Point-of-care ultrasound with pocket-size devices in emergency department

Revolutionizing Bladder Health: Artificial-Intelligence-Powered Automatic Measurement of Bladder Volume Using Two-Dimensional Ultrasound

INTRODUCTION

Measuring elevated post-void residual volume is important for diagnosing urinary outflow tract obstruction and cauda equina syndrome. Catheter placement is exact but painful, invasive, and may cause infection, whereas an ultrasound is accurate, painless, and safe.

AIM

The purpose of this single-center study is to evaluate the accuracy of a module for artificial-intelligence (AI)-based fully automated bladder volume (BV) prospective measurement using two-dimensional ultrasound images, as compared with manual measurement by expert sonographers.

METHODS

Pairs of transverse and longitudinal bladder images were obtained from patients evaluated in an urgent care clinic. The scans were prospectively analyzed by the automated module using the prolate ellipsoid method. The same examinations were manually measured by a blinded expert sonographer. The two methods were compared using the Pearson correlation, kappa coefficients, and the Bland-Altman method.

RESULTS

A total of 111 pairs of transverse and longitudinal views were included. A very strong correlation was found between the manual BV measurements and the AI-based module with r = 0.97 [95% CI: 0.96-0.98]. The specificity and sensitivity for the diagnosis of an elevated post-void residual volume using a threshold ≥200 mL were 1.00 and 0.82, respectively. An almost-perfect agreement between manual and automated methods was obtained (kappa = 0.85). Perfect reproducibility was found for both inter- and intra-observer agreements.

CONCLUSION

This AI-based module provides an accurate automated measurement of the BV based on ultrasound images. This novel method demonstrates a very strong correlation with the gold standard, making it a potentially valuable decision-support tool for non-experts in acute settings.

Therapeutic impact of basic critical care echocardiography performed by residents after limited training

BACKGROUND

The objective was to assess the agreement between therapeutic proposals derived from basic critical care echocardiography performed by novice operators in ultrasonography after a limited training (residents) and by experts considered as reference. Secondary objectives were to assess the agreement between operators' answers to simple clinical questions and the concordance between basic two-dimensional measurements.

METHODS

This observational, prospective, single-center study was conducted over a 3-year period in a medical-surgical intensive care unit. Adult patients with acute circulatory and/or respiratory failure requiring a transthoracic echocardiography (TTE) examination were studied. In each patient, a TTE was performed by a resident novice in ultrasonography after a short training program and by an expert, independently but within 1 h and in random order. Each operator addressed standardized simple clinical questions and subsequently proposed a therapeutic strategy based on a predefined algorithm.

RESULTS

Residents performed an average of 33 TTE studies in 244 patients (156 men; age: 63 years [52-74]; SAPS2: 45 [34-59]; 182 (75%) mechanically ventilated). Agreement between the therapeutic proposals of residents and experienced operators was good-to-excellent. The concordance was excellent for suggesting fluid loading, inotrope or vasopressor support (all Kappa values > 0.80). Inter-observer agreement was only moderate when considering the indication of negative fluid balance (Kappa: 0.65; 95% CI 0.50-0.80), since residents proposed diuretics in 23 patients (9.5%) while their counterparts had the same suggestion in 35 patients (14.4%). Overall agreement of responses to simple clinical questions was also good-to-excellent. Intraclass correlation coefficient exceeded 0.75 for measurement of ventricular and inferior vena cava size.

CONCLUSIONS

A limited training program aiming at acquiring the basic level in critical care echocardiography enables ICU residents novice in ultrasonography to propose therapeutic interventions with a good-to-excellent agreement with experienced operators.

The MINUTES bundle for the initial 30 min management of undifferentiated circulatory shock: an expert opinion

Acute circulatory shock is a life-threatening emergency requiring an efficient and timely management plan, which varies according to shock etiology and pathophysiology. Specific guidelines have been developed for each type of shock; however, there is a need for a clear timeline to promptly implement initial life-saving interventions during the early phase of shock recognition and management. A simple, easily memorable bundle of interventions could facilitate standardized management with clear targets and specified timeline. The authors propose the "MINUTES" acronym which summarizes essential interventions which should be performed within the first 30 min following shock recognition. All the interventions in the MINUTES bundle are suitable for any patient with undifferentiated shock. In addition to the acronym, we suggest a timeline for each step, balancing the feasibility and urgency of each intervention. The MINUTES acronym includes seven sequential steps which should be performed in the first 30 min following shock recognition: Maintain "ABCs", INfuse vasopressors and/or fluids (to support hemodynamic/perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying Etiology, and Stabilize organ perfusion.

