Papel de la ecografía en el paciente crítico con ECMO / Role of ultrasound in the critical ill patient with ECMO

La ecografía es un instrumento diagnóstico fundamental en el paciente crítico con membrana de oxigenación extracorpórea (ECMO). Con ella podemos hacer una evaluación anatómica y funcional (cardiaca, pulmonar y vascular) para plantear una adecuada configuración; además, guía su implante, ayuda en la monitorización clínica y la detección de complicaciones, facilita su retirada y completa la evaluación postimplante. En los pacientes con ECMO como soporte respiratorio (veno-venosa), la ecografía torácica permite monitorizar la evolución de la enfermedad pulmonar y la ecocardiografía la evaluación de la función biventricular, especialmente la derecha, y el gasto cardiaco para optimizar el transporte de oxígeno. En la ECMO como soporte circulatorio (veno-arterial), la ecocardiografía supone la guía de la monitorización hemodinámica, permite detectar las principales complicaciones y ayuda al destete del dispositivo. En los equipos ECMO, para un adecuado manejo de estos pacientes, debe haber intensivistas entrenados y con conocimientos avanzados sobre esta técnica. (AU)

Ultrasound is an essential diagnostic tool in critically ill patients with extracorporeal membrane oxygenation (ECMO). With it, we can make an anatomical and functional (cardiac, pulmonary and vascular) evaluation which allows us to execute an adequate configuration, guides implantation, helps clinical monitorization and detects complications, facilitates withdrawal and complete post-implant evaluation. In patients with ECMO as respiratory support (veno-venous), thoracic ultrasound allows monitoring pulmonary illness evolution and echocardiography the evaluation of biventricular function, especially right ventricle function, and cardiac output to optimize oxygen transport. In ECMO as circulatory support (veno-arterial), echocardiography is the guide of hemodynamic monitoring, allows detecting the most frequent complications and helps the weaning. In ECMO teams, for a proper management of these patients, there must be trained intensivists with advanced knowledge on this technique. (AU)

Competencias básicas de la ecografía clínica en los servicios de urgencias y emergencias / Description of basic competencies in clinical ultrasound imaging for emergency departments

En los últimos años, la ecografía clínica (EC) ha sufrido un avance muy importante en su implantación dentro de los servicios de urgencias, tanto hospitalarios como extrahospitalarios, pero como toda técnica requiere un ámbito competencial definido, actualizado y enmarcado, tanto en la realidad clínica de la especialidad que desempeñamos como en la geográfica del país donde ejercemos. Por ello, un grupo de expertos en la materia ha desarrollado el presente documento en el que basándose por un lado en la evidencia disponible en la bibliografía científica y por otro en una metodología Delphi, planteó el objetivo de establecer un claro marco competencial base para todos los urgenciólogos, asumiendo como premisa inicial que la EC debería ser una competencia transversal común. (AU)

Recent years have seen great advances in the use of clinical ultrasound imaging in both hospital emergency departments and out-of-hospital settings. However, all new techniques require up-to-date definitions of competencies relevant to the clinical realities of different specialties and the geographic settings in which specialists work. To that end, a group of experts in clinical ultrasound reviewed the evidence available in the literature and strictly applied the Delphi method to define the competencies relevant to emergency physicians. The group worked with the starting premise that clinical ultrasound imaging should be a common competency across the special (AU)

Formación online en ecografía pulmonar para residentes de Pediatría / E-learning curriculum on newborn point-of-care lung ultrasound for Paediatric residents

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Aplicación de «Point-Of-Care-Ultrasound» (POCUS) en Atención Geriátrica a Domicilio (AGD): a propósito de un caso / Application of “Point-Of-Care-Ultrasound” (POCUS) in a Geriatric Home Care (AGD): A case report

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Maternal and fetal assessment update: imaging ultrasound before 24 weeks of pregnancy

This recommendation is an update of one of the 49 recommendations that were published in the WHO recommendations on antenatal care for a positive pregnancy experience. The recommendation was developed initially using the standardized operating procedures described in the WHO handbook for guideline development. In summary, the process included: (i) identification of priority question and outcomes; (ii) retrieval of evidence; (iii) assessment and synthesis of the evidence; (iv) formulation of recommendation; and (v) planning for the implementation, dissemination, impact evaluation and updating of the recommendation. This recommendation was identified by the Executive Guideline Steering Group (GSG) as a high priority for updating in response to new evidence on this question.

Recent advances in vascular ultrasound imaging technology and their clinical implications.

