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Easter SR, Hameed AB, Shamshirsaz A, Fox K, Zelop CM. Point of care maternal ultrasound in obstetrics. Am J Obstet Gynecol 2022; 228:509.e1-509.e13. [PMID: 36183775 DOI: 10.1016/j.ajog.2022.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 09/24/2022] [Accepted: 09/25/2022] [Indexed: 01/25/2023]
Abstract
Ultrasound is the hallmark imaging modality traditionally used by obstetricians for fetal diagnosis and surveillance. The COVID-19 pandemic highlighted the role of point of care ultrasound for expeditious assessment of the maternal cardiopulmonary status. The familiarity of obstetricians with ultrasound, coupled with the availability of ultrasound equipment without the need to transport the patient, make point of care ultrasound particularly valuable in the labor and delivery unit. The rising contribution of cardiopulmonary disorders to maternal morbidity and mortality carves out many potential applications for point of care ultrasound during labor and delivery. Obstetricians have access to the technology and the skills to obtain the basic views required to assess for the presence of pulmonary edema, ventricular dysfunction, or intra-abdominal free fluid. Point of care ultrasound can be used routinely for the evaluation of pulmonary complaints or in the assessment of hypotension and may play an essential role in the diagnosis and management of life-threatening emergencies such as shock, an amniotic fluid embolism, or cardiac arrest. We reviewed the currently established point of care ultrasound protocols for the evaluation of cardiopulmonary complaints through the lens of the obstetrician. We call on educators and academic leaders to incorporate maternal point of care ultrasound teachings into existing curricula. Point of care ultrasound is of enormous value for providers with limited access to diagnostic imaging or subspecialty providers. With the growing complexity of the obstetrical population, acquiring the clinical skills to meet these evolving needs is a requisite step in the ongoing efforts to reduce maternal morbidity and mortality.
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Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Afshan B Hameed
- Division of Maternal Fetal Medicine and Cardiology, University of California, Irvine, CA
| | - Amir Shamshirsaz
- Division of Maternal-Fetal Medicine and Surgical Critical Care, Baylor College of Medicine, Houston, TX
| | - Karin Fox
- Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Carolyn M Zelop
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Valley Hospital, Ridgewood, NJ; Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
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2
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Dubey J, Shian B. Point-of-Care Ultrasound for Musculoskeletal Injection and Clinical Evaluation. Prim Care 2022; 49:163-189. [DOI: 10.1016/j.pop.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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3
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Bastos MG, Vieira AL, Pazeli JM, Galil AG. Diastolic dysfunction for nephrologists: diagnosis at the point of care. ACTA ACUST UNITED AC 2021; 66:1750-1756. [PMID: 33331588 DOI: 10.1590/1806-9282.66.12.1750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 08/10/2020] [Indexed: 11/21/2022]
Abstract
Cardiovascular diseases are important causes of morbidity and mortality in the course of chronic kidney disease (CKD). Diastolic dysfunction (DD) may progress with the clinical manifestation of heart failure, known as heart failure with preserved ejection fraction, a condition that precedes systolic dysfunction. The early identification of DD by echocardiography at the point-of-care before the appearance of symptoms and signs of pulmonary congestion and the implementation of appropriate treatment can improve the prognosis of CKD. This review article briefly addresses DD in kidney disease and presents a practical approach to the echocardiographic diagnosis of DD at the point of care.
