Thoracic ultrasound combined with low-dose computed tomography may represent useful screening strategy in highly exposed population in the industrial city of Taranto (Italy).

Objectives: We validated a screening protocol in which thoracic ultrasound (TUS) acts as a first-line complementary imaging technique in selecting patients which may deserve a second-line low-dose high resolution computed tomography (HRCT) scan among a population of asymptomatic high-risk subjects for interstitial lung abnormalities (ILA) and lung cancer. Due to heavy environmental pollution burden, the district Tamburi of Taranto has been chosen as "case study" for this purpose. Methods: From July 2018 to October 2020, 677 patients aged between 45 and 65 year and who had been living in the Tamburi district of Taranto for at least 10 years were included in the study. After demographic, clinical and risk factor exposition data were collected, each participant underwent a complete TUS examination. These subjects were then asked to know if they agreed to perform a second-level examination by low-dose HRCT scan. Results: On a total of 167 subjects (24.7%) who agreed to undergo a second-level HRCT, 85 patients (50.9%) actually showed pleuro-pulmonary abnormalities. Interstitial abnormalities were detected in a total of 36 patients on HRCT scan. In particular, 34 participants presented subpleural ILAs, that were classified in the fibrotic subtype in 7 cases. The remaining 2 patients showed non-subpleural interstitial abnormalities. Subpleural nodules were observed in 46 patients. TUS showed an overall diagnostic accuracy of 88.6% in detecting pleuro-pulmonary abnormalities in comparison with HRCT scan, with a sensitivity of 95.3%, a specificity of 81.7%, a positive predictive value of 84.4% and a negative predictive value of 94.4%. The matched evaluation of specific pulmonary abnormalities on HRTC scan (i.e., interstitial abnormalities or pulmonary nodules) with determinate sonographic findings revealed a reduction in both TUS sensibility and specificity. Focusing TUS evaluation on the assessment of interstitial abnormalities, a thickened pleural line showed a sensitivity of 63.9% and a specificity of 69.5%, hypoechoic striae showed a sensitivity of 38.9% and a specificity of 90.1% and subpleural nodules showed a sensitivity of 58.3% and a specificity of 77.1%. Regarding to the assessment of subpleural nodules, TUS showed a sensitivity of 60.9% and a specificity of 81.0%. However, the combined employment of TUS examination and HRCT scans allowed to identify 34 patients with early subpleural ILA and to detect three suspicious pulmonary nodules (of which two were intraparenchymal and one was a large subpleural mass), which revealed to be lung cancers on further investigations. Conclusion: A first-line TUS examination might aid the identification of subjects highly exposed to environmental pollution, who could benefit of a second-line low-dose HRCT scan to find early interstitial lung diseases as well as lung cancer. Protocol registration code: PLEURO-SCREENING-V1.0_15 Feb, 17.

Caseous Calcification of the Mitral Valve.

Teaching Point: Caseous calcification of the mitral annulus is a benign mass-like lesion which can mimic cardiac tumor or abscess; therefore, multimodal imaging should be considered, avoiding unnecessary interventions.

Non Invasive Detection of Coronary Sinus Flow Changes Over Time After CABG.

Background: Coronary New blood in the vascular bed after Coronary Artery Bypass Grafting (CABG) may represent a turning point between ischemia and normal tissue nutrition. Its quantification can help to better understand coronary artery hemodynamics after revascularization. Objective: Quantification of coronary sinus blood flow changes over time after Coronary Artery Bypass Grafting (CABG) using Transthoracic Echocardiography (TTE). Methods: Prospective basic research, with repeated measurements on hospital sample of 61 patients whom CABG was conducted. We performed TTE recordings to measure CS flow before and two times after CABG (1 and 6 postoperative day). We measure CS diameter, Velocity Time Integral (VTI) and systemic hemodynamic data. Data needed for LV mass calculation were recorded once. During statistical analysis we define: α = 0,01, ß = 0,01 (power = 1-ß ß= 0,99), Sample size = 60, Effect size= 0,68. We used ANOVA for Repeated Measures as main statistical test in SPSS. Results: Preoperatively we found low overall CS flow of 181 ±72 ml/min (0,68 ±0,30 ml/gram-LV/min). After surgery there was constant increase of CS flow from 276 ±79 ml/min (1,13 ±0,35 ml/gram-LV/min) first postoperative day, to 355 (±99) ml/min (1,30 ±0,46 ml/gram-LV/min) sixth postoperative day. Discussion: Amount of new blood was statistically significant after CABG with P<0,001. Same result was found after classifying patients per number of graft received, with the highest amount of new blood after four bypasses. Amount of new blood was not different if patient gets two or three bypasses. Conclusion: There was significantly new amount of blood in coronary bed after CABG, with constant increase over first 6 days.

