Introduction: Pneumothoraces are frequently treated by emergency physicians. Tube thoracostomy, the definitive treatment for a spontaneous pneumothorax, is associated with significant pain. Analgesia prior to tube thoracostomy often involves the administration of opioids and local infiltration of anesthetics. Thus far, regional anesthesia prior to pigtail tube thoracostomy in the emergency department (ED) has not been well described; it offers promise in alleviating pain associated with this procedure. Due to its ability to anesthetize all or most of the structures associated with tube thoracostomy—skin, serratus anterior muscles, intercostal muscles, and the parietal pleura—the serratus anterior plane block (SAPB) is a potentially promising fascial plane block prior to pigtail tube thoracostomy. Case Series: We present three cases of patients in the ED who received a SAPB and had nearly complete or complete anesthesia during pigtail tube thoracostomy. Conclusion: Pigtail tube thoracostomies are commonly performed in the ED and can be associated with significant pain despite a multimodal approach to pain management. The SAPB offers a safe and effective approach to anesthesia for patients in the ED undergoing a pigtail tube thoracostomy.

BACKGROUND AND PURPOSE:The Brain Tumor Reporting and Data System (BT-RADS) is a structured radiology reporting algorithm that was introduced to provide uniformity in posttreatment primary brain tumor follow-up and reporting, but its interrater reliability (IRR) assessment has not been widely studied. Our goal is to evaluate the IRR among neuroradiologists and radiology residents in the use of BT-RADS. MATERIALS AND METHODS:This retrospective study reviewed 103 consecutive MR studies in 98 adult patients previously diagnosed with and treated for primary brain tumor (January 2019 to February 2019). Six readers with varied experience (4 neuroradiologists and 2 radiology residents) independently evaluated each case and assigned a BT-RADS score. Readers were blinded to the original score reports and the reports from other readers. Cases in which at least 1 neuroradiologist scored differently were subjected to consensus scoring. After the study, a post hoc reference score was also assigned by 2 readers by using future imaging and clinical information previously unavailable to readers. The interrater reliabilities were assessed by using the Gwet AC2 index with ordinal weights and percent agreement. RESULTS:Of the 98 patients evaluated (median age, 53 years; interquartile range, 41-66 years), 53% were men. The most common tumor type was astrocytoma (77%) of which 56% were grade 4 glioblastoma. Gwet index for interrater reliability among all 6 readers was 0.83 (95% CI: 0.78-0.87). The Gwet index for the neuroradiologists' group (0.84 [95% CI: 0.79-0.89]) was not statistically different from that for the residents' group (0.79 [95% CI: 0.72-0.86]) (χ2 = 0.85; P = .36). All 4 neuroradiologists agreed on the same BT-RADS score in 57 of the 103 studies, 3 neuroradiologists agreed in 21 of the 103 studies, and 2 neuroradiologists agreed in 21 of the 103 studies. Percent agreement between neuroradiologist blinded scores and post hoc reference scores ranged from 41%-52%. CONCLUSIONS:A very good interrater agreement was found when tumor reports were interpreted by independent blinded readers by using BT-RADS criteria. Further study is needed to determine if this high overall agreement can translate into greater consistency in clinical care.

Download This Paper Open PDF in Browser Add Paper to My Library Share: Permalink Using these links will ensure access to this page indefinitely Copy URL Copy DOI

<p>Antibody information and primer sequences.</p>

A case of point-of-care-ultrasound identification of pyogenic flexor tenosynovitis (PFT) is presented here. 38 year old male presented one day after removing a splinter from the third digit of his left hand. He developed pain and swelling to the digit. He held the digit in passive flexion. Passive range of motion caused significant pain to the patient. X-Ray showed no foreign body or deformity but did show soft tissue edema. Point-of-care-ultrasound with the digit in a water bath revealed soft tissue edema, fluid surrounding the tendon, and no foreign body. Ultrasound of other digits on the same hand showed no pathological findings. Plastic surgery evaluated the patient initially concerned for cellulitis but agreed with concern for PFT given the exam and ultrasound findings. The patient was started on antibiotics, admitted for monitoring, elected non-operative management, eventually discharged on antibiotics, and has been having improved movement with physical therapy in the affected digit. Use of ultrasound in this case helped aid in the decision making process and disease management.

Supplemental Figure 1. Comparison of the anti-proliferative activity of SMAP across a panel of cell lines. Supplemental Figure 2. The chemical structure of SMAPs utilized in the studies detailed in the manuscript. Supplemental Figure 3. The effects of SMAPs on cell proliferation and cell survival. Supplemental Figure 4. Control studies for co-immunoprecipitation experiments. Supplemental Figure 5. Activity of SMAPs in vivo with the correlation of anti-tumor activity with SMAP-2 exposure in serum of treated mice.

