Diagnostic value of pulsed wave doppler in pneumothorax: a prospective study.

BACKGROUND: The diagnosis of pneumothorax is usually made through clinical examination and radiography. Pulsed wave (PW) Doppler mode has not previously been used in the diagnosis of pneumothorax on chest USG. AIMS: The aim of this study is to present, for the first time, a new finding demonstrating pleural movements using PW Doppler mode and to examine the value of the new sonographic finding in the diagnosis of pneumothorax. METHODS: We investigated the presence of PW artifact in patients with and without pneumothorax using the high-frequency probe in PW Doppler. The Dogan's sign, defined as the absence of PW artifact, was then compared with lung sliding and the barcode sign in pulsed wave Doppler for the diagnosis of pneumothorax. RESULTS: Of the 141 patients, 39 were in the pneumothorax group. The sensitivity and specificity of the Dogan's sign in the diagnosis of pneumothorax were 95.12% and 99.3%, respectively, in this study. The sensitivity and specificity of lung sliding were 95.12% and 98.08%, respectively; the sensitivity and specificity of the barcode sign were 92.86% and 98.08%, respectively, in the diagnosis of pneumothorax by ultrasonography in this study. CONCLUSION: PW Doppler is a useful tool in the diagnosis of pneumothorax. It has a high sensitivity and specificity for the detection of pneumothorax. It is also superior to both lung sliding and the barcode sign in detecting pneumothorax. The Dogan's sign can be used safely in the diagnosis of pneumothorax, together with lung sliding and the barcode sign.

Cervical sliding sign at second trimester in the prediction of early preterm birth in twin pregnancy.

OBJECTIVE: To examine the cervical sliding sign (CSS) alongside cervical length (CL) in twin pregnancies to predict preterm birth (PB). METHODS: Twin pregnancies (n = 37) with no known risk factor for PB were included in this prospective study. CSS was defined as the ultrasonographic finding in which the anterior lip of the cervix slides over the posterior lip with gentle and continuous pressure application. The CSS and CL measurements were held in the second trimester. Early PB was defined as the birth of the fetus before 32 weeks of gestation. The patients were divided into two groups as CSS-positive and CSS-negative. RESULTS: Whereas 11 (29.7%) of the twin pregnancies were CSS-positive, 26 (70.3%) were CSS-negative. CSS positivity had a sensitivity of 75.0%, a specificity of 82.2%, a positive predictive value of 54.5%, and a negative predictive value of 92.3% to predict early PB. Multivariate logistic regression analysis revealed that CSS positivity was the only significant independent factor related to early PB. CONCLUSION: CSS was shown to be superior to CL in providing a better insight to predict early PB. CSS evaluation should be performed in twin pregnancies.

Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study.

BACKGROUND: To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions. METHODS: This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery. RESULTS: Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0 years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002). CONCLUSIONS: Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.

CAR Practice Statement on Advanced Pelvic Ultrasound for Endometriosis.

The Canadian Association of Radiologists (CAR) Endometriosis Working Group was tasked with providing guidance and benchmarks to ensure the quality of technique and interpretation for advanced imaging modalities associated with diagnosing endometriosis. This practice statement provides an overview of the state of the art of advanced pelvic ultrasound in the diagnosis and mapping of pelvic endometriosis. While acknowledging that advanced pelvic ultrasound in some practices falls within the scope of clinical colleagues rather than imaging departments, the statement seeks to guide radiologists interested in implementing these techniques into their practice for patients referred for evaluation and diagnosis of endometriosis. The statement covers indications, some components of the ultrasound assessment and technique, reporting, and recommendations for starting an ultrasound endometriosis evaluation program.

Role of cervical sliding sign in predicting preterm delivery in pregnancies complicated with preterm premature rupture of membranes.