Echographic septation: A potentially useful indicator discriminating tuberculous from malignant pleural effusion.

BACKGROUND: Tuberculous (TBE) and malignant (MPE) pleural effusions present with similar lymphocytic exudates. As TBE is an inflammatory and hypersensitivity process, we hypothesized that echographic septation may be more prevalent in TBE than in MPE, potentially serving as a good clinical predictor for TBE. METHODS: A total of 183 TBE and 266 MPE patients were recruited retrospectively. Multivariate logistic regression was performed to determine significant predictors for TBE. RESULTS: TBE diagnosis was confirmed histologically (caseating granuloma) in 84.7% of the cases, while MPE was biopsy-proven in 63.9% of the cases. Echographic septation was more evident in TBE than in MPE (46.5% vs. 8.2%, p < 0.001). Multivariate logistic regression analysis showed that male sex, serum leucocyte count ≤9 × 109/L or pleural fluid protein ≥50 g/L, and echographic septation (aOR: 9.28, p < 0.001) were independent predictors for TBE. These parameters collectively provided a diagnostic accuracy of 79.61% (95% CI 74.13-84.38). CONCLUSIONS: Echographic septation may potentially facilitate discrimination between TBE and MPE as part of a clinical prediction model. Prospective validation of this prediction model in an external cohort is anticipated.

Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis.

PURPOSE: The purpose of the present study was to specifically evaluate the effectiveness and safety of real-time ultrasound-guided thoracentesis in a case series of pleural effusion. PATIENTS AND METHODS: An observational prospective study was conducted. From February 2018 to December 2019, a total of 361 consecutive real-time transthoracic ultrasound (TUS)-guided thoracentesis were performed in the Unit of Diagnostic and Interventional Ultrasound of the Research Hospital "Fondazione Casa Sollievo della Sofferenza" of San Giovanni Rotondo, Foggia, Italy. The primary indication for thoracentesis was therapeutic in all the cases (i.e., evacuation of persistent small/moderate pleural effusions to avoid super-infection; drainage of symptomatic moderate/massive effusions). For completeness, further diagnostic investigations (including chemical, microbiological, and cytological analysis) were conducted. All the procedures were performed by two internists with more than 30 years of experience in interventional ultrasound using a multifrequency convex probe (3-8 MHz). For pleural effusions with a depth of 2-3 cm measured at the level of the costo-phrenic sinus was employed a dedicated holed convex-array probe (5 MHz). RESULTS: In all the cases, the attempts at thoracentesis were successful, allowing the achievement of the therapeutic purpose of the procedure (i.e., the complete drying of the pleural space or the withdrawal of fluid till a "safe" quantity [a mean of 1.5 L, max 2 L] producing relief from symptoms) regardless of the initial extent of the pleural effusion. There were only 3 cases of pneumothorax, for a prevalence rate of complications in this population of 0.83%. No statistical difference was recorded in the rate of pneumothorax according to the initial amount of pleural fluid in the effusion (p = 0.12). All the pleural effusions classified as transudates showed an anechoic TUS appearance. Only the exudative effusions showed a complex nonseptated or a hyperechoic TUS appearance. However, an anechoic TUS pattern was not unequivocally associated with transudates. Some chronic transudates have been classified as exudates by Light's criteria, showing also a complex nonseptated TUS appearance. The cytological examination of the drained fluid allowed the detection of neoplastic cells in 15.89% cases. On the other hand, the microbiological examination of effusions yielded negative results in all the cases. CONCLUSIONS: Real-time TUS-guided thoracentesis is a therapeutically effective and safe procedure, despite the diagnostic yield of the cytological or microbiological examinations on the collected liquid being very low. Future blinded randomized studies are required to definitely clarify the actual benefit of the real-time TUS-guided procedure over percussion-guided and other ultrasound-based procedures.

