Ultrasound Views Research Articles

Cannulation needle-induced anterior wall tenting of internal jugular vein causing posterior wall penetration.

Unintentional posterior venous wall penetration during internal jugular vein (IJV) cannulation may cause critical arterial injuries in spite of ultrasound guidance. We aimed to evaluate whether small venous diameter and anterior venous wall tenting by a needle would be associated with posterior venous wall penetration, and to seek factors related to the venous wall tenting. We conducted a retrospective review in patients who underwent IJV cannulation. Using an ultrasound view obtained when puncturing, venous diameter, venous wall thickness, anterior venous wall tenting length, and needle angle were measured, and posterior venous wall penetration was determined. Eleven cannulations in 56 patients were assigned to posterior venous wall penetration. Small venous diameter (p = 0.004), and long anterior venous wall tenting (p = 0.007) were associated with posterior venous wall penetration. The longer anterior venous tenting would be expected with reducing needle angle (p = 0.004) or increasing anterior venous wall thickness (p = 0.006). In conclusion, small IJV and anterior venous wall tenting lead to posterior venous wall penetration. Anterior venous wall tenting is longer with reducing needle angle, or increasing the anterior venous wall thickness.

Forward-viewing linear echoendoscope: a new option in the endoscopic ultrasound armamentarium (with video).

The forward-viewing linear echoendoscope (FV-EUS) has been developed with the aim of overcoming limitations of standard curved linear-array echoendoscopes (CLA-EUS) and to further expand interventional applications of EUS. The main characteristic of the FV-EUS is a shifting in the orientation of both endoscopic and ultrasound views from oblique to forward, with the exit of the working channel at the tip of the instrument. This allows exit of the devices parallel to the longitudinal axis of the endoscope, thus resulting in a more direct and stable access to the lesion while increasing the precision and force applied to the target. Accumulating evidence has shown that the FV-EUS can be used instead of the standard CLA-EUS scope for routine fine needle aspiration, with extremely good performance for subepithelial lesions and for difficult to reach locations. Several areas of use of this echoendoscope are yet to be better defined, such as its potential for therapeutic and interventional procedures, as well as for natural orifice transluminal endoscopic surgery. The current report provides an updated overview of the available evidence for both diagnostic and interventional uses of the FV-EUS.

Summative clinical competency assessment: A survey of ultrasound practitioners' views.

Clinical competency and the assessment of core skills is a crucial element of any programme leading to an award with a clinical skills component. This has become a more prominent feature of current reports on quality health care provision. This project aimed to determine ultrasound practitioners' opinions about how best to assess clinical competency. An on-line questionnaire was sent to contacts from the Consortium for the Accreditation of Sonographic Education and details distributed at the British Medical Ultrasound Society conference in 2011. One hundred and sixteen responses were received from a range of clinical staff with an interest in ultrasound assessment. The majority of respondents suggested that competency assessments should take place in the clinical departments with or without an element of assessment at the education centre. Moderation was an important area highlighted by respondents, with 84% of respondents suggesting that two assessors were required and 66% of those stating some element of external moderation should be included. The findings suggest that respondents' preference is for some clinical competency assessments to take place on routine lists within the clinical department, assessed by two people one of which would be an external assessor. In view of recent reports relating to training and assessment of health care professionals, the ultrasound profession needs to begin the debate about how best to assess clinical competence and ensure appropriate first post-competency of anyone undertaking ultrasound examinations.

Could all coarctation of the aorta be identified at prenatal ultrasound?

