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Abstract The digitization of medicine will play an increasingly significant role in future years. In particular, telemedicine, Virtual Reality (VR) and innovative Artificial Intelligence (AI) systems offer tremendous potential in imaging diagnostics and are expected to shape ultrasound diagnostics and teaching significantly. However, it is crucial to consider the advantages and disadvantages of employing these new technologies and how best to teach and manage their use. This paper provides an overview of telemedicine, VR and AI in student ultrasound education, presenting current perspectives and controversies.

Primary pulmonary sarcoma and mesothelioma are rare malignancies. The review article discusses the appearance of these tumors in B-mode ultrasound (US), color Doppler ultrasound and contrast-enhanced ultrasound (CEUS). In particular, the article is intended to inspire the examination of thoracic wall tumors and pleural masses with the possibilities of ultrasonography and to obtain histologically evaluable material using US or CEUS-guided sampling.

Ultrasound is used in cardiopulmonary resuscitation (CPR) and advanced life support (ALS). However, there is divergence between the recommendations of many emergency and critical care societies who support its use and the recommendations of many international resuscitation organizations who either recommend against its use or recommend it only in limited circumstances. Ultrasound offers potential benefits of detecting reversable causes of cardiac arrest, allowing specific interventions. However, it also risks interfering with ALS protocols and increasing unhelpful interventions. As with many interventions in ALS, the evidence base for ultrasound use is weak, and well-designed randomized trials are needed. This paper reviews the current theory and evidence for harms and benefits.

Lung ultrasound is a well-established diagnostic approach used in detecting pathological changes near the pleura of the lung. At the acoustic boundary of the lung surface, it is necessary to differentiate between the primary visualization of pleural parenchymal pathologies and the appearance of secondary artifacts when sound waves enter the lung or are reflected at the visceral pleura. The aims of this pictorial essay are to demonstrate the sonographic patterns of various pleural interface artifacts and to illustrate the limitations and pitfalls of the use of ultrasound findings in diagnosing any underlying pathology.

Purpose: The purpose of current study was to investigate the value of the late-phase enhancement features of pancreas contrast-enhanced ultrasound (CEUS) in the detection of liver metastases in patients with pancreatic ductal adenocarcinomas (PDAC).Methods: From October 2020 to March 2021, 86 patients were prospectively enrolled. The gold standard of liver metastatic and PDAC lesions were based on histopathologically diagnoses and multiple imaging modalities results. B-mode ultrasound (BMUS) was performed to detect suspected liver metastases before CEUS. During the late phase of pancreas CEUS, the entire liver was scanned again to detect hypoenhanced liver metastases. Liver metastases were confirmed by biopsy and histopathological results. The number and size of liver metastases detected by BMUS and during CEUS late phase were recorded and compared.Results: Suspected liver metastases were detected in 14 patients by BMUS (n = 23). During the late phase of CEUS, hypoenhanced liver metastases were detected in 23 patients (n = 87). When compared with BMUS, whole-liver scan during the late phase of CEUS detected more isoechoic, small, or superficially located lesions. Compared with BMUS, the specificity, sensitivity, positive predictive value, and negative predictive value of CEUS in diagnosing of liver metastases in PDAC patients were significantly improved (96.72% vs. 100%, 48% vs. 92%, 85.71% vs. 100%, and 83.10% vs. 96.83%, respectively) (P < 0.05).Conclusion: The late phase whole liver scan during CEUS of pancreas helps to detect more liver metastases, which is important for further clinical decision-making.

Purpose The aim of this study was to retrospectively evaluate contrast-enhanced ultrasound (CEUS) findings in patients with peliosis hepatis (PH). Methods A retrospective analysis was conducted of CEUS features in 24 patients with histopathologically confirmed PH (11 men and 13 women; mean age, 32.4±7.1 years; range, 28 to 41 years). All lesions were histologically proven, either by core needle biopsy (n=10) or by hepatic surgery (n=14). Results The mean size was 36.8±12.4 mm (range, 10 to 80 mm). On B-mode ultrasonography (BMUS), all PH lesions were heterogeneously hypoechoic, with well-defined margins but irregular shapes. No mass effect was observed. During the arterial phase of CEUS, all lesions displayed mild heterogeneous hyperenhancement (83.3%, 20/24) or isoenhancement (16.7%, 4/24). Furthermore, 87.5% of the PH lesions showed mild washout after 1 minute in the portal venous phase (30-120 seconds) and mild washout in the late phase (>120 seconds). Conclusion The lack of a mass effect on BMUS, mild heterogeneous arterial hyperenhancement, and washout in the very late portal venous phase (after 1 minute) on CEUS are characteristic of PH. Although it is a histological diagnosis, PH should be considered in the differential diagnosis when the clinical context does not favor a malignancy or infection.