In this paper recent advances in vascular ultrasound imaging technology are discussed, including three-dimensional ultrasound (3DUS), contrast-enhanced ultrasound (CEUS) and strain- (SE) and shear-wave-elastography (SWE). 3DUS imaging allows visualisation of the actual 3D anatomy and more recently of flow, and assessment of geometrical, morphological and mechanical features in the carotid artery and the aorta. CEUS involves the use of microbubble contrast agents to estimate sensitive blood flow and neovascularisation (formation of new microvessels). Recent developments include the implementation of computerised tools for automated analysis and quantification of CEUS images, and the possibility to measure blood flow velocity in the aorta. SE, which yields anatomical maps of tissue strain, is increasingly being used to investigate the vulnerability of the carotid plaque, but is also promising for the coronary artery and the aorta. SWE relies on the generation of a shear wave by remote acoustic palpation and its acquisition by ultrafast imaging, and is useful for measuring arterial stiffness. Such advances in vascular ultrasound technology, with appropriate validation in clinical trials, could positively change current management of patients with vascular disease, and improve stratification of cardiovascular risk.

Recent ultrasound advancements for the manipulation of nanobiomaterials and nanoformulations for drug delivery.

Recent advances in ultrasound (US) have shown its great potential in biomedical applications as diagnostic and therapeutic tools. The coupling of US-assisted drug delivery systems with nanobiomaterials possessing tailor-made functions has been shown to remove the limitations of conventional drug delivery systems. The low-frequency US has significantly enhanced the targeted drug delivery effect and efficacy, reducing limitations posed by conventional treatments such as a limited therapeutic window. The acoustic cavitation effect induced by the US-mediated microbubbles (MBs) has been reported to replace drugs in certain acute diseases such as ischemic stroke. This review briefly discusses the US principles, with particular attention to the recent advancements in drug delivery applications. Furthermore, US-assisted drug delivery coupled with nanobiomaterials to treat different diseases (cancer, neurodegenerative disease, diabetes, thrombosis, and COVID-19) are discussed in detail. Finally, this review covers the future perspectives and challenges on the applications of US-mediated nanobiomaterials.

Current and Emerging Tools for Hepatocellular Carcinoma Surveillance.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Early detection of HCC enables patients to avail curative therapies that can improve patient survival. Current international guidelines advocate for the enrollment of patients at high risk for HCC, like those with cirrhosis, in surveillance programs that perform ultrasound every 6 months. In recent years, many studies have further characterized the utility of established screening strategies and have introduced new promising tools for HCC surveillance. In this review, we provide an overview of the most promising new imaging modalities and biomarkers for the detection of HCC. We discuss the role of imaging tools like ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) in the early detection of HCC, and describe recent innovations which can potentially enhance their applicability, including contrast enhanced ultrasound, low-dose CT scans, and abbreviated MRI. Next, we outline the data supporting the use of three circulating biomarkers (i.e., alpha-fetoprotein [AFP], AFP lens culinaris agglutinin-reactive fraction, and des-gamma-carboxy prothrombin) in HCC surveillance, and expand on multiple emerging liquid biopsy biomarkers, including methylated cell-free DNA (cfDNA), cfDNA mutations, extracellular vesicles, and circulating tumor cells. These promising new imaging modalities and biomarkers have the potential to improve early detection, and thus improve survival, in patients with HCC.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal.

BACKGROUND: Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized. OBJECTIVES: To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal. METHODS: An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date. RESULTS: We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps. DISCUSSION: Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography. CONCLUSIONS: To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

Contrast-Enhanced Lung Ultrasound: A New Horizon / Ecografía pulmonar con contraste: un nuevo horizonte

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Clinical application of lung ultrasound score on COVID-19 setting: a regional experience in Southern Italy.

OBJECTIVE: We aimed to assess the correlation between LUS Soldati proposed score and clinical presentation, course of disease and the possible need of ventilation support/intensive care. PATIENTS AND METHODS: All consecutive patients with laboratory confirmed SARS-CoV-2 infection and hospitalized in two COVID Centers were enrolled. All patients performed blood gas analysis and lung ultrasound (LUS) at admission. The LUS acquisition was based on standard sequence of 14 peculiar anatomic landmarks with a score between 0-3 based on impairment of LUS picture. Total score was computed with their sum with a total score ranging 0 to 42, according to Soldati LUS score. We evaluated the course of hospitalization until either discharge or death, the ventilatory support and the transition in intensive care if needed. RESULTS: One hundred and fifty-six patients were included in the final analysis. Most of patients presented moderate-to-severe respiratory failure (FiO2 <20%, PaO2 <60 mmHg) and consequent recommendation to invasive mechanic ventilation (CPAP/NIV/OTI). The median ultrasound thoracic score was 28 (IQR 18-36) and most of patients could be ascertained either in a score 2 (40%) or score 3 pictures (24.4%). The bivariate correlation analysis displayed statistically significant and high positive correlations between the LUS score and the following parameters: ventilation (rho=0.481, p<0.001), lactates (rho=0.464, p<0.001), dyspnea (rho=0.398, p=0.001) mortality (rho=0.410, p=0.001). Conversely, P/F (rho= -0.663, p<0.001), pH (rho = -0.363, p=0.003) and pO2 (rho = -0.400 p=0.001) displayed significant negative correlations. CONCLUSIONS: LUS score improve the workflow and provide an optimal management both in early diagnosis and prognosis of COVID-19 related lung pathology.

