Health system-scale language models are all-purpose prediction engines

Physicians make critical time-constrained decisions every day. Clinical predictive models can help physicians and administrators make decisions by forecasting clinical and operational events. Existing structured data-based clinical predictive models have limited use in everyday practice owing to complexity in data processing, as well as model development and deployment1-3. Here we show that unstructured clinical notes from the electronic health record can enable the training of clinical language models, which can be used as all-purpose clinical predictive engines with low-resistance development and deployment. Our approach leverages recent advances in natural language processing4,5 to train a large language model for medical language (NYUTron) and subsequently fine-tune it across a wide range of clinical and operational predictive tasks. We evaluated our approach within our health system for five such tasks: 30-day all-cause readmission prediction, in-hospital mortality prediction, comorbidity index prediction, length of stay prediction, and insurance denial prediction. We show that NYUTron has an area under the curve (AUC) of 78.7-94.9%, with an improvement of 5.36-14.7% in the AUC compared with traditional models. We additionally demonstrate the benefits of pretraining with clinical text, the potential for increasing generalizability to different sites through fine-tuning and the full deployment of our system in a prospective, single-arm trial. These results show the potential for using clinical language models in medicine to read alongside physicians and provide guidance at the point of care.

Sample Preparation and Diagnostic Methods for a Variety of Settings: A Comprehensive Review

Sample preparation is an essential step for nearly every type of biochemical analysis in use today. Among the most important of these analyses is the diagnosis of diseases, since their treatment may rely greatly on time and, in the case of infectious diseases, containing their spread within a population to prevent outbreaks. To address this, many different methods have been developed for use in the wide variety of settings for which they are needed. In this work, we have reviewed the literature and report on a broad range of methods that have been developed in recent years and their applications to point-of-care (POC), high-throughput screening, and low-resource and traditional clinical settings for diagnosis, including some of those that were developed in response to the coronavirus disease 2019 (COVID-19) pandemic. In addition to covering alternative approaches and improvements to traditional sample preparation techniques such as extractions and separations, techniques that have been developed with focuses on integration with smart devices, laboratory automation, and biosensors are also discussed.

Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives

The advent of portable devices in the early 80s has brought ultrasonography to the patient's bedside. Currently referred to as 'point of care ultrasonography' (POCUS), it has become an essential tool for clinicians. Initially developed in the emergency and critical care settings, POCUS has gained increasing importance in internal medicine wards in the last decade, with both its growing diagnostic accuracy and portability making POCUS an optimal instrument for everyday clinical assessment and procedures. There is large body of evidence to confirm POCUS' superiority when compared to clinical examination and standard X-ray imaging in a variety of clinical situations. On the contrary, only few indications, such as procedural guidance, have a proven additional benefit for patients. Since POCUS is highly user-dependent, pre- and post-graduate curricula are needed and the range of use should be clearly defined. This review focuses on trends and perspectives of POCUS in the management of diseases frequently encountered in emergency and internal medicine. In addition, questions are raised regarding the teaching and supervision of POCUS needing to be addressed in the near future.

Microfluidic Point-of-Care Devices: New Trends and Future Prospects for eHealth Diagnostics

Point-of-care (PoC) diagnostics is promising for early detection of a number of diseases, including cancer, diabetes, and cardiovascular diseases, in addition to serving for monitoring health conditions. To be efficient and cost-effective, portable PoC devices are made with microfluidic technologies, with which laboratory analysis can be made with small-volume samples. Recent years have witnessed considerable progress in this area with “epidermal electronics”, including miniaturized wearable diagnosis devices. These wearable devices allow for continuous real-time transmission of biological data to the Internet for further processing and transformation into clinical knowledge. Other approaches include bluetooth and WiFi technology for data transmission from portable (non-wearable) diagnosis devices to cellphones or computers, and then to the Internet for communication with centralized healthcare structures. There are, however, considerable challenges to be faced before PoC devices become routine in the clinical practice. For instance, the implementation of this technology requires integration of detection components with other fluid regulatory elements at the microscale, where fluid-flow properties become increasingly controlled by viscous forces rather than inertial forces. Another challenge is to develop new materials for environmentally friendly, cheap, and portable microfluidic devices. In this review paper, we first revisit the progress made in the last few years and discuss trends and strategies for the fabrication of microfluidic devices. Then, we discuss the challenges in lab-on-a-chip biosensing devices, including colorimetric sensors coupled to smartphones, plasmonic sensors, and electronic tongues. The latter ones use statistical and big data analysis for proper classification. The increasing use of big data and artificial intelligence methods is then commented upon in the context of wearable and handled biosensing platforms for the Internet of things and futuristic healthcare systems.

Microfluidics-Implemented Biochemical Assays: From the Perspective of Readout

Over the past decades, microfluidics has emerged as an increasingly important tool to perform biochemical assays for diagnosis and healthcare. The precise fluid control and molecule manipulation within microfluidics greatly contribute to developing assays with simplicity and convenience. The advantages of microfluidics, including decreased consumption of reagents and samples, lower operating and analysis time, much lower cost, and higher integration and automation over traditional systems, offer a great platform to meet the needs of point-of-care applications. In this Review, versatile strategies are outlined and recent advances in microfluidics-implemented assays are discussed from the perspective of readout, because a convenient and straightforward readout is what a biochemical assay requires and the end user desires. Functions and properties arising from each readout are reviewed and the advantages and limitations of each readout are discussed together with current challenges and future perspectives.

