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Torres Macho, F.J. García Sánchez, P. Garmilla Ezquerra, L. Beltrán Romero, J. Canora Lebrato, J.M. Casas Rojo, P. Arribas Arribas, S. López Palmero, S. Pintos Martínez, J.M. Cepeda Rodrigo, D. Luordo, M. Beltrán López, M. Méndez Bailón, E. Rodilla Sala, L. Manzano Espinosa, A. Zapatero Gaviria, G. García de Casasola" "autores" => array:18 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Torres Macho" "email" => array:1 [ 0 => "jtorresmacho@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F.J." "apellidos" => "García Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "P." 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"apellidos" => "Méndez Bailón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 13 => array:3 [ "nombre" => "E." "apellidos" => "Rodilla Sala" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] 14 => array:3 [ "nombre" => "L." "apellidos" => "Manzano Espinosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">l</span>" "identificador" => "aff0060" ] ] ] 15 => array:3 [ "nombre" => "A." "apellidos" => "Zapatero Gaviria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 16 => array:3 [ "nombre" => "G." "apellidos" => "García de Casasola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 17 => array:1 [ "colaborador" => "on behalf of the Sociedad Española de Medicina Interna y de su Grupo de Trabajo de Ecografía Clínica" ] ] "afiliaciones" => array:12 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna-Urgencias, Hospital Universitario Infanta Cristina, Parla (Madrid), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital de Santa Bárbara, Soria, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Medicina Interna, Hospital de Torrecárdenas, Almería, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital de Denia, Alicante, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Vega Baja, Orihuela (Valencia), Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Virgen del Camino, Sanlúcar de Barrameda (Cádiz), Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital de Sagunto, Valencia, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de posicionamiento sobre la incorporación de la ecografía clínica en los servicios de Medicina Interna" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background and concepts</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical ultrasonography or point-of-care ultrasound consists of the systematic application of ultrasound as an extension and supplement to conventional physical examinations. The Spanish Society of Cardiology (SEC) also refers to clinical cardiac ultrasonography as echocardiography. Similarly, the concept of multiorgan ultrasonography has been suggested as an instrument for the comprehensive evaluation of various regions of the body. Clinical ultrasonography in no way replaces board-certified evaluations performed in radiology rooms or cardiac imaging laboratories.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The main purpose of clinical ultrasonography is to rule out a relevant disease (given the technique's high sensitivity and negative predictive value). Given that ultrasonography competence is achieved within a short training period, incorporating ultrasound training within the internal medicine specialty program is feasible. Moreover, the procedure lasts approximately 15<span class="elsevierStyleHsp" style=""></span>min and should therefore be acceptable for the internist's clinical practice. This basic tool offers the following features:</p><p id="par0015" class="elsevierStylePara elsevierViewall">Streamlining of the diagnostic process, which can provide a prognostic benefit in some cases.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">Screening of numerous diseases.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Monitoring of certain treatments.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Implementation of invasive procedures, such as extraction of fluids and cannulation of central venous pathways.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Assessment of the patient's hemodynamic and congestive state.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the main indications for clinical ultrasonography and the elements that should be assessed.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Key aspects of clinical ultrasonography in internal medicine</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient safety</span><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrasonography facilitates the safety of certain procedures. Specifically, the ultrasound-guided cannulation of central pathways markedly decreases associated complications.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">2–7</span></a> In the hands of nurses, ultrasonography also enables the cannulation of peripheral pathways of complex access, avoiding the need to use central venous catheters.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Other “interventionist” procedures in which ultrasonography is of considerable assistance include thoracentesis and paracentesis. Reducing the risk of pneumothorax associated with thoracentesis is especially important.<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">9,10</span></a> Performing a blind thoracentesis is therefore considered inappropriate when the center has an ultrasound machine.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Another essential point related to patient safety is the promoting of measures that prevent nosocomial infections associated with the use of catheters and tubes. Ultrasonography is useful for detecting acute urine retention and pathological postvoid residue and for monitoring blood volume and central venous pressure. Ultrasonography could help reduce the indications for bladder catheterization in internal medicine departments.