Underused Tool Research Articles

Telemedical Direction to Optimize Resource Utilization in a Rural Emergency Medical Services System.

Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers. This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality. The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019-September 10, 2020) and the post-implementation period (September 11, 2020-December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45-2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as "good." In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as "good."

Myocardial Involvement in Catastrophic Antiphospholipid Syndrome during Pregnancy or Puerperium: A Case of a Young Breastfeeding Woman and Literature Review.

Catastrophic Antiphospholipid Syndrome (CAPS) is a rare complication that can occur in patients with Antiphospholipid Syndrome (APS). CAPS occurs even more rarely during pregnancy/puerperium and pregnant patients, even less likely to show cardiac involvement without signs of damage on ultrasound and angiography with non-obstructive coronary arteries. We present a case of a 26-year-old breastfeeding woman, the youngest described with CAPS and acute myocardial infarction, whose diagnosis was made with cardiac magnetic resonance imaging (CMRI). A literature review of pregnant patients with similar problems was performed. There are diagnostic and therapeutic difficulties in treating these patients. CMRI demonstrated a transmural late enhancement area. A combination of therapies led to rapid clinical improvement. CMRI is an underused tool that reaffirms the pathophysiology of CAPS and leads clinicians to the possibility of a diffuse thrombotic process. CAPS involves more organs with high mortality rates. CMRI could be optimized in order to reach an early diagnosis and the most effective treatment. This study provides real-world evidence of the feasibility of MRI in a primary care setting during pregnancy/puerperium. Evidence from this study may influence future APS screening and inform policymakers regarding the use of leading MRI technology in the detection of the thrombotic process in a primary care setting.

Conventional and Contrast-enhanced US of the Lung: From Performance to Diagnosis.

In recent years, lung US has evolved from a marginal tool to an integral component of diagnostic chest imaging. Contrast-enhanced US (CEUS) can improve routine gray-scale imaging of the lung and chest, particularly in diagnosis of peripheral lung diseases (PLDs). Although an underused tool in many centers, and despite inherent limitations in evaluation of central lung disease caused by high acoustic impedance between air and soft tissues, lung CEUS has emerged as a valuable tool in diagnosis of PLDs. Owing to the dual arterial supply to the lungs via pulmonary and bronchial (systemic) arteries, different enhancement patterns can be observed at lung CEUS, thereby enabling accurate differential diagnoses in various PLDs. Lung CEUS also assists in identifying patients who may benefit from complementary diagnostic tests, including image-guided percutaneous biopsy. Moreover, lung CEUS-guided percutaneous biopsy has shown feasibility in accessible subpleural lesions, enabling higher histopathologic performance without significantly increasing either imaging time or expenses compared with conventional US. The authors discuss the technique of and basic normal and pathologic findings at conventional lung US, followed by a more detailed discussion of lung CEUS applications, emphasizing specific aspects of pulmonary physiology, basic concepts in lung US enhancement, and the most commonly encountered enhancement patterns of different PLDs. Finally, they discuss the benefits of lung CEUS in planning and guidance of US-guided lung biopsy. ©RSNA, 2024 Supplemental material is available for this article.

Serial electrodiagnostic testing: Utility and indications in adult neurological disorders.

Although existing guidelines address electrodiagnostic (EDX) testing in identifying neuromuscular conditions, guidance regarding the uses and limitations of serial (or repeat) EDX testing is limited. By assessing neurophysiological change longitudinally across time, serial electrodiagnosis can clarify a diagnosis and potentially provide valuable prognostic information. This monograph presents four broad indications for serial electrodiagnosis in adult peripheral neurological disorders. First, where clinical change has raised suspicion for a new or ongoing lesion, EDX reassessment for spatial spread of abnormality, involvement of previously normal muscle or nerve, and/or evolving pathophysiology can clarify a diagnosis. Second, where diagnosis of a progressive neuromuscular condition is uncertain, electrophysiological data from a second time point can confirm or refute suspicion. Third, to establish prognosis after a static nerve injury, a repeat study can assess the presence and extent of reinnervation. Finally, faced with a limited initial study (as when complicated by patient or environmental factors), a repeat EDX study can supplement missing or limited data to provide needed clarity. Repeat EDX studies carry certain limitations, however, such as with prognostication in the setting of remote or chronic lesions, sensory predominant fascicular injury, or mild axonal injury. Nevertheless, serial electrodiagnosis remains a valuable and underused tool in the diagnostic and prognostic evaluation of neuromuscular conditions.

