Evaluation of a survey for acute care programme directors on the utilisation of point-of-care ultrasound.

PURPOSE: Point-of-care ultrasound (POCUS) is ultrasound brought to the patient's bedside and performed in 'real time' by the healthcare provider. The utility of POCUS to facilitate management of the acutely ill patient has been demonstrated for multiple pathologies. However, the integration of ultrasonography and echocardiography training into residency curriculum varies across the acute care specialties. STUDY DESIGN: After an institutional review board approval, anaesthesiology, emergency medicine, family medicine, internal medicine, paediatrics and general surgery programme directors (PDs) were surveyed. The survey consisted of 11 questions evaluating the primary bedside assessment tool for common acute care situations, POCUS topics that the PDs were comfortable practising and topics that the PDs felt were useful for their specialty. Barriers to POCUS use, certification and documentation were also surveyed. RESULTS: Overall, 270 PD surveys were completed. The preferred primary assessment tool for common acute care situations varied with specialty; emergency medicine PDs consistently responded that POCUS was the diagnostic modality of choice (p<0.0001). The majority of the PDs reported lack of educational opportunities as the primary barrier to learning POCUS (64%). Most PDs indicated that POCUS examinations should be documented (95.7%), and 39% reported that departmental certification would be sufficient. CONCLUSIONS: This study is the first to evaluate differences in the preferred initial bedside assessment tool between the acute care specialties. Although POCUS is a superior tool for evaluating acute pathologies, disconnect between education and utilisation remains. This study highlights the need to incorporate POCUS into the acute care specialty curriculum.

Impact of a lung ultrasound course for rheumatology specialists (IMPACT-2).

OBJECTIVES: Lung ultrasound (LUS) plays an increasing role in diagnosis and monitoring of interstitial lung disease (ILD). Connective tissue disorders (CTD) frequently cause ILD, and often presents symptomatically after irreversible fibrosis has ensued. As point-of-care musculoskeletal ultrasound (US) is commonly utilised by rheumatologists, translating this US expertise towards LUS places the rheumatologist in a position to screen for ILD. However, a standardised curriculum for the rheumatology community is lacking. The aim of this study is to determine the effectiveness of a formalised lung US training course for rheumatologists. METHODS: Four rheumatology fellows and four board-certified rheumatologists participated in a 4-hour training session. Pre-course, post-course and 6-month follow-up surveys evaluated perceptions towards previous US experience, training, clinical utility and attitudes toward lung US. Didactics explained the protocols utilised in ILD evaluation. Evaluation of knowledge in US physiology, lung anatomy, artifact and pathology recognition were done through written exams before, after training, and at 6 months and through a practical exam using live models and simulation. RESULTS: Temporally there was overall improvement in written test scores. Improvement was noted in overall practical skill score following training course (17.4% vs. 92.9%, p<0.001), in written test scores 49.3% vs. 72.5% p<0.001), and pathology identification (26.5% vs. 79.6%, p<0.001). Six-month follow assessments were similar to post-test results revealing similar written scores (70.6%) and practical scores (89.7%). CONCLUSIONS: This formalised lung ultrasound training course was effective in improving skills and knowledge of rheumatology specialists.

Patient-Centered Structured Interdisciplinary Bedside Rounds in the Medical ICU.

