Sources of error in emergency ultrasonography

How many is enough? Measuring the number of FAST exams needed by emergency medicine trainees to reach competence

BACKGROUND

For patients with blunt abdominal trauma, the Focused Assessment with Sonography in Trauma (FAST) exam is the initial imaging modality employed to diagnose and risk stratify. A positive FAST exam in this patient population denotes intraperitoneal hemorrhage. In a hemodynamically unstable patient, it necessitates rapid surgical intervention. Ultrasound is highly dependent on the operator's ability to obtain quality images for interpretation. Failure to obtain adequate images prevents accurate interpretation and reduce its diagnostic accuracy. Previous studies evaluating whether the FAST exam can be improved solely by experience had conflicting results. None of those studies used an objective method to evaluate the FAST exam's quality. Our study aimed to objectively determine the number of FAST exams required by an emergency medicine (EM) resident to reach sufficient quality for independent scanning.

METHODS

59 first-year EM residents from a single site were included in this study. All FAST exams that were saved in the Qpath archival system by the 59 EM residents, whether the exam was performed for educational or clinical purposes, were reviewed, and scored using a Task-Specific Checklist (TSC) score. This score is an objective way to assess the proficiency and quality of the FAST scan. The TSC was based on whether the imaging of 24 specific anatomic landmarks, split into four anatomic regions, was completed successfully or not. The AEMUS (Advanced EM Ultrasonography) faculty provided feedback to trainees wither electronically via Qpath or at the bedside. According to the quality of ultrasound imaging and competence (QUICK Score), if the average TSC score for the first 10 exams was 18 or higher, the resident was considered an expert. However, if the resident failed to achieve that score, we skipped the first exam performed by the resident and the average score for the second through eleventh exams was then calculated. If the resident did not achieve the desired result, the first and second exams were skipped and the average score for the remaining 10 exams was determined. This sequence was repeated until the resident achieved an average score of 18 or higher on their TSC score.

RESULTS

In total, 663 FAST scans performed by EM residents were scored. The average number of FAST exams needed for independent scanning is 11.23 (95% CI, 10.6-11.85). 66.1% of enrolled residents achieved an average score of 18 or higher in their first 10 FAST exams, and 33.8% of residents required more than 10 scans. The average scores for the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvic, and subxiphoid views were 5 (95% CI, 4.88-5.1), 4.7 (95% CI, 4.59-4.8), 5.1 (95% CI, 4.96-5.24), and 3.7 (95% CI 3.6-3.8) respectively.

CONCLUSION

This study demonstrated that when constructive feedback on each FAST exam was given, the average first-year emergency medicine resident achieves competency in performing FAST exams independently after completing 10-12 (average of 11.23) FAST exams. Further research is required to validate the findings.

Cardiac ultrasound simulation for autonomous ultrasound navigation

Introduction

Ultrasound is well-established as an imaging modality for diagnostic and interventional purposes. However, the image quality varies with operator skills as acquiring and interpreting ultrasound images requires extensive training due to the imaging artefacts, the range of acquisition parameters and the variability of patient anatomies. Automating the image acquisition task could improve acquisition reproducibility and quality but training such an algorithm requires large amounts of navigation data, not saved in routine examinations.

Methods

We propose a method to generate large amounts of ultrasound images from other modalities and from arbitrary positions, such that this pipeline can later be used by learning algorithms for navigation. We present a novel simulation pipeline which uses segmentations from other modalities, an optimized volumetric data representation and GPU-accelerated Monte Carlo path tracing to generate view-dependent and patient-specific ultrasound images.

Results

We extensively validate the correctness of our pipeline with a phantom experiment, where structures' sizes, contrast and speckle noise properties are assessed. Furthermore, we demonstrate its usability to train neural networks for navigation in an echocardiography view classification experiment by generating synthetic images from more than 1,000 patients. Networks pre-trained with our simulations achieve significantly superior performance in settings where large real datasets are not available, especially for under-represented classes.

Discussion

The proposed approach allows for fast and accurate patient-specific ultrasound image generation, and its usability for training networks for navigation-related tasks is demonstrated.

Safety of methotrexate administration in women with pregnancy of unknown location at high risk of ectopic pregnancy

OBJECTIVES

To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs).

METHODS

This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated.

RESULTS

A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non-viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non-viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724).

CONCLUSIONS

Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Dual-energy CT in acute cholecystitis- features predicting culture-positive bile and outcome

PURPOSE

Low mono-energetic CT has been shown to improve visualization of acute abdominal inflammatory processes. We aimed to determine its utility in patients with acute cholecystitis and potential added value in clinical decision making.

METHODS

Sixty-seven consecutive patients with radiological signs of cholecystitis on contrast-enhanced dual-layer CT imaging were retrospectively identified over a four-year period (2/17-8/21). A ranked Likert scale was created for imaging findings present in acute cholecystitis, including gallbladder mucosal integrity and enhancement and pericholecystic liver parenchymal enhancement. These rankings were correlated with laboratory data, followed by sensitivity, specificity, and odds-ratios calculations.

RESULTS

Mucosal integrity and pericholecystic liver enhancement were better seen on low-energetic images by unanimous consensus. Presence of pericholecystic liver enhancement and poorer mucosal wall integrity correlated with positive bile cultures (sensitivity: 93.8 % and 96.9 %, specificity: 37.5 and 50.0 %; odds-ratio: 9.0[1.1-68.1 95 %CI] and 31.0 [2.7-350.7 95 %CI], p = 0.017 and p ≤ 0.001) in patients undergoing cholecystostomy (n = 40/67). Moreover, binary regression modeling showed that the strongest predictor variable for bile culture positivity was the score for pericholecystic liver enhancement (Exp(B) = 0.6, P = 0.022). By contrast, other laboratory markers and other imaging findings (such as GB wall thickness) showed lower sensitivities (76-82 %), specificities (16-21 %) and odds ratios (0.2-4.4) for the prediction of infected bile.

CONCLUSIONS

Pericholecystic liver enhancement and gallbladder wall integrity are better visualized on low-DECT images. These findings also potentially predict bile culture positivity in patients with cholecystitis, which may influence clinical management including the need for intervention.

Point-of-Care Ultrasound in the Emergency Department: Training, Perceptions, Applications, and Barriers from Different Healthcare Professionals

Background

Point-of-care ultrasound (POCUS) is a valuable tool that assists in diagnosis and management of patients in the emergency department (ED) while being cost-efficient and without the use of ionizing radiation. To discern the opinions and perceptions of ED staff about POCUS applications and barriers, we conducted a cross-sectional survey of employees of 12 EDs in North Texas.

Methods

Participants completed a 20-item online survey about POCUS with questions pertaining to four domains: (1) employee and training information, (2) perceived benefits, (3) common applications, and (4) barriers to use. Out of 805 eligible ED employees, 103 completed the survey (16.1% response rate).

