Assessing The Performance Characteristics of Handheld Ultrasound In A Rheumatic Heart Disease Screening Program

Background: Rheumatic heart disease affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Penicillin prophylaxis has been shown to improve valvular function among patients with clinically silent or mild disease. Efforts to expand echocardiographic screening are focusing on simplified protocols, non-physician ultrasonographers, and portable ultrasound devices, including handheld ultrasound. Recent advances support the use of single-view screening protocols. With the increasing availability and low cost of handheld devices, prospective studies are needed to evaluate their performance in these settings. Methods: We conducted a cross-sectional pilot study among 19 at-risk school-children participating in a rheumatic heart disease screening program in Ethiopia comparing a handheld ultrasound device (Phillips Lumify) to a fully-equipped portable ultrasound machine (Sonosite M-Turbo). Results: Agreement between devices was similar for expert and non-expert review (84%). However, when reviewed by a non-expert the Lumify identified fewer screen-positive cases (p-value 0.083). We also compared non-expert to expert interpretation by device and found a significant difference in interpretation for the Lumify (p-value 0.025). There was a trend towards shorter jet length by color Doppler in the handheld ultrasound device for both expert and non-expert review. Conclusions: Our study highlights that screening echocardiograms for RHD may yield different results when a handheld ultrasound device is used.

AI-Enabled, Ultrasound-Guided Handheld Robotic Device for Femoral Vascular Access

Hemorrhage is a leading cause of trauma death, particularly in prehospital environments when evacuation is delayed. Obtaining central vascular access to a deep artery or vein is important for administration of emergency drugs and analgesics, and rapid replacement of blood volume, as well as invasive sensing and emerging life-saving interventions. However, central access is normally performed by highly experienced critical care physicians in a hospital setting. We developed a handheld AI-enabled interventional device, AI-GUIDE (Artificial Intelligence Guided Ultrasound Interventional Device), capable of directing users with no ultrasound or interventional expertise to catheterize a deep blood vessel, with an initial focus on the femoral vein. AI-GUIDE integrates with widely available commercial portable ultrasound systems and guides a user in ultrasound probe localization, venous puncture-point localization, and needle insertion. The system performs vascular puncture robotically and incorporates a preloaded guidewire to facilitate the Seldinger technique of catheter insertion. Results from tissue-mimicking phantom and porcine studies under normotensive and hypotensive conditions provide evidence of the technique’s robustness, with key performance metrics in a live porcine model including: a mean time to acquire femoral vein insertion point of 53 ± 36 s (5 users with varying experience, in 20 trials), a total time to insert catheter of 80 ± 30 s (1 user, in 6 trials), and a mean number of 1.1 (normotensive, 39 trials) and 1.3 (hypotensive, 55 trials) needle insertion attempts (1 user). These performance metrics in a porcine model are consistent with those for experienced medical providers performing central vascular access on humans in a hospital.

Establishing a risk assessment framework for point-of-care ultrasound

Point-of-care ultrasound (POCUS) refers to the use of portable ultrasound (US) applications at the bedside, performed directly by the treating physician, for either diagnostic or procedure guidance purposes. It is being rapidly adopted by traditionally non-imaging medical specialties across the globe. Recent international evidence-based guidelines on POCUS for critically ill neonates and children were issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Currently there are no standardized national or international guidelines for its implementation into clinical practice or even the training curriculum to monitor quality assurance. Further, there are no definitions or methods of POCUS competency measurement across its varied clinical applications.Conclusion: The Hippocratic Oath suggests medical providers do no harm to their patients. In our continued quest to uphold this value, providers seeking solutions to clinical problems must often weigh the benefit of an intervention with the risk of harm to the patient. Technologies to guide diagnosis and medical management present unique considerations when assessing possible risk to the patient. Frequently risk extends beyond the patient and impacts providers and the institutions in which they practice. POCUS is an emerging technology increasingly incorporated in the care of children across varied clinical specialties. Concerns have been raised by clinical colleagues and regulatory agencies regarding appropriate POCUS use and oversight. We present a framework for assessing the risk of POCUS use in pediatrics and suggest methods of mitigating risk to optimize safety and outcomes for patients, providers, and institutions. What is Known: • The use POCUS by traditionally non-imaging pediatric specialty physicians for both diagnostic and procedural guidance is rapidly increasing. • Although there are international guidelines for its indications, currently there is no standardized guidance on its implementation in clinical practice. What is New: • Although standards for pediatric specialty-specific POCUS curriculum and training to competency have not been defined, POCUS is likely to be most successfully incorporated in clinical care when programmatic infrastructural elements are present. • Risk assessment is a forward-thinking process and requires an imprecise calculus that integrates considerations of the technology, the provider, and the context in which medical care is delivered. Medicolegal considerations vary across countries and frequently change, requiring providers and institutions to understand local regulatory requirements and legal frameworks to mitigate the potential risks of POCUS.

