Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?

The utility of point-of-care ultrasound in critical care nephrology

Point-of-care ultrasonography (POCUS) is gaining heightened significance in critical care settings as it allows for quick decision-making at the bedside. While computerized tomography is still considered the standard imaging modality for many diseases, the risks and delays associated with transferring a critically ill patient out of the intensive care unit (ICU) have prompted physicians to explore alternative tools. Ultrasound guidance has increased the safety of invasive procedures in the ICU, such as the placement of vascular catheters and drainage of collections. Ultrasonography is now seen as an extension of the clinical examination, providing quick answers for rapidly deteriorating patients in the ICU. The field of nephrology is increasingly acknowledging the value of diagnostic point-of-care ultrasound (POCUS). By employing multi-organ POCUS, nephrologists can address specific queries that arise during the diagnosis and treatment of patients with acute kidney injury. This approach aids in ruling out hydronephrosis and offers immediate information on hemodynamics, thereby consolidating patient data and facilitating the development of personalized treatment strategies.

Algorithm for predicting valvular heart disease from heart sounds in an unselected cohort

Objective

This study aims to assess the ability of state-of-the-art machine learning algorithms to detect valvular heart disease (VHD) from digital heart sound recordings in a general population that includes asymptomatic cases and intermediate stages of disease progression.

Methods

We trained a recurrent neural network to predict murmurs from heart sound audio using annotated recordings collected with digital stethoscopes from four auscultation positions in 2,124 participants from the Tromsø7 study. The predicted murmurs were used to predict VHD as determined by echocardiography.

Results

The presence of aortic stenosis (AS) was detected with a sensitivity of 90.9%, a specificity of 94.5%, and an area under the curve (AUC) of 0.979 (CI: 0.963-0.995). At least moderate AS was detected with an AUC of 0.993 (CI: 0.989-0.997). Moderate or greater aortic and mitral regurgitation (AR and MR) were predicted with AUC values of 0.634 (CI: 0.565-703) and 0.549 (CI: 0.506-0.593), respectively, which increased to 0.766 and 0.677 when clinical variables were added as predictors. The AUC for predicting symptomatic cases was higher for AR and MR, 0.756 and 0.711, respectively. Screening jointly for symptomatic regurgitation or presence of stenosis resulted in an AUC of 0.86, with 97.7% of AS cases (n = 44) and all 12 MS cases detected.

Conclusions

The algorithm demonstrated excellent performance in detecting AS in a general cohort, surpassing observations from similar studies on selected cohorts. The detection of AR and MR based on HS audio was poor, but accuracy was considerably higher for symptomatic cases, and the inclusion of clinical variables improved the performance of the model significantly.

Clinical comparison of a handheld cardiac ultrasound device for the assessment of left ventricular function

PURPOSE

Recently developed handheld ultrasound devices (HHUD) represent a promising method to evaluate the cardiovascular abnormalities at the point of care. However, this technology has not been rigorously evaluated. The aim of this study was to explore the correlation and the agreement between the LVEF (Left Ventricular Ejection Fraction) visually assessed by a moderately experienced sonographer using an HHUD compared to the routine LVEF assessment performed at the Echocardiography Laboratory.

METHODS

This was a prospective single center study which enrolled 120 adult inpatients and outpatients referred for a comprehensive Echocardiography (EC).

RESULTS

The mean age of the patients was 69.9 ± 12.5 years. There were 47 females (39.2%). The R-squared was r 0.94 (p < 0.0001) and the ICC was 0.93 (IC 95% 0.91-0.95, p ≤ 0.0001). The Bland-Altman plot showed limits of agreement (LOA): Upper LOA 10.61 and Lower LOA - 8.95. The overall agreement on the LVEF assessment when it was stratified as "normal" or "reduced" was 89.1%, with a kappa of 0.77 (p < 0.0001). When the LVEF was classified as "normal", "mildly reduced", "moderately reduced", or "severely reduced," the kappa was 0.77 (p < 0.0001). The kappa between the HHUD EC and the comprehensive EC for the detection of RWMAs in the territories supplied by the LAD, LCX and RCA was 0.85, 0.73 and 0.85, respectively.

CONCLUSION

With current HHUD, an averagely experienced operator can accurately bedside visual estimate the LVEF. This may facilitate the incorporation of this technology in daily clinical practice improving the management of patients.

Diagnostic accuracy of point-of-care ultrasound with artificial intelligence-assisted assessment of left ventricular ejection fraction

