Focused cardiac ultrasound: recommendations from the American Society of Echocardiography.

doi:10.1016/J.ECHO.2013.04.001

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Focused cardiac ultrasound: recommendations from the American Society of Echocardiography.

Journal Article•DOI•

Focused cardiac ultrasound: recommendations from the American Society of Echocardiography.

Kirk T. Spencer¹, Bruce J. Kimura², Claudia E. Korcarz³, Patricia A. Pellikka⁴, Peter S. Rahko³, Robert J. Siegel⁵ - Show less +2 more•Institutions (5)

University of Chicago¹, Scripps Mercy Hospital², University of Wisconsin-Madison³, Mayo Clinic⁴, Cedars-Sinai Medical Center⁵

01 Jun 2013-Journal of The American Society of Echocardiography (J Am Soc Echocardiogr)-Vol. 26, Iss: 6, pp 567-581

TL;DR: This guideline states that FCU should be used as an Adjunct to Physical Examination when Echocardiography is not Promptly Available and when the patient has no alternative source of care.

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Abstract: 1. Why is a guideline needed? 567 2. Definitions 568 a. What is FCU? 568 b. Terminology 568 3. Differentiation of FCU and ‘‘Limited TTE’’ 568 a. Examination Expectations 569 b. Equipment 570 c. Image Acquisition 570 d. Image Interpretation 570 e. Billing 571 4. Considerations for Successful Use of FCU as an Adjunct to Physical Examination 571 a. Personnel 571 b. Equipment 571 c. Potential Limitations of FCU 572 5. FCU Scope of Practice 573 a. FCU When Echocardiography is Not Promptly Available 573 b. FCU When Echocardiography is Not Practical 574

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Journal Article•DOI•

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

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Gabriele Via, Arif Hussain¹, Mike Wells², Robert F. Reardon³, Mahmoud Elbarbary⁴, Vicki E. Noble⁵, James W. Tsung⁶, Aleksandar N. Neskovic⁷, Susanna Price, Achikam Oren-Grinberg⁸, Andrew S. Liteplo⁵, Ricardo Cordioli, Nitha Naqvi, Philippe Rola, Jan Poelaert, Tatjana Golob Guliĉ, Erik Sloth⁹, Arthur J. Labovitz¹⁰, Bruce J. Kimura¹¹, Raoul Breitkreutz, Navroz Masani¹², Justin Bowra¹³, Daniel Talmor⁸, Fabio Guarracino, Adrian Goudie, Wang Xiaoting¹⁴, Rajesh Chawla¹⁵, Maurizio Galderisi, Micheal Blaivas¹⁶, Tomislav Petrovic, Enrico Storti, Luca Neri, Lawrence Melniker¹⁷ - Show less +29 more•Institutions (17)

King Abdulaziz Medical City¹, University of the Witwatersrand², University of Minnesota³, King Saud University⁴, Harvard University⁵, Icahn School of Medicine at Mount Sinai⁶, University of Belgrade⁷, Beth Israel Deaconess Medical Center⁸, Aarhus University Hospital⁹, University of South Florida¹⁰, Scripps Mercy Hospital¹¹, University Hospital of Wales¹², Sydney Adventist Hospital¹³, Peking Union Medical College Hospital¹⁴, Apollo Hospitals¹⁵, University of South Carolina¹⁶, Cornell University¹⁷

01 Jul 2014-Journal of The American Society of Echocardiography

TL;DR: For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

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Abstract: Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

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397 citations

Cites background or methods from "Focused cardiac ultrasound: recomme..."

...The same terminology was proposed by a recent ASE and American College of Emergency Physicians consensus document(32) and an ASE position paper.(34) The present document refers only to the transthoracic cardiac ultrasound technique....
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...Spencer et al.34 produced an expert consensus statement for the ASE in 2013....
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...Indeed, the previous guidelines do not consider color Doppler a basic cardiac ultrasound technique(32) or simply cautiously recommend it as a screening tool.(30,34,111)...
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...Thus, FoCUS is conceived as a targeted diagnostic test rather than as comprehensive diagnostic test and should trigger consideration of referral to comprehensive standard echocardiography when findings are not conclusive and/or fall beyond the boundaries of the technique.(34) Consistent with recommendation 3, care was taken by the panel to leave the statement’s phrasing so as to apply not only to cardiac ultrasound practice in critically ill patients but also to a wider medical praxis potentially entailing all specialties in which cardiovascular clinical assessment is performed....
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...Spencer et al.(34) produced an expert consensus statement for the ASE in 2013....
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Journal Article•DOI•

Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A Report from the American Society of Echocardiography

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Thomas R. Porter¹, Sasha K. Shillcutt¹, Mark S. Adams², Georges Desjardins³, Kathryn E. Glas⁴, Joan Olson¹, Richard W. Troughton⁵ - Show less +3 more•Institutions (5)

University of Nebraska Medical Center¹, Harvard University², University of Utah³, Emory University⁴, University of Otago⁵

01 Jan 2015-Journal of The American Society of Echocardiography

TL;DR: Echocardiographic Monitoring During Liver, Kidney, and Lung Transplantation, Perioperative Medicine, and Trauma; and Advantages, Disadvantages, and Recommendations of EchOCardiography as a Monitoring Tool are reviewed.

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Abstract: General Considerations 40 Scope of Work 41 I. Echocardiographic Hemodynamic Monitoring Tools 41 Two-Dimensional Echocardiographic Monitoring Parameters 42 LV Chamber Dimensions 42 Inferior Vena Cava (IVC) Size and Collapsibility 43 Doppler Monitoring Parameters 43 Mitral Inflow 43 TDI 43 Calculated Monitoring Parameters 44 SV, Cardiac Output (CO), and SVR Calculations 44 RV Systolic Function 44 PA Systolic Pressure 45 II. Advantages, Disadvantages, and Recommendations of Echocardiography as a Monitoring Tool 45 III. Clinical Scenarios 45 Acute CHF Monitoring 45 Critical Care Monitoring 47 Pericardial Tamponade Monitoring 48 Pulmonary Embolism Therapy Monitoring 48 Prosthetic Valve Thrombosis Monitoring 48 Echocardiographic Monitoring in Trauma 48 IV. Perioperative Medicine 49 Echocardiographic Monitoring During Liver, Kidney, and Lung Transplantation 49

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321 citations

Journal Article•DOI•

Point-of-Care Ultrasonography for Primary Care Physicians and General Internists

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Anjali Bhagra¹, David M. Tierney², Hiroshi Sekiguchi¹, Nilam J. Soni³•Institutions (3)

Mayo Clinic¹, Abbott Northwestern Hospital², University of Texas Health Science Center at San Antonio³

01 Dec 2016

TL;DR: 2 common patient scenarios (heart failure and sepsis) are described to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure.

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Abstract: Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.

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157 citations

Cites background from "Focused cardiac ultrasound: recomme..."

...It is generally agreed that training must include basic knowledge of ultrasound physics and supervised image acquisition and interpretation practice.(25,104,110,111,130-133) Other potential challenges include the availability of templates for documentation, electronic storage for image archiving, and...
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...n December 2016;91( ultrasonography can expeditiously assess global LV and right ventricular function and detect the presence of a pericardial effusion.(25) Other common POCUS applications include vascular, musculoskeletal, sinus, ocular, nerve, thyroid, gallbladder, liver, spleen, renal, testicular, and bladder imaging (Figure 1)....
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...Interestingly, these studies have clearly confirmed the superiority of POCUS....
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...Although a movement to integrate POCUS education into medical schools or internal medicine residency programs has been gaining momentum over the past decade,(43,121,123-129) there is no consensus on the training required to reach adequate POCUS competency levels in general internal medicine.(25,104,110,111,130-133) It is generally agreed that training must include basic knowledge of ultrasound physics and supervised image acquisition and interpretation practice....
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...Emergency medicine societies have addressed these issues and assisted physicians in understanding correct and compliant coding for the past 2 decades.37,39,40 In terms of billing, POCUS can potentially influence the evaluation and management code by affecting the complexity of medical decision making (Current Procedural Terminology).112-115 Some believe that reimbursement is essential to cover the substantial cost of POCUS education and equipment purchasing and maintenance.112-115 Conversely, others view POCUS as an extension of the physical examination, which raises concerns that a heavy focus on billing may block the routine use of POCUS.116-118 Future reimbursement systems that capture an “episode of care,” also known as “bundling,” will likely change the perspectives on POCUS billing, documentation, and image archiving.112,117 As the workflow for POCUS in internal medicine matures, medical practices will be required to provide the administrative infrastructure needed to meet these evolving standards of care for use of POCUS.25,104,116 For effective integration of POCUS into clinical care, quality assurance is an important consideration....
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Journal Article•DOI•

A decade of progress in critical care echocardiography: a narrative review.

