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Lung ultrasound (LUS) reduces time to diagnosis and treatment of acute decompensated heart failure (ADHF) in emergency department (ED) patients with undifferentiated dyspnea. We conducted a systematic review to evaluate the diagnostic accuracy and clinical impact of LUS for ADHF in the prehospital setting. We performed a keyword search of multiple databases from inception through June 1, 2023. Included studies were those enrolling prehospital patients with undifferentiated dyspnea or suspected ADHF, and specifically diagnostic studies comparing prehospital LUS to a gold standard and intervention studies with a non-US comparator group. Title and abstract screening, full text review, risk of bias (ROB) assessments, and data extraction were performed by multiple authors. and adjudicated. The primary outcome was pooled sensitivity, specificity, and diagnostic likelihood ratios (LR) for prehospital LUS. A test-treatment threshold of 0.7 was applied based on prior ADHF literature in the ED. Intervention outcomes included mortality, mechanical ventilation, and time to HF specific treatment. Eight diagnostic studies (n = 691) and two intervention studies (n = 70) met inclusion criteria. No diagnostic studies were low-ROB. Both intervention studies were critical-ROB, and not pooled. Pooled sensitivity and specificity of prehospital LUS for ADHF were 86.7% (95%CI:70.8%–94.6%) and 87.5% (78.2%–93.2%), respectively, with similar performance by physician vs. paramedic LUS and number of lung zones evaluated. Pooled LR+ and LR- were 7.27 (95% CI: 3.69–13.10) and 0.17 (95% CI: 0.06–0.34), respectively. Area under the summary receiver operating characteristic curve was 0.922. At the observed 42.4% ADHF prevalence (pre-test probability), positive pre-hospital LUS exceeded the 70% threshold to initiate treatment (post-test probability 84%, 80–88%). LUS had similar diagnostic test characteristics for ADHF diagnosis in the prehospital setting as in the ED. A positive prehospital LUS may be sufficient to initiate early ADHF treatment based on published test-treatment thresholds. More studies are needed to determine the clinical impact of prehospital LUS.

Interactive cognitive-motor training (ICMT) requires individuals to perform both gross motor movements and complex information processing. This study investigated the effectiveness of ICMT on cognitive functions associated with falls in older adults. A single-blinded randomized controlled trial was conducted in community-dwelling older adults (N = 90, mean age 81.5±7) without major cognitive impairment. Participants in the intervention group (IG) played four stepping games that required them to divide attention, inhibit irrelevant stimuli, switch between tasks, rotate objects and make rapid decisions. The recommended minimum dose was three 20-minute sessions per week over a period of 16 weeks unsupervised at home. Participants in the control group (CG) received an evidence-based brochure on fall prevention. Measures of processing speed, attention/executive function (EF), visuo-spatial ability, concerns about falling and depression were assessed before and after the intervention. Eighty-one participants (90%) attended re-assessment. There were no improvements with respect to the Stroop Stepping Test (primary outcome) in the intervention group. Compared to the CG, the IG improved significantly in measures of processing speed, visuo-spatial ability and concern about falling. Significant interactions were observed for measures of EF and divided attention, indicating group differences varied for different levels of the covariate with larger improvements in IG participants with poorer baseline performance. The interaction for depression showed no change for the IG but an increase in the CG for those with low depressive symptoms at baseline. Additionally, low and high-adherer groups differed in their baseline performance and responded differently to the intervention. Compared to high adherers, low adherers improved more in processing speed and visual scanning while high-adherers improved more in tasks related to EF. This study shows that unsupervised stepping ICMT led to improvements in specific cognitive functions associated with falls in older people. Low adherers improved in less complex functions while high-adherers improved in EF. Australian New Zealand Clinical Trials Registry ACTRN12613000671763.

Introduction: While gamification of point-of-care ultrasound (POCUS) is well received by learners, little is known about the knowledge gained from material taught during these events. We set out to determine whether a POCUS gamification event improved knowledge of interpretation and clinical integration of POCUS. Methods: This was a prospective observational study of fourth-year medical students who participated in a 2.5-hour POCUS gamification event consisting of eight objective-oriented stations. Each station had one to three learning objectives associated with the content taught. Students completed a pre-assessment; they then participated in the gamification event in groups of three to five per station and subsequently completed a post-assessment. Differences between pre- and postsession responses were matched and analyzed using Wilcoxon signed-rank test and Fisher’s exact test. Results: We analyzed data from 265 students with matched pre- and post-event responses; 217 (82%) students reported no to little prior POCUS experience. Most students were going into internal medicine (16%) and pediatrics (11%). Knowledge assessment scores significantly improved from pre- to post-workshop, 68% vs 78% (P=0.04). Self-reported comfort with image acquisition, interpretation, and clinical integration all significantly improved from pre- to post-gamification event (P<0.001). Conclusion: In this study we found that gamification of POCUS, with clear learning objectives, led to improved student knowledge of POCUS interpretation, clinical integration, and self-reported comfort with POCUS.

