Radiology-performed Ultrasonography Research Articles

Surgeon-performed ultrasound changes surgical management in patients with thyroid cancer.

A comprehensive neck ultrasound (US) is essential in the operative planning of patients with thyroid disease. Recent literature has shown surgeon-performed US (SUS) can be more accurate than radiology-performed US for the purpose of surgical planning. Missed findings on radiology-performed ultrasound may lead to inadequate surgical management. A retrospective cohort study of patients undergoing total thyroidectomy with lateral neck dissection for thyroid cancer, with both radiology-performed US and SUS performed by a Head and Neck surgeon. Ultrasound findings and adherence to American Thyroid Association (ATA) guidelines were compared, and changes in management based on SUS findings were identified. A total of 26 patients who underwent total thyroidectomy with lateral neck dissection met the inclusion criteria. Preconsultation US investigations fulfilled criteria as recommended by the American Thyroid Association (ATA) guidelines in 57.7%% of cases. The central and lateral neck compartments were assessed in 57.7% and 84.6% of preconsultation US investigations respectively. Central and lateral metastatic neck metastases were incorrectly reported or not reported in 78.6% and 42.3% of cases. The SUS findings prompted a change in surgical management in 65.4% of cases. SUS changed surgical management in two thirds (65.4%) of patients. Reliance on radiology-performed ultrasound alone may result in incorrect staging. Awareness of the additional benefits of SUS is important for surgeons treating patients with thyroid disease to prevent inadequate surgery being performed.

Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis

Chest ultrasonography has been reported as an accurate imaging modality and potentially superior to chest radiographs in diagnosing traumatic rib fractures. However, few studies have compared ultrasonography to the reference standard of computed tomography (CT), with no systematic reviews published on the topic to date. Our objective was to summarize the evidence comparing the test characteristics of chest ultrasonography to CT in diagnosing rib fractures. This study was performed and reported in adherence to PRISMA guidelines. We searched 5 databases plus gray literature from inception to October 2021. Two independent reviewers completed study selection, data extraction, and a QUADAS-2 risk of bias assessment. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model. From 1,660 citations, we identified 7 studies for inclusion, of which 6 had available 2×2 data for meta-analysis (n= 663). Of the 6 studies, 3 involved emergency department-performed ultrasonography and 3 radiology-performed ultrasonography. Chest ultrasonography had a pooled sensitivity of 89.3% (95% confidence interval [CI], 81.1 to 94.3) and specificity of 98.4% (95% CI, 90.2 to 99.8) compared with CT imaging for the diagnosis of any rib fracture. The finding of a fracture on ultrasonography, defined as an underlying cortical irregularity, was associated with a+likelihood ratio (LR) of 55.7 (95% CI, 8.5 to 363.4) for CT diagnosed rib fracture, while the absence of ultrasonography fracture held a -LR of 0.11 (95% CI, 0.06 to 0.20). We were unable to detect a difference in test characteristics between emergency department- and radiology-performed ultrasonography (P=.11). The overall risk of bias of included studies was high, with patient selection identified as the highest risk domain. Chest ultrasonography is both sensitive and highly specific in diagnosing rib fractures following blunt trauma.

Efficacy of surgeon performed ultrasound scan in localization of parathyroid adenomas in patients with primary hyperparathyroidism

Abstract Introduction The success of minimally invasive parathyroid surgery is largely based on accurate preoperative localization of parathyroid adenomas. In the U.K, NICE guidance recommends either ultrasound scanning alone or combined with sestamibi scintigraphy to help guide surgery. In the recent past, surgeon performed ultrasound (SUS) has been adopted in North America and Australia for preoperative localization with a sensitivity of 63–91%. This was equivalent or superior to radiology performed ultrasound (RUS). In comparison, data from the U.K for surgeon performed imaging is sparse. In this study, we investigate the efficacy of surgeon performed ultrasound in localization of parathyroid disease and discuss its cost benefits. Methods This is a prospective study with data collected from November 2019 to June 2021. All patients had primary hyperparathyroidism and underwent either MIBI, radiology performed ultrasound or both. A single experienced surgeon performed ultrasound on all patients under general anaesthesia. The intraoperative findings were used to determine the accuracy of all imaging techniques. Results A total of 46 patients underwent surgery and were found to have single gland disease. The categories were: Double imaging (n=17), MIBI (n=34), RUS (n=22), SUS(n=46), no imaging (n=9). MIBI, radiology performed ultrasound and surgeon performed ultrasound had sensitivities of 58%, 55% and 81% respectively. 8 patients had ectopic glands and were not included in the sensitivity analysis of ultrasound scans. Conclusion Surgeon performed ultrasound by an experienced provider is effective in localizing parathyroid adenomas and guides minimally invasive surgery. It could significantly reduce costs associated with outpatient radiology performed ultrasound scanning

