Correspondence - Evaluation of a basic point-of-care ultrasound course for residents in internal medicine.

Point-of-care ultrasound (POCUS) integrates imaging into the physical examination at the bedside. This offers the advantage of instant clinical information and has shown to speed up the diagnostic process, and to improve diagnostic accuracy and correct treatment.

Predicting whether patients in an acute medical unit are physiologically fit-for-discharge using machine learning: A proof-of-concept.

INTRODUCTION: Delays in discharging patients from Acute Medical Units hamper patient flows throughout the hospital. The decision to discharge a patient is mainly based on the patients' physiological condition, but may vary between physicians. An objective decision-support system based on patients' physiological data may help minimizing unnecessary delays in discharge. The aim of this proof-of-concept study is to assess the feasibility of predicting whether patients in an Acute Medical Unit are physiologically fit-for-discharge using machine learning with commonly available hospital data. Furthermore, this study investigated how long before actual time of discharge from the Acute Medical Unit we could predict discharge fitness. Also, the predictive importance of features extracted from these data was assessed. METHODS: Electronic Medical Records of patients who participated in a Randomized Controlled Trial conducted in an Acute Medical Unit were used retrospectively (N = 199). Only commonly available hospital data were used. Logistic Regression and Random Forest models were applied to predict every hour whether patients were physiologically fit-for-discharge. Nested 5-fold cross-validation with 5 repeats was used to optimize the model hyperparameters and to estimate the predictive performances. RESULTS: Physiological discharge fitness was predictable with reasonable performance for Logistic Regression (mean AUROC: 0.67) and Random Forest (mean AUROC: 0.69). For an intuitively chosen classification threshold of 0.8, mean specificity was 93.3 % and sensitivity 14.1 %. Models could predict physiological discharge fitness more than 24 h earlier than actual time of discharge for most patients who were correctly predicted to be fit-for-discharge. Patient characteristics, vital signs and laboratory results were shown to be important predictors. CONCLUSION: This proof-of-concept study showed that it is feasible to predict with machine learning whether patients in an Acute Medical Unit are physiologically fit-for-discharge using commonly available hospital data.

Screening for asymptomatic deep vein thrombosis in COVID-19 patients admitted to the medical ward: a cross-sectional study.

PURPOSE: Patients with COVID-19 have an increased risk for venous thrombo-embolism (VTE), especially pulmonary embolism. The exact prevalence of asymptomatic DVT is not known, as is the usefulness of screening for DVT in patients admitted to ward with COVID-19. We have studied the prevalence of asymptomatic DVT. METHODS: We performed a cross-sectional observational multi-center study at four university medical centers in The Netherlands. All adult patients admitted with COVID-19 to a medical ward were eligible for inclusion, including patients who were transferred back from the ICU to the ward. The study protocol consisted of weekly cross-sectional rounds of compression ultrasound. RESULTS: In total, 125 patients were included in the study. A significant proportion of patients (N = 34 (27%)) had developed a VTE during their admission for COVID-19 before the study ultrasound was performed. In most VTE cases (N = 27 (79%)) this concerned pulmonary embolism. A new asymptomatic DVT was found in 5 of 125 patients (4.0%; 95% CI 1.3-9.1%) (Table 2). Nine patients (7.2%; 95% CI 3.3-13.2%) developed a VTE (all PE) diagnosed within 28 days after the screening US was performed. CONCLUSION: We have shown a low prevalence (4%) of newly discovered asymptomatic DVT outside the ICU-setting in COVID-19 patients. Despite this low prevalence, nine patients developed PE (7%) within 28 days after ultrasound. This favors the hypothesis of local thrombus formation in the lungs. Based on our findings and literature, we do not recommend US-screening of asymptomatic patients with COVID-19 admitted to the ward.

Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

A point-of-care thoracic ultrasound protocol for hospital medical emergency teams (METUS) improves diagnostic accuracy.

BACKGROUND: Point-of-care ultrasound (POCUS) has proven itself in many clinical situations. Few data on the use of POCUS during Medical Emergency Team (MET) calls exist. In this study, we hypothesized that the use of POCUS would increase the number of correct diagnosis made by the MET and increase MET's certainty. METHODS: Single-center prospective observational study on adult patients in need for MET assistance. Patients were included in blocks (weeks). During even weeks, the MET physician performed a clinical assessment and registered an initial diagnosis. Subsequently, the POCUS protocol was performed and a second diagnosis was registered (US+). During uneven weeks, no POCUS was performed (US-). A blinded expert reviewed the charts for a final diagnosis. The number of correct diagnoses was compared to the final diagnosis between both groups. Physician's certainty, mortality and possible differences in first treatment were also evaluated. RESULTS: We included 100 patients: 52 in the US + and 48 in the US- group. There were significantly more correct diagnoses in the US+ group compared to the US- group: 78 vs 51% (P  = 0.006). Certainty improved significantly with POCUS (P  <  0.001). No differences in 28-day mortality and first treatment were found. CONCLUSIONS: The use of thoracic POCUS during MET calls leads to better diagnosis and increases certainty. TRIAL REGISTRATION: ClinicalTrials.gov. Registered 12 July 2017, NCT03214809 https://www.clinicaltrials.gov/ct2/show/NCT03214809?term=metus&cntry=NL&draw=2&rank=1.

