Bedside Clinical Tool Research Articles

Current trends and latest developments in echocardiographic assessment of right ventricular function: load dependency perspective.

Right ventricle (RV) failure is a common complication of many cardiopulmonary diseases. Since it has a significant adverse impact on prognosis, precise determination of RV function is crucial to guide clinical management. However, accurate assessment of RV function remains challenging owing to the difficulties in acquiring its intricate pathophysiology and imaging its complex anatomical structure. In addition, there is historical attention focused exclusively on the left ventricle assessment, which has led to overshadowing and delayed development of RV evaluation. Echocardiography is the first-line and non-invasive bedside clinical tool for assessing RV function. Tricuspid annular plane systolic excursion (TAPSE), RV systolic tissue Doppler velocity of the tricuspid annulus (RV S'), and RV fractional area change (RV FAC) are conventional standard indices routinely used for RV function assessment, but accuracy has been subject to several limitations, such as load-dependency, angle-dependency, and localized regional assessment. Particularly, load dependency is a vexing issue, as the failing RV is always in a complex loading condition, which alters the values of echocardiographic parameters and confuses clinicians. Recently, novel echocardiographic methods for improved RV assessment have been developed. Specifically, "strain", "RV-pulmonary arterial (PA) coupling", and "RV myocardial work" are newly applied methods for RV function assessment, a few of which are designed to surmount the load dependency by taking into account the afterload on RV. In this narrative review, we summarize the latest data on these novel RV echocardiographic parameters and highlight their strengths and limitations. Since load independency is one of the primary advantages of these, we particularly emphasize this aspect.

Automated multivolume placental reconstruction using three-dimensional power Doppler ultrasound and infrared camera tracking.

Placental insufficiency contributes to many obstetric pathologies however there is no bedside clinical tool to evaluate placental perfusion. We have developed a method to acquire multiple three-dimensional power Doppler ultrasound (3D PD-US) volumes of placental vasculature with infrared camera tracking providing global coordinates. These are automatically reconstructed ('stitched') into a model of the entire placenta. The purpose of the study was to evaluate the accuracy of automated reconstruction in an US phantom and apply this technique to human placentas. A custom-designed acrylic phantom was constructed with dimensions mimicking a third-trimester placenta, containing 12 quadrilateral towers of varying heights submersed in tissue-mimicking solution. Triplicated three-dimensional ultrasound volumes of this phantom were acquired at three different acquisition angles using infrared camera tracking. Data was transformed into a three-dimensional cartesian volume and automatically stitched. A single-centre, cross-sectional feasibility study was conducted on uncomplicated second-to-third trimester singleton pregnancies using standardised obstetric settings. Multiple 3D PD-US and grayscale volumes of the placenta were acquired with infrared camera tracked coordinates. Volumes were stitched to create a model of placental vasculature. 6 phantom datasets were reconstructed at each of 3 volume angles with a median of 9 volumes required. Perfect volume alignment occurred in 66.7% of 648 datapoints. Mean distance error for volume misalignment was 2.92mm. Measurements of 210 distances in each stitched volume (2160 total distances) differed an average of 1.51mm from true measurements. These compare favourably with recent literature, though for a substantially larger phantom. 17 participants were scanned with 92% reconstruction success per placental volume set and 100% participant achievability. Median reconstruction time was 10 minutes. Placental vasculature was qualitatively assessed to be present, continuous, and detailed throughout. Volume measurement of entire segmented placentas was highly repeatable (ICC 0.96). We present an automated method to model the entire structure and vasculature of second-to-third trimester placentas, with verified accuracy and clinical feasibility for grayscale and power Doppler. This study builds the foundation to develop a practical screening tool for detecting placental insufficiency, and expansion to adult organ perfusion evaluation. This article is protected by copyright. All rights reserved.

