How to Commercialize Ultrasound Technology

A few years ago, I had the opportunity to commercialize an ultrasound technology. Reflecting upon this process, I am very grateful that there were so many team members and things (including those beyond our control) that contributed to the success of the project. By sharing our journey from the research bench to public use, I hope that people will get an idea of what is involved in a commercialization process and appreciate the importance of team work.Chen_Shigao_2016

It started with our research team who sketched out an idea of using multiple push beams spaced out like a comb to generate multiple shear waves at the same time. It could be used to improve both signal-to-noise ratio and the frame rate for ultrasound elastography. Fortunately our lab had a research scanner that came with a programmable platform. This idea was prototyped and tested on the same day and it worked! Were it not for the research scanner, it would have taken months to get this done. The alternative process involves contacting an ultrasound company (if we ever find one), gaining their support (a research agreement could take months to reach), and testing on a commercial prototype scanner (which is much harder compared to using a research scanner).

It was soon discovered afterwards that the interference of shear waves from the comb push beams make it very hard to calculate the wave speed for elasticity imaging accurately. A mathematician in our team offered to apply a signal processing algorithm that detangles the complicated shear waves into simpler component waves. It solved our problem and helped the idea pass the initial functionality test. The next step was to show the industry the translational potential of this technology and out-license it to them for further development and testing.

Back then, the clinical ultrasound division at our institution was developing a strategic partnership with a leading ultrasound company, which was looking for a shear wave elastography solution for their products. The company soon decided to license our technology. To speed up the progress, our intellectual property (IP) office negotiated the licensing agreement with the company, while we worked with the company engineers on the technology in parallel. Both parties shared a common culture of openness, which allowed us to exchange codes with each other. This trusting relationship was found to be very beneficial by both sides as we shared the dedication to achieve common goals quickly.

To ensure the successful implementation of the prototype, the collaboration continues in the form of site visits and numerous teleconferences between the sites until satisfied phantom and in vivo results were yielded. When the near-end prototype was available, an independent clinical study was performed at our institution to verify the performance and establish cut points for liver fibrosis staging. It greatly exemplified the benefit of affiliating with a large medical center. The extensive interdisciplinary research and medical environment at our institution has provided a unifying framework that bridges the gap of technical creation and clinical deployment. Upon positive results from clinical trials, the company was able to launch the product in 2014. The technique was FDA-approved and released at RSNA. We are very pleased to see the research outcome has been taken from the bench to the bedside and is improving the effectiveness of patient care worldwide.

It truly takes a village to make this happen. The success came with the supports of a huge team of ultrasound physicist, PhD student, mathematician, study coordinator, sonographer, radiologist, IP staff, and licensing manager. It calls for an industrial partner that has shared appreciation of value and common core objectives. Looking back at our journey, it is without question that every step presents its own challenge. By sharing our experiences, we hope to contribute to your future successful technology commercialization.

 

Have you tried to commercialize an ultrasound technology? Have you had a different experience commercializing ultrasound technology? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Shiago Chen, PhD, is a Professor at the Department of Radiology, Mayo Clinic College of Medicine.

Bigger and Better in the Big Apple

Last week a near-record 1,500 physicians, sonographers, scientists, students, and educators from across the country and around the world gathered in New York City to network, share, and learn. It was, by all accounts, one of the biggest and best AIUM Conventions yet!

What it made so great? A variety of educational opportunities covering a wide range of topics addressing at least 19 different specialties is just the start. More interaction across disciplines to share techniques, more hands-on learning labs, new product releases, and collaborative learning events added to the excitement and collegiality.

If you were in New York City, we hope you shared your feedback in the follow-up surveys. If you were unable to make it this year, here are a few of the highlights:

New Offerings—As if putting on the AIUM Convention weren’t enough, we decided to make a host of changes. We doubled the number of hands-on learning labs (most sold out), we added the more intimate Meet-the-Professor sessions (again, most sold out), we enhanced networking by adding exhibit hall receptions, we brought back the mobile app to make navigating the event easier, and we invited our corporate partners to host Industry Symposia, which included education, networking, and food. Whew!