Screening for coarctation of the aorta (CoA) during fetal ultrasound (US) in a low-risk population is based on the great vessels asymmetry (GVA) with small aorta. Over the last ten years, our screening rate was 49%. Some of the undetected CoA, that we had in care, seemed to us, to the view of the postnatal US, identifiable during pregnancy. We sought to assess the possible performance of fetal cardiac screening of CoA in an unselected population by the evaluation of aortic valve size measurement. We retrospectively analysed data from 199 neonates born after 32 weeks of gestation between January 2003 and December 2012: 77 were diagnosed for CoA among them 38 were prenatally considered at risk, 122 were referred in utero due to GVA to evaluate during pregnancy the risk of CoA after birth, but did not developed CoA. We compared them to a control group of 166 patients without significant congenital heart disease. US aortic annulus valve (AVA) sizes were measured (as we did prenatally) in parasternal long axis view between hinge points during systole and normalized to body size with Pettersen's Z-score equation. Mean AVA Z-scores were −0,05 in the controls, −1 in the GVA and −2,4 in the CoA group. AVA Z-scores were significantly smaller in the CoA group than in the control ( P < 0.05) and in the GVA group ( P < 0.05). The best cut-off point for Coa discrimination with ROC analysis was a Z-score of −1,84. Among the 39/77 CoA not identified prenatally, 19 had a Z-score < −2 and should probably have been identified. Five had a Z-score > −0,05 and could not be diagnosed. This study confirms that aortic annulus of newborns with CoA are significantly smaller than those with normal or even asymmetric in late pregnancy hearts. Although, on that basis alone, it is not possible to identify before birth all newborns who will develop CoA, as at least 6.5% presented CoA despite a normal AVA Z-score.

Feasibility of prediction of cesarean section scar dehiscence in the third trimester by three-dimensional ultrasound

Purpose: To assess the role of three-dimensional (3D) ultrasound mutiplanar view in prediction of cesarean section (CS) scars dehiscence.Subjects and methods: One hundred pregnant women with previous CS scars were investigated by ultrasound to measure the scar thickness by 2D ultrasound and to depict the uterine wall by 3D coronal plane, using 3D multiplanar view. Straight line cut section by 3D multiplanar view was used and prediction of dehiscence was by detecting fenestration of the wall.Results: Operative findings revealed that 95 cases (95%) of the studied group had intact uterine scar, while dehiscence was detected among five ladies (5%). Validity of 3D U/S versus operative findings revealed a sensitivity of 83.3%, specificity 100%, positive predictive value 100%, negative predictive value 99% and accuracy 99%. C technique was superior to straight line technique in multiplanar view for assessment of the scars.Conclusion: Three-dimensional ultrasound is useful in prediction of dehiscent scars during pregnancy with perfect sensitivity. Machines with the availability of C dissection in the multiplanar view are more useful in this field.

Embryo catheter loading and embryo culture techniques: results of a worldwide Web-based survey.

To identify trends in embryo catheter loading and embryo culture techniques performed worldwide. A retrospective evaluation using the results of a web-based survey, (IVF Worldwide ( www.IVF-worldwide.com ), was performed. Responses from 265 centers in 71 countries were obtained. Most centers (97 %) preferred a catheter with its orifice on top, with only 3 % preferring a catheter with the orifice on its side; 41 % preferred a catheter marked for clear ultrasound view. The most commonly-reported methods of embryo loading were medium-air-embryo-air-medium (42 %), medium in catheter with embryo at end (20 %) and medium-air-embryo (15 %). In 68 % of centers the final volume of the catheter was up to 0.3 ml, with only 19 % using 0.3-0.5 ml and 1 % using 0.5-0.7 ml. Using reduced oxygen concentrations for embryo culture was divided between those who used it in combination with the two-gas system (34 %) and those who did not use it at all (39 %); 24 % reported using a three-gas system. Most clinics using reduced oxygen concentrations used it throughout the entire culture period. Half of centers (51 %) reported using reduced oxygen concentrations for the entire IVF population while 6 % reserved it only for blastocyst transfer. The use of sequential media was highly dominant with 40 % reporting its use.

Radial Probe Endobronchial Ultrasound for Peripheral Pulmonary Lesions. A 5-Year Institutional Experience