OBJECTIVE: To investigate the effect of cervical sliding sign (CSS) to predict preterm delivery in patients with premature rupture of membranes. METHODS: This prospective cohort study included 88 pregnant women between 240/7 and 366/7  weeks of gestation who were complicated with preterm premature rupture of membranes (PPROM) between June 2020 and January 2022. We measured the cervical length (CL) and applied pressure to the anterior fornix of the cervix with the transvaginal probe to investigate the CSS, which is defined as the sliding of the anterior lip of the cervix on the posterior lip. RESULTS: The time between PPROM and delivery was significantly shorter in the CSS+ group (P < 0.001). Receiver operating characteristic curve analysis was performed for CSS with regard to predicting delivery within 7 days following PPROM (area under the curve, 0.749 [95% confidence interval, 0.642-0.857], P < 0.001). On logistic regression analysis, CL <25 mm increased the predictive accuracy of delivery within 7 days following PPROM 1.91-fold, and CSS increased the predictive accuracy of delivery within 7 days following PPROM 10.71-fold. CONCLUSION: CSS is an effective sonographic marker in predicting preterm delivery and provides better information of oncoming preterm delivery in patients with PPROM than CL measurement.

The use of ultrasound sliding sign for prediction of adhesions in women undergoing repeated caesarean section.

We carried out this study to validate the use of ultrasound sliding sign to predict intraperitoneal adhesions in women undergoing repeated caesarean section (CS). A cross-section study was performed in women with at least one CS scheduled for an elective CS. We used the sliding sign of the uterus against the anterior abdominal wall to assess intraperitoneal adhesions, positive sliding sign if uterus moved freely and a negative sliding sign if limited mobility. The obstetrician was blind to the ultrasound results, asked to report if adhesions were absent or present during CS to validate accuracy of the sliding sign. We examined 120 women, negative sliding was reported in 54 patients, positive sliding in 66 women. The presence of intra-abdominal adhesions was confirmed in 44/54 cases assigned to the high-risk group, while the prediction of low risk for adhesions confirmed in 66/66 patients with a sensitivity of 100%, specificity of 86.84%. Sliding sign is an effective method to detect intra-abdominal adhesions in women with a history of repeated caesarean delivery.Impact statementWhat is already known on this subject? There has been a dramatic increase in the caesarean section (CS) rate worldwide; repeated CSs may be associated with intraperitoneal adhesions that result in difficulty during the procedure and may be related to bowel or bladder injuries and neonatal morbidities.What do the results of this study add? The sliding sign by ultrasound has a sensitivity of 100%, specificity of 86.84%, a positive predictive value of 81.5, a negative predictive value of 100, and accuracy of 91.67, considering it rapid, easy and reliable method for prediction of intraperitoneal adhesions.What are the implications of these findings for clinical practice and/or future research? The use of sliding sign by ultrasound in cases with repeated CSs offers a good predictor tool for presence of intraperitoneal adhesions and subsequently avoid severe sequels during surgery and good preparation.

Preoperative sonographic sliding sign for prediction of intra-abdominal adhesions before repeat cesarean delivery.

OBJECTIVE: To evaluate the usefulness of the uterine sliding sign for predicting intra-abdominal adhesions in women undergoing repeat cesarean section (CS) and the association of the sliding sign with other operative and neonatal outcomes. METHODS: A prospective cohort study was conducted among pregnant women with at least one previous CS. Transabdominal ultrasonography was performed and classified as a positive or negative sliding sign. Surgeons blinded to the sonographic results assessed intra-abdominal adhesions. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Operative and neonatal outcomes of the positive and negative sliding sign groups were compared. Factors associated with intraoperative adhesions were also analyzed. RESULTS: A total of 380 women were recruited. The sensitivity and specificity of the uterine sliding sign to detect moderate-to-thick adhesions were 60.6% and 91.9%, respectively. A negative sliding sign was significantly associated with a higher incidence of adhesions, longer skin-to-delivery time, longer total operative time, and lower 5-min APGAR score in newborns. A negative sliding sign and history of two or more previous CS were significant predictors of moderate-to-thick adhesions. CONCLUSION: The uterine sliding sign is an independent predictor of intraoperative adhesions, with acceptable sensitivity and high specificity and negative predictive value.

Cervical strain elastography: pattern analysis and cervical sliding sign in preterm and control pregnancies.