Results

The results indicated a generally positive perception of POCUS among all employee types. Physician had significant exposure and training of POCUS than non-physician group ( p < 0.001). Physicians tend to find cardiac assessments more useful for clinical management than non-physicians (47% vs. 23%, p = 0.01), while non-physicians find soft tissue/abscess assessments more useful (27% vs. 9%, p = 0.01).

Conclusion

The most significant barriers to POCUS use were time constraints for physicians and a lack of training for non-physician employees. Our study provides valuable insights into the perceptions of multiple ED professionals, serving as a foundation for promoting POCUS use in the ED.

Ultrasound technology assisted colloidal nanocrystal synthesis and biomedical applications

Non-invasive and high spatiotemporal resolution mythologies for the diagnosis and treatment of disease in clinical medicine promote the development of modern medicine. Ultrasound (US) technology provides a non-invasive, real-time, and cost-effective clinical imaging modality, which plays a significant role in chemical synthesis and clinical translation, especially in in vivo imaging and cancer therapy. On the one hand, the US treatment is usually accompanied by cavitation, leading to high temperature and pressure, so-called "hot spot", playing a significant role in sonochemical-based colloidal synthesis. Compared with the classical nucleation synthetic method, the sonochemical synthesis strategy presents high efficiency for the fabrication of colloidal nanocrystals due to its fast nucleation and growth procedure. On the other hand, the US is attractive for in vivo and medical treatment, with applications increasing with the development of novel contrast agents, such as the micro and nano bubbles, which are widely used in neuromodulation, with which the US can breach the blood-brain barrier temporarily and safely, opening a new door to neuromodulation and therapy. In terms of cancer treatment, sonodynamic therapy and US-assisted synergetic therapy show great effects against cancer and sonodynamic immunotherapy present unparalleled potentiality compared with other synergetic therapies. Further development of ultrasound technology can revolutionize both chemical synthesis and clinical translation by improving efficiency, precision, and accessibility while reducing environmental impact and enhancing patient care. In this paper, we review the US-assisted sonochemical synthesis and biological applications, to promote the next generation US technology-assisted applications.

Simulation-based assessment of upper abdominal ultrasound skills

BACKGROUND

Ultrasound is a safe and effective diagnostic tool used within several specialties. However, the quality of ultrasound scans relies on sufficiently skilled clinician operators. The aim of this study was to explore the validity of automated assessments of upper abdominal ultrasound skills using an ultrasound simulator.

METHODS

Twenty five novices and five experts were recruited, all of whom completed an assessment program for the evaluation of upper abdominal ultrasound skills on a virtual reality simulator. The program included five modules that assessed different organ systems using automated simulator metrics. We used Messick's framework to explore the validity evidence of these simulator metrics to determine the contents of a final simulator test. We used the contrasting groups method to establish a pass/fail level for the final simulator test.

RESULTS

Thirty seven out of 60 metrics were able to discriminate between novices and experts (p < 0.05). The median simulator score of the final simulator test including the metrics with validity evidence was 26.68% (range: 8.1-40.5%) for novices and 85.1% (range: 56.8-91.9%) for experts. The internal structure was assessed by Cronbach alpha (0.93) and intraclass correlation coefficient (0.89). The pass/fail level was determined to be 50.9%. This pass/fail criterion found no passing novices or failing experts.

CONCLUSIONS

This study collected validity evidence for simulation-based assessment of upper abdominal ultrasound examinations, which is the first step toward competency-based training. Future studies may examine how competency-based training in the simulated setting translates into improvements in clinical performances.

Cardiac ventricular false tendons: A meta-analysis

Ventricular false tendons are fibromuscular structures that travel across the ventricular cavity. Left ventricular false tendons (LVFTs) have been examined through gross dissection and echocardiography. This study aimed to comprehensively evaluate the prevalence, morphology, and clinical importance of ventricular false tendons using a systematic review. In multiple studies, these structures have had a wide reported prevalence ranging from less than 1% to 100% of cases. This meta-analysis found the overall pooled prevalence of LVFTs to be 30.2%. Subgroup analysis indicated the prevalence to be 55.1% in cadaveric studies and 24.5% in living patients predominantly studied by echocardiography. Morphologically, left and right ventricular false tendons have been classified into several types based on their location and attachments. Studies have demonstrated false tendons have important clinical implications involving innocent murmurs, premature ventricular contractions, early repolarization, and impairment of systolic and diastolic function. Despite these potential complications, there is evidence demonstrating that the presence of false tendons can lead to positive clinical outcomes.

OMA1 and YME1L as a Diagnostic Panel in Hepatocellular Carcinoma

Identifying new hepatocellular carcinoma (HCC)-driven signaling molecules and discovering their molecular mechanisms are crucial for efficient and better outcomes. Recently, OMA1 and YME1L, the inner mitochondrial proteases, were displayed to be associated with tumor progression in various cancers; however, their role in HCC has not yet been studied. Therefore, we evaluated the possible role of OMA1/YME1L in HCC staging and discussed their potential role in cellular apoptosis and proliferation. Our study was performed using four groups of male albino rats: a normal control and three diethyl nitrosamine-treated groups for 8, 16, and 24 weeks. The OMA1 and YME1L, matrix-metalloproteinase-9 (MMP-9), and cyclin D1 content were measured in liver tissues, while alpha-fetoprotein (AFP) level was assessed in serum. Additionally, Ki-67 expression was evaluated by immunohistochemistry. The relative hepatic expression of Bax, and tissue inhibitor matrix metalloproteinase (TIMP-3) was measured. Herein, we confirmed for the first time that OMA1 is down-regulated while YME1L is up-regulated in HCC in the three studied stages with subsequent inhibition of apoptosis and cell cycle progression. Furthermore, these proteases have a possible role in metastasis. These newly recognized results suggested OMA1 and YME1L as possible diagnostic tools and therapeutic targets for HCC management.

Tailored photoacoustic apertures with superimposed optical holograms

A new method of generating potentially arbitrary photoacoustic wavefronts with optical holograms is presented. This method uses nanosecond laser pulses at 1064 nm that are split into four time-delayed components by means of a configurable multipass optical delay apparatus, which serves to map the pulses onto phase-delayed regions of a given acoustic wavefront. A single spatial light modulator generates separate holograms for each component, which are imaged onto a photoacoustic transducer comprised of a thermoelastic polymer. As a proof of concept of the broader arbitrary wavefront construction technique, the spatially- and temporally-modulated holograms in this study produce a phased array effect that enables beam steering of the resulting acoustic pulse. For a first experimental demonstration of the method, as verified by simulation, the acoustic beam is steered in four directions by around 5 degrees.

Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment

Introduction

Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners.

Methods

With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge.

Results

Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful.

Discussion

The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.

Partial volvulus, entrapment, and extraluminal obstruction of the jejunum in a cat

A 2-year-old, spayed female, domestic shorthair cat was presented in compensated hypovolemic shock after 24 h of anorexia, vomiting, and lethargy. An enterotomy had been performed at 9 mo of age to remove a foreign body. Due to inconclusive findings on abdominal imaging, an exploratory laparotomy was done. An adhesion at the root of the mesentery, likely associated with the previous surgery, had resulted in partial volvulus, entrapment, and extraluminal obstruction of the jejunum. Transection of the adhesion allowed repositioning of the bowel without the need for resection. The cat was discharged from the hospital 7 d postoperatively. Adhesions have not previously been reported to cause small bowel volvulus in cats. Key clinical message: Abdominal adhesions as a cause of clinical disease in cats have apparently not been reported. This case report demonstrates how malposition of the gastrointestinal tract, secondary to adhesions, should be included as a differential diagnosis for feline patients presenting with acute abdomens. Previous abdominal surgery is a risk factor for development of adhesions. This case emphasized the importance of Halsted's principles of surgery to reduce the risk of postoperative adhesions, even in species not predisposed to forming adhesions.

TC-SegNet: robust deep learning network for fully automatic two-chamber segmentation of two-dimensional echocardiography

Heart chamber quantification is an essential clinical task to analyze heart abnormalities by evaluating the heart volume estimated through the endocardial border of the chambers. A precise heart chamber segmentation algorithm using echocardiography is essential for improving the diagnosis of cardiac disease. This paper proposes a robust two chamber segmentation network (TC-SegNet) for echocardiography which follows a U-Net architecture and effectively incorporates the proposed modified skip connection, Atrous Spatial Pyramid Pooling (ASPP) modules and squeeze and excitation modules. The TC-SegNet is evaluated on the open-source fully annotated dataset of cardiac acquisitions for multi-structure ultrasound segmentation (CAMUS). The proposed TC-SegNet obtained an average value of F1-score of 0.91, an average Dice score of 0.9284 and an IoU score of 0.8322 which are higher than the reference models used here for comparison. Further, Pixel error (PE) of 1.5109 which are significantly less than the comparison models. The segmentation results and metrics show that the proposed model outperforms the state-of-the-art segmentation methods.

Segmentation of Anatomical Structures of the Left Heart from Echocardiographic Images Using Deep Learning

Knowledge about the anatomical structures of the left heart, specifically the atrium (LA) and ventricle (i.e., endocardium-Vendo-and epicardium-LVepi) is essential for the evaluation of cardiac functionality. Manual segmentation of cardiac structures from echocardiography is the baseline reference, but results are user-dependent and time-consuming. With the aim of supporting clinical practice, this paper presents a new deep-learning (DL)-based tool for segmenting anatomical structures of the left heart from echocardiographic images. Specifically, it was designed as a combination of two convolutional neural networks, the YOLOv7 algorithm and a U-Net, and it aims to automatically segment an echocardiographic image into LVendo, LVepi and LA. The DL-based tool was trained and tested on the Cardiac Acquisitions for Multi-Structure Ultrasound Segmentation (CAMUS) dataset of the University Hospital of St. Etienne, which consists of echocardiographic images from 450 patients. For each patient, apical two- and four-chamber views at end-systole and end-diastole were acquired and annotated by clinicians. Globally, our DL-based tool was able to segment LVendo, LVepi and LA, providing Dice similarity coefficients equal to 92.63%, 85.59%, and 87.57%, respectively. In conclusion, the presented DL-based tool proved to be reliable in automatically segmenting the anatomical structures of the left heart and supporting the cardiological clinical practice.

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part 1 - identifying the main safety concerns, a qualitative study

Introduction

Patient safety has been an undervalued component of quality healthcare but is a challenging area of research.Ultrasound is the most common imaging modality in the world. Research on patient safety in ultrasound is generally focused on bioeffects and safe operation of ultrasound equipment. However, other safety issues exist in practice that warrant consideration.This paper forms the first part of a PhD study exploring patient safety in medical diagnostic ultrasound, beyond the notion of bioeffects.The ultimate aim of the study is to inform the final phase of the research study which will consider the next steps in improving the quality and safety of healthcare experienced by patients.

Methods

A qualitative study using semi-structured, one-on-one interviews. A thematic analysis categorised data into codes and generated final themes.

Results

A heterogeneous mix of 31 sonographers, who reflected the profile of the profession in Australia, were interviewed between September 2019 and January 2020. Seven themes emerged from the analysis. These were bioeffects, physical safety, workload, reporting, professionalism, intimate examinations and infection control.

Conclusion

This study presents a comprehensive analysis of sonographers' perceptions of patient safety in ultrasound imaging, not previously available in the literature. Consistent with the literature, patient safety in ultrasound tends to be viewed in technical terms through the potential for bioeffects of tissue damage or physical harm to the patient. However, other patient safety issues have emerged, and while not as well recognised, have the potential to negatively impact on patient safety.

Prenatal Diagnosis of Retinoblastomas: A Scoping Review

Purpose

The objective of this review is to explore the prenatal diagnosis of retinoblastoma and the recommended screening practices.

Patients and Methods

An electronic literature search on prenatal diagnosis of retinoblastoma was conducted on the PubMed database. Publications within the last 20 years that matched the inclusion criteria were selected. The literature search included the following keywords: retinoblastoma, prenatal, diagnosis, screening, and associated synonyms to increase search sensitivity. Nine studies were included for investigation and extracted to identify prenatal diagnostic and screening techniques for retinoblastoma, their associated impact, and the target population that should receive prenatal screening for retinoblastoma.

Results

Familial retinoblastoma has an autosomal inheritance pattern and 90% penetrance. Therefore, future parents with a family history of retinoblastoma are strongly advised to get tested for retinoblastoma (Rb) gene mutations; if one of the parents is positive for a mutated allele of the RB1 gene, there is a 45% chance that their child will inherit a mutated allele of the retinoblastoma gene, rendering the allele non-functional in all of the cells of the individual and predisposing the child to a higher risk of developing retinoblastoma as well as other secondary cancers. Thus, prenatal screening and diagnosis of retinoblastoma is crucial for early diagnosis and optimal treatment.

Conclusion

Prenatal testing for retinoblastoma in high-risk families is important for everyone in the family. For the parents, prenatal screening has been shown to improve their family planning decisions and psychological well-being as they can mentally prepare beforehand and make informed decisions. More importantly, these practices have shown to yield better treatment and vision outcomes in the newborn.

