Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced

Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion

Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

POCUS for Infectious Enteritis-A Retrospective Case Series Analysis

INTRODUCTION

The abdominal pain associated with diarrhea can be difficult to distinguish from appendicitis. We present a case series of all children found on pediatric emergency department point-of-care ultrasound (POCUS) to have right-sided bowel wall edema.

METHODS

Over the study period June 2020 through September 2023, POCUS images were collected by a pediatric emergency physician with 6 years of experience with POCUS. Children found to have small bowel wall edema on POCUS were identified, and hospital charts were reviewed.

RESULTS

One hundred thirteen children were found on POCUS to have right-sided small bowel wall edema. Thirty-one (27%) were referred by their pediatrician or urgent care provider to evaluate for appendicitis. Seventy-eight children (69%) provided stool samples. Of those, 58% resulted Campylobacter, 8% Salmonella, and 8% Shigella. Forty (35%) were discharged after POCUS without further evaluation. One child in our case series was subsequently diagnosed with uncomplicated appendicitis. To date, no child in the series has subsequently been diagnosed with inflammatory bowel disease.

CONCLUSIONS

Enteritis can initially be difficult to distinguish on clinical grounds from acute appendicitis. Bowel wall edema on POCUS in a child without sonographic signs of appendicitis strongly suggests bacterial enteritis. Early POCUS demonstrating enteritis without signs of appendicitis may decrease hospital resource usage.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Past and Present of Point-of-Care Ultrasound (PoCUS): A Narrative Review

This article aims to conduct a literature review to gain insight into point-of-care ultrasound (PoCUS). PoCUS is a rapid, accurate, non-invasive, and radiation-free imaging modality that can be used in stable and unstable patients. PoCUS can be performed parallel to physical examination, resuscitation, and stabilization; repeated exams in critical patients are essential for improving sensitivity. The review highlights how PoCUS, which was initially used to detect free intraperitoneal fluid in trauma patients, has developed into a life-saving diagnostic tool that could be utilized by treating physicians during various stages of diagnosis, resuscitation, operation, and postoperative critical care when managing sick patients. The review also notes the barriers to the widespread uptake of PoCUS in general internal medicine and the recent commercial availability of "pocket" or handheld probes that have made PoCUS more readily available. This review concludes that adopting a focused binary decision-making approach can maximize PoCUS's value in many clinical settings, including emergency departments, intensive care units, and operation theatres. Overall, the review emphasizes the importance of awareness of common indications, limitations, and strengths of this evolving and promising technology to determine its future trajectory: Providing comprehensive PoCUS training within internal medicine curriculums and supporting trainers to do so.

Size-exclusion chromatography-based extracellular vesicle size subtyping and multiplex membrane protein profiling for differentiating gastrointestinal cancer prognosis

Extracellular vesicles (EVs), as a type of subcellular structure, have been extensively researched for their potential for developing advanced diagnostic technologies for various diseases. However, the biomolecular and biophysical heterogeneity of EVs has restricted their application in clinical settings. In this article, we developed a size-exclusion chromatography-based technique for simultaneous EV size subtyping and protein profiling. By eluting fluorescent aptamer-treated patient plasma through a size-exclusion column, the mixture can be classified into 50 nm aptamer-bound EVs, 100 nm aptamer-bound EVs and free-floating aptamers, which could further enable multiplex EV membrane protein profiling by analyzing the fluorescence intensities of EV-bound aptamers. Using this technique, we successfully identified EV size subtypes for differentiating gastrointestinal cancer prognosis states. Overall, we developed a rapid, user-friendly and low-cost EV size subtyping and protein profiling technique, which holds great potential for identifying crucial EV size subtypes for disease diagnosis in the clinic.

Esophageal Stent Migration Diagnosed With Point-of-Care Ultrasound

This unique case depicts the first published report of a physician using point-of-care ultrasound to diagnose an esophageal stent migration. Discussed in this article are the sonographic findings that clinicians should be familiar with when evaluating patients with abdominal pain or chest pain who have a history of an esophageal stent. When coupled with a high index of suspicion, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques for making a rapid diagnosis of esophageal stent migration.

