Point-of-care ultrasound (POCUS) in the surgery of a paraplegic pregnant female: A case of "do no harm".

We present here a case of multidisciplinary management of a 20-year-old pregnant woman who presented with sudden paraplegia attributed to a large paraspinal tumor. Magnetic resonance imaging (MRI) revealed compressive dorsal myelopathy due to an extramedullary tumor. Given the urgency of her symptoms and pregnancy status, a multidisciplinary team decided to proceed with surgery while avoiding radiation exposure (eg, O/C-arm). Intraoperative point-of-care ultrasound (POCUS) was utilized for tumor localization and surgical guidance, facilitating successful gross total excision with minimal risk to the fetus. Postoperative recovery was uneventful, with improvement in muscle strength and preservation of the pregnancy. Beyond tumor localization, POCUS offers additional benefits in assessing maternal hemodynamics and detecting potential complications. This case highlights the utility of POCUS as a radiation-free theranostic imaging modality in pregnant patients with spinal tumors, enhancing safety in surgery and optimizing outcomes for both mother and fetus.

Usefulness of point of care ultrasound in older adults: a multicentre study across different geriatric care settings in Spain and the United Kingdom.

BACKGROUND: Point of care ultrasound (POCUS) is an imaging technique performed bedside. To date, few published studies have reported the usefulness of multiorgan POCUS in Geriatrics. The objective of this study was to describe the utility of multiorgan POCUS in the care of older adults admitted to geriatric care settings. METHODOLOGY: Observational retrospective study of patients admitted to geriatric settings in Spain and UK. Multiorgan POCUS was performed when there was a specific clinical suspicion or unexplained torpid clinical course despite physical examination and complementary tests. A geriatrician with a certificate degree in comprehensive ultrasound and long-standing experience in POCUS carried out POCUS. All patients underwent multiorgan POCUS in a cephalo-caudal manner. RESULTS: Out of 368 patients admitted to geriatric units, 29% met the inclusion criteria. Average age was 85.9 years (SD ± 6.1). POCUS identified 235 clinically significant findings (2.2 per patient). Findings were classified as 37.9% confirmed diagnosis, 16.6% ruled out diagnosis, 14.9% unsuspected relevant diagnoses and 30.6% clinical follow-ups. POCUS findings led to changes in pharmacological and non-pharmacological treatment in 66.3 and 69.2% respectively, resulted in completion or avoidance of invasive procedures in 17.8 and 15.9%, respectively, facilitating early referrals to other specialities in 14.9% and avoiding transfers in 25.2% of patients. CONCLUSION: Multiorgan POCUS is a tool that aids in the assessment and treatment of patients receiving care in geriatrics units. These results show the usefulness of POCUS in the management of older adults and suggest its inclusion in any curriculum of Geriatric Medicine speciality training.

Relative Value of Point-of-Care Ultrasound in Person Specification of UK Consultant Job Advertisements Across Multiple Acute Specialties.

Background Point-of-care ultrasound (POCUS) skills are very useful in the management of acute patients. It is unknown how highly valued they are at the consultant level. The objective of this study was to investigate the prevalence of POCUS skills being listed as essential or desirable in consultant job advertisements for acute medicine (AM), intensive care medicine (ICM), and emergency medicine (EM) in the United Kingdom (UK). Methods We investigated the frequency with which POCUS skills are listed in person specification of consultant jobs advertised in the UK in three acute specialties (AM, ICM, and EM). Data were collected prospectively between May and June 2022 from the NHS Jobs website. Results A total of 286 jobs were identified, and 11 jobs (3.85%) listed POCUS skills as either essential or desirable. In AM consultant jobs, only two (1.83%) categorized POCUS as desirable or essential compared to five (11.6%) in ICM and four (3%) in EM. Conclusion POCUS skills are mentioned in the person specification in a minority of consultant job advertisements in acute specialties and currently do not seem to be widely viewed as essential or desirable for consultant practice in these specialties. It may be due to not many consultants are currently trained for this new skill, which in turn has led to the scarcity of the skill set demanded by the employing trusts in the UK.

