Ultrasound at 18,000 ft.

A brief history of the making of Solar‐Powered Point‐of‐Care Sonography: Our Himalayan Experience (J Ultrasound Med 2019 doi.org/10.1002/jum.14923).

Dr Mark Kushinka and Dr Rob Razick are sitting at camp in Phirste La Pass at 18,208 ft. The camp is designated by banners of alternating color flags attached to the top of a pole and pinned to the ground. Mountains are shown around them with blue sky.

Dr Marc Kushinka (left) and Dr Rob Razick (right)
 in Phirste La Pass at 18,208 ft.

Full disclosure… I wasn’t actually there.  Anyone who knows me knows I am not the “sleeping with yaks, no shower for a month” kinda girl. I also have no shame in admitting that I had no chance of surviving the 80+-mile trek 3 miles high amongst the clouds. Fortunately for me, and the people who inhabit the Zanskar Mountain Range, I had 4 residents who wanted to spend several months hiking through a mostly impassable mountain trail providing care to those who live in this spectacular part of the world. Our Lumify’s passport had already amassed an impressive collection of stamps, but none of them as remote as the Himalayas. There is no electrical infrastructure in this region, and all sources of energy come from kerosene, dung briquettes, or solar power. As Dan and Zac departed for India, we had no idea if this crazy plan to operate the ultrasound solely off of a portable solar pad was going to work. Frankly, I was a bit worried that I was adding a few extra pounds to their pack for no good reason. But, after spending 30 days in one of the most remote locations on this Earth, the guys returned with some great stories, good images, and a ton more facial hair.

Dr Daniel Baker and Dr Zac Hardy are shown standing together in Phirste La Pass by a snow-tipped mountain peak.

Dr Daniel Baker (left) and Dr Zac Hardy (right) 

 As I sat curled up in my leather chair with a supple cabernet, I reviewed the data from their trip and realized just how awesome this was. There had never before been medical imaging accessible at this elevation, and its availability had a direct impact on patient care. We repeated the adventure the following year with a new set of residents and the same cheap solar pad from Amazon. After some minor modifications based on our lessons learned from our inaugural year, Marc and Rob yielded more consistent scan times and reliable use.

I truly believe solar powered POCUS can change the face of austere medicine. All you need is a solar pad, a portable ultrasound, and the desire and willingness to leave the comfort of home. Or at least have a few residents up for the adventure.

Cheers from Kashmir!


Have you performed ultrasound examinations in remote regions? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. Visit the Journal of Ultrasound in Medicine online.

Laura Nolting, MD, FACEP, is the Director of Emergency Ultrasound and the Ultrasound Fellowship Director for the Department of Emergency Medicine at Palmetto Health Richland in Columbia, South Carolina.

Richard G. Barr, MD, the Journal of Ultrasound in Medicine’s New Editor-in-Chief

The American Institute of Ultrasound in Medicine (AIUM) is proud to announce that Richard G. Barr, MD, PhD, FAIUM, FSRU, FACR, is the new editor-in-chief of the Journal of Ultrasound in Medicine (JUM). Dr Barr’s tenure as editor-in-chief officially began January 1, 2019.

Barr

Congratulations on your new role as JUM editor‑in‑chief, Dr Barr.

A regular contributor to, and reviewer for, the JUM, Dr Barr has a diverse background that is well suited for the journal’s continued growth. He is a board-certified radiologist and PhD chemist who currently serves as assistant chairman of the Department of Radiology at Northside Medical Center and as president of Radiology Consultants Inc. In addition, Dr Barr is a professor of radiology at Northeastern Ohio Medical University.

Dr Barr has already instituted some changes to the journal to help with the increased submission rate: he has increased the number of deputy editors from 3 to 5. Dr Barr has selected Michael Blaivas, MD, FAIUM, and Andrej Lyshchik, MD, PhD, to join Flemming Forsberg, PhD, FAIUM, Wesley Lee, MD, FAIUM, and Mark Lockhart, MD, FAIUM, as his deputy editors. Dr Barr has also stated that at present, the JUM will be accepting the same number of articles, but they are discussing the possibility of online-only articles as the number of submissions continues to increase.

An additional change coming to the JUM is that invitations will be sent to experts inviting them to write and submit articles reviewing topics of interest for JUM readers. The topics may be in areas of controversy or reviewing how to image an organ, etc.

