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Ultrasound (US) provides the most accurate technique for thickness measurements of subcutaneous adipose tissue (SAT) layers. This US method was recently standardised using eight sites to capture SAT patterning and allows distinguishing between fat and embedded fibrous structures. These eight sites chosen for fat patterning studies do not represent the mean SAT thickness measured all over the body that is necessary for determining subcutaneous fat mass. This was obtained by SAT measurements at 216 sites distributed randomly all over the body. Ten participants with BMI below 28.5kgm −2 and SAT means (from eight sites) ranging from 3 mm to 10 mm were selected. The means from eight sites overestimated the means obtained from 216 sites (i.e. 2160 US measurements in the ten participants); the calibration factor of 0.65 corrects this; standard deviation (SD) was 0.05, i.e. 8%. The SD of the calibration factor transforms linearly when estimating the error range of the whole body’s SAT volume (body surface area times the calibrated mean SAT thickness). The SAT masses ranged from 3.2 to 12.4 kg in this group. The standard deviations resulting from solely the calibration factor uncertainty were ±0.3 and ±1.0 kg, respectively. For these examples, the SAT percentages were 4.9(±0.4)% and 13.3(±1.0)%.

Mammography has limited accuracy in breast cancer screening. Ultrasonography, when used in conjunction with mammography screening, is helpful to detect early-stage and invasive cancers for asymptomatic women with dense and nondense breasts. To evaluate the performance of adjunctive ultrasonography with mammography for breast cancer screening, according to differences in breast density. This study is a secondary analysis of the Japan Strategic Anti-cancer Randomized Trial. Between July 2007 and March 2011, asymptomatic women aged 40 to 49 years were enrolled in Japan. The present study used data from cases enrolled from the screening center in Miyagi prefecture during 2007 to 2020. Participants were randomly assigned in a 1:1 ratio to undergo either mammography with ultrasonography (intervention group) or mammography alone (control group). Data analysis was performed from February to March 2020. Ultrasonography adjunctive to mammography for breast cancer screening regardless of breast density. Sensitivity, specificity, recall rates, biopsy rates, and characteristics of screen-detected cancers and interval breast cancers were evaluated between study groups and for each modality according to breast density. A total of 76 119 women were enrolled, and data for 19 213 women (mean [SD] age, 44.5 [2.8] years) from the Miyagi prefecture were analyzed; 9705 were randomized to the intervention group and 9508 were randomized to the control group. A total of 11 390 women (59.3%) had heterogeneously or extremely dense breasts. Among the overall group, 130 cancers were found. Sensitivity was significantly higher in the intervention group than the control group (93.2% [95% CI, 87.4%-99.0%] vs 66.7% [95% CI, 54.4%-78.9%]; P < .001). Similar trends were observed in women with dense breasts (sensitivity in intervention vs control groups, 93.2% [95% CI, 85.7%-100.0%] vs 70.6% [95% CI, 55.3%-85.9%]; P < .001) and nondense breasts (sensitivity in intervention vs control groups, 93.1% [95% CI, 83.9%-102.3%] vs 60.9% [95% CI, 40.9%-80.8%]; P < .001). The rate of interval cancers per 1000 screenings was lower in the intervention group compared with the control group (0.5 cancers [95% CI, 0.1-1.0 cancers] vs 2.0 cancers [95% CI, 1.1-2.9 cancers]; P = .004). Within the intervention group, the rate of invasive cancers detected by ultrasonography alone was significantly higher than that for mammography alone in both dense (82.4% [95% CI, 56.6%-96.2%] vs 41.7% [95% CI, 15.2%-72.3%]; P = .02) and nondense (85.7% [95% CI, 42.1%-99.6%] vs 25.0% [95% CI, 5.5%-57.2%]; P = .02) breasts. However, sensitivity of mammography or ultrasonography alone did not exceed 80% across all breast densities in the 2 groups. Compared with the control group, specificity was significantly lower in the intervention group (91.8% [95% CI, 91.2%-92.3%] vs 86.8% [95% CI, 86.2%-87.5%]; P < .001). Recall rates (13.8% [95% CI, 13.1%-14.5%] vs 8.6% [95% CI, 8.0%-9.1%]; P < .001) and biopsy rates (5.5% [95% CI, 5.1%-6.0%] vs 2.1% [95% CI, 1.8%-2.4%]; P < .001) were significantly higher in the intervention group than the control group. In this secondary analysis of a randomized clinical trial, screening mammography alone demonstrated low sensitivity, whereas adjunctive ultrasonography was associated with increased sensitivity. These findings suggest that adjunctive ultrasonography has the potential to improve detection of early-stage and invasive cancers across both dense and nondense breasts. Supplemental ultrasonography should be considered as an appropriate imaging modality for breast cancer screening in asymptomatic women aged 40 to 49 years regardless of breast density. NIPH Clinical Trial Identifier: UMIN000000757.

