La ecografía en manos del internista: ¿el estetoscopio del sigloxxi?

Impact of point-of-care ultrasound on the hospital length of stay for internal medicine inpatients with cardiopulmonary diagnosis at admission: study protocol of a randomized controlled trial-the IMFCU-1 (Internal Medicine Focused Clinical Ultrasound) study

Background

Point-of-care ultrasound (POCUS) is emerging as a reliable and valid clinical tool that impacts diagnosis and clinical decision-making as well as timely intervention for optimal patient management. This makes its utility in patients admitted to internal medicine wards attractive. However, there is still an evidence gap in all the medical setting of how its use affects clinical variables such as length of stay, morbidity, and mortality.

Methods/design

A prospective randomized controlled trial assessing the effect of a surface POCUS of the heart, lungs, and femoral and popliteal veins performed by an internal medicine physician during the first 24 h of patient admission to the unit with a presumptive cardiopulmonary diagnosis. The University of Melbourne iHeartScan, iLungScan, and two-point venous compression protocols are followed to identify left and right ventricular function, significant valvular heart disease, pericardial and pleural effusion, consolidation, pulmonary edema, pneumothorax, and proximal deep venous thrombosis. Patient management is not commanded by the protocol and is at the discretion of the treating team. A total of 250 patients will be recruited at one tertiary hospital. Participants are randomized to receive POCUS or no POCUS. The primary outcome measured will be hospital length of stay. Secondary outcomes include the change in diagnosis and management, 30-day hospital readmission, and healthcare costs.

Discussion

This study will evaluate the clinical impact of multi-organ POCUS in internal medicine patients admitted with cardiopulmonary diagnosis on the hospital length of stay. Recruitment of participants commenced in September 2018 and is estimated to be completed by March 2020.

Trial registration

Australian and New Zealand Clinical Trial Registry, ACTRN12618001442291. Registered on 28 August 2018.

Teaching the basics of echocardiography in the undergraduate: Students as mentors

OBJECTIVE

To analyse the ability of medical students to incorporate the practical teaching of basic echocardiography planes using a peer mentoring design.

METHODOLOGY

Thirty-six medical students previously trained in obtaining echocardiography planes (mentors) taught the other 5th-year students (n=126). The teaching methodology included three stages: theory (online course), basic training (three 15h sessions of practical experience in ultrasound and at least 20 echocardiographic studies per mentor) and objective structured clinical assessment (OSCA), which scored the appropriateness of the basic ultrasound planes and the correct identification of 16 cardiac structures.

RESULTS

The students' weighted mean score in the OSCA was 8.66±1.98 points (out of 10). Only 10 students (8.4%) scored less than 5, and 15 (12.6%) scored less than 7. Fifty students (42%) scored 10 points. The most easily identified structure was the left ventricle in the short-axis parasternal plane, with 89.9% of correct answers. The most poorly identified structure was the mitral valve in the subxiphoid plane, with 69.7% of correct answers.

CONCLUSIONS

Peer mentoring-based teaching achieves an appropriate level of training in obtaining basic echocardiography planes. The training period is relatively short. The peer mentoring system can facilitate the implementation of teaching on basic aspects of ultrasound to a large number of undergraduate students.

Basic Abdominal Point-of-Care Ultrasound Training in the Undergraduate: Students as Mentors

OBJECTIVES

To analyze the ability of medical students to be integrated in the teaching of basic abdominal ultrasound using a peer-mentoring design.

METHODS

Thirty medical students previously trained in basic abdominal ultrasound (mentors) had to teach all fourth-year students (n = 136) from a single academic year the same training they had received. There were 3 stages to the ultrasound teaching: theoretical (online course); basic training (3 practical sessions in which students were guaranteed to have had a minimum of 15 hours of practical experience with ultrasound and performed at least 20 basic abdominal ultrasound studies); and evaluation (objective structured clinical examination in which students had to obtain the basic abdominal views and to identify 17 structures).

