12th WINFOCUS world congress on ultrasound in emergency and critical care

Artificial Intelligence-Augmented Pediatric Lung POCUS: A Pilot Study of Novice Learners

OBJECTIVE

Respiratory symptoms are among the most common chief complaints of pediatric patients in the emergency department (ED). Point-of-care ultrasound (POCUS) outperforms conventional chest X-ray and is user-dependent, which can be challenging to novice ultrasound (US) users. We introduce a novel concept using artificial intelligence (AI)-enhanced pleural sweep to generate complete panoramic views of the lungs, and then assess its accuracy among novice learners (NLs) to identify pneumonia.

METHODS

Previously healthy 0- to 17-year-old patients presenting to a pediatric ED with cardiopulmonary chief complaint were recruited. NLs received a 1-hour training on traditional lung POCUS and the AI-assisted software. Two POCUS-trained experts interpreted the images, which served as the criterion standard. Both expert and learner groups were blinded to each other's interpretation, patient data, and outcomes. Kappa was used to determine agreement between POCUS expert interpretations.

RESULTS

Seven NLs, with limited to no prior POCUS experience, completed examinations on 32 patients. The average patient age was 5.53 years (±1.07). The median scan time of 7 minutes (minimum-maximum 3-43; interquartile 8). Three (8.8%) patients were diagnosed with pneumonia by criterion standard. Sensitivity, specificity, and accuracy for NLs AI-augmented interpretation were 66.7% (confidence interval [CI] 9.4-99.1%), 96.5% (CI 82.2-99.9%), and 93.7% (CI 79.1-99.2%). The average image quality rating was 2.94 (±0.16) out of 5 across all lung fields. Interrater reliability between expert sonographers was high with a kappa coefficient of 0.8.

CONCLUSION

This study shows that AI-augmented lung US for diagnosing pneumonia has the potential to increase accuracy and efficiency.

Lung ultrasound in predicting COVID-19 clinical outcomes: A prospective observational study

STUDY OBJECTIVE

We sought to determine the ability of lung point-of-care ultrasound (POCUS) to predict mechanical ventilation and in-hospital mortality in patients with coronavirus disease 2019 (COVID-19).

METHODS

This was a prospective observational study of a convenience sample of patients with confirmed COVID-19 presenting to 2 tertiary hospital emergency departments (EDs) in Iran between March and April 2020. An emergency physician attending sonographer performed a 12-zone bilateral lung ultrasound in all patients. Research associates followed the patients on their clinical course. We determined the frequency of positive POCUS findings, the geographic distribution of lung involvement, and lung severity scores. We used multivariable logistic regression to associate lung POCUS findings with clinical outcomes.

RESULTS

A total of 125 patients with COVID-like symptoms were included, including 109 with confirmed COVID-19. Among the included patients, 33 (30.3%) patients were intubated, and in-hospital mortality was reported in 19 (17.4%). Lung POCUS findings included pleural thickening 95.4%, B-lines 90.8%, subpleural consolidation 86.2%, consolidation 46.8%, effusions 19.3%, and atelectasis 18.3%. Multivariable logistic regression incorporating binary and scored POCUS findings were able to identify those at highest risk for need of mechanical ventilation (area under the curve 0.80) and in-hospital mortality (area under the curve 0.87). In the binary model ultrasound (US) findings in the anterior lung fields were significantly associated with a need for intubation and mechanical ventilation (odds ratio [OR] 3.67; 0.62-21.6). There was an inverse relationship between mortality and posterior lung field involvement (OR 0.05; 0.01-0.23; and scored OR of 0.57; 0.40-0.82). Anterior lung field involvement was not associated with mortality.

CONCLUSIONS

In patients with COVID-19, the anatomic distribution of findings on lung ultrasound is associated with outcomes. Lung POCUS-based models may help clinicians to identify those patients with COVID-19 at risk for clinical deterioration.Key Words: COVID-19; Lung Ultrasound; Mechanical ventilation; Prediction; ICU admission; Mortality; Clinical outcome; Risk stratification; Diagnostic accuracy.

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Background

In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally.

Methods

This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement.

Results

Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties.

Conclusions

Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

Three miRNAs cooperate with host genes involved in human cardiovascular disease

Background

Understanding the roles of miRNAs in cardiovascular disease remains a challenge. Genomic linkage indicates a functional relationship between intronic miRNAs and their host genes. However, few studies have shown functional association between intronic miRNAs and their host coding genes that are genetically associated with cardiovascular disease.

Methods

In this study, we investigated functional relationship between three protein-coding genes genetically associated with cardiovascular disease, i.e., CDH13, SLC12A3, and CKAP5, and their intronic miRNAs using a data-driven approach.

Results

We found that the three protein-coding genes functionally interact with targets of their intronic miRNAs, i.e., miR-3182, miR-6863, and miR-5582, in a tissue-specific pattern. The intronic miRNAs preferentially impact important genes for the three host genes in the network, indicating their roles in maintaining the integrity of the interactome where the host genes are involved. Targets of the intronic miRNAs display functional similarity to the host genes. We furthermore present sets of target genes for future investigation on the possible miRNA-target interactions that potentially contribute to cardiovascular diseases.

Conclusions

Our work provides new insight into the regulatory network of the cardiovascular-associated pathways and opens the possibility for future experimental research.

