The 2025 FIGO Cancer Report updates recommendations for the diagnosis, staging, and management of the 6 major gynecologic malignancies, including cervical, endometrial, vaginal, vulvar, ovarian, and fallopian tube cancer, and gestational trophoblastic disease (GTD). The role of ultrasound differs considerably across the 6 cancers. In cases of endometrial and GTD, ultrasound is used to guide initial diagnosis, risk stratification, and surgical planning. In postmenopausal bleeding, a transvaginal ultrasound can assess endometrial thickness and determine the need for further evaluation. In cervical cancer, transrectal ultrasound allows local tumor assessment and brachytherapy guidance. Ovarian and fallopian tube cancers rely on ultrasound as the first-line tool for adnexal mass assessment and contribute to the Risk of Malignancy Index. For vaginal cancer, sonography has a complementary role in the anatomic assessment of the primary tumor. In vulvar cancer, ultrasound use is limited, as it is mainly for lymph node evaluation in early disease, when used in conjunction with clinical examination and cross-sectional imaging. Although ultrasound has limitations when assessing nodal spread or distant metastases, it can be used in combination with cross-sectional imaging and serial biomarkers to provide a complete evaluation. This review aims to summarize the ultrasound-relevant content from the 2025 FIGO update reports and serve as a practical reference for radiologists.
Point-of-care ultrasound (POCUS) training courses have been shown to increase knowledge and skills among physicians, but few studies have examined their impact on clinical outcomes. We assessed the frequency of ultrasound usage and complication rates of paracentesis after implementing a POCUS training course in the Veterans Affairs (VA) health care system. A retrospective observational study was conducted of VA medical centers that participated in a POCUS training course ("trained facilities") versus matched control facilities. Rates of paracentesis performed in non-radiology settings with and without ultrasound guidance and procedural complications were collected from the VA corporate data warehouse (CPT and ICD-10 procedure and diagnosis codes) and pre- and post-course surveys of course participants. A best fit linear regression line was established for quarterly rates of each group and the y-intercept and slope of each line was compared. Data were compared from 16 trained versus 32 matched control facilities where 10,375 and 22,103 paracenteses were performed, respectively, from October 2015 to March 2025. At baseline, ultrasound guidance was used less frequently in trained versus matched control facilities (39% vs. 78.3%, p < 0.0001). However, trained facilities demonstrated a greater quarterly increase in ultrasound use (1.20% vs. -0.14% per quarter, p < 0.0001). By the end of the study, trained facilities surpassed control facilities in use of ultrasound guidance (84.6% vs. 73.0%, p < 0.001). The overall complication rate was low (2.4 per 1,000 procedures) and there was no significant difference in trends between trained and matched control facilities. Participation in a national POCUS training course was associated with increased use of ultrasound guidance for paracentesis but not with statistically significant changes in complication rates. Further study is warranted to explore effect of POCUS training on procedural outcomes of paracentesis.
This study aims to evaluate the implementation of the uterine sliding sign in routine pelvic ultrasound examinations for improving the diagnosis of deep endometriosis. A retrospective analysis was conducted at Mayo Clinic's Florida and Arizona campuses, including 200 premenopausal and perimenopausal women with chronic pelvic pain, infertility, or suspected endometriosis. Sonographers performed a uterine sliding maneuver during transvaginal ultrasound, and the acquisition times were recorded. Sonographer experience and the time required to perform the sliding sign were analyzed using Microsoft Excel. The median acquisition time for the uterine sliding sign was 26 seconds, with no statistically significant difference based on sonographer experience. The addition of this maneuver extended the ultrasound examination by <1 minute on average, regardless of sonographer experience level. Incorporating the uterine sliding sign into routine pelvic ultrasound protocols is a quick and efficient method that enhances the detection of deep endometriosis, potentially reducing the significant diagnostic delay associated with endometriosis. This study supports the feasibility and minimal time impact of implementing the Society of Radiologists in Ultrasound (SRU) recommendations for augmented pelvic ultrasound in clinical practice.
