Diagnostic Accuracy of a Handheld Ultrasound vs a Cart-based Model: A Randomized Clinical Trial.

Introduction: Numerous studies have demonstrated the accuracy of point-of-care ultrasound (POCUS). Portable, handheld devices have expanded the clinical scope of POCUS at a fraction of the cost of traditional, cart-based models. There is a paucity of data assessing the diagnostic accuracy of portable devices. Our objective in this study was to compare the diagnostic accuracy of a portable device with a cart-based model. Methods: This was an institutional review board-approved, observational, prospective, randomized clinical trial (NCT05196776) of a convenience sample of adult patients who presented to a university-based health system. Patients who required a cardiac, lung, renal, aorta, or biliary POCUS were randomized to a portable device or to a cart-based model. We hypothesized that the cart-based model would have a 90% diagnostic accuracy vs 70% for the handheld device. To detect a 20% difference, the sample size was calculated to be 98, with 49 patients randomized to each arm. We used standard 2x2 tables to calculate test characteristics with 95% confidence intervals (CI). Results: A total of 110 patients were enrolled, with 56 patients randomized to the cart-based model and 54 to the handheld device. The sensitivity, specificity, and diagnostic accuracy of the cart-based vs handheld were 77.8% (40-97.2) vs 92.9% (66.1-99.8), 91.5% (79.6-97.6) vs 92.3% (79.1-98.4%), and 89.3% (78.1-96) vs 92.5% (81.8-97.9), respectively. Conclusion: The diagnostic accuracy of a portable, handheld device is similar to that of a cart-based model.

Evaluation of the VioOne HIV profile supplemental assay.

HIV is an ongoing global epidemic with estimates of more than a million new infections occurring annually. To combat viral spread, continuous innovations in areas including testing and treatment are necessary. In the United States, the Centers for Disease Control and Prevention recommend that laboratories follow an HIV testing algorithm that first uses a US Food and Drug Administration approved immunoassay to detect antibodies to HIV-1 or HIV-2 as well as HIV-1 p24 antigen in serum or plasma samples. An initially reactive specimen is tested by a supplemental assay for confirmation and to differentiate antibodies to HIV-1 or HIV-2. There are few Food and Drug Administration (FDA)-approved supplemental differentiation tests currently available. A multicenter investigation was conducted to determine the clinical performance for two independent versions of the Avioq VioOne HIV Profile Supplemental Assay (Avioq, Inc., Research Triangle Park, NC). The performance of both assay versions compared favorably with the performance parameters for the Geenius HIV 1/2 Supplemental Assay as published in that assay package insert (Bio-Rad Laboratories, Hercules, CA), the current gold standard for HIV supplemental testing. When comparing the two VioOne assays, version 2 (lacking HIV-2 p27 antibody detection) demonstrated improved reproducibility, specificity, and sensitivity as compared to its predecessor. IMPORTANCE We evaluated the reproducibility, sensitivity, and specificity data for two versions of the VioOne HIV Profile Supplemental Assay and compared these results back to similar results for the Geenius HIV 1/2 Supplemental Assay that are publicly available. Our study concluded that the VioOne HIV Profile Supplemental Assay compared favorably with the Geenius HIV 1/2 Supplemental Assay, thus providing an additional option for clinical laboratories to improve and expand their HIV testing capabilities.

The effect of display size on ultrasound interpretation.

OBJECTIVES: Ultrasound (US) is an essential component of emergency department patient care. US machines have become smaller and more affordable. Handheld ultrasound (HUS) machines are even more portable and easy to use at the patient's bedside. However, miniaturization may come with consequences. The ability to accurately interpret ultrasound on a smaller screen is unknown. This pilot study aims to assess how screen size affects the ability of emergency medicine clinicians to accurately interpret US videos. METHODS: This pilot study enrolled a prospective convenience sample of emergency medicine physicians. Participants completed a survey and were randomized to interpret US videos starting with either a phone-sized screen or a laptop-sized screen, switching to the other device at the halfway point. 50 unique US videos depicting right upper quadrant (RUQ) views of the Focused Assessment with Sonography in Trauma (FAST) examination were chosen for inclusion in the study. There were 25 US videos per device. All of the images were previously obtained on a cart-based machine (Mindray M9) and preselected by the study authors. Participants answered "Yes" or "No" in response to whether they identified free fluid. The time that each participant took to interpret each video was also recorded. Following the assessment, participants completed a post-interpretation survey. The goal of the pilot was to determine the accuracy of image interpretation on a small screen as compared to a laptop-sized screen. Statistical analyses were performed using MATLAB (The MathWorks, Inc., Natick, MA). Nonparametric statistical tests were utilized to compare subgroups, with a Wilcoxon signed rank test used for paired data and a Wilcoxon rank sum test for unpaired data. RESULTS: 52 emergency medicine physicians were enrolled in the study. The median accuracy of US interpretation for phone versus laptop image screen was 88.0% and 87.6% (p = 0.67). The mean time to interpret with phone versus laptop screen was 293 and 290 s (p = 0.66). CONCLUSIONS: The study found no statistically significant difference in the accuracy of US interpretation nor time spent interpreting when the pre-selected RUQ videos generated on a cart-based ultrasound machine were reviewed on a phone-sized versus a laptop-sized screen. This pilot study suggests that the accuracy of US interpretation may not be dependent upon the size of the screen utilized.