A systematic review and meta-analysis of diagnostic test accuracy of chest ultrasound in diagnosing pediatric pulmonary tuberculosis.

INTRODUCTION: Despite medical advancement, pediatric pulmonary tuberculosis (PTB) still has high morbidity and mortality, due to challenging detection in clinical practice. Ultrasound has been touted as the next best diagnostic tool but currently, this claim is unfounded. Therefore, this study aims to systematically review the diagnostic parameters of chest ultrasound in diagnosing pediatric PTB. METHODS: The literature search started and ended on December 23, 2023. We searched MEDLINE, Cochrane Library, Pubmed, Science Direct, and Google Scholar. Our research question could be formulated as "In pediatric patients who present with signs and symptoms of PTB such as fever, cough, and poor weight gain, how accurate is chest ultrasound in ruling in and ruling out pediatric PTB when the diagnosis is compared to culture, PCR or CXR?" This systematic review adhered to the PRISMA-DTA guidelines while the meta-analysis was conducted with STATA program using the "midas" and "metandi" commands. RESULTS: There are five studies included with 137 positive PTB children. The combined sensitivity is 84% (95% confidence interval [CI]: 76-89), specificity of 38% (95% CI: 24-54), and summary receiver operating curve yields an area under the curve of 0.83 (95% CI: 0.80-0.86). The I2 value is 24% (95% CI: 0-100) with a p-value of 0.13. The combined negative predictive value is 0.68 (95% CI: 0.58-0.79), and the positive predictive value is 0.57 (95% CI: 0.51-0.63). The positive likelihood ratio is 1 with a 6% increase from the baseline while the negative likelihood ratio is 0.43 with a 12% decrease from the baseline. CONCLUSION: Chest ultrasound is sensitive but currently could neither exclude nor confirm pediatric PTB.

Precision medicine: "Point of Care Ultrasound" (PoCUS) in the diagnostic approach to the patient with hyponatremia.

Hyponatremia is a multifactorial disorder defined as a decrease in plasma sodium concentration. Its differential diagnosis requires an adequate evaluation of the extracellular volume (ECV). However, ECV determination, simply based on the clinical history, vital signs, physical examination, and laboratory findings can leads to misdiagnosis and inappropriate treatment. The use of Point-of-Care Ultrasound (POCUS), through the combination of Lung Ultrasound (LUS), Venous Excess UltraSound (VExUS) and Focused Cardiac Ultrasound (FoCUS), allows a much more accurate holistic assessment of the patient's ECV status in combination with the other parameters.

Gas Forming Pyogenic Liver Abscess Diagnosed by Point of Care Ultrasound.

Gas-forming pyogenic liver abscess (GFLPA) carries a high mortality rate. Early identification of the source of infection in sepsis results in better survival. Bedside point of care ultrasound (POCUS) can be used to help localize a source of infection. A 59-year-old man presented with systemic inflammatory response syndrome (SIRS) and was diagnosed with GFLPA on the initial encounter via clinical assessment and POCUS examination. After commencing antibiotics, optimal glucose control, adequate fluid resuscitation, and early infective source control, he achieved full recovery and was followed up in outpatient medical and surgical clinics. This case illustrates the role of POCUS as a diagnostic tool in sepsis and raises awareness among clinicians to recognize the features of GFLPA on POCUS.

Emergency Physician Performed Ultrasound-Guided Abdominal Paracentesis: A Retrospective Analysis.

