Abstract Background Point-of-care ultrasound (POCUS) has emerged as an essential bedside tool for clinicians, but lack of access to ultrasound equipment has been a top barrier to POCUS use. Recently, several handheld ultrasound devices (“handhelds”) have become available, and clinicians are seeking data to guide purchasing decisions. Few comparative studies of different handhelds have been done. We conducted a cross-sectional study comparing 6 handhelds readily available in the United States (Butterfly iQ + ™ by Butterfly Network Inc.; Clarius™ by Clarius Mobile Health; Kosmos™ by EchoNous; TE Air™ by Mindray; Vscan Air™ SL and CL by General Electric; and Lumify™ by Philips Healthcare). A multi-specialty group of physician POCUS experts (n = 35) acquired three standard ultrasound views (abdominal right upper quadrant, cardiac apical 4-chamber, and superficial neck and lung views) in random order on the same standardized patients and rated the image quality. Afterward, a final survey of the overall ease of use, image quality, and satisfaction of each handheld was completed. Results Thirty-five POCUS experts specializing in internal medicine/hospital medicine, critical care, emergency medicine, and nephrology acquired and rated right upper quadrant, apical 4-chamber, and superficial neck and lung views with 6 different handhelds. For image quality, the highest-rated handhelds were Vscan Air™ for the right upper quadrant view, Mindray TE Air™ for the cardiac apical 4-chamber view, and Lumify™ for superficial views of the neck and lung. Overall satisfaction with image quality was highest with Vscan Air™, Lumify™, and Mindray, while overall satisfaction with ease of use was highest with Vscan Air™. The 5 most desirable characteristics of handhelds were image quality, ease of use, portability, probe size, and battery life. Ultimately, all 6 handhelds had notable advantages and disadvantages, with no single device having all desired qualities or features. Conclusions The overall satisfaction with image quality was rated highest with Vscan Air™, Lumify™, and Mindray TE Air™when acquiring right upper quadrant, apical 4-chamber, and superficial neck and lung views. No single handheld was perceived to be superior in image quality for all views. Vscan Air™ was rated highest for overall ease of use and was the most preferred handheld for purchase by POCUS experts.

BACKGROUND:Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist. OBJECTIVE:This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs). DESIGN, SETTING, AND PARTICIPANTS:A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015. RESULT:Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices. CONCLUSION:From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.

BACKGROUND:Point-of-care ultrasound (POCUS) training has been increasing among internal medicine (IM) residency programs, but few programs can provide longitudinal training due to barriers such as lack of trained faculty.AIM:Describe the development of a longitudinal POCUS track for IM residents using local and external resources, including a national POCUS certificate program.SETTING:University-based IM residency program affiliated with a public and veterans affairs hospital.PARTICIPANTS:Twelve IM residents from 2018 to 2021.PROGRAM DESCRIPTION:Residents complete a national POCUS certificate program by attending live courses and completing online modules, an image portfolio, and final knowledge/skills assessments. Locally, residents participate in 1-month procedure and diagnostic POCUS rotations and provide peer-to-peer POCUS teaching of residents and medical students.PROGRAM EVALUATION:The POCUS track increased residents' use and comfort with diagnostic and procedural applications. All residents rated being satisfied or very satisfied with the track and would recommend it to prospective applicants (100%). The most commonly reported barriers to utilizing POCUS per residents were time constraints (83%), lack of available ultrasound equipment (83%), and lack of trained faculty (58%).DISCUSSION:IM residency programs with limited faculty expertise in POCUS can leverage external resources to provide longitudinal POCUS training to its residents.

Background Many institutions are training clinicians in point-of-care ultrasound (POCUS), but few POCUS skills checklists have been developed and validated. We developed a consensus-based multispecialty POCUS skills checklist with anchoring references for basic cardiac, lung, abdominal, and vascular ultrasound, and peripheral intravenous line (PIV) insertion. Methods A POCUS expert panel of 14 physicians specializing in emergency, critical care, and internal/hospital medicine participated in a modified-Delphi approach to develop a basic POCUS skills checklist by group consensus. Three rounds of voting were conducted, and consensus was defined by ≥ 80% agreement. Items achieving < 80% consensus were discussed and considered for up to two additional rounds of voting. Results Thirteen POCUS experts (93%) completed all three rounds of voting. Cardiac, lung, abdominal, and vascular ultrasound checklists included probe location and control, basic machine setup, image quality and optimization, and identification of anatomical structures. PIV insertion included additional items for needle tip tracking. During the first round of voting, 136 (82%) items achieved consensus, and after revision and revoting, an additional 21 items achieved consensus. A total of 153 (92%) items were included in the final checklist. Conclusions We have developed a consensus-based, multispecialty POCUS checklist to evaluate skills in image acquisition and anatomy identification for basic cardiac, lung, abdominal, and vascular ultrasound, and PIV insertion.