New Offerings

SonoSlam—In its third year, a record number of medical schools (21) sent teams to compete for the coveted Peter Arger Cup. This year’s winning team, F.A.S.T. and Furious, is from the University of Connecticut. They competed last year and had so much fun they returned and were triumphant! Save the date for next year—April 6. Big thanks to headline sponsor CoapTech.

SonoSlam 2018

Global Plenary—AIUM President Brian Coley, MD, hosted the Plenary session that featured a lecture on global health from John Lawrence, MD, President of the Board of Directors for Doctors Without Borders-USA. This was followed by Roberto Romero, MD DMedSci, who presented the William J. Fry Memorial Lecture on ultrasound imaging and computational methods to improve the diagnosis and care of pregnant women and their unborn children. The entire Plenary Session is available on the AIUM Facebook Page.

Social Media—This year was the most active social media convention ever for the AIUM. StatsFrom streaming live videos on Facebook to more than 754 individuals participating and sharing on Twitter (a 50% increase over last year), the social media scene was active and engaging.

Fun Activities—Not only was #AIUM18 educational, it was also fun. This year attendees could participate in a morning jog through Central Park; do a scavenger hunt with the AIUM app (Congrats to Offir Ben-David, RDMS, from Stamford, CT, and Jefferson Svengsouk, MD, MBA, RDMS, from Rochester, NY, for winning prizes by completing the scavenger hunt); network during 3 different AIUM receptions and the new Industry Symposia; and win prizes at the AIUM booth (Congrats to Jenna Rothblat who won a free 2019 AIUM Convention registration).

Fun Activities

Sold-out Exhibit Hall—This year’s exhibit hall was the most exciting and active it has ever been. At least 3 companies unveiled new ultrasound machines and several others shared their insights with live video feeds. Combine that with networking receptions and New York street fare at lunch time, and the exhibit hall was always the place to be.

Award Winners—AIUM was proud to recognize the following award winners (look for upcoming blog posts and videos from some of these individuals):

Wesley Lee, MD, FAIUM—Joseph H. Holmes Clinical Pioneer Award

William D. Middleton, MD—Joseph H. Holmes Clinical Pioneer Award

Thomas R. Yellen-Nelson, PhD, FAAPM, FAIUM—Joseph H. Holmes Basic Science Pioneer Award

Tracy Anton, BS, RDMS, RDCS, FAIUM—Distinguished Sonographer Award

Alfred Abuhamad, MD, FAIUM—Peter H. Arger, MD Excellence in Medical Student Education Award

Creagh Boulger—Carmine M. Valente Distinguished Service Award

Rachel Liu—Carmine M. Valente Distinguished Service Award

Lexie Cowger—Carmine M. Valente Distinguished Service Award

Adriana Suely de Oliveira Melo, MD, PhD—AIUM Honorary Fellow

Simcha Yagel, MD, FAIUM—AIUM Honorary Fellow

E-poster winners—Every year, the AIUM supports an e-poster program. This year, a record number of abstracts were submitted and the AIUM recognized the following e-poster winners:

  • First place, Basic Science: Construction and Characterization of an Economical PVDF Membrane Hydrophone for Medical Ultrasound, presented by Yunbo Liu, PhD, from the FDA, Silver Spring, MD.
  • First place, Education: Investigation into the Role of Novel Anthropomorphic Breast Ultrasound Phantoms in Radiology Resident Education, presented by Donald Tradup, RDMS, RT, from Mayo Clinic-Department of Radiology, University of Pittsburgh Medical Center-Department of Radiology, Dublin Institute of Technology, Ireland.
  • First place, Clinical Science: Sonography of Pediatric Superficial Lumps and Bumps: Illustrative Examples from Head to Toe presented by Anmol Bansal, MD, Mount Sinai Hospital, Icahn School of Medicine.
  • Second place, Basic Science: Strain Rate Imaging for Visualization of Mechanical Contraction, presented by Martin V. Andersen, MS, from Duke University.
  • Second place, Education: Tommy HeyneSonography in Internal Medicine, Baseline Assessment (MGH SIMBA Study), presented by Tommy Heyne, MD, MSt, Massachusetts General Hospital-Department of Internal Medicine and Department of Emergency Medicine.
  • Second place, Clinical Science: Serial Cervical Consistency Index Measurements and Prediction of Preterm Birth < 34 Weeks in Twin Pregnancies, presented by Vasilica Stratulat, CRGS, ARDMS, MD, Sunnybrook Health Sciences.