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Affiliation(s)
- Marcus G Bastos
- Faculdade de Medicina da Universidade Federal de Juiz de Fora, MG, Brasil.,UNIFAGOC, Ubá, MG, Brasil.,Faculdade de Cieências Médicas e da Saúde (SUPREMA), Juiz de Fora, MG, Brasil
| | - Ana Luisa Vieira
- Serviço de nefrologia, Santa Casa de Misericórdia de Barbacena, Faculdade de Medicina de Barbacena, Barbacena, MG, Brasil
| | - José M Pazeli
- Serviço de nefrologia, Santa Casa de Misericórdia de Barbacena, Faculdade de Medicina de Barbacena, Barbacena, MG, Brasil
| | - Arise Gs Galil
- Faculdade de Medicina da Universidade Federal de Juiz de Fora, MG, Brasil
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Agut A, Martinez M, Anson A, Soler M. Ultrasonographic measurement of adrenal gland-to-aorta ratio as a method of estimating adrenal size in dogs. Vet Rec 2019; 186:e27. [PMID: 31727851 DOI: 10.1136/vr.105188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/12/2019] [Accepted: 10/17/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Adrenal size has been used as the principal criterion for differentiating a normal gland from adrenal hyperplasia. The objectives of this study were to establish an ultrasonographic measurement of adrenal gland-to-aorta (adrenal/Ao) ratio to estimate the adrenal size and to assess the effects of bodyweight, age and sex on the adrenal/Ao ratio in non-adrenal gland disease dogs. METHODS Two hundred and thirty-four dogs (120 entire females and 114 entire males) considered non-adrenal gland disease were included in this study. Dogs were allocated into three bodyweight categories (<10 kg, 10-20 kg and >20 kg), and four age groups (<1 year, 1-5 years, 5-10 years and >10 years old). Measurements of the maximal thickness of caudal pole of both adrenal glands and the aortic luminal diameter in sagittal plane were performed on the ultrasonographic images. Three different ratios were calculated for each dog. RESULTS Sex and age did not influence on the adrenal/Ao ratio. There were differences (P<0.05) between the three dog sizes for adrenal/Ao ratio, being the highest value for small size and the lowest value for large size. CONCLUSIONS In this study, only bodyweight influences the ultrasound measurement of the adrenal/Ao ratio in non-adrenal gland disease dogs.
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Affiliation(s)
- Amalia Agut
- Department of Medicine and Surgery, University of Murcia, Murcia, Spain .,Veterinary Teaching Hospital, University of Murcia, Murcia, Spain
| | - Miryam Martinez
- Veterinary Teaching Hospital, University of Murcia, Murcia, Spain.,Department of Diagnostic Imaging, Southfields Veterinary Specialists, Basildon, UK
| | - Agustina Anson
- Veterinary Teaching Hospital, University of Murcia, Murcia, Spain.,Department of Clinical Sciences, Tufts University Cummings School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Marta Soler
- Department of Medicine and Surgery, University of Murcia, Murcia, Spain.,Veterinary Teaching Hospital, University of Murcia, Murcia, Spain
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5
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Han PJ, Tsai BT, Martin JW, Keen WD, Waalen J, Kimura BJ. Evidence Basis for a Point-of-Care Ultrasound Examination to Refine Referral for Outpatient Echocardiography. Am J Med 2019; 132:227-233. [PMID: 30691553 DOI: 10.1016/j.amjmed.2018.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) examination in the outpatient setting to assist diagnosis of significant cardiac disease. Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS examination for cardiac application and model its potential use for prognostication and cost-effective echo referral. METHODS For POCUS examination derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS "signs" contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior vena cava plethora, and lung apical B-lines. The corresponding formal echo reports were then queried for any significant abnormality. The optimal POCUS examination for identifying an abnormal echo was determined. We then reviewed 244 consecutive outpatient echo studies from another institution for associations between the optimal POCUS examination, clinical variables, and referral source with major adverse cardiac events and all-cause mortality in univariate and multivariate models. Assuming a referral model where the absence of POCUS signs or variables would negate initial echo referral, theoretical cost savings were expressed as a percentage in reduction of echo studies. RESULTS In the derivation cohort, the combination of two signs, denoting left atrial enlargement and inferior vena cava plethora resulted in the highest accuracy of 72% [95% CI: 65%, 78%] in detecting an abnormal echocardiogram. In the validation cohort, mortality at 5.5 years was 14.6% overall, 23% in patients with the left atrial enlargement sign (OR 3.5 [1.6, 7.6]), 25% with inferior vena cava plethora sign (OR 2.2 [0.8, 6.0]), and 8.0% (OR 0.3 [0.2, 0.7]) in those lacking both signs. After adjusting for age, both diabetes (OR 4.8 [2.0, 11.6]), and the left atrial enlargement sign (OR 2.4 [1.1, 5.4]) remained independently associated with mortality (p<0.05). In the referral model, patients younger than 65 years of age without diabetes and without the left atrial enlargement sign would not have received echo referral, resulting in a 33% reduction in total echo cost and would have constituted a low-risk group with a 1.2% 5.5-year mortality. CONCLUSIONS A quick-look sign for left atrial enlargement is associated with 5-year mortality and could function as an easily obtained outpatient POCUS examination to help in identifying patients in need of echo referral.