Focused cardiac ultrasound (FoCUS) is becoming standard practice in a wide spectrum of clinical settings. There is limited data evaluating the real-world use of FoCUS with artificial intelligence (AI). Our objective was to determine the accuracy of FoCUS AI-assisted left ventricular ejection fraction (LVEF) assessment and compare its accuracy between novice and experienced users. In this prospective, multicentre study, participants requiring a transthoracic echocardiogram (TTE) were recruited to have a FoCUS done by a novice or experienced user. The AI-assisted device calculated LVEF at the bedside, which was subsequently compared to TTE. 449 participants were enrolled with 424 studies included in the final analysis. The overall intraclass coefficient was 0.904, and 0.921 in the novice (n = 208) and 0.845 in the experienced (n = 216) cohorts. There was a significant bias of 0.73% towards TTE (p = 0.005) with a level of agreement of 11.2%. Categorical grading of LVEF severity had excellent agreement to TTE (weighted kappa = 0.83). The area under the curve (AUC) was 0.98 for identifying an abnormal LVEF (<50%) with a sensitivity of 92.8%, specificity of 92.3%, negative predictive value (NPV) of 0.97 and a positive predictive value (PPV) of 0.83. In identifying severe dysfunction (<30%) the AUC was 0.99 with a sensitivity of 78.1%, specificity of 98.0%, NPV of 0.98 and PPV of 0.76. Here we report that FoCUS AI-assisted LVEF assessments provide highly reproducible LVEF estimations in comparison to formal TTE. This finding was consistent among senior and novice echocardiographers suggesting applicability in a variety of clinical settings.

Current use, training, and barriers in point-of-care ultrasound in hospital medicine: A national survey of VA hospitals

BACKGROUND

Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist.

OBJECTIVE

This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs).

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015.

RESULT

Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices.

CONCLUSION

From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Clinical Impact of Point-of-Care Ultrasound in Internal Medicine Inpatients: A Systematic Review

The aim in this systematic review was to determine the effect of point-of-care ultrasound (POCUS) on the clinical decision-making process and patient outcomes in adults admitted to the general medicine ward. A comprehensive search was performed in MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library, ClinicalTrials.gov, Scopus, LILACS and Cinahl. Articles had to fulfill the inclusion criteria of randomised or non-randomised studies assessing the impact of POCUS on the diagnosis, management, length of hospital stay or mortality of patients admitted to the internal medicine ward. Six studies were included involving a total of 1836 patients. The influence of POCUS on the diagnosis was reported as a change in the main diagnosis or the addition of a relevant diagnosis in up to 18% and 24% of the cases, respectively. Impact on the management plan was reported in 37% to 52.1% of the participants. Three studies documented the impact of POCUS on the length of stay. Two of them reported no difference between groups, and the other reported a significant reduction of 1 d of the hospital stay. In conclusion, POCUS appears to have positive effects on the clinical decision-making process with impacts on optimal patient management and possible reduction in the hospital length of stay.

Handheld Echocardiography in a Clinical Practice Scenario: Concordances Compared to Standard Echocardiographic Reports

BACKGROUND

The purpose of this study was to assess the utility of a handheld device (HH) used during common daily practice and its agreement with the results of a standard echocardiography study (STD) performed by experienced sonographers and echocardiographer.

METHODS

A prospective follow-up was conducted in an adult outpatient echocardiography clinic. Experienced sonographers performed the STD and an experienced echocardiographer performed the HH. STD included 2-dimensional images, Doppler and hemodynamics analysis. Hemodynamic assessment was not performed with the HH device because the HH does not include such technology. The images were interpreted by blinded echocardiographers, and the agreement between the reports was analyzed.

RESULTS

A total of 108 patients were included; and the concordance for left ventricle (LV) ejection fraction (EF), wall motion score index, LV and right ventricle (RV) function, RV size, and mitral and aortic stenosis was excellent with κ values greater than 0.80. Wall motion abnormalities had good concordance (κ value 0.78). The agreement for LV hypertrophy, mitral and aortic regurgitation was moderate, and tricuspid and pulmonary regurgitation agreements were low (κ values of 0.26 and 0.25, respectively).

CONCLUSIONS

In a daily practice scenario with experienced hands, HH demonstrated good correlation for most echocardiography indications, such as ventricular size and function assessment and stenosis valve lesion analyses.

Screening of Native Valvular Heart Disease Using a Pocket-Sized Transthoracic Echocardiographic Device

BACKGROUND

The authors assessed the performance of pocket-sized transthoracic echocardiography (pTTE) compared with standard transthoracic echocardiography (sTTE) and auscultation for early screening of valvular heart disease (VHD). Early diagnosis of significant VHD is a challenge, but it enables appropriate follow-up and implementation of the best therapeutic strategy.

METHODS

sTTE, pTTE, and auscultation were performed by three different experienced physicians on 284 unselected patients. All cases of VHD detected by each of these three techniques were noted. sTTE was the gold standard. Each physician performed one examination and was blinded to the results of other examinations.

RESULTS

We diagnosed a total of 301 cases of VHD, with a large predominance of regurgitant lesions: 269 cases (89.3%) of regurgitant VHD and 32 (10.7%) of stenotic VHD. pTTE was highly sensitive (85.7%) and specific (97.9%) for screening for VHD, while auscultation detected only 54.1%. All significant cases of VHD (at least mild severity) were detected on pTTE. The weighted κ coefficient between pTTE and sTTE for the assessment of mitral regurgitation was 0.71 (95% CI, 0.70-0.72), indicating good agreement. The weighted κ coefficients between pTTE and sTTE for the assessment of aortic regurgitation and aortic stenosis were 0.97 (95% CI, 0.96-0.98) and 0.98 (95% CI, 0.97-0.99), respectively, indicating excellent agreement.

CONCLUSIONS

pTTE performed by physicians with level III competency in echocardiography is reliable for identifying significant VHD and should be proposed as a new screening tool.

