Gamified Crowdsourcing as a Novel Approach to Lung Ultrasound Data Set Labeling: Prospective Analysis.

BACKGROUND: Machine learning (ML) models can yield faster and more accurate medical diagnoses; however, developing ML models is limited by a lack of high-quality labeled training data. Crowdsourced labeling is a potential solution but can be constrained by concerns about label quality. OBJECTIVE: This study aims to examine whether a gamified crowdsourcing platform with continuous performance assessment, user feedback, and performance-based incentives could produce expert-quality labels on medical imaging data. METHODS: In this diagnostic comparison study, 2384 lung ultrasound clips were retrospectively collected from 203 emergency department patients. A total of 6 lung ultrasound experts classified 393 of these clips as having no B-lines, one or more discrete B-lines, or confluent B-lines to create 2 sets of reference standard data sets (195 training clips and 198 test clips). Sets were respectively used to (1) train users on a gamified crowdsourcing platform and (2) compare the concordance of the resulting crowd labels to the concordance of individual experts to reference standards. Crowd opinions were sourced from DiagnosUs (Centaur Labs) iOS app users over 8 days, filtered based on past performance, aggregated using majority rule, and analyzed for label concordance compared with a hold-out test set of expert-labeled clips. The primary outcome was comparing the labeling concordance of collated crowd opinions to trained experts in classifying B-lines on lung ultrasound clips. RESULTS: Our clinical data set included patients with a mean age of 60.0 (SD 19.0) years; 105 (51.7%) patients were female and 114 (56.1%) patients were White. Over the 195 training clips, the expert-consensus label distribution was 114 (58%) no B-lines, 56 (29%) discrete B-lines, and 25 (13%) confluent B-lines. Over the 198 test clips, expert-consensus label distribution was 138 (70%) no B-lines, 36 (18%) discrete B-lines, and 24 (12%) confluent B-lines. In total, 99,238 opinions were collected from 426 unique users. On a test set of 198 clips, the mean labeling concordance of individual experts relative to the reference standard was 85.0% (SE 2.0), compared with 87.9% crowdsourced label concordance (P=.15). When individual experts' opinions were compared with reference standard labels created by majority vote excluding their own opinion, crowd concordance was higher than the mean concordance of individual experts to reference standards (87.4% vs 80.8%, SE 1.6 for expert concordance; P<.001). Clips with discrete B-lines had the most disagreement from both the crowd consensus and individual experts with the expert consensus. Using randomly sampled subsets of crowd opinions, 7 quality-filtered opinions were sufficient to achieve near the maximum crowd concordance. CONCLUSIONS: Crowdsourced labels for B-line classification on lung ultrasound clips via a gamified approach achieved expert-level accuracy. This suggests a strategic role for gamified crowdsourcing in efficiently generating labeled image data sets for training ML systems.

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score.

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectives of this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48 h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24 hr, 30 days, and 1 year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89 days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

Point-of-Care Ultrasound Unveiling Rotator Cuff Injuries in the Emergency Department: A Case Series.

Acute shoulder pain is a common ED presentation with a wide range of pathologies that are often initially investigated with radiography. However, diagnosing rotator cuff injuries often requires further imaging for proper diagnosis and management. Bedside shoulder ultrasound is an application that allows for the evaluation of ligaments and tendons in addition to bony structures, all while utilizing direct patient feedback of focally tender areas, expediting diagnosis and therapeutic intervention. In this case series, we discuss our evaluation of patients with suspected rotator cuff pathology and the practice of using the stepwise shoulder ultrasound protocol. Four cases are presented that illustrate the use of shoulder ultrasound in diagnosing biceps tendon injury, supraspinatus tear, chronic supraspinatus tear with hemarthrosis, and subacromial-subdeltoid bursitis. This narrative highlights the valuable role of shoulder ultrasound for the expedited diagnosis and management of patients whose initial shoulder radiographs do not indicate any bony abnormalities.

Accuracy of "TICS" ultrasound protocol in detecting simple and complicated diverticulitis: A prospective cohort study.

