Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department

Reproducibility and accuracy of a pocket-size ultrasound device in assessing liver steatosis

BACKGROUND

This diagnostic prospective study compared the feasibility and diagnostic accuracy of Pocket-size Ultrasound Devices (PUDs) against standard ultrasound (US) in detecting liver steatosis using the controlled attenuation parameter (CAP) and liver biopsy as reference standards.

MATERIALS AND METHODS

Consecutive patients with chronic liver diseases were assessed for the presence of steatosis using PUD and US. A CAP cut-off value >275 dB/m was applied to establish ≥S1. A 26-patient subgroup underwent liver biopsy. PUD reproducibility was evaluated using Cohen's k statistic. Diagnostic accuracy of PUD and US was given as Sensibility (Sn), Specificity (Sp), Positive and Negative Predictive Values (PPV, NPV), positive and negative Likelihood Ratio (LR+, LR-).

RESULTS

81 consecutive patients (69% males) with multiple etiologies were enroled. PUD inter-observer agreement was good (k 0.77, 95%CI 0.62-0.93). PUD and US identified ≥S1 according to CAP values respectively with Sn 0.87, Sp 0.61, PPV 0.49, NPV 0.91, LR+ 2.04, LR- 0.07, AUROC 0.74 and Sn 0.96, Sp 0.54, PPV 0.47, NPV 0.97, LR+ 2.10, LR- 0.07, AUROC 0.75.

CONCLUSIONS

PUD shows good reproducibility and diagnostic accuracy in ruling liver steatosis out, representing a useful point-of-care tool to avail of hepatologists interested in excluding NAFLD, but with basic US skills.

A Cadaveric Study Examining the Accuracy of Wireless Hand-Held Guided Ultrasound Injections Versus Blind Injections in the Flexor Tendon Sheath

Purpose

Hand-held ultrasound (HHUS) is gaining popularity among clinicians. Although its use for procedural guidance could have several advantages in hand surgery, other surgeons may wonder about its added benefits. This cadaveric study aimed to examine the hypothesis of increased accuracy of wireless HHUS-guided injections versus that of blind injections into the flexor sheath.

Methods

Our series included 20 fresh cadaveric hands with 80 fingers randomly assigned to 2 groups. In group A, 10 hands were randomly assigned to receive a landmark injection and then received a blinded injection to the flexor tendon sheath (FTS). In group B, 10 hands were blinded in the same manner and received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomic dissection was performed to evaluate the injection accuracy based on the dye's filling pattern in the FTS as stage I (no filling), stage II (<50% filling), and stage III (>50% filling). Statistical analysis was performed, and P <.05 indicated a significant difference.

Results

One finger was excluded because of severe Dupuytren contracture. In group A, 39 blind injections of the FTS were performed, with 82% (32/39) fingers achieving stage III filling. In group B, 40 ultrasound-guided FTS injections were performed, with 90% (36/40) of fingers achieving stage III filing. Our study did not reveal any superiority in accuracy when ultrasound guidance was used (P = .35).

Conclusions

Hand-held ultrasound-guided FTS injections were not more accurate than blind injections performed by an experienced hand surgeon. These findings suggest that blind injections can be used as routine practice when performed by experienced operators to treat trigger finger. However, the use of HHUS may offer other advantages in hand surgery practice.

Clinical relevance

Ultimately, choosing to perform HHUS-guided injection versus blind injection to treat trigger finger depends on the surgeon's experience and preference for a particular technique.

Accuracy of Wireless Hand-Held Guided Ultrasound Injections in the Trapeziometacarpal Joint: A Cadaveric Study

Background Symptomatic trapeziometacarpal osteoarthrosis can be treated with an ultrasound-guided injection in the early stages. This cadaveric study aimed to assess the hypothesis suggesting enhanced accuracy and reliability of hand-held ultrasound (HHUS) injections compared to blind injections into the trapeziometacarpal joint (TMC). Materials and method Our series included 20 fresh cadaveric hands, with a total of 20 TMC randomly assigned to two groups. In group A, 10 TMC received a blinded injection, and in group B, 10 TMC received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomical dissection was performed to assess the intra-articular location of the dye. The injection was considered accurate if the intra-articular synovial fluid was stained after opening the articular capsule on the dorsal approach. If there was no injection, it was inaccurate. A statistical analysis was performed, and p <.05 indicated a significant difference. Results Two thumbs were excluded during the study due to an existing trapeziectomy. In group A, 10 blind injections of TMC were performed, with 70% (7/10) of injections graded as accurate. In group B, eight ultrasound-guided injections were performed, with 75% (6/8) achieving accuracy. A Fisher's exact test was performed, and the results indicated no statistically significant difference in injection accuracy between the two groups (P = 1, odds ratio = 0.788). Conclusion Hand-held ultrasound guided TMC injections were not more accurate than blind injections performed by an experienced hand surgeon. Nonetheless, additional studies with a larger sample and comparative studies with conventional cart-based machines are necessary to evaluate the potential of this newly accessible device.

