[Use of thoracic and lung ultrasound in general anesthesia]. / A mellkas és a tüdo ultrahangvizsgálatának szerepe az általános érzéstelenítés során.

The use of ultrasound became an essential tool in the everyday practice of anesthesiology and intensive care as an indispensable prerequisite for the precise guidance of invasive procedures and also as a point-of-care diagnostic method. Despite the limitations of imaging the lung and thoracic structures, the COVID-19 pandemic and recent advances made this technology an evolving field. The intensive therapy applies these methods with important experience for differential diagnosis and assessment of disease severity or prognosis. Minor modifications of these results make the method beneficial for anesthesia and perioperative medicine. In the present review, the authors accentuate the most important imaging artefacts of lung ultrasonography and the principles of lung ultrasound diagnostic steps. Methods and artefacts of high importance supported by evidence for the assessment of airway management, attuning of intraoperative mechanical ventilation, respiratory disorders during surgery, and postoperative prognosis are articulated. This review intends to focus on evolving subfields in which technological or scientific novelties are expected. Orv Hetil. 2023; 164(22): 864-870.

Pediatric Point-of-Care Lung Ultrasonography: A Narrative Review.

Point-of-care lung ultrasonography is an evidence-based application that may play a vital role in the care of critically ill pediatric patients. Lung ultrasonography has the advantage of being available at the patient's bedside with results superior to chest radiography and comparable to chest computed tomography for most lung pathologies. It has a steep learning curve. It can be readily performed in both advanced healthcare systems and resource-scarce settings. The purpose of this review is to discuss the basic principles of lung ultrasonography and its applications in the evaluation and treatment of critically ill pediatric patients.

The role of Lung Ultrasound in the diagnosis of SARS-COV-2 disease in pregnant women.

AIM: To evaluate the role of lung ultrasound (LUS) in recognizing lung abnormalities in pregnant women affected by COVID-19 pneumonia. MATERIALS AND METHODS: An observational study analyzing LUS patterns in 60 consecutively enrolled pregnant women affected by COVID-19 infection was performed. LUS was performed by using a standardized protocol by Soldati et al. The scoring system of LUS findings ranged from 0 to 3 in increasing alteration severity. The highest score obtained from each landmark was reported and the sum of the 12 zones examined was calculated. RESULTS: Patients were divided into two groups: 26 (43.3%) patients with respiratory symptoms and 32 (53.3%) patients without respiratory symptoms; 2 patients were asymptomatic (3.3%). Among the patients with respiratory symptoms 3 (12.5%) had dyspnea that required a mild Oxygen therapy. A significant correlation was found between respiratory symptoms and LUS score (p < 0.001) and between gestational weeks and respiratory symptoms (p = 0.023). Regression analysis showed that age and respiratory symptoms were risk factors for highest LUS score (p < 0.005). DISCUSSION: LUS can affect the clinical decision course and can help in stratifying patients according to its findings. The lack of ionizing radiation and its repeatability makes it a reliable diagnostic tool in the management of pregnant women.

Feasibility of a point-of-care ultrasound protocol for cardiorespiratory evaluation of horses in different clinical settings.

BACKGROUND: A point-of-care ultrasound (POCUS) protocol for evaluation of the cardiac and respiratory systems in horses does not exist. OBJECTIVES: (a) Describe the windows of a POCUS protocol for cardiorespiratory assessment of horses (CRASH); (b) Estimate the number of acoustic windows that can be acquired by a sonographer-in-training; (c) Estimate the time required to complete the protocol for specific groups of horses; (d) Describe the sonographic abnormalities detected in horses presented with cardiovascular, respiratory, or systemic disease. ANIMALS: Twenty-seven healthy horses, 14 horses competing in athletic events, and 120 horses with clinical disease. METHOD: A pocket-sized ultrasound device was used to acquire 7 sonographic cardiorespiratory windows in various clinical scenarios. The duration of the examination was timed, and images were evaluated for diagnostic quality. Abnormalities in horses with clinical disease were determined by an expert sonographer. RESULTS: The CRASH protocol could be performed in healthy and diseased horses in hospital, barn, and competition settings between 5.5 ± 0.9 (athletic horses) and 6.9 ± 1.9 min (horses with clinical disease). Thoracic windows were obtained most consistently, followed by right parasternal long-axis echocardiographic windows. Frequently detected abnormalities were pleural fluid, lung consolidation, B-lines, and moderate-to-severe left-sided heart disease. CONCLUSIONS: The CRASH protocol was feasible using a pocket-sized ultrasound device in various groups of horses, could be completed rapidly in a variety of settings, and frequently identified sonographic abnormalities when evaluated by an expert sonographer. The diagnostic accuracy, observer agreement, and utility of the CRASH protocol merit further evaluation.

