Point-of-care ultrasound induced changes in management of unselected patients in the emergency department - a prospective single-blinded observational trial

Background Point-of-Care ultrasound (POCUS) changes the management in specific groups of patients in the Emergency Department (ED). It seems intuitive that POCUS holds an unexploited potential on a wide variety of patients. However, little is known about the effect of ultrasound on the broad spectrum of unselected patients in the ED. This study aimed to identify the effect on the clinical management if POCUS was applied on unselected patients. Secondarily the study aimed to identify predictors of ultrasound changing management. Methods This study was a blinded observational single center trial. A basic whole body POCUS protocol was performed in extension to the physical examination. The blinded treating physicians were interviewed about the presumptive diagnosis and plan for the patient. Subsequently the physicians were unblinded to the POCUS results and asked to choose between five options regarding the benefit from POCUS results. Results A total of 403 patients were enrolled in this study. The treating physicians regarded POCUS examinations influence on the diagnostic workup or treatment as following: 1) No new information: 249 (61.8%), 2) No further action: 45 (11.2%), 3) Further diagnostic workup needed: 52 (12.9%), 4) Presumptive diagnosis confirmed 38 (9.4%), and 5) Immediate treatment needed: 19 (4.7%). Predictors of beneficial ultrasound were: (a) triage > 1, (b) patient comorbidities (cardiac disease, hypertension or lung disease), or (c) patients presenting with abdominal pain, dyspnea, or syncope. Conclusion POCUS was found to be potentially beneficial in 27.0% of all patients. High triage score, known cardiac disease, hypertension, pulmonary diseases, a clinical presentation with abdominal pain, dyspnea, or syncope are predictors of this. Future research should focus on patient-important outcomes when applying POCUS on these patients. Trial registration The trail was registered prior to patient inclusion with the Danish Data Protection Agency (https://www.datatilsynet.dk/ Case no: 1–16–02-603-14) and Clinical Trials (www.clinicaltrials.gov/ Protocol ID: DNVK1305018)

Musculoskeletal misdiagnoses in children with brain tumors:A nationwide, multicenter case-control study

ObjectiveChildhood brain tumors belong to the cancer type with the longest diagnostic delay, the highest health care utilization prior to diagnosis, and the highest burden of long-term sequelae. We aimed to clarify whether prior musculoskeletal diagnoses in childhood brain cancer were misdiagnoses and whether it affected the diagnostic delay.Study designIn this retrospective, chart-reviewed case-control study we compared 28 children with brain tumors and a prior musculoskeletal diagnosis to a sex and age-matched control group of 56 children with brain tumors and no prior musculoskeletal diagnosis. Using the Danish registries, the cases were identified from consecutive cases of childhood brain cancers in Denmark over 23 years (1996-2018).ResultsOf 931 children with brain tumors, 3% (28/931) had a prior musculoskeletal diagnosis, of which 39% (11/28) were misdiagnoses. The misdiagnoses primarily included torticollis-related diagnoses which tended to a longer time interval from first hospital contact until a specialist was involved: 35 days (IQR 6-166 days) compared to 3 days (IQR 1-48 days), p = 0.07. When comparing the 28 children with a prior musculoskeletal diagnosis with a matched control group without a prior musculoskeletal diagnosis, we found no difference in the non-musculoskeletal clinical presentation, the diagnostic time interval, or survival. Infratentorial tumor location was associated with a seven-fold risk of musculoskeletal misdiagnosis compared to supratentorial tumor location.ConclusionMusculoskeletal misdiagnoses were rare in children with brain tumors and had no significant association to the diagnostic time interval or survival. The misdiagnoses consisted primarily of torticollis- or otherwise neck-related diagnoses

Point-of-care focused lung ultrasound in emergency medicine: Protocol for a scoping review