No set guidelines to guide disposition decisions from the emergency department (ED) in patients with COVID-19 exist. Our goal was to determine characteristics that identify patients at high risk for adverse outcomes who may need admission to the hospital instead of an observation unit. We retrospectively enrolled 116 adult patients with COVID-19 admitted to an ED observation unit. We included patients with bilateral infiltrates on chest imaging, COVID-19 testing performed, and/or COVID-19 suspected as the primary diagnosis. The primary outcome was hospital admission. We assessed risk factors associated with this outcome using univariate and multivariable logistic regression. Of 116 patients, 33 or 28% (95% confidence interval [CI] 20–37%) required admission from the observation unit. On multivariable logistic regression analysis, we found that hypoxia defined as room-air oxygen saturation < 95% (OR 3.11, CI 1.23–7.88) and bilateral infiltrates on chest radiography (OR 5.57, CI 1.66–18.96) were independently associated with hospital admission, after adjusting for age. Two three-factor composite predictor models, age > 48 years, bilateral infiltrates, hypoxia, and Hispanic race, bilateral infiltrates, hypoxia yield an OR for admission of 4.99 (CI 1.50–16.65) with an AUC of 0.59 (CI 0.51–0.67) and 6.78 (CI 2.11–21.85) with an AUC of 0.62 (CI 0.54–0.71), respectively. Over 1/4 of suspected COVID-19 patients admitted to an ED observation unit ultimately required admission to the hospital. Risk factors associated with admission include hypoxia, bilateral infiltrates on chest radiography, or the combination of these two factors plus either age > 48 years or Hispanic race.

Background Point of care ultrasound (POCUS) education has grown significantly over the past two decades. Like most curricular items, POCUS education is siloed within individual graduate medical education (GME) programs. The purpose of this study was to evaluate the effectiveness of a shared GME POCUS curriculum between five GME programs at a single institution. Methods Post-graduate-year-1 (PGY-1) residents from emergency medicine (EM), family medicine (FM), internal medicine (IM), combined internal medicine-pediatrics (IM-Peds) and combined emergency medicine-pediatrics (EM-Peds) residency programs were enrolled in a core POCUS curriculum. The curriculum included eleven asynchronous online learning modules and ten hands-on training sessions proctored by sonographers and faculty physicians with POCUS expertise. Data was gathered about the curriculum’s effectiveness including participation, pre- and post-curricular surveys, pre- and post-knowledge assessments, and an objective skills assessment. Results Of the 85 residents enrolled, 61 (72%) participated in the curriculum. Engagement varied between programs, with attendance at hands-on sessions varying the most (EM 100%, EM-Peds 100%, FM 40%, IM 22%, Med-Peds 11%). Pre- and post-knowledge assessment scores improved for all components of the curriculum. Participants felt significantly more confident with image acquisition, anatomy recognition, interpreting images and incorporating POCUS findings into clinical practice ( p  < 0.001) after completing the curriculum. Conclusion In this shared GME POCUS curriculum, we found significant improvement in POCUS knowledge, attitudes, and psychomotor skills. This shared approach may be a viable way for other institutions to provide POCUS education broadly to their GME programs.

Background There is little to no data evaluating long term usage of point of care ultrasound (POCUS) after a training intervention for medical students. The purpose of this study was to examine the impact of an intensive POCUS training program on medical student’s usage at 9-months post-program. Methods This was a prospective cross-sectional study of rising second year medical students who participated in a 2-week summer POCUS training program. Instruction consisted of 8 h of asynchronous online didactic material, 2–4 h of daily hands-on instructor-led and independent scanning, and instruction on how to teach POCUS. Students were assessed pre- and post-program, and again at 9 months post-program to evaluate POCUS usage. Results A total of 56 students participated in the program over 2 summers; 52 (92.9%) responded to the 9-month post-program survey. At 9 months, 49 (94.2%) of students taught POCUS after the program to peers or faculty. Students reported serving as a POCUS instructor in 283 subsequent teaching sessions accounting for 849 h of POCUS instruction time. Six (11.5%) students were involved in the creation of a POCUS interest group on their regional campus, 7 (13%) created a POCUS curriculum for their student interest group, and 4 (7.7%) created an opt-in co-curricular POCUS program for students at their regional campus. Three (5.8%) students did not serve as educators after the program and only one student reported not using POCUS again after the program. Conclusion After a 2-week intensive POCUS training program for medical students, the majority of students demonstrated continued involvement in POCUS learning and education at 9-month follow-up including serving as peer instructors and assisting with limitations in financial resources and trained faculty.

