Patient-reported outcomes and associations with pleural effusion in outpatients with heart failure: an observational cohort study.

OBJECTIVES: We aimed to study whether patient-reported outcomes, measured by quality of life (QoL) and functional class, are sensitive to pleural effusion (PLE) in patients with heart failure (HF), and to study changes in QoL and functional class during follow-up of PLE. METHODS: A cohort of 62 patients from an outpatient HF clinic was included. The amount of PLE was quantified using a pocket-sized ultrasound imaging device. Self-reports of QoL and functional class were collected using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the New York Heart Association (NYHA) functional classification. RESULTS: At baseline, 26 (42%) patients had PLE of which 19 (31%) patients had moderate to severe amounts of PLE. Patients with no to mild PLE had a lower MLHFQ score (mean 42, SD 21) compared with patients with a moderate to severe amount of PLE (mean 55, SD 24), p=0.03. For 28 patients (45%) with follow-up data, we observed a linear improvement of the MLHFQ-score (3.2, 95% CI 1.2 to 5.1) with each centimetre reduction of PLE. Correspondingly, patient-reported NYHA-class followed the same pattern as the MLHFQ-score. CONCLUSIONS: Our study indicates that patient-reported outcome measures as MLHFQ may be sensitive tools to identify patients with HF at highest risk of symptomatic PLE and that treatment targeting reduction of PLE during follow-up is essential to improvement of QoL and functional capacity of outpatients with HF. TRIAL REGISTRATION NUMBER: NCT01794715; Results.

Diagnostic influence of routine point-of-care pocket-size ultrasound examinations performed by medical residents.

OBJECTIVES: We aimed to investigate the potential benefit of adding goal-directed ultrasound examinations performed by on-call medical residents using a pocket-size imaging device in patients admitted to a medical department. METHODS: A total of 992 emergency admissions to the medical department at a nonuniversity hospital in Norway were included. Patients admitted on dates with an on-call medical resident randomized to use a pocket-size imaging device were eligible for pocket-size cardiac and abdominal ultrasound examinations or standard care. The cardiac examination included estimation of right and left ventricular sizes and global systolic function and regional left ventricular systolic function, evaluation for pleural and pericardial effusion, and valvular disease. The abdominal examination looked for signs of gross abnormalities of the liver, gallbladder, abdominal aorta, inferior vena cava, and urinary system. Six of 12 medical residents with limited ultrasound experience were randomized to perform the examinations. Diagnostic corrections were made, and findings were confirmed by reference standard diagnostics. RESULTS: A total of 199 patients were examined. Median times used were 5.7 minutes for the cardiac examination and 4.7 minutes for the abdominal examination. In 13 patients (6.5%), the examination resulted in a major change in the primary diagnosis. In 21 patients (10.5%), the diagnosis was verified, and in 48 (24.0%), an additional important diagnosis was made. CONCLUSIONS: By implementing pocket-size ultrasound examinations that took less than 11 minutes to the usual care, we corrected, verified, or added important diagnoses in more than 1 of 3 emergency medical admissions. Point-of-care examinations with a pocket-size imaging device increased medical residents' diagnostic accuracy and capability.

Feasibility and reliability of pocket-size ultrasound examinations of the pleural cavities and vena cava inferior performed by nurses in an outpatient heart failure clinic.

BACKGROUND: Routine assessment of volume state by ultrasound may improve follow-up of heart failure patients. AIMS: We aimed to study the feasibility and reliability of focused pocket-size ultrasound examinations of the pleural cavities and the inferior vena cava performed by nurses to assess volume state at an outpatient heart failure clinic. METHODS: Ultrasound examinations were performed in 62 included heart failure patients by specialized nurses with a pocket-size imaging device (PSID). Patients were then re-examined by a cardiologist with a high-end scanner for reference within 1 h. Specialized nurses were able to obtain and interpret images from both pleural cavities and the inferior vena cava and estimate the volume status in all patients. RESULTS: Time consumption for focused ultrasound examination was median 5 min. In total 26 patients had any kind of pleural effusion (in 39 pleural cavities) by reference. The sensitivity, specificity, positive and negative predictive values were high, all ≥ 92%. The correlations with reference were high for all measurements, all r ≥ 0.79. Coefficients of variation for end-expiratory dimension of inferior vena cava and quantification of pleural effusion were 10.8% and 12.7%, respectively. CONCLUSIONS: Specialized nurses were, after a dedicated training protocol, able to obtain reliable recordings of both pleural cavities and the inferior vena cava by PSID and interpret the images in a reliable way. Implementing focused ultrasound examinations to assess volume status by nurses in an outpatient heart failure clinic may improve diagnostics, and thus improve therapy.