OBJECTIVES: We examined the effects of introducing patient-centered structured interdisciplinary bedside rounds in the medical ICU with respect to rounding efficiency, provider satisfaction, and patient/family satisfaction. DESIGN: A prospective, nonblinded, nonrandomized, parallel group study from June 21, 2016, to August 15, 2016. SETTING: The medical ICU at a tertiary care academic medical center. SUBJECTS: A consecutive sample of adult patients, family members, and healthcare providers. The patients and healthcare providers were arbitrarily assigned to either the patient-centered structured interdisciplinary bedside rounds or nonstructured interdisciplinary bedside round care team. INTERVENTIONS: Healthcare providers on the patient-centered structured interdisciplinary bedside rounds team were educated about their respective roles and the information they were expected to discuss on rounds each day. Rounds completion data and satisfaction questionnaires from healthcare providers, patients, and family members were obtained from both patient-centered structured interdisciplinary bedside rounds and nonstructured interdisciplinary bedside round teams. MEASUREMENTS AND MAIN RESULTS: Data were obtained from 367 patient-centered structured interdisciplinary bedside rounds and 298 nonstructured interdisciplinary bedside round patient encounters. Family members were present during 31.1% rounding encounters on the patient-centered structured interdisciplinary bedside rounds team and 10.1% encounters on the nonstructured interdisciplinary bedside round team (p < 0.01). Total rounding and interruption times were significantly shorter on patient-centered structured interdisciplinary bedside rounds compared with nonstructured interdisciplinary bedside round patients, 16.9 ± 10.0 versus 22.4 ± 14.9 and 2.0 ± 2.2 versus 3.9 ± 5.5 minutes, respectively (both p < 0.01). Mechanical ventilation, patient-centered structured interdisciplinary bedside rounds, and attending style independently contributed to the earlier completion of rounds (all p < 0.01). Surveys of 338 healthcare provider encounters on the patient-centered structured interdisciplinary bedside rounds team compared with 301 nonstructured interdisciplinary bedside round encounters showed perceptions of improved communication of patient management plans, increased input from the entire team, and clarity on task assignments (all p < 0.05). The attending physicians provided teaching points on 51.2% of patient-centered structured interdisciplinary bedside rounds compared with 33.9% of nonstructured interdisciplinary bedside round patient encounters (p < 0.01). For the patients and family members surveyed, 38 patient-centered structured interdisciplinary bedside rounds, and 30 nonstructured interdisciplinary bedside round, there were no differences in measures of satisfaction. CONCLUSIONS: Patient-centered structured interdisciplinary bedside rounds provide a venue for increased rounding efficiency, provider satisfaction, and consistent teaching, without impacting patient/family perception.

Predicting treatment Response based on Dual assessment of magnetic resonance Imaging kinetics and Circulating Tumor cells in patients with Head and Neck cancer (PREDICT-HN): matching 'liquid biopsy' and quantitative tumor modeling.

BACKGROUND: Magnetic resonance imaging (MRI) has improved capacity to visualize tumor and soft tissue involvement in head and neck cancers. Using advanced MRI, we can interrogate cell density using diffusion weighted imaging, a quantitative imaging that can be used during radiotherapy, when diffuse inflammatory reaction precludes PET imaging, and can assist with target delineation as well. Correlation of circulating tumor cells (CTCs) measurements with 3D quantitative tumor characterization could potentially allow selective, patient-specific response-adapted escalation or de-escalation of local therapy, and improve the therapeutic ratio, curing the greatest number of patients with the least toxicity. METHODS: The proposed study is designed as a prospective observational study and will collect pretreatment CT, MRI and PET/CT images, weekly serial MR imaging during RT and post treatment CT, MRI and PET/CT images. In addition, blood sample will be collected for biomarker analysis at those time intervals. CTC assessments will be performed on the CellSave tube using the FDA-approved CellSearch® Circulating Tumor Cell Kit (Janssen Diagnostics), and plasma from the EDTA blood samples will be collected, labeled with a de-identifying number, and stored at - 80 °C for future analyses. DISCUSSION: The primary objective of the study is to evaluate the prognostic value and correlation of weekly tumor response kinetics (gross tumor volume and MR signal changes) and circulating tumor cells of mucosal head and neck cancers during radiation therapy using MRI in predicting treatment response and clinical outcomes. This study will provide landmark information as to the utility of CTCs ('liquid biopsy) and tumor-specific functional quantitative imaging changes during treatment to guide personalization of treatment for future patients. Combining the biological information from CTCs and the structural information from MRI may provide more information than either modality alone. In addition, this study could potentially allow us to determine the optimal time to obtain MR imaging and/ or CTCs during radiotherapy to assess tumor response and provide guidance for patient selection and stratification for future dose escalation or de-escalation strategies. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT03491176 ). Date of registration: 9th April 2018. (retrospectively registered). Date of enrolment of the first participant: 30th May 2017.

Effects of Student-Performed Point-of-Care Ultrasound on Physician Diagnosis and Management of Patients in the Emergency Department.

