In the ultrasound group, clinicians graded gastric contents using the Perlas system and calculated the antral cross-sectional area from the anteroposterior and craniocaudal diameters. A cross-sectional area threshold of 340 mm² was built into a predefined risk-stratification algorithm that determined which induction strategy the anaesthetic team would use. The study’s authors describe this as an integrated protocol rather than a standalone measurement.

The recorded differences were substantial. Perioperative nausea or vomiting was documented in 1 of 80 patients (1.25%) in the ultrasound group versus 9 of 78 (11.54%) in the control group. Reflux or aspiration events occurred in 1 of 80 patients (1.25%) compared with 8 of 78 (10.26%). Haemodynamic fluctuations were also smaller in the ultrasound group. Because these figures come from a retrospective design, the authors treat them as associations rather than proof of causation.

The workflow indicators pointed in the same direction. Preoperative assessment, surgical waiting time, anaesthetic induction, post-anaesthesia care unit stay, time to first oral intake, and total hospital stay were all shorter in the ultrasound group, and anaesthetic induction-related adverse events were less frequent, a pattern the authors link to more individualised anaesthetic planning. Not every outcome moved in parallel, however: pulmonary complications within 72 hours of surgery did not differ significantly between the two groups.

The study has important limitations that the authors state plainly. It was conducted at a single centre, and the retrospective design means patients were not randomly allocated to the two assessment strategies. Temporal and clinical confounders could have contributed to the observed gaps, and the authors call for prospective multicentre studies with standardised operator training, formal measurement-reliability assessment, and adjustment for such confounders before causal conclusions can be drawn. Within those constraints, the study reports that gastric ultrasound-guided aspiration-risk stratification was associated with more individualised anaesthetic planning and favourable perioperative process and safety outcomes in this population.

Subject of Research: Gastric ultrasound for aspiration-risk assessment in emergency laparoscopic appendectomy

Article Title: Ultrasound-guided gastric antral cross-sectional area assessment for anaesthetic management in emergency laparoscopic appendectomy: a retrospective cohort study

Article References: Wu, T., & Liu, X. (2026). Ultrasound-guided gastric antral cross-sectional area assessment for anaesthetic management in emergency laparoscopic appendectomy: a retrospective cohort study. BMC Medical Imaging. https://doi.org/10.1186/s12880-026-02949-1

Image Credits: AI Generated

DOI: 10.1186/s12880-026-02949-1

Keywords: gastric ultrasound, antral cross-sectional area, aspiration risk, laparoscopic appendectomy, anaesthesia, retrospective cohort, Perlas grading, perioperative outcomes, point-of-care ultrasound, airway safety, Ultrasound-guided, gastric

Heartworm infection is estimated to affect more than 1 million dogs in the United States. While many infected dogs have no symptoms or only mild clinical signs, some develop life-threatening cardiopulmonary disease. For dogs showing clinical signs, ultrasound is commonly used to investigate cavitary effusions, in which fluid collects within body cavities, and to identify intracardiac heartworms.

The review distinguishes a quick “fluid check” from more extensive point-of-care ultrasound examinations. A fluid check can establish the presence of cavitary effusions, while comprehensive examinations may employ standardized ultrasound views to locate heartworms within the heart. The article presents these applications as ways to assess the cardiopulmonary condition of symptomatic dogs rather than as a single, uniform ultrasound protocol.

With more advanced training, ultrasound can also identify interstitial abnormalities in the lungs and evaluate the morphology of the right side of the heart. These capabilities extend the assessment beyond fluid detection and the visualization of intracardiac heartworms, but the evidence presented is a review rather than a report of a new clinical trial. The supplied article was published as an open-access, peer-reviewed review on 21 October 2026 and was identified as an early version that remained subject to further edits before replacement by the final Version of Record.

Subject of Research: Point-of-care ultrasound for assessing heartworm-related cardiopulmonary disease in dogs

Article Title: Point-of-care ultrasound in dogs with clinical signs due to heartworm disease

Article References: Ames, M. K. (2026). Point-of-care ultrasound in dogs with clinical signs due to heartworm disease. Parasites & Vectors. https://doi.org/10.1186/s13071-026-07720-7

Image Credits: AI Generated

DOI: 10.1186/s13071-026-07720-7

Keywords: heartworm disease, dogs, point-of-care ultrasound, Dirofilaria immitis, cardiopulmonary disease, intracardiac heartworms, cavitary effusions, interstitial lung abnormalities, right-heart morphology, veterinary diagnostics, Point-of-care, ultrasound

Fluid management during haemodialysis is delicate because excessive fluid removal can precipitate intradialytic hypotension, while persistent fluid accumulation can contribute to hypertension, heart failure and pulmonary oedema. The protocol notes that reported intradialytic hypotension prevalence ranges from 8% to 40% across studies and definitions. Clinicians commonly combine clinical examination, blood-pressure trends, weight changes and chest radiography when assessing volume status, but these approaches have important limitations for estimating ultrafiltration tolerance. The proposed study will therefore use a standardised bedside assessment combining focused cardiac ultrasound, eight-zone lung ultrasonography and a modified venous excess ultrasound approach.

The cardiac component will use focused transthoracic echocardiography to measure left ventricular systolic function, estimated cardiac output, diastolic measures, left atrial volume and right-heart function. Pulmonary artery systolic pressure, pulmonary-vein Doppler and Simpson biplane ejection fraction will be assessed when image quality and clinical conditions permit. Doppler measurements in participants with arrhythmia will be averaged over ten consecutive beats. The lung protocol will count B-lines in eight zones across the two hemithoraces, producing a total of 0 to 80 when every zone is assessable. These vertical reverberation artefacts are used as an indirect marker of extravascular lung water. The venous assessment will combine inferior vena cava diameter and respiratory variation with hepatic-vein and portal-vein Doppler waveforms. Intrarenal venous Doppler, included in the original VEXUS framework, will be omitted because the protocol reports limited feasibility and interpretability in kidney failure, particularly with small or atrophic kidneys and altered renal perfusion.

The resulting inferior vena cava, hepatic-vein and portal-vein combination will be described as a modified VEXUS phenotype rather than as equivalent to the original composite score. Grade 0 may be assigned when the inferior vena cava is narrower than 2.0 cm. At a diameter of 2.0 cm or more, interpretable Doppler waveforms from both veins are required: grade 1 denotes no severe Doppler abnormality, grade 2 one severe abnormality, and grade 3 severe abnormalities in both veins. Inferior vena cava collapsibility will be recorded separately but will not contribute to the modified grade. Unavailable or technically inadequate Doppler recordings will be classified as non-assessable rather than normal, and the composite will not be prorated from incomplete components. The protocol states that the diagnostic and prognostic validity of this modified measure in maintenance haemodialysis has not been established.

Each participant will be assigned at enrolment to have scheduled scans during either the first dialysis session after the long interdialytic interval or a mid- or late-week session, with the allocation kept consistent at all follow-up visits. This is intended to capture both peak fluid accumulation and more steady-state conditions. Blood pressure will be measured immediately before dialysis, every 30 minutes during treatment and at the end, with additional measurements obtained when symptoms occur or staff suspect haemodynamic instability. The primary intradialytic hypotension definition requires a documented systolic-pressure decrease of at least 20 mmHg from the pre-dialysis reference value together with at least one compatible symptom or acute nursing intervention undertaken in response. A separate definition based on a session nadir below 90 mmHg, or below 100 mmHg when the pre-dialysis pressure was at least 160 mmHg, will also be applied and reported independently.