BackgroundLung ultrasound (LUS) is an effective tool for diagnosing pneumonia; however, this has not been well studied in resource-limited settings where pneumonia is the leading cause of death in children under 5 years of age.ObjectiveThe objective of this study was to evaluate the diagnostic accuracy of bedside LUS for diagnosis of pneumonia in children presenting to an emergency department (ED) in a resource-limited setting.MethodsThis was a prospective cross-sectional study of children presenting to an ED with respiratory complaints conducted in Nepal. We included all children under 5 years of age with cough, fever, or difficulty breathing who received a chest radiograph. A bedside LUS was performed and interpreted by the treating clinician on all children prior to chest radiograph. The criterion standard was radiographic pneumonia, diagnosed by a panel of radiologists using the Chest Radiography in Epidemiological Studies methodology. The primary outcome was sensitivity and specificity of LUS for the diagnosis of pneumonia. All LUS images were later reviewed and interpreted by a blinded expert sonographer.ResultsThree hundred and sixty-six children were enrolled in the study. The median age was 16.5 months (IQR 22) and 57.3% were male. Eighty-four patients (23%) were diagnosed with pneumonia by chest X-ray. Sensitivity, specificity, positive and negative likelihood ratios for clinician’s LUS interpretation was 89.3% (95% CI 81–95), 86.1% (95%CI 82–90), 6.4, and 0.12 respectively. LUS demonstrated good diagnostic accuracy for pneumonia with an area under the curve of 0.88 (95% CI 0.83–0.92). Interrater agreement between clinician and expert ultrasound interpretation was excellent (k = 0.85).ConclusionBedside LUS when used by ED clinicians had good accuracy for diagnosis of pneumonia in children in a resource-limited setting.

Patients with shoulder dislocations commonly present to the emergency department. Ultrasound has the potential to save time, radiation exposure, healthcare costs, and possible need for re-sedation. We conducted this systematic review to compare the diagnostic accuracy of ultrasound compared with plain radiography in the assessment of shoulder dislocations. We searched PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials for relevant trials. Primary data and test characteristics were obtained for all included studies. We used QUADAS-2 to assess study quality. Meta-analysis was not performed due to significant heterogeneity. Four studies met our inclusion criteria, comprising 531 assessments with 202 dislocations. Most studies had a sensitivity of 100% for identifying dislocations. One study demonstrated a sensitivity of 54%, and another had only one dislocation that was misidentified. All studies were 100% specific for detecting dislocation. Ultrasound may be considered as an alternative diagnostic method for the detection of shoulder dislocation and reduction, but further studies are necessary before routine use.

Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The goal of this study was to determine if a heterogeneous group of emergency physicians (EP) could diagnose acute appendicitis on CUS in patients with a moderate to high pre-test probability. This was a prospective, observational study of a convenience sample of adult and pediatric patients with suspected appendicitis. Sonographers received a structured, 20-minute CUS training on appendicitis prior to patient enrollment. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure was considered a positive study. Non-visualization or indeterminate studies were considered negative. We collected pre-test probability of acute appendicitis based on a 10-point visual analog scale (moderate to high was defined as >3), and confidence in CUS interpretation. The primary objective was measured by comparing CUS findings to surgical pathology and one week follow-up. We enrolled 105 patients; 76 had moderate to high pre-test probability. Of these, 24 were children. The rate of appendicitis was 36.8% in those with moderate to high pre-test probability. CUS were recorded by 33 different EPs. The sensitivity, specificity, and positive and negative likelihood ratios of EP-performed CUS in patients with moderate to high pre-test probability were 42.8% (95% confidence interval [CI] [25-62.5%]), 97.9% (95% CI [87.5-99.8%]), 20.7 (95% CI [2.8-149.9]) and 0.58 (95% CI [0.42-0.8]), respectively. The 16 false negative scans were all interpreted as indeterminate. There was one false positive CUS diagnosis; however, the sonographer reported low confidence of 2/10. A heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. This data adds support for surgical consultation without further imaging beyond CUS in the appropriate clinical setting.

Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary. We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure. A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93). This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.