Main applications of point-of care ultrasound in palliative care

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

Effectiveness of ultrasound screening in right upper quadrant pain: A comparative study in a basic emergency service

Background and Aims

The use of ultrasound screening is primarily facilitated by point-of-care ultrasound (POCUS) and its integration into healthcare systems is a result of the versatility of this imaging technique. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with that of radiologists at referral hospital (RH) in Portugal.

Methods

Twenty patients with right upper quadrant (RUQ) pain and suspected cholecystitis or biliary pathology underwent sonography screening using POCUS in the BES. They were then forwarded to the RH where a radiologist performed a conventional ultrasound exam on the same patients. The results of both exams were compared to determine if the findings obtained in the BES were confirmed by the radiologist in the RH.

Results

In our sample, 60% of cases were related to biliary pathology, 20% were liver-related, 10% had hepatopancreatic biliary etiology, and 10% had unknown etiology. A strong association between the sonographic findings in the BES and the RH was found in the variables "Sonographic Murphy sign" (V = 0.859; p = 0.001), "Cholelithiasis/Gallbladder sludge" (V = 0.840; p = 0.001), and "Intrahepatic biliary tract dilatation" (V = 0.717; p = 0.006). Adequate measures of agreement between the findings of the radiographer and radiologist were obtained for the "Sonographic Murphy sign" (k = 0.664; p = 0.001) and the presence of "Cholelithiasis/Gallbladder sludge" (k = 0.712; p = 0.000).

Conclusion

Major biliary abnormalities were detected in patients with RUQ pain in BES using sonography. The correlation between the sonographic findings obtained by the sonographers at BES and those obtained by radiologists at the RH in Portugal was strong, showing that POCUS screening could be extended to other similar settings; however, more studies are needed.

Utilization of Point-of-Care Ultrasound in a Specialist Palliative Care Team Across Multiple Care Settings: A Retrospective Chart Review

BACKGROUND

Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study was to examine the use of POCUS in a specialist palliative care setting.

METHODS

A retrospective chart review was conducted from January 2018 to June 2019 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS, and, if applicable, volume of fluid drained.

RESULTS

We identified 126 uses of POCUS in 89 unique patients. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia, and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance.

CONCLUSION

We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.

Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation

How to cite this article: Srinivasan S, Kumar PG, Govil D, Gupta S, Kumar V, Pichamuthu K, et al. Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation. Indian J Crit Care Med 2022;26(S2):S7-S12.

The Benefits and Barriers of Using Point-of-Care Ultrasound in Primary Healthcare in the United States

An effective healthcare system should embrace practices that enhance overall quality and productivity. Training primary care physicians in Point-of-Care Ultrasound (POCUS) has become part of the processes that improve the quality of patient care and serve to guide the diagnostic impression quickly and effectively. With the purpose of highlighting the applications and challenges of POCUS use in US primary health care, we conducted a narrative review based on PubMed-indexed and Cochrane Library English text publications searched in May-July 2022 using a combination of key terms including point of care ultrasound, primary care, and US healthcare. Many studies have shown that POCUS has a positive impact on fostering medical attention and reducing morbidity, mortality, and healthcare costs. Besides assisting in procedures, POCUS has a head-to-toe application in evaluating inflammatory and infectious conditions, acute abdomen, cardiopulmonary function, musculoskeletal and vascular pathologies. However, its uniform implementation is limited across the US healthcare system due to multitudes of barriers such as lack of training, resource scarcity, and low reimbursement. Training primary care physicians in general and emergency care providers, in particular, is key to scaleup POCUS use. Large size studies are paramount to further explore the effectiveness of POCUS and identify key challenges to its implementation.