BACKGROUND: Despite the increasing integration of ultrasound training into medical education, there is an inadequate body of research demonstrating the benefits and practicality of medical student-performed point-of-care ultrasound (SP-POCUS) in the clinical setting. OBJECTIVES: The primary purpose of this study was to evaluate the effects that SP-POCUS can have on physician diagnosis and management of patients in the emergency department, with a secondary purpose of evaluating the diagnostic accuracy of SP-POCUS. METHODS: SP-POCUS examinations were performed in the emergency department by medical students who completed year one of a 4-year medical school curriculum with integrated ultrasound training. Scans were evaluated by an emergency physician who then completed a survey to record any changes in diagnosis and management. RESULTS: A total of 641 scans were performed on the 482 patients enrolled in this study. SP-POCUS resulted in a change in management in 17.3% of scans performed. For 12.4% of scans, SP-POCUS discovered a new diagnosis. SP-POCUS reduced time to disposition 33.5% of the time. Because of SP-POCUS, physicians avoided ordering an additional imaging study for 53.0% of the scans performed. There was 94.7% physician agreement with SP-POCUS diagnosis. CONCLUSIONS: This study showed that SP-POCUS is feasible and may potentially have a meaningful impact on physician diagnosis and management of patients in the emergency department. In addition, the implementation of SP-POCUS could serve as an ideal method of developing ultrasound skills in medical school while positively impacting patient care.

Integration of Ultrasound in Medical Education at United States Medical Schools: A National Survey of Directors' Experiences.

OBJECTIVES: Despite the rise of ultrasound in medical education (USMED), multiple barriers impede the implementation of such curricula in medical schools. No studies to date have surveyed individuals who are successfully championing USMED programs. This study aimed to investigate the experiences with ultrasound integration as perceived by active USMED directors across the United States. METHODS: In 2014, all allopathic and osteopathic medical schools in the United States were contacted regarding their status with ultrasound education. For schools with required point-of-care ultrasound curricula, we identified the USMED directors in charge of the ultrasound programs and sent them a 27-question survey. The survey included background information about the directors, ultrasound program details, the barriers directors faced toward implementation, and the directors' attitudes toward ultrasound education. RESULTS: One-hundred seventy-three medical schools were contacted, and 48 (27.7%) reported having a formal USMED curriculum. Thirty-six USMED directors responded to the survey. The average number of years of USMED curriculum integration was 2.8 years (SD, 2.9). Mandatory ultrasound curricula had most commonly been implemented into years 1 and 2 of medical school (71.4% and 62.9%, respectively). The most common barriers faced by these directors when implementing their ultrasound programs were the lack of funding for faculty/ equipment (52.9%) and lack of time in current medical curricula (50.0%). CONCLUSIONS: Financial commitments and the full schedules of medical schools are the current prevailing roadblocks to implementation of ultrasound education. Experiences drawn from current USMED directors in this study may be used to help programs starting their own curricula.

Medical Student Core Clinical Ultrasound Milestones: A Consensus Among Directors in the United States.

OBJECTIVES: Many medical schools are implementing point-of-care ultrasound in their curricula to help augment teaching of the physical examination, anatomy, and ultimately clinical management. However, point-of-care ultrasound milestones for medical students remain unknown. The purpose of this study was to formulate a consensus on core medical student clinical point-of-care ultrasound milestones across allopathic and osteopathic medical schools in the United States. Directors who are leading the integration of ultrasound in medical education (USMED) at their respective institutions were surveyed. METHODS: An initial list of 205 potential clinical ultrasound milestones was developed through a literature review. An expert panel consisting of 34 USMED directors across the United States was used to produce consensus on clinical ultrasound milestones through 2 rounds of a modified Delphi technique, an established anonymous process to obtain consensus through multiple rounds of quantitative questionnaires. RESULTS: There was a 100% response rate from the 34 USMED directors in both rounds 1 and 2 of the modified Delphi protocol. After the first round, 2 milestones were revised to improve clarity, and 9 were added on the basis of comments from the USMED directors, resulting in 214 milestones forwarded to round 2. After the second round, only 90 milestones were found to have a high level of agreement and were included in the final medical student core clinical ultrasound milestones. CONCLUSIONS: This study established 90 core clinical milestones that all graduating medical students should obtain before graduation, based on consensus from 34 USMED directors. These core milestones can serve as a guide for curriculum deans who are initiating ultrasound curricula at their institutions. The exact method of implementation and competency assessment needs further investigation.

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience.

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

Ultrasound Integration in Undergraduate Medical Education: Comparison of Ultrasound Proficiency Between Trained and Untrained Medical Students.

