Does physician experience influence the interpretability of focused echocardiography images performed by a pocket device?

Evaluation of left ventricular ejection fraction by a new automatic tool on a pocket ultrasound device: Concordance study with cardiac magnetic resonance imaging

INTRODUCTION

Assessment of left ventricular ejection fraction (LVEF) is one of the primary objectives of echocardiography. The gold standard assessment technique in emergency medicine is eyeballing. A new tool is now available on pocket ultrasound devices (PUD): automatic LVEF. The primary aim of this study was to evaluate the concordance between LVEF values estimated by automatic LVEF with PUD and by cardiac magnetic resonance imaging (MRI).

MATERIALS

This was a prospective, monocentric, and observational study. All adult patients with an indication for cardiac MRI underwent a point-of-care ultrasound. Blinded to the MRI results, the emergency physician assessed LVEF using the automatic PUD tool and by visual evaluation.

RESULTS

Sixty patients were included and analyzed. Visual estimation of LVEF was feasible for all patients and automatic evaluation for 52 (87%) patients. Lin's concordance correlation coefficient between automatic ejection fraction with PUD and by cardiac MRI was 0.23 (95% CI, 0.03-0.40).

CONCLUSION

Concordance between LVEF estimated by the automatic ejection fraction with PUD and LVEF estimated by MRI was non-existent.

[Prehospital ultrasound in emergency medicine]

Small, portable hand-held ultrasound devices nowadays enable a widespread use of prehospital point-of-care ultrasound (pPOCUS), which has so far only been used hesitantly, especially in ground-based emergency services. Many critical or even life-threatening conditions or internal injuries can often be better diagnosed or ruled out using pPOCUS, which can enable faster and more suitable goal-directed treatment and hospital transport. This article critically discusses relevant data, clinical benefits, limitations and challenges to be overcome when using pPOCUS for the most important life-threatening situations and aims to call for intensifying training and the extensive use of pPOCUS.

Exploring the Potential of Artificial Intelligence in Pediatric Echocardiography-Preliminary Results from the First Pediatric Study Using AI Software Developed for Adults

(1) Background: Transthoracic echocardiography is the first-line non-invasive investigation for assessing pediatric patients' cardiac anatomy, physiology, and hemodynamics, based on its accessibility and portability, but complete anatomic and hemodynamic assessment is time-consuming. (2) Aim: This study aimed to determine whether an automated software developed for adults could be effectively used for the analysis of pediatric echocardiography studies without prior training. (3) Materials and Methods: The study was conducted at the University Hospital of Bordeaux between August and September 2022 and included 45 patients with normal or near normal heart architecture who underwent a 2D TTE. We performed Spearman correlation and Bland-Altman analysis. (4) Results: The mean age of our patients at the time of evaluation was 8.2 years ± 5.7, and the main reason for referral to our service was the presence of a heart murmur. Bland-Altman analysis showed good agreement between AI and the senior physician for two parameters (aortic annulus and E wave) regardless of the age of the children included in the study. A good agreement between AI and physicians was also achieved for two other features (STJ and EF) but only for patients older than 9 years. For other features, either a good agreement was found between physicians but not with the AI, or a poor agreement was established. In the first case, maybe proper training of the AI could improve the measurement, but in the latter case, for now, it seems unrealistic to expect to reach a satisfactory accuracy. (5) Conclusion: Based on this preliminary study on a small cohort group of pediatric patients, the AI soft originally developed for the adult population, had provided promising results in the evaluation of aortic annulus, STJ, and E wave.

Utility of hand-held ultrasound for image acquisition and interpretation by trained Kenyan providers

BACKGROUND

Point-of-care ultrasound (POCUS) plays a prominent role in the timely recognition and management of multiple medical, surgical, and obstetric conditions. A POCUS training program for primary healthcare providers in rural Kenya was developed in 2013. A significant challenge to this program is the acquisition of reasonably priced ultrasound machines with adequate image quality and the ability to transmit images for remote review. The goal of this study is to compare the utility of a smartphone-connected, hand-held ultrasound with a traditional ultrasound device for image acquisition and interpretation by trained healthcare providers in Kenya.