The main association analysis will use an embedded case-crossover design based on scheduled pre-dialysis examinations. It will compare sessions in which hypotension occurred with other sessions from the same patient in which it did not, so each participant serves as their own control. This controls by design for time-invariant characteristics such as age, sex, comorbidities, dialysis vintage and vascular access type, while preserving temporal ordering because each measurement precedes dialysis. Conditional logistic regression stratified by patient will analyse within-patient differences. Time-varying factors such as interdialytic weight gain, pre-dialysis blood pressure, prescribed ultrafiltration volume, dialysate composition and prescribed session duration may be included if the number of outcome-informative patients and within-patient measurement variation support stable estimation. The analysis is explicitly exploratory and non-confirmatory, and the protocol makes no formal power claim for a specified conditional effect size.

Additional intradialytic scans may be performed when clinically feasible and safe for current hypotension, suspected clinically significant fluid overload or a suspected mismatch between prescribed target weight and the best clinically tolerated weight. These event-triggered examinations will not be pooled with scheduled sessions and will not contribute cases to the primary case-crossover analysis. A separate exploratory model will include only scans completed while participants were clinically stable, before the first hypotension event in that session and not in response to evolving instability. Scans obtained during or after hypotension will be used solely to describe the peri-event haemodynamic phenotype. The researchers will account for the planned treatment time remaining at each scan because the likelihood of hypotension varies with time into dialysis, and will report the number of eligible scans, subsequent events, contributing patients and repeated observations per patient.

After each scheduled session and its outcome data have been recorded, study ultrasound findings will normally be disclosed to the treating physician. Before disclosure, the physician will record intended management for the session; afterward, the physician will report whether the findings appeared clinically relevant, increased confidence or prompted a change. A documented change must be entered in the routine dialysis prescription program, providing evidence of an implemented change rather than a hypothetical intention, and applies only after the completed index session. Findings meeting prespecified emergency criteria may be communicated immediately. The protocol will not impose a therapeutic algorithm or require the research team to recommend changes. The questionnaire component can therefore document prescribing behaviour but cannot establish whether disclosure produces safer, more appropriate or more effective treatment.

The study is sized primarily for feasibility. Four scheduled assessments could yield as many as 240 profiled sessions, with approximately 216 expected after allowing for missed visits, incomplete examinations or withdrawal. Using a 10% planning assumption for intradialytic hypotension, the investigators estimate about 24 events with complete follow-up and about 22 after a 10% allowance for missing or incomplete visits. Repeated sessions from the same patient are not statistically independent, however, and the number of patients contributing both hypotensive and non-hypotensive sessions is likely to be smaller than the raw event count suggests. The protocol consequently anticipates imprecise estimates and says that null findings will be interpreted as inconclusive rather than as evidence that no association exists. Longitudinal analyses of hospitalisation, cardiovascular events and mortality will also remain exploratory; approximately nine to 12 deaths are expected over 12 months.

Reliability and missing data will be addressed through prespecified procedures. A second experienced physician, either a cardiologist or critical-care physician with relevant echocardiography certification, will independently reassess a random 20% sample from each ultrasound domain while blinded to the original measurements and clinical outcomes. Agreement will be evaluated using intraclass correlation coefficients, Bland–Altman analysis for continuous measurements and weighted Cohen’s kappa for ordinal classifications. Unavailable measurements will be separated into four categories: not applicable, not interpretable, not obtained and obtained but quality-limited. Only measurements classified as “not obtained” will be eligible for imputation, while structurally inapplicable or uninterpretable values will remain un-imputed. Sensitivity analyses will compare complete-domain, domain-specific, multiple-imputation and complete-case results. The single-centre design, modest sample, low expected event count, dependence on one trained acquisition operator and absence of an inter-operator acquisition assessment limit generalisability and interpretation, but the protocol is intended to generate feasibility and variability estimates for evaluation in a larger multicentre cohort or future interventional trial.

Subject of Research: Prospective observational evaluation of multi-organ point-of-care ultrasound for haemodynamic profiling during maintenance haemodialysis

Article Title: Ultrasound-guided haemodynamic profiling in haemodialysis patients: a single-centre prospective observational study protocol

Article References: Larsen, S., Taccone, F. S., Le Moine, A., Annoni, F., & Baudoux, T. (2026). Ultrasound-guided haemodynamic profiling in haemodialysis patients: a single-centre prospective observational study protocol. Frontiers in Nephrology, 6, Article 1939088. https://doi.org/10.3389/fneph.2026.1939088

Image Credits: AI Generated

DOI: 10.3389/fneph.2026.1939088

Keywords: haemodialysis, intradialytic hypotension, point-of-care ultrasound, lung ultrasound, echocardiography, venous congestion, fluid management, VEXUS, observational cohort, clinical protocol, Ultrasound-guided, haemodynamic

The physics behind lung ultrasound is deceptively simple. The probe, placed on the chest wall, cannot image aerated lung directly, because air scatters ultrasound almost completely. Instead, clinicians read artifacts: the shimmering, to-and-fro movement of the pleural line known as lung sliding, the horizontal reverberation lines called A-lines that indicate normal aeration, and the vertical comet-tail artifacts known as B-lines that signal fluid or collapsed, non-aerated tissue beneath the probe. In preterm infants with respiratory distress syndrome, a disease of surfactant deficiency in which alveoli collapse, the typical pattern includes diffuse B-lines, thickened or irregular pleural lines, and consolidated, tissue-like areas where lung has lost its air entirely. As surfactant therapy recruits alveoli and aeration returns, these findings evolve in real time, giving clinicians a functional, dynamic picture of the lung rather than the static snapshot offered by a chest radiograph.

That dynamism is precisely what makes the technology attractive for one of the most consequential decisions in neonatology: whether and when to administer surfactant. The review highlights a multicenter pragmatic study by Raimondi and colleagues, published in Chest in 2021, in which lung ultrasound findings were used to guide surfactant administration in preterm infants with respiratory distress. Related work by De Martino and colleagues showed that a lung ultrasound score obtained shortly after birth could predict the need for surfactant in extremely preterm neonates, and Badurdeen and colleagues demonstrated that ultrasound performed during newborn resuscitation predicted surfactant requirement in very and extremely preterm infants. Even more striking, the ULTRASURF randomized controlled trial by Rodriguez-Fanjul and colleagues tested early surfactant replacement guided by lung ultrasound against conventional management in preterm newborns with respiratory distress syndrome, providing some of the strongest evidence that the modality can drive treatment decisions rather than merely describe disease.

The scoring systems at the heart of these studies deserve technical attention. Most divide the chest into a grid of zones, commonly four, six, eight, or twelve, and assign each zone a numerical grade based on the worst finding present: zero for normal aeration with A-lines, rising through increasing numbers of well-separated B-lines, to coalescent B-lines, and finally to large consolidations with air bronchograms for the most severely affected regions. Summing the zone scores yields a global aeration index. The review compares these protocols explicitly, noting that the choice of zone count affects sensitivity, examination time, and reproducibility. A 2025 systematic review by Sartorius, Brunet, and De Luca catalogued the characteristics of the many neonatal lung ultrasound scores now in circulation, and a 2022 narrative review by Corsini and colleagues mapped how they are used in clinical practice. The proliferation of scoring schemes, the authors caution, is both a sign of the field’s vitality and a source of its fragmentation.

