Point-of-care ultrasound (POCUS) is increasingly integrated into residency training; however, POCUS education within Canadian internal medicine (IM) residency programs is not standardized. To support curriculum development and evaluation, the Canadian internal medicine ultrasound (CIMUS) group has previously published consensus-based education indicators (EIs). This study seeks to refine operational working definitions for the published EIs and characterize POCUS education in Canadian IM residency programs. Eleven POCUS experts developed consensus-based working definitions for the previously published EIs. The refined EIs were then used to collect data to evaluate existing POCUS curricula in Canadian IM training programs. The previously 22 published EIs were refined to 17 through expert consensus, with two forms being created to account for programs with POCUS electives. All Canadian IM training programs (n = 17) completed data collection. Significant heterogeneity was noted. Programs have a median of one POCUS faculty (range 0–5), with median annual teaching time of 18 h (ranging from 0 to 204 h). Only one program has assessment processes in place for all POCUS learners. Ten programs (59

Point-of-care ultrasound proficiency requires the integration of spatial anatomic knowledge, technical hands-on image acquisition, and the ability to interpret images and incorporate findings into clinical decision-making. Effectively teaching these skills requires a structured approach. This article presents a comprehensive framework for designing a point-of-care ultrasound course tailored to continuing professional development. We demonstrate how applying the learning theories of cognitivism, behaviorism, and constructivism can facilitate the educational experience. In addition, we offer guidance on maintaining learner engagement, organizing didactic sessions, and delivering standardized feedback.

BACKGROUND:Point-of-care ultrasound (POCUS) use continues to expand across multiple clinical subspecialties, and the need for standardization of training and quality assurance has become increasingly important. Despite the need for training, there are currently no widely accepted multispecialty criteria to define an acceptable quality POCUS image for common POCUS applications used by clinicians. Without such criteria, discrepancies in rating POCUS image quality occur, leading to inconsistencies in training and quality assurance, which can ultimately compromise patient care and safety. METHODS:To address this gap, the Society of Hospital Medicine (SHM) Point-of-care Ultrasound Task Force convened an expert panel of 32 national POCUS experts trained in hospital medicine (n = 24), critical care (n = 4), emergency medicine (n = 3), radiology (n = 2), and cardiology (n = 1) and employed a modified-Delphi approach to develop minimum image quality criteria for five common POCUS applications: heart, lungs, abdomen, lower extremity veins, and skin/soft tissues. RESULTS:After three rounds of voting and group discussion, the panel achieved consensus on a comprehensive list of 215 items to define standard image quality criteria in five different body systems. CONCLUSIONS:These POCUS image quality criteria offer a structured, consensus-based framework for evaluating POCUS images and establish a minimum standard for defining an acceptable quality image. Use of these criteria can improve inter-rater reliability and advance standardization of POCUS imaging, which affects training, quality assurance, and credentialing/privileging practices.

This is letter to the editor: we point to a statistical error in a recent article published in the journal by Movahed MR, Soltani Moghadam A. A normal and particularly small (<35 mm) left atrial size measured during echocardiography suggests low likelihood of moderate or severe left ventricular systolic dysfunction, which may have resulted in a biased conclusion.

Neurologists in both the inpatient and outpatient settings are increasingly using ultrasound to diagnose and manage common neurological diseases. Advantages include cost‐effectiveness, the lack of exposure to ionizing radiation, and the ability to perform at the bedside to provide real‐time data. There is a growing body of literature that supports using ultrasonography to improve diagnostic accuracy and aid in performing procedures. Despite the increasing utilization of this imaging modality in medicine, there has been no comprehensive review of the clinical applications of ultrasound in the field of neurology. We discuss the current uses and limitations of ultrasound for various neurological conditions. We review the role for ultrasound in commonly performed neurologic procedures including lumbar puncture, botulinum toxin injections, nerve blocks, and trigger point injections. We specifically discuss the technique for ultrasound‐assisted lumbar puncture and occipital nerve block as these are commonly performed. We then focus on the utility of ultrasound in the diagnosis of neurologic conditions. This includes neuromuscular diseases such as motor neuron disorders, focal neuropathies, and muscular dystrophy as well as vascular conditions such as stroke and vasospasm in subarachnoid hemorrhage. We also address ultrasound's use in critically ill patients to aid in identifying increased intracranial pressure, hemodynamics, and arterial and/or venous catheterization. Finally, we address the importance of standardized ultrasound curricula in trainee education and make recommendations for the future directions of research and competency guidelines within our specialty.