Long-Term Prevalence of Disaster-Related Deep Vein Thrombosis in Minamiaso Village After the 2016 Kumamoto Earthquakes: A Prospective Cross-Sectional Analysis

Objective: This study aimed to examine the prevalence of deep vein thrombosis (DVT) among evacuees in Minamiaso, a village which was temporarily isolated after the earthquakes, from the acute to recovery phase after the 2016 Kumamoto Earthquakes (GLIDE no: EQ-2016-000033-JPN). Methods: This prospective study, which was approved by Fukui University Medical Research Ethics Committee (approval no. 20160024 and 20160089), enrolled 181 evacuees (73.9 ± 11.6 y) who participated in a series of 3 DVT screenings using portable ultrasound machines conducted over 19 mo. All participants completed a questionnaire before the screenings, and none of the participants attended all 3 screenings. Data analysis was performed using EZR version 1.41. Results: The DVT prevalence was 14.3% (79.4 ± 8.2 y) at first screening of evacuees staying in shelters and 18.5% (71.5 ± 13.1 y) and 12.2% (72.8 ± 10.9 y) in second and third screenings of evacuees staying in temporary housing, respectively. Multivariate analysis revealed age ≥75 y and alcohol consumption as independent risk factors in the entire cohort and in patients aged ≤74 y, respectively. Conclusions: A high DVT prevalence over a long time period of 19 mo was observed where survivors were temporarily isolated after the disaster.

Quantitative ultrasound assessment of the effect of parity on bone mineral density in females

Background The effect of pregnancy and breastfeeding on a female’s bone mineral density (BMD) is controversial. This prospective study aims to investigate the effect of parity on BMD among pre-menopausal multiparous females using quantitative ultrasound as a screening method and females with no pregnancies (nulliparous) as a control group. Methods A portable ultrasound-based bone densitometer (DMS PEGASUS SMART, Mauguio, France) was used to indirectly assess the BMD in 51 multiparous (29–45 years) and 51 nulliparous Arabic females (18–35 years) by quantifying the broadband ultrasound attenuation (BUA) from their right calcaneus bone. BUA > 70 db/mhz = normal, BUA 65–69.9 db/mhz = below average, BUA 55–64.9 db/mhz = osteopenia and BUA < 55 db/mhz = osteoporosis. Results There was a significant difference in mean BUA between multiparous and nulliparous females (74.1 db/mhz vs. 69.3 db/mhz, p = 0.006). The prevalence of normal BMD was significantly higher in the nulliparous group than in the multiparous group (70.6% vs. 47.1%, p = 0.02). Osteoporosis was found in the multiparous group only (3/51). Among the multiparous females who breastfed (43/51), a total of 51.2% (22/43) had normal BMD, 25.6% (11/43) had BMD below average, 18.6% (8/43) had osteopenia and 4.7% (2/43) had osteoporosis. No significant differences in mean BUA (p = 0.2) were found between the group of females who breastfed for one year (13/43; BUA: 70.5 ± 9.4), the group of females who breastfed for 6–11 months (8/43; BUA: 70.6 ± 10.0) and those who breastfed for less than six months (22/43; BUA: 71.6 ± 9.4). A binary logistic regression model built for predicting BMD normality showed significance for the variable parity (p = 0.03), while the effect of the possible confounding variables BMI and age on BMD normality was found to be non- significant (p = 0.1 and p = 0.6, respectively). Conclusion Parity affects the BMD, as assessed by a portable ultrasound-based bone densitometer, of young and middle-aged females as compared to the BMD of nulliparous females.