OBJECTIVES: The aim of this study was to assess the value of cervical strain elastography and Cervical Sliding Sign (CSS) for predicting spontaneous preterm birth (sPTB). METHODS: In our case-control study we performed an elastographic assessment of the cervix in 82 cases of preterm birth (preterm group) and 451 control pregnancies (control group) between the 20th and 37th week of gestation. We divided the anterior cervical lip first into two ("Intern2", "Extern2") and into three sectors ("Intern3", "Middle3", "Extern3"). The tissue deformation pattern after local compression with an ultrasound probe was recorded. We distinguished between an irregularly distributed ("Spotting") and homogeneous pattern presentation. Additionally, the presence of a sliding of the anterior against the posterior cervical lip (positive CSS) during compression was evaluated. A logistic regression analysis and the Akaike Information Criterion (AIC) were used to estimate the probability of sPTB and to select a prediction model. RESULTS: Spotting and positive CSS occurred more frequently in the preterm group compared to control group (97.8 vs. 2.2%, p<0.001; 26.8 vs. 4.2%, p<0.001; respectively). The model with the parameters week of gestation at ultrasound examination, Intern3, Middle3 and CSS was calculated as the highest quality model for predicting sPTB. The AUC (Area Under the Curve) was higher for this parameter combination compared to cervical length (CL) (0.926 vs. 0.729). CONCLUSIONS: Cervical strain elastography pattern analysis may be useful for the prediction of sPTB, as the combination of Spotting analysis and CSS is superior to CL measurement alone.

Prediction of Intraperitoneal Adhesions in Repeated Cesarean Section Using Sliding Sign, Striae Gravidarum, and Cesarean Scar.

Background: Intraabdominal adhesions are associated with an increase in complications during cesarean section because of recurrent cesarean sections. This is why the possibility of predicting adhesions is important. In this study, the diagnostic value of depressed scar, severe striae gravidarum, and negative sliding sign, and their combinations were evaluated for predicting intraabdominal adhesions of cesarean candidates. Methods: This prospective descriptive study was performed during 2019-2020 on 123 pregnant women referred to Ayatollah Taleghani university hospital with a gestational age of ≥36 weeks 0 days who were candidates for cesarean section because of a previous cesarean section. In each patient, the presence of a depressed scar, a severe striae gravidarum, the absence of a sliding sign, and the presence and severity of adhesions during the operation were examined. Sensitivity and specificity, and positive and negative predictive values of each of the 3 indicators and their combinations were calculated. Results: The frequency distribution of severe adhesion in these individuals was 16.27%. The highest sensitivity was related to depressed scar and negative sliding sign (65%). The highest specificity was related to the negative sliding sign and its combinations (97%-99%). The highest positive predictive value was related to negative sign sliding and its combinations (81%-92%). The negative predictive values of depressed scar, negative sliding sign, and severe striae gravidarum, and even their combinations were almost the same and approximately between 89% and 93%. Conclusion: To predict the presence of adhesions in a cesarean candidate because of a previous cesarean section, you should first examine the striae gravidarum and scar. In the absence of a depressed scar and severe striae gravidarum, there is a 90% chance of no adhesions. According to this study, if both signs are present, it is recommended to check the sliding sign to obtain a more accurate estimate.

Point-of-care ultrasound to confirm the position of bronchial blockers in children.

PURPOSE: We described the accuracy of ultrasound in determining the position of bronchial blockers (BBs) in children underwent thoracoscopic surgery. METHODS: We enrolled 52 children with ASA grade I-III who received thoracoscopic surgery with placement of BBs. Point-of-care ultrasound was performed according to the BLUE protocol. The ultrasound-guided lung sliding sign and curtain sign were used to assess the position of BBs. The accuracy of ultrasound in evaluating the position of BBs, as well as the accuracy and operating time of sliding sign and curtain sign at each examination point were recorded and compared. RESULTS: The accuracy of ultrasound in evaluating the position of BBs was 88% (46/52, 95% CI 0.69-0.97). When using the curtain sign to assess the position of BBs, the accuracy was 90% (94/104, 95% CI 0.78-0.96), which was significantly higher than when using the sliding sign (65% (136/208), 95% CI 0.55-0.74) (p = 0.002). The accuracy of curtain sign at the left mid-axillary line-diaphragm and the right mid-axillary line-diaphragm was respectively 96% (50/52, 95% CI 0.80-0.99) and 84% (44/52, 95% CI 0.65-0.95), which were higher than that of sliding sign at upper blue points and lower blue points. There was no significant difference in the operating time between two ultrasound signs (the curtain sign, 13.4 ± 8.2 s vs. the lung sliding sign, 16.2 ± 10.0 s, p = 0.065). CONCLUSION: Point-of-care ultrasound can effectively assess the position of BBs. The accuracy of using the curtain sign at the mid-axillary line-diaphragm is higher than that of using the lung sliding sign at the anterior chest wall.