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The increase in ultrasound-guided cannulation of peripheral venous pathways under conditions of difficult venous access decreases the use of central pathways and thereby the infections associated with central catheters.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">4,12–15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical ultrasonography as a supplement to physical examinations</span><p id="par0065" class="elsevierStylePara elsevierViewall">Physical examinations are a subjective diagnostic procedure, whose precision and reliability vary significantly and depend on the physician's ability and patient's characteristics.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Clinical ultrasonography is an excellent supplement for improving the cost-effectiveness of classical physical examinations.<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">17–19</span></a> Ultrasonography helps visualize and objectively measure the structures and their potential abnormalities. For example, ultrasonography is especially useful for detecting and quantifying pleural effusion, pericardial effusion and ascites, assessing and typing heart murmurs, calculating the central venous pressure and detecting aortic aneurysms, processes that can go unnoticed during conventional physical examinations.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical ultrasonography in the patient follow-up</span><p id="par0075" class="elsevierStylePara elsevierViewall">Board-certified ultrasonography is useful for accurately assessing patients on an as-needed basis (“freeze frame”) but is obviously not feasible for implementing on a frequent basis. Clinical ultrasonography can be efficiently applied at the point of care in a “serial” or “dynamic” manner to a patient to monitor certain complications (pulmonary congestion, pleural effusion, ascites, blood volume estimation, cholestasis, etc.).</p><p id="par0080" class="elsevierStylePara elsevierViewall">In a significant percentage of patients who are admitted to internal medicine departments, a progressive follow-up of multiple medical complications is essential.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">21–27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Multiorgan ultrasonography</span><p id="par0085" class="elsevierStylePara elsevierViewall">In some clinical scenarios, such as patients with dyspnea, shock or suspected thromboembolism disease, the comprehensive ultrasound assessment of various organs is highly useful for the diagnosis and follow-up.<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">20,28–31</span></a> The characteristic specialization of the radiology and cardiology departments limits the implementation of these types of procedures, which can be performed by general practitioners. Moreover, some organs such as the lungs can be considered orphans from the ultrasound viewpoint.<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">26,27</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Limitations of clinical ultrasonography</span><p id="par0090" class="elsevierStylePara elsevierViewall">The characteristics of patients treated in internal medicine departments frequently hinder the ability to obtain good acoustic windows, a fact that needs to be considered when training internists in the use of ultrasonography. Another limitation is the type of ultrasound, which should be standardized according to the competencies assumed by the practitioner. There are systematic errors that should also be considered when learning clinical ultrasonography, such as obtaining inadequate images and the lack of systemization in the implementation of the study.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Settings for the use of clinical ultrasonography in internal medicine</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Emergency department and hospital ward</span><p id="par0095" class="elsevierStylePara elsevierViewall">Point-of-care ultrasonography is extraordinarily useful as a supplement to physical examinations in these healthcare settings, especially in life-threatening situations.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">32</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Specialized consultations</span><p id="par0100" class="elsevierStylePara elsevierViewall">Clinical ultrasonography can be of considerable use in this type of consultation, in which internists can acquire experience and skill in assessing specific aspects of ultrasonography (“limited ultrasonography”), similar or even superior to those performed in other departments. Some examples are listed below:</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Consultation for cardiovascular risk</span><p id="par0105" class="elsevierStylePara elsevierViewall">Ultrasonography is essential in detecting subclinical lesions of target organs (carotid, heart, leg arteries, abdominal aorta), which helps improve the estimate of cardiovascular risk and treatment optimization.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">33–40</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Consultation for heart failure</span><p id="par0110" class="elsevierStylePara elsevierViewall">Ultrasonography is essential in the diagnosis and follow-up of patients with heart failure. Ultrasonography helps monitor pulmonary congestion (quantifying B-lines, pleural effusion), central venous pressure (size and collapse of the inferior vena cava) and ascites. The tool can also be of value for adjusting the diuretic treatment.<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">22,41–43</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Other consultations</span><p id="par0115" class="elsevierStylePara elsevierViewall">Ultrasonography can also be practical in rapid diagnosis consultations, chronic-complex patient consultations and in specialized consultations of systemic autoimmune diseases (detection and monitoring of interstitial lung disease, pulmonary hypertension, joint involvement, etc.).