Point-of-care ultrasound (POCUS) is becoming an essential skill for internists. To date, there are no professional guidelines for how POCUS skills should be taught to medical students. A panel of POCUS experts from seven academic medical centers in the United States was convened to describe the components of independently developed IM clerkship POCUS training programs, identify areas of similarity and difference, and propose recommendations for alignment.

Point of care ultrasound (POCUS) training is increasingly being integrated into internal medicine residency curricula. This change is occurring in the context of strengthening evidence for POCUS applications,1 marked improvements in technology and affordability, increasing training and use by practicing internists, and growing interest in POCUS training among residents.2-4

Schott, Christopher1,2; LoPresti, Charles3,4; Boyd, Jeremy5,6; Core, Megan7,8; Haro, Elizabeth9,10; Mader, Michael9,10; Pascual, Sergio10; Finley, Erin9,10; Lucas, Brian11,12; Colon-Molero MD, Angel13; Restrepo, Marcos14,9; Pugh, Jacqueline9,10; Soni, Nilam15,9 Author Information

BACKGROUND: Point-of-care ultrasound (POCUS) use continues to increase in many specialties, but lack of POCUS training is a known barrier among practicing physicians. Many physicians are obtaining POCUS training through postgraduate courses, but the impact of these courses on skill retention and frequency of POCUS use post-course is unknown. The purpose of this study was to assess the change in POCUS knowledge, skills, and frequency of use after 6-9 months of participating in a brief training course. METHODS: Course participants' POCUS knowledge and hands-on technical skills were tested pre-course using an online, 30-question knowledge test and a directly observed skills test, respectively. The same knowledge and skills tests were repeated immediately post-course and after 6-9 months using remote tele-ultrasound software. Course participants completed a survey on their POCUS use pre-course and after 6-9 months post-course. RESULTS: There were 127 providers who completed the POCUS training course from October 2016 to November 2017. Knowledge test scores increased from a median of 60% to 90% immediately post-course followed by a slight decrease to 87% after 8 months post-course. Median skills test scores for 4 common POCUS applications (heart, lung, abdomen, vascular access) increased 36-74 points from pre-course to immediately postcourse with a 2- 7-point decrease after 8 months. Providers reported more frequent POCUS use post-course, which suggests application of their POCUS knowledge and skills in clinical practice. More frequent use of cardiac POCUS applications was associated with significantly greater retention of cardiac skills at 8 months. CONCLUSIONS: Practicing physicians can retain POCUS knowledge and hands-on skills 8 months after participating in a 2.5-day POCUS training course, regardless of frequency of POCUS use post-course. Published by Elsevier Inc.

