The value of ultrasound-guidance of nerves and muscles for patient tolerance and parameters electrodiagnostic studies.

Objective: To assess impact of ultrasound guidance (USG) on patient's perception of nerve conduction studies (NCS). Methods: In this single-center, randomized, sham-controlled, parallel, single-blind trial, we evaluated ultrasound (US) in identifying NCS stimulation site. Consecutive adults (18-80 old) without neuropathy referred for NCS were electronically randomized 1:1 to USG or Sham US. The primary outcome was sensory supramaximal intensity (SSMI) for each site/nerve; motor supramaximal intensity (MSMI), amplitudes, number of non-routine muscle punctured, Visual Analogue Scale (VAS), satisfaction were secondary outcomes. Results: 290 participants were randomized, with 145 in the USG and 144 Sham US groups, respectively. No difference in SSMI, CMAP or SNAP, VAS, satisfaction was recorded. With USG, the median at the elbow and fibular MMSI were lower (p = 0.04; p = 0.02). With normal NCS or overweight and obese subgroups patients had lower median SSMI (p = 0.05/ p = 0.02), higher median and sural SNAP with normal NCS (p = 0.04; p = 0.007) and the sural SNAP for the expert US subgroup (p = 0.02). Conclusions: USG is useful for nerves, that are anatomically variable or in obesity. The sural SNAP gain with US in the normal NCS subgroup could facilitate routine NCS. Significance: In standard NCS the USG does not modify the patient's tolerance.Trial Registration: clinicaltrials.gov (NCT03868189).

High success rates of ultrasound-guided distal internal jugular vein and axillary vein approaches for central venous catheterization: A randomized controlled open-label pilot trial.

BACKGROUND: Ultrasound (US)-guided axillary vein (AV) catheterization has been considered as the preferred site of insertion to minimize catheter-related infections. Given its difficulty of realization, internal jugular vein (IJV) access remains, thus, the first choice of catheter insertion site. This descriptive study was aimed to assess the success and complication rates of in-plane short axis approach of IJV in the lower neck and the AV approach under US-guidance. METHODS: In a prospective randomized controlled open-label pilot trial, all patients requiring central venous catheterization (CVC) in intensive care unit or operating room were randomly assigned to low IJV or AV groups. The primary objective was to estimate the overall success rate of both approaches. The secondary objectives were immediate complication rates, procedure durations, success rate after the first puncture, late complication rates (i.e., thrombosis, catheter colonization, and catheter-related infections), and nurse satisfaction regarding insertion site dressings. RESULTS: One hundred and seventy-three out of two hundred and ten included patients were fully analyzed (90 and 83 in the IJV and AV approach groups, respectively). Overall success rates for IJV and AV sites were 96% (95% confidence interval (CI) [90-99]) and 89% (95% CI [81-94]) respectively. First puncture success rates were 90% and 80% respectively. The median overall procedure duration from US pre-procedural screening to guidewire insertion was 8 and 10 min in IJV and AV groups. Overall immediate complications rates for IJV and AV sites were 11.6% and 14.6%, respectively. Incidence of catheter colonization were 7.9% and 6.8% and catheter-related infection rate were 2.6% and 0%, respectively. CONCLUSION: In this pilot study, US-guided low IJV and AV approaches are safe and efficient techniques for CVC insertion associated with high success and low complications rates. Duration for guidewire insertion seemed to be shorter in the short axis in-plane IJV approach. It provides the basis for a future randomized trial comparing these two approaches.

Early results of ultra-low-dose CT-scan for extremity traumas in emergency room.

