Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.
TL;DR: In an emergency setting, this new ultraportable echoscope (PUD) was reliable for the real-time detection of focused cardiac abnormalities.
Abstract: Introduction
In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.
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TL;DR: Focused cardiac ultrasonography (FoCUS) can be done (and repeated) quickly, allowing clinicians to interpret results in the context of the individual patient and guide management accordingly, and benefits extend across a wide range of clinical settings where formal echocardiography is not immediately available, is cost-prohibitive, or is not indicated on the basis of current guidelines.
Abstract: Background Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation. Purpose To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation. Data Sources English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations. Study Selection Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard. Data Extraction Three study investigators independently abstracted data and assessed study quality. Data Synthesis Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%). Limitation Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias. Conclusion Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination. Primary Funding Source None. (PROSPERO: CRD42019124318).
19 citations
TL;DR: The evidence for FoCUS in clinical practice is reviewed, specifically evaluating the diagnostic accuracy, the impact on clinical decision making, and the effect on clinical outcomes.
17 citations
TL;DR: Some of the key literature on the use of focused, point-of-care ultrasound by noncardiologists is reviewed and feasibility, clinical utility, and emerging trends are reviewed.
Abstract: Cardiac ultrasound has been used for decades to assess a wide variety of structural and functional pathology, as well as to monitor response to therapy. It offers the advantages of noninvasive, real-time dynamic functional assessment without the risk of radiation. Cardiologists have traditionally employed this modality and have established robust guidelines on the use of echocardiography. However, other specialties such as emergency medicine and critical care have realized the benefit of cardiac ultrasound and have established specialty guidelines in its use. There is growing evidence for the benefit of cardiac ultrasound at the point of care on hospital wards, clinics, and even pre-hospital environments as well. The pervasive use of focused ultrasound is perhaps most evident in the advent of ultrasound training in undergraduate medical curricula. This paper reviews some of the key literature on the use of focused, point-of-care ultrasound by noncardiologists. Feasibility, clinical utility, and emerging trends are reviewed.
15 citations
Cites methods from "Evaluation of a new pocket echoscop..."
...Hand-held echocardiography was then studied in 61 ICU patients, and the ability of residents to address clinical questions was assessed....
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...Adequate image acquisition was demonstrated by emergency physicians in all 151 patients enrolled in another study of pocket-sized ultrasound devices in an ICU [26]....
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...Left ventricular function and inferior vena cava diameter were assessed in 31 pediatric ICU patients....
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...Another study of clinical utility in the ICU assessed a protocol of focused transthoracic echo; adequate images were obtained in 97% of cases....
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...Vignon et al. [28] studied residents in an ICU environment who underwent a focused training program consisting of a 3-h training course and 5 h of hands-on practice....
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TL;DR: Some of the challenges with rapid uptake of focused cardiac ultrasonography are examined and possible mechanisms for cross‐specialty collaboration, quality improvement, and oversight are proposed.
Abstract: Focused cardiac ultrasonography is performed by clinicians at the bedside and is used in time-sensitive scenarios to evaluate a patient's cardiovascular status when comprehensive echocardiography is not immediately available This simplified cardiac ultrasonography is often performed by noncardiologists using small, portable devices to augment the physical examination, triage patients, and direct management in both critical care and outpatient settings However, as the use of focused cardiac ultrasonography continues to expand, careful consideration is required regarding training, scope of practice, impact on patient outcomes, and medicolegal implications In this review, we examine some of the challenges with rapid uptake of this technique and explore the benefits and potential risk of focused cardiac ultrasonography We propose possible mechanisms for cross-specialty collaboration, quality improvement, and oversight
13 citations
TL;DR: HHE provided the basis for correct cardiac diagnoses and management for all the subjects with acceptable HHE imaging and has potential as a tool to complement physical examination in outpatient pediatric cardiology.