Bedside Sonographic Duplex Technique as a Monitoring Tool in Patients after Decompressive Craniectomy: A Single Centre Experience

Background and objectives: Bedside sonographic duplex technique (SDT) may be used as an adjunct to cranial computed tomography (CCT) to monitor brain-injured patients after decompressive craniectomy (DC). The present study aimed to assess the value of SDT in repeated measurements of ventricle dimensions in patients after DC by comparing both techniques. Materials and Methods: Retrospective assessment of 20 consecutive patients after DC for refractory intracranial pressure (ICP) increase following subarachnoid hemorrhage (SAH), bleeding and trauma which were examined by SDT and CCT in the context of routine clinical practice. Whenever a repeated CCT was clinically indicated SDT examinations were performed within 24 hours and correlated via measurement of the dimensions of all four cerebral ventricles. Basal cerebral arteries including pathologies such as vasospasms were also evaluated in comparison to selected digital subtraction angiography (DSA). Results: Repeated measurements of all four ventricle diameters showed high correlation between CCT and SDT (right lateral r = 0.997, p < 0.001; left lateral r = 0.997, p < 0.001; third r = 0.991, p < 0.001, fourth ventricle r = 0.977, p < 0.001). SDT performed well in visualizing basal cerebral arteries including pathologies (e.g., vasospasms) as compared to DSA. Conclusions: Repeated SDT measurements of the dimensions of all four ventricles in patients after DC for refractory ICP increase delivered reproducible results comparable to CCT. SDT may be considered as a valuable bedside monitoring tool in patients after DC.

Point-of-care blood tests during home visits by out-of-hours primary care clinicians; a mixed methods evaluation of a service improvement

OBJECTIVES

We aimed to evaluate test usage and patient and clinician experience following the introduction of point-of-care (POC) blood tests into a primary care out-of-hours service.

DESIGN

A mixed methods service evaluation comprising quantitative records of the clinical contexts of tests taken and qualitative interviews with clinicians. Research permissions and governance were obtained for patient interviews.

SETTING

Out-of-hours primary care.

PARTICIPANTS

All patients requiring home visits from the service during the implementation period.

INTERVENTIONS

The i-STAT POC blood test platform was introduced to two bases providing home visits for a period of 8 months. Venous blood samples were used and two cartridges were available. The CHEM8 cartridge measures sodium, potassium, chloride, total carbon dioxide (TCO2), anion gap, ionised calcium, glucose, urea, creatinine, haematocrit and haemoglobin. The CG4 cartridge measures lactate, pH, PaO2 and PCO2, TCO2, bicarbonate, base excess and oxygen saturation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportion of home visits where tests were taken, the clinical contexts of those tests, the extent to which clinicians felt the tests had influenced their decisions, time taken to perform the test and problems encountered. Clinician and patient experiences of using POC tests.

RESULTS

i-STAT POC tests were infrequently used, with successful tests taken at just 47 contacts over 8 months of implementation. The patients interviewed felt that testing had been beneficial for their care. Clinician interviews suggested barriers to POC tests, including practical challenges, concerns about time, doubt over whether they would improve clinical decision making and concern about increased medicolegal risk. Suggestions for improving adoption included sharing learning, adopting a whole team approach and developing protocols for usage.

CONCLUSIONS

POC tests were not successfully adopted by an out-of-hours home visiting service in Oxfordshire. While some clinicians felt they could not add value, in other cases they resulted in improved patient experience. Adoption could be promoted by improving technical, team and education factors.

Point-of-Care Ultrasound for Obstructive Sleep Apnea Screening: Are We There Yet? A Systematic Review and Meta-analysis

BACKGROUND

Perioperative diagnosis of obstructive sleep apnea (OSA) has important resource implications as screening questionnaires are overly sensitive, and sleep studies are expensive and time-consuming. Ultrasound (US) is a portable, noninvasive tool potentially useful for airway evaluation and OSA screening in the perioperative period. The objective of this systematic review was to evaluate the correlation of surface US with OSA diagnosis and to determine whether a point-of-care ultrasound (PoCUS) for OSA screening may help with improved screening in perioperative period.

METHODS

A search of all electronic databases including Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from database inception to September 2017. Inclusion criteria were observational cohort studies and randomized controlled trials of known or suspected OSA patients undergoing surface US assessment. Article screening, data extraction, and summarization were conducted by 2 independent reviewers with ability to resolve conflict with supervising authors. Diagnostic properties and association between US parameters (index test) and OSA diagnosis using sleep study (reference standard) were evaluated. The US parameters were divided into airway and nonairway parameters. A random-effects meta-analysis was planned, wherever applicable.