Diagnostic accuracy of transvaginal ultrasound for detection of endometriosis using International Deep Endometriosis Analysis (IDEA) approach: prospective international pilot study.

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in predicting deep endometriosis (DE) following the International Deep Endometriosis Analysis (IDEA) consensus methodology. METHODS: This was an international multicenter prospective diagnostic accuracy study involving eight centers across six countries (August 2018-November 2019). Consecutive participants with endometriosis suspected based on clinical symptoms or historical diagnosis of endometriosis were included. The index test was TVS performed preoperatively in accordance with the IDEA consensus statement. At each center, the index test was interpreted by a single sonologist. Reference standards were: (1) direct visualization of endometriosis at laparoscopy, as determined by a non-blinded surgeon with expertise in endometriosis surgery; and (2) histological assessment of biopsied/excised tissue. Surgery was performed within 12 months following the index TVS. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios (LR+ and LR-) of TVS in the diagnosis of DE were calculated. RESULTS: Included in the study were 273 participants with complete clinical, TVS, laparoscopic and histological data. Of these, based on histology, 256 (93.8%) were confirmed to have endometriosis, including superficial endometriosis, and 190 (69.6%) were confirmed to have DE. Based on surgical visualization, 207/273 (75.8%) patients had DE. For DE overall, the diagnostic performance of TVS based on surgical visualization as the reference standard was as follows: accuracy, 86.1%; sensitivity, 88.4%; specificity, 78.8%; PPV, 92.9%; NPV, 68.4%; LR+, 4.17; LR-, 0.15, and the diagnostic performance of TVS based on histology as the reference standard was as follows: accuracy, 85.9%; sensitivity, 89.8%; specificity, 75.9%; PPV, 90.4%; NPV, 74.6%; LR+, 3.72; LR-, 0.13. CONCLUSIONS: Using the IDEA consensus methodology provides strong diagnostic accuracy for TVS assessment of DE. We found a higher TVS detection rate of DE overall than that reported by the most recent meta-analysis on the topic (sensitivity, 79%), albeit with a lower specificity. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic accuracy of sliding sign for detecting pouch of Douglas obliteration and bowel involvement in women with suspected endometriosis: systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of the sliding sign on transvaginal ultrasound (TVS) in detecting pouch of Douglas obliteration and bowel involvement in patients with suspected endometriosis, using laparoscopy as the reference standard. METHODS: A search for studies evaluating the role of the sliding sign in the assessment of pouch of Douglas obliteration and/or bowel involvement using laparoscopy as the reference standard published from January 2000 to October 2021 was performed in PubMed/MEDLINE, Web of Science, CINAHL, The Cochrane Library, ClinicalTrials.gov and SCOPUS databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to evaluate the quality of the studies. Analyses were performed using MIDAS and METANDI commands in STATA. RESULTS: A total of 334 citations were identified. Eight studies were included in the analysis, resulting in 938 and 963 patients available for analysis of the diagnostic accuracy of the sliding sign for pouch of Douglas obliteration and bowel involvement, respectively. The mean prevalence of pouch of Douglas obliteration was 37% and the mean prevalence of bowel involvement was 23%. The pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the sliding sign on TVS for detecting pouch of Douglas obliteration were 88% (95% CI, 81-93%), 94% (95% CI, 91-96%), 15.3 (95% CI, 10.2-22.9), 0.12 (95% CI, 0.07-0.21) and 123 (95% CI, 62-244), respectively. The heterogeneity was moderate for sensitivity and low for specificity for detecting pouch of Douglas obliteration. The pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the sliding sign on TVS for detecting bowel involvement were 81% (95% CI, 64-91%), 95% (95% CI, 91-97%), 16.0 (95% CI, 9.0-28.6), 0.20 (95% CI, 0.10-0.40) and 81 (95% CI, 34-191), respectively. The heterogeneity for the meta-analysis of diagnostic accuracy for bowel involvement was high. CONCLUSION: The sliding sign on TVS has good diagnostic performance for predicting pouch of Douglas obliteration and bowel involvement in women with suspected endometriosis. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Spiders and mushrooms: Reporting bowel endometriosis shape on preoperative MRI to flag surgical complexity.

