Should You Include CEUS and Elastography in Your Liver US Practice?

 

Today, the liver is regarded with high importance by our clinical colleagues. The obesity epidemic, with its considerable impact in North America, is associated with severe metabolic disturbances including nonalcoholic fatty liver disease (NAFLD). Further, liver cancer is the only solid organ cancer with an increasing incidence in North America. Where do we as ultrasonographers fit into the imaging scheme to most appropriately deal with these new challenges?

The liver is the largest organ in the body, and certainly the most easily accessed on an abdominal ultrasound (US). It has been the focus of countless publications since the introduction of abdominal ultrasound many decades ago. Exquisite resolution allows for excellent detailed liver evaluation allowing US to play an active role in the study of both focal and diffuse liver disease. Focal liver masses are often incidentally detected on US examinations performed for other reasons and on scans performed on symptomatic patients. Abdominal pain, elevated liver function tests and nonspecific systemic symptoms may all be associated with liver disease. The introduction of color Doppler to abdominal US scanners many years ago elevated the role of US by allowing for improved capability of US to participate in assessment of the hemodynamic function of the liver as well.

malignant tumor ceus

The well-recognized value of abdominal US, including detailed morphologic liver assessment, has made this examination the most frequent study performed in diagnostic imaging departments worldwide. However, in recent years, US has been relegated to an inferior status relative to CT and MR scan, as their use of intravenous contrast agents has made them the corner stone modalities for virtually all imaging related to the presence of focal liver masses. As we now live in an era of noninvasive diagnosis of focal liver disease, greyscale US has fallen out of favor, as it is nonspecific for liver mass diagnosis. While US is the recommended modality for surveillance scans in those at risk for development of hepatocellular carcinoma, today, all identified nodules are then investigated further with contrast-enhanced CT and/or MR scan.

In the more recent past, US has been augmented by 2 incredible noninvasive biomarkers: elastography, which measures tissue stiffness, and contrast-enhanced ultrasound, which shows perfusion to the microvascular level for the first time possible with US. These noninvasive additions are invaluable and their adoption in routine US practices may allow the reemergence of US as a major player in the field of liver imaging.

Most conventional US machines today are equipped with the capability to perform elastography, especially with point shear wave techniques (pSWE). In pSWE, an ARFI pulse is used to generate shear waves in the liver in a small (approximately 1 cm3) ROI. B mode imaging is used to monitor the displacement of liver tissue due to the shear waves. From the displacements monitored over time at different locations from the ARFI pulse, the shear wave speed is calculated in meters per second, with higher velocities associating with increased tissue stiffness. The accuracy for the determination of liver fibrosis and cirrhosis with pSWE as compared with gold standard liver biopsy, is now undisputable. Because of the great significance of liver fibrosis secondary to fatty liver and the obesity epidemic, the development of this technique as a routinely available study is essential. Because of the frequent selection of US as the first test chosen for any patient suspect to have undiagnosed diffuse liver disease, the opportunity for elastography to be included with the diagnostic morphologic US test should be developed as a routine.

Contrast-enhanced US (CEUS), similarly, is available on most currently available mid- and high-range US systems, allowing for nondestructive low MI techniques to image tumor and liver vascularity following the injection of microbubble contrast agents for US. This allows for a similar algorithmic approach to contrast-enhanced CT and MR scan for noninvasive diagnosis of focal liver masses. CEUS additionally offers unique imaging benefits that include no requirement for ionizing radiation and also imaging without risk of nephrotixity, invaluable in the many patients who present for imaging with high creatinine, preventing injection of both CT and MR contrast agents.

Incorporation of pSWE and CEUS into standard liver US in patients with suspect diffuse or focal liver disease is a cost-effective and highly appropriate consideration as this is readily available, performed without ionizing radiation, and at a considerable cost saving over all other choices.

Can you diagnose a hepatocellular carcinoma or other liver tumor with CEUS?  And, can you determine if a liver is cirrhotic or not?  With the addition of pSWE and CEUS to your liver US capability, yes, you can.