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.

Novel Strategies in Diagnosing Heart Failure with Preserved Ejection Fraction: A Comprehensive Literature Review

Heart failure (HF) with preserved ejection fraction (HFpEF) is a prevalent global condition affecting approximately 50% of the HF population. With the aging of the worldwide population, its incidence and prevalence are expected to rise even further. Unfortunately, until recently, no effective medications were available to reduce the high mortality and hospitalization rates associated with HFpEF, making it a significant unmet need in cardiovascular medicine. Although HFpEF is commonly defined as HF with normal ejection fraction and elevated left ventricular filling pressure, performing invasive hemodynamic assessments on every individual suspected of having HFpEF is neither feasible nor practical. Consequently, several clinical criteria and diagnostic tools have been proposed to aid in diagnosing HFpEF. Overall, these criteria and tools are designed to assist healthcare professionals in identifying and evaluating patients who may have HFpEF based on a combination of signs, symptoms, biomarkers, and non-invasive imaging findings. By employing these non-invasive diagnostic approaches, clinicians can make informed decisions regarding the best pharmacological and rehabilitation strategies for individuals with suspected HFpEF. This literature review aims to provide an overview of all currently available methods for diagnosing and monitoring this disabling condition.

Bedside Clinical Hand-held Ultrasound in an Internal Medicine Department: The "Bed Med-Us" Experience of Codogno and its Clinical Utility in the Management of Diagnosis and Therapy in 1007 Patients

Purpose Handheld ultrasound (HH-US) answers simple clinical questions in emergencies. We performed conventional US with HH-US at the patient's bedside (BED) during a medical visit (MED) (BED MED-US). The purpose of this prospective study is to estimate BED MED-US reliability, its clinical impact in helping the clinician to formulate correct diagnoses, and its ability to save time and money. Materials and Methods 1007 patients (519 M; age:76.42) were assessed (from March 2021 to November 2022) in one or more districts. Final diagnosis was determined with clinical and reference tests (chest RX/CT, abdominal CT, endoscopy, etc.). Sensitivity, specificity, LR+ and LR-, and corresponding AUROC were evaluated. HH-US diagnoses were classified as: confirmation (HH-US revealed the sonographic signs that confirmed the clinical diagnosis) (CO), exclusion (HH-US excluded the presence of the ultrasound signs of other pathologies, in the clinical differential diagnosis) (EX), etiological (HH-US reaches diagnosis in clinically doubtful cases) (ET), or clinically relevant incidental (HH-US diagnoses that change the patient's process completely) (INC). Results HH-US reliability: true-pos: 752; true-neg: 242; false-pos: 7; false-neg: 6 (sens: 99.1%, spec: 97.6%, LR+: 98.5; LR-: 00.15, AUROC: 0.997); clinical impact: CO-diagnosis: 21%; EX: 25%; ET: 47%; INC: 7%; saved time and money: approximately 35,572 minutes of work and 9324 euros. Conclusion BED MED-US is a reliable clinical imaging system, with an important clinical impact both in diagnosis (etiological in 47%, incidental in 7%) and in the management of personnel resources.