RESULTS

Of the initial 3865 screened articles, 21 studies (7 airway and 14 nonairway) evaluating 3339 patients were included. Majority of studies were conducted in the general population (49%), respirology (23%), and sleep clinics (12%). No study evaluated the use of US for OSA in perioperative setting. Majority of included studies had low risk of bias for reference standard and flow and timing. Airway US parameters having moderate-good correlation with moderate-severe OSA were distance between lingual arteries (DLAs > 30 mm; sensitivity, 0.67; specificity, 0.59; 1 study/66 patients); mean resting tongue thickness (>60 mm; sensitivity, 0.85; specificity, 0.59; 1 study/66 patients); tongue base thickness during Muller maneuver (MM; sensitivity, 0.59; specificity, 0.78; 1 study/66 patients); and a combination of neck circumference and retropalatal (RP) diameter shortening during MM (sensitivity, 1.0; specificity, 0.65; 1 study/104 patients). Nonairway US parameters having a low-moderate correlation with moderate-severe OSA were carotid intimal thickness (pooled correlation coefficient, 0.444; 95% confidence interval [CI], 0.320-0.553; P value = .000, 8 studies/727 patients) and plaque presence (sensitivity, 0.24-0.75; specificity, 0.13-1.0; 4 studies/1183 patients).

CONCLUSIONS

We found that a number of airway and nonairway parameters were identified with moderate to good correlation with OSA diagnosis in the general population. In future studies, it remains to be seen whether PoCUS screening for a combination of these parameters can address the pitfalls of OSA screening questionnaires.

Recent trends in molecular diagnostics of yeast infections: from PCR to NGS

The incidence of opportunistic yeast infections in humans has been increasing over recent years. These infections are difficult to treat and diagnose, in part due to the large number and broad diversity of species that can underlie the infection. In addition, resistance to one or several antifungal drugs in infecting strains is increasingly being reported, severely limiting therapeutic options and showcasing the need for rapid detection of the infecting agent and its drug susceptibility profile. Current methods for species and resistance identification lack satisfactory sensitivity and specificity, and often require prior culturing of the infecting agent, which delays diagnosis. Recently developed high-throughput technologies such as next generation sequencing or proteomics are opening completely new avenues for more sensitive, accurate and fast diagnosis of yeast pathogens. These approaches are the focus of intensive research, but translation into the clinics requires overcoming important challenges. In this review, we provide an overview of existing and recently emerged approaches that can be used in the identification of yeast pathogens and their drug resistance profiles. Throughout the text we highlight the advantages and disadvantages of each methodology and discuss the most promising developments in their path from bench to bedside.

Current Status and Future Directions for Electronic Point-of-Care Clinical Decision Support to Improve Diabetes Management in Primary Care

In the past decade there have been major improvements in the design, use, and effectiveness of point-of-care clinical decision support (CDS) systems to improve quality of care for patients with diabetes and related conditions. Advances in data exchange, data security, and human factors research have driven these improvements. Current diabetes CDS systems have high use rates, high clinician/user satisfaction rates, and have measurably improved glucose control, blood pressure control, and cardiovascular risk trajectories in adults with diabetes. As diabetes care increasingly relies on complex biomarker-driven risk prediction methods to optimize care goals and prioritize treatment options based on potential benefit to an individual patient, CDS systems will become indispensable tools to guide clinician and patient decision-making. In this study we describe specific challenges that must be addressed further to improve the design, implementation, and effectiveness of primary care diabetes CDS systems in coming years.

Emerging Point-of-care Technologies for Food Safety Analysis

Food safety issues have recently attracted public concern. The deleterious effects of compromised food safety on health have rendered food safety analysis an approach of paramount importance. While conventional techniques such as high-performance liquid chromatography and mass spectrometry have traditionally been utilized for the detection of food contaminants, they are relatively expensive, time-consuming and labor intensive, impeding their use for point-of-care (POC) applications. In addition, accessibility of these tests is limited in developing countries where food-related illnesses are prevalent. There is, therefore, an urgent need to develop simple and robust diagnostic POC devices. POC devices, including paper- and chip-based devices, are typically rapid, cost-effective and user-friendly, offering a tremendous potential for rapid food safety analysis at POC settings. Herein, we discuss the most recent advances in the development of emerging POC devices for food safety analysis. We first provide an overview of common food safety issues and the existing techniques for detecting food contaminants such as foodborne pathogens, chemicals, allergens, and toxins. The importance of rapid food safety analysis along with the beneficial use of miniaturized POC devices are subsequently reviewed. Finally, the existing challenges and future perspectives of developing the miniaturized POC devices for food safety monitoring are briefly discussed.

Effort Thrombosis Provoked by Saxophone Performance

BACKGROUND

Internal jugular venous thrombosis (IJVT) is an uncommon condition rarely diagnosed in the outpatient setting. IJVT carries significant morbidity and mortality and must be considered in the differential diagnosis for new-onset neck pain and swelling, especially in the emergency setting. Paget-Schroetter syndrome (PSS), or primary thrombosis secondary to effort, is an uncommon, likely under-recognized etiology of thrombosis. We report a case of PSS extending from the right subclavian vein into the right internal jugular vein, suspected based upon patient history and physical examination and confirmed by point-of-care ultrasound (POCUS). We then review the presentation, causes, and diagnostic standards for PSS.