Perhaps the most clinically consequential application is the prediction of bronchopulmonary dysplasia, the chronic lung disease of prematurity that remains one of the most common and feared outcomes for infants born extremely early. Because BPD is diagnosed clinically at 36 weeks postmenstrual age, clinicians often spend weeks caring for an infant without a clear sense of that infant’s long-term pulmonary trajectory. Lung ultrasound offers a potential early warning system. A prospective multicenter diagnostic accuracy study by Alonso-Ojembarrena and colleagues, published in Chest in 2021, evaluated the predictive value of lung ultrasound scores for developing BPD, and a multicenter longitudinal cohort study by Loi and colleagues in the American Journal of Respiratory and Critical Care Medicine showed that serial ultrasound could monitor extremely preterm infants and predict BPD. Oulego-Erroz and colleagues demonstrated that early assessment of lung aeration using an ultrasound score could serve as a biomarker of subsequent BPD, and Mohamed and colleagues reported similar predictive performance in a prospective diagnostic cohort of extreme preterm neonates.

The prognostic reach of the technique extends beyond the diagnosis itself. Zong and colleagues showed that a lung ultrasound score could predict the severity of bronchopulmonary dysplasia in neonates born at or before 25 weeks of gestation, while Aldecoa-Bilbao and colleagues characterized distinct ultrasound patterns and predictors in very preterm infants with the disease. In a comparison that underscores the score’s discriminative power, Alonso-Ojembarrena and colleagues found that lung ultrasound outperformed NT-proBNP, a widely used biomarker, in predicting moderate to severe BPD. Modified scores have been developed specifically for the BPD population, and Hoshino and colleagues used lung ultrasound to predict respiratory outcomes in patients with established disease. Savoia and colleagues even showed that the ultrasound score follows the trajectory of chronic pulmonary insufficiency of prematurity into early infancy, suggesting the technique can track disease evolution well beyond the NICU.

That longer-term horizon is where the review points toward the future. Shen and colleagues reported that a modified lung ultrasound score for BPD predicted late respiratory outcomes in preterm infants, and a 2024 study published in JAMA Network Open by Bonadies and colleagues linked lung ultrasonography scores in preterm infants to respiratory outcomes at age two. Stephenson and her own group had previously published work on outpatient assessment of bronchopulmonary dysplasia using point-of-care lung ultrasound, extending the modality from the intensive care unit into the clinic. The review also notes emerging data on monitoring pulmonary edema: Kasniya and colleagues assessed pulmonary edema in neonates with chronic lung disease before and after diuretic therapy, and a pilot study by Alonso-Ojembarrena and colleagues examined lung ultrasound scores and diuretics in infants born before 32 weeks. Together, these studies sketch a vision of lung ultrasound as a continuous, longitudinal readout of pulmonary health from the delivery room through early childhood.

The modality’s diagnostic repertoire is not limited to surfactant decisions and BPD prediction. The review situates lung ultrasound within the broader landscape of neonatal pulmonary imaging, citing evidence that it can diagnose and differentiate transient tachypnea of the newborn from respiratory distress syndrome, detect pneumothorax with performance that a systematic review by Fei and colleagues suggested may make it a better first choice than radiography, and identify pneumonia, including in neonates with fungal infections. It can also inform weaning from mechanical ventilation: Soliman and colleagues used lung ultrasound to predict extubation readiness in preterm infants, and El Amrousy and colleagues evaluated its value in predicting weaning success in ventilated neonates. Because extubation failure carries real costs in a preterm population, a bedside tool that quantifies aeration and diaphragm-adjacent lung recruitment at the moment of decision could meaningfully change practice.

Yet the review is candid about the field’s limitations. Interpretation of the existing evidence is constrained by heterogeneity in acquisition protocols, scoring systems, and the timing of assessments, and by the fact that lung ultrasound is fundamentally operator dependent. A score obtained with a twelve-zone protocol by an experienced sonographer is not interchangeable with a four-zone scan performed by a trainee, and the timing of an assessment, whether in the first minutes of life, during the first days of respiratory distress, or in the weeks before a BPD diagnosis, can dramatically alter its predictive meaning. Most studies to date have been single center or modest in size, and few have tested whether ultrasound-guided management actually improves hard outcomes such as mortality, ventilator days, or long-term neurodevelopment, as opposed to simply changing when surfactant is given. The authors call explicitly for further multicenter studies with standardized protocols to define the role of lung ultrasound in routine neonatal respiratory care.

Even with those caveats, the trajectory is unmistakable. A technique that requires no radiation, sits at the bedside, delivers results in minutes, and can be repeated without limit addresses nearly every weakness of the chest radiograph in neonatology, where transport to the X-ray suite is hazardous, images are snapshots rather than movies, and cumulative dose is a genuine concern for infants who may need hundreds of days of intensive care. If ongoing trials confirm that standardized lung ultrasound scores can reliably triage surfactant, time extubation, and stratify BPD risk early enough to change management, the handheld probe may become as fundamental to the preterm infant’s care as the stethoscope once was, turning the NICU’s most vulnerable lungs into an open book read in real time.

Subject of Research: Lung ultrasound applications for respiratory distress syndrome and bronchopulmonary dysplasia in preterm infants

Article Title: Applications of lung ultrasound in preterm infants: implications for respiratory distress syndrome and bronchopulmonary dysplasia

Article References: Stephenson, N., Carr, C. B., Park, D., & Laughon, M. (2026). Applications of lung ultrasound in preterm infants: implications for respiratory distress syndrome and bronchopulmonary dysplasia. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02849-w

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02849-w

Keywords: lung ultrasound, preterm infants, respiratory distress syndrome, bronchopulmonary dysplasia, surfactant therapy, neonatal intensive care, medical imaging, lung ultrasound score, extubation readiness, predictive markers, neonatology, point-of-care ultrasound

The central conceptual shift, according to the authors, is the explicit separation between the diagnostic and the quantitative uses of lung ultrasound. Both roles existed in 2012, but the new documents make clear that they demand different approaches and different techniques. Diagnosis answers a categorical question through a focused, pattern-based scan. Quantification translates findings into a reproducible measure through a standardized, multi-zone acquisition of the chest. The distinction matters because the two applications are easily conflated at the bedside, and the techniques that serve one do not automatically serve the other.

Quantification, the commentary stresses, does not concern aeration alone. Semi-quantitative techniques now extend to pulmonary congestion, pneumothorax volume and pleural effusion. In purely diagnostic applications, dividing the chest into zones and counting artifacts is usually unnecessary, with one exception: the differential diagnosis between diffuse and focal interstitial syndrome, assessed over the antero-lateral chest, where a criterion based on the number of positive zones provides a first orientation in the acutely ill patient. The quantitative techniques for aeration and congestion, by contrast, rest on zone division and apply semi-quantification to each scanned region.

The most substantial advance over 2012, the authors argue, is prognostic. A within-patient trajectory of repeated measurements enables monitoring, but it also underpins stratification that positions an individual patient’s risk relative to others. The commentary draws a careful line between two roles that are often blurred: as a prognostic tool, lung ultrasound predicts outcome, associating a measurement with a patient’s risk at a given moment; as a tool for treatment guidance, it informs a therapeutic decision and, through that decision, may alter the clinical course. The evidence base for the prognostic role, the authors note, is currently more robust than the evidence for treatment guidance.

