Objectives Lung ultrasound (LUS) is accurate for diagnosing pneumonia in the emergency department (ED), but standard training is time-intensive, limiting its widespread implementation. We evaluated LUS proficiency for pneumonia diagnosis and perceived adoption barriers after a short training programme. Setting This study was conducted in the frame of the PLUS-IS-LESS trial (Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments) ( NCT05463406 ), a pragmatic stepped-wedge cluster-randomised clinical trial evaluating a clinical management algorithm combining LUS and procalcitonin to guide antibiotic use for lower respiratory tract infections (LRTIs) in 10 Swiss EDs. Participants All medical supervisors (senior registrars and senior physicians) from the participating EDs were invited to go through the PLUS-IS-LESS LUS training programme and all those who completed the training programme were included in this study. Methods The training programme included an e-learning course, followed by a half-day on-site training session with theory and hands-on practice. For proficiency evaluation, a validated structured assessment of LUS skills (LUS-OSAUS) was adapted into a 32-question online quiz and five bedside LUS examinations. Success was defined as achieving a score ≥80% on both the online quiz and supervised practical assessment. Success rates were compared between physicians according to their characteristics (age, sex, medical experience, previous use of ultrasound or LUS, linguistic region of work and type of hospital) using a χ² test. A 6-month follow-up survey identified factors associated with non-certification and barriers to the clinical use of LUS for managing LRTIs. Results Of 122 trained physicians, 83 (68 %) completed both quiz and supervised LUS and 61 (50%) achieved certification. The most challenging items were pleural line assessment (83% success), recognition of consolidations (83%) and decision-making based on LUS findings (72%). Physicians <40 years had a higher success rate (p=0.009). Among those without complete certification, limited access to an ultrasound machine and low perceived added value of LUS were the main identified reasons. Lack of time was the most frequently reported barrier overall to LUS integration into ED workflows (77%). Conclusion After receiving short training and focused proficiency testing, only half of physicians achieved certification, underscoring the challenges of broad LUS implementation. Limited time, equipment access and low perceived clinical value were key barriers, and integrating LUS findings into decision-making remained difficult. Ongoing support, supervision and protected time may be needed to enhance LUS adoption in EDs. Trial registration number NCT05463406 .
Background: Sarcoidosis is a multisystem inflammatory disorder characterized by non‑caseating granulomas. Skeletal involvement, present in up to 13% of cases, frequently remains underrecognized due to its asymptomatic course and imaging features that closely mimic metastatic disease, creating significant diagnostic challenges. Case Presentation: A 63‑year‑old woman presented for neurological evaluation of potential early cognitive decline prompted by family history. Neuroimaging incidentally revealed multiple osteolytic calvarial lesions. Further imaging demonstrated widespread mixed osteolytic and osteoblastic lesions involving the skeleton, bilateral perilymphatic pulmonary nodules, mediastinal and hilar lymphadenopathy, and hepatic lesions. Laboratory investigation showed elevated CA 15‑3 (43.7 kU/l) with normal CEA and CYFRA 21‑1. Whole‑body FDG PET/CT revealed hypermetabolic osteolytic lesions and metabolically active pulmonary infiltrates. An interdisciplinary tumor board considered carcinoma of unknown primary with suspected breast origin; however, breast MRI revealed no suspicious findings. Multiple myeloma was excluded by negative immunofixation electrophoresis. Percutaneous liver biopsy demonstrated non‑caseating granulomas without malignancy, with negative special stains for acid‑fast bacilli and fungi, establishing sarcoidosis as the underlying diagnosis. Management and Outcome: The patient was initiated on corticosteroids with calcium and vitamin D supplementation. At one‑month follow‑up, symptomatic improvement was noted with normalization of serum ACE levels and decline in CA 15‑3. Pulmonary function remained stable with mild DLCO reduction. The patient was continued on a corticosteroid taper with addition of inhaled corticosteroids for residual bronchial hyperreactivity. Conclusion: This case emphasizes the critical importance of maintaining broad differential diagnosis in multisystem disease with skeletal involvement. Although metastatic malignancy must be considered, sarcoidosis remains a key diagnostic consideration. Definitive histopathological confirmation is essential for accurate diagnosis and prevention of unnecessary oncologic intervention.
