Pocket-size imaging device: effectiveness for ward-based transthoracic studies

Physicians' perceptions of the daily use of a handheld ultrasound device in the labor room

OBJECTIVE

The objective of our study was to describe the perception of physicians who use a handheld ultrasound (US) device in an intensive perinatal care unit.

METHODS

We conducted a prospective observational study in the labor ward of an intensive perinatal care unit between November 2021 and May 2022. Obstetrics & Gynecology residents in rotation in our department during this time were recruited as participants in this study. All the participants were provided with a handheld US device Vscan Air™ (GE Healthcare, Zipf, Austria) to use during their normal days and nights practice in labor ward. At the end of their 6 months rotation, participants completed an anonymous surveys about their perceptions of the handheld US device. The survey included questions about the ease of use in clinical situations, the amount of time of initial diagnosis, performances of the device, feasibility to use, and patient's satisfaction with the use of the device.

RESULTS

6 residents in their last year of residency were included. All the participants were satisfied with the device and would like to use it in their future practice. They all agreed that the probe was easy to handle and that the mobile application was easy to use. Image quality was always considered good by the participants and 5/6 of them declared that the handheld US device was always sufficient and did not require any confirmation with a conventional US machine. 5/6 of the participants considered that the handheld US device allowed them to gain time for clinical decision but half of them did not estimate that the use of the handheld US device improved their ability to make a clinical diagnosis.

CONCLUSION

Our study suggests that the Vscan Air™ is easy to use, with a good quality image and reduces the amount of time to make a clinical diagnosis. Handheld US device could be useful in the daily practice in maternity hospital.

The potential clinical value of pairing procalcitonin and lung ultrasonography to guide antibiotic therapy in patients with community-acquired pneumonia: a narrative review

INTRODUCTION

Lower respiratory tract infections (LRTIs) are among the most frequent infections and are prone to inappropriate antibiotic treatments. This results from a limited accuracy of diagnostic tools in identifying bacterial pneumonia. Lung ultrasound (LUS) has excellent sensitivity and specificity in diagnosing pneumonia. Additionally, elevated procalcitonin (PCT) levels correlate with an increased likelihood of bacterial infection. LUS and PCT appear to be complementary in identifying patients with bacterial pneumonia who are likely to benefit from antibiotics.

AREAS COVERED

This narrative review aims to summarize the current evidence for LUS to diagnose pneumonia, for PCT to guide antibiotic therapy and the clinical value of pairing both tools.

EXPERT OPINION

LUS has excellent diagnostic accuracy for pneumonia in different settings, regardless of the examiner's experience. PCT guidance safely reduces antibiotic prescription in LRTIs. The combination of both tools has demonstrated an enhanced accuracy in the diagnosis of pneumonia, including CAP in the ED and VAP in the ICU, but randomized controlled studies need to validate the clinical impact of a combined approach.

The Point-of-Care Ultrasound (POCUS) by the Handheld Ultrasound Devices (HUDs) in the COVID-19 Scenario: a Review of the Literature

The use of portable ultrasound (US) devices is increasing, due to its accessibility, versatility, non-invasiveness, and its significant support in the patient management, extending the traditional physical examination through the POCUS (point-of-care ultrasound). The pocket-size or handheld ultrasound devices (HUDs) can easily perform focused exams, not aiming to substitute for the high-end US systems (gold standard), since the HUDs usually have more limited functions. The HUDs are promising tools for the diagnosis, prognosis, and monitoring of the COVID-19 infection and its related disorders. In conclusion, the routine use of HUDs may ameliorate the management of COVID-19 pandemic, according to the guidelines for the POCUS approach and the procedures for the protection of the patients and the professionals.

