Top cited articles on ultrasound in the Emergency Department
Correspondence
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American Journal of Emergency Medicine
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Takotsubo cardiomyopathy associated with Miller-Fisher syndrome
Miller-Fisher syndrome is a rare variant of Guillain-Barre syndrome and has the following triad, ataxia, areflexia and ophthalmoplegia [1]. It is only observed in only 1%-5% of cases of Guillain-Barre Syndrome [2, 3]. Miller-Fisher syndrome is a relatively uncommon condition in which the body’s immune system attacks part of the Peripheral nervous system [1]. It can affect the nerves that control muscle movement, pain, temperature sensation and can be potentially fatal if it affects the respiratory muscles [2]. Although Guillain-Barre Syndrome has rarely been associated with Takotsubo cardiomyopathy, a transient cardiac syndrome that mimics acute coronary syndrome, there have been no re- ports of Miller-Fisher syndrome association with stress cardiomyopa- thy. Here, we present a case of a 51 year old female who developed Takotsubo cardiomyopathy in association with Miller-Fisher syndrome. 51-year-old female presented with progressive paresthesia of lower extremities, Double Vision, and trouble walking. Vitals were remarkable for tachycardia and tachypnea. Physical exam demonstrated areflexia, and ptosis. She had respiratory distress and was intubated. Her initial electrocardiogram showed nonspecific ST segment changes and her Tro- ponin T was elevated to 0.41 ng/mL, which peaked at 0.66 ng/mL. Patient was also started on norepinephrine due to hypotension. Repeat electro- cardiogram in the morning showed nonspecific ST-T segment changes with T wave flattening. A 2D echocardiogram showed a depressed left ventricular ejection fraction to 35% with severely hypokinetic anterior wall and left ventricular apex was severely hypokinetic. An electromyog- raphy nerve conduction study showed severely decreased conduction ve- locity and prolonged distal latency in all nerves consistent with Demyelinating disease. She was treated with 5 days of intravenous immu- noglobulin therapy to which she showed significant improvement in strength in her lower extremities. Repeated echocardiogram showed an improved left ventricular ejection fraction of 55% and no left ventricular wall motion abnormalities. She was weaned off pressor requirement,
and transitioned to Carvedilol and Lisinopril.
Takotsubo cardiomyopathy is a rare complication of Miller-Fisher syndrome and literature review did not reveal any cases. Miller-Fisher syndrome is an Autoimmune process that affects the peripheral nervous system causing Autonomic dysfunction which may involve the heart [2, 3]. Due to the significant autonomic dysfunction seen in Miller-Fisher syndrome, it could lead to arrhythmias, blood pressure changes, acute coronary syndrome and myocarditis, Takotsubo cardiomyopathy can be difficult to distinguish. The criteria to diagnose Takotsubo cardiomy- opathy include a transient hypokinesis, akinesis, or dyskinesis of the left ventricle wall with or without apical involvement in the absence of ob- structive coronary artery disease, and is often related to a stressful trig- ger [4,5]. Dysregulation of autonomic tone with excessive sympathetic activation in Miller-Fisher syndrome with elevated catecholamine levels is one hypothesis [5]. The pathophysiology of Takotsubo cardio- myopathy seems to be from sympathetic excitation of brain triggering Catecholamine release causing hyperdynamic basal contraction, and
apical systolic dysfunction [4-6]. The treatment of Takotsubo cardiomy- opathy is supportive with beta-blockers and angiotensin-converting enzyme inhibitor is recommended until left ventricle ejection fraction improvement. Takotsubo cardiomyopathy is a rare complication of Miller-Fisher syndrome and must be distinguished from autonomic dysfunction as both diagnoses have different approaches to treatment.
Funding
No funding was involved in the production of this manuscript.
Dalvir Gill Department of Internal Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA
Corresponding author at: 60 Presidential Plaza, Apartment 1104,
Syracuse 13202, NY, USA.