Efficacy of Handheld Ultrasound in Medical Education: A Comprehensive Systematic Review and Narrative Analysis

Miniaturization has made ultrasound (US) technology ultraportable and, in association with their relatively low cost, made handheld devices attractive for medical education training programs. However, performing an ultrasound requires complex skills, and it is unclear whether handheld devices are suitable for the training of novices. Our study aimed to identify to what extent handheld US devices can be employed in medical undergraduates' and residents' education. We selected studies that evaluate the results obtained by students and/or residents who have participated in ultrasound training programs using handheld devices. The studies were included if they reported post-test (pre-test optional) achievements or a comparison with a control group (a group of experts or novices who underwent a different intervention). Twenty-six studies were selected, and their characteristics were summarized. Handheld ultrasound devices were used in training programs to learn echocardiography, abdominal, and/or musculoskeletal ultrasound. Statistically significant progress was noted in the ability of naïve participants to capture and interpret ultrasound images, but training duration influenced the outcomes. While ultrasound training using handheld devices has proven to be feasible for various body regions and purposes (e.g., better understanding of anatomy, clinical applications, etc.), the long-term impacts of handheld education interventions must be considered in addition to the short-term results to outline guidelines for targeted educational needs.

Prospective Comparison of Handheld Ultrasound Devices from Different Manufacturers with Respect to B-Scan Quality and Clinical Significance for Various Abdominal Sonography Questions

BACKGROUND

Handheld ultrasound (HHUS) devices have chiefly been deployed in emergency medicine, where they are considered a valid tool. The data situation is less clear in the case of internal questions in abdominal sonography. In our study, we investigate whether HHUS devices from different manufacturers differ in their B-scan quality, and whether any differences are relevant for the significance of an internal ultrasound examination.

METHOD

The study incorporated eight HHUS devices from different manufacturers. Ultrasound videos of seven defined sonographic questions were recorded with all of the devices. The analogue recording of the same findings with a conventional high-end ultrasound (HEUS) device served as an evaluation criterion. Then, the corresponding findings were played side by side and evaluated by fourteen ultrasound experts using a point scale (5 points = very good; 1 point = insufficient).

RESULTS

The HHUS devices achieved relatively good results in terms of both the B-scan quality assessment and the ability to answer the clinical question, regardless of the manufacturer. One of the tested HHUS devices even achieved a significantly (p < 0.05) higher average points score in both the evaluation of B-scan quality and in the evaluation of clinical significance than the other devices. Regardless of the manufacturer, the HHUS devices performed best when determining the status/inferior vena cava volume and in the representation of ascites/free fluid.

CONCLUSION

In various clinical abdominal sonography questions, HHUS systems can reliably reproduce findings, and are-while bearing their limitations in mind-an acceptable alternative to conventional HEUS systems. Irrespective of this, the present study demonstrated relevant differences in the B-scan quality of HHUS devices from different manufacturers.

Evaluation of parameters used in echocardiography and ultrasound protocol for the diagnosis of shock etiology in emergency setting

BACKGROUND

Early recognition and appropriate treatment has shown to decrease morbidity and mortality in patients with undifferentiated shock. There are many ultrasound protocols in shock; each protocol combines core ultrasound elements such as IVC and cardiac assessment which includes detection of cardiac tamponade, left ventricular function and right ventricular strain.Valvular assessment is absent in majority of ultasound protocols, while lung ultrasound is included in some of them.

OBJECTIVE

In this study we investigated which parameters used in Echo - US protocol help differentiate shock types.

METHODS

This cross sectional study was conducted on 150 patients with shock (140 patients were included while, 10 patients were excluded).Sensitivity and specificity of different parameters used in the Echo-US protocol were analyzed to detect which parameters can diffentiate shock types.

RESULTS

Velocity time integral of Aorta and IVC maximum diameter were good discriminators for distributive shock, with area under the ROC curve (AUC) = 0.8885 (95% CI 0.8144 to 0.9406) and 0.7728 (95% CI 0.6832 to 0.8473) (Z = 10.256 p < 0.0001) and (Z = 5.079 p < 0.0001) respectively. Left ventricular systolic function, presence of pneumonia, pneumothorax or valve vegetations were of great value in differentiating shock types, while CUST, FAST, TAPSE and RV diameter were not useful in differentiating shock types.

CONCLUSION

Ultrasound and echocardiography are powerful tools that can be used to identify shock etiology when the clinical picture overlaps.