A second structural novelty is the articulation of three diagnostic levels. The first concerns fundamental signs, for which the update refines nomenclature and definitions. The second, described as the genuine novelty, uses additional features to sharpen differential diagnosis between conditions that share the same elementary pattern: the distribution and quantity of B-lines, the characteristics of the pleural line, the correlation with clinical severity, the shape, margins, air bronchograms and size of consolidations, and the complexity of pleural effusion in relation to any associated consolidation. The third level is the final clinical interpretation, in which sonographic findings are integrated into a wider diagnostic puzzle where lung ultrasound may be decisive but should never be sufficient on its own.

The authors are explicit about why these levels need spelling out: they are too often collapsed in practice. A sign identified at the first level does not by itself deliver a diagnosis, and errors attributed to lung ultrasound frequently arise not in image acquisition but in the interpretation that follows. Competence in the technique and competence in clinical interpretation are distinct skills. The sonographic finding is a premise for reasoning, not a conclusion, and treating it as one is a recurring source of diagnostic misattribution.

Perhaps the most striking reframing concerns the power of exclusion. While confirming specific diagnoses, particularly in dedicated settings such as acute respiratory distress syndrome, is identified as one of the most promising future applications in intensive care, the commentary emphasizes the role of lung ultrasound in ruling conditions out and thereby narrowing the differential. This rule-out power rests on the high sensitivity, and therefore high negative predictive value, of the elementary signs: their absence renders the corresponding condition improbable even where a positive finding alone would not confirm it. Exclusion is typically achieved at the elementary-sign level, whereas confirmation requires the interpretive steps that follow.

The clinical applications where the new evidence bites hardest include heart failure and dialysis. In decompensated heart failure, the number of B-lines correlates with severity and predicts rehospitalization and death both at admission and at discharge, capturing residual, often subclinical congestion that clinical evaluation alone can miss. Because this prognostic value is independent of ejection fraction, it underscores the separation between cardiac function and cardiogenic congestion, and it extends to moderate-to-severe aortic stenosis, ST-elevation myocardial infarction and cardiogenic shock. In chronic heart failure, B-lines can also support therapeutic guidance: in one randomized trial, therapy titrated on sonographic monitoring reduced hospitalization for decompensation. In dialysis patients, sonographic congestion is often uncoupled from signs and symptoms, meaning an asymptomatic patient is not always euvolemic, and this occult overload predicts death and cardiac events. The authors caution, however, that there is not yet robust evidence that titrating fluid removal according to sonographic congestion during dialysis improves survival.

In mechanically ventilated patients, the lung aeration score monitors the effects of positive end-expiratory pressure, recruitment maneuvers and drugs, and carries prognostic weight, but it must be read alongside respiratory mechanics and gas exchange and is meaningful only when repeated acquisitions are rigorously standardized. The score provides no more than a coarse semi-quantification: it correlates with gold standards and with severity of lung involvement, yet it remains highly approximate because of the artifactual nature of the sonographic signs and the absence of a linear progression between score classes. A specific blind spot is overdistension, since overinflation of already aerated regions produces no change in the score; assessing reduced pleural sliding may eventually help close this gap. Lung ultrasound may also help select the ventilatory strategy itself: by distinguishing focal from non-focal lung morphology, it can guide a tailored approach assigning higher PEEP and recruitment maneuvers to non-focal ARDS and lower PEEP with prone positioning to focal ARDS, a strategy currently being compared with conventional ventilation in the ongoing PEGASUS trial.

The new guidelines also introduce, for the first time, an explicit distinction between aeration and congestion scores as separate techniques, validated in different populations against different gold standards and assessed over different chest regions, along with the concept of fluid tolerance: the absence of congestion signs defines a margin of safety for fluid administration. Fluid tolerance and fluid responsiveness are distinct questions, and lung ultrasound speaks to the former, functioning as a safety limit rather than a decision to give fluid, and is best complemented by focused cardiac ultrasound. Semi-quantification of pneumothorax, graded from the laterality of the lung point, and approximation of pleural effusion volume extend the same move from binary reading to graded measure, aiding decisions about drainage and enabling bedside monitoring without repeated radiographic exposure. The authors close with a caveat that doubles as a research agenda: prognostic weight is established, but validated numerical cut-offs for severity, characterization and prognosis in cardiogenic pulmonary edema, interstitial lung disease and ARDS are still missing, and that gap weighs most heavily on treatment guidance rather than prognosis.

Subject of Research: Updated evidence-based recommendations for diagnostic and quantitative point-of-care lung ultrasound in critical care

Article Title: What’s new in point-of-care lung ultrasound: reading the new recommendations

Article References: Volpicelli, G., Gargani, L., & Zieleskiewicz, L. (2026). What’s new in point-of-care lung ultrasound: reading the new recommendations. Intensive Care Medicine. https://doi.org/10.1007/s00134-026-08649-2

Image Credits: AI Generated

DOI: 10.1007/s00134-026-08649-2

Keywords: lung ultrasound, point-of-care ultrasound, intensive care, B-lines, ARDS, heart failure, aeration score, congestion, fluid tolerance, pneumothorax, pleural effusion, prognostication

Point-of-care ultrasound is a compact diagnostic technology: a handheld probe, often paired with a tablet or smartphone, transmits high-frequency sound waves into the body and renders real-time images of fluid collections, organs, and anatomy at the bedside. Unlike a conventional radiograph, which requires a machine, a technician, and a trip to the imaging suite, POCUS can be performed by the clinician examining the patient, in seconds. In hospitals where imaging is limited to plain radiography, the technology effectively collapses the distance between the clinical question and the diagnostic answer. It is also an experiential learning tool, letting trainees see anatomy and pathology directly rather than inferring it from a stethoscope.

Yet despite consensus recommendations from groups in Canada, Europe, and the United States calling for POCUS training in internal medicine, no rounds-integrated curriculum for internal medicine had ever been described in Latin America, and most existing programs fall short of practice-based bedside assessment. The Guatemalan program, led by Dr. Philip K. Angelides of the University of Colorado School of Medicine together with Guatemalan and international collaborators, was designed to close both gaps at once.

The curriculum combined three technical components. First, students completed flipped-classroom prework, studying ultrasound principles and image interpretation before hands-on sessions. Second, they attended a 2-day intensive course focused on pleural and abdominal fluid detection, the core skills for identifying pleural effusions, ascites, and bladder volume. Third, and most importantly, they entered a 2-month longitudinal program in which POCUS was embedded into daily rounds, so that every ward encounter became an opportunity to scan, interpret, and receive feedback in real time.

The program used Butterfly iQ+ handheld ultrasound probes, donated for the educational initiative, paired with Butterfly Cloud, a cloud-based platform where students uploaded their scans for portfolio review by faculty. Feedback flowed through WhatsApp, the messaging platform already ubiquitous in Guatemala, allowing instructors to critique images asynchronously and students to ask questions between rounds. The program also designated three of the eight learners as local champions in a train-the-trainer model, empowering them to teach peers and sustain the program after visiting faculty departed.

Evaluation showed that knowledge and confidence gains largely persisted at 2 months, a finding that matters because competency retention in ultrasound training is notoriously difficult to sustain. Hands-on performance was strongest for pelvic and bladder view acquisition, artifact recognition, and image optimization, skills that involve relatively fixed anatomy and reproducible technique. Performance was lowest for spine sign recognition, the sonographic finding of vertebral bodies appearing in the chest when pleural fluid accumulates behind the lung, and for probe orientation and manipulation, the motor skills that require precise hand-eye coordination and spatial reasoning.

