Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound.

OBJECTIVES: A bowel diameter threshold of ≥2.5 cm, originally derived from the research using computed tomography, is frequently used for diagnosing small bowel obstruction (SBO) with point-of-care ultrasound (POCUS). We sought to determine the optimal bowel diameter threshold for diagnosing SBO using POCUS and its accuracy in predicting surgical intervention. METHODS: We conducted a secondary analysis using individual patient-level data from a previous systematic review on POCUS for SBO diagnosis across five academic EDs. Patient data were collected, including imaging results, surgical findings, and final diagnosis. The measured diameter of the small bowel using POCUS was recorded. ROC area under the receiver operating characteristic curves (AUC) were constructed to determine the optimal threshold for bowel diameter in predicting SBO diagnosis and surgical intervention. Subgroup analyses were performed based on sex and age. RESULTS: A total of 403 patients had individual patient-level data available, with 367 patients included in the final analysis. The most accurate bowel diameter overall for predicting SBO was 2.75 cm (AUC = 0.76, 95% CI 0.71-0.81). A bowel diameter of ≤1.7 cm had 100% sensitivity with no miss rate, while a bowel diameter of ≥4 cm had 90.7% specificity in confirming SBO. Patients under 65 had an optimal threshold of 2.75 cm versus 2.95 cm in patients over 65. Females had an optimal threshold of 2.75 cm, while males had a value of 2.95 cm. There was no significant correlation between bowel diameter thresholds and surgical intervention. CONCLUSION: A bowel diameter threshold of 2.75 cm on POCUS is more discriminative diagnostic accuracy for diagnosing SBO. Patients' age and sex may impact diagnostic accuracy, suggesting that tailored approaches may be needed.

Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA.

BACKGROUND: In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes. METHODS: This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020). RESULTS: Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase. CONCLUSION: We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis.

OBJECTIVE: The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS: We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS: We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS: POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION: PROSPERO registration number: CRD42022303598.

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience.

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

A 2-week elective experience provides comparable training as longitudinal exposure during residency for pelvic sonography.

OBJECTIVES: The purpose of this study was to compare the accuracy of first-trimester pelvic sonography done by physicians after a 2-week emergency ultrasound elective to similarly numbered examinations done by physicians longitudinally over several years of residency training. METHODS: We conducted a secondary analysis of a previously reported prospective study of pelvic sonography for symptomatic first-trimester pregnancy. The 21st through 40th examinations were compared between those who completed an emergency ultrasound elective and those who did not. The reference standard was pelvic sonography done by the department of radiology. RESULTS: Eighty-six examinations (34%) were done by 12 operators who did not participate in an emergency ultrasound elective, and 171 examinations (67%) were done by 13 operators who completed an emergency ultrasound elective. There was no statistical difference between the groups with regard to identifying an intrauterine pregnancy, molar pregnancy, ectopic pregnancy, or adnexal mass. CONCLUSIONS: The accuracy of pelvic sonography for first-trimester pregnancy was comparable between physicians who participated in a 2-week emergency ultrasound elective and those who performed the same number of examinations over a longer period during residency training.

Assessment of emergency physician-performed ultrasound in evaluating nonspecific abdominal pain.

STUDY OBJECTIVE: The objective of this pilot study was to lay the groundwork for future studies assessing the impact of emergency physician-performed ultrasound (EPUS) on diagnostic testing and decision making in emergency department (ED) patients with nonspecific abdominal pain (NSAP). METHODS: This was a prospective, noninterventional study using a consecutive sample of patients presenting to the ED with NSAP as determined by nursing triage when a participating physician was available. Nonspecific abdominal pain was defined as abdominal pain for which the patient was seeking evaluation without a presumed diagnosis or referral for specific evaluation. Patients were evaluated by a physician who documented their differential diagnosis and planned diagnostic workup. Then, the physician performed EPUS, recorded their findings, and documented their post-EPUS differential diagnosis and planned diagnostic workup. This was compared with the patient's final diagnosis as determined by 2 emergency physicians blinded to the EPUS results. RESULTS: A total of 128 patients were enrolled. Fifty-eight (45%; 95% confidence interval [CI], 36%-54%) had an improvement in diagnostic accuracy and planned diagnostic workup using EPUS. Sixty-four (50%; 95% CI, 41%-59%) would have been treated without further radiographic imaging. Fifty (39%; 95% CI, 31%-48%) would have been treated without any further laboratory testing or imaging. DISCUSSION: Based on our findings, a future trial of 164 consecutive patients would have 90% power to confirm a 25% reduction in testing and a 25% improvement in decision making. CONCLUSION: Emergency physician-performed ultrasound appears to positively impact decision making and diagnostic workup for patients presenting to the ED with NSAP and should be studied further.

