Ultrasound guided lumbar erector spinae block: A case series on a novel technique for the treatment of acute low Back pain

Low back pain is among one of the most common presentations to the emergency department (ED). Regional anesthesia has recently gained traction as an option for analgesia in ED patients, especially in the wake of the opioid epidemic. Data on lumbar application of the ESPB in the setting of acute, refractory low back pain in the ED is scarce. We describe a series of three cases of patients who presented to the ED with severe low back pain refractory to traditional therapy, successfully treated using lumbar ESPB. Lumbar ESPB may be an effective approach to achieving rapid analgesia in patients who present with low back pain who may otherwise be poor candidates for more traditional therapy, such as with opioids or NSAIDs, or who may have refractory pain despite use of these medications.

Ultrasound guided transgluteal sciatic nerve hydrodissection for the treatment of acute sciatica in the emergency department

Radicular pain due to sciatica is a common occurrence with a lifetime incidence of up to 40%. Typical approaches to treatment vary and may include topical and oral analgesics, such as opioids, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs); however, these medications may be contraindicated in some or result in untoward effects in others. The use of ultrasound-guided regional anesthesia is an important component of multimodal analgesia in the emergency department. Transgluteal sciatic nerve block has been described as an effective method to treat patients with sciatica but carries risk of injury and falls due to its resultant loss of motor function and potential for systemic toxicity when higher volumes are used. Ultrasound-guided peripheral nerve hydrodissection with D5W has been shown to be an effective treatment of various compressive neuropathies in the outpatient setting. Here we present 4 cases of patients who presented to the emergency department with severe acute sciatica and were treated successfully using an ultrasound guided transgluteal sciatic nerve hydrodissection (TSNH). This technique may offer a safe and effective approach to treating patients with sciatica, but more studies are needed to assess its utility on a larger scale.

Morphologic changes in red blood cells: An illustrated review of clinically important light microscopic findings

In this article, we provide an illustrated review that may serve as a microscope companion, as well as a reference for the diagnosis of red blood cells alterations and the interpretation of their significance. Beginners in the fields of clinical haematology and haematopathology may benefit from this manuscript's brevity and practical points, while the more advanced will find it useful as a teaching tool.

Point-of-Care Ultrasound in the Evaluation of COVID-19

BACKGROUND

The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care.

OBJECTIVES

This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic.

DISCUSSION

The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings.

CONCLUSION

Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.

Is this a blast? An illustrated practical review on peripheral blood smear examination in the paediatric patient

The morphologic findings on a peripheral blood smear can provide important clues that help establish a diagnosis or guide the workup of many clinical disorders. Finding a blast - whether clinically expected or not - is one of the most impactful of such findings. Pathologists, clinical haematologists, technologists, and trainees in the medical field often feel the need to refer to an illustrated reference when encountering suspected blasts and blast-mimics. This article provides a practical concise resource that demonstrates the morphological features of the various types of blasts and illustrates the cytologic characteristics that help distinguish them from their benign mimickers in the paediatric population.

More feed efficient sheep produce less methane and carbon dioxide when eating high-quality pellets