Utility of Point of Care Ultrasound for Intussusception

Utility of Point of Care Ultrasound for Intussusception

Yield of Plain Radiography in Addition to Ultrasound Among Children with Hip Pain.

Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs. We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion. This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds. We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa=0.82). We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests

To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

A retrospective evaluation of point of care ultrasound for acute cholecystitis in a tertiary academic hospital setting

BackgroundIn 2008 the Council of Emergency Medicine Residency Directors delineated consensus recommendations for training in biliary ultrasound for the “detection of biliary pathology”.ObjectivesWhile studies have looked at the accuracy of emergency provider performed clinical ultrasound (ECUS), we sought to evaluated if ECUS could be diagnostic for acute cholecystitis and thus obviate the need for follow-up imaging.MethodWe reviewed all ECUS performed between 2012 and 2017 that had a matching radiology performed ultrasound (RADUS) and a discharge diagnosis. 332 studies were identified. The sensitivity and specificity of both ECUS and RADUS were compared to the patient’s discharge diagnosis. The agreement between the ECUS and RADUS was assessed using an unweighted Cohen’s Kappa. The time from patient arrival to diagnosis by ECUS and RADUS was also compared.ResultsUsing discharge diagnosis as the gold standard ECUS was 67% (56–78%) sensitive, 88% (84–92%) specific, NPV 90% (87–95%), PPV 60% (50–71%), +LR 5.6 (3.9–8.2), −LR 0.37 (0.27–0.52) for acute cholecystitis. RADUS was 76% (66–87%) sensitive, 97% (95–99%) specific, NPV 95% (092–97%), PPV 86% (76–95%), +LR 25.6 (12.8–51.4), and −LR 0.24 (0.15–0.38). ECUS was able to detect gallstones with 93% (89–96%) sensitivity and 94% (90–98%) specificity leading to a NPV 90% (85–95%), PPV of 95% (92–98%), +LR 14.5 (7.7–27.4), −LR 0.08 (0.05–0.13). The unweighted kappa between ECUS and RADUS was 0.57. The median time between obtaining ECUS vs. RADUS diagnosis was 124 min.ConclusionsECUS can be beneficial in ruling out acute cholecystitis, but lacks the test characteristics to be diagnostic for acute cholecystitis.

Agreement of emergency physician-performed ultrasound versus RADiology-performed UltraSound for cholelithiasis or cholecystitis: a systematic review.

Cholecystitis secondary to gallstone migration is the most common suspected diagnosis for right upper quadrant pain in emergency departments, with radiology-performed ultrasound (RADUS) being the main diagnostic tool. The primary aim of this review was to assess the ability of emergency physicians to perform emergency ultrasound (EUS) compared to RADUS to diagnose cholelithiasis and cholecystitis. A systematic search was performed using Embase, Central (Cochrane library), Web of Science, MEDLINE, Google Scholar, prospective trial registries, and OpenSIGLE databases as well as hand-search of articles. Two physicians independently selected the articles. Assessment of methodological quality was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Clinical and methodological heterogeneity were qualitatively reported and discussed. Seven prospective studies were selected involving a total of 1061 subjects undergoing EUS. The included studies all used RADUS as the reference standard and emergency physician-performed EUS as the index test. Included studies mostly reported diagnostic accuracy for cholelithiasis diagnosis whereas only one study mentioned diagnostic accuracy for cholecystitis. Clinical and methodological heterogeneity between included studies prevented a meta-analysis. This review shows there is good agreement between EUS and RADUS to assess the gallbladder for cholelithiasis and therefore supports its use by emergency physicians for that matter. Nevertheless, this work identified clinical and methodological heterogeneity along with a poor description EUS operators' experience. In the future, larger studies should include a larger population of EUS operators, specify their background, and compare EUS to the final diagnosis to evaluate performances for gallbladder diagnostic accuracy.

