Background Acute aortic dissection (AAD) is a life-threatening medical condition with high early fatality. Therefore, a prompt and precise diagnosis, which can be achieved through invasive and non-invasive techniques is vital. Echocardiography, unlike MRI and CT, is accessible in emergency units and bedside-compatible. The recommended echocardiographic techniques for AAD are transthoracic and transoesophageal echocardiography (TTE and TOE). Therefore, our review compares their diagnostic roles in AAD. Methods Studies relevant to our topic were attained through a database search and manual scrutiny of references lists of articles obtained from the electronic databases. The Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) has been used for quality assessment. All quantitative analyses were performed using either STATA 16 or Comprehensive Meta-Analyst software. Results The search strategy yielded 1,798 articles, of which only 11 were eligible for inclusion. Our subgroup analysis showed that conventional TTE had a sensitivity and specificity of 85.35% and 84.51% for the diagnosis of Stanford type A AAD and was 45.89% sensitive and 87.05% specific for the diagnosis of type B AAD. However, the subgroup analysis shows that contrast-enhancement of TTE results in a sensitivity and specificity of 93.30% and 97.60% for diagnosis of type A AAD, and 83.60% and 94.50% for diagnosis of type B AAD, respectively. On the other hand, conventional TOE was 93.64% sensitive and 95.50% specific for the diagnosis of type A AAD, 99.80% sensitive and 99.87% specific for the diagnosis of type B AAD. Moreover, our analyses show that TTE has pooled false negative and positive rates of 28.6% and 18.6%, while TOE has shown false negative and positive rates of 2.4% and 4.3%, respectively. Conclusion TOE is the more favorable diagnostic tool for AAD diagnosis than TTE. However, it cannot be used as a stand-alone diagnostic tool since misdiagnosis cases are being reported. Contrast-enhanced TTE can also diagnose AAD since it provides similar results to conventional TOE.
The United Arab Emirates (UAE) has experienced substantial development in infrastructure and transportation in the last few decades. Although available evidence suggests that the incidence of injuries has considerably increased in the previous few years, there is a scarcity of literature that comprehensively analyzed the mortality due to different types of injuries in the UAE. Therefore, the current study was designed to report mortality due to various intentional and unintentional injuries in the UAE. Secondary data was obtained from the World Health Organization (WHO) mortality database. We targeted injuries-specific mortality datasets. We applied a filter (UAE) to retrieve mortality data from unintentional and intentional injuries in the UAE. The latest data in the WHO mortality database was for 2020-21. A total of 10,357 death records from the UAE were present in the WHO mortality database. The percentage of injury-specific deaths out of total deaths was 8.69% (n=900). Injury-specific mortality rate per 100,000 population was 9.09. The percentage of injury-specific deaths was higher for males (87.3%, n=786) and the age group 25-34 years (n=323, 35.9%). Of the 900 injury-specific deaths, 449 (49.9%) were due to unintentional injuries, 216 (24.0%) were due to unintentional injuries, while the remaining (26.1%, n=235) deaths occurred due to Ill-defined injuries. More than half (53.7%, n=241) of unintentional injuries were because of road traffic injuries (RTIs) followed by fall (14.7%, n=66), exposure to mechanical forces (6.5%, n=29), drowning (6.0%, n=27) fire (1.1%, n=5), poisonings (1.1%, n=5), natural disasters (n=1, 0.2%) and other unintentional injuries (16.7%, n=75). More than three-quarters (83.3%, n=180) of intentional injuries were because of self-inflicted injuries while the remaining (16.7%, n=36) intentional injuries-specific deaths occurred due to violence. Many deaths in the UAE occur due to unintentional and intentional injuries. RTIs and falls are the leading causes of unintentional injury-specific deaths, while self-inflicted injuries and violence are the leading causes of intentional injury-specific deaths.
