Background: Lung Ultrasound Evaluation (LUS) is usefully applied in the Emergency Department (ED) to patients with suspected or confirmed COVID-19. Diaphragmatic Ultrasound (DUS) may provide ...additional insight into ventilatory function. This proof-of-concept study aimed to evaluate the feasibility of LUS and DUS in a third level ED during the COVID-19 pandemic. Methods: Adult patients presenting with COVID-19 symptoms were eligible. After the physical examination, both LUS and DUS (i.e., diaphragmatic motion and thickness) were performed. All patients were followed after 30 days to determine their need for ventilation, admission, and/or a new ED evaluation after discharge. The diagnostic accuracies of diaphragm measurements in assessing the risk of the 30-day outcome were calculated as well as the measurements’ usefulness. Bland–Altman plots were used for comparing bedside and off-line diaphragm measurements. Results: 118 patients were enrolled. Median thickness and motion were 1.7 mm (iqr 0.4) and 1.8 cm (iqr 0.7), respectively, with a mean difference of 0.009 mm (95% CI −0.037–0.056 mm) and −0.051 cm (95% CI −0.108–0.006 cm), respectively. The 30-day outcome was associated with an increase in thickness (OR 5.84, 95% CI 0.96–35.4), and a lower motion (OR 0.49, 95% CI 0.2–1.21). Conclusion: DUS seemed to be feasible and reliable in the ED in a population of patients presenting with symptoms related to COVID-19 infection.
The prevalence of hypertension mediated organ damage (HMOD) in patients attending the Emergency Department (ED) with symptomatic blood pressure (BP) rise is unknown, and whether HMOD varies between ...asymptomatic and symptomatic patients with grade 3 hypertension is unclear.
This study aimed to investigate cardiac and vascular HMOD in hypertensive urgencies (HU) and asymptomatic outpatients with grade 1-3 hypertension.
Patients attending the ED with a symptomatic BP rise ≥180/110 mmHg were prospectively enrolled (HU group), after the exclusion of acute organ damage. HMOD and BP were assessed after 72 h from ED discharge in an office setting. These patients were matched by age and sex to outpatients with grade 3 hypertension (Grade 3 group), and by age, sex, and 72 h office BP values to outpatients with any grade hypertension (Control group).
A total of 304 patients were enrolled (76 patients in the HU group, 76 in the Grade 3 group, and 152 in the Control group). Grade 3 patients had increased left ventricular mass (LVMi) compared to patients with HU (106.9 ± 31.5 vs. 96.1 ± 30.7 g/m
,
= 0.035). Severe left ventricular hypertrophy (LVH) was more frequent in grade 3 (21.1 vs. 5.3%,
= 0.004), and pulse wave velocity (PWV) was similar in the two groups. There was no difference in LVMi between ED and Control patients (96.1 ± 30.7 vs. 95.2 ± 26.6 g/m
,
= 0.807). LVH prevalence was similar (43.4 vs. 35.5%,
= 0.209, respectively), but patients with HU had thicker interventricular septum (11.9 ± 2.2 vs. 11.1 ± 2.2 mm,
= 0.007). PWV was similar between these two groups. Patients with HU needed more antihypertensive drugs than Control patients (2 vs. 1,
< 0.001).
Patients with HU had a better cardiac HMOD profile than outpatients with grade 3 hypertension. Their cardiac and vascular HMOD is more comparable to an outpatient with similar in-office BP, although they need more antihypertensive medications.
Aims:
Pre-test probability assessment is key in the approach to suspected acute
aortic syndromes (AASs). However, most patients with AAS-compatible symptoms
are classified at low probability, ...warranting further evaluation for
decision on aortic imaging. White blood cell count, platelet count and
fibrinogen explore pathophysiological pathways mobilized in AASs and are
routinely assayed in the workup of AASs. However, the diagnostic performance
of these variables for AASs, alone and as a bundle, is unknown. We tested
the hypothesis that white blood cell count, platelet count and/or fibrinogen
at presentation may be applied as additional tools to standard clinical
evaluation for pre-test risk assessment in patients at low probability of
AAS.