Transthoracic lung ultrasound is becoming increasingly important in the diagnosis and treatment of interstitial lung disease. However, no standard examination has been developed for pulmonary ultrasound scanning. The purpose of this study was to evaluate the clinical value of simplified transthoracic pulmonary ultrasound scoring through 6 intercostal spaces for the assessment of interstitial lung disease severity. Two hundred nineteen patients who underwent pulmonary ultrasound at our institution were included. Patients were divided into a non-interstitial lung disease group (57 participants) and an interstitial lung disease group (162 participants). The 6-intercostal space method was used for pulmonary ultrasound examination and scoring. The Warrick score of high-resolution computed tomography and lung function indicators were used as the gold standards to evaluate the consistency of the 3 methods in grading interstitial lung disease severity. When lung function indicators were used as the gold standard, a strong consistency was observed between the 6-rib interstitial lung ultrasound scores and the lung function indicators (κ value = 0.841, 95% CI = 0.740-0.941); a strong consistency was also observed between the high-resolution computed tomography scores and the lung function indicators (κ value = 0.664, 95% CI = 0.525-0.803). When the high-resolution computed tomography score was used as the gold standard, a strong consistency was observed between the 6-rib interstitial lung ultrasound score and the high-resolution computed tomography score (κ value of 0.718 (95% CI = 0.618-0.818). A simplified 6-intercostal space pulmonary ultrasound score can be used to evaluate interstitial lung disease severity and better facilitate clinical treatment.
Given the realities of current radiologist and sonographer staffing shortages, increasing caseloads, productivity metrics for performance, and pressure for faster turnaround times in ultrasound, this survey polled members of the Society of Radiologists in Ultrasound. The membership includes academic and private radiologist practitioners, experts, and directors in the field. The goal was to define the state of ultrasound practice today in various settings, understand the tradeoffs between speed and accuracy, and offer solutions that can mitigate these trends. An anonymous survey regarding specific details of individual ultrasound practice was circulated to the 500 members of the Society of Radiologists in Ultrasound, with 101 responses tallied in total. The majority of respondents reported a difference in their practice of ultrasound, including increased case volumes, decreased review of cases by radiologists before patients leave the department, and decreased time for academics and teaching. Results of this survey reveal threats to academic practice, oversight, and quality of scan reports, resident education, and staff retention. Possible solutions to mitigate these trends are discussed.
Cardiovascular ultrasound is an operator-dependent modality that requires careful sequencing of the theoretical and practical training to optimize skills acquisition. This study compares lecture-first (LF) versus practical-first (PF) teaching strategies in undergraduate radiologic sciences students to evaluate the impact of 2 different teaching strategies on students' scores. In a randomized controlled trial, 54 students were allocated to LF (n=25) or PF (n=29) groups. The LF group received didactic lectures followed by hands-on practice, while the PF group reversed this sequence. Outcomes were measured using a multiple-choice question (MCQ) exam for theoretical knowledge and an objective structured clinical examination (OSCE) for practical skills. Evaluation was performed by blinded faculty using standardized rubrics. An exploratory analysis of the impact of supplemental practice sessions was also performed. LF students demonstrated superior overall performance (median score: 0.9 vs. 0.82, P=0.009, effect size: d=0.72) and practical skills (0.95 vs. 0.82, P=0.002, effect size: d=0.85). Theoretical knowledge scores were comparable between groups, with median scores of 0.86 for LF and 0.85 for PF (P=0.9). Students attending extra practice sessions achieved significantly higher scores across all domains (overall: 0.9 vs. 0.83, P=0.004; skills: 0.93 vs. 0.87, P=0.01). Teaching strategy in which a lecture is delivered first, followed by a practical session, was associated with improved scores compared with the design starting with a practical session. Attending additional hands-on sessions can significantly enhance students' knowledge and skills for performing ultrasound examinations. This study suggests that sequencing can influence student academic achievement and indicates that arranging practical sessions after lectures and providing extra practical sessions can enhance learning in the cardiovascular ultrasound curriculum.
Non-alcoholic fatty liver disease is emerging as a global health concern. Screening is the only way to alleviate its burden. Grayscale evaluation is the most commonly used non-invasive method for this purpose, but it lacks precision and reproducibility. In contrast, attenuation imaging is an innovative technique that has not yet been extensively studied. The aim of our study is to determine the correlation between hepatic steatosis grading obtained through attenuation measurement and grayscale ultrasound assessment performed by both a physician and a resident. In addition, we aim to evaluate the reproducibility of results obtained using both methods. A prospective study was conducted on 112 patients who underwent 2 double-blinded ultrasound examinations executed by an experienced radiologist with 30 years of expertise and a fifth-year resident from October to December 2023. Consequently, for each patient, a grayscale assessment of liver fat and attenuation coefficient measurement was done by the 2 readers, and graded accordingly. For attenuation coefficient, 5 measurements were taken with respect to the quality criteria set by the vendor. No significant difference was shown in the grading of liver fat using subjective method and attenuation imaging, obtained by the physician and the resident. Our results showed good reproducibility for grading fat liver using grayscale (Cohen Kappa=0.682) and attenuation imaging (Cohen Kappa=0.729) and excellent agreement for attenuation coefficient (ICC=0.956, 2k model). Attenuation imaging is an objective ultrasound application, with better inter-observer evaluation compared with grayscale evaluation, which remains a subjective method.
