Introduction: Point-of-care ultrasound (POCUS) is integral to emergency medicine (EM) training. It is unclear how EM residents use POCUS and how these skills are maintained as they progress in residency training. The purpose of this study was to evaluate resident use of POCUS at various timepoints in EM training. Methods: This was a retrospective cohort study of EM residents at a single, three-year training program between July 1, 2014–June 30, 2022. Residents were included if they had completed three consecutive years of training and an ultrasound rotation in their postgraduate year (PGY)-1. The following time points were assessed: PGY-1 rotation and 3-, 6-, 12-, 18-, and 24-months post-rotation. Number of scans, accuracy of interpretation, acceptability for credit, and percentage of technically limited studies (TLS) were collected at each point. We analyzed performance characteristics using mixed-effects binomial logistic regression with time as a fixed effect and resident as a random effect. Models were fit separately for each performance characteristic and likelihood ratio tests were performed to determine whether performance varied over time. Results: A total of 65 residents were included with a total of 13,229 exams performed during the study period. Cardiac and focused assessment with sonography in trauma examinations were performed most commonly. Overall accuracy of all exams during the examination period was 97.1% (95% confidence interval [CI] 96.2-98.0%), TLS was 14.5% (95% CI 9.7-20.6%), and acceptability was 82.9% (95% CI 76.3-88.2%). Trend over time (3, 6, 12, 18, and 24 months) found no differences in accuracy (P = 0.84), TLS (P = 0.20), or acceptability (P = 0.28). Further analyses by individual exam types also showed no significant differences in accuracy, acceptability, nor TLS. Conclusion: Accuracy, acceptability, and percentage of technically limited scans did not significantly vary over time, suggesting that POCUS skills are maintained from PGY-1 rotation to each time point evaluated in this study.

OBJECTIVES:While lumbar puncture (LP) remains gold standard for assessing intracranial pressure (ICP), LP can be difficult to perform and lead to complications. Noninvasive correlations for elevated ICP via ocular ultrasound (OUS) have shown mixed results. The primary objective of this study is to identify the frequency and test characteristics of the crescent sign on OUS for elevated ICP. Secondary objectives include comparison of test characteristics to optic nerve sheath diameter (ONSD) and optic disc elevation (ODE). DESIGN:Single center, prospective, observational cohort study enrolling adults (age ≥ 18 years) who presented to an outpatient Neurology LP clinic. An OUS protocol was performed prior to scheduled LP, with measurement of the opening pressure (OP) by manometry. Patients were excluded if LP was unable to be completed (for any reason) or if completed in the sitting position. Elevated OP was defined as ≥25cmH2O. RESULTS:In total, 68 patients were enrolled; seven were excluded due to no OP measured, leaving 61 patients for analysis. Forty-six patients had normal OP, while 15 had elevated OP. The crescent sign was observed in 19 patients (31 %). Overall sensitivity, specificity, and accuracy of the crescent sign was 67 %, 80 %, and 74 %, respectively. Comparison of accuracy between the six other OUS findings demonstrated no significant differences between test characteristics (p > 0.10 for each). CONCLUSIONS:The crescent sign was observed in 31 % of patients, with moderate sensitivity, specificity, and accuracy for elevated ICP. This study has several limitations and evaluations in the acute care setting are needed.

BACKGROUND: More primary care providers (PCPs) have begun to embrace the use of point-of-care ultra-sound (POCUS), but little is known about how PCPs are currently using POCUS and what barriers exist. In this prospective study, the largest systematic survey of POCUS use among PCPs, we assessed the cur-rent use, barriers to use, program management, and training needs for POCUS in primary care.METHODS: We conducted a prospective observational study of all VA Medical Centers (VAMCs) between June 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of pri-mary care clinics (PCCs).RESULTS: Chiefs of PCCs at 105 VAMCs completed the survey (82% response rate). Only 13% of PCCs currently use POCUS, and the most common applications used were bladder and musculoskeletal ultra-sound. Desire for POCUS training exceeded current use, but lack of trained providers (78%), ultrasound equipment (66%), and funding for training (41%) were common barriers. Program infrastructure to sup-port POCUS use was uncommon, and only 9% of VAMCs had local policies related to POCUS. Most PCC chiefs (64%) would support POCUS training.CONCLUSIONS: Current use of POCUS in primary care is low despite the recent growth of POCUS training in Internal Medicine residency programs. Investment in POCUS training and program infrastructure is needed to expand POCUS use in primary care and ensure adequate supervision of trainees.Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/) center dot The American Journal of Medicine (2023) 136:592-595