Emerging applications of clinical ultrasonography.

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

Exploring the use of musculoskeletal ultrasound imaging by podiatrists: an international survey.

BACKGROUND: Podiatrists, in musculoskeletal services, are demonstrating an expansion of their practice skills through the use of ultrasound imaging. There is an assumption that this practice is beneficial within the context of patient care and health systems. The aim of this research was to further investigate the use of musculoskeletal ultrasound (MSUS) by podiatrists within their clinical setting and gain additional insights into the impact that they perceive use of MSUS has on their approaches to management of musculoskeletal foot and ankle problems. METHOD: An international study utilising a cross-sectional design and an internet-based platform was undertaken. The survey was developed and implemented through three phases: 1. survey development, 2. face validity agreement via questionnaire review, and 3. survey distribution and data collection. Twenty-two survey questions were developed and set as a two-step approach collecting quantitative data (part 1) and qualitative free text data (part 2). Data was exported from SurveyMonkey and analysed using Microsoft Excel software. Counts and frequencies were calculated for responses to all twenty closed questions. Responses to the two final open-ended questions were analysed using thematic analysis to search for patterns related to podiatrists' perceptions of impact. RESULTS: Two hundred and thirty-two eligible participants consented to complete the survey. The majority (n = 159) of respondents were from the UK and Spain. Commonly MSUS has been used in practice for (i) diagnosing pathology, (ii) supporting rehabilitation, (iii) supporting interventions or (iv) research purposes. Most frequently, MSUS was used to assist in the diagnosis of injury/pathology (84%). A range of free text comments were received from the participants in response to the question relating to their thoughts on the impact of using MSUS imaging in their practice (n = 109) and on their perceptions of how the use of MSUS has influenced their approaches to management of their patients' musculoskeletal foot and ankle problems (n = 108). Thematic analysis of the free text comments generated four themes: (i) diagnosis, (ii) delivery and access of care, (iii) patient education and engagement, and (iv) patient empowerment. CONCLUSION: The perceived benefit podiatrists indicated in using MSUS as part of their practice is the perceived improvement in patient journeys through tighter, focused management plans and reduced waiting times. An additional novel finding was that MSUS provided the capacity for podiatrists to better inform patients of their diagnosis, which they believed led to improved engagement and consequent empowerment of patients in their treatment plans. We propose further investigation of patient experiences as well as testing of the model that embeds podiatrists' use of MSUS as a key skill in musculoskeletal foot and ankle services.

One year of SARS-CoV-2 and lung ultrasound: what has been learned and future perspectives.

A first screening by ultrasound can be relevant to set a specific diagnostic and therapeutic route for a patient with a COVID-19 infection. The finding of bilateral B-lines and white lung areas with patchy peripheral distribution and sparing areas is the most suggestive ultrasound picture of COVID-19 pneumonia. Failure to detect bilateral interstitial syndrome (A pattern) on ultrasound excludes COVID-19 pneumonia with good diagnostic accuracy, but does not exclude current infection. The use of shared semiotic and reporting schemes allows the comparison and monitoring of the COVID-19 pulmonary involvement over time. This review aims to summarise the main data on pulmonary ultrasound and COVID-19 to provide accurate and relevant information for clinical practice.

Long-term medical imaging use in children with central nervous system tumors.

BACKGROUND: Children with central nervous system (CNS) tumors undergo frequent imaging for diagnosis and follow-up, but few studies have characterized longitudinal imaging patterns. We described medical imaging in children before and after malignant CNS tumor diagnosis. PROCEDURE: We conducted a retrospective cohort study of children aged 0-20 years diagnosed with CNS tumors between 1996-2016 at six U.S. integrated healthcare systems and Ontario, Canada. We collected computed topography (CT), magnetic resonance imaging (MRI), radiography, ultrasound, nuclear medicine examinations from 12 months before through 10 years after CNS diagnosis censoring six months before death or a subsequent cancer diagnosis, disenrollment from the health system, age 21 years, or December 31, 2016. We calculated imaging rates per child per month stratified by modality, country, diagnosis age, calendar year, time since diagnosis, and tumor grade. RESULTS: We observed 1,879 children with median four years follow-up post-diagnosis in the U.S. and seven years in Ontario, Canada. During the diagnosis period (±15 days of diagnosis), children averaged 1.10 CTs (95% confidence interval [CI] 1.09-1.13) and 2.14 MRIs (95%CI 2.12-2.16) in the U.S., and 1.67 CTs (95%CI 1.65-1.68) and 1.86 MRIs (95%CI 1.85-1.88) in Ontario. Within one year after diagnosis, 19% of children had ≥5 CTs and 45% had ≥5 MRIs. By nine years after diagnosis, children averaged one MRI and one radiograph per year with little use of other imaging modalities. CONCLUSIONS: MRI and CT are commonly used for CNS tumor diagnosis, whereas MRI is the primary modality used during surveillance of children with CNS tumors.