Background Guidelines currently do not recommend the routine use of chest x-ray (CXR) in bronchiolitis. However, CXR is still performed in a high percentage of cases, mainly to diagnose or rule out pneumonia. The inappropriate use of CXR results in children exposure to ionizing radiations and increased medical costs. Lung Ultrasound (LUS) has become an emerging diagnostic tool for diagnosing pneumonia in the last decades. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in hospitalized children with bronchiolitis and to evaluate the agreement between LUS and CXR in diagnosing pneumonia in these patients. Methods We enrolled children admitted to our hospital in 2016–2017 with a diagnosis of bronchiolitis and undergone CXR because of clinical suspicion of concomitant pneumonia. LUS was performed in each child by a pediatrician blinded to the patient’s clinical, laboratory and CXR findings. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines. Results Eighty seven children with bronchiolitis were investigated. A final diagnosis of concomitant pneumonia was made in 25 patients. Sensitivity and specificity of LUS for the diagnosis of pneumonia were 100% and 83.9% respectively, with an area under-the-curve of 0.92, while CXR showed a sensitivity of 96% and specificity of 87.1%. When only consolidation > 1 cm was considered consistent with pneumonia, the specificity of LUS increased to 98.4% and the sensitivity decreased to 80.0%, with an area under-the-curve of 0.89. Cohen’s kappa between pediatrician and radiologist sonologists in the first 30 patients showed an almost perfect agreement in diagnosing pneumonia by LUS (K 0.93). Conclusions This study shows the good accuracy of LUS in diagnosing pneumonia in children with clinical bronchiolitis. When including only consolidation size > 1 cm, specificity of LUS was higher than CXR, avoiding the need to perform CXR in these patients. Added benefit of LUS included high inter-observer agreement. Trial registration Identifier: NCT03280732 . Registered 12 September 2017 (retrospectively registered).

Intubation is a frequently performed procedure in emergency medicine that is associated with significant morbidity and mortality when unrecognized esophageal intubation occurs. However, it may be difficult to visualize the endotracheal tube (ETT) in some patients. This study assessed whether the addition of color Doppler was able to improve the ability to visualize the ETT location. This study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumference. Cadavers were randomized to tracheal or esophageal intubation. Blinded sonographers then assessed the location of the ETT using either grayscale or color Doppler imaging. Accuracy of sonographer identification of ETT location, time to identification, and operator confidence were assessed. One hundred and fifty intubations were performed and each was assessed by both standard and color Doppler techniques. There were 78 tracheal intubations and 72 esophageal intubations. The standard technique was 99.3% (95% CI 96.3 to 99.9%) accurate. The color flow technique was also 99.3% (95% CI 96.3 to 99.9%) accurate. The mean operator time to identification was 3.24s (95% CI 2.97 to 3.51s) in the standard approach and 5.75s (95% CI 5.16 to 6.33s) in the color flow technique. The mean operator confidence was 4.99/5.00 (95% CI 4.98 to 5.00) in the standard approach and 4.94/5.00 (95% CI 4.90 to 4.98) in the color flow technique. When added to standard ultrasound imaging, color flow did not improve accuracy or operator confidence for identifying ETT location and resulted in a longer examination time.