Derivation and Validation of Spontaneous Coronary Artery Dissection Prediction Score in Patients With Myocardial Infarction

Spontaneous coronary artery dissection (SCAD) is an important cause of acute myocardial infarction (AMI); however, the prevalence of SCAD and its predictors in AMI are unknown. We sought to derive and validate a simple score that can help predict SCAD in patients with AMI. We analyzed the Nationwide Readmissions Database and created a risk score for SCAD in patients with an index hospitalization for AMI. We used a multivariate logistic regression analysis to determine the independent predictors of SCAD, and each was assigned points proportional to its regression coefficient. Among 1,155,164 patients with AMI, 8,630 (0.75%) had SCAD. Based on the derivation cohort, the independent predictors of SCAD were fibromuscular dysplasia (odds ratio [OR] 67.0, 95% confidence interval [CI] 42.0 to 107.9, p <0.01), Marfan or Ehlers-Danlos syndrome (OR 4.7, 95% CI 1.7 to 12.5, p <0.01), polycystic ovarian syndrome (OR 5.4, 95% CI 3.0 to 9.8, p <0.01), female gender (OR 1.99, 95% CI 1.9 to 2.1, p <0.01), and aortic aneurysm (OR 1.41, 95% CI 1.1 to 1.7, p <0.01). The SCAD risk score included fibromuscular dysplasia (5 points), Marfan or Ehlers-Danlos syndrome (2 points), polycystic ovarian syndrome (2 points), female gender (1 point), and aortic aneurysm (1 point). The C-statistics of the score were 0.58 (derivation cohort) and 0.61 (validation cohort). In conclusion, the SCAD score is an easy bedside clinical tool that can help clinicians identify patients with AMI who are at risk for SCAD.

Prognostic Value Of Shock Index In Children With Sepsis/ Septic Shock

Objective- To investigate the association between PICU shock index and mortality in children with sepsis/septic shock and to explore cut off values for ICU mortality, how change in shock index over the first 6 hours of ICU admission is associated with outcome. Methods- 50 children who presented with sepsis/ septic shock were included in the study. Children were classified as per their age as &lt; 1 year,&gt; 1 year - &lt; 6 years and &gt; 6 years.They were also grouped as sepsis, severe sepsis and septic shock as per the International Sepsis Consensus Conference definition of sepsis in 2005. Clinical parameters like heart rate and systolic blood pressure was recorded, following which shock index was calculated over 0,1,2,4 and 6 hours of PICU admission and trend was noticed.Patients were finally divided into 2 groups as per outcome, i.e. survival/ death. Results : Data analysis was done using GraphPad Prism 5. Cut-off values of shock index were analysed using Receiver Operator Curve and their relative risk of mortality was studied. Higher values of shock index and increasing trend of shock index was associated with increased mortality. Conclusion : SI can be a promising marker for risk of mortality in children with sepsis/ septic shock. It is simple, non-invasive and bedside clinical tool to identify high-risk children and help us keep vigilant.The obtained cut-off values indicate that higher the SI,higher is the risk of mortality.

Lung Aeration in COVID-19 Pneumonia by Ultrasonography and Computed Tomography.

We conducted a prospective single-center observational study to determine lung ultrasound reliability in assessing global lung aeration in 38 hospitalized patients with non-critical COVID-19. On admission, fixed chest CT scans using visual (CTv) and software-based (CTs) analyses along with lung ultrasound imaging protocols and scoring systems were applied. The primary endpoint was the correlation between global chest CTs score and global lung ultrasound score. The secondary endpoint was the association between radiographic features and clinical disease classification or laboratory indices of inflammation. Bland–Altman analysis between chest CT scores obtained visually (CTv) or using software (CTs) indicated that only 1 of the 38 paired measures was outside the 95% limits of agreement (−4 to +4 score). Global lung ultrasound score was highly and positively correlated with global software-based CTs score (r = 0.74, CI = 0.55–0.86; p < 0.0001). Significantly higher median CTs score (p = 0.01) and lung ultrasound score (p = 0.02) were found in severe compared to moderate COVID-19. Furthermore, we identified significantly lower (p < 0.05) lung ultrasound and CTs scores in those patients with a more severe clinical condition manifested by SpO2 < 92% and C-reactive protein > 58 mg/L. We concluded that lung ultrasound is a reliable bedside clinical tool to assess global lung aeration in hospitalized non-critical care patients with COVID-19 pneumonia.

Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study.

Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history-based score ABCD2. This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD2≥4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion-weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination. We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+]= 3.71, negative likelihood ratio [LR-]= 0.09) than the HINTS test (67% and 44%, respectively; LR+= 2.96, LR-= 0.04). The ABCD2 score was specific (82%, LR+= 3.04, LR-= 0.56) but had a very low PPV (44%). In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.

Correlation of qSOFA with Severity of COVID-19 Infection Assessed on Admission at Tertiary Care Hospital in Lahore

Introduction: The COVID-19 crisis is continuously taxing the world with a huge impact on mortality, morbidity and disease related mental stress. COVID-19 has a variable presentation encompassing from simple myalgias to development of ARDS. Early detection of patients with severe COVID 19 infection by utilizing simple bed side clinical tool like qSOFA, which has been previously used for detection of severity of sepsis could help us in early triage and subsequent management of these patients in specialized dedicated units of the hospital. Thus help in limiting the mortality and morbidity because of this deadly contagion. &#x0D; Aims &amp; Objectives: To correlate the severity of qSOFA score with the clinical severity and outcome of COVID-19 infection at presentation among admitted patients in tertiary care hospitals of Lahore.&#x0D; Place and duration of study: This study was conducted simultaneously at three tertiary care hospitals of Lahore, including Lahore General Hospital, Jinnah Hospital Lahore and Chaudhary Muhammad Akram Teaching and Research Hospital, Lahore.&#x0D; Material &amp; Methods: A retrospective descriptive study on 120 RT PCR positive confirmed COVID-19 patients of both genders, more than 18 years of age. Case records of patients admitted in General Corona ward, Isolation wards, HDUs and ICUs were analyzed. The data analysis was done in SPSS version 20. Factors including blood pressure, respiratory rate, and conscious level were used to calculate the qSOFA score. COVID 19 infection was divided into mild, moderate, severe and critically ill. The relationship of qSOFA score was studied with severity of COVID-19 infection, outcome of disease and age by using the Pearson correlation.&#x0D; Results: Eighty-four (70%) patients were male and thirty-six (30%) were female, with mean age of 59.42 ± 13.49 years. Sixty-eight, twenty-five, five and 0.8 percent patients had critical, severe, moderate and mild disease respectively. Most frequent comorbids found were hypertension, diabetes, ischemic heart disease. A statistically significant correlation was observed between qSOFA with severity of COVID 19, age, and outcome of infection at the level of 0.01.&#x0D; Conclusion: qSOFA is a reliable bedside tool to measure severity and predict outcome of COVID 19 infection.

Evaluation of Two Fast Virtual Stenting Algorithms for Intracranial Aneurysm Flow Diversion

Endovascular treatment of intracranial aneurysms (IAs) by flow diverter (FD) stents depends on flow modification. Patient-specific modeling of FD deployment and computational fluid dynamics (CFD) could enable a priori endovascular strategy optimization. We developed a fast, simplistic, expansion-free balls-weeping algorithm to model FDs in patientspecific aneurysm geometry. However, since such strong simplification could result in less accurate simulations, we also developed a fast virtual stenting workflow (VSW) that explicitly models stent expansion using pseudo-physical forces. To test which of these two fast algorithms more accurately simulates real FDs, we applied them to virtually treat three representative patient-specific IAs. We deployed Pipeline Embolization Device into 3 patient-specific silicone aneurysm phantoms and simulated the treatments using both balls-weeping and VSW algorithms in computational aneurysm models. We then compared the virtually deployed FD stents against experimental results in terms of geometry and post-treatment flow fields. For stent geometry, we evaluated gross configurations and porosity. For post-treatment aneurysmal flow, we compared CFD results against experimental measurements by particle image velocimetry. We found that VSW created more realistic FD deployments than balls-weeping in terms of stent geometry, porosity and pore density. In particular, balls-weeping produced unrealistic FD bulging at the aneurysm neck, and this artifact drastically increased with neck size. Both FD deployment methods resulted in similar flow patterns, but the VSW had less error in flow velocity and inflow rate. In conclusion, modeling stent expansion is critical for preventing unrealistic bulging effects and thus should be considered in virtual FD deployment algorithms. Also endowed with its high computational efficiency and superior accuracy, the VSW algorithm is a better candidate for implementation into a bedside clinical tool for FD deployment simulation.