That pattern of strengths and weaknesses is technically revealing. Fluid detection in the bladder and abdomen involves identifying anechoic, or black, collections against relatively predictable landmarks, making it accessible to novices. Spine sign, by contrast, requires understanding the relationship between the lung, the pleural space, and the thoracic spine in three dimensions, and probe manipulation requires the kind of fine motor control that develops only with repeated scanning. The findings align with a growing body of evidence from novice learners showing that cognitive gains in ultrasound come quickly, while motor skill retention follows longer learning curves.

Barriers included probe scarcity and limited institutional support, constraints familiar from POCUS programs across low- and middle-income countries. The champions emerged as key drivers of peer learning, suggesting that the train-the-trainer model may be as important as the technology itself in sustaining programs where faculty time and equipment are limited. The program was reviewed and deemed exempt by the Colorado Multiple Institutional Review Board, and all participants provided informed consent.

The implications reach beyond Guatemala. POCUS has been shown to influence clinical decision-making in emergency departments in Tanzania, to build diagnostic capacity in Rwanda, Malawi, Kenya, and Ghana, and to support training programs in Oman and across Latin America. The Guatemalan study adds a specific technical model: rounds-integrated training, cloud-based portfolio review, messaging-platform feedback, and local champion development, all feasible in a resource-limited internal medicine setting. The authors conclude that rounds-integrated POCUS training is feasible in resource-limited settings and may support early skill development when paired with longitudinal mentorship and local champion development.

For a hospital where imaging has been limited to plain radiography, the arrival of handheld ultrasound represents a shift in what a physical examination can reveal. For medical education, it suggests that the technology need not wait for residency or fellowship, and that the wards themselves, even in hospitals with scarce resources, can become the classroom. The study was published on 8 September 2026 in the Journal of General Internal Medicine.

Subject of Research: POCUS for the People: A Rounds-Integrated Point-of-Care Ultrasound Curriculum for Medical Students at a Guatemalan Public Hospital

Article Title: POCUS for the People: A Rounds-Integrated Point-of-Care Ultrasound Curriculum for Medical Students at a Guatemalan Public Hospital

Article References: Angelides, P. K., León, R., Stelmach, A., Ortiz-López, C., Sánchez, H. A. H., Bolaños, G., Fleshner, M., Sawaya, A., Gamboa, J. E., Hanna, R. M., & Olson, D. (2026). POCUS for the People: A Rounds-Integrated Point-of-Care Ultrasound Curriculum for Medical Students at a Guatemalan Public Hospital. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10797-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10797-6

Keywords: point-of-care ultrasound, medical education, global health, Guatemala, POCUS, resource-limited settings, People, Rounds-Integrated, Point-of-Care, Ultrasound, Curriculum, Medical

Point-of-care ultrasound, commonly abbreviated as POCUS, refers to the use of portable ultrasound devices at the bedside to answer focused clinical questions in real time. Unlike comprehensive diagnostic imaging performed by radiologists, POCUS is designed to be quick, targeted, and immediately actionable. In hospital settings, it has transformed how clinicians assess patients with breathlessness, abdominal pain, or suspected fluid overload. But in home care, particularly in rural and remote regions where physician shortages make timely assessment difficult, the technology has remained largely out of reach for the nurses who actually visit patients in their homes.

The research team, led by Toru Yamada of the Institute of Science Tokyo, recognized this gap. Japan’s rapidly aging population and rising health care costs have intensified demand for home care services, yet the physician workforce is concentrated in urban centers. On islands like Fukue, a physician may not be able to reach a deteriorating patient quickly. If nurses on the ground could acquire ultrasound images and transmit them for remote interpretation, the diagnostic delay that currently plagues rural home care could be substantially reduced. The concept, known as Tele-POCUS, combines bedside ultrasound acquisition by trained nurses with real-time or asynchronous image review by physicians located elsewhere.

To test whether such a model is educationally feasible, the researchers designed a training course consisting of three components: didactic lectures covering ultrasound physics and normal anatomy, hands-on scanning sessions with real equipment, and workflow training that simulated remote collaboration between nurses and physicians. The simulation component was critical, because the ultimate goal is not simply to produce nurses who can operate a probe, but to establish a communication protocol in which image acquisition, transmission, and physician feedback function smoothly across distance. Participants were recruited through an island-wide open call, and 36 nurses from five visiting nursing stations and six long-term care facilities completed the program and were included in the analysis.

The primary outcome measured was the change in image interpretation score, assessed through an examination using ultrasound video clips. The examination included two distinct domains: a basic domain testing recognition of normal anatomy and fundamental findings, and a case-based domain requiring participants to interpret clinically realistic scenarios. Before the course, the overall interpretation score averaged 31.4 out of 100, with a standard deviation of 16.1. After training, the mean rose to 50.8, with a standard deviation of 13.0. The mean difference of 19.4 points carried a 95 percent confidence interval of 14.4 to 24.5 and a p-value below 0.001, indicating a statistically robust improvement.

Breaking the results down by domain revealed a more nuanced picture. The basic domain score increased dramatically, from 14.1 to 31.7, a mean difference of 17.6 points with a confidence interval of 14.3 to 20.9. This suggests that the lectures and hands-on sessions were highly effective at teaching fundamental image recognition skills. However, the case-based domain showed no statistically significant change, moving only from 17.3 to 19.2, with a mean difference of 1.8 points and a confidence interval spanning from negative 1.2 to positive 4.9. The p-value of 0.229 confirmed that this modest gain could easily have occurred by chance.

This dissociation between basic and case-based performance is perhaps the most scientifically interesting finding of the study. It suggests that short-term training can reliably build pattern recognition for normal anatomy and straightforward pathological findings, but that clinical reasoning, the ability to integrate ultrasound findings into a broader diagnostic picture, requires sustained exposure to real patients over time. The authors acknowledge this limitation explicitly, noting that short-term training alone may be insufficient for developing advanced clinical reasoning abilities. This aligns with established educational theory, which distinguishes between declarative knowledge that can be transmitted through lectures and procedural expertise that accumulates only through deliberate practice.

Confidence, a separate but clinically important outcome, told a different story. Measured on a scale where participants rated their self-assessed competence across multiple subdomains, confidence scores rose from a median of 20.0 before the course to 60.0 afterward, with interquartile ranges shifting from 20.0 to 21.5 to 47.5 to 69.5. All subdomains showed statistically significant improvement, with p-values below 0.001. The magnitude of this confidence gain, roughly tripling the median score, suggests that the training succeeded in making nurses feel capable of engaging with ultrasound technology, which is a prerequisite for any future implementation of Tele-POCUS in actual home care practice.

However, the proportion of participants achieving at least 60 percent on the post-course examination was only 27.8 percent for the overall score. This figure is a sobering reminder that improved scores do not necessarily translate into clinical competence. A mean improvement of 19.4 points, while statistically significant, still leaves the average participant below the halfway mark on the interpretation examination. The researchers frame Tele-POCUS education as an introductory approach, suitable for establishing supervised remote collaboration between nurses and physicians, rather than as a standalone pathway to independent diagnostic capability. This framing is important for policy makers considering similar programs in other rural settings.