CASE REPORT

We present a case of a 79-year-old man who presented to the Emergency Department with acute right-sided neck pain 1 day after playing the saxophone for 4 h the prior evening. POCUS confirmed Paget-Schroetter syndrome, or primary effort thrombosis of the internal jugular vein. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first documented case of PSS resulting from venous stasis with prolonged Valsalva maneuver and vascular trauma with activity of playing the saxophone. The significance of this case is the unusual etiology of a rare presentation and the ability to diagnose this condition quickly and accurately with POCUS.

Point-of-care microfluidic devices for pathogen detection

The rapid diagnosis of pathogens is crucial in the early stages of treatment of diseases where the choice of the correct drug can be critical. Although conventional cell culture-based techniques have been widely utilized in clinical applications, newly introduced optical-based, microfluidic chips are becoming attractive. The advantages of the novel methods compared to the conventional techniques comprise more rapid diagnosis, lower consumption of patient sample and valuable reagents, easy application, and high reproducibility in the detection of pathogens. The miniaturized channels used in microfluidic systems simulate interactions between cells and reagents in microchannel structures, and evaluate the interactions between biological moieties to enable diagnosis of microorganisms. The overarching goal of this review is to provide a summary of the development of microfluidic biochips and to comprehensively discuss different applications of microfluidic biochips in the detection of pathogens. New types of microfluidic systems and novel techniques for viral pathogen detection (e.g. HIV, HVB, ZIKV) are covered. Next generation techniques relying on high sensitivity, specificity, lower consumption of precious reagents, suggest that rapid generation of results can be achieved via optical based detection of bacterial cells. The introduction of smartphones to replace microscope based observation has substantially improved cell detection, and allows facile data processing and transfer for presentation purposes.

Challenges in identifying antibiotic resistance targets for point-of-care diagnostics in general practice

General practitioners stand at the front line of healthcare provision and have a pivotal role in the fight against increasing antibiotic resistance. In this respect, targeted antibiotic prescribing by general practitioners would help reduce the unnecessary use of antibiotics, leading to reduced treatment failures, fewer side-effects for patients and a reduction in the (global) spread of antibiotic resistances. Current 'gold standard' antibiotic resistance detection strategies tend to be slow, taking up to 48 h to obtain a result, although the implementation of point-of-care testing by general practitioners could help achieve the goal of targeted antibiotic prescribing practices. However, deciding on which antibiotic resistances to include in a point-of-care diagnostic is not a trivial task, as outlined in this publication.

Impact of smartphone-assisted prenatal home visits on women's use of facility delivery: Results from a cluster-randomized trial in rural Tanzania

BACKGROUND

About half of births in rural Tanzania are assisted by skilled providers. Point-of-care mobile phone applications hold promise in boosting job support for community health workers aiming to ensure safe motherhood through increased facility delivery awareness, access and uptake. We conducted a controlled comparison to evaluate a smartphone-based application designed to assist community health workers with data collection, education delivery, gestational danger sign identification, and referrals.

METHODS

Community health workers in 32 randomly selected villages were cluster-randomized to training on either smartphone (intervention) or paper-based (control) protocols for use during household visits with pregnant women. The primary outcome measure was postnatal report of delivery location by 572 women randomly selected to participate in a survey conducted by home visit. A mixed-effects model was used to account for clustering of subjects and other measured factors influencing facility delivery.

FINDINGS

The smartphone intervention was associated with significantly higher facility delivery: 74% of mothers in intervention areas delivered at or in transit to a health facility, versus 63% in control areas. The odds of facility delivery among women counseled by smartphone-assisted health workers were double the odds among women living in control villages (OR, 1.96; CI, 1.21-3.19; adjusted analyses). Women in intervention areas were more likely to receive two or more visits from a community health worker during pregnancy than women in the control group (72% vs. 60%; chi-square = 6.9; p < 0.01). Previous facility delivery, uptake of antenatal care, and distance to the nearest facility were also strong independent predictors of facility delivery.

INTERPRETATION

Community health worker use of smartphones increased facility delivery, likely through increased frequency of prenatal home visits. Smartphone-based job aids may enhance community health worker support and effectiveness as one component of intervention packages targeting safe motherhood.

TRIAL REGISTRATION

NCT03161184.

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound

BACKGROUND

Gonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis.

CASE REPORT

A 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 10³/μL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

Point of Care Diagnostics for HIV in Resource Limited Settings: An Overview

Human immunodeficiency virus (HIV) is a global health problem. Early diagnosis, rapid antiretroviral therapy (ART) initiation and monitoring of viral load are the key strategies for effective HIV management. Many people in resource limited settings where timely access to medical care is a challenge and healthcare infrastructure is poor have no access to laboratory facilities and diagnosis is dependent on the presence of point of care (POC) devices. POC instruments have shown to be easy to operate, maintain and transport and can easily be operated by less skilled health workers. Additionally, POC tests do not require laboratory technicians to operate. POC devices have resulted in a growing number of people testing for HIV and thereby receiving treatment early. In recent years, there has been great improvement in the development of POC technologies for early HIV diagnosis, HIV viral load and cluster of differentiation 4 (CD4) measurement. This review discusses POC technologies that are currently available and in the pipeline for diagnosing and monitoring HIV. We also give an overview of the technical and commercialization challenges in POC diagnostics for HIV.