Background: Ultra-low dose computed tomography (ULD-CT) was shown to be a good alternative to digital radiographs in various locations. This study aimed to assess the diagnostic sensitivity and specificity of ULD-CT versus digital radiographs in patients consulting for extremity traumas in emergency room. Methods: Digital radiography and ULD-CT scan were performed in patients consulting at the emergency department (February-August 2018) for extremity traumas. Fracture detection was evaluated retrospectively by two blinded independent radiologists. Sensitivity and specificity were evaluated using best value comparator (BVC) and a Bayesian latent class model (LCM) approaches and clinical follow-up. Image quality, quality diagnostic and diagnostic confidence level were evaluated (Likert scale). The effective dose received was calculated. Results: Seventy-six consecutive patients (41 men, mean age: 35.2±13.2 years), with 31 wrists/hands and 45 ankles/feet traumas were managed by emergency physicians. According to clinical data, radiography had 3 false positive and 10 false negative examinations, and ULD-CT, 2 of each. Radiography and ULD-CT specificities were similar; sensitivities were lower for radiography, with BVC and Bayesian. With Bayesian, ULD-CT and radiography sensitivities were 90% (95% CI: 87-93%) and 76% (95% CI: 71-81%, P<0.0001) and specificities 96% (95% CI: 93-98%) and 93% (95% CI: 87-97%, P=0.84). The inter-observer agreement was higher for ULD-CT for all subjective indexes. The effective dose for ULD-CT and radiography was 0.84±0.14 and 0.58±0.27 µSv (P=0.002) for hand/wrist, and 1.50±0.32 and 1.44±0.78 µSv (P=NS) for foot/ankle. Conclusions: With an effective dose level close to radiography, ULD-CT showed better detection of extremities fractures in the emergency room and may allow treatment adaptation. Further studies need to be performed to assess impact of such examination in everyday practice. Trial Registration: ClinicalTrials.gov Identifier: NCT04832490.

Comparison of interface pressures in two dynamic pressure ulcer prevention supports (NIMBUS 3 and SUMMIT): A randomized controlled trial.

BACKGROUND: Pressure ulcers are a risk for bedridden patients and various supports exist to prevent them. The Pressure Relief Index (PRI) evaluates pressure relief of dynamic mattresses over time. This study compared the PRI of the SUMMIT mattress (AKS-France) and the NIMBUS 3 (HNE Medical). METHODS: In this non-blinded, randomized, crossover, non-inferiority study, patients aged ≥60 with a BMI of 16-35 kg/m2, predominantly confined to bed, able to walk with aid and with pelvic symmetry were recruited from a hospital rehabilitation department from March-April 2012. Exclusion criteria included past or present pressure ulcers, inability to remain supine and deep vein thrombosis. Peak pressures of the sacrum were recorded at 0.1 Hz during a single complete 10-min inflating cycle on both mattresses, with the order determined via electronic randomization allocation. RESULTS: Thirty-one subjects were included and randomized; with 14 finally analyzed in the SUMMIT-NIBMUS 3 order group and 16 in the NIMBUS 3-SUMMIT group. The difference in PRI <30 mmHg between the two mattresses was 13.2% [0.3-26.1] (p < 0.05), allowing a non-inferiority - superiority switch. The SUMMIT mattress demonstrated a significantly higher percentage of time <30 mmHg (p = 0.0454). No significant difference in mean minimal pressure was seen (p = 0.3231) and mean maximal pressure was in favor of SUMMIT mattress (p = 0.0096). BMI did not affect pressure profile. There were no adverse events. CONCLUSIONS: Evaluated by the PRI, the SUMMIT mattress had a better interface pressure profile than the NIMBUS 3 in older patients. The PRI is a promising tool for clinical decision-making and research, warranting validation.

Pressure ulcers microbiota dynamics and wound evolution.