Dr Barr is a fellow of the AIUM, Society of Radiologists in Ultrasound, and American College of Radiology, and his interests include breast imaging, contrast-enhanced ultrasound, and elastography. He has published more than 100 scientific articles and has given more than 300 talks around the world. He received a 2017 Radiological Society of North America Honored Educator Award and Aunt Minnie named him a semifinalist for the most influential radiology researcher in 2017.

“I look forward to serving as editor-in-chief for the JUM,” said Barr. “My predecessors have done an excellent job creating an international journal for all ultrasound subspecialties. I hope to continue this great work while increasing the readership and quality of the content.”

Do you want to know more about the JUM? Visit the Journal of Ultrasound in Medicine online, and if you have any comments, add them below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Richard G. Barr, MD, PhD, FAIUM, FSRU, FACR, is the assistant chairman of the Department of Radiology at Northside Medical Center, and president of Radiology Consultants Inc, both in Ohio. In addition, Dr Barr is a professor of radiology at Northeastern Ohio Medical University.

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.

Research in Ultrasound: Why We Do It

“Medicine, the only profession that labors incessantly to destroy the reason for its existence.” –James Bryce

We all know the important medical discoveries clinical research has given us over time. stamatia-v-destounis-md-facrYou could even make the case that the high standards of care we have today are built on centuries of research.

The world of medical ultrasound is no stranger to clinical research—dating back to the early work of transmission ultrasound of the brain. This work was especially important, as it was the first ultrasonic echo imaging of the human body.

Since then, research has brought about gray scale imaging, better transducer design, better understanding of beam characteristics, tissue harmonics and spatial compounding, and the development of Doppler. All of these research developments, as well as many others, were highly significant and have lead us to today’s high-quality handheld, real-time ultrasound imaging.

For me, the biggest and most important developments were and have been in breast ultrasound. In 1951, the research of Wild and Neal discovered and qualified the acoustic characteristics of benign and malignant breast tumors through use of an elementary high-frequency (15-MHz) system that produced an A-mode sonogram. These researchers published the results of additional ultrasound examinations in 21 breast tumors: 9 benign and 12 malignant, with two of the cases becoming the first 2-dimensional echograms (B-mode sonograms) of breast tissue ever published.

It is research that leads to landmark publications that change the way we practice. The ACRIN 6666 trial led by Dr Wendie Berg and her co-authors evaluated women at elevated risk of breast cancer with screening mammography compared with combined screening mammography and ultrasound. This pivotal study demonstrated that adding a single screening ultrasound to mammography can increase cancer detection in high-risk women. In our current environment this is even more relevant, as breast density notification legislation is being adopted in states across the country. With the legislation, patients with dense breast tissue are often being referred for additional screening services, with ultrasound most often being the screening modality of choice.

Screening ultrasound is an area on which I have focused much of my own research. I practice in New York State, where our breast density notification legislation became effective in January 2013. I have been interested in reviewing my practice’s experience with screening ultrasound in these patients to evaluate cancer detection and biopsy rates. My initial experience was published in the Journal of Ultrasound in Medicine in 2015, and supported what other breast screening ultrasound studies have found, an additional cancer detection rate of around 2 per 1000. Through my continued evaluation of our screening breast ultrasound program, I have found a persistently higher cancer detection rate by adding breast ultrasound to the screening mammogram–which is of great importance to all breast imagers, as we are finding cancers that were occult on mammography.

Participating in valuable research is important to me and my colleagues because part of our breast center’s mission is to investigate new technologies and stay on the cutting-edge by offering the latest and greatest to our patients. Participating in clinical research provides us important experience with new technology, and an opportunity to evaluate firsthand new techniques, new equipment, and new ideas and determine what will most benefit our patients. This is what I find the most important aspect of research, and why I do it; to be able to find new technologies that improve upon the old, to continue to find breast cancers as early as possible, and to improve patient outcomes.

Why is medical research/ultrasound research so important to you? What research questions would you like to see answered? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Stamatia Destounis, MD, FACR, is an attending radiologist and managing partner at Elizabeth Wende Breast Clinic. She is also Clinical Professor of Imaging Sciences at the University of Rochester School of Medicine & Dentistry.

5 Questions with Dr Lee

Every year, the AIUM William J. Fry Memorial Lecture Award recognizes an AIUM member who has significantly contributed in his or her particular field to the scientific progress of medical ultrasound.

