Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators

PURPOSE

Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension.

METHODS

This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis.

RESULTS

Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9-98.5) vs.93.8% (87.7-97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88-97.2) vs 93.6% (87.8-97.2)]. Diagnostic performance measures were similar across sub-categories of shock.

CONCLUSION

This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.

The role of CCN family genes in haematological malignancies

Haematological malignancies, although a broad range of specific disease types, continue to show considerable overlap in classification, and patients are treated using similar chemotherapy regimes. In this review we look at the role of the CCN family of matricellular proteins and indicate their role in nine haematological malignancies including both myeloid and lymphoid neoplasms. The potential for further haematological neoplasms with CCN family associations is argued by summarising the demonstrated role of CCN family genes in the differentiation of haematopoietic stem cells (HSC) and mesenchymal stem cells. The expanding field of knowledge encompassing CCN family genes and cancers of the HSC-lineage highlights the importance of extracellular matrix-interactions in both normal physiology and tumorigenesis of the blood, bone marrow and lymph nodes.

Novel CT domain-encoding splice forms of CTGF/CCN2 are expressed in B-lineage acute lymphoblastic leukaemia

INTRODUCTION

Connective tissue growth factor (CTGF/CCN2) has been shown previously to be aberrantly expressed in a high proportion of paediatric precursor B cell acute lymphoblastic leukaemia (pre-B ALL), suggesting a potential oncogenic role in this tumour type. We therefore assessed CTGF mRNA transcript diversity in B-lineage ALL using primary patient specimens and cell lines.

METHODS

CTGF mRNA expression was evaluated by quantitative real-time PCR and Northern blotting. We performed a structural analysis of CTGF mRNA by nested reverse-transcriptase PCR and examined CTGF protein diversity by immunoblotting.

RESULTS

Northern blot analysis of pre-B ALL cell lines revealed short CTGF transcripts that were expressed in association with the active phase of cellular growth. Structural analysis confirmed the synthesis of several novel CTGF mRNA isoforms in B-lineage ALL cell lines that were uniformly characterised by the retention of the coding sequence for the C-terminal (CT) domain. One of these novel spliceforms was expressed in a majority (70%) of primary pre-B ALL patient specimens positive for canonical CTGF mRNA. Evidence that these alternative transcripts have coding potential was provided by cryptic CTGF proteins of predicted size detected by immunoblotting.

CONCLUSION

This study identifies for the first time alternative splicing of the CTGF gene and shows that a short CTGF splice variant associated with cell proliferation is expressed in most cases of primary CTGF-positive pre-B ALL. This novel variant encoding only the CT domain may play a role in pre-B ALL tumorigenesis and/or progression.

Burnout in emergency department healthcare professionals is associated with coping style: a cross-sectional survey

INTRODUCTION

Ineffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency physicians, nurses and support staff at seven small, medium and large emergency departments (ED) in a Canadian health region (population 500,000).

METHODS

Linear regression with the Coping Inventory for Stressful Situations (CISS) and Maslach Burnout Inventory (MBI) was used to evaluate the effect of coping style on levels of burnout in a cross-sectional survey of 616 ED staff members. CISS measures coping style in three categories: task-oriented, emotion-oriented and avoidance-oriented coping; MBI, in use for 30 years, assesses the level of burnout in healthcare workers.

RESULTS

Task-oriented coping was associated with decreased risk of burnout, while emotion-oriented coping was associated with increased risk of burnout.

DISCUSSION

Specific coping styles are associated with varied risk of burnout in ED staff across several different types of hospitals in a regional network. Coping style intervention may reduce burnout, while leading to improvement in staff well-being and patient outcomes. Further studies should focus on building and sustaining task-oriented coping, along with alternatives to emotion-oriented coping.

Outcomes of salvage therapy for steroid-refractory acute severe ulcerative colitis: ciclosporin vs. infliximab

BACKGROUND

Up to 40% of patients who present with acute severe ulcerative colitis (UC) fail to make an adequate response to intravenous corticosteroids. Ciclosporin or infliximab are currently employed as salvage therapy in this clinical scenario.

AIM

To compare clinical outcomes in patients treated with ciclosporin or infliximab in the setting of steroid-refractory acute severe UC.

METHODS

A prospective study of 83 consecutive presentations of steroid-refractory acute severe UC from 1999 to 2009 was conducted. All study participants satisfied the Truelove and Witts' criteria for acute severe UC. The primary outcome measures were rates of colectomy at discharge from hospital and at 3 months and 12 months following admission.

