Using LUNG US to diagnose Pediatric Pneumonia.

By Kate Madden Yee, AuntMinnie.com staff writer

June 28, 2019 -- Lung ultrasound is a viable alternative to chest x-ray and CT for diagnosing pneumonia in children -- with a sensitivity of 94% and a specificity of 92% -- but it is dependent on operator experience, according to a study published online June 18 in Academic Emergency Medicine.

Although using ultrasound to diagnose pneumonia in children appears to be effective, sonographer experience must be taken into account, wrote a team led by Dr. Po-Yang Tsou of Driscoll Children's Hospital in Corpus Christi, TX.

"To our knowledge, this is the first article demonstrating significant differences in lung ultrasound's diagnostic accuracy for pneumonia between novice and advanced sonographers," Tsou and colleagues wrote. "[Our] findings suggest that the sonographer's experience level should be considered when using lung ultrasound to diagnose pneumonia in children."

Difficult diagnosis

Pneumonia is a leading cause of death in children around the world, the authors noted. In developed countries, the annual incidence rate is 33 per 10,000 children 0 to 5 years of age, with a mortality rate of less than one per 1,000 children. But in developing countries, the condition is more serious with an annual incidence rate of 2,900 per 10,000 children age 0 to 5 and a mortality rate of 26 per 1,000 children.

To make matters worse, diagnosis of pediatric pneumonia can be challenging, in part due to the variation in signs and symptoms. The illness has typically been identified with chest x-ray and clinical presentation. Chest CT is also used and has excellent diagnostic accuracy, but its drawbacks include radiation exposure, high cost, and the possible need for sedation of pediatric patients.

Past studies have suggested that lung ultrasound may be a viable alternative to these modalities for pediatric pneumonia, but it has been unclear whether operator dependence affects its accuracy.

"Studies measuring the diagnostic accuracy of lung ultrasound for childhood pneumonia generally report excellent sensitivity and specificity," the group wrote. "However, ultrasound's accuracy varies by user skill and training."

The researchers conducted a review study to assess the diagnostic accuracy of the modality and compared performance between novice and experienced sonographers. The team searched PubMed and EMBASE from their inception to February 2018 for studies that evaluated the utility of lung ultrasound in children with suspected pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. The group also assessed diagnostic accuracy between novice (seven days or fewer of training) and advanced sonographers.

The analysis included 25 studies with a total of 3,389 patients presenting with pneumonia symptoms. Of these 25, 18 were prospective cohort studies, five were retrospective cohort studies, one was a randomized controlled trial, and one case was a control study. Subjects were mostly infants, children, and adolescents. Of the studies included in the research, 16 used advanced sonographers, seven used novice sonographers, and two used sonographers of unknown training level in lung ultrasound.

Lung ultrasound showed an overall sensitivity of 94%, specificity of 92%, and an area under the curve (AUC) of 0.97. However, the group did find a significant difference in diagnostic accuracy for pneumonia between less experienced and more experienced sonographers, with novice sonographers showing less sensitivity than their advanced counterparts.

Tsou and colleagues also found that point-of-care lung ultrasound performed better than exams conducted in the radiology department.

Comparison of sonographer experience and location for lung ultrasound
Performance measure	Novice sonographers	Advanced sonographers	All sonographers	Point-of-care lung ultrasound	Radiology department lung ultrasound
Sensitivity	80%	96%	94%	94%	91%
Specificity	96%	90%	92%	94%	86%
AUC	0.97	0.97	0.97	0.98	0.93

Not only does lung ultrasound show promise as a diagnostic tool for pediatric pneumonia, it also can be used to monitor disease progression without exposing children to radiation, costs less than more invasive tests, and may even decrease the length of stay in the emergency department.

Standardized curriculum

Novice sonographers included in this study had experience ranging from one hour to seven days of training. So what can be done to improve novice sonographers' ability to use lung ultrasound to diagnose pneumonia effectively? It comes down to instituting a standardized curriculum in the department, according to the research team.