E-mail address: [email protected]
Kan Liu
Department of Cardiology, SUNY Upstate Medical University, 750 East
Adams Street, Syracuse, NY 13210, USA E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2016.12.050
References
- Mori M, Kuwabara S, Fukutake T, Yuki N, Hattori T. Clinical features and prognosis of Miller Fisher syndrome. Neurology 2001;56:1104-6.
- Iga K, Himura Y, Izumi C, Miyamoto T, Kijima K, Gen H, et al. Reversible left ventricular dysfunction associated with Guillain-Barre syndrome–an expression of catechol- amine cardiotoxicity? Jpn Circ J 1995;59:236-40.
- Berlit P, Rakicky J. The Miller Fisher syndrome. Review of literature. J Clin Neuroophthalmol 1992;12:57-63.
- Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118:
Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27:1523-9.
- Lee VH, Connolly HM, Fulgham JR, Manno EM, Brown Jr RD, Wijdicks EF. Tako-tsubo cardiomyopathy in Aneurysmal subarachnoid hemorrhage: an underappreciated ven- tricular dysfunction. J Neurosurg 2006;105:264-70.
Top cited articles on ultrasound in the Emergency Department
To the Editor:
In the July issue of the American Journal of Emergency Medicine, Dr. Bayram et al. [1] reviewed the most-cited clinical studies and provided the developmental trend of ultrasound in the Emergency Department (ED). We have some suggestions to the study methods which may pro- vide different perspectives on this study.
0735-6757/
First, the list of top 100 articles with leading annual citation rate should be provided for comparison. As the authors mentioned in the discussion, older articles often have a greater number of total citations. The impact of recent published articles may be underestimated if we only focus on total citations. The limitation was reflected on the result that no article published between 2011 and 2015 was enrolled in the top cited list of this study. In Table 3 [1], the median of annual citations showed an increasing trend (4.3 to 10.5) when the publications were classified according to year of publication. This phenomenon indicated that the impact of recent publica- tions was not underestimated from the perspective of annual citation rate. Second, cited times and annual citation rate within recent certain time should be calculated in addition to overall cited times and annual citation rate. The top cited articles in this study ranged from 1988 to 2010, a span of 22 years. The meaning of the same cited times in 1990s and 2010s was different, but the difference couldn’t be identified by the overall cumulat- ed cited times. The previous indicated that the study topic used to be pop-
ular and the later referred to recent study popularity.
Third, in Table 3 [1], the correlation between total and annual cita- tions rate with year of publication can be evaluated by regression in- stead of grouping articles into 5-year period and evaluated by analysis of variance. Year of publication is numerically variable and classified into 5-year period become categorically variable which may decrease the information amount.
Fourth, in Table 3 [1], the annual citations p-values of year of publi- cation and USG area analysis were all b 0.05 and considered statistically significant but the clinical significance needs clarification. The statistical difference indicated that there was difference between these 6 and 13 subgroups but we did not know that the difference was between which of the two, three, or more subgroups. This analysis did not tell the temporal and topic trends of studies of ultrasound in the ED. The ap- plication of this analysis was limited.
Bayram et al. disclosed the growing popularity of point of care ultra- sound in ED performed by emergency physicians. Further analysis can provide detail temporal and topic trends of studies of ultrasound in the ED.
Ching-Hsing Lee, MD Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University College of Medicine, Taoyuan,
Taiwan, No.222, Maijin Rd., Anle Dist.,
Keelung City 204, Taiwan E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2017.01.022
[1] Bayram B, Limon O, Limon G, Hanci V. Bibliometric analysis of top 100 most-cited clinical studies on ultrasound in the Emergency Department. Am J Emerg Med 2016;34:1210-6.
Impact of Patient race and primary language on ED triage in a system that relies on chief
complaint and general appearance?