Diagnostic accuracy of handheld cardiac ultrasound device for assessment of left ventricular structure and function: systematic review and meta-analysis

Objective

Handheld ultrasound devices (HUD) has diagnostic value in the assessment of patients with suspected left ventricular (LV) dysfunction. This meta-analysis evaluates the diagnostic ability of HUD compared with transthoracic echocardiography (TTE) and assesses the importance of operator experience.

Methods

MEDLINE and EMBASE databases were searched in October 2020. Diagnostic studies using HUD and TTE imaging to determine LV dysfunction were included. Pooled sensitivities and specificities, and summary receiver operating characteristic curves were used to determine the diagnostic ability of HUD and evaluate the impact of operator experience on test accuracy.

Results

Thirty-three studies with 6062 participants were included in the meta-analysis. Experienced operators could predict reduced LV ejection fraction (LVEF), wall motion abnormality (WMA), LV dilatation and LV hypertrophy with pooled sensitivities of 88%, 85%, 89% and 85%, respectively, and pooled specificities of 96%, 95%, 98% and 91%, respectively. Non-experienced operators are able to detect cardiac abnormalities with reasonable sensitivity and specificity. There was a significant difference in the diagnostic accuracy between experienced and inexperienced users in LV dilatation, LVEF (moderate/severe) and WMA. The diagnostic OR for LVEF (moderate/severe), LV dilatation and WMA in an experienced hand was 276 (95% CI 58 to 1320), 225 (95% CI 87 to 578) and 90 (95% CI 31 to 265), respectively, compared with 41 (95% CI 18 to 94), 45 (95% CI 16 to 123) and 28 (95% CI 20 to 41), respectively, for inexperienced users.

Conclusion

This meta-analysis is the first to establish HUD as a powerful modality for predicting LV size and function. Experienced operators are able to accurately diagnose cardiac disease using HUD. A cautious, supervised approach should be implemented when imaging is performed by inexperienced users. This study provides a strong rationale for considering HUD as an auxiliary tool to physical examination in secondary care, to aid clinical decision making when considering referral for TTE.

Trial registration number

CRD42020182429.

The Conundrum of Volume Status Assessment: Revisiting Current and Future Tools Available for Physicians at the Bedside

Assessment of patients’ volume status at the bedside is a very important clinical skill that physicians need in many clinical scenarios. Hypovolemia with hypotension and tissue under-perfusion are usually more alarming to physicians, but hypervolemia is also associated with poor outcomes, making euvolemia a crucial goal in clinical practice. Nevertheless, the assessment of volume status can be challenging, especially in the absence of a gold standard test that is reliable and easily accessible to assist with clinical decision-making. Physicians need to have a broad knowledge of the individual non-invasive clinical tools available for them at the bedside to evaluate volume status. In this review, we will discuss the strengths and limitations of the traditional tools, which include careful history taking, physical examination, and basic laboratory tests, and also include the relatively new tool of point-of-care ultrasound.

Feasibility of point-of-care cardiac ultrasound performed by clinicians at health centers in Tanzania

BACKGROUND

Point-of-care cardiac ultrasound (cardiac POCUS) has potential to become a useful tool for improving cardiovascular care in Tanzania. We conducted a pilot program to train clinicians at peripheral health centers to obtain and interpret focused cardiac POCUS examinations using a hand-held portable device.

METHODS

Over a 5-day period, didactic and experiential methods were used to train clinicians to conduct a pre-specified scanning protocol and recognize key pathologies. Pre- and post-training knowledge and post-training image acquisition competency were assessed. In their usual clinical practices, trainees then scanned patients with cardiovascular signs/symptoms, recorded a pre-specified set of images for each scan, and documented their interpretation as to presence or absence of key pathologies on a case report form. A cardiologist subsequently reviewed all images, graded them for image quality, and then documented their interpretation of key pathologies in a blinded fashion; the cardiologist interpretation was considered the gold standard.

RESULTS

8 trainees (6 Clinical Officers, 1 Assistant Medical Officer, and 1 Medical Doctor) initiated and completed the training. Trainees subsequently performed a total of 429 cardiac POCUS examinations in their clinical practices over a 9 week period. Stratified by trainee, the median percent of images that were of sufficient quality to be interpretable was 76.7% (range 18.0-94.2%). For five of eight trainees, 75% or more of images were interpretable. For detection of pre-specified key pathologies, kappa statistics for agreement between trainee and cardiologist ranged from - 0.03 (no agreement) for detection of pericardial effusion to 0.42 (moderate agreement) for detection of tricuspid valve regurgitation. Mean kappa values across the key pathologies varied by trainee from 0 (no agreement) to 0.32 (fair agreement).

CONCLUSIONS

The 5-day training program was sufficient to train most clinicians to obtain basic cardiac images but not to accurately interpret them. Proficiency in image interpretation may require a more intensive training program.

Tele-Clinic Visits in Pediatric Patients with Marfan Syndrome Using Parentally Acquired Echocardiography

OBJECTIVE

To test feasibility of tele-clinic visits using parentally acquired vital signs and focused echocardiographic images in patients with Marfan syndrome.

