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This study aims to evaluate the feasibility and clinical interest of shear wave elastography, by quantitatively estimating the baseline stiffness of the myometrium before and after placental expulsion. We conducted a prospective cohort study of women at term, without known risk factors for postpartum hemorrhage, who gave birth via spontaneous labor in our tertiary center. Myometrium tonicity was evaluated based on measurements of shear wave speed (SWS) in the anterior uterine corpus. All data points were collected by a single operator. Measurements were carried out at three different time points: after fetal delivery (T1), after placental delivery (T2) and 30 min after placental delivery (T3). Our primary objective was to assess the feasibility of this new imaging technique. Ten valid SWS measurements obtained at each of the three different time points were considered as a positive primary outcome. Our secondary objectives were to evaluate the difference in median myometrial shear wave velocity between each time point, as well as to determine the correlation between myometrial shear wave velocity and patients’ characteristics. 38 women were recruited during the study period, of whom 34 met the study criteria. 1017 SWS measurements were obtained. The median time to perform measurements was 16 s for one value, and 2 min 56 s for ten. For 11 women (32%) it was not possible to achieve ten SWS at T1 as placental expulsion immediately followed the birth of the newborn. One patient experienced placental retention and only measurements at T1 were performed. For all other patients, we were successfully able to obtain all measures as intended. There was no difference in the mean shear wave speed between the three time points. After adjustments for confounders, we observed a significant correlation for total blood loss (correlation coefficient = − 0.26, p  < 0.001, units of oxytocin (correlation coefficient = − 0.34, p  = 0.03), and newborn weight (correlation coefficient = − 0.08, p  = 0.001). It is feasible to assess uterine tonicity by shear wave imaging, after placental expulsion. We did not observe a variance in uterine tonicity between the three time points. Women who had higher blood loss, received more units of oxytocin and/or those with newborns of a higher weight exhibited lower shear wave speed measures.

High-resolution micro-ultrasound (micro-US) is a novel precise imaging modality that allows targeted prostate biopsies and multiparametric magnet resonance imaging (mpMRI) fusion. Its high resolution relying on a 29 MHz transducer allows real-time visualisation of prostate cancer lesions; this might overcome the inaccuracy of conventional MRI-US fusion biopsy strategies. We compared cancer detection rates in patients who underwent transrectal (TR-B) versus transperineal (TP-B) MR-micro-US fusion biopsy. 1:2 propensity score matching was performed in 322 consecutive procedures: 56 TR-B and 266 TP-B. All prostate biopsies were performed using ExactVuTM micro-US system with mpMRI image fusion. Clinically significant disease was defined as grade group ≥2. The primary objective was to evaluate the detection of clinically significant disease according to access route. The secondary outcomes were to compare the respective detection rates of random and targeted biopsies stratified per access route and to evaluate micro-US for its potential added value. 47 men undergoing TR-B and 88 undergoing TP-B were matched for age, PSA, clinical stage, prostate volume, PIRADS score, number of mpMRI-visible lesions and indication to biopsy. The detection rates of clinically significant and of any prostate cancer did not differ between the two groups (45% TR-B vs 42% TP-B; p = 0.8, and 57% TR-B vs 59% TP-B; p = 0.9, respectively). Detection rates also did not differ significantly between random (p = 0.4) and targeted biopsies (p = 0.7) stratified per access route. Micro-US targeted biopsy detected 36 MRI-invisible lesions in 33 patients; 19% of these lesions were positive for clinically significant disease. Overall, micro-US targeted biopsies upgraded 2% of patients to clinically significant disease that would have been missed otherwise. MR-micro-US-fusion TR-B and TP-B have similar diagnostic yields in terms of detection rates of clinically significant prostate cancer. Micro-US targeted biopsy appears to have an additional diagnostic value over systematic and MRI-targeted biopsies.