Reproducibility and feasibility of a handheld ultrasound device compared to a standard ultrasound machine in muscle thickness measurements

Objective

To test the feasibility and reproducibility of a handheld ultrasound device (HUD) compared to a standard ultrasound machine for muscle thickness measurements in healthy participants.

Methods

A prospective cross-sectional study was designed where two novice operators tested the thickness of the vastus lateralis, rectus femoris, and vastus intermedius muscles on recruited asymptomatic participants with no history of muscle diseases. The anterior-posterior thickness of each muscle was measured three times per operator to evaluate intra-operator reproducibility and using two machines to evaluate inter-system reproducibility. Scanning started using the HUD followed by the standard system. Intraclass correlation coefficients (ICC) and simple linear regression were used to test for reproducibility and proportional bias respectively.

Results

A total of 33 male participants volunteered to take part in this study with a mean age of 22.7 years (6.8). Intra-operator reproducibility was almost perfect for both operators on both machines (ICC > 0.80). The measurements difference percentage between the machines ranged from 1.8% to 6.6% and inter-system reproducibility ICC ranged from 0.815 to 0.927 showing excellent reproducibility. Inter-operator reproducibility was poor to moderate on both machines (ICC: 0.522-0.849). Regression analysis showed no proportional bias in the measurements. All measurements were completed successfully using the HUD.

Conclusion

The HUD demonstrated excellent accuracy compared to the standard ultrasound machine for measuring thigh muscle thickness.

Ultrasound-assisted examination in internal medicine practice

The guidelines have been developed for internists, general practitioners, emergency physicians, and paramedics. The guidelines are based on expert consensus papers, accumulated clinical and scientific experience. The methodology for organizing and conducting ultrasound-assisted examinations is described in detail. Algorithms for diagnosing the main syndromes in internal medicine practice are presented to help the practitioner. Particular attention is paid to the methodology of ultrasoundassisted examinations. These guidelines will be of interest to doctors, heads of medical facilities, as well as students of medical universities.

Handheld Ultrasound or Conventional Ultrasound Devices in Patients Undergoing HCT: A Validation Study

Abdominal ultrasound exams play a major role in the diagnosis of sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD). The development of portable hand-held ultrasound devices (HHUS) has been shown to facilitate the diagnosis of many diseases, but little data on the value of HHUS in the diagnosis of SOS/VOD are available. We performed a study aimed at validating portable ultrasound (US) devices in the setting of hematopoietic stem cell transplant (HCT). Sixteen evaluable patients undergoing allogeneic HCT were studied using conventional US and HHUS during the first 3 weeks after transplant. The results obtained demonstrate that there is a close correlation between conventional and handheld ultrasound examination in the measurement of the right hepatic lobe (r = 0.912, p < 0.0001), the left hepatic lobe (r = 0.843, p < 0.0001), the portal vein (PV) (r = 0.724, p < 0.0001), and the spleen (r = 0.983, p < 0.0001) based on Pearson’s correlation. The same data, analyzed through Lin’s concordance correlation coefficient, evidenced a substantial level of agreement in the comparison of the spleen and right hepatic lobe, while a lower grade of agreement in the measurement of the portal vein and left hepatic lobe. Moreover, there was good agreement between results obtained by the two types of ultrasound devices in assessing ascites (p < 0.0001), gallbladder thickening (p < 0.0001), and the direction of PV flow (p < 0.0001). HHUS device allows the study of HokUs-10 parameters with an excellent agreement with conventional US, and may contribute to SOS/VOD diagnosis.

