Jessica R. Balderston's research while affiliated with Virginia Commonwealth University and other places

Introduction The use of a reliable scoring system for quality assessment (QA) is imperative to limit inconsistencies in measuring ultrasound acquisition skills. The current grading scale used for QA endorsed by the American College of Emergency Physicians (ACEP) is non-specific, applies irrespective of the type of study performed, and has not been rigorously validated. Our goal in this study was to determine whether a succinct, organ-specific grading scale designed for lung-specific QA would be more precise with better interobserver agreement. Methods This was a prospective validation study of an objective QA scale for lung ultrasound (LUS) in the emergency department. We identified the first 100 LUS performed in normal clinical practice in the year 2020. Four reviewers at an urban academic center who were either emergency ultrasound fellowship-trained or current fellows with at least six months of QA experience scored each study, resulting in a total of 400. The primary outcome was the level of agreement between the reviewers. Our secondary outcome was the variability of the scores given to the studies. For the agreement between reviewers, we computed the intraclass correlation coefficient (ICC) based on a two-way random-effect model with a single rater for each grading scale. We generated 10,000 bootstrapped ICCs to construct 95% confidence intervals (CI) for both grading systems. A two-sided one-sample t-test was used to determine whether there were differences in the bootstrapped ICCs between the two grading systems. Results The ICC between reviewers was 0.552 (95% CI 0.40–0.68) for the ACEP grading scale and 0.703 (95% CI 0.59–0.79) for the novel grading scale (P < 0.001), indicating significantly more interobserver agreement using the novel scale compared to the ACEP scale. The variance of scores was similar (0.93 and 0.92 for the novel and ACEP scales, respectively). Conclusion We found an increased interobserver agreement between reviewers when using the novel, organ-specific scale when compared with the ACEP grading scale. Increased consistency in feedback based on objective criteria directed to the specific, targeted organ provides an opportunity to enhance learner education and satisfaction with their ultrasound education.

Study objective: There is conflicting data regarding the accuracy of thoracic point of care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by Emergency Physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients. Methods: We conducted a retrospective IRB approved study of trauma patients 15-years or older presenting to our urban level 1 academic trauma center from December 2021 to June 2022. All study patients were imaged with single view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound with tube thoracostomy placement. Results: Eight hundred and forty-six patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant pneumothoraces (defined as >35mm of pleural separation on a blinded over-read or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% CI 58-97), specificity of 100% (95% CI 99-100), positive predictive value of 81% (95% CI 54-95%), and negative predictive value of 100% (95% CI 99-100). The positive likelihood ratio was 4.3 and the negative likelihood ratio was 0.001. CXR identified 8 (53%) clinically significant pneumothoraces, with a sensitivity of 53% (95% CI 27-78) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert blinded over-read was failure to recognize a lung point sign that was present on ultrasound. Conclusion: Thoracic POCUS accurately identifies the majority of clinically significant pneumothoraces in both blunt and penetrating trauma patients. Common themes for false negative thoracic ultrasound in the expert blinded over-read process identified key gaps in training to inspire ultrasound education and medical education research.

Study objective Covert brain infarctions are focal lesions detected on brain imaging consistent with ischemia in the absence of a history of overt stroke or neurologic dysfunction. Covert brain infarctions are associated with an increased risk of future stroke. We evaluated the prevalence of covert brain infarctions in patients undergoing computed tomography (CT) in the emergency department (ED), as well as clinician response to the findings. Methods Patients aged more than 50 years who underwent CT of the head and were seen and discharged from our ED from January to September 2018 were identified. Patients with a history of stroke, or prior brain imaging with ischemia, were excluded. Patient data and clinician response (patient notification, neurology referral, and risk factor modification) were collected. Results We included 832 patients, with an average age of 62 years, and 50% of the patients were women. Covert brain infarctions were present in 11% of patients (n=95). Only 9% of patients with covert brain infarctions were clearly made aware of the finding. Of the patients with covert brain infarctions, 27% were already on aspirin and 28% on a statin. Aspirin was added for 2 patients, and statin medication was not started on any patient. The blood pressure medication was added or adjusted for 2 patients with covert brain infarctions. The neurology department was consulted for 9% of the patients with covert brain infarctions. Conclusion The prevalence of covert brain infarctions in patients older than 50 years presenting to the ED who underwent CT of the head and were subsequently discharged from the ED was 11%. Only 9% of these patients were made aware of the finding, with minimal intervention for stroke prevention at the time of their visit. Interventions targeting this population should be considered.

Background Focused cardiac ultrasound (FOCUS) can aid in evaluation and management of patients with cardiac arrest, but image quality in this population has been questioned. Our goal was to determine how often adequate imaging can be obtained in cardiac arrest patients. Methods We conducted a prospective cohort study to examine the utility of FOCUS in cardiac arrest. All patients who presented to the Emergency Department (ED) in cardiac arrest or who had cardiac arrest while in the ED over 6 months were prospectively identified. FOCUS images were obtained as part of routine clinical care. Patients with images obtained were paired with age- and gender-matched controls who underwent FOCUS for another indication during the study period. Image quality was scored by two blinded reviewers using a 0–4 scale, with a score of ≥ 2 considered adequate. Results There were 137 consecutive cardiac arrests, 121 out-of-hospital and 16 in-hospital, during the study period. FOCUS images were recorded in 126 (92%), who were included in the analysis. The average age was 58 years, and 45% were female. Ninety-seven studies (77%) were obtained during advanced cardiac life support while 29 (23%) were obtained after return of spontaneous circulation. The controls were appropriately matched. Of the cardiac arrest studies, 106 (84%) were rated adequate, compared to 116 (92%) in controls ( p = 0.08). When compared to control FOCUS studies, the scores given to studies of cardiac arrest patients were lower ( p = 0.001). Conclusions FOCUS can reliably be used during cardiac arrest to obtain images adequate to answer clinical questions and guide therapies.

Black patients frequently fare worse than White patients with respect to numerous health outcomes even after controlling for socioeconomic factors.¹ In clinical situations where pathophysiology does not vary by race, patient race may predict differences in treatment and ultimate outcome.²⁻⁴ This suggests that racial bias is present and may be associated with variations in patient care. Our study looked for evidence of explicit racial bias in clinician documentation.

Objectives We evaluated the utility of focused cardiac ultrasound to predict the length of stay in patients presenting to the emergency department with dyspnea of unclear etiology. Methods Patients with focused cardiac ultrasound examinations performed in the emergency department for dyspnea over a 34‐month period were retrospectively identified. Patients were excluded if they had a prior diagnosis of heart failure, dialysis requirement, or an etiology of dyspnea unrelated to the volume status. Left ventricular function was categorized as normal or reduced, and the inferior vena cava was categorized as normal or increased volume. A fast limited ultrasound to investigate dyspnea (FLUID) score was calculated by adding 1 point for reduced left ventricular function and 1 point for increased volume, producing a score of 0, 1, or 2. Results There were 123 patients included. There was a significant correlation between the FLUID score and length of stay, with longer stays for higher scores (FLUID score 0, 7.4 hours median; FLUID score 1, 2.34 days; FLUID score 2, 5.56 days; analysis of variance P < .001). Of the other variables collected, only age, hypertension, diabetes, heart rate, and brain natriuretic peptide were significantly correlated with the length of stay. A multivariate analysis including those variables and the FLUID score showed that the FLUID score was the strongest independent predictor of the length of stay. Conclusions Focused cardiac ultrasound and calculation of a FLUID score for patients with undifferentiated dyspnea can be a powerful tool to predict the hospital length of stay.