Up and Comers—In addition to our national awards and our eposter winners, the AIUM also recognizes its New Investigators, which this year were sponsored by Canon.

Nonclinical
Winner— Ivan M. Rosado-Mendez, PhD, for “Quantitative Ultrasound Assessment of Neurotoxicity of Anesthetics in the Young Rhesus Macaque Brain.”

Clinical Ultrasound
Winner— Ping Gong, PhD, for “Ultra-Sensitive Microvessel Imaging for Breast Tumors:  Initial Experiences.”

Honorable Mentions
Juvenal Ormachea, MS,
for “Reverberant Shear Wave Elastography: Implementation and Feasibility Studies.”

Kathryn Lupez, MD, for “Goal Directed Echo and Cardiac Biomarker Prediction of 5-Day Clinical Deterioration in Pulmonary Embolism.”

2019

 

 

Life Hacks for the 2018 AIUM Annual Convention

Plan
View the full program online and, to keep on top of all things #AIUM18, download the eventScribe app now from the Apple store or Google Play store and search for AIUM 2018. imageBefore and during the convention, use the app to plan your schedule, read about sessions, take notes, learn about exhibitors, and engage with other attendees.

Learn all about the app by checking out these videos on using the app: Quick Navigation Guide, Browsing Style, Taking and Sending Notes, E-mailed Notes, Messages, and Events.

Go
Travel to the convention via plane, train, or automobile. The hotel, New York Hilton Midtown, is located on Avenue of the Americas (6th Ave) between West 53rd and West 54th Streets. To get to the hotel from 1 of the 3 nearby airports, or Grand Central station, Penn Station, or Port Authority, which are all within approximately 20 minutes of the hotel, you can take a taxi or rideshare service. To get around the city, walk or take the subway, a taxi, or a rideshare.

 

Follow
Stay in the know by following the AIUM and the Convention on Twitter (#AIUM18), Instagram (AIUMultrasound), vimeo, LinkedIn, and Facebook as we share news and events, as well as photos and videos.

Learn and Network

  • Two preconvention postgraduate courses will be offered on Saturday, March 24. Additional fees apply.
  • We doubled the number of hands-on Learning Labs. Our Learning Labs provide an up-close and personal learning experience while earning CME credit.
  • Learn from leading ultrasound experts in small group settings in Meet-the-Professor sessions. There are a dozen Meet-the-Professor events to choose from. Each comes with lunch. Separate registration fee is required. If you haven’t registered, act quickly because more than half the sessions are sold out.
  • The AIUM has added 2 networking receptions to the Convention schedule. Plan to meet up with colleagues, explore the latest technology, and ask questions you may have during these cocktail and hors d’oeuvre events on the Exhibit Hall floor.
  • The AIUM received a record number of research abstracts for the 2018 AIUM Convention. This research will be shared by AIUM’s new investigators, abstract presenters, and e-poster submitters throughout the event.
  • Community and Interest Group Meetings: Meet with other ultrasound professionals who share your interests, plan future AIUM educational programs, and discuss the issues in your specialty.

 

Exercise
Start your day off with some exercise: join your colleagues and AIUM staff each morning from 6:30–7:15 am for a 3-mile run/walk around New York City’s Central Park. You’ll meet up in the Main Lobby at 6:30.

Hunt
Join the Scavenger Hunt at the convention: download the eventScribe app (search AIUM18) to get started on your chance to win one of several prizes that will be awarded upon completion of the game. A grand prize winner will be announced Tuesday afternoon.

Earn

CME      Earn up to 6.5 CME credits during the Preconvention and 29.5 CME credits during the Convention.

ARRT    Earn up to 6.5 ARRT credits during the Preconvention and 29.5 ARRT credits during the Convention.

SAMs     The American Board of Radiology (ABR) has approved 7 Self-Assessment Modules (SAMs) activities from our upcoming 2018 Convention.

UGRA    One session at the Preconvention and 8 sessions at the Convention have been added to the UGRA Portfolio program’s course offerings.

Please note that although the AIUM provides CME certificates to those who have participated in an AIUM educational activity, the AIUM does not submit credits to regulating bodies or certifying organizations on behalf of the participant. It is the participant’s responsibility to submit proof of credits on his or her own behalf.