The Australian sheep industry aims to increase the efficiency of sheep production by decreasing the amount of feed eaten by sheep. Also, feed intake is related to methane production, and more efficient (low residual feed intake) animals eat less than expected. So we tested the hypothesis that more efficient sheep produce less methane by investigating the genetic correlations between feed intake, residual feed intake, methane, carbon dioxide, and oxygen. Feed intake, methane, oxygen, and carbon dioxide were measured on Merino ewes at postweaning (1,866 at 223 d old), hogget (1,010 sheep at 607 d old), and adult ages (444 sheep at 1,080 d old). Sheep were fed a high-energy grower pellet ad libitum for 35 d. Individual feed intake was measured using automated feeders. Methane was measured using portable accumulation chambers up to 3 times during this feed intake period. Heritabilities and phenotypic and genotypic correlations between traits were estimated using ASReml. Oxygen (range 0.10 to 0.20) and carbon dioxide (range 0.08 to 0.28) were generally more heritable than methane (range 0.11 to 0.14). Selecting to decrease feed intake or residual feed intake will decrease methane (genetic correlation [] range 0.76 to 0.90) and carbon dioxide ( range 0.65 to 0.96). Selecting to decrease intake ( range 0.64 to 0.78) and methane ( range 0.81 to 0.86) in sheep at postweaning age would also decrease intake and methane in hoggets and adults. Furthermore, selecting for lower residual feed intake ( = 0.75) and carbon dioxide ( = 0.90) in hoggets would also decrease these traits in adults. Similarly, selecting for higher oxygen ( = 0.69) in hoggets would also increase this trait in adults. Given these results, the hypothesis that making sheep more feed efficient will decrease their methane production can be accepted. In addition, carbon dioxide is a good indicator trait for feed intake because it has the highest heritability of the gas traits measured; is cheaper, faster, and easier to measure than feed intake and has strong phenotypic and genetic correlations with feed intake. Furthermore, selection for feed intake, feed efficiency, methane, and carbon dioxide can be done early in sheep at postweaning age or hoggets. This early selection reduces the generation interval for breeding, thereby increasing response to selection.

Ultrasound-guided dorsal penile nerve block performed in a case of zipper entrapment injury

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:589-591, 2017.

Air and its Sonographic Appearance: Understanding the Artifacts

BACKGROUND

Although air has traditionally been considered a barrier to sonographic imaging, when encountered in unusual settings it can serve as an important indicator of various pathologic states as well. Clinician recognition and thorough understanding of the characteristic pattern of artifacts generated by air are critical for making a number of important diagnoses.

CASE SERIES

We present five emergency department cases in which air was visualized in a pathologic location. Pneumothorax, pneumoperitoneum, necrotizing fasciitis, or Fournier's gangrene, and subcutaneous emphysema and pneumomediastinum, can be rapidly and easily identified on ultrasound by the presence of air artifacts. The relevant sonographic findings are described and discussed in this article. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to its inherent impedance mismatch with other human tissues, air has a characteristic appearance on ultrasound that includes irregular hyperechoic structures, "dirty shadowing," A-lines, and decreased visualization of deeper structures. Knowledge of the sonographic appearance of air artifacts can assist the physician in making a diagnosis, selecting appropriate additional imaging, and enlisting specialist consultation.

Sonographer preference for Knox versus ballistic gelatin for the creation of deep venous thrombosis ultrasound phantoms

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Ultrasound for the evaluation of soft tissue foreign bodies before and after the addition of fluid to the surrounding interstitial space in a cadaveric model

BACKGROUND

Point-of-care ultrasound may be used to facilitate foreign body (FB) localization and removal. We hypothesized that injection of normal saline adjacent to an FB may make it easier to detect.

METHODS

The study was performed on one embalmed human cadaver. Potential FB sites were created of wood (24), metal (24), and null (24). Two sonographers evaluated each of the 72 sites both before and after a 25-gauge needle was inserted into each incision and 3 cc of normal saline was injected. Accuracy, sensitivity, and specificity were calculated both before and after injection of normal saline. Binomial tests were used to determine the statistical significance of FB detection before and after injection. A 2-tailed Student's t test was used to determine if there was a statistically significant difference between the 2 methods.

RESULTS

Preinjection, 116 (81%) of the 144 interpretations (P≤ .001) were correct in their assessment of whether or not an FB was present, with a sensitivity of 81% (95% confidence interval [CI], 72%-88%) and a specificity of 79% (95% CI, 65%-90%). Postinjection, 119 (83%) of these 144 interpretations (P≤ .001) were correct in their assessment of whether or not an FB was present, with a sensitivity of 85% (95% CI, 77%-92%) and a specificity of 77% (95% CI, 63%-88%). This difference was not significant (P=.08; 95% CI, -0.04 to 0.01).