Utility of UV Signature Mutations in the Diagnostic Assessment of Metastatic Head and Neck Carcinomas of Unknown Primary.

Metastatic carcinoma of unknown primary origin to the head and neck lymph nodes (HNCUP) engenders unique diagnostic considerations. In many cases, the detection of a high-risk human papillomavirus (HR-HPV) unearths an occult oropharyngeal squamous cell carcinoma (SCC). In metastatic HR-HPV-independent carcinomas, other primary sites should be considered, including cutaneous malignancies that can mimic HR-HPV-associated SCC. In this context, ultraviolet (UV) signature mutations, defined as ≥ 60% C→T substitutions with ≥ 5% CC→TT substitutions at dipyrimidine sites, identified in tumors arising on sun exposed areas, are an attractive and underused tool in the setting of metastatic HNCUP. A retrospective review of institutional records focused on cases of HR-HPV negative HNCUP was conducted. All cases were subjected to next generation sequencing analysis to assess UV signature mutations. We identified 14HR-HPV negative metastatic HNCUP to either the cervical or parotid gland lymph nodes, of which, 11 (11/14, 79%) had UV signature mutations, including 4 (4/10, 40%) p16 positive cases. All UV signature mutation positive cases had at least one significant TP53 mutation and greater than 20 unique gene mutations. The management of metastatic cutaneous carcinomas significantly differs from other HNCUP especially metastatic HR-HPV-associated SCC; therefore, the observation of a high percentage of C→T with CC →TT substitutions should be routinely incorporated in next generation sequencing reports of HNCUP. UV mutational signatures testing is a robust diagnostic tool that can be utilized in daily clinical practice.

Objective Structured Clinical Examination: Underused Tool in Epilepsy Fellowship Programs?

Objective Structured Clinical Examination: Underused Tool in Epilepsy Fellowship Programs?

Descriptive cross-sectional survey of tobacco and cannabis restrictions on state and local film incentives in the USA

BackgroundReducing tobacco depictions in media has significant health benefits because tobacco placements in films normalise tobacco use and are linked to youth initiation. Cannabis depictions may have similar effects. Placing...

Abstract 17011: Correlation of Surface Atrial ECG Dominant Frequency to Intracardiac Atrial Electrogram Dominant Frequency