Journal of Ultrasound in MedicineVolume 40, Issue 12 p. 2785-2786 Letter to the Editor On Recommending Specific Lung Ultrasound Protocols in the Assessment of Medical Inpatients with Known or Suspected Coronavirus Disease-19 Reply Irene W. Y. Ma MD, PhD, RDMS, RDCS, Corresponding Author Irene W. Y. Ma MD, PhD, RDMS, RDCS [email protected] orcid.org/0000-0002-7580-0171 Division of General Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USA Address correspondence to Irene W. Y. Ma, MD, PhD, RDMS, RDCS, Division of General Internal Medicine, Department of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. E-mail: [email protected]Search for more papers by this authorVicki E. Noble MD, FACEP, Vicki E. Noble MD, FACEP Department of Emergency Medicine, University Hospitals, Cleveland Medical Center, Case Western Reserve School of Medicine, Cleveland, Ohio, USASearch for more papers by this authorGregory Mints MD, Gregory Mints MD orcid.org/0000-0002-3013-2608 Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorTanping Wong MD, Tanping Wong MD Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorAna Claudia Tonelli MD, PhD, Ana Claudia Tonelli MD, PhD Department of General Internal Medicine, Hospital de Clinicas de Porto Alegre and Department of Medicine, Unisinos University, São Leopoldo, RS, BrazilSearch for more papers by this authorArif Hussain MD, FRCA, FCCP, Arif Hussain MD, FRCA, FCCP Division of Cardiac Critical Care, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi ArabiaSearch for more papers by this authorRachel B. Liu MD, Rachel B. Liu MD orcid.org/0000-0002-3997-0325 Section of Emergency Ultrasound, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USASearch for more papers by this authorChristopher A. Hergott MD, Christopher A. Hergott MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorElaine Dumoulin MD, Elaine Dumoulin MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorAlex Chee MD, Alex Chee MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorDaniel J. Miller MD, Daniel J. Miller MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrandie Walker MD, PhD, Brandie Walker MD, PhD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrian Buchanan MD, Brian Buchanan MD Department of Critical Care, University of Alberta, Edmonton, Alberta, CanadaSearch for more papers by this authorMichael Wagner MD, Michael Wagner MD Division of Hospital Medicine, Department of Medicine, Prisma Health-Upstate, Greenville, South Carolina, USASearch for more papers by this authorShane Arishenkoff MD, Shane Arishenkoff MD Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, CanadaSearch for more papers by this authorAndrew S. Liteplo MD, Andrew S. Liteplo MD Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author Irene W. Y. Ma MD, PhD, RDMS, RDCS, Corresponding Author Irene W. Y. Ma MD, PhD, RDMS, RDCS [email protected] orcid.org/0000-0002-7580-0171 Division of General Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USA Address correspondence to Irene W. Y. Ma, MD, PhD, RDMS, RDCS, Division of General Internal Medicine, Department of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. E-mail: [email protected]Search for more papers by this authorVicki E. Noble MD, FACEP, Vicki E. Noble MD, FACEP Department of Emergency Medicine, University Hospitals, Cleveland Medical Center, Case Western Reserve School of Medicine, Cleveland, Ohio, USASearch for more papers by this authorGregory Mints MD, Gregory Mints MD orcid.org/0000-0002-3013-2608 Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorTanping Wong MD, Tanping Wong MD Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorAna Claudia Tonelli MD, PhD, Ana Claudia Tonelli MD, PhD Department of General Internal Medicine, Hospital de Clinicas de Porto Alegre and Department of Medicine, Unisinos University, São Leopoldo, RS, BrazilSearch for more papers by this authorArif Hussain MD, FRCA, FCCP, Arif Hussain MD, FRCA, FCCP Division of Cardiac Critical Care, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi ArabiaSearch for more papers by this authorRachel B. Liu MD, Rachel B. Liu MD orcid.org/0000-0002-3997-0325 Section of Emergency Ultrasound, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USASearch for more papers by this authorChristopher A. Hergott MD, Christopher A. Hergott MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorElaine Dumoulin MD, Elaine Dumoulin MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorAlex Chee MD, Alex Chee MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorDaniel J. Miller MD, Daniel J. Miller MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrandie Walker MD, PhD, Brandie Walker MD, PhD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrian Buchanan MD, Brian Buchanan MD Department of Critical