Point-of-care ultrasound with handheld devices in hematology: a monocentric single-stage phase II study

Point of care ultrasound (PoCUS) with pocket-size devices is an efficient and safe imaging modality that became a standard of care in various clinical settings. However, its implementation in hematology has never been evaluated so far. We conducted a prospective monocentric study aiming to harvest data on its usage and to assess its diagnostic and interventional performance in improving the accuracy of basic physical examination in hematological patients. After a focused training program, six hematologists were trained and conducted this study. Sixty-two patients were included. Only in 19 cases, further specialized imaging was required, whereas, in 43 patients PoCUS was sufficient to address the clinical inquiries. The use of PoCUS devices was assessed for its performance difficulty and usefulness perception with satisfactory outcomes. This study represents a proof-of-concept application of PoCUS in hematology, suggesting benefits over the physical examination.KEY POINTSPoCUS is particularly attractive in a hematological setting because able to improve the accuracy of physical examination.A hematology-focused training in PoCUS using handheld devices can allow hematologists to perform bed-side diagnostic and interventional US-based exams.

Pocket-sized echocardiography for screening structural heart disease: diagnostic accuracy and cost-effectiveness for population-based studies

BACKGROUND

The standard transthoracic echocardiography has some limitations in emergent and community-based situations. The emergence of pocket-sized ultrasound has led to influential advancements.

METHODS

In this prospective study, in the hospital-based phase, children with suspected structural heart diseases were enrolled. In the school-based phase, healthy children were randomly selected from six schools. All individuals were examined by experienced operators using both the standard and the pocket-sized echocardiography.

RESULTS

A total of 73 individuals with a mean age of 9.9 ± 3.2 years in the hospital-based cohort and 143 individuals with a mean age of 12.8 ± 2.9 years in the school-based cohort were examined. The agreements between the standard and the pocket-sized echocardiography were good or excellent for major CHDs in both cohorts (κ statistics > 0.61). Among valvular pathologies, agreements for tricuspid and pulmonary valves' regurgitation were moderate among school-based cohorts (0.56 [95% confidence interval 0.12-1] and 0.6 [95% confidence interval 0.28-0.91], respectively). The agreements for tricuspid and pulmonary valves' regurgitation were excellent (>0.9) among hospital-based population. Other values for valvular findings were good or excellent. The overall sensitivity and specificity were 87.5% (95% confidence interval 47.3-99.7) and 93.8% (95% confidence interval 85-98.3) among the hospital-based individuals, respectively, and those were 88% (95% confidence interval 77.8-94.7) and 68.4% (95% confidence interval 56.7-78.6) among the school-based individuals, respectively. The cost of examination was reduced by approximately 70% for an individual using the pocket-sized device.

CONCLUSIONS

When interpreted by experienced operators, the pocket-sized echocardiography can be used as screening tool among school-aged population.

Smartphone interfaced handheld echocardiography for focused assessment of ventricular function and structure in children: A pilot study

INTRODUCTION

Miniaturized echocardiographic machines improve availability and portability and can be particularly useful for underserved and resource-limited settings. The goal of this study was to compare left ventricular fractional shortening (FS) and left ventricular ejection fraction (LVEF) obtained by a newer handheld echo (HHE) machine to standard transthoracic echocardiogram (TTE) in children.

METHODS

Pediatric outpatients (Birth-18 years) undergoing TTE were prospectively enrolled. HHE protocol included 2D and M-mode images from the parasternal long, short, and apical-4 chamber views. HHE and TTE measurements were reviewed for agreement. Kappa statistic was used to analyze qualitative indices while FS and LVEF were analyzed with Lin's concordance correlation coefficient (CCC) and Bland-Altman limits of agreement (loa).