Comparison between myocardial function assessed by echocardiography during hospitalization for COVID-19 and at 4 months follow-up.

In patients hospitalized for corona virus infectious disease 19 (COVID-19) it is currently unknown whether myocardial function changes after recovery and whether this is related to elevated cardiac biomarkers. In this single center, prospective cohort study we consecutively enrolled hospitalized COVID-19 patients between 1 April and 12 May 2020. All patients underwent transthoracic echocardiography (TTE) evaluation during hospitalization and at a median of 131 days (IQR; 116-136) follow-up. Of the 51 patients included at baseline, 40 (age: 62 years (IQR; 54-68), 78% male) were available for follow-up TTE. At baseline, 68% of the patients had a normal TTE, regarding left ventricular (LV) and right ventricular (RV) volumes and function, compared to 83% at follow-up (p = 0.07). Median LV ejection fraction (60% vs. 58%, p = 0.54) and tricuspid annular plane systolic excursion (23 vs 22 mm, p = 0.18) were comparable between hospitalization and follow-up, but a significantly lower RV diameter (39 vs. 34 mm, p = 0.002) and trend towards better global longitudinal strain (GLS) (- 18.5% vs - 19.1%, p = 0.07) was found at follow-up. Subgroup analysis showed no relation between patients with and without elevated TroponinT and/or NT-proBNP during hospitalization and myocardial function at follow-up. Although there were no significant differences in individual myocardial function parameters at 4 months follow-up compared to hospitalisation for COVID-19, there was an overall trend towards normalization in myocardial function, predominantly due to a higher rate of normal GLS at follow-up.

[POCUS is a great asset to general practice]. / POCUS is een grote aanwinst voor de algemene praktijk.

Point of care ultrasonography (POCUS) is a specific form of ultrasonography that aims to quickly rule in or out specific abnormalities with a high impact on diagnostic or therapeutic management as an adjunct to physical examination. As such, it is of great value to every physician who performs physical examinations, especially if there is an acute problem that may involve several organ systems.

The implementation of POCUS and POCUS training for residents: the Rijnstate approach.

Point-of-care ultrasound (POCUS) is gaining interest in intensive care medicine and good reviews and guidelines on POCUS are available. Unfortunately, how to implement POCUS and practical examples how to train staff and junior doctors is not well described in literature. We discuss the process of POCUS implementation, and a POCUS training program for residents prior to their intensive care rotation in a Dutch teaching hospital intensive care unit. The described four-day basic POCUS course consists of short tutorials and ample time for hands-on practice. Theoretical tests are taken shortly before, on the last day of the course, and after three months to assess learning retention. Practical tests are taken on the last day of the course and after three months. We stress the importance of POCUS for intensive care and hope that our experiences will help colleagues who also want to go forward with POCUS.

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine.

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

A cross-sectional investigation of communication in Do-Not-Resuscitate orders in Dutch hospitals.

BACKGROUND: The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives. AIM: To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding. METHODS: This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire. RESULTS: A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically. CONCLUSIONS: The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

Metabolic acidosis improves airway conductance in patients with asthma.

The objective was to investigate whether acute metabolic acidosis could cause bronchodilation in patients with asthma. Twelve patients with asthma (8 females, mean age 39 (+/- SD 12) years, forced expiratory volume in 1 second [FEV(1)] 93 [+/-9] % predicted, PC(20) 1.9 (+/-1.0) mg/mL) participated in a double-blind, placebo-controlled trial. Subjects ingested calculated amounts of ammonium chloride to induce acidosis or saline as placebo, in random order, each on a separate day. Airway resistance (R(aw)), specific airway conductance (sG(aw)), FEV(1), and PEF were measured as primary variables. To evaluate the consequences of alterations in bronchial contractility on the airway responsiveness, the histamine provocation test (PC(20)) was measured as secondary variable. The intervention resulted in a mean (SD) decrease in base excess from -0.5 (+/-1.4) to -3.9 (+/-1.1) mmol/L (p < 0.01) and a decrease in pH from 7.41 (+/-0.02) to 7.36 (+/-0.02) (p < 0.01). This caused a statistically significant increase in sG(aw) from 1.15 (+/-0.16) to 1.26 (+/-0.13) 1/kPa.s) (p < 0.05). Tendencies towards increase were found in PEF (7.79 (+/-2.2) versus 8.09 (+/-1.9) (NS, p = 0.10) and in FEV(1) (2.98 (+/-0.9) versus 3.06 (+/-0.9) (NS, p = 0.15). PC(20) did not change significantly. It was concluded that acute metabolic acidosis has a modest bronchodilating effect in patients with asthma.

