Menstrual Pain: Is it Adenomyosis?

Frequently, during daily ultrasound consultations, female patients complain about certain symptoms during their menstrual period, whereas other women go through their monthly cycle without experiencing pain and might feel just a little discomfort associated with their period.Ticci

For those women who do suffer from various common menstrual disorders that can cause stress, pelvic ultrasound is commonly used to investigate any underlying medical problems in menstrual abnormalities.

For example, before speaking with her physician, Brianna didn’t know which symptoms were normal and which were not, since she always thought that a cycle that’s “regular” for her may be abnormal for someone else. She was just chilling at a regular doctor’s checkup when the physician advised her about a vaginal ultrasound after she told him about her symptoms during her menstrual period.

Brianna had never experienced a transvaginal ultrasound before and she thought that it was a little weird and awkward, although some of her friends had told her a while back that the procedure was not painful.

Brianna was referred to my office for the ultrasound exam. She complained about a persistent pelvic pain during her period and about heavy bleeding.

Ultrasound findings:

  • enlarged globular uterus with different densities within the myometrium
  • pockets of fluid within the muscle of the uterus (myometrial cysts)
  • linear acoustic shadowing without the presence of fibroids and echogenic linear striations, like stripes

That’s adenomyosis and it’s very common. And she’s probably never heard of it.

 

 

 

Adenomyosis

Adenomyosis is a common benign gynecologic disorder and its etiology and association with infertility are still unclear. It is a benign disorder previously associated with multiparity but recently, an association with infertility has emerged.

Adenomyosis can be asymptomatic or present with menorrhagia, dysmenorrhea, and metrorrhagia.

Other symptoms may be painful intercourse and/or persistent bladder pressure. These symptoms usually occur in patients aged 35 to 50, and the condition may affect 65% of women.

The patient looked at me while I tried to quell her fears, trying to explain that it is just an unusual thickening of the uterine wall, caused by glandular tissue being pushed into the muscle.

“It’s cancer?” That’s the first question.

“No, it’s not cancer.” I try to explain: it’s something I saw on the ultrasound called adenomyosis and it’s not going to turn into cancer.

The patient probably had never heard that word before and she’s asking how to spell it so she could go home and Google it.

“Is that a bad thing?” That’s the next question.

I answer, “no, it just doesn’t sound like a good thing. ”

 

Adenomyosis and Endometriosis

Brianna is actually very worried at this point. She’s heard the word “Endometriosis” before because some of her female friends have had it and they thought that, perhaps, that was the cause of their fertility problem.

That’s the next question.

“Is adenomyiosis similar to endometriosis?”

I try to explain that endometriosis happens when endometrial cells are outside the uterus. Adenomyosis is when these cells grow into the uterine wall.

This is my answer and I’m trying to reassure my patient that the two syndromes are quite different. Endometriosis is much more severe. Because Brianna remembers that her friends had pregnancy problems, she’s now scared to death.

Pregnancy and fertility, that’s the great issue.

 

Pregnancy and fertility

“Is it possible to get pregnant with Adenomyosis?”

“Don’t be too concerned, Madam” is my answer.

Evidence that links adenomyosis to fertility is limited to case reports and small case series. But there is a significant association between pelvic endometriosis and adenomyosis (54% to 90% of cases), and it is well known that endometriosis causes infertility. For this reason, findings of infertility were due to endometriosis rather than adenomyosis.

At this point in the conversation, I really think that it is very important to calm the patient.

“In most women, it’s not going to have a medical impact. Sometimes, doctors don’t even tell their findings because it’s not really clinically significant,” I say to her.

 

Treatment

Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, including a high risk of miscarriage and obstetric complications.

The therapeutic choice depends on the woman’s age, reproductive status, and clinical symptoms. However, so far, few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed, and no drugs labeled for adenomyosis are currently available. Nonetheless, the disease is increasingly diagnosed in young women with reproductive desire, and conservative treatments should be preferred.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. An antiproliferative effect of progestins suggests their use for treating adenomyosis by reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to induce regression of adenomyosis by relieving pain and reducing bleeding.

There is evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

 

 Let’s go back to our office

After this long talk, Brianna realized she didn’t need to freak out.

One thing she really couldn’t understand is why she’d never heard the name of this condition.

She was also kind of upset because she spent her teenage years suffering so much from pelvic pain during periods and now that she’s ready to have a family and give birth, a doctor tells her about an annoying medical condition, gives her all this news that explains all her symptoms, which may cause fertility problems and she’d never heard of it before!

Any suggestions for getting the word out about adenomyosis?

 

Do you have any suggestions for getting the word out about adenomyosis? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Pietro Ticci, MD, is originally from Florence, Italy, and has been a medical doctor in the Florence Area (Tuscany) since 1995. Currently, he is an Ultrasound Physician at his private medical facilities in the Florence Area.