Assessment of E/A ratio helps emergency clinicians in the management of patients with acute dyspnea

Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Department (ED). In the last years integrated ultrasound examination (IUE) of lung, heart and inferior vena cava (IVC) has become an extension of clinical examination for a fast differential diagnosis. The aim of present study is to assess the feasibility and diagnostic accuracy of E/A ratio for diagnosing acute heart failure (aHF) in patients with acute dyspnea. We included 92 patients presenting to the ED of CTO Hospital in Naples (Italy) for AD. All patients underwent IUE of lung-heart-IVC with a portable ultrasound device. Left ventricle diastolic function was assessed using pulse wave doppler at the tips of the mitral valve and E wave velocity and E/A ratio were recorded. The FINAL diagnosis was determined by two expert reviewers: acute HF or non-acute HF (non-aHF). We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive and negative predictive value of ultrasound parameters for the diagnosis of AD, comparing with the FINAL diagnosis. Lung ultrasound (LUS) showed high sensitivity, good specificity and accuracy in identification of patients with aHF. However, the highest accuracy was obtained by diastolic function parameters. The E/A ratio showed the highest diagnostic performance with an AUC for aHF of 0.93. In patients presenting with AD, E/A ratio is easy to obtain in a fast ultrasound protocol and showed an excellent accuracy for diagnosis of aHF.

Role of Point-of-Care Diagnostics in Lower- and Middle-Income Countries and Austere Environments

INTRODUCTION

Austere environments include the wilderness and many lower- and middle-income countries, with many of these countries facing unrest and war. The access to advanced diagnostic equipment is often unaffordable, even if available, and the equipment is often liable to break down.

METHODS

A short review paper examining the options available to medical professionals to undertake clinical and point-of-care diagnostic testing in resource-constrained environments that also illustrates the development of mobile advanced diagnostic equipment. The aim is to provide an overview of the spectrum and functionality of these devices beyond clinical acumen.

RESULTS

Details and examples of products covering all aspects of diagnostic testing are provided. Where relevant, reliability and cost implications are discussed.

CONCLUSIONS

The review highlights the need for more cost-effective accessible and utilitarian products and devices that will bring cost-effective health care to many in lower- and middle-income or austere environments.

Feasibility of Ultrasound-Guided, Peripherally Inserted Central Catheter Placement at the Bedside in a Communicable-Disease Isolation Unit

BACKGROUND

Previous studies have investigated the safety of peripherally inserted central catheters (PICCs) in the intensive care unit (ICU). However, it remains uncertain whether PICC placement can be successfully carried out in settings with limited resources and a challenging environment for procedures, such as communicable-disease isolation units (CDIUs).

METHODS

This study investigated the safety of PICCs in patients admitted to CDIUs. These researchers used a handheld portable ultrasound device (PUD) to guide venous access and confirmed catheter-tip location with electrocardiography (ECG) or portable chest radiography.

RESULTS

Among 74 patients, the basilic vein and the right arm were the most common access site and location, respectively. The incidence of malposition was significantly higher with chest radiography compared to ECG (52.4% vs. 2.0%, p < 0.001).

CONCLUSIONS

Using a handheld PUD to place PICCs at the bedside and confirming the tip location with ECG is a feasible option for CDIU patients.

ANMCO-SIMEU consensus document: appropriate management of atrial fibrillation in the emergency department

Atrial fibrillation (AF) accounts for 2% of the total presentations to the emergency department (ED) and represents the most frequent arrhythmic cause for hospitalization. It steadily increases the risk of thromboembolic events and is often associated with several comorbidities that negatively affect patient's quality of life and prognosis. AF has a considerable impact on healthcare resources, making the promotion of an adequate and coordinated management of this arrhythmia necessary in order to avoid clinical complications and to implement the adoption of appropriate technological and pharmacological treatment options. AF management varies across regions and hospitals and there is also heterogeneity in the use of anticoagulation and electric cardioversion, with limited use of direct oral anticoagulants. The ED represents the first access point for early management of patients with AF. The appropriate management of this arrhythmia in the acute setting has a great impact on improving patient's quality of life and outcomes as well as on rationalization of the financial resources related to the clinical course of AF. Therefore, physicians should provide a well-structured clinical and diagnostic pathway for patients with AF who are admitted to the ED. This should be based on a tight and propositional collaboration among several specialists, i.e. the ED physician, cardiologist, internal medicine physician, anesthesiologist. The aim of this ANMCO-SIMEU consensus document is to provide shared recommendations for promoting an integrated, accurate, and up-to-date management of patients with AF admitted to the ED or Cardiology Department, in order to make it homogeneous across the national territory.