STUDY DESIGN

We included patients with Marfan syndrome aged 5-19 years followed in our clinic. We excluded patients with Marfan syndrome and history of previous aortic root (AoR) surgery, cardiomyopathy, arrhythmia, or AoR ≥4.5 cm. We trained parents in-person to acquire focused echocardiographic images on their children using a hand-held device as well as how to use a stadiometer, scale, blood pressure (BP) machine, and a digital stethoscope. Before tele-clinic visits, parents obtained the echocardiographic images and vital signs. We compared tele-clinic and on-site clinic visit data. Parental and clinic echocardiograms were independently analyzed.

RESULTS

Fifteen patient/parent pairs completed tele-clinic visits, conducted at a median of 7.0 (IQR 3.0-9.9) months from the in-person training session. Parents took a median of 70 (IQR 60-150) minutes to obtain the height, weight, heart rate, BP, cardiac sounds, and echocardiographic images before tele-clinic visits. Systolic BP was greater on-site than at home (median +13 mm Hg, P = .014). Height, weight, diastolic BP, heart rate, and AoR measurements were similar.

CONCLUSIONS

This study provides information for implementing tele-clinic visits using parentally acquired vital signs and echocardiographic images in patients with Marfan syndrome. The results show that tele-clinic visits are feasible and that parents were able to obtain focused echocardiographic images on their children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03581682.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

Rapid, Single-View Speckle-Tracking-Based Method for Examining Left Ventricular Systolic and Diastolic Function in Point of Care Ultrasound

OBJECTIVES

A rapid, reliable quantitative assessment of left ventricular systolic and diastolic function is important for patient treatment in urgent and dynamic settings. Quantification of annular velocities based on a single 2-dimensional image loop, rather than on Doppler velocities, could be useful in point-of-care or focused cardiac ultrasound. We hypothesized that novel speckle-tracking-based mitral annular velocities would correlate with reference standard tissue Doppler imaging (TDI) velocities in a focused cardiac ultrasound-esque setting.

METHODS

Two echocardiographers each performed transthoracic echocardiographic measurements before and after induction of anesthesia in supine patients undergoing cardiac surgery. Speckle-tracking echocardiography (STE)-based systolic (S'_STE ) and diastolic (E'_STE and A'_STE ) velocities were compared to TDI and global longitudinal strain/strain rate. We also compared mitral annular displacement by speckle tracking with M-mode imaging.

RESULTS

Twenty-five patients were included and examined in both preinduction and postinduction states. Speckle-tracking-based velocities correlated with TDI measurements in both states (S', r = 0.73 and 0.76; E', r = 0.87 and 0.65; and A', r = 0.65 and 0.73), showing a mean bias of 25% to 30% of the reference standard measurement. The correlation of S'_STE with strain and the strain rate (S-wave) and E'_STE with the strain rate (E-wave) was good in awake, spontaneously breathing patients but was less strong in the ventilated state. Similarly, displacement by speckle tracking correlated with M-mode measurements in both states (r = 0.91 and 0.84). Measurements required medians of 31 and 34 seconds; reproducibility was acceptable for S'_STE and E'_STE .

CONCLUSIONS

Speckle-tracking-based mitral annular velocities and displacement correlate well with conventional measures as well as with deformation imaging. They may be clinically useful in rapidly assessing both systolic and diastolic function from a single 2-dimensional image loop.

A Shifting Paradigm: The Role of Focused Cardiac Ultrasound in Bedside Patient Assessment

Transthoracic echocardiography is the standard of care in anatomic and functional cardiovascular assessment; however, focused cardiac ultrasound (FoCUS) performed with portable ultrasound equipment is increasingly being used as an adjunct to comprehensive history and physical examination. FoCUS assessments, unlike formal echocardiography, are intended to assist physicians in answering explicit clinical questions with a narrow differential diagnosis in real time. Over the past decade, a growing body of literature has repeatedly shown the value that FoCUS adds to clinical evaluation. Specifically, FoCUS improves point-of-care diagnostic accuracy, which in turn modifies treatment plans, decreases time to diagnosis, and reduces resource utilization. Although less robust, there is also evidence showing improvement in clinical outcomes. Based on this evidence, clinicians, training programs, and clinical societies have embraced FoCUS as a tool to complement bedside patient evaluation. Herein, we review the evidence for FoCUS in clinical practice, specifically evaluating the diagnostic accuracy, the impact on clinical decision-making, and the effect on clinical outcomes.

Development of a Focused Cardiac Ultrasound Image Acquisition Assessment Tool

Background: Focused cardiac ultrasound (FCU) is widely used by healthcare providers to answer specific questions about cardiac structure and function at the bedside. Currently, no widely accepted FCU image acquisition checklist exists to assess learners with varying skill levels from different specialties.

Objective: The primary objective of this project was to develop a consensus-based FCU image acquisition checklist using a multispecialty group of point-of-care ultrasound (POCUS) experts.