349 Comparison of Common Bile Duct Measurement by Point-of-Care Ultrasound to Radiology-Performed Ultrasound

Exact incidence of common bile duct (CBD) stones is not known, but they have been found in 10-18% of patients undergoing cholecystectomies. They are associated with significant morbidity, resulting in pancreatitis or cholangitis if left untreated. Unfortunately, physical exam and lab tests are unreliable in detecting CBD stones. Limited data exists evaluating the use of point-of-care ultrasound (POCUS) in the emergency department (ED) to evaluate for CBD stones. Our objective was to evaluate the accuracy of CBD diameter measured on POCUS compared to radiology-performed ultrasound. In this retrospective chart review of one academic medical institution, we analyzed 4.5 years of POCUS data to find all cases where CBD dilation was measured and documented by an emergency physician in a POCUS report. We compared these results to radiology-performed ultrasound results of those same patients and compared the two values using paired Student’s T-test to test for significance, mean absolute error (MAE), and Pearson’s correlation coefficient. A total of 126 potential cases of CBD dilation were identified based on POCUS reports that had CBD dilation recorded. Of these, 53 (42%) had radiology imaging studies performed. Thirty-nine (74%) of those included were female. The mean CBD diameter measured on POCUS was 7.61mm (range: 1.3-16.8mm). The mean CBD diameter measured on formal radiology studies for these same patients was 7.34mm (range: 1.0-16.0mm). The two means were not significantly different by paired Student’s T-test (p = 0.63). However, mean absolute error between the two samples was 2.73mm. Pearson’s correlation coefficient was 0.27 (with +1/-1 indicating perfect correlation). While there was not a significant difference between the two samples’ means, there was poor agreement between POCUS and formal radiology US in the evaluation of CBD diameter. We cannot conclude that the two modalities are equivalent in their ability to accurately measure CBD diameter at this time. Limitations of this study include: retrospective chart review with small sample size and no standardization in the qualifications of the physicians performing the POCUS. Future work should include prospective cases and explore how ED providers who receive standardized POCUS training perform versus radiology-performed US for the measurement of CBD diameter.

Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department.

Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED). The study sample consisted of patients aged>18 years who presented to the ED with abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0= not present, 100= certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared. A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI]= 87.2%-95.8%), 95.8% (89.5%-98.8%), 21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range [IQR]= 50-65) and 95 (IQR= 20-98), respectively (p=0.000). Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs.

My patient has abdominal and flank pain: Identifying renal causes.

Acute flank and abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound (PoCUS), emergency physicians have an added tool to help identify renal problems as a cause of a patient's pain. PoCUS for hydronephrosis has a sensitivity of 72-83.3% and a varying specificity, similar to radiology-performed ultrasonography. In addition to assessment for hydronephrosis, PoCUS can help emergency physicians to exclude other serious causes of flank and abdominal pain such as the presence of an abdominal aortic aneurysm, or free fluid in the intraperitoneal space, which could represent hemorrhage. Use of PoCUS for the assessment of flank pain has resulted in more rapid diagnosis, decreased use of computed tomography, and shorter emergency department length of stay.

My patient has got abdominal pain: identifying biliary problems.

Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient's right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4-92.5%) and specificity of 88.0% (83.7-91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.

Emergency Physician–performed Ultrasound to Diagnose Cholelithiasis: A Systematic Review

The authors sought to determine the diagnostic test characteristics of bedside emergency physician (EP)-performed ultrasound (US) for cholelithiasis in symptomatic emergency department (ED) patients. A search was conducted of MEDLINE, EMBASE, the Cochrane Library, bibliographies of previous systematic reviews, and abstracts from major emergency medicine conference proceedings. We included studies that prospectively assessed the diagnostic accuracy of emergency US (EUS) for cholelithiasis, compared to a criterion reference standard of radiology-performed ultrasound (RADUS), computed tomography (CT), magnetic resonance imaging (MRI), or surgical findings. Two authors independently performed relevance screening of titles and abstracts, extracted data, and performed the quality analysis. Disagreements were resolved by conference between the two reviewers. EUS performance was assessed with summary receiver operator characteristics curve (SROC) analysis, with independently pooled sensitivity and specificity values across included studies. The electronic search yielded 917 titles; eight studies met the inclusion criteria, yielding a sample of 710 subjects. All included studies used appropriate selection criteria and reference standards, but only one study reported uninterpretable or indeterminate results. The pooled estimates for sensitivity and specificity were 89.8% (95% confidence interval [CI] = 86.4% to 92.5%) and 88.0% (95% CI = 83.7% to 91.4%), respectively. This study suggests that in patients presenting to the ED with pain consistent with biliary colic, a positive EUS scan may be used to arrange for appropriate outpatient follow-up if symptoms have resolved. In patients with a low pretest probability, a negative EUS scan should prompt the clinician to consider an alternative diagnosis.