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Affiliation(s)
- Paul J Han
- Department of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, Calif
| | - Ben T Tsai
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - Julie W Martin
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - William D Keen
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - Jill Waalen
- Scripps Translational Science Research Institute, San Diego, Calif
| | - Bruce J Kimura
- Department of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, Calif.
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6
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Phillips CT, Manning WJ. Advantages and pitfalls of pocket ultrasound vs daily chest radiography in the coronary care unit: A single-user experience. Echocardiography 2017; 34:656-661. [PMID: 28295525 DOI: 10.1111/echo.13509] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pocket ultrasonography may enhance patient diagnosis and care. We sought to assess pocket ultrasound in detecting common conditions in the coronary care unit (CCU) compared to portable daily chest radiography (CXR) and conventional transthoracic echocardiography (TTE). METHODS An experienced pocket ultrasound user performed a pocket ultrasound examination for interstitial edema, pneumonia, central line seen in the right ventricle, pleural and pericardial effusions, left atrial enlargement, and cardiomegaly. Data were blindly compared to the radiologist CXR interpretation and cardiologist TTE interpretation. RESULTS A total of 102 CXR and pocket ultrasound examinations were performed in 66 patients. The most common CXR indication was "interval change" (37%) and finding central line (65%). Pocket ultrasound demonstrated overall good concordance with CXR ranging from 77% for pleural effusion to 92% for pneumonia. Additionally, the pocket ultrasound examination appeared to anticipate resolution of pulmonary edema prior to the CXR. Compared to TTE, pocket ultrasound had excellent sensitivity for cardiac findings with values ranging from 85% for left atrial enlargement to 100% for cardiomegaly, but limited specificity of cardiomegaly at just 51%. CONCLUSION In the CCU, bedside pocket ultrasound reliably diagnoses common conditions identified by CXR with the advantage of lack of ionizing radiation and the suggestion of detecting the resolution of pulmonary edema prior to CXR. Pitfalls include only modest concordance for pleural effusions and limited specificity for cardiomegaly. Larger, multicenter studies are needed to determine whether pocket ultrasound can reduce routine daily CXR in the CCU and other intensive care settings.
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Affiliation(s)
- Colin T Phillips
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Warren J Manning
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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7
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Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart 2017; 103:987-994. [PMID: 28259843 DOI: 10.1136/heartjnl-2016-309915] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/02/2017] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Bruce J Kimura
- Department of Cardiology, Scripps Mercy Hospital, San Diego, California, USA.,Department of Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
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8
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Kim Y, Lee SH. Embolic stroke and after-admission atrial fibrillation. Int J Cardiol 2016; 222:576-580. [PMID: 27513654 DOI: 10.1016/j.ijcard.2016.07.265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/29/2016] [Accepted: 07/30/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although atrial fibrillation (AF) is a leading cause of recurrent embolic stroke, secondary AF after stroke has been reported frequently. Because of the different treatment each uses, it is important to detect the exact stroke-etiology. OBJECTIVES The aim of this study was to compare the embolic stroke in patients with known AF and after-admission AF (AAAF). METHODS Between October 2002 and July 2009, those who were diagnosed with AF (n=354) were enrolled in our study out of a total of 2026 acute ischemic stroke (IS) patients. The embolic lesion patterns were assessed by two stroke specialists who were blinded to the clinical information. RESULTS Among 354 IS patients with AF, the number of patients with embolic stroke was 314. Patients with embolic stroke were younger and more likely to have larger left atrial (LA)/Aortic diameter ratio. Approximately 90.4% of those with known AF had embolic stroke, while <60% of patients with AAAF had embolic stroke. Nevertheless, anticoagulants were prescribed similarly in both groups at discharge. The LA/Aortic diameter ratio<1.5 was significantly related to AAAF. After adjusting for multiple co-variables, compared to the patients with known AF, patients with AAAF had reduced risk of embolic stroke (Odds ratio 0.11, 95% Confidence interval 0.03-0.36, p-value<0.001). CONCLUSIONS Compared to AAAF after stroke, known AF was associated with embolic stroke. Therefore, we suggest that stroke etiology and some novel echocardiographic indicators such as LA enlargement might be contemplated before routine using of anticoagulants in IS patients with AF.
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Affiliation(s)
- Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Seung-Hoon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea.