Transthoracic ultrasound shear wave elastography for the study of subpleural lung lesions.

PURPOSE: The aim of this study was to assess whether new-generation shear wave elastography (SWE) is suitable for the characterization of lung subpleural lesions. METHODS: In total, 190 consecutive patients with subpleural lung lesions received ultrasonography and SWE. Patients with suspected malignancy underwent ultrasound-guided transthoracic needle biopsy. Final diagnoses were made on the basis of patients' clinical course, microbiological studies, and histological results. SWE was also performed in 25 healthy volunteers. RESULTS: We found no statistically significant differences in stiffness between lung carcinomas, lung metastases, and pneumonia (P=0.296) or between different histological types of lung cancer (P=0.393). Necrosis was associated with reduced stiffness in pneumonia. Excluding necrotic lesions, pneumonia showed higher stiffness than lung carcinomas (2.95±0.68 m/s vs. 2.60±0.54 m/s, P=0.006). Chronic pneumonia showed increased stiffness (3.03±0.63 m/s), probably due to the presence of fibrotic tissue on histology. Pleural effusion was associated with a statistically significant reduction in stiffness, both in lung carcinomas (P=0.004) and lung metastases (P=0.002). The presence of air in healthy lung tissue may lead to incorrect speed estimates due to shear wave reflection (very high values, 14.64±2.19 m/s). CONCLUSION: Transthoracic SWE could not distinguish lung malignancy from pneumonia, or between different histological types of lung carcinomas. In particular, SWE seems unable to resolve the clinical dilemma of chronic subpleural consolidations.

Effectiveness and Safety of Transthoracic Ultrasound in Guiding Percutaneous Needle Biopsy in the Lung and Comparison vs. CT Scan in Assessing Morphology of Subpleural Consolidations.

(1) Background: The aim of this study was to conduct a prospective analysis on the diagnostic accuracy of transthoracic ultrasound-guided percutaneous needle biopsy (TUS-PNB) for the histological assessment of peripheral lung lesions and to assess the performance of transthoracic ultrasound (TUS) examination vs. chest CT (gold standard) in the differentiation between malignant and benign peripheral lung lesions. (2) Methods: A total of 961 consecutive patients with subpleural pulmonary lesions were enrolled. All the patients received a CT scan with contrast; 762 patients underwent TUS-PTNB for suspicion of malignancy, and the remaining 199 enrolled patients underwent only TUS examination as a part of routine follow-up for known non-malignant subpleural consolidations. (3) Results: Among the 762 TUS-guided biopsies, there were 627 (82.28%) malignant lesions, 82 (10.76%) benign lesions, and 53 (6.96%) indeterminate lesions. The overall diagnostic accuracy was 93.04%. The rates of pneumothorax not requiring chest-tube insertion and self-limited hemoptysis were 0.79 and 0.26%, respectively. Patients were divided into two groups based on the benign or malignant nature of the subpleural consolidations. On TUS, both malignant and benign lesions showed mostly irregular margins and a hypoechoic pattern, but no differences were assessed in terms of sonographic margins and pattern between the two groups. There was poor agreement between TUS and chest CT in assessing air bronchograms and necrotic areas. The only finding in the detection of which TUS showed superiority compared to chest-CT was pleural effusion. (4) Conclusions: TUS-PNB was confirmed to be an effective and safe diagnostic method for peripheral pulmonary consolidation, but their sonographic pattern did not allow to rule out a malignant nature. A pre-operative evaluation on CT images, combined with the possibility of performing additional immunohistochemical and cytological investigations and the experience of the medical staff, may improve the diagnostic yield of TUS-guided biopsies.

Intraoperative Lung Ultrasound (ILU) for the Assessment of Pulmonary Nodules.