Methods and results:
This was a retrospective observational study conducted on consecutive
patients managed in our Emergency Department from 2009 to 2014 for suspected
AAS. White blood cell count, platelet count and fibrinogen were assayed
during evaluation in the Emergency Department. The final diagnosis was
obtained by computed tomography angiography. The pre-test probability of AAS
was defined according to guidelines. Of 1210 patients with suspected AAS,
1006 (83.1%) were classified at low probability, and 271 (22.4%) were
diagnosed with AAS. Within patients at low probability, presence of at least
one alteration among white blood cell count >9*103/µl,
platelet count <200*103/µl and fibrinogen <350 mg/dl was
associated with a sensitivity of 95.5% (89.7–98.5%) and a specificity of
18.3% (15.6–21.2%). In patients at low probability, white blood cell count
>9*103/µl and platelet count <200*103/µl
were found as independent predictors of AAS beyond established clinical risk
markers. Within patients at low probability, the estimated risk of AAS based
on the number of alterations amongst white blood cell count
>9*103/µl and platelet count <200*103/µl was
2.7% (1.2–5.7%) with zero alterations, 11.3% (8.8–14.3%) with one alteration
and 31.9% (24.8–40%) with two alterations (p<0.001).
Conclusion:
In addition to standard clinical evaluation, white blood cell count and
platelet count may be used in patients at low pre-test probability to
fine-tune risk assessment of AAS.
Aims
Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point‐of‐care diagnostic tool, ...but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in conjunction with clinical evaluation.
Methods and results
This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non‐ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT‐proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT‐proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy area under the receiver operating characteristic curve (AUC) 0.95 than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT‐proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS‐integrated approach was higher then that of the CXR/Nt‐proBNP‐integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt‐proBNP group.
Conclusion
Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT‐proBNP.
Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still ...raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.
We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.
The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% 95% CI, 95%-98.3%; specificity, 97.4% 95% CI, 95.7%-98.6%) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% 95% CI, 81.8%-88.4%; specificity, 90% 95% CI, 87.2%-92.4%), chest radiography alone (sensitivity, 69.5% 95% CI, 65.1%-73.7%; specificity, 82.1% 95% CI, 78.6%-85.2%), and natriuretic peptides (sensitivity, 85% 95% CI, 80.3%-89%; specificity, 61.7% 95% CI, 54.6%-68.3%; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.
The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.
Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.
Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic ...strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown.
In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0-3) per current guidelines. DD was considered negative (DD-) if <500 ng/mL. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or 14-day follow-up. Outcomes were the failure rate and efficiency of a diagnostic strategy for ruling out AAS in patients with ADD-RS=0/DD- or ADD-RS ≤1/DD-.
A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval CI, 93.6-98.6) and a specificity of 64% (95% CI, 61.6-66.4) for the diagnosis of AAS; 8 patients with AAS had DD-. In 294 patients with ADD-RS=0/DD-, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1.9) and an efficiency of 15.9% (95% CI, 14.3-17.6) for the ADD-RS=0/DD- strategy. In 924 patients with ADD-RS ≤1/DD-, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1) and an efficiency of 49.9% (95% CI, 47.7-52.2) for the ADD-RS ≤1/DD- strategy.
Integration of ADD-RS (either ADD-RS=0 or ADD-RS ≤1) with DD may be considered to standardize diagnostic rule out of AAS.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT02086136.
Accurate diagnostic testing to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is critical. Although highly specific, SARS-CoV-2 reverse transcriptase–polymerase chain ...reaction (RT-PCR) has been shown in clinical practice to be affected by a noninsignificant proportion of false-negative results. This study seeks to explore whether the integration of lung ultrasonography with clinical evaluation is associated with increased sensitivity for the diagnosis of coronavirus disease 2019 pneumonia, and therefore may facilitate the identification of false-negative SARS-CoV-2 RT-PCR results.
This prospective cohort study enrolled consecutive adult patients with symptoms potentially related to SARS-CoV-2 infection who were admitted to the emergency department (ED) of an Italian academic hospital. Immediately after the initial assessment, a lung ultrasonographic evaluation was performed and the likelihood of SARS-CoV-2 infection, based on both clinical and lung ultrasonographic findings (“integrated” assessment), was recorded. RT-PCR SARS-CoV-2 detection was subsequently performed.