A Hybrid Musculoskeletal Ultrasound Curriculum for Physical Medicine and Rehabilitation Residents-a Multi-center Pilot Program

Purpose of Review

The increased use of musculoskeletal ultrasound (MSKUS) in clinical practice warrants achieving competency earlier in physiatrists' careers. Physical Medicine and Rehabilitation (PM&R) residency programs have started incorporating formal MSKUS training in their curricula; however, significant heterogeneity remains in MSKUS education.

Recent Findings

Numerous barriers contribute to the lack of consensus for MSKUS training during residency, but the COVID-19 pandemic severely disrupted in-person learning. As an adjunct or alternative to in-person learning, teleguided technology is being utilized.

Summary

This curriculum demonstrates the role of a hybrid MSKUS training with interinstitutional collaboration. Twenty PM&R learners, from two institutions, were divided into a fundamental or advanced track. Virtual didactic sessions alternated weekly with hands-on ultrasonographic scanning sessions. Following a 12-month longitudinal curriculum, an end-of-year practical examination was used for competency assessment, in addition to a survey assessing resident perceptions and feedback. To our knowledge, this is the first collaborative and hybrid MSKUS curriculum for PM&R learners that can be easily reproduced at most training institutions and circumvent some of the barriers amplified by the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40141-023-00380-z.

Omental infarction and anterior wall adhesion presenting as surgical abdomen in a pediatric patient

Omental infarction is a rare cause of acute abdomen that can present in both the pediatric and adult populations causing adhesions or abscesses. Presentation may mimic appendicitis; however, ultrasonography may not be sufficient. We discuss the importance of CT imaging for the pre-surgical diagnosis to avoid serious port-site injuries.

Exploring the use of knobology for image optimisation in final year sonography students

Introduction

Image optimisation is essential for acquisition of quality images in ultrasound and critical to the diagnostic ability of the examination. These skills are taught to sonography students early in their education, but research has found that retention of non-rehearsed knowledge decreases significantly after a year. The aim of this study was to determine which optimisation tools (knobology) final year sonography students use, how often and why they chose to adjust parameters and assess barriers to optimisation of knobology tools.

Methods

A prospective study using data from an anonymous online survey of 34 final year sonography students.

Results

Survey results showed that 19/34 (55%) of students "frequently" optimise all Doppler settings and 23/34 (67%) of students "frequently" optimise basic parameter settings (depth, focus, time gain compensation). Time constraints (24/34 (70%)) and loss of gained knowledge of sonography principles and instrumentation (17/34 (50%)) were the major barriers to the use of knobology. The majority 28/34 (82%) believed they would benefit from further training.

Conclusion

This study demonstrates that although most students are optimising settings to improve image quality, sonography principles and instrumentation knowledge loss and time constraints prevent students from maximising machine capabilities. This study supports the need for further training prior to final year clinical placement.

Routine Ultrasonography for Intensified Tuberculosis Case Finding in High Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) Burdened Countries: A Proposed Frame Work

Sonography has proven to be valuable diagnostic imaging equipment in the work-up of patients infected with acquired immune deficiency syndrome (AIDS) and tuberculosis (TB) coinfection. An extensive literature search was conducted between 1994 and 2021 for original peer-reviewed articles in the English language on ultrasound application in the diagnosis of extrapulmonary TB (EPTB), ultrasound application in infectious diseases in resource-constrained settings, point-of-care ultrasound in resource-scarce settings among others, across various electronic databases including MEDLINE, PubMed, POPLINE, Scopus and Google Scholar, among others and some gray literature were also retrieved. Emerging themes were identified by their recurrence in literature. Ultrasound imaging is a rapid diagnostic tool and can accurately identify and characterize pathologic findings in patients infected with HIV/AIDS and TB co-infection, such as enlarged lymph nodes, pericarditis, and pleural effusion, among others for prompt patient management. Ultrasonography is cheaper and portable; interfacing software has become more users friendly and image quality significantly improved, making it possible for the provision of imaging services in an increasing number of clinical settings in resource-limited settings where access to diagnostic imaging is scarce. The use of focused assessment with sonography for HIV (FASH) for prompt diagnosis of EPTB in regions with a high incidence of HIV/AIDS and TB co-infection will aid in prompt diagnosis and treatment of patients with undifferentiated TB, thus impacting on morbidity and mortality. The training and deployment of sonographers in endemic regions with a high prevalence of HIV/AIDS and TB co-infection, to diagnose EPTB using FASH protocol is a viable option that is in line with the global drive for intensified case finding and treatment algorithm, with a view to meeting the sustainable development goals target of ending HIV and TB epidemics and achieving universal health coverage.

Errors in MDCT diagnosis of acute mesenteric ischemia

The causes of diagnostic errors during daily medical practice can be several, mainly attributable to perceptual, interpretive and communication factors. The eventuality of radiological error is much more amplified in the emergency setting where a high number of complex multidetector-row computed tomography (MDCT) images must be evaluated quickly and critical time decisions need to be taken. In particular, in this context, the diagnosis of vascular intestinal diseases represents a crucial and difficult challenge in case of acute abdominal pain given the importance of being able to identify patient with high suspicious for intestinal ischemia and for a specific patient to judge if his ischemia is reversible or irreversible. Awareness of potential biases which can lead to diagnostic errors together with an extensive knowledge of the imaging features of these pathologies can lead to promptly recognize them with fewer mistakes, improving patients' outcome. This article reviews the MDCT findings of acute intestinal ischemia and acute colonic ischemia and analyzes the main types of diagnostic errors, underlining the importance of being familiarized with them to avoid misdiagnosis.

Diagnostic value of endoscopic retrograde cholangiopancreatography and therapeutic value of endoscopic sphincterotomy in dogs with suspected hepatobiliary disorders

Background

Conventional diagnostic methods have some limitations in diagnosing specific causes of canine hepatobiliary disorders. In the evaluation of the hepatobiliary system in dogs, ultrasonography (US) is the first imaging method of choice. Nonetheless, endoscopic retrograde cholangiopancreatography (ERCP) has also been proven to be a practicable technique for evaluating canine hepatobiliary (endoscopic retrograde cholangiography, ERC) and pancreatic duct (endoscopic retrograde pancreatography, ERP) disorders, providing additional therapeutic options by sphincterotomy (EST). To date, the efficacy and safety of diagnostic and therapeutic ERCP has not been evaluated in veterinary medicine literature. The present study sought to report complications and outcomes of dogs undergoing ERCP and EST, and to assess the usefulness of diagnostic ERCP by comparing the findings of US, ERCP and histopathological findings in liver and pancreas.