High Efficacy of Oral Tetracyclines in Prosthetic Joint Infection Treated With Debridement, Antibiotics, and Implant Retention (DAIR) or Resection Arthroplasty With Destination Spacer Placement.

Prosthetic joint infections are often managed with debridement and implant retention (DAIR) or resection arthroplasty with destination spacer placement. Both surgical approaches require long courses of postoperative antibiotics, for which tetracycline antibiotics have not been well-studied. In this retrospective case series, we included patients at our institution treated for staphylococcal prosthetic joint infection managed with DAIR or destination spacer placement who were switched from IV antibiotics to oral tetracycline within 12 weeks of surgery. Our primary outcome of interest was treatment failure within one year of initial surgery. Among the patients in our series, 88.2% (n = 15) of patients who underwent DAIR and 100% (n = 7) of patients who underwent resection arthroplasty with destination spacer remained event-free for one year. These results demonstrated that the use of oral tetracyclines as long-term therapy in the treatment of these infections was effective and well-tolerated.

Emergency ultrasound of the gall bladder: comparison of a concentrated elective experience vs. longitudinal exposure during residency.

BACKGROUND: It is unknown how an intensive emergency ultrasound (EUS) experience compares with comparable exposure done over the course of residency training. OBJECTIVE: Our objective was to compare the accuracy of EUS of the gall bladder done by physicians after a 2-week EUS elective with similarly numbered examinations done by physicians longitudinally over several years of residency training. METHODS: This was a secondary analysis of a previously reported prospective study of EUS for biliary disease. The 21(st)-40(th) examinations were compared between those who participated in an EUS elective and those who did not. The gold standard was ultrasound done by the Department of Radiology. RESULTS: Mean time to complete 40 EUS examinations for biliary disease was 14 months for those participating in an EUS elective compared with 29 months for those who did not. One hundred and ninety-one examinations (49%) were done by 19 operators who did not participate in an EUS elective and 202 examinations (51%) were done by 23 operators who completed an EUS elective. There was no statistical difference between the two groups with regard to detecting the presence of gall stones, gall bladder wall thickening, pericholecystic free fluid, ductal dilation, or sludge. CONCLUSIONS: Physicians who participated in a 2-week, semi-structured EUS elective demonstrated EUS accuracy for biliary disease that was comparable with those who performed the same number of examinations over a longer period of time.

Xanthogranulomatous pyelonephritis - A diagnostic and therapeutic dilemma.

Xanthogranulomatous pyelonephritis (XGP) is a rare variant of chronic pyelonephritis, occurring in the setting of obstructive uropathy and recurrent urinary tract infections (UTIs). It is difficult to diagnose as it can be asymptomatic until late-stage disease. Localized symptoms such as flank pain and dysuria may be attributed to nephrolithiasis or UTIs without prompting need for further workup. Extrarenal manifestations, most notably fistula formation, may present distal to the kidney and not be readily attributed to a renal pathology. The only known definitive therapy is nephrectomy. A delay in diagnosis can lead to fulminant complications or a more technically difficult nephrectomy. We present three cases of XGP, which serve to highlight the possibility of earlier diagnosis and resultant management options, including the potential for nephron-saving strategies. Early clinical and radiologic suspicion through awareness of risk factors may play an important role in preventing disease progression, avoiding late-stage complications, and improving treatment outcomes.

Predictive value of signs and symptoms for small bowel obstruction in patients with prior surgery.

BACKGROUND: The aim of this study was to determine the predictive value of various signs and symptoms for small bowel obstruction (SBO) in patients with prior abdominal surgery. METHODS: This was a secondary analysis of a previously reported prospective study of ultrasonography for SBO. Patients with prior abdominal surgery were identified and presenting signs and symptoms were compared to the CT diagnosis of SBO. RESULTS: No signs or symptoms were predictive of SBO. CONCLUSION: No constellation of signs and symptoms can be used to reliably exclude a SBO in patients with prior abdominal surgery.