A Call for Development of Point-of-Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency

Point-of-care ultrasound (POCUS) skillsets are now taught throughout training levels from medical school through fellowship given the broad utility in assisting with bedside procedures and triaging clinical presentations for expedited workup. This is reflected in training curricula for emergency medicine, internal medicine, and general surgery residencies. However, these skillsets are not formally taught or required in obstetrics and gynecology residency. We present the opinion that these skillsets and curricula should be developed for obstetrics and gynecology trainees given their exposure to patients with similar clinical presentations in which the clinical management would be aided by POCUS.

David Against Goliath: Direct Comparison of Handheld Bowel Sonography and Magnetic Resonance Enterography for Diagnosis of Crohn's Disease

BACKGROUND

Diagnosis of Crohn's disease (CD) requires ileo-colonoscopy (IC) and cross-sectional evaluation. Recently, "echoscopy" has been used effectively in several settings, although data about its use for CD diagnosis are still limited. Our aim was to evaluate the diagnostic accuracy of handheld bowel sonography (HHBS) in comparison with magnetic resonance enterography (MRE) for CD diagnosis.

METHODS

From September 2019 to June 2021, we prospectively recruited consecutive subjects attending our third level IBD Unit for suspected CD. Patients underwent IC, HHBS, and MRE in random order with operators blinded about the result of the other procedures. Bivariate correlation between MRE and HHBS was calculated by Spearman coefficient (r). To test the consistency between MRE and HHBS for CD location and complications, the Cohen's k measure was applied.

RESULTS

Crohn's disease diagnosis was made in 48 out of 85 subjects (56%). Sensitivity, specificity, positive predictive values, and negative predictive values for CD diagnosis were 87.50%, 91.89%, 93.33%, and 85% for HHBS; and 91.67%, 94.59%, 95.65%, and 89.74% for MRE, without significant differences in terms of diagnostic accuracy (89.41% for HHBS vs 92.94% for MRE, P = NS). Magnetic resonance enterography was superior to HHBS in defining CD extension (r = 0.67; P < .01) with a better diagnostic performance than HHBS for detecting location (k = 0.81; P < .01), strictures (k = 0.75; P < .01), abscesses (k = 0.68; P < .01), and fistulas (k = 0.65; P < .01).

CONCLUSION

Handheld bowel sonography and MRE are 2 accurate and noninvasive procedures for diagnosis of CD, although MRE is more sensitive in defining extension, location, and complications. Handheld bowel sonography could be used as effective ambulatory (or out-of-office) screening tool for identifying patients to refer for MRE examination due to high probability of CD diagnosis.

Estimation of the plasma volume status of elderly patients with acute decompensated heart failure using bedside clinical, biological, and ultrasound parameters

OBJECTIVE

Assessment of intravascular volume status to ensure optimization before hospital discharge could significantly reduce readmissions. It is difficult to evaluate congestion on clinical signs during an episode of acute heart failure (ADHF) in elderly patients.

HYPOTHESIS

There is an association between various volume overload parameters in patients older than 75 years.

METHODS

We performed a single-center prospective longitudinal study of patients older than 75 years hospitalized for acute heart failure. We analyzed the association between congestion assessment based on clinical signs, inferior vena cava (IVC) diameter measured by ultrasound, biological evaluation with N terminal pro brain natriuretic peptide (NT-proBNP), and estimated plasma volume (EPV) during decongestive therapy. We also monitored changes in renal function.

RESULTS

Fifty consecutive ADHF patients (85.2 ± 5.9 years, 68% female) were included in the study. At admission, a dilated, noncompliant IVC was found in all patients. The strongest correlations between different parameters of volume overload estimation were found between IVC and jugular vein distention (r = .8; p < .001), then IVC and oedema (r = .6; p < .001), IVC and crackles (r = .3; p < .036), then IVC and NT-proBNP (r = .3; p = .02). There was no correlation between EPV and signs of congestion. Patients who had no congestive signs on clinical or IVC examination at Day 2, more often presented with acute renal failure.

CONCLUSION

In ADHF patients older than 75 years, clinical and IVC evaluation of intravascular congestion correlate well. The concomitant assessment of clinical signs and IVC may prevent depletion-related renal failure.

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.

A comparison of handheld and standard ultrasound in Swiss medical students

BACKGROUND

The use of ultrasound (US) within healthcare has inspired the development of new US technology. There have been few studies comparing the use of handheld US to standard US for medical education. This research aims to determine whether a handheld US device can provide a comparable primary learning experience to that of a standard US machine.