Ultrasonography in Community Emergency Departments in the United States: Access to Ultrasonography Performed by Consultants and Status of Emergency Physician-Performed Ultrasonography

Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians. A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004. Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed. Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.

Accuracy of Surgeon‐performed Ultrasound in Parathyroid Localization

Ultrasound is one of the preferred modalities for localization of abnormal parathyroids. Accuracy of ultrasound is technician-dependent. This study was undertaken to determine the accuracy of surgeon-performed ultrasound (SPU) for the localization of parathyroid tumors in comparison to radiology-performed ultrasound (RPU) and nuclear scintigraphy (NS). In this series 74 consecutive patients with untreated primary hyperparathyroidism underwent SPU at the initial clinic visit; 21 of these patients did not undergo surgery and are excluded from the analysis. Of the 53 patients remaining, RPU was obtained in 26, and 52 patients underwent NS. Directed parathyroidectomy was performed with use of the intraoperative parathyroid hormone assay (IOPTH). In all, 46 patients had a single adenoma as indicated by IOPTH and final pathology. Two patients had double gland disease, and 5 patients had multi-gland hyperplasia. The sensitivity of SPU was 82% and the specificity was 90% in detecting the diseased glands on the correct side (right versus left). The sensitivity for RPU was 42% and the specificity was 92% (n = 26). The sensitivity of NS was 44% and the specificity was 98% (n = 52). In only one case did RPU or NS detect a gland not found by SPU. SPU can be done with accuracy comparable to other ultrasound series in the literature, and it may be superior to RPU or NS in some institutions. It is important for surgeons to be aware of local institutional expertise when relying on RPU and NS during preoperative evaluation prior to directed parathyroidectomy.

A retrospective analysis of the use of bedside ultrasonography in the diagnosis of acute appendicitis

Study objectives: Acute appendicitis is the most common abdominal surgical emergency. The main factor that leads to perforation is time delay to diagnosis. With increasingly overburdened emergency departments (EDs) already relying heavily on radiology performed imaging studies, the time savings of bedside ultrasonography to obtain a diagnosis of appendicitis would be valuable. The aim of this project is to determine whether emergency physicians who have skills in the other applications of ultrasonography could apply these to diagnosing appendicitis. No physician was instructed on the use of ultrasonography for appendicitis. No previous study has been published in the United States about the use of bedside ultrasonography in the diagnosis of appendicitis. Methods: All physicians in this study perform ultrasonography at the bedside for various applications, including aorta, renal, focused abdominal sonography for trauma, pelvic, procedure guidance, and cardiac. No physician had focused training, lectures, seminars, or hands-on experience in the use of bedside ultrasonography for appendicitis. All patients received at least 1 of the following: radiology-performed ultrasonography, computed tomographic (CT) scan, laparoscopy, or direct surgical exploration. Patients discharged home from the ED without an imaging study done by the department of radiology, or surgical exploration, were not considered for data analysis. Surgeons and radiologists were not blinded to the results of the bedside ultrasonography. Results: A total of 186 bedside ultrasonographic examinations for appendicitis were performed between January 2002 and January 2004. There were 27 cases in which the bedside ultrasonograph was positive and agreed with the surgical pathology report (true positives). There were 42 cases in which bedside ultrasonography was unable to visualize the appendix that ultimately proved positive for appendicitis by surgical pathology (false negatives). There were 108 cases in which bedside ultrasonography was unable to visualize the appendix (true negatives). In 9 cases, bedside ultrasonography suggested appendicitis, but CT scan with surgical consultation concluded no evidence of appendicitis (false positives). The sensitivity and specificity of bedside ultrasonography to diagnose appendicitis was 39% (95% confidence interval [CI] 27% to 51%) and 92% (95% CI 86% to 96%), respectively. The positive and negative predictive values were 19% (95% CI 14% to 25%) and 80% (95% CI 74% to 86%), respectively. Conclusion: The results from 186 patients enrolled retrospectively suggest that emergency physicians without focused training may only be able to use bedside ultrasonography as a limited screening modality in the evaluation of patients for right lower quadrant pain. With further training focusing on the use of ultrasonography in the right lower quadrant, emergency physicians may be able to reduce the time, costs, and morbidity associated with delayed diagnosis of this common surgical emergency.