Explore

Lid5nyGET

When you’re not attending the convention, check out some of what New York has to offer. Here is a short list of just a small portion of what is out there, including museums, parks, iconic buildings, and more. And, don’t forget to check out minus5° in the hotel’s lobby, where everything in the bar is made of ice, including the glasses.

To My Fellow Sonographers

Dear fellow sonographers,

I am proud to say that I have worked as a sonographer since 1983 and have been on an incredible journey for 34 years. I started out at the Washington Hospital Center in Washington, DC, as a radiologic technologist and had the privilege to work on the job as a sonographer. I have evolved, grown, and through my profession I have continued to educate myself. When I passed the ARDMS certification in 1984, I decided that I would continue to set goals for myself and keep my career in ultrasound exciting and challenging.

Over the next 33 years, I worked in a Radiology office, in private practice, and in maternal fetal medicine. Now, I am honored to be part of the American Institute of Ultrasound (AIUM). So, why am I saying all this? Because I now want to encourage all of you to use my experiences to take your profession to the next level.

My personal goal is to educate sonographers. To encourage sonographers to love their jobs and be the best. Times have changed, especially in the ultrasound world. Doing an OB exam and showing only a 4-chamber heart is no longer enough. Now, we are expected to do outflow tracts, aorta, ductus, and sometimes the infamous 3-vessel trachea view.

If you are asking what is the 3-vessel trachea view? Well, let me just tell you about this amazing cardiac image. If you can acquire and document a normal 3-vessel trachea you can rule out Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF), and Right-sided Aortic Arch. You can also be the hero of the office when you go to your doctor at your practice and say “Hey, the 3-vessel trachea view looks abnormal, what do you think?” Not only will you impress them and possibly save a life, but you will earn respect and, hopefully, you are reminded as to why you wanted to be a sonographer in the first place.

I have always loved my job and continue to learn every day. There is a whole world of ultrasound information out there. I challenge you to go beyond what you know to get the job done, be the best, and always treat your patient as your best friend, whoever that might be. My challenge for you is to read about the 3-vessel trachea view and, if it is not a part of your daily OB routine, add it.

Please join me and expand your education!

Haylea Weiss, RDMS (AB FE OB/GYN)
American Institute of Ultrasound in Medicine

Apply for AIUM’s new Sonographer Scholarship Grant, a program that provides $500 and free registration to an AIUM post-graduate event. Applications due March 1.

If ultrasound was a…

Let’s not beat about the bush; I absolutely love ultrasound. Ever since I picked up some rudimentary ultrasound device to measure bladder volumes when working as an intern on a spinal injuries unit in England, I was hooked. The ability to cast an acoustic eye within someone’s body still continues to impress me 20 years later and ultrasound continues to amaze, thrill and impress me with its understated power and image generating magic.

However, as time passes, I have begun thinking more and more about ultrasound in a different way. What is its ‘style,’ its ‘look’ and its ‘feel’; in essence, what is its ‘personality.’ If it had an emoji, what would it be? How would you describe how ultrasound makes you feel and what images does it conjure up in your mind’s eye? To take this a step further, I have begun toying with the idea of what ultrasound would be if it was something else entirely. To explain what I mean, humor me as you read this blog which gives me the opportunity to explain how I have started to see ultrasound’s ‘personality’ in many different guises….

If Ultrasound was painter, it would be…

Georgia O’Keefe. Georgia O’Keefe was a radical painter who generated many beautiful images during her life in the early 1900s. She is most famous for her vivid depictions of the New Mexico desert when she lived at her evocatively named ‘Ghost Ranch’ in the middle of the wilderness. Before that, she worked in New York and produced some exquisite images of plants and flowers. My favorite is ‘Abstraction White Rose’ pictured below – and as a pediatric radiologist you can see why…

OKeefe

© 2017 Georgia O’Keeffe Museum / Artists Rights Society (ARS), New York

If Ultrasound was a country, it would be…

Sweden. Sweden as a country strikes me as being somewhere rather monochromatic but also somewhere extremely beautiful once the snows clear. This always reminds me of that sinking feeling we all had when learning ultrasound as a trainee. While struggling to generate something vaguely resembling an organ, all one could see was snow. Snow, snow and more snow. Then, without any tweaking of knobs or any change of probe, your teacher would take the transducer from your hand, place it on the patient and generate the most exquisite image. The blizzard clears and a beautiful landscape is revealed.

