Publications by authors named "Alan Chiem"

31 Publications

Feasibility of patient-performed lung ultrasound self-exams (Patient-PLUS) as a potential approach to telemedicine in heart failure.

ESC Heart Fail 2021 10 20;8(5):3997-4006. Epub 2021 Jul 20.

Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive North Annex, Sylmar, Los Angeles, California, 91342, USA.

Aims: Patient-performed lung ultrasound (LUS) in a heart failure (HF) telemedicine model may be used to monitor worsening pulmonary oedema and to titrate therapy, potentially reducing HF admission. The aim of the study was to assess the feasibility of training HF patients to perform a LUS self-exam in a telemedicine model.

Methods And Results: A pilot study was conducted at a public hospital involving subjects with a history of HF. After a 15 min training session involving a tutorial video, subjects performed a four-zone LUS using a handheld ultrasound. Exams were saved on a remote server and independently reviewed by two LUS experts. Studies were determined interpretable according to a strict definition: the presence of an intercostal space, and the presence of A-lines, B-lines, or both. Subjects also answered a questionnaire to gather feedback and assess self-efficacy. The median age of 44 subjects was 53 years (range, 36-64). Thirty (68%) were male. Last educational level attained was high school or below for 31 subjects (70%), and one-third used Spanish as their preferred language. One hundred fifty of 175 lung zones (85%) were interpretable, with expert agreement of 87% and a kappa of 0.49. 98% of subjects reported that they could perform this LUS self-exam at home.

Conclusions: This pilot study reports that training HF patients to perform a LUS self-exam is feasible, with reported high self-efficacy. This supports further investigation into a telemedicine model using LUS to reduce emergency department visits and hospitalizations associated with HF.
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http://dx.doi.org/10.1002/ehf2.13493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497224PMC
October 2021

Ultrasound Treasure Hunt: A Novel Teaching Method that Overcomes Direct-Patient Care Restrictions brought on by the COVID-19 Pandemic.

AEM Educ Train 2020 Oct 3. Epub 2020 Oct 3.

Department of Emergency Medicine David Geffen School of Medicine UCLA and Olive View UCLA Medical Center Los Angeles USA.

Prioritizing trainee safety during the COVID-19 era is paramount. In March 2020, the AAMC recommended prohibiting medical students from direct patient care in significantly affected regions. Guidelines continue evolving; however, the AMA continues to recommend clinical experiences, not requiring direct patient care, be achieved through virtual formats.
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http://dx.doi.org/10.1002/aet2.10541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675246PMC
October 2020

Pick Up Your Probes: A Call for Clinically Oriented Point-of-Care Ultrasound Research in COVID-19.

J Ultrasound Med 2021 Feb 20;40(2):391-396. Epub 2020 Jul 20.

Harbor-UCLA Medical Center, West Carson, California, USA.

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http://dx.doi.org/10.1002/jum.15394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405186PMC
February 2021

A Novel Three-Dimensional-Printed Ultrasound-Guided Hip Arthrocentesis Model.

J Ultrasound Med 2021 Jan 18;40(1):175-181. Epub 2020 Jun 18.

David Geffen School of Medicine at UCLA, Los Angeles, California, USA.

When evaluating patients with hip pain, clinicians may be trained to both evaluate for a hip effusion and perform ultrasound-guided arthrocentesis to evaluate the etiology of the effusion. We present a novel 3-dimensional-printed hip arthrocentesis model, which can be used to train clinicians to perform both tasks under ultrasound guidance. Our model uses a combination of a 3-dimensional-printed hip joint, as well as readily available materials such as an infant Ambu (Ballerup, Denmark) bag, syringe, intravenous line kit, and silicone. We present our experience so that others may use and adapt our model for their training purposes.
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http://dx.doi.org/10.1002/jum.15374DOI Listing
January 2021

Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department.

JAMA Netw Open 2019 04 5;2(4):e192162. Epub 2019 Apr 5.

Department of Emergency Medicine, University of California, Irvine.