Renal infarction after cocaine abuse: a case report and review.

A 36-year-old male presented with sudden pain in the left lower abdomen caused by a left renal infarction. Cocaine metabolites were found in the urine and a cocaine-induced renal infarction was diagnosed. Cocaine-induced renal infarction is not frequently reported in the literature. Pathophysiologic mechanisms include direct cocaine-induced platelet activation in combination with vasoconstriction and endothelial damage. There is no proven therapy for this complication.

The use of an external ultrasound fixator (Probefix) on intensive care patients: a feasibility study.

BACKGROUND: In critical care medicine, the use of transthoracic echo (TTE) is expanding. TTE can be used to measure dynamic parameters such as cardiac output (CO). An important asset of TTE is that it is a non-invasive technique. The Probefix is an external ultrasound holder strapped to the patient which makes it possible to measure CO using TTE in a fixed position possibly making the CO measurements more accurate compared to separate TTE CO measurements. The feasibility of the use of the Probefix to measure CO before and after a passive leg raising test (PLR) was studied. Intensive care patients were included after detection of hypovolemia using Flotrac. Endpoints were the possibility to use Probefix. Also CO measurements with and without the use of Probefix, before and after a PLR were compared to the CO measurements using Flotrac. Side effects in terms of skin alterations after the use of Probefix and patient's comments on (dis)comfort were evaluated. RESULTS: Ten patients were included; in eight patients, sufficient recordings with the use of Probefix could be obtained. Using Bland-Altman plots, no difference was found in accuracy of measurements of CO with or without the use of Probefix before and after a PLR compared to Flotrac generated CO. There were only mild and temporary skin effects of the use of Probefix. CONCLUSIONS: In this small feasibility study, the Probefix could be used in eight out of ten intensive care patients. The use of Probefix did not result in more or less accurate CO measurements compared to manually recorded TTE CO measurements. We suggest that larger studies on the use of Probefix in intensive care patients are needed.

Point-of-care Ultrasound (PoCUS) for the internist in Acute Medicine: a uniform curriculum.

The use of Point-of-care Ultrasound (PoCUS) is rapidly increasing in internal medicine as it is useful in the primary assessment of acutely ill internal medicine patients for enhanced diagnostics and resuscitation. PoCUS can be taught in a modular fashion including basic core applications and advanced applications which can be combined for a symptom-based approach. Several PoCUS curriculum guidelines, especially for emergency medicine, exist throughout the world but a clear Dutch guideline for internists has not been developed. In this review we propose 'core' ultrasound competencies for internists that may also be incorporated into the European Training Requirements Internal Medicine. We suggest the use of an Entrustable Professional Activities (EPA) competencybased training system with EPAs specifically designed for ultrasound.

Reality of severe metformin-induced lactic acidosis in the absence of chronic renal impairment.

BACKGROUND: Lactic acidosis in metformin use is a widely recognised but rare side effect. Case reports usually describe elderly patients with conditions which in themselves can cause lactic acidosis or with known contraindications to metformin. We present cases of an elderly woman, a younger woman and a man who developed serious metformin-induced lactic acidosis in the absence of chronic renal impairment. RESULTS: Laboratory results showed acute renal failure in all patients. The pH was 6.77, 6.98 and 6.7, respectively, and lactate levels were 18.2, 18.4 and 11.7 mmol/l, respectively. Metformin plasma levels were 58, 57 and 39 mg/l. All patients received continuous veno-venous haemofiltration (CVVH), using bicarbonate as a buffer solution shortly after arrival on our ICU. In the subsequent hours, a steep decline in the plasma levels was observed, with a concomitant increase in pH. No other diagnoses were made, so we concluded that all patients were suffering from metformin-induced lactic acidosis. Despite the severity of the metabolic acidosis, both female patients survived. Our male patient died after a prolonged stay in the ICU, but this was not related to metformin. CONCLUSION: Metformin-induced lactic acidosis does exist. Metformin-induced lactic acidosis may occur in patients with previously normal renal function, even in young patients. Patients with extreme (lactic) metabolic acidosis caused by metformin can survive when CVVH treatment is initiated rapidly. Intercurrent symptoms or diseases that affect renal perfusion can precipitate lactic acidosis.

