Prehospital emergency medical technicians can perform ultrasonography and blood analysis in prehospital evaluation of patients with chronic obstructive pulmonary disease: a feasibility study.

INTRODUCTION: Crowding of the emergency departments is an increasing problem. Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are often treated in the emergency departments for a very short period before discharged to their homes. It is possible that this treatment could take place in the patients' homes with sufficient diagnostics supporting the treatment. In an effort to keep the diagnostics and treatment of some of these patients in their homes and thus to reduce the patient load at the emergency departments, we implemented a prehospital treat-and-release strategy based on ultrasonography and blood testing performed by emergency medical technicians (EMT) or paramedics (PM) in patients with acute exacerbation of COPD. METHOD: EMTs and PMs were enrolled in a six-hour educational program covering ultrasonography of the lungs and point of care blood tests. During the seasonal peak of COPD exacerbations (October 2018 - May 2019) all patients who were treated by the ambulance crews for respiratory insufficiency were screened in the ambulances. If the patient had uncomplicated COPD not requiring immediate transport to the hospital, ultrasonographic examination of the lungs, measurements of C-reactive protein and venous blood gases analyses were performed. The response to the initial treatment and the results obtained were discussed via telemedical consultation with a prehospital anaesthesiologist who then decided to either release the patient at the scene or to have the patient transported to the hospital. The primary outcome was strategy feasibility. RESULTS: We included 100 EMTs and PMs in the study. During the study period, 771 patients with respiratory insufficiency were screened. Uncomplicated COPD was rare as only 41patients were treated according to the treat-and-release strategy. Twenty of these patients (49%) were released at the scene. In further ten patients, technical problems were encountered hindering release at the scene. CONCLUSION: In a few selected patients with suspected acute exacerbations of COPD, it was technically and organisationally feasible for EMTs and PMs to perform prehospital POCT-ultrasound and laboratory testing and release the patients following treatment. None of the patients released at the scene requested a secondary ambulance within the first 48 h following the intervention.

Education in Focused Assessment With Sonography for Trauma Using Immersive Virtual Reality: A Prospective, Interventional Cohort Study and Non-inferiority Analysis With a Historical Control.

OBJECTIVE: Focused assessment with sonography for trauma (FAST) is a valuable ultrasound procedure in emergency settings, and there is a need for evidence-based education in FAST to ensure competencies. Immersive virtual reality (IVR) is a progressive training modality gaining traction in the field of ultrasound training. IVR holds several economic and practical advantages to the common instructor-led FAST courses using screen-based simulation (SBS). METHODS: This prospective, interventional cohort study investigated whether training FAST using IVR unsupervised and out-of-hospital was non-inferior to a historical control group training at a 90 min SBS course in terms of developing FAST competencies in novices. Competencies were assessed in both groups using the same post-training simulation-based FAST test with validity evidence, and a non-inferiority margin of 2 points was chosen. RESULTS: A total of 27 medical students attended the IVR course, and 27 junior doctors attended the SBS course. The IVR group trained for a median time of 117 min and scored a mean 14.2 ± 2.0 points, compared with a mean 13.7 ± 2.5 points in the SBS group. As the lower bound of the 95% confidence interval at 13.6 was within the range of the non-inferiority margin (11.7-13.7 points), training FAST in IVR for a median of 117 min was found non-inferior to training at a 90 min SBS course. No significant correlation was found between time spent in IVR and test scores. CONCLUSION: Within the limitations of the use of a historical control group, the results suggest that IVR could be an alternative to SBS FAST training and suitable for unsupervised, out-of-hospital courses in basic FAST competencies.

Renal Function After CT-Guided Cryoablation of Small Renal Tumours in Patients with Solitary Kidney: An Analysis of European Multinational Prospective EuRECA Registry.