Lung Ultrasound vs. Chest X-Ray Study for the Radiographic Diagnosis of COVID-19 Pneumonia in a High-Prevalence Population.

BACKGROUND: The viral illness severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly known as Coronavirus 2019 (COVID-19), has become a global pandemic, infecting over 100 million individuals worldwide. OBJECTIVES: The objective of this study was to compare the test characteristics of point-of-care lung ultrasound (LUS) with chest x-ray study (CXR) at radiographically detecting COVID-19 pneumonia. METHODS: This was a single-center, prospective, observational study at an urban university hospital with > 105,000 patient visits annually. Patients ≥ 18 years old, who presented to the Emergency Department with predefined signs and symptoms of COVID-19, were eligible for enrollment. Each patient received an LUS using a portable, handheld ultrasound followed by a single-view, portable anteroposterior CXR. Patients with an abnormal LUS or CXR underwent a non-contrast-enhanced computed tomography scan (NCCT). The primary outcome was the radiographic diagnosis of COVID-19 pneumonia on NCCT. RESULTS: One hundred ten patients underwent LUS, CXR, and NCCT; 99 LUS and 73 CXRs were interpreted as positive; 81 NCCTs were interpreted as positive, providing a prevalence of COVID-19 pneumonia of 75% (95% confidence interval [CI] 66-83.2) in our study population. LUS sensitivity was 97.6% (95% CI 91.6-99.7) vs. 69.9% (95% CI 58.8-79.5) for CXR. LUS specificity was 33.3% (95% CI 16.5-54) vs. 44.4% (95% CI 25.5-64.7) for CXR. LUS positive predictive value and negative predictive value were 81.8% (95% CI 72.8-88.9) and 81.8% (95% CI 48.2-97.7), respectively, vs. 79.5% (95% CI 68.4-88), and 32.4% (95% CI 18-49.8), respectively, for CXR. CONCLUSION: LUS was more sensitive than CXR at radiographically identifying COVID-19 pneumonia.

Point-of-Care Ultrasound Diagnosis of Cesarean Scar Ectopic Pregnancy: A Case Series.

BACKGROUND: A cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy. CASE REPORT: We present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.

Cross-specialty Collaboration and Education for Neurosurgical Trainees: Teaching Arterial Line Placement Under Ultrasound Guidance.

Introduction Interprofessional collaboration (IPC) increases patient safety. IPC is learned through task-based exercises, such as ultrasound (U/S)-guided arterial lines. We set out to teach U/S-guided arterial lines as a framework to improve IPC between emergency medicine and neurosurgery residents. The objectives of the study were to provide a U/S session to teach the proper arterial line placement technique, to assess post-workshop arterial line placement competency and attitude toward U/S for procedural guidance, and to improve interdepartmental relationships through IPC. Methods The course was completed in 2018 and consisted of pre-workshop assignments, the workshop, a competency assessment, and a post-workshop survey for neurosurgical residents. After a didactic and hands-on training session, trainees completed a simulated U/S-guided arterial line placement. Trainees then completed a post-workshop assessment. Results There were a total of 21 participants out of 24 total residents, an 87.5% participation rate. Prior to the workshop, on a 5-point Likert scale, where 1 is not at all likely and 5 is very likely, the residents reported they would use U/S 1.7/5, with 57% of respondents answering 1 out of 5. After the workshop, on the same Likert scale, the residents reported using U/S first 3.6/5 (P < 0.05) with 52% of the respondents answering 4 out of 5. After the course, the belief that the landmark technique is non-inferior decreased to 28.6% of respondents. Conclusions The overall goal of this workshop was to improve patient care through continuing education. Using IPC as the framework, the workshop significantly increased the reported likelihood of using U/S for arterial line placement.

Unorthodox Use of Point-of-care Ultrasound to Evaluate Seizures.