Infectious pathogens meet point-of-care diagnostics

The field of point-of-care (POC) diagnostics provides the rapid diagnosis of infectious diseases which is essential and critical for improving the general public health in resource-limited settings. POC platforms offer many advantages for detection of various pathogens including portability, automation, speed, cost, and efficiency. In this review, we provide an overview of the recent trends for POC diagnostics of infectious diseases with focus on portable platforms. We review here the present status of POC platforms, emphasizing in period of the past three years, then extrapolate their advance into the future applications for diagnosis of infectious pathogens.

Lab-on-Chip Devices: Gaining Ground Losing Size

Portable analytical devices are notably gaining relevance in the panorama of urgent testing. Such devices have the potential to play an important role as easy-to-handle tools in critical situations. Epidemic infectious disease agents (e.g., Ebola virus, Coronavirus, Zika virus) could be controlled more easily by testing travelers on-site at the country borders to prevent outbreaks from spreading. The increasing incidence of hospital-acquired infections caused by antibiotic resistant pathogens could be minimized by point-of-care microbial analysis as well as rapid screening tests of bacteria resistance. The threat of bioterrorism using novel unknown bioweapons has never been so high, thus, in-the-field early identification of the biological agent is crucial for triggering a coordinated response. Food allergies are a growing public health concern-allergic reactions can result in anaphylactic shock, which can prove fatal in minutes-thus, the ability to test foods for common allergens, rapidly and locally, before ingestion, would improve food safety for those with allergies. Lab-on-chip devices are becoming widely available for diverse applications and are becoming increasingly affordable. However, to shrink in price and size simultaneously, some trade-offs must be made. In this Perspective, we present considerations about product specifications, design concepts, and application scenarios.

Point-of-Care Ultrasound: A Trend in Health Care

PURPOSE

To discuss the current and growing use of point-of-care (POC) ultrasound in the management and care of patients.

METHODS

Several electronic research databases were searched to find articles that emphasized the use of POC ultrasound by health care providers who manage and treat critically ill or injured patients. Thirty-five relevant peer-reviewed journal articles were selected for this literature review.

RESULTS

Common themes identified in the literature included the use of POC ultrasound in emergency medicine, military medicine, and remote care; comparison of POC ultrasound to other medical imaging modalities; investigation of the education and training required for nonimaging health care professionals who perform POC ultrasound in their practices; and discussion of the financial implications and limitations of POC ultrasound.

DISCUSSION

POC ultrasound provides clinicians with real-time information to better manage and treat critically ill or injured patients in emergency medicine, military medicine, and remote care. In addition to providing immediate bedside diagnostic information, use of POC ultrasound has increased because of concerns regarding radiation protection. Finally, the expansion of POC ultrasound to other specialty areas requires nonimaging health care professionals to perform bedside ultrasound examinations and interpret the resulting images. Because POC ultrasound is user-dependent, adequate training is essential for all who perform and interpret the examinations.

CONCLUSION

Research involving POC ultrasound will continue as innovations and confidence in ultrasound applications advance. Future research should continue to examine the broad use of POC ultrasound in patient care and management.

Point-of-Care Ultrasonography: Is It Time Nephrologists Were Equipped With the 21th Century's Stethoscope?

In the past 3 decades, ultrasonography has gifted internal organs visualization to physicians to have a better detection of various diseases. Previously performed solely by radiologists as a method with high feasibility and accuracy, recently ultrasonography is being recommended and used by many other physicians in practice. Ultrasonography not only can be used to diagnose and manage kidney diseases, but also is an essential tool in nephrology for the guidance of invasive procedures. This method of bedside ultrasonography by physicians in real time is called point-of-care ultrasonography (POCUS). Given the limitations of collecting information by routine physical examination in kidney diseases and the simplicity of performing ultrasonography to examine kidney location, architecture, and restricted pathologies, nephrologists that have been lagging in this area, should join the spectrum of clinicians using the POCUS to provide safe and rapid diagnosis of common renal abnormalities. Although physicians may imagine POCUS as a difficult tool to use and there has been an initial resistance and reluctance to use ultrasonography by nonradiologists, investigations have shown that learning and doing POCUS was possible even for undergraduate medical students during a short course. According to the collected evidence in the field of POCUS in different branches of medicine, it seems that it should be added to nephrology examination room in the near future.

Blood Gas Analyzer Accuracy of Glucose Measurements

OBJECTIVE

To investigate the comparability of glucose levels measured with blood gas analyzers (BGAs) and by central laboratories (CLs).

MATERIAL AND METHODS

Glucose measurements obtained between June 1, 2007, and March 1, 2016, at the Vanderbilt University Medical Center were reviewed. The agreement between CL and BGA results were assessed using Bland-Altman, consensus error grid (CEG), and surveillance error grid (SEG) analyses. We further analyzed the BGAs' performance against the US Food and Drug Administration (FDA) 2014 draft guidance and 2016 final guidance for blood glucose monitoring and the International Organization for Standardization (ISO) 15197:2013 standard.

