Yuka Miura

BACKGROUND: Transabdominal ultrasound is used to detect fecal impaction, but the rectum is difficult to visualize without bladder urine or with gastrointestinal gas. OBJECTIVE: We developed a transgluteal cleft approach that is unaffected by these factors and sought to determine if our ultrasound method could detect and classify fecal matter in the lower rectum using this approach. METHODS: We classified ultrasound images from hospitalized patients into four groups: Group 1 (bowed and rock-like echogenic areas), Group 2 (irregular and cotton candy-like hyperechoic areas), Group 3 (flat and mousse-like hyperechoic areas), and Group 4 (linear echogenic areas in the lumen). Stool characteristics were classified as hard, normal, and muddy/watery. Sensitivity and specificity were determined based on fecal impaction and stool classification accuracy. RESULTS: We obtained 129 ultrasound images of 23 patients. The sensitivity and specificity for fecal retention in the rectum were both 100.0%. The recall rates were 71.8% for Group 1, 93.1% for Group 2, 100.0% for Group 3, and 100.0% for Group 4. The precision rates were 96.6% for Group 1, 71.1% for Group 2, 88.9% for Group 3, and 100.0% for Group 4. Our method was 89.9% accurate overall. CONCLUSION: Transgluteal cleft approach ultrasound scanning can detect and classify fecal properties with high accuracy.

AIM: This clinical practice guideline aims to provide and recommend methods of assessing aspiration and pharyngeal residue during eating and swallowing and methods of selecting and implementing nursing care for adults to prevent the development of aspiration pneumonia through early and appropriate management of oropharyngeal dysphagia. METHODS: In April 2018, the Japan Academy of Nursing Science established the Supervisory Committee in Nursing Care Development/Standardization Committee to develop clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care. This clinical practice guideline was developed according to the Minds Manual for Guideline Development 2017, with the aim of providing a specific pathway for nurses to determine the policy for selecting management for oropharyngeal dysphagia based on research evidence and multifaceted factors including the balance of benefits and harms and patients' values. RESULTS: Based on the 10 clinical questions related to assessment by physical assessment, the Repetitive Saliva Swallowing Test, Modified Water Swallowing Test, Food Test, cervical auscultation, observation using an ultrasound diagnostic device, and an endoscope, 10 recommendations have been developed. Eight recommendations have been evaluated as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 2C, and the other two have been evaluated as no GRADE. CONCLUSION: The first reliable clinical practice guideline has been produced from an academic nursing organization that focuses on assessment for nursing care and incorporates the latest findings.

The classification of ultrasound (US) findings of pressure injury is important to select the appropriate treatment and care based on the state of the deep tissue, but it depends on the operator’s skill in image interpretation. Therefore, US for pressure injury is a procedure that can only be performed by a limited number of highly trained medical professionals. This study aimed to develop an automatic US image classification system for pressure injury based on deep learning that can be used by non-specialists who do not have a high skill in image interpretation. A total 787 training data were collected at two hospitals in Japan. The US images of pressure injuries were assessed using the deep learning-based classification tool according to the following visual evidence: unclear layer structure, cobblestone-like pattern, cloud-like pattern, and anechoic pattern. Thereafter, accuracy was assessed using two parameters: detection performance, and the value of the intersection over union (IoU) and DICE score. A total of 73 images were analyzed as test data. Of all 73 images with an unclear layer structure, 7 showed a cobblestone-like pattern, 14 showed a cloud-like pattern, and 15 showed an anechoic area. All four US findings showed a detection performance of 71.4–100%, with a mean value of 0.38–0.80 for IoU and 0.51–0.89 for the DICE score. The results show that US findings and deep learning-based classification can be used to detect deep tissue pressure injuries.

BACKGROUND: The effectiveness of point-of-care ultrasound (POCUS) for nurses has been demonstrated; however, only a limited number of nurses have been trained to perform POCUS. This article reports on a POCUS train-the-trainer program for nurse educators that targets lower urinary track dysfunction. METHOD: Nurse educators (n = 38) were invited to participate in a POCUS train-the-trainer program, which comprised an e-learning module and a hands-on seminar. Acquisition of knowledge and skills were assessed after the module and seminar, respectively. RESULTS: Questions from the "Basic Knowledge of Ultrasonography" test were answered correctly at a rate of 93.0% (SD, 8.5%). Measured values of bladder urinary volume using ultrasonography were in close agreement with actual values. All of the participants indicated that the program covered the content necessary to use in practice. CONCLUSION: The POCUS train-the-trainer program equips nurse educators with the knowledge and skills needed for training nurses at their institutions. [J Contin Educ Nurs. 2021;52(8):375-381.].