Background: The surface Atrial ECG (A-ECG) is an underused tool in persistent atrial fibrillation (PeAF) that can provide dominant frequency (DF) of atrial activation. The association between A-ECG DF and left (LA) and right atrial (RA) DF has not been established. Research Question: Does surface A-ECG DF correlate with intracardiac DF? Aims: To investigate the correlation between A-ECG peak DF and peak DF of intracardiac RA and LA electrograms (EGM) in patients with PeAF. Methods: Thirty-two patients (age 63±9 years; 71% males) with PeAF underwent 5-minute epochs of surface ECG and comprehensive LA (261.5±185.1 sites/patient) and RA (211.5±174.6 sites/patient) intracardiac mapping with 15 second recordings. The A-ECG was derived by QRST subtraction and independent component analysis filtering, and divided into overlapping10-second windows which were subjected to Fast Fourier Transform (FFT). 4 were excluded for significant artifact. A-ECG DF was calculated for each lead from the power spectrum as the average of all 10-second segments. Peak A-ECG DF was determined by regional lead location and for all 12 leads. The intracardiac EGM DF was calculated from the FFT, and peak RA and LA DF was determined. Results: A-ECG peak DF was significantly lower than intracardiac peak DF 6.08±0.64 vs 9.72±1.19 Hz, p<0.0001(LA: 9.72±1.20 Hz, p<0.0001; RA: 8.40±0.80 Hz, p<0.0001). Figure shows that A-ECG peak DF correlated with peak RA DF, r=0.77 (p<0.0001), but not with peak LA DF (r=0.31, p=0.10). Regional A-ECG lead group DF correlated with RA DF (Inferior (II, III, aVF): r=0.79, p<0.0001; Lateral (I, aVL, V5-6): r=0.78, p<0.0001; Anterior (V1-3): r=0.75, p<0.0001) but not with peak LA DF. Conclusion: Surface A-ECG DF correlates with intracardiac RA DF and not LA DF. As in atrial flutter, the RA plays a prominent role in the surface ECG manifestation of the f waves. Further study is needed to determine whether A-ECG DF can be used to identify RA versus LA drivers that may require ablation.

Canine Systemic Insecticides Fluralaner and Lotilaner Induce Acute Mortality of Triatoma gerstaeckeri, North American Vector of the Chagas Disease Parasite.

Chagas disease is a health concern for humans and animals across the Americas, and control options targeting the triatomine vectors of Trypanosoma cruzi, the causative agent of Chagas disease, are limited. Host-targeted interventions may be a useful and underused tool in controlling the spread of T. cruzi from vectors to hosts. Domestic dogs are known to be key bloodmeal hosts for triatomines as well as T. cruzi reservoirs and may be an effective and practical target for host-targeted insecticide deployment. We hypothesized that treating dogs with commercially available systemic insecticides (labeled for flea and tick control) would result in mortality of triatomines after consuming treated blood. We enrolled 16 privately owned dogs into five treatment groups to receive either fluralaner (Bravecto) or lotilaner (Credelio), alone or in combination with ivermectin. Blood from dogs before the initiation of treatment served as controls. Blood was collected 0, 7, 30, 45, and 90 days after the initial canine insecticide treatment and fed to 10 Triatoma gerstaeckeri nymphs through a membrane feeder, and survival was tracked daily for 7 days and weekly thereafter. All triatomines in the control and ivermectin groups survived the initial period, with no significant difference in long-term survival. In contrast, 99.7% of triatomines that fed on blood from dogs treated with either fluralaner or lotilaner died within 3 days. Although the impact of canine treatment on suppressing vector populations is unknown, fluralaner and lotilaner appear to be a compelling option for an integrated vector management approach to triatomine control.

Cleaning potential of interdental brushes around orthodontic brackets – an in vitro investigation

This study evaluated the brushing efficacy of different interdental brushes around a multibracket appliance in vitro. In four models displaying misaligned and aligned teeth with and without attachment loss, the brushing capacities of three interdental brushes (IDB) were tested: A waist-shaped IDB with a diameter of 9 mm at both ends and 5 mm in the middle (B1), a cylindrical brush with a diameter of 9 mm (B2) and one with 5 mm (B3). Before cleaning, the black teeth in the respective models were stained white with titanium (IV) oxide and the percentage of cleaned surface was planimetrically assessed. In addition, the forces applied to the IDB were also recorded. The effect of brush and model on expected cleaning performance was examined using an analysis of variance (ANOVA). The cleaning performance of the brushes in decreasing order was B2>B3>B1; no significant differences between the different tooth areas and models were found. With regard to force measurements, significant differences were found with the highest and lowest forces IDB (2) and (1), respectively. There was a significant correlation between force and cleaning performance: The higher the force needed the higher was the cleaning performance. In summary, this study showed that cylindrical interdental brushes achieved a better cleaning performance than the waist-shaped IDB. Given some shortcomings of this first laboratory study, more research is still needed, but IDB may represent a valuable yet still clinically underused tool. Accepted for publication: April 3, 2023 Published online: April 25, 2023