RESULTS

Sixty children were enrolled; 55 were included in the quantitative analysis. Mean age was 7.5 ± 5.5 years; 67% males; median HHE image acquisition duration was 2.3(1-5) minutes. Fractional shortening and EF by HHE showed good agreement with TTE [CCC = 0.82, 95%CI (0.73,0.90), mean bias -3.18%, loa (-7.00,6.44%) vs CCC = 0.81 (0.72,0.90), mean bias -0.87%, loa (-6.94,5.17%], respectively. In children ≤5 years, HHE FS (n = 20) and EF (n = 21) agreed with TTE measurement [0.59 (0.31, 0.88), mean bias 0.30%, loa (-8.5, 9.1%); 0.79 (0.63, 0.96), mean bias 0.10%, loa (-5.99, 6.14)]. Kappa values for RV size, function, and LV function were 1.00 (P < .05); 0.75 for LV size (P < .05) and 0.66 for pericardial effusion (P < .05).

CONCLUSION

Handheld echo demonstrates good correlation with standard TTE for focused assessment of ventricular chamber sizes and function in children.

Point-of-care ultrasound with pocket-size devices in emergency department

Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.

The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update)

Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.

The use of focused cardiac ultrasound to screen for occult heart disease in asymptomatic cats

Background

Focused cardiac ultrasound (FCU) helps detect occult heart disease in human patients.

Hypothesis

Focused cardiac ultrasound by a nonspecialist practitioner (NSP) will increase the detection of occult heart disease in asymptomatic cats compared with physical examination and ECG.

Animals

Three hundred forty‐three client‐owned cats: 54 excluded and 289 analyzed.

Methods

Multicenter prospective cohort study. Twenty‐two NSPs were trained to perform FCU. Cats without clinical signs of heart disease were recruited, and NSPs performed the following in sequential order: physical examination, ECG, FCU, and point‐of‐care N‐terminal pro‐B‐type natriuretic peptide assay (POC‐BNP). After each step, NSPs indicated yes, no, or equivocal as to whether they believed heart disease was present. The level of agreement between the NSP diagnosis and a blinded cardiologist's diagnosis after echocardiogram was evaluated using Cohen's kappa test.

Results

Cardiologist diagnoses included 148 normal cats, 102 with heart disease, and 39 equivocal ones. Agreement between NSP and cardiologist was slight after physical examination (kappa 0.253 [95% CI, 0.172‐0.340]), did not increase after ECG (0.256 [0.161‐0.345]; P = .96), increased after FCU (0.468 [0.376‐0.558]; P = .002), and the level of agreement was similar after POC‐BNP (0.498 [0.419‐0.580]; P = .67). In cats with mild, moderate, and marked occult heart disease, the proportion of cats having a NSP diagnosis of heart disease after FCU was 45.6%, 93.1%, and 100%, respectively.

Conclusions and Clinical Importance

Focused cardiac ultrasound performed by NSPs increased the detection of occult heart disease, especially in cats with moderate to marked disease. Focused cardiac ultrasound appears to be a feasible and useful tool to assist NSPs in the detection of heart disease in cats.

A systematic review of pocket-sized imaging devices: small and mighty?

Introduction

Hand-held imaging devices are widely used in clinical practice and are a useful tool. There is no published review examining the diagnostic parameters achieved with these devices in clinical practice.

Methods

We searched three online medical literature databases (PubMed, EMBASE and MEDLINE) for all literature published up until January 2018. We selected studies that (1) were conducted in the adult population; (2) used a truly hand-held device; (3) featured sensitivities and/or specificities on the use of the hand-held scanner. We extracted and summarised the diagnostic metrics from the literature.

Results

Twenty-seven articles were excluded from the initial 56 relevant articles, as the device featured was not truly hand-held. Ultimately a total of 25 studies were analysed. Sixteen studies were carried out by experienced users, seven by users with little previous experience and two studies by nurses. High diagnostic parameters were achieved by all three groups when scanning cardiac pathology and intra-abdominal structures. Training of non-expert users varied, taking a mean of 21.6 h. These hand-held devices can change diagnoses at the bedside and be used as gate-keepers to formal echocardiography. Individual studies show them to be cost-effective.

Conclusion

Hand-held echocardiography is a useful tool in the hands of experts and novices alike. Studies conducted are highly heterogeneous making it difficult to pool data for the diagnostic metrics. Further studies with rigorous methodology are needed to evaluate the true diagnostic potential in the hands of non-experts and in the community as well as to validate training protocols.