Recognized and Unrecognized Value of Echocardiography in Guideline and Consensus Documents Regarding Patients With Chest Pain

Guideline and consensus documents have recently been published on the important topic of the noninvasive evaluation of patients presenting with chest pain (CP) or patients with known acute or chronic coronary syndromes. Authors for these documents have included members representing multispecialty imaging societies, yet the process of generating consensus and the need to produce concise written documents have led to a situation where the particular advantages of echocardiography are overlooked. Broad guidelines such as these can be helpful when it comes to "when to do" noninvasive cardiac testing, but they do not pretend to offer nuances on "how to do" noninvasive cardiac testing. This report details the particular value of echocardiography and potential explanations for its understated role in recent guidelines. This report is categorized into the following sections: (1) impact of the level of evidence on guideline creation; (2) versatility of echocardiography in the assessment of CP and the inimitable role for echo Doppler echocardiography in the assessment of dyspnea; (3) value of point-of-care ultrasound in assessing CP and dyspnea; and (4) the future role of echocardiography in ischemic heart disease.

Point-of-care ultrasound use in emergencies: what every anaesthetist should know

Point-of-care ultrasound has been embraced by anaesthetists as an invaluable tool for rapid diagnosis of haemodynamic instability, to ensure procedural safety and monitor response to treatments. Increasingly available, affordable and portable, with emerging evidence of improved patient outcomes, point-of-care ultrasound has become a valuable tool in the emergency setting. This state-of-the-art review describes the feasibility of point-of-care ultrasound practice, training and maintenance of competence. It also describes the many uses of point-of-care ultrasound for the anaesthetist and describes the most salient point-of-care ultrasound views for anaesthetic emergencies including: undifferentiated shock; hypoxemia; and trauma. Procedural safety is also discussed in addition to relevant important governance aspects. Cardiac function should be assessed using the parasternal long axis, parasternal short basal/mid-papillary/apical, apical four chamber and subcostal four chamber views, and should include a visual estimation of global left ventricular ejection fraction. Other cardiovascular conditions that can be identified using point-of-care ultrasound include: pericardial effusion; cardiac tamponade; and pulmonary embolism. Pulmonary emergency conditions that can be diagnosed using point-of-care ultrasound include pneumothorax; pleural effusion; and interstitial syndrome. The extended focused assessment with sonography for trauma examination may of value in patients who are hypotensive in order to identify intra-abdominal haemorrhage, pneumothoraces and haemothoraces.

Point-of-care ultrasound in the head and neck region

Point-of-care ultrasound (POCUS) in the head and neck region plays a particularly significant role in the diagnosis and treatment of upper airway stenosis, swelling, and painful diseases in the neck, and in the evaluation of swallowing function. Therefore, it should be performed in various medical settings beyond the boundaries of the clinical department such as general medicine, emergency medicine, anesthesiology, orthopedics, and pediatrics. The target diseases are salivary gland disease, lymph node disease, pharyngeal disease, laryngeal disease, esophageal disease, thyroid disease, and dysphagia and dyspnea due to various causes. Head and neck POCUS is an extremely useful diagnostic method for both patients and doctors, and its use is expected to become more widespread in the future.

[Perspectives and Challenges of hand-held Ultrasound]

The use of handheld ultrasound devices from a technical and data protection point of view, device properties, functionality, documentation, indications, delegation of performance, applications by doctors, students and non-medical staff is examined and discussed.

Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have?