"This study also importantly reveals the training of lung ultrasound impacts its diagnostic accuracy for pneumonia," the authors concluded. "[These] results indicate the need for a standardized curriculum, ideally consisting of a certain number of supervised scans and a post-test administered by ultrasound experts. ... Future studies are needed to standardize the curriculum for lung ultrasound training and determine the [number] of scans and duration of training required for a novice to achieve adequate proficiency in lung ultrasound."

ACUTE APPENDICITIS: CT and US

ONSD detects Increased Intracranial Pressure

Purpose: Increased intracranial pressure (ICP) is one of the prevalent symptoms of trauma, especially traumatic headache, which requires quick action for the diagnosis and treatment. The optic nerve sheath diameter (ONSD) is a newly proposed technique for the detection of an increase in ICP. The aim of this study was to assess the efficacy of this new diagnostic method in patients with increased ICP induced by trauma. Methods: This prospective study was conducted between December 2016 and February 2017. The patients with traumatic headache and who had been diagnosed with increased ICP using clinical signs and computed tomography scan were compared to the voluntary healthy group. In each patient, measurements were performed employing ultrasound three times on each eye in an axial region, and the mean of these sizes was obtained as the ONSD. Results: A total of 112 participants were examined. The mean ONSD measurement of the patients and the voluntary healthy group was 6.01 ± 0.76 and 3.41 ± 0.56 mm in the right eye, 6.11 ± 0.75 and 3.39 ± 0.54 mm in the left eye, and 6.06 ± 0.75 and 4.02 ± 1.07 mm in both sides, respectively. The ONSD in the right and left sides had high and significant correlation in the patients (r = 0.929, P < 0.000) and voluntary healthy (r = 0.630, P < 0.000) group. The mean ONSD of one of the patients was 6.24 ± 0.56 mm, and in another patient with no clinical sign of increased ICP, the mean ONSD was 4.61 ± 0.09 mm. Conclusions: Ultrasound performed on the diaphragm of the optic nerve with acceptable sensitivity can detect patients with an increase in ICP and can be efficacious in expediting the action needed to reduce ICP. Due to the sensitivity and specificity of the ultrasound and high accuracy of the diameter of optic nerve sheath in detecting increase in ICP, as well as considering the fact that ultrasound is a noninvasive and available technique; it can be performed at the patient's bedside.

5 trends shaping the future of global ultrasound

By Simon Harris, AuntMinnie.com contributing writer

June 17, 2019 -- 2018 was a record year for the world ultrasound equipment market, with revenues increasing by 6.8%, tipping the market over the $7 billion mark for the first time. Despite the backdrop of global economic uncertainty, the ultrasound market is forecast to continue to grow relatively strongly in the coming years, with the following five trends driving growth.

1. Ultrasound attracts new users

Over the years, the use of ultrasound has gradually expanded beyond radiology, cardiology, and ob/gyn to a wide range of clinical specialties, including surgery, musculoskeletal, and gastroenterology, to name a few, expanding the customer base and driving additional revenue growth.

This trend started out in developed countries, but more recently it has spread to developing markets, particularly India and China, where specialty departments at larger hospitals now often have their own budgets to buy ultrasound scanners.

Additionally, ultrasound is gaining acceptance in acute and primary care settings as both a screening and diagnostic tool, as well as for procedure guidance. With the use of handheld ultrasound gaining pace (see trend No. 4 below), this trend will accelerate in the coming years.

All images courtesy of Signify Research.

2. New clinical applications evolve

Along with the growing customer base, the use of ultrasound with existing customers is expanding, typically as a lower-cost and/or radiation-free alternative to other imaging modalities, such as MRI and CT. The global shift to value-based care as a replacement to the traditional fee-for-service approach will support this trend.

For example, ultrasound is playing an increasingly important role as a screening tool for women with dense breast tissue. In acute care, ultrasound is increasingly being used for lung imaging to diagnose conditions such as pleural effusion, pulmonary edema, and pneumothorax. In another example, the use of shear-wave elastography is expanding beyond hepatology (e.g., liver fibrosis) to other body areas, including the breast, prostate, thyroid, and spleen. Musculoskeletal imaging is another relatively untapped market for ultrasound, including orthopedics, rheumatology, and sports medicine.