Point of Care Ultrasound (POCUS) is rapidly gaining international acceptance in the field of internal medicine. Realizing POCUS's potential to decrease procedural complication rates [ 1 Franco-Sadud R. Schnobrich D. Matthews B. Candotti C. Abdel-Ghani S. Perez M. Rodgers S. Mader M. Haro E. Dancel R. Cho J. Grikis L. Lucas B. Soni N Recommendations on the use of ultrasound guidance for central and peripheral vascular access in adults: a position statement of the society of hospital medicine. J Hosp Med. 2019; 14: E1-E22https://doi.org/10.12788/jhm.3287 Crossref Scopus (58) Google Scholar , 2 Cho J. Jensen T. Reierson K. Mathews B. Bhagra A. Franco-Sadud R. Grikis L. Mader M. Dancel R. Lucas B. Soni N. Society of Hospital Medicine Point-of-care Ultrasound Task ForceRecommendations on the use of ultrasound guidance for adult abdominal paracentesis: a position statement of the society of hospital medicine. J Hosp Med. 2019; 14: E7-E15https://doi.org/10.12788/jhm.3095 Crossref PubMed Scopus (33) Google Scholar , 3 Dancel R. Schnobrich D. Puri N. Franco-Sadud R. Cho J. Grikis L. Lucas B.P. El-Barbary M. Soni N.J Society of Hospital Medicine Point of Care Ultrasound Task ForceRecommendations on the use of ultrasound guidance for adult thoracentesis: a position statement of the society of hospital medicine. J Hosp Med. 2018; 13: 126-135https://doi.org/10.12788/jhm.2940 Crossref PubMed Scopus (40) Google Scholar ] improve diagnostic accuracy [ [4] Soni N.J. Schnobrich D. Mathews B.K. Tierney D.M. Jensen T.P. Dancel R. Cho J. Dversdal R.K. Mints G. Bhagra A. Reierson K. Kurian L.M. Liu G.Y. Candotti C. Boesch B. LoPresti C.M. Lenchus J. Wong T. Johnson G. Maw A.M. Franco-Sadud R. Lucas B.P Point-of-care ultrasound for hospitalists: a position statement of the society of hospital medicine. J Hosp Med. 2019; 14: E1-E6https://doi.org/10.12788/jhm.3079 Crossref PubMed Scopus (72) Google Scholar ], reduce time to diagnosis [ [5] Zanobetti M. Scorpiniti M. Gigli C. Nazerian P. Vanni S. Innocenti F. Stefanone V.T. Savinelli C. Coppa A. Bigiarini S. Caldi F. Tassinari I. Conti A. Grifoni S. Pini R Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017; 151 (Epub 2017 Feb 16): 1295-1301https://doi.org/10.1016/j.chest.2017.02.003 Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar , [6] Fischer E.A. Kinnear B. Sall D. Kelleher M. Sanchez O. Mathews B. Schnobrich D. Olson A.P.J Hospitalist-operated compression ultrasonography: a point-of-care ultrasound study (HOCUS-POCUS). J Gen Intern Med. 2019; 34 (Epub 2019 Aug 6): 2062-2067https://doi.org/10.1007/s11606-019-05120-5 Crossref PubMed Scopus (17) Google Scholar ], improve patient satisfaction [ [7] Howard Z.D. Noble V.E. Marill K.A. Sajed D. Rodrigues M. Bertuzzi B. Liteplo A.S Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014; 46 (Epub 2013 Aug 12): 46-53https://doi.org/10.1016/j.jemermed.2013.05.044 Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar ], and facilitate shared diagnostic understanding at the bedside [ [8] Mathews B.K. Miller P.E. Olson A.P.J Point-of-care ultrasound improves shared diagnostic understanding between patients and providers. South Med J. 2018; 111: 395-400https://doi.org/10.14423/SMJ.0000000000000833 Crossref PubMed Scopus (13) Google Scholar ], internists are turning to ultrasound as one of the most practice-altering innovations since the invention of the stethoscope over 200 years ago. While some enthusiasts have been teaching and advocating for POCUS's internal medicine applications for years, there seems to have been a spike in demand for learning POCUS more recently; initially by those providers in the acute medicine fields of hospital medicine and critical care [ [9] Point of care ultrasound certificate of completion, https://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/SHM-COC; 2020[accessed 3 February 2020]. Google Scholar , [10] LoPresti C.M. Boyd J.S. Schott C. Core M. Lucas B.P. Colon-Molero A. Kessler C. Mader M.J. Haro E.K. Finley E.P. Restrepo M.I. Pugh J. Soni N.J A national needs assessment of point-of-care ultrasound training for hospitalists. Mayo Clin Proc. 2019; 94 (Erratum in: Mayo Clin Proc. 2019 Dec;94(12):2597): 1910-1912https://doi.org/10.1016/j.mayocp.2019.07.016 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar ], but more recently by those in the outpatient setting as well [ [11] ACP statement in support of point of care ultrasound in internal medicine, https://www.acponline.org/meetings-courses/focused-topics/point-of-care-ultrasound-pocus-for-internal-medicine/acp-statement-in-support-of-point-of-care-ultrasound-in-internal-medicine; 2019[accessed 3 February 2020]. Google Scholar ].