Care, University of Alberta, Edmonton, Alberta, CanadaSearch for more papers by this authorMichael Wagner MD, Michael Wagner MD Division of Hospital Medicine, Department of Medicine, Prisma Health-Upstate, Greenville, South Carolina, USASearch for more papers by this authorShane Arishenkoff MD, Shane Arishenkoff MD Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, CanadaSearch for more papers by this authorAndrew S. Liteplo MD, Andrew S. Liteplo MD Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author First published: 08 February 2021 https://doi.org/10.1002/jum.15650Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Soldati G, Smargiassi A, Perrone T, et al. There is a validated acquisition protocol for lung ultrasonography in Covid-19 pneumonia. J Ultrasound Med 2020. 10.1002/jum.15284 Web of Science®Google Scholar 2Perrone T, Soldati G, Padovini L, et al. A new lung ultrasound protocol able to predict worsening in patients affected by severe acute respiratory syndrome coronavirus 2 pneumonia. J Ultrasound Med 2020. https://doi.org/10.1002/jum.15548 10.1002/jum.15548 Web of Science®Google Scholar 3Mento F, Perrone T, Macioce VN, et al. On the impact of different lung ultrasound imaging protocols in the evaluation of patients affected by coronavirus disease 2019. J Ultrasound Med 2020. https:/doi.org/10.1002/jum.15580 10.1002/jum.15580 Web of Science®Google Scholar 4Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med 2020; 39: 1413–1419. 10.1002/jum.15285 PubMedWeb of Science®Google Scholar 5Ma IWY, Hussain A, Wagner M, et al. Canadian Internal Medicine Ultrasound (CIMUS) expert consensus statement on the use of lung ultrasound for the assessment of medical inpatients with known or suspected coronavirus disease 2019. J Ultrasound Med 2020. https://doi.org/10.1002/jum.15571 10.1002/jum.15571 Web of Science®Google Scholar 6Ji L, Cao C, Gao Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care 2020; 24: 700. 10.1186/s13054-020-03416-1 PubMedWeb of Science®Google Scholar 7Vassalou EE, Karantanas AH, Antoniou KM. Proposed lung ultrasound protocol curing the COVID-19 outbreak. J Ultrasound Med 2020; 40(2): 397–399. 10.1002/jum.15402 PubMedWeb of Science®Google Scholar 8Millington SJ, Koenig S, Mayo P, Volpicelli G. Lung ultrasound for patients with coronavirus disease 2019 pulmonary disease. Chest 2021; 159: 205–211. 10.1016/j.chest.2020.08.2054 CASPubMedWeb of Science®Google Scholar 9Tung-Chen Y, Martí de Gracia M, Díez-Tascón A, et al. Correlation between chest computed tomography and lung ultrasonography in patients with coronavirus disease 2019 (COVID-19). Ultrasound Med Biol 2020; 46: 2918–2926. 10.1016/j.ultrasmedbio.2020.07.003 PubMedWeb of Science®Google Scholar 10Gargani L, Soliman-Aboumarie H, Volpicelli G, Corradi F, Pastore MC, Cameli M. Why, when, and how to use lung ultrasound during the COVID-19 pandemic: enthusiasm and caution. Eur Heart J Cardiovasc Imaging 2020; 21: 941–948. 10.1093/ehjci/jeaa163 PubMedWeb of Science®Google Scholar 11de Alencar JCG, Marchini JFM, Marino LO, et al. Lung ultrasound score predicts outcomes in COVID-19 patients admitted to the emergency department. Annals of Intensive Care. 2021; 11:6. https://doi.org/10.1186/s13613-020-00799-w. 10.1186/s13613-020-00799-w PubMedWeb of Science®Google Scholar 12Hussain A, Via G, Melniker L, et al. Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus. 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A 68-year-old man with a history of recent COVID-19 ARDS with prolonged respiratory failure requiring a tracheostomy was transferred to the medical ICU because of new-onset shock. The patient's hospital course from COVID-19 was complicated by ventilator-associated pneumonia attributable to Pseudomonas aeruginosa and Klebsiella pneumoniae, which were successfully treated, and a left femoral vein DVT requiring therapeutic anti-coagulation with enoxaparin. On admission to the ICU, the patient was hypotensive, requiring norepinephrine at 28 μg/min, and phenylephrine at 100 μg/min to maintain a systolic BP of 90 mm Hg. Bedside physical examination was notable for lethargy, and laboratory results were relevant for a lactate of 8 mmol/L and a hemoglobin of 5.6 g/dL, which was a decrease from 9.7 g/dL 24 hours earlier. A portable chest radiograph illustrated reticular opacities at the bases (shown in Fig 1). A focused bedside ultrasound assessment of the heart, lungs, and abdomen was performed. Relevant findings are illustrated in Videos 1 and 2, which were obtained using a phased array transducer oriented in the coronal plane in the patient's right 4th and 6th intercostal spaces at the midaxillary line. Video 3 is taken at the 6th intercostal space posterior axillary line. All videos were obtained while the patient was in the sitting position at 60 degrees. Question: What do the ultrasound findings in Video 1 illustrate, and what is the most likely cause of the patient's shock? Answer: The series of videos show an extra thoracic fluid collection outside of the chest wall with an anechoic region representing blood and a hyperechoic area consistent with a hematoma suggesting hemorrhage as the etiology of shock Video 1 obtained from the 4th intercostal space at the midaxillary line shows that the lung, diaphragm, chest wall, and liver are all continuous; therefore, the anechoic structure that is present is located outside the thorax and within the soft tissue of the chest. Video 2 is taken from the 6th intercostal space, along the same line as Video 1. Video 2 provides illustration of the key anatomical relationship that exists between the rib spaces and the pleura, as the visualized pleural line on ultrasound is 0.5 cm below the periosteal reflection of the ribs regardless of habitus.1Cardenas-Garcia J. Mayo P.H. Folch E. Ultrasonographic evaluation of the pleura.2015: 2https://doi.org/10.1177/2373997515610270Crossref Google Scholar Identifying this key relationship confirms that the anechoic collection with fibrous stranding and the hematoma that is visualized is located outside of the thorax. Video 3, taken from the posterior axillary line along the 6th intercostal space, once again confirms that the fluid collection is outside the chest, as the juxtaposition of the liver, lung, and chest wall can be appreciated (Please see Discussion Video for further explanation). Given the new-onset shock, decrease in hemoglobin, therapeutic dosing of anticoagulation, and ultrasound findings of a complex fluid collection outside the chest, hemorrhagic shock from a spontaneous intercostal arterial bleed became the leading diagnosis. The blood supply of the intercostal spaces within the chest arises from the intercostal arteries, which have anterior and posterior components. The anterior intercostal arteries, if coming from the first six intercostal spaces, are fed by the internal thoracic artery, and below the 6th intercostal space by the musculophrenic artery. The first two posterior intercostal arteries come from the costocervical trunk; from the 3rd rib space downward the posterior intercostal artery arises directly from the aorta.2Brennan P.A. Standring S. Wiseman S.M. Gray's Surgical Anatomy. Elsevier, Amsterdam2020Google Scholar The blood flow within the intercostal arteries is quite robust, with flow reaching up to 70 mL/min on the right and 99.5 mL/min on the left, highlighting how a patient can quickly develop shock if these vessels were to bleed.3Koyanagi T. Kawaharada N. Kurimoto Y. et al.Examination of intercostal arteries with transthoracic Doppler sonography.Echocardiography. 2010; 27: 17-20Crossref PubMed Scopus (22) Google Scholar The overall incidence of chest wall hematoma caused by intercostal arterial bleeding is unknown, but the few case reports available suggest that it is a rarely encountered condition, with causes being iatrogenesis, chest wall trauma, or spontaneous.4Roddy S.P. Transcatheter arterial embolization for the management of iatrogenic and Blunt TRAUMATIC intercostal artery injuries.J Vasc Surg. 2009; 49: 1624Abstract Full Text Full Text PDF Scopus (2) Google Scholar,5Jang J.Y. Lim Y.S. Woo J.H. Jang J.H. Spontaneous rupture of intercostal artery after severe cough.Am J Emerg Med. 2015; 33: e1-e3Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar When examining the chest with ultrasound, a hematoma can have a variety of appearances depending on the age of the lesion. In the acute stage, a hematoma appears as an echogenic structure, progressing to a hypoechoic structure over time, with septations observed in 44% of hematomas after 5 days of being present.6Wicks J. Silver T. Bree R. Gray scale features of hematomas: an ultrasonic spectrum.Am J Roentgenol. 1978; 131: 977-980Crossref PubMed Scopus (90) Google Scholar Enoxaparin is a low-molecular-weight heparin (LMWH) that is commonly given for DVT and pulmonary embolus at a dosage of 1 mg/kg twice daily. In patients receiving enoxaparin for DVT or pulmonary embolus, the incidence of major bleeding (defined as being clinically overt and associated with a hemoglobin decrease of 2 g/dL or requiring a transfusion of 2 units of packed RBCs) is 2.9% at 3 months.7Mismetti P. Quenet S. Levine M. et al.Enoxaparin in the treatment of deep vein thrombosis with or without pulmonary embolism.Chest. 