METHODS

This study took place during a routine re-training and testing session for healthcare providers who had already received POCUS training. The testing session involved a locally validated Observed Structured Clinical Exam (OSCE) that assessed trainees' skills in performing the Extended Focused Assessment with Sonography for Trauma (E-FAST) and focused obstetric exams. Each trainee performed the OSCE twice, once using a smartphone-connected hand-held ultrasound and once using their notebook ultrasound model.

RESULTS

Five trainees obtained a total of 120 images and were scored on image quality and interpretation. Overall E-FAST imaging quality scores were significantly higher for the notebook ultrasound compared to the hand-held ultrasound but there was no significant difference in image interpretation. Overall focused obstetric image quality and image interpretation scores were the same for both ultrasound systems. When separated into individual E-FAST and focused obstetric views, there were no statistically significant differences in the image quality or image interpretation scores between the two ultrasound systems. Images obtained using the hand-held ultrasound were uploaded to the associated cloud storage using a local 3G-cell phone network. Upload times were 2-3 min.

CONCLUSION

Among POCUS trainees in rural Kenya, the hand-held ultrasound was found to be non-inferior to the traditional notebook ultrasound for focused obstetric image quality, focused obstetric image interpretation, and E-FAST image interpretation. However, hand-held ultrasound use was found to be inferior for E-FAST image quality. These differences were not observed when evaluating each E-FAST and focused obstetric views separately. The hand-held ultrasound allowed for rapid image transmission for remote review.

The assessment of point-of-care-ultrasound (POCUS) in acute care settings is benefitted by early medical school integration and fellowship training

CONTEXT

Point-of-care ultrasound (POCUS) has widespread utilization in multiple clinical settings. It has been shown to positively influence clinician confidence in diagnosis and can help appropriately manage patients in acute care settings. There has been a growing trend of increased emphasis on incorporating POCUS training in the first 2 years of the medical school curriculum.

OBJECTIVES

This article aims to analyze the clinical use of POCUS in acute settings and how training early in medical school may strengthen clinician confidence and utilization.

METHODS

An anonymous 10-question survey on POCUS use was conducted via a secure online platform and distributed to board-certified practicing physicians (MDs and DOs) with educational agreements with Midwestern University (MWU) across acute care specialties. This included preceptors within the MWU graduate medical education clinical consortium. Survey questions were aimed at assessing frequency of use, machine type, reasons for utilizing POCUS, initial ultrasound training, confidence in performing/interpreting POCUS, and perceived impact on patient outcomes. Surveys less than 50% complete were excluded. All surveys returned were more than 50% complete and thus included in the study. Statistical analyses were conducted utilizing the statistical software R version 4.0.

RESULTS

Surveys were sent out to 187 participants with 68 responses (36.4% response rate). The survey results demonstrated a relationship between learning POCUS earlier in one's medical career (medical school, residency, or fellowship) to increased use in acute settings when compared to learning POCUS during clinical practice. Of the 68 respondents, 65 (95.6%) indicated that they agree or strongly agree that POCUS use improves patient care, and 64 (94.1%) indicated that they agree or strongly agree that the use of POCUS can improve patient outcomes.

CONCLUSIONS

Our survey of acute care physicians indicated that most respondents utilize POCUS daily or weekly (90.8%), and this was related to fewer years of practice (under 10 years from medical school graduation, 94.6%). Moreover, POCUS was utilized primarily in acute care settings for procedures (25%, n=17/68 respondents). These survey results indicate that early integration of POCUS education in osteopathic medical school curricula and throughout fellowship training could likely enhance POCUS utilization in acute care settings.

Helicopter Emergency Medical Services Ultrasound Use in the Diagnosis of Pericardial Effusion Due to Aortic Dissection

Ultrasound has historically been limited to in-hospital use for the diagnosis and management of various conditions. However, with the advent of smaller and more portable devices, this technology can be used outside the hospital. This report describes a patient with chest pain and hypotension for whom a point-of-care cardiac ultrasound (POCUS) was performed to diagnose cardiac tamponade during critical care transport. She was subsequently found to have an acute type A aortic dissection, and her care was expedited to the operating room. Cardiac tamponade in the setting of acute type A aortic dissection requires urgent surgical repair; therefore, early diagnosis is crucial to survival. In this case, prehospital ultrasound facilitated rapid care for the patient. Further study is needed to define its role in the prehospital setting.