Ultrasound has been increasingly utilized for the identification of endotracheal tube (ETT) location after an intubation attempt, particularly among patients in cardiac arrest. However, prior studies have varied with respect to the choice of transducer and no studies have directly compared the accuracy between transducer types. Our study is the first to directly compare the accuracy of ETT confirmation between the linear and curvilinear transducer. This study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumferences. Cadavers were randomized to tracheal or esophageal intubation. Blinded sonographers assessed the location of the ETT using either a linear or curvilinear transducer in an alternating sequence. Accuracy of sonographer identification, time to identification, and operator confidence were assessed. Four hundred and five assessments were performed with 198 (48.9%) tracheal and 207 (51.1%) esophageal intubations. The linear transducer was 98% (95% CI 95.1% to 99.2%) accurate. The curvilinear transducer was 95% (95% CI 91.1% to 97.3%) accurate. The mean time to identification was significantly lower with the linear transducer [7.46 s (95% CI 6.23 to 8.7 s)] as compared with the curvilinear transducer [11.63 s (95% CI 9.05 to 14.2 s)]. The mean operator confidence was significantly higher with the linear transducer [4.84/5.0 (95% CI 4.76 to 4.91)] than with the curvilinear transducer [4.44/5.0 (95% CI 4.3 to 4.57)]. All operators preferred the linear transducer over the curvilinear transducer. The diagnostic accuracy of ultrasound for ETT confirmation did not significantly differ between ultrasound transducer types, but the curvilinear transducer was associated with a longer time to confirmation and lower operator confidence. Further studies are needed to determine if the accuracy would change with more novice providers or in specific patient populations.

Background and Objectives: Ultrasonography is useful in evaluating patients with renal colic and it has high sensitivity and specificity for diagnosing ureter stones by revealing hydronephrosis. We evaluated the efficacy of point-of-care ultrasonography protocol in managing patients with acute renal colic who visited the emergency department (ED). Materials and Methods: Between March 2019 and July 2019, patients who visited the ED because of renal colic were randomly assigned by date of visit either to the conventional group (CG), who underwent routine diagnostic work-up without ultrasonography, or to the ultrasonography group (UG), who underwent bedside ultrasonography as an initial diagnostic testing. When hydronephrosis was detected in the UG group, a confirmatory non-contrast abdomen computed tomography scan was promptly performed. The ED length of stay, complications, and missed or delayed high-risk diagnosis were evaluated. Results: In total, 128 of 147 analyzed patients were confirmed to have ureter stones. The ED length of stay was significantly lower in the UG group than in the CG group (mean 172 min; 95% confidence interval (CI): 151–194 min vs. mean 234 min; 95% CI: 216–252 min). The medical cost was also remarkably lower in the UG group than in the CG group (259 USD vs. 319 USD; p < 0.001). The incidence of complications within 30 days after visiting ED and missed or delayed high-risk diagnosis were not significantly different between the two groups. Conclusions: We found that protocolized point-of-care ultrasonography in patients with acute renal colic who visited the ED can more effectively reduce the length of stay and medical cost without 30-day complication than usual clinical practice.

ABSTRACT BACKGROUND Proficiency and self-confidence in the physical examination is poor among internal medicine residents and interest in ultrasound technology has expanded. OBJECTIVE We aimed to determine whether a pocket-sized ultrasound improves the diagnostic accuracy and confidence of residents after a 3-h training session and 1 month of independent practice. DESIGN This was a randomized parallel group controlled trial. PARTICIPANTS Forty internal medicine residents in a single program at an academic medical center participated in the study. INTERVENTION Three hours of training on use of pocket-sized ultrasound was followed by 1 month of independent practice. MAIN MEASURES The primary outcome was a comparison of the diagnostic accuracy of a physical exam alone versus a physical examination augmented with a pocket-sized ultrasound. Other outcomes included confidence in exam findings and a survey of attitudes towards the physical exam and the role of ultrasound. KEY RESULTS Residents in the intervention group using a pocket-sized ultrasound correctly identified an average of 7.6 of the 17 abnormal findings (accuracy rate of 44.9 %). Those in the control group correctly identified an average of 6.4 abnormal findings (accuracy rate of 37.6 %, p  = 0.11). Residents in the intervention group identified on average 15.9 findings as abnormal when no abnormality existed (false positive rate of 16.8 %). Those in the control group incorrectly identified an average of 15.5 positive findings (false positive rate of 16.3 %). There was no difference between groups regarding self-assessed confidence in physical examination. Residents in the intervention group identified 6.1 of 13 abnormal cardiac findings versus the control group’s 4.5 of 13, an accuracy rate of 47.0 % versus 34.6 % ( p  = 0.023). CONCLUSIONS The diagnostic ability of internal medicine residents did not significantly improve with use of a pocket-sized ultrasound device after a 3-h training session and 1 month of independent practice. Trial Registration: clinicaltrials.gov: number NCT01948076; URL http://clinicaltrials.gov/ct2/show/study/NCT01948076?term=ultrasound+physical+exam&rank=2