It can be difficult to distinguish between syncope and seizure. Some stigmata of seizure include post-ictal period, tongue-biting or incontinence. A less common finding after a seizure is a posterior shoulder dislocation. Posterior shoulder dislocation is commonly missed and may be the only finding after a seizure, thus aiding in diagnosis. In this case report, we discuss the incidence of posterior shoulder dislocations and their utility in differentiating syncope from seizure, as well as the ability to diagnose and evaluate for proper reduction of posterior shoulder dislocations using ultrasound.

Xanthogranulomatous Pyelonephritis: A Complicated Febrile Urinary Tract Infection Detected by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Febrile urinary tract infections (UTIs) include a spectrum of pathologies from uncomplicated pyelonephritis to urosepsis, including xanthogranulomatous pyelonephritis (XGP). Most febrile UTIs are treated with antibiotics alone, but studies indicate nearly 12% of cases of presumed simple pyelonephritis require emergent urologic intervention. How to identify these individuals, while limiting unnecessary advanced imaging and delays in diagnosis, challenges all emergency providers. We review the diagnosis and management of XGP, as well as the evidence regarding the role of renal ultrasound in the identification of complicated presentations of febrile UTIs. CASE REPORT: We present a case of XGP, a complicated febrile UTI requiring immediate urologic intervention, diagnosed by point-of-care ultrasound. A 40-year-old female presented in severe sepsis and complaining of flank pain. Prompt bedside ultrasound demonstrated hydronephrosis, expediting definitive urologic treatment via percutaneous nephrostomy tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With a mortality rate exceeding 40%, obstructed pyonephrosis requires prompt decompression. Given its exceptional sensitivity for identifying hydronephrosis and ability to detect abscesses and emphysematous changes, we advocate a point-of-care ultrasound-first approach to screen for cases of complicated febrile UTIs in order to expedite treatment and limit radiation in uncomplicated presentations.

A Three-dimensional Printed Low-cost Anterior Shoulder Dislocation Model for Ultrasound-guided Injection Training.

Anterior shoulder dislocations are the most common, large joint dislocations that present to the emergency department (ED). Numerous studies support the use of intraarticular local anesthetic injections for the safe, effective, and time-saving reduction of these dislocations. Simulation training is an alternative and effective method for training compared to bedside learning. There are no commercially available ultrasound-compatible shoulder dislocation models. We utilized a three-dimensional (3D) printer to print a model that allows the visualization of the ultrasound anatomy (sonoanatomy) of an anterior shoulder dislocation. We utilized an open-source file of a shoulder, available from embodi3D® (Bellevue, WA, US). After approximating the relative orientation of the humerus to the glenoid fossa in an anterior dislocation, the humerus and scapula model was printed with an Ultimaker-2 Extended+ 3D® (Ultimaker, Cambridge, MA, US) printer using polylactic acid filaments. A 3D model of the external shoulder anatomy of a live human model was then created using Structure Sensor®(Occipital, San Francisco, CA, US), a 3D scanner. We aligned the printed dislocation model of the humerus and scapula within the resultant external shoulder mold. A pourable ballistics gel solution was used to create the final shoulder phantom. The use of simulation in medicine is widespread and growing, given the restrictions on work hours and a renewed focus on patient safety. The adage of "see one, do one, teach one" is being replaced by deliberate practice. Simulation allows such training to occur in a safe teaching environment. The ballistic gel and polylactic acid structure effectively reproduced the sonoanatomy of an anterior shoulder dislocation. The 3D printed model was effective for practicing an in-plane ultrasound-guided intraarticular joint injection. 3D printing is effective in producing a low-cost, ultrasound-capable model simulating an anterior shoulder dislocation. Future research will determine whether provider confidence and the use of intraarticular anesthesia for the management of shoulder dislocations will improve after utilizing this model.

Simultaneous high-speed gas property measurements at the exhaust gas recirculation cooler exit and at the turbocharger inlet of a multicylinder diesel engine using diode-laser-absorption spectroscopy.