Prehospital Ultrasound: A Narrative Review

Background: Point-of-care ultrasound is rapidly becoming more prevalent in the prehospital environment. Though considered a relatively new intervention in this setting, there is growing literature that aims to explore the use of prehospital ultrasound by EMS personnel.Methods: To better understand and report the state of the science on prehospital ultrasound, we conducted a narrative review of the literature.Results: Following a keyword search of MEDLINE in Ovid from inception to August 2, 2022, 2,564 records were identified and screened. Based on review of abstracts and full texts, with addition of seven articles via bibliography review, 193 records were included. Many included studies detail usage in air medical and other critical care transport environments. Clinicians performing prehospital ultrasound are often physicians or other advanced practice personnel who have previous ultrasound experience, which facilitates implementation in the prehospital setting. Emerging literature details training programs for prehospital personnel who are novices to ultrasound, and implementation for some study types appears feasible without prior experience. Unique use scenarios that show promise include during critical care transport, for triage in austere settings, and for thoracic evaluation of patients at risk of life-threatening pathology.Conclusion: There is a growing mostly observational body of literature describing the use of ultrasound by prehospital personnel. Prehospital ultrasound has demonstrated feasibility for specific conditions, yet interventional studies evaluating benefit to patient outcomes are absent.

Focal cardiac ultrasound learning with pocked ultrasound device: A bicentric prospective blinded randomized study

PURPOSE

Point-of-care ultrasound using a pocket-ultrasound-device (PUD) is increasing in clinical medicine but the optimal way to teach focused cardiac ultrasound is not clear. We evaluated whether teaching using a PUD or a conventional-ultrasound-device (CUD) is different when the final exam was conducted on a PUD. The primary aim was to compare the weighted total quality scale (WTQS, out of 100) obtained by participants in the two groups (CUD and PUD) on a live volunteer 2-4 weeks after their initial training. The secondary aims were to compare examination time and students' confidence levels (out of 50).

METHODS

This bicentric, prospective single-blind randomized trial included undergraduate medical students. After watching a 15 min video about echocardiography views, students had a 45 min hands-on training session with a live volunteer using a PUD or a CUD. The final examination was conducted with a PUD on a live volunteer.

RESULTS

Eighty-six comparable students were included, with 4 ± 1 years of medical training. In the PUD group, the mean WTQS was 65 ± 16 versus 60 ± 15 in the CUD group [p = 0.22; in multivariate analysis, OR 0.8 95% CI (0.1;1.6), p = 0.34]. The examination time was 10.0 [6.2-12.4] min in the PUD group versus 11.4 [7.3-13.2] in the CUD group (p = 0.39), while the confidence level was 27.9 ± 7.7 in the PUD group versus 27.4 ± 7.2 in the CUD group (p = 0.76).

CONCLUSION

There was no difference between teaching echocardiographic views using a PUD as compared to a CUD on the PUD image quality, exam time, or confidence level of students.

Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study

Background

Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes.

Methods

A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group).

Results

We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10–25] min vs. 34 [15–40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53).

Conclusion

Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure.

Clinical Trial Registration NCT02967809. Registered 18 November 2016, https://clinicaltrials.gov/ct2/show/NCT02967809.

A comparison of handheld ultrasound versus traditional ultrasound for acquisition of RUSH views in healthy volunteers

Few studies evaluate the use of handheld ultrasound devices for point-of-care ultrasonography in the emergency department. We hypothesized that image acquisition time and image quality are similar between a handheld device and a traditional device. We compared these 2 types of devices in healthy, non-pregnant adults with using a crossover non-inferiority design while acquiring Rapid Ultrasound for Shock and Hypotension (RUSH) view. We excluded those with a history of surgical intervention or known abnormality to the lungs, abdomen, or pelvis. Images were compiled into a de-identified video clip reviewed for image quality by 2 blinded reviewers. Cohen's Kappa was used to determine interrater agreement. Disagreements were adjudicated by an independent physician. Imaging time was compared using a paired Student's t test. Of 59 screened participants, 9 were excluded. Most subjects (N = 30, 60%) were female with a mean age of 39 (Range: 19-67) years. The median time to complete the RUSH exam did not differ (handheld 249.4, interquartile range 33.5 seconds); traditional 251.4, interquartile range 66.3 seconds); [P = 0.81]). Agreement between ultrasound reviewers was good (agreement 83%; k = 0.69; 95% CI, 0.49-0.88). Images were determined to be of adequate quality for interpretation in 41/50 (82%) and 43/50 (86%) in the handheld and traditional devices, respectively (P = 0.786). Neither time to image acquisition nor image quality differed between the handheld and traditional devices. The handheld device may be an alternative for use in RUSH exams.