Baggrund Point-of-care fokuseret lungeultralyd er en central kompetence i akutmedicin. Meta-analyser for diagnostiske studier af point-of-care fokuseret lungeultralyd har vist lovende diagnostiske resultater for pneumothorax, pleura effusion, interstitielt syndrom, lungeemboli og pneumoni. Men manglende evidens på patient-nære endemål og et fåtal af randomiserede kontrollerede studier synes at være begrænsende for den videre implementering af point-of-care ultralyd. En metodisk kortlægning af eksisterende studier indenfor et forskningsfelt kan vejlede fremtidige forskningsindsatser. Formålet med dette review er at give et overblik over original forskning i point-of-care fokuseret lungeultralyd i akutmedicin med særlig vægt på studiedesign og patient-relevansen af endemål. Metoder Reviewet designes som et scoping review og det vil inkludere originale studier i point-of-care fokuseret lungeultralyd til voksne patienter i akutafdelinger. Reviewet vil fokusere på point-of-care fokuseret lungeultralyd; studier i fyldestgørende thorakal ultralyd er uden for denne afgrænsning (f.eks. ultralydsundersøgelser som vurderer mediastinale lymfeknuder, diafragma bevægelse, kontrast- eller procedure lunge ultralyd). Vi vil ekskludere studier uden tilgængeligt engelsk manuskript. Grå litteratur og udelukkende kvalitative studier vil ikke blive inkluderet. Reviews, protokoller, meta-analyser, case artikler, letters, og konference abstrakts vil blive ekskluderet. Dataudtrækket vil inkludere adskillige metodiske og sonografiske karakteristika (f.eks. sampling metoden [lejlighedsvis/fortløbende], diagnostisk rolle af ultralyd [triage, tillæg, erstatning], antal af sonografører, sonograførernes ekspertise [træning og erfaring] og sonograførernes rolle [behandlende læge eller forsker]. Den narrative syntese af alle inkluderede studier vil blive gennemført med særlig vægt på studie designs og patient-relevans af endemål. Figurer og diagrammer vil opsummere tidsmæssige tendenser, metode karakteristika og endemål. Diskussion Dette scoping review vil tilbyde et overblik som systematiske reviews ikke kan sammenfatte eller kortlægge. Kortlægningen af studie designs og patient-relevans af endemål vil vejlede fremtidige studier og systematiske reviews i forsøget på at vejlede klinikere og patienter til den mest hensigtsmæssige brug af point-of-care fokuseret lungeultralyd i akutmedicin. Reviewet vil også biddrage med et overblik over område-specifikke metodiske og sonografiske karakteristika, som gør det muligt for andre forskere at identificere de utilstrækkeligheder, som bør opgives, og de fremskridt som bør dyrkes

Trauma facilities in Denmark - a nationwide cross-sectional benchmark study of facilities and trauma care organisation

Background Trauma is a leading cause of death among adults aged < 44 years, and optimal care is a challenge. Evidence supports the centralization of trauma facilities and the use multidisciplinary trauma teams. Because knowledge is sparse on the existing distribution of trauma facilities and the organisation of trauma care in Denmark, the aim of this study was to identify all Danish facilities that care for traumatized patients and to investigate the diversity in organization of trauma management. Methods We conducted a systematic observational cross-sectional study. First, all hospitals in Denmark were identified via online services and clarifying phone calls to each facility. Second, all trauma care manuals on all facilities that receive traumatized patients were gathered. Third, anesthesiologists and orthopedic surgeons on call at all trauma facilities were contacted via telephone for structured interviews. Results A total of 22 facilities in Denmark were found to receive traumatized patients. All facilities used a trauma care manual and all had a multidisciplinary trauma team. The study found three different trauma team activation criteria and nine different compositions of teams who participate in trauma care. Training was heterogeneous and, beyond the major trauma centers, databases were only maintained in a few facilities. Conclusion The study established an inventory of the existing Danish facilities that receive traumatized patients. The trauma team activation criteria and the trauma teams were heterogeneous in both size and composition. A national database for traumatized patients, research on nationwide trauma team activation criteria, and team composition guidelines are all called for

Is point-of-care ultrasound disruptive innovation? Formulating why POCUS is different from conventional comprehensive ultrasound

Abstract Background Point-of-care ultrasound (PoCUS) is spreading throughout Emergency Medicine, Critical Care and Pre-hospital Care. However, there is an underlying inherited conflict with the established specialties performing comprehensive examinations. It has been stated that PoCUS is disruptive innovation. If this is true the definition might open up for a new perspective on differentiating comprehensive ultrasound from PoCUS. PoCUS in the light of disruptive innovation is a different perspective on ultrasound that has not before been academically scrutinized. Methods In this paper we investigate if PoCUS is in fact disruptive innovation. This is done by comparative analysis with the point of departure in disruptive innovation theory known from the business world. Results We find that a disruptive innovation process is happening. This new knowledge allows us to put forward advice for the stakeholders in the field of ultrasound. It also allows us to challenge the conventional pyramid of expertise used to describe different types of ultrasound. The perspective of this paper is mutual understanding of similarities and differences between conventional and point-of-care ultrasound. Only with this understanding the stakeholders can collaborate and use the full spectrum of ultrasound for the benefit of the patient