Splenomegaly is an important clinical sign associated with diverse pathologies. Traditional bedside physical examination maneuvers used to detect splenomegaly demonstrate poor diagnostic performance. Point-of-care ultrasound (POCUS) is a potential alternative. We sought to compare the diagnostic performance of structured physical examination maneuvers and POCUS in the bedside detection of splenomegaly. Internal medicine and hematology inpatients at Kingston Health Sciences Centre from February 2023 to June 2024 were prospectively enrolled. Participants underwent a structured physical exam comprised of Castell's Method, Traube's Method, Nixon's Method, and one-handed palpation followed by a POCUS examination. Radiographic confirmation of splenomegaly (spleen length >12 cm) was obtained via abdominal ultrasound, computed tomography, or magnetic resonance imaging within 1 month of enrollment. The performance of each diagnostic test was determined. Of 130 patients enrolled, 55 (38.5%) had radiographically confirmed splenomegaly. POCUS demonstrated higher diagnostic performance (sensitivity 70.9%, specificity 72.0%, Matthew's correlation coefficient 0.43) compared with physical exam maneuvers. The most specific physical exam maneuver was Nixon's method (90.8%), while percussion of Traube's space had the highest sensitivity (52.7%). POCUS measurements strongly correlated with formal imaging (Spearman rho=0.630; P<0.001). The diagnostic accuracy of POCUS was reduced in patients with elevated body mass index (P=0.027) and in those scanned within 2 hours of eating (P=0.047). The POCUS examination took almost twice as long as the combined physical exam maneuvers (median 142 vs. 82). POCUS outperforms traditional physical examination in detecting splenomegaly and correlates well with formal imaging, supporting its integration into bedside practice and medical education.
To investigate the diagnostic value of contrast-enhanced ultrasound (CEUS) in idiopathic retroperitoneal fibrosis (IRPF) activity and establish an optimal ultrasound-supplemented scoring method to evaluate the activity of IRPF. The retrospective study included 139 CEUS examinations of 59 IRPF patients treated in our hospital from January 2017 to January 2025. They were divided into the IRPF active group (66 examinations) and the inactive group (73 examinations). The parameters between the 2 groups were compared by univariate analysis. Spearman rank correlation was used to analyze the association between the parameters and IRPF activity. Significant parameters were scored according to the correlation coefficients (rs). The receiver operating characteristic (ROC) curve was drawn to evaluate the diagnostic efficiency of the scoring method. Univariate analysis showed that the incidence of back pain, ESR, CRP, lesion thickness, and CEUS grade was higher in the active group than in the inactive group (P<0.01). The CEUS grade and thickness had the strongest association with IRPF activity [rs=0.710 (95% CI: 0.616-0.784) and 0.703 (95% CI: 0.608-0.778), respectively]. The total score of the active group was significantly higher than that of the inactive group (P<0.001). The ROC curve showed that the optimal cutoff value was 3 scores. The sensitivity, specificity, positive, and negative predictive values were 84.85%, 83.56%, 82.35%, and 85.92%, respectively. The area under the ROC curve was 0.935 (95% CI: 0.880-0.970). In conclusion, CEUS was an excellent noninvasive diagnostic tool for assessing the activity of IRPF.