PSR_ti model, an adapted pressure-state-response (PSR) framework for measuring tourism impacts: the case of Madrid

PurposeAssessing the impacts generated by tourism has become an essential element for the industry’s sustainability. The increasing intensity of the impacts and the need to evaluate them from a resident’s perspective calls for new approaches to assist tourism management. This paper aims to advance from the pressure-state-response framework (PSR) to measure the tourism impacts in urban destinations with a holistic model called PSR-ti.Design/methodology/approachA multiple linear regression method was adopted to apply the PSR-ti model in the city of Madrid, estimating the relationship between the pressure (objective) and state (subjective) variables. Local statistical yearbook data was used to construct the pressure variables. Regarding the state variables, a survey was designed to assess residents’ perceptions of tourism. A total of 652 responses were obtained.FindingsThe results obtained from the study of pressure indicators unveil that these indicators can support decision-making processes as an underused management tool. This work represents a step forward in considering the transversality of tourism concerning urban planning, the development of equipment and infrastructures or activities such as commerce and culture for the analysis of the state indicators; the results obtained determine the need to periodically evaluate the perception of residents on the impacts of tourism, given its crucial role in the sustainability of the destination.Originality/valueThe PSR-ti model offers a holistic vision, including objective and subjective indicators in the model, which enhances the appraisal of the impacts of tourism by identifying pressure and state factors as a starting point for possible responses by the decision makers of the tourist destination.

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

Halting vaccine-derived poliovirus circulation: the novel type 2 oral vaccine might not be enough

Halting vaccine-derived poliovirus circulation: the novel type 2 oral vaccine might not be enough

Use of Bedside Ultrasound at Wexford General Hospital Emergency Department: Compliance to NICE Guidelines [NG158] for Venous Thromboembolic Disease

Introduction:Ultrasound is the standard imaging technique for diagnosing lower limb deep venous thrombosis (DVT). The National Institute for Health and Care Excellence (NICE) guidance 158 recommendation 1.1.3 states that all patients with sufficient pretest probability for DVT should be offered a proximal leg vein ultrasound within four hours. However, due to high patient volumes, formal radiology department ultrasound wait times often exceed one week. Point-of-care ultrasound (POCUS) is used to bridge diagnostic delay in our emergency department (ED) .This study aimed to quantify numbers offered POCUS for suspected proximal lower DVT in our ED and accuracy of such studies.Method:A retrospective review of electronic records was conducted for patients who underwent formal lower-limb ultrasound for suspected DVT at our hospital over a three-month period (August 1, 2022-October 12, 2022). Patient charts for all ED presentations were assessed to determine whether POCUS was offered and whether DVT was diagnosed.Statistical analysis was conducted using PRISM v9.Results:80 formal ultrasound scans were performed at our hospital for lower limb DVT. 58 were requested for patients presenting to ED, of which 42 had complete records available meeting selection criteria.POCUS was offered to 24 patients in ED (57.1%). Sensitivity was 66% (95% CI 12%- 98%), and specificity was 94.1% (95% CI 75%-99%). Overall accuracy was 90%, with only one false negative study identified at formal follow-up ultrasound.Conclusion:Although sample size was small, our results suggest that POCUS is an accurate but underused tool to diagnose lower limb DVT. Developing a standardized protocol for performing and reporting POCUS DVT scans in ED should allow for earlier diagnosis and initiation of appropriate treatment where necessary.

Vapor Sorption and Halogen-Bond-Induced Solid-Form Rearrangement of a Porous Pharmaceutical.