RESULTS

We analyzed 2671 paired glucose measurements, including 50 pairs of hypoglycemic values (1.9%). Bland-Altman analysis yielded a mean bias of -3.1 mg/dL, with 98.1% of paired values meeting the 95% limits of agreement. In the hypoglycemic range, the mean bias was -0.8 mg/dL, with 100% of paired values meeting the 95% limits of agreement. When using CEG analysis, 99.9% of the paired values fell within the no risk zone. Similar results were found using SEG analysis. For the FDA 2014 draft guidance, our data did not meet the target compliance rate. For the FDA 2016 final guidance, our data partially met the target compliance rate. For the ISO standard, our data met the target compliance rate.

CONCLUSION

In this study, the agreement for glucose measurement between common BGAs and CL instruments met the ISO 2013 standard. However, BGA accuracy did not meet the stricter requirements of the FDA 2014 draft guidance or 2016 final guidance. Fortunately, plotting these results on either the CEG or the SEG revealed no results in either the great or extreme clinical risk zones.

The Role of Pharmacists and Pharmacy Education in Point-of-Care Testing

Point-of-care testing (POCT) is defined as laboratory testing conducted close to the site of patient care. Although performed originally primarily by clinical staff for acute conditions, recent advances in technology have made such testing possible for disease screening and prevention across a wide range of conditions in virtually any setting, and often by individuals with little or no training. With the ongoing evolution in POCT, numerous concerns have arisen about the quality and accuracy of the tests, comparability between multiple tests for the same endpoint, interpretation of test results, and whether and how results should be used for therapeutic decisions and included in a patient's medical record. The pharmacist is well-positioned to manage and interpret POCT performed outside of the usual clinical settings. However, educational and regulatory changes are needed to enable pharmacists to take on this emerging activity effectively.

Describing complex clinical scenarios at the bed-side: Is a systems science approach useful? Exploring a novel diagrammatic approach to facilitate clinical reasoning

Clinicians often encounter patients having complex clinical scenarios (CCS) where diverse and dynamic diagnostic and therapeutic issues interact. A limited range of bedside methods are available to describe such patients and most often it is a diagnostic summary, a problem list, or a list of differential diagnoses. These methods fail to portray the interconnected nature of CCCs. They prevent visualization of a system of networks or a web of causation operative in CCSs.A more holistic conceptualization is required and the author argues for an approach based on systems science. The latter views the human body to consist of several closely linked organ systems, constantly interacting with each other and embedded in, and 'open' to the external environment. In order to capture the systems nature at bedside, a tool based on network diagrams, termed a Clinical Reasoning Map (CRM) is proposed which depicts diseases or conditions as nodes linked to each other by lines or arrows. The latter linkages follow simple rules: possible causes or associations as mere lines; probable cause using a single dotted arrow with directionality (from 'cause' to 'effect'); definite causal pathways by directional arrows; and bi-directional arrows to indicate organs-systems influencing each other.CRM's utility was investigated in several groups of undergraduate medical students. The results varied: 289, 5th year and 4th year medical students showed that 245 (85.5 %) perceived CRM improve their understanding of the case. However, there was no clear advantage in the CRM over a list of diagnoses in recall of key information. A majority (83.9 %) were keen to learn the technique of drawing a CRM. Postgraduates too found the tool to be useful to understand the interconnected nature of real-life complex case scenarios and pathogenesis of their multifaceted condition to generate differential diagnosis and to select appropriate investigations. Effectiveness of CRM is supported by adult learning theories such as meaningful learning and experiential learning.The author proposes that systems science and tools based in this approach such as CRM has utility in understanding and managing complex case scenarios. They differ significantly from other diagrammatic methods available in the medical literature.

Advances in biosensing strategies for HIV-1 detection, diagnosis, and therapeutic monitoring

HIV-1 is a major global epidemic that requires sophisticated clinical management. There have been remarkable efforts to develop new strategies for detecting and treating HIV-1, as it has been challenging to translate them into resource-limited settings. Significant research efforts have been recently devoted to developing point-of-care (POC) diagnostics that can monitor HIV-1 viral load with high sensitivity by leveraging micro- and nano-scale technologies. These POC devices can be applied to monitoring of antiretroviral therapy, during mother-to-child transmission, and identification of latent HIV-1 reservoirs. In this review, we discuss current challenges in HIV-1 diagnosis and therapy in resource-limited settings and present emerging technologies that aim to address these challenges using innovative solutions.

Practical "pearls" to help improve your care

This month's review of the current uses of ultrasound in family medicine made me wonder whether ultrasound might become the stethoscope of the future.

Point-of-care diagnostics for niche applications

Point-of-care or point-of-use diagnostics are analytical devices that provide clinically relevant information without the need for a core clinical laboratory. In this review we define point-of-care diagnostics as portable versions of assays performed in a traditional clinical chemistry laboratory. This review discusses five areas relevant to human and animal health where increased attention could produce significant impact: veterinary medicine, space travel, sports medicine, emergency medicine, and operating room efficiency. For each of these areas, clinical need, available commercial products, and ongoing research into new devices are highlighted.