BACKGROUND: The primary aim of this study was to confirm the validity of intraoperative lung ultrasound (ILU) as a safe and effective method of localization for difficult to visualize pulmonary nodules during Video-Assisted Thoracoscopic Surgery (VATS) and open thoracotomy. The secondary aim was to enhance knowledge on the morphological patterns of presentation of pulmonary nodules on direct ultrasound examination. MATERIALS AND METHODS: 131 patients with lung nodule and indication for surgery were enrolled. All patients underwent pre-operative imaging of the chest, including Chest Computed Tomography (CT) and Transthoracic Ultrasound (TUS), and surgical procedures for histological assessment of pulmonary nodules (VATS or open thoracotomy). RESULTS: The identification of 100.00% of lung nodules was allowed by ILU, while the detection rate of digital palpation was 94.66%. It was not possible to associate any specific ILU echostructural pattern to both benign or malignant lesions. However, the actual histological margins of the lesions in the operating samples were corresponding to those visualized at ILU in 125/131 (95.42%) cases. No complications have been reported with ILU employment. CONCLUSIONS: In our experience, ILU performed during both open surgery and VATS demonstrated to be a reliable and safe method for visualization and localization of pulmonary nodules non previously assessed on digital palpation. In addition, ILU showed to allow a clear nodule's margins' definition matching, in most cases, with the actual histological margins.

The Role of Transthoracic Ultrasound in the Study of Interstitial Lung Diseases: High-Resolution Computed Tomography Versus Ultrasound Patterns: Our Preliminary Experience.

Transthoracic ultrasound (TUS) is a readily available imaging tool that can provide a quick real-time evaluation. The aim of this preliminary study was to establish a complementary role for this imaging method in the approach of interstitial lung diseases (ILDs). TUS examination was performed in 43 consecutive patients with pulmonary fibrosis and TUS findings were compared with the corresponding high-resolution computed tomography (HRCT) scans. All patients showed a thickened hyperechoic pleural line, despite no difference between dominant HRCT patterns (ground glass, honeycombing, mixed pattern) being recorded (p > 0.05). However, pleural lines' thickening showed a significant difference between different HRCT degree of fibrosis (p < 0.001) and a negative correlation with functional parameters. The presence of >3 B-lines and subpleural nodules was also assessed in a large number of patients, although they did not demonstrate any particular association with a specific HRCT finding or fibrotic degree. Results allow us to suggest a complementary role for TUS in facilitating an early diagnosis of ILD or helping to detect a possible disease progression or eventual complications during routine clinical practice (with pleural line measurements and subpleural nodules), although HRCT remains the gold standard in the definition of ILD pattern, disease extent and follow-up.

Role of Bedside Ultrasonography in Assessment of Diaphragm Function as a Predictor of Success of Weaning in Mechanically Ventilated Patients.

BACKGROUND: Weaning failure is common in mechanically ventilated patients, and if ultrasound can predict weaning outcome remains controversial. The purpose of this study was to evaluate the diaphragmatic function (thickness and excursion) measured by ultrasound as a predictor of the extubation outcome. METHODS: We included 62 mechanically ventilated patients from the chest intensive care unit in this study. Sixty-two patients who successfully passed the spontaneous breathing trial (SBT) were enrolled. The transthoracic ultrasound of the diaphragm was performed during an SBT to the assess diaphragmatic function (excursion and thickness), and they were classified into the successful extubation group and the failed extubation group. RESULTS: There was a statistically significant increase in the successful extubation group in the diaphragmatic excursion and thickness fraction (p<0.001), a statistically significant negative correlation between the diaphragmatic function and the duration of the mechanical ventilation, and a statistically significant negative correlation between the diaphragmatic excursion and the Acute Physiology and Chronic Health Evaluation II. The diaphragmatic excursion cutoff value predictive of weaning was 1.25 cm, with a specificity of 82.1% and a sensitivity of 97.1% respectively, and the diaphragmatic thickness cut-off value predictive of weaning was 21.5%, with a specificity of 60.7% and a sensitivity of 91.2%, respectively. CONCLUSION: The diaphragmatic ultrasonography was found to be a promising tool for predicting the extubation outcome for mechanically ventilated patients.