3. New markets emerge

The ultrasound market in developed regions, such as Western Europe, North America, and Japan, is largely saturated, and the outlook is for low-single-digit to midsingle-digit growth. While these markets will continue to account for the lion's share of the world market, developing markets continue to represent a growth opportunity. In 2019, the fastest growth is forecast for Southeast Asia, Brazil, China, and India.

That said, ultrasound market growth is slowing in many of the emerging markets, particularly China, largely due to slowing global economic growth.

4. Handheld ultrasound picks up steam

As we discussed in a previous insight ("Handheld Ultrasound Market Poised for Next Wave of Growth"), the handheld ultrasound market is growing rapidly as the latest generation of ultraportable devices gains acceptance among a diverse range of customer groups, from emergency medicine physicians and intensivists to internists, office-based specialists, and -- looking forward -- primary care physicians.

The expanding customer base of handheld systems, coupled with the increased availability of affordable handheld scanners, is forecast to boost global sales of handheld ultrasound by more than 50% in 2019. By 2023, the global market for handheld ultrasound is forecast to exceed $400 million.

5. Artificial intelligence to transform market

Artificial intelligence (AI) will have a transformative effect on the ultrasound market as AI addresses some of the key limitations associated with ultrasound; namely, the shortage of trained sonographers and the relatively steep learning curve, high operator dependency during image acquisition and interpretation, poor image quality for certain exam types, and relatively lengthy exam time compared with other modalities.

The first wave of ultrasound AI applications are entering the market and are mainly for image optimization (noise reduction) and automation of time-consuming and repetitive tasks, such as anomaly detection, image labeling, and feature quantification. However, the greatest impact of AI will be on guided ultrasound (ultrasound navigation), which will provide real-time support during image acquisition (i.e., probe placement and anatomy detection).

The first AI-enabled guided ultrasound systems are expected to be released in the second half of 2019. These systems are expected to expand the user base by making ultrasound more accessible to novice users, particularly in acute and primary care.

Which biopsy method best detects prostate cancer?

By Wayne Forrest, AuntMinnie.com staff writer

June 18, 2019 -- The combination of ultrasound- and MRI-guided biopsy yields the best chance of detecting prostate cancer, as each method can find malignant lesions missed by the other, researchers from the University of California, Los Angeles (UCLA) reported in a study published online June 12 in JAMA Surgery.

In the three-year Prospective Assessment of Image Registration in the Diagnosis of Prostate Cancer (PAIREDCAP) study, the researchers found that using ultrasound and MRI in tandem can identify up to one-third more cancers than standard techniques.

"Our research suggests that the different biopsy methods identify different tumors," said senior author Dr. Leonard Marks, from UCLA's department of urology, in a statement. "To maximize our ability to identify prostate cancer, we need to take advantage of all the information we can. Our cancer detection rate, while using different methods in tandem, surpasses that from using either method alone."

While the clinical value of MRI-guided prostate biopsy has been proved in previous large prospective studies, some debate remains over the optimum approach with the modality. Clinicians have debated whether biopsy should focus on areas with lesions only visible on MRI or if ultrasound-guided systematic biopsy -- in which 12 biopsy cores are acquired of multiple areas of the prostate -- is sufficient.

"Answers to these questions are vital because of the importance of diagnosing prostate cancer early vis-a-vis cost-effectiveness issues," the authors wrote.

The prospective study included 300 men who were undergoing prostate biopsy for the first time: 248 consecutive subjects (mean age, 65.5 ± 7.7 years) had MRI-visible lesions, while the control population consisted of 52 men (mean age, 63.6 ± 5.9 years) with no visible lesions on MRI. Each biopsy was preceded by a 3-tesla multiparametric MRI scan (Magnetom Trio, Siemens Healthineers) with an abdominal coil within 60 days of the procedure.