 

What is your experience with treating liver disease? What aspect is most difficult for you? What other area do you think would benefit from the addition of CEUS? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie R Wilson is a Clinical Professor at the University of Calgary.

 

Excellence in Education

It is an honor to receive the 2017 Peter H. Arger, MD, Excellence in Medical Student Education Award. I am fortunate to know Dr. Arger and recognize his remarkable achievements in education, accreditation, and leadership in ultrasound. It’s my great privilege to work with different students, whether they are medical students, residents, fellows, sonography students, vascular technology students, or physicians of different medical specialties. I have had many great teachers and mentors toJohn_Pellerito learn from. Some of my favorite teachers like Barry Goldberg, Ken Taylor, Chris Merritt, and Peter Arger have the gift to communicate complex ideas and make them simple and easy to understand. Teachers at that level inspire me to be the best I can be.

I know there are many educators who understand that feeling when a student “gets it.” The anatomy and physiology that they’ve been studying comes to life. When the ultrasound unit is no longer a confusing mess of dials and buttons and becomes a window into the human body. When they realize that in their hands, ultrasound can make a difference in patient care.

I am lucky to work with  a team of physicians and sonographers who enjoy teaching our medical students. We meet to devise new ways to integrate ultrasound into our longitudinal 4-year ultrasound program. One of the techniques we use to engage our students is to integrate games into our classes. Our SONICS (SONographic Integration of Clinical skills and Structure) faculty has enjoyed putting together ultrasound games for our students. We find that gaming increases their excitement and takes advantage of their competitive edge. One of our latest creations, the Hunger Games (J Ultrasound Med 2017; 36:361–365), has proven very successful.

During this class, we ask one member of each student team to fast prior to a scan of the gallbladder and mesenteric arteries. Following a breakfast of a bagel and cream cheese, the students are rescanned to assess for changes in gallbladder size and mesenteric blood flow. All scanning is performed by the students with faculty guidance. One team is deemed the “winner” and awards are given. The session combines both anatomic and physiologic principles to learn about gastrointestinal and vascular function and incorporate Doppler techniques. This activity provides the foundation for a powerful integration of Doppler ultrasound into medical education.

What are some of the ways that you have engaged your students with fun and interactive ultrasound programs? Do you have any stories from your own education to share? Comment below or let us know on Twitter: @AIUM_Ultrasound.

John S. Pellerito, MD, is professor of Radiology at Hofstra Northwell School of Medicine and Vice Chairman of Radiology at Northwell Health.

A Victory for Humanity

Imagine the impact on healthcare in this country and around the world if all healthcare providers were equipped with a diagnostic and patient-management tool with the extraordinary power of ultrasound. Access to care would be improved, especially in under-served areas, quality of care would be improved across virtually every area of medicine, patient safety would be improved almost overnight, and the cost of healthcare could be decreased if the tool were used wisely.

Horace Mann, the great American education reformer, said “Be ashamed to die until you have won some victory for humanity.” What a victory for humanity it would be to improve healthcare for billions of people throughout the world. As educators and practitioners of ultrasound, we are in a position to win a huge victory for humanity if we collectively embrace the “victory goal” of improved healthcare for all with ultrasound.

Hoppman Blog picture 3.7.17

I believe the place to start in the quest for this victory for humanity is with education. There are many we must educate about ultrasound—healthcare practitioners of virtually every specialty and at every level of healthcare provision and training; those who teach healthcare providers; those who make decisions concerning healthcare education, practice, financing, and regulations; biomedical researchers and the healthcare industry; and those who will ultimately be the greatest beneficiaries of every practitioner competently using ultrasound: patients and their families.

There are roles for all of us in the education of this diverse group of players. I would encourage you to give some thought to how you might help individuals in these various groups understand the power of ultrasound to transform healthcare. At the core of this transformation will need to be excellent education of all ultrasound practitioners at all levels of service they provide. This will require pooling the knowledge, skill, experience, and wisdom of all involved in ultrasound regardless of specialty, level of practice, or global location.