OBJECTIVES: The benefit of formal ultrasound implementation in undergraduate medical education remains unclear. The goal of this study was to evaluate the effectiveness of ultrasound curriculum implementation during year 1 medical student physical examination teaching on the ultrasound proficiency of medical students. METHODS: An ultrasound curriculum was formally implemented at our institution in August 2012 and since then has successfully trained 2 classes of medical students (year 1 and year 2). Year 3 and year 4 medical students did not receive any formal ultrasound training, as the curriculum had not yet been implemented during their preclinical years. With the use of a 22-point ultrasound objective structured clinical examination (US-OSCE), trained medical students were compared to untrained medical students. The US-OSCE tested image acquisition and interpretation of the following systems: ocular, neck, vascular, pulmonary, cardiovascular, and abdominal. Emergency medicine (EM) residents formally trained in bedside ultrasound were also tested with the US-OSCE to provide a reference standard. RESULTS: There were 174 year 1, 25 year 2, and 19 year 3/year 4 medical students and 30 EM residents tested on the US-OSCE. Ultrasound-trained medical students were compared to untrained medical students, and overall US-OSCE scores ± SD were 91.4% ± 14.0% versus 36.1% ± 21.4% (P < .001), respectively. The EM resident group had an overall score of 99.1% ± 1.8%. The absolute percentage differences were 7.7% between EM resident and ultrasound-trained medical student scores and 63.0% between EM resident and untrained medical student scores (P < .001). CONCLUSIONS: Implementation of an ultrasound curriculum in undergraduate medical education showed a significant increase in trained versus untrained medical student ultrasound capabilities.

A Cost-effective, Gelatin-Based Phantom Model for Learning Ultrasound-Guided Fine-Needle Aspiration Procedures of the Head and Neck.

The rise in popularity of ultrasound imaging has seen a corresponding increase in demand for effective training tools such as phantom models. They are especially useful for teaching and practice of invasive procedures, such as fine-needle aspiration of lesions of the head and neck. We have created 2 gelatin models out of inexpensive, commonly available materials that can be used in sequence to learn head and neck fine-needle aspiration. Fundamental skills can be learned first on the flat, rectangular model, whereas the second, cylindrical model more closely represents human anatomy and can be used to develop more advanced technique.

Head and Neck Ultrasound Education-A Multimodal Educational Approach in the Predoctoral Setting: A Pilot Study.

OBJECTIVES: With the increased implementation of ultrasound in medical education, it is important to continually improve instructional methods. In this study, we demonstrate that by augmenting the traditional methods of instructor demonstration and student practice on a healthy volunteer with additional modalities, such as didactic presentation, simulated pathologic cases, and simulated procedures, students gain a more comprehensive understanding of and confidence in ultrasound technique and pathology. METHODS: A multimodal curriculum was developed and applied to head and neck ultrasound sessions of our institution's Ultrasound Symposium. Participants were asked to fill out surveys rating each instructional modality as well as preinstructional and postinstructional confidence. The survey results were divided into a group of first- and second-year medical students who had previous ultrasound training and a group of third- and fourth-year students who were ultrasound "naïve." RESULTS: The survey showed that the first- and second-year student group (n = 8) had an average preinstructional confidence of 4.14/10 compared to 1.44/10 in the third- and fourth-year student group (n = 9) (P = .003). Following the instructional sessions, the students' confidence increased respectively to 8.14/10 and 7.78/10 (P= .53), showing a 4.00 (96%) increase in the first- and second-year group and a 6.34 (440%) increase in the third- and fourth-year group. The combined results of all student teaching modality ratings showed that instructor demonstration was rated the highest (9.47) and computerized simulation lowest (8.25). CONCLUSIONS: Overall, our study shows that multimodal ultrasound instruction was beneficial in increasing both ultrasound-trained and ultrasound-naïve medical students' confidence in head and neck ultrasound.

Effects of ultrasound implementation on physical examination learning and teaching during the first year of medical education.

OBJECTIVES: Increasing emphasis has been placed on point-of-care ultrasound in medical school. The overall effects of ultrasound curriculum implementation on the traditional physical examination skills of medical students are still unknown. We studied the effects on the Objective Standardized Clinical Examination (OSCE) scores of year 1 medical students before and after ultrasound curriculum implementation. METHODS: An ultrasound curriculum was incorporated into the physical diagnosis course for year 1 medical students in the 2012-2013 academic year. We performed a prospective observational study comparing traditional OSCE scores of year 1 medical students exposed to the ultrasound curriculum (post-ultrasound) versus historic year 1 medical student controls (pre-ultrasound) with no ultrasound exposure. Questionnaire data were also obtained from year 1 medical students and physical diagnosis faculty to assess attitudes toward ultrasound implementation. RESULTS: The final overall OSCE scores were graded with a 5-point Likert-type scale from unsatisfactory to outstanding. There was a significant increase in outstanding scores in the post-ultrasound compared to the pre-ultrasound group (27.0% versus 10.9%; P< .001). The post-ultrasound group had significantly (P< .05) increased first-time pass rates on blood pressure measurements, the abdominal examination, and professionalism. Student and physical diagnosis faculty questionnaire data showed an overall positive response, with most agreeing or strongly agreeing that ultrasound should be included in the future year 1 medical student curriculum. CONCLUSIONS: Ultrasound implementation into a physical diagnosis curriculum for year 1 medical students is feasible and may improve their overall traditional physical examination skills.

Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique.

OBJECTIVES: Sonographic evaluation of neck anatomy before performing percutaneous dilatational tracheostomy (PDT) has been shown to predict PDT success. In this study, we compared the real-time, long-axis, in-plane approach to the traditional bronchoscopically guided landmark technique. METHODS: Data were analyzed from a prospectively maintained PDT database at a university tertiary care medical intensive care unit. A convenience sample of adult patients requiring PDT for prolonged mechanical ventilation dependence was enrolled. Critical care fellows, under direct supervision of an attending intensivist, performed all PDTs. Tracheostomy performance from the sonographically guided and landmark techniques was compared. RESULTS: Twenty-three patients were enrolled: 11 in the sonography group and 12 in the landmark group. Initial midline introducer needle puncture was achieved in 72.7% in the sonography group compared to 8.3% in the landmark group (P< .001). The mean number of introducer needle punctures ± SD was significantly lower in the sonography group compared to the landmark group (1.4 ± 0.7 versus 2.6 ± 0.9; P < .001). The total tracheostomy time was 11.4 ± 4.2 minutes in the sonography group versus 15.3 ± 6.8 minutes in the landmark group (P = .12). Sonography accurately predicted tracheal ring space insertion in 90.9% of patients. Procedural complications did not differ significantly between the groups. CONCLUSIONS: Percutaneous dilatational tracheostomy under real-time sonographic guidance using a long-axis approach may increase the rate of midline punctures and decrease the number of needle punctures when compared to the landmark technique. Sonographic guidance can also help guide accurate and efficient placement of a tracheostomy tube into the desired tracheal ring space.

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients.

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED) using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans 83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion  This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

Comorbidity Burden and Treatment Patterns of Psoriasis in Vietnam: Real-World Data from the EXPAND Study.

INTRODUCTION: Psoriasis is a multi-faceted, immune-mediated inflammatory disease associated with a wide range of comorbidities. Real-world data on treatment patterns, comorbidities, and economic burden in patients with psoriasis are needed for comprehensive patient care in Vietnam. METHODS: A retrospective chart review study was conducted using secondary data extracted from patients' medical records of two hospitals in Vietnam, with the aim of identifying adult patients with a confirmed diagnosis of psoriasis. The index date was defined as the date of first diagnosis between 1 January 2020 and 31 October 2021. Sociodemographic factors, disease characteristics, comorbidities, medication usage, drug survival, and medication costs were analyzed. RESULTS: A total of 661 patients were identified (mean ± standard deviation [SD] age 43.5 ± 14.8 years). The most prevalent comorbidity was dyslipidemia (49.6% of patients), followed by hypertension (23.4%), and psoriatic arthritis (10.4%). In total, 44% of patients received biologic therapies. Overall, 66.7% and 54.3% of patients receiving biologic and non-biologic therapies, respectively, had ≥ 1 comorbidity. Only 23.2% of patients with psoriasis-related comorbidities stopped therapy with biologics. Biologics had a longer retention time (17.0 months) than non-biologics (6.0 months) in patients with comorbidities. Patients with comorbidities had significantly higher total annual healthcare costs than those without comorbidities (in US dollars: USD901 vs. USD304; p < 0.001), mainly due to the relatively higher costs associated with the use of biologics. CONCLUSION: Patients with psoriasis in Vietnam experience a high disease and economic burden due to comorbidities. Evidence from this real-world study supports the need for routine monitoring of and an appropriate treatment course for psoriasis-related comorbidities.

Measuring cardiac index with a focused cardiac ultrasound examination in the ED.

