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Wednesday, August 20, 2014

Researchers can perform imaging exams using robotic arms controlled remotely via the Internet, according to two papers published in the August issue of JACC: Cardiovascular Imaging.

 

Partho Sengupta, MD, the director of cardiac ultrasound research at Icahn School of Medicine at Mount Sinai in New York, used a computer from Germany in one study to perform a robot-assisted ultrasound on a patient in Boston. He and his colleagues were able to complete a robotic ultrasound exam of a patient's carotid artery in four minutes.

 

Kurt Boman, MD, of Umea University of Sweden, in cooperation with Mount Sinai, used the robotic device in a second study to perform an echocardiography on patients in a remote location 135 miles away. Boman and colleagues were able to reduce the total diagnostic time for heart-failure patients receiving remote consultation from 114 to 27 days.

 

More details are available at http://bit.ly/1oUZoVb.

 


Tuesday, August 19, 2014

MedEx Ambulance Service, an Illinois-based health care transportation company, is experimenting with Google Glass in an effort to provide better care for patients.

 

The company has acquired two pairs of Google Glass installed with software and connected to the Internet, allowing paramedics to transmit live video and audio from an ambulance to a doctor in an emergency room who will be able to watch the video stream on a tablet or desktop computer.

 

Google Glass does not comply with Health Insurance Portability and Accountability Act, the federal privacy law, but Pristine, Inc., a startup based in Austin, TX, has customized the device for the medical profession in a way that the company said meets data security and patient privacy standards.

 

Read more about this at http://bit.ly/1tgGmNc, and read EMN’s article on Google Glass use in the ED at http://bit.ly/MRV4ve.


Monday, August 18, 2014

Twenty percent of adolescent girls and 12.5 percent of adolescent boys who visited the emergency department in the past year have reported dating violence, according to a study published online June 29 by Annals of Emergency Medicine.

 

Nearly 73 percent of 4,089 adolescents seeking care in a suburban ED for dating violence were Caucasian, 86.9 percent were enrolled in school, and 25.8 percent were on public assistance, according to the study, “Dating Violence Among Male and Female Youth Seeking Emergency Department Care.” (http://bit.ly/1rjCJs2.)

 

Adolescents who experienced violence in their dating lives were strongly associated with alcohol and illicit drug use or depression. Young women reporting prior dating violence were more likely to be on public assistance, have a D average or below, and have visited the ED in the past year for an intentional injury.


Friday, August 15, 2014

More than 40 percent of Social Security Disability Insurance (SSDI) recipients take opioid pain relievers, while the prevalence of chronic opioid use is more than 20 percent and rising, reported a study in the September issue of Medical Care. (2014;52[9]:852; http://bit.ly/1t2VoWT.)

 

The high proportion of SSDI recipients who are chronic opioid users — in many, at high and very high daily doses — “is worrisome in light of established and growing evidence that intense opioid use to treat nonmalignant pain may not be effective and may confer important risk,” wrote Nancy Elizabeth Morden, MD, and colleagues of the Dartmouth Institute for Health Policy & Clinical Practice in Lebanon, NH.

 

The researchers analyzed trends in use of prescription opioids among disabled Medicare beneficiaries under age 65 between 2007 and 2011. Nearly all under-65 Medicare beneficiaries are SSDI recipients; patients who go on SSDI are eligible for Medicare after two years.

 

Consistent with reports of an “opioid epidemic” in the United States, the results showed high and rising prevalence of opioid use by SSDI recipients. The percentage of beneficiaries taking opioids increased from 2007 through 2010. Prevalence dipped slightly to 43.7 percent in 2011, the most recent year for which data were available.

 

The percentage of these beneficiaries with chronic opioid use rose steadily, from 21.4 percent in 2007 to 23.1 percent in 2011. Chronic opioid users received numerous opioid prescriptions — at least six and generally 13 per year — typically prescribed by multiple doctors. Women were at greater risk of becoming chronic opioid users than men.