AIMS: While bowel preparation for colonoscopy is the key to successful examination, taking laxatives and showing stools to others causes both physical and mental distress to the patient. Thus, an alternative method to evaluation bowel preparation is necessary. In the current study, we studied the colonic fecal retention by ultrasonography (US) and examined the US finding which reflected completion of BP. MATERIAL AND METHODS: The subjects were outpatients who underwent colonoscopy. This report summarizes the ultrasonographic images of patients who underwent multiple US examinations for all five sites of the colon just before, during, and immediately after bowel preparation. According to the standard protocol, the patients took 2 L of polyethylene glycol-ascorbic acid as a laxative, which was discontinued when the nurse visually judged the stool to be clear. RESULTS: Seven patients in their 50s-80s, none of whom were unable to complete a colonoscopy due to residual feces were included in study. Following bowel preparation, the US images showed anechoic areas with haustration in four or all five areas of the colon. Three of the seven patients received low-dose laxatives (1.1-1.2 L); all three had watery stools in three or more colon areas and none of them were constipated at the time of taking 1 L of laxatives. CONCLUSIONS: Completion of bowel preparation can be assessed by the observation of anechoic areas with haustration in multiple colonic sites by ultrasonography.

AIM: To estimate diagnostic accuracy of ultrasonography for detecting aspiration and pharyngeal residue in patients with dysphagia. METHODS: A systematic search was conducted in MEDLINE (via PubMed), CINAHL, EMBASE, Ichushi-Web, and Cochrane Library databases to identify articles that showed diagnostic accuracy of ultrasonography for detecting aspiration and residue published in English and Japanese until August 2019. Cross-sectional studies, case-control studies, and cohort studies were included. The diagnostic accuracy results were extracted and the pooled estimated sensitivity and specificity were calculated. The risk of bias of the studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies 2. The certainty of the evidence was assessed using the Grades of Recommendation Assessment, Development, and Evaluation methodology. RESULTS: Five studies were included in this review. The pooled estimated sensitivity and specificity for detecting aspiration were 0.82 (95% CI: 0.72-0.89) and 0.87 (95% CI: 0.81-0.92), respectively. One study was included that evaluated ultrasound assessments of pharyngeal residue. The sensitivity and specificity were 0.62 (95% CI: 0.32-0.86) and 0.67 (95% CI: 0.22-0.96), respectively. The certainty of the evidence was low and very low for the diagnostic accuracy of aspiration and pharyngeal residue, respectively. CONCLUSION: Ultrasound is a non-invasive method with good sensitivity and specificity in detecting aspiration as well as reference standards. While risk of bias and small number of studies limited the strength of this systematic review, our results suggested that ultrasound examination was useful as a bedside screening tool for detecting aspiration.

The purpose of this study was to develop a method for more accurate evaluation of fecal retention by an artificial intelligence interpretation support application that determines and displays in red extraction area the presence of fecal retention for rectal ultrasonographic videos taken by home-visiting nurses. In this study, static images were output from rectal ultrasonographic videos taken from medical records of one home-care nursing station. For each static image, the ultrasound expert and the application judged the presence of fecal retention based on half-moon or crescent-shaped hyperechoic findings as extraction area. This study focused on images that were false-positive results for the application when the ultrasound expert’s answer was correct. Extracted regions with a depth of less than 50 mm and a longitudinal diameter of less than 14.5 mm were excluded to distinguish them from stool and gas retentions outside the rectum. As a result, the sensitivity was 81.1%, specificity 87.8%, and correct rate 83.7%. A method of adjusting the depth and long diameter of the extraction area was developed as a means for improving the judgement accuracy of the application.