Sonographic assessment of jugular venous distension and B-type natriuretic peptide levels in patients with dyspnoea.

BACKGROUND: Sonographic assessment of jugular venous distension (US-JVD) has been described as a sensitive test for pulmonary oedema on chest x-ray in patients with dyspnoea, but chest x-ray may not detect all patients with raised B-type natriuretic peptide (BNP) levels. OBJECTIVE: To compare US-JVD and initial BNP levels in patients with dyspnoea. METHODS: This was a secondary analysis of a previously collected dataset from a prospective study of US-JVD in patients with dyspnoea due to suspected congestive cardiac failure. Initial BNP levels were obtained for each patient. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and likelihood ratios (LR) of US-JVD ≥8 cm H(2)O for BNP ≥500 pg/ml were calculated. The product moment correlation coefficient between US-JVD and BNP was also calculated. RESULTS: 119 patients were included in the initial study. US-JVD ≥8 cm H(2)O had a sensitivity of 100% (95% CI 92% to 100%), specificity of 43% (95% CI 31% to 56%), PPV of 61% (95% CI 50% to 71%), NPV of 100% (95% CI 84% to 100%), LR+=1.75 (95% CI 1.41 to 2.17), and LR-=0 for a BNP ≥ 500 pg/ml. The Pearson correlation coefficient between US-JVD and BNP was 0.35 (95% CI 0.18 to 0.50) and the Spearman correlation coefficient was 0.73 (95% CI 0.63 to 0.80), suggesting a monotonic, but non-linear relationship between US-JVD and BNP. CONCLUSION: US-JVD correlates with initial BNP levels and is a sensitive test for raised BNP levels in patients with dyspnoea due to suspected congestive cardiac failure.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department.

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

Jugular venous distension on ultrasound: sensitivity and specificity for heart failure in patients with dyspnea.

BACKGROUND: Accurately diagnosing congestive heart failure (CHF) in patients with dyspnea can be difficult because clinical history and physical examination are often nondiagnostic and may be inaccurate, especially when patients have complicated comorbid conditions. OBJECTIVE: To prospectively assess jugular venous distension on ultrasound (JVD-US) performed by emergency physicians for identifying CHF on echocardiography by the department of cardiology (C-ECHO) in patients with dyspnea. MEASUREMENTS: This was a secondary analysis of a previously collected data set from a prospective study of JVD-US in ED patients with dyspnea due to suspected CHF. C-ECHO results were obtained and used as the criterion standard. RESULTS: Jugular venous distension on ultrasound had a sensitivity of 99% (95% confidence interval [CI], 92.2%-100%), specificity of 59% (95% CI, 40.9%-74.4%), positive likelihood ratio of 2.4 (95% CI, 1.6-3.6), and negative likelihood ratio of 0.01 (95% CI, 0.0007-0.20) for identifying CHF on C-ECHO in patients with dyspnea. CONCLUSION: This initial study suggests that JVD-US by emergency physicians is predictive of CHF using echocardiography performed by the department of cardiology as the criterion standard.

Bedside ultrasonography for the detection of small bowel obstruction in the emergency department.

BACKGROUND: Plain film radiography (x-ray) is often the initial study in patients with suspected small bowel obstruction (SBO) to expedite patient care. OBJECTIVE: To compare bedside ultrasonography (US) and x-ray for the detection of SBO. METHODS: This was a prospective study using a convenience sample of patients presenting to the emergency department (ED) with abdominal pain, vomiting, or other symptoms suggestive of a SBO. Patients were evaluated with US prior to x-ray and CT. US was performed by emergency physicians (EPs) who completed a 10 min training module and five prior US exams for SBO. The criterion standard for the diagnosis of SBO was the results of CT read by board-certified radiologists. RESULTS: In all, 76 patients were enrolled and evaluated with US for SBO. A total of 33 (43%) were diagnosed as having SBO. Dilated bowel on US had a sensitivity of 91% (95% CI 75 to 98%) and specificity of 84% (95% CI 69 to 93%) for SBO, compared to 27% (95% CI 14 to 46%) and 98% (95% CI 86 to 100%) for decreased bowel peristalsis on US. X-ray had a sensitivity of 46.2% (95% CI 20.4 to 73.9%) and specificity of 66.7% (95% CI 48.9 to 80.9%) for SBO when diagnostic, but was non-diagnostic 36% of the time. CONCLUSION: EP-performed US compares favourably to x-ray in the diagnosis of SBO.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021.