BACKGROUND: Emergency physicians commonly perform ultrasound-assisted abdominal paracentesis, using point of care ultrasound (POCUS) to identify ascites and select a site for needle insertion. However, ultrasound-guided paracentesis has the benefit of real-time needle visualization during the entire procedure. Our objective was to characterize the performance of emergency physician-performed ultrasound-guided paracentesis using POCUS, their ability to achieve good in-plane needle visualization, and factors associated with procedural success. METHODS: A POCUS database was retrospectively reviewed for examinations where abdominal paracentesis was performed by an emergency physician at two academic urban emergency departments over a six-year period. Medical records were reviewed for demographics, presenting history, complications, and hospital course. Descriptive statistics were used to summarize the data. RESULTS: 131 patients were included in the final analysis. The success rate for ultrasound-guided paracentesis was 97.7% (84/86 [95% CI: 92-100%]) compared to 95.6% (43/45 [95% CI: 85-99%]) for ultrasound-assisted paracentesis (p=0.503). 58% (50/86) demonstrated good in-plane needle visualization; 17% (15/86) had partial or out-of-plane visualization; and 24% (21/86) did not demonstrate needle visibility on their saved POCUS images. All four procedural failures were performed by first- or second-year residents using a curvilinear transducer, while all procedures using a linear transducer were successful. The most common complications were ascites leak, infection at the site, and minor bleeding. CONCLUSIONS: Emergency physicians with training in real-time needle guidance with ultrasound were able to use POCUS to perform ultrasound-guided paracentesis in the emergency department with a high success rate and no fatal complications. Based on our experience, we recommend performing ultrasound-guided paracentesis using a linear transducer, with attention to identifying vessels near the procedure site and maintaining sterile technique.

Evolving the Scope of Cardiac Point-of-Care Ultrasound in the Current Era.

Point-of-care ultrasound (POCUS) has become a flexible and multifaceted diagnostic instrument in the realm of cardiac care, transforming the landscape of cardiovascular assessment. This review aims to explore the extensive scope of POCUS applications in cardiac care, highlighting its diverse utility across various medical specialties. POCUS, conducted at the patient's bedside, offers real-time insights into cardiac anatomy and function, providing a valuable adjunct to traditional diagnostic methods. In critically ill patients, POCUS has demonstrated its effectiveness in the rapid evaluation of the left and right ventricular function, identification of pericardial effusion and tamponade, assessment of volume status, and detection of valvular lesions. Its role as an adjunct to the physical examination has been particularly impactful, leading to early diagnoses and significantly influencing medical management decisions. The review also discusses the current limitations of POCUS technology. As the utilization of POCUS continues to expand across diverse medical disciplines, its ability to offer timely and accurate diagnostic information is poised to reshape the standard of care in cardiac medicine. This comprehensive review provides insights into the evolving role of POCUS in cardiac care and underscores its potential to enhance patient outcomes through rapid and informed decision-making at the point of care.

Ten Influential Point-of-Care Ultrasound Papers: 2023 in Review.

In an effort to help keep busy clinicians up to date with the latest ultrasound research, our group of experts has selected 10 influential papers from the past 12 months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.

Impact of point-of-care ultrasound use on patient referral decisions in rural Kenya: a mixed methods study.

BACKGROUND: Point-of-care ultrasound (POCUS) is recognized as a key imaging modality to bridge the diagnostic imaging gap in Low- and Middle-Income Countries (LMICs). POCUS use has been shown to impact patient management decisions including referral for specialist care. This study explored the impact of POCUS use on referral decisions among trained healthcare providers working in primary rural and peri-urban health facilities in Kenya. METHODS: A concurrent mixed methods approach was used, including a locally developed survey (N = 38) and semi-structured interviews of POCUS trained healthcare providers (N = 12). Data from the survey was descriptively analyzed and interviews were evaluated through the framework matrix method. RESULTS: Survey results of in-facility access to Xray, Ultrasonography, CT scan and MRI were 49%, 33%, 3% and 0% respectively. Only 54% of the facilities where trainees worked had the capacity to perform cesarean sections, and 38% could perform general surgery. Through a combined inductive and deductive evaluation of interview data, we found that the emerging themes could be organized through the framework of the six domains of healthcare quality as described by the Institute of Medicine: Providers reported that POCUS use allowed them to make referral decisions which were timely, safe, effective, efficient, equitable and patient-centered. Challenges included machine breakdown, poor image quality, practice isolation, lack of institutional support and insufficient feedback on the condition of patients after referral. CONCLUSION: This study highlighted that in the setting of limited imaging and surgical capacity, POCUS use by trained providers in Kenyan primary health facilities has the potential to improve the patient referral process and to promote key dimensions of healthcare quality. Therefore, there is a need to expand POCUS training programs and to develop context specific POCUS referral algorithms.

