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This document summarises best practice recommendations for medical imaging use of ultrasound in Europe, representing the agreed consensus of experts from the Ultrasound Subcommittee of the European Society of Radiology (ESR), the European Union of Medical Specialists (UEMS) Section of Radiology, and the European Federation of Societies for Ultrasound in Medicine and Biology. Recommendations are given for education and training, equipment and its maintenance, documentation, hygiene and infection prevention, and medico-legal issues.

Purpose: This study aimed to compare: the performance of K-TIRADS, EU-TIRADS and ACR TIRADS when used by observers with different levels of experience compared with the gold standard of cytology, and to evaluate the diagnostic performance of CAD (computer-aided design) compared with TI-RADS systems. Methods and Materials: In total, 323 thyroid nodules were evaluated in patients who were candidates for needle aspiration. Three observers with different levels of experience evaluated the diagnostic accuracy of three risk stratification systems (ACR TI-RADS, EU-TIRADS and K-TIRADS) and CAD software (S-Detect, made by Samsung) in characterizing the nodules. The results were compared with cytology examination. All nodules were characterized in terms of shape, margins, composition, calcifications, size, echogenicity and microcalcifications, and by stratifying individual nodules by using the three TIRADS systems; then S-detect software was applied and the data were compared with each other and with the gold standard. Results: Through cytology, 308 benign and 33 malignant nodules were identified. ACR-TIRADS showed a sensitivity of 100%, a specificity of 86%, a positive predictive value of 43% and a negative predictive value of 100%. EU-TIRADS showed a sensitivity of 100%, a specificity of 79%, a positive predictive value of 33% and a negative predictive value of 100%. K-TIRADS showed a sensitivity of 100%, a specificity of 89%, a positive predictive value of 50% and a negative predictive value of 100%. S-Detect combined with EU-TIRADS showed a high agreement (>95%) with the gold standard. Conclusions: K-TIRADS’s positive predictive power was slightly better than the other TIRADS, suggesting greater accuracy in correctly diagnosing positive cases. S-DETECT combined with EU-TIRADS has similar results to S-Detect with ACR- and K-TIRADS in terms of sensitivity, specificity and negative predictive power. However, it has a slightly better positive predictive power, suggesting greater accuracy in correctly diagnosing positive cases than the ACR- and K-TIRADS classification systems. In general, S-Detect cannot yet be considered a substitute for the human observer but only as an important support for human evaluation and an excellent and fast help to provide a comprehensive and complete report. Clinical Relevance/Application: S-Detect is a valuable tool for characterizing thyroid nodules when integrated with radiologist evaluation. It is also an important support tool for less experienced observers. Particularly interesting is the approach of use in integrated combination of the K-TIRADS by the human observer with S-Detect using EU-TIRADS, which could increase the overall diagnostic efficiency of the systems.