Importance: Ocular symptoms represent approximately 2% to 3% of all emergency department (ED) visits. These disease processes may progress to permanent vision loss if not diagnosed and treated quickly. Use of ocular point-of-care ultrasonography (POCUS) may be effective for early and accurate detection of ocular disease.

Objective: To perform a large-scale, multicenter study to determine the utility of POCUS for diagnosing retinal detachment, vitreous hemorrhage, and vitreous detachment in the ED.

Design, Setting, And Participants: A prospective diagnostic study was conducted at 2 academic EDs and 2 county hospital EDs from February 3, 2016, to April 30, 2018. Patients who were eligible for inclusion were older than 18 years; were English- or Spanish-speaking; presented to the ED with ocular symptoms with concern for retinal detachment, vitreous hemorrhage, or vitreous detachment; and underwent an ophthalmologic consultation that included POCUS. Patients with ocular trauma or suspicion for globe rupture were excluded. The accuracy of the ultrasonographic diagnosis was compared with the criterion standard of the final diagnosis of an ophthalmologist who was masked to the POCUS findings. Seventy-five unique emergency medicine attending physicians, resident physicians, and physician assistants performed ocular ultrasonography.

Exposure: Point-of-care ultrasonography performed by an emergency medicine attending physician, resident physician, or physician assistant.

Main Outcomes And Measures: Sensitivity and specificity of POCUS in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment in patients presenting to the ED with ocular symptoms.

Results: Two hundred twenty-five patients were enrolled. Of these, the mean age was 51 years (range, 18-91 years) and 135 (60.0%) were men; ophthalmologists diagnosed 47 (20.8%) with retinal detachment, 54 (24.0%) with vitreous hemorrhage, and 34 (15.1%) with vitreous detachment. Point-of-care ultrasonography had an overall sensitivity of 96.9% (95% CI, 80.6%-99.6%) and specificity of 88.1% (95% CI, 81.8%-92.4%) for diagnosis of retinal detachment. For diagnosis of vitreous hemorrhage, the sensitivity of POCUS was 81.9% (95% CI, 63.0%-92.4%) and specificity was 82.3% (95% CI, 75.4%-87.5%). For vitreous detachment, the sensitivity was 42.5% (95% CI, 24.7%-62.4%) and specificity was 96.0% (95% CI, 91.2%-98.2%).

Conclusions And Relevance: These findings suggest that emergency medicine practitioners can use POCUS to accurately identify retinal detachment, vitreous hemorrhage, and vitreous detachment. Point-of-care ultrasonography is not intended to replace the role of the ophthalmologist for definitive diagnosis of these conditions, but it may serve as an adjunct to help emergency medicine practitioners improve care for patients with ocular symptoms.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.2162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481597PMC
April 2019

Effect of insonation angle on peak systolic velocity variation.

Am J Emerg Med 2020 02 29;38(2):173-177. Epub 2019 Jan 29.

Olive View-UCLA Medical Center, United States of America. Electronic address:

Objectives: As point of care ultrasound (POCUS) has become more integrated into emergency and critical care medicine, there has been increased interest in utilizing ultrasound to assess volume status. However, recent studies of carotid POCUS on volume status and fluid responsiveness fail to recognize the effect insonation angle has on their results. To address this, we studied the effect of insonation angle on peak systolic velocity (PSV) change associated with respiratory variation (RV) and passive leg raise (PLR).

Methods: Doppler measurements were obtained from 51 subjects presenting to the ED. Minimal and maximal PSV were obtained using insonation angles of 46°, 60°, and 90°. ∆PSV was calculated using PLR and RV as trial methods. Results were categorized into two groups, those with a ∆PSV > 10% and those with a ∆PSV ≤ 10%. ∆PSV mean and standard error, as well as measures of agreement were calculated.

Results: Mean ∆PSV associated with PLR test was 9% in the 46° and 60° groups, and 18% in the 90° group, with standard errors of 6, 7, and 14%, respectively. Using 46° as our relative gold standard, Kappa was 0.23 at 60° and 0.11 at 90° with RV as the trial method, and 0.23 at 60° and 0.01 at 90° with a PLR as the trial method.