OBJECTIVES: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. METHODS: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. RESULTS: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). CONCLUSION: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department.

STUDY OBJECTIVE: Compression ultrasonography of the lower extremity is an established method of detecting proximal lower extremity deep venous thrombosis when performed by a certified operator in a vascular laboratory. Our objective is to determine the sensitivity and specificity of bedside 2-point compression ultrasonography performed in the emergency department (ED) with portable vascular ultrasonography for the detection of proximal lower extremity deep venous thrombosis. We did this by directly comparing emergency physician-performed ultrasonography to lower extremity duplex ultrasonography performed by the Department of Radiology. METHODS: This was a prospective, cross-sectional study and diagnostic test assessment of a convenience sample of ED patients with a suspected lower extremity deep venous thrombosis, conducted at a single-center, urban, academic ED. All physicians had a 10-minute training session before enrolling patients. ED compression ultrasonography occurred before Department of Radiology ultrasonography and involved identification of 2 specific points: the common femoral and popliteal vessels, with subsequent compression of the common femoral and popliteal veins. The study result was considered positive for proximal lower extremity deep venous thrombosis if either vein was incompressible or a thrombus was visualized. Sensitivity and specificity were calculated with the final radiologist interpretation of the Department of Radiology ultrasonography as the criterion standard. RESULTS: A total of 47 physicians performed 199 2-point compression ultrasonographic examinations in the ED. Median number of examinations per physician was 2 (range 1 to 29 examinations; interquartile range 1 to 5 examinations). There were 45 proximal lower extremity deep venous thromboses observed on Department of Radiology evaluation, all correctly identified by ED 2-point compression ultrasonography. The 153 patients without proximal lower extremity deep venous thrombosis all had a negative ED compression ultrasonographic result. One patient with a negative Department of Radiology ultrasonographic result was found to have decreased compression of the popliteal vein on ED compression ultrasonography, giving a single false-positive result, yet repeated ultrasonography by the Department of Radiology 1 week later showed a popliteal deep venous thrombosis. The sensitivity and specificity of ED 2-point compression ultrasonography for deep venous thrombosis were 100% (95% confidence interval 92% to 100%) and 99% (95% confidence interval 96% to 100%), respectively. CONCLUSION: Emergency physician-performed 2-point compression ultrasonography of the lower extremity with a portable vascular ultrasonographic machine, conducted in the ED by this physician group and in this patient sample, accurately identified the presence and absence of proximal lower extremity deep venous thrombosis.

Learning curve of emergency physicians using emergency bedside sonography for symptomatic first-trimester pregnancy.

OBJECTIVE: The purpose of this study was to prospectively assess the learning curve of emergency physician training in emergency bedside sonography (EBS) for first-trimester pregnancy complications. METHODS: This was a prospective study at an urban academic emergency department from August 1999 through July 2006. Patients with first-trimester vaginal bleeding or pain underwent EBS followed by pelvic sonography (PS) by the Department of Radiology. Results of EBS were compared with those of PS using a predesigned standardized data sheet. RESULTS: A total of 670 patients underwent EBS for first-trimester pregnancy complications by 1 of 25 physicians who would go on to perform at least 25 examinations. The sensitivity and specificity of EBS for an intrauterine pregnancy increased from 80% (95% confidence interval [CI], 71%-87%) and 86% (95% CI, 76%-93%), respectively, for a physician's first 10 examinations to 100% (95% CI, 73%-100%) and 100% (95% CI, 63%-100%) for those performed after 40 examinations. Likewise, the sensitivity and specificity for an adnexal mass or ectopic pregnancy changed from 43% (95% CI, 28%-64%) and 94% (95% CI, 89%-97%) to 75% (95% CI, 22%-99%) and 89% (95% CI, 65%-98%), whereas the sensitivity and specificity for a molar pregnancy changed from 71% (95% CI, 30%-95%) and 98% (95% CI, 94%-99%) to 100% (95% CI, 20%-100%) and 100% (95% CI, 81%-100%). Although detection of an intrauterine or a molar pregnancy improved with training, even with experience including 40 examinations, the sensitivity of EBS for an adnexal mass or ectopic pregnancy was less than 90%. CONCLUSIONS: There is an appreciable learning curve among physicians learning to perform EBS for first-trimester pregnancy complications that persists past 40 examinations.