The study’s implications extend beyond Fukue Island. As populations age across high-income countries and health systems struggle to distribute clinical expertise geographically, the combination of portable ultrasound and telemedicine represents a potentially scalable solution. The technology required, a handheld ultrasound probe and a video connection, is increasingly affordable. The bottleneck is human: building a workforce of nurses who can acquire diagnostically useful images and communicate them effectively to remote physicians. This study provides early evidence that the first step of that workforce development is achievable, while also delineating the boundaries of what a short course can accomplish. Future research, the authors note, must evaluate long-term competency development and practical application in real clinical settings, questions that this pre-post educational design cannot answer on its own.

Subject of Research: Tele-POCUS ultrasound training for home care nurses in remote and rural Japan

Article Title: Educational effectiveness of a Tele-POCUS training program for home care nurses in remote and rural settings

Article References: Yamada, T., Miyazaki, T., Nin, H., Yoshino, S., Ouchi, S., Mabuchi, S., Shinohara, T., Ichige, H., Kimura, T., Ishida, T., & Hashimoto, M. (2026). Educational effectiveness of a Tele-POCUS training program for home care nurses in remote and rural settings. BMC Nursing. https://doi.org/10.1186/s12912-026-05345-w

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05345-w

Keywords: Tele-POCUS, point-of-care ultrasound, home care nursing, rural health, remote islands, nursing education, ultrasound training, Japan, telemedicine, medical education, physician shortage, clinical competence

The research, published in the journal Neurocritical Care, was conducted by a team of critical care physicians, neurologists, radiologists, and clinical pharmacists affiliated with Kasr Al-Ainy Medical School at Cairo University Hospital and collaborating institutions in Egypt. The investigators enrolled 100 neurocritical intensive care unit patients with acute, nontraumatic brain injury, either ischemic stroke caused by a blocked vessel or intracerebral hemorrhage driven by hypertension. All patients had severely depressed consciousness, scoring below 9 on the Glasgow Coma Scale, the standard measure of awareness that ranges from 3 for unresponsive to 15 for fully alert. Each patient underwent a computed tomography scan of the brain on admission and a bedside ultrasound measurement of the optic nerve sheath diameter.

The logic behind the technique rests on a quirk of anatomy. The optic nerve is not a free-floating cable; it is wrapped in a sleeve of dura mater, the same tough membrane that encases the brain, and this sleeve communicates with the space around the brain where cerebrospinal fluid circulates. When intracranial pressure rises, fluid is pushed along the nerve, and the sheath distends like a pressurized hose. Because the sheath is most distensible just behind the eyeball, a few millimeters of measurement through the orbit can serve as a proxy for pressure deep inside the skull. The probe emits high-frequency sound waves, receives the echoes, and displays the nerve and its sheath in cross-section, allowing clinicians to measure the diameter in seconds at the bedside.

To establish what a normal reading looks like, the researchers also recruited 60 age- and sex-matched healthy volunteers. Importantly, these controls were included only to provide descriptive reference values for physiological optic nerve sheath diameter; they were not part of the primary diagnostic or prognostic analyses. The results formed a striking staircase. Healthy volunteers averaged 4.62 millimeters, with a standard deviation of 0.33. Stroke patients whose CT scans showed no radiologic signs of elevated pressure averaged 5.52 millimeters. Patients whose scans did show CT-based surrogates of raised intracranial pressure averaged 6.50 millimeters, nearly two millimeters wider than the healthy cohort.

Because the study used CT-based radiologic surrogates as the reference standard rather than invasive pressure monitors, the team could calculate how well the ultrasound measurement discriminated between patients with and without imaging evidence of elevated pressure. Using a cutoff derived from their own cohort of 6.00 millimeters or greater, the measurement achieved 86.7 percent sensitivity, meaning it correctly identified nearly nine out of ten patients with CT-positive elevated pressure, and 85.0 percent specificity, correctly clearing about nine out of ten patients without it. The positive predictive value was 89.7 percent, the negative predictive value 81.0 percent, and overall accuracy 86.0 percent. The area under the receiver operating characteristic curve, a summary of discrimination that ranges from 0.5, no better than chance, to 1.0, perfect, reached 0.901, a figure that places the technique in the range of genuinely useful clinical tests.

Diagnostic accuracy alone would be noteworthy, but the prognostic findings may carry even greater weight. In an exploratory survival analysis, patients whose optic nerve sheath diameter exceeded the 6.00 millimeter threshold had significantly higher in-hospital mortality than those below it, with a log-rank p-value of 4.77 multiplied by 10 to the power of minus 13, an extraordinarily small probability of observing such a survival difference by chance. In other words, a single number obtained with a handheld probe in the first hours of admission carried information about who would live or die during the hospitalization.

The researchers did not stop at raw associations. Elevated intracranial pressure tends to accompany other adverse features, including deeper coma and lower blood pressure, so a crude link between sheath diameter and outcome could simply reflect that patients with big hemorrhages have both wide sheaths and poor prognoses. To address this, the team ran exploratory multivariable models adjusting for age, body mass index, Glasgow Coma Scale score, and systolic blood pressure. Even after these adjustments, an optic nerve sheath diameter above the threshold remained independently associated with CT-positive elevated intracranial pressure, supporting the interpretation that the ultrasound signal reflects pressure itself rather than merely the severity of the underlying brain insult.

Why does this matter globally? Invasive intracranial pressure monitoring requires neurosurgical expertise, sterile operating conditions, and equipment that many hospitals in low- and middle-income settings simply cannot guarantee around the clock. Egypt, like much of the world, faces a substantial burden of hypertensive intracerebral hemorrhage, a condition in which pressure dynamics evolve rapidly and every hour of unrecognized elevation worsens outcomes. A noninvasive tool that any trained clinician can deploy with a portable ultrasound machine changes the calculus of triage: it can identify patients who need aggressive pressure-lowering therapy, transfer to a facility capable of invasive monitoring, or repeated serial examinations to track an evolving crisis. The authors specifically highlight its potential for early triage and longitudinal bedside surveillance, particularly when invasive monitoring is unavailable or delayed.

The technique is not without caveats. The reference standard here was radiologic rather than a directly measured intracranial pressure in millimeters of mercury, which means the study validates ONSD against imaging surrogates rather than against the gold standard itself. The cutoff of 6.00 millimeters was derived from this specific cohort, and different populations or different ultrasound protocols may warrant different thresholds; indeed, systematic reviews and meta-analyses across traumatic brain injury, pediatric populations, and other neurological conditions have reported a spread of proposed cutoffs, reflecting variation in technique, anatomy, and patient mix. Measurement of the sheath also demands careful technique and operator training, which is why international consensus groups have published quality criteria for image acquisition and measurement. Furthermore, the survival and adjustment analyses are described by the authors as exploratory, and the prognostic signal, however striking, would need confirmation in independent cohorts before sheath diameter becomes a standard element of stroke prognostication.

Nevertheless, the study adds an important piece of evidence in a field long dominated by data from traumatic brain injury. Nontraumatic brain injury patients, those with spontaneous strokes and hemorrhages, have been underrepresented in the ultrasound literature, and this prospective cohort of 100 severely affected patients provides some of the clearest data yet that the eye can serve as a window on the injured brain. The stepwise increase from healthy controls to CT-negative patients to CT-positive patients is internally consistent, the discrimination statistics are strong, and the mortality signal is dramatic. If larger, multicenter studies reproduce these findings, a probe, a dollop of gel, and a closed eyelid could become part of the standard first assessment of every comatose stroke patient, turning a routine ultrasound exam into a rapid, radiation-free estimate of one of neurocritical care’s most feared variables.

