Early Diagnosis of Rare Diaphragmatic Synovial Sarcoma in a Pediatric Patient With Epigastric Pain Using Point-of-Care Ultrasound.

ABSTRACT: Synovial cell sarcoma is a rare mesenchymal tumor that typically originates from the soft tissues of the extremities of young adults. Only 3 cases of primary diaphragmatic synovial cell sarcoma have been described in the literature: 2 in adult males and 1 in a 12-year-old pediatric patient.1-3 When this tumor is found in the mediastinum or pericardial region, prognosis is historically poor because of the advanced disease stage at time of diagnosis. The surgical course and pathology have been described in this 12-year-old boy.3 This is the first case, to our knowledge, of the use of cardiac point-of-care ultrasound in the early identification and diagnosis of a primary diaphragmatic synovial sarcoma in a pediatric patient.

Massive Ovarian Cyst Mimics Constipation.

BACKGROUND: Abdominal pain and constipation are common presenting symptoms of pediatric patients presenting to the emergency department. Sometimes these symptoms are related to uncomplicated constipation from stool burden, and other cases may be secondary to more serious pathologies, including obstruction from intra- or extra-intestinal compression. Point-of-care ultrasound (PoCUS) can be helpful in discerning the etiology for this undifferentiated symptomatology. CASE REPORT: A 14-year-old girl presented with 3 days of constipation and abdominal pain. This was similar to previous symptoms that resolved with laxatives. This time, however, her symptoms were associated with one episode of vomiting. PoCUS expanded a narrow differential with the discovery of a large ovarian cyst. This finding helped to expedite her transfer to a pediatric hospital for definitive treatment in the operating room. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Constipation is one of the leading reasons pediatric patients present to the ED with abdominal pain. PoCUS can detect uncommon causes of constipation, especially pathologies associated with large volumes of fluid, such as a large ovarian cyst, bladder outlet obstruction, or small bowel obstruction.

Impact of an epic-integrated point-of-care ultrasound workflow on ultrasound performance, compliance, and potential revenue.

OBJECTIVES: The purpose of this study was to describe the design and impact of a point-of-care ultrasound (PoCUS) workflow integrated into the electronic medical record (EMR) on PoCUS utilization, documentation compliance, and resultant revenue potential. METHODS: This was a single-center retrospective study at an academic center. The study period spanned from December 1, 2018 to June 30, 2019 (pre-implementation) to August 1, 2019 to February 29, 2020 (post-implementation). The implementation date was July 11, 2019 at which time a PoCUS workflow was integrated into the EMR in the emergency department without the purchase of middleware. Prior to this new workflow, a non-automated workflow was in place. PoCUS scan data were extracted from the EMR and archived examinations. The mean number of PoCUS examinations performed per month per 100 ED visits before and after implementation of the new workflow were compared using an unpaired t-test, stratified by all health care professionals, and attending physicians alone. The rate of documentation compliance before and after implementation of the new workflow were compared using a chi square contingency test. Potential revenue was calculated for each period by multiplying the number of eligible examinations by the respective 2020 Medicare conversion factor Relative Value Units. RESULTS: Utilization of PoCUS from pre-implementation to post-implementation increased 28.7% from 5.01 to 6.45 mean examinations per month per 100 ED visits by all health care professionals (p = 0.063), and 75.1% from 2.01 to 3.52 by attending physicians (p = 0.0001). Examinations in compliance with workflow requirements increased from 153 (14.7%) to 1307 (94.0%). The rate of workflow compliance improved from 14.7% to 94.0% of examinations (p < 0.0001). Potential revenue increased from $546.01 to $22,014.47. CONCLUSIONS: The implementation of a middleware-free PoCUS workflow at our institution was associated with increased PoCUS utilization, documentation compliance, and potential revenue.

Effectiveness of Near-Peer Versus Faculty Point-of-Care Ultrasound Instruction to Third-Year Medical Students.

Background: Incorporation of point-of-care ultrasound (POCUS) in undergraduate medical education (UME) is expanding; however, its effective implementation is impeded by a lack of trained faculty. Recruitment of near-peer (NP) instructors is a potential solution, but there are concerns surrounding NP teaching effectiveness compared to faculty instruction. While some institutions have assessed supplemental NP instruction, or NP-taught sessions with strict faculty supervision, few if any have compared effectiveness of NP POCUS instruction alone to faculty instruction through a multi-dimensional assessment. The aim of this study was to compare the effectiveness of near-peer (NP) instruction to faculty instruction at an undergraduate medical education clinical POCUS session for third-year medical students. Methods: This was a randomized controlled trial where third-year medical students were assigned to one of two groups for a 90-minute POCUS session: NP instruction or faculty instruction. A pre- and post-session multiple-choice test and a post-session objective structured clinical examination (OSCE) were administered to assess conceptual and hands-on clinical POCUS knowledge gained. Students' perceptions of the instructors and session were evaluated using a Likert scale. Results: Seventy-three students (66% of the class) participated; 36 taught by faculty and 37 by NP instructors. Both groups showed a significant score increase from pre-test to post-test (p =0.002); however, there was no significant difference between groups in post-test (p=0.27) nor OSCE scores (p=0.20). Student perceptions of instructor competency were not statistically significant. Conclusions: NP instructors were as effective at teaching clinical POCUS to third-year medical students as faculty instructors at our institution.