2005; 128: 2203-2210Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Monitoring of antithrombotic effects is not usually necessary but can be considered in obese patients and those with renal dysfunction, targeting an anti-Xa level of 0.6 to 1.0 units/mL measured 4 hours after the third dose. In patients receiving LMWH, such as enoxaparin, there is no proven reversal agent. Protamine can neutralize the anti-IIa activity of LMWH; however, the effect of neutralization on anti-Xa is variable. Nonetheless, CHEST recommends that protamine be given at a dosage of 1 mg per 100 anti-Xa units, up to a maximum single dose of 50 mg.8Hirsh J. Bauer K.A. Donati M.B. Gould M. Samama M.M. Weitz J.I. Parenteral anticoagulants.Chest. 2008; 133: 141S-159SAbstract Full Text Full Text PDF PubMed Scopus (664) Google Scholar The patient was resuscitated with two units of packed RBCs, and a CT of the chest with IV contrast was performed, which showed a large right posterolateral chest wall hematoma with active arterial extravasation from the 4th and 5th intercostal arteries, confirming the diagnosis of a spontaneous intercostal arterial bleed. Interventional radiology was consulted, and the patient underwent successful embolization, with resolution of his shock state shortly thereafter. 1.In patients with undifferentiated shock in the ICU, bedside assessment with point-of-care ultrasound can be valuable in narrowing the differential.2.Identification of the periosteal reflection from the ribs aids in visualization of the pleural line, which is located 0.5 cm below the reflection. Recognition of this anatomic relationship on chest ultrasound can help identify whether the abnormality is intrathoracic or extrathoracic.3.Hematomas have a variable sonographic presentation, appearing more echogenic early on and becoming hypoechoic over time. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the videos, see the online article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3ZWEyMmQ2YjViMjUxNzg1MTk2M2ZmOTAzZDk4NjIwMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzEzNDgxOTEzfQ.ISpnEnOK6-b2qG4jp4_bHh22rVJ2sDuspPJqkj2MWrOJtpQVn0q0_ktW19-g64W920W6I8J_g7rCFh1zOgJg9mcsAVFrvQWmgtdA6ZCuyzfGgQiE4W-b3KJ8hsJNITJ8YaD7OpwijWM3eY10Tmy0aBQOYnsb0ESA8CumevEaFUpaisNlefiatAuhSvihws86gUsPe8Xo_ao7LIcb0zTi8_QiAoLMSgEgJxQkd7iZE_n7juZCGT7VHqYwog07G170CPFqNfas6w0rmobDv6sReWjw15XIKQZtbR69fCBx8-rDe7EjerhElvoaJBYucqUcMtwUHHgXsYCkLgc-9E6lDw Download .mp4 (12.09 MB) Help with .mp4 files Video 1eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3NDlmMjYwNDc5ZTA1ODcyY2Q1ZTk5YmI3MGUyNTk4YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzEzNDgxOTE0fQ.iEaO8mCa1inUqLw2lNOrq8OBuBiKHTQ_KOeBxkH-tkClaf3xBPQWBpPtKGgru8mal1skkeMUemBeGYkHZGWIGswRxCnmPvhNb9ZoXcPYl8YbgR2mygImhCXPWGwJWg3Fa1g9nsu7wT8WXwr7atSMXs2gcezOSicm223xYL9EaYjj_8kypDg90kqaHnCNHwdwzH0K9kXBkdgcrSoNEYlJ3tey9dim92-HTC1Rg3-GdTPeN6YUKkxRkY_OEBD_BaLZxQCZvJsECAsEL178iUmsUFI-e-YYeY73oqWBdrITfquqr_dgVpf_mcJFOzMLwW4QXrCLy7LR97tmU6_ZAjm5bQ Download .mp4 (16.09 MB) Help with .mp4 files Video 2

Background Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in improving this training gap. Due to travel restrictions and physical distancing requirements during the COVID-19 pandemic, most in-person POCUS training courses were cancelled. Though tele-ultrasound technology has existed for several years, use of tele-ultrasound technology to deliver hands-on training during a POCUS CME course has not been previously described. Methods We conducted a retrospective observational study comparing educational outcomes, course evaluations, and learner and faculty feedback from in-person versus tele-ultrasound POCUS courses. The same POCUS educational curriculum was delivered to learners by the two course formats. Data from the most recent pre-pandemic in-person course were compared to tele-ultrasound courses during the COVID-19 pandemic. Results Pre- and post-course knowledge test scores of learners from the in-person ( n = 88) and tele-ultrasound course ( n = 52) were compared. Though mean pre-course knowledge test scores were higher among learners of the tele-ultrasound versus in-person course (78% vs. 71%; p = 0.001), there was no significant difference in the post-course test scores between learners of the two course formats (89% vs. 87%; p = 0.069). Both learners and faculty rated the tele-ultrasound course highly (4.6–5.0 on a 5-point scale) for effectiveness of virtual lectures, tele-ultrasound hands-on scanning sessions, and course administration. Faculty generally expressed less satisfaction with their ability to engage with learners, troubleshoot image acquisition, and provide feedback during the tele-ultrasound course but felt learners completed the tele-ultrasound course with a better basic POCUS skillset. Conclusions Compared to a traditional in-person course, tele-ultrasound POCUS CME courses appeared to be as effective for improving POCUS knowledge post-course and fulfilling learning objectives. Our findings can serve as a roadmap for educators seeking guidance on development of a tele-ultrasound POCUS training course whose demand will likely persist beyond the COVID-19 pandemic.

