Ultrasound Journal最新文献

Background: Transcranial doppler ultrasound (TCD) allows for the assessment of the cerebrovascular hemodynamics in critically ill children. Given the increasing availability of machines equipped with TCD capabilities globally, it may be a useful approach to detect cerebral hypoperfusion and guide neurologic resuscitation for pediatric patients in resource limited settings where other neuromonitoring techniques are unavailable. However, the current need to evaluate waveform characteristics and to age correct values to determine if a study is abnormal decreases the feasibility of using point of care TCD in this way. The brain shock index (BSI), a repurposing of the Lindegaard Ratio, overcomes these limitations.

Methods: We performed a prospective study of children with cerebral malaria (CM). On admission and daily thereafter, TCD was used to evaluate the middle cerebral (MCA) and extra-cranial carotid arteries (Ex-ICA), and the BSI was calculated bilaterally (MCA mean flow velocity ((Vm))/Ex-ICA Vm). Neurologic outcome at discharge was assessed.

Results: A cohort of 291 children with CM were evaluated. BSI calculation was successful in all of them. The mean time to perform TCD and calculate the BSI was 4 ± 2 min. Overall, 222 participants (76%) had a good outcome and 69 (24%) a poor outcome. The BSI had an AUC of 0.98 (95% CI 0.97-0.99, p < 0.0001) to predict death or moderate to severe disability. The highest sensitivity and specificity of the BSI to predict adverse outcomes occurred at a cut off value ≤ 1.1. The adjusted odds ratio of poor outcome was 3.2 (95% CI 1.6-6.1, p = 0.001) if any BSI measurement during hospitalization fell below this threshold. No intracranial pressure monitoring was available to determine the relationship between the BSIs and an invasively measured cerebral perfusion pressure.

Conclusion: The BSI is a rapid, feasible point of care ultrasound measurement of cerebral hypoperfusion, with values ≤ 1.1 strongly correlating with poor neurologic outcomes in children with CM. Future studies should be performed to assess the utility of BSI to detect the presence and measure the severity of reduced cerebral perfusion pressure in other populations of critically ill children.

Background: Current methods to classify developmental dysplasia of the hip (DDH) on ultrasound (US) images, such as the Graf method, provide limited prognostic information. This study aimed to improve the prediction of the clinical course and outcome at age five of decentered hips, diagnosed on the first US made in the first months after birth, by identifying acetabular shape variants on these US images using a statistical shape model (SSM).

Patients and methods: US images of the hip were retrieved from a single-center retrospective cohort of patients with DDH Graf type D/III/IV. A SSM was created from the US images made at initial diagnosis.. The association between the identified acetabular shape variants and an unfavorable outcome (residual DDH at age five and open reduction and/or a pelvic osteotomy before age five) was established with multivariable regression models.

Results: 92 decentered dysplastic hips with full history could be retrieved from the database and were included. At age five, 12 patients (13%) had undergone open reduction, 13 (14%) had a pelvic osteotomy, and 32 (35%) patients showed residual DDH. Four shape variants represented 95% of the variance in acetabular shape. Mode 4 was associated with an unfavorable outcome (odds ratio (OR): 1.80 (95% CI 1.12-2.90). Mode 1 was associated with less risk on open reductions or pelvic osteotomies (OR: 0.56 (95% CI 0.33-0.96).

Conclusions: A potential new method of analyzing US images for DDH using SSM established four distinct acetabular shapes on neonatal US images with unstable DDH, of which two were associated with outcomes at five years of age. This tool could serve as a basis for a better prediction of outcome and a more personalized and effective guide for treatment.

Background: As more specialties have begun to use Point-of-Care Ultrasound (POCUS) in patient care, hospitals and healthcare systems have been investing increasing resources in POCUS infrastructure (training, equipment, and administration). Since each specialty uses different POCUS applications, healthcare systems seek to identify commonalities and differences between specialties to make thoughtful investments in POCUS infrastructure to support each specialty's use of POCUS while minimizing redundancies. Historically, past studies have focused on POCUS use in individual specialties, primarily emergency medicine and critical care, but comparative studies of different specialties are needed to guide investment in POCUS infrastructure and bolster POCUS implementation across healthcare systems. We conducted a cross-sectional survey of all Veterans Affairs (VA) medical centers in the United States and compared data from 5 different specialties on current usage, training needs, and barriers to POCUS implementation.