Optokinetic nystagmus in patients with SCA: A bedside test for oculomotor dysfunction grading.

To characterize the clinical features in patients with spinocerebellar ataxia (SCA) type 1, SCA2, and SCA3 and to evaluate the oculomotor dysfunction by using optokinetic nystagmus (OKN) testing, which may be a sensitive marker. In this prospective observational study, all patients underwent detailed neurologic examination with special emphasis on eye movements. OKN was evaluated with a tape. Disease severity was measured with the International Co-Operative Ataxia Rating Scale (ICARS). A total of 73 genetically confirmed patients were included, of whom 28, 30, and 15 patients were positive for SCA1, SCA2, and SCA3, respectively. Dystonia was more common in patients with SCA3 (46%), and absent ankle jerk was more common in those with SCA2 (21.4%). Brisk deep tendon reflexes were common in patients with SCA1 (46.6%), followed by patients with SCA3 (26.6%) and SCA2 (7.1%). Vertical OKN was impaired in all patients and absent in 86.6% of patients with SCA1, 96% of those with SCA2, and 80% of those with SCA3. Horizontal OKN was absent in 30% of patients with SCA1, 57% of patients with SCA2, and 33% of those with SCA3. Higher motor disability (posture and gait, kinetic functions [Motor Disability] subscore on the ICARS) was associated with higher oculomotor dysfunction measured by OKN-saccades impairment grading but not with the Ocular Disorder subscore of ICARS (ICARS-OD). OKN-saccades are a better and sensitive bedside clinical tool to quantify oculomotor dysfunction in neurodegenerative ataxias. Its role needs to be tested further in presymptomatic carriers. The current ICARS-OD scale to grade oculomotor dysfunction in degenerative ataxias need to be modified.

A bedside clinical tool using creatinine kinetics to predict worsening renal injury and early recovery.

BackgroundChanging creatinine concentrations during acute renal failure are often confusing to clinicians to interpret and can cloud the patient’s true current state of renal injury. By modifying the formula for kinetic estimate of glomerular filtration rate (KeGFR), a simple bedside clinical tool can be used to identify subtle changes in renal function.MethodsThe KeGFR was rewritten to instead calculate a predicted peak creatinine after renal injury. By comparing the changes in predicted peak creatinine at two or more subsequent time intervals, the patient’s current state of renal injury can be determined: whether improving, worsening or unchanged from prior.ResultsThree case examples are provided using the equation for predicted peak creatinine. In each case, the creatinine concentration has continued to rise at three sequentially measured times. The change in predicted peak creatinine is analyzed for each case, demonstrating scenarios involving (i) improving renal injury, (ii) unchanged renal injury continued by unfavorable hemodynamics and (iii) worsening renal injury despite interventions.ConclusionsThe use of this model may provide clinicians with an easy bedside tool to assess a patient’s state of acute kidney injury. Reassessment of how the creatinine is changing is already a nonquantitative part of a nephrologist's approach to acute kidney injury. Providing an assessment of the patient's changing renal function would be a useful addition to potentially detect early renal recovery or worsening renal injury and appropriately adjust treatment strategies.