AIM: Nurses have difficulty assessing the type of constipation by ordinal assessment methods and may therefore struggle to select an appropriate defecation care. Although previous studies described the safety and effectiveness of defecation care based on ultrasonographic observations in the colorectum, no standardized educational program has been established. This study aimed to determine the feasibility of the constipation point-of-care ultrasound (POCUS) educational program regarding the use of ultrasonography as an assessment tool to determine different types of constipation. METHODS: This descriptive study was conducted for visiting nurses working in Japan. The constipation POCUS educational program that nurses can learn in as short as 7 days comprised four elements: E-learning, a hands-on seminar, self-learning, and objective structured clinical examinations (OSCEs). The nurses were asked to complete a questionnaire regarding the education materials. OSCEs were used to assess the participants' skills in assessing patients based on the use of ultrasound observation in the colorectum. RESULTS: Of the 44 participants who enrolled, 40 were able to complete the program. All the 40 participants (100.0%) who took the OSCEs were able to pass at the first attempt. Moreover, 94.9% of the trainees indicated that this program was able to cover the content necessary to use ultrasonography in home care settings. CONCLUSIONS: The results of this study suggest that the 7-day constipation POCUS educational program provided trainees with a foundational knowledge and skills to observe fecal retention in the colorectum. Thus, further educational program enhancements and clinical skill evaluations are needed to maximize the program's effectiveness in the future.

AIM: The present study aimed to analyze the use of machine learning in ultrasound (US)-based fecal retention assessment. METHODS: The accuracy of deep learning techniques and conventional US methods for the evaluation of fecal properties was compared. The presence or absence of rectal feces was analyzed in 42 patients. Eleven patients without rectal fecal retention on US images were excluded from the analysis; thus, fecal properties were analyzed in 31 patients. Deep learning was used to classify the transverse US images into three types: absence of feces, hyperechoic area, and strong hyperechoic area in the rectum. RESULTS: Of the 42 patients, 31 tested positive for the presence of rectal feces, zero were false positive, zero were false negative, and 11 were negative, indicating a sensitivity of 100% and a specificity of 100% for the detection of rectal feces in the rectum. Of the 31 positive patients, 14 had hard stools and 17 had other types. Hard stool was detected by US findings in 100% of the patients (14/14), whereas deep learning-based classification detected hard stool in 85.7% of the patients (12/14). Other stool types were detected by US findings in 88.2% of the patients (15/17), while deep learning-based classification also detected other stool types in 88.2% of the patients (15/17). CONCLUSIONS: The results showed that US findings and deep learning-based classification can detect rectal fecal retention in older adult patients and distinguish between the types of fecal retention.

BACKGROUND: Assessing the presence of pharyngeal residue in the pyriform sinus and epiglottic vallecula is important because insufficient pharyngeal clearance is a risk factor for aspiration pneumonia. Improvements in the performance of ultrasound to visualize the pyriform sinus and epiglottic vallecula are needed. The aim of this study was to establish a method to visualize the pyriform sinus and epiglottic vallecula with ultrasound to detect pharyngeal residue. METHODS: We used real-time virtual sonography (ie, a fusion of magnetic resonance imaging and ultrasound imaging) as the scanning method to visualize the pyriform sinus and epiglottic vallecula without residue in 4 healthy individuals. Using established ultrasound methodology and fiberoptic endoscopic evaluation of swallowing, 35 subjects with dysphagia were studied to investigate the performance of ultrasound to detect pharyngeal residue. RESULTS: The fusion ultrasound images showed that transverse scans at the level of the laryngeal prominence and above the hyoid bone using a linear array transducer can be used to visualize the pyriform sinus and the epiglottic vallecula, respectively. We obtained 238 ultrasound images of the pyriform sinus from 35 subjects and 82 images of epiglottic vallecula from 26 of 35 subjects. The ultrasound images with fiberoptic endoscopic evaluation of swallowing showed that areas of high echogenicity in the pyriform sinus and epiglottic vallecula are related to the presence of pharyngeal residue. The presence of high-echogenicity areas resulted in a sensitivity of 92.0% and specificity of 71.9% for detecting pharyngeal residue in the pyriform sinus and a sensitivity of 86.7% and specificity of 63.6% for detecting pharyngeal residue in the epiglottic vallecula. CONCLUSIONS: Transverse ultrasound scans at the level of the laryngeal prominence and above the hyoid bone enable the visualization of the pyriform sinus, epiglottic vallecula, and pharyngeal residue.