The purpose of this study was to determine current use, training needs, and barriers to point-of-care ultrasound (POCUS) use among anesthesiologists in practice.Multicenter, prospective, observational study.Anesthesiology departments in the Veterans Affairs Healthcare System in the United States.Chiefs of staff and chiefs of anesthesiology departments.A web-based survey was conducted between June 2019 and March 2020. Chiefs of staff answered questions about facility-level POCUS use, training, competency, and policies. Anesthesiology chiefs responded to a follow-up survey with specialty-specific POCUS questions. The results of the 2020 survey were compared with a similar survey conducted by the authors' group in 2015.All chiefs of staff (n = 130) and 77% of anesthesiology chiefs (n = 96) completed the survey. The most common POCUS applications used were central and peripheral vascular access (69%-72%), peripheral nerve blocks (66%), and evaluation of cardiac function (29%-31%). Compared with 2015, there was a statistically significant increase in desire for training (p = 0.00015), but no significant change in POCUS use (p = 0.31). Training was most desired for volume-status assessment (52%), left ventricular function (47%), pneumothorax (47%), central line placement (40%), peripheral nerve blocks (40%), and pleural effusion (40%). The most common barriers to POCUS use were lack of funding for training (35%), trained providers (33%), and training opportunities (28%).A significant increase in desire for POCUS training was seen among anesthesiologists practicing in the Veterans Affairs healthcare system since 2015, and lack of training continues to be a top barrier for POCUS use among anesthesiologists.

Background: Cardiopulmonary ultrasound (CPUS) is commonly used to assess cardiac function and preload status in patients with septic shock. However, the re-liability of CPUS findings at the point of care is unknown. Objective: To assess interrater reliability (IRR) of CPUS in patients with suspected septic shock between treating emergency physicians (EPs) vs emergency ultrasound (EUS) experts. Methods: Single-center, prospective, observational cohort enrolling patients (n = 51) with hypotension and sus-pected infection. Treating EPs performed and interpreted CPUS for cardiac function parameters (left ventricular [LV] function and right ventricular [RV] function and size) and preload volume parameters (inferior vena cava [IVC] di-ameter and pulmonary B-lines). The primary outcome was IRR (assessed by Kappa values [ K] and intraclass correlation coefficient [ICC]) between EP and EUS-expert consensus. Secondary analyses examined the effects on IRR of opera-tor experience, respiratory rate, and known difficult views on a Cardiology-performed echocardiogram. Results: IRR was fair for LV function, K = 0.37, 95% confidence inter-val (CI) 0.1-0.64; poor for RV function, K = -0.05, 95% CI -0.6-0.5; moderate for RV size, K = 0.47, 95% CI 0.07-0.88; and substantial for B-lines, K = 0.73, 95% CI 0.51-0.95 and IVC size, ICC = 0.87, 95% CI 0.2-0.99. In-volvement of ultrasound-trained faculty was associated with improved IRR of RV size ( p = 0.002), but not other CPUS domains. Conclusions: Our study demonstrated high IRR for preload volume parameters (IVC size and presence of B-lines), but not for cardiac parameters (LV function and RV function and size) in patients presenting with concern for septic shock. Future research must focus on determin-ing sonographer and patient-specific factors affecting CPUS interpretation in real-time. (c) 2023 Elsevier Inc. All rights reserved.

