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Background Point-of-care ultrasound (POCUS) training courses have been shown to increase knowledge and skills among physicians, but few studies have examined their impact on clinical outcomes. We assessed the frequency of ultrasound usage and complication rates of paracentesis after implementing a POCUS training course in the Veterans Affairs (VA) health care system. Methods A retrospective observational study was conducted of VA medical centers that participated in a POCUS training course (“trained facilities”) versus matched control facilities. Rates of paracentesis performed in non-radiology settings with and without ultrasound guidance and procedural complications were collected from the VA corporate data warehouse (CPT and ICD-10 procedure and diagnosis codes) and pre- and post-course surveys of course participants. A best fit linear regression line was established for quarterly rates of each group and the y-intercept and slope of each line was compared. Results Data were compared from 16 trained versus 32 matched control facilities where 10,375 and 22,103 paracenteses were performed, respectively, from October 2015 to March 2025. At baseline, ultrasound guidance was used less frequently in trained versus matched control facilities (39% vs. 78.3%, p  < 0.0001). However, trained facilities demonstrated a greater quarterly increase in ultrasound use (1.20% vs. -0.14% per quarter, p  < 0.0001). By the end of the study, trained facilities surpassed control facilities in use of ultrasound guidance (84.6% vs. 73.0%, p  < 0.001). The overall complication rate was low (2.4 per 1,000 procedures) and there was no significant difference in trends between trained and matched control facilities. Conclusions Participation in a national POCUS training course was associated with increased use of ultrasound guidance for paracentesis but not with statistically significant changes in complication rates. Further study is warranted to explore effect of POCUS training on procedural outcomes of paracentesis.

Background Point-of-care ultrasound (POCUS) can aid geriatricians in caring for complex, older patients. Currently, there is limited literature on POCUS use by geriatricians. We conducted a national survey to assess current POCUS use, training desired, and barriers among Geriatrics and Extended Care (“geriatric”) clinics at Veterans Affairs Medical Centers (VAMCs). Methods We conducted a prospective observational study of all VAMCs between August 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of geriatric clinics. Results All Chiefs of Staff ( n =130) completed the survey (100% response rate). Chiefs of geriatric clinics (“chiefs”) at 76 VAMCs were surveyed and 52 completed the survey (68% response rate). Geriatric clinics were located throughout the United States, mostly at high-complexity, urban VAMCs. Only 15% of chiefs responded that there was some POCUS usage in their geriatric clinic, but more than 60% of chiefs would support the implementation of POCUS use. The most common POCUS applications used in geriatric clinics were the evaluation of the bladder and urinary obstruction. Barriers to POCUS use included a lack of trained providers (56%), ultrasound equipment (50%), and funding for training (35%). Additionally, chiefs reported time utilization, clinical indications, and low patient census as barriers. Conclusions POCUS has several potential applications for clinicians caring for geriatric patients. Though only 15% of geriatric clinics at VAMCs currently use POCUS, most geriatric chiefs would support implementing POCUS use as a diagnostic tool. The greatest barriers to POCUS implementation in geriatric clinics were a lack of training and ultrasound equipment. Addressing these barriers systematically can facilitate implementation of POCUS use into practice and permit assessment of the impact of POCUS on geriatric care in the future.

Introduction Point-of-care ultrasound (POCUS) can assist rheumatologists in monitoring disease activity, establishing diagnoses, and guiding procedural interventions. POCUS use has been increasing, but little is known about current use and barriers among rheumatologists. The purpose of this study was to characterize current POCUS use, training needs, and barriers to use among rheumatologists in practice. Methods A prospective observational study of all Veterans Affairs (VA) medical centers was conducted using a web-based survey sent to all chiefs of staff and rheumatology chiefs about current POCUS use, training needs, barriers, and policies. Results All chiefs of staff ( n  = 130) and rheumatology chiefs at VA medical centers ( n  = 95) were surveyed with 100% and 84% response rates, respectively. The most common diagnostic POCUS applications were evaluation of synovitis, joint effusion, tendinopathies, bursitis, and rotator cuff. The most common procedural applications were arthrocentesis and joint, bursa, and tendon injection. Most rheumatology chiefs (69%) expressed interest in training for their group. The most common barriers to POCUS use were lack of trained providers (68%), funding for training (54%), training opportunities (38%), funding for travel (38%), and ultrasound equipment (31%). Lack of POCUS infrastructure was common, and few facilities had POCUS policies (20%), image archiving (25%), or quality assurance processes (6%). Conclusion Currently, half of rheumatology groups use diagnostic and procedural ultrasound applications. Most rheumatology groups desire training, and lack of training and equipment were the most common barriers to ultrasound use. Deliberate investment is needed in ultrasound training and infrastructure for systematic adoption of POCUS in rheumatology. Graphical Abstract available for this article. Trial Registration NCT03296280. Graphical Abstract

Point-of-care ultrasound (POCUS) can improve diagnostic accuracy, reduce procedural complications and enhance physician-patient interactions in nephrology. Currently, there is limited knowledge about how practicing nephrologists are using POCUS. This study aimed to characterize current POCUS use, training needs, and barriers to use among nephrology groups. A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of staff and nephrology specialty chiefs. Chiefs of staff (n = 130) and nephrology chiefs (n = 79) completed surveys on facility- and service-level POCUS use (response rates of 100% and 77%, respectively). Current diagnostic or procedural POCUS use was reported by 41% of nephrology groups, and the most common POCUS applications were central line insertion (28%) and assessment of urinary retention (23%), hydronephrosis (18%), volume status (15%), and bladder (14%). Lack of training was the most common barrier (72%), and most nephrology groups (65%) desired POCUS training. Limited access to ultrasound equipment and POCUS training were barriers reported by 54% and 18% of groups, respectively. A minority of nephrology groups currently use common POCUS applications including evaluation of urinary retention, hydronephrosis, and volume status. The most common barriers to POCUS use in nephrology were lack of trained providers and ultrasound equipment. Investment in POCUS training and infrastructure is needed to expand and standardize POCUS use in nephrology.