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Antoine Vieillard-Baron¹, Antoine Vieillard-Baron², S. J. Millington³, Filippo Sanfilippo, Michelle S Chew⁴, José L. Díaz-Gómez⁵, Anthony S. McLean⁶, Michael R. Pinsky⁷, J. Pulido, Paul H. Mayo⁸, N. Fletcher⁹, N. Fletcher¹⁰ - Show less +8 more•Institutions (10)

University of Paris¹, French Institute of Health and Medical Research², University of Ottawa³, Linköping University⁴, Mayo Clinic⁵, University of Sydney⁶, University of Pittsburgh⁷, Hofstra University⁸, Cleveland Clinic⁹, St George's, University of London¹⁰

25 Mar 2019-Intensive Care Medicine

TL;DR: This narrative review focusing on critical care echocardiography has been written by a group of experts in the field, with the aim of outlining the state of the art in CCE in the 10 years after its official recognition and definition.

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Abstract: This narrative review focusing on critical care echocardiography (CCE) has been written by a group of experts in the field, with the aim of outlining the state of the art in CCE in the 10 years after its official recognition and definition. In the last 10 years, CCE has become an essential branch of critical care ultrasonography and has gained general acceptance. Its use, both as a diagnostic tool and for hemodynamic monitoring, has increased markedly, influencing contemporary cardiorespiratory management. Recent studies suggest that the use of CCE may have a positive impact on outcomes. CCE may be used in critically ill patients in many different clinical situations, both in their early evaluation of in the emergency department and during intensive care unit (ICU) admission and stay. CCE has also proven its utility in perioperative settings, as well as in the management of mechanical circulatory support. CCE may be performed with very simple diagnostic objectives. This application, referred to as basic CCE, does not require a high level of training. Advanced CCE, on the other hand, uses ultrasonography for full evaluation of cardiac function and hemodynamics, and requires extensive training, with formal certification now available. Indeed, recent years have seen the creation of worldwide certification in advanced CCE. While transthoracic CCE remains the most commonly used method, the transesophageal route has gained importance, particularly for intubated and ventilated patients. CCE is now widely accepted by the critical care community as a valuable tool in the ICU and emergency department, and in perioperative settings.

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143 citations

Journal Article•DOI•

Point-of-Care Ultrasound in General Practice: A Systematic Review

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Camilla Aakjær Andersen¹, Sinead Holden¹, Jonathan Vela¹, Michael Skovdal Rathleff¹, Martin Bach Jensen¹ - Show less +1 more•Institutions (1)

Aalborg University¹

01 Jan 2019-Annals of Family Medicine

TL;DR: POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs, and future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners.

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Abstract: PURPOSE Ultrasound examinations are currently being implemented in general practice. This study aimed to systematically review the literature on the training in and use of point-of-care ultrasound (POCUS) by general practitioners. METHODS We followed the Cochrane guidelines for conduct and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. We searched the databases MEDLINE (via PubMed), EMBASE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials using the key words ultrasonography and general practice in combination and using thesaurus terms. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS We included in our review a total of 51 full-text articles. POCUS was applied for a variety of purposes, with the majority of scans focused on abdominal and obstetric indications. The length of training programs varied from 2 to 320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused POCUS scans were reported to have a higher diagnostic accuracy and be associated with less harm than more comprehensive scans or screening scans. The included studies were of a low quality, however, mainly because of issues with design and reporting. CONCLUSIONS POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs. Future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners, further explore how these clinicians should be trained, and evaluate the clinical course of patients who undergo scanning by general practitioners.

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122 citations

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References

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Journal Article•DOI•

Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.

[...]