Electronic supplementary material

The online version of this article (10.1186/s40246-019-0232-4) contains supplementary material, which is available to authorized users.

Point-of-care ultrasound in obstetrics

Point-of-care ultrasound, or PoCUS, where imaging is undertaken at the bedside, clinic or emergency department (ED) by the clinician overseeing treatment, is a rapid form of assessment that may be undertaken alongside or as an alternative to traditional, formal ultrasound performed by a radiology service. PoCUS reduces the time to diagnosis, thus allowing lifesaving treatment to be initiated. This is particularly relevant in Obstetrics and Gynaecology (OBGYN), where delayed diagnosis of pregnancy complications is often fatal or highly debilitating to the mother or fetus. The literature suggests that PoCUS is particularly useful in areas that are inadequately resourced, as it is relatively cheap and accessible. High-quality training is essential to ensure that the staff performing the scans are adequately qualified to deliver the service. Clinicians who perform PoCUS in their practice should be aware of the appropriate indications, as well as when to refer for formal imaging.

Point of care ultrasonography in the pediatric emergency department

IMPORTANCE

Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications.

OBJECTIVE

We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs).

FINDINGS

US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification.

CONCLUSIONS AND RELEVANCE

Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.

Incorporation of point-of-care ultrasound into morning round is associated with improvement in clinical outcomes in critically ill patients with sepsis

OBJECTIVES

Point-of-care ultrasound (POCUS) has been widely used in the intensive care unit (ICU). However, it is largely unknown whether the use of POCUS is associated with improved patient-important outcomes. The study aimed to investigate whether incorporation of POCUS during morning round on a routine basis was able to improve clinical outcomes in critically ill patients with sepsis.

DESIGN

It was a prospective observational study.

SETTING

A tertiary care emergency intensive care unit.

PATIENTS

All patients admitted to the emergency ICU from January 2016 to December 2017 were screened for potential eligibility. Sepsis was defined as infection plus signs of organ dysfunction.

INTERVENTION

The intervention group incorporated POCUS during morning round on a routine basis, and a checklist was developed to improve the compliance. The control group did not have the mandates to perform POCUS during morning round, but could use POCUS when necessary.

MEASUREMENTS

Clinical outcomes of mortality, length of stay in ICU, durations of vasopressors and mechanical ventilation were compared between the intervention and control groups. Multivariable regression model was employed to adjust for confounding factors.

MAIN RESULTS

A total of 129 subjects, including 88 in the control group and 41 in the intervention group, were included for analysis. Univariate analysis showed that the intervention group had shorter durations of mechanical ventilation (MV) (4.5 ± 1.2 vs. 5.7 ± 1.0 days; p = 0.034) and more negative fluid balance (-143 vs. 48 ml/24 h; p = 0.003) on day 3. In multivariable model, routine incorporation of POCUS was associated with lower risk of prolonged (>7 days) ICU stay (OR: 0.39, 95% CI: 0.29-0.88; p = 0.029).

CONCLUSIONS

The study showed that incorporation of POCUS during morning round on a routine basis was associated with shortened duration of MV and length of stay in ICU. The possible mechanism underlying the relationship may be via reduced fluid administration. Future randomized controlled trials are needed to validate current findings.

Evaluation of the fluid responsiveness in patients with septic shock by ultrasound plus the passive leg raising test

BACKGROUND

Prompt, accurate, and noninvasive prediction of fluid responsiveness is still lacking in intensive care unit. This study is to investigate the value of the Doppler ultrasound evaluation of variation in brachial artery peak velocity (VVpeak_brach) and passive leg raising (PLR)-induced changes in the brachial artery peak velocity (ΔVpeak_PLR) in predicting the fluid responsiveness in mechanically ventilated patients with severe sepsis or septic shock.

METHODS

A prospective study was conducted involving 62 patients. Semirecumbent positioning, PLR, and a return to the semirecumbent position were performed with all patients before volume expansion. VVpeak_brach, ΔVpeak_PLR, and stroke volume were observed by Doppler ultrasound. A patient with an increase of ≥15% in the stroke volume on volume expansion was defined as a responder. The predictive value was evaluated on the receiver operating characteristic curve analysis.

RESULTS

A total of 28 patients were classified as responders. The area under the receiver operating characteristic curve of ΔVpeak_PLR and VVpeak_brach was 0.898 and 0.891, respectively. A ΔVpeak_PLR value of more than 10.6% predicted the fluid responsiveness with a sensitivity of 82.1% and a specificity of 88.2%. A VVpeak_brach value of more than 10.95% predicted the fluid responsiveness with a sensitivity of 78.6% and a specificity of 91.2%. The positive predictive value was 94.4% when both were positive. In contrast, the negative predictive value was 96.6%.

CONCLUSIONS

Doppler ultrasound evaluation of VVpeak_brach and ΔVpeak_PLR could be a feasible method for the noninvasive assessment of fluid responsiveness in mechanically ventilated patients with severe sepsis or septic shock. The combination of two indicators can improve the predictive value.

Ultrasound and Other Innovations for Fluid Management in the ICU

Ultrasound is a user-dependent tool that can help guide therapy. The use of ultrasound to guide central line placement decreases complication rates. Cardiac ultrasound can help with the diagnosis of cases of hypotension. Lung and pleura ultrasound is a useful adjunct for diagnosis causes of desaturation. Abdominal ultrasound can help in rapid visitation of fluid and intra-abdominal structures.