Contrast echocardiography: a practical guideline from the British Society of Echocardiography.

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

Fluctuation-Corrected Phase Diagrams for Diblock Copolymer Melts.

New developments in field-theoretic simulations (FTSs) are used to evaluate fluctuation corrections to the self-consistent field theory of diblock copolymer melts. Conventional simulations have been limited to the order-disorder transition (ODT), whereas FTSs allow us to evaluate complete phase diagrams for a series of invariant polymerization indices. The fluctuations stabilize the disordered phase, which shifts the ODT to higher segregation. Furthermore, they stabilize the network phases at the expense of the lamellar phase, which accounts for the presence of the Fddd phase in experiments. We hypothesize that this is due to an undulation entropy that favors curved interfaces.

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study.

BACKGROUND: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. METHODS: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. RESULTS: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually. CONCLUSION: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

Myocardial oedema in the setting of immersion pulmonary oedema - Cause or effect?

Immersion pulmonary oedema (IPE) is an under-reported and poorly understood phenomenon thought to be related to exercise-induced haemodynamic changes while submersed in water. Previous work has demonstrated reversible myocardial dysfunction during acute episodes. We present a case of IPE with concomitant, transient, left ventricular myocardial oedema characterised via MRI. This is a novel finding and may be evidence of left ventricular strain due to pressure overload or secondary to a subclinical myocarditis.

IMproving PULmonary hypertension Screening by Echocardiography: IMPULSE.

BACKGROUND: The world symposium on pulmonary hypertension (PH) has proposed that PH be defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg as assessed by right heart catheterisation (RHC). Transthoracic echocardiography (TTE) is an established screening tool used for suspected PH. International guidelines recommend a multi-parameter assessment of the TTE PH probability although effectiveness has not been established using real world data. STUDY AIMS: To determine accuracy of the European Society of Cardiology (ESC) and British Society of Echocardiography (BSE) TTE probability algorithm in detecting PH in patients attending a UK PH centre. To identify echocardiographic markers and revised algorithms to improve the detection of PH in those with low/intermediate BSE/ESC TTE PH probability. METHODS: TTE followed by RHC (within 4 months after) was undertaken in patients for suspected but previously unconfirmed PH. BSE/ESC PH TTE probabilities were calculated alongside additional markers of right ventricular (RV) longitudinal and radial function, and RV diastolic function. A refined IMPULSE algorithm was devised and evaluated in patients with low and/or intermediate ESC/BSE TTE PH probability. RESULTS: Of 310 patients assessed, 236 (76%) had RHC-confirmed PH (average mPAP 42.8 ± 11.7). Sensitivity and specificity for detecting PH using the BSE/ESC recommendations was 89% and 68%, respectively. 36% of those with low BSE/ESC TTE probability had RHC-confirmed PH and BSE/ESC PH probability parameters did not differ amongst those with and without PH in the low probability group. Conversely, RV free wall longitudinal strain (RVFWLS) was lower in patients with vs. without PH in low BSE/ESC probability group (- 20.6 ± 4.1% vs - 23.8 ± 3.9%) (P < 0.02). Incorporating RVFWLS and TTE features of RV radial and diastolic function (RVFAC and IVRT) within the IMPULSE algorithm reduced false negatives in patients with low BSE/ESC PH probability by 29%. The IMPULSE algorithm had excellent specificity and positive predictive value in those with low (93%/80%, respectively) or intermediate (82%/86%, respectively) PH probability. CONCLUSION: Existing TTE PH probability guidelines lack sensitivity to detect patients with milder haemodynamic forms of PH. Combining additional TTE makers assessing RV radial, longitudinal and diastolic function enhance identification of milder forms of PH, particularly in those who have a low BSE/ESC TTE PH probability.

COVID-19 Infection and Symptoms Among Emergency Medicine Residents and Fellows in an Urban Academic Hospital Setting: Cross-sectional Questionnaire Study.