BACKGROUND: Point-of-care ultrasound (US) has been suggested as the primary imaging in evaluating patients with suspected diverticulitis. Discrimination between simple and complicated diverticulitis may help to expedite emergent surgical consults and determine the risk of complications. This study aimed to: (1) determine the accuracy of an US protocol (TICS) for diagnosing diverticulitis in the emergency department (ED) setting and (2) assess the ability of TICS to distinguish between simple and complicated diverticulitis. METHODS: Patients with clinically suspected diverticulitis who underwent a diagnostic computed tomography (CT) scan were identified prospectively in the ED. Emergency US faculty and fellows blinded to the CT results performed and interpreted US scans. The presence of simple or complicated diverticulitis was recorded after each US evaluation. The diagnostic ability of the US was compared to CT as the criterion standard. Modified Hinchey classification was used to distinguish between simple and complicated diverticulitis. RESULTS: A total of 149 patients (55% female, mean ± SD age 58 ± 16 years) were enrolled and included in the final analyses. Diverticulitis was the final diagnosis in 75 of 149 patients (50.3%), of whom 53 had simple diverticulitis and 22 had perforated diverticulitis (29.4%). TICS protocol's test characteristics for simple diverticulitis include a sensitivity of 95% (95% confidence interval [CI] 87%-99%), specificity of 76% (95% CI 65%-86%), positive predictive value of 80% (95% CI 71%-88%), and negative predictive value of 93% (95% CI 84%-98%). TICS protocol correctly identified 12 of 22 patients with complicated diverticulitis (sensitivity 55% [95% CI 32%-76%]) and specificity was 96% (95% CI 91%-99%). Eight of 10 missed diagnoses of complicated diverticulitis were identified as simple diverticulitis, and two were recorded as negative. CONCLUSIONS: In ED patients with suspected diverticulitis, US demonstrated high accuracy in ruling out or diagnosing diverticulitis, but its reliability in differentiating complicated from simple diverticulitis is unsatisfactory.

Novice-performed point-of-care ultrasound for home-based imaging.

Patient-performed point-of-care ultrasound (POCUS) may be feasible for use in home-based healthcare. We investigated whether novice users can obtain lung ultrasound (LUS) images via self-scanning with similar interpretability and quality as experts. Adult participants with no prior medical or POCUS training, who were capable of viewing PowerPoint slides in their home and who could hold a probe to their chest were recruited. After training, volunteers self-performed 8-zone LUS and saved images using a hand-held POCUS device in their own home. Each 8-zone LUS scan was repeated by POCUS experts. Clips were independently viewed and scored by POCUS experts blinded to performing sonographers. Quality and interpretability scores of novice- and expert-obtained LUS images were compared. Thirty volunteers with average age of 42.8 years (Standard Deviation (SD) 15.8), and average body mass index of 23.7 (SD 3.1) were recruited. Quality of novice and expert scans did not differ (median score 2.6, interquartile range (IQR) 2.3-2.9 vs. 2.8, IQR 2.3-3.0, respectively p = 0.09). Individual zone quality also did not differ (P > 0.05). Interpretability of LUS was similar between expert and novice scanners (median 7 zones interpretable, IQR 6-8, for both groups, p = 0.42). Interpretability of novice-obtained scans did not differ from expert scans (median 7 out of 8 zones, IQR 6-8, p = 0.42). Novice-users can self-obtain interpretable, expert-quality LUS clips with minimal training. Patient-performed LUS may be feasible for outpatient home monitoring.

Timing of pericardiocentesis and clinical outcomes: Is earlier pericardiocentesis better?

BACKGROUND: Pericardial tamponade is critical clinical diagnosis that requires prompt management and intervention. However, it is unknown if early pericardiocentesis is associated with better or worse patient outcomes. METHODS: A retrospective chart review was performed on all emergency department patients from two large academic hospitals with pericardial tamponade who underwent pericardiocentesis during the index hospitalization between March 2015-August 2020. We included only those who underwent pericardiocentesis within 24 h of their ED presentations. Subjects were stratified based on the time of pericardiocentesis, with early intervention defined as pericardiocentesis within <12 h and late intervention as those 12-24 h. Clinical outcomes of interest were; procedural complications, intensive care unit (ICU) admission, hospital length of stay (LOS), in hospital mortality, 30-day and first year survival. The effect of early vs. late intervention on survival was analyzed using log-rank tests for univariate analyses, Cox proportional hazard models for multivariable analyses and propensity matching. RESULTS: 205 patients with a mean age of 60 years, and 53.2% female were included. The median door-to-pericardiocentesis time for the early and late group were 5.0 h [interquartile range (IQR) 3.3-7.4] and 18.5 h (IQR 15.9-21.0), respectively. Transthoracic echocardiography (TTE) in patients in the early group more frequently demonstrated right atrial collapse (78.7% vs 58.6%) and exaggerated mitral inflow velocity variances (84.8% vs 70.0%). Early pericardiocentesis was associated with a hazard ratio of 2.909 (95% CI: 0.926-9.137, p = 0.067) for 30-day survival and 3.124 (95% CI, 1.648-5.924, p < 0.001) for 1-year survival. CONCLUSION: Early pericardiocentesis was associated with decreased 1-year survival. Future prospective analysis adjusting for patients' complexities is required.

Perineural Dexamethasone as a Peripheral Nerve Block Adjuvant in the Emergency Department: A Case Series.