Abstract Aims To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). Methods We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of “strongly agree” and “agree” on the Likert scale responses. Findings and Recommendations One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3–5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6–8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). Conclusion These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
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Abstract Background The assessment of deep venous thrombosis (DVT) is clinically difficult diagnosis. The “gold standard test” for DVT diagnosis is venography; however, various point-of-care ultrasound (POCUS) protocols have been suggested for DVT evaluation in the emergency department. Aims This review evaluated the role of different POCUS protocols in diagnosing DVT in the emergency department. Methods A systematic review and meta-analysis was conducted based of PRISMA guideline and registered on PROSEPRO (CRD42023398871). An electronic database search in Embase, PubMed, ScienceDirect, and Google scholar and a manual search were performed to identify eligible studies till February 2023. Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was used to assess the risk of bias in included studies. Quantitative analysis was carried out using STATA 16 and Review Manager software (RevMan 5.4.1). Sensitivity, specificity of POCUS protocols for DVT diagnosis compared to reference standard test was calculated. Results Heterogeneity was identified between 26 included studies for review. The pooled sensitivity, specificity, PPV, and NPV for the 2-point POCUS protocol were 92.32% (95% CI: 87.58–97.06), 96.86% (95% CI: 95.09–98.64), 88.41% (95% CI: 82.24–94.58) and 97.25% (95% CI: 95.51–98.99), respectively. Similarly, the pooled sensitivity, specificity, PPV, and NPV for 3-point POCUS were 89.15% (95% CI: 83.24–95.07), 92.71% (95% CI: 89.59–95.83), 81.27% (95% CI: 73.79–88.75), and 95.47% (95% CI: 92.93–98). The data pooled for complete compression ultrasound, and whole-leg duplex ultrasound also resulted in a sensitivity and specificity of 100% (95% CI: 98.21–100) and 97.05% (95% CI: 92.25–100), respectively. On the other hand, the time from triage to DVT diagnosis was significantly shorter for emergency physician-performed POCUS than diagnostic tests performed by radiologists. Conclusion The diagnostic performance of POCUS protocols performed by emergency physicians was excellent. Combined with the significant reduction in time to diagnosis. POCUS can be used as the first-line imaging tool for DVT diagnosis in the emergency department. We also recommended that attending emergency physicians with POCUS training are present during DVT diagnosis to improve diagnostic performance even though high diagnostic performance is observed even with the minimum training.
Ventricular tachycardia (VT) is a type of broad complex tachycardia originating from a focus in the ventricle. It is one of the four important rhythms which can lead to cardiac arrest. Accurate and timely diagnosis of true VT is the cornerstone for proper management in the emergency department (ED). We present an interesting case of an electrocardiographic artifact mimicking VT, which led to a diagnostic dilemma in the ED.
Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced, in patients presenting to ED.
Abstract Objective To evaluate the evidence and produce a summary and recommendations for the most common heart and lung point-of-care ultrasound (PoCUS). Methods We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendations were produced, including assigning levels of evidence (LoE) and grading of recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement of the summary and recommendation for each question (using a 5-point Likert scale), which was approved in the case of a level of agreement of greater than 75 %. A level of agreement was defined as a summary of “strongly agree” and “agree” on the Likert scale responses. Findings and Recommendations One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1), the remaining 9 questions achieved broad agreement with an assigned LoE of 4 and a weak GRADE recommendation (question 2), three achieved an LoE of 3 with a weak GRADE recommendation (questions 3–5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6–8) and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). Conclusion These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
Patients with chronic kidney disease (CKD) that progresses to end-stage renal disease (ESRD) typically present with uremic symptoms. CKD causes renal osteodystrophy, which leads to disturbances in mineral and bone metabolism. Pathological bone fractures after seizures activity has been reported in literature. In this study, we present what we consider the first case of combined bilateral femoral neck fractures, bilateral temporomandibular joint dislocations, and right shoulder anterior fracture dislocation in a patient who had a seizure activity due to electrolyte imbalance resulting from ESRD. The patient is a 36-year-old man with CKD that progressed to ESRD. Joint dislocations and bone fractures are rare complications of seizures activity. Diagnosis is usually delayed due to the low prevalence of these complications after seizures. Clinicians should always bear in mind that ESRD places patients at high risk of these rare complications.
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