US and snow

If Ultrasound was an animal, it would be…

A bee. The frenetic to-ings and fro-ings of the portable ultrasound list is exhausting, varied, challenging but also somewhat satisfying. The uniqueness of ultrasound as a tool that can be taken anywhere in the hospital is one of its finest attributes. Like the bumble bee, it flits from patient flower to patient flower gathering the information it needs like pollen, before returning back to the hive for the Queen to marvel as its conquests. I can almost hear the buzzing.

Bee

If Ultrasound was a drink, it would be…

A hot Italian latte. Have you ever drunk an Italian latte in a glass and noticed the differing layers of coffee and milk? Doesn’t that remind you of something? If not, you need to do more lung ultrasound.

Seashore and latte

So, what about you? Do you have any favorite ‘if ultrasound was a <blank>, it would be a…’ thoughts? We’d love to hear your favorite connotations and understand how ultrasound resonates (ha – geddit?) with you. Comment below or let us know on Twitter: @AIUM_Ultrasound.

Rob Goodman, MB, BChir, is Professor and Acting Chair of the Department of Radiology & Biomedical Imaging at Yale University School of Medicine in New Haven, Connecticut.

 

Patient Zero

My rock, my reminder, my inspiration, my failure

Soucy

 

Case 1
It was fall 2009 and early in my second year of residency. Having spent multiple months off service, I was excited to get back into the swing of emergency care in “critical” bay. The patient was a 44-year-old male presenting with syncope. Admittedly, he was an alcoholic who was an on-the-wagon, off-the-wagon type. His trip to the ED found him off the wagon for several weeks, deeply depressed, and outwardly self-neglected.

His story was not unfamiliar to the ED; lots of alcohol without eating or drinking much else and lots of time on the couch. Today, he got up to get something from the fridge but found himself at the bottom of a set of stairs. A housemate was kind enough to call EMS when it took more than a few minutes for him to wake up. He didn’t remember much and complained of a headache, some rib pain, and significant fatigue getting around the house recently.

It was early morning so I had a bit more time than usual to chitchat. He wore a Minnesota Twins jersey. Though I was from the northeast, I told him how I was a big Kirby Puckett fan growing up, which segued into discussion about their current season, game soon-to-be in progress, and the Vikings acquisition of Farve. “Who would have thought,” he said; “No kidding,” I reaffirmed. Our conversation was natural, comfortable, and enjoyable. Before I left the room, I recognized his oxygen saturation at 91% and blood pressure had dropped to systolics in the 90s but recovered into the low 100s.

All the usual suspects were considered but we thought his low saturations (sats) were most likely due to his smoking history and low blood pressure due to dehydration. Fluids and albuterol went in, labs came back, and time ticked by. Acute renal insufficiency, hyponatremia, hypomagnesemia, and normal chest x-ray without any improvement in vitals despite our interventions. Radiology called and said they could do the CT of the head but chest with contrast would have to wait until after fluids and a creatinine recheck. Critical bay became busy and his clock continued to tick.

I was surprised by how quickly my body reacted to the “code blue in CT” called out overhead. I didn’t know why I knew it was him, but I did. As my body turned the corner to CT, my mind was unprepared to absorb what I saw. His head and neck had turned a deep unnatural blue. He was confused and was asking for help. In between explaining that his heart had briefly stopped and quickly moving him from the scanner, a wide-eyed radiology resident appeared in the doorway, “saddle PE” (pulmonary embolism).

We rolled quickly. Sats and blood pressure were down, heart rate was up—mine included. I assured him everything was going to be okay and he believed me. “Wake me up when the Twins score doc,” he said with a smile. Intubation was smooth as lytics were mobilized.

With cardiothoracic surgery at the bedside, his tachycardia devolved into PEA (pulseless electrical activity). I ran the code while thoracics prepped ECMO (extracorporeal membrane oxygenation). Both groins were inaccessible and I was told we would do an ED thoracotomy. “Ready,” the surgeon said. “Yes,” I said confidently, not knowing what would happen next. The clamshell and cannulation were smoother and quicker than I could have imagined. The machine worked, but his body didn’t.