Results: Data were collected from facility chiefs of staff (n = 130; 100% response rate) and chiefs of emergency medicine (n = 101; 92% response rate), critical care (n = 93; 83% response rate), hospital medicine (n = 105; 90% response rate), anesthesiology (n = 96; 77% response rate), and surgery (n = 104; 95% response rate). All specialties surveyed reported current POCUS use (surgery 54%, hospital medicine 64%, anesthesiology 83%, emergency medicine 90%, and critical care 93%) but more importantly, a greater desire for training was seen. Procedural POCUS applications were most often used by all specialties, despite decreased procedural POCUS use since 2015 for all specialties except critical care. Diagnostic POCUS use generally increased from 2015 to 2020, although use of specific POCUS applications varied significantly between specialties. Barriers limiting POCUS use included lack of training (53-80%), access to ultrasound equipment (25-57%), and POCUS infrastructure (36-65%).

Conclusions: From 2015 to 2020, POCUS use increased significantly in emergency medicine, critical care, internal medicine, anesthesiology, and surgery, although use of specific applications varied significantly between specialties. Lack of training and POCUS infrastructure were common barriers to POCUS use across specialties. Desire for training exceeded current use for several POCUS applications. These findings can guide implementation and standardization of  POCUS use  in hospitals and healthcare systems.

Background: Point-of-care ultrasound (POCUS) is a potent diagnostic tool especially in resource-limited settings. The implementation of POCUS diagnostics requires adequate training of POCUS operators. This scoping review aimed to identify and describe POCUS training concepts that have been applied in low-and middle-income countries (LMICs).

Methods and findings: All studies on diagnostic POCUS training in LMICs that could be found in the Cochrane, Embase, Google Scholar, and Medline databases up to July 6, 2023, were included and data was extracted for descriptive analysis. The review protocol was registered at OSF https://doi.org/10.17605/OSF.IO/8FQJW . A total of 53 publications were included with 59% of studies (n = 31) conducted in Africa and 23% (n = 12) in Asia. The majority of studies (n = 41, 81%) described short courses amongst which 40% were one-off sessions and 60% described longitudinal trainings. Curricula were mostly related to emergency medicine and obstetrics and organ-focused protocols (lung n = 29 (54%), cardiac n = 28 (53%), obstetric n = 23 (43%)). Trainees were largely medical doctors and clinical officers with minimal or absent ultrasound skills. Training challenges included resource constraints and lack of context adaptation. Best practice recommendations included focus on hands-on training, low trainer to trainee ratio, protected training time, online training options, use of local trainers, short and concise training manuals in print, continuous supervision and early and on-going evaluation, as well as tele-mentoring.

Conclusions: Context integration and focus on local needs, trainer availability and suitability, durable equipment and maintenance, as well as emphasis on hands on training including patients with relevant pathology, were key aspects for targeted and sustainable POCUS training in LMICs identified in this review.

Cost-effective screening methods for Renal Cell Carcinoma (RCC) are still lacking. Angiogenesis is a recognized hallmark of cancer growth, leading to distinguishable perfusion patterns in tumors from those in normal tissue. This establishes the basis for diagnostic imaging solutions by dynamic contrast-enhanced ultrasound (DCE-US). In the past years, we have developed contrast-ultrasound dispersion imaging (CUDI) techniques to quantify prostate DCE-US acquisitions, obtaining promising results for prostate cancer localization. In this pilot study, we investigated for the first time its feasibility for RCC localization. DCE-US acquisitions of the kidney in 5 patients were used to perform CUDI analysis. With the obtained CUDI parameters and the delineated tumor and parenchyma regions, we performed pixel-based classification, from which the highest area under the receiver-operating-characteristic curve (AUC) = 0.96 was obtained for an individual patient, and an average AUC = 0.68 was obtained for the full patient dataset, showing the potential of CUDI for solid RCC localization. Further validation in a larger dataset and evaluation of the compatibility of point-of-care diagnosis are required.

Background: Intra-aortic balloon pump is used for temporary mechanical support of failing left ventricle. It works by reducing the arterial afterload during ventricular systole to reduce myocardial work and increasing diastolic proximal aortic pressure to improve coronary perfusion. Rarely, intra-aortic balloon pump (IABP) can become the cause of severe haemodynamic compromise, causing dynamic left ventricular outflow tract obstruction.

Case presentation: An 88-yo man presented with angiotensin converting enzyme inhibitor (ACEI) - induced angioedema. He received steroids and adrenaline, but progressed to the respiratory arrest, requiring emergency awake fiberoptic intubation and mechanical ventilation. Echocardiography revealed catecholamine-induced reversed Takotsubo cardiomyopathy. The patient suffered asystolic cardiac arrest on arrival to intensive care unit (ICU), requiring cardiopulmonary resuscitation (CPR). Bradycardia and hypotension were treated with atrial pacing and (IABP). Icatibant was administered for angioedema. After several hours of haemodynamic stability, severe hypotension returned. Bedside echocardiographic diagnosis of recovery from Takotsubo and new development of IABP-induced dynamic left ventricular outflow tract obstruction (DLVOTO) was made. Stopping IABP resulted in rapid haemodynamic recovery. Repeated doses of Icatibant were needed. The patient survived and returned to independent living.