Results

This retrospective case series comprises data collected from 15 dogs that underwent successful ERC/ERCP. Nine dogs underwent EST following ERC. US and ERC were best in agreement when assessing the common bile duct. In case of disagreement between the modalities, the ERC findings of the ductal structures were in line with the available pathology findings more often than the US findings, whereas the opposite was noted for the gallbladder. The technical success rates were 88.2% for ERC, 66.7% for ERP, and 81.8% for EST, with no major complications during or immediately after the procedure. Immediate bile flow after EST was recorded in 7/9 dogs but only four showed coinciding clinical and laboratory improvement and four dogs were euthanized within 1-6 days after EST.

Conclusions

US remains a valuable initial diagnostic imaging method for hepatobiliary disorders and allows good assessment of the gallbladder. ERC can serve as a complementary procedure for diagnostic assessment of the hepatobiliary duct disorders. However, in order to improve the outcomes of EST, careful selection of patients for the procedure would require more advanced diagnostic imaging of the hepatobiliary area.

Cardiac assessment accuracy by students using palm-held ultrasound compared to physical examination by skilled cardiologists: a pilot study with a single medical student

Background

Despite the inherent limitations of the traditional cardiac physical examination (PE), it has not yet been replaced by a more accurate method.

Methods

We hypothesized that a single medical student, following a brief training (two academic hours) with the PHU, will better identify abnormal findings including significant valvular diseases, pericardial effusion and reduced LV function, as compared to PE performed by senior cardiologists and cardiology fellows. Transthoracic echocardiogram (TTE) served as a ‘gold standard’.

Results

Seventy-seven patients underwent TTE, of them 64 had an abnormal finding. PE identified 34 patients with an abnormal finding compared to 52 identified by PHU (p < 0.05). Ejection fraction (EF) below 50% was found in 35 patients on TTE, compared to only 15 and 6 patients by PE and PHU, respectively (p < 0.05). There was no difference in valvular dysfunction diagnosis detected by PE and medical students using PHU. The overall accuracy of PHU compared to TTE was 87%, with a specificity of 94% and sensitivity of 64% (the low sensitivity was driven mainly by EF assessment), whereas the accuracy of PE was 91%, specificity 91% and sensitivity 38% (again driven by poor EF assessment).

Conclusions

Cardiac evaluation using PHU by a single medical student was able to demonstrate similar accuracy as PE done by cardiac specialists or cardiology fellows. The study topic should be validated in future studies with more medical students with a very brief training of cardiac ultrasound.

Common and Uncommon Errors in Emergency Ultrasound

Errors in emergency ultrasound (US) have been representing an increasing problem in recent years thanks to several unique features related to both the inherent characteristics of the discipline and to the latest developments, which every medical operator should be aware of. Because of the subjective nature of the interpretation of emergency US findings, it is more prone to errors than other diagnostic imaging modalities. The misinterpretation of US images should therefore be considered as a serious risk in diagnosis. The etiology of error is multi-factorial: it depends on environmental factors, patients and the technical skills of the operator; it is influenced by intrinsic US artifacts, poor clinical correlation, US-setting errors and anatomical variants; and it is conditioned by the lack of a methodologically correct clinical approach and excessive diagnostic confidence too. In this review, we evaluate the common and uncommon sources of diagnostic errors in emergency US during clinical practice, showing how to recognize and avoid them.

Implementation of point-of-care ultrasonography in an infectious disease ward

INTRODUCTION

Point-of-care ultrasonography (POCUS) has emerged as an essential supplement to physical examination in many specialties. In contrast, its use by infectious diseases (ID) specialists remains anecdotal. Here, we report on the acquisition of an ultrasonography device in a French ID ward, and we describe its everyday use.

METHODS

A preliminary audit was conducted to evaluate the potential impact of the acquisition of an ultrasonography device. A second audit was performed during the first year following the acquisition of the device to quantify its everyday use. We also evaluated the impact of POCUS implementation on medical imaging requests by comparing the number of intra-hospital transports before and after the acquisition.

RESULTS

According to the first audit, 81 of the 199 (41%) imaging examinations that were prescribed during a two-month period could have been replaced by POCUS. During the first year following the acquisition of the ultrasonography device, POCUS was performed 240 times by 31 different operators. The operators were a senior physician, an intern, and a medical student in 94 (39%), 135 (57%), and 11 (5%) cases, respectively. The organs most frequently explored were the genito-urinary tract (n=74), the joints (n=35), and the lungs/pleura (n=35). Acquisition of the device was followed by a significant decrease in the number of transports to the ultrasonography room, whereas the total number of transports to the medical imaging ward did not change.

CONCLUSION

Opportunities to use POCUS in the ID ward are numerous. POCUS training should be part of the ID specialist's curriculum.

Prevalence of femoral vein duplication: systematic review and metaanalysis

Background: Duplication of the femoral vein is an important anatomical variation of the venous anatomy which has been shown to have an impact on the diagnosis of deep venous thrombosis by compression ultrasonography. The presence of duplication may result in false negative findings while evaluating for deep venous thrombosis, with serious consequences such as pulmonary embolism and death. This metaanalysis aims to determine the pooled prevalence of duplicated femoral veins. Methods: A systematic search was conducted through the major databases PubMed, Hinari, Embase and Medline to identify studies eligible for inclusion. Appropriate data were extracted and pooled into a random-effects metaanalysis using MetaXL software. The primary and secondary outcomes of the study included the pooled prevalence of duplicated femoral veins and the prevalence of bilaterally duplicated femoral veins, respectively. Results: A total of 11 studies (n = 3,682 limbs) were included. The overall pooled prevalence of duplicated femoral veins was 19.7% (95% CI 11–30). There was a significant difference in prevalence between cadaveric studies (2%, 95% CI 1–4) and imaging studies (25%, 95% CI 17–34). Conclusion: Duplication of the femoral vein is a common variation in the lower limbs. Routine watch-out should be practiced especially when performing lower limb Doppler studies in cases of deep venous thrombosis in order to avoid misdiagnosis and improve diagnostic accuracy.

