Incidental Findings and How to Manage Them: Testis— A WFUMB Position Paper

Testicular incidentalomas are non-palpable, asymptomatic lesions, most frequently detected on ultrasound examinations. Each incidentaloma should undergo a standardized diagnostic workup to exclude malignancy and recognize other potentially significant non-malignant conditions that may first present with an incidental finding on scrotal ultrasound. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on management of testicular incidentalomas and describes efficient management strategies with particular reference to the role of ultrasound techniques.     

Incidental Findings of Gallbladder and Bile Ducts—Management Strategies: General Aspects,Gallbladder Polyps and Gallbladder Wall Thickening—A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.     

Training Midwives to Perform Basic Obstetric Point-of-Care Ultrasound in Rural Areas Using a Tablet Platform and Mobile Phone Transmission Technology—A WFUMB COE Project

Point-of-care ultrasound (POCUS) has become a topical subject and can be applied in a variety of ways with differing outcomes. The cost of all diagnostic procedures including obstetric ultrasound examinations is a major factor in the developing world and POCUS is only useful if it can be equated to good outcomes at a lower cost than a routine obstetric examination. The aim of this study was to assess a number of processes including accuracy of images and reports generated by midwives, performance of a tablet-sized ultrasound scanner, training of midwives to complete ultrasounds, teleradiology solution transmissions of images via internet, review of images by a radiologist, communication between midwife and radiologist, use of this technique to identify high-risk patients and improvement of the education and teleradiology model components. The midwives had no previous experience in ultrasound. They were stationed in rural locations where POCUS was available for the first time. After scanning the patients, an interim report was generated by the midwives and sent electronically together with all images to the main hospital for validation. Unique software was used to send lossless images by mobile phone using a modem. Transmission times were short and quality of images transmitted was excellent. All reports were validated by two experienced radiologists in our department and returned to the centers using the same transmission software. The transmission times, quality of scans, quality of reports and other parameters were recorded and monitored. Analysis showed excellent correlation between provisional and validated reports. Reporting accuracy of scans performed by the midwives was 99.63%. Overall flow turnaround time (from patient presentation to validated report) was initially 35 min but reduced to 25 min. The unique mobile phone transmission was faultless and there was no degradation of image quality. We found excellent correlation between final outcomes of the pregnancies and diagnoses on the basis of reports generated by the midwives. Only 1 discrepancy was found in the midwives' reports. Scan results versus actual outcomes revealed 2 discrepancies in the 20 patients identified as high risk. In conclusion, we found that it is valuable to train midwives in POCUS to use an ultrasound tablet device and transmit images and reports via the internet to radiologists for review of accuracy. This focus on the identification of high-risk patients can be valuable in a remote healthcare facility.     

Value of Contrast-Enhanced Ultrasound Parameters in the Evaluation of Adnexal Masses with Ovarian–Adnexal Reporting and Data System Ultrasound

ObjectiveThe aim of this study was to determine whether incorporating qualitative parameters of contrast-enhanced ultrasound (CEUS) can increase the accuracy of adnexal lesion assessments with Ovarian–Adnexal Reporting and Data System (O-RADS) ultrasound category 4 or 5.MethodsRetrospective analysis of patients with adnexal masses who underwent conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) examinations between January and August of 2020. The study investigators reviewed and analyzed the morphological features of each mass before categorizing the US images independently according to the O-RADS system published by the American College of Radiology. In the CEUS analysis, the initial time and intensity of enhancement involving the wall and/or septation of the mass were compared with the uterine myometrium. Internal components of each mass were observed for signs of enhancement. The sensitivity, specificity, and Youden's index were calculated as the contrast variables and O-RADS.ResultsReceiver operating characteristic curve analysis revealed that the best cutoff value was higher than O-RADS 4. When information on the extent of enhancement was applied to selectively upgrade O-RADS category 4 and selectively downgrade O-RADS category 5, the overall sensitivity increased to 90.2%, while the level of specificity (91.3%) remained the same.ConclusionIncorporating additional information from CEUS with respect to the extent of enhancement helped to improve the sensitivity of O-RADS category 4 and 5 masses without loss of specificity.     

Can the Contrast-Enhanced Ultrasound Washout Rate Be Used to Predict Microvascular Invasion in Hepatocellular Carcinoma?

