Lower blood pressure and abnormal diurnal blood pressure regulation occur in patients with CFS. We would suggest the need for a randomized, placebo-controlled trial of agents to increase blood pressure such as midodrine in CFS patients with an autonomic phenotype.

Background Patients with altered level of consciousness secondary to alcohol use disorders (AUDs) often undergo imaging in the emergency department (ED), although the frequency and yield of this practice over time are unknown. Study Objectives We describe the use of imaging, the associated ionizing radiation exposure, cumulative costs, and identified acute and chronic injuries and abnormalities among frequent users of the ED with AUDs. Methods This is a retrospective case series of individuals identified through an administrative database having 10 or more annual ED visits in 2 consecutive years who were prospectively followed for a third year. International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology codes were used to select individuals with alcohol-related diagnoses, track imaging procedures, and calculate cost. Diagnoses, imaging results, and radiation exposure per computed tomography (CT) study were abstracted from the medical record. Results Fifty-one individuals met inclusion criteria and had a total of 1648 imaging studies over the 3-year period. Subjects had a median of 5 (interquartile range [IQR] 2–10) CT scans, 20 (IQR 10–33) radiographs, 28.3 mSv (IQR 8.97–61.71) ionizing radiation, 0.2% (IQR 0.07–0.4) attributable risk of cancer, and $2979 (IQR 1560–5440) in charges using a national rate. The incidence of acute fracture or intracranial head injury was 55%, and 39% of the cohort had a history of moderate or severe traumatic brain injury. Conclusion The remarkable use of imaging and occurrence of injury among these highly vulnerable and frequently encountered individuals compels further study to refine clinical practices through the development of evidence-based, effective interventions.

The issue of recurrent attenders to eye casualties has received little discussion in the ethics and health policy literature. As many ophthalmology departments offer a walk-in emergency service, protocols need to be in place to ensure appropriate use of this resource and also to identify potential psychiatric comorbidity in such attenders. We illustrate the problem with a recent case. A 42-year-old woman self-presented 14 times over a 4-month period to the same ophthalmic accident and emergency (A&E) unit. On each occasion, she complained of a recurrent eye infection or requested removal of bandage contact lenses and instillation of topical fluorescein. Corrected visual acuity was 6/6 in each eye. The eyes were white and not infected or inflamed and no contact lens was found at any visit. It is likely that she was also co-attending a separate ophthalmic A&E unit. Ophthalmologists are perhaps unique in the UK in providing a casualty service distinct from the main accident and emergency department. This service is often ''walk-in'' and ''free at the point of delivery'' so that the normal gatekeeping mechanisms within the NHS are bypassed. Whether a walk-in service is right or wrong remains a contentious issue and is closely linked with patient empowerment and the recent drive toward a patient-centred health service. The need for an ophthalmic opinion is also fuelled by the general lack of specialist ophthalmic knowledge among general practitioners, casualty officers and other colleagues due to limitations in the undergraduate curriculum. The patience of both staff and fellow patients is often tested when such clients attend in an inappropriate and recurrent manner. It has been shown that increasing attendances are positively associated with older age, male gender and living locally, and inversely associated with being married. 1 Additionally, psychiatric illness has been shown to be twice as frequent among frequent attenders than controls. 2 To address this issue, appropriate hospital information systems and continuous departmental audit should be in place to allow early identification of such patients. Ophthalmology trainees should be competent in recognising common psychiatric syndromes, performing a mental state examination and be familiar with the Mental Health Act 1983 and associated law. 3 In particular, a psychiatry liaison service is an expanding and invaluable resource 4 , and early referral will result in better meeting the true needs of the patient and more efficient utilisation of ophthalmic A&E units.

Background: The anesthesiologist's emerging role as a perioperative physician has challenged the field to broaden its scope of practice to meet the demands of the patient undergoing surgery today. This brief report aims to identify the indications, clinical impact on management decisions, and perioperative focused cardiac ultrasound accuracy in patients scheduled for non-cardiac surgery. Methods: A review from the Department of Anesthesia Perioperative Echocardiography database on transthoracic echocardiography was performed, including clinical, demographic, indications, therapeutic impact, and accuracy from February 1, 2017 to October 10, 2019. Results: A total of 220 FoCUS exams were identified. FoCUS was performed in 55% males and 45% females. The average age was 66.5 years, and 68% of patients were designated ASA 3 classification. The majority underwent thoracic procedures with a history of cardiovascular disease for hemodynamic instability in the post-anesthesia care unit (PACU). In this group, 94% had a change in management. New findings in 9 patients resulted in pre-induction management change. FoCUS was also performed intraoperatively to differentiated hemodynamic instability, significantly altering care. Postoperatively, new wall motion abnormalities findings hasten care to the cardiology service. Immediate assessment of hemodynamic instability altered care and postoperative recovery location in a significant number of patients. In all cases, FoCUS was used to guide management in the differential diagnosis of the acute event and to assess treatment response. Conclusion: This review demonstrates that FoCUS is an excellent clinical adjunct in the perioperative period. Diagnostic accuracy and efficiency by pattern recognition helped answer clinically significant questions and guide management. The non-invasive approach of POCUS and its rapid adaptation makes it an exciting area of future research.