Generating and Weighting Semantically Consistent Sample Pairs for Ultrasound Contrastive Learning.

Well-annotated medical datasets enable deep neural networks (DNNs) to gain strong power in extracting lesion-related features. Building such large and well-designed medical datasets is costly due to the need for high-level expertise. Model pre-training based on ImageNet is a common practice to gain better generalization when the data amount is limited. However, it suffers from the domain gap between natural and medical images. In this work, we pre-train DNNs on ultrasound (US) domains instead of ImageNet to reduce the domain gap in medical US applications. To learn US image representations based on unlabeled US videos, we propose a novel meta-learning-based contrastive learning method, namely Meta Ultrasound Contrastive Learning (Meta-USCL). To tackle the key challenge of obtaining semantically consistent sample pairs for contrastive learning, we present a positive pair generation module along with an automatic sample weighting module based on meta-learning. Experimental results on multiple computer-aided diagnosis (CAD) problems, including pneumonia detection, breast cancer classification, and breast tumor segmentation, show that the proposed self-supervised method reaches state-of-the-art (SOTA). The codes are available at https://github.com/Schuture/Meta-USCL.

Plantar Vein Thrombosis in a Patient with COVID-19: Case Report.

Plantar thrombophlebitis is a rare abnormality with few cases reported in the literature. Coexistence with severe acute respiratory syndrome coronavirus 2 infection increases its relevance. The disease is generally classified as idiopathic, and it is suggested that it is attributed to conditions that lead to hypercoagulability. We present the case of a 68-year-old female patient with thrombosis of the lateral plantar veins and a diagnosis of coronavirus disease of 2019. The plantar vein thrombosis diagnosis was made by means of Doppler ultrasonography and magnetic resonance imaging. Severe acute respiratory syndrome coronavirus 2 infection was suspected per clinical information and confirmed with reverse-transcriptase polymerase chain reaction technique. Treatment was successful using rivaroxaban and nonsteroidal antiinflammatory drugs.

Ten Influential Point-of-Care Ultrasound Papers: 2022 in Review.

Keeping up with the latest developments in the point-of-care ultrasound (POCUS) literature is challenging, as with any area of medicine. Our group of POCUS experts has selected 10 influential papers from the past 12 months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.

"It has been the most difficult time in my career": A qualitative exploration of UK obstetric sonographers' experiences during the COVID-19 pandemic.

INTRODUCTION: Substantial changes were made to the provision of pregnancy ultrasound services during the COVID-19 pandemic with the intention of minimising virus transmission and maintaining service continuity. Published literature describing the impact of the pandemic on obstetric sonographers is predominantly quantitative in nature, however statistics cannot fully convey sonographers' voices. This study aimed to gain a deeper understanding of the lived experiences of UK obstetric sonographers performing pregnancy ultrasound scans during the pandemic. METHODS: A UK-wide, online, anonymous cross-sectional survey on Qualtrics XM™ was open to responses between 9th March and 6th May 2021. Whilst this survey contained some quantitative elements, open questions were included to capture additional qualitative detail from respondents about their perceptions and experiences of scanning during the pandemic. Key themes were generated from free text responses using thematic analysis. RESULTS: Written responses were received from 111/138 sonographers participating in the survey. Five themes were generated, depicting the impact of the pandemic on obstetric sonographers: 1) continuity in a crisis; 2) decisions about me, without me; 3) battle scars - the lasting damage of COVID-19; 4) what people think I do vs. what I really do; and 5) the human touch. A cross-cutting theme was sonographers' feelings of disconnection from senior figures and expectant parents which created a sense of abandonment and distrust. CONCLUSION: Survey respondents' self-reported experiences of ineffective leadership and management, and perceived lack of understanding of the complexity of the sonographer role are potential contributory factors in the high levels of moral injury and occupational burnout reported within the workforce during the pandemic.

Evaluation of testicles by sonoelastography in men recovering after Covid-19 disease.

INTRODUCTION: Testicular cells, seminiferous tubule cells, spermatogonia, Leydig and Sertoli cells showing angiotensin-converting enzyme 2 expression have the potential to be targets and to be damaged by the coronavirus. We aimed to use Two-Dimensional Shear Wave Elastography (2D-SWE) as an effective technique to identify parenchymal damage in the testicles of patients recovering from COVID-19 infection. METHODS: 35 Male patients (group 1) who recovered after COVID-19 infection between 4 and 12 weeks were included in this prospective study. Before 2D-SWE, these male patients were confirmed with control Rt-PCR test negativity. In addition, the first Rt-PCR test positivity of these patients was confirmed. A control group was formed of 31 healthy subjects (group 2). These two groups were compared in terms of age, volume of each testis, and SWE values. Ultrasound including SWE was applied to all the testes. A total of 9 measurements were taken as 3 SWE measurements from each third of the testis (superior, mid, inferior) and the average of these was calculated. Data obtained in the study were analyzed statistically. A value of p < 0.05 was accepted as statistically significant. RESULTS: The mean SWE values for the right testis and the left testis were determined to be statistically significantly higher in Group 1 than in Group 2, respectively (p < 0.001, p < 0.001). CONCLUSION: There is an increase in testicular stiffness in males who have recovered from COVID-19 infection. The underlying cause of testicular damage is changes at the cellular level. The 2D-SWE technique can predict potential testicular parenchymal damage in male patients recovering from COVID-19 infection. IMPLICATIONS FOR PRACTICE: Two-Dimensional Shear Wave Elastography (2D-SWE) seems to be a promising imaging technique in the evaluation of testis parenchyma.

