Background Hospitalized patients are frequently referred for transthoracic echocardiograms (TTE). The availability of a pocket, mobile echocardiography (PME) device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative. Methods This was a cross-sectional study designed to compare the accuracy of PME images with those acquired by TTE in a sample of hospitalized patients. Each patient referred for echocardiography underwent PME acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, a TTE was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities. Results 240 hospitalized patients underwent echocardiography with PME and TTE. The mean age was 71 ± 17 years. PME imaging time was 6.3 ± 1.5 min. Sensitivity of PME varied by parameter; was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter; was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the PME outcomes to be significantly equivalent to the TTE outcomes with no discernible differences in image quality between the PME and TTE (p=7.22×10-7). All outcomes remain significant after correcting for multiple testing using the false discovery rate (FDR). Conclusion The results from rapid bedside PME examinations performed by experienced cardiology fellows compared favorably with those from formal TTE studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.
Medicine that all residents must develop ''technical proficiency'' in several procedures, including central venous line placement.1 Developing competency in common procedural skills has long been a part of medical training. The philosophy of ''see-1, do-1, teach-1'' is still the most common means by which most residents seek to obtain this proficiency, even though serious concerns have been raised about this approach. 2 A typical first experience in central line placement usually involves an eager (or terrified) trainee making several clumsy attempts on an actual patient, under the hurried guidance of a senior resident who themselves received an unknown degree of training. In this scenario, rarely does standardized instruction, formal evaluation, or structured follow-up occur. A revitalized emphasis is now being placed on patient safety in healthcare, including an industry-wide commitment to minimizing procedural complications. The most common complications associated to central line placement include vascular damage and catheter-related bloodstream infections. A number of creative approaches are being developed to improve the quality of instruction on proper procedural techniques, all varying considerably in sophistication, scope, and rigor. Examples include the use of computer-assisted methods for training ultrasound-guided needle insertion techniques and ureteroscopy training, hands-on training with synthetic models for thoracentesis training, video training, and uterine aspiration using papayas.3-11 Implicit in this trend is recognition that we, as educators, healthcare providers, and patient advocates, must design more cost effective and efficient ways to teach medical and surgical procedural techniques to clinicians. Our approach was previously described in phase I of the Procedural Patient Safety Initiative (PPSI).12 In PPSI-I, we introduced a nonhuman tissue model (NHTM; Figure 1) as the basis for teaching physicians a more rigorous curriculum of essential central line placement skills. By way of brief review, the NHTMs were constructed by tunneling 0.2-mmthick rubber tubing (vessels) lengthwise through raw, whole chickens purchased at the grocery store. The vessels were filled with colored water to simulate blood. The NHTM has several unique features, including: (1) realistic-appearing vessels when viewed under ultrasound, which mimic the appearance of human internal jugular veins and carotid arteries ( Figure 2); (2) tissue turgor and vessel composition that produce realistic pops and flashes upon puncture and allow for multiple cannulations; (3) the ability to perform a complete central line placement (including wire advancement, dilation, line insertion, suturing, and sterile dressing placement); (4) cost effectiveness relative to other commercially-available products (each NHTM costs $120 and can withstand multiple cannulations over 2 days). [13][14][15][16][17] During the training sessions of Phase I, participants were oriented to the ultrasound machines, shown the contents of our central line kit,...
ImportanceThe Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care.ObjectiveTo determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM.Design, Setting, and ParticipantsThis was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022.InterventionsICM monitoring vs site-specific usual care (short-duration external cardiac monitoring).Main Outcomes and MeasuresThe ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates.ResultsThe analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001).Conclusions and RelevanceAmong patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance.Trial RegistrationClinicalTrials.gov Identifier: NCT02700945
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