Background: COVID-19, an illness caused by the novel coronavirus SARS-CoV-2, affected many aspects of health care worldwide in 2020. From March to May 2020, New York City experienced a large surge of cases. Objective: The aim of this study is to characterize the prevalence of illness and symptoms experienced by residents and fellows in 2 New York City hospitals during the period of March to May 2020. Methods: An institutional review board-exempt survey was distributed to emergency medicine housestaff in May 2020, and submissions were accepted through August 2020. Results: Out of 104 residents and fellows, 64 responded to our survey (a 61.5% response rate). Out of 64 responders, 27 (42%) tested positive for SARS-CoV-2 antibodies. Most residents experienced symptoms that are consistent with COVID-19; however, few received polymerase chain reaction testing. Out of 27 housestaff with SARS-CoV-2 antibodies, 18 (67%) experienced fever and chills, compared with 8 out of 34 housestaff (24%) without SARS-CoV-2 antibodies. Of the 27 housestaff with SARS-CoV-2 antibodies, 19 (70%) experienced loss of taste and smell, compared with 2 out of 34 housestaff (6%) without SARS-CoV-2 antibodies. Both fever and chills and loss of taste and smell were significantly more commonly experienced by antibody-positive compared to antibody-negative housestaff (P=.002 and <.001, respectively). All 13 housestaff who reported no symptoms during the study period tested negative for SARS-CoV-2 antibodies. Conclusions: Our study demonstrated that in our hospitals, the rate of COVID-19 illness among emergency department housestaff was much higher than previously reported. Further studies are needed to characterize illness among medical staff in emergency departments across the nation. The high infection rate among emergency medicine trainees stresses the importance of supplying adequate personal protective equipment for health care professionals.

Residency Leadership Lessons From the Epicenter of the COVID-19 Surge.

Emergency medicine residency program directors (PDs) in areas hit hardest by the initial U.S. COVID-19 pandemic surge faced novel and rapidly evolving organizational, educational, and resident wellness challenges. Despite variations in residency size, hospital setting, and patient population, PDs from eight residencies in "the epicenter" found uniformity in many of the lessons learned. Here we present those lessons and suggestions for high-yield preparation for running a residency during a surge. Of particular importance were frequent, transparent communication and stepwise staffing plans. Illness of residents and other staff occurred early and were substantially reduced as personal protective equipment protocols tightened. Wellness was compromised by anxiety and illness, with varying timelines. New, rich educational opportunities emerged. All programs declared ACGME pandemic status but remained able to maintain some educational offerings. Planning ahead for future surges can significantly reduce the real-time burden for residency leadership, which is particularly important as clinical demands on leadership may also increase with a surge.

A practical guideline for performing a comprehensive transthoracic echocardiogram in adults: the British Society of Echocardiography minimum dataset.

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined 'standard' 2D and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.

Recreational marathon running does not cause exercise-induced left ventricular hypertrabeculation.

BACKGROUND: Marathon running in novices represents a natural experiment of short-term cardiovascular remodeling in response to running training. We examine whether this stimulus can produce exercise-induced left ventricular (LV) trabeculation. METHODS: Sixty-eight novice marathon runners aged 29.5 ± 3.2 years had indices of LV trabeculation measured by echocardiography and cardiac magnetic resonance imaging 6 months before and 2 weeks after the 2016 London Marathon race, in a prospective longitudinal study. RESULTS: After 17 weeks unsupervised marathon training, indices of LV trabeculation were essentially unchanged. Despite satisfactory inter-observer agreement in most methods of trabeculation measurement, criteria defining abnormally hypertrabeculated cases were discordant with each other. LV hypertrabeculation was a frequent finding in young, healthy individuals with no subject demonstrating clear evidence of a cardiomyopathy. CONCLUSION: Training for a first marathon does not induce LV trabeculation. It remains unclear whether prolonged, high-dose exercise can create de novo trabeculation or expose concealed trabeculation. Applying cut off values from published LV noncompaction cardiomyopathy criteria to young, healthy individuals risks over-diagnosis.

Cardiovascular Remodeling Experienced by Real-World, Unsupervised, Young Novice Marathon Runners.