We enrolled 228 patients; 107 (46.9%) had SARS-CoV-2 infection. Sensitivity and negative predictive value of the clinical–lung ultrasonographic integrated assessment were higher than first RT-PCR result (94.4% 95% confidence interval {CI} 88.2% to 97.9% versus 80.4% 95% CI 71.6% to 87.4% and 95% 95% CI 89.5% to 98.2% versus 85.2% 95% CI 78.3% to 90.6%, respectively). Among the 142 patients who initially had negative RT-PCR results, 21 tested positive at a subsequent molecular test performed within 72 hours. All these false-negative cases were correctly identified by the integrated assessment.
This study suggests that, in patients presenting to the ED with symptoms commonly associated with SARS-CoV-2 infection, the integration of lung ultrasonography with clinical evaluation has high sensitivity and specificity for coronavirus disease 2019 pneumonia and it may help to identify false-negative results occurring with RT-PCR.
The insertion of peripheral intravenous (PIV) catheters is one of the most performed invasive procedures in acute healthcare settings. However, peripheral difficult vascular access (PDVA) is not ...uncommon and can lead to delays in administering essential medications. Ultrasound (US) has emerged as a valuable tool for facilitating PIV cannulation. Advancements in technology have introduced a technique known as bi-plane imaging, allowing the simultaneous display of both longitudinal and transverse views of vessels. We aimed to investigate whether the utilization of bi-plane imaging, as opposed to the single-plane approach, would yield superior results for PDVA in the emergency department (ED).
This study was a single-center randomized controlled trial. We included adult patients admitted to the ED who required PIV cannulation. Patients were randomly assigned to undergo cannulation using either the mono-plane or bi-plane approach, both performed by skilled providers. The primary outcome of the study was to compare the first attempt success rates between the two techniques.
A total of 442 patients were enrolled, with 221 undergoing cannulation attempts using the mono-plane approach. Successful placement of a functioning PIV catheter was achieved in a single attempt for 313 out of 442 patients (70.8%). There was no significant difference in the success rates between the two study groups: 68.3% in the mono-plane group and 73.3% in the bi-plane group (p = 0.395). The median time required for a successful attempt differed between the groups, with 45 s (range 18–600) in the mono-plane group and 35 s (range 20–600) in the bi-plane group (p = 0.03).
Our study confirms that US is a highly effective tool for facilitating PIV cannulation in patients with PDVA presenting to the ED. However, our investigation into the use of bi-plane imaging did not reveal a significant improvement when compared to mono-plane imaging.
This prospective cohort enrolled all patients above 16 years of age presenting to the in the emergency department (ED) for a reported syncope was designed to test the accuracy of a point-of-care ...ultrasound (POCUS) integrated approach in risk stratification. The emergency physician responsible for the patient care was asked to classify the syncope risk after the initial clinical assessment and after performing POCUS evaluation. All risk group definitions were based on the 2018 European Society of Cardiology guidelines. Thirty days after the index event, all participants were followed up to assess the frequency of short-term serious outcomes as defined in the San Francisco Syncope Rule (SFSR) cohorts. We estimated the accuracy of clinical and POCUS-integrated evaluation in predicting SFSR outcomes. Between February 2016 and January 2018, 196 patients were enrolled 109 women (55.6%). Median age was 64 years (interquartile range 31 years). After a follow-up of 30 days, 19 patients experienced 20 SFSR outcomes. Positive and negative likelihood ratios were 1.73 (95% CI 0.87–3.44) and 0.84 (95% CI 0.62–1.12) for the clinical evaluation, and 5.93 (95% CI 2.83–12.5) and 0.63 (95% CI 0.45–0.9) for the POCUS-integrated evaluation. The POCUS-integrated approach would reduce the diagnostic error of the clinical evaluation by 4.5 cases/100 patients. This cohort study suggested that the integration of the clinical assessment with POCUS results in patients presenting to the ED for non-high-risk syncope may increase the accuracy of predicting the risk of SFSR outcomes and the usefulness of the clinical assessment alone.
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