Self-administered at-home lung ultrasound with remote guidance in patients without clinical training

BACKGROUND

Access to timely and accurate diagnostic imaging is essential for high-quality healthcare. Point-of-care ultrasound has been shown to be accessible and effective in many aspects of healthcare, including assessing changes in lung pathology. However, few studies have examined self-administered at-home lung ultrasound (SAAH-LUS), in particular performed by non-clinical patients (NCPs).

RESEARCH QUESTION

Are NCPs able to perform SAAH-LUS using remote teleguidance and produce interpretable images?

STUDY DESIGN

Patients were enrolled to the study in a mix of in-person and virtual recruitment, and shipped a smartphone as well as a point of care ultrasound device. Tele-guidance was provided by a remote physician using software integrated with the point of care ultrasound device, allowing real-time remote visualization and guidance of a patient scanning their own chest. A post-intervention survey was conducted to assess patient satisfaction, feasibility, and acceptability of SAAH-LUS. Two POCUS expert reviewers reviewed the scans for interpretability, and inter-rater agreement between the two reviewers was also computed.

RESULTS

Eighteen patients successfully underwent 7-14 days of daily telemedicine in parallel to daily SAAH-LUS. Across 1339 scans obtained from ten different lung zones, the average proportion of interpretability was 96% with a chance-corrected agreement, or Cohen's kappa, reported as κ = 0.67 (significant agreement). 100% of NCPs surveyed found SAAH-LUS to be a positive experience, particularly for its ease of operation and ability to increase access to healthcare services.

INTERPRETATION

This study demonstrates that NCPs can obtain interpretable LUS images at home, highlighting the potential for SAAH-LUS to increase diagnostic capacity, particularly for rural and remote regions where complex imaging and healthcare providers are difficult to obtain. Trial registration The clinical trials has been registered (clinicaltrials.gov).

REGISTRATION NUMBER

NCT04967729.

POCUS literature primer: key papers on POCUS in cardiac arrest and shock

OBJECTIVE

The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients.

METHODS

An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock.

RESULTS

The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation.

CONCLUSION

We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.

Optimizing Care for High-Risk Multiple Pregnancy with POCUS - A Case of Quadruplet Pregnancy Early Diagnosis

Managing multiple pregnancies is challenging and requires careful evaluation. Point of care ultrasound (POCUS) has emerged as a potentially crucial tool in assessing suspected first-trimester pregnancies. However, its role in evaluating multiple pregnancies remains uncertain. We present the case of a 36-year-old Ghanaian female who presented with acute vaginal bleeding after undergoing in vitro fertilization. A bedside transabdominal POCUS identified four intrauterine gestations with fetal poles and cardiac activity, suggesting a quadruplet viable pregnancy. A subsequent transvaginal ultrasound confirmed the findings. The patient was discharged with a follow-up appointment with an Obstetrician-Gynecologist. This case highlights the significance of POCUS in early pregnancy diagnosis, facilitating accurate identification and appropriate referral for further management. It also demonstrates the utility of POCUS in determining gestational age and viability. To our knowledge, no published case reports specifically address the diagnosis of a quadruplet pregnancy, emphasizing the role of POCUS in optimizing care for high-risk multiple pregnancies.

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators

INTRODUCTION

Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis.

OBJECTIVE

A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care.

METHODS

A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today.

CONCLUSION

Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Point-of-Care Ultrasound (POCUS) Literature Primer: Key Papers on Renal and Biliary POCUS

Objective The objective of this study is to identify the top five influential papers published on renal point-of-care ultrasound (POCUS) and the top five influential papers on biliary POCUS in adult patients. Methods A 14-member expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. All panel members have had ultrasound fellowship training or equivalent, are actively engaged in POCUS scholarship, and are involved with POCUS at their local site and nationally in Canada. We used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five influential papers for renal POCUS and biliary POCUS. Results The panel identified 27 relevant papers on renal POCUS and 30 relevant papers on biliary POCUS. All panel members participated in all three rounds of the modified Delphi process, and after completing this process, we identified the five most influential papers on renal POCUS and the five most influential papers on biliary POCUS. Conclusion We have developed a list, based on expert opinion, of the top five influential papers on renal and biliary POCUS to better inform all trainees and clinicians on how to use these applications in a more evidence-based manner. This list will also be of interest to clinicians and researchers who strive to further advance the field of POCUS.