However, even with excellent education, I do not believe we can achieve this victory for humanity without the engagement and support of our colleagues in primary care. According to a report by the Association of American Medical Colleges in 2014, one third of the almost 850,000 active physicians in the United States were Family Physicians, Internists, or Pediatricians. These are the 3 specialties usually classified as primary care providers but other specialties such as Emergency Medicine and Obstetrics and Gynecology also regularly provide primary care. There is also an increasing percentage of primary care being provided and supported by other healthcare providers such as nurse practitioners and physician assistants, as well as sonographers, mid-wives, medics, and emergency medical technicians. Thus, primary care providers as a group are the largest group of healthcare professionals in the country and probably the world.

On the frontlines of healthcare, these primary care practitioners can have an immediate and profound impact on healthcare through the use of ultrasound. It is very encouraging to note that within the various primary care sectors there are now champions of ultrasound emerging among both general membership as well as leadership as evidenced by the initiation of ultrasound interest groups and associated ultrasound societies in organizations such as the American College of Physicians, the American Academy of Family Practitioners, and the American Academy of Physician Assistants. And kudos to the AIUM, its leadership, and membership for all they have done and are doing in education and in welcoming our primary care colleagues into our ultrasound family. We need to support the ultrasound efforts of these individuals and organizations and other organizations in any way we can. Working together we can take ultrasound education and practice to a level that will ensure a great victory for all of humanity.

In conclusion, as quoted by Nelson Mandela, “Education is the most powerful weapon which you can use to change the world.”

 

What are your thoughts on ways to support the ultrasound efforts of primary care practitioners? How can medical education be modified to encourage the widespread use of ultrasound by future primary care practitioners? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Richard Hoppmann, MD, FACP, is Professor of Medicine, Past Dean, and Director of the Ultrasound Institute at University of South Carolina School of Medicine.

SonoSlam 2017

16SonoSlam_logoIf you attended the AIUM convention the past 2 years you may have heard mention of SonoSlam in passing. So what is it? SonoSlam is a medical student ultrasound competition and educational event. It was conceived as an idea to promote medical student ultrasound and was officially born in Orlando in 2015. A few members of the medical education committee were discussing how to get students more engaged in ultrasound at the national level. A national ultrasound student interest group had been formed and got behind the idea of nationalizing ultrasound activities for medical students. Many of us had been involved in regional events such as Ultrafest or had participated in Sonogames™, an emergency medicine resident ultrasound competition. As we brainstormed, SonoSlam came to fruition. We wanted this event to be more than a game, making sure to integrate education into the proceedings. Given the diversity of exposure to ultrasound in undergraduate medical education, the faculty wanted to ensure that this event would be appealing to students of all levels of experience. In addition, the unique offering of AIUM is that this event would be multidisciplinary. With these key components of education, competition, and a multidisciplinary approach SonoSlam was created. The inaugural SonoSlam was held in New York in 2016 with the winning team awarded the Peter Arger Cup, named after the famed radiologist who championed medical student ultrasound education at the AIUM. Seventeen teams from 12 different schools participated in this inaugural event with more than 30 faculty from across the country. This year in Orlando we grew to 23 teams from 17 schools from across the country—Oregon to New York to Florida and all in between. We had more than 50 faculty from a multitude of specialties, including emergency medicine, internal medicine, critical care, obstetrics and gynecology, radiology, and pediatrics. We plan to continue to host this event annually with the lofty goal of having representation from every medical school in the country. We hope to see you in New York March 24, 2018!

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For more information about SonoSlam or if you are interested getting involved please email us: sonoslam@gmail.com.

Written by Creagh Boulger, Rachel Liu, and Dave Bahner. Creagh Boulger, MD, RDMS, FACEP, is Assistant Professor, Assistant Director of Ultrasound, and Assistant Fellowship Director of Emergency Ultrasound at Ohio State University Wexner Medical Center. Rachel Liu, BAO, MBBCh, is Assistant Professor of Emergency Medicine and Director of Point-of-Care Ultrasound Education at Yale University School of Medicine. Dave Bahner, MD, RDMS, FAIUM, FAAEM, FACEP, is Professor and Director of Ultrasound, Fellowship Director, Investigator, and Core Faculty at Ohio State University.