ObjectiveTo investigate a cohort of children with symptomatic joint hypermobility.MethodsCase notes for 318 children with joint hypermobility attending a rheumatology clinic were reviewed for clinical presentation, medical history, psychosocial factors and physical examination findings. Seven key variables were extracted and used as indicator variables in a latent class analysis to estimate the presence and number of subgroups of children with symptomatic joint hypermobility.ResultsTwo subgroups with differing clinical presentations were identified accounting for age and gender: an ‘athletic-persistent’ class (62%) characterised by higher probabilities for recurrent and chronic musculoskeletal pain, and less severe hypermobility; and a ‘systemic-profound’ class (38%) characterised by generalised hypermobility, recurrent musculoskeletal pain, gastro-oesophageal reflux and motor delay.ConclusionFindings suggest the presence of two distinct presentations of children with hypermobility. This finding may be important for clinical decision-making and management of this group of children.

Abstract Background Metabolomics, the study of small-molecule metabolites, has increased understanding of human metabolic diseases, but has not been used to study equine metabolic syndrome (EMS). Objectives (1) To examine the serum metabolome of Welsh Ponies with and without insulin dysregulation before and during an oral sugar test (OST). (2) To identify differences in metabolites in ponies with insulin dysregulation, obesity, or history of laminitis. Animals Twenty Welsh Ponies (mean ± SD; 13.8 ± 9.0 years) classified as non-insulin dysregulated [CON] (n = 10, insulin < 30 mU/L) or insulin dysregulated [ID] (n = 10, insulin > 60 mU/L) at 75 minutes after administration of Karo syrup, obese (n = 6) or nonobese (n = 14), and history of laminitis (n = 9) or no history of laminitis (n = 11). Methods Case-control study. Metabolomic analysis was performed on serum obtained at 0 minutes (baseline) and 75 minutes during the OST. Data were analyzed with multivariable mixed linear models with significance set at P ≤ .05. Results Metabolomic analysis of 646 metabolites (506 known) detected significant metabolite differences. At baseline, 55 metabolites (insulin response), 91 metabolites (obesity status), and 136 metabolites (laminitis history) were different. At 75 minutes, 51 metabolites (insulin response), 102 metabolites (obesity status), and 124 metabolites (laminitis history) were different. Conclusions and Clinical Importance Use of metabolomics could have diagnostic utility for early detection of EMS and provide new knowledge regarding the pathophysiology of metabolic perturbations associated with this condition that might lead to improved clinical management.

Juvenile idiopathic arthritis (JIA) comprises a group of heterogeneous disorders of chronic arthritis in childhood and remains the commonest pediatric rheumatic disease associated with significant long-term morbidity. Advances in understanding of the pathogenesis, better definition of disease control/remission measures, and the arrival of biological agents have improved the outcomes remarkably. Methotrexate (Mtx) remains the first-line disease modifying (DMARD) therapy for most children with JIA due to its proven efficacy and safety. Sulphosalazine (SSz) (especially for enthesitis) and leflunomide may also have a secondary role. Tumor necrosis factor inhibitors (TNF-I), alone or in combination with Mtx have shown tremendous benefit in children with polyarticular JIA, enthesitis related arthritis (ERA) and psoriatic arthritis. Tocilizumab appears very efficacious in systemic arthritis and abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear, though clearly beneficial in adult RA. TNF-I with Mtx is also effective in uveitis associated with JIA. Biologicals have demonstrated an impressive safety record in children with JIA, although close monitoring for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of cancers is warranted.

A 6 year old female with symptoms of small bowel obstruction underwent an exploratory laparotomy which revealed widespread evidence of inflammatory fibrotic adhesions involving the jejunal mesentery. In view of persistent growth failure, chronic anaemia, elevated acute phase reactants and imaging evidence of a diffuse progressive inflammatory process, the child was treated with corticosteroids and methotrexate with complete response. The literature on juvenile idiopathic sclerosing mesenteritis has been reviewed.

Following traumatic musculoskeletal injuries, prolonged bedrest and loss of physical activity may limit muscle plasticity and drive metabolic dysfunction. One specific injury, volumetric muscle loss (VML), results in frank loss of muscle and is characterized by whole-body and cellular metabolic dysfunction. However, how VML and restricted physical activity limit plasticity of the whole-body, cellular, and metabolomic environment of the remaining uninjured muscle remains unclear. Adult mice were randomized to posterior hindlimb compartment VML or were age-matched injury naïve controls, then randomized to standard or restricted activity cages for 8-wks. Activity restriction in naïve mice resulted in ~5% greater respiratory exchange ratio (RER); combined with VML, carbohydrate oxidation was ~23% greater than VML alone, but lipid oxidation was largely unchanged. Activity restriction combined with VML increased whole-body carbohydrate usage. Together there was a greater pACC:ACC ratio in the muscle remaining, which may contribute to decreased fatty acid synthesis. Further, β-HAD activity normalized to mitochondrial content was decreased following VML, suggesting a diminished capacity to oxidize fatty acids. The muscle metabolome was not altered by the restriction of physical activity. The combination of VML and activity restriction resulted in similar ( ~ 91%) up- and down-regulated metabolites and/or ratios, suggesting that VML injury alone is regulating changes in the metabolome. Data supports possible VML-induced alterations in fatty acid metabolism are exacerbated by activity restriction. Collectively, this work adds to the sequalae of VML injury, exhausting the ability of the muscle remaining to oxidize fatty acids resulting in a possible accumulation of triglycerides.