Bacterial species and their role in delaying the healing of pressure ulcers (PU) in spinal cord injury (SCI) patients have not been well described. This pilot study aimed to characterise the evolution of the cutaneous microbiota of PU in SCI cohort. Twenty-four patients with SCI from a French neurological rehabilitation centre were prospectively included. PU tissue biopsies were performed at baseline (D0) and 28 days (D28) and analysed using 16S rRNA gene-based sequencing analysis of the V3-V4 region. At D0, if the overall relative abundance of genus highlighted a large proportion of Staphylococcus, Anaerococcus and Finegoldia had a significantly higher relative abundance in wounds that stagnated or worsened in comparison with those improved at D28 (3.74% vs 0.05%; p = 0.015 and 11.02% versus 0.16%; p = 0.023, respectively). At D28, Proteus and Morganella genera were only present in stagnated or worsened wounds with respectively 0.02% (p = 0.003) and 0.01% (p = 0.02). Moreover, Proteus, Morganella, Anaerococcus and Peptoniphilus were associated within the same cluster, co-isolated from biopsies that had a poor evolution. This pathogroup could be a marker of wound degradation and Proteus could represent a promising target in PU management.

A new clinical approach to improve the appropriate use of peripherally inserted central catheters: a prospective study.

OBJECTIVES: Peripherally inserted central catheters (PICCs) are central venous catheters commonly used for administration of chemotherapy, prolonged antibiotic treatment, or parenteral nutrition. It is advisable to use the PICC with the fewest lumens and the smallest possible diameter to reduce major complications. A pharmaceutical analysis and validation of PICC requests was designed to improve efficiency and patient safety. The aim of this study was to evaluate the impact of pharmaceutical interventions (PIs) by the clinical pharmacist in the PICC process. METHODS: A prospective pilot study was conducted in a French university hospital. Four categories of PIs were defined according to the different stages of the PICC insertion process: before insertion to validate with the physician the relevance of the request and the choice of PICC model (PI applicant); during insertion (PI installer); during usage by nurses for analysis of drug incompatibilities (PI user); and at hospital discharge for reassessment of the device maintenance (PI reassessment). Each PI applicant was designated a potential harm from 1 to 4, with a cut-off of 2 representing harm for the patient. RESULTS: Over 6 months, 277 requests were analysed and 297 PIs were completed (109 applicants, 98 installers, 84 users, and 6 PIs for reassessment). The acceptance rate by the physicians was 93.6%. 52% of the PI applicants had a potential harm of 2 or more. 5% of PICC requests were refused by the pharmacist due to an inappropriate choice of device. A total of 207 (74.7%) of the requests analysed by the clinical pharmacist led to insertion. CONCLUSIONS: The implementation of a clinical pharmacy activity applied to PICC requests analysis and validation leads to improved patient care by securing the PICC circuit. This analysis demonstrates the beneficial role of the clinical pharmacist in PIs associated with medical devices.

Ultra-low-dose CT versus radiographs for minor spine and pelvis trauma: a Bayesian analysis of accuracy.

OBJECTIVES: To compare diagnosis performance and effective dose of ultra-low-dose CT (ULD CT) versus radiographs in suspected spinal or pelvic ring or hip fracture for minor trauma. METHODS: ULD CT, in addition to radiography, was prospectively performed in consecutive patients admitted to the emergency department for minor traumas, during working hours over 2 months. Presence of a recent fracture was assessed by two blind radiologists independently. Sensitivities and specificities were estimated using the best valuable comparator (BVC) as a reference and using a latent class model in Bayesian inference (BLCM). Dosimetric indicators were recorded and effective doses (E) were calculated using conversion coefficient. RESULTS: Eighty areas were analyzed in 69 patients, including 22 dorsal spine, 28 lumbar spine, and 30 pelvic ring/hip. Thirty-six fractures (45%) were observed. Applying the BVC method, depending on location, ULD CT sensitivity was 80 to 100% for reader 1 and 85 to 100% for reader 2, whereas radiographic sensitivity was 60 to 85% for reader 1 and 50 to 92% for reader 2. With BLCM approach for reader 2, ULD CT sensitivity for all locations/dorsal spine/lumbar spine and pelvic ring-hip was 87.1/75.9/84.2/76.9% respectively. Corresponding radiograph sensitivity was 73.8, 54.8, 80.4, and 68.7%. Effective doses of ULD CT were similar to radiographs for dorsal and hip locations whereas for lumbar spine, ULD CT effective dose was 1.83 ± 0.59 mSv compared with 0.96 ± 0.59 mSv (p < 0.001). CONCLUSION: Sensitivity for fracture detection was higher for ULD CT compared with radiographs with an effective dose comparable to radiographs. KEY POINTS: • Ultra-low-dose spine and pelvis CT demonstrates better fracture detection when compared with radiographs. • The effective dose of ultra-low-dose spine and pelvis CT scan and radiographs is comparable. • Replacement of radiographs by ULD CT in daily practice for trauma patients is an option to consider and should be evaluated by a randomized trial.