OBJECTIVES:To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19). METHODS:Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered. RESULTS:Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus. CONCLUSIONS:In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Introduction Buprenorphine in the treatment of opioid use disorder (OUD) has several benefits including better long-term treatment adherence (1) and is a safer option for many patients due to buprenorphine’s limited potential to cause respiratory depression (4). In comparison to standard buprenorphine induction, induction via micro-dosing does not require a period of withdrawal and dramatically shortens the time required to complete induction. Prior micro-dosing protocols using sublingual (SL) (7-10) and transdermal forms (11) have been reported. We present a case of buprenorphine induction using a novel inpatient intravenous micro-dosing 4-day protocol in a patient on methadone. Case Presentation A 62-year-old man with chronic obstructive pulmonary disease (COPD) on chronic methadone 80mg daily for OUD presented with respiratory failure and was diagnosed with opioid overdose. He was transitioned from a naloxone infusion to intravenous micro-doses of buprenorphine and low dose methadone without experiencing significant withdrawal, and he was discharged on buprenorphine/naloxone SL. Discussion This case demonstrates a successful and well tolerated buprenorphine induction without interruption of methadone treatment or precipitation of significant opioid withdrawal. To the best of our knowledge, this is the first report describing micro-induction with intravenous buprenorphine.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.1 Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

A man in his late 40s with active IV heroin use presented with 4 weeks of lower back pain, generalized weakness, night sweats, and weight loss. He last used IV drugs 5 weeks prior to admission, around which time he had fallen while walking in a subway station. Since then, he noticed worsening lower back pain. He had no limitations in mobility, and no urinary complaints or stool incontinence. He denied fevers. On admission, the patient was afebrile and normotensive without tachycardia. He was cachectic and had no murmurs on cardiac examination. He had no spinal or paraspinal tenderness, and his neurologic examination was normal. Laboratory tests revealed a normal WBC count and a hemoglobin of 11.7 g/dL. Erythrocyte sedimentation rate was 29 mm/h, and C-reactive protein level was 3.7 mg/dL. An MRI of the lumbar spine was suspicious for L4-5 and L5-S1 discitis/osteomyelitis with involvement of the left psoas muscle. Blood cultures were drawn, and antibiotics were held in anticipation of obtaining a vertebral bone biopsy. We were concerned for endocarditis with bacterial seeding in a patient with active IV drug use and requested an official transthoracic echocardiogram. We also performed a point-of-care ultrasound (POCUS) examination of the heart (Video 1). Question: What is the most likely explanation for the observed right atrial findings and what is their clinical significance? Answer: The right atrial structures seen are normal anatomic variants. In the subcostal view, attached to the posterior margin of the inferior vena cava is a prominent eustachian valve. The thin free-flowing strands throughout the right atrium emanate from the eustachian valve and represent a large Chiari network. A ridge at the posterior lateral wall of the right atrium is the crista terminalis (Video 2, Narration Video). All of these structures are in themselves benign, although their appearance can mimic right atrial pathology, including vegetations, thrombi, and intra-atrial masses. Their interpretation depends on the clinical context. With increasing use of POCUS, practitioners must have an understanding of normal anatomy and anatomic variants that may mimic pathology. In this patient with suspected osteomyelitis and active IV drug use, a potential endovascular source of bacterial seeding of the vertebral bodies was on our differential. On further review, we concluded that the ultrasound findings were more consistent with benign anatomic variants of the right atrium. Knowledge of fetal cardiac development may facilitate proper identification of these structures. The most common right atrial anatomic variants are all remnants of a single embryonal structure, the right venous valve. In fetal circulation, the organ of gas exchange is not the lungs but the placenta. The vessel carrying the most highly oxygenated blood is the umbilical vein, which drains into the inferior vena cava (IVC) before emptying into the right atrium. In the fetal right atrium, the flow of oxygenated blood from the IVC is separated from deoxygenated blood draining from the brain via the superior vena cava. The eustachian valve is a thin spiral membrane which originates from the inferior edge of the IVC and directs oxygenated blood from the IVC through the foramen ovale, creating a right-to-left atrial shunt bypassing the lungs (Fig 1A).1Moral S. Ballesteros E. Huguet M. Panaro A. Palet J. Evangelista A. Differential diagnosis and clinical implications of remnants of the right valve of the sinus venosus.J Am Soc Echocardiogr. 