Objective To evaluate the feasibility and diagnostic performance of acoustic radiation force impulse (ARFI) elastography in different omental masses (OM).Design This was a retrospective analysis of 106 patients with OM defined as omental thickness ≥1 cm, who underwent abdominal B-mode ultrasound (US) and standardised ARFI examinations of the OM between September 2018 and June 2021 at our university hospital. A cytohistological confirmation was available in 91/106 (85.8%) of all OM, including all 65/65 (100%) malignant OM (mOM) and 26/41 (63.4%) of benign OM (bOM). In 15/41 (36.6%) of bOM; cross-sectional imaging and or US follow-up with a mean duration of 19.8±3.1 months was performed. To examine the mean ARFI velocities (MAV) for potential cut-off values between bOM and mOM a receiver operating characteristic analysis was implemented.Results The MAV in the mOM group (2.71±1.04 m/s) was significantly higher than that of bOM group (1.27±0.87 m/s) (p

Medical schools are increasingly incorporating ultrasound into undergraduate medical education. The global integration of ultrasound into teaching curricula and physical examination necessitates a strict evaluation of the technology's benefit and the reporting of results. Course structures and assessment instruments vary and there are no national or worldwide standards yet. This systematic literature review aims to provide an up-to-date overview of the various formats for assessing ultrasound skills. The key questions were framed in the PICO format (Population, Intervention, Comparator, and Outcome). A review of literature using Embase, PubMed, Medline, Cochrane and Google Scholar was performed up to May 2021, while keywords were predetermined by the authors. Inclusion criteria were as follows: prospective as well as retrospective studies, observational or intervention studies, and studies outlining how medical students learn ultrasound. In this study, 101 articles from the literature search matched the inclusion criteria and were investigated. The most frequently used methods were objective structured clinical examinations (OSCE), multiple choice questions, and self-assessments via questionnaires while frequently more than one assessment method was applied. Determining which assessment method or combination is ideal to measure ultrasound competency remains a difficult task for the future, as does the development of an equitable education approach leading to reduced heterogeneity in curriculum design and students attaining equivalent skills.

The diagnostic capabilities of ultrasound extend far beyond the evaluation of the pleural space and lungs. Sonographic evaluation of the chest wall is a classic extension of the clinical examination of visible, palpable, or dolent findings. Unclear mass lesions of the chest wall can be differentiated accurately and with low risk by additional techniques such as color Doppler imaging, contrast-enhanced ultrasound, and, in particular, ultrasound-guided biopsy. For imaging of mediastinal pathologies, ultrasound has only a complementary function but is valuable for guidance of percutaneous biopsies of malignant masses. In emergency medicine, ultrasound can verify and support correct positioning of endotracheal tubes. Diaphragmatic ultrasound benefits from the real-time nature of sonographic imaging and is becoming increasingly important for the assessment of diaphragmatic function in long-term ventilated patients. The clinical role of thoracic ultrasound is reviewed in a combination of narrative review and pictorial essay.

Background and Aims: To investigate the frequency of different benign and malignant focal liver lesions (FLLs) in relation to clinical and sonographic features among patients with liver cirrhosis (LC) and newly detected FLLs. Methods: This study was a retrospective analysis of 225 cirrhotic patients with newly detected FLLs who underwent hepatic ultrasound (US) examinations at our university hospital from 2011 to 2022. The diagnosis of FLLs was based on histology and/or consensus radiological criteria, in accordance with the current diagnostic guidelines. The FLLs were classified into benign (bFLLs) or malignant (mFLLs) lesions and the latter group was subclassified into HCC and non-HCC mFLLs. The frequency, clinical parameters, and sonographic features of the different groups were examined and compared. Results: Of the 225 FLLs, 154 (68.4%) were mFLLs and 71 (31.6%) bFLLs. HCC was the most frequent subcategory of FLLs (132; 58.7%). There were (22; 9.8%) non-HCC mFLLs with 11 (4.9%) metastases and 11 (4.9%) non-HCC primary liver tumors. Regenerative nodules (RNs) were the most frequent form of bFLLs (25; 11.1%), followed by simple cysts (22; 9.8%) and hemangiomas (14; 6.2%). The other bFLLs (10; 14.1%) were fat deposition/sparing (5), hematomas (2), abscesses (2), and echinococcal cysts (1). The distribution of bFLLs and HCC and non-HCC mFLLs varied significantly according to the clinical scenarios. HCC mFLLs were more frequent in males (p = 0.001), in those with no history of active non-hepatic primary malignant disease (NHPMD) (p < 0.001), in those with a hepatitis B or C etiology of LC (p = 0.002), when located in the right lobe (p = 0.008), and when portal vein thrombosis was present (p = 0.03). Conclusion: In cirrhotic patients with newly detected FLLs, the non-HCC etiology was more frequently diagnosed in lesions that were located in the left lobe, in females, and in patients with a history of active NHPMD. Thus, the lower frequency of HCC in the abovementioned groups demonstrated that a cautious implementation of the current consensus radiological criteria would be required for these groups, particularly in patients with an active NHPMD, given the fact that the consensus criteria were not validated in these populations. A more active diagnostic approach may ultimately be needed for these patients. Large prospective studies are needed to validate these findings.