DISCUSSION

Ultrasound was reasonably accurate, sensitive, and specific in identifying 1-cm metal and wood FBs. Although accuracy and sensitivity did improve after normal saline injection, this difference was not significant.

Diagnosis of Atypical Chest Pain Using Ultrasound

While the common organs assessed in chest pain are the heart, lungs, and inferior vena cava, one must also consider other diagnoses. Splenic rupture can be either traumatic or atraumatic, and splenomegaly can make this vulnerable organ even more susceptible to injury. A case is reported of a patient who presented to the emergency department with a complaint of left-sided chest pain; a focused assessment with sonography for trauma (FAST) examination showed significant intraperitoneal free fluid consistent with splenic injury. The role of bedside sonography in acquiring a rapid and accurate diagnosis is discussed.

Increasing the visibility of thin NITINOL vascular implants

New implants for vascular therapy like flow diverters are made of tiny braided wires. The radio opacity of these wires is poor, which makes assessment of implant expansion and exact positioning difficult. Additional markers only allow the estimation of the current device position, but they also induce artefacts that impair the assessment during the intervention and in follow-up examination. A new strategy to increase implant visibility is the braiding of composite wires with a radiopaque core along the whole implant. This paper shows some useful combinations of these new wires on a phantom study with five vascular implants.

Ultrasound accurately identifies soft tissue foreign bodies in a live anesthetized porcine model

BACKGROUND

Some subcutaneous foreign bodies (FBs) are not easily visualized during physical examination and may not be detected on radiographic evaluation. Ultrasound (US) is capable of visualizing FBs of varying compositions. Previous studies have examined the use of US to detect FBs in deceased animal or human tissue. This study used live anesthetized porcine tissue to more closely model clinical conditions.

OBJECTIVES

The objectives were to examine the test characteristics of US in the evaluation of FBs in living tissue and to evaluate if secondary findings such as surrounding edema and hematoma improve diagnostic accuracy.

METHODS

Institutional Animal Care and Use Committee (IACUC) approval was obtained. FBs 1 cm in length and 1 to 3 mm in width were created from toothpicks (wood), 21-gauge needles (metal), and a broken ampule (glass) and inserted subcutaneously into an anesthetized 20-kg Yorkshire swine. There were 72 sites implanted with equal proportions of each FB type and null sites. Half of the FBs were inserted at time 0 and half were inserted after 2 hours. Immediately after placement, four blinded physicians performed US evaluations of the first 36 sites. At 2 hours after placement, they evaluated each of the original 36 sites and the 36 new sites. They documented the presence or absence of FBs and surrounding edema.

RESULTS

After initial FB placement, 122 of the 144 interpretations (85%) were correct, with a sensitivity of 85% (95% confidence interval [CI] = 79% to 92%) and a specificity of 86% (95% CI = 76% to 98%). No sites demonstrated surrounding edema. At 2 hours after placement, 127 of 144 interpretations (88%) for these same sites were correct, with a sensitivity of 87% (95% CI = 82% to 93%) and a specificity of 89% (95% CI = 81% to 97%). Of the 108 observations (27 sites that contained FBs), eight of the 108 (7%) observations had surrounding edema (four glass, three wood, one metal). For the 36 new sites with FBs placed 2 hours later, 126 of the 144 interpretations (83%) were correct, with a sensitivity of 88% (95% CI = 82% to 94%) and a specificity of 83% (95% CI = 73% to 95%). No sites had surrounding edema present.

CONCLUSIONS

Ultrasound was sensitive, specific, and accurate in identifying FBs in live anesthetized porcine tissue. Surrounding edema or hematoma 2 hours after placement was so infrequently observed that it was not possible to determine its influence on the test characteristics.

