Background: Volume overload in patients on hemodialysis (HD) is an independent risk factor for cardiovascular mortality. B-lines detected on lung ultrasound (BLUS) assess extravascular lung water. This raises interest in its utility for assessing volume status and cardiovascular outcomes. Methods: End-stage renal disease patients on HD at the Island Rehab Center being older than 18 years were screened. Patients achieving their dry weight (DW) had a lung ultrasound in a supine position. Scores were classified as mild (0-14), moderate (15-30), and severe (>30) for pulmonary congestion. Patients with more than 60 were further classified as very severe. Patients were followed for cardiac events and death. Results: 81 patients were recruited. 58 were males, with a mean age of 59.7 years. 44 had New York Heart Association (NYHA) class 1, 24 had class 2, and 13 had class 3. In univariate analysis, NYHA class was associated with B-line classes (<0.001) and diastolic dysfunction (0.002). In multivariate analysis, NYHA grade strongly correlated with B-line classification (0.01) but not with heart function (0.95). 71 subjects were followed for a mean duration of 1.19 years. 9 patients died and 20 had an incident cardiac event. A Kaplan-Meier survival analysis demonstrated an interval decrease in survival times in all-cause mortality and cardiac events with increased BLUS scores (p = 0.0049). Multivariate Cox regression analysis showed the independent predictive value of BLUS class for mortality and cardiac events with a heart rate of 2.98 and 7.98 in severe and very severe classes, respectively, compared to patients in the mild class (p = 0.025 and 0.013). Conclusion: At DW, BLUS is an independent risk factor for death and cardiovascular events in patients on HD.

BackgroundThe use of emergency ultrasonography (EUS) has gained much popularity in the past few decades, and is now a mainstay of diagnostic decision-making. This expanded use is now highlighting the substantial issue of individual hospitals in credentialing its emergency medicine attending physicians in EUS in the United States. This issue is also of importance as more hospitals are now requesting reimbursements for emergency ultrasounds. The objective of this study is to gain an understanding of how many emergency departments are currently credentialing its attending staff in EUS, what the internal structure and staffing are of these emergency departments, and how they are currently performing quality assurance of the ultrasounds performed.MethodsThis was a cross-sectional, web-based survey sent to 160 ACGME-accredited EM residency programs from July 2013 to November 2013. The survey consisted of 23 questions regarding: (1) number of emergency medicine attendings on staff, (2) presence of an EUS fellowship, (3) quality assurance (QA) process, and (4) current US credentialing process.ResultsThere was a 50 % response rate. Fifty percent of the total respondents (n = 40) had an EUS fellowship program. Of the sites with an EUS fellowship, 36 had EUS fellowship-trained attendings. Of the sites without an EUS fellowship, 19 had EUS fellowship-trained faculty, p ≤ 0.0001. Sites with an EUS fellowship had a greater percentage of staff credentialed to perform EUS as compared to sites with no EUS fellowship, p = 0.0161. All sites with an EUS fellowship had EUS-credentialed attendings. In sites with an EUS fellowship, 35 conducted a formal QA of ED performed EUS scans versus 22 at sites without an EUS fellowship, p = 0.003.ConclusionsThe survey results support hiring emergency attendings that have completed postgraduate training in emergency ultrasonography to aid in credentialing staff. This also seems to be helpful in completing a timelier QA of all ED ultrasounds.

or autopsy). Studies were excluded if they examined only specific comorbidities (eg, cancer, liver disease, etc); were on pediatric or pregnant patients; used healthy volunteers as controls; did not have a calculable sensitivity (Sn) and specificity (Sp) from the data presented; or were reviews, commentaries, or editorials. All articles were screened for inclusion by two independent reviewers, with 97% agreement; k ¼ 0.77, P < .001. Both reviewers decided a priori to err on the side of inclusion, and if either reviewer selected an article, it was ordered for full text review. A single reviewer then determined if the full text articles met the inclusion criteria, and any questions were discussed with the team to reach a final decision on inclusion. Sn and Sp were combined using equal weighting methods and calculated using Microsoft Excel. Results: Our search strategy yielded 4,472 articles without duplicates. Of these, 389 were ordered for full text review, and 22 were included in the final analysis. The most commonly cited use of echo to detect PE was through a combination of findings suggestive of PE. These findings were termed and defined variably across 16 studies. Terms for combined measures included: right ventricular (RV) dysfunction, RV strain, and acute cor pulmonale. These combined measures had a Sn of 57% and a Sp of 78%, and those only in point of care studies had a Sn of 60% and an Sp of 87%. The most common (n¼7) stand-alone signs used were an increased RV:LV ratio (Sn¼64%, Sp ¼85%), abnormal septal motion (Sn¼29%, Sp¼ 96%), and tricuspid insufficiency (Sn¼49%, Sp¼80%). The most specific test was visualizing a RV thrombus, with a Sp of 100% in 2 studies. However, 3 other markers showed a Sp greater than 95%: RV hypokinesis (98%, n¼4), McConnell's sign (98%, n¼3), and abnormal septal motion (96%, n¼7). The most sensitive test was an increased RV end diastolic diameter, with a Sn of 78% in 3 studies. The test with the highest diagnostic odds ratio (DOR) was RV wall hypokinesis, with a DOR of 34.7, a Sn of 39% and a Sp of 98% in 3 studies. Conclusion: Studies have consistently shown a high specificity for echo in the diagnosis of PE, making it potentially adequate as a rule-in test at the bedside in the emergency department for patients unable to get other confirmatory studies. Future research should examine if combining echo with other modalities, such as lung and deep venous thrombosis ultrasound improves accuracy.

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