Point-of-Care Abdominal Ultrasonography (POCUS) on the Way to the Right and Rapid Diagnosis

Point-of-Care ultrasound (POCUS) is based on target ultrasound that is performed wherever a patient is being treated, and by a non-radiologist directly involved in the patient’s care. It is used either for quick diagnosis or procedural guidance. Abdominal pain is one of the most common complaints in emergency departments, and POCUS can help in the differentiation of patients who need additional diagnostic tests or hospital treatment, which eventually reduces the overall costs of health care. POCUS has high sensitivity and specificity in abdominal pathology, it can be helpful in the evaluation of biliary, intestinal, and urinary tract, and it is especially used in trauma. Additionally, the gold standard for abdominal aortic aneurysm detection, follow up and screening is precisely this diagnostic procedure. Unfortunately, the quality of ultrasound examination can be affected by the experience of the physician performing it and the patient’s body weight. There is no doubt that POCUS is being increasingly recognized, but all motivated physicians should be provided with dedicated tutors and enough time for learning. This would certainly help to implement this diagnostic method as a routine in emergency and critical care departments, and significantly shorten the time until definitive diagnosis.

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit

Purpose of Review

Recent Findings

Summary

Supplementary Information

The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Diagnostic Accuracy of Point-of-Care Ultrasound Integrated into Clinical Examination for Acute Diverticulitis: A Prospective Multicenter Study

PURPOSE

 Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis.

MATERIALS AND METHODS

 This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan.

RESULTS

 Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 ± 102 vs. 330 ± 319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity.

CONCLUSION

 Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.

Surgeon-performed ultrasound for the staging of acute diverticulitis: Preliminary results of a prospective study

INTRODUCTION

Although contrast-enhanced abdominal computed tomography (CEACT) is still considered the criterion standard for the assessment of suspected acute diverticulitis, in recent years, the use of point-of-care ultrasound (POCUS) has been spreading more and more in this setting. The aim of this study was to compare CEACT to POCUS for the diagnosis and staging of suspected acute diverticulitis.

METHODS

This is a prospective study conducted on 55 patients admitted to the emergency department of two Italian Hospitals with a clinical suspicion of acute diverticulitis between January 2014 and December 2017. All the patients included underwent POCUS first and CEACT immediately afterward, with the diagnosis and the staging reported according to the Hinchey (H) classification modified by Wasvary et al. [Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65:632-635.] Three surgeons performed all the POCUS, and the same two radiologists retrospectively analyzed all the CEACT images. The radiologists were informed of the clinical suspicion but unaware of the POCUS findings. The CEACT was used as the criterion standard for the comparison.

RESULTS

The final cohort included 30 females (55%) and 25 males (45%). The median age was 62 years (range, 24-88 years), and the median body mass index was 26 kg/m2 (range, 19-42 kg/m2). Forty-six of 55 patients had a confirmed diagnosis of acute diverticulitis on both POCUS and CEACT, whereas, in 7 patients, the diagnosis was not confirmed by both methods. Point-of-care ultrasound sensitivity and specificity were 98% and 88%, respectively. Point-of-care ultrasound positive and negative predictive values were 98% and 88%, respectively. Point-of-care ultrasound accuracy was 96%. Point-of-care ultrasound classified 33 H1a, 11 H1b, 1 H2, and 1 H3 acute diverticulitis. This staging was confirmed in all patients but three (93%) by CEACT.

CONCLUSION

Point-of-care ultrasound appeared a reliable technique for the diagnosis and the staging of clinically suspected H1 and H2 acute diverticulitis. It could contribute in saving time and resources and in avoiding unnecessary radiation exposure to most patients.

LEVEL OF EVIDENCE

Diagnostic test, level III.

The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias

INTRODUCTION

Traditional evaluation for suspicion of gallstone or gallbladder-related disease includes evaluation with a formal technician-performed ultrasound. However, the use of point-of-care bedside ultrasounds (Bedside US) has been shown to be a viable alternative for the diagnosis of gallstones and gallbladder-related diseases. Purpose Statement: The purpose of this study was to evaluate the impact of Bedside US use in gallbladder evaluation on key patient care outcomes within our community-based emergency department setting.

METHODS

This retrospective study compared the use of no ultrasound (No US), a formal technician performed ultrasound (Tech US) and Bedside US for gallstone and gallbladder related diseases within a community hospital emergency department between January 1, 2015 and January 1, 2018. Initial vitals, lab work, patient socio-demographics, medical history, emergency department length of stay in hours and disposition were reviewed.