Purpose: This study aimed to evaluate the value of contrast-enhanced ultrasound (CEUS) in the evaluation of perfusion disturbance in irreducible abdominal wall hernias (AWHs). Methods: From 2006 to 2018, 50 patients with an irreducible AWH were examined using B-mode ultrasound (B-US) and CEUS. The ultrasound findings were correlated with subsequent surgical and histological results. The presence of non-enhanced areas (NEAs) in hernia contents on CEUS and the presence of non-perfused areas (NPAs) on surgical and histological evaluation were analyzed retrospectively. Results: On CEUS, 13/50 hernia contents (26.0%) revealed NEAs during complete CEUS examination and 37/50 (74.0%) revealed no NEAs during CEUS examination. On surgical and histological evaluation, NPAs in hernia contents were identified in 11/13 cases (93.3%) with NEAs on CEUS. CEUS was found to have a sensitivity of 100.0%, a specificity of 94.9%, a positive predictive value of 84.6%, and a negative predictive value of 100.0% for the identification of perfusion disturbance in AWHs. Conclusions: The findings of this study demonstrate that using CEUS as an imaging method may be helpful for evaluating the perfusion of hernia contents in incarcerated AWHs. On CEUS, the presence of NEAs may suggest perfusion disturbance in hernia contents.

Purpose: To evaluate the diagnostic performance of ultrasound point shear wave elastography (pSWE) using acoustic radiation force impulse (ARFI) technology in different benign and malignant mesenteric masses (MMs). Methods: A total of 69 patients with MMs diagnosed from September 2018 to November 2021 were included retrospectively in the study. The inclusion criteria were (1) an MM over 1 cm; (2) valid ARFI measurements; and (3) confirmation of the diagnosis of an MM by histological examination and/or clinical and radiological follow-up. To examine the mean ARFI velocities (MAVs) for potential cut-off values between benign and malignant MMs, a receiver operating characteristics analysis was implemented. Results: In total, 37/69 of the MMs were benign (53.6%) and 32/69 malignant (46.4%). Benign MMs demonstrated significantly lower MAVs than mMMs (1.59 ± 0.93 vs. 2.76 ± 1.01 m/s; p < 0.001). Selecting 2.05 m/s as a cut-off value yielded a sensitivity and specificity of 75.0% and 70.3%, respectively, in diagnosing malignant MMs (area under the curve = 0.802, 95% confidence interval 0.699–0.904). Conclusion: ARFI elastography may represent an additional non-invasive tool for differentiating benign from malignant MMs. However, to validate the results of this study, further prospective randomized studies are required.

Purpose: To describe the perfusion patterns of peripheral organizing pneumonia (POP) by contrast-enhanced ultrasound (CEUS) and their correlation with vascularization patterns (VPs) represented by immunohistochemical CD34 endothelial staining. Methods: From October 2006 until December 2020, 38 consecutive patients with histologically confirmed POPs were standardized-examined by CEUS. The time to enhancement (TE; classified as an early pulmonary-arterial [PA] pattern of enhancement vs. delayed bronchial-arterial [BA] pattern of enhancement), the extent of enhancement (EE; classified as marked or reduced), the homogeneity of enhancement (HE; classified as homogeneous or inhomogeneous), and the decrease of enhancement (DE; classified as rapid washout [Results: The majority of POPs showed a BA pattern of enhancement (71.1%), an isoechoic marked enhancement (76.3%), and an inhomogeneous enhancement (81.6%). A rapid DE was observed in 50.0% of cases. On CD34 staining, all POPs had a chaotic VP, indicating BA neoangiogenesis. AAs (abscess, necrosis, hemorrhage) were identified in (41.9%) cases with an inhomogeneous enhancement on CEUS. Conclusion: On CEUS, POPs predominantly revealed a marked inhomogeneous BA pattern of enhancement with a rapid washout in 50% of cases. Furthermore, we demonstrated that the presence of a PA pattern of enhancement, found in 28.9% of POPs, did not exclude a BA neoangiogenesis as an important feature of chronic inflammatory and malignant processes.

Purpose: To evaluate the value of CEUS in differentiating malignant from benign pleural effusions (PEs). Methods: From 2008 to 2017, 83 patients with PEs of unknown cause were examined using B-mode thoracic ultrasound (B-TUS), CEUS, and cytological examination. The extent of enhancement of the pleural thickening, the presence of enhancement of septa or a solid mass within the PE, and the homogeneity of the enhancement in the associated lung consolidation, were examined. Subsequently, the diagnostic value of cytology, B-TUS, and CEUS in differentiating malignant from benign PEs was determined. Results: With CEUS, markedly enhanced pleural thickening and inhomogeneous enhanced lung consolidation were significantly more frequently associated with malignancy (p < 0.05). In the subgroup analysis, the use of CEUS increased the sensitivity from 69.2 to 92.3 in patients with initial negative cytology but clinical suspicion of malignant PE; it also increased the specificity from 63.0 to 90.0, the positive predictive value from 69.2 to 92.3, the negative predictive value from 63.0 to 90.0, and the diagnostic accuracy from 66.7 to 87.5, in the evaluation of PE malignancy. Conclusion: The use of clinically based B-TUS and CEUS as a complementary method to cytological evaluation may be beneficial for evaluating a PE of unknown cause. CEUS patterns of enhanced pleural thickening and inhomogeneous enhanced lung consolidation may suggest a malignant PE.