</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Alternatives to conventional hospitalization</span><p id="par0120" class="elsevierStylePara elsevierViewall">Portable ultrasound machines enable the comprehensive evaluation of patients outside the hospital.<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">32,44,45</span></a> There is sufficient evidence to confirm that ultrasonography can substitute chest radiography for the diagnosis and follow-up of pneumonia and heart failure.<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">46,47</span></a> Ultrasound can therefore be of considerable assistance for palliative medicine and home care physicians, including nursing homes.<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">48,49</span></a></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Clinical ultrasonography in undergraduate training and research</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Undergraduate training</span><p id="par0125" class="elsevierStylePara elsevierViewall">The training of basic clinical ultrasonography does not take long and facilitates training in anatomy, physiology and pathophysiology. Most importantly, the training improves the performance and reliability of the physical examination. Ultrasound training for medical students is implemented progressively in numerous faculties, especially in the United States and Germany.<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">50–53</span></a> This training requires sufficiently qualified teachers, human resources and sufficient materials for the individual training of a large number of students.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In recent years, the Clinical Ultrasonography workgroup of the Spanish Society of Internal Medicine (SEMI) has been developing a practical undergraduate teaching system for ultrasonography, based on the integration of students as teachers. Thus, after a small group of students have been trained, these students can in turn teach their classmates (“peer mentoring”).<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">54,55</span></a> This teaching model is easily exportable to any department of internal medicine involved in teaching undergraduate and postgraduate courses.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Research</span><p id="par0135" class="elsevierStylePara elsevierViewall">The number of publications related to clinical ultrasonography has grown exponentially in recent years. The first example was the development of lung ultrasonography in critical patients, followed by studies on the use of clinical ultrasonography in cardiac arrest, hypotension-shock and the diagnosis of dyspnea. Other lines of research related to the internal medicine field include cardiovascular risk, heart failure and autoimmune diseases.</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Recommendations on the training of internal medicine residents and specialists in general clinical ultrasonography</span><p id="par0140" class="elsevierStylePara elsevierViewall">The established rotation model is based on the combination of scientific evidence and the experience of numerous training centers that have been progressively set up in Spain in the past 10 years.<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">56–60</span></a> There is still the need for a common accreditation system, which will come from the inclusion of clinical ultrasonography in the official program of the specialty.</p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Objectives</span><p id="par0145" class="elsevierStylePara elsevierViewall">The general objective is to understand the foundations of point-of-care ultrasonography as a supplement to the physical examination. The aspects that students should learn are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> of this document.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In addition to a rotation in general clinical ultrasonography, residents may request a rotation in a center that has experience in specific areas of clinical ultrasonography.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Duration and number of examinations</span><p id="par0155" class="elsevierStylePara elsevierViewall">The optimal duration of a training cycling is 4 to 8 weeks. During this time, the resident should perform at least 150 supervised multiorgan ultrasounds on various selected patients. This workload consists of performing 5 examinations per day, which ensures the acquisition of technical skills to optimally view the basic layers of each organ and the application of the technique to an appropriate case mix.</p><p id="par0160" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows an approach for the components and learning times of basic ultrasound training, separated into 3 sequential levels according to their difficulty. Undoubtedly, the basic echocardiographic layers are the most complicated to learn.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ultrasound examination system</span><p id="par0165" class="elsevierStylePara elsevierViewall">Each clinical ultrasound examination should systematically include the pulmonary, cardiac and abdominal assessment. Depending on the medical indication, other structures may be added, such as the carotid territory, deep venous system of the legs and temporal artery.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Material resources</span><p id="par0170" class="elsevierStylePara elsevierViewall">An ultrasound machine should be available for every 2 internists on rotation and should be portable, for performing point-of-care examinations. The equipment should have at least 2D and color Doppler images.