I still critique my conversation with his mother. It was my first time breaking bad news alone. I was inexperienced and unpolished, but honest and raw. We cried together. I wish I could have been better for him and for his mother.

Case 2
Several months and various rotations passed, including ED ultrasound, which I took a liking to. I again found myself in “critical” working with one of my favorite attendings. EMS patch was for a 78-year-old female being brought in from her rehab facility hypotensive, hypoxic, tachypnic, and ill appearing. The report did not disappoint. The patient was postoperative day 5 from a transabdominal hysterectomy for leiomyomas. The patient was doing well until the day before presentation when she felt fatigued and feverish and then in the morning when she felt shortness of breath and extreme fatigue, which had progressed. She looked like she might die any second.

My attending listened to the reports, watched my exam, and performed his own. “So, what do you think?” I hesitated. Literally any organ system or combination of systems could be failing. A trip down the wrong diagnostic or therapeutic pathway could lead to delay, decompensation, and death. I was relieved when he told me to prepare for a central line so we could start pressors and antibiotics for her septic shock. It was clear to me that she was dying and I did not know the etiology, but my veteran attending did.

The patient was sterilely prepped and ultrasound placed on the neck. The internal jugular (IJ) was plump, very plump, the plumpest IJ I had ever seen. “Cake,” I thought. Simultaneously it then dawned on me that physiologically this wonderfully plump IJ did not make sense in septic shock. I consulted my attending and given the patients worsening cardiovascular collapse despite fluid resuscitation, we proceeded.

As I secured the sutures, I ran through the types of shock, differential for each, and ways I could figure it out at the bedside. Antibiotics started and I pulled up to the bedside with the ultrasound. I was suspicious for an obstructive process; however, due to the patient’s postoperative status I performed the FAST (focused assessment with sonography for trauma) exam. “Negative belly,” I thought to myself as I quickly moved to the patients left chest. The focused cardiac exam quickly aligned all the puzzle pieces. I personally had never seen acute right ventricular strain at the bedside but the septal D-ing of her hyperdynamic heart on parasternal short and apical 4 was irrefutable.

My attending agreed and we changed our trajectory. Instead of MICU (Medical Intensive Care Unit) admission, antibiotics, fluids, and pressors, ultrasound indicated the patient needed something different. Given her recent extensive operation, an emergent CT was performed showing saddle embolus. In coordination with OB/GYN and critical care, the patient received thrombolytics. 2 weeks later, I was there when she walked out of the hospital with her children and grandchildren.

The Lesson
I could not reconcile the 2 poignantly different outcomes. Both were getting pulmonary embolism workup and I ordered all the right emergent testing. So, how could an elderly patient with every comorbidity in the throws of dying live while a middle aged otherwise fairly healthy patient who cracked a joke minutes before he arrested not? Ultrasound (and thrombolytics) of course!

Point-of-care ultrasound (POCUS) is an incredible diagnostic tool that is transforming clinical practice and medical school education. Numerous studies have shown it to be a critical component of directed resuscitation in the emergency and ICU departments’ critically ill population. In various disease processes, its use has been shown to decrease procedural complications, improve mortality, and decrease time to safe disposition. All technology is not created equal; ultrasound is unique. Instead of pulling me away from the patient, POCUS allows me to stay at the bedside gathering important information; improving my efficiency, addressing concerns, and talking with loved ones. Undoubtedly the extra time communicating and caring for the patient has improved my job satisfaction and is one of the reasons patients like it. But, there is an often overlooked significance to POCUS’s story, which has caused ripples to be felt for generations.

I believe the soul of POCUS rests firmly in what makes our profession exceptional; our willingness to self-evaluate, improve, and innovate for those we serve. POCUS stands as an early example of disruptive innovation, which has transformed the way we think about our job as clinicians. At the time of its introduction in the 70s and 80s this type of “out-of-the-box” thinking did not conform to the traditional framework. Its existence challenged many long-held beliefs and medicine’s titanic momentum perpetuated throughout generations. These innovators took the road less traveled and persevered in the face of adversity. Their gift has enabled countless others to save lives and improve patient care around the world as well as demonstrate our profession’s ability to adapt in rapidly changing times.

