Alexander Loch

Performance of emergency physicians in point-of-care echocardiography following limited training

Objectives The aim of this study was to evaluate if emergency medicine trainees with a short duration of training in echocardiography could perform and interpret bedside-focused echocardiography reliably on emergency department patients. Methods Following a web-based learning module and 3 h of proctored practical training, emergency medicine trainees were evaluated in technical and interpretative skills in estimating left ventricular function, detection of pericardial effusion and inferior vena cava (IVC) diameter measurements using bedside-focused echocardiography on emergency department patients. An inter-rater agreement analysis was performed between the trainees and a board-certified cardiologist. Results 100 focused echocardiography examinations were performed by nine emergency medicine trainees. Agreement between the trainees and the cardiologist was 93% (K=0.79, 95% CI 0.773 to 0.842) for visual estimation of left ventricular function, 92.9% (K=0.80, 95% CI 0.636 to 0.882) for quantitative left ventricular ejection fraction by M-mode measurements, 98% (K=0.74, 95% CI 0.396 to 1.000) for the detection of pericardial effusion, and 64.2% (K=0.45, 95% CI 0.383 to 0.467) for IVC diameter assessment. The Bland–Altman limits of agreement for left ventricular function was −9.5% to 13.7%, and a Pearsons correlation yielded a value of 0.82 (p<0.0001, 95% CI 0.734 to 0.881). The trainees detected pericardial effusion with a sensitivity of 60%, specificity of 100%, positive predictive value of 100% and negative predictive value of 97.9%. Conclusions Emergency medicine trainees were found to be able to perform and interpret focused echocardiography reliably after a short duration of training.

Are health professionals responsible for the shortage of organs from deceased donors in Malaysia

The rate of organ donations from deceased donors in Malaysia is among the lowest in the world. This may be because of the passivity among health professionals in approaching families of potential donors. A questionnaire‐based study was conducted amongst health professionals in two tertiary hospitals in Kuala Lumpur, Malaysia. Four hundred and sixty‐two questionnaires were completed. 93.3% of health professionals acknowledged a need for organ transplantation in Malaysia. 47.8% were willing to donate their organs (with ethnic and religious differences). Factors which may be influencing the shortage of organs from deceased donors include: nonrecognition of brainstem death (38.5%), no knowledge on how to contact the Organ Transplant Coordinator (82.3%), and never approaching families of a potential donor (63.9%). There was a general attitude of passivity in approaching families of potential donors and activating transplant teams among many of the health professionals. A misunderstanding of brainstem death and its definition hinder identification of a potential donor. Continuing medical education and highlighting the role of the Organ Transplant Coordinator, as well as increasing awareness of the public through religion and the media were identified as essential in improving the rate of organ donations from deceased donors in Malaysia.

Differences in Attitude towards Cadaveric Organ Donation: Observations in a Multiracial Malaysian Society

Background Willingness to donate organs is affected by socio-cultural and religious values. The Malaysian society is made up of three ethnic groups: Malay, Chinese, and Indian, with Islam, Buddhism and Hinduism as their religions respectively. This study examined the knowledge and perception towards organ donation for each group. Methods This study was conducted at University Malaya Medical Centre, Kuala Lumpur, Malaysia. Relatives of patients awaiting treatment at the emergency department answered a questionnaire on knowledge and attitude on organ transplantation. Results A total of 904 questionnaires were completed; 90.6% would accept organs, 43.6% would donate, and 4.0% carried donor cards. The reasons for reluctance to donate included: fear of organs being used for research (18.8%), desire to be buried whole (18.0%), fear of less active treatment if patient is known to be a donor (12.8%). Malays were less willing to accept organs from a different race (63.5%) compared to Chinese (83.3%) and Indians (83.8%) (OR=0.35, 95%CI: 0.23-0.54 and OR=0.34, 95%CI: 0.22-0.51 respectively) and also less likely to donate organs (29.8%) as compared to Chinese (42.1%) and Indians (63.2%) (OR=0.57, 95%CI 0.40-0.83 and OR=0.24, 95%CI 0.17-0.35 respectively). Malays were less willing to donate organs to another race compared to Chinese or Indians (OR=0.48, 95%CI 0.33-0.70 and OR=0.22, 95%CI 0.15-0.31 respectively). Only 34.7% of Muslims are aware of fatwa supporting organ donation. Conclusions The awareness of organ donation was low. Clear differences exist among ethnic groups. Cultural-religious attitudes and lack of trust in the medical systems were reasons for reluctance to donation. Identifying socio-cultural barriers and reassuring donors regarding medical care are required.