ObjectivesWe aimed to explore the acceptance and opinions of general practitioners (GPs) on the use of procalcitonin point-of-care and lung ultrasonography for managing patients with lower respiratory tract infections in primary care. We suppose that there are several factors that can influence the physician’s antibiotic prescribing decision, and the implementation of a new tool will only be possible when it can be inserted into the physician’s daily practice, helping him/her in the decision-making process.DesignSemistructured interviews; data analysis using the grounded theory method.SettingLausanne, Switzerland.Participants12 GPs who participated in the randomised clinical trial UltraPro, which evaluated the impact of the use of procalcitonin only or an algorithm combining procalcitonin and lung ultrasonography on antibiotic prescription.ResultsGPs had mostly positive attitudes towards the use of point-of-care procalcitonin in lower respiratory tract infections and uncertainties regarding the usefulness of ultrasonography. Physicians’ prescribing decisions result from interactions between three kinds of TrustS (core category): ‘self-confidence’, ‘trust in the results’ and ‘trust in the doctor–patient relationship’. Procalcitonin reinforced the three levels of trust, while ultrasonography only strengthened the physician–patient relationship. To facilitate implementation of procalcitonin, physicians pointed out the need of coverage by insurance and of clear guidelines describing the targeted patient population.ConclusionsOur data show that there is a preference for the implementation of procalcitonin rather than lung ultrasonography for the management of patients with lower respiratory tract infections in primary care. Coverage by insurance plans and updated guidelines are prerequisite to the successful implementation of procalcitonin testing in primary care.Trial Registration numberNCT03191071

Objectives: We investigated spatial patterns between primary and recurrent tumor sites and assessed long-term toxicity after dose escalation stereotactic body radiation therapy (SBRT) to the dominant intra-prostatic nodule (DIN). Materials and methods: In 33 patients with intermediate–high-risk prostate cancer (PCa), doses up to 50 Gy were administered to the DIN. Recurrence sites were determined and compared to the original tumor development sites through multiparametric MRI and 68Ga-labeled prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (68Ga-PSMA-PET/CT) images. Overlap rates, categorized as 75% or higher for full overlap, and 25–74% for partial overlap, were assessed. Long-term toxicity is reported. Results: All patients completed treatment, with only one receiving concomitant androgen deprivation therapy (ADT). Recurrences were diagnosed after a median of 33 months (range: 17–76 months), affecting 13 out of 33 patients (39.4%). Intra-prostatic recurrences occurred in 7 patients (21%), with ≥75% overlap in two, a partial overlap in another two, and no overlap in the remaining three patients. Notably, five patients with intra-prostatic recurrences had synchronous bone and/or lymph node metastases, while six patients had isolated bone or lymph node metastasis without intra-prostatic recurrences. Extended follow-up revealed late grade ≥ 2 GU and GI toxicity in 18% (n = 6) and 6% (n = 2) of the patients. Conclusions: Among patients with intermediate–high-risk PCa undergoing focal dose-escalated SBRT without ADT, DIN recurrences were infrequent. When present, these recurrences were typically located at the original site or adjacent to the initial tumor. Conversely, relapses beyond the DIN and in extra-prostatic (metastatic) sites were prevalent, underscoring the significance of systemic ADT in managing this patient population. Advances in knowledge: Focal dose-escalated prostate SBRT prevented recurrences in the dominant nodule; however, extra-prostatic recurrence sites were frequent.

ObjectivesEarly identification of SARS-CoV-2 infection is important to guide quarantine and reduce transmission. This study evaluates the diagnostic performance of lung ultrasound (LUS), an affordable, consumable-free point-of-care tool, for COVID-19 screening.Design, setting and participantsThis prospective observational cohort included adults presenting with cough and/or dyspnoea at a SARS-CoV-2 screening centre of Lausanne University Hospital between 31 March and 8 May 2020.InterventionsInvestigators recorded standardised LUS images and videos in 10 lung zones per patient. Two blinded independent experts reviewed LUS recording and classified abnormal findings according to prespecified criteria to investigate their predictive value to diagnose SARS-CoV-2 infection according to PCR on nasopharyngeal swabs (COVID-19 positive vs COVID-19 negative).Primary and secondary outcome measuresWe finally combined LUS and clinical findings to derive a multivariate logistic regression diagnostic score.ResultsOf 134 included patients, 23% (n=30/134) were COVID-19 positive and 77% (n=103/134) were COVID-19 negative; 85%, (n=114/134) cases were previously healthy healthcare workers presenting within 2–5 days of symptom onset (IQR). Abnormal LUS findings were significantly more frequent in COVID-19 positive compared with COVID-19 negative (45% vs 26%, p=0.045) and mostly consisted of focal pathologic B lines. Combining clinical findings in a multivariate logistic regression score had an area under the receiver operating curve of 80.3% to detect COVID-19, and slightly improved to 84.5% with the addition of LUS features.ConclusionsCOVID-19-positive patients are significantly more likely to have lung pathology by LUS. However, LUS has an insufficient sensitivity and is not an appropriate screening tool in outpatients. LUS only adds little value to clinical features alone.