Update on bedside ultrasound diagnosis of pericardial effusion

Pericardial effusion (PE) is the presence of an excess of fluid in the pericardial cavity. PE symptoms depend from the rate of fluid accumulation, ranging from mild dyspnea on exertion to shock due to cardiac tamponade. Echocardiography is usually the primary diagnostic tool when PE is suspected, as it is accurate, non-invasive, widely available, and feasible also with pocket size devices. Studies have shown a high degree of sensitivity and specificity in the detection of PE using focused cardiac ultrasound (FOCUS), which can be performed also by non-cardiologist in emergency setting or at bedside. A PE is visualized as an echo-free space between the heart and the parietal layer of the pericardium. A semi-quantification of the PE may be obtained measuring the distance between the two pericardial layers. Once PE diagnosis has been made, characterization of fluid and search for signs of possible cardiac tamponade have to be performed. While unechogenic space is usually associated with serous fluid, hemorrhagic, and purulent effusions may be suspected in the presence of corpuscolated/echogenic fluid. Echocardiography may identify cardiac tamponade before it is clinically evident, and can guide pericardiocentesis. B-mode echocardiographic signs of cardiac tamponade include cardiac chambers collapse (with right chambers collapse occurring at earlier stages), opposite changes in right and left cardiac chamber filling during respiratory cycle, inferior vena cava and hepatic vein plethora. Doppler analysis of tricuspidalic and mitral flow velocities are used for a more detailed analysis of ventricular interdependence, even though more advanced operator expertise is required.

Electrochemical detection of Pseudomonas in wound exudate samples from patients with chronic wounds

In clinical practice, point-of-care diagnostic testing has progressed rapidly in the last decade. For the field of wound care, there is a compelling need to develop rapid alternatives for bacterial identification in the clinical setting, where it generally takes over 24 hours to receive a positive identification. Even new molecular and biochemical identification methods require an initial incubation period of several hours to obtain a sufficient number of cells prior to performing the analysis. Here we report the use of an inexpensive, disposable electrochemical sensor to detect pyocyanin, a unique, redox-active quorum sensing molecule released by Pseudomonas aeruginosa, in wound fluid from patients with chronic wounds enrolled in the WE-HEAL Study. By measuring the metabolite excreted by the cells, this electrochemical detection strategy eliminates sample preparation, takes less than a minute to complete, and requires only 7.5 μL of sample to complete the analysis. The electrochemical results were compared against 16S rRNA profiling using 454 pyrosequencing. Blind identification yielded 9 correct matches, 2 false negatives, and 3 false positives giving a sensitivity of 71% and specificity of 57% for detection of Pseudomonas. Ongoing enhancement and development of this approach with a view to develop a rapid point-of-care diagnostic tool is planned.

[Trends in indication of selected laboratory methods by general practitioners]

The indication of laboratory methods in general practice is significantly influenced by practical guidelines and protocols for preventive care. The financial regulation pushes on rationalisation of the use of laboratory methods. Point of care testing is more and more important in prevention, diagnostics and follow up in primary care settings.Based on the data available from Škoda Insurance Company authors aimed to describe trends in induction and cost of laboratory methods, the most frequent methods used in primary care and trends in the use of POCT methods within general practice.The expenditures for laboratory methods in general practice are stable for a long term and suggest a rational behaviour of general practitioners. The most frequently indicated methods in general practice are glycaemia, ALT and AST. From expensive methods the most frequent are PSA, troponin and tumormarkers. The number of general practices performing POCT methods and also the number of POCT examinations increase. More than one half of INR examinations and nearly half of all CRP examinations are performed in POCT regime.

KEY WORDS

laboratory methods, clinical biochemistry, general practitioner, primary care, POCT.

The Development and Use of Evidence Summaries for Point of Care Information Systems: A Streamlined Rapid Review Approach

BACKGROUND

A systematic review of evidence is the research method which underpins the traditional approach to evidence-based health care. As systematic reviews follow a rigorous methodology, they can take a substantial amount of time to complete ranging in duration from 6 months to 2 years. Rapid reviews have been proposed as a method to provide summaries of the literature in a more timely fashion.

AIM

The aim of this paper is to outline our experience of developing evidence summaries in the context of a point of care resource as a contribution to the emerging field of rapid review methodologies.

METHODS

Evidence summaries are defined as a synopsis that summarizes existing international evidence on healthcare interventions or activities. These summaries are based on structured searches of the literature and selected evidence-based healthcare databases. Following the search, all studies are assessed for internal validity using an abridged set of critical appraisal tools. Once developed, they undergo three levels of peer review by internal and external experts.

RESULTS

As of November 2014, there are 2458 evidence summaries that have been created across a range of conditions to inform evidence-based healthcare practices. In addition, there is ongoing development of various new evidence summaries on a wide range of topics. Approximately 60-70 new evidence summaries are published every month, covering research in various medical specialty areas. All summaries are updated annually.