The Feasibility of Using Point of Care Ultrasound as a Visual Substitute for Physical Examination During Telehealth Visits: A Pilot Project.

Telehealth provides greater opportunity for specialty access but lacks components of the physical exam. Point-of-care ultrasound (POCUS) may assist telehealth as a visual substitute for the provision of palpation. We conducted a prospective observational pilot project to survey oncologists about (1) their expectations of POCUS, (2) their use of POCUS in oncology telehealth visits, and (3) post-project assessment of their experiences. The results of the pre-assessment survey showed an interest among the oncologists in the ability to evaluate structures remotely via POCUS. POCUS was utilized in 6.4% of visits, most commonly for lymph node assessment (60% of use). POCUS was not utilized most often due to not being applicable to the patient's visit. There were 14 instances of technical issues limiting views of the relevant anatomy reported. Oncologists rated the use of POCUS as very satisfied or satisfied in the vast number of recorded responses. This pilot study suggests POCUS can be integrated into oncology telehealth visits for specific applications such as lymph node assessment. The surveys indicated a potential interest and positive responses that provide for the foundation of expansion to subspecialty care access for patients with telehealth supported by POCUS.

Critical Care Ultrasound Competency of Fellows and Faculty in Pulmonary and Critical Care Medicine: A Nationwide Survey.

Purpose: Competency assessment standards for Critical Care Ultrasonography (CCUS) for Graduate Medical Education (GME) trainees in pulmonary/critical care medicine (PCCM) fellowship programs are lacking. We sought to answer the following research questions: How are PCCM fellows and teaching faculty assessed for CCUS competency? Which CCUS teaching methods are perceived as most effective by program directors (PDs) and fellows. Methods: Cross-sectional, nationwide, electronic survey of PCCM PDs and fellows in accredited GME training programs. Results: PDs and fellows both reported the highest rates of fellow competence to use CCUS for invasive procedural guidance, but lower rates for assessment of deep vein thrombosis and abdominal organs. 54% and 90% of PDs reported never assessing fellows or teaching faculty for CCUS competency, respectively. PDs and fellows perceived hands-on workshops and directly supervised CCUS exams as more effective learning methods than unsupervised CCUS archival with subsequent review and self-directed learning. Conclusions: There is substantial variation in CCUS competency assessment among PCCM fellows and teaching faculty nationwide. The majority of training programs do not formally assess fellows or teaching faculty for CCUS competence. Guidelines are needed to formulate standardized competency assessment tools for PCCM fellowship programs.

Twinkle Artifact Observed During POCUS of a Human Myiasis Caused by the Dermatobia hominisBotfly.

An 81-year-old man presented to urgent care for assessment of an area of erythema and tenderness on his right thigh after recent travel to Belize. Point of care ultrasound (POCUS) revealed a hyperechoic structure with acoustic shadowing in the subcutaneous tissue. Colour Doppler assessment of the structure produced a twinkle artifact. The structure was removed and pathology identified the object as a Dermatobia hominis larva (human botfly). The use of POCUS helped identify and localize the subcutaneous foreign body. The use of colour Doppler produced the twinkle artifact, which has not been previously reported as a finding produced during ultrasonographic assessment of botfly larvae.