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

Differences in Diagnosis and Management of Hypertensive Urgencies and Emergencies According to Italian Doctors from Different Departments Who Deal With Acute Increase in Blood Pressure-Data from Gear (Gestione Dell'emergenza e Urgenza in ARea Critica) Study

Background: Diagnosis and treatment of hypertension emergency (HE) and urgency (HU) may vary according to the physicians involved and the setting of the treatment. The aim of this study was to investigate differences in management of HE and HU according to the work setting of the physicians. Methods: The young investigators of the Italian Society of Hypertension developed a 23-item questionnaire spread by email invitation to the members of Italian Scientific societies involved in the field of emergency medicine and hypertension. Results: Six-hundred and sixty-five questionnaires were collected. No differences emerged for the correct definitions of HE and HU or for the investigation of possible drugs that may be responsible for an acute increase in BP. The techniques used to assess BP values (p < 0.004) and the sizes of cuffs available were different according to the setting. Cardiologists more frequently defined epistaxis (55.2% p = 0.012) and conjunctival hemorrhages (70.7%, p < 0.0001) as possible presentation of HE, and rarely considered dyspnea (67.2% p = 0.014) or chest pain (72.4%, p = 0.001). Intensive care (IC) unit doctors were more familiar with lung ultrasound (50% p = 0.004). With regard to therapy, cardiologists reported the lowest prescription of i.v. labetalol (39.6%, p = 0.003) and the highest of s.l. nifedipine (43.1% p < 0.001). After discharge, almost all categories of physicians required home BP assessment or referral to a general practitioner, whereas hypertensive center evaluation or ambulatory BP monitoring were less frequently suggested. Conclusion: Management and treatment of HE and HU may be different according to the doctor’s specialty. Educational initiatives should be done to standardize treatment protocols and to improve medical knowledge.

Integrating Point of Care Ultrasound Education into Clinical Practice at the Emergency Department

Point of care ultrasound (POCUS) competency is now required learning for emergency medicine trainees. However, there is a wide range of areas that need to be assessed when determining competence. Therefore, this study aims to evaluate competence levels of POCUS skill acquisition including the areas of image acquisition, image interpretation and clinical integration of the emergency medicine residents while on shift in real clinical practice situations. This was a retrospective descriptive study. This study was conducted at Srinagarind Hospital, Thailand from January 2021 through December 2021. The data were collected and reviewed from electronic medical records, ultrasound images and video clips. All POCUS competency skills were assessed by researcher staff. Our results demonstrated that our learners had overall satisfactory competence of image acquisition, satisfactory image interpretation skills, and good clinical integration skills. However, obstetrics and gynecology (OB-GYN) ultrasound scores were poor and cardiac ultrasound had the most varied score of image quality. This study clearly showed the measurable benefits of a POCUS course being integrated into real clinical practice.

Reproducibility and diagnostic accuracy of pocket-sized ultrasound devices in ruling out compensated cirrhosis of mixed etiology

Objective

Fibrosis is the key prognostic factor in chronic liver disease patients. Liver surface nodularity (LSN) is the ultrasonographic sign with the highest accuracy to detect advanced liver fibrosis. The use of pocket-sized ultrasound devices (PUDs) has been assessed in several clinical settings but never as regards chronic liver disease (CLD) severity. Our study aimed at evaluating the feasibility, reproducibility, and diagnostic accuracy of PUD in LSN identification.

Methods

We enrolled all the consecutive adults referred for percutaneous liver biopsy. Two independent operators evaluated LSN by PUD; one sonographer used standard ultrasound (US). Transient elastography (TE) and liver biopsy were performed on all the patients. PUD reproducibility was evaluated by Cohen’s k statistic. PUD, standard US, and TE results were compared with histology staging.

Results

A total of 104 consecutive patients (aged 54 ± 14 years) with mixed-etiology CLD were studied. Assessment by PUD was feasible in all the patients and showed very good inter-observer agreement with Cohen’s k = 0.87 (95% CI 0.72–0.95). The diagnostic accuracy estimates for PUD in diagnosing compensated cirrhosis (F = 4) were 87.5% sensitivity, 76.8% specificity, positive likelihood ratio (LR) 3.78, and negative likelihood ratio (LR-) 0.16, while those for standard US and TE (> 12.5 kPa) were, respectively, 87.5% sensitivity, 72.6% specificity, LR+ 3.2, and LR- 0.17, and 87.5% sensitivity, 90.5% specificity, LR + 9.2, and LR- 0.13.

Conclusions

PUD reproducibility in assessing LSN was excellent even with operators of different experience. PUD performed very well in excluding advanced CLD. PUD can be used as a first-line tool for screening patients to undergo more invasive techniques, thus shortening the time for clinical decision-making.