AIMS: Marathon running is a popular ambition in modern societies inclusive of non-athletes. Previous studies have highlighted concerning transient myocardial dysfunction and biomarker release immediately after the race. Whether this method of increasing physical activity is beneficial or harmful remains a matter of debate. We examine in detail the real-world cardiovascular remodeling response following competition in a first marathon. METHODS: Sixty-eight novice marathon runners (36 men and 32 women) aged 30 ± 3 years were investigated 6 months before and 2 weeks after the 2016 London Marathon race in a prospective observational study. Evaluation included electrocardiography, cardiopulmonary exercise testing, echocardiography, and cardiovascular magnetic resonance imaging. RESULTS: After 17 weeks unsupervised marathon training, runners revealed a symmetrical, eccentric remodeling response with 3-5% increases in left and right ventricular cavity sizes, respectively. Blood pressure (BP) fell by 4/2 mmHg (P < 0.01) with reduction in arterial stiffness, despite only 11% demonstrating a clinically meaningful improvement in peak oxygen consumption with an overall non-significant 0.4 ml/min/kg increase in peak oxygen consumption (P = 0.14). CONCLUSION: In the absence of supervised training, exercise-induced cardiovascular remodeling in real-world novice marathon runners is more modest than previously described and occurs even without improvement in cardiorespiratory fitness. The responses are similar in men and women, who experience a beneficial BP reduction and no evidence of myocardial fibrosis or persistent edema, when achieving average finishing times.

Echocardiographic assessment of the right heart in adults: a practical guideline from the British Society of Echocardiography

The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.

Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography.

Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has been estimated on echo by utilising the simplified Bernoulli equation from the peak tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous studies have demonstrated a correlation between this estimate of pulmonary arterial systolic pressure and that obtained from invasive measurement across a cohort of patients. However, for an individual patient significant overestimation and underestimation can occur and the levels of agreement between the two is poor. Recent guidance has suggested that echocardiographic assessment of pulmonary hypertension should be limited to determining the probability of pulmonary hypertension being present rather than estimating the pulmonary artery pressure. In those patients in whom the presence of pulmonary hypertension requires confirmation, this should be done with right heart catheterisation when indicated. This guideline protocol from the British Society of Echocardiography aims to outline a practical approach to assessing the probability of pulmonary hypertension using echocardiography and should be used in conjunction with the previously published minimum dataset for a standard transthoracic echocardiogram.

A guideline update for the practice of echocardiography in the cardiac screening of sports participants: a joint policy statement from the British Society of Echocardiography and Cardiac Risk in the Young.

Sudden cardiac death (SCD) in an athlete is a rare but tragic event. In view of this, pre-participation cardiac screening is mandatory across many sporting disciplines to identify those athletes at risk. Echocardiography is a primary investigation utilized in the pre-participation setting and in 2013 the British Society of Echocardiography and Cardiac Risk in the Young produced a joint policy document providing guidance on the role of echocardiography in this setting. Recent developments in our understanding of the athlete's heart and the application of echocardiography have prompted this 2018 update.