To quantify C-arm-registered radiation exposure during ultrasound- and fluoroscopy-guided spinal interventional pain management in dogs, and to measure operator-based radiation levels to identify discrepancies between delivered and received dose. A retrospective observational study. A total of 82 canine spinal interventional pain management procedures performed at a single referral institution. Radiation data [dose-area product (Gy·cm2) and absorbed dose (mGy)] were collected from a mobile C-arm fluoroscopy system for procedures conducted from September 2020 to August 2024. Effective dose (mSv) was calculated using a standard conversion factor applied to dose-area product (Gy·cm2). Operator exposure was monitored via thermoluminescent dosimeters (TLDs) placed at chest level and at the C-arm arc. TLD readings were retrieved quarterly through the Public Health England/UK Health Security Agency databases. The Shapiro-Wilk test was used to assess normality, and data were expressed as median (minimum-maximum) or mean ± standard deviation, as appropriate. The median absorbed dose for all spinal interventions was 3.97 (0.07-25.8) mGy. The corresponding median dose-area product and effective dose was 0.63 (0.01-4.12) Gy·cm2 and 0.15 (0.002-0.95) mSv, respectively. Procedural radiation exposure lay near the lower end of reported human ranges and operator TLD readings remained below detection thresholds despite cumulative procedural doses exceeding these levels. Ultrasound- and fluoroscopy-guided spinal interventional pain management in dogs resulted in relatively low radiation exposure levels for both animals and operators. Incorporating ultrasound aligns with the 'as low as reasonably achievable' principle, helping reduce fluoroscopy time and associated risks. These findings support the development of targeted radiation safety protocols for veterinary interventional procedures and underscore the importance of continued operator training and dosimetry monitoring.
Lung ultrasound (LUS) is increasingly utilized for diagnosing pediatric pneumonia due to its bedside accessibility, radiation-free nature, and high diagnostic sensitivity. However, broader clinical adoption remains hindered by operator dependency, inconsistent interpretation, and training challenges, particularly among trainees and less-experienced health care providers. Currently, there is an unmet need for practical tools that help trainees reliably detect pneumonia-related ultrasound findings. In this technical innovation study, we evaluated a semi-automated, artificial intelligence (AI)-assisted system designed to identify clinically relevant lung abnormalities, including pleural line thickening, consolidation morphology, and B-line patterns. Our computerized analysis demonstrated the system's technical capability to accurately detect these structural changes with minimal user interaction. Although our primary aim was to assess diagnostic feasibility, the intuitive nature and real-time visual annotations provided by this AI tool highlight its strong potential for future integration into educational contexts. By visually assisting trainees in recognizing key sonographic features, this technology can facilitate learning, improve detection skills, and effectively support the training of health care providers performing pediatric LUS.
This retrospective observational study aimed to develop a regression model to estimate the controlled attenuation parameter (CAP) from the ultrasound-guided attenuation parameter (UGAP) attenuation coefficient (AC), and to evaluate the agreement, biases, and potential interchangeability between the 2 measurements in a routine clinical setting. A total of 85 patients who underwent both UGAP and CAP measurements on the same day were included. UGAP-AC values were converted from dB/cm/MHz to dB/m to match CAP units. Pearson's correlation and linear regression analyses were performed to derive a predictive equation for CAP based on UGAP-AC. Agreement and biases between the 2 attenuation values were assessed using Bland-Altman analysis. In addition, repeated-measures analysis of variance was conducted to assess the influence of body mass index (BMI) on measurement differences. UGAP-AC and CAP showed a strong positive correlation (r=0.947, P<0.0001). The regression equation was CAP (dB/m)=371.5× UGAP-AC + 12.3 (R²=0.8946). Bland-Altman analysis revealed a fixed bias of 28.6 dB/m and a BMI-dependent proportional bias. However, this proportional bias disappeared observed when analysis was limited to the clinically relevant CAP range (228 to 300 dB/m), suggesting good comparability between UGAP and CAP within the diagnostic range. UGAP-AC can reliably estimate CAP using a simple linear regression model. While some systematic biases exist, their clinical impact is limited. These findings support the potential interchangeability of UGAP and CAP for noninvasive hepatic steatosis assessment in high-throughput clinical practice.
Necrotizing soft tissue infections (NSTIs), particularly necrotizing fasciitis (NF), are life-threatening conditions with high mortality, where early diagnosis is essential to improve outcomes. However, the clinical presentation often mimics less severe infections, contributing to diagnostic delays. This case series explores the utility of point-of-care ultrasound (POCUS) in the early recognition of NF through the presentation of 3 adult patients evaluated in the Emergency Department of a tertiary care center. All patients underwent bedside ultrasound at the time of admission, with findings corroborated by computed tomography (CT) imaging and surgical exploration. Key sonographic features included subcutaneous gas, fascial thickening, and fluid tracking along fascial planes-hallmarks suggestive of NSTI. These findings were consistent with CT scans and intraoperative assessments. Two patients underwent early surgical debridement with favorable clinical outcomes, while one was managed with palliative care due to poor baseline status. This series highlights the value of POCUS as an immediate, noninvasive, and valuable diagnostic tool that complements clinical and laboratory evaluation, facilitates prompt surgical intervention, and may contribute to improved survival in patients with NSTI.