2016; 29: 183-194Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar The eustachian valve is one part of an earlier embryonal structure known as the sinus venosus. The sinus venosus ultimately splits into the primitive superior vena cava and the IVC.1Moral S. Ballesteros E. Huguet M. Panaro A. Palet J. Evangelista A. Differential diagnosis and clinical implications of remnants of the right valve of the sinus venosus.J Am Soc Echocardiogr. 2016; 29: 183-194Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar At the junction of the sinus venosus and the right atrium are two valves: the left and the right sinus venosus valves. After involution of the right sinus venosus valve multiple residual structures derived from it remain present in the right atrium. The cranial portion of the valve forms a fibrous ridge near the superior vena cava called the crista terminalis. The caudal portion of the valve is incorporated into the IVC and the coronary sinus. The incomplete involution of the caudal portion of the valve may result in a prominent eustachian valve and Chiari network (Fig 1B). Despite its name, the eustachian valve is not a true valve, in that its function is not to prevent the regurgitation of blood. Although usually benign, prominent eustachian valves are associated with patent foramen ovale,1Moral S. Ballesteros E. Huguet M. Panaro A. Palet J. Evangelista A. Differential diagnosis and clinical implications of remnants of the right valve of the sinus venosus.J Am Soc Echocardiogr. 2016; 29: 183-194Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar which likely reflects their embryonal function of directing oxygenated blood from the IVC toward the fetal intra-atrial septum and into the developing left heart. On ultrasound, the subcostal view allows for the visualization of the IVC and the eustachian valve in the same plane.2Kim M.J. Jung H.O. Anatomic variants mimicking pathology on echocardiography: differential diagnosis.J Cardiovasc Ultrasound. 2013; 21: 103-112Crossref PubMed Scopus (29) Google Scholar A eustachian valve can appear “leaf-like” and can protrude into the right atrium to give the appearance of an intra-atrial mass. The Chiari network is an aggregate of filamentous structures that also results from incomplete involution of the right venous valve. On ultrasound, it appears as thin, rapidly moving echogenic strands within the right atrium, which originate from the eustachian valve and can extend to the crista terminalis, intra-atrial septum, and coronary sinus valve.1Moral S. Ballesteros E. Huguet M. Panaro A. Palet J. Evangelista A. Differential diagnosis and clinical implications of remnants of the right valve of the sinus venosus.J Am Soc Echocardiogr. 2016; 29: 183-194Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Chiari networks are also usually benign and have little clinical significance, although one study noted an association with patent foramen ovale and atrial septal aneurysms on contrast echocardiography.3Schneider B. Hofmann T. Justen M.H. Meinertz T. Chiari’s network: normal anatomic variant or risk factor for arterial embolic events?.J Am Coll Cardiol. 1995; 26: 203-210Crossref PubMed Scopus (175) Google Scholar In addition, there are case reports of thrombi and right heart catheter entrapment within Chiari network.2Kim M.J. Jung H.O. Anatomic variants mimicking pathology on echocardiography: differential diagnosis.J Cardiovasc Ultrasound. 2013; 21: 103-112Crossref PubMed Scopus (29) Google Scholar,4Loukas M. Sullivan A. Tubbs R.S. Weinhaus A.J. DerDerian T. Hanna M. Chiari’s network: review of the literature.Surg Radiol Anat. 2010; 32: 895-901Crossref PubMed Scopus (59) Google Scholar The crista terminalis is the fibromuscular ridge located at the divide between the trabeculated and smooth muscle of the right atrium.4Loukas M. Sullivan A. Tubbs R.S. Weinhaus A.J. DerDerian T. Hanna M. Chiari’s network: review of the literature.Surg Radiol Anat. 2010; 32: 895-901Crossref PubMed Scopus (59) Google Scholar It appears as a nodular mass, best seen in the apical four-chamber view on the postero-lateral wall of the right atrium. This structure is usually of minimal clinical significance other than its potential to mimic an intra-atrial mass. The patient in our study remained afebrile with negative blood cultures throughout hospitalization. Lumbar spine bone biopsy culture grew Streptococcus parasanguinis. The patient’s official transthoracic echocardiogram did not reveal any valvular vegetation. We initially questioned whether the presence of these variants increased the patient’s likelihood of having endocarditis. Although cases of eustachian valve endocarditis have been reported in patients with IV drug use,5Edwards A.D. Vickers M.A. Morgan C.J. Infective endocarditis affecting the eustachian valve.Heart. 1986; 56: 561-562Crossref Scopus (29) Google Scholar,6Vilacosta I. San Roman J.A. Roca V. Eustachian valve endocarditis.Heart. 1990; 64: 340-341Crossref Scopus (29) Google Scholar in the absence of positive blood cultures or evidence of valvular disease, the study patient did not meet the modified Duke criteria for the diagnosis of infective endocarditis.7Li J.S. Sexton D.J. Mick N. et al.Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.Clin Infect Dis. 2002; 30: 633-638Crossref Scopus (2857) Google Scholar We discharged him on ceftriaxone 2 g daily for a 6-week course for the treatment of vertebral osteomyelitis. We concluded the structures of interest to be anatomic variants and, essentially, incidental findings. 