Diagnostic accuracy of point-of-care lung ultrasound in COVID-19.

BACKGROUND: A promising modality for diagnosing pulmonary manifestations of COVID-19 in the emergency department (ED) is point-of-care ultrasound (POCUS) of the lungs. The currently used PCR as well as chest X-ray and CT scanning have important disadvantages. The aim of this study is to evaluate the diagnostic accuracy of POCUS in patients with suspected pulmonary manifestations of COVID-19 in the ED. METHODS: This prospective diagnostic accuracy study was conducted at the ED of our non-academic level 1 trauma centre (Isala, Zwolle, the Netherlands). Patients were enrolled between 14 April and 22 April 2020. Patients (aged ≥16 years) with suspected COVID-19 presenting to the ED underwent POCUS. All patients received current standard of care, including PCR (naso-oropharyngeal swab). Outcome of POCUS was compared with PCR or CT scan outcome to determine diagnostic accuracy. Diagnostic accuracy measures were calculated using 2×2 contingency tables. RESULTS: 100 patients were eligible to participate in this study, data of 93 patients were analysed. 27 (29%) patients were found positive for COVID-19 by PCR or CT. POCUS had a sensitivity of 89% (95% CI 70% to 97%), specificity of 59% (95% CI 46% to 71%), negative predictive value of 93% (95% CI 79% to 98%) and positive predictive value of 47% (95% CI 33% to 61%). In a subgroup of patients without previous cardiopulmonary disease (n=37), POCUS had a sensitivity of 100% (95% CI 70% to 100%), specificity of 76% (95% CI 54% to 90%), negative predictive value of 100% (95% CI 79% to 100%) and positive predictive value of 67% (95% CI 41% to 86%). CONCLUSION: POCUS of the lungs could serve as a valuable, radiation-free tool for excluding pulmonary manifestations of COVID-19 in patients in the ED at the point of assessment, especially in patients without previous cardiopulmonary disease. TRIAL REGISTRATION: Dutch Trial Register, No: NTR8544.

A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules.

BACKGROUND: In most hospitals, children with acute wrist trauma are routinely referred for radiography. OBJECTIVE: To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required. MATERIALS AND METHODS: We prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography. RESULTS: Included in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model. CONCLUSION: The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.

The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma.

BACKGROUND: Although only 39 % of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. METHODS: This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays. RESULTS: A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95 % CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 95-99 %) and 21 % (95 % CI: 15 %-28). The negative predictive value was 90 % (95 % CI: 81-99 %). CONCLUSIONS: The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs. TRIAL REGISTRATION: This study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1(st), 2010.

Amsterdam wrist rules: a clinical decision aid.

BACKGROUND: Acute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures. METHODS/DESIGN: This study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (≥18 years) presenting with acute wrist trauma at the Emergency Department in the participating hospitals. This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated. In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study. DISCUSSION: Wrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are obtained of all patients entering one of the participating hospitals with trauma to the wrist. However, this is ethically and logistically not feasible and one could argue that patients, for whom no radiography is required according to their physician, are not suspected of having a distal radius fracture and thus are not part of the domain. TRIAL REGISTRATION: This study is registered at the Netherlands Trial Register (NTR 2544) and was granted permission by the Medical Ethical Committee of the Academic Medical Center Amsterdam on 06-01-2011.

Factors determining outcome in gastroschisis: clinical experience over 18 years.

Although the survival in gastroschisis has improved to more than 85%, serious morbidity with consequent long hospital stay is still very common. Alternative strategies such as planned early delivery and amniotic fluid exchange are being explored. In order to evaluate these approaches, adequate risk stratification of patients with gastroschisis is required. The aim of this study was to identify the risk factors associated with increased morbidity and mortality. A retrospective analysis of all patients with gastroschisis treated at our institution between 1988 and 2005 was conducted. Patients' data were collected from the files and compared for statistical significance with three outcome measures: (1) complicated post-operative course; (2) time to full enteral feeding (TFE); (3) length of hospital stay (LOS). SPSS was used for statistical analysis. Fifty-nine newborns with gastroschisis were admitted during the study period. Antenatal diagnosis was made in 40 cases (68%). Associated malformations (other than intestinal anomalies) were present in eight patients. One patient with trisomy 13 was excluded from the analysis. Ten patients (17%) had compromised bowel (atresia, severe ischaemia or a combination). Primary repair was successful in 47 (81%) and in 11 patients a silo was applied. Overall survival was 54/58 children (93%), four patients died. Complications associated with closure occurred in eight patients. Post-operative course was uncomplicated in 45 patients and complicated in 13. The RR for patients with compromised bowel to have a complicated post-operative course is 9 (95% CI 2-39) and the RR to die is 20 (95% CI 2-222) for these patients. Risk stratification of patients with gastroschisis appears possible based on the presence of compromised bowel before closure.

Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results.

PURPOSE: Percutaneous transluminal angioplasty (PTA) is one of the treatment options for localized obstruction of the subclavian artery. To document long-term durability of this kind of PTA we report a 10-year single-center experience in 110 patients. METHODS: From January 1993 to July 2003, 110 patients (72 women; mean age, 62 +/- 10 years) underwent PTA of symptomatic (>75%) stenosis (n = 90) or occlusion of the proximal subclavian artery (84 left-sided). Forty one patients (37%) had symptoms of vertebrobasilar insufficiency, 29 patients (26%) had disabling chronic arm ischemia, and 20 patients had both symptoms. Twenty patients with coronary artery disease underwent PTA in preparation for myocardial revascularization with the internal mammary artery. Duplex scans and arteriograms confirmed significant stenosis or occlusion. All PTA procedures were performed with the patient under local anesthesia, through the femoral artery (n = 89), brachial artery (n = 6), or combined route (n = 15). In 59 patients (58%) an additional stent was placed. RESULTS: Angioplasty was initially technically and clinically successful in 102 patients (93%). Seven occlusions could not be recanalized, and 1 procedure had to be stopped because of ischemic stroke. Of the 102 patients in whom treatment was successful, 1 patient (1%) had a minor stroke in the contralateral hemisphere 2 hours post-PTA. Seven patients (7%) had minor problems, all without permanent sequelae. Follow-up with duplex scanning ranged from 3 months to 10 years (mean, 34 months). Primary clinical patency at 5 years was 89%, with a median recurrent obstruction-free period of 23 months. The local complication rate was 4.5%, and the combined stroke and death rate was 3.6%. Significant recurrent obstruction (>70%) developed in 8 patients with clinical symptoms. Four stenoses were successfully treated with repeat PTA (2 with additional stent placement); 4occlusions required surgery. CONCLUSIONS: PTA of obstructive lesions of the proximal subclavian artery is not only an effective initial treatment, but is also successful over the long-term. Inasmuch as all clinical failures occured within 26 months after initial therapy, we recommend regular follow-up for at least 2 years post-PTA. All clinically significant recurrent stenoses can be treated with repeat endovascular procedures. We could not prove positive or negative influence of additional placement of stents; however, the number of recurrent stenoses might be too small in this retrospective study to draw firm conclusions. Adverse events of any kind are certainly no greater than with invasive surgical procedures. Therefore PTA must be seriously considered in patients with localized obstruction of the proximal subclavian artery.