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.

Moving the needle towards the democratization of echocardiography: a case report

Background

Echocardiography has been traditionally performed in echo labs and the potential benefits of its use by primary care physicians (PCPs) are still unexplored. We present a case where POCUS (point-of-care ultrasound) was used as a complement of physical examination by a family doctor, allowing a prompt clinical decision in a heart failure (HF) patient.

Case summary

An 85-year-old woman, living independently, asks her family doctor for a home consultation due to increasing dyspnoea. On examination, severe dyspnoea and bilateral ankle oedema was noted and a point-of-care echocardiogram was performed by the primary care physician, who observed: severely compromised left ventricular systolic function, moderate mitral and tricuspid regurgitation, and severe dilation of the inferior vena cava. As a result, the diagnosis of HF with decreased ejection fraction was formed supporting the therapeutic decision.

Discussion

This case represents an elderly patient with dyspnoea, without previous HF diagnosis. The primary care physician, used portable ultrasound as a complement of physical examination, which confirmed a HF diagnosis, allowing a prompt decision-making on therapy. POCUS, can be a powerful tool to expedite treatment in different settings, including the home consultations by PCPs.

Place de l’échographie clinique en médecine d’urgence

L’échographie clinique en médecine d’urgence (ECMU) devient une pratique intégrée à l’exercice de la spécialité. Quatre étapes semblent nécessaires au déploiement de cet outil : l’existence de preuves scientifiques sur sa pertinence clinique, l’implantation d’échographes dans les structures d’urgences (SU), la formation des médecins et l’objectivation d’un impact secondaire à son utilisation. Les preuves sur la pertinence diagnostique des techniques utilisées datent des années 1990 pour la majorité des applications utilisées aujourd’hui. La disponibilité d’un échographe adapté est également nécessaire. Si la majorité des SU disposent aujourd’hui d’un échographe, selon les recommandations françaises, toutes le devraient. Des échographes de mieux en mieux adaptés à la pratique de l’ECMU arrivent sur le marché. L’objectif doit être de permettre des examens rapides et fiables. Pour cela, une ergonomie épurée et l’implication de techniques d’intelligence artificielle semblent être l’avenir. Les médecins doivent également être formés. En France, l’utilisation de l’ECMU va se généraliser grâce à la formation de tous les nouveaux internes de médecine d’urgence. Cependant, beaucoup d’urgentistes exerçant actuellement doivent encore être formés. Pour répondre à cette demande, de nombreuses formations sont aujourd’hui accessibles. Enfin, peu de données sur l’impact clinique secondaire à l’utilisation de cet outil dans les SU sont disponibles. Après avoir défini l’ECMU, l’objectif de ce texte est d’expliquer la place de l’échographie clinique dans la spécialité de médecine d’urgence. Des perspectives d’évolution de l’ECMU sont également proposées.

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

Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.

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.

Pratique de l’échographie clinique au sein d’un réseau territorial d’urgence

Objectif : L’échographie clinique en médecine d’urgence (ECMU) est un outil essentiel de notre pratique. L’objectif principal de notre étude était d’évaluer les caractéristiques des médecins pratiquant l’ECMU au sein de notre territoire. L’objectif secondaire était d’analyser les facteurs influençant une pratique régulière.

Matériel et méthodes : Étude descriptive multicentrique et déclarative, réalisée auprès de médecins urgentistes travaillant au sein d’un réseau territorial de médecine d’urgence à l’aide d’un questionnaire en ligne.

Résultats : Cent onze questionnaires sur 120 envoyés ont été renseignés (92 %). Onze services (92 %) étaient dotés en échographe dont neuf (82 %) en dotation propre. Soixantesix médecins (59 %) déclaraient pratiquer l’échographie régulièrement. La FAST (focused assessment with sonography for traumas) était la plus pratiquée (80 médecins, 72 %), suivie de l’exploration hémodynamique (50 médecins, 45 %) et pleurale (44 médecins, 40 %). Dans le groupe des médecins ne pratiquant pas l’ECMU, 17 médecins sur 22 (77 %) l’expliquaient par un manque de formation. Dans le même temps, l’intérêt porté à l’ECMU par les urgentistes était coté à 7 ± 2 sur une échelle de 0 à 9. Les facteurs associés à la fréquence de la pratique de l’ECMU étaient le sexe (p < 0,001), le type d’activité (p = 0,005), le type de formation à l’échographie (p < 0,001) et l’ancienneté d’équipement de son service en échographe (p < 0,001).