BACKGROUND: Point-of-care ultrasound (POCUS) has become an integral part of critical care medicine for procedural guidance, bedside diagnostics, and assessing response to treatment. Multiple critical care societies recommend POCUS use, and POCUS training has been a requirement for critical care fellowship since 2012. Yet, current practice patterns of POCUS use in ICUs are not well known. RESEARCH QUESTION: This study aimed to characterize current POCUS use, training needs, and barriers to use among intensivists. STUDY DESIGN AND METHODS: A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between June 2019 and March 2020 using a web-based survey of all chiefs of staff and ICU chiefs. These data were compared with those from a similar survey conducted in 2015. RESULTS: Chiefs of staff and ICU chiefs from 130 VA medical centers were surveyed with 100% and 83% response rates, respectively. At least one physician currently uses POCUS in 93% of ICUs, and 62% of individual physicians were estimated to be using POCUS. The most common POCUS applications were procedural guidance (59%), cardiac ultrasound (55%), and thoracic ultrasound (56%). Most chiefs (57%) reported teaching POCUS to trainees in their ICU. The most frequently reported barriers to POCUS use were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving (34%). From 2015 through 2020, POCUS use increased across most applications and an increase in desire for training was seen. INTERPRETATION: POCUS use increased across VA ICUs between 2015 and 2020, but significant gaps remain. Without a deliberate investment in POCUS training and infrastructure for physicians in practice, institutions are unlikely to benefit fully from standardized POCUS use in ICUs.

BackgroundPoint-of-care ultrasound (POCUS) can aid geriatricians in caring for complex, older patients. Currently, there is limited literature on POCUS use by geriatricians. We conducted a national survey to assess current POCUS use, training desired, and barriers among Geriatrics and Extended Care ("geriatric") clinics at Veterans Affairs Medical Centers (VAMCs).MethodsWe conducted a prospective observational study of all VAMCs between August 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of geriatric clinics.ResultsAll Chiefs of Staff (n=130) completed the survey (100% response rate). Chiefs of geriatric clinics ("chiefs") at 76 VAMCs were surveyed and 52 completed the survey (68% response rate). Geriatric clinics were located throughout the United States, mostly at high-complexity, urban VAMCs. Only 15% of chiefs responded that there was some POCUS usage in their geriatric clinic, but more than 60% of chiefs would support the implementation of POCUS use. The most common POCUS applications used in geriatric clinics were the evaluation of the bladder and urinary obstruction. Barriers to POCUS use included a lack of trained providers (56%), ultrasound equipment (50%), and funding for training (35%). Additionally, chiefs reported time utilization, clinical indications, and low patient census as barriers.ConclusionsPOCUS has several potential applications for clinicians caring for geriatric patients. Though only 15% of geriatric clinics at VAMCs currently use POCUS, most geriatric chiefs would support implementing POCUS use as a diagnostic tool. The greatest barriers to POCUS implementation in geriatric clinics were a lack of training and ultrasound equipment. Addressing these barriers systematically can facilitate implementation of POCUS use into practice and permit assessment of the impact of POCUS on geriatric care in the future.

BACKGROUND:Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist. OBJECTIVE:This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs). DESIGN, SETTING, AND PARTICIPANTS:A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015. RESULT:Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices. CONCLUSION:From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.

Background Many institutions are training clinicians in point-of-care ultrasound (POCUS), but few POCUS skills checklists have been developed and validated. We developed a consensus-based multispecialty POCUS skills checklist with anchoring references for basic cardiac, lung, abdominal, and vascular ultrasound, and peripheral intravenous line (PIV) insertion. Methods A POCUS expert panel of 14 physicians specializing in emergency, critical care, and internal/hospital medicine participated in a modified-Delphi approach to develop a basic POCUS skills checklist by group consensus. Three rounds of voting were conducted, and consensus was defined by ≥ 80% agreement. Items achieving < 80% consensus were discussed and considered for up to two additional rounds of voting. Results Thirteen POCUS experts (93%) completed all three rounds of voting. Cardiac, lung, abdominal, and vascular ultrasound checklists included probe location and control, basic machine setup, image quality and optimization, and identification of anatomical structures. PIV insertion included additional items for needle tip tracking. During the first round of voting, 136 (82%) items achieved consensus, and after revision and revoting, an additional 21 items achieved consensus. A total of 153 (92%) items were included in the final checklist. Conclusions We have developed a consensus-based, multispecialty POCUS checklist to evaluate skills in image acquisition and anatomy identification for basic cardiac, lung, abdominal, and vascular ultrasound, and PIV insertion.