RESULTS

The mean grade ± SD obtained was 8.71 ± 1.53 of a possible 10 points. Only 2 students (1.56%) obtained a grade lower than 5, and 14 students (10.86%) obtained a grade lower than 7. A total of 33 students (25.5%) achieved the maximum grade. The structures most easily identified were the liver, the right kidney, and the urinary bladder, with 97.7% of correct answers. Students obtained the poorest results when trying to identify the left and right cardiac cavities (subxiphoid view), with only 53.5% and 55.8% of correct answers, respectively.

CONCLUSIONS

Teaching based on peer mentoring achieved an adequate level of training in basic abdominal ultrasound. The students acquired these skills in a relatively short training period. These results suggest that peer mentoring can facilitate the large-scale implementation of ultrasound teaching in undergraduate students.

Spontaneous intrathyroidal hematoma causing airway obstruction: A case report

INTRODUCTION

Spontaneous thyroid hemorrhage is a rare occurrence that results in pain, discomfort, and occasionally compressive symptoms. Infrequently, extensive thyroid hemorrhage can result in a rapidly expanding hematoma resulting in airway compromise. This is a case of an otherwise healthy young woman, 3 months postpartum, with a slowly expanding spontaneous thyroid hemorrhage that measured at 7 × 5.5 × 5 cm by computed tomography. She ultimately required intubation to manage respiratory distress and subsequently a hemithyroidectomy for definitive treatment. The case presentation is followed by a literature review where known etiologies of thyroid hematoma including traumatic and nontraumatic causes, precipitating anticoagulation, and spontaneous rupture of branches of the external carotid artery are outlined. The potential links to pregnancy are explored. The roles of bedside thyroid ultrasound in the emergency department and lateral neck roentgenogram in diagnosis are explored. The importance of airway management and indications for conservative versus surgical treatments are discussed.

CONCLUSIONS

This is a case of a spontaneous intrathyroidal hemorrhage, which progressed over days to ultimately cause airway compromise. It is imperative that physicians are educated on the appropriate detection and management of the potentially life-threatening spontaneous thyroid hematoma.

Acute Complex Care Model: An organizational approach for the medical care of hospitalized acute complex patients

BACKGROUND

Chronic diseases are the major cause of death (59%) and disability worldwide, representing 46% of global disease burden. According to the Future Hospital Commission of the Royal College of Physicians, Medical Division (MD) will be responsible for all hospital medical services, from emergency to specialist wards. The Hospital Acute Care Hub will bring together the clinical areas of the MD that focus on the management of acute medical patients. The Chronic Care Model (CCM) places the patient at the center of the care system enhancing the community's social and health support, pathways and structures to keep chronic, frail, poly-pathological people at home or out of the hospital. The management of such patients in the hospital still needs to be solved. Hereby, we propose an innovative model for the management of the hospital's acute complex patients, which is the hospital counterpart of the CCM.

ACUTE COMPLEX CARE MODEL (ACCM)

The target population are acutely ill complex and poly-pathological patients (AICPPs), admitted to hospital and requiring high technology resources. The mission is to improve the management of medical admissions through pre-defined intra-hospital tracks and a global, multidisciplinary, patient-centered approach. The ACCM leader is an internal medicine specialist (IMS) who summarizes health problems, establishes priorities, and restores health balance in AICPPs.

CONCLUSIONS

The epidemiological transition leading to a progressive increase in "chronically unstable" and complex patients needing frequent hospital treatment, inevitably enhances the role of hospital IMS in the coordination and delivery of care. ACCM represents a practical response to this epochal change of roles.

[Ultrasound of the large abdominal vessels]

Ultrasound has recently become an indispensable tool for the family physician, whether exercised in primary care and emergency department; and likewise it has spread to many other specialties: internal medicine, critical care, neurology, pneumology, digestive, etc. and that ultrasound has proven to be a safe diagnostic tool and have great capacity. We firmly believe that ultrasound done to «bedside» the patient by the family doctor, can greatly complement the physical examination and greatly improve clinical effectiveness, allowing the browser an immediate view of the anatomy and physiology of certain structures. It is within this context is particularly relevant ultrasonography of the Aorta and large abdominal vessels, made by the family doctor or the emergency itself, which will develop along this chapter.