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To determine the diagnostic accuracy of thoracic ultrasound (TUS) for detecting interstitial lung disease (ILD) in rheumatoid arthritis (RA) with respiratory symptoms. Individuals with RA visiting rheumatologic outpatient clinics in the Region of Southern Denmark were systematically screened for dyspnea, cough, recurrent pneumonia, prior severe pneumonia, or a chest x‐ray indicating interstitial abnormalities. Eighty participants with a positive screening were consecutively included. Individuals were not eligible if they had a chest high‐resolution computed tomography (HRCT) less than 12 months ago or were already diagnosed with ILD. A blinded TUS expert evaluated TUS, and TUS was registered as positive for ILD if at least 10 B‐lines or bilateral thickened and fragmented pleura were present. The primary outcomes were TUS's sensitivity, specificity, and positive predictive value and negative predictive value. An ILD‐specialized thoracic radiologist assessed HRCT, followed by a multidisciplinary team discussion, which was the reference standard. The accepted window of HRCT was less than 30 days after TUS was performed. A total of 77 participants received HRCT less than 30 days after TUS, and 23 (30%) were diagnosed with ILD. TUS had a sensitivity of 82.6% (95% confidence interval [CI] 61.2%–95.0%) and a specificity of 51.9% (95% CI 37.8%–65.7%), corresponding to a positive predictive value of 42.2% (95% CI 27.7%–57.8%) and a negative predictive value of 87.5% (95% CI 71.0%–96.5%). To our knowledge, this prospective study is the first to use respiratory symptoms in RA as inclusion criteria. Systematic screening for respiratory symptoms combined with TUS can reduce the diagnostic delay of ILD in RA.

BackgroundSerial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to investigate if treatment guided by monitoring patients with acute dyspnoea with serial cardiopulmonary PoCUS and usual care could reduce the severity of dyspnoea compared with usual care alone.MethodsThis was a randomised, controlled, blinded-outcome trial conducted in three EDs in Denmark between 9 October 2019 and 26 May 2021. Patients aged ≥18 years admitted with a primary complaint of dyspnoea were allocated 1:1 with block randomisation to usual care, which included a single cardiopulmonary PoCUS within 1 hour of arrival (control group) or usual care (including a PoCUS within 1 hour of arrival) plus two additional PoCUS performed at 2 hours interval from the initial PoCUS (serial ultrasound group). The primary outcome was a reduction of dyspnoea measured on a verbal dyspnoea scale (VDS) from 0 to 10 recorded at inclusion and after 2, 4 and 5 hours.ResultsThere were 206 patients recruited, 102 in the serial ultrasound group and 104 in the control group, all of whom had complete follow-up. The mean difference in VDS between patients in the serial ultrasound and the control group was −1.09 (95% CI −1.51 to −0.66) and −1.66 (95% CI −2.09 to −1.23) after 4 and 5 hours, respectively. The effect was more pronounced in patients with a presumptive diagnosis of acute heart failure (AHF). A larger proportion of patients received diuretics in the serial ultrasound group.ConclusionTherapy guided by serial cardiopulmonary PoCUS may, together with usual care, facilitate greater improvement in the severity of dyspnoea, especially in patients with AHF compared with usual care with a single PoCUS in the ED. Serial PoCUS should therefore be considered for routine use to aid the physician in stabilising the patient faster.Trial registration numberNCT04091334.

ObjectiveTo determine the diagnostic accuracy of point-of-care ultrasound in suspected pulmonary embolism.DesignSystematic review and meta-analysis.Data sourcesMEDLINE, Embase, CINAHL and Cochrane library were searched on 2 July 2020 with no restrictions on the date of publication. Subject headings or subheadings combined with text words for the concepts of pulmonary embolism, ultrasound and diagnosis were used.Eligibility criteria and data analysisEligible studies reported sensitivity and specificity of deep venous, lung, cardiac or multiorgan ultrasound in patients with suspected pulmonary embolism, using an adequate reference-test. Prospective, cross-sectional and retrospective studies were considered for eligibility. No restrictions were made on language. Studies were excluded if a control group consisted of healthy volunteers or if transesophageal or endobronchial ultrasound was used. Risk of bias was assessed using quality assessment of diagnostic accuracy studies-2. Meta-analysis of sensitivity and specificity was performed by construction of hierarchical summary receiver operator curves. I2was used to assess the study heterogeneity.Main outcome measuresThe primary outcome was overall sensitivity and specificity of reported ultrasound signs, stratified by organ approach (deep venous, lung, cardiac and multiorgan). Secondary outcomes were stratum-specific sensitivity and specificity within subgroups defined by pretest probability of pulmonary embolism.Results6378 references were identified, and 70 studies included. The study population comprised 9664 patients with a prevalence of pulmonary embolism of 39.9% (3852/9664). Risk of bias in at least one domain was found in 98.6% (69/70) of included studies. Most frequently, 72.8% (51/70) of studies reported >24 hours between ultrasound examination and reference test or did not disclose time interval at all. Level of heterogeneity ranged from 0% to 100%. Most notable ultrasound signs were bilateral compression of femoral and popliteal veins (22 studies; 4708 patients; sensitivity 43.7% (36.3% to 51.4%); specificity 96.7% (95.4% to 97.6%)), presence of at least one hypoechoic pleural-based lesion (19 studies; 2134 patients; sensitivity 81.4% (73.2% to 87.5%); specificity 87.4% (80.9% to 91.9%)), D-sign (13 studies; 1579 patients; sensitivity 29.7% (24.6% to 35.4%); specificity 96.2% (93.1% to 98.0%)), visible right ventricular thrombus (5 studies; 995 patients; sensitivity 4.7% (2.7% to 8.1%); specificity 100% (99.0% to 100%)) and McConnell’s sign (11 studies; 1480 patients; sensitivity 29.1% (20.0% to 40.1%); specificity 98.6% (96.7% to 99.4%)).ConclusionSeveral ultrasound signs exhibit a high specificity for pulmonary embolism, suggesting that implementation of ultrasound in the initial assessment of patients with suspected pulmonary embolism may improve the selection of patients for radiation imaging.PROSPERO registration numberCRD42020184313.