LINKING EVIDENCE TO ACTION

Systematic reviews, although the ideal type of research to inform practice, often do not meet the needs of users at the point of care. This article describes the development framework for the creation of evidence summaries, a type of rapid review. Although evidence summaries may result in a less rigorous process of development, they can be useful for improving practice at the point of care.

Point-of-care testing in the diagnosis of gastrointestinal cancers: Current technology and future directions

Point-of-care (POC) tests enable rapid results and are well established in medical practice. Recent advances in analytical techniques have led to a new generation of POC devices that will alter gastrointestinal diagnostic pathways. This review aims to identify current and new technologies for the POC diagnosis of gastrointestinal cancer. A structured search of the Embase and Medline databases was performed. Papers reporting diagnostic tests for gastrointestinal cancer available as a POC device or containing a description of feasibility for POC application were included. Studies recovered were heterogeneous and therefore results are presented as a narrative review. Six diagnostic methods were identified (fecal occult blood, fecal proteins, volatile organic compounds, pyruvate kinase isoenzyme type M2, tumour markers and DNA analysis). Fecal occult blood testing has a reported sensitivity of 66%-85% and specificity greater than 95%. The others are at a range of development and clinical application. POC devices have a proven role in the diagnosis of gastrointestinal cancer. Barriers to their implementation exist and the transition from experimental to clinical medicine is currently slow. New technologies demonstrate potential to provide accurate POC tests and an ability to diagnose gastrointestinal cancer at an early stage with improved clinical outcome and survival.

Bedside diagnosis of dysphagia: a systematic review

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Portable ultrasound in disaster triage: a focused review

Ultrasound technology has become ubiquitous in modern medicine. Its applications span the assessment of life-threatening trauma or hemodynamic conditions, to elective procedures such as image-guided peripheral nerve blocks. Sonographers have utilized ultrasound techniques in the pre-hospital setting, emergency departments, operating rooms, intensive care units, outpatient clinics, as well as during mass casualty and disaster management. Currently available ultrasound devices are more affordable, portable, and feature user-friendly interfaces, making them well suited for use in the demanding situation of a mass casualty incident (MCI) or disaster triage. We have reviewed the existing literature regarding the application of sonology in MCI and disaster scenarios, focusing on the most promising and practical ultrasound-based paradigms applicable in these settings.

Non-invasive bedside assessment of central venous pressure: scanning into the future

BACKGROUND

Noninvasive evaluation of central venous pressure (CVP) can be achieved by assessing the Jugular Venous Pressure (JVP), Peripheral Venous Collapse (PVC), and ultrasound visualization of the inferior vena cava. The relative accuracy of these techniques compared to one another and their application by trainees of varying experience remains uncertain. We compare the application and utility of the JVP, PVC, and handheld Mini Echo amongst trainees of varying experience including a medical student, internal medicine resident, and cardiology fellow. We also introduce and validate a new physical exam technique to assess central venous pressures, the Anthem sign.

METHODS

Patients presenting for their regularly scheduled echocardiograms at the hospital echo department had clinical evaluations of their CVP using these non-invasive bedside techniques. The examiners were blinded to the echo results, each other's assessments, and patient history; their CVP estimates were compared to the gold standard level 3 echo-cardiographer's estimates at the completion of the study.

RESULTS

325 patients combined were examined (mean age 65, s.d. 16 years). When compared to the gold standard of central venous pressure by a level 3 echocardiographer, the JVP was the most sensitive at 86%, improving with clinical experience (p<0.01). The classic PVC technique and Anthem sign had better specificity compared to the JVP. Mini Echo estimates were comparable to physical exam assessments.

CONCLUSIONS

JVP evaluation is the most sensitive physical examination technique in CVP assessments. The PVC techniques along with the newly described Anthem sign may be of value for the early learner who still has not mastered the art of JVP assessment and in obese patients in whom JVP evaluation is problematic. Mini Echo estimates of CVPs are comparable to physical examination by trained clinicians and require less instruction. The use of Mini Echo in medical training should be further evaluated and encouraged.

Advancing stem cell therapy from bench to bedside: lessons from drug therapies

The inadequacy of existing therapeutic tools together with the paucity of organ donors have always led medical researchers to innovate the current treatment methods or to discover new ways to cure disease. Emergence of cell-based therapies has provided a new framework through which it has given the human world a new hope. Though relatively a new concept, the pace of advancement clearly reveals the significant role that stem cells will ultimately play in the near future. However, there are numerous uncertainties that are prevailing against the present setting of clinical trials related to stem cells: like the best route of cell administration, appropriate dosage, duration and several other applications. A better knowledge of these factors can substantially improve the effectiveness of disease cure or organ repair using this latest therapeutic tool. From a certain perspective, it could be argued that by considering certain proven clinical concepts and experience from synthetic drug system, we could improve the overall efficacy of cell-based therapies. In the past, studies on synthetic drug therapies and their clinical trials have shown that all the aforementioned factors have critical ascendancy over its therapeutic outcomes. Therefore, based on the knowledge gained from synthetic drug delivery systems, we hypothesize that by employing many of the clinical approaches from synthetic drug therapies to this new regenerative therapeutic tool, the efficacy of stem cell-based therapies can also be improved.