Conclusions: Variation in PSV is heavily dependent on insonation angle. There was only slight to fair agreement in ∆PSV among the various insonation angles. Further investigation of the optimal insonation angle to assess ∆PSV should be undertaken.
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http://dx.doi.org/10.1016/j.ajem.2019.01.050DOI Listing
February 2020

Passive Leg Raise: Feasibility and Safety of the Maneuver in Patients With Undifferentiated Shock.

J Intensive Care Med 2020 Oct 20;35(10):1123-1128. Epub 2018 Dec 20.

Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.

Purpose: Passive leg raise (PLR), in combination with technologies capable of capturing stroke volume changes, has been widely adopted in the management of shock. However, dedicated evaluation of safety, feasibility, and receptiveness of patients and nursing staff to PLR maneuver is missing.

Methods: A noninterventional, prospective trial recruited adult patients with onset of undifferentiated shock within 24 hours with persistent vasopressor requirements despite fluid resuscitation. A standardized PLR maneuver was used to compare two noninvasive hemodynamic monitoring systems, each without significant impact on the performance of the maneuver. Safety and efficacy of the PLR were evaluated via subjective and objective measures. Objective measures of patient comfort and tolerance were evaluated through changes in vital signs, sedation, and analgesia requirements. Nurses and awake patients completed surveys on their experience.

Results: Seventy-nine patients were enrolled. Testing was aborted in 2 cases for medical reasons (one patient developed rapid atrial fibrillation, second had profound desaturation). Of all, 5.4% of patients required additional vasopressor support after completion of the PLR maneuver due to persistent hypotension and 4.1% of patients required additional sedation. Among awake patients (N = 35), 6% reported pain and 29% reported discomfort. A total of 11% of nurses reported minor technical difficulties with the maneuver.

Conclusion: Passive leg raise maneuver leads to a few serious but reversible complications in a selected population of hemodynamically unstable patients. Although it provides relevant diagnostic information, it may impact patient care. Treating physician should be aware of infrequent but possible complications and appreciate the impact of the maneuver on patients' comfort and nursing workload.
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http://dx.doi.org/10.1177/0885066618820492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8896338PMC
October 2020

A National Point-of-Care Ultrasound Competition for Medical Students.

J Ultrasound Med 2019 Jan 21;38(1):253-258. Epub 2018 May 21.

Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.

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http://dx.doi.org/10.1002/jum.14670DOI Listing
January 2019

Time to correct the flow of corrected flow time.

Crit Ultrasound J 2017 Oct 4;9(1):18. Epub 2017 Oct 4.

Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, USA.

Recently published study of Ma et al. evaluates two relatively novel measures of fluid responsiveness, carotid blood flow and corrected carotid flow time (ccFT). Both measures have been recently quoted as possibly useful, technically simple, and noninvasive dynamic tools in predicting fluid responsiveness. Recently, more research interest has been focused on ccFT and, intrigued by the data presented in this study, we discuss here the impact of the data presented in the paper of Ma et al. to the significance of this metric as a potential tool in the assessment of fluid responsiveness.
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http://dx.doi.org/10.1186/s13089-017-0076-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628080PMC
October 2017

Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study.

World J Emerg Med 2017 ;8(1):25-28

Department of Emergency Medicine, University of California, Irvine, Orange, California 92868, USA.

Background: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation.

Methods: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC.

Results: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95% 77.1%-93.5%) and specificity of 100% (95% 15.8%-100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10-29) and 32 minutes (IQR 19-45), respectively.

Conclusion: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2017.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263031PMC
January 2017

Role of Ultrasound in the Identification of Longitudinal Axis in Soft-Tissue Foreign Body Extraction.

West J Emerg Med 2016 Nov 29;17(6):819-821. Epub 2016 Sep 29.

Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California.

Identification and retrieval of soft-tissue foreign bodies (STFB) poses significant challenges in the emergency department. Prior studies have demonstrated the utility of ultrasound (US) in identification and retrieval of STFBs, including radiolucent objects such as wood. We present a case of STFB extraction that uses US to identify the longitudinal axis of the object. With the longitudinal axis identified, the foreign body can be excised by making an incision where the foreign body is closest to the skin. The importance of this technique as it pertains to minimizing surrounding tissue destruction and discomfort for patients has not been previously reported.
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http://dx.doi.org/10.5811/westjem.2016.8.30988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102617PMC
November 2016

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay.

World J Emerg Med 2016 ;7(3):178-82

Department of Emergency Medicine, University of California Irvine, Irvine, California 92697, USA.

Background: The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS).

Methods: This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment.

Results: We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01).

Conclusion: In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2016.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4988106PMC
August 2016

Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers.

West J Emerg Med 2016 May 26;17(3):377-82. Epub 2016 Apr 26.

University of California Irvine, Department of Emergency Medicine, Orange, California.

Introduction: The goal of this study was to investigate the efficacy of diagnosing shoulder dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed by undergraduate research students, and to establish the range of measured distance that discriminates dislocated shoulder from normal.

Methods: We enrolled a prospective, convenience sample of adult patients presenting to the emergency department with acute shoulder pain following injury. Patients underwent ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa and the humeral head. The sonographic measurement of the distance between these two anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD represented a posterior position of the glenoid rim relative to the humeral head and a negative GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of the derived US method were calculated.

Results: A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation on conventional radiography, all of which were anterior. All confirmed dislocations had a negative measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation. This method demonstrated a sensitivity of 100% (95% CI [82.4-100]), specificity of 100% (95% CI [94.5-100]), positive predictive value of 100% (95% CI [82.4-100]), and negative predictive value of 100% (95% CI [94.5-100]).

Conclusion: Our study suggests that a single, posterior-approach POCUS can diagnose anterior shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as non-medical trainees, after a brief educational session. Further validation studies are necessary to confirm these findings.
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http://dx.doi.org/10.5811/westjem.2016.2.29290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4899074PMC
May 2016

Integration of Ultrasound in Medical Education at United States Medical Schools: A National Survey of Directors' Experiences.

J Ultrasound Med 2016 Feb 18;35(2):413-9. Epub 2016 Jan 18.

Department of Emergency Medicine and Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University Medical Center, Loma Linda, California USA (V.A.D.); School of Medicine, Loma Linda University, Loma Linda, California USA (J.Y.F., S.L.); Department of Emergency Medicine, University of California, Los Angeles, California (A.C.); Department of Emergency Medicine, University of California, Irvine, California (J.C.F.); and Department of Medicine, University of South Carolina, Columbia, South Carolina USA (M.B.).

Objectives: Despite the rise of ultrasound in medical education (USMED), multiple barriers impede the implementation of such curricula in medical schools. No studies to date have surveyed individuals who are successfully championing USMED programs. This study aimed to investigate the experiences with ultrasound integration as perceived by active USMED directors across the United States.

Methods: In 2014, all allopathic and osteopathic medical schools in the United States were contacted regarding their status with ultrasound education. For schools with required point-of-care ultrasound curricula, we identified the USMED directors in charge of the ultrasound programs and sent them a 27-question survey. The survey included background information about the directors, ultrasound program details, the barriers directors faced toward implementation, and the directors' attitudes toward ultrasound education.

Results: One-hundred seventy-three medical schools were contacted, and 48 (27.7%) reported having a formal USMED curriculum. Thirty-six USMED directors responded to the survey. The average number of years of USMED curriculum integration was 2.8 years (SD, 2.9). Mandatory ultrasound curricula had most commonly been implemented into years 1 and 2 of medical school (71.4% and 62.9%, respectively). The most common barriers faced by these directors when implementing their ultrasound programs were the lack of funding for faculty/ equipment (52.9%) and lack of time in current medical curricula (50.0%).

Conclusions: Financial commitments and the full schedules of medical schools are the current prevailing roadblocks to implementation of ultrasound education. Experiences drawn from current USMED directors in this study may be used to help programs starting their own curricula.
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http://dx.doi.org/10.7863/ultra.15.05073DOI Listing
February 2016

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience.

J Ultrasound Med 2016 Feb 13;35(2):221-33. Epub 2016 Jan 13.