METHODS

Over two days of instruction, participants were taught and evaluated on core US fundamentals. The standard group received instruction on standard US machines, while the handheld group received instruction on handheld US devices. Participants completed a qualitative survey regarding their experience. Six hundred and four images were obtained and graded by two emergency medicine physicians.

RESULTS

A total of 119 Swiss medical students were enrolled in our study. There was no statistically significant difference in the US assessment measurements, except for faster endpoint septal separation (EPSS) vascular setup time in the handheld group (P=0.001). There was no statistically significant difference in participants' perceived difficulty of US learning (P=0.198), comfort level (P=0.188), or self-estimated capability to perform US in the future (P=0.442). There was no statistically significant difference in the percentage of correctly obtained images (P=0.211) or images that were clinically useful (P=0.256). The median quality score of images obtained by the standard group was eight compared to seven in handheld group (P<0.01).

CONCLUSION

Our data suggest a handheld US machine can perform as well as a standard US machine as an educational tool despite sacrifices in image quality.

Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial

IMPORTANCE

There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms.

OBJECTIVE

To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs.

DESIGN, SETTING, AND PARTICIPANTS

This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021.

INTERVENTIONS

The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation.

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs.

RESULTS

A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.

Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine

Purpose

To provide consensus, and a list of experts’ recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting.

Methods

The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians–researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against.

Results

This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus.

Conclusions

This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06486-z.

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.

Strategies to Improve Bedside Clinical Skills Teaching

The bedside encounter between a patient and physician remains the cornerstone of the practice of medicine. However, physicians and trainees spend less time in direct contact with patients and families in the modern healthcare system. The current pandemic has further threatened time spent with patients. This lack of time has led to a decline in clinical skills, and a decrease in the number of faculty who are confident in teaching at the bedside. In this review we offer several strategies to get physicians and trainees back to the bedside to engage in clinical skills teaching and assessment. We recommend that providers pause before bedside encounters to be present with patients and learners and develop clear goals for a bedside teaching session. We suggest that clinical teachers practice an evidence-based approach, including a hypothesis-driven physical examination. We encourage the use of point-of-care technology to assist in diagnosis and allow learners to calibrate traditional physical exam skills with real-time visualization of pathology. Tools like point-of-care ultrasound can be powerful levers to get learners excited about bedside teaching, and to engage patients in their clinical care. We value telemedicine visits as unique opportunities to engage with patients in their home environment and to participate in patient-directed physical exam maneuvers. Finally, we recommend that educators provide feedback to learners on specific clinical exam skills, whether in the clinic, the wards, or during dedicated clinical skills assessments.

Point-of-care ultrasound with handheld devices in hematology: a monocentric single-stage phase II study

Point of care ultrasound (PoCUS) with pocket-size devices is an efficient and safe imaging modality that became a standard of care in various clinical settings. However, its implementation in hematology has never been evaluated so far. We conducted a prospective monocentric study aiming to harvest data on its usage and to assess its diagnostic and interventional performance in improving the accuracy of basic physical examination in hematological patients. After a focused training program, six hematologists were trained and conducted this study. Sixty-two patients were included. Only in 19 cases, further specialized imaging was required, whereas, in 43 patients PoCUS was sufficient to address the clinical inquiries. The use of PoCUS devices was assessed for its performance difficulty and usefulness perception with satisfactory outcomes. This study represents a proof-of-concept application of PoCUS in hematology, suggesting benefits over the physical examination.KEY POINTSPoCUS is particularly attractive in a hematological setting because able to improve the accuracy of physical examination.A hematology-focused training in PoCUS using handheld devices can allow hematologists to perform bed-side diagnostic and interventional US-based exams.

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.