Conclusions: Immediate echocardiographic recognition of iatrogenic DLVOTO caused by IABP allows discontinuation of IABP support as a life-saving intervention. Dynamic application of spectral Doppler with changes in IABP settings is required for correct diagnosis.

Peripheral nerve injuries negatively impact patients' quality of life and healthcare resources. This review discusses using high-resolution neurosonography (HRNUS) for mapping peripheral nerves and detecting pathologic lesions. It emphasizes the importance of HRNUS in diagnosing nerve disorders and briefs the widely accepted schemes for peripheral nerve injury classification. It also highlights the non-intrusive, flexible, patient-friendly, and cost-effective nature of HRNUS, making it a valuable tool in managing nerve disorders. The authors recommend the use of HRNUS to enable precise diagnoses, prevent permanent disabilities, and contribute to the efficient utilization of healthcare resources.

Structural muscle properties are critical in health and athletic settings, with magnetic resonance imaging considered the gold standard assessment procedure under static conditions due to its reliability and objectivity. Practical limitations, including cost and accessibility, have led to the increasing use of ultrasound as an alternative for skeletal muscle morphological parameters. However, ultrasound measurements are sensitive to evaluation conditions and assessor experience, which has not been sufficiently explored, yet. Therefore, this study investigated the influence of assessor experience on the reliability of ultrasound measurements. A double-blind design was used, involving an experienced assessor (> 12,000 images for several years) and multiple inexperienced assessors (< 100 images) to collect data from 39 recreationally active participants. Measurements of muscle architecture were conducted in the leg muscles over two consecutive days, generating 1,248 ultrasound images. Relative and absolute reliability were analyzed using intraclass correlation coefficients (ICCs), standard error of measurement, minimal detectable change, mean absolute error (MAE), mean absolute percentage error (MAPE) and Bland-Altman analyses. Relative reliability was good to excellent in all measurement spots and time-points for muscle thickness (ICC = 0.76-0.98) irrespective of assessor experience, except for the inter-day comparison for the gastrocnemius lateralis by the inexperienced assessors, (ICC = 0.58). The pennation angle assessment ranged from insufficient to excellent reliability (ICC = 0.18-0.94) and experience contributed greatly to better results. The random error for the inexperienced assessors was reflected in two- to three-times higher MAEs/MAPEs and limits of agreement in the Bland-Altman analyses, respectively. The findings emphasize the importance of experience and standardization in achieving reliable ultrasound data, particularly for (a) sensitive parameters like the pennation angle and/or (b) inter-day, intra-subject comparisons.

Purpose: To compare the effectiveness of ultrasound-guided (US) versus non-US femoral artery puncture (FAP) methods, including fluoroscopy-guided (FL) and non-guided (NG) techniques.

Materials: This meta-analysis included 11 randomized controlled trials and 1 non-randomized retrospective study, comprising a total of 12 studies involving 5534 patients across diverse clinical settings. Studies varied in operator experience, institutional settings, and procedural protocols. Key outcomes assessed included complication rates, vessel access time, first-pass success rates, number of attempts, and the risk of accidental venipuncture.

Results: Analysis of the heterogeneous dataset showed that guided techniques were associated with reduced complication rates compared to NG methods (pooled odds ratio (OR): 0.45, 95% Confidence Interval (CI) 0.28-0.73). US guidance was associated with decreased vessel access time (mean difference: - 16.30 s, 95% CI - 29.83 to - 2.76), higher first-pass success rates (pooled OR: 3.54, 95% CI 2.36 to 5.30), and required fewer attempts compared to non-US techniques. US guidance also showed lower risk of inadvertent venipuncture (pooled OR: 0.22, 95% CI 0.14 to 0.34).

Conclusion: This meta-analysis suggests potential benefits of US femoral artery puncture techniques over non-US methods, while acknowledging significant heterogeneity across studies. The observed advantages in procedural outcomes varied across different clinical settings and operator experience levels. These findings provide setting for institutional decision-making regarding the implementation of guided puncture methods, considering factors such as operator expertise, resource availability, and specific patient populations.

While there are different protocols for in-hospital transesophageal echocardiography, there is no existing protocol for prehospital usage during out-of-hospital cardiac arrest. Herein, the "assess-improve-detect-guide" protocol is described. This protocol includes four mid-esophageal views to address the most time-sensitive aspects during out-of-hospital cardiac arrest. This protocol can be used in services with and without the capability for eCPR, with the benefit of profiting from additional diagnostic and personal resources. This protocol provides a standardized approach for performing transesophageal echocardiography during out-of-hospital cardiac arrest and reporting the results.