Technological advances have improved the ability of bronchoscopists to access peripheral pulmonary lesions for tissue sampling. Radial probe endobronchial ultrasound (EBUS) provides real-time feedback to guide biopsies of peripheral lesions, thereby potentially improving diagnostic yield over conventional bronchoscopy. We assessed the overall diagnostic yield of peripheral bronchoscopy using radial probe EBUS for peripheral pulmonary lesions, as well as factors that might influence the diagnostic yield, such as radial ultrasound view, lesion size, and ability to locate the peripheral lesion. We conducted a retrospective review of peripheral bronchoscopy cases in which radial probe EBUS was utilized to diagnose peripheral pulmonary lesions at a tertiary care university hospital. Our study cohort comprised 496 patients who underwent bronchoscopies between January 2008 and December 2012 for the diagnosis of peripheral pulmonary lesions. Radial probe EBUS was used alone for diagnostic purposes in 467 patients. A diagnosis was made on that basis in 321 (69%) of 467 patients. A diagnosis was obtained for 83 of 144 (58%) of nodules 1-2 cm in diameter, 99 of 137 (72%) of nodules 2.1-3 cm, 54 of 70 (77%) of nodules 3.1-4 cm, 41 of 47 (87%) of nodules 4.1-5 cm, and 35 of 40 (88%) of nodules larger than 5.1 cm. Of all 467 nodules, 446 (96%) were successfully identified using radial probe EBUS. When the radial probe position was within the target lesion, the diagnostic yield was 84% compared with 48% when the probe was positioned adjacent to the lesion. Radial probe EBUS can be used to guide biopsy during peripheral bronchoscopy. This technique provides real-time ultrasound-based confirmation of target lesion localization prior to biopsy. Using radial probe EBUS, the vast majority of peripheral pulmonary nodules can be identified. Radial EBUS probe position relative to the target lesion significantly affects the diagnostic yield.

Bilateral hypoplasia of the minor tubercle of the humerus with medial luxation of the biceps tendon in two Quarter Horses

Summary Two Quarter Horses were examined at the Washington State University Veterinary Teaching Hospital with forelimb lameness. Case 1 was a 4-year-old female with a 4 month history of intermittent forelimb lameness that had partially responded to oral anti-inflammatories. The horse was in full training and actively competing in cutting. Case 2 was a one-year-old filly bred for cutting that presented with a right forelimb lameness of 3 weeks’ duration, which was not responsive to oral anti-inflammatories. The horse was not in training. On lameness examination, Case 1 was grade 1/5 (American Association of Equine Practitioners scale) lame in the left forelimb in a straight line on a hard surface, extension and flexion of the shoulder was resented and exacerbated the lameness. Case 2 was grade 3/5 lame in the right forelimb in a straight line on a hard surface, flexion and extension of the shoulder was resented and exacerbated the lameness. Both horses had a characteristic dished appearance to the dorsal aspect of the shoulder, with prominence of the proximal aspect of the humerus. Ultrasound and proximodistal oblique (skyline) radiographic views of the scapulohumeral joints demonstrated bilateral hypoplasia of the minor tubercle of the humerus with bilateral medial luxation of the proximal biceps tendon in both cases. To the authors' knowledge this is the first report of 2 cases of bilaterally affected horses, as well as the first report of the condition in the Quarter Horse breed.

Abdominal Ultrasound and Medical Education

Abstract Introduction Ultrasound is a very versatile diagnostic modality that permits real-time visualization of multiple internal organs. It is of invaluable help for the physical examination of the patients. Aim To assess if ultrasound can be incorporated into medical education and if the students can perform a basic abdominal ultrasound examination without the necessity of a long period of training. Methodology Twelve medical students were trained in basic abdominal ultrasound during a 15-h training program including a 5-h theoretical and practical course and supervised practice in 20 selected patients. Subsequently, we conducted an evaluation test that assessed the ability of students to obtain the ultrasound views and to detect various pathologies in five different patients. Results The students were able to correctly identify the abdominal views more than 90% of the times. This percentage was only lower (80%) in the right subcostal view to locate the gallbladder. The accuracy or global efficiency of the ultrasound for the diagnosis of relevant pathological findings of the patients was greater than 90% (91.1% gallstones, abdominal aortic aneurysm 100%; splenomegaly 98.3%, ascites 100%; dilated inferior vena cava 100%; acute urinary retention 100%). Conclusion The ultrasound may be a feasible learning tool in medical education. Ultrasound can help students to improve the physical examination.