The artificial count of artifacts for thoracic ultrasound: what is the clinical usefulness?

Many works in the literature have shown that the increase in the number of B lines is a nonspecific sign of underlying pulmonary disease. Actually these artifacts are the result of a physical effect of ultrasound between the chest wall and the pulmonary air. Nevertheless the intra- and inter-operator variability in B-lines counting does not only reside only in the count itself but depends also on the type and frequency of the probe used, as well as the ultrasound scan machine setting and the patient's chest shape. In our opinion, proposing a software algorithm to count lines B seems like an unproductive effort.

Safety maximization of percutaneous transthoracic needle biopsy with ultrasound guide in subpleural lesions in the evaluation of pulmonary consolidation.

The study by Kiranantawat et al. "Clinical role, safety and diagnostic accuracy of percutaneous transthoracic needle biopsy in the evaluation of pulmonary consolidation" highlights how "pulmonary consolidation can be safely evaluated with CT-guided percutaneous needle biopsy". Even if we agree about the role of CT guidance, we would like to point out how Thoracic Ultrasound could be better than CT for biopsy of subpleural lesions that could easily be detected and reached with this "real-time" and quicker technique.

Pseudoaneurisma ventricular izquierdo / Left ventricular pseudoaneurysm

El pseudoaneurisma cardíaco es una entidad poco frecuente, que se produce cuando existe una rotura incompleta de la pared del corazón y el pericardio sella dicha rotura. Se desarrolla una neocavidad comunicada con la cavidad ventricular por un orificio estrecho. El objetivo del presente trabajo es reportar un caso de pseudoaneurisma ventricular izquierdo, entidad muy poco frecuente. Se presenta un paciente masculino de 69 años, con antecedentes de infarto del miocardio tres años previos al ingreso, que acude al cuerpo de guardia por dolor torácico y disnea. Se le realiza radiografía de tórax, vista póstero-anterior, donde se observa imagen radiopaca con tendencia nodular que borra el contorno cardiaco izquierdo, se complementa con ecografía transtorácica y tomografía helicoidal computarizada, se visualiza una imagen sacular por adición en la pared lateral del ventrículo izquierdo, con trombo mural en su interior, que comunicaba con este a través de cuello estrecho. Se llegó a la conclusión de que se trataba de un pseudoaneurisma ventricular izquierdo. Esta es una entidad que presenta una alta mortalidad, por lo que es necesario realizar un diagnóstico oportuno, a fin de tomar la conducta adecuada para prevenir las complicaciones(AU)

The cardiac pseudoaneurysm is a rare entity, which occurs when there is an incomplete rupture of the heart wall and the pericardium seals the rupture. A neocavity develops communicating with the ventricular cavity through a narrow orifice. The objective of this study is to report a rare case of left ventricular pseudoaneurysm. We present a 69-year-old male patient with a history of myocardial infarction three years prior to admission. The patient goes to the emergency room for chest pain and dyspnea. He underwent chest X-rays for rear-anterior view showing a radiopaque image with nodular tendency that erases the left cardiac line. Transthoracic ultrasound and computerized helical tomography are used to complement the examination. A saccular image is shown by adding to the lateral wall of the left ventricle with wall thrombus inside, a communicating narrow neck. It was concluded that it was a left ventricular pseudoaneurysm. This is an entity that presents high mortality, so it is necessary to make timely diagnosis, in order to take the appropriate medical behavior for preventing complications(AU)