Early Point-of-Care Ultrasound Assessment for Medical Patients Reduces Time to Appropriate Treatment: A Pilot Randomized Controlled Trial

Numerous studies emphasize the diagnostic importance of point-of-care ultrasound (POCUS), but the level of evidence remains low as most data are gathered from observational studies. We conducted a pilot, randomized controlled trial to evaluate the effect of POCUS exam on medical patient's management and clinical outcomes. Patients presenting with chest pain or dyspnea were enrolled and randomly allocated to an early POCUS scan group and a control group. POCUS assessment, within 24 h of internal ward admission, was conducted only for the intervention group. The primary outcome was time to correct diagnosis. Secondary outcomes included time to appropriate treatment, POCUS-related rate of primary diagnosis alteration and new clinically relevant findings and time to hospital discharge. Sixty patients were enrolled. Thirty patients were randomly allocated to each study arm. The POCUS exam revealed clinically relevant findings among 79% of patients and led to alteration of the primary diagnosis among 28% of patients. Time to appropriate treatment was significantly shorter among patients in the POCUS group compared with the control group (median time of 5 h [95% confidence interval: 0.5-9] vs. 24 h [95% CI: 19-29] p = 0.014). The time needed to achieve correct diagnosis by the primary team was shorter in the POCUS group compared with the control group, yet it did not reach statistical significance (median time of 24 h [95% CI: 18-30] vs. 48 h [95% CI: 20-76], p = 0.12). These results indicate that POCUS assessment conducted early among patients with dyspnea or chest pain improves diagnostic accuracy and shortens significantly the time to appropriate treatment.

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.

Handheld ultrasound in training - The future is getting smaller!

Traditional ultrasound teaching is normally delivered using large, costly and often quite advanced cart-based systems. These carts are often large systems on wheels, usually limited to the departments that own them i.e. clinics, wards or radiology. Portability has been further improved by the development of laptop style systems, which are easier to wheel in-between patients/departments. In our experience and anecdotally, many of these systems can be intimidating to the novice and can lead to early attrition or poor uptake of ultrasound into clinical practice. Carts can also restrict the amount of training deliverable to practitioners, as they are limited in number due to cost and can take quite some time to boot up, reducing convenience. This dogma is being progressively changed with the advent of smaller handheld devices, some clearly within the financial grasps of most practitioners, and even to the point of medical schools offering students their own personal device.^1,2 This relative inexpensiveness can lead to the purchase of these devices for novelty and convenience, over need. Obvious caution is needed in these circumstances, but with increased ease of purchase, better availability and inbuilt simplicity, ultrasound learning can be seamlessly integrated into day-to-day practice. This review discusses how one of the most disruptive innovations in modern medicine is changing ultrasound from a classic imaging modality to become integrated as the fifth pillar of clinical examination, and how these new devices can serve as springboards to more advanced ultrasound training. In fact, within what has become a bigger area of clinical examination, things are getting smaller.

Is pocket-size ultrasound a reliable tool for bowel investigation? A study on its feasibility, reproducibility and diagnostic accuracy

BACKGROUND

Intestinal ultrasound (IUS) examination is a first-line non-invasive imaging procedure for patients with suspicion of bowel diseases.

AIM

To assess the feasibility, reproducibility and diagnostic accuracy of a pocket-size ultrasound device (PUD) in identifying the presence of intestinal alterations in patients consecutively recruited to undergo IUS examination.

METHODS

200 consecutive patients (57% female, 48.8 years) underwent both PUD (two independent investigators) and IUS examination on the same day. Nine ultrasonographic signs were systematically searched for. PUD inter-observer reproducibility was assessed by kappa statistic and ICC. The diagnostic accuracy of PUD as compared to IUS results was assessed by calculating sensitivity, specificity and corresponding positive and negative likelihood ratios.

RESULTS

PUD and IUS examinations were successful in 100% of the patients. PUD reproducibility was good/excellent at evidencing the presence (ICC 0.84) and length (ICC 0.85) of an intestinal tract with thickened wall and abdominal free fluid (ICC 0.87). The diagnostic accuracy of PUD, compared to traditional IUS, was good with regard to the presence of bowel wall thickening (sensitivity 92%, specificity 95%), the length of the thickened bowel (sensitivity 94%, specificity 95%) and the presence of free fluid (sensitivity 81%, specificity 99%).

CONCLUSIONS

PUD is a feasible, reproducible and accurate first-line screening tool for the assessment of the gastro-intestinal tract.

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).

Assessment of peripheral muscle thickness and architecture in healthy volunteers using hand-held ultrasound devices; a comparison study with standard ultrasound

BACKGROUND

Pocket-sized ultrasound devices are increasingly used in a variety of clinical situations, and perform well against standard ultrasound machines. We sought to investigate if a pocket-sized ultrasound device can assess muscle thickness and architecture in healthy volunteers.