Methods: The essential components of an FCU examination were identified on the basis of published recommendations from echocardiography and international ultrasound societies. A checklist of the essential components of an FCU examination was drafted. A panel of POCUS experts from different medical specialties in the United States and Canada was convened to vote on each checklist item by answering two questions: 1) Is this item important to include in a checklist of essential FCU skills applicable to any medical specialty? and 2) Should the learner be required to successfully complete this item to be considered competent? A modified Delphi approach was used to assess the level of agreement for each checklist item during four rounds of voting. Checklist items that achieved an agreement of 80% or greater were included in the final checklist.

Results: Thirty-one POCUS experts from seven different medical specialties voted on sixty-five items to be included in the FCU image acquisition assessment tool. The majority of POCUS experts (61%) completed all four rounds of voting. During the first round of voting, 59 items reached consensus, and after revision and revoting, an additional 3 items achieved 80% or greater consensus. A total of 62 items were included in the final checklist, and 57 items reached consensus as a requirement for demonstration of competency.

Conclusion: We have developed a multispecialty, consensus-based FCU image acquisition checklist that may be used to assess the skills of learners from different specialties. Future steps include studies to develop additional validity evidence for the use of the FCU assessment tool and to evaluate its utility for the translation of skills into clinical practice.

A Prospective Analysis of Motor and Cognitive Skill Retention in Novice Learners of Point of Care Ultrasound

OBJECTIVES

To identify the time at which point of care ultrasound static image recognition and image acquisition skills decay in novice learners.

SETTING

The University of Iowa Hospitals and Clinics.

SUBJECTS

Twenty-four subjects (23 first-year medical students and one first-year physician assistant student).

DESIGN

The subjects completed an initial didactic and hands-on session with immediate testing of learned image acquisition and static image identification skills.

INTERVENTIONS

Retesting occurred at 1, 4, and 8 weeks after the initial training session with no retraining in between. Image acquisition skills were obtained on the same healthy male volunteers, and the students were given no immediate feedback on their performance. The image identification skills were assessed with a 10 question test at each follow-up session.

MEASUREMENTS AND MAIN RESULTS

For pleural ultrasound by 4 weeks, there was a significant decline of the ability to identify A-lines (p = 0.0065). For pleural image acquisition, there was no significant decline in the ability to demonstrate lung sliding. Conversely, cardiac image recognition did not significantly decline throughout the study, while the ability to demonstrate cardiac images at 4 weeks (parasternal short axis view) did (p = 0.0008).

CONCLUSIONS

Motor and cognitive skills decay at different times for pleural and cardiac images. Future ultrasound curricula should retrain skills at a maximum of 8 weeks from initial training. They should focus more on didactic sessions related to image identification for pleural images, and more hands-on image acquisition training for cardiac images, which represents a novel finding.

Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial

BACKGROUND

Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.

OBJECTIVE

This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.

METHODS

Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.

RESULTS

Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.

CONCLUSIONS

Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.

Diagnostic Capacity of Pocket-Sized Ultrasound Devices at Point of Care by a Non-radiologist Resident in Patients with Suspected Abdominal Pathology

Studies have reported the usefulness and tolerability in practice of abdominal ultrasound performed by non-radiologists in various clinical situations. This prospective observational single-center study included 184 patients hospitalized in an internal medicine department who underwent conventional abdominal ultrasound. A medical resident with basic training performed point-of-care clinical ultrasound using a pocket-sized device. The concordance obtained between the researcher and the radiologist was good (k >0.6) for the gallbladder, splenomegaly, longitudinal diameter of the kidney, presence of renal cysts and hydronephrosis. The specificity was >90% for all parameters assessed except normal renal size. A negative predictive value >90% was obtained for all variables studied except the presence of hepatic space-occupying lesions and gallbladder pathology, the negative predictive values for which were >80%. A positive predictive value >80% was obtained for all of these variables, except the presence of adenopathies, hepatomegaly, space-occupying lesions, echogenicity and/or enlargement of the biliary tract, left renal atrophy and right renal masses. We conclude there was a high concordance between a conventional abdominal study and that performed with a pocket-sized ultrasound device after a brief learning curve.

Prognostic Implications of a Point-of-Care Ultrasound Examination on Hospital Ward Admission

OBJECTIVES

Few data exist regarding the use of ultrasound (US) to risk stratify ward admissions. Therefore, we evaluated associations between a cardiopulmonary limited ultrasound examination (CLUE) on admission and subsequent hospital outcomes.

METHODS

Over a 22-month period in a 300-bed hospital, CLUE data reviewed from a series of nonelective ward admissions were correlated with the composite outcome of a hospital stay of longer than 2 days, disposition to hospice, or death. The CLUE included 5 quick-look signs of left ventricular dysfunction, left atrial enlargement, lung B-lines, pleural effusions, and inferior vena cava plethora and had been performed as warranted by 1 of 31 US-trained admitting residents and then repeated by a cardiologist as the reference standard. The admitting condition, medical history, results of routine admission testing, and CLUE were assessed for an association with the outcome in univariate and multivariable models.