A diode-laser-absorption-spectroscopy-based sensor system was used to perform high-speed (100 Hz to 5 kHz) measurements of gas properties (temperature, pressure, and H(2)O vapor concentration) at the turbocharger inlet and at the exhaust gas recirculation (EGR) cooler exit of a diesel engine. An earlier version of this system was previously used for high-speed measurements of gas temperature and H(2)O vapor concentration in the intake manifold of the diesel engine. A 1387.2 N m tunable distributed feedback diode laser was used to scan across multiple H(2)O absorption transitions, and the direct absorption signal was recorded using a high-speed data acquisition system. Compact optical connectors were designed to conduct simultaneous measurements in the intake manifold, the EGR cooler exit, and the turbocharger inlet of the engine. For measurements at the turbocharger inlet, these custom optical connectors survived gas temperatures as high as 800 K using a simple and passive arrangement in which the temperature-sensitive components were protected from high temperatures using ceramic insulators. This arrangement reduced system cost and complexity by eliminating the need for any active water or oil cooling. Diode-laser measurements performed during steady-state engine operation were within 5% of the thermocouple and pressure sensor measurements, and within 10% of the H(2)O concentration values derived from the CO(2) gas analyzer measurements. Measurements were also performed in the engine during transient events. In one such transient event, where a step change in fueling was introduced, the diode-laser sensor was able to capture the 30 ms change in the gas properties; the thermocouple, on the other hand, required 7.4 s to accurately reflect the change in gas conditions, while the gas analyzer required nearly 600 ms. To the best of our knowledge, this is the first implementation of such a simple and passive arrangement of high-temperature optical connectors as well as the first documented application of diode-laser absorption for high-speed gas dynamics measurements in the turbocharger inlet and EGR cooler exit of a diesel engine.

Screening for childhood eating disorders in primary care.

OBJECTIVE: Early identification is essential to reduce disabling complications of eating disorders that occur during stages of bone growth and organ development. This study sought to examine health-screening practices of pediatricians and adolescent medicine physicians in a metropolitan area of the Pacific Northwest. METHOD: 70 pediatric and adolescent medicine practices were contacted, 34 (49%) participated, and 20 (29%) returned health forms. Five pediatricians participated in a follow-up focus group. Data collection and analysis occurred between June 2005 and April 2006. RESULTS: 71% (N = 24) of participating practices relied on clinical interviews to detect eating disorders. Less than half of analyzed health-screening forms included questions specific to eating disorders. A pediatrician focus group revealed barriers to identification of eating disorders. CONCLUSION: Fast-paced appointments and patients who withhold information compromise identification of eating disorders in pediatric and adolescent medicine practices. Barriers to detection highlight the need for enhanced professional and parent education, practical changes in screening tools and processes, and more frequent appointments when risk factors are present.

Relationship of hemoglobin A1c to mortality in nonsmoking insurance applicants.

OBJECTIVE: Determine the relationship between hemoglobin A1c value and 5-year, all-cause mortality in nonsmoking life insurance applicants. METHOD: By use of the Social Security Master Death Index, mortality was examined in 286,443 non-smoking insurance applicants aged 40 and up for whom blood samples for hemoglobin A1c were submitted to the Clinical Reference Laboratory. Results were stratified by hemoglobin A1c value, gender and age bands 40 to 59, 60 to 69 and 70 and up. RESULTS: Increased mortality is apparent at hemoglobin A1c values of 6% and above, is linear, and on a percentage basis decreases with age. Hemoglobin A1c values less than 5% also are associated with increased mortality. Absolute mortality rates for females with elevated hemoglobin A1c are generally lower than rates for males, although mortality relative to the gender-specific reference group with hemoglobin A1c of 5% to 5.9% is generally the same for both. CONCLUSION: The importance of even small elevations of hemoglobin A1c above 5.9% is apparent. For screening, it is the degree of blood sugar elevation as measured by hemoglobin A1c rather than any diagnostic label that is critical in risk assessment.

Increased mortality associated with elevated carcinoembryonic antigen in insurance applicants.

OBJECTIVE: Determine the relationship between the carcinoembryonic antigen (CEA) value and all-cause mortality in life insurance applicants aged 50 years and over. METHOD: By use of the Social Security Master Death Index, mortality was examined in 115,590 insurance applicants aged 50 and up for whom blood samples for CEA were submitted to the Clinical Reference Laboratory. Results were stratified by CEA value (<5 ng/mL, 5 to 9.9 ng/mL, 10+ ng/mL), smoking status, and age groups (50-59 years, 60-69 years, and 70 years and up). RESULTS: Relative mortality is increased at CEA values between 5 and 9.9 ng/mL and further increased at 10+ ng/mL for all age groups, with the most dramatic increase at the youngest ages. Excess mortality appears to last at least 3 to 4 years after the elevated result. Five-year all-cause mortality in applicants with CEA values of 10+ ng/mL is 25.2% with a mortality ratio relative to those with a CEA <5 ng/mL of 1156%. CONCLUSION: This study shows that CEA can detect the risk of early excess mortality in life insurance applicants; CEA levels of 5 ng/mL and over may be of concern. CEA testing beginning at age 50 years for life insurance applicants could capture 4.6% of early mortality if the threshold for further evaluation was set at 10 ng/mL. Only 0.4% of all applicants aged 50 and over have CEA values at or above this threshold.