U S can determine lung congestion in kidney patients

 By Amerigo Allegretto, AuntMinnie.com staff writer

June 10, 2021 -- Ultrasound is a useful guide in determining lung congestion for hemodialysis patients at high cardiovascular risk, according to research presented on June 6 at the European Renal Association -- European Dialysis and Transplant Association virtual congress.

A team of researchers led by Dr. Claudia Torino from the National Research Council of Italy found that patients with end-stage kidney disease who underwent lung ultrasound showed significantly less frequent episodes of decompensated heart failure and major cardiovascular events.

"Ultrasound examinations are available virtually everywhere in the hospital environment and do not take long to perform, so they can be deployed to diagnose and treat an ominous complication like lung congestion in hemodialysis patients," Torino said.

Lung congestion is common for hemodialysis patients, including those at high cardiovascular risk. While x-ray imaging can detect heart alterations, they cannot be heard easily through a stethoscope.

For hemodialysis patients, lung congestion is a strong risk factor for mortality. Between dialysis sessions, all fluid that patients introduce is retained. Severe overhydration may follow, which can lead to heart decompensation.

Ultrasound has been shown to determine just how much lung congestion there is. This in turn can help clinicians adjust fluid removal during hemodialysis and drug therapies.

"Extravascular lung water can be easily measured by lung ultrasound, being quantified on the basis of the number of ultrasound B-lines," Torino said.

The team studied 363 patients from several hospital systems in Europe and Asia to see if ultrasound can improve patient outcomes over standard care, with 183 patients being tested with ultrasound and the remaining 180 patients in the control group. Out of those, 152 patients completed the ultrasound-guided study and 155 completed the standard care study.

The primary endpoints the researchers studied were mortality, heart attack, and decompensated heart failure. This strategy was compared with standard care in hemodialysis patients with a high cardiovascular risk.

Sonographers measured B-lines in images, with the target for hemodialysis management being less than 15 sonographic B-lines, a threshold that signified less fluid accumulation in the lungs.

Torino said the team used a 28-point lung ultrasound technique. Depending on the user's experience, scans took between three and 15 minutes.

Impact of ultrasound on treatment of hemodialysis patients
	Control group		Ultrasound group
Change in number of B‑lines from start to end of study	16 B‑lines	30 B‑lines	15 B‑lines	9 B‑lines
Number of patients reaching target of less than 15 B‑lines	85 patients		117 patients
Number of patients reaching primary endpoint	71 patients		62 patients*

*Difference is not statistically significant

Secondary analyses showed significantly less frequent episodes of decompensated heart failure and major cardiovascular events for the sonography group. For heart failure, lung ultrasound showed an incidence reduction rate of 63% while for cardiovascular events, that rate decreased by 37%.

"Because decompensated heart failure was not the primary end point of the study, new trials are still needed to confirm this finding," Torino noted.

Education leads to confidence for new POCUS users

By Amerigo Allegretto, AuntMinnie.com staff writer

June 9, 2021 -- Instructional training increases confidence among family medicine residents using point-of-care ultrasound (POCUS), according to a study published June 4 in Family Medicine.

A team of researchers from the University of New Mexico led by Dr. Jerica Johnson found residents felt "significantly more confident" in their ability to perform and interpret a POCUS exam after a curriculum was implemented and that baseline attitudes toward POCUS were "very" favorable in both the pre- and postintervention surveys.

"Our residents and faculty have all been very excited to use POCUS. There are of course barriers to adoption of any new technology," Johnson told AuntMinnie.com. "The most significant barrier has been residents and faculty feeling that they are trained well enough to use POCUS and that there is not enough time to obtain this training."

The use of POCUS in family medicine residency training is increasing. However, researchers said attitudes about the technology, including confidence levels with performing and interpreting POCUS exams, are unknown.

The team wanted to find out attitudes and confidence levels of family medicine residents before and after the implementation of a new POCUS curriculum.

Residents in their postgraduate years at the University of New Mexico Family Medicine Residency Program were trained with POCUS in a yearlong program. The university's current POCUS curriculum was implemented in 2017.

"We had a loose curriculum with limited POCUS experiences prior to this when we made intentional changes to create a robust POCUS curriculum," Johnson said.

Attitudes and confidence levels with various POCUS exams were assessed through pre and postintervention surveys. On a 5-point confidence scale, a score of 1 meant strong disagreement while 5 indicated strong agreement.

The research team held a three-hour, hands-on workshop for residents, an 18-hour workshop for faculty and residents who participated as volunteer models, and 30-minute sessions every other week for residents who were rotating on the program's inpatient service.

Twenty-one residents responded to the preintervention survey. The average confidence scale score for education on ultrasound principles for performing and interpreting POCUS exams was 4.38. For the postintervention survey, which included 25 residents, that score was 3.96 (p = 0.05).

While agreement was high among residents when it came to ready access to ultrasound equipment and hands-on training, the results did not achieve statistical significance.

The team wrote that future research opportunities include investigating the effectiveness of different POCUS training technologies among family medicine residents and effects on patient-oriented outcomes.

Johnson told AuntMinnie.com that the team is hoping to implement an outpatient-based curriculum for the university's family medicine residents that is geared toward POCUS applications that are useful in the outpatient clinic.

"We are hoping to demonstrate that minimal training interventions can lead to improved revenue generation from the POCUS exams and essentially provide evidence that POCUS training for family medicine residents 'pays for itself,'" she said. "We hope that this outpatient-based curriculum can then be shared and applied by other family medicine residency programs.