Olive View-UCLA Medical Center, UCLA Geffen School of Medicine, Sylmar, California USA (A.T.C.); Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA (Z.S.); Loma Linda University School of Medicine, Loma Linda, California USA (V.A.D.); University of Southern California Keck School of Medicine, Los Angeles, California USA (M.C.); Stanford University School of Medicine, Stanford, California USA (L.G., V.L.); University of California San Diego School of Medicine, San Diego, California USA (V.S., A.M.); Highland General Hospital, University of California San Francisco School of Medicine, Oakland, California USA (A.N.); Harbor-UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California USA (T.J., A.H.); UCLA Geffen School of Medicine, Los Angeles, California USA (E.S.); Touro University College of Medicine, San Francisco, California USA (A.P.); and University of California Irvine School of Medicine, Irvine, California USA (J.C.F.).

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.
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http://dx.doi.org/10.7863/ultra.15.05006DOI Listing
February 2016

Commentary.

Authors:
Alan T Chiem

Ann Emerg Med 2015 Jul;66(1):83-4

Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.

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http://dx.doi.org/10.1016/j.annemergmed.2015.04.001DOI Listing
July 2015

Comparison of expert and novice sonographers' performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome.

Acad Emerg Med 2015 May 22;22(5):564-73. Epub 2015 Apr 22.

Department of Anesthesiology, The University of Texas, Southwestern, Dallas, TX.

Objectives: The goal of this study was to examine the ability of emergency physicians who are not experts in emergency ultrasound (US) to perform lung ultrasonography and to identify B-lines. The hypothesis was that novice sonographers are able to perform lung US and identify B-lines after a brief intervention. In addition, the authors examined the diagnostic accuracy of B-lines in undifferentiated dyspneic patients for the diagnosis of acute heart failure syndrome (AHFS), using an eight-lung-zone technique as well as an abbreviated two-lung-zone technique.

Methods: This was a prospective, cross-sectional study of patients who presented to the emergency department (ED) with acute dyspnea from May 2009 to June 2010. Emergency medicine (EM) resident physicians, who received a 30-minute training course in thoracic US examinations, performed lung ultrasonography on patients presenting to the ED with undifferentiated dyspnea. They attempted to identify the presence or absence of sonographic B-lines in eight lung fields based on their bedside US examinations. An emergency US expert blinded to the diagnosis and patient presentation, as well as to the residents' interpretations of presence of B-lines, served as the criterion standard. A secondary outcome determined the accuracy of B-lines, using both an eight-lung-zone and a two-lung-zone technique, for predicting pulmonary edema from AHFS in patients presenting with undifferentiated dyspnea. Two expert reviewers who were blinded to the US results determined the clinical diagnosis of AHFS.

Results: A cohort of 66 EM resident physicians performed lung US on 380 patients with a range of 1 to 28 examinations, a mean of 5.8 examinations, and a median of three examinations performed per resident. Compared to expert interpretation, lung US to detect B-lines by inexperienced sonographers achieved the following test characteristics: sensitivity 85%, specificity 84%, positive likelihood ratio (+LR) 5.2, negative likelihood ratio (-LR) 0.2, positive predictive value (PPV) 64%, and negative predictive value (NPV) 94%. Regarding the secondary outcome, the final diagnosis was AHFS in 35% of patients (134 of 380). For novice sonographers, one positive lung zone (i.e., anything positive) had a sensitivity of 87%, a specificity of 49%, a +LR of 1.7, a -LR of 0.3, a PPV of 50%, and an NPV of 88% for predicting AHFS. When all eight lung zones were determined positive (i.e., totally positive) by novice sonographers, the sensitivity was 19%, specificity was 97%, +LR was 5.7, -LR was 0.8, PPV was 76%, and NPV was 68% for predicting AHFS. The areas under the curve for novice and expert sonographers were 0.77 (95% CI = 0.72 to 0.82) and 0.76 (95% CI = 0.71 to 0.82), respectively.