IntroductionThe plantar plate, also called the plantar ligament, is a fibrocartilaginous structure found in the metatarsophalangeal (MTP) and interphalangeal (IP) joints. Our study aimed to evaluate the role of magnetic resonance imaging (MRI) performed with the patient in the standard position or with joint hyperextension (the “stress test”, ST) in the study of plantar plate (PP) disease that involves metatarsophalangeal joints.Materials and methodsAll patients underwent forefoot MRI (Atroscan C, Esaote, Genoa, Italy), operating at 0.2 T. All patients first underwent a standard MRI examination (coronal T1 and T2 weighted image (WI) with fat suppression and axial and sagittal T2 WI); the examination was completed by performing a stress test (hyperextension of toes). The ST is an easy task to perform and is not time-consuming (requiring only one additional sagittal fast spin echo (FSE) T2-weighted MRI sequence; repetition time/ echo time (TR/TE): 3200/90 ms) for patients and operators. A 45°-dorsiflexion ST was performed for approximately 2.30 min, the time required to complete the sequence. No further diagnostic investigations were necessary; no patients underwent arthrography or arthro-MRI. The examinations were performed in a double-blind mode by two operators with proven experience in musculoskeletal radiology; no cases of intra-operator discordance were found.ResultsTwenty-five patients were recruited into our study over a 2-year period; 15 were positive for metatarsal pain and 10 were controls. Before treatment (surgery), all patients displaying symptoms underwent evaluation. As a result, the imaging features accurately represented the natural and actual conditions of the lesions. Among the symptomatic patients, 11 out of the 15 exhibited a PP tear or dysfunction in both the standard position and the ST. Additionally, two out of the 15 individuals displayed a tear in the ST alone, with no indication of it in the standard position. In contrast, two out of 15 patients showed no evidence of a PP tear in either the standard position or the ST. However, these two patients demonstrated dorsal subluxation during the ST, likely due to micro-instability resulting from PP failure. In the asymptomatic patients, nine out of the 10 individuals were found to be negative for PP dysfunction. Only one out of the 10 patients exhibited dorsal subluxation solely in the ST, indicative of plantar plate dysfunction, but no evidence of a tear in the PP. In the asymptomatic patients, standard MRI provided a specificity of 100% and a high negative predictive value (NPV) (90%), while the latter increased with the ST (specificity and NPV equal to 100%). In symptomatic patients, standard MRI gave a sensitivity of 75% when assessing a PP tear, which increased to 100% with the ST; the sensitivity of standard MRI the evaluation of MF subluxation was 60%, but it reached 100% with the ST.ConclusionsIn our study, by introducing the ST, the sensitivity in both the diagnosis of a PP tear and the evaluation of MTP subluxation reached 100% (a surgical assessment was performed on all positive patients for confirmation). Ultrasound has the advantage of being a non-invasive method. However, comparing the results of our study with the data available in the literature, ultrasound has a lower sensitivity and a negative predictive value. Also, ultrasound does not allow for the assessment of possible bone marrow oedema or the degree of concomitant arthritis. If other studies in the literature confirm these results, it will be possible to consider incorporating the ST into diagnostic practice in the future.

Ultrasound (US) is the first imaging modality for thyroid parenchyma evaluation. In the last decades, the role of ultrasound has been improved with the introduction of new US software, such as contrast-enhanced ultrasound (CEUS) and US-elastography (USE). USE is nowadays recognized as an essential part of the multiparametric ultrasound (MPUS) examination, in particular for the indeterminate thyroid nodule with possible fine-needle aspiration cytology (FNAC) number reduction; even if further and larger studies are needed to validate it. More controversial is the role of CEUS in thyroid evaluation, due to its high variability in sensitivity and specificity. Semi-automatic US systems based on the computer-aided diagnosis (CAD) system are producing interesting results, especially as an aid to less experienced operators. New knowledge on the molecular mechanisms involved in thyroid cancer is allowing practitioners to identify new genomic thyroid markers that could reduce the number of “diagnostic” thyroidectomies. We have therefore drawn up an updated representation of the current evidence in the literature for thyroid nodule multiparametric ultrasound (MPUS) evaluation with particular regard to USE, the US CAD system and CEUS.