RESULTS

Of 547 patients, the mean age ± SD was 62.9 ± 15.5 years; 59% were male; and the mean stay was 5.6 ± 8.1 days, with 355 (65%) lasting longer than 2 days and 21 (4%) having hospice disposition or death. An abnormal CLUE exam was found in 368 (67%) of patients, was related to the outcome (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.23-2.68; P = .001) when obtained by a resident or cardiologist, and was included in a best-fit multivariable model with renal failure (OR, 2.44; 95% CI, 1.44-4.14; P < .001), infection/sepsis (OR, 2.25; 95% CI, 1.17-4.32; P = .02), and chest pain (OR, 0.36; 95% CI, 0.21-0.61; P < .001).

CONCLUSIONS

An abnormal admission point of care ultrasound exam was related to complex hospitalization, specifically a longer length of stay.

Smartphone interfaced handheld echocardiography for focused assessment of ventricular function and structure in children: A pilot study

INTRODUCTION

Miniaturized echocardiographic machines improve availability and portability and can be particularly useful for underserved and resource-limited settings. The goal of this study was to compare left ventricular fractional shortening (FS) and left ventricular ejection fraction (LVEF) obtained by a newer handheld echo (HHE) machine to standard transthoracic echocardiogram (TTE) in children.

METHODS

Pediatric outpatients (Birth-18 years) undergoing TTE were prospectively enrolled. HHE protocol included 2D and M-mode images from the parasternal long, short, and apical-4 chamber views. HHE and TTE measurements were reviewed for agreement. Kappa statistic was used to analyze qualitative indices while FS and LVEF were analyzed with Lin's concordance correlation coefficient (CCC) and Bland-Altman limits of agreement (loa).

RESULTS

Sixty children were enrolled; 55 were included in the quantitative analysis. Mean age was 7.5 ± 5.5 years; 67% males; median HHE image acquisition duration was 2.3(1-5) minutes. Fractional shortening and EF by HHE showed good agreement with TTE [CCC = 0.82, 95%CI (0.73,0.90), mean bias -3.18%, loa (-7.00,6.44%) vs CCC = 0.81 (0.72,0.90), mean bias -0.87%, loa (-6.94,5.17%], respectively. In children ≤5 years, HHE FS (n = 20) and EF (n = 21) agreed with TTE measurement [0.59 (0.31, 0.88), mean bias 0.30%, loa (-8.5, 9.1%); 0.79 (0.63, 0.96), mean bias 0.10%, loa (-5.99, 6.14)]. Kappa values for RV size, function, and LV function were 1.00 (P < .05); 0.75 for LV size (P < .05) and 0.66 for pericardial effusion (P < .05).

CONCLUSION

Handheld echo demonstrates good correlation with standard TTE for focused assessment of ventricular chamber sizes and function in children.

Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis

BACKGROUND

Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation.

PURPOSE

To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation.

DATA SOURCES

English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations.

STUDY SELECTION

Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard.

DATA EXTRACTION

Three study investigators independently abstracted data and assessed study quality.

DATA SYNTHESIS

Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%).

LIMITATION

Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias.

CONCLUSION

Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42019124318).

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update)

Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.

Insonation versus Auscultation in Valvular Disorders: Is Aortic Stenosis the Exception? A Systematic Review

BACKGROUND

Handheld echocardiography is being proposed as the fifth pillar of bedside physical cardiovascular examination (PE) and is referred to as insonation. Although there is emerging consensus that insonation is superior to PE for diagnosis of various cardiac conditions, superiority has not been consistently demonstrated for various valvular heart disease (VHD) lesions. The objective of this review is to systematically review the accuracy of insonation and auscultation in published literature for detection of common VHD.

METHODS

An extensive literature search across three commonly used public databases allowed comparison of diagnostic characteristics of insonation and auscultation for common VHD including aortic stenosis, mitral regurgitation, aortic regurgitation, tricuspid regurgitation. Sensitivity, specificity, and accuracy of insonation and auscultation for the detection of these VHD lesions were extracted for further analysis. The quality of evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Eight hundred eighty studies were screened, and seven observational studies were selected for full analysis. Due to heterogeneity of data, this study was not amenable to meta-analysis. Insonation was superior to auscultation for the detection of all regurgitant lesions, but there was no significant difference in diagnostic ability of the two strategies for detection of aortic stenosis.

CONCLUSIONS

Compared to auscultation, insonation, in its currently available form, is a superior diagnostic tool for regurgitant lesions. However, insonation fails to improve upon auscultation for recognition of aortic stenosis. This limitation is likely due to absence of spectral Doppler and inability of HE to assess transvalvular velocity and gradient.

Internal medicine residents' point-of-care ultrasound skills and need assessment and the role of medical school training

