocardial Infarction. Ann Emerg Med 2019; 73:317-319. [DOI: 10.1016/j.annemergmed.2019.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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30
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Spiegel R, Radecki R. Epinephrine in Out-of-Hospital Cardiac Arrest: Saving Lives or Prolonging Death? Ann Emerg Med 2019; 73:206-207. [DOI: 10.1016/j.annemergmed.2018.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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Radecki R, Spiegel R. How Might Procalcitonin Testing and Bougies Affect Your Clinical Practice? A Review of These Emergency Department–Based Investigations. Ann Emerg Med 2018; 72:617-620. [DOI: 10.1016/j.annemergmed.2018.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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32
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Spiegel R, Rothschild S, Sutter R, Kalla R. Painkiller-related dizziness in malignant tumors: A systematic review. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy300.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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33
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Spiegel R, Farkas JD, Rola P, Kenny JE, Olusanya S, Marik PE, Weingart SD. The 2018 Surviving Sepsis Campaign's Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use. Ann Emerg Med 2018; 73:356-358. [PMID: 30193754 DOI: 10.1016/j.annemergmed.2018.06.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Rory Spiegel
- Department of Emergency Medicine and Division of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, Quebec, Canada
| | | | - Segun Olusanya
- Department of Perioperative Medicine, St Bartholomew's Hospital, London, UK
| | - Paul E Marik
- Department of Internal Medicine and Pulmonary and Critical Care Medicine, Eastern Virginia Medical School
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34
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Spiegel R, Kleist S. Hyperpronation Method for Reduction of Nursemaid's Elbow. Am Fam Physician 2018; 97:Online. [PMID: 29763276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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35
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Higgins R, Jensen A, Wachstein J, Has C, Bruckner-Tuderman L, Spiegel R, Traber H, Achermann J, Schaller M, Röcken M, Ignatova D, Chang Y, Fischer T, French L, Hötzenecker W, Hornung R, Malzacher A, Cozzio A, Navarini A, Guenova E. 814 Uniparental inheritance of junctional epidermolysis bullosa (JEB) through mutation of ITGA6 and trisomic rescue. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.03.824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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36
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Abstract
We studied a family with pattern dystrophy of the retina (PDR) in order to elucidate the clinical course of the disorder, relations between the different forms, and the mode of inheritance. Thirty-nine family members, representing three generations, underwent a thorough ophthalmological examination, with fluorescein angiography whenever a macular abnormality was suspected. Of family members over the age of 32 years, 46.7% showed signs of PDR. We classified the clinical forms of PDR in this family into four types: minimal lesion, pseudovitelliform type, butterfly-spider type, and late-stage lesion. These forms were predominant in the order cited in age groups 31-40 years, 41-50, 51-60, and > 60 years. Significant visual loss occurred only after the age of 50 years, when 8 of 14 eyes had visual acuity of less than 20/25. Inheritance was autosomal dominant. PDR presented different clinical forms in members of this family, and in successive age classes patterns of increasing severity prevailed. Thus, the different phenotypic forms apparently represent transient stages related to the age of the patient.
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Affiliation(s)
- U Thomann
- University Eye Hospital, Basel, Switzerland
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37
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Shah R, Spiegel R, Lu C, Crnosija I, Ahmad S. Relationship Between the Subcostal and Right Lateral Ultrasound Views of Inferior Vena Cava Collapse: Implications for Clinical Use of Ultrasonography. Chest 2017; 153:939-945. [PMID: 29032036 DOI: 10.1016/j.chest.2017.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 08/26/2017] [Accepted: 10/02/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The collapsibility index of the inferior vena cava is traditionally visualized from the subcostal region in the sagittal plane, referred to here as cIVCSS. Alternatively, the collapsibility index of the inferior vena cava can be visualized from the right midaxillary line in the coronal plane, referred to here as cIVCRC. It is unclear whether values of cIVCRC are comparable with values of cIVCSS because the inferior vena cava collapses asymmetrically into an elliptical form, quantified as the flat ratio of the inferior vena cava (F-IVC). This study aimed (1) to establish if cIVCRC is concordant or discordant to cIVCSS, and (2) to describe how this concordance or discordance is related to F-IVC. METHODS This single-center cross-sectional study enrolled 110 spontaneously breathing patients. Values of cIVCRC were compared with cIVCSS. Performance of cIVCRC ≥ 42% in predicting fluid responsiveness, defined as cIVCSS ≥ 42%, was assessed. F-IVC was also correlated to the difference between cIVCSS and cIVCRC. RESULTS cIVCRC ≥ 42% was 61.5% sensitive (95% CI, 31.58%-86.14%) and 67.1% specific (95% CI, 55.81%-77.06%) for predicting cIVCSS ≥ 42%. cIVCRC underestimated cIVCSS. The degree of discordance between cIVCRC and cIVCSS was proportional to the value of F-IVC. CONCLUSIONS cIVCRC and cIVCSS measures are discordant, where cIVCRC underestimates cIVCSS. The degree of discordance is directly proportional to the value of F-IVC. Therefore, we recommend that cIVCRC ≥ 42% be used to rule in, but not to rule out, fluid responsivity. Wherever possible, F-IVC should be assessed to understand the clinical relevance of cIVCRC.
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Affiliation(s)
- Rian Shah
- Department of Internal Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - Rory Spiegel
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - Christina Lu
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - Ivan Crnosija
- Department of Internal Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - Sahar Ahmad
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Stony Brook University Hospital, Stony Brook, NY.