The use of contrast-enhanced ultrasound (CEUS) in clinical practice is theoretically limited to the licensed indications: focal liver lesions, breast, peripheral arterial system, and the heart. In reality, there has been a continuous expansion of the deployment of CEUS examinations to many other organs and body parts over the last 20 years. Many of these applications are a natural extension of the diagnostic capabilities of the CEUS examination, used to achieve a better imaging outcome. These applications have been supported by guidelines issued by scientific societies, detailing the application, accuracy, and safety of the clinical performance. Nevertheless, there are some areas in which it remains more difficult to establish the use of CEUS in the diagnostic pathway. In the pregnant patient, CEUS is an ideal examination—a natural extension of B-mode ultrasound, avoiding ionising radiation and iodinated contrast. The contrast agents used in ultrasound do not cross the placental barrier. Ultrasound in the paediatric patient is used widely, and extending this to a CEUS examination improves diagnostic capabilities, avoiding less child-friendly imaging techniques. The parent can be in the room at the time of the ultrasound examination. Other aspects of CEUS usage are hampered by the lack of physician engagement despite the proven advantages of the technique, the reduction in the morbidity associated with CT and MR imaging, particularly the contrast agents used in these modalities. Complex renal cyst classification, follow-up of blunt abdominal trauma and the surveillance following placement of an aortic stent graft are all areas of potential benefit to the diagnosis. All these are better imaged on a CEUS examination. Furthermore, cost savings can be achieved using CEUS, mostly by alleviating downstream costs of CT and MR imaging. Critical relevance statement CEUS use outside licensed uses is becoming established, driven by the unique ability to achieve diagnostic standards safely and with patient acceptability, pushing the boundaries in areas of abdominal trauma, pregnancy, paediatrics, aortic implants, and complex renal cysts. Key Points CEUS has a narrow range of licensed applications in medical imaging, but is used widely. An exclusively intravascular agent allows assessment of vascular flow at the capillary level. CEUS is extremely safe and can be used in many areas that require repeated high-resolution imaging.

Quantitative ultrasound (US) elastography (Q-USE), able to evaluate tissue stiffness has been indicated as a new diagnostic tool to differentiate benign from malignant thyroid lesions. Aim of this prospective study, conducted at the Department of Surgical Sciences, of the \"Sapienza\" University of Rome, was to evaluate the diagnostic accuracy of Q-USE, compared with US parameters, in thyroid nodules with indeterminate cytology (Thy3).The case study included 140 nodules from 140 consecutive patients. Patient's thyroid nodules were evaluated by Q-USE, measuring the strain ratio (SR) of stiffness between nodular and surrounding normal thyroid tissue, and conventional US parameters prior fine-needle aspiration cytology. Those with Thy3 diagnosis were included in the study. Forty of the nodules analyzed harbored a malignant lesion. Q-USE demonstrated that malignant nodules have a significant higher stiffness with respect to benign one and an optimun SR cut-off value of 2.05 was individuated following ROC analysis. Univariate analysis showed that hypoechogenicity, irregular margins and SR >2.05 associated with malignancy, with an accuracy of 67.2%, 81,0% and 89.8%, respectively. Data were unaffected by nodule size or thyroiditis. These findings were confirmed in multivariate analysis demonstrating a significant association of the SR and the irregular margins with thyroid nodule's malignancy. In conclusion, we demonstrated the diagnostic utility of Q-USE in the differential diagnosis of thyroid nodules with indeterminate cytology that, if confirmed, could be of major clinical utility in patients' presurgical selection.

Background and Objectives: Cellulite, or edemato-fibro-sclerotic panniculopathy (EFP), is characterized by dermal and hypodermal changes leading to adipose tissue accumulation and compromised venous circulation. This study investigates the efficacy of a hypertonic cream containing concentrated sodium chloride (Jovita Osmocell®) in addressing water retention and structural alterations in adipose tissue, aiming to interrupt the cellulite formation process. Materials and Methods: A 12-week, prospective, monocentric, double-blind, placebo-controlled study enrolled 30 female subjects with grade II or III cellulite. Patients were randomized to receive hypertonic cream or a placebo. Thigh circumference, ultrasound evaluations, and standardized photographs were collected at baseline, intermediate, and endpoint visits. Adverse events were monitored. Results: After 84 days, the hypertonic cream group exhibited a significant reduction in thigh circumference compared to the placebo group (p = 0.0037). B-mode ultrasound examinations revealed significant changes in the parameters studied, such as the thickness of the subcutaneous tissue. No statistically significant changes were noticed in the placebo group. Volunteers reported the investigational product’s pleasantness and good anti-cellulite activity, with no reported adverse events. Conclusions: The hypertonic cream demonstrated efficacy in reducing thigh circumference, addressing water retention and structural alterations in adipose tissue. The proposed mechanism involves osmosis, releasing accumulated fluids between fat cells, supporting drainage, and reducing inflammation. This study supports the efficacy and safety of hypertonic sodium chloride emulsions in cellulite treatment and confirms safety and user satisfaction.

