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.

Point-of-Care Lung Ultrasound for Differentiating COVID-19 From Influenza.

Background and objectives Patients infected with influenza and COVID-19 exhibit similar clinical presentations; thus, a point-of-care test to differentiate between the diseases is needed. Here, we sought to identify features of point-of-care lung ultrasound (LUS) that can discriminate between influenza and COVID-19. Methods In this prospective, cross-sectional study, LUS clips of patients presenting to the emergency department (ED) with viral-like symptoms were collected via a 10-zone scanning protocol. Deidentified clips were interpreted by emergency ultrasound fellows blinded to patients' clinical context and influenza or COVID-19 diagnosis. Modified Soldati scores were calculated for each lung zone. Logistic regression identified the association of pulmonary pathologies with each disease. Results Ultrasound fellows reviewed LUS clips from 165 patients, of which 30.9% (51/165) had confirmed influenza, 33.9% (56/165) had confirmed COVID-19, and 35.1% (58/165) had neither disease. Patients with COVID-19 were more likely to have irregular pleura and B-lines in all lung zones (p<0.01). The median-modified Soldati score for influenza patients was 0/20 (IQR 0-2), 9/20 (IQR 2.5-15.5) for COVID-19 patients, and 2/20 (IQR 0-8) for patients with neither disease (p<0.0001). In multivariate regression analysis adjusted for age, sex, and congestive heart failure (CHF), the presence of B-lines (OR = 1.29, 95% CI 1.09-1.53) was independently associated with COVID-19 diagnosis. The presence of pleural effusion was inversely associated with COVID-19 (OR = 0.09, 95% CI 0.01-0.65). Conclusions LUS may help providers preferentially identify the presence of influenza versus COVID-19 infection both visually and by calculating a modified Soldati score. Further studies assessing the utility of LUS in differentiating viral illnesses in patients with variable illness patterns and those with variable illness severity are warranted.

Longitudinal accuracy analysis of ultrasound performed during a four-year emergency medicine residency.

BACKGROUND: The objective of this study was to analyze patterns of point-of-care ultrasound (POCUS) performance over 4 years of emergency medicine (EM) residency. Specifically, we aimed to study how accuracy and adherence to standards of scanning changed by postgraduate year (PGY). METHODS: This was a retrospective observational study of resident-performed POCUS at an academic emergency department over 6 years. We reviewed records of POCUS scans performed by PGY-1 to -4 residents that had been collected for quality assurance purposes. Data that were collected about EM residents' performance included the total number and type of scans per year, rate of technically limited scans (TLS), and accuracy on interpreting ultrasound images. Resident performances in each year (PGY-1 to -4) were independently evaluated and reported. RESULTS: During a 6-year period, 137 different EM residents performed 50,815 ultrasound scans. The median number of scans was 177 for PGY-1, 124 for PGY-2, 118 for PGY-3, and 76 for residents in PGY-4. The accuracy of scan interpretations were high across all PGY levels (>97%), but slight degradation was observed as residents progressed through residency. The TLS rate increased from 4.7% among PGY-1s to 13.6% as PGY-4s. CONCLUSIONS: In this large cohort of POCUS studies by EM residents, POCUS accuracy rates decreased and rates of TLS significantly increased as residents progressed through residency.

Carotid Ultrasound in Assessing Fluid Responsiveness in Patients with Hypotension and Suspected Sepsis.

PURPOSE: We sought to assess whether ultrasound (US) measurements of carotid flow time (CFTc) and carotid blood flow (CBF) predict fluid responsiveness in patients with suspected sepsis. METHODS: This was a prospective observational study of hypotensive (systolic blood pressure < 90) patients "at risk" for sepsis receiving intravenous fluids (IVF) in the emergency department. US measurements of CFTc and CBF were performed at time zero and upon completion of IVF. All US measurements were repeated after a passive leg raise (PLR) maneuver. Fluid responsiveness was defined as normalization of blood pressure without persistent hypotension or need for vasopressors. RESULTS: A convenience sample of 69 patients was enrolled. The mean age was 65; 49% were female. Fluid responders comprised 52% of the cohort. CFTc values increased significantly with both PLR (P = 0.047) and IVF administration (P = 0.003), but CBF values did not (P = 0.924 and P = 0.064 respectively). Neither absolute CFTc or CBF measures, nor changes in these values with PLR or IVF bolus, predicted fluid responsiveness, mortality, or the need for intensive care unit admission. CONCLUSION: In patients with suspected sepsis, a fluid challenge resulted in a significant change in CFTc, but not CBF. Neither absolute measurement nor delta measurements with fluid challenge predicted clinical outcomes.

Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients.

BACKGROUND: Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. METHOD: This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. RESULTS: 153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%). CONCLUSION: A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism.

BACKGROUND: Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition. OBJECTIVES: In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality. METHODS: This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality. RESULTS: The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32). CONCLUSION: In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.