Osteogenesis Imperfecta (OI) is a rare hereditary disease mainly resulting in reduced or altered collagen type I. Collagen type I is a major constituent of the respiratory system, and normal collagen type I is vital for the pulmonary tissue function.

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In patients admitted with respiratory failure, a large proportion is diagnosed incorrectly in the emergency department and an even larger proportion seems to receive inappropriate treatment. Inappropriate initial treatment of these patients in the emergency department is associated with increased mortality. Focused cardiac ultrasound is a simplified echocardiography, performed by a clinician to answer specific, predefined, clinical questions in a given clinical context. The examination has been validated for use in a variety of clinical settings and scenarios including the guidance of prehospital triage, patients with cardiac arrest, patients with undifferentiated shock, patients with cardiopulmonary instability, patients with respiratory symptoms, trauma patients with suspected cardiac injuries, and assessment of the fluid status before fluid loading. When using focused cardiac ultrasound (US) in patients with respiratory symptoms, the typical objectives would be to identify pericardial effusion and enlargement of cardiac cavities, to estimate global systolic left-ventricular function, and to assess the volume status. The routine use of focused cardiac US in patients with respiratory symptoms may help improve the diagnostic accuracy, the proportion of patients receiving appropriate treatment, and possibly the patient outcome. This article gives a practical guide and an overview of some of the current concepts of using focused cardiac US in patients admitted with respiratory symptoms.

BackgroundThe prognosis for patients with severe infection is related to early treatment, including early administration of antibiotics. The study aim was to compare the short-term mortality among patients admitted with severe infection with and without systemic inflammatory response syndrome (SIRS) at arrival, and to ascertain whether the presence of SIRS might affect the timing of antibiotic administration.MethodsIn this retrospective follow-up study, we included all adult patients (≥15 years) presenting to a medical emergency department in the period between September 2010 and August 2011 with a first-time admission of community-acquired severe infection (infection with evidence of organ dysfunction), with and without SIRS at arrival. The presence of SIRS was defined as two or more of the criteria according to the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) definitions. Cases were identified by manual chart review using predefined criteria of infection. Data on vital signs, laboratory values and antibiotic treatment were obtained electronically.ResultsWe included 1169 patients with infection and organ dysfunction, treated with antibiotics within 24 h after arrival (median age 76.1 years (IQR 63.1–83.5), 567 (48.5%) men). In all, 886 (75.8%) presented with SIRS, and 283 (24.2%) presented without SIRS. Median time to antibiotics was 4.6 h (IQR 2.9–7.0) in patients with SIRS and 6.7 h (IQR 4.5–10.3) in patients without SIRS (p<0.0001). Thirty-day mortality in patients with and without SIRS was 18.4% (95% CI 15.9% to 21.1%) and 16.6% (95% CI 12.5% to 21.5%), respectively.ConclusionsSIRS was absent in one-quarter of patients admitted with severe infection. The ‘door-to-antibiotics’ time was significantly shorter for patients with SIRS compared with patients without SIRS, but no difference was found in 30-day mortality.

Ultra-low dose computed tomography (ULD-CT) assessed by non-radiologists in a medical Emergency Department (ED) has not been examined in previous studies. To (i) investigate intragroup agreement among attending physicians caring for ED patients (i.e., radiologists, senior- and junior clinicians) and medical students for the detection of acute lung conditions on ULD-CT and supine chest X-ray (sCXR), and (ii) evaluate the accuracy of interpretation compared to the reference standard. In this prospective study, non-traumatic patients presenting to the ED, who received an sCXR were included. Between February and July 2019, 91 patients who underwent 93 consecutive examinations were enrolled. Subsequently, a ULD-CT and non-contrast CT were performed. The ULD-CT and sCXR were assessed by 3 radiologists, 3 senior clinicians, 3 junior clinicians, and 3 medical students for pneumonia, pneumothorax, pleural effusion, and pulmonary edema. The non-contrast CT, assessed by a chest radiologist, was used as the reference standard. The results of the assessments were compared within each group (intragroup agreement) and with the reference standard (accuracy) using kappa statistics. Accuracy and intragroup agreement improved for pneumothorax on ULD-CT compared with the sCXR for all groups. Accuracy and intragroup agreement improved for pneumonia on ULD-CT when assessed by radiologists and for pleural effusion when assessed by medical students. In patients with acute lung conditions ULD-CT offers improvement in the detection of pneumonia by radiologists and the detection of pneumothorax by radiologists as well as non-radiologists compared to sCXR. Therefore, ULD-CT may be considered as an alternative first-line imaging modality to sCXR for non-traumatic patients who present to EDs.

When used with standard diagnostic testing, point-of-care ultrasonography might improve the proportion of patients admitted with respiratory symptoms who are correctly diagnosed 4 h after admission to the emergency department. We therefore assessed point-of-care ultrasonography of the heart, lungs, and deep veins in addition to the usual initial diagnostic testing in this patient population.

Patients with acute respiratory symptoms still remain a diagnostic challenge. The aim of the study was to evaluate whether focused sonography could potentially diagnose life-threatening conditions missed at the primary assessment in a patient population consisting of admitted patients with acute respiratory symptoms.

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