Conclusions: Novice sonographers can identify sonographic B-lines with similar accuracy compared to an expert sonographer. Lung US has fair predictive value for pulmonary edema from acute heart failure in the hands of both novice and expert sonographers.
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http://dx.doi.org/10.1111/acem.12651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5225273PMC
May 2015

False positive appendicitis on bedside ultrasound.

West J Emerg Med 2014 Nov 21;15(7):832-3. Epub 2014 Oct 21.

Olive View - University of California at Los Angeles Medical Center, Department of Emergency Medicine, Sylmar, California.

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http://dx.doi.org/10.5811/westjem.2014.9.23550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251229PMC
November 2014

Pelvic ultrasonography and length of stay in the ED: an observational study.

Am J Emerg Med 2014 Dec 6;32(12):1464-9. Epub 2014 Sep 6.

Department of Emergency Medicine, University of California-Irvine Medical Center, Orange, CA.

Objectives: We compared emergency physician-performed pelvic ultrasonography (EPPU) with radiology department-performed pelvic ultrasonography (RPPU) in emergency department (ED) female patients requiring pelvic ultrasonography and their outcomes in relation to ED length of stay, ED readmission, and alternative diagnosis, within a 14-day follow-up period.

Methods: This was a prospective, observational study of female patients of reproductive age who required either an EPPU or RPPU for their ED evaluation. We hypothesized that patients receiving EPPU would have a length of stay reduction greater than or equal to 60 minutes, as compared with RPPU. Statistical analyses included an independent-samples t test and multivariate regression modeling to control for factors associated with ED LOS.

Results: Eighteen resident physicians performed EPPU, with 15 attending physicians supervising. Forty-eight patients received only EPPU, and 84 patients received only RPPU. In univariate analysis, those who received EPPU had an ED LOS 162 minutes less than those who received RPPU (95% confidence interval, 106-209 minutes). In multivariate analysis controlling for gynecologist consultation, disposition, and pregnancy status, patients who received EPPU had an ED LOS reduction of 108 minutes when compared with RPPU (95% confidence interval, 38-166 minutes). Five patients (10%) who had received EPPU and were discharged from the ED returned to the ED within 2 weeks, but none had alternative diagnoses.

Conclusions: Patients with EPPU had statistically and clinically significant reductions in ED LOS, even when controlling for disposition, gynecologist consultation in the ED, and pregnancy status. No patients in the study had an alternative diagnosis within 2 weeks of EPPU.
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http://dx.doi.org/10.1016/j.ajem.2014.09.006DOI Listing
December 2014

USEFUL: Ultrasound Exam for Underlying Lesions incorporated into physical exam.

West J Emerg Med 2014 May 9;15(3):260-6. Epub 2014 Jan 9.

University of California, Irvine School of Medicine, Irvine, California ; Department of Emergency Medicine, University of California, Irvine, Orange, California.

Introduction: The Ultrasound Screening Exam for Underlying Lesions (USEFUL) was developed in an attempt to establish a role for bedside ultrasound in the primary and preventive care setting. It is the purpose of our pilot study to determine if students were first capable of performing all of the various scans required of our USEFUL while defining such an ultrasound-assisted physical exam that would supplement the standard hands-on physical exam in the same head-to-toe structure. We also aimed to assess the time needed for an adequate exam and analyze if times improved with repetition and previous ultrasound training.

Methods: Medical students with ranging levels of ultrasound training received a 25-minute presentation on our USEFUL followed by a 30-minute hands-on session. Following the hands-on session, the students were asked to perform a timed USEFUL on 2-3 standardized subjects. All images were documented as normal or abnormal with the understanding that an official detailed exam would be performed if an abnormality were to be found. All images were read and deemed adequate by board eligible emergency medicine ultrasound fellows.

Results: Twenty-six exams were performed by 9 students. The average time spent by all students per USEFUL was 11 minutes and 19 seconds. Students who had received the University of California, Irvine School of Medicine's integrated ultrasound curriculum performed the USEFUL significantly faster (p< 0.0025). The time it took to complete the USEFUL ranged from 6 minutes and 32 seconds to 17 minutes, and improvement was seen with each USEFUL performed. The average time to complete the USEFUL on the first standardized patient was 13 minutes and 20 seconds, while 11 minutes and 2 seconds, and 9 minutes and 20 seconds were spent performing the exam on the second and third patient, respectively.