POCUS: My Path to Be an Effective Global Citizen

Bus 22 from Stanford to Pacific Free Clinic (PFC) – 1.5 hours. Bus 22 and 25 from PFC to Santa Clara Valley Medical Center – 1 hour. Bus 70 from PFC to Foothill Family Community Clinic – 30 minutes. Bus 70 and 26 from PFC to Community Health Partnership – 30 minutes. Without a car, I managed the PFC and networked with community clinics and hospitals by bus. These bus rides provided me with a glimpse of one barrier disadvantaged patients endure in order to access the healthcare system. If my weekly navigation of San Jose’s health care system has been one long bus ride, so too has my medical training–a long seamless journey of exploring three vital components of medicine: community service to the underserved, translational/epidemiologic research, and internal medicine.

As stated in the opening of my personal statement for residency application (above) community service was one of my main motivations to go into internal medicine. Yet, despite 7 years of volunteering and managing 3 free clinics in 3 cities, I became focused on developing clinical skills and establishing an academic career instead. I pushed community service aside during my residency training and beyond until my trip to Gros-Morne, Haiti, where I, together with Atria Connect (https://www.atriaconnect.org), taught point-of-care ultrasound (POCUS).

Through Atria Connect, 14 other physicians from around the world and I trained 12 Haitian physicians at Hospital Alma Mater, where there were no echocardiograms, CT imaging, or MRI. There were 2 diagnostic imaging modalities available: a nonfunctional x-ray machine and an ancient ultrasound machine with just a transvaginal probe. For 3 months, we rotated weekly to provide hands-on training in a longitudinal POCUS curriculum that combined flipped classroom learning with online modules, onsite hands-on teaching (Picture 1), and remote hands-on training via a tele-ultrasound platform. At the end of the curriculum, the 2 youngest Haitian physicians then spearheaded a longitudinal training program for the remaining clinical staff within the hospital.

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Picture 1. Left to Right: Dr. Bruno Exame (Haiti), Dr. Ricardo Henri (Haiti), Dr. Jesper Danielson (Sweden), Dr. Michel Hugues (Haiti). Dr. Hugues, the Chief Medical Officer of Hospital Alma Mater, is shown performing focused cardiac ultrasound under the guidance of Dr. Danielson and Dr. Henri. Dr. Exame was evaluating the quality of the ultrasound image.

Similar to many global health efforts with POCUS, the 15 trainers, including myself, and the Haitian physicians experienced an evolution in clinical care. It ranged from expedited diagnoses of tuberculosis through the FASH protocol (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3554543/) to an unexpected evaluation of left heart failure possibly due to thiamine deficiency, to immediate trauma triages of patients from motor vehicle accidents in a town where traffic laws do not exist. With POCUS, Haitians have access to diagnostic medicine that would otherwise be denied in rural Haiti, where it would take a 4-hour bus/motorcycle ride on unpaved road to obtain. The evolution went beyond clinical management and access to basic health care, however.

Besides transforming medicine in resource-low settings, POCUS rekindled my initial drive to go into internal medicine: community service for the underserved. It empowers me to serve more effectively by training providers with an innovative technology of sustainable impact. With a tele-ultrasound platform and WhatsApp, POCUS draws me closer to the underserved in remote places, thus expanding community service on to a global scale, onsite and offsite.

More importantly, POCUS loops me back to community service at the local level, the original start of my journey to internal medicine. Similar to the Haitians in Gros-Morne, the disadvantaged in the United States face obstacles in which an additional trip to basic diagnostic radiology or cardiology, other than limited outpatient medicine encounters, proves to be difficult. An expedited evaluation with POCUS for simple clinical questions can maximize diagnostic capability and further advance clinical care as a way of improving access in this vulnerable population.

One instance in which I had a missed opportunity was during my residency in expediting care for my favorite clinic patient at an urban health clinic. She, unfortunately, suffered from multi-organ manifestations of sarcoidosis. One day, she presented with an acute onset of dyspnea and chest pain without hypoxia. Her examination was not significant for volume overload, pneumonia, or reactive airway disease. Her breath sound was mildly reduced on the right side. A chest X-ray was ordered. However, due to transportation cost and her inability to take off additional time from work, she did not obtain a chest X-ray until 3 days later. Her chest X-ray showed a spontaneous pneumothorax of 8 cm in size due to structural lung changes from her sarcoidosis. She was immediately sent to the emergency room for pigtail placement. Had I learned lung ultrasound, an immediate diagnosis would have been made and her care would be further advanced at minimal cost. While POCUS benefits all patients, POCUS magnifies the impact for the underserved by overcoming socioeconomic barriers.