How do you make ultrasound education engaging? Do you have any ideas for bringing students from across the country together? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Money, Politics, and Ego

The AIUM is a unique organization of professionals passionate about the capabilities and potential of ultrasound to help our patients. With the annual convention freshly over, and a long list of things to work on for next year, I’ve been thinking about the AIUM and
why it’s an important group for me.

Although the AIUM is not the primary organization for any of us, that’s what is special and interesting about the AIUM. We all belong to our separate subspecialty interest groups, our tribes, where there is familiarity and comfort in being surrounded by people who are like us, and do what we do, and think like we do. But what other society do you belong to that has the mix of medical and surgical specialties, sonographers, scientists, residents, students, and industry partners? The AIUM’s 19 communities and interest groups cover a diversity of interests and practices, and bring people together that in the “real world” of our day-to-day work may find themselves at odds with each other.

ColeyAnd that’s the challenge of the AIUM: to be our best and fulfill our mission of providing the best ultrasound imaging care to our patients means that we have to set aside (at least in part and as best that we can) issues of money, politics, and ego.

This is not always easy.

The world around us is often not encouraging toward cooperation and service to ideals greater than immediate self-interests.

But that’s what AIUM members try to do. Even if it isn’t easy.

If you attended the recent convention in Orlando, I hope that you spent some time attending sessions or talking to people from outside your main area of interest. That’s an opportunity that you just can’t get at other meetings: to exchange ideas and excitement, to challenge and provoke, and ultimately a chance to learn and advance both personally and as medical professionals.

Similarly, the next time you pick up a copy of the Journal of Ultrasound in Medicine, read an article in an area that you don’t practice. Even if you can’t appreciate the nuances, appreciate the creativity of the work and the varied applications of ultrasound in medicine. There are a lot of bright people out there doing cool things. I would especially recommend reading the basic science articles. The technology, instrumentation, and techniques that we take for granted come from here. You may not fully grasp them any more than I do, but this is where the big leaps are going to come from, and it’s good to know what could be just over the horizon.

I hope that you’ll get as much out of the AIUM as I have over the years. I hope that you’ll step out of your comfort zone and talk with people from other disciplines and interests. I hope that you’ll ask questions and get involved. I hope that the AIUM helps you learn and grow, and that you will help the AIUM to figure out how to do that well. If we can do this together, then we and our patients will be the better for it.

What about your AIUM membership do you find most valuable? How do you benefit from the diversity of medical specialties within the AIUM? Comment below or let us know on Twitter: @AIUM_Ultrasound. Interested in volunteering for the AIUM? Check out the volunteer page.

Brian Coley, MD, AIUM President (2017–2019), is radiologist-in-chief and the Frederic N. Silverman chair for pediatric radiology at the Cincinnati Children’s Hospital Medical Center, as well as professor of radiology and pediatrics at the University of Cincinnati College of Medicine.

Awesome Content + Great Speakers + Fun Activities = One Amazing Event

Do you know what makes a great event? At AIUM’s Annual Convention, it’s the combination of awesome content (attendees were sent a link to all the presentations), great speakers, and fun activities. Last week more than 1,200 physicians, sonographers, scientists, and educators from across the country and around the world gathered in Orlando to network, share, and learn.

The AIUM Annual Convention is the culmination of a lot of hard work by a lot of dedicated individuals. Past President Beryl Benacerraf, MD, worked tirelessly to create a President’s Program that brought in speakers from around the world to discuss cutting-edge topics. AIUM’s community leaders created program content that was reflective of the needs, expertise, and research being done across 19 ultrasound specialties. The AIUM Annual Convention Committee worked to ensure that the event had something for everyone. And last, but not least, the AIUM staff spent thousands of hours working to make the event run as smoothly as possible.

If you were in Orlando last week, we hope you returned home armed with the resources, contacts, and information you need to improve patient care. We also hope you filled out your evaluations. If you were unable to join us this year, here are a few of the highlights:

First-Time Content—This year was the first time the AIUM hosted a preconvention workshop on Dermatologic Ultrasound. Nearly 50 attendees heard tips, tricks, and insights from an international faculty. The AIUM is planning even more for 2018.