Background: Teaching medical ultrasound has increased in popularity in medical schools with hands-on workshops as an essential part of teaching. However, the lockdown due to COVID-19 kept medical schools from conducting these workshops. Objective: The aim of this paper is to describe an alternative method used by our medical school to allow our students to acquire the essential psychomotor skills to produce ultrasound images. Methods: Our students took online ultrasound courses. Consequently, they had to practice ultrasound exercises on a virtual simulator, using the mouse of their computer to control a simulated transducer. Our team measured the precision reached at the completion of simulation exercises. Before and after completion of the courses and simulator’s exercises, students had to complete a questionnaire dedicated to psychomotor skills. A general evaluation questionnaire was also submitted. Results: A total of 193 students returned the precourse questionnaire. A total of 184 performed all the simulator exercises and 181 answered the postcourse questionnaire. Of the 180 general evaluation questionnaires that were sent out, 136 (76%) were returned. The average precourse score was 4.23 (SD 2.14). After exercising, the average postcourse score was 6.36 (SD 1.82), with a significant improvement (P<.001). The postcourse score was related to the accuracy with which the simulator exercises were performed (Spearman rho 0.2664; P<.001). Nearly two-thirds (n=84, 62.6%) of the students said they enjoyed working on the simulator. A total of 79 (58.0%) students felt that they had achieved the course’s objective of reproducing ultrasound images. Inadequate connection speed had been a problem for 40.2% (n=54) of students. Conclusions: The integration of an online simulator for the practical learning of ultrasound in remote learning situations has allowed for substantial acquisitions in the psychomotor field of ultrasound diagnosis. Despite the absence of workshops, the students were able to learn and practice how to handle an ultrasound probe to reproduce standard images. This study enhances the value of online programs in medical education, even for practical skills.

Background A minority of patients presenting with lower respiratory tract infection (LRTI) to their general practitioner (GP) have community-acquired pneumonia (CAP) and require antibiotic therapy. Identifying them is challenging, because of overlapping symptomatology and low diagnostic performance of chest X-ray. Procalcitonin (PCT) can be safely used to decide on antibiotic prescription in patients with LRTI. Lung ultrasound (LUS) is effective in detecting lung consolidation in pneumonia and might compensate for the lack of specificity of PCT. We hypothesize that combining PCT and LUS, available as point-of care tests (POCT), might reduce antibiotic prescription in LRTIs without impacting patient safety in the primary care setting. Methods This is a three-arm pragmatic cluster randomized controlled clinical trial. GPs are randomized either to PCT and LUS-guided antibiotic therapy or to PCT only-guided therapy or to usual care. Consecutive adult patients with an acute cough due to a respiratory infection will be screened and included if they present a clinical pneumonia as defined by European guidelines. Exclusion criteria are previous antibiotics for the current episode, working diagnosis of sinusitis, severe underlying lung disease, severe immunosuppression, hospital admission, pregnancy, inability to provide informed consent and unavailability of the GP. Patients will fill in a 28 day-symptom diary and will be contacted by phone on days 7 and 28. The primary outcome is the proportion of patients prescribed any antibiotic up to day 28. Secondary outcomes include clinical failure by day 7 (death, admission to hospital, absence of amelioration or worsening of relevant symptoms) and by day 28, duration of restricted daily activities, episode duration as defined by symptom score, number of medical visits, number of days with side effects due to antibiotics and a composite outcome combining death, admission to hospital and complications due to LRTI by day 28. An evaluation of the cost-effectiveness and of processes in the clinic using a mixed qualitative and quantitative approach will also be conducted. Discussion Our intervention targets only patients with clinically suspected CAP who have a higher pretest probability of definite pneumonia. The intervention will not substitute clinical assessment but completes it by introducing new easy-to-perform tests. Trial registration The study was registered on the 19th of June 2017 on the clinicaltrials.gov registry using reference number; NCT03191071 .