Failure to improve door-to-needle time by switching to emergency physician-initiated thrombolysis for ST elevation myocardial infarction

Introduction Achieving target door–needle times for ST elevation myocardial infarction remains challenging. Data on emergency department (ED) doctor-led thrombolysis in developing countries and factors causing delay are limited. Objectives To assess the effect on door–needle times by transferring responsibility for thrombolysis to the ED doctors and to identify predictors of prolonged door–needle times. Methodology Data on medical on-call team-led thrombolysis at a tertiary Asian hospital were prospectively collected from May 2007 to Aug 2008 (1st study period). In September 2008, ED doctors were empowered to perform thrombolysis. The practice change was accompanied by new guidelines, tick chart implementation, and training sessions. Data were then consecutively collected from September 2008 to May 2009 (2nd study period). Door-to-needle times for the 1st and 2nd study periods were compared. All cases were analysed for factors of delay by multiple logistic regression. Results 297 patients were thrombolysed, 169 by the medical on-call team during the 1st study period and 128 by the ED doctors during the 2nd study period. Median door–needle times were 54 and 48 min, respectively (p=0.76). Significant delays were predicted by ‘incorrect initial ECG interpretation’ (adjusted OR (aOR) 14.3), ‘inappropriate triage’ (aOR 10.4) and ‘multiple referrals’ (aOR 5.9). No cases of inappropriate thrombolysis were recorded. Conclusions Transfer of responsibility for thrombolysis to the ED doctors did not improve door–needle times despite measures introduced to facilitate this change. Key causative factors for this failure were identified.

The SPEED (sepsis patient evaluation in the emergency department) score: a risk stratification and outcome prediction tool.

Objectives The aim of the study was to identify covariates associated with 28-day mortality in septic patients admitted to the emergency department and derive and validate a score that stratifies mortality risk utilizing parameters that are readily available. Methods Patients with an admission diagnosis of suspected or confirmed infection and fulfilling at least two criteria for severe inflammatory response syndrome were included in this study. Patients’ characteristics, vital signs, and laboratory values were used to identify prognostic factors for mortality. A scoring system was derived and validated. The primary outcome was the 28-day mortality rate. Results A total of 440 patients were included in the study. The 28-day hospital mortality rate was 32.4 and 25.2% for the derivation (293 patients) and validation (147 patients) sets, respectively. Factors associated with a higher mortality were immune-suppressed state (odds ratio 4.7; 95% confidence interval 2.0–11.4), systolic blood pressure on arrival less than 90 mmHg (3.8; 1.7–8.3), body temperature less than 36.0°C (4.1; 1.3–12.9), oxygen saturation less than 90% (2.3; 1.1–4.8), hematocrit less than 0.38 (3.1; 1.6–5.9), blood pH less than 7.35 (2.0; 1.04–3.9), lactate level more than 2.4 mmol/l (2.27; 1.2–4.2), and pneumonia as the source of infection (2.7; 1.5–5.0). The area under the receiver operating characteristic curve was 0.81 (0.75–0.86) in the derivation and 0.81 (0.73–0.90) in the validation set. The SPEED (sepsis patient evaluation in the emergency department) score performed better (P=0.02) than the Mortality in Emergency Department Sepsis score when applied to the complete study population with an area under the curve of 0.81 (0.76–0.85) as compared with 0.74 (0.70–0.79). Conclusion The SPEED score predicts 28-day mortality in septic patients. It is simple and its predictive value is comparable to that of other scoring systems.

Giant left atrium in a patient with prosthetic mitral valve

A 76-year-old female patient presented complaining of chronic cough and dyspnoea. She underwent mitral valve replacement and tricuspid annuloplasty for rheumatic mixed mitral valve disease with severe tricuspid regurgitation 13 years ago. Clinically, the patient had features of congestive cardiac failure. Chest X-ray revealed asymmetrical cardiomegaly with the right heart border extending to the right lateral chest wall. Echocardiography demonstrated …