Mathematical Models for Blood Flow Quantification in Dialysis Access Using Angiography: A Comparative Study

Blood flow rate in dialysis (vascular) access is the key parameter to examine patency and to evaluate the outcomes of various endovascular interve7ntions. While angiography is extensively used for dialysis access–salvage procedures, to date, there is no image-based blood flow measurement application commercially available in the angiography suite. We aim to calculate the blood flow rate in the dialysis access based on cine-angiographic and fluoroscopic image sequences. In this study, we discuss image-based methods to quantify access blood flow in a flow phantom model. Digital subtraction angiography (DSA) and fluoroscopy were used to acquire images at various sampling rates (DSA—3 and 6 frames/s, fluoroscopy—4 and 10 pulses/s). Flow rates were computed based on two bolus tracking algorithms, peak-to-peak and cross-correlation, and modeled with three curve-fitting functions, gamma variate, lagged normal, and polynomial, to correct errors with transit time measurement. Dye propagation distance and the cross-sectional area were calculated by analyzing the contrast enhancement in the vessel. The calculated flow rates were correlated versus an in-line flow sensor measurement. The cross-correlation algorithm with gamma-variate curve fitting had the best accuracy and least variability in both imaging modes. The absolute percent error (mean ± SEM) of flow quantification in the DSA mode at 6 frames/s was 21.4 ± 1.9%, and in the fluoroscopic mode at 10 pulses/s was 37.4 ± 3.6%. The radiation dose varied linearly with the sampling rate in both imaging modes and was substantially low to invoke any tissue reactions or stochastic effects. The cross-correlation algorithm and gamma-variate curve fitting for DSA acquisition at 6 frames/s had the best correlation with the flow sensor measurements. These findings will be helpful to develop a software-based vascular access flow measurement tool for the angiography suite and to optimize the imaging protocol amenable for computational flow applications.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Point-of-care diagnostic lung ultrasound is highly applicable to the practice of medicine in Saudi Arabia but the current skills gap limits its use

CONTEXT

Coronavirus disease 2019 (COVID-19) has put a spotlight on point-of-care diagnostic lung ultrasound (POCDLUS). However, the spectra of respiratory disease and resources available for investigation vary internationally. The applicability of POCDLUS to internal medicine (IM) practice in Saudi Arabia and the current use by Saudi physicians are unknown.

AIMS

The aim of the present study was to determine the applicability of POCDLUS to IM practice in Saudi Arabia and quantify the residents' current skills, accreditation, and use of POCDLUS.

METHODS

A questionnaire was distributed to the IM residents at our institution to assess their knowledge, use of POCDLUS, and their perceptions of its applicability in IM.

STATISTICAL ANALYSIS

Standard descriptive statistical techniques were used. Categorical data, presented as frequency, were compared using the Chi-squared test. The Likert scale responses, presented as mean ± standard deviation, were compared with a Student's t-test.

RESULTS

In total, 100 residents participated (response rate 92.6%) and reported that POCDLUS was applicable to their practice. Identifying pleural effusions was most applicable. A small proportion (n = 7) had received training, nine used POCDLUS regularly, none were accredited and the overall self-reported level of knowledge was poor.

CONCLUSIONS

Whilst POCDLUS is applicable to IM practice in Saudi Arabia, the significant skills gap preclude the provision of a POCDLUS service. As COVID-19 can cause an interstitial syndrome, our pandemic preparation response should include POCDLUS training. The current study is supported by a similar Canadian study and the international standardisation of POCDLUS training may be feasible. The findings of the current study may facilitate the development of POCDLUS training programs for internists throughout Saudi Arabia.

Potential role of an athlete-focused echocardiogram in sports eligibility

Sudden cardiac death (SCD) of an athlete is a rare but tragic event and sport activity might play a trigger role in athletes with underlying structural or electrical heart diseases. Preparticipation screenings (PPs) have been conceived for the potential to prevent SCD in young athletes by early identification of cardiac diseases. The European Society of Cardiology protocol for PPs includes history collection, physical examination and baseline electrocardiogram, while further examinations are reserved to individuals with abnormalities at first-line evaluation. Nevertheless, transthoracic echocardiography has been hypothesized to have a primary role in the PPs. This review aims to describe how to approach an athlete-focused echocardiogram, highlighting what is crucial to focus on for the different diseases (cardiomyopathies, valvulopathies, congenital heart disease, myocarditis and pericarditis) and when is needed to pay attention to overlap diagnostic zone ("grey zone") with the athlete's heart. Once properly tested, focused echocardiography by sports medicine physicians may become standard practice in larger screening practices, potentially available during first-line evaluation.

Reliability of ultrasound hepatorenal index and magnetic resonance imaging proton density fat fraction techniques in the diagnosis of hepatic steatosis, with magnetic resonance spectroscopy as the reference standard

PURPOSE

To evaluate the reliability of ultrasound hepatorenal index (US-HRI) and magnetic resonance imaging proton density fat fraction (MRI-PDFF) techniques in the diagnosis of hepatic steatosis, with magnetic resonance spectroscopy proton density fat fraction (MRS-PDFF) as the reference standard.

MATERIALS AND METHODS

Fifty-two adult volunteers (30 men, 22 women; age, 31.5 ± 6.5 years) who had no history of kidney disease or viral/alcoholic hepatitis were recruited to undergo abdominal US, MRI, and MRS examinations. US-HRI was calculated from the average of three pairs of regions of interest (ROIs) measurements placed in the liver parenchyma and right renal cortex. On MRI, the six-point Dixon technique was employed for calculating proton density fat fraction (MRI-PDFF). An MRS sequence with a typical voxel size of 27 ml was chosen to estimate MRS-PDFF as the gold standard. The data were evaluated using Pearson's correlation coefficient and receiver operating characteristic (ROC) curves.

RESULTS

The Pearson correlation coefficients of US-HRI and MRI-PDFF with MRS-PDFF were 0.38 (p = 0.005) and 0.95 (p<0.001), respectively. If MRS-PDFF ≥5.56% was defined as the gold standard of fatty liver disease, the areas under the curve (AUCs), cut-off values, sensitivities and specificities of US-HRI and MRI-PDFF were 0.74, 1.54, 50%, 91.7% and 0.99, 2.75%, 100%, 88.9%, respectively. The intraclass correlation coefficients (ICCs) of US-HRI and MRI-PDFF were 0.70 and 0.85.

CONCLUSION

MRI-PDFF was more reliable than US-HRI in diagnosing hepatic steatosis.

The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED

BACKGROUND

Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis.

METHODS

This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS).

RESULTS

1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001).

CONCLUSIONS

A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

Access to ultrasound imaging: A qualitative study in two northern, remote, Indigenous communities in Canada

Ultrasound imaging is an essential component of healthcare services. This study sought to explore perceptions of access, and factors which shape access, to ultrasound imaging in two northern, remote, Indigenous communities in Canada. Using interpretive description as a methodological approach and a multi-dimensional conceptualisation of access to care as a theoretical framework, 15 semi-structured interviews were conducted in the northern Canadian communities of Stony Rapids and Black Lake, Saskatchewan. All participants had an obstetrical or non-obstetrical ultrasound exam performed in the past 10 years. Interviews were audio recorded and interview transcripts were analysed using constant comparative analysis. Geographic isolation from imaging facilities was a central barrier to participants accessing ultrasound imaging. Other barriers became apparent when participants had to travel for ultrasound, including fear of air travel, isolation from family, financial means, and unfamiliarity with larger cities. Barriers such as family and work responsibilities were exacerbated by the barrier of geography. Participants overcame these barriers as they were motivated by potential diagnostic benefits of ultrasound imaging. This study highlights disparities in access to ultrasound for northern, remote, Indigenous populations. Future efforts to improve access to imaging should consider barriers of distance to imaging facilities and strategies to bridge these barriers.