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Supervision</span><p id="par0175" class="elsevierStylePara elsevierViewall">Ultrasound examinations should be supervised, especially during the first week of rotation. The resident should then perform ultrasonography independently, requesting supervision by the tutor on demand and storing the images for subsequent consultation.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Activity record</span><p id="par0180" class="elsevierStylePara elsevierViewall">All ultrasound activity should be recorded in a patient file in which detected pathological findings are noted. Ultrasounds can thereby be quantified and the findings compared with those from board-certified ultrasounds and other additional tests available to the patient.</p><p id="par0185" class="elsevierStylePara elsevierViewall">The results of the supervised ultrasound examinations should be reflected in the patient's medical history in the same way the results of classical physical examinations are reflected.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Assessing the level of competence</span><p id="par0190" class="elsevierStylePara elsevierViewall">Upon completion of the rotation period, the tutor will have proof of the number of examinations performed by each resident to qualify the level of acquired competence.</p><p id="par0195" class="elsevierStylePara elsevierViewall">SEMI will define, with the advice of the Clinical Ultrasonography workgroup, homogeneous criteria for assessing the level of competence in general clinical ultrasonography and thereby establish specific accreditation. SEMI is also working with the SEC and other scientific societies to develop joint accreditation in echocardiography.</p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">SEMI and the Clinical Ultrasonography workgroup recommend the incorporation of clinical ultrasonography into the internist's standard clinical practice. To this end, the training of residents and specialists in internal medicine needs to be promoted and facilitated. To achieve these objectives, ultrasound equipment should be acquired by internal medicine departments. Through the National Committee of Internal Medicine, SEMI will propose the incorporation of clinical ultrasonography in the training program for the specialty.</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of interests</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1022764" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec980850" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1022765" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec980851" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background and concepts" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Key aspects of clinical ultrasonography in internal medicine" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient safety" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical ultrasonography as a supplement to physical examinations" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical ultrasonography in the patient follow-up" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Multiorgan ultrasonography" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Limitations of clinical ultrasonography" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Settings for the use of clinical ultrasonography in internal medicine" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Emergency department and hospital ward" ] 1 => array:3 [ "identificador" => "sec0050" "titulo" => "Specialized consultations" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Consultation for cardiovascular risk" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Consultation for heart failure" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Other consultations" ] ] ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Alternatives to conventional hospitalization" ] ] ] 7 => array:3 [ "identificador" => "sec0075" "titulo" => "Clinical ultrasonography in undergraduate training and research" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Undergraduate training" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Research" ] ] ] 8 => array:3 [ "identificador" => "sec0090" "titulo" => "Recommendations on the training of internal medicine residents and specialists in general clinical ultrasonography" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Duration and number of examinations" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Ultrasound examination system" ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Material resources" ] 4 => array:2 [ "identificador" => "sec0115" "titulo" => "Supervision" ] 5 => array:2 [ "identificador" => "sec0120" "titulo" => "Activity record" ] 6 => array:2 [ "identificador" => "sec0125" "titulo" => "Assessing the level of competence" ] ] ] 9 => array:2 [ "identificador" => "sec0130" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0135" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack345344" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-15" "fechaAceptado" => "2018-02-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec980850" "palabras" => array:4 [ 0 => "Point-of-care ultrasound" 1 => "Ultrasound" 2 => "Internal medicine" 3 => "Training" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec980851" "palabras" => array:4 [ 0 => "Ecografía clínica" 1 => "Ultrasonidos" 2 => "Medicina Interna" 3 => "Formación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Este documento de posicionamiento describe los aspectos más importantes de la ecografía clínica en el ámbito de la Medicina Interna, desde sus indicaciones fundamentales hasta el período de formación recomendado. Actualmente ya no quedan dudas sobre la gran utilidad de esta herramienta para la práctica clínica habitual del internista en múltiples escenarios clínicos y ámbitos de actuación (urgencias, planta de hospitalización, consulta general y específica y atención domiciliaria). Su uso tiene un impacto relevante en la capacidad de resolución del profesional, al aumentar su fiabilidad y seguridad diagnóstica, además de proporcionar información pronóstica y evolutiva importante. Además, en los últimos años se ha incorporado como una herramienta en la enseñanza pregrado con excelentes resultados. Por tanto, es necesario generalizar su uso y para ello se debe fomentar la formación estructurada y la adquisición de equipos. El documento ha sido elaborado por el Grupo de Trabajo de Ecografía Clínica y avalado por la Sociedad Española de Medicina Interna.