Abstract: Adult patient series have shown hand-held echocardiography (echo) units (HHE) to be accurate for rapid diagnosis and triage. This is the first study to evaluate the ability of HHE to inform decision making in outpatient pediatric cardiology. New pediatric cardiology patients in outpatient clinics staffed by six pediatric cardiologists (experience 1–17 years) were prospectively enrolled if an echocardiogram (echo) was ordered during their initial visit. After history and physical examination and before a standard echo, the cardiologists performed a bedside HHE examination (GE Vscan 1.7–3.8 MHz), documented findings, and made a clinical decision. Diagnoses and decisions based on HHE were compared with final management after the standard echo. The study enrolled 101 subjects (ages 9 days to 19 years). The cardiologists considered HHE imaging adequate for decision making for 80 of the 101 subjects. For 77 of the 80 subjects with acceptable HHE imaging (68/68 normal and 9/12 abnormal standard echoes), the HHE-based primary diagnoses and decisions agreed with the final management. The sensitivity of HHE was 75 % (95 % confidence interval [CI] 43–94 %) and the positive predictive value 100 % (95 % CI 66–100 %) for pediatric heart disease. The agreement between standard echocardiography and HHE imaging was substantial (κ = 0.82). Excluding one of the least experienced cardiologists, HHE provided the basis for correct cardiac diagnoses and management for all the subjects with acceptable HHE imaging (58/58 normal and 9/9 abnormal echoes). In outpatient pediatric cardiology, HHE has potential as a tool to complement physical examination. Further investigation is needed to evaluate how value improves with clinical experience.
13 citations
References
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TL;DR: A general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies is presented and tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interob server agreement are developed as generalized kappa-type statistics.
Abstract: This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
64,109 citations
TL;DR: An alternative approach, based on graphical techniques and simple calculations, is described, together with the relation between this analysis and the assessment of repeatability.
43,884 citations
"Evaluation of a new pocket echoscop..." refers methods in this paper
...LVEFs obtained with the two devices were compared by using linear correlation and Bland and Altman analysis [25]....
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TL;DR: In this article, the authors present a procedure for having two or more judges independently categorize a sample of units and determine the degree, significance, and significance of the units. But they do not discuss the extent to which these judgments are reproducible, i.e., reliable.
Abstract: CONSIDER Table 1. It represents in its formal characteristics a situation which arises in the clinical-social-personality areas of psychology, where it frequently occurs that the only useful level of measurement obtainable is nominal scaling (Stevens, 1951, pp. 2526), i.e. placement in a set of k unordered categories. Because the categorizing of the units is a consequence of some complex judgment process performed by a &dquo;two-legged meter&dquo; (Stevens, 1958), it becomes important to determine the extent to which these judgments are reproducible, i.e., reliable. The procedure which suggests itself is that of having two (or more) judges independently categorize a sample of units and determine the degree, significance, and
34,965 citations
"Evaluation of a new pocket echoscop..." refers methods in this paper
...The ability of the PUD to discriminate the severity of the global LV systolic dysfunction (normal was greater than 50%, moderately depressed was 30% to 50%, and severely depressed was less than 30%) was tested by using Cohen’s coefficient, and 95% confidence intervals (CIs) were calculated [26]....
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...The agreement between the clinical responses provided by the two devices was assessed by using Cohen’s coefficient, and 95% CIs were calculated [26]....
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TL;DR: This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.
Abstract: Quantification of cardiac chamber size, ventricular mass and function ranks among the most clinically important and most frequently requested tasks of echocardiography. Over the last decades, echocardiographic methods and techniques have improved and expanded dramatically, due to the introduction of higher frequency transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and other technological advancements. Furthermore, echocardiography due to its portability and versatility is now used in emergency rooms, operating rooms, and intensive care units. Standardization of measurements in echocardiography has been inconsistent and less successful, compared to other imaging techniques and consequently, echocardiographic measurements are sometimes perceived as less reliable. Therefore, the American Society of Echocardiography, working together with the European Association of Echocardiography, a branch of the European Society of Cardiology, has critically reviewed the literature and updated the recommendations for quantifying cardiac chambers using echocardiography. This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.
4,014 citations
"Evaluation of a new pocket echoscop..." refers methods in this paper
...For the purpose of this study, the systematic examination using conventional TTE was considered the reference diagnostic method to measure each variable, as recommended by the European Association of Echocardiography [21]....
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...Recently, a consensus statement by the American Society of Echocardiography/American College of Emergency Physicians emphasized the complementary role of focused cardiac US to that of a more comprehensive echocardiography [9]....
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...A report from the Echocardiography Task Force on New Technology of the Nomenclature and Standards Committee of the American Society of Echocardiography....
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TL;DR: This review includes videos demonstrating the use of ultrasonography to guide central venous access, detect pneumothorax, detect evidence of hemorrhage after trauma, and screen for abdominal aortic aneurysm.
Abstract: Compact ultrasound technology has facilitated growth in point-of-care uses in many specialties. This review includes videos demonstrating the use of ultrasonography to guide central venous access, detect pneumothorax, detect evidence of hemorrhage after trauma, and screen for abdominal aortic aneurysm.
1,267 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...Because standard echocardiographic equipment may be heavy and difficult to handle, hand-carried ultrasound (US) devices have been developed for bedside use, facilitating the growth of point-of-care ultrasonography [5]....
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