Point-of-care ultrasonography for risk stratification of non-critical suspected COVID-19 patients on admission (POCUSCO): A prospective binational study.

BACKGROUND: Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening. METHODS: POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion. RESULTS: Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 [95%CI:0.60-0.94]. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and ≥16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%[95%CI:0-3.9]) for low-risk patients (score = 0), 4/184 (2.17%[95%CI:0.8-5.5]) for intermediate-risk patients (score 1-15) and 4/17 (23.5%[95%CI:11.4-42.4]) for high-risk patients (score ≥16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 [95%CI:0.92-1.00]. CONCLUSION: L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.

Development of Hands-On Skills in Diagnostics of Lung Diseases Using Ultrasonography in Undergraduate Medical Education.

This study evaluated advanced pulmonary ultrasonography training for COVID-19 lung examination. Students completed identical pretests and post-tests and a survey. Changes were found for individual questions and overall scores (all P≤.02), specifically image identification, previous material, and COVID-19 questions. Students were receptive to the training for education and future practice (P<.001), and they felt capable using ultrasound for diagnosis and management of COVID-19 patients. Pulmonary ultrasonography training should be considered for the medical school curriculum.

Thoracic Ultrasound in COVID-19: Use of Lung and Diaphragm Ultrasound in Evaluating Dyspnea in Survivors of Acute Respiratory Distress Syndrome from COVID-19 Pneumonia in a Post-ICU Clinic.

INTRODUCTION: Dyspnea is a common symptom in survivors of severe COVID-19 pneumonia. While frequently employed in hospital settings, the use of point-of-care ultrasound in ambulatory clinics for dyspnea evaluation has rarely been explored. We aimed to determine how lung ultrasound score (LUS) and inspiratory diaphragm excursion (DE) correlate with patient-reported dyspnea during a 6-min walk test (6MWT) in survivors of COVID-19 acute respiratory distress syndrome (ARDS). We hypothesize higher LUS and lower DE will correlate with dyspnea severity. STUDY DESIGN AND METHODS: Single-center cross-sectional study of survivors of critically ill COVID-19 pneumonia (requiring high-flow nasal cannula, invasive, or non-invasive mechanical ventilation) seen in our Post-ICU clinic. All patients underwent standardized scanning protocols to compute LUS and DE. Pearson correlations were performed to detect an association between LUS and DE with dyspnea at rest and exertion during 6MWT. RESULTS: We enrolled 45 patients. Average age was 61.5 years (57.7% male), with average BMI of 32.3 Higher LUS correlated significantly with dyspnea, at rest (r = + 0.41, p = < 0.01) and at exertion (r = + 0.40, p = < 0.01). Higher LUS correlated significantly with lower oxygen saturation during 6MWT (r = -0.55, p = < 0.01) and lower 6MWT distance (r = -0.44, p = < 0.01). DE correlated significantly with 6MWT distance but did not correlate with dyspnea at rest or exertion. CONCLUSION: Higher LUS correlated significantly with patient-reported dyspnea at rest and exertion. Higher LUS significantly correlated with more exertional oxygen desaturation during 6MWT and lower 6MWT distance. DE did not correlate with dyspnea.

Utility of Point-of-Care Lung Ultrasound for Clinical Classification of COVID-19.

In this study, the utility of point-of-care lung ultrasound for clinical classification of coronavirus disease (COVID-19) was prospectively assessed. Twenty-seven adult patients with COVID-19 underwent bedside lung ultrasonography (LUS) examinations three times each within the first 2 wk of admission to the isolation ward. We divided the 81 exams into three groups (moderate, severe and critically ill). Lung scores were calculated as the sum of points. A rank sum test and bivariate correlation analysis were carried out to determine the correlation between LUS on admission and clinical classification of COVID-19. There were dramatic differences in LUS (p < 0.001) among the three groups, and LUS scores (r = 0.754) correlated positively with clinical severity (p < 0.01). In addition, moderate, severe and critically ill patients were more likely to have low (≤9), medium (9-15) and high scores (≥15), respectively. This study provides stratification criteria of LUS scores to assist in quantitatively evaluating COVID-19 patients.

