ObjectiveThe aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department.MethodsOvid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock.ResultsA total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock.ConclusionThe rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.
A 16-year-old female with cystic fibrosis (CF) presented with an acute respiratory exacerbation during which black flecks were observed in the spontaneously expectorated sputum. The production of this pigmented sputum was subsequently attributed to Exophiala dermatitidis hyphae. Treatment with antibiotics, corticosteroids, and antifungal medications led to an initial resolution of symptoms and clearance of the black pigment from her sputum. However, the patient again presented nine months later with reappearance of the pigmented flecks and concomitant clinical deterioration and was subsequently treated with an extended course of voriconazole. To the authors' knowledge, this is the first case report of fungal colonization by E. dermatitidis presenting as black flecks spontaneously expectorated in CF sputum.
Delivery of MedlinePlus-based HIPs in clinic is more effective using email prescriptions than paper. Satisfaction with the HIP information was high, but overall response was low and deserves further investigation to improve compliance and related outcomes.
Clinicians should be aware of this adverse reaction when facing similar complex neurologic symptoms in patients who are receiving the antibiotic treatment described here, especially vancomycin.
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