Gastrointestinal stromal tumors (GISTs) are the most common malignant subepithelial lesions (SELs) of the gastrointestinal tract. They originate from the interstitial cells of Cajal located within ...the muscle layer and are characterized by over-expression of the tyrosine kinase receptor KIT. Pathologically, diagnosis of a GIST relies on morphology and immunohistochemistry KIT and/or discovered on gastrointestinal stromal tumor 1 (DOG1) is generally positive. The prognosis of this disease is associated with the tumor size and mitotic index. The standard treatment of a GIST without metastasis is surgical resection. A GIST with metastasis is usually only treated by tyrosine kinase inhibitors without radical cure; thus, early diagnosis is the only way to improve its prognosis. However, a GIST is usually detected as a SEL during endoscopy, and many benign and malignant conditions may manifest as SELs. Conventional endoscopic biopsy is difficult for tumors without ulceration. Most SELs have therefore been managed without a histological diagnosis. However, a favorable prognosis of a GIST is associated with early histological diagnosis and R0 resection. Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (EUS-FNA) are critical for an accurate diagnosis of SELs. EUS-FNA is safe and effective in enabling an early histological diagnosis and adequate treatment. This review outlines the current evidence for the diagnosis and management of GISTs, with an emphasis on early management of small SELs.
Focused cardiac ultrasonography is performed by clinicians at the bedside and is used in time‐sensitive scenarios to evaluate a patient's cardiovascular status when comprehensive echocardiography is ...not immediately available. This simplified cardiac ultrasonography is often performed by noncardiologists using small, portable devices to augment the physical examination, triage patients, and direct management in both critical care and outpatient settings. However, as the use of focused cardiac ultrasonography continues to expand, careful consideration is required regarding training, scope of practice, impact on patient outcomes, and medicolegal implications. In this review, we examine some of the challenges with rapid uptake of this technique and explore the benefits and potential risk of focused cardiac ultrasonography. We propose possible mechanisms for cross‐specialty collaboration, quality improvement, and oversight.
Gastric outlet obstruction (GOO) can be caused by benign and malignant diseases and often leads to a reduction in patient quality of life. Lately, endoscopic ultrasonography (EUS)‐guided ...gastroenterostomy (EUS‐GE) has emerged. At the present time, there are three types of EUS‐GE using lumen‐apposing biflanged metal stents (LAMS): (i) direct EUS‐GE; (ii) assisted EUS‐GE using retrieval/dilating balloon, single balloon overtube, nasobiliary drain and ultraslim endoscope; and (iii) EUS‐guided double‐balloon‐occluded gastrojejunostomy bypass (EPASS). Overall technical success rate is approximately 90% regardless of technique used, although this is based on two retrospective studies only. In the EPASS procedure, the success rate of the one‐step procedure was higher than that of the two‐step procedure (100% vs 82%). Clinical success was almost uniform when stent placement was technically successful. Although there have been no‐stent induced procedural deaths, adverse events were seen in several cases. One technically failed case carried out using balloon‐assisted EUS‐GE was converted to laparoscopic gastrojejunostomy. Two failed cases in EPASS procedure improved with conservative treatment. In the present review, we show the feasibility and outcomes using novel EUS‐GE using LAMS. Clinical prospective trials with comparison to luminal enteral stents and surgical GE are warranted.
This study investigates the usefulness of contrast-enhanced ultrasound (CEUS) and real-time elastography (RTE) for the characterization of testicular masses by comparing pre-operative ultrasound ...findings with post-operative histology. Sixty-seven patients with 68 sonographically detected testicular masses underwent B-mode, color-coded Doppler sonography (CCDS), CEUS and RTE according to defined criteria. For RTE, elasticity score (ES), difference of elasticity score (D-ES), strain ratio (SR) and size quotient (Qsize) were evaluated. Histopathologically, 54/68 testicular lesions were neoplastic (47 malignant, 7 benign). Descriptive statistics revealed the following results (neoplastic vs. non-neoplastic) for sensitivity, specificity, positive predictive value, negative predictive value and accuracy, respectively: B-mode, 100%, 43%, 87%, 100%, 88%; CCDS 81%, 86%, 96%, 55%, 82%; CEUS 93%, 85%, 96%, 73%, 91%; ES 98%, 25%, 85%, 75%, 85%; D-ES 98%, 50%, 90%, 83%, 89%; SR 90%, 45%, 86%, 56%, 81%; and Qsize 57%, 83%, 94%, 28%, 61%. B-mode with CCDS remains the standard for assessing testicular masses. In characterization of testicular lesions, CEUS clearly outperformed all other modalities. Our study does not support the routine use of RTE in testicular ultrasonography because of its low specificity.