To the Editor:
As the number of Emergency Department (ED) visits in the United States continues to rise, many hospitals are implementing new triage
? This work was presented at the ACEP Academic Assembly in Las Vegas, October 2016. There is no grant support or involvement. There are no conflicts of interest.Drs. Davey and Egan conceived the study, designed the trial, and wrote the IRB. Dr. Rabrich supervised the conduct of the trial and data collection, undertook recruitment of participating centers and patients and managed the data, including quality control. Drs. Olivieri and Atmar provided statistical advice on study design and analyzed the data. Dr. Davey drafted the manuscript, and all authors contributed substantially to its revision. Dr. Davey takes responsibility for the paper as a whole.
and patient flow systems with the goal of decreasing wait times and ED length of stay . Multiple studies have shown the deleterious ef- fects of ED overcrowding including delays in treatment, longer LOS, higher mortality, and decreased patient satisfaction [1-3]. One triage model, the “split-flow” model, aims to reduce ED LOS by splitting the ED into high and low acuity treatment areas [4]. One of the key compo- nents of this model is the concept of “rapid” triage in which patients are sent to the high or low acuity treatment areas based on their general ap- pearance and ability to ambulate. Our institution recently implemented a version of split-flow in which vital signs, medical history and a focused physical examination are all deferred to the patients’ primary nurse at bedside.
Given that no vital signs or medical history are collected and no focused physical examination performed during rapid triage, a patient’s initial evaluation may be subject to the biases of the triage nurse. Multiple studies have described the role that race may play in ED decision-making, including in the Administration of analgesia and wait times [5-8]. Additionally, prior studies demonstrate that limited English proficiency is associated with decreased use of pre- ventative services, healthcare access, comprehension of medical in- formation and an increased risk of adverse medication reactions [9-10]. We sought to identify differences in triage destination with regards to the patient’s race or primary language in our hospital’s modified split-flow system.
This was a retrospective chart review of adult patients at an urban ED with 101 000 visits per year during a 3 month period. Patients with chief complaints of chest pain or abdominal pain were included. Patients were excluded if they were triaged as ESI category 1 or age b 22. ESI category, triage destination, race, age, primary language, and final disposition were collected. Chi square test, unpaired two sam- ple t-tests and multiple variable chi square test were used in the analysis.
During the study period, 2983 patients were enrolled. Patient demographics are reported in Table 1. Table 2 shows presenting complaint, race, primary language and triage destination.1125 pa- tients presented with chest pain and a documented race. 85 pa- tients were White with 88% triaged to the high Acuity area and 12% triaged to the low acuity area. 1040 were non-White with 76% triaged to the high acuity area and 24% triaged to the low acu- ity area. This difference was statistically significant (p = 0.012). 1809 patients presented with abdominal pain. No statistical differ- ence was found in the triage patterns based on White or non- white race (p = 0.58).
76% of chest pain patients who preferred English were triaged to the high acuity area and 24% were triaged to the low acuity area. 80% of those with a Preferred language other than English went to the high acuity area and 20% went to the low acuity area. This was not statistical- ly significant (p = 0.22). 53% of abdominal pain patients who preferred English went to the high acuity area and 47% went to the low acuity area. 52% of those with a preferred language other than English went to the high acuity area and 48% went to the low acuity area. This was not statistically significant (p = 0.87). When comparing the patients’ ultimate disposition (admission, observation unit, discharge), no statis- tically significant difference was found (Table 3).
Our split-flow model for ED triage resulted in a statistically higher
proportion of non-White chest pain patients triaged to the low acuity area. While the reasons for this may be multifactorial, the inherent sus- ceptibility to bias of a triage system that lacks objective indicators of health may be a contributing factor. A study by Schrader et al., found that among common complaints (including chest and abdominal pain), that African Americans were significantly more likely to be triaged a lower ESI score [11]. These results emphasize the need for ob- jective measures (e.g. vital signs, physical examination) to guide triage decisions.
In this study, regardless of initial triage location, after vital signs, physical examination, laboratory testing and imaging there was no