Cough is a common symptom for which patients seek medical attention and can be caused by a multiplicity of disorders located in a variety of locations. 1 Dalal B Geraci SA. Office management of the patient with chronic cough. Am J Med. 2011; 124: 206-219 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ,2 Irwin RS Boulet LP Cloutier MM et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest. 1998; 114: 133S-181S Abstract Full Text Full Text PDF PubMed Scopus (542) Google Scholar Although transdiaphragmatic communications are thought to be rare, abdominal disease processes can extend into the thorax when fistulae occur across the diaphragm. 3 Chaturvedi A Rajiah P Chaturvedi A Imaging of acquired transdiaphragmatic fistulae and communications. Clin Imaging. 2019; 53: 78-88 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Herein, we present an unusual case of productive cough with yellow sputum, which instructed us to focus not only on causes above the diaphragm but also on causes below the diaphragm.

Point-of-care ultrasound (POCUS) is the use of ultrasound at the bedside to answer a specific diagnostic question or guide performance of an invasive procedure.1,2 Though many medical schools and internal medicine residency programs have started teaching POCUS,3 most practicing hospitalists completed their training without any experience in POCUS.1-3 Now, many practicing hospitalists are seeking continuing medical education courses to learn how to use POCUS. Currently, it is unknown how hospitalists are using POCUS and what training needs exist.

Point-of-care ultrasound (POCUS) is defined as ultrasound used at the bedside by the provider to answer directed clinical questions and guide clinical care. While POCUS first gained popularity in emergency medicine, its application is rapidly expanding in the field of internal medicine.1 This method of ultrasound can conceptually be split into 2 groups: procedural and diagnostic. Procedural POCUS (ultrasound-guidance of common bedside procedures) improves patient safety and is now standard of care for many procedures.

Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED).Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers.206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was “No structured curriculum to educate physicians on POCUS.” The top-ranked personal barriers were “I do not feel comfortable with my POCUS skills” and “I do not have sufficient time to dedicate to learning POCUS.” The top-ranked barriers for resident physicians were “Time to retrieve and operate the machine” and “Chaotic milieu.”While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

Background: Ever-expanding uses have been developed for ultrasound, including its focused use at the bedside, often referred to as point-of-care ultrasound (POCUS). POCUS has been well developed and integrated into training in numerous fields, but remains relatively undefined in internal medicine training. This training has been shown to be desirable to both educators and trainees, but has proven difficult to implement. We sought to create a road map for internal medicine residency programs looking to create a POCUS program. Results: Four internal medicine residency programs that have successfully integrated POCUS training describe their programs, as well as the principles and concepts underlying program development and execution. Review of educational teaching and assessment methods is outlined, as well as suggestions for integration into an already busy residency curriculum. Commonly reported barriers to POCUS implementation such as faculty development, equipment purchasing, resident supervision and quality assurance are addressed. Specific POCUS applications to target are touched upon, and a comparison of applications taught within these four programs suggest that there may be enough similarities to suggest a common curriculum. Finally, future needs are discussed. Conclusions: POCUS can be successfully taught to internal medicine residents as a part of internal medicine training. Many common elements and principles are evident on review of these four described successful programs. Future support, in the form of endorsed medical society guidelines, will be needed before POCUS is universally incorporated across internal medicine residency training programs.

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

In the era of duty-hour regulations, there is increasing concern regarding resident workload compression. We conducted a retrospective, observational assessment of all internal medicine resident admissions to a Veterans Affairs hospital over a 15-year period to evaluate several admission components that impact resident workload and workload intensity, including electronic health record (EHR) data burden and patient comorbidity. A total of 67,346 admissions were included in the analysis. Mean patient comorbidity, as measured by the Charlson Comorbidity Index, increased throughout the study period. EHR data burden, measured by numbers of notes, medications, and discharge summaries available per patient at the time of admission, also increased over the study period. These findings suggest that EHR data burden and comorbidity have increased over time, which impacts resident workload in the era of duty hour restrictions.