Acquisition and retention of lung ultrasound skills by respiratory therapists: A curriculum for respiratory therapists

Purpose

Lung point-of-care ultrasound (POCUS) is a versatile bedside tool. The utility of POCUS has grown during the coronavirus disease 2019 pandemic, as it allows clinicians to obtain real-time images without requiring transport of the patient outside the intensive care unit. As respiratory therapists (RTs) are involved in caring for those with respiratory failure, there is a good rationale for their adoption of lung ultrasound. However, no training standards have been defined. Our objective was to develop and implement a training programme for RTs to achieve and sustain competence in lung ultrasound.

Methods

This was a single-centre, prospective, single-cohort observational study. A total of 10 RTs completed our curriculum and were tasked with independently completing and interpreting 10 initial lung ultrasound exams and 3 subsequent exams after a 6-week interim period. All exams were blindly overread by a local expert in lung ultrasound.

Results

After completing the curriculum, RTs were able to acquire and accurately interpret their images over 85% of the time. They were more successful in the upper lung zone image acquisition and interpretation compared with the lower lung zones. After 6 weeks, the RTs' lung POCUS skills remained stable, and their lower lung zone image interpretation improved. The RTs reported that their confidence improved throughout the study.

Conclusion

The RTs in our study have demonstrated competence in acquisition and interpretation of upper lung zone images. They have also reported confidence in acquiring and interpreting upper lung zone images. More experience appears to be required to gain competence and confidence in lower lung zone ultrasound. Next steps would be to repeat the present study with a higher number of RTs completing at least 20 lung POCUS studies.

Point of Care Ultrasound Literature Primer: Key Papers on Focused Assessment With Sonography in Trauma (FAST) and Extended FAST

Objective

The objective of this study is to identify the top five most influential papers published on focused assessment with sonography in trauma (FAST) and the top five most influential papers on the extended FAST (E-FAST) in adult patients.

Methods

An expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. These experts are ultrasound fellowship-trained or equivalent, are involved with point-of-care ultrasound (POCUS) research and scholarship, and are leaders in both the POCUS program at their local site and within the national Canadian POCUS community. This 14-member expert group used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for FAST and E-FAST.

Results

The expert panel identified 56 relevant papers on FAST and 40 relevant papers on E-FAST. After completing all three rounds of the modified Delphi process, the authors identified the top five most influential papers on FAST and the top five most influential papers on E-FAST.

Conclusion

We have developed a reading list of the top five influential papers for FAST and E-FAST that will benefit residents, fellows, and clinicians who are interested in using POCUS in an evidence-informed manner.

Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions

Objectives

Gallstone disease is a common reason for emergency department (ED) presentation. Surgeons often prefer radiology department ultrasound (RUS) over point of care ultrasound (POCUS) because of perceived of unreliability. Our study was designed to test the hypothesis that POCUS is sufficient to guide the management of surgeons treating select cases of biliary disease as compared to RUS.

Methods

This was a prospective cohort study. Patients who presented to the ED with abdominal pain and findings of biliary disease on POCUS were included. The surgeon was then presented the case with POCUS only and recorded their management decision. Patients then proceeded to RUS, were followed through their stay, and analysis was performed to analyze the proportion of patients where the introduction of the RUS changed the management plan.

Results

100 patients were included in this study, and all received both POCUS and RUS. Depending on the surgeons’ POCUS based management decisions, the patients were divided into three groups: (1) surgery, (2) duct clearance, (3) no surgery. Total bilirubin was 34±22 mmol/L in the duct clearance group vs 8.4±6.5 mmol/L and 16±12 mmol/L in the surgery and no surgery groups, respectively (p<0.05). POCUS results showed 68 patients would have been offered surgery, 21 offered duct clearance, and 11 no surgery. In 90% of cases, the introduction of RUS did not change management. The acute care surgeons elected to operate on patients more frequently than other surgical subspecialties (p<0.05).

Conclusions

This study showed that fewer than 10% of patients with biliary disease seen on POCUS had a change in surgical decision-making based on the addition of RUS imaging. In uncomplicated cases of biliary disease, relying on POCUS imaging for surgical decision-making has the potential to improve patient flow.

Level of evidence

II Prospective Cohort Study.

Point-of-Care Resuscitative Echocardiography Diagnosis of Intracardiac Thrombus during cardiac arrest (PREDICT Study): A retrospective, observational cohort study

Background

Point-of-care ultrasound (POCUS) has been previously studied in cardiac arrest, without definitive markers for futile resuscitation efforts identified. Intracardiac thrombus during cardiac arrest has not been systematically studied. Our objective was to describe the incidence of intracardiac thrombus and spontaneous echo contrast found during cardiac arrest.