Diaphragmatic excursion measurement in emergency department patients with acute dyspnea to predict mechanical ventilation use.

INTRODUCTION: Ultrasound is a feasible and reproducible method for measuring right diaphragmatic excursion (RDE) in ED patients with acute dyspnea (AD). In AD patients, the correlation between the RDE value and the need for mechanical ventilation (MV) is not known. MATERIALS: This was a bicentric, observational prospective study. The RDE measurement was done at admission. The need for MV was defined by the use of MV within 4 h of AD management. An optimal threshold for RDE was determined as the value that minimized the incorrect predictions of the use of MV in the first 4 h as the highest Youden index. RESULTS: We analyzed 102 patients (79 [70; 86] years), 38 (37%) of whom had been ventilated. The RDE value was 1.7 cm [1.4; 2.0] and 2.2 cm [1.8; 2.6] in the ventilated and non-ventilated groups, respectively (p = 0.06). The AUC was 0.68 95% CI [0.57; 0.80]. With a threshold of 2 cm, the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were 76% [60%; 89%], 59% [46%; 71%], 81% [67%; 91%], and 53% [39%; 66%], respectively. In the non-COPD patients, the RDE values were 1.5 cm [1.2; 1.9] and 2.2 cm [1.8; 2.6] (p < 0.01) in the ventilated and not-ventilated groups, respectively. The AUC was 0.77 95% CI [0.64; 0.90]. With a threshold of 2.18 cm, the sensitivity, specificity, NPV, and PPV were 91% [71%; 99%], 51% [36%; 66%], 92% [75%; 99%], and 54% [38%; 69%], respectively. CONCLUSION: The RDE values at ED admission were unable to define a prognostic threshold value associated with subsequent MV need in the AD patients. In non-COPD patients, the NPV was 92%.

Efficacy and safety of remifentanil in a rapid sequence induction in elderly patients: A three-arm parallel, double blind, randomised controlled trial.

BACKGROUND: Rapid sequence induction (RSI) is recommended in patients at risk of aspiration, but induced haemodynamic adverse events, including tachycardia. In elderly patients, this trial aimed to assess the impact of the addition of remifentanil during RSI on the occurrence of: tachycardia (primary outcome), hypertension (due to intubation) nor hypotension (remifentanil). METHODS: In this three-arm parallel, double blind, multicentre controlled study, elderly patients (65 to 90 years old) hospitalised in three centres and requiring RSI were randomly allocated to three groups, where anaesthesia was induced with etomidate (0.3mg/kg) followed within 15seconds by either placebo, or low (0.5µg/kg), or high (1.0µg/kg) doses of remifentanil, followed by succinylcholine 1.0mg/kg. Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction and after intubation. RESULTS: In total, eighty patients were randomised and analysed. Baseline HR and MAP were similar between groups. For primary endpoint, the absolute change in HR between induction and intubation was greater in the control group (15 bpm; 95% CI [8-21]) than that in the remifentanil 0.5µg/kg group (4 bpm; 95% CI [-1-+8]; P=0.005) and the remifentanil 1.0µg/kg group (-3 bpm; 95% CI [-9-+3]; P<0.0001). The increase in MAP was greater in the placebo group than in both remifentanil groups (P<0.0001). Twice as many hypertension episodes were recorded in the placebo group compared to the remifentanil 0.5µg/kg and 1.0µg/kg groups (60%, 30%, and 28% patients respectively; P=0.032), but no placebo patients experienced hypotension episodes versus 11% and 24% in the remifentanil 0.5µg/kg and 1.0µg/kg groups respectively (P=0.016). CONCLUSION: Remifentanil (0.5-1.0µg/kg) prevents the occurrence of tachycardia and hypertension in elderly patients requiring RSI.