Establishing a Risk Assessment Framework for Point-of-Care Ultrasound

Point of Care Ultrasound (POCUS) refers to the use of portable ultrasound (US) applications at the bedside, performed directly by the treating physician, for either diagnostic or procedure guidance purposes. It is being rapidly adopted by traditionally non-imaging medical specialties across the globe. Recent international evidence-based guidelines on POCUS for critically ill neonates and children were issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Currently there are no standardized national or international guidelines for its implementation into clinical practice or even the training curriculum to monitor quality assurance. Further, there are no definitions or methods of POCUS competency measurement across its varied clinical applications.The Hippocratic Oath suggests medical providers do no harm to their patients. In our continued quest to uphold this value, providers seeking solutions to clinical problems must often weigh the benefit of an intervention with the risk of harm to the patient. Technologies to guide diagnosis and medical management present unique considerations when assessing possible risk to the patient. Frequently risk extends beyond the patient and impacts providers and the institutions in which they practice. Point-of-care ultrasound (POCUS) is an emerging technology increasingly incorporated in the care of children across varied clinical specialties. Concerns have been raised by clinical colleagues and regulatory agencies regarding appropriate POCUS use and oversight. We present a framework for assessing the risk of POCUS use in pediatrics and suggest methods of mitigating risk to optimize safety and outcomes for patients, providers and institutions.

Monitoring of the Reproductive Cycle in Captive-Bred Female Boa constrictor: Preliminary Ultrasound Observations

The Boa constrictor is one of the most common reptiles bred in captivity. To achieve a successful breeding season, thorough knowledge of the females’ reproductive activity is necessary. In this regard, information on the Boa constrictor is still rather scarce. The aim of the present study was to monitor the ovarian activity and the embryonic development of boas by ultrasound. We performed brief scans on thirty non-anaesthetized snakes using a portable ultrasound system and a 7.5–10 MHz linear array transducer (Esaote MyLab™ Classic). Ultrasound features, dimensions, and echogenicity of the preovulatory and postovulatory follicles were determined. As gestation progresses, the postovulatory follicle size increases, and the embryonic silhouette becomes increasingly recognizable. During the second month after ovulation, by using color Doppler, early embryos’ heart activity could be evaluated. It is possible to highlight vascular connections between the mother and the membrane covering the embryonic structures. Ultrasound also allows one to identify follicular regression or slugs (nonfertilized eggs) early. The present study suggests that ultrasound could be an excellent noninvasive technique to evaluate the reproductive activity of Boa constrictor, allowing us to precisely identify the correct time for mating, monitor embryo development and viability, and allow the early diagnosis of follicular regression.

Prehospital FAST reduces time to admission and operative treatment: a prospective, randomized, multicenter trial

Background The focused assessment with sonography in trauma (FAST) exam is an established trauma care diagnostic procedure. Ultrasound performed during prehospital care can improve early treatment and management of the patients. In this prospective randomized clinical trial, we wanted to assess whether a pre-hospital FAST (p-FAST) influences pre-hospital strategy and the time to operative treatment. Methods We studied 296 trauma victims in a prehospital setting. Inclusion criteria were potential abdominal injuries identified either by clinical examination or suggested by the mechanism of injury. Physician-staffed helicopters and emergency ambulances were equipped with portable ultrasound devices. According to a scheme related to calendar weeks, a clinical exam only (CEX) or a clinical exam together with a p-FAST (CEX-p-FAST) was conducted. Outcome variables were prehospital diagnosis and strategy, the time to admission to the trauma room and to operation theater. The study was approved by the university ethical committee (REB#: 46/06). Results CEX-p-FAST showed a high sensitivity (94.7%) and specificity (97.6%) in detection of free fluid compared to CEX-only (80.0%, 84.4%). The median time to admission was reduced significantly by 13 min and to operative treatment by 15 min after CEX-p-FAST. We observed a cross-over rate of 30.8% of p-FAST (n = 36) to CEX-p-FAST during the CEX-only weeks. Conclusion According to the experience of the principal investigators, CEX-p-FAST was superior to CEX-only. Despite the time needed for p-FAST, the relevant admission time was significantly shorter. Thus, p-FAST is recommended in addition to CEX if possible for decision-making in prehospital trauma care. Trial registration German Clinical Trials Register #DRKS00022117—Registered 10 July 2020—Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022117.

