The syndrome of haemolysis, elevated liver enzymes and low platelets is a rare condition specific to pregnancy, affecting approximately 5-20% of all pre-eclamptic pregnancies. Described here is a woman in her first pregnancy, who experienced an intrauterine death following a significant hepatic haematoma and capsular rupture, in the absence of classical clinical features suggestive of pre-eclampsia. The events that followed suggested haemolysis, elevated liver enzymes and low platelets syndrome as the likely diagnosis. The patient's clinical course highlights the difficulties that may be encountered when making decisions about pregnant women with complicated medical and obstetric issues.

@ERSpublications Focused thoracic ultrasound is essential in the guidance of pleural interventions to reduce unwanted complications. It forms a crucial component of physician training. Current training standards and assessment methods vary.ABSTRACT Focused thoracic ultrasound has become essential in the guidance and direction of pleural interventions to reduce unwanted complications and as a result now forms a crucial component of physician training. Current training standards along with assessment methods vary widely, and are often not robust enough to ensure adequate competence. This review assesses the current state of training and assessment of thoracic ultrasound competence in various settings, allowing comparison with alternative competency based programmes. Future directions for training and assessment of thoracic ultrasound competence are discussed. Epidemiology and relevancePleural disease is common, with an estimated annual incidence of 3000 people per million population. This translates to approximately 200 000 new cases of pleural disease yearly in the UK and this incidence continues to rise, therefore representing a significant burden on healthcare systems. There are more than 40 000 new cases of malignant pleural effusion in the UK annually, contributing to an annual incidence of approximately 300 000 cases across the USA and UK combined. Incidence rates for all cancers combined in the UK have increased by 7% over the past 10 years and are projected to rise by a further 2% between 2014 and 2035 to 742 cases per 100 000, which is likely to result in an ongoing increase in the incidence of malignant pleural effusion. In addition, there are approximately 2500 deaths per year in the UK from mesothelioma. The incidence has steadily risen over the past 50 years and is expected to peak in 2020 [1-5].The combined UK and US population also has an estimated annual incidence of 80 000 cases of pleural infection. This frequency has doubled over the past decade and continues to rise [6,7]. Role of ultrasound for pleural proceduresAs the prevalence of pleural disease has continued to rise, so has the need for increasingly specialised interventions. This includes local anaesthetic thoracoscopy with or without pneumothorax induction, pleural biopsy and indwelling catheter insertion along with more traditional procedures such as pleural aspiration and chest drain insertion. The role of ultrasound guidance for these procedures has also increased. A Intermediate-level TUS operatorMinimum of 2 years' experience as a basic-level TUS operator Ability to detect A-lines and B-lines in lung ultrasound Ability to identify and assess pleural thickening Ability to assess diaphragm function on ultrasound Ability to perform real-time pleural aspiration and chest drain insertion when required Ability to use ultrasound help guide site for indwelling pleural catheter insertion (scanning patients in lateral decubitus position) Annual review and appraisal of practice including standardised outcome measures Advanced-level TUS operator...

Introduction There is an increasing awareness that the cardiovascular pathophysiology of sepsis extends beyond vasodilatation and distributive shock. Acute left ventricular systolic dysfunction is seen in 40-60% of patients admitted to critical care who require organ support. The exact distribution, timing and aetiology of this phenomenon remain unclear as does the therapeutic implications. Although often affecting the left ventricle, cases describing synchronous biventricular or isolated right ventricular dysfunction have been described. This septic cardiomyopathy appears to be fully reversible in survivors. We describe three cases admitted to our intensive care unit who were demonstrated to have an acute isolated dilated right ventricular cardiomyopathy using trans thoracic echocardiography. Methods and results 3 patients admitted to the Adult ICU were echoed on admission to the ICU, all with severe sepsis and multi organ failure. Two required invasive ventilation, all three required inotrope and vasopressor support, with two requiring haemofiltration. All patients had CT contrast pulmonary angiography to exclude pulmonary embolus as a differential diagnosis. The source

Point-of-care ultrasound is emerging as an important adjunct to the clinical examination. Ultrasonography has long been seen as a modality for experts but this is changing and it is hoped that, with appropriate training, point-of-care ultrasound will become a modern-day diagnostic necessity.