Preferences of air-blood-saline sonographic microbubble contrast agents among emergency medicine resident physicians

INTRODUCTION

The placement of a central venous catheter (CVC) remains an important intervention in the care of critically ill patients in the emergency department, and bedside ultrasound can be used for procedural guidance as well as conformation of placement. Microbubble contrast-enhanced ultrasound may facilitate CVC tip position localization, and the addition of autologous blood can significantly increase its echogenicity. The purpose of this study was to describe the preferences of a group of resident physicians regarding the performance of various concentrations of air-blood-saline sonographic microbubble contrast agents.

METHODS

Institutional Animal Care and Use Committee approved prospective study. A CVC was inserted into the right internal jugular vein of a 20-kg Yorkshire swine under general anesthesia. Contrast mixtures were created with air, saline, and varying amounts of blood and were injected while echocardiographic video clips were recorded and reviewed by 25 physician sonographers.

RESULTS

All reading physicians reported increased overall echogenicity, a higher peak echogenicity, and greater personal preference for blood containing solutions. Nearly all reading physicians preferred the lower percentage blood containing mixtures over the higher percentage blood containing mixture.

CONCLUSION

The inclusion of 1 to 3 parts of 10 of the patient's blood in the preparation of a sonographic contrast mixture increased the echogenicity of the contrast, resulted in better visualization of both the contrast and the endocardial border and was the preferred mixture among the resident physicians studied.

A novel technique for the measurement of CBF and CBV with robot-arm-mounted flat panel CT in a large-animal model

BACKGROUND AND PURPOSE

Endovascular therapy is an emerging treatment option in patients with acute ischemic stroke and especially in cases presenting late after symptom onset. Information about remaining viable tissue as measured with perfusion imaging is crucial for proper patient selection. The aim of this study was to investigate whether perfusion imaging with C-arm CT in the angiography suite is feasible and provides measurements comparable with ones made by CTP.

MATERIALS AND METHODS

The MCA was occluded surgically in 6 sheep. Perfusion studies were performed before surgery, immediately after, and at 3 hours after MCA occlusion by using a robotic flat panel detector C-arm angiographic system. For comparison, conventional CTP was performed at the same time points. Two different protocols with the C-arm CT were tested. Images were analyzed by 2 readers with regard to the presence and size of perfusion abnormalities.

RESULTS

With C-arm CT, perfusion abnormalities were detected with a high sensitivity and specificity when vessel occlusion was confirmed by criterion standard DSA. No difference was found between lesions sizes measured with the 2 C-arm CT protocols and CTP. Growth of the CBV lesions with time was captured with C-arm CT and CTP.

CONCLUSIONS

In this small study, it was feasible to qualitatively measure CBV and CBF by using a flat panel detector angiographic system.

Genetic correlations between body weight change and reproduction traits in Merino ewes depend on age

Merino sheep in Australia experience periods of variable feed supply. Merino sheep can be bred to be more resilient to this variation by losing less BW when grazing poor quality pasture and gaining more BW when grazing good quality pasture. Therefore, selection on BW change might be economically attractive but correlations with other traits in the breeding objective need to be known. The genetic correlations (rg) between BW, BW change, and reproduction were estimated using records from approximately 7,350 fully pedigreed Merino ewes managed at Katanning in Western Australia. Number of lambs and total weight of lambs born and weaned were measured on approximately 5,300 2-yr-old ewes, approximately 4,900 3-yr-old ewes, and approximately 3,600 4-yr-old ewes. On a proportion of these ewes BW change was measured: approximately 1,950 2-yr-old ewes, approximately 1,500 3-yr-old ewes, and approximately 1,100 4-yr-old ewes. The BW measurements were for 3 periods. The first period was during mating period over 42 d on poor pasture. The second period was during pregnancy over 90 d for ewes that got pregnant on poor and medium quality pasture. The third period was during lactation over 130 d for ewes that weaned a lamb on good quality pasture. Genetic correlations between weight change and reproduction were estimated within age classes. Genetic correlations were tested to be significantly greater magnitude than 0 using likelihood ratio tests. Nearly all BW had significant positive genetic correlations with all reproduction traits. In 2-yr-old ewes, BW change during the mating period had a positive genetic correlation with number of lambs weaned (rg = 0.58); BW change during pregnancy had a positive genetic correlation with total weight of lambs born (rg = 0.33) and a negative genetic correlation with number of lambs weaned (rg = -0.49). All other genetic correlations were not significantly greater magnitude than 0 but estimates of genetic correlations for 3-yr-old ewes were generally consistent with these findings. The direction of the genetic correlations mostly coincided with the energy requirements of the ewes and the stage of maturity of the ewes. In conclusion, optimized selection strategies on BW changes to increase resilience will depend on the genetic correlations with reproduction and are dependent on age.