1.There are anatomic variants in the right atrium that mimic pathology. These variants include the eustachian valve, a Chiari network, and the crista terminalis; they all originate from the right venous valve of the fetal heart.2.As the number of providers who perform POCUS increases, we must be aware of anatomic variants to prevent the misinterpretation of normal structures. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the videos, see the online version of this article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiNzJjODAzNDMyMGQ1ZGY4Y2VmZTI2ZjA0Mzg3OGUwZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDk2NzU0fQ.eM4VqGjl8pit1-6HddTxghohp-tLdRPN4MiwTmmmIT53OTpozA3d9sCLxlHr8X5RDvJ2SpTPz7dGQJQDsSaSGAe2iLqHvU87o2tHvi3rLbsrZyaqyzT-UHGHTuX_UhcPBPqy4YSNgLrgIfdfU2hZf1LPfVbXFarhYdZHOXPjLYqIhVnDOnwQKToyRh1otFe9RksH8MwAzLSLZozxkd7k-iH72JZ5_7yQb32mnyzjctkw5QlWga-LwP2cpyexxDNW2_8jO_FirK9yfW1mjEyHUaeEzH2Remk00JsA0NacPN9a2uhp5bAZKo8CLvUokRz71R6XqeUplQeZlni2z_ndKg Download .mp4 (10.64 MB) Help with .mp4 files Video 1Right Atrial Findings.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4Mzg4NjMyNjdiOTJhZmYwZWE0ZDdmMDlhMDdjM2IxNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDk2NzU0fQ.TDOSoZmuwpmWczFxUlk47AMZEjo6N1QzZqP2IJyXUeSCbC9c26tbZ_zWzJUIwjqUl_l1ejlXlv-07d7vAvbxH4R3q6VhNEMYD02N0vwN25QZIQt46Ub9kwdaJf3UhiL367QpBx-cXU0hqnmyDY3fO8aLRu4aCPqjAaXDGHtfBoZwQ6Qks5W8sWsVVRfjnmLGY5cU-0Dte_bq18ecwlggS5GoqLCSJZCS13DictRs8K0P7WKI3XUpVzLvo-UVEHVFHj4_NUfUmBtj4gRRH9worFzzH13Nl82divKc6ChMStzx5TviacXz3olP4Rm2qt7VuhY0qoD5xueKxwuhpD3gfw Download .mp4 (16.05 MB) Help with .mp4 files Video 2Right Atrial Anatomic Variants.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4NmM3NGYzOTU5N2U5MDE1OTQ1YjA4YTU4NzAyZDBhMyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDk2NzU0fQ.RU6TKOOLNPAE5gfgmDOG4B5FylkcBc_w7cZWrYNDDqLXqB4o9tWgt40d5lBZc38VN6Z1soc3oKXWvlh6CaF-QOwYjg-P64trkp9GjG_fG4629an7wJ_GZBjPC6gKEwcX2ty1aFx7m79O1bUBsrIo25dkDPmlWmqdmkXjz_f1hf1srvNImD30jB70-RcfdhijJ_Bt62HjSMkla_tjWunvTbs8pP6XcaJyhIDaCup0gRcZvFQoDUhRcyEk-C7Xt2DpJjfjrpPZlbEEjcyguRs1IPV3mJhrPlTOGnxZPJAPbKZ7yIMz_cdAC_9QgvH-Eixx3e_SDbjmbRekZ5LPiRUw2g Download .mp4 (12.83 MB) Help with .mp4 files Video 3

The novel coronavirus disease 2019 (COVID-19) pandemic has led to more than 24 million confirmed cases and over 820,000 deaths worldwide as of late August 2020. Early observational studies reported high rates of venous thromboembolism (VTE) in critically ill patients with COVID-19 [1]. A recent meta-analysis reported an incidence of 26% for VTE among 3487 patients from 30 studies based on very low-quality evidence due to heterogeneity and risk of bias [2]. Furthermore, studies have reported that elevated D-dimer values in COVID-19 are associated with a higher risk of VTE, mechanical ventilation, and mortality [3–5].

Neurologic complications of COVID-19 are not well described. We report 2 patients who were diagnosed with COVID-19 after presenting with diplopia and ophthalmoparesis.

Journal of Ultrasound in MedicineVolume 39, Issue 1 p. 203-203 Letter to the Editor Ultrasound-Guided Lumbar Puncture Gregory Mints MD, Gregory Mints MD orcid.org/0000-0002-3013-2608 Hospital Medicine Point-of-Care Ultrasound Program, Department of Medicine, Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USASearch for more papers by this authorJina Bai MS, Jina Bai MS Hospital Medicine Point-of-Care Ultrasound Program, Department of Medicine, Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USASearch for more papers by this authorTanping Wong MD, Tanping Wong MD Hospital Medicine Point-of-Care Ultrasound Program, Department of Medicine, Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USASearch for more papers by this author Gregory Mints MD, Gregory Mints MD orcid.org/0000-0002-3013-2608 Hospital Medicine Point-of-Care Ultrasound Program, Department of Medicine, Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USASearch for more papers by this authorJina Bai MS, Jina Bai MS Hospital Medicine Point-of-Care Ultrasound Program, Department of Medicine, Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USASearch for more papers by this authorTanping Wong MD, Tanping Wong MD Hospital Medicine Point-of-Care Ultrasound Program, Department of Medicine, Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USASearch for more papers by this author First published: 21 June 2019 https://doi.org/10.1002/jum.15076Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume39, Issue1January 2020Pages 203-203 RelatedInformation

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

Journal Article Beta-cell apoptosis in the pathogenesis of human type 2 diabetes mellitus Get access O Leonardi, O Leonardi Department of Medicine, New York University School of Medicine, New York, USA Search for other works by this author on: Oxford Academic Google Scholar G Mints, G Mints Department of Medicine, New York University School of Medicine, New York, USA Search for other works by this author on: Oxford Academic Google Scholar M A Hussain M A Hussain Department of Medicine, New York University School of Medicine, New York, USADepartment of Pharmacology, New York University School of Medicine, New York, USA (Correspondence should be addressed to M A Hussain, 550 First Avenue MSB 424, New York, New York 10016, USA; Email: hussam02@popmail.med.nyu.edu) Search for other works by this author on: Oxford Academic Google Scholar European Journal of Endocrinology, Volume 149, Issue 2, Aug 2003, Pages 99–102, https://doi.org/10.1530/eje.0.1490099 Published: 01 August 2003 Article history Received: 13 May 2003 Accepted: 26 May 2003 Published: 01 August 2003