INTRODUCTION: Preoperative imaging of patients with endometriosis allows adequate counselling, referral to appropriate centres of expertise and workforce planning. The objective of this study was to assess the feasibility of simplified three-category preoperative endometriosis MRI morphological descriptors to predict subsequent surgical management. METHODS: A single-centre observational study in 76 patients (median age 38 years, range 18-55) with preoperative endometriosis mapping MRI between 1 Jan 2015 and 31 Dec 2019. MRI studies were prospectively re-read blind-to-surgical outcome to categorise rectosigmoid morphology as normal, spider-shaped (linear T2-dark fibrotic bands) superficial endometriosis or typical crescentic or mushroom-shaped deep infiltrating endometriosis (DIE). Bowel motility was similarly categorised as normal, tethered or distorted/fixed. The reference standard was subsequent surgery within 3 years of MRI, categorised as no bowel surgery, adhesiolysis only or more complex surgeries. RESULTS: Despite three-quarters of surgical cases having normal bowel morphology on preoperative MRI (72%, 55/76; 12% linear superficial endometriosis, 10% crescentic and 5% mushroom-shaped DIE) more than half showed bowel tethering (54%, 41/76) or distortion/fixation (10%, 8/76) and most patients underwent adhesiolysis (79%, 60/76). Complex surgery such as bowel resection, laparotomy conversion or complex adhesiolysis is predicted by morphology (crescentic or mushroom-shaped DIE, P < 0.001) and motility (tethered or distorted bowel, P = 0.002) descriptors. CONCLUSIONS: Comprehensive and clinically relevant diagnostic reporting does not have to be convoluted to have clinical impact: in our study population, categorising bowel morphology as normal, spider-shaped (superficial) or crescentic/mushroom-(DIE) shaped and motility as normal, tethered (superficial) or distorted/fixed (deep endometriosis) correlates to subsequent surgical complexity.

MRI sliding sign: Using MRI to assess rectouterine mobility in pelvic endometriosis.

INTRODUCTION: Surgical excision of deep infiltrating endometriosis (DIE) is complex and associated with morbidity. Diagnostic imaging plays an important role in the preoperative workup. We sought to determine the utility of single sagittal T2-weighted MRI motion sequence in the preoperative assessment of pelvic mobility in patients with endometriosis. METHODS: An observational study at a single tertiary public referral centre in Australia. Eighty-one MRI studies from 1 May 2019 to 3 December 2019, were enrolled. Studies were included if they were performed to stage endometriosis, including a T2-weighted motion series, adequately covering a uterus, cervix and rectum. Fifty-seven studies met inclusion criteria. The reference standard was a contemporaneous transvaginal ultrasound (TVUS) reporting on pelvic organ mobility. Three subspecialist radiologists were then blindly asked to identify, on the cine loop: rectouterine immobility, superficial endometriosis (pelvic bowel adhesions), rectosigmoid Deep Infiltrating Endometriosis (DIE). Fleiss' Kappa assessed interobserver agreement. Consensus MRI sensitivity and specificity were estimated against the reference standard (TVUS). RESULTS: Median age was 35 years (range 19-51). Forty-three cases had a contemporaneous TVUS; 14 reporting a sliding sign, 29 with fixed pelves. Interobserver agreement was 'substantial' (k = 0.79) for absent MRI sliding sign and 'almost perfect' (k = 0.90) for absence of DIE. Consensus MRI had 90% sensitivity (95% CI 73-98%) for pelvic immobility at TVUS (absent sliding sign). Interobserver agreement and consensus MRI sensitivity were higher for adhesions and immobility than normal findings. CONCLUSION: An MRI motion sequence can identify patients with pelvic adhesions and immobility, helping determine surgical difficulty when TVUS is not diagnostic.

Predicting Intra-abdominal Adhesions for Repeat Cesarean Delivery with the Ultrasound Sliding Sign.