Identification of the main determinants of abdominal aorta size: a screening by Pocket Size Imaging Device

Background

Ultrasound exam as a screening test for abdominal aorta (AA) can visualize the aorta in 99% of patients and has a sensitivity and specificity approaching 100% in screening settings for aortic aneurysm. Pocket Size Imaging Device (PSID) has a potential value as a screening tool, because of its possible use in several clinical settings. Our aim was to assess the impact of demographics and cardiovascular (CV) risk factors on AA size by using PSID in an outpatient screening.

Methods

Consecutive patients, referring for a CV assessment in a 6 months period, were screened. AA was visualized by subcostal view in longitudinal and transverse plans in order to determine the greatest anterior-posterior diameter. After excluding 5 patients with AA aneurysm, 508 outpatients were enrolled. All patients underwent a sequential assessment including clinical history with collection of CV risk factors, physical examination, PSID exam and standard Doppler echoc exam using a 2.5 transducer with harmonic capability, both by expert ultrasound operators, during the same morning. Standard echocardiography operators were blinded on PSID exam and viceversa.

Results

Diagnostic accuracy of AA size by PSID was tested successfully with standard echo machine in a subgroup (n = 102) (rho = 0.966, p < 0.0001). AA diameter was larger in men than in women and in ≥50 -years old subjects than in those <50 -years old (both p < 0.0001). AA was larger in patients with coronary artery disease (CAD) (p < 0.0001). By a multivariate model, male sex (p < 0.0001), age and body mass index (both p < 0.0001), CAD (p < 0.01) and heart rate (p = 0.018) were independent predictors of AA size (cumulative R² = 0.184, p < 0.0001).

Conclusion

PSID is a reliable tool for the screening of determinants of AA size. AA diameter is greater in men and strongly influenced by aging and overweight. CAD may be also associated to increased AA diameter.

Usefulness of Hand-Held Ultrasonography as a Gatekeeper to Standard Echocardiography for "Rarely Appropriate" Echocardiography Requests

Adoption of appropriate use criteria has not had a major impact on the frequency of "rarely appropriate" tests, with the rarely appropriate tests rate remaining at ∼20% in most institutions. We sought whether access to hand-held ultrasound (HHU) could be an alternative means of reducing rarely appropriate requests. We compared 2 approaches to rarely appropriate requests; "standard transthoracic echocardiography" (SE) as requested (control) and HHU as a gatekeeper (HHU). Patients were followed up for 6 months and assessed for end points including time until scan, repeat echocardiography/cost of either strategy, new major pathology, and change in management. The most common rarely appropriate requests in both groups were assessment of infective endocarditis without positive blood cultures and precordial murmur evaluation in absence of any other signs or symptoms of cardiovascular disease. The groups had comparable age, gender, requesting physician, and inpatient versus outpatient distribution. HHU led to a 59% reduction in rarely appropriate requests requiring SE. HHU significantly reduced time to decision for inpatients (0 [interquartile range 0, 1] vs 2 days [interquartile range 1, 4], p <0.001) and total cost of echocardiography (109 ± 86 vs 181 ± 37 USD, p <0.001). New major pathology was identified in 29% and 23% of HHU and SE, respectively. There was no difference with respect to change in management. In conclusion, HHU can be an effective gatekeeper to SE for rarely appropriate echocardiograms, reducing time to echocardiography and cost while satisfying the referring physician and avoiding repeat requests for SE. HHU provides a safety net that identifies potential important findings in rarely appropriate requests.

Pocket-size imaging device as a screening tool for aortic stenosis

AIM

The aim of this study was to assess the usefulness of a pocket-size imaging device in the hands of a noncardiologist as a screening tool for diagnosing aortic stenosis in individuals with newly discovered systolic murmur.