The study protocol used three biopsy techniques:

• Systematic biopsy, performed with a standard handheld transrectal ultrasound-guided technique in which 12 cores were acquired, with the operator blinded to the MRI results
• Targeted cognitive fusion, in which a radiologist used MR images on a screen next to the patient to guide the urologic biopsy operator to aim an ultrasound-guided biopsy at the area of the prostate corresponding to where the lesion was seen on MRI; three biopsy cores were obtained cognitively from the index region of interest (ROI)
• Software fusion, in which researchers fused MRI and 3D ultrasound images using commercially available software (Artemis, Eigen), and an operator performed three targeted biopsies on the coregistered images

The illustration shows the difference between ultrasound- and MRI-guided methods to obtain tissue samples (black needles) from different regions in the prostate (brown oval object). MRI (right) allows doctors to detect lesions (green oval object) and take tissue samples from specific lesions. Images courtesy of UCLA Health.

The combination of methods produced the highest results, the researchers found.

Cancer detection rate of prostate biopsy methods
Biopsy method	Cancer detection rate
Combination of systematic, cognitive, and software fusion biopsy	70.2%
Cognitive fusion or software fusion	62.1%
Cognitive targeting	46.8%

The cancer detection rate of 70% is considerably higher than the cancer detection rate of conventional biopsy in previous studies, likely reflecting the outcomes of the MRI screening, the researchers noted. "These data thus serve to confirm the value of MRI for providing risk assessment when considering biopsy," they wrote.

Indeed, the researchers found that if only a single biopsy method was used, from 11.5% to 33.3% of cancers would have been missed, based on patient population.

Interestingly, among the 52 healthy controls, traditional ultrasound found prostate cancer in eight men (15%). This means that MRI does not identify all tumors, thus heightening the need to also incorporate traditional ultrasound-guided systematic biopsy as well, according to the researchers.

Ultrasound helps assess DVT risk after ablation

By Kate Madden Yee, AuntMinnie.com staff writerJune 18, 2019

The researchers from Stanford University also found that ultrasound helped clarify which ablation technique is safer.

"The rates of DVT decreased over time, suggesting an improvement in overall procedural safety; however, LA demonstrated a considerable decreased risk for DVT when compared to RFA," first author Dr. Nathan Itoga and colleagues wrote.

Studies have shown that both radiofrequency ablation and laser ablation are at least as successful as surgery for treating conditions such as varicose veins, and they can be performed without general anesthesia and tend to have fewer negative effects. But the rates of complications such as DVT after venous ablation procedures have been unclear, the group noted.

"Despite the relative safety of these techniques, LA and RFA may cause endovenous heat-induced thrombosis which ... may extend or propagate, leading to deep vein thrombosis," the researchers wrote. "In rare cases, LA and RFA procedures may also lead to pulmonary embolism. The overall risk for thromboembolic complication after endovenous ablation is controversial, and estimates in the literature vary greatly, from less than 1% to 18%."

The study included data from Truven Health Analytics MarketScan databases from 2007 and 2016 for a cohort of patients who underwent RFA or LA and had a follow-up duplex ultrasound scan within seven days and 30 days of the ablation procedure. Of the patient cohort, 256,999 underwent 433,286 ablations, 44.4% of which were radiofrequency and 55.6% of which were laser.

Of these patients, 1.9% had a newly diagnosed DVT within seven days of the procedure, and 3.1% had a newly diagnosed DVT within 30 days of the procedure. Factors associated with a decreased risk of DVT within 30 days included having had laser ablation, being female, and having sclerotherapy performed on the same day as the ablation; factors associated with an increased risk of DVT included a diagnosis of peripheral artery disease and undergoing stab phlebectomy.

Screening ultrasound revealed laser ablation to be the safer method, showing an 18% decrease in the incidence of DVT at 30 days (2.8%) compared to radiofrequency ablation (3.4%).

The study results demonstrate ultrasound's usefulness in tracking patients who have undergone ablation procedures for complications, according to the researchers.

"Some have suggested that postoperative evaluation of DVT is unnecessary, arguing that ultrasound overdiagnoses DVT, leading to overtreatment," Itoga and colleagues wrote. "However, if postoperative ultrasound were reserved for only those with symptoms, a considerable number of DVT would be missed."

Better ultrasound protocols slash trauma imaging overuse.