Serial High-Resolution Ultrasound Findings of Acute Nasal Fracture: A Potential Implication to Predict the Time of Facial Injury

Background: Despite the fact that physical examination is the gold standard for diagnosing nasal fractures, high-resolution ultrasonography can also be used as a noninvasive method to evaluate facial injuries especially in legal cases with old nasal trauma and also for medico-legal purposes to determine whether the findings are of recent onset. Objectives: The aim of this study was to investigate the ultrasound findings of nasal fracture over time. Patients and Methods: Thirty-six patients with the diagnosis of nasal fracture according to their physical examinations were enrolled in the current study. All patients underwent nasal bone ultrasound, and both longitudinal and transverse views were obtained and evaluated by an expert radiologist using a SonixOP system (Ultrasonix Medical Corporation, Richmond, Canada). The first ultrasound exam was performed within the first five days of nasal trauma, and the follow-up studies were done 3, 6, 12, and 24 weeks after the trauma. Any abnormality in the nasal bone, including subperiosteal hematoma, nasal bone stepping, and hypoechoic/anechoic fracture lines were searched for on ultrasound investigation. Results: We found that in the first sonographic investigation, the sensitivities of subperiosteal hematoma, lucency in the lateral nasal bone, and nasal bone stepping were 100%, 90.32%, and 77.42%, respectively for the diagnosis of recent fracture. During the first three weeks after nasal trauma, subperiosteal hematoma and lucency in the lateral nasal bone had the highest diagnostic values which were statistically significant (P < 0.0001). The predictive values of subperiosteal hematoma and lateral nasal bone lucency in sonographic investigation for estimating the time of nasal trauma were 86.3% and 67.7%, respectively. Furthermore, in the performed serial ultrasound exams, subperiosteal hematoma and lucency in the lateral nasal bone were persistent for 25 and 85 days, respectively. Conclusions: High-resolution ultrasound can be helpful to diagnose nasal fracture and to estimate the actual time of nasal bone fracture. The latter has potential implications in forensic medicine to predict the time of facial injury, e.g. a patient with a nasal fracture between 25 and 85 days ago may have lucency in the lateral nasal bone with no subperiosteal hematoma.

The right supraclavicular ultrasound view for real-time ultrasound-guided definite placement of a central venous catheter with a microconvex transducer

The right supraclavicular ultrasound view for real-time ultrasound-guided definite placement of a central venous catheter with a microconvex transducer

Relationship Between Ultrasound Viewing and Proceeding to Abortion

Ultrasound scanning is a routine part of preprocedure abortion care, and many health care providers offer patients the opportunity to view their ultrasound images. It has been speculated that ultrasound viewing will dissuade women from having an abortion. We examine whether viewing the image is associated with choosing to continue the pregnancy. Data from medical records for 15,575 visits by women seeking abortion care at a large, urban abortion provider in 2011 were analyzed for factors associated with choosing to continue the pregnancy. All patients received a preprocedure ultrasound scan and were offered the opportunity to view the image. Patients opted to view the ultrasound image 42.5% of the time. Nearly all pregnancies (98.8%) were terminated: 98.4% of pregnancies among women who viewed their ultrasound images and 99.0% of pregnancies among the patients who did not. Among women with high decision certainty, viewing was not associated with deciding to continue the pregnancy. Viewing was significantly associated with deciding to continue the pregnancy only among the 7.4% of women who reported medium or low decision certainty about having an abortion (adjusted odds ratio 3.21, 95% confidence interval 1.18-8.73). Voluntarily viewing the ultrasound image may contribute to a small proportion of women with medium or low decision certainty deciding to continue the pregnancy; such viewing does not alter decisions of the large majority of women who are certain that abortion is the right decision. II.

Ultrasound-guided anterior axilla musculocutaneous nerve block

This paper presents a technique of ultrasound-guided localisation and block of the musculocutaneous nerve through the anterior wall of the axilla. Twenty patients (7 males and 13 females; mean age, 35years) had axillary nerve block for upper extremity trauma. With the arm adducted, the ultrasound probe was positioned on the anterior axillary wall; the axillary artery, coracobrachialis and pectoralis major muscles and lateral cord of brachial plexus were visualised in cross section. With continuous imaging of the axillary artery in cross section, the ultrasound probe was slowly moved towards the biceps muscle until the musculocutaneous nerve appeared crossing the coracobrachialis muscle. After ultrasound localisation of the musculocutaneous nerve, the arm was abducted and externally rotated, and the nerve was identified with nerve stimulation and blocked. The quality of sensory and motor nerve block, as well as of ultrasound imaging were evaluated. Ultrasound-guided block of the musculocutaneous nerve was excellent and complete in 18 of the 20 patients. In two patients, the musculocutaneous nerve was fused with the median nerve and the nerve block was repeated successfully with the same technique. The quality of ultrasound imaging was excellent in all patients. No patient experienced pain or tourniquet discomfort during surgery, or any other nerve block-related complication. The anterior axillary ultrasound view provides for complete nerve block and imaging of the entire course of the musculocutaneous nerve and its relations with adjacent structures with excellent quality.