Table S1. KSEA Analysis and the Mean FC Method in LNCaP treated with SMAP. Table S2. ANOVA with multiple comparisons and Dunnett''s post-hoc test for SMAP treated LNCaP colony formation assay. Table S3. ANOVA with multiple comparisons and Dunnett''s post-hoc test for SMAP treated 22Rv1 colony formation assay. Table S4. ANOVA with multiple comparisons and Dunnett''s post-hoc test for Annexin V staining of LNCap and 22Rv1 cells. Table S5. PPI of the phosphoproteomics dataset. Table S6. Kinase Substrate Database for LNCaP treated with SMAP. Table S7. ANOVA with multiple comparisons and Tukey''s post-hoc test for SMAP treatment in LNCaP cells phosphorylated to total AR ratio protein. Table S8. ANOVA for qRT-PCR RNA for AR targets in LNCaP and 22Rv1 cells in presence of SMAPs. Table S9. ANOVA with multiple comparisons and Dunnett''s post-hoc test for LNCaP and 22Rv1 cells treated with SMAP, bortezomib, and combination. Table S10. ANOVA with multiple comparisons and Tukey''s post-hoc test for relative AR protein expression in LNCaP- Small T stably expressing lines treated with SMAP. Table S11. ANOVA with multiple comparisons and Tukey''s post-hoc test for relative AR protein expression in LNCaP cells in FBS or CSS in presence or absence of R1881. Table S12. ANOVA for qRT-PCR RNA AR targets statistical analysis for LNCaP cells in FBS or CSS in presence or absence of R1881. Table S13. ANOVA with multiple comparisons and Dunnett''s post-hoc test for LnCaP/AR xenograft treatment study: vehicle control, SMAP 400mg/kg, SMAP 100mg/kg and MDV3100 100mg/kg. Table S14. ANOVA with multiple comparisons and Dunnett''s post-hoc test for castrated LNCaP/AR tumor volumes for individual treatments groups: Vehicle control, SMAP-2 100mg/kg and SMAP-2 30mg/kg. Table S15. ANOVA with multiple comparisons and Dunnett''s post-hoc test for TUNEL positive staining quantification from castrated LNCaP/AR tumors from individual treatments groups: Vehicle control, SMAP-2 30mg/kg and SMAP-2 100mg/kg. Table S16. ANOVA with multiple comparisons and Dunnett''s post-hoc test for PCNA positive staining quantification from castrated LNCaP/AR for individual treatments groups: Vehicle control, SMAP-2 100mg/kg and SMAP-2 30mg/kg.

<p>STR DNA Profiling for Cell Line Authentication</p>

BACKGROUND:Shoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction.CASE REPORT:We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

Background: Various commercially available and do-it-yourself (DIY) models are used to teach emergency medicine (EM) residents and medical students ultrasound (US)-guided i.v. insertion. Expensive commercial models degrade over time, but DIY models are inexpensive, easily prepared, and readily discarded. Objective: We tested the hypothesis that DIY models are equally effective as commercial models for teaching US-guided i.v. insertion, and using a controlled trial to subjectively evaluate how well DIY models and commercially manufactured models compare with human tissue both tactilely and sonographically. Methods: We tested three models for US-guided i.v. teaching-a commercially available model US training block model, a homemade tofu model, and a homemade gelatin model. All three models were compared with US-guided i.v. insertion involving human tissue. Study participants were EM residents and EM attendings experienced in US-guided i.v. placement in real patients. After practicing peripheral i.v. placement under US guidance using the three media, participants at various levels of training and experience with US-guided i.v. insertion subjectively described how each media compared tactilely and sonographically, which model was most similar to a live human overall, and which model was best for instructing learners. Results: The overall score (sum of visual and sonographic scores) for the gelatin model was significantly higher than either of the other models, indicating that the gelatin model was evaluated as most approximate to the anatomy of a human compared with the other models. Conclusions: Inexpensive homemade alternatives to commercial simulators can be realistic and effective surrogates for learning US-guided peripheral i.v. placement. (C) 2022 Published by Elsevier Inc.

Background Spondylolisthesis is often misdiagnosed on magnetic resonance imaging (MRI) as the slip may reduce to a normal alignment when the patient lies supine. Often, disc herniation is reported at the level of spondylolisthesis. Purpose To determine the incidence rates of disc herniation at the level of spondylolisthesis. Material and Methods This is a retrospective study included 258 consecutive patients with spondylolisthesis who had lumbar spine MRI. The archived reports were collectively put in Group 1. A musculoskeletal radiologist and a spine surgeon reviewed the imaging studies together. Their readings were referred to as Group 2. The findings of both groups were compared to evaluate whether disc herniation was overreported. Results Group 1 reported findings of true disc herniation in 112 (41.6%) cases and pseudo disc herniation or no findings of disc herniation at the level of spondylolisthesis in 157 (58.4%) cases. Group 2 reported findings of a true disc herniation in 25 (9.3%) cases and pseudo disc herniation or no findings of disc herniation in the remaining 244 (90.7%) cases. There was a statistically significant difference in the reporting rates between these two groups (P < 0.02). The most overreported finding was the disc bulging (P < 0.01). Conclusion The current study showed overreporting of disc herniation in lumbar spine MRI scans performed for patients with established spondylolisthesis. The majority of disc pathology at the level of spondylolisthesis are pseudo disc rather than a true disc herniation. An accurate diagnosis is vital in planning surgical intervention.