Roberto M. Lang¹, Michelle Bierig², Richard B. Devereux³, Frank A. Flachskampf⁴, Elyse Foster⁵, Patricia A. Pellikka⁶, Michael H. Picard⁷, Mary J. Roman³, James B. Seward⁶, Jack S. Shanewise⁸, Scott D. Solomon, Kirk T. Spencer¹, Martin St. John Sutton⁹, William J. Stewart¹⁰ - Show less +10 more•Institutions (10)

University of Chicago¹, Saint Louis University², Cornell University³, University of Erlangen-Nuremberg⁴, University of California, San Francisco⁵, Mayo Clinic⁶, Harvard University⁷, Columbia University⁸, University of Pennsylvania⁹, Cleveland Clinic¹⁰

01 Dec 2005-Journal of The American Society of Echocardiography

TL;DR: Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, Fase, Michelle Bierig, MPH, RDCS, FASE, Richard B. Devereux,MD, Frank A. Flachskampf, MD and Elyse Foster, MD.

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Abstract: Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, Michelle Bierig, MPH, RDCS, FASE, Richard B. Devereux, MD, Frank A. Flachskampf, MD, Elyse Foster, MD, Patricia A. Pellikka, MD, Michael H. Picard, MD, Mary J. Roman, MD, James Seward, MD, Jack S. Shanewise, MD, FASE, Scott D. Solomon, MD, Kirk T. Spencer, MD, FASE, Martin St John Sutton, MD, FASE, and William J. Stewart, MD

...read moreread less

10,834 citations

"Focused cardiac ultrasound: recomme..." refers background in this paper

...In addition, there are comprehensive guidelines that incorporate extensive recom mendations for echocardiogra phic use in clinical practice.(6-12) The expertise required to use advanced platforms and the extensive training required to appropriately analyze and inter pret transthoracic images have traditionally only been fulfilled by specialists in cardiovascular medicine....
[...]
...There are detailed documents about how to properly measure the cardiac chambers, ventricular performance, valvular lesions, and vessels.(7,9-12) Devices used for FCU imaging have a variable degree of measurement capabilities....
[...]

Journal Article•DOI•

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

[...]

Lawrence G. Rudski¹, Wyman W. Lai², Jonathan Afilalo¹, Lanqi Hua³, Mark D. Handschumacher³, Krishnaswamy Chandrasekaran⁴, Scott D. Solomon⁵, Eric K. Louie, Nelson B. Schiller⁶ - Show less +5 more•Institutions (6)

McGill University¹, Morgan Stanley Children's Hospital², Harvard University³, Mayo Clinic⁴, Brigham and Women's Hospital⁵, University of California, San Francisco⁶

01 Jul 2010-Journal of The American Society of Echocardiography

TL;DR: The Society of Echocardiography (SEDC) is an educational activity for cardiovascular physicians and cardiac sonographers with a knowledge base in the field of echo-cardiography as discussed by the authors.

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Abstract: on Statement: Society of Echocardiography is accreditedby theAccreditationCouncil for edical Education to provide continuingmedical education for physicians. n Society of Echocardiography designates this educational activity for of 1.0 AMA PRA Category 1 Credits . Physicians should only claim credit te with the extent of their participation in the activity. CCI recognize ASE’s certificates and have agreed to honor the credit hours registry requirements for sonographers. Society of Echocardiography is committed to ensuring that its educational ll sponsored educational programs are not influencedby the special interests ation or individual, and itsmandate is to retain only those authors whose fists canbeeffectively resolved tomaintain thegoals andeducational integrity y. While a monetary or professional affiliation with a corporation does not fluence an author’s presentation, the Essential Areas and policies of the ire that any relationships that could possibly conflict with the educational activity be resolved prior to publication and disclosed to the audience. f faculty and commercial support relationships, if any, have been indicated. ience: is designed for all cardiovascular physicians and cardiac sonographers with erest and knowledge base in the field of echocardiography; in addition, reschers, clinicians, intensivists, and other medical professionals with a spein cardiac ultrasound will find this activity beneficial.

...read moreread less

5,151 citations

Journal Article•DOI•

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography

[...]

Lawrence G. Rudski, Wyman W. Lai, Jonathan Afilalo, Lanqi Hua, Mark D. Handschumacher, Krishnaswamy Chandrasekaran, Scott D. Solomon, Eric K. Louie, Nelson B. Schiller - Show less +5 more

01 Jan 2014

TL;DR: This activity is designed for all cardiovascular physicians and cardiac sonographers with arest and knowledge base in the field of echocardiography and reschers, clinicians, intensivists, and other medical professionals with a spein cardiac ultrasound will find this activity beneficial.