Transitional cell tumours of the lacrimal drainage apparatus

BACKGROUND

Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours.

METHODS

A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London.

RESULTS

Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free.

CONCLUSION

A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

Do patients with chronic rhinosinusitis with nasal polyps suffer with facial pain?

BACKGROUND

Many patients attribute their symptoms of facial pain or headache to sinus problems. Facial pain is one of the symptoms of rhinosinusitis according to European and American consensus documents. This symptom, however, has been insufficiently studied in the group of patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The aim of this work is to study the symptom of facial pain in patients with CRSwNP.

METHODS

Patients with CRSwNP were prospectively asked to score their facial pain according to the scoring system used in the Sino Nasal Outcome Test 22 (SNOT 22).

RESULTS

Fifty patients fulfilled the inclusion criteria. Thirty-one patients had grade II polyps and 19 patients had grade III polyps. Of these patients, 76% had absent or very mild facial pain. Only 16% of patients had moderate or severe facial pain. All patients with severe facial pain had viscid secretions within their sinuses.

CONCLUSION

Significant facial pain is uncommon in patients with CRSwNP. It is important to consider this when counselling patients before surgery.

Transitional cell tumours of the lacrimal drainage apparatus

BACKGROUND

Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours.

METHODS

A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London.

RESULTS

Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free.

CONCLUSION

A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

Merino ewes can be bred for body weight change to be more tolerant to uncertain feed supply

Sheep in Australia experience periods with different feed supply causing them to gain and lose BW during the year. It is more efficient if ewes lose less BW during periods of poor nutrition and gain more BW during periods of good nutrition. We investigated whether BW loss during periods of poor nutrition and BW gain during periods of good nutrition are genetically different traits. We used BW measurements from 2,336 adult Merino ewes managed over 5 yr in a Mediterranean climate in Katanning, Australia. Body weight loss is the difference between 2 BW measured 42 d apart during mating, a period of poor nutrition. Body weight gain is the difference between 2 BW measured 131 d apart during a period of good nutrition between prelambing and weaning. We estimated variance compnents of BW change using 3 methods: 1) as a trait calculated by subtracting the first BW from the second, 2) multivariate analysis of BW traits, and 3) random regression analysis of BW. The h(2) and genetic correlations (rg) estimated using the multivariate analysis of BW and the BW change trait were very similar whereas the random regression analysis estimated lower heritabilities and more extreme negative genetic correlations between BW loss and gain. The multivariate model fitted the data better than random regression based on Akaike and Bayesian information criterion so we considered the results of the multivariate model to be more reliable. The heritability of BW loss (h(2) = 0.05-0.16) was smaller than that of BW gain (h(2) = 0.14-0.37). Body weight loss and gain can be bred for independently at 2 and 4 yr of age (rg = 0.03 and -0.04) whereas at 3 yr of age ewes that genetically lost more BW gained more BW (rg = -0.41). Body weight loss is genetically not the same trait at different ages (rg range 0.13-0.39). Body weight gain at age 3 yr is genetically the same trait at age 4 yr (rg = 0.99) but is different between age 2 yr and the older ages (rg = 0.53 and 0.51). These results suggest that as the ewes reach their mature BW, BW gain at different ages becomes the same trait. This does not apply to BW loss. We conclude that BW change could be included in breeding programs to breed adult Merino ewes that are more tolerant to variation in feed supply.