How Do Emergency Medicine Residency Programs Structure Their Clinical Competency Committees? A Survey.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) recently has mandated the formation of a clinical competency committee (CCC) to evaluate residents across the newly defined milestone continuum. The ACGME has been nonproscriptive of how these CCCs are to be structured in order to provide flexibility to the programs. OBJECTIVES: No best practices for the formation of CCCs currently exist. We seek to determine common structures of CCCs recently formed in the Council of Emergency Medicine Residency Directors (CORD) member programs and identify unique structures that have been developed. METHODS: In this descriptive study, an 18-question survey was distributed via the CORD listserv in the late fall of 2013. Each member program was asked questions about the structure of its CCC. These responses were analyzed with simple descriptive statistics. RESULTS: A total of 116 of the 160 programs responded, giving a 73% response rate. Of responders, most (71.6%) CCCs are chaired by the associate or assistant program director, while a small number (14.7%) are chaired by a core faculty member. Program directors (PDs) chair 12.1% of CCCs. Most CCCs are attended by the PD (85.3%) and selected core faculty members (78.5%), leaving the remaining committees attended by any core faculty. Voting members of the CCC consist of the residency leadership either with the PD (53.9%) or without the PD (36.5%) as a voting member. CCCs have an average attendance of 7.4 members with a range of three to 15 members. Of respondents, 53.1% of CCCs meet quarterly while 37% meet monthly. The majority of programs (76.4%) report a system to match residents with a faculty mentor or advisor. Of respondents, 36% include the resident's faculty mentor or advisor to discuss a particular resident. Milestone summaries (determination of level for each milestone) are the primary focus of discussion (93.8%), utilizing multiple sources of information. CONCLUSIONS: The substantial variability and diversity found in our CORD survey of CCC structure and function suggest that there are myriad strategies that residency programs can use to match individual program needs and resources to requirements of the ACGME. Identifying a single protocol for CCC structure and development may prove challenging.

Impact of methodology and the use of allometric scaling on the echocardiographic assessment of the aortic root and arch: a study by the Research and Audit Sub-Committee of the British Society of Echocardiography.

The aim of the study is to establish the impact of 2D echocardiographic methods on absolute values for aortic root dimensions and to describe any allometric relationship to body size. We adopted a nationwide cross-sectional prospective multicentre design using images obtained from studies utilising control groups or where specific normality was being assessed. A total of 248 participants were enrolled with no history of cardiovascular disease, diabetes, hypertension or abnormal findings on echocardiography. Aortic root dimensions were measured at the annulus, the sinus of Valsalva, the sinotubular junction, the proximal ascending aorta and the aortic arch using the inner edge and leading edge methods in both diastole and systole by 2D echocardiography. All dimensions were scaled allometrically to body surface area (BSA), height and pulmonary artery diameter. For all parameters with the exception of the aortic annulus, dimensions were significantly larger in systole (P<0.05). All aortic root and arch measurements were significantly larger when measured using the leading edge method compared with the inner edge method (P<0.05). Allometric scaling provided a b exponent of BSA(0.6) in order to achieve size independence. Similarly, ratio scaling to height in subjects under the age of 40 years also produced size independence. In conclusion, the largest aortic dimensions occur in systole while using the leading edge method. Reproducibility of measurement, however, is better when assessing aortic dimensions in diastole. There is an allometric relationship to BSA and, therefore, allometric scaling in the order of BSA(0.6) provides a size-independent index that is not influenced by the age or gender.

Right ventricular normal measurements: time to index?

BACKGROUND: Despite the common practice of indexing left ventricular dimensions to body surface area, there remains a lack of indexed normal right ventricular (RV) two-dimensional caliper measurements. Variations in ranges for normal RV dimensions have been shown to exist, and indexing RV dimensions according to body surface area may help reduce this and provide a standardization useful for clinical practice. The aim of this study was to prospectively establish both absolute and indexed normal dimensions for the right ventricle using standardized positions in a multiethnic population. Furthermore, the effects of both gender and ethnicity on both the absolute and indexed results were also evaluated. METHODS: Two hundred five healthy volunteers from four ethnic backgrounds (Indian, Chinese, Malay, and European) were prospectively enrolled and underwent two-dimensional echocardiography according to a set protocol. Ten measurements were made in conjunction with previous research. Intraobserver and interobserver and test-retest variability was assessed using coefficients of variation and intraclass correlation coefficients. RESULTS: Male absolute results exceeded female absolute results in 90% of measurements (P = .003). European absolute results (male and female) were significantly larger in up to eight of 10 measurements (P = .01). When indexed, female results became significantly larger (P < .001) than male results. Indexing was able to reduce the number of statistical differences between male ethnic groups. Measurements showed good levels of intraobserver and interobserver variability for apical and short-axis measurements. CONCLUSIONS: Gender and body surface area play an important part in the determination of normal RV reference ranges, whereas ethnicity has little influence. Results using the suggested RV markers for these measurements showed good repeatability.