• Sign Ou 

By Kate Madden Yee, AuntMinnie.com staff writer

June 11, 2019 -- When lower extremity duplex ultrasound screening (LEDUS) protocols for the trauma department are refined, overuse of hospital resources is reduced by more than a third -- and without negative effect on patient outcomes, according to a new study published June 5 in the Journal of Surgical Research.

The findings translate to more efficient trauma departments -- and better patient care, wrote a team led by Dr. Jennifer Baker of the University of Cincinnati in Ohio.

"Refinement of LEDUS protocols can decrease overutilization of hospital resources without compromising trauma patient outcomes," the researchers concluded.

A tool called the risk assessment profile (RAP) is typically used in the trauma center to identify patients who would most benefit from lower extremity duplex ultrasound screening. But it can lead to overuse of imaging and needs refinement, Baker's group wrote.

The researchers conducted a study for which they hypothesized that revising their hospital's LEDUS protocol so that screening ultrasound examinations were performed in patients with a RAP score ≥ 8 within 48 hours of admission would reduce the number of screenings performed -- without changing patient outcomes.

The study included 1,014 trauma patients admitted from July 2014 to June 2015 and July 2016 to June 2017. From 2014 to 2015, patients with a RAP score ≥ 5 had weekly LEDUS examinations starting on the fourth hospital day, while from 2016 to 2017, the protocol changed to screening patients with a RAP score ≥ 8 by the second hospital day. Both protocols included screening with weekly ultrasound after the first examination. Baker's team gathered data on demographics, injury characteristics, LEDUS exam findings, and venous thromboembolism incidences.

The group found that from 2014 to 2015, 602 patients underwent LEDUS exams, but from 2016 to 2017, only 412 patients did: a 32% drop. Significantly, the team noted no difference in the number of patients diagnosed with deep vein thrombosis (DVT) or pulmonary embolism between the two protocols; in fact, DVT was often identified in the first LEDUS exam in both year groups.

Regarding those patients who received a DVT diagnosis on first LEDUS exam, the group also found the following:

• These patients had significantly higher RAP scores than those who did not have a DVT diagnosis (12 versus 10).
• The time to their first LEDUS exam was shorter (one day versus three days).
• The DVT diagnosis was made more quickly (two versus four days).

A simple change to protocol can make a big difference without harming patients, according to the researchers.

"[This protocol change caused] no significant difference ... in the number of patients diagnosed with DVT or pulmonary embolism," they concluded.

RATIONAL ARRANGEMENT of MESURING SWE SPEED in LIVER

CORE BIOPSY for LARGE THYROID NODULES

Ultrasound shows Heart disease Risk from Psoriasis.

By Kate Madden Yee, AuntMinnie.com staff writer

June 6, 2019 -- Ultrasound imaging of the carotid arteries can help identify patients with psoriasis and psoriatic arthritis who are at increased risk for heart disease by revealing the extent of clogging in patients' arteries, according to a new study published online June 5 in Arthritis & Rheumatology.

The results show that combining ultrasound imaging data with traditional cardiovascular risk factors -- as measured by, for example, the Framingham risk score -- could identify which patients with psoriatic disease may benefit from more intensive heart-protective therapies, wrote lead author Dr. Curtis Sobchak, of the University of Toronto, and colleagues.

"Ultrasound is widely used in rheumatology settings as a point of care to detect joint inflammation. Our study suggests that ultrasound can also be used to identify patients that are at high cardiovascular risk who may be missed by the conventional methods such as the Framingham risk score," senior author Dr. Lihi Eder, PhD, said in a statement released by the journal. "This will allow early intervention, such as initiation of lipid lowering therapy, which will ultimately lower the risk of developing cardiovascular events."

Sobchack and colleagues evaluated whether carotid ultrasound could predict incident cardiovascular events in patients with psoriatic disease and whether using ultrasound imaging data would improve the performance of the Framingham risk score for cardiovascular risk prediction.

The study included 559 patients with psoriatic disease. Of these, 23 had experienced cardiovascular events that suggested heart disease. Patients underwent ultrasound of the carotid arteries between December 2009 and December 2015; the researchers then assessed the extent of atherosclerosis by measuring carotid intima media thickness and total plaque area, evaluating the patients' risk of experiencing further cardiovascular events using a hazard ratio (HR) model (with base HR equal to 1).