Methods

A two hospital, retrospective, observational cohort study of 56 cardiac arrest patients who were assessed with POCUS (between January 1st, 2017 to April 30th, 2020). Eligible studies were reviewed for echocardiographic findings (e.g. presence of intracardiac thrombus or spontaneous echo contrast), baseline patient demographics, cardiac arrest-related data, and clinical outcomes. Primary outcome was in-hospital mortality.

Results

Fifty-six intra-arrest POCUS echocardiograms were identified (out of 738 out-of-hospital cardiac arrests). The median patient age was 63 years (interquartile range [IQR]: 51–72), with 25% female patients, and median Charlson Comorbidity Index score of 4 (IQR: 2–6). The incidence of intracardiac thrombus was 21 out of 56 patients (38%). Time-to-new thrombus formation during cardiac arrest was approximately 6 minutes (IQR: 2-–8). All patients with intracardiac thrombus during cardiac arrest had termination of resuscitation.

Conclusions

Intracardiac thrombus is potentially common during out-of-hospital cardiac arrests and was observed more frequently in those in whom termination of resuscitation was recommended. However, this is only hypothesis-generating at this time, and further study is required to determine if the presence of intracardiac thrombus may be used as a potential marker of resuscitation futility.

Point-of-care ultrasonography for the diagnosis of testicular torsion: a practical resident curriculum

Background

Prompt Doppler ultrasonography to aid in diagnosis is often key to managing testicular torsion, but there may be delays in access; a faster, more widely available alternative is point-of-care ultrasonography (POCUS). The purpose of this study was to develop and evaluate a scrotal POCUS curriculum for urology and emergency medicine residents.

Methods

Content experts in urology, emergency medicine and diagnostic imaging collaborated in a modified Delphi method to design a practical didactic curriculum for scrotal POCUS for the identification of testicular torsion. Training included 3 online video teaching modules and a 1-hour hands-on teaching session with standardized adult patients. We evaluated participants’ competency in scrotal POCUS using a validated scale. We assessed participants’ knowledge, comfort and confidence in performing scrotal POCUS before and after the intervention and at 3 months.

Results

Twenty-four urology (n = 12) and emergency medicine (n = 12) residents participated in the curriculum. After hands-on practice, 23 participants (96%) were deemed competent at scrotal POCUS. Pre–post testing showed significant improvement in knowledge (mean score 63% v. 80%, p < 0.001), comfort (mean Likert score 0.6 v. 3.6, p < 0.001) and confidence (mean Likert score 1.0 v. 2.1, p < 0.001) after the intervention. These effects were maintained at the 3-month assessment.

Conclusion

The scrotal POCUS curriculum was effective and acceptable to both urology and emergency medicine residents. The findings suggest that scrotal POCUS can be learned effectively through a short hands-on session and didactic instruction.

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study

STUDY OBJECTIVE

We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope.

METHODS

This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes.

RESULTS

Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses.

CONCLUSION

Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.

Surgeon attitudes toward point of care ultrasound for biliary disease: a nationwide Canadian survey

Summary

Multiple studies confirm that point of care ultrasound (PoCUS) has a high sensitivity and specificity for cholelithiasis and cholecystitis. However, there is poor perceived reliability of biliary PoCUS by surgeons. This survey was performed to assess surgeons’ opinions on using PoCUS in gallstone disease and barriers that exist for its institution. The majority (60.3%) of respondents reported a total lack of confidence in PoCUS for the diagnosis of biliary disease. Most felt the sensitivity of PoCUS was poor and had concerns about the user-dependent nature of the test and the lack of imaging details provided. If offered ideal clinical/laboratory findings with PoCUS results, only 4.7% of surgeons would definitely operate for unremitting biliary colic and 5.4% for cholecystitis. The ability to replicate findings independently increased confidence in clinical decision-making. Our findings suggest there is substantial distrust in biliary PoCUS but that specific ultrasound training for the surgical workforce may prove tremendously beneficial for its utilization.

Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system

INTRODUCTION

Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitive and often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates.

OBJECTIVE

The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis.

STUDY DESIGN

A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture).

RESULTS

A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptom onset to ED presentation for patients with possible TT was 4 h. After triage, a median of 79.8 min was required for ED physician assessment and an additional 48 min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration.