Conclusion : Cette enquête a montré que la pratique régulière était majoritaire avec un intérêt porté par les praticiens à l’ECMU élevé. Cependant, le frein principal à son développement était un niveau de formation jugé insuffisant par certains praticiens.

The role of point of care ultrasound in prehospital critical care: a systematic review

Background

In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers.

Methods and results

By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting.

Conclusion

Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations – a large part of these needs to be supervised.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0518-x) contains supplementary material, which is available to authorized users.

Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France

OBJECTIVE

Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011.

METHODS

We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone.

RESULTS

Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS.

CONCLUSION

Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Compression with a pocket-sized ultrasound device to diagnose proximal deep vein thrombosis

INTRODUCTION

Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket-sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD.

MATERIALS

This was a prospective, diagnostic test assessment, single-center study. Patients underwent VCU performed by a trained EP with PUD (CUS-PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS-PUD's diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV).

RESULTS

The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS-PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS-PUD's Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%].

CONCLUSION

CUS-PUD performed with a pocket-sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.

Échographie et prise en charge de l’arrêt cardiaque

L’arrêt cardiorespiratoire (ACR) est une situation fréquente pour les structures d’urgences et de réanimation, et l’utilisation de l’échographie y est recommandée par les sociétés savantes. Elle doit impérativement se faire sans augmentation des temps d’interruption du massage cardiaque externe. Après formation, elle permet de détecter rapidement et facilement la présence d’une contractilité myocardique qui est un élément pronostique important pouvant aider dans la décision d’arrêter la RCP. Le recours à des protocoles bien établis avec des équipes entraînées permet d’éviter une interruption prolongée de la RCP. Cependant, aucune étude humaine de grande ampleur n’a permis de décrire de manière fiable pendant l’ACR la sémiologie échographique des causes curables que constituent l’hypovolémie, l’embolie pulmonaire, la tamponnade et le pneumothorax compressif.

Diagnostic accuracy study of routine echocardiography for bicuspid aortic valve: a retrospective study and meta-analysis

BACKGROUND

Transthoracic echocardiography (TTE) is the standard procedure to distinguish tricuspid aortic valve (TAV) from bicuspid aortic valve (BAV). Published studies assessed the accuracy of TTE for BAV under ideal conditions. Conversely, we aimed at assessing accuracy of TTE for BAV under routine conditions.

METHODS

This retrospective, cross-sectional study of 216 adults included 132 men aged 62±14 years. Of these, 108 had BAV and 108 were age-matched individuals with TAV. All diagnoses were confirmed at surgery. We assessed TTE in two patient groups. First, in the (I) group of all 216 individuals, where we assessed accuracy for BAV according to the original diagnoses as documented by the primary investigators during original TTE examination. Second, we assessed accuracy for BAV according to expert re-evaluation in (II) all 158 TTE with availability of original recordings. Third, we performed a meta-analysis of published results on the accuracy of TTE for BAV according to PRISMA standards.

RESULTS

Sensitivity, specificity and accuracy of (I) primary investigators was 46.3%, 97.2, and 71.8% as compared to (II) expert re-evaluation with 59.7%, 93%, and 77.8%, respectively. Sensitivity was significantly higher at re-evaluation (P<0.001). TTE at a non-tertiary care center (P=0.012), presence of aortic aneurysm (P=0.001) and presence of severe aortic valve calcification (P=0.003) predicted an inaccurate diagnosis of BAV. Conversely, meta-analysis of published TTE studies identified a pooled sensitivity of 87.7% and a pooled specificity of 88.3% for BAV.

CONCLUSIONS

The current study shows that TTE yields almost ideal diagnostic accuracy when ideal investigators examine ideal patients. However, the study also shows that TTE yields suboptimal diagnostic accuracy under routine conditions. TTE in non-tertiary care settings, concomitant aortic aneurysm, and presence of severe aortic valve calcification predict an inaccurate diagnosis of BAV.