The team found that the rate at which patients experienced their first cardiovascular event during the study period was 1.11 events per 100 patient years. The group also found the following factors predicted incident cardiovascular events after controlling for the Framingham risk score:

Factors on carotid ultrasound that predict cardiovascular events
	Hazard ratio
Total plaque area	3.74
High total plaque area category	3.25
Mean carotid intima media thickness	1.21
Max carotid intima media thickness	1.11

Since carotid atherosclerosis is associated with an increased risk of developing future heart disease -- and since patients with psoriatic disease are known to be at increased risk of heart disease -- using ultrasound-generated vascular imaging data with information on traditional cardiovascular risk factors could improve the accuracy of cardiovascular risk assessment in these patients, according to the group. And ultrasound has many benefits when compared with other imaging modalities.

"The advantage of ultrasound over other modalities for vascular imaging includes lack of radiation, low cost of the examination, and its widespread use in rheumatology for joint evaluation," the team concluded. "Thus, this assessment could potentially be performed 'at the bedside' during consultation to provide immediate valuable information to complement clinical data from history, physical examination, and laboratory data."

Lung Comet US Reveal Subclinical Congestion in HF Patients

ATHENS, Greece — A small but groundbreaking randomized trial has strengthened the case for lung ultrasound (LUS) examinations, which can show likely subclinical pulmonary congestion, in outpatients with heart failure (HF).

The blinking appearance of "B lines" on LUS images, an artifact caused by echo differences between tissue and accumulated fluid, is a confirmed diagnostic and prognostic indicator of congestion. More B lines, also called ultrasound lung comets for the way they streak across the scan from the pleural line, mean more fluid.

The current study suggests the lines could potentially serve as a target for managing volume-depletion therapy, in that adding diuretics in response to them might improve clinical outcomes.

There was a marginally significant 48% decline in 6-month risk for a clinical composite primary endpoint, driven by a more highly significant 75% drop in urgent clinic visits for worsening HF in recently discharged patients whose outpatient diuretic therapy was guided by B lines on LUS.

Scans were obtained using highly portable, pocket-sized systems in all patients, and clinicians who used their findings to adjust diuretics in those assigned to guided therapy didn't follow a defined treatment protocol.

Because of that, the patient population numbering only about 120 from one center, the marginal primary outcome, and other reasons, the study dubbed LUS-HF is more food for thought than an endorsement of LUS-guided HF therapy.

"We propose lung ultrasound as a tool to complement clinical examination and to detect subclinical congestion," said Mercedes Rivas-Lasarte, MD, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, during the presentation of LUS-HF here at European Society of Cardiology Heart Failure (ESC-HF) 2019.

"The lung-ultrasound guided strategy was safe and reduced the number of decompensations," Lasarte said. "We think that lung ultrasound is a rapid, easy, inexpensive, and broadly available tool that may be recommended in heart failure follow-up to improve outcomes."

However, regarding the use of B lines on LUS to guide diuretic therapy, Lasarte added, "We have to take our study as a proof of concept, and we think that multicenter studies are needed to confirm our results and to test harder endpoints."

Even though there was no treatment protocol in the study, how clinicians managed diuretics for the patients was a good reflection of real-world practice, said Peter S. Pang, MD, Indiana University, Indianapolis, an emergency physician and early adopter of LUS in patients with HF.

The trial's primary endpoint, which included mortality and urgent clinic visit or rehospitalization for worsening HF, may have been significantly reduced in the LUS-guided group, "but I think we need to be careful how we interpret the positive trial because it was driven only by urgent heart-failure visits," Pang, who was not involved in LUS-HF, told theheart.org | Medscape Cardiology.

Still, that can be important. "I think it's fair to say that many patients don't want to come back to the doctor to say they feel worse. So perhaps by using lung ultrasound as a measure of congestion, we can make patients feel better."

Lung ultrasound is safe and it sharpens diagnosis and prognostic evaluations, "so adding it to the bedside examination is strongly encouraged," Pang said.