Pseudoaneurisma ventricular izquierdo / Left ventricular pseudoaneurysm

El pseudoaneurisma cardíaco es una entidad poco frecuente, que se produce cuando existe una rotura incompleta de la pared del corazón y el pericardio sella dicha rotura. Se desarrolla una neocavidad comunicada con la cavidad ventricular por un orificio estrecho. El objetivo del presente trabajo es reportar un caso de pseudoaneurisma ventricular izquierdo, entidad muy poco frecuente. Se presenta un paciente masculino de 69 años, con antecedentes de infarto del miocardio tres años previos al ingreso, que acude al cuerpo de guardia por dolor torácico y disnea. Se le realiza radiografía de tórax, vista póstero-anterior, donde se observa imagen radiopaca con tendencia nodular que borra el contorno cardiaco izquierdo, se complementa con ecografía transtorácica y tomografía helicoidal computarizada, se visualiza una imagen sacular por adición en la pared lateral del ventrículo izquierdo, con trombo mural en su interior, que comunicaba con este a través de cuello estrecho. Se llegó a la conclusión de que se trataba de un pseudoaneurisma ventricular izquierdo. Esta es una entidad que presenta una alta mortalidad, por lo que es necesario realizar un diagnóstico oportuno, a fin de tomar la conducta adecuada para prevenir las complicaciones(AU)

The cardiac pseudoaneurysm is a rare entity, which occurs when there is an incomplete rupture of the heart wall and the pericardium seals the rupture. A neocavity develops communicating with the ventricular cavity through a narrow orifice. The objective of this study is to report a rare case of left ventricular pseudoaneurysm. We present a 69-year-old male patient with a history of myocardial infarction three years prior to admission. The patient goes to the emergency room for chest pain and dyspnea. He underwent chest X-rays for rear-anterior view showing a radiopaque image with nodular tendency that erases the left cardiac line. Transthoracic ultrasound and computerized helical tomography are used to complement the examination. A saccular image is shown by adding to the lateral wall of the left ventricle with wall thrombus inside, a communicating narrow neck. It was concluded that it was a left ventricular pseudoaneurysm. This is an entity that presents high mortality, so it is necessary to make timely diagnosis, in order to take the appropriate medical behavior for preventing complications(AU)

The usefulness of thoracic ultrasonography in diagnosis and staging of bronchogenic carcinoma.

AIM: To evaluate (1) the usefulness of thoracic ultrasound in diagnosis and staging of bronchogenic carcinoma by comparing lesion detectability between thoracic- ultrasound and computed tomography and (2) the outcome of thoracic-ultrasound-guided biopsy in diagnosing bronchogenic carcinoma. METHODS: We conducted a cross-sectional study on 53 patients of confirmed bronchogenic carcinoma. All patients had been investigated by thoracic-ultrasound and chest-computed tomography; data regarding the presence of mass (its size, necrosis), lymph nodes invasion, peritumoural atelectasis, consolidations, pleural effusion, chest wall invasion, and paralysis of the diaphragm were recorded. Thoracic-ultrasound-guided biopsy was done for 41 patients. RESULTS: Thoracic-ultrasound had significantly higher detection rate of peritumoural atelectasis, paralysis of the diaphragm, and supraclavicular lymph nodes invasion, while it has significantly lower detection rate of pulmonary masses and mediastinal lymph nodes invasion than computed tomography. It has nonsignificant higher detection rate of pleural effusion, consolidations, chest wall invasion and necrosis within mass than computed tomography. Thoracic-ultrasound detects static air-bronchogram and/or fluid bronchogram in 53.3% of bronchogenic carcinoma-associated consolidation. Thoracic-ultrasound-guided biopsy revealed positive yield in 78.0% (32/41) of patients. All patients with negative thoracic-ultrasound biopsy had mass size >5 cm with necrosis within the mass. Self-limited complications occurred in 26.8% after thoracic-ultrasound-guided biopsy (haemoptysis 22.0%, pneumothorax 2.4% and subcutaneous emphysema 2.4%). CONCLUSION: Thoracic-ultrasound has a significant complementary role to computed tomography in diagnosis and staging of bronchogenic carcinoma. Thoracic-ultrasound-guided biopsy revealed good positive yield (78%), its yield was negatively affected by mass size and necrosis. It is a simple, practical and accurate procedure without significant patients' risks.

Transthoracic ultrasonography for the immunocompromised patient. A pilot project that introduces transthoracic ultrasonography for the follow-up of hematological patients in Romania.