METHODS AND RESULTS

A total of 200 consecutive patients with systolic murmur were included; a limited focused cardiac ultrasound was performed with a pocket-size imaging device and compared to standard echocardiography. It was performed by a noncardiologist with no formal training in echocardiography. In all, 150 patients had morphological changes on the aortic valve, 77 had more than mild aortic stenosis, 30 had more than mild mitral regurgitation, 64 patients had more than moderate hypertrophy, 113 had more than moderately enlarged left atriums, and 3 had severely enlarged left ventricles. There were no significant difference in recognizing severe changes between Vscan focused cardiac ultrasound and comprehensive echocardiography.

CONCLUSION

Pocket-size ultrasound imaging devices without continuous and pulse wave Doppler modalities can, even in the hands of a noncardiologist with limited cardiac ultrasound instructions with high sensitivity and specificity, be a useful tool for detecting more than mild aortic stenosis and more than mild mitral regurgitation. As such a focused cardiac ultrasound can be an extension of physical examinations for patients with newly discovered systolic murmur.

Focused cardiac ultrasound: where do we stand?

Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.

Early markers of right heart involvement in regular smokers by Pocket Size Imaging Device

PURPOSE

To test the diagnostic power of Pocket Size Imaging Device (PSID) in detecting early signs of right heart (RH) involvement in regular smokers (RS) free of overt cardiac involvement.

METHODS

One-hundred-forty-three regular smokers and 51 healthy controls, comparable for age and sex, underwent physical exam (PE), PSID exam and standard echocardiography. Based on a simplified Boston score, ≥1 of clinical signs (jugular venous distension, hepatomegaly, peripheral pitting oedema and abnormal pulmonary sounds) were considered indicative of RH involvement. A composite score (1 to 4) obtained by summing the points of four quantitative RH abnormalities detectable by PSID (inferior vena cava [IVC] dilatation, reduced IVC respiratory variation, right ventricular dilatation and right atrial dilatation), was generated and ≥1 of PSID abnormal signs was considered indicative of RH involvement.

RESULTS

Boston score was not significantly different between the two groups. By using PSID, smokers exhibited greater IVC diameter (p < 0.0001), right atrial diameter (p < 0.002) and higher PSID score (p < 0.005) than controls. Compared to PE, the additional diagnostic power of PSID (≥1 abnormal sign of both Boston and PSID score) was 44.9% in smokers. By dividing smokers in tertiles according to number of cigarettes per day, the third tertile showed the largest values of both IVC and right atrial dimension. Differences were confirmed by standard echocardiography. Reproducibility of PSID measurements and concordance of linear measurements between PSID and standard echo measurements was very good except for concordance of right ventricular basal diameter.

CONCLUSIONS

PSID detects early ultrasound signs of RH involvement in regular otherwise healthy smokers in comparison with PE.

Pocket-sized focused cardiac ultrasound: strengths and limitations

Focused cardiac ultrasound (FCU) has emerged in recent years and has created new possibilities in the clinical assessment of patients both in and out of hospital. The increasing portability of echocardiographic devices, with some now only the size of a smartphone, has widened the spectrum of potential indications and users, from the senior cardiologist to the medical student. However, many issues still need to be addressed, especially the acknowledgment of the advantages and limitations of using such devices for FCU, and the extent of training required in this rapidly evolving field. In recent years, an increasing number of studies involving FCU have been published with variable results. This review outlines the evidence for the use of FCU with pocket-echo to address specific questions in daily clinical practice.

Focused cardiac ultrasound using a pocket-size device in the emergency room

BACKGROUND

Cardiovascular urgencies are frequent reasons for seeking medical care. Prompt and accurate medical diagnosis is critical to reduce the morbidity and mortality of these conditions.

OBJECTIVE

To evaluate the use of a pocket-size echocardiography in addition to clinical history and physical exam in a tertiary medical emergency care.