RESULTS

Of a total N = 449 patients included, patients who received a Bedside US had the fewest computerized tomography scans (No US 62% vs. Tech US 29% vs. Bedside US 16%; p < 0.0001), the shortest median emergency department length of stay (No US 4.5 days vs. Tech US 5.0 days vs. Bedside US 3.0 days; p < 0.0001), and were more likely to be discharged home (No US 41% vs. Tech US 55% vs. Bedside US 81%; p = 0.0006) compared to those that received no ultrasound or a formal ultrasound. Patients who received a Bedside US also had the statistically significant highest incidence of prior cholelithiasis (No US 29.4% vs Tech US 14.3% vs. Bedside US 31.3%; p = 0.001) and lowest total median bilirubin levels (No US 0.5 vs. Tech US 0.5 vs. Bedside US 0.3; p = 0.016) when compared to the other two groups.

CONCLUSIONS

Although there was a confirmation bias, these study results indicate that point-of-care bedside ultrasound could be a viable alternative for gallstones and gallbladder-related diseases with benefits of use in a community hospital setting.

Modern pulmonary imaging of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a complex and serious cardiopulmonary morbidity in infants who are born preterm. Despite advances in clinical care, BPD remains a significant source of morbidity and mortality, due in large part to the increased survival of extremely preterm infants. There are few strong early prognostic indicators of BPD or its later outcomes, and evidence for the usage and timing of various interventions is minimal. As a result, clinical management is often imprecise. In this review, we highlight cutting-edge methods and findings from recent pulmonary imaging research that have high translational value. Further, we discuss the potential role that various radiological modalities may play in early risk stratification for development of BPD and in guiding treatment strategies of BPD when employed in varying severities and time-points throughout the neonatal disease course.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound

Undifferentiated abdominal pain is a common presentation often requiring immediate medical or surgical intervention. Providing an accurate diagnosis involves a detailed patient history and thorough physical exam. Point of care ultrasound is gaining acceptance as a rapid diagnostic tool that can be used to accurately detect life-threatening conditions while potentially avoiding unnecessary radiation exposure and facilitating rapid treatment. Detection of pneumoperitoneum with point-of-care ultrasound is a simple procedure that relies heavily on the experience of the investigating practitioner. Standard technique involves placing a high-frequency linear-array transducer in the right upper quadrant, where abdominal free air is most likely to accumulate. Detection of the ‘gut point’, which is the transition of abdominal wall sliding to lack thereof in a single image, is the pathognomonic finding of pneumoperitoneum. If visualization is difficult, moving the patient to the left lateral decubitus position or using the scissors technique can provide additional image views. This representative case report and review highlights the use of abdominal POCUS for the diagnosis of pneumoperitoneum. Ultrasound should continue to be explored by clinicians to narrow the differential diagnosis of acute abdominal pain.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Focus on PoCUS or hocus pocus? Integrating point-of-care ultrasound into residency and clinical practice

Point-of care ultrasound (PoCUS) is a new clinical diagnostic paradigm that plays an instrumental role in the ongoing anesthesiologist’s evolving role towards a perioperative physician. Currently, there are few approved curricula that incorporate a PoCUS program into anesthesia residency. This article examines relevant PoCUS applications for anesthesiologists, presents an overview of existing international guidelines for education and training, and reflects on the need for specialty-wide standards. We present a possible framework, that could offer a first move towards a structured PoCUS pathway for Belgian anesthesia residents and facilitate its incorporation into national anesthesia practice.

Acute epiploic appendagitis: ultrasound and computed tomography findings of a rare case of acute abdominal pain and the role of other imaging techniques

Purpose

Acute epiploic appendagitis (EA) is a relatively rare, benign and local inflammatory disease involving the epiploic appendices. Unlike its mimics, EA is generally a self-limiting inflammatory disease and can be treated conservatively.

Case presentation

A 33-year-old Caucasian man presented to our emergency department with a sever and sharp left iliac fossa pain. He underwent abdominal X-ray, ultrasound (US) and computed tomography (CT) evaluations.