Abstract Introduction: Liver disease is often marked by changes in hemostasis. Vitamin K is frequently administered to cirrhotic patients with an elevated INR to improve their coagulopathy, though strong evidence justifying this approach is lacking. Questions regarding the efficacy of vitamin K have been gathering based on an increased understanding of the rebalanced hemostasis of liver disease. This study evaluated the effect of vitamin K on the INR 24-72 hours after administration. Methods: This retrospective chart review used the VA Informatics and Computing Infrastructure (VINCI) database to identify 886 admissions for patients with liver disease who received vitamin K between January 1, 2001 and March 31, 2014. Patients were included if they had a coded diagnosis of cirrhosis, acute hepatitis, non-alcoholic steatohepatitis, hepatocellular carcinoma, or end stage liver disease. Charts for patients with one of those diagnoses who received vitamin K at the LSCDVAMC were included. All data was collected from the Computerized Patient Record System (CPRS). Medication route and dosing was determined from the pharmacy administration record. Patients were excluded if they received heparin, LMWH, FFP, or if they did not have an INR value before the administration of vitamin K or 24-72 hours after the dose was given. Results: A total 886 individual admissions were identified, 333 admissions met inclusion criteria for analysis. The mean INR on admission for the included encounters was 1.88 (95% CI 1.798 - 1.955) the lowest INR was 0.86 and the highest was 5.99. In the 333 admissions analyzed the mean decrease in the INR was 0.08 (95% CI 0.028 - 0.132). 180 encounters had a repeat INR during the hospitalization. The mean decrease in INR from admission to the second post-vitamin K INR was 0.123 (95% CI 0.058 - 0.187). Of the 333 included patient encounters 37 had a change in INR (increase or decrease) >0.4, of which in 11 the INR increased and in 24 the INR decreased (mean change in INR 0.313; 95% CI -0.139 to 0.765). The average INR of those 37 encounters was 2.83 (95% CI 2.497 - 3.171). There was no significant difference in albumin in encounters when the INR increased vs. decreased in response to vitamin K. There was a trend towards higher total bilirubin (TBILI) when the INR did not decrease in response to vitamin K. Mean TBILI was 5.9 in INR responders (95% CI 5.011 - 6.789) and was 6.66 (95% CI 5.219 - 8.101) in the encounters where the INR increased despite vitamin K. Conclusion: Vitamin K administration to improve the coagulopathy of patients with liver disease is common and often administered in response to an elevated INR. This is the largest retrospective review to date evaluating the effect of vitamin K on the INR of patients with liver disease. While a statistically significant decrease in INR of 0.08 was found, it is unclear if such a difference from vitamin K would be clinically significant. Moreover, only a very small portion of the patients included in this study (24/333) had an INR decrease of greater than 0.4. A limitation of our study is that patient centered outcomes, such as bleeding events, were not assessed. Future research should evaluate if there is a role for vitamin K in liver disease patients with a significantly elevated INR and low total bilirubin. Disclosures No relevant conflicts of interest to declare.

An increasing number of patients with abdominal aortic aneurysms (AAAs) are undergoing endovascular aortic repair (EVAR) instead of open surgery. These patients require lifelong surveillance, and the follow-up imaging modality of choice has been traditionally computed tomography angiography (CTA). Repetitive CTA imaging is associated with cumulative radiation exposure and requires the administration of multiple doses of nephrotoxic contrast agents. Contrast-enhanced ultrasound (CEUS) has emerged as an alternative strategy in the follow-up of patients with EVAR and demonstrates high sensitivity and specificity for detection of endoleaks. In fact, a series of studies have shown that CEUS is at least performing equal to computed tomography for the detection and classification of endoleaks. This article summarizes current evidence of CEUS after EVAR and demonstrates its usefulness via various patient cases.

BACKGROUND The clinical learning model in medical education is driven by knowledge acquisition through direct patient-care experiences. Despite the emphasis on experiential learning, the ability of educators to quantify the clinical exposures of learners is limited. OBJECTIVE To utilize Veterans Affairs (VA) electronic medical record information through a data warehouse to quantify clinical exposures during an inpatient internal medicine rotation. METHODS We queried the VA clinical data warehouse for the patients encountered by each learner completing an acting internship rotation at the Cleveland VA Medical Center from July 2008 to November 2011. We then used discharge summary information to identify team exposures-patients seen by the learner's inpatient team who were not primarily assigned to the learner. Based on the learner and team exposures, we complied lists of past medical problems, medications prescribed, laboratory tests that resulted, radiology evaluated, and primary discharge diagnoses. RESULTS Primary learner and team-based clinical exposures were evaluated for a total of 128 acting internship students. The percentage of learners who had a primary exposure to a medication/lab value/imaging result/diagnosis was calculated. The percentage of learners with at least 1 primary or team-based exposure to an item was also calculated. The most common exposures in each category are presented. CONCLUSIONS Analysis of the clinical exposures during an inpatient rotation can augment the ability of educators to understand learners' experiences. These types of analyses could provide information to improve learner experience, implement novel curricula, and address educational gaps in clinical rotations.