Re-usage of external pacing electrodes results in skin burns

A 29 year old woman with a background of poorly controlled iabetes was admitted to our hospital in cardiogenic shock due o acute inferior myocardial infarction and complete heart block. ecycled external electrodes (“stat.padz®”) were placed to the right f the upper sternal border below the clavicle and to the left of he nipple with the centre of the electrode in the mid-axillary line. xternal pacing was commenced with an output of 90 mA at a rate f 70 stimulations per minute. Mechanical capture was confirmed y echocardiography. Primary percutaneous coronary intervention o the right coronary artery was performed with insertion of a ransvenous temporary pacemaker. The patient developed intrarocedurally ventricular fibrillation for which a shock of 200 J was elivered through the external electrodes. The total duration of xternal pacing was about 90 min. Upon removal of the external lectrodes, multiple 2nd degree circular skin burns were noticed elow the apical electrode with burnt and necrotic skin flakes dherent to the electrode (Panel A). No burn was observed in the rea of the right sided electrode (see Fig. 1). Many of our patients do not have medical insurance nor are they ble to pay their hospital bills. The price for a set of external pacing lectrodes is about 50 USD in our setting. Every patient requiring ife-saving treatment will be treated regardless of insurance status. his policy however results frequently in the hospital not recoverng cost for consumable products like pacing electrodes. In an effort o reduce cost, external electrodes are re-used – despite the manfacturer’s advice. The gel of re-used electrodes is often dried out ith pockets of gel missing in addition to general contamination nd cracks (Panel B). We assume that the relatively severe burns

Late intravascular embolization of a chemo port catheter.

A 51-year-old woman was referred for angiographic extraction of a foreign body. She underwent left mastectomy with axillary clearance for breast cancer followed by chemotherapy and radiotherapy 8 years before this. A chemotherapy port was implanted below the right clavicle with catheter access into the right subclavian vein at that time. After she had completed chemotherapy, she was lost to follow-up, until she represented 8 years later with persistent cough. The chest x-ray (Figure 1A) showed a foreign body comprising an ellipsoid head and a flagellating tail on fluoroscopy (see video, Supplemental Digital Content 1 [http:// links.lww.com/JTO/A86]; see video, Supplemental Digital Content 2 [http://links.lww.com/JTO/A87] for a close-up; and see video, Supplemental Digital Content 3 [http://links. lww.com/JTO/A88] for a 180° surround view). A computed tomography scan of chest demonstrated embolization of the fractured chemo port catheter. The catheter segment (Figure 1B, arrow) was lodged between the pulmonary artery trunk and a branch of the left pulmonary artery. The distal end of the catheter was surrounded by a 3.7-mm-diameter calcified tissue mass (Figure 1B, arrowhead). The patient declined angiography in view of the risks associated with extracting a heavily calcified and embedded catheter tip. The chemo port was still located below the right clavicle with a stump of the catheter connected to it. We hypothesize that entrapment (“pinch off”) and friction of the catheter between clavicle and first rib over many years resulted in fracture and embolization of the catheter. Increasingly, specialist nurses are responsible for the care of patients with central venous catheters and the removal of the devices.1 Current guidelines recommend the removal of unused ports.2 Case reports of embolized port catheters or so-called totally implanted venous devices are rare. Only about a third of the embolic events reported were localized in the pulmonary arteries, and about a quarter of patients were asymptomatic at the time of diagnosis.3 Catheter embolism may go undetected for prolonged periods of time and is often diagnosed incidentally. The risk of serious complications for patients with asymptomatic catheter embolism is unknown. Embolized catheter fragments should be removed to prevent further complications.

Early and aggressive ISR with a polymer- and carrier-free drug-coated stent system

The LEADERS FREE trial concluded that the polymer free drug-coated BioFreedom™ stent appeared to be both safer and more effective than bare-metal stents (BMS) with an ISR rate comparable to traditional DES without the need for prolonged DAPT. We implanted 45 BioFreedom™ stents in 34 patients over a 4-month period. 4 patients represented early (106–238 days after the implant procedure) with angina symptoms and severe ISR was detected in all patients. The rate of severe and early ISR detected in our patient population of 11.8% is comparable to that of traditional BMS. Further studies are warranted.

Cardiac magnetic resonance imaging: a tool to diagnose parasitic infection?

A 48-year-old Somali camel farmer presented with symptoms of heart failure. He reported a 1 year history of exertional dyspnoea, loss of appetite, and weight loss. Clinically, there were signs of right heart failure with ascites and splenomegaly. Blood tests were unremarkable apart from an elevated eosinophil count of 1750 mm …