METHODS

Healthy male volunteers (n = 21) across a range of ages were recruited to the study. Laying supine, ultrasound images were taken from the right anterior and lateral thigh. Thickness of the rectus femoris (RFMT), vastus intermedius (VIMT), and the two combined (anterior thigh, AMT) were measured, along with thickness of vastus lateralis (VLMT), pennation angle (VLPA) and derived fascicle length (VLFL). These scans were performed initially using a pocket-sized ultrasound (VScan) and then using a standard device (Telemed Echoblaster 128).

RESULTS

In all six variables, there was no significant difference between the two sets of measurements. Intra-class correlation co-efficients (ICC) for VLMT, VLPA, and AMT were all excellent (0.93, 0.89, 0.90 respectively) with the derived value of VLFL having an ICC of 0.84. All ICC values were statistically significant. Regression analysis demonstrated no evidence of proportional bias in any of the measured or derived variables.

CONCLUSION

A pocket-sized ultrasound device gives similar measurements of lower limb muscle thickness and architecture as a standard device in healthy volunteers.

Recent technological advancements in regional anesthesia

Just two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and largely improved outcomes. Ultrasound (US) technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment. The US technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage and effective treatments and providing timelier interventions. In recent years, several different strategies to help improve and ease US-guided needle identification and placement have been developed, including magnetically guided needle US technology. Three-dimensional (3D) and four-dimensional (4D) US use is another potential way to help improve first-pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under US has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during US-guided procedures. To reduce variability and to reduce the anesthesiologist's workload, the use of robots in regional anesthesia has been assessed in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.

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.

Hand-Held Ultrasound Devices Compared with High-End Ultrasound Systems: A Systematic Review

The aim of this study was to review the scientific literature available on the comparison of hand-held ultrasound devices with high-end systems for abdominal and pleural applications. PubMed, Embase, Web of Science and Cochrane were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Original research describing hand-held ultrasound devices compared with high-end systems was included and assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2. The search was limited to articles published since 1 January 2012. A total of 2486 articles were found and screened by title and abstract. A total of 16 articles were chosen for final review. All of the included articles showed good overall agreement between hand-held and high-end ultrasound systems. Strong correlations were found when evaluating ascites, hydronephrosis, pleural cavities, in detection of abdominal aortic aneurysms and for use with obstetric and gynaecological patients. Other articles found good agreement for cholelithiasis and for determining the best site for paracentesis. QUADAS-2 analysis suggested few risks of bias and almost no concerns regarding applicability. For distinct clinical questions, hand-held devices may be a valuable supplement to physical examination. However, evidence is inadequate, and more research is needed on the abdominal and pleural use of hand-held ultrasound with more standardised comparisons, using only blinded reviewers.

Application of mobile health, telemedicine and artificial intelligence to echocardiography

The intersection of global broadband technology and miniaturized high-capability computing devices has led to a revolution in the delivery of healthcare and the birth of telemedicine and mobile health (mHealth). Rapid advances in handheld imaging devices with other mHealth devices such as smartphone apps and wearable devices are making great strides in the field of cardiovascular imaging like never before. Although these technologies offer a bright promise in cardiovascular imaging, it is far from straightforward. The massive data influx from telemedicine and mHealth including cardiovascular imaging supersedes the existing capabilities of current healthcare system and statistical software. Artificial intelligence with machine learning is the one and only way to navigate through this complex maze of the data influx through various approaches. Deep learning techniques are further expanding their role by image recognition and automated measurements. Artificial intelligence provides limitless opportunity to rigorously analyze data. As we move forward, the futures of mHealth, telemedicine and artificial intelligence are increasingly becoming intertwined to give rise to precision medicine.

Personal mobile device-based pocket echocardiograph-The diagnostic value and clinical utility

PURPOSE

A microUSB ultrasound probe, which can be connected to a personal mobile device constitutes a new class of diagnostic pocket-size imaging devices (PSID). The aim of this study was to assess the feasibility and diagnostic value of brief transthoracic echocardiographic examination (bTTE) performed with the use of such equipment.

MATERIAL AND METHODS

The study population comprised 87 consecutive patients (58 men, mean age 61 ± 16 years), 53 of whom were admitted to intensive cardiac care unit and 34 patients, who were referred for transthoracic echocardiography from outpatient clinic. All patients underwent bTTE performed by cardiologist with the use of personal mobile device-based PSID. Within 18 h of bTTE all subjects underwent a standard TTE (sTTE) using a full sized echocardiograph by expert echocardiographer.