A porous, nonsolvated polymorph of the voltage-gated sodium channel blocker mexiletine hydrochloride absorbs iodine vapor to give a pharmaceutical cocrystal incorporating an I2Cl- anion that forms a halogen-π interaction with the mexiletine cations. The most thermodynamically stable form of the compound does not absorb iodine. This example shows that vapor sorption is a potentially useful and underused tool for bringing about changes in pharmaceutical solid form as part of a solid form screening protocol.

Applying clinical audit for quality improvement in canine dystocia cases seen at a UK primary-care emergency practice.

The paucity of published veterinary clinical audits suggests that clinical audit is an under-used tool for quality improvement (QI) in the veterinary profession. Therefore, a continuous QI process was designed and implemented at a UK multisite small animal emergency practice, focusing on audit of clinical management of canine dystocia. Data collection phases were undertaken in 2014, 2019 and 2021, with intervening knowledge dissemination activities. Nine variables relating to clinical management of canine dystocia were selected as audit criteria in the initial dataset, and 21 variables were measured in each subsequent phase. Between 2014 and 2021, statistically significant increases (p < 0.05) were demonstrated in recording of bodyweight, use of diagnostic imaging, use of ultrasonography, recording of fetal heart rates, use of calcium gluconate, and use during caesarean section of intravenous fluid therapy, multimodal analgesia, full agonist opioids, paracetamol and local anaesthesia. Statistically significant decreases were demonstrated in median first quantity and median first dose of oxytocin, and in the use of NSAIDs during caesarean section. A clinical audit planning template was created for future audits. Typical case presentation and management of canine dystocia cases may vary between dedicated emergency and non-emergency primary-care settings. This study demonstrates the feasibility of large-scale veterinary clinical audit and suggests that the application of the clinical audit process promotes learning within the veterinary team and improved clinical outcomes.

USING NATURALLY OCCURRING QUALITATIVE DATA IN GERONTOLOGICAL CANCER RESEARCH

Abstract Cancer therapies for older adults have accelerated at breakneck speed in the last few decades, necessitating evaluation of their delivery and uptake to ensure patients receive their maximum benefit. Among the vast array of evaluation tools available, those utilizing naturally occurring data—data produced without intervention from a researcher—are a powerful but underused tool. In this presentation, we will review two methods for examining naturally occurring data, participant observation and conversation analysis (CA), in an educational intervention study of multiple myeloma patients receiving autologous stem cell transplant. First, we will review how participant observation of nurse-led education visits (n=70) was incorporated to iteratively improve video-based education. Next, we will review use of CA in reviewing audio recordings containing reference to the education videos of 12 nurse-led education visits (1011 minutes of audio). Ultimately, understanding the purposes of and ways of using naturally occurring data have potential for improving the evaluation of patient education.

Comparison of Post Transplant Outcomes between Refrigerated and Cryopreserved Autologous Hematopoietic Stem Cells in Patients with Multiple Myeloma