As for whether resolution or improvement of B lines on serial lung scans after diuretic intensification predicts improved clinical outcomes, "the jury is still out."

The reported number needed to treat with LUS-guided therapy to avoid one primary endpoint was a mere five patients, Pang had pointed out earlier as the invited discussant following Lasarte's presentation.

That indicates an absolute risk reduction of 20%, "an impressive finding, in fact so impressive that we should be cautious. It is unlikely such an effect size would be observed in other populations or in larger studies," he said.

"The good thing about this technology is that it's very easy to do. It's noninvasive, and once you have the ultrasound in your hand, there's no additional cost to it," Mandeep R. Mehra, MD, Brigham and Woman's Hospital, Boston, who is not connected to LUS-HF, observed for theheart.org | Medscape Cardiology.

Although he is cautious about the magnitude of its significance, "this study is at least a step in the right direction. But it's small study, and its confounding by detection of a problem is not to be ignored," he said. That is, because all the patients received LUS, clinicians treating those in the control group could potentially have become aware of and been influenced by the ultrasound findings.

"I always look at these kinds of data with some degree of skepticism."

The LUS-HF design specified that only clinicians who treated patients in the guided-therapy group would have access to the ultrasound results. Treating physicians could take their lead from the scans on any treatment adjustments.

Indeed, they "were strongly directed to change treatment in relation to number of B lines," Lasarte said when presenting LUS-HF.

The trial included 124 patients recently discharged from hospitalization with a primary diagnosis of acute HF. They were required to have had dyspnea and X-ray evidence of pulmonary congestion, high age-adjusted natriuretic peptide levels, but no severe lung diseases.

They were randomized single-blind prior to discharge to receive standard care with guidance from LUS in 61 patients and without LUS guidance in 63 patients. The groups were similar at baseline with respect to mean left-ventricular ejection fraction, natriuretic peptide levels, cardiovascular and pulmonary comorbidities, 6-minute walk distance, and number of B lines on LUS.

Natriuretic peptides were measured and LUS performed thereafter at 2 weeks, 1 month, 3 months, and 6 months.

Six-month rates for death or urgent clinic visits or rehospitalization for worsening HF were 23% in the LUS-guided group and 40% in the control group, for a hazard ratio (HR) of 0.52 (95% CI, 0.27 - 0.99; P = .046).

There were no significant differences in natriuretic peptide levels, measures of quality of life, or the individual components of the primary endpoint except for urgent visits for worsening HF, a prespecified secondary endpoint.

Six-Month Secondary Endpoint Outcomes, LUS-HF

Endpoints	LUS Guidance, n = 61	Non-LUS Guidance, n = 63	P
Urgent visits for worsening heart failure, %	5	21	.008
Change in 6-minute walk distance, m	+60	+37	.023
Proportion receiving loop diuretics, %	91	75	.023

Other potential applications for LUS using hand-held ultrasound systems in the chronic HF setting, Pang said, include use in a broader population to monitor for signs of impending decompensation, in the hope that early therapy can avoid hospitalization. "The promise for that is great," he said.

"It's not going to replace things like history or physical exam, but maybe it's another thing to add that helps us better decide how to treat patients. That's what I think it adds more than anything else."

Lasarte has reported no relevant financial relationships. Pang has previously disclosed consulting for Baxter, Bristol-Myers Squibb, and Novartis; and receiving support from Bristol-Myers Squibb, Roche, Novartis, Ortho Diagnostics, and Abbott. Mehra has previously disclosed being a consultant for Abbott, Portola, Bayer, and Xogenex; a trial steering committee member for Medtronic and Janssen; a scientific advisory board member for NuPulseCV and FineHeart; and a data safety monitoring board member for Mesoblast; and receiving travel support from Abbott.

ESC-HF 2019. Presented May 25, 2019. Late breaking trial I, Abstract 25.

Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitterand Facebook.

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Cite this: Ultrasound 'Lung Comets' Reveal Subclinical Congestion, Hint at Treatment-Target Value in HF Outpatients - Medscape - May 27, 2019.