RESULTS

In all patients, PSID imaging provided sufficient diagnostic image quality. Echocardiographic measurements were completed for both bTTE and sTTE in 98% of patients. The linear measurements obtained during bTTE showed good to excellent correlation with sTTE results (r = 0.65-0.98; p < 0.001). The agreement in detection of various pathologies between the bTTE and sTTE examination was very good (k = 0.62-0.97; p < 0.01).

CONCLUSION

Personal mobile device-based PSID allows for performing bTTE. The diagnostic value of such PSID in basic assessment of cardiac morphology and function as compared to standard echocardiography is very good.

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).

Educational value of pocket-sized ultrasound devices to improve understanding of ultrasound examination principles and sonographic anatomy for medical student

Purpose

Medical students must understand the principles of ultrasonography (US), because US examinations are an important component of patient care in clinical practice. Pocket-sized ultrasound devices have the benefits of accessibility and ease of use. The primary objective of the present study was to evaluate the educational value of these devices in terms of improving medical student interest and understanding of US and sonographic anatomy.

Methods

We added a US training program comprised of a self-study learning module and a hands-on training session to a two-week block curriculum of medical imaging for first year medical students (n = 40). Multiple pocket-sized US devices were used on a small-group basis during a single afternoon. Students were asked to complete a questionnaire before and after the US training session; these two questionnaires contained 6 and 10 questions, respectively, which were rated by students using a five-point Likert scale. In addition, understanding of sonographic anatomy was tested before and after the training program.

Results

Forty students completed the two questionnaires and the anatomy-related tests. Students found the program educationally valuable (4.37 ± 0.54 of 5) and reported that US practice was useful for improving their understanding of the principles of US examinations (4.23 ± 0.66 of 5) and sonographic anatomy (4.40 ± 0.55 of 5). Overall confidence at performing US examinations and understanding of sonographic anatomy were significantly increased after US training (increased overall confidence score, 1.87 ± 0.91 and improvement in sonographic anatomy score, 6.55 ± 1.55, p values < 0.001).

Conclusion

US training using pocket-sized ultrasound devices was found to be educationally valuable for medical students in terms of improving understanding of US principles and familiarizing students with sonographic anatomy.

The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum

BACKGROUND

Teaching cardiac ultrasound to medical students in a brief course is a challenge. We aimed to evaluate the feasibility of teaching large groups of medical students the acquisition and interpretation of cardiac ultrasound images using a pocket ultrasound device (PUD) in a short, specially designed course.

METHODS

Thirty-one medical students in their first clinical year participated in the study. All were novices in the use of cardiac ultrasound. The training consisted of 4 hours of frontal lectures and 4 hours of hands-on training. Students were encouraged to use PUD for individual practice. Finally, the students' proficiency in the acquisition of ultrasound images and their ability to recognize normal and pathological states were evaluated.

RESULTS

Sixteen of 27 (59%) students were able to demonstrate all main ultrasound views (parasternal, apical, and subcostal views) in a six-minute test. The most obtainable view was the parasternal long-axis view (89%) and the least obtainable was the subcostal view (58%). Ninety-seven percent of students correctly differentiated normal from severely reduced left ventricular function, 100% correctly differentiated a normal right ventricle from a severely hypokinetic one, 100% correctly differentiated a normal mitral valve from a rheumatic one, and 88% correctly differentiated a normal aortic valve from a calcified one, while 95% of them correctly identified the presence of pericardial effusion.

CONCLUSIONS

Training of medical students in cardiac ultrasound during the first clinical year using a short, focused course is feasible and enables students with modest ability to acquire the main transthoracic ultrasound views and gain proficiency in the diagnosis of a limited number of cardiac pathologies.

Clinical utility and diagnostic accuracy of palm-held, mini-sized ultrasonocardiographic scanner in congenital heart disease

BACKGROUND/PURPOSE

To investigate whether a palm-held ultrasonocardiographic scanner would be useful for screening and follow-up in congenital heart disease (CHD).