SonoSlam—In its second year, SonoSlam had 26 teams (10 more than last year) compete for the coveted Peter Arger Cup. This year’s winning team, “Rolling Sonigrams,” hails from The Ohio State University. AIUM is looking to expand this event next year to 30 teams so mark your calendars!

SonoSlam grp

Awesome Plenary—AIUM President Beryl Benacerraf, MD, hosted the Opening Plenary session that featured a video presentation on Zika from Anthony S. Fauci, MD, Director of NIAID. This was followed by Stephanie Wilson, MD, who presented the William J. Fry Memorial Lecture. The morning session was rounded out by Alfred Abuhamad, MD, who shared details on the OB/GYN Ultrasound Curriculum and lecture series that will be released soon.

Social Media—This year was the most active social media convention ever for the AIUM. From streaming videos on Twitter and Facebook to more than 500 individuals participating and sharing through their personal accounts, the social media scene was active and engaging.

Twitter users 2017AIUM17_shuffle board

Fun Activities—Attendees had multiple opportunities to network, including during the New Member reception; earn prizes at AIUM’s booth; show their creative side on the coloring walls; play ultrasound Jeopardy; and enjoy the wonderful Florida weather.

Sold-out Exhibit Hall—From new companies to new technology to incredible offers, this year’s exhibit hall featured a one-stop shopping opportunity for all attendees.

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

Alfred B. Kurtz, MD, FAIUM—Joseph H. Holmes Clinical Pioneer Award

Levon N. Nazarian, MD, FAIUM, FACR—Joseph H. Holmes Clinical Pioneer Award

Kai E. Thomenius, PhD, FAIUM—Joseph H. Holmes Basic Science Pioneer Award

Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM—Distinguished Sonographer Award

John S. Pellerito, MD, FACR, FAIUM, FSRU—Peter H. Arger, MD Excellence in Medical Student Education Award

Caterina Exacoustos, MD—AIUM Honorary Fellow

Gustavo Malinger, MD—AIUM Honorary Fellow

Carlo Martinoli, MD—AIUM Honorary Fellow

E-poster winners—Every year, the AIUM supports an e-poster program. This year, nearly 500 e-posters were submitted and the AIUM recognized the following winners:

  • First place: Ultrasound-Stimulated Drug Delivery of Reconstituted High-Density Lipoprotein Nanoparticles Loaded With an Optical Reporter, presented by Kenneth Hoyt from Richardson, Texas
  • Second place: First-Trimester Echocardiographic Findings in Women With Chronic Hypertension and Superimposed Preeclampsia, presented by Jennifer Barr from Amherst, New York
  • Third place: Ultrasound Evaluation of Bursae: Anatomy and Pathologic Appearances, presented by Thumanoon Ruangchaijatuporn from Yasothon, Thailand
  • Honorable Mention: Implementation of an Ultrasound Interest Group Research Initiative to Improve Productivity of Student Involvement in Research, presented by Malik Sams from Columbus, Ohio

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Up and Comers—During its annual Leadership Banquet, the AIUM recognized 4 outstanding papers in its New Investigator Program.

Basic Science

Winner—Tommaso Di Ianni, MSc, for “In Vivo Vector Flow Imaging for a Portable Ultrasound Scanner”

Honorable Mention—Carolina Amador, PhD, for “Work-Related Repetitive-Use Injuries in Ultrasound Fellow”

Clinical Ultrasound

Winner—Lourdes Hereter, MD, for “Ultrasound Assessment of Changes in the Pelvic Hiatal Area Before and After Childbirth”

Honorable Mention—Kristine Robinson, MD, for “Renal Transplant Viscoelasticity as a Predictor of Allograft Rejection: A Feasibility Study With a Clinical Ultrasound Scanner”

More Winners—At AIUM’s booth, Merry Sebelik, MD, won a free registration to next year’s convention, and Sue Ann Boris, RDMS and MaryBeth Anderson, MD, won discounts off their AIUM practice accreditation application fees. Congratulations to these winners!

The AIUM would like to thank all the attendees, speakers, and exhibitors who helped make this an incredible event. Look for videos and presentations to be uploaded into the members-only communities in the near future.