In chronic diseases, accelerated muscle mass loss is associated with poor clinical outcomes. Computed tomography (CT) is considered a reference standard for assessing muscle mass, but it is limited for longitudinal assessment. Ultrasound (US) is more suitable for longitudinal measurements, but limited reliability data or reference values exist to inform clinical adoption. This pilot study evaluated the reliability of rectus femoris (RF) muscle US measurements [cross-sectional area (CSA) and shear-wave elastography (SWE) stiffness] and investigated their relationship with CT-derived truncal muscle mass. Forty healthy living liver donors undergoing abdominal CT were included. CT-derived skeletal muscle area and skeletal muscle index at T12 and L3 were quantified using deep learning. US B-mode and SWE RF images obtained with manual and automated measurements. Reliability was assessed using intraclass correlation (ICC). Agreement between manual and automated methods was evaluated using the Dice coefficient. US and CT measurements associations were evaluated using Pearson correlation and multiple linear regression. Inter-reader agreement for manual US CSA was excellent (ICC=0.95, 95% CI: 0.88-0.97). Test-retest reliability of SWE was good (ICC=0.78, 95% CI: 0.67-0.87). Automated and manual methods showed strong agreement (Dice coefficient 0.94) and good reliability (ICC=0.85, 95% CI: 0.75-0.91). RF CSA demonstrated weak but significant correlations with CT-derived skeletal muscle area at both T12 and L3 levels (r=0.37 to 0.40, P<0.05). US parameters showed moderate predictive value for CT-derived skeletal muscle index at L3 (adjusted R²=0.70). In conclusion, RF US measurements are reliable, and automated measurements are feasible but show a modest correlation with CT-derived muscle mass measurements.
A novel ultrasound technique was used to assess the superior segment of the internal jugular vein (IJV) in healthy individuals, evaluating the feasibility of visualizing this vein through the parotid gland and examining positional changes. Eighty-five patients undergoing unrelated carotid ultrasound were included, excluding those with headaches, migraines, or other neurological symptoms. A transducer was placed over the parotid gland, and gray scale images-with and without diameter measurement-and color and spectral Doppler of the IJV were obtained in neutral and head turned contralaterally. Technical feasibility and quantitative measurements with mean values and standard deviations were reported. Significant positional changes were assessed if paired data were available. Successful diameter measurements were obtained in at least one side in 79% to 80% of patients and bilaterally in 75%. Mean diameters were 5.5 cm (right) and 5 cm (left). Velocities were acquired in 82% (unilaterally) and 78% (bilaterally). Mean peak systolic velocities were 42 cm/s (right) and 32 cm/s (left). With head rotation, mean velocities were 46 cm/s (right) and 38 cm/s (left). In patients with paired measurements, velocities increased by over 50% in 19% to 28% of patients (P<0.05 for both sides). There was no significant change in the diameter when the head was turned. Visualization of the superior IJV using a parotid window and evaluation of its diameter and internal velocities are feasible with the head in both neutral position and turned contralaterally.
Lung ultrasound has become a standard practice in acute care as an adjunct to the physical exam, providing valuable insights to guide clinical decision making at the point of care. Lung ultrasound can rapidly uncover anatomic detail, help resolve undifferentiated respiratory failure, and delineate equivocal findings on standard plain film without the need for transport to access additional diagnostic imaging. In the following review, basic concepts of lung ultrasound are reviewed including its role in detecting and assessing a variety of common problems.