Key Points

• PUD is highly reproducible in assessing the sign of liver surface nodularity.

• PUD showed high diagnostic accuracy in excluding the presence of advanced chronic liver disease.

• PUD can be used as a first-line tool for screening patients with CLD who should undergo more invasive techniques.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-08572-2.

Lung ultrasound: a narrative review and proposed protocol for patients admitted to Cardiac Rehabilitation Unit

Lung ultrasonography (LUS) has become in the last 10 years a technique that has reduced the need of second level diagnostic methods such as chest X-ray (CXR) and computerize tomography (CT) for the diagnostic imaging of lung and pleural space, throughout its diagnostic accuracy, radiation free, low cost, real time and bedside approach. The common use of LUS has been recently extend to cardiac and pulmonary disease even in context of Cardiac Rehabilitation Unit and it could be an additional tool for physiotherapist for the management of patients during Rehabilitation course. The authors performed a literature review in PubMed and suggested a new standardize protocol for LUS, based on guidelines and expert consensus document, for patients admitted to Cardiac Rehabilitation Unit. In this protocol, LUS should be performed in six scan each hemithorax, covering twelve imagine regions. For each scan will be noted a specific physiologic or pathological patterns. Furthermore, we suggest for each patient, the use of the Lung Ultrasound Score (LUS score) to obtain a global view of lung aeration and to monitor any changes during the hospitalization. An increase in score range indicates a more severe condition. This Lung Ultrasonography Protocol should be performed in all patients at the time of admission to Cardiac Rehabilitation Unit to monitoring the aeration of the lungs and the possible lung and/or pleura complications after a cardiac disease avoiding the use of second level surveys.

The Use of Handheld Ultrasound Devices in Emergency Medicine

Purpose of Review

Ultraportable handheld ultrasound (HHU) devices are being rapidly adopted by emergency medicine (EM) physicians. Though knowledge of the breadth of their utility and functionality is still limited compared to cart-based systems, these machines are becoming more common due to ease-of-use, extreme affordability, and improving technology.

Recent Findings

Images obtained with HHU are comparable to those obtained with traditional machines but create unique issues regarding billing and data management. HHU devices are increasingly used successfully to augment the education of practitioners-in-training, by emergency physicians in austere environments, and in the burgeoning fields of "tele-ultrasound" and augmented reality scanning.

Summary

This review seeks to describe the current state of use of HHU devices in the emergency department (ED) including device overview, institutional concerns, unique areas of use, recent literature since their adoption into clinical EM, and their future potential.

Continuous positive airway pressure therapy in the management of hypercapnic cardiogenic pulmonary edema

Continuous positive airway pressure (CPAP) therapy or non-invasive ventilation (NIV) represent the first line therapy for acute cardiogenic pulmonary edema (CPE) together with medical therapy. CPAP benefits in acute CPE with normo-hypocapnia are known, but it is not clear whether the use of CPAP is safe in the hypercapnic patients. The aim of this study is to evaluate CPAP efficacy in the treatment of hypercapnic CPE. We enrolled 9 patients admitted to the emergency room with diagnosis of acute CPE based on history, clinical examination, arterial blood gas analysis (ABG) and lung-heart ultrasound examination. We selected patients with hypercapnia (pCO2 >50 mmHg) and bicarbonate levels <30 mEq/L. All patients received medical therapy with furosemide and nitrates and helmet CPAP therapy. All patients received a second and a third ABG, respectively at 30 and 60 min. Primary end-points of the study were respiratory distress resolution, pCO2 reduction, pH improvement, lactates normalization and the no need for non-invasive ventilation or endo-tracheal intubation. All patients showed resolution of respiratory distress with CPAP weaning and shift to Venturi mask with no need for NIV or endo-tracheal intubation. Serial ABG tests showed clear reduction in CO2 levels with improvement of pH and progressive lactate reduction. CPAP therapy can be effective in the treatment of hypercapnic CPE as long as the patients have no signs of chronic hypercapnia on ABG and as long as the diagnosis of heart failure is supported by bedside lung-heart ultrasound examination.

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.