METHODS

One hundred adult patients without known cardiac or lung diseases who sought emergency care with cardiac complaints were included. Patients with ischemic changes in the electrocardiography or fever were excluded. A focused echocardiography with GE Vscan equipment was performed after the initial evaluation in the emergency room. Cardiac chambers dimensions, left and right ventricular systolic function, intracardiac flows with color, pericardium, and aorta were evaluated.

RESULTS

The mean age was 61 ± 17 years old. The patient complaint was chest pain in 51 patients, dyspnea in 32 patients, arrhythmia to evaluate the left ventricular function in ten patients, hypotension/dizziness in five patients and edema in one patient. In 28 patients, the focused echocardiography allowed to confirm the initial diagnosis: 19 patients with heart failure, five with acute coronary syndrome, two with pulmonary embolism and two patients with cardiac tamponade. In 17 patients, the echocardiography changed the diagnosis: ten with suspicious of heart failure, two with pulmonary embolism suspicious, two with hypotension without cause, one suspicious of acute coronary syndrome, one of cardiac tamponade and one of aortic dissection.

CONCLUSION

The focused echocardiography with pocket-size equipment in the emergency care may allow a prompt diagnosis and, consequently, an earlier initiation of the therapy.

Diagnostic capability of comprehensive handheld vs transthoracic echocardiography

OBJECTIVE

To assess the diagnostic capability of handheld echocardiography (HHE) compared with transthoracic echocardiography (TTE) performed and evaluated by experienced sonographers and expert echocardiographers.

PATIENTS AND METHODS

We conducted a prospective study of adult outpatients undergoing comprehensive TTE between July 9, 2012, and April 3, 2013. Experienced sonographers performed a detailed, standardized examination using a handheld ultrasound device that included 2-dimensional and color Doppler images from standard imaging windows. Images from TTE and HHE were independently interpreted by expert echocardiographers to whom the other study was masked. Agreement between the standard TTE and the HHE reports was analyzed.

RESULTS

The study group contained 190 patients (mean ± SD age, 62 ± 17 years; 49% male [n=93]). The κ values were 0.52 for left ventricular (LV) enlargement, 0.52 for right ventricular enlargement, 0.62 for regional wall motion abnormalities, 0.73 for aortic stenosis, and 0.61 for mitral regurgitation. Lin concordance correlation coefficients ranged from 0.89 for LV end-systolic diameter to 0.78 for LV end-diastolic diameter. In 51 patients (27%), echocardiographic findings were discordant between HHE and standard TTE. The most common discordant finding was the presence vs absence of any regional wall motion abnormalities. In discordant cases, HHE tended to underestimate, rather than overestimate, the severity of abnormal findings.

CONCLUSION

In experienced hands, HHE shows moderate correlation with standard TTE, but discordant findings were present in 27% of patients. Even when performed and interpreted by experienced operators, HHE should not be used as a surrogate for standard TTE.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01558518.

Characterization of the rdar morphotype, a multicellular behaviour in Enterobacteriaceae

The rdar morphotype, a multicellular behaviour of Salmonella enterica and Escherichia coli is characterized by the expression of the adhesive extracellular matrix components cellulose and curli fimbriae. The response regulator CsgD, which transcriptionally activates the biosynthesis of the exopolysaccharide cellulose and curli, also transforms cell physiology to the multicellular state. However, the only role of CsgD in cellulose biosynthesis is the activation of AdrA, a GGDEF domain protein that mediates production of the allosteric activator cyclic-di-(3'-5')guanylic acid (c-di-GMP). In S. enterica serovar Typhimurium a regulatory network consisting of 19 GGDEF/EAL domain-containing proteins tightly controls the concentration of c-di-GMP. c-di-GMP not only regulates the expression of cellulose, but also stimulates expression of adhesive curli and represses various modes of motility. Functions of characterized GGDEF and EAL domain proteins, as well as database searches, point to a global role for c-di-GMP as a novel secondary messenger that regulates a variety of cellular functions in response to diverse environmental stimuli already in the deepest roots of the prokaryotes.