A healthy 30-year-old man presented to the emergency department with blurred vision and floaters described as “cobwebs” in the left eye, occurring acutely while he lifted weights 4 days before. Visual acuity was normal in the right eye and 20/40 in the left eye. The remainder of the physical examination was unremarkable, aside from a lower visual field deficit in the left eye. Bedside ocular ultrasonography was performed (Figure 1). Given the vision loss, ophthalmology was consulted for further evaluation. Valsalva retinopathy. Bedside ocular ultrasonography revealed elevation of the retina and a thin, hypoechoic fluid collection temporal to the optic nerve, concerning for pre- versus intraretinal bleeding. Dilated funduscopic examination confirmed a superficial, intraretinal hemorrhage superotemporal to the optic nerve, as well as overlying vitreous hemorrhage. No retinal detachments were identified. In Valsalva retinopathy, the sudden increase in venous blood pressure from Valsalva maneuvers leads to an acute increase in intraocular venous pressure, resulting in hemorrhagic detachment of the internal retinal layers bordering the vitreous humor.1Duane T.D. Valsalva hemorrhagic retinopathy.Trans Am Ophthalmol Soc. 1972; 70: 298-313PubMed Google Scholar, 2Garcia Fernandez M. Navarro J.C. Castano C.G. Long-term evolution of Valsalva retinopathy: a case series.J Med Case Rep. 2012; 6: 346Crossref PubMed Scopus (36) Google Scholar, 3Simakurthy S. Tripathy K. Valsalva retinopathy.in: StatPearls. StatPearls Publishing, Treasure Island, FL2020Google Scholar The hallmark of this pathology is that the hemorrhage is intraretinal, distinct from vitreous hemorrhage and retinal detachment. Treatment aims to reduce straining (ie, stool softeners and avoidance of strenuous exercise) and avoiding anticoagulating medications.3Simakurthy S. Tripathy K. Valsalva retinopathy.in: StatPearls. StatPearls Publishing, Treasure Island, FL2020Google Scholar Most patients achieve complete return of vision when hemorrhage spontaneously clears, often within weeks to months; however, management may vary, depending on the location of the bleeding.3Simakurthy S. Tripathy K. Valsalva retinopathy.in: StatPearls. StatPearls Publishing, Treasure Island, FL2020Google Scholar4Chen Y.J. Kou H.K. Krypton laser membranotomy in the treatment of dense premacular hemorrhage.Can J Ophthalmol. 2004; 39: 761-766Abstract Full Text PDF PubMed Scopus (7) Google Scholar Funduscopic examination 1 week later demonstrated resolving hemorrhage (Figure 2). The patient followed up 2 months later and reported significant improvement in his vision.

Emergency medicine (EM) clinicians who care for critically ill patients often make clinical decisions with relatively little information. Patients with septic shock in particular pose a challenge as they frequently require several time-sensitive decisions. Point-of-care cardiopulmonary ultrasound (CPUS) has emerged as a promising, rapidly available test to assess patient volume and respiratory status to guide interventions. The purpose of this study is to assess the reliability of real-time clinician interpretation of CPUS findings. We performed a prospective, observational, pilot study enrolling patients with hypotension (systolic blood pressure <90) and clinician suspected infection. Clinicians performed a focused CPUS and recorded their interpretation on a data entry form. Two ultrasound fellowship trained physicians recorded an "expert" interpretation of the recorded images. Disagreement between the two experts were resolved in a consensus conference by the study team, and the final expert consensus agreement was compared to the recorded clinician interpretation. Cardiac variables included left ventricular systolic function (LVF), right ventricular (RV) function, RV size. Lung ultrasound (LUS) was interpreted for absence of B-lines and presence of unilateral or bilateral B-lines. We enrolled 51 patients. Cohen's kappa interrater coefficient and percent agreement are shown in Table 1. LUS showed the highest agreement between expert and clinician, Cohen's kappa = 0.73 (95% CI: 0.51 to 0.95), indicating substantial agreement. RV function showed very poor agreement, Cohen's kappa = -0.05 (95% CI: -0.6 to 0.5). Interpretation of LV function and RV size demonstrated fair to moderate agreement, Cohen's kappa = 0.37 (95% CI: 0.1 to 0.64) and 0.47 (95% CI: 0.07 to 0.88). LUS findings exhibit the highest reliability when interpreted by clinicians compared to expert reviewer. Care must be exercised when interpreting CPUS variables in an acute setting, especially with respect to cardiac findings. Further work is needed to understand patient- and sonographer-specific variables which may contribute to unreliable CPUS interpretation.

ObjectivesEmergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment.MethodsThis study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents.ResultsThere were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM.ConclusionsEM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

Ultrasound measurement of dynamic changes in inferior vena cava (IVC) diameter can be used to assess intravascular volume status in critically ill patients, but published studies vary in accuracy as well as recommended diagnostic cutoffs. Part of this variability may be related to movements of the vessel relative to the transducer during the respiratory cycle which results in unintended comparison of different points of the IVC at end expiration and inspiration, possibly introducing error related to variations in normal anatomy. The objective of this study was to quantify both craniocaudal and mediolateral movements of the IVC as well as the vessel's axis of collapse during respirophasic ultrasound imaging.

Study objective: The incidence of skin and soft tissue infections has increased dramatically during the last decade, in part because of increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Incision and drainage is considered the primary intervention; however, some clinicians prefer ultrasonographically guided needle aspiration because it represents a less invasive alternative. Our hypothesis is that ultrasonographically guided needle aspiration is equivalent to incision and drainage in treating simple skin and soft tissue abscesses.Methods: This study was a nonblinded randomized controlled trial. Patients with uncomplicated superficial abscesses were randomized to incision and drainage with packing or ultrasonographically guided needle aspiration. Purulence obtained from the abscess was cultured to identify the causative organism. Bedside ultrasonography was performed pre- and postintervention to confirm the presence or absence of an abscess cavity. Patients were followed up at 48 hours (in person by a clinician) and on day 7 (telephone follow-up by research staff). The primary outcome was a combination of sonographic resolution and clinical resolution of the signs and symptoms of ongoing infection at day 7. The signs and symptoms of ongoing infection include increasing pain, erythema, and the presence of pus. Resolution was assessed with both sonographic resolution (day 0 and day 2) and improvement of clinical symptoms (day 2) and resolution of clinical symptoms (day 7) without further intervention.Results: A total of 101 patients were enrolled, 54 incision and drainage and 47 ultrasonographically guided needle aspiration patients. At initial presentation, 60% (95% confidence interval [CI] 45% to 70%) of needle aspirations yielded little or no purulence, despite sonographic visualization of an abscess cavity and sonographic guidance during the procedure. The overall success of ultrasonographically guided needle aspiration was 26% (95% CI 18% to 44%) compared with 80% (95% CI 66% to 89%) success in patients randomized to incision and drainage. The difference between groups was 54% (95% CI 35% to 69%). Overall success of both incision and drainage and ultrasonographically guided needle aspiration was lower in patients with CA-MRSA. Patients with CA-MRSA (n=33) were less likely to receive successful drainage with needle aspiration (8% versus 55%) or incision and drainage (61% versus 89%). The difference for needle aspiration and incision and drainage was 47% (95% CI 15% to 57%) and 28% (95% CI 4% to 45%), respectively.Conclusion: Ultrasonographically guided needle aspiration is insufficient therapy for skin abscesses. The presence of CA-MRSA decreases the success of both incision and drainage and ultrasonographically guided needle aspiration. [Ann Emerg Med. 2011;57:483-491.]