Purpose To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. Methods An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. Results The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. Conclusions These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Aim: To evaluate the effect of ultrasound (US) on learning curve and inter-subject performance variability of residents in radial artery cannulation.Material and methods: Twenty non-anesthesiology residents who received standardized training in an anesthesiology department were selected and divided into two groups: anatomy group or US group. After training of relevant anatomy, US recognition and puncture skill, residents selected 10 patients either under US or anatomical localization performing radial artery catheterization. The number and time of successful cases of catheterization were recorded, success rate of first attempt and catheterization, as well as the total success rate of catheterization were calculated. The learning curve and inter-subject performance variability of residents were also calculated. Complications and the residents’ satisfaction for teaching and self-confidence before puncture were also recorded.Results: Compared to the anatomy group, total success rate and the success rate at first attempt were higher in US-guided group (88% vs. 57%, 94% vs. 81%). The average performance time in the US group was significantly less (2.9±0.8 min vs. 4.2±2.1 min) and the mean number of attempts was 1.6, while 2.6 for the anatomy group. With performing cases increasing, the average puncture time of residents in the US group decreased by 19s, while 14s in the anatomy group. More local hematoma occurred in the anatomy group. The satisfaction and confidence degree of residents were higher in US group ([98.5±6.5] vs [68.5±7.3], [90.2±8.6] vs [56.3±5.5]).Conclusion: US can significantly shorten the learning curve, reduce the inter-subject performance variability, improve the first attempt and total success rate of radial artery catheterization for non-anesthesiology residents.

The diagnostic accuracy of ultrasonography for differentiating between benign and malignant adnexal masses is proportional to the expertise of the operator. However, we do not know whether improved diagnostic accuracy will affect the management of these tumours. We assessed the effect of the quality of gynaecological ultrasonography on the management of patients with suspected ovarian cancer in a randomised controlled trial. 165 patients who were referred to the regional gynaecological cancer centre at Guy's and St Thomas' NHS Foundation Trust (London, UK), between June 7, 2004, and April 23, 2006, with suspected adnexal tumours met the inclusion criteria. Of these, 150 patients were randomly assigned to either level II (routine) ultrasonography (n=73) or to level III (expert) ultrasonography (n=77). The primary endpoint was the number of major surgical staging procedures (including a laparotomy and at least an oophorectomy and omental biopsy) in each group of the study. Secondary endpoints were: total number of surgical procedures; number of minimally invasive procedures (eg, operative laparoscopy or ultrasonography-guided cyst aspiration); number of additional diagnostic tests (eg, CT or laparoscopy); number of follow-up scans; diagnostic accuracy of level II and level III ultrasonography; and duration of hospital stay. All analyses were by intention to treat. This study is registered on the Current Controlled Trials website http://www.controlled-trials.com/mrct/trial/230201/ISRCTN02631195. More major surgical staging procedures for suspected ovarian cancer were done in the level II group than in the level III group of the study (27 of 73 [37%] vs 17 of 77 [22%], respectively; difference between groups 15% [95% CI 0–29]; RR 1·68 [1·00–2·81]; p=0·049). The total number of surgical procedures was similar between the two groups: 35 of 73 (48%) in the level II group and 33 of 77 (43%) in the level III group (RR 1·12 [0·79–1·59]; p=0·53). The median duration of hospital stay for patients who were operated on was 6 days (range 3–13) in the level II group and 5 days (range 1–9) in the level III group (p=0·01). A likely histological diagnosis was provided to clinicians after ultrasonography for 76 of 77 (99%) patients in the level III group compared with only 38 of 73 (52%) patients in the level II group. 18 of 150 (12%) patients recruited were eventually diagnosed with ovarian malignancy. The sensitivity and specificity of ultrasonography was 2 of 5 (40%; [95% CI 6·5–84·6]) and 10 of 10 (100%; [34–100]), respectively, in the level II group and 7 of 8 (88%; [47–98]) and 27 of 28 (96%; [82–99]), respectively, in the level III group. Improved quality of ultrasonography has a measurable effect on the management of patients with suspected ovarian cancer in a tertiary gynaecology cancer centre, and results in a significant decrease in the number of major staging procedures and a shorter inpatient hospital stay.