Impact of gynecologic cancer on pelvic floor disorder symptoms and quality of life: an observational study.

The objective of our observational prospective study was to investigate the severity and prevalence of urinary and pelvic floor disorders in gynecologic cancer survivors. All patients surviving gynecological cancer in the region as well as women receiving invitations to attend breast-screening checkups as the control population were asked to fill-in questionnaires assessing pelvic prolapse symptoms (PFDI-20, Wexner) and associated quality of life (PFIQ-7). Eighty-nine women were included in the cancer survivor group and 1088 in the control group. Pelvic floor symptoms (PFDI-20 questionnaire) were significantly worse in cancer survivors than in control women (score: 33.3 [14.6-74.1] vs. 20 [4.2-50.0], p = 0.0003). Urge incontinence was significantly worse in cancer survivors in both univariable (ORb = 2.061 [95% CI = 1.284-3.309], p = 0.0027) and multivariable analyses (ORa = 1.672 [95% CI = 1.014-2.758], p = 0.0442), as was fecal incontinence in univariable (ORb = 3.836 [95% CI = 1.710-8.602], p = 0.0011) and in multivariable (ORa = 3.862 [95% CI = 1.657-9.001], p = 0.0018) analyses. Women with benign hysterectomies had poorer quality of life and increased pelvic floor disorders compared to women with no history of surgery. Survivors of gynecological cancer experience significantly more pelvic floor symptoms and an associated reduction in quality of life.

Minor Blunt Thoracic Trauma in the Emergency Department: Sensitivity and Specificity of Chest Ultralow-Dose Computed Tomography Compared With Conventional Radiography.

STUDY OBJECTIVE: To evaluate the diagnostic performance of chest ultralow-dose computed tomography (CT) compared with chest radiograph for minor blunt thoracic trauma. METHODS: One hundred sixty patients with minor blunt thoracic trauma were evaluated first by chest radiograph and subsequently with a double-acquisition nonenhanced chest CT protocol: reference CT and ultralow-dose CT with iterative reconstruction. Two study radiologists independently assessed injuries with a structured report and subjective image quality and calculated certainty of diagnostic confidence level. RESULTS: Ultralow-dose CT had a sensitivity and specificity of 100% compared with reference CT in the detection of injuries (187 lesions) in 104 patients. Chest radiograph detected abnormalities in 82 patients (79% of the population), with lower sensitivity and specificity compared with ultralow-dose CT (P<.05). Despite an only fair interobserver agreement for ultralow-dose CT image quality (κ=0.26), the diagnostic confidence level was certain for 95.6% of patients (chest radiograph=79.3%). Ultralow-dose CT effective dose (0.203 mSv [SD 0.029 mSv]) was similar (P=.14) to that of chest radiograph (0.175 mSv [SD 0.155 mSv]) and significantly less (P<.001) than that of reference CT (1.193 mSv [SD 0.459 mSv]). CONCLUSION: Ultralow-dose CT with iterative reconstruction conveyed a radiation dose similar to that of chest radiograph and was more reliable than a radiographic study for minor blunt thoracic trauma assessment. Radiologists, regardless of experience with ultralow-dose CT, were more confident with chest ultralow-dose CT than chest radiograph.

The Back Belief Questionnaire is efficient to assess false beliefs and related fear in low back pain populations: A transcultural adaptation and validation study.