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torres Macho J, García Sánchez FJ, Garmilla Ezquerra P, Beltrán Romero L, Canora Lebrato J, Casas Rojo JM, et al. Documento de posicionamiento sobre la incorporación de la ecografía clínica en los servicios de Medicina Interna. Rev Clin Esp. 2018;218:192–198.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(a) Abdominal ultrasound:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Detection of free intraperitoneal fluid, hepatomegaly or splenomegaly, hepatic steatosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Extrahepatic assessment of the gallbladder and bile duct. Cholelithiasis, cholecystitis. Assessment of patients with cholestasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Assessment of patients with chronic liver disease and portal hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(b) Echocardiography:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Estimating the measurements of cardiac cavities (left atrium, interventricular septum, atrium and right ventricle and ascending aorta). Assessment of patients with radiological cardiomegaly \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Assessment of left and right ventricular function. Usefulness of ultrasonography for assessing patients with suspected heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Detection and estimation of severity of pericardial effusion. Diagnosis of tamponade. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Identification of possible significant valvular heart disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Estimation of blood volume and central venous pressure: inferior vena cava, suprahepatic veins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(c) Urological ultrasonography:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Detection of hydronephrosis and bladder balloon. Renal diameter and echogenicity. Assessment of patients with renal failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(d) Pulmonary ultrasonography:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Identification of pneumothorax, pleural effusion, interstitial syndrome and pulmonary condensation (pneumonia). Usefulness of pulmonary ultrasonography for assessing patients with dyspnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(e) Vascular ultrasonography:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Detection of thoracic and abdominal aortic aneurysm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Detection of deep vein thrombosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Detection of carotid plaques \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(f) Invasive procedures with ultrasound control:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Cannulation of central and peripheral pathways, thoracentesis, paracentesis and arthrocentesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">(g) Multiorgan ultrasonography:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Usefulness of ultrasonography for assessing venous thromboembolism disease. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Assessment of patients in shock. Assessment of patients in shock, in cardiopulmonary arrest or electromechanical dissociation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>- Overall assessment of cardiovascular risk \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1738113.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Competencies and Indications for Clinical Ultrasonography.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">For level 1, at least 20 supervised examinations are needed. For levels 2 and 3, between 30 and 50 examinations are needed.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level 3 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Detection of free abdominal fluid (FAST) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney and urinary bladder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inferior vena cava \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gallbladder and bile duct \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal aorta \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Echocardiography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deep venous system of the lower limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulmonary ultrasonography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1738114.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Difficulty levels of clinical ultrasonography.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0305" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ecocardiografía clínica en Medicina Interna" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. 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We would also like to thank the Board of Directors of SEMI and all members of the Clinical Ultrasonography workgroup of SEMI.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021800000004/v2_201805060420/S2254887418300444/v2_201805060420/en/main.assets" "Apartado" => array:4 [ "identificador" => "3982" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special Article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021800000004/v2_201805060420/S2254887418300444/v2_201805060420/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887418300444?idApp=WRCEE" ]