Conclusion

We illustrate US and CT findings to increase the radiologists’ awareness of this condition and to avoid diagnostic delay and unnecessary use of antibiotics, hospitalization and surgery.

Point-of-care ultrasound for the acute abdomen in the primary health care

Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.

Point-of-care Ultrasound Training During an Emergency Medicine Clerkship: A Prospective Study

Aim This study evaluated the effects of three-hour instructor-led training courses in the Extended Focused Assessment Sonography for Trauma (EFAST) and Rapid Ultrasound in Shock and Hypotension (RUSH) protocols on knowledge gain and retention by final-year medical students. Methods This prospective study evaluated 79 final year medical students participating in an emergency medicine (EM) clerkship during the 2017-2018 academic year. None of the included students had prior formal ultrasound training or hands-on experience. All students participated in three-hour training courses on the EFAST and RUSH protocols, with training on each protocol involving one hour of didactic training and two hours of practical training. Knowledge improvement was measured by testing before and after each course, and knowledge retention was evaluated on a final clerkship multiple choice question (MCQ) examination. Results Median scores were significantly higher after rather than before both the EFAST (15; range, 12-19 vs. 7; range, 2-18; p < 0.0001) and RUSH (16; range, 6-20 vs. 6; range, 1-13; p < 0.0001) courses. EFAST knowledge was significantly higher than RUSH knowledge before (p = 0.04) but not after (p = 0.82) taking the respective course. The RUSH score was significantly lower than the EFAST score on the final clerkship MCQ examination (p < 0.0001). Conclusions Three hours of instructor-led ultrasound training given during an EM clerkship significantly increased knowledge of both the EFAST and RUSH protocols. Knowledge retention after two weeks was higher for the EFAST than the RUSH protocol. A longer period of RUSH training may improve the retention of knowledge.

Acute Epiploic Appendagitis: A Nonsurgical Abdominal Pain

Epiploic appendagitis is a relatively rare disease characterized by an inflammation of fat-filled serosal outpouchings of the large intestine, called epiploic appendices. Diagnosis of epiploic appendagitis is made challenging by the lack of pathognomonic clinical features and should therefore be considered as a potential diagnosis by exclusion first of all with appendicitis or diverticulitis which are the most important causes of lower abdominal pain. Currently, with the increasing use of ultrasound and computed tomography in the evaluation of acute abdominal pain, epiploic appendagitis can be diagnosed by characteristic diagnostic imaging features. We present a case of epiploic appendagitis with objective of increasing knowledge of this disease and its diagnostic imaging findings, in order to reduce harmful and unnecessary surgical interventions.

Kunafa knife and play dough is an efficient and cheap simulator to teach diagnostic Point-of-Care Ultrasound (POCUS)

Background

Point-of-Care Ultrasound (POCUS) is a useful diagnostic tool. Nevertheless, it needs proper training to reach its required level of competency. Educators who work in low-income countries find it difficult to purchase expensive training computer-based simulators. We aim in this communication to describe the methods to build up and use an efficient, simple, and cheap simulator which can be used for teaching POCUS globally.

Methods

It took our group 2 years to develop the simulator to its current form. The required material for the simulator includes a Kunafa knife, a carton gift box and its cover and colored play dough. The Kunafa knife with its blade is an excellent simulator for the small print convex array probe (3–5 MHz) and its ultrasound sections. It is useful to teach two important principles. First, the three basic hand movements used to control the ultrasound probe (fanning, tilting, and shifting). Second, the thin blade of the knife (1 mm thick) simulates the shape of the two-dimensional ultrasound images. The play dough is used to simulate different organs to be cut in different directions like the aorta and inferior vena cava.

Results

The simulator was used to teach 88 fifth year medical students during the period of November 2017 to November 2018 at the College of Medicine and Health Sciences, UAE University. The simulator was valid, simple, portable, and sustainable. The students greatly enjoyed its use. The cost of the simulator is less than 10 US dollars.

Conclusions

Surgical educators who work in low-income countries are encouraged to develop their educational tools that are tailored to their own needs. Our simulator can help our colleagues who want to teach POCUS and cannot purchase expensive mannequins and computer-based simulators.