Save the Date: March 24–28, 2018, in New York City!

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Did you attend this year’s event? If so, share your thoughts and feedback. Going next year? Let us know what you want to learn! Comment below or let us know on Twitter: @AIUM_Ultrasound.

Peter Magnuson is AIUM’s Director of Communications and Member Services.

Ultrasound in the Age of Telehealth, Telemonitoring, Telemedicine, Robots, and Kimonos

Today, there is online access to almost everything; groceries, a video chat with your grandmother across the globe, step-by-step instructions on how to fix your lawnmower, and a virtual doctor to help with pain in your abdomen. The healthcare applications of the internet have exploded in recent years with digital health and telemedicine assuming one of the highest growth areas for start-up entrepreneurs. The expansion of telehealth resources (IT infrastructure/capabilities) has allowed telemedicine to extend to isolated, inaccessible, remote spaces (maybe even your living room). And telehealth has gone beyond just a video chat with incorporation of sensing technologies including cameras, digital stethoscopes, and ultrasound.
Kat and Scott

Ultrasound imaging in austere locations is not just about access to an ultrasound system; it requires both the ultrasound operator, and the interpreter, to have specific knowledge, competency, and ultimately accountability about the quality of the examination, and the diagnosis it helps to provide. Our NASA-sponsored research team has shown that novice ultrasound operators can acquire diagnostic quality ultrasound images after a short training period with remote tele-ultrasound guidance in a space medicine environment. The astronaut operators were able to perform terrestrial standard abdominal, cardiovascular, and musculoskeletal ultrasound examinations with modest remote guidance oversight; zero gravity specific exams of the eyes, spine, and sinus were also completed. Importantly, the astronaut crewmembers quickly became more autonomous during their 6-month mission in space and were able to self-direct image acquisition.

But a major challenge with tele-ultrasound is operator training. William R. Buras, Sr, Director, Life Sciences at Tietronix Software Inc, and his team are making an augmented reality user interface for ultrasound scanning using a wearable heads-up display with imbedded guidance to improve ultrasound competency. This innovative Houston team is being funded by a NASA grant.

Unfortunately, when it gets to real-world practicality, neither the ultrasound machine nor the examination is intuitive. A team in Canada led by Dr Andy Kirkpatrick are working on a sustainable ultrasound solution using both remote ultrasound system operation and telemonitoring. They investigated the ability of non-trained firefighters to perform ultrasound in Edmonton being guided from Calgary. “We found that by using just-in-time–training with motivated firefighters, the remote examiner guiding the firefighters was 97% correct in determining the presence of a simulated hemo-peritoneum. Ironically, while this trial design also attempted to examine the utility of remote ultrasound knobology control, the firefighters were so good at the task that the remote knobology control became less of a relevant problem” said Dr Kirkpatrick.

To reduce the challenges of novice ultrasound operators, at team in France, led by Dr Phillipe Arbelle, linked a robot-coupled ultrasound device with a remote operator. The distant clinician can move the ultrasound probe with a joystick to acquire the ultrasound images. His concept has been implemented in a French ultrasound device, SonoScanner, that the European Space Agency will begin investigating on the International Space Station.

Similar work in robotic ultrasound is being done in Australia, where a team is building a robotic ultrasound machine that can perform abdominal ultrasound.

Have you seen the guy in a kimono buying a car? Online resourcing is indeed pants-optional. But if you plan on telemonitoring be suitably dressed.

Alien

What other areas have come a long way when it comes to ultrasound? What areas are poised to be next? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Kathleen M Rosendahl-Garcia, BS, RDMS, RVT, RDCS, is a NASA contractor working for KBRWyle and is a senior scientist and clinical sonographer in the Space Medicine division working under the Human Health and Performance Contract. Scott Dulchavsky, MD, PhD, is the Roy D. McClure Chairman of Surgery and Surgeon-in-Chief at Henry Ford Hospital in Detroit, and Professor of Surgery, Molecular Biology and Genetics at the Wayne State University School of Medicine. He is also a principal investigator for NASA and heads a project teaching astronauts how to use medical ultrasound in space.