RESULTS

Eighty-three steroid-refractory acute severe UC events were generated by 83 patients. Salvage therapy was instituted with ciclosporin in 45 patients and infliximab in the remaining 38 patients. Of those patients who received ≥72 h of ciclosporin (2-4 mg/kg), 56% (24/43) avoided colectomy at the time of discharge, while this figure was 84% (32/38) for those administered one dose of infliximab (5 mg/kg) (P = 0.006). At 3 months, the colectomy-free rate was 53% for ciclosporin (23/43) vs. 76% for infliximab (28/37) (P = 0.04), and 42% (18/43) vs. 65% (24/37) at 12 months (P = 0.04). There were no deaths and two serious adverse events, both occurring in the ciclosporin group.

CONCLUSIONS

In this large cohort of patients presenting with acute severe UC, we have observed that infliximab salvage therapy is associated with lower rates of both severe adverse events and colectomy than ciclosporin in the short-term and medium-term.

Towards non-invasive screening of skin lesions by near-infrared spectroscopy

A noninvasive tool for skin tumor diagnosis would be a useful clinical adjunct. The purpose of this study was to determine whether near-infrared spectroscopy can be used to noninvasively characterize skin lesions. In vivo visible- and near-infrared spectra (400--2500 nm) of skin neoplasms (actinic keratoses, basal cell carcinomas, banal common acquired melanocytic nevi, dysplastic melanocytic nevi, actinic lentigines, and seborrheic keratoses) were collected by placing a fiberoptic probe on the skin. Paired t tests, repeated measures analysis of variance and linear discriminant analysis were used to determine whether significant spectral differences existed and whether spectra could be classified according to lesion type. Paired t tests showed significant differences (p < 0.05) between normal skin and skin lesions in several areas of the near-infrared spectrum. In addition, significant differences were found between the lesion groups by analysis of variance. Linear discriminant analysis classified spectra from benign lesions compared with premalignant or malignant lesions with high accuracy. Near-infrared spectroscopy is a promising noninvasive technique for the screening of skin lesions.

Drug use, self report and urinalysis

Stimulated by the ever present demand to consider the financial implications in management decisions, this study examines the use of urinalysis and self-report in the treatment of drug users, to question if urinalysis, rather than being a routine investigation, could be used with greater discrimination without jeopardising its effectiveness. It concludes that urinalysis remains of importance, as an adjunct to self-report, in providing information and in the treatment of drug users. Suggestions are made as to how it might be used more selectively in treatment based on a clinical knowledge of individual patients and their progress in treatment. However further research is needed to support and define this more clearly.

The effects of dietary folate and zinc on the outcome of pregnancy and early growth in rats

1. The objective of the present study was to determine the effects of two levels of folic acid and two levels of zinc in the diets of rats during pregnancy and lactation. It addressed, among other things, the question of whether an inhibitory effect of folic (pteroylmonoglutamic) acid on Zn absorption might result in a secondary Zn deficiency in either the dams or the pups. 2. A purified diet was given to four groups of female DNL (Norwegian) Hooded rats, before and during pregnancy and during lactation. It contained the four possible combinations of: no added folic acid or 100 micrograms added pteroylmonoglutamic acid/g, and 6.6 or 20.2 micrograms Zn/g. Pups and dams were killed on day 20 of gestation or on day 20 postpartum. Measurements of body-weights, food intakes, blood folate and tissue Zn levels were performed. 3. The group with low Zn and low folate intake had a satisfactory reproductive outcome, and there were only minor effects of the supplements on body-weights. 4. Additional folate greatly increased blood (erythrocyte and plasma) folate levels, but did not compromise tissue Zn concentrations. Zn supplementation also enhanced blood folate levels, for reasons which are not yet clear. 5. There was a moderate enhancing effect of the Zn supplement on Zn levels in the livers and kidneys of pregnant dams, and the kidneys of lactating dams. 6. If the conclusions can be extrapolated to humans, then the results provide some reassurance that a high folate intake from prenatal supplementation need not necessarily cause Zn depletion, and hence functional Zn deficiency in pregnant women and their offspring.

Building an occupational health unit library

It is unreasonable to expect occupational health nurses (OHNs) to memorize all the information needed for effective practice. OHNs should have adequate resource materials (library) available to aid them in quickly obtaining needed information.

The library could also be of use to other safety and health personnel, management and employees. Nine content areas for the library are described.