Structured Neonatal Point-of-Care Ultrasound Training Program

OBJECTIVE

Point-of-care ultrasound (POC US) has been increasingly used by intensive care physicians. Growing use of POC US necessitates defining distinct clinical indications for its application, as well as structured POC US training programs. Homogeneous approach to POC US education combined with rigorous quality assurance should further enable POC US to become standard-of-care clinical tool. This study aimed to present the first, innovative, and structured POC US program in neonatal-perinatal medicine field. In addition, we reviewed the availability of the POC US training programs across different medical specialties.

STUDY DESIGN

Available English-language publications on POC US training programs in general and neonatal-perinatal medicine were reviewed in this study.

DISCUSSION

Mounting body of evidence suggests improved procedural completion rates, as well as clinical decision making with the use of POC US. However, limited research supported the existence of structured, comprehensive POC US programs. It was recognized that medical institutions need to develop syllabuses, teach, and credential increasing number of health care professionals in the use of POC US. We defined intuitive educational strategy that encompasses POC US clinical indications, educational curriculum, scanning protocols, competence evaluation, and finally credentialing process. In addition, we offered description of the imaging quality assurance, as well as POC US coding, and reimbursement.

CONCLUSION

Future efforts need to be dedicated to the ongoing development of neonatal POC US as a clinical instrument. It should allow for eventual paradigm change and improved effectiveness in management of critically ill neonates.

Education in the placement of ultrasound-guided peripheral venous catheters: a systematic review

BACKGROUND

Placing a peripheral vein catheter can be challenging due to several factors, but using ultrasound as guidance increases the success rate. The purpose of this review is to investigate the knowledge already existing within the field of education in ultrasound-guided peripheral vein catheter placement and explore the efficacy and clinical impact of different types of education.

METHODS

In accordance with PRISMA-guidelines, a systematic search was performed using three databases (PubMed, EMBASE, CINAHL). Two reviewers screened titles and abstracts, subsequently full-text of the relevant articles. The risk of bias was assessed using the Cochrane Collaboration risk of bias assessment tool and the New Ottawa scale.

RESULTS

Of 3409 identified publications, 64 were included. The studies were different in target learners, study design, assessment tools, and outcome measures, which made direct comparison difficult. The studies addressed a possible effect of mastery learning and found e-learning and didactic classroom teaching to be equally effective.

CONCLUSION

Current studies suggest a potential benefit of ultrasound guided USG-PVC training on success rate, procedure time, cannulation attempts, and reducing the need for subsequent CVC or PICC in adult patients. An assessment tool with proven validity of evidence to ensure competence exists and education strategies like mastery learning, e-learning, and the usage of color Doppler show promising results, but an evidence-based USG-PVC-placement training program using these strategies combined is still warranted.

Anterior neck soft tissue measurements on computed tomography to predict difficult laryngoscopy: a retrospective study

Predicting difficult laryngoscopy is an essential component of the airway management. We aimed to evaluate the use of anterior neck soft tissue measurements on computed tomography for predicting difficult laryngoscopy and to present a clear measurement protocol. In this retrospective study, 281 adult patients whose tracheas were intubated using a direct laryngoscope for thyroidectomy were enrolled. On computed tomography, the distances from the midpoint of the thyrohyoid membrane to the closest concave point of the vallecular (membrane-to-vallecula distance; dMV), and to the most distant point of the epiglottis (membrane-to-epiglottis distance; dME) were measured, respectively. The extended distances straight to the skin anterior from the dMV and dME were called the skin-to-vallecula distance (dSV) and skin-to-epiglottis distance (dSE), respectively. Difficult laryngoscopy was defined by a Cormack-Lehane grade of > 2. Difficult laryngoscopy occurred in 40 (14%) cases. Among four indices, the dMV showed the highest prediction ability for difficult laryngoscopy with an area under the receiver operating characteristic curve of 0.884 (95% confidence interval 0.841–0.919, P < 0.001). The optimal dMV cut-off value for predicting difficult laryngoscopy was 2.33 cm (sensitivity 75.0%; specificity 93.8%). The current study provides novel evidence that increased dMV is a potential predictive indicator of difficult laryngoscopy.

Quantitative pleural line characterization outperforms traditional lung texture ultrasound features in detection of COVID-19

BACKGROUND AND OBJECTIVE

Lung ultrasound is an inherently user-dependent modality that could benefit from quantitative image analysis. In this pilot study we evaluate the use of computer-based pleural line (p-line) ultrasound features in comparison to traditional lung texture (TLT) features to test the hypothesis that p-line thickening and irregularity are highly suggestive of coronavirus disease 2019 (COVID-19) and can be used to improve the disease diagnosis on lung ultrasound.

METHODS

Twenty lung ultrasound images, including normal and COVID-19 cases, were used for quantitative analysis. P-lines were detected by a semiautomated segmentation method. Seven quantitative features describing thickness, margin morphology, and echo intensity were extracted. TLT lines were outlined, and texture features based on run-length and gray-level co-occurrence matrix were extracted. The diagnostic performance of the 2 feature sets was measured and compared using receiver operating characteristics curve analysis. Observer agreements were evaluated by measuring interclass correlation coefficients (ICC) for each feature.

RESULTS

Six of 7 p-line features showed a significant difference between normal and COVID-19 cases. Thickness of p-lines was larger in COVID-19 cases (6.27 ± 1.45 mm) compared to normal (1.00 ± 0.19 mm), P < 0.001. Among features describing p-line margin morphology, projected intensity deviation showed the largest difference between COVID-19 cases (4.08 ± 0.32) and normal (0.43 ± 0.06), P < 0.001. From the TLT line features, only 2 features, gray-level non-uniformity and run-length non-uniformity, showed a significant difference between normal cases (0.32 ± 0.06, 0.59 ± 0.06) and COVID-19 (0.22 ± 0.02, 0.39 ± 0.05), P = 0.04, respectively. All features together for p-line showed perfect sensitivity and specificity of 100; whereas, TLT features had a sensitivity of 90 and specificity of 70. Observer agreement for p-lines (ICC = 0.65-0.85) was higher than for TLT features (ICC = 0.42-0.72).

CONCLUSION

P-line features characterize COVID-19 changes with high accuracy and outperform TLT features. Quantitative p-line features are promising diagnostic tools in the interpretation of lung ultrasound images in the context of COVID-19.

Clinical Prediction Score for Ruptured Appendicitis in ED

Background

Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population.

Methods

This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis.

Result

During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times.