Introduction: Point-of-care-ultrasound (POCUS) as a useful bedside tool is growing. Few studies have examined residents' attitude towards POCUS or compared POCUS image interpretation skills between residents with and without POCUS training in medical school. Material and Methods: We distributed an anonymous survey and image interpretation test to assess residents' attitude towards POCUS, confidence, and skills in interpreting POCUS images and videos. Using independent samples t-tests, we compared mean confidence levels and test scores between residents with and without prior POCUS training. Results: Fifty-two residents responded to survey (response rate 68%) and 59 took the image interpretation test (77%). Most residents (90%) reported being interested in POCUS. Residents with prior POCUS training (n=13) were either PGY-1 (9) or PGY-2 (4). No PGY-3 resident had prior training. Most residents (83%) thought POCUS could be extremely useful in the inpatient setting compared to 29% for outpatient setting. PGY-1 residents with prior training had a higher mean confidence level than PGY-1 residents without prior training, but the difference was not statistically significant (3.26 vs 2.64; p=0.08). PGY-1 with prior training had a mean confidence level that was close to that of PGY-3 residents. PGY-1 residents with prior training scored significantly higher than PGY-1 residents without prior training in image interpretation test (10.25 vs 7; p=0.01). Residents felt most confident in interpreting inferior vena cava images (mean 3.7; max. 5), which also had the highest score in image interpretation test (correct response rate of 88%). Conclusion: Our residents seem very interested in POCUS. PGY-1 residents with prior POCUS training in medical school seem to have higher confidence in their POCUS skills than PGY-1 residents without prior training and outperformed them in image interpretation test. The study is very instructive in building our future POCUS curriculum for residents.

Focused Cardiac Ultrasonography: Current Applications and Future Directions

Focused cardiac ultrasonography is performed by clinicians at the bedside and is used in time-sensitive scenarios to evaluate a patient's cardiovascular status when comprehensive echocardiography is not immediately available. This simplified cardiac ultrasonography is often performed by noncardiologists using small, portable devices to augment the physical examination, triage patients, and direct management in both critical care and outpatient settings. However, as the use of focused cardiac ultrasonography continues to expand, careful consideration is required regarding training, scope of practice, impact on patient outcomes, and medicolegal implications. In this review, we examine some of the challenges with rapid uptake of this technique and explore the benefits and potential risk of focused cardiac ultrasonography. We propose possible mechanisms for cross-specialty collaboration, quality improvement, and oversight.

[Usefulness and reliability of point of care ultrasound in Family Medicine: Focused cardiac and lung ultrasound]

The family doctor incorporates clinical ultrasound as an exploration and diagnosis technique in his care activity, the same way as the rest of the specialists. His generalist role makes him a potential user of all possible applications of this technique, which can provide a high impact on his ability to manage, focus and solve a large number of clinical situations. In this article we focus on assessing the usefulness and reliability of clinical ultrasound performed by the family doctor in their most novel aspects such as focused cardiac ultrasound and lung ultrasound.

A systematic review of pocket-sized imaging devices: small and mighty?

Introduction

Hand-held imaging devices are widely used in clinical practice and are a useful tool. There is no published review examining the diagnostic parameters achieved with these devices in clinical practice.

Methods

We searched three online medical literature databases (PubMed, EMBASE and MEDLINE) for all literature published up until January 2018. We selected studies that (1) were conducted in the adult population; (2) used a truly hand-held device; (3) featured sensitivities and/or specificities on the use of the hand-held scanner. We extracted and summarised the diagnostic metrics from the literature.

Results

Twenty-seven articles were excluded from the initial 56 relevant articles, as the device featured was not truly hand-held. Ultimately a total of 25 studies were analysed. Sixteen studies were carried out by experienced users, seven by users with little previous experience and two studies by nurses. High diagnostic parameters were achieved by all three groups when scanning cardiac pathology and intra-abdominal structures. Training of non-expert users varied, taking a mean of 21.6 h. These hand-held devices can change diagnoses at the bedside and be used as gate-keepers to formal echocardiography. Individual studies show them to be cost-effective.

Conclusion

Hand-held echocardiography is a useful tool in the hands of experts and novices alike. Studies conducted are highly heterogeneous making it difficult to pool data for the diagnostic metrics. Further studies with rigorous methodology are needed to evaluate the true diagnostic potential in the hands of non-experts and in the community as well as to validate training protocols.

Ultrasonography in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

The purpose of this study was to conduct a systematic review of the evidence of educational outcomes associated with teaching ultrasonography (US) to medical students.

METHODS

A review of databases through 2016 was conducted for research studies that reported data on teaching US to medical students. Each title and abstract were reviewed by teams of 2 independent abstractors to determine whether the article would be ordered for full-text review and subsequently by 2 independent authors for inclusion. Data were abstracted with a form developed a priori by the authors.

RESULTS

Ninety-five relevant unique articles were included (of 6936 identified in the databases). Survey data showed that students enjoyed the US courses and desired more US training. Of the studies that assessed US-related knowledge and skill, most of the results were either positive (16 of 25 for knowledge and 24 of 58 for skill) or lacked a control (8 of 25 for knowledge and 27 of 58 for skill). The limited evidence (14 of 95 studies) of the effect of US training on non-US knowledge and skill (eg, anatomy knowledge or physical examination skill) was mixed.

CONCLUSIONS

There is ample evidence that students can learn US knowledge and skills and that they enjoy and want US training in medical school. The evidence for the effect of US on external outcomes is limited, and there is insufficient evidence to recommend it for this purpose at this time.