OBJECTIVES: Noninvasive technology may assist the emergency department (ED) physician in determining the hemodynamic status in critically ill patients. The objective of our study was to show that ED physicians can accurately measure cardiac index (CI) by performing a bedside focused cardiac ultrasound examination. METHODS: A convenience sample of adult subjects were prospectively enrolled. Cardiac index, left ventricular outflow tract (LVOT) diameter, velocity time integral (VTI), stroke volume index, and heart rate were obtained by trained ED physicians and a certified cardiac sonographer. The primary outcome was percent of optimal LVOT diameter and VTI measurements as verified by an expert cardiologist. RESULTS: One hundred patients were enrolled, with obtainable CI measurements in 97 patients. Cardiac index, LVOT diameter, VTI, stroke volume index, and heart rate measurements by ED physician were 2.42 ± 0.70 L min(-1) m(-2), 2.07 ± 0.22 cm, 18.30 ± 3.71 cm, 32.34 ± 7.92 mL beat(-1) m(-2), and 75.32 ± 13.45 beats/min, respectively. Measurements of LVOT diameter by ED physicians and sonographer were optimal in 90.0% (95% confidence interval, 82.6%-94.5) and 91.3% (73.2%-97.6%) of patients, respectively. Optimal VTI measurements were obtained in 78.4% (69.2%-85.4%) and 78.3% (58.1%-90.3%) of patients, respectively. In 23 patients, the correlation (r) for CI between ED physician and sonographer was 0.82 (0.60-0.92), with bias and limits of agreement of -0.11 (-1.06 to 0.83) L min(-1) m(-2) and percent difference of 12.4% ± 10.1%. CONCLUSIONS: Emergency department ED physicians can accurately measure CI using standard bedside ultrasound. A focused ultrasound cardiac examination to derive CI has potential use in the management of critical ill patients in the ED.

Clinical Epidemiology Characteristics and Etiology of Febrile Neutropenia in Children: Analysis of 421 Cases.

The congenital immune system includes neutrophils, which perform a variety of functions. Congenital and acquired neutropenia are rare illnesses with an underestimated prevalence in children. The aim of this study is to examine the epidemiology and etiology of febrile neutropenia in children at Haiphong Children's Hospital, Haiphong, Vietnam. Methods: A cross-sectional study was carried out on 421 febrile neutropenia children. Clinical and laboratory characteristics were examined. Results: The median age (IQR) was 25.0 (12.5-59.5) months. The male-to-female ratio was 1.35/1. There were twice as many children living in the suburbs (66.98%) as in urban areas (33.02%). The mean (SD) temperature at admission was 38.50 ± 0.59 °C. Diagnosed causes associated with neutropenia included acute respiratory infections 250 (59.45%), gastrointestinal infections 68 (16.1%), erythema 37 (8.79%), acute leukemia 15 (3.56%), urinary tract infection 5 (1.19%), and encephalitis/meningitis 4 (0.95%). Viral etiology accounted for 61.52% (259): influenza type A-50.19% (130), influenza type B-31.27% (81), dengue virus-14.67% (38), measles virus 1-93% (5), rotavirus-1.54% (4), and EBV-0.4% (1). Twenty-five patients (5.94%) were found to have bacteria in their cultures, with Streptococcus pneumonia being the most common (eight patients; 32%). Conclusions: Febrile neutropenia was common in children under 2 years old. Primary clinical manifestations were acute upper respiratory tract infections, and viruses most commonly caused febrile neutropenia. Further studies with larger sample sizes are needed to determine the cause of febrile neutropenia.

Endotracheal Tube Placement Confirmation with Bedside Ultrasonography in the Pediatric Intensive Care Unit: A Validation Study.

Critically ill patients who are intubated undergo multiple chest X-rays (CXRs) to determine endotracheal tube position; however, other modalities can save time, medical expenses, and radiation exposure. In this article, we evaluated the validity and interrater reliability of ultrasound to confirm endotracheal tube (ETT) position in patients. A prospective study was performed on intubated patients with cuffed ETTs. The accuracy of ultrasound to confirm correct ETT placement in 92 patients was 97.8%. Sensitivity, positive predictive value, and agreement of 97.7, 93.3, and 91.3% were found on comparing ultrasound to CXR findings. Ultrasound is feasible, reliable, and has good interrater reliability in assessing correct ETT position in children.

Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series.

The importance of functional right ventricular failure and resultant splanchnic venous congestion has long been under-appreciated and is difficult to assess by traditional physical examination and standard diagnostic imaging. The recent development of the venous excess ultrasound score (VExUS) and growth of point-of-care ultrasound in the last decade has made for a potentially very useful clinical tool. We review the rationale for its use in several pathologies and illustrate with several clinical cases where VExUS was pivotal in clinical management.