Biliary ultrasonography for cholelithiasis: A retrospective analysis of the first two years of an emergency ultrasonography training program

Study objectives: Traditional diagnostic evaluation for patients presenting to the emergency department (ED) with right upper quadrant (RUQ) pain involves an ultrasonography performed by a sonographer and interpreted by a radiologist, which can result in long delays, higher costs, and patient dissatisfaction. Emergency physicians performing the initial RUQ ultrasonography to investigate for cholelithiasis can potentially shorten this evaluation. Previous studies in the emergency medicine literature report the accuracy of emergency physicians performing RUQ ultrasonography but have relatively small sample sizes. The study objective is to analyze the accuracy of bedside RUQ ultrasonography for evaluation of cholelithiasis by emergency physicians. Methods: A retrospective study was conducted on patients presenting to the ED who received a focused RUQ ultrasonography performed by an emergency medicine resident or attending physician between July 2001 and November 2003 in our urban, university, Level I trauma center. Physicians performing bedside ultrasonography were given various lectures on abdominal ultrasonography, including hands-on practice with quality assurance follow-up of videotaped scans. Emergency ultrasonographic examinations were performed using a 3.5-Mhz microconvex probe. All scans included in this study were reviewed by the quality assurance committee consisting of an emergency ultrasonography fellowship–trained attending physician and an emergency ultrasonography fellow. The quality assurance committee was blinded to the findings of the radiology ultrasonographs. Emergency ultrasonographic findings were limited to the presence or absence of gallstones. Three sets of comparisons were made: (1) emergency ultrasonographic findings versus the ED quality assurance committee's findings; (2) emergency ultrasonographic findings versus the radiology ultrasonographic findings; and (3) ED quality assurance committee's findings versus the radiology ultrasonographic findings. Results: Of a total of 1,577 emergency RUQ ultrasonographs during the study period, a total of 1,191 scans met inclusion criteria. Three hundred eighty-six scans were excluded because of documentation errors and poor image quality. Overall, 411 (35%) patients were confirmed to have gallstones, and 780 (65%) were without gallstones. Emergency resident interpretation had an 88% sensitivity, 97% specificity, and 93% accuracy when compared when compared with the ED quality assurance committee's findings. Of the 1,191 patients in the study, 429 (36%) patients also had a radiology ultrasonograph. From these, 257 (60%) patients were confirmed to have gallstones, and 172 (40%)patients were without gallstones. Compared with a radiology ultrasonograph as the criterion standard, emergency resident interpretation had an 88% sensitivity, 87% specificity, and 88% accuracy. When comparing the ED quality assurance committee's findings of this same subset against the radiology ultrasonograph (the criterion standard), the ED quality assurance committee was found to have a 91% sensitivity, 91% specificity, and 91% accuracy. Conclusion: Emergency bedside RUQ ultrasonography is an effective method of diagnosing cholelithiasis. Emergency physicians with a moderate amount of training have a high sensitivity and specificity for diagnosing cholelithiasis compared with radiology-performed ultrasonography. Furthermore, we demonstrate that review of recorded ultrasonographs from the ED by a fellowship-trained quality assurance committee can increase the accuracy of diagnosing cholelithiasis and serve as an important educational tool. These data add to a growing support for the use of bedside ultrasonography in the ED.