Subject of Research: Optic nerve sheath diameter ultrasonography for detecting elevated intracranial pressure and prognosis in ischemic stroke and hypertensive intracerebral hemorrhage

Article Title: Diagnostic and Prognostic Value of Sonographic Optic Nerve Sheath Diameter in Patients with Ischemic Stroke or Hypertensive Intracerebral Hemorrhage

Article References: Alasar, H., Kandeel, A., Hamdi, M., Fotooh, A. M. A., Amin, F., Abdeltawab, M., & Kenawy, M. (2026). Diagnostic and Prognostic Value of Sonographic Optic Nerve Sheath Diameter in Patients with Ischemic Stroke or Hypertensive Intracerebral Hemorrhage. Neurocritical Care. https://doi.org/10.1007/s12028-026-02697-8

Image Credits: AI Generated

DOI: 10.1007/s12028-026-02697-8

Keywords: optic nerve sheath diameter, intracranial pressure, ultrasonography, ischemic stroke, intracerebral hemorrhage, neurocritical care, diagnostic accuracy, prognosis, point-of-care ultrasound, Glasgow Coma Scale, ICU monitoring, computed tomography

The research, conducted at Hospital Alberto Barton Thompson in Callao and published in Frontiers in Nephrology, set out to answer a deceptively simple question: when a bedside exam, a bioimpedance scan, and a lung ultrasound are all performed on the same patient on the same morning, do they agree? The answer, quantified with statistical rigor, was largely no. The three methods captured overlapping but partially distinct slices of a patient’s true fluid status, and the disagreements were not random noise but appeared to reflect genuinely different physiology.

The technical centerpiece of the study is the B-line, a vertical, laser-like reverberation artifact that streaks down an ultrasound image from the pleural line and moves in synchrony with lung sliding. B-lines increase when fluid accumulates in the interlobular septa and alveoli of the lung, making their count a practical surrogate for extravascular lung water. The team used an abbreviated six-zone protocol, scanning two intercostal spaces along the midclavicular line and one along the midaxillary line on each side, a compromise that previous validation work has shown performs comparably to the traditional 28-zone survey while cutting acquisition time dramatically. Two formally trained nephrologists performed all scans with a handheld Butterfly iQ+ device, blinded to every other clinical and bioimpedance finding, and adjudicated disagreements by consensus.

Alongside the ultrasound, each patient underwent whole-body bioimpedance spectroscopy using a Fresenius Body Composition Monitor, which estimates how many liters of excess extracellular fluid a person carries relative to their normohydrated state. The investigators also performed a standardized clinical examination, recording dyspnea, crackles, peripheral edema, blood pressure, and interdialytic weight gain, and defined clinical euvolemia as the absence of all congestion signs. All measurements were taken immediately before the same midweek dialysis session, eliminating the temporal drift that has muddied earlier comparisons.

The headline result is striking. Of the 49 patients judged clinically euvolemic, 27, or 55.1 percent, had three or more B-lines on lung ultrasound, meeting the prespecified definition of subclinical pulmonary congestion. That subgroup alone constituted 23.3 percent of the entire cohort. In other words, nearly one in four dialysis patients in this study was walking around with objectively wet lungs despite a clean physical examination, no edema, and no crackles. Overall, 70.7 percent of participants had ultrasound-defined pulmonary congestion, and 41.4 percent had moderate-to-severe congestion with ten or more B-lines.

Agreement statistics drove the point home. Clinical examination showed only fair agreement with lung ultrasound at the three-B-line threshold, with a Cohen’s kappa of 0.28, improving to a still-modest 0.41 at the ten-B-line cutoff. Agreement between lung ultrasound and bioimpedance-defined overhydration was slight, at kappa 0.16, and the ultrasound agreed barely at all with elevated interdialytic weight gain, at kappa 0.08. Even the two objective technologies, which might naively be expected to converge, classified the same patients differently. The authors argue this physiological discordance is the story itself: fluid overload describes expansion of the body’s extracellular compartment, whereas congestion describes where that fluid actually accumulates and redistributes, and the two do not move in lockstep.

By combining clinical and ultrasound findings, the team carved the cohort into four volume phenotypes. Twenty-two patients were concordantly euvolemic, 55 were concordantly congested, 12 showed clinical signs without ultrasound congestion, and 27 occupied the discordant zone of subclinical pulmonary congestion. The phenotypes sorted cleanly along physiological gradients: concordantly congested patients had the highest weight gain, the greatest bioimpedance overhydration, and the heaviest B-line burden, while concordantly euvolemic patients sat at the bottom of every measure. The subclinical group fell in between, with intermediate overhydration that a stethoscope simply could not see.

Regression analysis sharpened the clinical message. Among euvolemic patients, each additional liter of bioimpedance-derived overhydration was associated with a 24 percent higher prevalence of subclinical pulmonary congestion, while interdialytic weight gain, the traditional dialysis-unit benchmark, lost all statistical significance after adjustment. Male sex was independently associated with a 45 percent lower prevalence of occult congestion. Blood pressure told a similarly bifurcated tale: systolic pressure correlated moderately with systemic overhydration but not with B-lines, whereas diastolic pressure showed only a weak link to lung water. These patterns reinforce the idea that whole-body fluid volume, weight fluctuation, and pulmonary congestion are separable physiological dimensions rather than interchangeable labels.

The findings resonate with a growing international literature. Meta-analyses report pulmonary congestion in roughly one half to two thirds of maintenance hemodialysis patients worldwide, and the landmark LUST study found that pulmonary crackles, the classic auscultatory sign, detected significant congestion with a sensitivity of only about 22 percent. Studies from Asia and Europe have likewise shown that patients deemed normohydrated by bioimpedance frequently carry ultrasound-visible lung water. The Peruvian cohort, notable as one of the first Latin American populations examined with this triple assessment, adds weight to the argument that clinically silent congestion is a reproducible global phenomenon rather than a local artifact.

What the study cannot yet say is whether acting on this hidden information saves lives. Its cross-sectional design precludes causal inference, it came from a single center where most patients dialyzed through central venous catheters, and echocardiography was available for only about half the cohort. The three-B-line threshold for subclinical congestion was prespecified but not universally validated, though sensitivity analyses at five and ten B-lines produced similar patterns. Still, the clinical direction is clear. The authors do not propose replacing the hands and stethoscope of conventional assessment, but they make a strong case for layering lung ultrasound and bioimpedance on top of it when fluid status is uncertain. With randomized trials of ultrasound-guided fluid management already underway, the era in which a wet lung could hide in plain sight on a dialysis chair may soon be ending.