METHODS

We retrospectively reviewed the echocardiographic images from June 1, 2014 to November 1, 2014. All patients underwent two ultrasonographic examinations including palm-held scanner examination and standard echocardiography. To compare the quality of the two instruments, we developed a diagnostic scoring system ranging from 1 point to 10 points, with 10 points indicating the best quality. Two experienced echocardiographers retrospectively reviewed all recorded images blindedly and gave each examination a score. Comparisons of diagnostic score between two equipments were performed.

RESULTS

A total of 262 patients' images were reviewed. All cardiac lesions could be detected with both instruments. The mean diagnostic score of palm-held scanner and standard echocardiography were 8.20±0.53 versus 9.64±0.37 (p<0.05) in color image and 7.00±1.05 versus 8.56±1.14 (p<0.05) in gray-scale two-dimensional image, respectively. When we compared the score between the two instruments in individual CHDs, we found standard echocardiography had better quality except for detecting muscular ventricular septal defect and pulmonary regurgitation.

CONCLUSION

The diagnostic sensitivity of palm-held scanner in detecting CHD was very good. Despite both instruments having a high diagnostic score in detecting CHD, standard echocardiography had better quality. Traditional echocardiography is still the standard tool for CHD evaluation. However, the palm-held scanner can support physical examination for initial screening and follow-up, and offer cardiologists an opportunity to visualize and listen to the heart at any time.

Actual use of pocket-sized ultrasound devices for cardiovascular examination by trained physicians during a hospitalist rotation

Background

In actual clinical practice as opposed to published studies, the application of bedside ultrasound requires a perception of need, confidence in one's skills, and convenience.

Objective

As the frequency of ultrasound usage is evidence to its perceived value in patient care, we observed the pattern of autonomous use of a pocket-sized device (PSD) by ultrasound-trained residents during a night hospitalist rotation.

Methods

Consecutive internal medicine residents (n=24), trained in a cardiac limited ultrasound examination (CLUE) as a mandatory part of their curriculum, were sampled on their PSD use after their admitting nights, regarding perceived necessity, deterring factors, detected abnormalities, and imaging difficulties. A detailed analysis was performed with one resident who used a PSD on every admission to compare the proportion of abnormal CLUEs and utility in patients with and without a perceived need.

Results

Residents admitted 542 patients (mean age: 55±17 years, range: 17–95 years) during 101 shifts and performed CLUE on 230 patients (42%, range: 17–85%). Residents elected not to scan 312 (58%) patients due to 1) lack of perceived necessity (231, 74%), 2) time constraints (44, 14%), and 3) patient barriers (37, 12%). In the detailed analysis (n=71), the resident felt CLUE was necessary in 32 (45%) patients versus unnecessary in 39 (55%) patients, with abnormality rates of 50% versus 20.5% (p=0.01) and utility rates of 28.1% versus 15.4% (p=0.25), respectively.

Conclusion

When unbiased residents acting as hospitalists are provided with a PSD to augment initial cardiac examination, usage is frequent and suggests clinical value in hospital medicine.

Impact of Point-of-Care Ultrasound Examination on Triage of Patients With Suspected Cardiac Disease

Complementing the physical examination with a point-of-care ultrasound study (POCUS) can improve patient triage. We aimed to study the impact of POCUS on the diagnosis and management of outpatients and hospitalized patients with suspected cardiac disease. In this multicenter study, a pocket-sized device was used to perform POCUS when the diagnosis or patient management was unclear based on anamnesis, physical examination, and basic diagnostic testing. Eighteen physicians (cardiac fellows 49%, cardiologists 30%, and echocardiographers 21%) performed physical examinations extended by POCUS on 207 patients (inpatients 83% and outpatients 17%). POCUS findings resulted in a change in the primary diagnosis in 14% of patients. In patients whose diagnosis remained unchanged, POCUS results reinforced the initial diagnosis in 48% of the cases. In 39% of the patients, the diagnostic plan was altered, including referral (16%) or deferral (23%) to other diagnostic techniques. Alteration in medical treatment (drug discontinuation or initiation) occurred in 11% of the patients, and in 7% POCUS results influenced the decision whether to perform a therapeutic procedure. Hospitalization or discharge was determined after POCUS in 11% of the patients. In conclusion, during patient triage, extension of the physical examination by POCUS can cause physicians to alter their initial diagnosis, resulting in an immediate change of diagnostic and therapeutic procedures. Based on POCUS results, physicians altered the diagnostic plan either by avoiding or referring patients to other diagnostic procedures in almost half of the studied population.