OBJECTIVE: To evaluate the diagnostic value of the "sliding sign", a sonographic test, in predicting intra-abdominal adhesions for women undergoing repeat cesarean delivery. METHODS: This was a prospective observational study of women undergoing a scheduled repeat cesarean delivery at a regional hospital. The sliding sign is a sonographic observation of sliding movement between the uterus and the abdominal wall during deep breathing. The absence of the sliding sign was considered indicative of a high risk for dense uterine-abdominal adhesions, and this finding was compared with the operative findings. The primary outcome was the accuracy of the sliding sign in predicting adhesions. Secondary outcomes included incision-to-delivery time, operative time, and blood loss. RESULTS: We examined 112 pregnant women. Dense uterine-abdominal adhesions were found in 15 women, 8 of whom had no sliding sign identified on ultrasound. Therefore, the presence of the sliding sign detected 78 out of 97 women without uterine-abdominal adhesions. The sensitivity, specificity, and positive and negative predictive values of the sliding sign were 53.3%, 80.4%, 29.6%, and 91.8%, respectively. The intra- and inter-observer reliability using the kappa coefficient showed moderate consistency at 0.43 and 0.45, respectively. CONCLUSION: The sliding sign was less predictive than desired for clinical use, and it only detected half of the women with dense uterine-abdominal adhesions. Furthermore, a moderately low kappa coefficient indicates a lack of reproducibility, further emphasizing the sign's limited clinical value.

Deep learning to diagnose pouch of Douglas obliteration with ultrasound sliding sign.

OBJECTIVES: Pouch of Douglas (POD) obliteration is a severe consequence of inflammation in the pelvis, often seen in patients with endometriosis. The sliding sign is a dynamic transvaginal ultrasound (TVS) test that can diagnose POD obliteration. We aimed to develop a deep learning (DL) model to automatically classify the state of the POD using recorded videos depicting the sliding sign test. METHODS: Two expert sonologists performed, interpreted, and recorded videos of consecutive patients from September 2018 to April 2020. The sliding sign was classified as positive (i.e. normal) or negative (i.e. abnormal; POD obliteration). A DL model based on a temporal residual network was prospectively trained with a dataset of TVS videos. The model was tested on an independent test set and its diagnostic accuracy including area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, and positive and negative predictive value (PPV/NPV) was compared to the reference standard sonologist classification (positive or negative sliding sign). RESULTS: In a dataset consisting of 749 videos, a positive sliding sign was depicted in 646 (86.2%) videos, whereas 103 (13.8%) videos depicted a negative sliding sign. The dataset was split into training (414 videos), validation (139), and testing (196) maintaining similar positive/negative proportions. When applied to the test dataset using a threshold of 0.9, the model achieved: AUC 96.5% (95% CI: 90.8-100.0%), an accuracy of 88.8% (95% CI: 83.5-92.8%), sensitivity of 88.6% (95% CI: 83.0-92.9%), specificity of 90.0% (95% CI: 68.3-98.8%), a PPV of 98.7% (95% CI: 95.4-99.7%), and an NPV of 47.7% (95% CI: 36.8-58.2%). CONCLUSIONS: We have developed an accurate DL model for the prediction of the TVS-based sliding sign classification. LAY SUMMARY: Endometriosis is a disease that affects females. It can cause very severe scarring inside the body, especially in the pelvis - called the pouch of Douglas (POD). An ultrasound test called the 'sliding sign' can diagnose POD scarring. In our study, we provided input to a computer on how to interpret the sliding sign and determine whether there was POD scarring or not. This is a type of artificial intelligence called deep learning (DL). For this purpose, two expert ultrasound specialists recorded 749 videos of the sliding sign. Most of them (646) were normal and 103 showed POD scarring. In order for the computer to interpret, both normal and abnormal videos were required. After providing the necessary inputs to the computer, the DL model was very accurate (almost nine out of every ten videos was correctly determined by the DL model). In conclusion, we have developed an artificial intelligence that can interpret ultrasound videos of the sliding sign that show POD scarring that is almost as accurate as the ultrasound specialists. We believe this could help increase the knowledge on POD scarring in people with endometriosis.

Negative Sliding Sign during Dynamic Ultrasonography Predicts Low Endometriosis Fertility Index at Laparoscopy.