 

The average “morphine-equivalent dose” (MED) also dipped in 2011 among chronic opioid users. Still, nearly 20 percent of chronic users were taking a dose of at least 100 mg MED, while 10 percent were taking 200 mg. “Opioid use of this intensity has been associated with risk of overdose death in the general U.S. population and more specifically in disabled workers,” Dr. Morden and colleagues wrote.

 

The researchers also found variations in opioid use across U.S. health care regions. The regional prevalence of opioid use among SSDI recipients ranged from 33.0 to 58.6 percent; chronic use ranged from 14.0 to 36.6 percent. Drug dosage and specific opioids prescribed also varied by region.

 

The high prevalence and intensity of opioid use among SSDI recipients parallels the preponderance of musculoskeletal disorders, such as back pain — some type of musculoskeletal condition was present in 94 percent of chronic opioid users. The researchers also note the high rate of depression, 38 percent, among patients taking chronic opioids.

 

Dr. Morden and colleagues voiced concern about the trends in opioid use by SSDI recipients, particularly chronic use at potentially hazardous doses. “We are not suggesting that all chronic opioid use is more harmful than beneficial,” they wrote, “but rather that the common and increasing chronic use we observed seems inconsistent with the uncertainties surrounding such prescribing practice.”

 

The regional variation identified in the study “shows a lack of standardized approach, and revealed regions with mean MED levels associated with overdose risk,” the researchers added. They urged further study to assess the clinical outcomes of opioid use by under-65 disabled workers and factors associated with chronic opioid use. They also call for the development of policies and programs that balance safety with high-quality pain management for this complex group of patients.


Monday, July 07, 2014

By Christine Butts, MD

We have been taking a close look at the RADiUS protocol for the past several months, but now it’s time to put all of the pieces of the protocol together in assessing patients. RADiUS — rapid assessment of dyspnea with ultrasound — evaluates the heart, IVC, pleura, and lung parenchyma. It is a useful bedside tool for quickly assessing patients with undifferentiated shortness of breath, an extremely valuable tool for emergency physicians. These patients are challenging and require speedy appraisal and treatment.

A 60-year-old man is brought to the ED by EMS complaining of shortness of breath for a past day. EMS has little history, but carries a bag of the patient’s medications, which includes two inhalers, a diuretic, and an ACE inhibitor. The patient is in some distress, and is only able to speak a word or two at a time. His blood pressure is 180/90 mm Hg, heart rate is 120 bpm, respiratory rate is 40 bpm, and SpO2 is 80%. He is obese, and his breath sounds are diminished throughout but no wheezing is noted. He has questionable edema to his lower extremities, although his size makes this difficult to assess.

Using the RADiUS protocol, we begin by evaluating his heart for overall contractility, pericardial effusion, and evidence of right heart strain. Video 1 shows that his overall left ventricular function is severely decreased. No effusion or right heart strain is noted.

Shifting gears, we examine the IVC for overall size and change with respiration. Video 2 reveals that the IVC is enlarged, and shows very little change with respiration. These findings correlate with an elevated central venous pressure.

Using the high-frequency transducer, the pleura are assessed for sliding to evaluate for a possible pneumothorax. Video 3 shows that the patient has normal lung sliding bilaterally, ruling out a pneumothorax. An M-mode tracing of the patient’s pleura can be seen in Image 1, further confirming a normal pleural interface.


Finally, evaluation of the lung parenchyma shows the presence of diffuse bilateral B-lines (Image 2), consistent with the interstitial syndrome.

Putting all of these findings together gives a likely diagnosis of cardiogenic pulmonary edema, allowing the EP to initiate the correct treatment pathway rapidly. It also enables the EP to rule out other life-threatening causes of dyspnea, such as pericardial effusion.

Dr. Butts is the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her @EMNSpeedofSound, and read her past columns at http://bit.ly/ButtsSpeedofSound.