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Nardi M, Shaw DJ, Amundson SA, Phan JN, Kimura BJ. Creating a Novel Cardiac Limited Ultrasound Exam Curriculum for Internal Medical Residency: Four Unanticipated Tasks. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016; 3:10.4137_JMECD.S18932. [PMID: 29349308 PMCID: PMC5736268 DOI: 10.4137/jmecd.s18932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/14/2016] [Accepted: 08/15/2016] [Indexed: 05/18/2023]
Abstract
Over the past two decades, our internal medicine residency has created a unique postgraduate education in internal medicine by incorporating a formal curriculum in point-of-care cardiac ultrasound as a mandatory component. The details regarding content and implementation were critical to the initial and subsequent success of this novel program. In this paper, we discuss the evidence-based advances, considerations, and pitfalls that we have encountered in the program's development through the discussion of four unanticipated tasks unique to a point-of-care ultrasound curriculum. The formatted discussion of these tasks will hopefully assist development of ultrasound programs at other institutions.
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Affiliation(s)
- Melissa Nardi
- Department of Graduate Medical Education, Internal Medicine Residency, Scripps Mercy Hospital, San Diego, CA, USA
| | - David J. Shaw
- Department of Graduate Medical Education, Internal Medicine Residency, Scripps Mercy Hospital, San Diego, CA, USA
| | - Stanley A. Amundson
- Department of Graduate Medical Education, Internal Medicine Residency, Scripps Mercy Hospital, San Diego, CA, USA
| | - James N. Phan
- Department of Graduate Medical Education, Internal Medicine Residency, Scripps Mercy Hospital, San Diego, CA, USA
| | - Bruce J. Kimura
- Department of Graduate Medical Education, Internal Medicine Residency, Scripps Mercy Hospital, San Diego, CA, USA
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10
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Kimura BJ, Shaw DJ, Amundson SA, Phan JN, Blanchard DG, DeMaria AN. Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1683-90. [PMID: 26269293 DOI: 10.7863/ultra.15.14.09002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/29/2014] [Indexed: 05/23/2023]
Abstract
The current practice of physical diagnosis is dependent on physician skills and biases, inductive reasoning, and time efficiency. Although the clinical utility of echocardiography is well known, few data exist on how to integrate 2-dimensional screening "quick-look" ultrasound applications into a novel, modernized cardiac physical examination. We discuss the evidence basis behind ultrasound "signs" pertinent to the cardiovascular system and elemental in synthesis of bedside diagnoses and propose the application of a brief cardiac limited ultrasound examination based on these signs. An ultrasound-augmented cardiac physical examination can be taught in traditional medical education and has the potential to improve bedside diagnosis and patient care.
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Affiliation(s)
- Bruce J Kimura
- Scripps Mercy Hospital, San Diego, California USA (B.J.K., D.J.S., S.A.A., J.N.P.); and University of California, San Diego Medical Center, San Diego, California USA (D.G.B., A.N.D.).
| | - David J Shaw
- Scripps Mercy Hospital, San Diego, California USA (B.J.K., D.J.S., S.A.A., J.N.P.); and University of California, San Diego Medical Center, San Diego, California USA (D.G.B., A.N.D.)
| | - Stan A Amundson
- Scripps Mercy Hospital, San Diego, California USA (B.J.K., D.J.S., S.A.A., J.N.P.); and University of California, San Diego Medical Center, San Diego, California USA (D.G.B., A.N.D.)
| | - James N Phan
- Scripps Mercy Hospital, San Diego, California USA (B.J.K., D.J.S., S.A.A., J.N.P.); and University of California, San Diego Medical Center, San Diego, California USA (D.G.B., A.N.D.)
| | - Daniel G Blanchard
- Scripps Mercy Hospital, San Diego, California USA (B.J.K., D.J.S., S.A.A., J.N.P.); and University of California, San Diego Medical Center, San Diego, California USA (D.G.B., A.N.D.)
| | - Anthony N DeMaria
- Scripps Mercy Hospital, San Diego, California USA (B.J.K., D.J.S., S.A.A., J.N.P.); and University of California, San Diego Medical Center, San Diego, California USA (D.G.B., A.N.D.)