Objectives
Point‐of‐care lung ultrasonography (US) is an alternative to chest radiography for imaging of suspected community‐acquired pneumonia (CAP) in children. We compared pediatric emergency ...department (ED) time metrics between children who received point‐of‐care lung US versus chest radiography. Secondary objectives were comparisons of health system costs and other resources in these imaging groups.
Methods
This work was a retrospective matched cohort study of children aged 0 to 18 years in an academic urban pediatric ED who were imaged for suspected CAP with either point‐of‐care lung US or chest radiography.
Results
A total of 202 patients (101 in each group) were included in the study. The point‐of‐care lung US group spent a mean of 75.9 (SE, 14.3) minutes less from physician assessment to discharge (P < .0001) and 60.9 (SE, 18.1) minutes less in the overall ED length of stay (P = .0008). Physician billings and facility fees were both significantly lower (P < .0001) in the point‐of‐care lung US group, for a mean health systems savings of CAN$187.1 (SE, CAN$21.9).
Conclusions
In children undergoing imaging for suspected CAP in our pediatric ED, point‐of‐care lung US by pediatric emergency medicine physicians was associated with decreased time and cost compared with chest radiography.
A noninvasive and accurate method of determining fluid responsiveness in ventilated patients would help to mitigate unnecessary fluid administration. Although carotid ultrasound has been previously ...studied for this purpose, several studies have recently been published. We performed an updated systematic review and meta-analysis to evaluate the accuracy of carotid ultrasound as a tool to predict fluid responsiveness in ventilated patients.
Studies eligible for review investigated the accuracy of carotid ultrasound parameters in predicting fluid responsiveness in ventilated patients, using sensitivity and specificity as markers of diagnostic accuracy (International Prospective Register of Systematic Reviews PROSPERO CRD42022380284). All included studies had to use an independent method of determining cardiac output and exclude spontaneously ventilated patients. Six bibliographic databases and 2 trial registries were searched. Medline, Embase, Emcare, APA PsycInfo, CINAHL, and the Cochrane Library were searched on November 4, 2022. Clinicaltrials.gov and Australian New Zealand Clinical Trials Registry were searched on February 24, 2023. Results were pooled, meta-analysis was conducted where possible, and hierarchical summary receiver operating characteristic models were used to compare carotid ultrasound parameters. Bias and evidence quality were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines.
Thirteen prospective clinical studies were included (n = 648 patients), representing 677 deliveries of volume expansion, with 378 episodes of fluid responsiveness (58.3%). A meta-analysis of change in carotid Doppler peak velocity (∆CDPV) yielded a sensitivity of 0.79 (95% confidence interval CI, 0.74-0.84) and a specificity of 0.85 (95% CI, 0.76-0.90). Risk of bias relating to recruitment methodology, the independence of index testing to reference standards and exclusionary clinical criteria were evaluated. Overall quality of evidence was low. Study design heterogeneity, including a lack of clear parameter cutoffs, limited the generalizability of our results.
In this meta-analysis, we found that existing literature supports the ability of carotid ultrasound to predict fluid responsiveness in mechanically ventilated adults. ∆CDPV may be an accurate carotid parameter in certain contexts. Further high-quality studies with more homogenous designs are needed to further validate this technology.
Objective. The aim was to compare skin assessment by palpation and by high-frequency ultrasound in patients with SSc with disease duration <2 yrs. Methods. Skin thickness and skin echogenicity were ...measured by 20 MHz ultrasound at five different anatomical sites in 106 individuals within 2 yrs from the first non-Raynaud's symptom and compared with the modified Rodnan skin score (mRss). Results. The patients with short disease duration were characterized by high skin thickness and low skin echogenicity, which correlated inversely, reflecting oedema. Patients with diffuse skin involvement displayed higher skin thickness and lower skin echogenicity than did patients with limited skin involvement. The ultrasound measurements correlated to the local mRss from the corresponding anatomical region and also to the total mRss. However, there was a considerable overlap in both skin thickness and skin echogenicity between different local mRss at all five anatomical sites. Skin involvement of the chest could be detected earlier by ultrasound than by palpation. Conclusion. In SSc patients with short disease duration, high-frequency ultrasound can identify the oedematous phase that may precede palpable skin involvement and may thus be useful to identify patients with diffuse skin involvement very early in the disease process. Ultrasound measurements also reflect the severity of the overall skin involvement.
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