My path to ultrasound resulted from those emotions that remained unresolved and the process unfinished after medicine left its first mark. Feelings of inadequacy loomed, challenging my perception of the limitations of medicine and my own abilities. Painful at the time, I like to think that generations of physicians have constructively, therapeutically, applied this driving force to be better than they were the day before in whatever field their passions lie. Ultrasound is my tool, my promise to him, to her, to myself to be my best and help others be theirs.

 

What struggles have you overcome in your career? And how has ultrasound helped you overcome them? How do you think POCUS will change in the future? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Zachary Soucy, DO, FAAEM, is Assistant Professor of Emergency Medicine, Director of Emergency Ultrasound, and Co-Director of the Emergency Ultrasound Fellowship at Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, in Lebanon, New Hampshire.

Dating Pearls

Assisted reproductive technology (ART) dating trumps all other sonographic dating. If the dating is off with ART, think about asking if the embryo was put in the uterus at 5 days, and not zero days, as that is how it is often calculated. This can be important if the embryo is larger than expected, as ART pregnancies have an increased incidence of Beckwith Weidman Syndrome, which is an overgrowth syndrome. If the embryo is smaller than expected, then the embryo should be followed more closely for possible congenital or chromosomal anomalies.

If the pregnancy is not ART, dating should be based on the 2014 ACOG/AIUM Committee Recommendations (Methods for Estimating the Due Date. Committee Opinion No, 700. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129:e150–154).

Measurement of the embryo or fetus in the first trimester is the most accurate method to determine gestational age. In the first trimester, the 2014 Recommendations state that if the pregnancy is less than 8 weeks 6 days, the embryo should be within 5 days of LMP (last menstrual period) and otherwise should be re-dated using ultrasound dates of the crown rump length. One mistake often made at this time is to include the gestational sac size in dating; the crown rump length is more accurate than the sac size and thus it should not be averaged into the estimated gestational age.

Crown rump length growth curves have been updated by Pexsters et al (Ultrasound Obstet Gynecol 2010; 35:650–655) using 4387 exams, whereas Hadlocks curves (Hadlock et al Radiology 1992; 182:501–505) were only based on 416 exams. These have some significant discrepancies in the 5–7 weeks gestational age range so we recommend using the Pexsters curves.

Crown Lump Length

From 9 weeks to 16 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 7 days and be re-dated if greater than “7-day” discrepancy.

From 16 weeks to 21 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 10 days and be re-dated if greater than “10-day” discrepancy.

From 22 weeks to 27 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 14 days and be re-dated if greater than “14-day” discrepancy.

From 28 weeks and beyond, the 2014 Recommendations suggest that the dating should be within 21 days and be re-dated if greater than “21-day” discrepancy.

We should not re-date a pregnancy in the second or third trimester if there are good ultrasound dates in the first trimester. If the patient gives “excellent dates” based on history (eg keeping a temperature chart, knowing date of conception based on specific dates of being with partner) and there is a greater than expected discrepancy of dates, then a follow-up sonogram should be recommended in 2–4 weeks, depending on the time of gestation (4 weeks in the second trimester and 2 weeks in the third trimester) so that appropriate growth can be assessed.

Serial growth is important in assessing dating. A fetus that grows 4 weeks in a 4-week period is likely dated appropriately. When the fetus grows more than 4 weeks in a 4-week period then accelerated growth should be reported, suggesting either an LGA (large for gestational age) or macrosomic fetus. History of prior pregnancies can be particularly helpful in these cases. Placement of the calipers at the outer edge of the subcutaneous tissue is particularly important in these cases. We often require 3 measurements, which are averaged to assess LGA/macrosomic fetuses.

When fetuses grow less than 4 weeks in a 4-week period then SGA (small for gestational age) or IUGR (intrauterine growth restriction) are suspected. Additional studies for well-being should be performed, such as umbilical artery Doppler, middle cerebral artery Doppler, maximum vertical pocket of amniotic fluid, biophysical profile, cerebroplacental ratio (CPR), or antenatal testing.

 

Do you have any tips on sonographic dating? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dolores H. Pretorius, MD, is a Professor of Radiology at University of California, San Diego, and Director of Imaging at UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

Andrew D. Hull, MD, is a Professor of Clinical Reproductive Medicine at University of California, San Diego, and Director of UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.