Study ObjectivesSonographic measurement of respiratory variation of inferior vena cava (IVC) diameter has been used as a non-invasive measure of volume status. The diameter, shape and location of the IVC changes as it courses inferiorly. Unintended movement of the probe relative to the IVC during the respiratory cycle or anatomical movement of the IVC during contraction of the diaphragm has potential to introduce error into IVC measurements by changing the sampling location of the IVC. To quantify these changes, we performed serial measurements of the IVC imaged on abdominal CT in multiple planes and locations.MethodsPatients undergoing computed tomography (CT) of the abdomen with intravenous contrast were enrolled sequentially over a 3-month period. Exclusion criteria were inability to adequately visualize the IVC by CT or axial cuts taken at increments other than 4 mm. Measurement locations were based on known anatomical movement of the IVC during respiration. The IVC anterior-posterior (AP) diameter was measured at multiple points along the course of the IVC. To determine changes in diameter related to unintended movement of the ultrasonography probe when obtaining images of the IVC in a transverse plane, a comparison of midline vessel diameters was performed on contiguous CT images in 4 mm increments spanning 12 mm above and 20 mm below the level of the hepatic veins. To determine changes in diameter related to unintended movement of the ultrasonography probe when obtaining images of the IVC in the long axis, additional AP measurements were performed parasagitally at 2 mm increments off midline. Measurements at each level were normalized to the midline diameter at the hepatic veins for statistical analysis. Statistical analysis was by a repeated measured ANOVA test. Approval for this study was obtained from the local institutional review board.Results490 patients were enrolled of which 206 met inclusion criteria. Successive 2mm movements off midline of the anatomic axis of the IVC introduced an average change from true diameter of 5.2%, 10.9% and 19.8% (p<0.0001). Successive 4mm movements along course of the IVC superior to the hepatic veins resulted in changes in IVC diameter of 9.2, 14.1 and 18.5% (p<0.0001) while 4mm movements inferiorly resulted changes of 9.7, 21.8, 21.0, 19.7, and 16.9% (p<0.0001). The IVC 8mm distal to the hepatic veins showed less overall variability with absolute diameters ranging from 18.77 to 17.6mm.ConclusionIVC diameter varied significantly with changes in sampling location both along the course of the IVC as well as off midline. Unintended movement off midline (ie, during long axis sonography of the IVC) would produce less error than unintended movement superiorly or inferiorly (ie, during transverse sonography of the IVC). 8mm inferior to the hepatic veins, IVC anatomic variability was greatly decreased. Study ObjectivesSonographic measurement of respiratory variation of inferior vena cava (IVC) diameter has been used as a non-invasive measure of volume status. The diameter, shape and location of the IVC changes as it courses inferiorly. Unintended movement of the probe relative to the IVC during the respiratory cycle or anatomical movement of the IVC during contraction of the diaphragm has potential to introduce error into IVC measurements by changing the sampling location of the IVC. To quantify these changes, we performed serial measurements of the IVC imaged on abdominal CT in multiple planes and locations. Sonographic measurement of respiratory variation of inferior vena cava (IVC) diameter has been used as a non-invasive measure of volume status. The diameter, shape and location of the IVC changes as it courses inferiorly. Unintended movement of the probe relative to the IVC during the respiratory cycle or anatomical movement of the IVC during contraction of the diaphragm has potential to introduce error into IVC measurements by changing the sampling location of the IVC. To quantify these changes, we performed serial measurements of the IVC imaged on abdominal CT in multiple planes and locations. MethodsPatients undergoing computed tomography (CT) of the abdomen with intravenous contrast were enrolled sequentially over a 3-month period. Exclusion criteria were inability to adequately visualize the IVC by CT or axial cuts taken at increments other than 4 mm. Measurement locations were based on known anatomical movement of the IVC during respiration. The IVC anterior-posterior (AP) diameter was measured at multiple points along the course of the IVC. To determine changes in diameter related to unintended movement of the ultrasonography probe when obtaining images of the IVC in a transverse plane, a comparison of midline vessel diameters was performed on contiguous CT images in 4 mm increments spanning 12 mm above and 20 mm below the level of the hepatic veins. To determine changes in diameter related to