Conclusion: Students were able to effectively complete all scans required by the USEFUL in a timely manner. Students who have been a part of the integrated ultrasound in medicine curriculum performed the USEFUL significantly faster than students who had not. Students were able to significantly improve upon the time it took them to complete the USEFUL with successive attempts. Future endpoints are aimed at assessing the feasibility and outcomes of an ultrasound-assisted physical exam in a primary care setting and the exam's effect on doctor-patient satisfaction. [West J Emerg Med. 2014;15(3):260-266.].
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http://dx.doi.org/10.5811/westjem.2013.8.19080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4025521PMC
May 2014

A dangerous cup of tea.

Wilderness Environ Med 2014 Mar 10;25(1):111-2. Epub 2014 Jan 10.

University of California-Los Angeles Emergency Medicine Center University of California-Los Angeles, Los Angeles, CA.

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http://dx.doi.org/10.1016/j.wem.2013.11.002DOI Listing
March 2014

Utilizing left ventricular outflow tract velocity changes to predict fluid responsiveness in septic patients: a case report.

Am J Emerg Med 2014 Mar 11;32(3):289.e3-6. Epub 2013 Oct 11.

Division of Pulmonary & Critical Care Medicine, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA.

Toxin-mediated vasodilation in the sepsis syndrome can lead to end-organ dysfunction and shock. Assessing for fluid responsiveness and preload optimization with intravenous fluids is a central tenet in the management of sepsis. Aggressive fluid administration can lead to pulmonary edema and heart failure, whereas premature inotropic or vasopressor support can worsen organ perfusion. Inferior vena cava ultrasonography is commonly used to assess for fluid responsiveness but has multiple limitations.
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http://dx.doi.org/10.1016/j.ajem.2013.10.006DOI Listing
March 2014

Web-based lectures, peer instruction and ultrasound-integrated medical education.

Med Educ 2012 Nov;46(11):1109-10

UCI School of Medicine, Medical Education Building, 836 Health Sciences Road, Irvine, CA 92697, USA.

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http://dx.doi.org/10.1111/medu.12039DOI Listing
November 2012

Point-of-care ultrasonography in assessing fluid responsiveness in sepsis patients: sonographer characteristics, noninferential statistics, and study design.

Authors:
Alan Chiem

Ann Emerg Med 2012 Sep;60(3):359-60

Olive View - University of California, Los Angeles Medical Center, Sylmar, USA.

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http://dx.doi.org/10.1016/j.annemergmed.2012.07.017DOI Listing
September 2012

High levels of inflammatory biomarkers are associated with increased allele-specific apolipoprotein(a) levels in African-Americans.

J Clin Endocrinol Metab 2008 Apr 5;93(4):1482-8. Epub 2008 Feb 5.

Department of Medicine, University of California, Davis, Sacramento, California 95817, USA.

Background: A role of inflammation for cardiovascular disease (CVD) is established. Lipoprotein(a) [Lp(a)] is an independent CVD risk factor where plasma levels are determined by the apolipoprotein(a) [apo(a)] gene, which contains inflammatory response elements.

Design: We investigated the effect of inflammation on allele-specific apo(a) levels in African-Americans and Caucasians. We determined Lp(a) levels, apo(a) sizes, allele-specific apo(a) levels, fibrinogen and C-reactive protein (CRP) levels in 167 African-Americans and 259 Caucasians.

Results: Lp(a) levels were increased among African-Americans with higher vs. lower levels of CRP [<3 vs. > or =3 mg/liter (143 vs. 108 nmol/liter), P = 0.009] or fibrinogen (<340 vs. > or =340 mg/liter, P = 0.002). We next analyzed allele-specific apo(a) levels for different apo(a) sizes. No differences in allele-specific apo(a) levels across CRP or fibrinogen groups were seen among African-Americans or Caucasians for small apo(a) sizes (<22 kringle 4 repeats). Allele-specific apo(a) levels for medium apo(a) sizes (22-30 kringle 4 repeats) were significantly higher among African-Americans, with high levels of CRP or fibrinogen compared with those with low levels (88 vs. 67 nmol/liter, P = 0.014, and 91 vs. 59 nmol/liter, P < 0.0001, respectively). No difference was found for Caucasians.