The objective and purpose of this research are to establish the definition of accuracy of diagnosis for both techniques, EUS-guided fine-needle aspirations (FNA) and ultrasound-guided core biopsies (US-CNB), in the assessment of the pancreatic lesion depending on its size, position, and type of lesions. This study retrospectively reviewed the clinical records of patients who underwent US-CNB or EUS-FNA biopsy for pancreatic lesions between January 2019 and 2022. For each patient, demographic information and information on lesion size, location, and type were obtained. A total of 229 subjects were recruited into the study, with 140 in the US-CNB group and 89 subjects in the EUS-FNA group. The results revealed higher diagnostic efficiency in the US-CNB group compared with the EUS-FNA group, with efficiencies of 96.4% and 70.8%, respectively (P<0.001). Multivariate logistic regression showed that, after adjusting for confounders, US-CNB remained an independent predictor (OR=3.051, P=0.011). After propensity score matching, US-CNB continued to demonstrate significantly higher diagnostic efficiency compared with EUS-FNA (98.4% vs. 71.0%, P<0.001). Diagnostic performance parameters were evaluated in 105 patients with histopathologically established final diagnosis and at least 1 year of follow-up. In addition, US-CNB demonstrated higher sensitivity and specificity when compared with EUS-FNA, which were 92.7% and 83%, respectively. In this retrospective cohort, US-CNB demonstrated higher sample adequacy and sensitivity compared with EUS-FNA for the diagnosis of pancreatic lesions. This advantage was particularly evident in lesions smaller than 4 cm and those located in the head-uncinate process and body of the pancreas.
To evaluate the diagnostic accuracy and safety of ultrasound (US)-guided omental biopsy in patients with omental involvement, and to assess the added value of pre-biopsy computed tomography (CT). This retrospective study included 75 patients who underwent US-guided omental biopsy between January 2023 and 2025. Demographics, clinical, surgical pathology, and cytology data of patients were reviewed. The Mann-Whitney U test and Pearson χ2 test were used to compare the benign and malignant groups as well as diagnostic and non-diagnostic groups. Diagnostic accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated using final diagnoses. Among the 75 patients [median age: 69 y (range: 28 to 87); 81% women], 70 had malignant and 5 had benign final diagnoses. US-guided omental biopsy achieved a diagnostic accuracy of 90.67%, with a sensitivity of 90%, specificity of 100%, NPV of 41.67%, PPV of 100%. No complications occurred. Ascitic fluid cytology was concordant with the final diagnosis in 70% of cases. On CT, higher omental attenuation was significantly associated with diagnostic biopsies, whereas other CT features showed no significant correlation. US-guided omental biopsy is a safe, minimally invasive, and highly accurate technique for evaluating omental involvement.
This study evaluates whether contrast-enhanced ultrasound (CEUS) serves as an effective next-step imaging modality for patients with end-stage renal disease (ESRD) who have indeterminate renal lesions on computed tomography (CT), assessing its diagnostic performance and potential impact on surgical decision-making. A retrospective chart review was conducted on patients with ESRD who underwent both CEUS and CT between 2021 and 2024 within the VCU Health System. The primary lesion analyzed in each case was the one most concerning for malignancy per the radiology report. If no malignancy was suspected, the largest lesion was selected. Imaging findings from CEUS and CT were assessed based on radiology reports and compared against histopathological results and clinical follow-up. A total of 76 patients met the inclusion criteria. There was no significant difference in lesion characterization accuracy between CEUS and CT (P=0.51), lesion diameter (P=0.70), or location (P=0.87). Among the 12 patients who underwent surgery due to suspected lesion malignancy, 11 (91.7%) were referred for surgery based on CEUS findings, with 100% confirmed malignancy on histopathology. CEUS demonstrates diagnostic performance comparable to CT for characterizing indeterminate renal lesions in patients with ESRD. When used as the next step after noncontrast CT, CEUS can reliably guide surgical decision-making while minimizing contrast and radiation exposure. Early integration of CEUS into structured clinical pathways may streamline evaluation, reduce delays to definitive management, and support timely progression toward transplant eligibility. Its safety, accessibility, and cost-effectiveness make CEUS a valuable tool for guiding care in this complex population.
During the past 20 years, there has been an increased integration of point-of-care ultrasound (POCUS) curricula in pediatric emergency medicine (PEM) fellowships. Locally, our fellows were not achieving the recommended 150 scans target we set for graduation. We undertook this quality improvement initiative to increase POCUS scanning in our PEM fellowship. We implemented a quality improvement project from July 2020 to June 2021. Our primary aim was to increase the number of scans performed monthly by the fellows from 3 to 5 scans per fellow per month. After querying the fellows and identifying barriers to POCUS scanning, we implemented interventions targeted at increasing longitudinal scanning, transparency, and accountability in the achievement of target scan numbers. The number of scans per fellow per month increased from a baseline of 3 to 7.6 scans per fellow per month. All graduating fellows met the target of 150 scans by graduation. The impact was sustained 5 years later. The most effective interventions included required quarterly supervised scanning, maintaining a transparent scan-count dashboard, and encouraging scanning with co-fellows when working clinically. These strategies can be incorporated by other PEM training programs.