Peripheral vascular access from the arms for invasive cardiac investigation using ultrasound guidance

Introduction Vascular access for invasive cardiac investigations has traditionally been gained from the femoral vessels, however, a “radial-first” approach has become increasingly popular for coronary interventions [1]. Transradial access has shown lower complication rates, shorter admission times, and reduced healthcare costs for coronary interventions [4]. A “superior” approach via the jugular and subclavian veins have been reported for electrophysiology (EP) studies and radiofrequency catheter ablation (RFCA) but is associated with an increased risk of complications such as pneumo- and haemothorax [9]. Purpose EP procedures often require the use of both venous and arterial catheters, and the potential advantage of non-femoral peripheral access is yet to be investigated. This study was performed to provide comprehensive anatomical evidence that the vessels of the arms are suitable for use during EP procedures, as assessed by vascular ultrasound. Methods A portable ultrasound device was used to measure the diameter of the brachial artery, brachial vein, basilic vein & cephalic vein on the left and right upper limbs of 63 healthy adult volunteers. Measurements were also taken of the circumference at the elbow and at the mid-bicep level on both arms. A subgroup of 15 volunteers had additional measurements taken of the same veins and artery on both arms with a tourniquet at the upper bicep level. Results The basilic vein was found to have the largest diameter with a median of 4.6 mm and 4.5 mm (right and left diameter, respectively), followed by the cephalic (median of 3.1 and 3.0 mm) and the brachial vein (median of 2.8 mm for both arms). 100% of volunteers had at least one vein that was equal to a 3 mm diameter (which would allow for a 8F sheath insertion), with 98% having 2 suitable veins and &gt;80% having 3 suitable venous vessels. More than 90% had a suitable diameter of more than 3 mm for both the right and left brachial artery. There was significant correlation between gender, and basilic vein and brachial artery diameters. There was no correlation between BMI, height, weight and elbow or bicep circumference. Conclusion To our knowledge, this is the first study to investigate the feasibility of adopting peripheral access in the electrophysiology lab. 100% of volunteers examined had one vein which was at least 3mm in size and would be suitable for 8F sheath insertion. We demonstrate the anatomic evidence that the vessels in the arm are capable of housing the size of sheath and catheters commonly used in the EP lab. FUNDunding Acknowledgement Type of funding sources: None. Figure 2. measurements Figure 3. Vessel diameters

Gunshot model of junctional femoral artery hemorrhage in swine under ultrasonic guidance

Background In a combat setting, uncontrolled junctional hemorrhage constitutes a major source of potentially preventable deaths. It is very important to establish a model of massive hemorrhage of gunshot wound at junction area which can simulate field rescue conditions. Methods Picco monitoring was instrumented for the anesthetized Landrace pigs, and the right femoral artery was located by portable ultrasound. The pistol bullet hit the right femoral artery, resulting in an artery rupture. After 30 seconds of uncontrolled hemorrhage, the ballistic wound was filled with combat gauze (QuikClot) to stop bleeding in the BT group (n = 10). Combat gauze was used to stop bleeding when the mean arterial pressure (MAP) decreased by 30% in the MD group (n = 10). The sham-operated pigs (n = 10) underwent the same anesthetic and surgical procedures, but neither shooting nor gauze filling therapy was performed. Blood samples were taken 15 min before injury, and then 10 min, 30 min, and 60 min after the injury. Results Histologic anatomy indicated that the right femoral artery and vein were completely ruptured in all 20 swine of MD and BT groups. The blood loss of pre-tamponade (4.97 ± 2.47 mL/kg vs 18.26 ± 3.47 mL/kg, P < 0.001), pro-tamponade (4.58 ± 1.49 mL/kg vs 7.20 ± 1.99 mL/kg, P = 0.004) and the total amount of bleeding (9.54 ± 3.80 mL/kg vs 25.46 ± 3.68 mL/kg, P < 0.001) in MD group were more than those in BT group. There were differences in body temperature, PH, PT, LAC of MD group compared with BT and SHAM groups 60 minutes after injury (all P < 0.0167). The survival time of MD group was shorter than that of BT group (P = 0.029). Conclusion We established a reliable gunshot model of junctional hemorrhage in swine, which had high accuracy for femoral arterial rupture under ultrasonic guidance and provided consistent and reproducible field-simulation conditions. In this junctional hemorrhage model, blood loss of 30-second free bleeding did not meet the criteria for shock. The MAP decrease of 30% emerged as a better predictor of a successful shock model.