Coexisting atopic conditions influence the likelihood of allergic bronchopulmonary aspergillosis in asthma

BackgroundThe diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in asthma is often made in patients with total serum IgE levels greater than 1,000 IU/mL in conjunction with evidence of Aspergillus sensitization. The specificity of total serum IgE for the diagnosis of ABPA is low even when combined with serum Aspergillus specific IgE. ObjectiveTo determine the prevalence of ABPA and to identify alternative clinical predictors for ABPA among asthmatic patients with a total serum IgE level greater than 1,000 IU/ml. MethodsThis study was conducted in a tertiary hospital in Melbourne, Australia, with a large asthma and allergy service. Patients with asthma and total serum IgE levels greater than 1,000 IU/ml from January 1, 2005, through December 31, 2014, were included. Patients were considered to have concomitant allergic conditions if they had atopic eczema, allergic rhinitis, or both. The diagnosis of ABPA was based on the managing physician's documented diagnosis and referenced to criteria proposed by the International Society for Human and Fungal Mycology. ResultsThe prevalence of ABPA in our cohort was 15.8%. Older age, elevated total serum IgE level, reduced lung function, and the absence of other concomitant allergic conditions increased the risk of ABPA. After multivariate logistic regression, patients without concomitant allergic conditions had an odds ratio of 4.4 (95% confidence interval, 1.9–10.1; P = .001) for ABPA when compared with patients with allergic conditions. ConclusionThe absence of atopic eczema and allergic rhinitis in these patients increases the likelihood of ABPA. Eliciting an accurate allergy history may be a useful bedside clinical tool when considering the diagnosis of ABPA.

Incremental value of thoracic ultrasound in intensive care units: Indications, uses, and applications.

Emergency physicians are required to care for unstable patients with life-threatening conditions, and thus must make decisions that are both quick and precise about unclear clinical situations. There is increasing consensus in favor of using ultrasound as a real-time bedside clinical tool for clinicians in emergency settings alongside the irreplaceable use of historical and physical examinations. B-mode sonography is an old technology that was first proposed for medical applications more than 50 years ago. Its application in the diagnosis of thoracic diseases has always been considered limited, due to the presence of air in the lung and the presence of the bones of the thoracic cage, which prevent the progression of the ultrasound beam. However, the close relationship between air and water in the lungs causes a variety of artifacts on ultrasounds. At the bedside, thoracic ultrasound is based primarily on the analysis of these artifacts, with the aim of improving accuracy and safety in the diagnosis and therapy of the various varieties of pulmonary pathologic diseases which are predominantly "water-rich" or "air-rich". The indications, contraindications, advantages, disadvantages, and techniques of thoracic ultrasound and its related procedures are analyzed in the present review.

Optokinetic Drum Testing: A Bedside Clinical Tool To Differentiate Migraine-Associated Vertigo and Phobic Postural Vertigo from Other Vestibular Disorders (P02.258)

Optokinetic Drum Testing: A Bedside Clinical Tool To Differentiate Migraine-Associated Vertigo and Phobic Postural Vertigo from Other Vestibular Disorders (P02.258)

Real-Time 3-Dimensional Global Speckle Tracking: A New Tool for Quantitative Stress Echocardiography

Background: Global longitudinal strain (GLS) by 2D speckle tracking (2D-ST) improves diagnostic accuracy of wall motion analysis during dobutamine stress echocardiography (DSE), but limited by time consumption and expertise. 3D speckle tracking (3D-ST) is a new method that may improve diagnostic usefulness and reduce study times. We examine the validity of GLS by 3D-ST during DSE. Methods: Twenty-six patients (mean age 72 ± 8, EF 58 ± 11%) underwent DSE as per clinical indication. Measurements of GLS by 2D-ST and 3D-ST were obtained at rest, low dose (LD), and peak dose (PD) dobutamine. 2D-ST data were acquired by three standard apical planes. 3D-ST data were obtained in a single apical 3D full volume acquisition over four cardiac cycles. GLS, EF, and wall motion were analysed offline using EchoPAC. Time for image acquisition and analysis were recorded. Results: There is good correlation of GLS between 3D-ST and 2D-ST at rest and LD but only modest correlation at PD (table). GLS by 3D-ST correlated well with EF (rest r = 0.66, p = 0.002; LD r = 0.8, p < 0.0001; PD r = 0.66, p = 0.001). Mean times for acquisition and analysis were 3.8 ± 0.5 min with 3D-ST and 5.9 ± 0.3 min with 2D-ST (p = 0.004).Tabled 13D-ST vs. 2D-ST GLSRESTLDPDR0.750.810.53p value<0.0001<0.00010.01 Open table in a new tab Conclusions: GLS by 3D-ST provide a faster, more effective method to quantify LV function during DSE compared with 2D-ST. Reduced correlation at peak dose reflects increased signal noise. 3D-STE is a potential bedside clinical tool for quantifying GLS.