BACKGROUND: According to the fear avoidance model, beliefs and thoughts can modify the outcome of patient with low back pain. The Back Belief Questionnaire (BBQ)-a 14 items scale-assesses these consequences of low back pain. OBJECTIVE: To test the psychometric properties of the French version of the BBQ. METHODS: The BBQ was translated using the forward-backward translation process. Throughout three repeated evaluation time points (D1, D7 and D30), various aspects of validity were analysed: acceptability, quality of items, unidimentionality, internal consistency, temporal stability (between D1 and D7), responsiveness (between D7 and D30), and construct validity comparing it to other validated scales. RESULTS: One hundred and thirty-one patients were enrolled and 128 were analyzed. The acceptability and the quality of the items were excellent. The scale was unidimensional and reliable (internal consistency: Cronbach's α = 0.8). The responsiveness was moderate but in line with other scores. The BBQ was, as expected, convergent with day-to-day activities and fear avoidance (FABQ and Tampa), disability (Quebec and Dallas scores), or anxiety and depression (HAD); and not correlated with pain. Best correlations were found with Tampa and FABQ. The temporal stability (test-retest reliability) was poor. However, similar changes were observed in near conceptual score (FABQ), which confirmed that clinical status may have not been stable and suggesting sensitivity to early changes for BBQ. CONCLUSIONS: The BBQ showed good psychometric properties to assess false beliefs and related fear in French or English LBP populations and can be used either for evaluation in international trials or as a part of self-care training.

Evaluation of prescription along three health-care periods in the elderly.

Polypharmacy, potentially inappropriate prescriptions and inadequate coordination between prescribers are among main factors explaining the occurrence of adverse drug events in elderly patients. Prospective and descriptive study of medication prescriptions for elderly patients during a continuous period of health-care: entry in an acute geriatric unit (T1), at discharge (T2) and two months after hospitalization (T3). A global iatrogenic risk was defined: presence of poly-pharmacy and/or PPI (Laroche criteria) and/or absence of quality indicators for prescription according to the French health authority. For the 79 patients (mean age 87), mean number of medication decreased from 7.33 (T1) to 6 (T2) (p=0.0018) and 6 (T3). Number of quality indicators for prescription improved from 6.67 (T1) to 6.92 (T2) (p=0.001) then decreased to 6.84 (T3). Number of PPI decreased from 1.16 to 0.42 between T1 and T2 (p=0.001) then increased to 0.59 at T3. The global iatrogenic risk indicator fluctuated from 80% (T1) to 64% (T2) and 75% (T3). Selected interventions were developed to prevent adverse drug events during hospitalization and ambulatory follow-up. If geriatric intervention can enhance quality of prescription, iatrogenic risk remains frequent all along health-care follow-up. A local study of prescriptions can be a first step to develop an adequate program for adverse drug events prevention.

[Chemotherapy for colorectal cancer: Pragmatic assessment of prescription changes and relative dose intensity]. / Chimiothérapies dans le cancer colorectal : étude pragmatique des modifications de prescription et de dose intensité.

INTRODUCTION: Chemotherapy induced toxicities can generate changes in prescribing and relative dose intensity which have an impact on therapeutic efficacy. METHOD: This is a prospective observational study performed in hepato-gastroenterology department for 6 months. All patients treated for colorectal cancer and beginning a protocol with at least one parenteral drug have been included. RESULTS: Among the 48 patients enrolled, 85.4% of them had at least one prescription change, which concerned 30.3% of 238 cycles. Of the 766 analyzed prescription lines, 16.6% of them were postponed and/or 6.7% had modified dosage and/or 5.6% were stopped prematurely. Grades 2 to 4 adverse reactions were responsible for at least one change prescribing to 64.6% of patients and 17.6% of cycles. Toxicity induced prescription changes were mainly due to clinical toxicities (79.3%). The rate of patients with a relative dose intensity greater than 70% was 92.9% in adjuvant state, 66.7% and 62.5% in metastatic state first line and second and subsequent line. CONCLUSION: High-grade clinical toxicities are the main chemotherapy prescription change pattern in colorectal cancer. Knowledge of toxicities before the patient's arrival is expected to target patients for which the drug preparation can be anticipated and for which a cycle postponement, dose adjustment or discontinuation is necessary.

Comparison of the visualisation of the subclavian and axillary veins: An ultrasound study in healthy volunteers.