Conclusion

Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Superficial anatomy of the neonatal cerebrum - an ultrasonographic roadmap

Neurosonography is an essential imaging modality for assessing the neonatal brain, particularly as a screening tool to evaluate intracranial hemorrhage, hydrocephalus and periventricular leukomalacia. The primary advantages of neurosonography include portability, accessibility and lack of ionizing radiation. Its main limitations are intrinsic operator dependence and the need for an open fontanelle. Neurosonographic imaging acquisition is typically performed by placing a sector transducer over the anterior fontanelle and following sagittal and coronal sweeps. The sensitivity of neurosonography has markedly improved thanks to the adoption of modern imaging equipment, the use of dedicated head probes, and the employment of advanced diagnostic US techniques. These developments have facilitated more descriptive identification of specific cerebral anatomical details, improving understanding of the cerebral anatomy by conventional US. Such knowledge is fundamental for enhanced diagnostic sensitivity and is a key to understanding pathological states. Furthermore, familiarity with normal anatomy is crucial for understanding pathological states. Our primary goal in this review was to supplement these technological developments with a roadmap to the cerebral landscape. We accomplish this by presenting a systematic approach to using routine US for consistent identification of the most crucial cerebral landmarks, reviewing their relationship with adjacent structures, and briefly describing their primary function.

Focused Cardiac Ultrasound is Applicable to Internal Medicine and Critical Care but Skill Gaps Currently Limit Use

Context

Coronavirus Disease 2019 (COVID-19) put a spotlight on focused cardiac ultrasound (FoCUS). However, the spectra of cardiac disease, and the resources available for investigation vary internationally. The applicability of FoCUS to internal medicine (IM) and critical care medicine (CCM) practice in Saudi Arabia and their current use of FoCUS are unknown.

Aims

To determine the applicability of FoCUS to IM and CCM practice in Saudi Arabia and quantify the residents’ current proficiency, accreditation and use of FoCUS.

Methods

A questionnaire was distributed to the residents in IM and CCM at our institution to determine their proficiency, use of FoCUS, and perceptions of its applicability.

Results

In total, 110 residents (IM 100/108; CCM 10/10) participated (Response rate 93.2%) and reported that FoCUS was very applicable to their practice, most specifically for pericardial effusion, right heart strain, and left ventricular function. Two IM residents had received postgraduate training, ten used FoCUS regularly, none were accredited and overall self-reported proficiency was poor. In contrast all CCM residents had received postgraduate training and reported regular use of FoCUS. Two were accredited.

Conclusions

Whilst FoCUS is applicable to IM practice in Saudi Arabia, significant skills gaps exist. The skills gap in CCM is lower but unaccredited practice is common. Our residents’ responses were similar to those from Canada. Thus, international standardization of FoCUS training could be considered.

Sigmoid cancer mimicking ovarian echotexture on transvaginal ultrasound: Case report with literature review

Ultrasound is a first line imaging modality for the evaluation of female pelvic pain. Pelvic pain constitutes one of the most common reasons for presentation to the emergency department with increasing use of point of care ultrasound. Infrequently, point of care or formal ultrasound evaluation may lead to misdiagnosis of extraovarian disease. This can have serious consequences, especially if an extraovarian malignancy is mistaken for a normal ovary or an ovary with a benign process. We present a case of a 41-year-old female who presented to the emergency department for a chief complaint of pelvic pain and vaginal bleeding. Transvaginal ultrasound demonstrated a left adnexal mass, later characterized as a sigmoid colon cancer on MRI and pathology, simulating ovarian echotexture with peripheral hypoechoic components resembling follicles. This article will review the literature of various cases of extraovarian pathology misidentified as ovarian processes and highlight the importance of considering these extraovarian mimickers to prevent potential morbidity and mortality of a missed diagnosis.

Use and impact of point-of-care ultrasonography in general practice: a prospective observational study

OBJECTIVES

To describe how general practitioners (GPs) use point-of-care ultrasonography (POCUS) and how it influences the diagnostic process and treatment of patients.

DESIGN

Prospective observational study using an online questionnaire before and after POCUS.

SETTING

Office-based general practice.

PARTICIPANTS

Twenty GPs consecutively recruited all patients examined with POCUS in 1 month.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the use of POCUS through the indication for use, the frequency of use, the time consumption, the extent of modification of the examination and the findings.The influence on the diagnostic process was estimated through change in the tentative diagnoses, change in confidence, the ability to produce ultrasound images and the relationship between confidence and organs scanned or tentative diagnoses.The influence of POCUS on patient treatment was estimated through change in plan for the patient, change in patient's treatment and the relationship between such changes and certain findings.

RESULTS

The GPs included 574 patients in the study. POCUS was used in patient consultations with a median frequency of 8.6% (IQR: 4.9-12.6). Many different organs were scanned covering more than 100 different tentative diagnoses. The median time taken to perform POCUS was 5 min (IQR: 3-8). Across applications and GPs, POCUS entailed a change in diagnoses in 49.4% of patients; increased confidence in a diagnosis in 89.2% of patients; a change in the management plan for 50.9% of patients including an absolute reduction in intended referrals to secondary care from 49.2% to 25.6%; and a change in treatment for 26.5% of patients.

CONCLUSIONS

The clinical utilisation of POCUS was highly variable among the GPs included in this study in terms of the indication for performing POCUS, examined scanning modalities and frequency of use. Overall, using POCUS altered the GPs' diagnostic process and clinical decision-making in nearly three out of four consultations.

TRIAL REGISTRATION NUMBER

NCT03375333.

Comparison of Hands-On Versus Online Learning in Teaching Ultrasound Skills for Achilles Tendon Rupture: A Pilot Study

Introduction

In the emergency department, the diagnosis of an Achilles tendon rupture (ATR) is reportedly missed in greater than 20% of cases. A limited number of studies evaluate the use of cadaver models as a potential ultrasound teaching and training modality. We hypothesize that emergency medicine residents can effectively utilize point-of-care ultrasound (POCUS) on cadaver models and a focused teaching intervention to assess their ability to detect ATRs.

Methods

A prospective study of 23 EM residents was performed. All participants in the study were divided into two learner groups: (a) independent and (b) hands-on. The independent learner group received a 30-minute online didactic lecture demonstrating how to diagnose ATRs. The hands-on learner group received direct instruction on cadaver lower leg models with a ruptured and normal Achilles tendon (AT). Both groups then participated in identifying either normal or ruptured ATs on six cadaver lower leg models.

Results

The sensitivity and specificity were 89% and 82% in the independent learner group 96% and 100% in the hands-on learner group, respectively. The overall sensitivity and specificity were 91% and 88%, respectively. There was a trend toward successful identification with increased years of residency training.

Conclusions

In this study, lower leg and ankle cadaver models were found to be as effective as an independent learner model for potential POCUS teaching and training modality in both novice and more advanced trainees.