Introduction: Approximately 10% of individuals with hematological malignancies are diagnosed with Multiple Myeloma (MM); in addition, the incidence and prevalence of the disease have progressively increased in recent decades. Despite the recent remarkable advances in treatment, autologous hematopoietic stem cell transplantation (ASCT) is still a fundamental part of the therapeutic management of this population. Particularly in developing countries, ASCT is an underused tool. Social and economic issues play an essential role in accessing the procedure. Refrigerated hematopoietic stem cells (R-HSC) can be an attractive alternative to the traditional use of cryopreserved hematopoietic stem cells (C-HSC) since cryopreservation demands highly trained human resources, high-cost supplies, and sophisticated equipment. Aim: In order to compare the applicability, safety, and possible clinical and economic benefits of ASCT with different types of cell storage before infusion, we analyzed the medical records of patients diagnosed with MM who were transplanted using R-HSC or C-HSC. Methods: The study was approved by the local Research Ethics Committee. We analyzed charts of patients diagnosed with MM and submitted to ASCT at Erasto Gaertner Hospital between January 2017 and July 2021. R-HSC: Cells were stored immediately after leukapheresis, without any handling procedure, kept in a standard refrigerator at a temperature between 2-6oC, and infused within 48 hours after collection. C-HSC: Cells were collected by leukapheresis and submitted to cryopreservation within 12 hours after the procedure. As a cryoprotectant, a solution with dimethyl sulfoxide (DMSO) at a final concentration of 5.5% was used. The product's temperature was reduced under a controlled cooling rate and stored in a freezer at -80oC. All patients received a single intravenous dose of melphalan (200-100mg/m2) 24 hours before receiving the cells as conditioning regimen. In the group of patients who received R-HSC, the cells were removed from the refrigerator and immediately infused at a rate of 10 ml/minute. However, in patients who received C-HSC, the cells were removed from the freezer, thawed in a water bath at 37oC, and infused intravenously at a rate of 10 ml/minute. All patients received G-CSF from D+5 until neutrophilic engraftment. Results: We reviewed records of 170 patients. One hundred eight subjects received R-HSC and 62 C-HSC. Demographic characteristics, CD34+ cell dose received, melphalan dose, febrile neutropenia, and early mortality related to the procedure were similar between the two groups. There was a significant statistical difference in favor of the group utilizing R-HSC related to days until neutrophil engraftment (10 vs. 14 days p<0.0001), days until platelet engraftment (12 vs. 15 days p<0.0001), days of hospitalization (13 vs. 16 days p<0.0001) and infusion-related adverse reactions (10.1% vs. 33.8% p=0.003). There were no cases of graft failure in both groups. A reduction of 32.4% in the total cost per transplant was noticed in the R-HSC group. Conclusions: We demonstrated in this analysis that the use of stem cells stored in a standard refrigerator, with a temperature between 2-6oC for up to 48 hours after the collection is a safe and efficient approach. It was capable of simplifying the ASCT, preventing infusion-related adverse reactions, assuring an early neutrophil and platelet engraftment, and reducing hospitalization days. This strategy should be considered especially in resource constrained settings to avoid unnecessary expenses, increase the number of transplant centers, and expand access to the procedure.

Lung ultrasound in neonates - An underused tool.

Point of care lung ultrasound (USG) can help in the diagnosis and management of critically sick neonates. It is based on seven simple principles that are comprehensive enough to diagnose all major lung pathologies. A compact small machine and a micro-convex or linear probe are the basic requirements to perform lung USG. In contrast to traditional USG principles, USG of the lung is based on artefacts. Some of the terminologies that are used to characterize normal lung include the pleural line, A-line, bat sign, lung sliding and seashore sign. Air/fluid mixture in varying ratios helps in diagnosis of normal lung, pneumothorax, interstitial syndrome (transient tachypnoea of newborn, respiratory distress syndrome, bronchopulmonary dysplasia), lung consolidation and pleural effusion.

Velocity-Time Integral: A Bedside Echocardiography Technique Finding a Place in the Emergency Department

BackgroundPoint-of-care ultrasound is a fundamental tool in the emergency department when managing the critically ill patient. Determining a patient's hemodynamic status at the bedside can better guide resuscitation efforts. The left ventricular outflow tract velocity–time integral (VTI) is a validated, noninvasive, and rapidly acquired echocardiographic measurement that is analogous to stroke volume. DiscussionVTI can be used to determine fluid responsiveness and to risk stratify patients, particularly in pulmonary embolism, heart failure, and sepsis. Emergency physicians with limited experience can successfully measure VTI in a timely and accurate manner. However, VTI measurement is not commonly taught in emergency medicine residency and, as a result, it is an underused tool. ConclusionsVTI is an objective tool for clinicians to assess the hemodynamic status of critically ill patients. Understanding the acquisition of VTI and proper application in the context of the patient's history, clinical examination, and other bedside ultrasound findings, should be reviewed within the emergency medicine residency ultrasound curriculum. This article provides a simple four-step protocol, as well as bedside applications and potential limitations for VTI in the ED.