Access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians in community emergency departments

Study objectives: Nearly all emergency medicine residency programs provide some training in emergency physician–performed ultrasonography, but the extent of emergency physician–performed ultrasonography in community emergency departments (EDs) is unknown. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians.Methods: A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician–performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. One thousand two hundred out of 5,264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from fall 2003 to spring 2004.Results: The response rate was 61%. Respondents were predominantly community EDs (88%). EDs reported being requested or required to limit ultrasonographic orders in 40% of EDs, whereas 40% of EDs described access to radiology-performed ultrasonography as “always easily available.” Ultrasonography was available in the ED for use by emergency physicians at all times in 23% of EDs, with 10% reporting a machine available from radiology for use by emergency physicians. Of EDs with emergency physician–performed ultrasonography, the most common applications were focused abdominal sonography for trauma examination (82%), code situation (77%), and check for pericardial effusion (75%). Of those performing ultrasonography, 21% stated they were currently requesting reimbursement (billing). Of those performing ultrasonography but not billing, 47% reported plans to begin billing. Ultrasonography was unavailable for use by emergency physicians in 63% of EDs. Of those who did not have ultrasonography, 40% reported plans to obtain ultrasonography for use by emergency physicians. The top 2 reasons cited for not implementing emergency physician–performed ultrasonography were lack of emergency physician training (57%) and resistance from radiology (42%). In regard to the statement “emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasound,” 85% of ED directors agreed, 14% were neutral, and less than 2% disagreed.Conclusion: A minority of community EDs have easily available access to ultrasonography performed by other specialists. Approximately one third of community EDs report ultrasonography available for use by emergency physicians; of those who do not, nearly half intend to obtain ultrasonography for use by emergency physicians. A majority of community ED directors support residency training in emergency physician–performed ultrasonography.

Emergency surgeon-performed hepatobiliary ultrasonography.

Acute hepatobiliary pathology is a common general surgical emergency referral. Diagnosis requires imaging of the biliary tree by ultrasonography. The accuracy and impact of surgeon-performed ultrasonography (SUS) on the diagnosis of emergent hepatobiliary pathology was examined. A prospective study, over a 6-month period, enrolled all patients with symptoms or signs of acute hepatobiliary pathology. Patients provided informed consent and underwent both SUS and standard radiology-performed ultrasonography (RUS). SUS was performed using a 2-5-MHz broadband portable ultrasound probe by two surgeons trained in ultrasonography, and RUS using a 2-5-MHz fixed unit. SUS results were correlated with those of RUS and pathological diagnoses. Fifty-three consecutive patients underwent 106 ultrasonographic investigations. SUS agreed with RUS in 50 (94.3 per cent) of 53 patients. SUS accurately detected cholelithiasis in all but two cases and no patient was inaccurately diagnosed as having cholelithiasis at SUS (95.2 per cent sensitivity and 100 per cent specificity). As an overall complementary diagnostic tool SUS provided the correct diagnosis in 96.2 per cent of patients. Time to scan was significantly shorter following SUS (3.1 versus 12.0 h, P < 0.05). SUS provides a rapid and accurate diagnosis of emergency hepatobiliary pathology and may contribute to the emergency management of hepatobiliary disease.

Six of the Best, General 21

Aims: Acute hepatobiliary pathology is a common general surgical emergency, and diagnosis requires imaging of the biliary tree by ultrasound. Herein, we examine the accuracy and impact of surgeon-performed ultrasound (SUS) on the diagnosis of emergent hepatobiliary pathology. Methods: This prospective study, over a 6-month period, enrolled all patients with symptoms or signs of acute hepatobiliary pathology. Patients provided informed consent and underwent both SUS and standard radiology-performed ultrasound (RUS). SUS was performed using a 2–5 MHz broadband portable ultrasound probe by two surgeons trained in ultrasound and RUS using a 2–5 MHz fixed unit. SUS results were correlated with RUS and pathological diagnoses. Results: Fifty-three consecutive patients received a total of 106 ultrasound investigations. SUS agreed with RUS in 50 of the 53 patients (94.3 per cent). SUS accurately detected cholilithiasis in all but two cases and no patients were inaccurately diagnosed to have cholilithiasis at SUS (95 per cent sensitivity and 100 per cent specificity). As an overall complimentary diagnostic tool, SUS provided the correct diagnosis in 94 per cent of the patients. Time to scan was significantly shorter following SUS (3.07 h versus 12 h, P < 0.05). Conclusions: SUS offers excellent alacrity in the diagnosis of emergency hepatobiliary pathology. SUS may be a useful adjuvant in the emergency management of hepatobiliary disease.