Purpose To compare logistic regression to elastic net for identifying and ranking clinical risk factors for blunt cerebrovascular injury (BCVI). Materials and methods Consecutive trauma patients undergoing screening CTA at a level 1 trauma center over a 2-year period. Each internal carotid artery (ICA) and vertebral artery (VA) was independently graded by 2 neuroradiologists using the Denver grading scale. Unadjusted odds ratios were calculated by univariate and adjusted odds ratios by multiple logistic regression with FDR correction. We applied logistic regression with the elastic net penalty and tenfold cross-validation. Results Total of 467 patients; 73 patients with BCVI. Maxillofacial fracture, basilar skull fracture, and GCS had significant unadjusted odds ratios (OR) for ICA injury and C-spine fracture, spinal ligamentous injury, and age for VA injury. Only transverse foramen fracture had significant adjusted OR for VA injury, with none for ICA injury, after FDR correction. Using elastic net, ICA injury variables included maxillofacial fracture, basilar skull fracture, GCS, and carotid canal fracture. For VA injury, these included cervical spine transverse foramen fracture, ligamentous injury, C1-C3 fractures, posterior element fracture, and vertebral body fracture. Conclusion Elastic net statistical learning methods identified additional risk factors and outperformed multiple logistic regression for BCVI. Elastic net allows the study of a large number of variables, and is useful when covariates are correlated.

Histology, a pillar of anatomical sciences for both health professional and graduate students, requires sufficient time and practice to develop the necessary visual literacy and skills in synthesis to achieve competency. However, histology contact hours in medical and graduate education have reduced significantly in the past decades due to disseminated curricular changes emphasizing integration of basic sciences, clinical content and self-directed learning. In turn, adjunct online resources have been in steady incline and in the past year, in response to COVID-19, quickly became an essential component of anatomical sciences education following campus closures. Self-directed learning is challenging in normal circumstances as success is impacted by the level of student preparedness and engagement, which in turn can be dependent on the quality of the asynchronous learning resources. Although many online histology resources are available, few are comprehensive and provide step-by-step instruction in identification of structures in tissue slides. In this pilot project, the efficacy of using a commercial online histology (COH) course (DaVinci Academy, Cleveland, OH) as a primary preparatory resource in a graduate histology curriculum implementing a flipped-classroom pedagogy was assessed. During fall 2020 (F2020), first-year graduate students enrolled in a hybrid histology course were required to review learning objectives, read textbook sections, and complete the COH lessons, consisting of complete lectures, lab videos, and quizzes as a set of pre-work to prepare for on-campus and virtual classes. The synchronous class sessions had minimal didactic lectures, but instead had a series of small group active learning tasks. In a COMIRB exempt retrospective study (#20-2891), the assessment outcomes of the F2020 cohort (n=26) were compared to a fall 2019 (F2019) cohort of students (n=25) who completed the identical histology curriculum delivered in a flipped-class style by the same instructor, but without the commercial online histology course. All course quiz and exam scores were compared across the F2019 and F2020 cohorts using a Kruskal Wallis test for non-parametric data. There were no significant differences in assessment outcomes between F2019 and F2020 cohorts (p>0.05). Survey of the F2020 cohort throughout the course revealed consistently high rating of the COH with 80% of students believing the resource improved their ability to read and interpret histology slides. Interestingly, students perceived the lecture and lab videos in the COH delivered by the same in-class instructor to be more valuable than those delivered by a third-party instructor, although the assessment performance was independent of the online instructor (p>0.05). The results suggest that the online histology course can be an effective asynchronous learning resource for a histology course, allowing for more efficient use of synchronous class time to support a higher taxonomy of learning.

The Fascia Iliaca Compartment Block (FICB) is a regional nerve block that allows for complete anesthesia of the hip, as well as some parts of the thigh and knee. It is frequently administered in the Emergency Department (ED) for hip dislocations and fractures, and its successful application is associated with significantly decreased morbidity and mortality. However, we believe that its value far exceeds hip fractures, and that it should be used to alleviate pain for any acute or acute on chronic form of hip pathology. As emergency room physicians, it is our responsibility to initiate this mortality reduction in the ED.