In the past decade, there has been significant progress in clinical hematology with the discovery of targeted molecules and thus the achievement of both hematologic and molecular responses. Nevertheless, chemotherapy remains the treatment of choice for many types of hematological malignancies. Aggressive chemotherapy leads to immunosuppression, accompanied by a high rate of infections and an increased rate of treatment-related mortality. Invasive fungal infections as well as more common bacterial and viral infections are frequent in immunocompromised patients as they are difficult to diagnose and treat. Pleuropulmonary infections in immunocompromised patients are diagnosed using clinical examination, imaging and laboratory tests. Many laboratory tests are run for several days before a final result is given and are expensive. Computer tomography is a reliable technique, but it is encumbered by high irradiation and high cost, and can assess lesions larger than 1 cm. Transthoracic ultrasound is a modern method, used in the diagnostic algorithm of pleuropulmonary pathology. It allows the diagnosis of small lesions, can be performed at the patients' bedside, with acceptable costs and no irradiation. A fast, informed and accurate medical decision is essential for a favorable outcome in immunosuppressed patients with an adjacent infection. In the current case series we present the implementation of a new protocol for the follow-up of immunocompromised patients using transthoracic ultrasonography, of great potential use in the clinic.

Ultrasound Skill and Application of Knowledge Assessment using an Innovative OSCE Competition-Based Simulation Approach.

BACKGROUND: Despite Point-of Care Ultrasound (PoC US) rapidly becoming an important tool in perioperative medicine structured education, PoC US is currently rarely integrated into the anesthesiology residency curriculum. The aim of this project was to assess the current ultrasound skills of anesthesiology residents at one institution and evaluate the needs for development of a formal ultrasound curriculum. METHODS: A event containing 6 different OSCE PoC US stations was developed with following stations: vascular, peripheral nerve block, lung ultrasound, transthoracic echocardiography (TTE) human model, pathologic TTE (simulator), and inferior vena cava (IVC) evaluation (simulator). The ability to obtain an US image or to interpret the US information was evaluated using a checklist and global rating scale. After IRB approval, anesthesiology residents participated in this event (n=30; PGY 2-4). RESULTS: All residents were able to identify vascular structures and demonstrated sufficient ultrasound skill for lung anatomy IVC assessment. The lowest scores were observed for performing and interpreting TTE. There were no differences in resident ultrasound skills for all OSCE stations except minor differences between PGY 2 and PGY 4 in TTE pathology station. While more advanced residents had more clinical exposure to ultrasound for procedures and point-of-care diagnosis, we did not find growth in ultrasound skill level. Despite performing sufficient ultrasound guided peripheral nerve blocks, PGY 4 residents were not able to consistently identify common nerve block targets. CONCLUSIONS: Our findings indicate that exposure and clinical use of ultrasound for procedures and point-of-care diagnosis is not sufficient for developing competency in PoC US and that a formal curriculum throughout the entire anesthesiology residency is needed to ensure PoC US competency.

B-lines: Transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases.

OBJECTIVE: This prospective study was conducted to evaluate the value of sonographic B-lines (previously called "comet tail artifacts"), which are long, vertical, well-defined, hyperechoic, dynamic lines originating from the pleural line in assessment of interstitial lung diseases (ILD) and compare them with the findings of chest high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs). MATERIALS AND METHODS: Sixty-one patients with ILD underwent transthoracic lung ultrasound for assessment of the presence of B-lines and the distance between them. These findings were compared with that of chest HRCT (ground glass, reticular, nodular or honey combing) and PFT as forced vital capacity (FVC), total lung capacity (TLC), diffusion capacity for carbon monoxide (DLCO) and partial arterial oxygen pressure (PaO2). RESULTS: All patients had diffuse bilateral B-lines. The distance between each of the two adjacent B lines correlated with the severity of the disease on chest HRCT where B3 (the distance was 3 mm) correlated with ground glass opacity and B7 (the distance was 7 mm) correlated with extensive fibrosis and honey combing. Also, the distance between B-lines inversely correlated with FVC (r = -0.848, P < 0.001), TLC (r = -0.664, P < 0.001), DLCO (r = -0.817, P < 0.001) and PaO2 (r = -0.902, P < 0.001). CONCLUSION: B-lines that are lung Ultrasound signs seem to be useful in the assessment of ILD.