A Prospective, Multicenter Evaluation of Point-of-care Ultrasound for Small-bowel Obstruction in the Emergency Department.

OBJECTIVE: The main objective of this study was to evaluate the accuracy of emergency physician-performed point-of-care ultrasound (POCUS) for the diagnosis of small-bowel obstruction (SBO) compared to computed tomography (CT). METHODS: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential SBO presenting to the emergency department (ED) between July 2014 and May 2017. Each POCUS was interpreted at the bedside by the performing emergency physician and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS, blinded expert interpretation, and specific POCUS parameters. RESULTS: A total of 217 subjects were included in the primary analysis with an overall SBO prevalence of 42.9%. For the diagnosis of SBO, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.88 (95% confidence interval [CI] = 0.80 to 0.94), 0.54 (95% CI = 0.45 to 0.63), 1.92 (95% CI = 1.56 to 2.35), and 0.22 (95% CI = 0.12 to 0.39), respectively. Expert review yielded a similar sensitivity (0.89 [95% CI = 0.81 to 0.95]) with a significantly higher specificity (0.82 [95% CI = 0.74 to 0.88]). The more sensitive sonographic parameters for both POC sonographers and expert reviewers were small-bowel dilation ≥ 25 mm (0.87 [95% CI = 0.79 to 0.93], 0.87 [95% CI = 0.79 to 0.93]) and abnormal peristalsis (0.82 [95% CI = 0.72 to 0.89], 0.85 [95% CI = 0.76 to 0.87]). The more specific parameters for both groups were transition point (0.82 [95% CI = 0.74 to 0.89], 0.98 [95% CI = 0.94 to 1.00]), intraperitoneal free fluid (0.82 [95% CI = 0.74 to 0.89], 0.93 [95% CI = 0.87 to 0.97]), and bowel wall edema (0.76 [95% CI = 0.67 to 0.83], 0.93 [95% CI = 0.87 to 0.97]). CONCLUSION: POCUS is moderately sensitive for SBO, although less specific, when performed by a diverse group of emergency physicians across multiple EDs. Interpretation of acquired POCUS images is significantly more accurate when performed by physicians with prior emergency ultrasound fellowship training and familiarity with the sonographic appearance of SBO.

Assessment of clinical dehydration using point of care ultrasound for pediatric patients in rural Panama.

BACKGROUND: Dehydration and its associated symptoms are among the most common chief complaints of children in rural Panama. Previous studies have shown that intravascular volume correlates to the ratio of the diameters of the inferior vena cava (IVC) to the aorta (Ao). Our study aims to determine if medical students can detect pediatric dehydration using ultrasound on patients in rural Panama. METHODS: This was a prospective, observational study conducted in the Bocas del Toro region of rural Panama. Children between the ages of 1 to 15 years presenting with diarrhea, vomiting, or parasitic infection were enrolled in the study. Ultrasound measurements of the diameters of the IVC and abdominal aorta were taken to assess for dehydration. RESULTS: A total of 59 patients were enrolled in this study. Twenty-four patients were clinically diagnosed with dehydration and 35 were classified to have normal hydration status. Of the 24 patients with dehydration, half (n=12) of these patients had an IVC/Ao ratio below the American threshold of 0.8. Of the remaining asymptomatic subjects, about half (n=18) of these subjects also had an IVC/Ao ratio below the American threshold of 0.8. CONCLUSION: Our study did not support previous literature showing that the IVC/Ao ratio is lower in children with dehydration. It is possible that the American standard for evaluating clinical dehydration is not compatible with the rural pediatric populations of Panama.

Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam (ROUTE) in rural Panama.

BACKGROUND: Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama. METHODS: Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral. RESULTS: A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation. CONCLUSION: Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

Randomized study of effectiveness of computerized ultrasound simulators for an introductory course for residents in Brazil.

PURPOSE: This study aimed to assess the impact of ultrasound simulation (SonoSim) on educational outcomes of an introductory point-of-care ultrasound course compared to hands-on training with live models alone. METHODS: Fifty-three internal medicine residents without ultrasound experience were randomly assigned to control or experimental groups. They participated in an introductory point-of-care ultrasound course covering eight topics in eight sessions from June 23, 2014 until July 18, 2014. Both participated in lecture and hands-on training, but experimental group received an hour of computerized simulator training instead of a second hour of hands-on training. We assessed clinical knowledge and image acquisition with written multiple-choice and practical exams, respectively. Of the 53 enrolled, 40 participants (75.5%) completed the course and all testing. RESULTS: For the 30-item written exam, mean score of the experimental group was 23.1±3.4 (n=21) vs. 21.8±4.8 (n=19), (P>0 .05). For the practical exam, mean score for both groups was 8.7 out of 16 (P>0 .05). CONCLUSION: The substitution of eight hours of ultrasound simulation training for live model scanning in a 24 hour training course did not enhance performance on written and image acquisition tests in an introductory ultrasound course for residents. This result suggests that ultrasound simulation technology used as a substitute for live model training on an hour-for-hour basis, did not improve learning outcomes. Further investigation into simulation as a total replacement for live model training will provide a clearer picture of the efficacy of ultrasound simulators in medical education.

Treatment of postmenopausal women with osteoporosis with PTH(1-84) for 36 months: treatment extension study.

OBJECTIVE: To determine the safety and efficacy of full-length parathyroid hormone, PTH(1-84), treatment for up to 36 months by evaluating bone mineral density (BMD) changes, bone histomorphometric indices, and clinical fracture incidence in postmenopausal women with osteoporosis. BACKGROUND: The TOP trial demonstrated increased lumbar spine BMD (6.9%) versus placebo after 18 months of PTH(1-84) treatment and reduced the incidence of new vertebral fractures (61%; p = 0.001). The therapeutic benefits of long-term treatment of postmenopausal women with PTH(1-84) are unknown. METHODS: The safety and efficacy of 36 months of once-daily dosing with 100 µg PTH(1-84) in postmenopausal women with osteoporosis were assessed. Women receiving placebo during the TOP trial were eligible for PTH(1-84) in the extension study. CLINICAL TRIAL REGISTRATION: NCT00172120. RESULTS: Lumbar spine BMD increased by 8.5% above baseline (p < 0.001) at 36 months of PTH(1-84) treatment, remaining stable during the last 12 months of treatment. Increases in total hip and femoral neck BMD occurred more slowly, reaching 3.2% and 3.4%, respectively above baseline at 36 months (p < 0.001). The total hip BMD showed no signs of reaching a limiting value although the femoral neck plateaued from months 24 to 36. Seven patients had vertebral fractures during the placebo phase of the TOP trial and before entering the extension study, but this rate decreased with the introduction of PTH(1-84) therapy, resulting in a single worsened vertebral fracture in the first 6 months and no further vertebral fractures from months 6 to 36. Treatment over 36 months with PTH(1-84) was well-tolerated and iliac crest biopsies showed no adverse effects on bone. LIMITATIONS: There was no placebo group for BMD comparisons. The number of patients assessed for fracture incidence was small. CONCLUSIONS: PTH(1-84) treatment for 36 months resulted in significant increases in BMD at the lumbar spine and hip, was associated with a lower incidence of vertebral fracture when compared to before therapy initiation, and was well-tolerated. The continuous increases in total hip BMD suggest that prolonged PTH(1-84) treatment may be beneficial for postmenopausal osteoporosis. Increased BMD at the femoral neck and lumbar spine also showed favourable changes but plateaued between 24 and 36 months. Long-term treatment was not associated with abnormalities in bone biopsies.