PURPOSE: Treatment of renal cell carcinoma (RCC) in patients with solitary kidneys remains challenging. The purpose of this multicentre cohort study was to explore how renal function is affected by percutaneous image-guided cryoablation in patients with solitary kidneys. MATERIAL AND METHODS: Data from the European Registry for Renal Cryoablation database were extracted on patients with RCC in solitary kidneys treated with image-guided, percutaneous cryoablation. Patients were excluded if they had multiple tumours, had received previous treatment of the tumour, or were treated with more than one cryoablation procedure. Pre- and post-treatment eGFR (within 3 months of the procedure) were compared. RESULTS: Of 222 patients with solitary kidneys entered into the database, a total of 70 patients met inclusion criteria. The mean baseline eGFR was 55.8 ± 16.8 mL/min/1.73 m2, and the mean 3-month post-operative eGFR was 49.6 ± 16.5 mL/min/1.73 m2. Mean eGFR reduction was - 6.2 mL/min/1.73 m2 corresponding to 11.1% (p = 0.01). No patients changed chronic kidney disease group to severe or end-stage chronic kidney disease (stage IV or V). No patients required post-procedure dialysis. CONCLUSION: Image-guided renal cryoablation appears to be safe and effective for renal function preservation in patients with RCC in a solitary kidney. Following cryoablation, all patients had preservation of renal function without the need for dialysis or progression in chronic kidney disease stage despite the statistically significant reduction in eGFR. LEVEL OF EVIDENCE 3: Observational study.

Education in Focused Lung Ultrasound Using Gamified Immersive Virtual Reality: A Randomized Controlled Study.

Focused lung ultrasound (FLUS) has high diagnostic accuracy in many common conditions seen in a variety of emergency settings. Competencies are essential for diagnostic success and patient safety but can be challenging to acquire in clinical environments. Immersive virtual reality (IVR) offers an interactive risk-free learning environment and is progressing as an educational tool. First, this study explored the educational impact of novice FLUS users participating in a gamified or non-gamified IVR training module in FLUS by comparing test scores using a test with proven validity evidence. Second, the learning effect was assessed by comparing scores of each group with known test scores of novices, intermediates and experienced users in FLUS. A total of 48 participants were included: 24 received gamified and 24 received non-gamified IVR training. No significant difference was found between gamified (mean = 15.5 points) and non-gamified (mean = 15.2 points), indicating that chosen gamification elements for our setup did not affect learning outcome (p = 0.66). The mean scores of both groups did not significantly differ from those of known intermediate users in FLUS (gamified p = 0.63, non-gamified p = 0.24), indicating that both IVR modules could be used as unsupervised out-of-hospital training for novice trainees in FLUS.

Systemic air embolism following computed-tomography-guided transthoracic needle biopsy of lung lesion - a systematic search of case reports and case series.

Background: Systemic air embolism is a rare, however potentially fatal, low incidence, complication to CT-guided transthoracic needle biopsy of lung lesions. Purpose: The purpose of this review of case reports and series was to pool data about this rare complication and glance for a pattern or similarities in the patients' initial symptoms and course, as well as the management of the patients in relation to current guidelines. Material and methods: PubMed was searched for case reports and case series about systemic air embolisms following CT-guided transthoracic needle biopsy of lung lesions from inception to November 2021. A reviewer screened the results for eligibility and included studies which reported at least two outcomes of interest. Data was extracted by one author and a descriptive analysis was conducted. Results: Of 1,136 studies screened, 83 were eligible for inclusion involving 97 patients. The mean age was 64.8±11.7 years and ≈60% of the patients were men. In 15 cases the outcome was fatal, and most of the fatal cases (n = 12) had cardiac arrest as the primary initial symptom. In addition to conventional oxygen therapy, 34 patients received hyperbaric oxygen therapy, and in 30 cases the physician in charge chose to change the patient from standard supine position to - most often - Trendelenburg position. Conclusion: No similarities were found that could lead to more rapid diagnosis or more correct management. The staff should keep systemic air embolisms in mind, when more common complications are ruled out, and consider hyperbaric oxygen therapy in case of suspicion.