unintended movement of the ultrasonography probe when obtaining images of the IVC in the long axis, additional AP measurements were performed parasagitally at 2 mm increments off midline. Measurements at each level were normalized to the midline diameter at the hepatic veins for statistical analysis. Statistical analysis was by a repeated measured ANOVA test. Approval for this study was obtained from the local institutional review board. Patients undergoing computed tomography (CT) of the abdomen with intravenous contrast were enrolled sequentially over a 3-month period. Exclusion criteria were inability to adequately visualize the IVC by CT or axial cuts taken at increments other than 4 mm. Measurement locations were based on known anatomical movement of the IVC during respiration. The IVC anterior-posterior (AP) diameter was measured at multiple points along the course of the IVC. To determine changes in diameter related to unintended movement of the ultrasonography probe when obtaining images of the IVC in a transverse plane, a comparison of midline vessel diameters was performed on contiguous CT images in 4 mm increments spanning 12 mm above and 20 mm below the level of the hepatic veins. To determine changes in diameter related to unintended movement of the ultrasonography probe when obtaining images of the IVC in the long axis, additional AP measurements were performed parasagitally at 2 mm increments off midline. Measurements at each level were normalized to the midline diameter at the hepatic veins for statistical analysis. Statistical analysis was by a repeated measured ANOVA test. Approval for this study was obtained from the local institutional review board. Results490 patients were enrolled of which 206 met inclusion criteria. Successive 2mm movements off midline of the anatomic axis of the IVC introduced an average change from true diameter of 5.2%, 10.9% and 19.8% (p<0.0001). Successive 4mm movements along course of the IVC superior to the hepatic veins resulted in changes in IVC diameter of 9.2, 14.1 and 18.5% (p<0.0001) while 4mm movements inferiorly resulted changes of 9.7, 21.8, 21.0, 19.7, and 16.9% (p<0.0001). The IVC 8mm distal to the hepatic veins showed less overall variability with absolute diameters ranging from 18.77 to 17.6mm. 490 patients were enrolled of which 206 met inclusion criteria. Successive 2mm movements off midline of the anatomic axis of the IVC introduced an average change from true diameter of 5.2%, 10.9% and 19.8% (p<0.0001). Successive 4mm movements along course of the IVC superior to the hepatic veins resulted in changes in IVC diameter of 9.2, 14.1 and 18.5% (p<0.0001) while 4mm movements inferiorly resulted changes of 9.7, 21.8, 21.0, 19.7, and 16.9% (p<0.0001). The IVC 8mm distal to the hepatic veins showed less overall variability with absolute diameters ranging from 18.77 to 17.6mm. ConclusionIVC diameter varied significantly with changes in sampling location both along the course of the IVC as well as off midline. Unintended movement off midline (ie, during long axis sonography of the IVC) would produce less error than unintended movement superiorly or inferiorly (ie, during transverse sonography of the IVC). 8mm inferior to the hepatic veins, IVC anatomic variability was greatly decreased. IVC diameter varied significantly with changes in sampling location both along the course of the IVC as well as off midline. Unintended movement off midline (ie, during long axis sonography of the IVC) would produce less error than unintended movement superiorly or inferiorly (ie, during transverse sonography of the IVC). 8mm inferior to the hepatic veins, IVC anatomic variability was greatly decreased.

Integrating ultrasound into clinical practice requires that emergency physicians possess an understanding of the images required to make an informed decision, the technical skills to acquire an interpretable image, and the cognitive skills necessary to interpret that image. Prior studies of ultrasound education have failed to separate these different cognitive processes. It has been unclear which types of errors are more common when learning emergency ultrasound, and therefore what areas should be emphasized in training.

Desmoid tumors occur infrequently in patients who undergo proctocolectomy for familial adenomatous polyposis but may result in significant morbidity and mortality depending on the sight of desmoid location. A case of successful ileal pouch salvage using a multimodality approach for treatment of a large ileal pouch associated desmoid tumor is presented. This approach used neoadjuvant chemotherapy to induce a partial response, followed by complete surgical excision with pouch preservation. This is the first reported case of combined chemotherapy and surgical treatment of a desmoid tumor involving an ileal pouch, and the second reported successful attempt at surgical excision with pouch salvage.