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Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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12
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Marques EB, Rocha NN, Dos Santos MCP, Nascimento JHM, Scaramello CBV. Cardiac programming in rats submitted to leptin treatment during lactation. Int J Cardiol 2014; 181:141-3. [PMID: 25497539 DOI: 10.1016/j.ijcard.2014.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 11/27/2014] [Accepted: 12/01/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Emiliana B Marques
- Laboratory of Experimental Pharmacology, Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, RJ, Brazil
| | - Nazareth N Rocha
- Laboratory of Experimental Pharmacology, Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, RJ, Brazil
| | - Mara C P Dos Santos
- Laboratory of Cardiac Eletrophysiology, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - José H M Nascimento
- Laboratory of Cardiac Eletrophysiology, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Christianne B V Scaramello
- Laboratory of Experimental Pharmacology, Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, RJ, Brazil.
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13
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Feasibility of remote real-time guidance of a cardiac examination performed by novices using a pocket-sized ultrasound device. Emerg Med Int 2013; 2013:627230. [PMID: 24024032 PMCID: PMC3762173 DOI: 10.1155/2013/627230] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/22/2013] [Indexed: 11/17/2022] Open
Abstract
Background. The potential of pocket-sized ultrasound devices (PUDs) to improve global healthcare delivery is limited by the lack of a suitable imaging protocol and trained users. Therefore, we investigated the feasibility of performing a brief, evidence-based cardiac limited ultrasound exam (CLUE) through wireless guidance of novice users. Methods. Three trainees applied PUDs on 27 subjects while directed by an off-site cardiologist to obtain a CLUE to screen for LV systolic dysfunction (LVSD), LA enlargement (LAE), ultrasound lung comets (ULC+), and elevated CVP (eCVP). Real-time remote audiovisual guidance and interpretation by the cardiologist were performed using the iPhone 4/iPod (FaceTime, Apple, Inc.) attached to the PUD and transmitted data wirelessly. Accuracy and technical quality of transmitted images were compared to on-site, gold-standard echo thresholds. Results. Novice versus sonographer imaging yielded technically adequate views in 122/135 (90%) versus 130/135 (96%) (P < 0.05). CLUE's combined SN, SP, and ACC were 0.67, 0.96, and 0.90. Technical adequacy (%) and accuracy for each abnormality (n) were LVSD (85%, 0.93, n = 5), LAE (89%, 0.74, n = 16), ULC+ (100%, 0.94, n = 5), and eCVP (78%, 0.91, n = 1). Conclusion. A novice can perform the CLUE using PUD when wirelessly guided by an expert. This method could facilitate PUD use for off-site bedside medical decision making and triaging of patients.
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14
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Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2013; 26:567-81. [DOI: 10.1016/j.echo.2013.04.001] [Citation(s) in RCA: 415] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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15
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Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med 2012; 7:537-42. [PMID: 22592969 DOI: 10.1002/jhm.1944] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 03/05/2012] [Accepted: 03/23/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite the future potential of using ultrasound stethoscopes to augment the bedside cardiac physical, few data exist on a general cardiovascular imaging protocol that can be taught to physicians on a perpetual basis as a curriculum in graduate medical education. METHODS During the past decade, we developed and integrated a cardiovascular limited ultrasound training program within the confines of an internal medicine residency. The evidence-based rationale for the exam, the teaching methods, and curriculum are delineated, and subsequent observations regarding program requirements, proficiency, and academic outcomes are explored. Analysis of variance and linear regression assessed for relationships between academic scores, chief resident selection, and gender to proficiency in ultrasound. RESULTS A brief, 5-minute cardiovascular limited ultrasound exam (CLUE) was taught using both didactic and bedside methods, and practiced primarily within the cardiology consult, outpatient clinic, and intensive care rotations. Program costs were minimized by employing readily available institutional resources. After a 2-year lead-in training phase, the subsequent 4 years of senior resident performance (n = 41 residents) showed an 81% pass rate in CLUE competency. Resident ultrasound performance did not relate to academic scores (r = 0.05, P = 0.75), chief resident selection, nor gender. Observations regarding resident pitfalls in CLUE practice and increased participation in extracurricular research are described. CONCLUSIONS We report our initial experience in developing and implementing a training program for bedside cardiovascular ultrasound examination that employed evidence-based techniques, set proficiency goals, and assessed resident performance. It may be feasible to teach future internist-hospitalists the technique of bedside ultrasound during residency.
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Affiliation(s)
- Bruce J Kimura
- Department of Medical Education, Scripps Mercy Hospital, San Diego, CA, USA.