Conclusions: Increased levels of CRP or fibrinogen are associated with higher allele-specific medium-sized apo(a) levels in African-Americans but not in Caucasians. These findings indicate that proinflammatory conditions result in a selective increase in medium-sized apo(a) levels in African-Americans and suggest that inflammation-associated events may contribute to the interethnic difference in Lp(a) levels between African-Americans and Caucasians.
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http://dx.doi.org/10.1210/jc.2007-2416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291489PMC
April 2008

Cigarette prices, smoking, and the poor: implications of recent trends.

Am J Public Health 2007 Oct 29;97(10):1873-7. Epub 2007 Aug 29.

Center for Health Services Research in Primary Care, School of Medicine, University of California, Davis, Sacramento, CA 95817, USA.

Objective: We examined the relationship between smoking participation and cigarette pack price by income group and time period to determine role of cigarette prices in income-related disparities in smoking in the United States.

Methods: We used data from the 1984-2004 Behavioral Risk Factor Surveillance System surveys linked to information on cigarette prices to examine the adjusted prevalence of smoking participation and smoking participation-cigarette pack price elasticity (change in percentage of persons smoking relative to a 1% change in cigarette price) by income group (lowest income quartile [lower] vs all other quartiles [higher]) and time period (before vs after the Master Settlement Agreement [MSA]).

Results: Increased real cigarette-pack price over time was associated with a marked decline in smoking among higher-income but not among lower-income persons. Although the pre-MSA association between cigarette pack price and smoking revealed a larger elasticity in the lower- versus higher-income persons (-0.45 vs -0.22), the post-MSA association was not statistically significant (P>.2) for either income group.

Conclusions: Despite cigarette price increases after the MSA, income-related smoking disparities have increased. Increasing cigarette prices may no longer be an effective policy tool and may impose a disproportionate burden on poor smokers.
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http://dx.doi.org/10.2105/AJPH.2006.090134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994180PMC
October 2007

Metabolic syndrome components in african-americans and European-american patients and its relation to coronary artery disease.

Am J Cardiol 2007 Sep 28;100(5):830-4. Epub 2007 Jun 28.

Department of Medicine, University of California Davis, Davis, California, USA.

A number of factors used to define the metabolic syndrome (MS) differ between African-American and European-American patients, which raises the question whether the individual constellation of MS components would impact cardiovascular risk. Our objectives were to assess the association between the MS and coronary artery disease (CAD) across ethnicities and to explore whether the constellation used to define the syndrome would impact any such association. We studied the distribution of the MS and its relation to CAD in 304 European-American subjects and 224 African-American subjects undergoing diagnostic coronary angiography. The overall prevalence of the MS in European-American and African-American subjects were 65.5% and 49.1%, respectively. Compared with European-American subjects, the lipid components of the syndrome were less frequent among African-American subjects (44% vs 64% [p <0.001] for high-density lipoprotein [HDL] cholesterol and 21% vs 51% [p <0.001] for triglyceride, respectively). The prevalence of CAD was significantly higher in subjects with MS across ethnicity (71.1% of European-American subjects and 56.6% of African-American subjects, p = 0.017 and p = 0.046, respectively). Multiple regression analyses demonstrated an association of blood pressure and HDL cholesterol with CAD among European-American subjects, which remained significant taking other risk factors into account (r(2) = 0.542, p <0.001). In conclusion, presence of CAD was more common among subjects with MS independently of ethnicity. Of the MS components, blood pressure was associated with CAD among European-American subjects. Although our findings may not be directly extrapolated to the population at large, they illustrate the importance of a high-risk metabolic environment as a cardiovascular risk factor.
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http://dx.doi.org/10.1016/j.amjcard.2007.04.025DOI Listing
September 2007
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