Ultrasound is becoming a fundamental first-line diagnostic tool for most medical specialties and an innovative tool to teach anatomy, physiology and pathophysiology to undergraduate and graduate students. However, availability of structured training programs during medical school is lagging behind and many physicians still acquire all their ultrasound skills during postgraduate training.There is wide variation in medical student ultrasound education worldwide. Sharing successful educational strategies from early adopter medical schools and learning from leading education programs should advance the integration of ultrasound into the university medical school curricula. In this overview, we present current approaches and suggestions by ultrasound societies concerning medical student educa-tion throughout the world. Based on these examples, we formulate a consensus statement with suggestions on how to integrate ultrasound teaching into the preclinical and clinical medical curricula.

Ultrasound (US) still represents the mainstay of scrotal imaging. However, contrast-enhanced ultrasound (CEUS) is a relatively novel, but increasingly utilized diagnostic modality. In consequence, we performed a systematic review (SR) and pooled meta-analysis to investigate the diagnostic performance of CEUS in the evaluation of testicular masses (TM). A SR up to June 2021 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The diagnostic performance of CEUS was evaluated basing on two different endpoints: neoplastic vs. non-neoplastic and malignant vs. benign TM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) from eligible studies were pooled and summary receiver operating characteristic (SROC) curves were constructed for each endpoint. Overall, six qualified studies were deemed suitable for this meta-analysis. Diagnostic performance of CEUS showed an accuracy of 0.96 in detecting neoplastic masses (sensitivity of 0.89, PPV of 0.85, specificity of 0.62, and NPV of 0.69) and an accuracy of 0.96 in detecting malignant masses (sensitivity of 0.86, PPV of 0.73, specificity of 0.87, and NPV of 0.91). Taken together, CEUS may represent a promising minimally invasive diagnostic tool for characterization of TM, since it allows clinicians to identify neoplastic lesions and exclude malignant tumor.

Background Stenoses of the outflow tract can compromise the function of arteriovenous fistulas (AVFs) used for haemodialysis. Limited data exists to differentiate stenosis types and understand their underlying causes. This study aims to develop a new classification system for AVF stenoses based on the morphology and location of the lesions as assessed by duplex ultrasound (DUS). Materials and methods A multicenter, cross-sectional cohort study was conducted in four hospitals from October 2017 to February 2024. After exclusions, 1122 patients with dysfunctional AVFs were evaluated. The DUS variables studied were intimal-media thickness (IMT), venous valve calcifications (VVC), and stenosis location. The stenosis location was classified as follows: juxta/post anastomotic tract; middle tract; proximal tract; arm cephalic vein tract; cephalic arch; and arm basilic vein tract. Results Intimal hyperplasia (corresponding to IMT ≥ 0.4 mm) was present in 718 AVFs (64%; 95% CI 0.61–0.67), with an average thickness of 0.72 ± 0.14 mm (95% CI 0.71–0.73); no intimal hyperplasia (corresponding to IMT < ≥≥0.4 mm) in 354 AVFs (32%; 95% CI 0.29–0.34), and valve calcification in 50 AVFs (4%; 95% CI 3–6). Stenoses were classified in 4 types: Type A, dominant IMT with thickness ≥ 0.6 mm; Type B, IMT 0.4 mm to 0.6 mm; Type C, IMT < 0.4 mm; and Type D, with calcifications of the venous valves. Most of the stenosis fell within Type A and C (79.5%). Type A stenosis was in 80% found in the juxta/post-anastomotic segments. The middle and proximal tract segments showed a similar distribution of all four types of stenosis. Type C and D stenosis were prevalent in the distal segments. Conclusion DUS reveals distinct characteristics of AVF stenoses, suggesting different underlying causes. This classification system may facilitate the development of targeted interventions for preventing and treating AVF stenosis. Clinical trial number Not applicable.