DISCUSSION

Almost 4 h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128 min; Fig. 1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS.

CONCLUSION

Patient flow delays to surgical intervention for patients with TT represent a preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2 h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.

Current State of Point-of-care Ultrasound Usage in Canadian Emergency Departments

Background Point-of-care ultrasound (POCUS) has many applications in emergency medicine, which have been proven to improve patient outcomes. Training programs and well-established guidelines for its use are available, but Canadian adoption rates and attitudes toward this technology have not been recently assessed. Objectives This study aimed to provide a national assessment of the current use of POCUS in Canadian emergency departments (ED) including patterns of use, attitudes towards its role, descriptors of training experience, as well as barriers to increased utilization. Methods An electronic survey was sent to physician members of the Canadian Association of Emergency Physicians. The survey included questions related to demographics, attitudes towards POCUS, POCUS utilization, and barriers to POCUS use. Responses were statistically analyzed to identify significant associations. Results Responses demonstrated a strong association between POCUS training and amount of POCUS usage. Neither hospital type nor community type was associated with the degree of POCUS usage. POCUS was most widely adopted for Canadian Point of Care Ultrasound Society (CPOCUS) core applications and has increased since the last national survey. The most commonly reported barrier to increased POCUS adoption was the lack of training. Most physicians have formal POCUS training in core applications, and approximately one third have advanced training. Conclusions POCUS training and utilization appear to have increased since the last national assessment. This provides a foundation for future POCUS research.

Point-of-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times

BACKGROUND

Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as a diagnostic tool. The purpose of this study is to analyze the usefulness of POCUS in predicting the need for surgical intervention in biliary disease.

METHODS

A retrospective study of patients visiting the emergency department who received a biliary POCUS from December 1, 2016 to July 15, 2017 was performed. The physician interpretations of the biliary POCUS scans were collected, as well as data from the electronic health records including lab values, the subsequent use of diagnostic imaging, surgical consultation or intervention, and 28 days follow-up for representation or complication.

RESULTS

Two hundred and eighty-three patients were identified as having received biliary POCUS. Of the patients referred to general surgery who received biliary POCUS 43% received a cholecystectomy. For the outcome of cholecystectomy, the finding of gallstones on POCUS was 55% sensitive (95% CI 40% to 70%) and 92% specific (95% CI 87% to 95%). A sonographic Murphy's sign was 16% sensitive (95% CI 7% to 30%) but 95% specific (95% CI 92% to 97%) and, gallbladder wall thickness was 18% sensitive (95% CI 9% to 33%) and 98% specific (95% CI 95% to 99%). Patients who received POCUS but did not proceed to confirmatory radiology department imaging had a shorter length of stay (433 min ± 50 min vs. 309 min ± 30 min, P<0.001).

DISCUSSION

Point-of-care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gallstones and increased gallbladder wall thickness are highly predictive of the need for surgical intervention, and use of POCUS is associated with shorter ER visits.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Long-term results of protocol kidney biopsy directing steroid withdrawal in simultaneous pancreas-kidney transplant patients

INTRODUCTION

We sought to determine whether protocol biopsies could be used to guide treatment and improve outcomes in simultaneous pancreas-kidney (SPK) patients.

METHODS

Between 2004 and 2013, protocol biopsies were performed on SPK patients at 3-6 months and one year post-transplant. Maintenance immunosuppression consisted of a calcineurin inhibitor, anti-proliferative agent, and corticosteroid. Corticosteroid was withdrawn in negative early biopsies, maintained in subclinical/ borderline biopsies, and increased if Banff IB or greater rejection was identified. Endpoints included presence of interstitial fibrosis and tubular atrophy on biopsy at one year (IF/TA), rejection episodes, and renal and pancreas function at five years' followup.

RESULTS

Forty-one SPK transplant patients were reviewed and a total of 75 protocol biopsies were identified. On early biopsy, 51% had negative biopsies, 44% had borderline rejection, and 5% had subclinical rejection. Renal and pancreas function were not significantly different at one, two, and five years post-transplant between negative vs. borderline early biopsy patients. No difference in the degree of IF/TA was found between these two groups.

CONCLUSIONS

To our knowledge, this is the first study to evaluate protocol biopsies as an investigative tool prior to steroid withdrawal in SPK patients. Our study suggests that there are no detrimental functional or histological effects at five years post-transplant, despite weaning steroids in the negative biopsy group.

Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes

OBJECTIVES

Distal forearm fractures are the most common fracture type in children. Point-of-care-ultrasound (POCUS) is increasingly being used, and preliminary studies suggest that it offers an accurate approach to diagnosis. However, outcomes such as pain, satisfaction, and procedure duration have not been explored but may be salient to the widespread acceptance of this technology by caregivers and children. Our objectives were to examine the test performance characteristics of POCUS for nonangulated distal forearm injuries in children and compare POCUS to x-ray with respect to pain, caregiver satisfaction, and procedure duration.

METHODS

We conducted a cross-sectional study involving children aged 4-17 years with a suspected nonangulated distal forearm fracture. Participants underwent both x-ray and POCUS assessment. The primary outcome was sensitivity between POCUS and x-ray, the reference standard. Secondary outcomes included self-reported pain using the Faces Pain Scale-Revised, caregiver satisfaction using a five-item Likert scale, and procedure duration.

RESULTS

POCUS was performed in 169 children of whom 76 were diagnosed with a fracture including 61 buckle fractures. Sensitivity of POCUS for distal forearm fractures was 94.7% (95% confidence interval [CI] = 89.7-99.8) and specificity was 93.5% (95% CI = 88.6-98.5). POCUS was associated with a significantly lower median (interquartile range [IQR]) pain score compared to x-ray: 1 (0-2) versus 2 (1-3), respectively (median difference = 0.5; 95% CI = 0.5-1; p < 0.001) and no significant difference in median (IQR) caregiver satisfaction score: 5 (0) versus 5 (4-5), respectively (median difference = 0, 95% CI = 0, p = 1.0). POCUS was associated with a significantly lower median (IQR) procedure duration versus x-ray: 1.5 (0.8-2.2) minutes versus 27 (15-58) minutes, respectively (median difference = 34.1, 95% CI = 26.8-41.5, p < 0.001).

CONCLUSIONS

Our findings suggest that POCUS assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction.

The Utility of Point-of-Care Ultrasound in Detecting Distal Forearm Buckle Fractures in Paediatric Patients

BACKGROUND: Distal forearm fractures are common paediatric injuries. The use of plain radiographs is almost universal for diagnosis but this technology can be painful and time consuming. It is well known that children’s pain in the emergency department (ED) is both under-recognized and suboptimally managed. Point-of-care ultrasound (POCUS) has demonstrated good accuracy in detecting cortical disruption in adults but test characteristics in the most common paediatric fracture type (buckle or torus fractures) have not been explored. POCUS may also lead to quicker assessment and be associated with less pain and improved caregiver satisfaction compared to plain radiographs. Our results may provide support an alternative diagnostic strategy for centres where plain radiographs are not readily accessible and where severe pain is an issue.

OBJECTIVES: The objectives of this study were to: (i) evaluate the diagnostic accuracy POCUS in detecting suspected non-angulated distal forearm fractures in children presenting to the ED compared to AP and lateral plain film x-rays of the forearm, (ii) determine the length of time required to complete a POCUS evaluation for a suspected distal forearm non-angulated fracture in children in the ED, (iii) explore the differences in caregiver satisfaction with POCUS evaluation compared to plain radiography, and (iv) explore differences in associated pain between POCUS and plain radiography.

DESIGN/METHODS: This was a prospective cohort study designed to test the hypothesis that POCUS provides comparable sensitivity and specificity to plain radiography and is associated with less pain and greater caregiver satisfaction. We included children aged 4-17 years who presented to the paediatric ED with a suspected non-angulated distal forearm fracture based on a typical mechanism of injury. The patient underwent an x-ray and a POCUS evaluation of the affected region by a Canadian Emergency Ultrasound (CEUS)-trained physician who was blinded to the x-ray results. Caregivers were asked to complete a satisfaction questionnaire using a five-point Likert scale and children were asked to complete the Faces Pain Scale – Revised (FPS-R) reflecting discomfort associated with the diagnostic modality. The primary POCUS diagnosis made by the physician was compared to the x-ray diagnosis made by the staff paediatric radiologist. All POCUS images were independently interpreted by a second expert POCUS sonographer blinded to the original POCUS interpretation, x-ray, and final diagnosis. The primary outcomes were sensitivity of POCUS and pain score using the FPS-R.