Wesley Lee MDAt the 2015 AIUM Convention, Wesley Lee, MD received this award.

  1. What did being named the William J. Fry Memorial Lecture Award winner mean to you?

The William J. Fry Memorial Lecture Award was an unexpected surprise because all of my professional accomplishments simply reflect who I am and what I enjoy doing.  I am truly honored and feel privileged to have received this special recognition among my special friends and colleagues.

  1. You have been involved with the AIUM for more than 3 decades. From your perspective, how has the AIUM changed over that span?

Over the past 3 decades, I have seen enthusiastic growth within our membership and more diversified multidisciplinary collaborations between many specialties for various areas of diagnostic and therapeutic ultrasonography. The AIUM has certainly raised the bar for technical and clinical practice standards that are now often developed with other professional organizations. The AIUM plays an pivotal role for political advocacy involving important issues that may impact how cost-effective and health care is delivered.

  1. You have written extensively and currently serve on the editorial board for Ultrasound in Obstetrics and Gynecology, as well as deputy editor of the Journal of Ultrasound in Medicine. Based on what you are seeing and writing, where is medical ultrasound headed?

The quality of medical ultrasound research has improved with the use of standard writing guidelines and detailed imaging protocols, as well as the application of evidenced-based medicine. We are seeing many novel applications of ultrasound technology that can now be delivered or used in combination with other imaging modalities in our patients. The Journal of Ultrasound in Medicine has become an important international resource with submissions from all over the world.  Original research articles constitute approximately 60% of the total papers submitted.

  1. What medical ultrasound question or concern keeps you up at night?

We use ultrasound imaging technology every day in our clinical practices. I am constantly trying to understand how diagnostic ultrasonography practice can be improved for patient care through development/application of new technologies, better education, and innovative research initiatives.

  1. Finish this sentence…”It’s best to use ultrasound first when…”

It’s best to use ultrasound first when providing obstetrical care to pregnant women because of its cost-effectiveness as a screening tool, established benefit for the prenatal diagnosis of fetal anomalies/complications, and long safety record in pregnant women.

Do you have any questions for Dr Lee? Comment below or let us know on Twitter: @AIUM_UltrasoundLearn more about the AIUM Awards Program at www.aium.org/aboutUs/awards.aspx.

Wesley Lee, MD, is Co-Director, Texas Children’s Fetal Center at Texas Children’s Hospital Pavilion for Women. He is also Professor, Department of Obstetrics and Gynecology; Section Chief, Women’s and Fetal Imaging; and Director of Fetal Imaging Research all at Baylor College of Medicine.

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Why My Relative is a Bad Writer

A relative of mine, whose privacy will be maintained, fancies herself a writer. Historical fiction is her self-proclaimed genre. Unfortunately, she is not a good writer and reading her stories is akin to listening to nails scratching a chalkboard. My suggestion to her, without revealing how I truly felt about her writing, was to read as much historical fiction written by others as she possibly could. Her response was, “I don’t like reading other people’s fiction.” You can imagine how hard it was to restrain the thought that ran through my head, “Now you know exactly how I feel about reading yours.”

HellerThe point of this anecdote is to help explain why I decided to become a reviewer for the Journal of Ultrasound in Medicine (JUM). You cannot possibly expect to be a good manuscript writer without reading as many manuscripts written by others as you can. And what’s even better than reading an already edited and published “fit-to-print” manuscript is to read one in its gestational state, (sometimes) full of awkward sentences, confusing presentations of data, and tables that are impossible to digest.

When I was first invited to become a reviewer for JUM, I was (presumably jokingly) instructed by top editorial staff members to “ignore the email invitation at your own peril.” Being a first-time manuscript reviewer can be a bit intimidating. You begin to question your own qualifications: “What makes my opinion valuable?” “Who am I to criticize someone else’s writing?” As a regular reader of this or any medical journal, you are exactly the person from whom opinions and criticism count. You are the intended audience of the writing and, as such, the manuscript needs to appeal to you, not only in medical accuracy, but also in relevance and in the style in which the information is presented.

A good manuscript needs to be consistent. It needs to flow effortlessly and consistently from abstract to discussion. The first step I take in reviewing a manuscript is to read it from beginning to end, without making any suggestions. I want to digest the information in the state in which it was originally presented. While this can sometimes lead to indigestion and heartburn, I resist the urge to scribble any comments, questions or suggestions along the margins of the article…at this point.