Diagnostic accuracy of low-dose and ultra-low-dose CT in detection of chest pathology: a systematic review.

PURPOSE: Studies have evaluated imaging modalities with a lower radiation dose than standard-dose CT (SD-CT) for chest examination. This systematic review aimed to summarize evidence on diagnostic accuracy of these modalities - low-dose and ultra-low-dose CT (LD- and ULD-CT) - for chest pathology. METHOD: Ovid-MEDLINE, Ovid-EMBASE and the Cochrane Library were systematically searched April 29th-30th, 2019 and screened by two reviewers. Studies on diagnostic accuracy were included if they defined their index tests as 'LD-CT', 'Reduced-dose CT' or 'ULD-CT' and had SD-CT as reference standard. Risk of bias was evaluated on study level using the Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted to compare the diagnostic accuracy measurements. RESULTS: Of the 4257 studies identified, 18 were eligible for inclusion. SD-CT (3.17 ± 1.47 mSv) was used as reference standard in all studies to evaluate diagnostic accuracy of LD- (1.22 ± 0.34 mSv) and ULD-CT (0.22 ± 0.05 mSv), respectively. LD-CT had high sensitivities for detection of bronchiectasis (82-96%), honeycomb (75-100%), and varying sensitivities for nodules (63-99%) and ground glass opacities (GGO) (77-91%). ULD-CT had high sensitivities for GGO (93-100%), pneumothorax (100%), consolidations (90-100%), and varying sensitivities for nodules (60-100%) and emphysema (65-90%). CONCLUSION: The included studies found LD-CT to have high diagnostic accuracy in detection of honeycombing and bronchiectasis and ULD-CT to have high diagnostic accuracy for pneumothorax, consolidations and GGO. Summarizing evidence on diagnostic accuracy of LD- and ULD-CT for other chest pathology was not possible due to varying outcome measures, lack of precision estimates and heterogeneous study design and methodology.

Lung ultrasound assessment for pneumothorax following transbronchial lung cryobiopsy.

BACKGROUND: Iatrogenic pneumothorax is a common and clinically important transbronchial cryobiopsy (TBCB) complication. A study was conducted to assess the diagnostic accuracy and clinical impact of immediate post-procedure lung ultrasound for diagnosing iatrogenic pneumothorax in patients suspected of interstitial lung disease (ILD) undergoing TBCB. STUDY DESIGN AND METHODS: In patients undergoing TBCB due to suspected ILD, lung ultrasound of the anterior surface of the chest was performed immediately after the TBCB procedure prior to extubation. Presence of lung point was used as a definite sign of pneumothorax. Chest radiography was routinely performed 2 h after TBCB and was used as the reference standard. RESULTS: A total of 141 consecutive patients were included. Post-procedure lung ultrasound identified definite pneumothorax in five patients (3.6%, 95% confidence interval (CI) 1.5-8.3%). Chest radiography at 2 h identified 19 patients (13.5%, 95% CI 8.7-20.2%) with pneumothorax following TBCB. The diagnostic accuracy of lung ultrasound for diagnosing pneumothorax was as follows: sensitivity: 21.1% (95% CI 6.1-45.6%), specificity: 99.2% (95% CI 95.5-100.0%), positive predictive value (PPV): 80.0% (95% CI 28.4-99.5%) and negative predictive value (NPV): 89.0% (95% CI 82.5-93.7%). Post-procedure lung ultrasound had a clinical impact in five patients (3.6%, 95% CI 1.5-8.3), of which four had a pleural drain inserted prior to extubation and one underwent prolonged observation prior to extubation. INTERPRETATION: Lung ultrasound performed immediately following TBCB has a clinical impact by identifying patients with pneumothorax in need of immediate treatment prior to extubation and by monitoring pneumothorax size in the operating room. Supplementary imaging prior to patient discharge is still needed however, as the majority of pneumothoraxes develop later in the post-procedure period.