RESULTS: Eighty-five participants were enrolled, of whom 33 (39%) sustained a buckle fracture. The mean (SD) age of the participants was 11 (3.4) years and 52 (61%) were male. Sensitivity and sensitivity of POCUS for detecting any cortical disruption was 97% [95% CI: 84.2, 99.9] and 96% [95% CI: 86.8, 99.5], respectively. Agreement (kappa) between sonographers was 0.74 [95% CI: 0.64, 0.87] representing substantial agreement. POCUS was associated with significantly lower mean (SD) pain scores compared to plain radiography [2.3 (2.5) vs 3.6 (3.0), p &lt; 0.01]. The median (IQR) time to perform POCUS was significantly lower that plain radiography [68 (42) vs 1200 (1440) seconds, p &lt; 0.01]. POCUS was associated with comparable mean caregiver satisfaction compared to plain radiography [4.7 (0.7) vs 4.4 (1.0), p = 0.15].

CONCLUSION: This prospective study of POCUS for non-angulated distal forearm injuries in children suggests that POCUS is associated with excellent sensitivity and specificity for the detection of cortical disruption. Furthermore, POCUS is associated with significantly less pain and procedure time compared to plain radiography. The results suggest that POCUS could be a useful diagnostic strategy in resource-limited settings for children with suspected forearm injuries and has the added benefit of lower associated pain.

Preoperative Cylex assay predicts rejection risk in patients with kidney transplant

INTRODUCTION AND OBJECTIVES

The ImmuKnow assay measures cell-mediated immunity by quantifying ATP release from CD4+ T-cells in peripheral blood. Herein, we hypothesized that this assay could predict complications associated with over-/under-immunosuppression in patients with kidney transplant (KT).

METHODS

Sixty-seven patients undergoing KT were recruited prospectively and had ATP levels measured preoperatively, and at specified intervals over two months. Clinicians were blinded to ATP levels. Clinical events including rejection and infection/cancer were documented with a median follow-up of 21 months. Parameters including absolute ATP levels and changes in ATP patterns (slopes, delta) were analyzed. Association between ATP parameters and clinical outcomes was compared using the likelihood-ratio test and Kaplan-Meier curves.

RESULTS

Absolute ATP values postoperatively had poor predictive value with regard to rejection or infection/malignancy. As well, changes in ATP values were poorly associated with complications. Importantly, patients with pre-transplant ATP values <300 ng/mL had significantly less rejection episodes vs. those with ATP values >300 ng/mL (p < 0.0001).

CONCLUSIONS

For the first time, we have evidence that a preoperative ImmuKnow level can stratify patients with KT into low/high risk groups for rejection. Future studies used to assess the utility of this assay to design individualized immunosuppressive regimens are required.

Low-volume interval training improves muscle oxidative capacity in sedentary adults

INTRODUCTION

High-intensity interval training (HIT) increases skeletal muscle oxidative capacity similar to traditional endurance training, despite a low total exercise volume. Much of this work has focused on young active individuals, and it is unclear whether the results are applicable to older less active populations. In addition, many studies have used "all-out" variable-load exercise interventions (e.g., repeated Wingate tests) that may not be practical for all individuals. We therefore examined the effect of a more practical low-volume submaximal constant-load HIT protocol on skeletal muscle oxidative capacity and insulin sensitivity in middle-aged adults, who may be at a higher risk for inactivity-related disorders.

METHODS

Seven sedentary but otherwise healthy individuals (three women) with a mean ± SD age, body mass index, and peak oxygen uptake (VO(2peak)) of 45 ± 5 yr, 27 ± 5 kg·m(-2), and 30 ± 3 mL·kg(-1)·min(-1) performed six training sessions during 2 wk. Each session involved 10 × 1-min cycling at ∼60% of peak power achieved during a ramp VO(2peak) test (eliciting ∼80%-95% of HR reserve) with 1 min of recovery between intervals. Needle biopsy samples (vastus lateralis) were obtained before training and ∼72 h after the final training session.

RESULTS

Muscle oxidative capacity, as reflected by the protein content of citrate synthase and cytochrome c oxidase subunit IV, increased by ∼35% after training. The transcriptional coactivator peroxisome proliferator-activated receptor γ coactivator 1α was increased by ∼56% after training, but the transcriptional corepressor receptor-interacting protein 140 remained unchanged. Glucose transporter protein content increased ∼260%, and insulin sensitivity, on the basis of the insulin sensitivity index homeostasis model assessment, improved by ∼35% after training.

CONCLUSIONS

Constant-load low-volume HIT may be a practical time-efficient strategy to induce metabolic adaptations that reduce the risk for inactivity-related disorders in previously sedentary middle-aged adults.