The objective of this study was to investigate use of the washout rate of hepatocellular carcinoma on contrast-enhanced ultrasound (CEUS) for pre-operative determination of the presence of microvascular invasion. The study included 271 patients who underwent liver resection for hepatocellular carcinoma between April 2008 and December 2012, and were examined with contrast-enhanced ultrasound before surgery. Patients were followed up at 3-mo intervals for 3 y. Four washout patterns were classified according to the start time of washout: rapid, portal, delayed and slow. Rapid washout, presence of two or more tumors and tumor size ≥5 cm were identified as independent pre-operative predictors of microvascular invasion on multivariate analysis. Recurrence rates for patients with none, one, two or three predictors were 22.6%, 34.7%, 57.6% and 75.0%, respectively. In combination with tumor number and tumor size, contrast-enhanced ultrasound washout rate may have a role in identifying hepatocellular carcinoma patients with microvascular invasion.     

A Model-Based Prediction of the Probability of Hepatocellular Adenoma and Focal Nodular Hyperplasia Based on Characteristics on Contrast-Enhanced Ultrasound

Contrast-enhanced ultrasound (CEUS) is an emerging imaging technique that is increasingly used to diagnose liver lesions. It is of the utmost importance to differentiate between the two most common solid focal liver lesions (i.e., hepatocellular adenoma [HCA] and focal nodular hyperplasia [FNH]), because their management and follow-up differ greatly. The main objective of this study was to determine how frequently the specific CEUS features of HCA and FNH are visible on CEUS and to define their predictive value for discrimination between HCA and FNH. We included 324 CEUS examinations performed on patients with FNH (n = 181) or HCA (n = 143). Patients with HCA and FNH significantly differed with respect to age and CEUS features of steatosis, echogenicity, homogeneity, the presence of a central scar, central artery, arterial enhancement pattern, necrosis or thrombus and enhancement in the late venous phase.     

Comparison of the Diagnostic Accuracy of Percutaneous Fistula Contrast-Enhanced Ultrasound Combined with Transrectal 360° 3-D Imaging and Conventional Transrectal Ultrasound in Complex Anal Fistula

This study compared the diagnostic accuracy of percutaneous fistula contrast-enhanced ultrasound (CEUS) combined with 360° 3-D transrectal ultrasound (TRUS) imaging (CEUS + 360°-TRUS) with that of conventional transrectal ultrasound in the diagnosis of complex anal fistulas. A total of 156 patients clinically diagnosed with complex anal fistula from January 2020 to December 2021 were studied and randomly divided into an experimental group (n = 82) and a control group (n = 74). Patients in the experimental group were examined by percutaneous fistula CEUS combined with CEUS + 360°-TRUS, while patients in the control group were examined using TRUS. The detection of fistulas (main tract, branch and internal orifice) and the accuracy of Parks classification were compared between the two groups. Recurrences were followed up at 1, 3 and 6 mo after the surgery. A total of 156 patients were included, aged 23–68 y (average: 37.7 ± 18.2 y). In both groups, the course of disease was <1 mo in 128 cases, 1–2 mo in 22 cases and >3 mo in 6 cases. A total of 474 fistulas were confirmed by surgery in the aforementioned patients, including 224 main fistulas, 250 branch pipes and 254 internal orifices. The CEUS + 360°-TRUS group had 96.87%, 90.41% and 90.14% diagnostic accuracy for the main tract, branch and internal orifice, which was statistically significant (p < 0.001) compared with the 85.00%, 70.00% and 72.46% for the TRUS group, respectively. The overall accuracy of Parks classification of anal fistula in the CEUS + 360°-TRUS group was significantly higher than that in the TRUS group (90.24% vs. 78.38%, p < 0.001). After 6 mo of follow-up, the recurrence rate in the CEUS + 360°-TRUS group was 4.87%, and the recurrence rate in the TRUS group was 18.91%. Percutaneous fistula CEUS combined with transrectal 360° 3-D imaging has significantly higher accuracy than conventional TRUS in the diagnosis of complex anal fistula, especially for anal fistula branches, internal openings and Parks classification and is beneficial in reducing post-operative occurrence of complex anal fistulas.     