Ecografía clínica abdominal y educación médica

IntroductionUltrasound is a very versatile diagnostic modality that permits real-time visualization of multiple internal organs. It is of invaluable help for the physical examination of the patients. AimTo assess if ultrasound can be incorporated into medical education and if the students can perform a basic abdominal ultrasound examination without the necessity of a long period of training. MethodologyTwelve medical students were trained in basic abdominal ultrasound during a 15-hour training program including a 5-hour theoretical and practical course and supervised practice in 20 selected patients. Subsequently, we conducted an evaluation test that assessed the ability of students to obtain the ultrasound views and to detect various pathologies in five different patients. ResultsThe students were able to correctly identify the abdominal views more than 90% of the times. This percentage was only lower (80%) in the right subcostal view to locate the gallbladder. The accuracy or global efficiency of the ultrasound for the diagnosis of relevant pathological findings of the patients was greater than 90% (91.1% gallstones, abdominal aortic aneurysm 100%; splenomegaly 98.3%, ascites 100%; dilated inferior vena cava 100%; acute urinary retention 100%). ConclusionThe ultrasound may be a feasible learning tool in medical education. Ultrasound can help students to the improve the physical examination.

Ultrasound-guided intrathecal anesthesia: Does scanning help?

Intrathecal anesthesia is widely used for many surgical procedures. Multiple attempts at needle placement may cause various complications and patient dissatisfaction.AimTo use a preprocedure ultrasound-guided surface marking, using a midline transverse interlaminar ultrasound view at L4–5 interspace, to guide needle insertion, aiming to decrease needle attempts.Subjects and methodsNinety patients ASA I–II, scheduled for intrathecal anesthesia, were included in the study. Patients were randomly allocated to one of 2 groups. Group I was the ultrasound group and Group II was the surface landmark group. For each block, we recorded patient’s and spine characteristics, number of needle attempts, and patient satisfaction, time for establishing landmarks by preprocedure ultrasound scanning or palpation, time to perform spinal anesthesia, and total time to perform the whole procedure.ResultsSuccessful first needle attempt was in (80%) in ultrasound group (I) and 17 (37.8%) in surface landmark group (II). Needle redirection attempts were 7 (15.6%) in group I and 16 (35.5%) in group II. Second attempt was in 2 (4.4%) in group I and 5 (11.1%) in group II. Third attempt was observed only in group II in 7 (15.6%). There was a significantly more time needed to establish landmarks and complete spinal anesthesia in group I compared to group II (8.7 ± 1.0 vs 5.4 ± 0.4, respectively). Patient’s satisfaction was significantly higher in group I (95.6%) than group II (77.8%).ConclusionPreprocedure ultrasound scanning improved the first needle attempt success rate, decreased redirection or further attempts, and gave better patient satisfaction.

Ultrasound screening of fetal structural abnormalities by standard ultrasound views during the first trimester

Ultrasound screening of fetal structural abnormalities by standard ultrasound views during the first trimester

Three-step method for ultrasound-guided central vein catheterization

The long-axis view and in-plane needle approach (LAX-IP) for ultrasound-guided central vein catheterization is considered ideal because of the quality of real-time imaging. We describe a novel technique, using a step-by-step procedure, to overcome the pitfalls associated with the LAX-IP. This study was undertaken to demonstrate the clinical utility of this approach. All operators underwent training before participation in this study. One hundred patients were enrolled in this study and underwent central venous catheterization using this method. Using a portable ultrasound and vein catheterization kit, patients were appropriately positioned and a straight portion of the vein identified (Step 1). A needle guide was used (Step 2) and the vein imaged in real time in two directions (Step 3), to identify the true long axis and prevent damage to surrounding tissues. The overall success rate for catheterization was 100% with a median of one puncture for each patient. All catheterizations were performed within three punctures. Problems with the first puncture included difficult insertion of the guide-wire due to coiling, difficult anterior wall puncture, less experience with the procedure, and other reasons. There were no complications associated with the procedure. This three-step method is not dependent on an operator's ability to proceed based on spatial awareness, but rather depends on logic. This method can prevent difficulties associated with a two-dimensional ultrasound view, and may be a safer technique compared with others. Further clinical trials are needed to establish the safety of this technique.