BACKGROUND: Acute pain is one of the most common complaints encountered in the emergency department (ED). Single-injection peripheral nerve blocks are a safe and effective pain management tool when performed in the ED. Dexamethasone has been explored as an adjuvant to prolong duration of analgesia from peripheral nerve blocks in peri- and postoperative settings; however, data surrounding the use of dexamethasone for ED-performed nerve blocks are lacking. CASE SERIES: In this case series we discuss our experience with adjunctive perineural dexamethasone in ED-performed regional anesthesia. Why Should an Emergency Physician be Aware of This?: Nerve blocks performed with adjuvant perineural dexamethasone may be a safe additive to provide analgesia beyond the expected half-life of local anesthetic alone. Prospective studies exploring the role of adjuvant perineural dexamethasone in ED-performed nerve blocks are needed. © 2021 Elsevier Inc.

A Stepwise Guide to Performing Shoulder Ultrasound: The Acromio-Clavicular Joint, Biceps, Subscapularis, Impingement, Supraspinatus Protocol.

Shoulder pain is a common and painful patient condition. Unfortunately, diagnostic imaging of shoulder pain in the emergency department (ED) is often limited to radiography. While diagnostic for fractures and dislocations, drawbacks of radiography include time delays and non-diagnostic imaging in the case of rotator cuff pathology. While bedside ultrasound has been incorporated into many procedural and diagnostic applications in the ED, its use for musculoskeletal complaints and specifically shoulder pain is infrequent among ED clinicians. The incorporation of shoulder ultrasound in the ED may improve diagnostic certainty while decreasing time to diagnosis and treatment, yielding patient and health system benefits. Herein, we present the ABSIS (Acromio-clavicular joint, Biceps, Subscapularis, Impingement, Supraspinatus) Protocol for performing bedside ultrasound of the shoulder including the rotator cuff and bony anatomy.

The Use of Angle-Independent M-Mode in the Evaluation of Diaphragmatic Excursion: Towards Improved Accuracy.

Assessment of diaphragmatic function has been well described in the intensive care setting as well as in emergency medicine and pediatrics. Conventional M-mode evaluation of diaphragmatic excursion is frequently associated with over and under-estimations of diaphragmatic excursion. Angle-independent M-mode allows free rotation and movement of the analysis line to obtain M-mode images in a direction that more accurately reflects diaphragmatic excursion. In order to provide a standardized approach to the evaluation of diaphragmatic excursion with angle-independent M-mode, we propose a landmark-based approach utilizing the spine in order to target the same diaphragmatic segment consistently throughout the diaphragmatic analysis. While the proposed approach is not intended to replace current methods, it may improve accuracy and inter-rater reliability. The relevant background, as well as three patient cases, are presented demonstrating the use of a landmark-based approach in the emergency department. Angle-independent M-mode may provide a more accurate and consistent evaluation of diaphragmatic excursion, an examination that can be used to guide clinical care and anticipate outcomes.

Ultrasound-Guided Transgluteal Sciatic Nerve Block for Gluteal Procedural Analgesia.

BACKGROUND: Adequate analgesia is difficult to achieve in patients with an abscess requiring incision and drainage (I&D). There has been a recent increase in regional anesthesia use in the emergency department (ED) to aid in acute musculoskeletal pain relief. Specifically, transgluteal sciatic nerve (TGSN) block has been used as an adjunct treatment for certain chronic lumbar and lower extremity pain syndromes in the ED. CASE REPORT: A 21-year-old woman presented to the ED with a painful gluteal abscess. The pain was so severe that the patient barely tolerated light palpation to the abscess area. Using dynamic ultrasound guidance, a TGSN block was performed with significant pain reduction. Ultrasonographic confirmation of abscess was obtained followed by definitive I&D. She was discharged from the ED and her incision site was healing well at the time of follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abscess I&D is a common procedure in the ED. Procedural analgesia for I&D can be difficult to obtain. We describe the TGSN block as an additional analgesic option to be used for procedural analgesia. The use of regional anesthesia has the potential to decrease unwanted and at times dangerous side effects of opiate use and resource utilization of procedural sedation while optimizing patient comfort.

Sonographic Assessment of the Effects of Mechanical Ventilation on Carotid Flow Time and Volume.