Accuracy and Efficacy of Hand-Held Echocardiography in Diagnosing Valve Disease: A Systematic Review

In recent years, advances in technology have enabled hand-held echocardiography (HHE) to generate high-quality 2-dimensional and color Doppler images. As these devices become smaller, simpler, and more affordable, the question of whether HHE can augment or replace auscultation as the primary mode of cardiovascular diagnosis has become increasingly more relevant. If widely implemented, HHE has the potential for significant cost savings and better resource utilization. This review examines studies comparing the sensitivities of auscultation, HHE, and standard echocardiography in detecting various valvular lesions and discusses why current evidence supports the use of HHE to augment the physical examination, which can lead to more reliable and rapid bedside diagnoses, triage, and appropriate treatment of structural cardiac abnormalities.

Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain

This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).

[Use of pocket-sized ultrasound in internal medicine (hospitalist) practice: Feedback and perspectives]

INTRODUCTION

Point of care ultrasound (POCUS) is routinely used by intensivists and emergency physicians for many years. Its interest is not arguable any more for these specialists, despite the large variety of diseases they care. Hospitalists and internists also should find some interest in POCUS, which convenience and wide range of indications responds well to the variety of their practice. However, it is still not widely used in internal medicine departments.

METHODS

We here report our experience of using a pocket-sized ultrasound device in a French internal medicine department. The device used was a Vscan Dual Probe, GE, whose two probes and presets allow for cardiac, abdominal, pulmonary, obstetric, vascular, pulmonary, and superficial soft tissue exploration. One physician of the ward received a course for POCUS that was initially dedicated for emergency physicians. This study reports on the results of the examinations made between January and September 2015. For each examination performed, clinical usefulness was assessed at the time of patient discharge, by two independent physicians who reviewed the clinical course and the results of conventional imaging and rated their evaluation on a Likert scale.

RESULTS

One hundred and four examinations were evaluated. The mean duration of the ultrasound examination was 9±5minutes. The POCUS conclusions were corrected by disease course or the results of conventional imaging in 10 (9.6%) cases. The presets of the device: heart, soft tissue, lung, abdomen and vascular were used respectively in 32, 30, 21, 12 and 5% of the examinations. The main indications of POCUS examination were for identification of pleural, pericardial or peritoneal effusion, and to assess the central venous pressure by inferior vena cava examination. Eighteen examinations were performed for puncture of effusion. The retrospectively evaluated clinical benefit was clearly demonstrated in 78% of cases. The agreement between the two blinded assessors was good (kappa coefficient at 0.82).

CONCLUSION

Pocket-sized ultrasound device could be used in internal medicine wards. However, its limited performance compared to more sophisticated echography limits the possible explorations and their reliability, which encourages caution and makes critical the question of the initial training of doctors and medical students.

Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol

Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.

Abdominal aortic aneurysm screening program using hand-held ultrasound in primary healthcare

We determined the feasibility of abdominal aortic aneurysm (AAA) screening program led by family physicians in public primary healthcare setting using hand-held ultrasound device. The potential study population was 11,214 men aged ≥ 60 years attended by three urban, public primary healthcare centers. Participants were recruited by randomly-selected telephone calls. Ultrasound examinations were performed by four trained family physicians with a hand-held ultrasound device (Vscan^®). AAA observed were verified by confirmatory imaging using standard ultrasound or computed tomography. Cardiovascular risk factors were determined. The prevalence of AAA was computed as the sum of previously-known aneurysms, aneurysms detected by the screening program and model-based estimated undiagnosed aneurysms. We screened 1,010 men, with mean age of 71.3 (SD 6.9) years; 995 (98.5%) men had normal aortas and 15 (1.5%) had AAA on Vscan^®. Eleven out of 14 AAA-cases (78.6%) had AAA on confirmatory imaging (one patient died). The total prevalence of AAA was 2.49% (95%CI 2.20 to 2.78). The median aortic diameter at diagnosis was 3.5 cm in screened patients and 4.7 cm (p<0.001) in patients in whom AAA was diagnosed incidentally. Multivariate logistic regression analysis identified coronary heart disease (OR = 4.6, 95%CI 1.3 to 15.9) as the independent factor with the highest odds ratio. A screening program led by trained family physicians using hand-held ultrasound was a feasible, safe and reliable tool for the early detection of AAA.

Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside

The development of hand-carried, battery-powered ultrasound devices has created a new practice in ultrasound diagnostic imaging, called 'point-of-care' ultrasound (POCUS). Capitalising on device portability, POCUS is marked by brief and limited ultrasound imaging performed by the physician at the bedside to increase diagnostic accuracy and expediency. The natural evolution of POCUS techniques in general medicine, particularly with pocket-sized devices, may be in the development of a basic ultrasound examination similar to the use of the binaural stethoscope. This paper will specifically review how POCUS improves the limited sensitivity of the current practice of traditional cardiac physical examination by both cardiologists and non-cardiologists. Signs of left ventricular systolic dysfunction, left atrial enlargement, lung congestion and elevated central venous pressures are often missed by physical techniques but can be easily detected by POCUS and have prognostic and treatment implications. Creating a general set of repetitive imaging skills for these entities for application on all patients during routine examination will standardise and reduce heterogeneity in cardiac bedside ultrasound applications, simplify teaching curricula, enhance learning and recollection, and unify competency thresholds and practice. The addition of POCUS to standard physical examination techniques in cardiovascular medicine will result in an ultrasound-augmented cardiac physical examination that reaffirms the value of bedside diagnosis.