AbstractObjectiveTo assess whether point-of care procalcitonin and lung ultrasonography can safely reduce unnecessary antibiotic treatment in patients with lower respiratory tract infections in primary care.DesignThree group, pragmatic cluster randomised controlled trial from September 2018 to March 2020.Setting60 Swiss general practices.ParticipantsOne general practitioner per practice was included. General practitioners screen all patients with acute cough; patients with clinical pneumonia were included.InterventionsRandomisation in a 1:1:1 of general practitioners to either antibiotics guided by sequential procalcitonin and lung ultrasonography point-of-care tests (UltraPro; n=152), procalcitonin guided antibiotics (n=195), or usual care (n=122).Main outcomesPrimary outcome was proportion of patients in each group prescribed an antibiotic by day 28. Secondary outcomes included duration of restricted activities due to lower respiratory tract infection within 14 days.Results60 general practitioners included 469 patients (median age 53 years (interquartile range 38-66); 278 (59%) were female). Probability of antibiotic prescription at day 28 was lower in the procalcitonin group than in the usual care group (0.40 v 0.70, cluster corrected difference −0.26 (95% confidence interval −0.41 to −0.10)). No significant difference was seen between UltraPro and procalcitonin groups (0.41 v 0.40, −0.03 (−0.17 to 0.12)). The median number of days with restricted activities by day 14 was 4 days in the procalcitonin group and 3 days in the usual care group (difference 1 day (95% confidence interval −0.23 to 2.32); hazard ratio 0.75 (95% confidence interval 0.58 to 0.97)), which did not prove non-inferiority.ConclusionsCompared with usual care, point-of-care procalcitonin led to a 26% absolute reduction in the probability of 28 day antibiotic prescription without affecting patients’ safety. Point-of-care lung ultrasonography did not further reduce antibiotic prescription, although a potential added value cannot be excluded, owing to the wide confidence intervals.Trial registrationClinicalTrials.gov NCT03191071.

Guidelines recommend chest X-rays (CXRs) to diagnose pneumonia and guide antibiotic treatment. This study aimed to identify clinical predictors of pneumonia that are visible on a chest X-ray (CXR+) which could support ruling out pneumonia and avoiding unnecessary CXRs, including oxygen saturation. A secondary analysis was performed in a clinical trial that included patients with suspected pneumonia in Swiss primary care. CXRs were reviewed by two radiologists. We evaluated the association between clinical signs (heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, abnormal auscultation, and oxygen saturation < 95%) and CXR+ using multivariate analysis. We also calculated the diagnostic performance of the associated clinical signs combined in a clinical decision rule (CDR), as well as a CDR derived from a large meta-analysis (at least one of the following: heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, or abnormal auscultation). Out of 469 patients from the initial trial, 107 had a CXR and were included in this study. Of these, 26 (24%) had a CXR+. We found that temperature and oxygen saturation were associated with CXR+. A CDR based on the presence of either temperature ≥ 37.8 °C and/or an oxygen saturation level < 95% had a sensitivity of 69% and a negative likelihood ratio (LR−) of 0.45. The CDR from the meta-analysis had a sensitivity of 92% and an LR− of 0.37. The addition of saturation < 95% to this CDR increased the sensitivity (96%) and decreased the LR− (0.21). In conclusion, this study suggests that pulse oximetry could be added to a simple CDR to decrease the probability of pneumonia to an acceptable level and avoid unnecessary CXRs.

Objective Contrast-enhanced ultrasound (CEUS) is a promising tool to assess renal microcirculation. However, its reproducibility has never been formally assessed. We aimed to assess the reproducibility and precision of CEUS measurements in critically ill patients. Methods We conducted an observational study in 20 critically ill patients in stable cardio-pulmonary condition. In group 1 ( n  = 10), to assess CEUS reproducibility, we performed three CEUS scans within a one-hour time frame in rigorously similar conditions and settings. In group 2 ( n  = 10), to assess the influence of ultrasound contrast agent rate, we performed two CEUS scans, one with standard settings and the second with a doubled ultrasound contrast agent rate. CEUS-derived parameters included relative blood volume (RBV), mean transit time (mTT) and perfusion index (PI). We used linear quantile mixed models to assess their reproducibility (stability across different time points), precision (variability of consecutive measurements), and the influence of a change in ultrasound contrast agent (UCA) infusion rate. Finally, we sought to determine patients’ related factors associated with signal instability. Results In Group 1, CEUS derived parameters remained similar across the three study timepoints (3 289 vs. 3 680 vs. 3 590 for RBV, 4.1 vs. 4.2 vs. 4.2 for mTT and 684 vs. 762 vs. 735 for PI, all p values > 0.05), indicating stability of these parameters within individual patients over time. Intra-measure coefficient of variability was 23.2% for RBV, 13.9% for mTT and 33.8% for PI. The median of five CEUS assessments yielded reliable estimates. In Group 2, doubling the UCA rate resulted in a significant increase in RBV (3 207 vs. 1 624, p  = 0.01), and in PI (977 vs. 617, p  = 0.01), while mTT remained stable (4.6 vs. 3.8, p  = 0.08). No patients-related parameter could be significantly associated with CEUS parameters variability. Conclusions Under controlled conditions, CEUS derived parameters are reproducible and have a fair precision in critically ill patients in stable hemodynamic condition. mTT might be more reliable under varying infusion conditions. Further studies are required to establish the clinical utility of CEUS in critically ill patients.