Subject of Research: Discordance among clinical examination, bioimpedance spectroscopy, and lung ultrasound for assessing fluid status and pulmonary congestion in maintenance hemodialysis patients

Article Title: Physiological discordance between clinical examination, bioimpedance spectroscopy, and lung ultrasound in maintenance hemodialysis patients without heart failure

Article References: Benites-Flores, I. R., Rodríguez Revilla, J., Taype-Rondan, A., Fernández-Anticona, L. C., Prado Ramírez, P. A., Seminario Alegre, N., Rodríguez Tudero, C., Moral Berrio, E., Jimenez Mayor, E., Chandu Nanwani, A., & De la Flor, J. C. (2026). Physiological discordance between clinical examination, bioimpedance spectroscopy, and lung ultrasound in maintenance hemodialysis patients without heart failure. Frontiers in Nephrology, 6, Article 2000700. https://doi.org/10.3389/fneph.2026.2000700

Image Credits: AI Generated

DOI: 10.3389/fneph.2026.2000700

Keywords: hemodialysis, lung ultrasound, bioimpedance spectroscopy, pulmonary congestion, B-lines, volume assessment, fluid overload, point-of-care ultrasound, nephrology, subclinical congestion, dry weight, cardiovascular risk

A new study published in BMC Medical Education now provides the first structured national answer. Researchers led by Antonio Leidi, André Juillerat, Thomas Agoritsas, and Olivier Grosgurin of Geneva University Hospitals, working with a large network of co-authors drawn from every Swiss university hospital and numerous accredited training centers, conducted a three-round modified Delphi consensus study between March and September 2025. The work was carried out under the banner of the Swiss Interest Group for Ultrasound in Internal Medicine, known as IG-USIM, and involved thirty hospital-based experts certified in point-of-care ultrasound who practice general internal medicine themselves. The goal was deliberately pragmatic: not to write another textbook of ultrasound applications, but to prioritize them for the physicians who actually staff Swiss medical wards.

The Delphi method is a well-established technique for extracting reliable consensus from expert panels without the distortions of group dynamics. Instead of convening a single contentious meeting, researchers circulate structured questionnaires over successive rounds, feeding anonymized group results back to participants so that opinions can converge or diverge on their merits. In this study, the experts rated the clinical relevance of 119 distinct POCUS applications using Likert scales, which measure degrees of agreement along a fixed range. Consensus was defined a priori, before the data were examined, as at least 70 percent agreement, a threshold designed to prevent a slim majority from masquerading as expert agreement. Each application could ultimately be classified as core, advanced, or irrelevant for hospital-based general internal medicine practice.

The results, published on 12 October 2026, are striking for both their clarity and their implications. Of the 119 items assessed across the three rounds, final consensus was reached for 71. Twenty-four applications were classified as core, meaning the panel judged them essential for any hospital-based internist; another 24 were deemed advanced, appropriate for context-dependent or specialized use; and 23 were rated irrelevant to the daily work of hospital internists. The core set is dominated by pulmonary ultrasound and ultrasound-guided procedures, supplemented by selected focused cardiac and abdominal applications. In practical terms, the experts agreed that a well-trained internist should be able to detect pleural effusions, pneumothoraces, and alveolar consolidations; safely guide vascular access and drainage procedures; and perform focused assessments of the heart and abdomen at the bedside.

The advanced tier captures a different philosophy of training. These applications, which include more nuanced cardiac assessments and context-dependent abdominal and vascular evaluations, are valuable but not universally necessary. The panel’s message is that training programs should distinguish between skills every internist must command and skills that deepen expertise in particular clinical environments, such as intensive care or emergency observation units. Perhaps most tellingly, the irrelevant category drew firm boundaries around the edges of internal medicine: obstetric and gynecologic ultrasound, ocular ultrasound, ear-nose-throat applications, and thyroid imaging were largely judged to lie outside the hospital internist’s remit, remaining the province of the relevant specialties.

Buried in the consensus list is a finding with immediate regulatory consequences. Several applications that reached core consensus are not currently included in the mandatory Swiss certification requirements for internal medicine training. In other words, the formal curriculum that governs what Swiss internists must demonstrate before certification does not yet match what a national panel of experienced practitioners considers indispensable bedside competence. This gap between formal requirements and clinical consensus is precisely the kind of misalignment the study was designed to expose, and it gives Swiss postgraduate training authorities a concrete, evidence-based starting point for revision.

The technical rigor of the study deserves attention. The panel was constructed to represent the full geography and institutional diversity of Swiss hospital medicine, from the five university hospitals in Geneva, Lausanne, Bern, Basel, and Zurich to cantonal and regional centers across the German-, French-, and Italian-speaking regions. The authors followed CREDES guidance, an international standard for conducting and reporting Delphi studies, which requires transparent documentation of panel selection, response rates, and consensus criteria. The Geneva Cantonal Research Ethics Commission reviewed the protocol and determined that it fell outside the scope of the Swiss Human Research Act, requiring no additional ethics approval. The study received no external funding from public, commercial, or non-profit organizations, and the authors disclosed their professional roles in ultrasound societies and training committees in detail.

What makes this study resonate beyond Switzerland is the broader problem it addresses. POCUS has exploded globally because the hardware has become cheap, portable, and increasingly integrated into smartphones and tablet-based devices. But hardware is the easy part. Ultrasound is an operator-dependent technique: the same probe that reveals a pericardial effusion in trained hands can produce confident misdiagnoses in untrained ones. Countries including the United States, Germany, and others have developed consensus curricula to standardize training, but Switzerland, despite its dense network of high-quality hospitals, had no comparable national framework. Training therefore varied substantially between institutions, and an internist certified in one canton might possess a very different ultrasound skill set from a colleague certified elsewhere.

The authors are careful about what their findings do and do not claim. They explicitly frame the consensus list not as a prescriptive recommendation but as a structured basis to inform national dialogue and subsequent curriculum development. They also acknowledge that considerations of cost-effectiveness, implementation resources, and long-term sustainability were beyond the scope of the study. Equipping training centers with machines, training supervisors, and assessing competency all carry real costs, and any national rollout will need to ensure that smaller regional hospitals are not left behind their university-hospital counterparts. Those feasibility questions, the authors write, should be addressed in future evaluations to ensure feasible and equitable integration across institutions.

Still, the study marks a genuine milestone in the professionalization of bedside imaging. For the first time, Swiss hospital internists have a nationally agreed, expert-validated map of what point-of-care ultrasound should mean in their specialty: twenty-four core skills that define baseline competence, twenty-four advanced skills that define depth, and a clear statement of what does not belong in their hands. As handheld ultrasound devices continue to proliferate through hospital corridors worldwide, this kind of disciplined, consensus-driven prioritization offers a template for other health systems grappling with the same question. The stethoscope took decades to earn its place in the physician’s routine; the ultrasound probe is earning its place far faster, and studies like this one are helping ensure that its adoption is matched by competence rather than merely enthusiasm.

Subject of Research: Delphi consensus on point-of-care ultrasound training priorities for hospital-based general internal medicine in Switzerland

Article Title: Defining core and advanced point-of-care ultrasound applications for hospital-based internal medicine in Switzerland: a Delphi consensus of the Swiss Interest Group for Ultrasound in Internal Medicine (IG-USIM)

Article References: Leidi, A., Juillerat, A., Schneider, C., Benmachiche, M., Cosma, T., Dratz, L., Esposito, F., Felser, R., Greiser, J., Hausherr, Y., Kirsch, M., Kistler, A. D., Knoblauch, C., Lambert, A.-C., Monti, M., Moret Bochatay, M., Mosimann, V., Muggetti, E. M. N., Öhrström, L., … Grosgurin, O. (2026). Defining core and advanced point-of-care ultrasound applications for hospital-based internal medicine in Switzerland: a Delphi consensus of the Swiss Interest Group for Ultrasound in Internal Medicine (IG-USIM). BMC Medical Education. https://doi.org/10.1186/s12909-026-10574-3

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10574-3

Keywords: point-of-care ultrasound, POCUS, general internal medicine, Delphi study, medical education, Switzerland, curriculum development, postgraduate training, ultrasonography, competency-based education, hospital medicine, consensus