Renal Transplant Artery Stenosis and Kinking: An Unusual Association.

Renal artery stenosis of the kidney allograft associated with kinking is not a frequent finding. As a correctable cause of graft dysfunction, it is important to diagnose it as soon as possible to avoid further graft damage and improve graft and patient survival. As pulsed wave Doppler ultrasound mapping of the graft's renal arteries is essential to diagnose possible alterations, point of care ultrasound (POCUS) is a highly useful tool for early diagnosis. We present a case in which nephrologists performed this examination promptly allowing a timely diagnosis and treatment plan.

Optimizing Care for High-Risk Multiple Pregnancy with POCUS - A Case of Quadruplet Pregnancy Early Diagnosis.

Managing multiple pregnancies is challenging and requires careful evaluation. Point of care ultrasound (POCUS) has emerged as a potentially crucial tool in assessing suspected first-trimester pregnancies. However, its role in evaluating multiple pregnancies remains uncertain. We present the case of a 36-year-old Ghanaian female who presented with acute vaginal bleeding after undergoing in vitro fertilization. A bedside transabdominal POCUS identified four intrauterine gestations with fetal poles and cardiac activity, suggesting a quadruplet viable pregnancy. A subsequent transvaginal ultrasound confirmed the findings. The patient was discharged with a follow-up appointment with an Obstetrician-Gynecologist. This case highlights the significance of POCUS in early pregnancy diagnosis, facilitating accurate identification and appropriate referral for further management. It also demonstrates the utility of POCUS in determining gestational age and viability. To our knowledge, no published case reports specifically address the diagnosis of a quadruplet pregnancy, emphasizing the role of POCUS in optimizing care for high-risk multiple pregnancies.

Association of Internal Medicine Point of Care Ultrasound (POCUS) with Length of Stay, Hospitalization Costs, and Formal Imaging: a Prospective Cohort Study.

Background: Point of care ultrasound (POCUS) use has rapidly expanded among internal medicine (IM) physicians in practice and residency training programs. Many benefits have been established; however, studies demonstrating the impact of POCUS on system metrics are few and mostly limited to the emergency department or intensive care setting. The study objective was to evaluate the impact of inpatient POCUS on patient outcomes and hospitalization metrics. Methods: Prospective cohort study of 12,399 consecutive adult admissions to 22 IM teaching attendings, at a quaternary care teaching hospital (7/1/2011-6/30/2015), with or without POCUS available during a given hospitalization. Multivariable regression and propensity score matching (PSM) analyses compared multiple hospital metric outcomes (costs, length of stay, radiology-based imaging, satisfaction, etc.) between the "POCUS available" vs. "POCUS unavailable" groups as well as the "POCUS available" subgroups of "POCUS used" vs. "POCUS not used". Results: Patients in the "POCUS available" vs. "POCUS unavailable" group had lower mean total and per-day hospital costs ($17,474 vs. $21,803, p<0.001; $2,805.88 vs. $3,557.53, p<0.001), lower total and per-day radiology cost ($705.41 vs. $829.12, p<0.001; $163.11 vs. $198.53, p<0.001), fewer total chest X-rays (1.31 vs. 1.55, p=0.01), but more chest CTs (0.22 vs 0.15; p=0.001). Mean length of stay (LOS) was 5.77 days (95% CI = 5.63, 5.91) in the "POCUS available" group vs. 6.08 95% CI (5.66, 6.51) in the "POCUS unavailable" group (p=0.14). Within the "POCUS available" group, cost analysis with a 4:1 PSM (including LOS as a covariate) compared patients receiving POCUS vs. those that could have but did not, and also showed total and per-day cost savings in the "POCUS used" subgroup ($15,082 vs. 15,746; p<0.001 and $2,685 vs. $2,753; p=0.04). Conclusions: Availability and selected use of POCUS was associated with a meaningful reduction in total hospitalization cost, radiology cost, and chest X-rays for hospitalized patients.