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38
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Spiegel R, Sutter R. P 152 Self-reflection on illusions and mental health in emergency medicine. Clin Neurophysiol 2017. [DOI: 10.1016/j.clinph.2017.06.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Spiegel R, Sutter R. P 96 Patients’ beliefs and resuscitation statistics – Mere coincidence or a causal link? Clin Neurophysiol 2017. [DOI: 10.1016/j.clinph.2017.06.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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40
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Sutter R, Semmlack S, Spiegel R, Tisljar K, Rüegg S, Marsch S. Distinguishing in-hospital and out-of-hospital status epilepticus: clinical implications from a 10-year cohort study. Eur J Neurol 2017; 24:1156-1165. [DOI: 10.1111/ene.13359] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/12/2017] [Indexed: 01/28/2023]
Affiliation(s)
- R. Sutter
- Medical Intensive Care Units; University Hospital Basel; Basel Switzerland
- University of Basel; Basel Switzerland
- Division of Clinical Neurophysiology; Department of Neurology; University Hospital Basel; Basel Switzerland
| | - S. Semmlack
- Medical Intensive Care Units; University Hospital Basel; Basel Switzerland
- University of Basel; Basel Switzerland
| | - R. Spiegel
- Medical Intensive Care Units; University Hospital Basel; Basel Switzerland
- University of Basel; Basel Switzerland
- Department of Emergency Medicine; University Hospital Basel; Basel Switzerland
| | - K. Tisljar
- Medical Intensive Care Units; University Hospital Basel; Basel Switzerland
- University of Basel; Basel Switzerland
| | - S. Rüegg
- University of Basel; Basel Switzerland
- Division of Clinical Neurophysiology; Department of Neurology; University Hospital Basel; Basel Switzerland
| | - S. Marsch
- Medical Intensive Care Units; University Hospital Basel; Basel Switzerland
- University of Basel; Basel Switzerland
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41
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Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers' Performance Under Stress. Ann Emerg Med 2017; 70:884-890. [PMID: 28460863 DOI: 10.1016/j.annemergmed.2017.03.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/04/2017] [Accepted: 03/10/2017] [Indexed: 11/19/2022]
Abstract
Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus "trigger word." The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.
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Affiliation(s)
- Michael J Lauria
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | | | - Stephen Rush
- United States Air Force Pararescue, 103 Rescue Squadron, Gabreski Air Base, Westhampton Beach, NY
| | - Jason Brooks
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Rory Spiegel
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD
| | - Scott D Weingart
- Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
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42
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Luo X, McIntosh J, Trifillis P, Gill A, Ong T, Riebling P, Souza M, Spiegel R, Peltz S, Muntoni F. Lung function in ataluren-treated, non-ambulatory patients with nonsense mutation Duchenne muscular dystrophy from a long-term extension trial versus untreated patients from a natural history study. Neuromuscul Disord 2017. [DOI: 10.1016/s0960-8966(17)30233-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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43
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Singer AJ, Ng J, Thode HC, Spiegel R, Weingart S. Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection. Ann Emerg Med 2017; 69:475-479. [PMID: 28110990 DOI: 10.1016/j.annemergmed.2016.10.007] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/21/2016] [Accepted: 10/03/2016] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection. METHODS We performed a single-site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast-track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality. RESULTS We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively. CONCLUSION qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY.
| | - Jennifer Ng
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
| | - Rory Spiegel
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
| | - Scott Weingart
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
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Shapiro G, Bedard P, Infante J, Bauer T, Prawira A, Laksin O, Weetall M, Baird J, Branstrom A, O'Mara E, Spiegel R. Phase 1 results of PTC596, a novel small molecule targeting cancer stem cells (CSCs) by reducing levels of BMI1 protein. Eur J Cancer 2016. [DOI: 10.1016/s0959-8049(16)33039-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Muntoni F, Luo X, Elfring G, Kroger H, Riebling P, Ong T, Spiegel R, Peltz S, McDonald C. Results of North Star ambulatory assessments in the phase 3 ataluren confirmatory trial in patients with nonsense mutation Duchenne muscular dystrophy (ACT DMD). Neuromuscul Disord 2016. [DOI: 10.1016/j.nmd.2016.06.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Shah R, Spiegel R, Lu C, Ahmad S. Inferior Vena Cava Flat Ratio as a Predictor of Concordance or Discordance Between Subcostal and Transhepatic Measurements of Collapsibility. Chest 2016. [DOI: 10.1016/j.chest.2016.08.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Shapiro G, Infante J, Bauer T, Prawira A, Bedard P, Laskin O, Weetall M, Baird J, O'Mara E, Spiegel R. Initial first-in-human phase 1 results of PTC596, a novel small molecule that targets cancer stem cells (CSCs) by reducing BMI1 protein levels. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw368.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Spiegel R, Shalev S, Bercovich D, Rabinovich D, Khayat M, Shaag A, Elpeleg O. Severe infantile male encephalopathy is a result of early post-zygotic WDR45 somatic mutation. Clin Genet 2016; 90:560-562. [PMID: 27681470 DOI: 10.1111/cge.12849] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- R Spiegel
- Department of Pediatrics B, Genetic Institute, Afula, Israel.,Genetic Institute, Afula, Israel
| | - S Shalev
- Department of Pediatrics B, Genetic Institute, Afula, Israel.,Rappaport School of Medicine, Technion, Haifa, Israel
| | - D Bercovich
- GGA Laboratories, Kazrin, Israel.,Tel-Hai College, Tel-Hai, Israel
| | | | - M Khayat
- Genetic Institute, Afula, Israel
| | - A Shaag
- Monique and Jacques Roboh Department of Genetic Research, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - O Elpeleg
- Monique and Jacques Roboh Department of Genetic Research, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Spiegel R. Perioperative Beta Blockers. Am Fam Physician 2016; 94:Online. [PMID: 27583431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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