Light microscopy of the hair: a simple tool to "untangle" hair disorders.

Light microscopy of the hair forms an important bedside clinical tool for the diagnosis of various disorders affecting the hair. Hair abnormalities can be seen in the primary diseases affecting the hair or as a secondary involvement of hair in diseases affecting the scalp. Hair abnormalities also form a part of various genodermatoses and syndromes. In this review, we have briefly highlighted the light microscopic appearance of various infectious and non-infectious conditions affecting the hair.

Use of Respiratory Inductance Plethysmography for the Detection of Swallowing in the Elderly

It is essential to have a user-friendly, noninvasive bedside procedure at our disposal in order to study swallowing and swallowing disorders in the elderly in view of the frailty of this age group. In the present work, respiratory inductance plethysmography (RIP) is proposed as an appropriate clinical tool for such studies. An automated process for the detection of swallowing is used involving the derivative of the respiratory volume signal. The accuracy of the automated detection is given by the area under the Receiver Operating Characteristic (ROC) curve and is found to be greater than 0.9. At the optimal threshold, RIP constitutes a reliable and objective bedside clinical tool for studying swallowing in the elderly, as well as being user-friendly and noninvasive. In addition, RIP can be used to monitor swallowing in order to analyze swallowing disorders and put in place medical supervision of swallowing for individuals who might aspirate.

Parkinson's Disease Sleep Scale: validation study of a Spanish version.

The Parkinson's Disease Sleep Scale (PDSS) is the first published bedside clinical tool to specifically measure sleep disturbances in Parkinson's disease (PD). The objective of the present study was to carry out a metric analysis of a Spanish version (PDSS-SV) using a cross-sectional study of 100 PD patients who participated in the study. Usual measures for PD and mental status were applied by neurologists. Patients completed the Epworth Sleepiness Scale, Parkinson's Disease Questionnaire-39 Items (PDQ-39), and PDSS-SV. PDSS internal consistency (Cronbach's alpha, 0.77; significant item-total correlation for 11 items) was satisfactory. PDSS showed high test-retest reliability (intraclass correlation coefficient for items, 0.79-0.99; for total score, 0.94). Standard error of measurement was 9.80 (crossover) and 5.01 (longitudinal). Scores were distributed uniformly, with low floor and ceiling effect (1%). PDSS scores were correlated significantly with depression (Hamilton Depression Rating Scale, r(S) = -0.55; P < 0.0001) and quality of life (PDQ-39 Summary Index, r(S) = -0.26; P = 0.007), but not with clinical variables. Self-perception of mood disorder, pain, or hallucinations correlated individually with PDSS scores, and a factor explaining 65% of the variance was found. The assessment of PD sleep disorders with the PDSS met some basic standards required for health status measures.

Pulmonary artery catheter.

Controversy concerning the pulmonary artery catheter (PAC) and its use as a bedside clinical tool continues to be a significant bone of contention. In the pursuit of evidence-based medicine, a substantial effort has been made over the last 25 years to demonstrate the benefit or lack thereof of PAC-led therapy, and this endeavor still persists with large, randomized, clinical trials currently in progress both in the United States and in the United Kingdom. This article reviews the core evidence for and against PAC efficacy and safety and considers the most appropriate method for validation of such a device.