A Non-invasive Method to Estimate the Stress–Strain Curve of Soft Tissue Using Ultrasound Elastography

Ultrasound elastography performed under small strain conditions has been intensively studied. However, small deformations may be not sufficiently large to differentiate some abnormal tissues. By combining quasi-static and shear wave elastography, we developed a non-invasive method to estimate the localized stress– strain curve of materials. This method exerts progressive multistep uniaxial compression on the materials, and shear wave measurements were performed at every compression step. This method estimates the 2-D displacements between steps via a 2-D region growing motion tracking method and accumulates these displacements to obtain the large material displacements with respect to the initial configuration. At each step, the shear modulus and stress were calculated according to linear elastic theory. The proposed method was tested on custom-made tissue-mimicking phantoms. Mechanical compression testing was conducted on the samples made of the same material as the phantoms and taken as the reference. The stress–strain curves for the same material from the proposed method and from mechanical testing are in good agreement. The root mean square error (RMSE) and area percentage error (APE) of the stress–strain curve between ultrasound measurement and mechanical testing for soft materials ranged from 0.18 to 0.26 kPa and from 5.6% to 7.8%, respectively. The RMSE and APE for stiff materials ranged from 0.56 to 1.17 kPa and 8.0% to 17.9%. Therefore, our method was able to provide good estimates of the stress–strain curve for tissue-mimicking materials.     

The AMANDUS Project—Advanced Microperfusion Assessed Non-Union Diagnostics With Contrast-Enhanced Ultrasound (CEUS) for the Detection of Infected Lower Extremity Non-Unions

The pre-operative determination of infection plays a decisive role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for the differentiation between aseptic and infected non-unions. Of 109 patients with lower extremity non-unions (tibia n = 78, femur n = 31) osseous perfusion with CEUS was prospectively assessed before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (PE) (arbitrary unit [au]). Significant perfusion differences between aseptic and infected non-unions were evident (PE, p < 0.001). The sensitivity and specificity for the detection of infected tibial and femoral non-unions could be determined with 85.1% and 88.7% (cutoff PE: 81.2 au). CEUS illustrates tibial and femoral non-union perfusion in real time and discriminates reliably between aseptic and infected non-unions. Consequently, when CEUS is integrated into the diagnostic routine algorithm, non-union revision surgery can be planned more accurately as a single or multistep procedure.     

Assessing the Impact of the Position Paper “Prescribing and Administering Opioid Doses Based Solely on Pain Intensity”

BackgroundA task force of members of the American Society for Pain Management Nursing (ASPMN) authored a position paper “Prescribing and Administering Opioid Doses Based Solely on Pain Intensity.” Some of the authors of this ASPMN position paper presented a concurrent session at the September 2016 ASPMN National Conference discussing the content of the position paper. As a follow-up, the authors designed a research study to identify the impact of the position statement in facilitating change in institutional practice of dosing analgesics based solely on pain intensity.AimsOur aim was to ascertain the effect of the American Society for Pain Management Nursing ASPMN position paper “Prescribing and Administering Opioid Doses Based Solely on Pain Intensity” (2016) on changes in institutional practices.DesignThe study used an online anonymous questionnaire that included open-ended questions.SettingsAn anonymous electronic questionnaire was used to assess the impact across the United States.Participants/SubjectsParticipants were members of the American Society for Pain Management Nursing.MethodsAn eight-question anonymous questionnaire created through Survey Monkey was sent to members of the American Society for Pain Management Nursing via an e-mail listserv and the monthly e-newsletter.ResultsOf the 142 members who consented to participate in the study, 120 members answered one or more questions. Those who responded to the question about changes in practice, only 13 (11.1%) reported that the position paper had influenced a change in practice at their institution. The majority, 89 (75%), reported that practice had not changed in their institution.ConclusionsAmong those clinicians who participated in this study, the position paper “Prescribing and Administering Opioid Doses Based Solely on Pain Intensity” reportedly had minimal impact on changing institutional practices.     

Can Ultrasound Be Used to Improve the Palpation Skills of Physicians in Training? A Prospective Study

Background

Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited.

Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound (CEUS) in the Liver–Update 2020 WFUMB in Cooperation with EFSUMB,AFSUMB, AIUM,and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.     

A Necrotizing Fasciitis Fake Out on Point-of-Care Ultrasound—Watch the Shadow

Background

Point-of-care ultrasound has an increasing role in characterizing soft-tissue infections and has been described previously in the evaluation of necrotizing fasciitis (NF). The identification of air within the soft tissues can be very suggestive of NF in the correct clinical context.