STUDY OBJECTIVE: Endometriosis fertility index (EFI) is a robust tool to predict the pregnancy rate in patients with endometriosis who are attempting non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Newly established imaging techniques such as sliding sign, which is used to diagnose pouch of Douglas obliteration, could provide a promising alternative. The objective of this study was to investigate the practicality of using ultrasound data to predict a low EFI (score ≤6). DESIGN: Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort, clinicaltrials.gov #NCT02911090). Analyzed data were captured from December 2013 to June 2017. SETTING: Tertiary referral center at British Columbia Women's Hospital. PATIENTS: We analyzed data for 2583 participants from the Endometriosis Pelvic Pain Interdisciplinary Cohort. In this cross-sectional study, we included 86 women aged <40 years. INTERVENTIONS: Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Logistic regression was used to obtain receiver operating characteristic area under the curve (AUC) for the prediction models. Significance was p <.05. Patients with a negative sliding sign were older and had severe endometriosis and longer duration of infertility. Patients with a negative sliding sign had significantly lower total EFI scores and lower surgical factors scores than patients with a positive sliding sign. Logistic regression showed that a negative sliding sign and EFI historic factors score can predict an EFI score ≤6 (sensitivity = 87.9%, specificity = 81.1%, AUC = 0.93 [95% confidence interval, 0.88-0.98]). Adding the diagnosis of endometrioma to the previous prediction model resulted in AUC = 0.95 (95% confidence interval, 0.90-0.995), sensitivity = 84.8%, and specificity = 92.5%. CONCLUSION: The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historic factors and the diagnosis of endometrioma to predict an EFI score ≤6 for patients who are not scheduled for immediate surgery.

The use of ultrasound to locate a tethered surgical drain: a novel way to achieve fast removal.

BACKGROUND: It is rare that drains cannot be removed after surgery, however, this situation cannot be completely avoided, and is also hard to deal with. The main reason for a tethered drain is inadvertent suture fixation. At present, no effective way was published or widely accepted to locate the tethered drain. METHODS: Three cases of orthopedic trauma patients experienced unsuccessful removal of the drain after surgery. The ultrasound was used to locate the sutured site of the drain. Based on the sliding sign and vanishing point which can be detected by the ultrasound, the sutured site of the drain can be clearly identified. Finally, the suture was loosened through a small incision, and the drain was completely removed. RESULTS: The surgical procedure was very successful in all patients. The tethered drain was quickly and completely removed through a small incision with locating by ultrasound. Intravenous antibiotics were administered within 24 h after surgery, and no wound or deep infections occurred. CONCLUSIONS: Ultrasound can be used to locate a tethered drain based on the sliding sign. This method can simplify the release procedure and achieve fast removal of the drain. Furthermore, it will help lower the risk of a retained drain and soft tissue complications.

Sliding Sign and Gel Sonovaginography: A Sneak Peek Prior to Laparoscopy in Patients with Endometriosis.

CONTEXT: The rising incidence of endometriosis may be due to improvisation in the diagnostic techniques. Transvaginal sonography has proven to be very useful in the diagnosis of complexity of the disease and in turn to predict the intraoperative findings on laparoscopy. AIMS: The aim was to study the use of sliding sign for detecting the status of the pouch of Douglas (POD) and to check for the presence of bowel and nonbowel deep infiltrating endometriosis (DIE) by gel sonovaginography. SETTINGS AND DESIGN: This is a prospective observational study carried out patient division of Department of OBG in Kasturba Hospital Manipal. METHODS: The study was carried out over a period of 2 years and included 136 women. After written informed consent, a detailed history and clinical examination was done. A detailed transvaginal sonography was done for each of the patients by a single observer on the Philips HD11XE machine two-dimensional transvaginal probe which included gel sonovaginography and real-time dynamic test called sliding sign. STATISTICAL ANALYSIS: Chi-square test was used in this study. RESULTS: Sliding sign is highly specific, sensitive, and accurate for the detection of POD obliteration. It is 96.6% sensitive and 89.5% specific. It is 94.1% accurate and 94.5% positively predictive for the same. Transvaginal sonography is >92% specific for the detection of bowel and nonbowel DIE. The accuracy is over 91%. The negative predictability is 93.6% and 94.6%, respectively. CONCLUSIONS: Sliding sign is a useful, easy-to-perform, reproducible, and noninvasive modality for assessing the status of POD. Gel sonovaginography is also useful in accurately detecting the presence of deep infiltrating endometriotic deposits.

One-Size-Fits-All Approach Does Not Work for Gynecology Trainees Learning Endometriosis Ultrasound Skills.

OBJECTIVES: To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations. METHODS: We performed a prospective study between December 2017 and December 2018. Three fellows (F1-F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. RESULTS: A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%-94%). The overall accuracy of POD state classification was 93% (range, 90%-96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans. CONCLUSIONS: Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.