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Kimura BJ, Yogo N, O'Connell CW, Phan JN, Showalter BK, Wolfson T. Cardiopulmonary limited ultrasound examination for "quick-look" bedside application. Am J Cardiol 2011; 108:586-90. [PMID: 21641569 DOI: 10.1016/j.amjcard.2011.03.091] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/31/2011] [Accepted: 03/31/2011] [Indexed: 11/18/2022]
Abstract
Although taking a "quick look" at the heart using a small ultrasound device is now feasible, a formal ultrasound imaging protocol to augment the bedside physical examination has not been developed. Therefore, we sought to evaluate the diagnostic accuracy and prognostic value of a cardiopulmonary limited ultrasound examination (CLUE) using 4 simplified diagnostic criteria that would screen for left ventricular dysfunction (LV), left atrial (LA) enlargement, inferior vena cava plethora (IVC+), and ultrasound lung comet-tail artifacts (ULC+) in patients referred for echocardiography. The CLUE was tested by interpretation of only the parasternal LV long-axis, subcostal IVC, and 2 lung apical views in each of 1,016 consecutive echocardiograms performed with apical lung imaging. For inpatients, univariate and multivariate logistic regression analyses were performed to assess the relations between mortality, CLUE findings, age, and gender. In this echocardiographic referral series, 78% (n = 792) were inpatient and 22% (n = 224) were outpatient. The CLUE criteria demonstrated a sensitivity, specificity, and accuracy for a LV ejection fraction of ≤40% of 69%, 91%, and 89% and for LA enlargement of 75%, 72%, and 73%, respectively. CLUE findings of LV dysfunction, LA enlargement, IVC+, and ULC+ were seen in 16%, 53%, 34%, and 28% of inpatients. The best multivariate logistic model contained 3 predictors of in-hospital mortality: ULC+, IVC+ and male gender, with adjusted odds ratios (95% confidence intervals) of 3.5 (1.4 to 8.8), 5.8 (2.1 to 16.4), and 2.3 (0.9 to 5.8), respectively. In conclusion, a CLUE consisting of 4 quick-look "signs" has reasonable diagnostic accuracy for bedside use and contains prognostic information.
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Affiliation(s)
- Bruce J Kimura
- Department of Cardiology, Scripps Mercy Hospital, San Diego, California, USA.
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Kimura BJ, Gilcrease GW, Showalter BK, Phan JN, Wolfson T. Diagnostic performance of a pocket-sized ultrasound device for quick-look cardiac imaging. Am J Emerg Med 2010; 30:32-6. [PMID: 21035983 DOI: 10.1016/j.ajem.2010.07.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 07/12/2010] [Accepted: 07/12/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Although pocket-sized, simplified ultrasound devices have emerged to enable subjective point-of-care assessment, few data on their cardiac application exist. We sought to examine the image quality and the accuracy of subjective diagnosis of video loops obtained from a pocket-sized ultrasound device for 2 significant cardiac abnormalities, left ventricular systolic dysfunction and left atrial enlargement, obtained from a single, quick-look view. METHODS Parasternal left ventricular long-axis images acquired with a miniaturized commercially available device (Acuson P10) were reviewed using subjective criteria for left ventricular systolic dysfunction and left atrial enlargement and were compared with M-mode measurements of left atrial systolic diameter and E-point septal separation from a fully featured echocardiograph in 78 inpatients referred for standard echocardiography. Interpretive confidence and image quality were evaluated with each interpretation. RESULTS Of 78 inpatient studies, 19% of pocket ultrasound and 13% of standard studies were technically limited (P = NS). Of 61 technically adequate studies, subjective interpretation of pocket ultrasound images had a sensitivity, specificity, and accuracy of 79%, 52%, and 64% for left atrial diameter more than 4 cm; 47%, 98%, and 82% for E-point septal separation more than 1 cm of; 83%, 62%, and 74% for either abnormality; and 92%, 82%, and 87% for either abnormality when interpretive confidence was present (n = 23). The pocket ultrasound image quality scores were significantly lower than the standard echocardiograph (P < .001). CONCLUSION The pocket-sized device provided adequate imaging for screening of 2 significant cardiac entities. Subjective interpretation of a single parasternal view may help identify patients with cardiac disease.
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Affiliation(s)
- Bruce J Kimura
- Department of Cardiology, Scripps Mercy Hospital, 4060 Fourth Ave #206, San Diego, CA 92103, USA
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