...read moreread less

Abstract: on Statement: Society of Echocardiography is accredited by the Accreditation Council for edical Education to provide continuing medical education for physicians. n Society of Echocardiography designates this educational activity for of 1.0 AMA PRA Category 1 Credits . Physicians should only claim credit te with the extent of their participation in the activity. CCI recognize ASE’s certificates and have agreed to honor the credit hours registry requirements for sonographers. Society of Echocardiography is committed to ensuring that its educational ll sponsored educational programs are not influenced by the special interests ation or individual, and its mandate is to retain only those authors whose fists can be effectively resolved to maintain the goals andeducational integrity y. While a monetary or professional affiliation with a corporation does not fluence an author’s presentation, the Essential Areas and policies of the ire that any relationships that could possibly conflict with the educational activity be resolved prior to publication and disclosed to the audience. f faculty and commercial support relationships, if any, have been indicated. ience: is designed for all cardiovascular physicians and cardiac sonographers with erest and knowledge base in the field of echocardiography; in addition, reschers, clinicians, intensivists, and other medical professionals with a spein cardiac ultrasound will find this activity beneficial.

...read moreread less

4,739 citations

"Focused cardiac ultrasound: recomme..." refers background in this paper

...In addition, there are comprehensive guidelines that incorporate extensive recom mendations for echocardiogra phic use in clinical practice.(6-12) The expertise required to use advanced platforms and the extensive training required to appropriately analyze and inter pret transthoracic images have traditionally only been fulfilled by specialists in cardiovascular medicine....
[...]
...There are detailed documents about how to properly measure the cardiac chambers, ventricular performance, valvular lesions, and vessels.(7,9-12) Devices used for FCU imaging have a variable degree of measurement capabilities....
[...]

Journal Article•DOI•

Recommendations for the evaluation of left ventricular diastolic function by echocardiography

[...]

Sherif F. Nagueh¹, Christopher P. Appleton², Thierry C. Gillebert³, Paolo Marino, Jae K. Oh², Otto A. Smiseth⁴, Alan D. Waggoner⁵, Frank A. Flachskampf⁶, Patricia A. Pellikka², Arturo Evangelista - Show less +6 more•Institutions (6)

Houston Methodist Hospital¹, Mayo Clinic², Ghent University³, University of Oslo⁴, Washington University in St. Louis⁵, University of Erlangen-Nuremberg⁶

01 Feb 2009-Journal of The American Society of Echocardiography

TL;DR: Recommendations for the evaluation of left ventricular diastolic function by echocardiography are made and further research is needed to determine the best method for this evaluation.

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Abstract: Recommendations for the evaluation of left ventricular diastolic function by echocardiography

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4,162 citations

Journal Article•DOI•

Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography

[...]

William A. Zoghbi, Maurice Enriquez-Sarano, Elyse Foster, Paul A. Grayburn, Carol D. Kraft, Robert A. Levine, Petros Nihoyannopoulos, Catherine M Otto, Miguel A. Quinones¹, Harry Rakowski, William J. Stewart, Alan D. Waggoner, Neil J. Weissman - Show less +9 more•Institutions (1)

Houston Methodist Hospital¹

01 Jul 2003-Journal of The American Society of Echocardiography

TL;DR: A report from the American Society of Echocardiography’s Nomenclature and Standards Committee and The Task Force on Valvular Regurgitation developed in conjunction with the American College of Cardiology EchOCardiography Committee.

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3,769 citations

"Focused cardiac ultrasound: recomme..." refers background in this paper

...In addition, there are comprehensive guidelines that incorporate extensive recom mendations for echocardiogra phic use in clinical practice.(6-12) The expertise required to use advanced platforms and the extensive training required to appropriately analyze and inter pret transthoracic images have traditionally only been fulfilled by specialists in cardiovascular medicine....
[...]
...There are detailed documents about how to properly measure the cardiac chambers, ventricular performance, valvular lesions, and vessels.(7,9-12) Devices used for FCU imaging have a variable degree of measurement capabilities....
[...]