[Serious and sometimes fatal consequences of high-altitude pulmonary oedema]. / Ernstige en soms fatale gevolgen van hoogtelongoedeem.

Three women aged 25, 34 and 22 years respectively, experienced high-altitude pulmonary oedema during a climbing holiday. The first patient presented with complaints arising from a fast ascent to high altitude and was treated with acetazolamide and rapid descent. She recovered without any complications. The second patient developed symptoms during the night, which were not recognised as high-altitude pulmonary oedema. The next morning she died while being transported down on a stretcher without having received any medication or oxygen. The third case was not a specific presentation of high-altitude pulmonary oedema but autopsy revealed pulmonary oedema. This woman had already been higher up on the mountain before she developed complications. The cases illustrate the seriousness of this avoidable form of high altitude illness. The current Dutch national guidelines advise against the use of medication by lay people. A revision is warranted: travellers to high altitude should be encouraged to carry acetazolamide, nifedipine and corticosteroids on the trip. Travel guides ought to be trained to use these drugs. In addition climbing travellers should be encouraged to adopt appropriate preventive behaviour and to start descending as soon as signs of high-altitude pulmonary oedema develop.

[Metformin-associated lactic acidosis: an insufficiently recognised problem]. / Metformine-geassocieerde lactaatacidose.

Metformin-associated lactic acidosis (MALA) is a rare but potentially fatal condition that can easily be avoided. As metformin is known to facilitate the production of lactate, predisposing factors can accelerate this process. In situations of infection or dehydration, metformin can accumulate due to kidney failure, hereby increasing the risk of MALA. Despite controversy in the literature about the presence of a relationship between metformin and lactic acidosis, the severity of the condition is cause for concern and allows for preventive measurements. Awareness of this condition among patients and clinicians is insufficient, resulting in many patients continuing metformin in situations where there is an increased risk of developing MALA. Metformin can easily be discontinued temporarily without causing any harm. We emphasize the importance of temporarily discontinuing metformin in situations where the risk of lactic acidosis is increased, such as severe infection, dehydration and acute kidney insufficiency. This requires increased awareness and adequate counselling by clinicians as well as pharmacists.

The use of ultrasound during and after central venous catheter insertion versus conventional chest X-ray after insertion of a central venous catheter.

BACKGROUND: After insertion of a central venous catheter (CVC) a conventional chest X-ray (CXR) is usually taken to check for complications and correct position. Ultrasound might be equally effective as CXR and is less time consuming. We studied the use of ultrasound versus CXR after insertion of a CVC in general ward patients. METHODS: General ward patients in need of a CVC were included. CVCs were inserted under direct ultrasound guidance. After insertion, ultrasound was performed and compared with CXR to check for complications and position. The waiting time for CXR was noted. RESULTS: In total, 53 patients were included. In 52/53 patients ultrasound was feasible. The results of ultrasound and CXR only differed in 3 of 53 patients. The sensitivity of ultrasound in detecting the correct CVC position was 98% (89.4-100%). No complications were detected (ultrasound or CXR). The median waiting time for CXR was 24.5 minutes. CONCLUSIONS: Our study shows that an integral use of ultrasound during and after CVC insertion is effective in establishing that the CVC is correctly positioned and for identifying post-procedural complications in patients from the general ward when compared with CXR.

A case of extreme hypokalaemia.

Hypokalaemia is a common clinical problem. It can lead to severe disturbances in cardiac, neurological and muscle function. We present the case of a 45-year-old woman who was transported to our hospital with cardiac arrest following ventricular fibrillation. Blood sampling revealed severe acidosis (pH 7.02) and extreme hypokalaemia (0.9 mmol/l). The low serum potassium level was most likely caused by the combination of a very deficient diet and use of a thiazide diuretic. She never reported any symptoms. An acute intracellular shift of potassium due to epinephrine and perhaps also the cathecholamines in Red Bull may have further decreased the serum potassium concentration. To our knowledge, this is the lowest potassium level reported in literature. Longer-lasting hypokalaemia might be asymptomatic but when combined with even minor triggers of acute hypokalaemia, serious morbidity or mortality can suddenly occur. Patients on diuretic treatment with suspected malnutrition or chronic gastrointestinal losses require regular monitoring of electrolytes.