I wait anywhere from several hours to several days to allow my digestive tract to return to normal (I find probiotics to be particularly helpful for this). Then I reread the article more carefully and more slowly, dissecting each sentence, in particular the data, making sure that information is consistently presented throughout the paper and that the numbers add up. I avoid correcting grammar and linguistic choices (my grandmother, the eternal grammarian, would roll over in her grave), knowing that there are great copy editors who will take care of this. I do ensure, however, that I correct any words that are medically inaccurate (i.e., incorrect abbreviations, suboptimal word choices for ultrasound techniques).

In addition to confirming that the information is presented in the correct section, (i.e., results are not included in the materials and methods section), I ask myself what I would do differently if I were to write the paper. Is the number of subjects adequate? Does the work add substantially to the literature? Is the conclusion appropriate for what was actually done? Might the work alter medical care? Are there any pertinent articles that have not been included in the references section? Do the tables help to more clearly represent the results or are they unnecessary? Is JUM the appropriate journal for this article?

In summary, the more articles you read and, in particular, the more unedited articles you read, the better a manuscript writer you will become. Of this, I am certain.  Whether or not you choose to write scientific manuscripts, historical fiction or perhaps screenplays for the next hit HBO series, the more you know about what’s already out there and how it was written, the better your own work will be.

What are your writing, reading, editing tips? Have you ever written for JUMComment below or let us know on Twitter: @AIUM_Ultrasound.

Howard Heller, MD, specializes in diagnostic radiology at Brigham and Women’s Hospital, Department of Radiology. He is also on JUM‘s editorial advisory board.

Because Adults Need to Play

One of my favorite TedMed 2014 talks is by Jill Vialet, CEO and Founder of Playworks titled “The Power of Play”.  In it Jill describes how people and circumstances are transformed through play. There is actually a physical and mental function which play serves in our daily lives. When I first began educating health care providers in ultrasound internationally, I noticed this. Amidst directing and organizing courses–alternating lectures first, then lectures last; hands-on stations first with flipped classroom pre-class; a half-day course; a two-day course; or even a three-day course. The combination matrix never really mattered and the post-course evaluations never varied.

SonoGames 3However, one key piece of each course always ensured a winning recipe for sealing the learners’ knowledge and ending on a greatly positive note.

That was the final day’s game of Jeopardy®.

Yes, splitting the adult course attendants in two competing teams and having them play a game. Despite the relatively benign prize of candy, having them play promised a room full of noise, laughter, positive feelings, and raving post-course evaluations.

From India, Ireland, Sri Lanka, and Ghana, it didn’t matter the country. It didn’t even matter if they knew the rules of the game. What mattered, and what made the course, was play. This was true for the learners as well as the educators.

As the president of the Academy of Emergency Ultrasound (AEUS) of the Society for Academic Emergency Medicine (SAEM) in 2011, I was allotted 4 hours of conference time to plan as I wished. I immediately saw this as an opportunity to create and innovate. I envisioned a 4-hour game event of fun, focused ultrasound education, and resident competition. My friend Y. Teresa Liu, M.D. (Harbor-UCLA Medical Center) had told me about running an ultrasound game event with our mutual good friend David Bahner, MD. (the Ohio State University Medical Center).  I conferred with my education officer Andrew Liteplo, MD. (Massachusetts General Hospital).  He loved the idea.

The SonoGames® was born.

Since that first year, we have increased the aspects and the intensity of play. This past year, the organizing committee dressed in costume commensurate with the conference city. There was a best team costume competition, a best team name award, and the teams competed for medals and for the opportunity to bring the SonoCup to their home institution.

I am convinced that the success of this event is due to its focus on play and fun. We are now planning for the 2016 SonoGames® and I suspect there will be even more play, fun, laughter, and learning.  If you want to learn more about the details of how we structured the games, check out the article that appeared in the Journal of Ultrasound in Medicine. And, if you think you are up to the challenge, get your 3-member ultrasound-savvy team ready to compete!

How do you play? What other ideas do you have to incorporate play and ultrasound? Have you ever competed in an ultrasound event? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Resa E. Lewiss (@ultrasoundREL) is the Director of Point-of-Care Ultrasound at the University of Colorado. She has published on medical education and Point-of-Care Ultrasound. Check out her TedMed2014 talk.