OBJECTIVE: To compare the area of the lumen of the axillary and subclavian veins using ultrasound (US) in 50 healthy volunteers. METHODS: Using an ultrasound device, depth, area, short axis vein length and long axis vein, vein-artery and vein-pleura distances were measured for axillary and subclavian approaches. RESULTS: The mean cross-sectional area of the axillary vein was greater than the mean cross-sectional area of the subclavian vein (327±89 mm2 versus 124±46 mm2, P<0.001). Both the mean transverse (10±2mm versus 9±2mm) and longitudinal axes (39±8mm versus 17±7mm) of the axillary vein were greater than those of subclavian vein (P<0.01, P<0.001, respectively). The depths of the axillary and subclavian veins were similar (21±6mm versus 20±6mm, P=0.43). The axillary and subclavian arteries were visualised in 3 and 45 volunteers, respectively (P<0.001). The pleura was seen in 25 and 37 volunteers with the axillary and subclavian approaches, respectively (P=0.01). The distance between the pleura and the subclavian vein was smaller (6±2mm versus 8±3mm, P<0.04). CONCLUSION: The present US study shows that visualisation of the axillary vein under US is greater than that for the subclavian vein, mainly due to a better alignment with the long axis of the axillary vein leading to a greater cross-sectional area of the axillary vein. TRIAL REGISTER NUMBER: NCT01647815.

Diaphragmatic excursion measurement in emergency patients with acute dyspnea: toward a new diagnostic tool?

INTRODUCTION: During acute dyspnea (AD), respiratory exhaustion is mainly due to diaphragm fatigue. The primary objective was to validate interobserver reproducibility of diaphragmatic excursion (DE) in emergency department (ED) patients admitted for AD. The secondary objectives were to assess the feasibility of DE measurement and intraobserver reproducibility. Finally, we examined whether the DE value was associated with a need for noninvasive ventilation (NIV). MATERIALS: This was a monocentric, prospective, technical reproducibility study. Adult patients in spontaneous ventilation admitted for AD were included. Two operators carried out 2 consecutive diaphragm excursion measurements each on the right and left hemidiaphragms. RESULTS: Twenty-four patients were analyzed. The feasibility was 96% on the right and 67% on the left. The interobserver concordance between the 2 measures was 0.80 (95% confidence interval [CI], 0.59-0.91) (average difference, -0.07±0.48 cm) on the right and 0.59 (95% CI, 0.19-0.82) (average difference, 0.30±0.91 cm) on the left. For right DE values inferior to 2.3 cm, the interobserver concordance between measures was 0.92 (95% CI, 0.78-0.97). The intraobserver concordance was 0.89 (95% CI, 0.81-0.94) (average difference, 0.02±0.35 cm) on the right and 0.90 (95% CI, 0.82-0.95) (average difference,-0.06±0.45 cm) on the left. When the DE was greater than 2 cm, no patient required NIV. CONCLUSION: Diaphragmatic excursion measurement of the right diaphragm is feasible, with good interobserver and intraobserver reproducibility in ED patients admitted for AD. When the DE value is greater than 2 cm at admission, no subsequent NIV is required.

The Influence of Arm Positioning on Ultrasonic Visualization of the Subclavian Vein: An Anatomical Ultrasound Study in Healthy Volunteers.

We hypothesized that placing the arm in 90° abduction, through 90° flexion and 90° external rotation, could improve ultrasound visualization of the subclavian vein. In 49 healthy volunteers, a single operator performed a view of the subclavian vein in neutral position and abduction position. A second blinded operator measured the cross-sectional area of the subclavian vein. Abduction position increased the cross-sectional area of the subclavian vein from 124 ± 46 (mean ± SD) to 162 ± 58 mm (P = 0.001). An increase of the cross-sectional area of ≥50% was observed in 41% volunteers (95% confidence interval, 27%-56%, n = 20); this technique offers an alternative approach (maybe safer) for ultrasound-guided catheterization of the subclavian vein.