Background Corrected carotid flow time (CFTc) and carotid blood flow (CBF) are sonographic measurements used to assess fluid responsiveness in hypotension. We investigated the impacts of mechanical ventilation on CFTc and CBF. Materials and methods Normotensive patients undergoing cardiac surgery were prospectively enrolled. Carotid ultrasound (US) was performed pre and post-intubation. Post-intubation measurements took place after the initiation of mechanical ventilation. To measure CFTc and CBF, a sagittal carotid view was obtained with pulse wave-Doppler (maximum angle 60°). CFTc was calculated with the Bazett formula (CFTc = systolic time/√cycle time). CBF was calculated using CBF (mL/min) = area (cm 2 ) x time average mean velocity (TAMEAN) (cm/sec) x 60 (sec/min). The maximum carotid diameter was measured at the level of the thyroid. Results Twenty patients were enrolled. Mean CFTc pre-intubation was 328 ms (SD 43.9 ms) compared to CFTc post-intubation 336 ms (SD 36 ms). There was no significant difference between pre and post-intubation CFTc (mean differences=-0.008; t(19)=-0.71, p=.49). Mean CBF pre-intubation was 487 mL/min (SD 176 mL/min) compared to CBF post-intubation 447 mL/min (SD 187 mL/min). There was no significant difference between pre and post-intubation CBF (mean differences= 40; t(19)=1.24, p=.23). Conclusions In this study of normotensive patients, there were no detected differences in CFTc or CBF pre and post-intubation with mechanical ventilation.

A comparison of homemade vascular access ultrasound phantom models for peripheral intravenous catheter insertion.

BACKGROUND: Ultrasound (U/S) guided peripheral IV catheter (PIV) placement is often needed after unsuccessful traditional IV attempts. Commercial U/S PIV training phantoms are expensive and difficult to alter. Non-commercial phantoms have been described; however, there has been no comparison of these models. The primary objectives of this study were to compare the echogenic and haptic properties of various non-commercial phantoms. Secondary objectives were to characterize the cost and ease of making the phantoms. METHODS: This prospective observational study trialed six unique phantom models: Amini Ballistics; Morrow Ballistics; University of California San Diego (UCSD) gelatin; Rippey Chicken; Nolting Spam; and Johnson Tofu. Total cost and creation time were noted. Emergency Ultrasound Fellowship trained physicians performed U/S guided PIV placement on each model to evaluate their resemblance to human tissue haptic and echogenicity properties, utility for training, and comparability to commercial phantoms (Likert scale 1-5; higher performance = 5). RESULTS: The Rippey model scored highest for each primary objective with an aggregate score of 4.8/5. UCSD ranked second and Nolting last for all primary objectives, with aggregate scores 3.7/5 and 1.3/5 respectively. Cost of production ranged from $4.39 (Johnson) to $29.76 (UCSD). Creation times ranged from 10 min (Johnson) to 120 min (UCSD). CONCLUSION: In our study the Rippey model performed best and offered a mid-level cost and creation time. Non-commercial U/S phantoms may represent cost-effective and useful PIV practice tools. Future studies should investigate the utility of these phantoms in teaching U/S guided PIV to novices and compare non-commercial to commercial phantoms.

Point-of-care ultrasound stewardship.

Rapid adoption and widespread use of point-of-care ultrasound (POCUS) has impacted diagnostic testing and clinical care across medical disciplines. The benefits of POCUS must be weighed against certain pitfalls, such as the risk of misdiagnosis and false assurance. Beyond technical error in image acquisition and interpretation, an important pitfall is reliance on POCUS results without considering pre-test patient characteristics or the diagnostic accuracy of POCUS in varying clinical contexts. In this article, we introduce the concept of POCUS stewardship that emphasizes critical evaluation of clinical indications prior to performing POCUS as well as the individual patient and test characteristics of POCUS when integrating results into clinical decisionmaking. Adherence to these principles can lead to optimized POCUS application and improved patient care.

Healthy Adults Display Long-Term Trait-Like Neurobehavioral Resilience and Vulnerability to Sleep Loss.

Sleep loss produces well-characterized cognitive deficits, although there are large individual differences, with marked vulnerability or resilience among individuals. Such differences are stable with repeated exposures to acute total sleep deprivation (TSD) within a short-time interval (weeks). Whether such stability occurs with chronic sleep restriction (SR) and whether it endures across months to years in TSD, indicating a true trait, remains unknown. In 23 healthy adults, neurobehavioral vulnerability to TSD exposures, separated by 27-2,091 days (mean: 444 days; median: 210 days), showed trait-like stability in performance and subjective measures (82-95% across measures). Similarly, in 24 healthy adults, neurobehavioral vulnerability to SR exposures, separated by 78-3,058 days (mean: 935 days; median: 741 days), also showed stability (72-92% across measures). Cognitive performance outcomes and subjective ratings showed consistency across objective measures, and consistency across subjective measures, but not between objective and subjective domains. We demonstrate for the first time the stability of phenotypic neurobehavioral responses in the same individuals to SR and to TSD over long-time intervals. Across multiple measures, prior sleep loss responses are strong predictors of individual responses to subsequent sleep loss exposures chronically or intermittently, across months and years, thus validating the need for biomarkers and predictors.