Presidential reflections: how we got here, where we might go.

Pieter van Keep was a founder and the third president of the International Menopause Society (IMS). He died, sadly, in 1991. Since then, every retiring president of the IMS has delivered the Pieter van Keep Memorial Lecture. This is an edited version of that lecture delivered at the 18th World Congress of the IMS in Lisbon, Portugal in 2022. In the article, President Steven R. Goldstein describes the path he followed that led him to the presidency of the IMS, including his original entry into transvaginal ultrasound, then gynecologic ultrasound and, ultimately, menopausal ultrasound. His was the first description of the benign nature of simple ovarian cysts, the ability of transvaginal ultrasound to exclude significant tissue in patients with postmenopausal bleeding and the significance of endometrial fluid collections in postmenopausal patients, just to name a few. However, it was his description of the unusual ultrasound appearance in the uterus of women receiving tamoxifen therapy that allowed his entry into the world of menopause. This, ultimately, led to leadership positions, and ultimately the presidency of the American Institute of Ultrasound in Medicine, the North American Menopause Society and, finally, the IMS, all chronicled in this article. In addition, the article describes in detail the activities of the IMS during the COVID pandemic.

Lung ultrasound score severity cut-off points in COVID-19 pneumonia. A systematic review and validating cohort.

OBJECTIVES: Our purpose was to establish different cut-off points based on the lung ultrasound score (LUS) to classify COVID-19 pneumonia severity. METHODS: Initially, we conducted a systematic review among previously proposed LUS cut-off points. Then, these results were validated by a single-centre prospective cohort study of adult patients with confirmed SARS-CoV-2 infection. Studied variables were poor outcome (ventilation support, intensive care unit admission or 28-days mortality) and 28-days mortality. RESULTS: From 510 articles, 11 articles were included. Among the cut-off points proposed in the articles included, only the LUS>15 cut-off point could be validated for its original endpoint, demonstrating also the strongest relation with poor outcome (odds ratio [OR]=3.636, confidence interval [CI] 1.411-9.374). Regarding our cohort, 127 patients were admitted. In these patients, LUS was statistically associated with poor outcome (OR=1.303, CI 1.137-1.493), and with 28-days mortality (OR=1.024, CI 1.006-1.042). LUS>15 showed the best diagnostic performance when choosing a single cut-off point in our cohort (area under the curve 0.650). LUS≤7 showed high sensitivity to rule out poor outcome (0.89, CI 0.695-0.955), while LUS>20 revealed high specificity to predict poor outcome (0.86, CI 0.776-0.917). CONCLUSIONS: LUS is a good predictor of poor outcome and 28-days mortality in COVID-19. LUS≤7 cut-off point is associated with mild pneumonia, LUS 8-20 with moderate pneumonia and ≥20 with severe pneumonia. If a single cut-off point were used, LUS>15 would be the point which better discriminates mild from severe disease.

A prospective follow-up of thyroid volume and thyroiditis features on ultrasonography among survivors of predominantly mild to moderate COVID-19.

Background: We previously showed that higher SARS-CoV-2 viral load correlated with smaller thyroid volumes among COVID-19 survivors at 2 months after acute COVID-19. Our current follow-up study evaluated the evolution of thyroid volumes and thyroiditis features within the same group of patients 6 months later. Methods: Adult COVID-19 survivors who underwent thyroid ultrasonography 2 months after infection (USG1) were recruited for follow-up USG 6 months later (USG2). The primary outcome was the change in thyroid volume. We also reassessed thyroiditis features on USG, thyroid function and anti-thyroid antibodies. Results: Fifty-four patients were recruited (mean age 48.1 years; 63% men). The mean thyroid volume increased from USG1 to USG2 (11.9 ± 4.8 to 14.5 ± 6.2 mL, p < 0.001). Thirty-two patients (59.3%) had significant increase in thyroid volume by ≥15%, and they had a median increase of +33.3% (IQR: +20.0% to +45.0%). Multivariable logistic regression analysis showed that only higher baseline SARS-CoV-2 viral load independently correlated with significant thyroid volume increase on USG2 (p = 0.022). Among the seven patients with thyroiditis features on USG1, six (85.7%) had the features resolved on USG2. None had new thyroiditis features on USG2. All abnormal thyroid function during acute COVID-19 resolved upon USG1 and USG2. Conclusion: Most COVID-19 survivors had an increase in thyroid volume from early convalescent phase to later convalescent phase. This increase correlated with high initial SARS-CoV-2 viral load. Together with the resolution of thyroiditis features, these may suggest a transient direct atrophic effect of SARS-CoV-2 on the thyroid gland with subsequent recovery of thyroid volume and thyroiditis features.