Epidural Catheter Placement in Morbidly Obese Parturients with the Use of an Epidural Depth Equation prior to Ultrasound Visualization

Background. Previously, Balki determined the Pearson correlation coefficient with the use of ultrasound (US) was 0.85 in morbidly obese parturients. We aimed to determine if the use of the epidural depth equation (EDE) in conjunction with US can provide better clinical correlation in estimating the distance from the skin to the epidural space in morbidly obese parturients. Methods. One hundred sixty morbidly obese (≥40 kg/m2) parturients requesting labor epidural analgesia were enrolled. Before epidural catheter placement, EDE was used to estimate depth to the epidural space. This estimation was used to help visualize the epidural space with the transverse and midline longitudinal US views and to measure depth to epidural space. The measured epidural depth was made available to the resident trainee before needle insertion. Actual needle depth (ND) to the epidural space was recorded. Results. Pearson's correlation coefficients comparing actual (ND) versus US estimated depth to the epidural space in the longitudinal median and transverse planes were 0.905 (95% CI: 0.873 to 0.929) and 0.899 (95% CI: 0.865 to 0.925), respectively. Conclusion. Use of the epidural depth equation (EDE) in conjunction with the longitudinal and transverse US views results in better clinical correlation than with the use of US alone.

Quantitative Diagnostic Method for Biceps Long Head Tendinitis by Using Ultrasound

Objective. To investigate the feasibility of grayscale quantitative diagnostic method for biceps tendinitis and determine the cut-off points of a quantitative biceps ultrasound (US) method to diagnose biceps tendinitis. Design. Prospective cross-sectional case controlled study. Setting. Outpatient rehabilitation service. Methods. A total of 336 shoulder pain patients with suspected biceps tendinitis were recruited in this prospective observational study. The grayscale pixel data of the range of interest (ROI) were obtained for both the transverse and longitudinal views of the biceps US. Results. A total of 136 patients were classified with biceps tendinitis, and 200 patients were classified as not having biceps tendinitis based on the diagnostic criteria. Based on the Youden index, the cut-off points were determined as 26.85 for the transverse view and 21.25 for the longitudinal view of the standard deviation (StdDev) of the ROI values, respectively. When the ROI evaluation of the US surpassed the cut-off point, the sensitivity was 68% and the specificity was 90% in the StdDev of the transverse view, and the sensitivity was 81% and the specificity was 73% in the StdDev of the longitudinal view to diagnose biceps tendinitis. Conclusion. For equivocal cases or inexperienced sonographers, our study provides a more objective method for diagnosing biceps tendinitis in shoulder pain patients.

Secondary confirmation of endotracheal tube position by diaphragm motion in right subcostal ultrasound view

Aims:To assess the sensitivity and specificity of right subcostal ultrasound view to confirm correct endotracheal tube intubation (ETT).Materials and Methods:In this prospective study, apneic or paralyzed patients who had an indication of intubation were selected. Intubation and ventilation with bag were performed by the skilled third-year emergency medicine residents. The residents, following a brief training course of ultrasonography, interpreted the diaphragm motion, and identified either esophageal or tracheal intubation. The confirmation of ETT placement was done by the sonographer. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for tracheal versus esophageal intubation.Results:A total of 57 patients aged 59 ± 5 who underwent ETT insertion were studied. Thirty-four of them were male (60%). Ultrasound correctly identified 11 out of 12 esophageal intubations for a sensitivity of 92% (95% CI = 62-100), but misidentified one esophageal intubation as tracheal. Sonographers correctly identified 43 out of 45 (96%) tracheal intubations for a specificity of 96% (95% CI = 85-99), but misdiagnosed two tracheal intubations as esophageal.Conclusions:This study suggests that diaphragm motion in right subcostal ultrasound view is an effective adjunct to diagnose ETT place in patients undergoing intubation in emergency department.