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Picture 2. Left to Right: Dr. Michel Hugues (Haiti), Dr. Bruno Exame (Haiti), Dr. Jesper Danielson (Sweden), Dr. Gigi Liu (United States), Dr. Ricardo Henri (Haiti), and Dr. Josue Bouloute (Haiti) on the last day of the 4-month POCUS training.

My life-changing trip to Gros-Morne, Haiti (Picture 2), expanded my global awareness and revived my sense of social responsibility through community service locally, regionally, nationally, and internationally. This is the essence of global citizenship (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726429/?report=reader; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6076566/?report=reader). Instead of just providing much-needed medical care to the underserved, POCUS empowers providers to be a more effective global citizen by expediting diagnosis and care efficiently and cost-effectively. It has been a privilege to be trained as a physician and be taught by amazing mentors with life-saving POCUS skills. As a global citizen, I vow to train health care workers on POCUS on multiple geographic levels as part of my social mission to improve access and care for the disadvantaged, even if this requires a very long bus ride…

 

How has POCUS changed your practice? What do you do to be a global citizen? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Dr. Gigi Liu, MD, MSc, FACP, is a hospitalist and proceduralist at Johns Hopkins Hospital who leads the POCUS curriculum for Osler Internal Medicine Residency program and Johns Hopkins Bayview Internal Medicine Residency program.

 

 

 

 

 

Ultrasound-Guided Cancer Imaging: The Future of Targeted Cancer Treatment

Tumor margins and malignant grade are best defined by vascular imaging modalities such as Doppler flow or contrast enhancement combined with videomicroscopy. The following are image-guided treatment options that can be performed on breast, prostate, liver, and skin cancers.

NEW DOPPLER APPLICATIONS

Blood vessel mapping using the various Doppler modalities is routinely used in both cancer treatment and reconstructive planning. In cancer surgery, it is critical to locate aberrant veins or arterial feeders in the operative site so postoperative blood loss is minimized. Advanced 3D Doppler systems allow for histogram vessel density measurement of neoplastic angiogenesis.

VESSEL DENSITY INDEX

(Fig 1) Baseline neovascularity is a treatment surrogate endpoint and therapy is maintained, increased, or suspended based on quantitative angiogenesis data.

SOLID ORGAN CANCER IMAGING UPDATES

Breast cancer, invading the lower dermis and nipple, discovered with high-resolution probes signifies the tumor has outflanked clinical observation essential for detecting the newly discovered entity of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This capability is also vital for diagnosing the recent epidemic of male breast cancers arising near the mammographically difficult nipple areolar complex, occurring in our 911 First Responders.

For prostate cancer, 4D ultrasound can identify low-grade cancer delimited by the capsule and with low vessel density, and should be followed serially at 6-month intervals.

CONTRAST-ENHANCED ULTRASOUND (CEUS)

In 1990, Dr. Rodolfo Campani developed ultrasound contrast for liver imaging and Drs. Cosgrove (London) and Lassau (Paris) extended the use to breast, skin, and prostate tumors. CEUS is currently used worldwide but is not Food and Drug Administration (FDA)-approved in the United States.

One use for CEUS is microbubble neovascularity, which demonstrates therapeutic response since the Response Evaluation Criteria in Solid Tumors (RECIST) studies noted tumor enlargement during treatment might be related to cell death with cystic degeneration or immune cell infiltration destroying malignant tissue. Doppler ultrasound or CEUS reliably verifies decreased angiogenesis in place of contrast CT or dynamic contrast-enhanced (DCE) MRI. If vascular perfusion ceases, thermal treatments, such as cryotherapy, high-intensity focused ultrasound (HIFU), or laser ablation, should be completed.

Four-dimensional (4D) ultrasound imaging is real-time evaluation of a 3D volume so we can show the patient immediately the depth and the probability of recurrence. Specific echoes in skin cancer generated by nests of keratin are strong indicators of aggression and analyzed volumetrically. Highly suspect areas are checked for locoregional spread and a search is performed for lymphadenopathy so we can determine if the disease is confined and whether further surgical intervention is unlikely at this time. Patients are reassured because they simultaneously see the exam proceed in systematic stages. In serious cases, the patient is forewarned that the operation involves skin grafts and tissue construction.  4D ultrasound permits image-guided biopsy of the most virulent area of the dermal tumor and allows the pathologist to focus on the most suspicious region of the lymph node mass excised from the armpit, neck, or groin. Some laboratories are using postop radiography and sonography for better specimen analysis.

VIDEO DIGITAL MICROSCOPY VS BIOPSY

Fear of complications can deter patients from seeking medical opinion and surgical intervention, so many opt for noninvasive options. Imaging can help to reduce unnecessary biopsies because it can help identify the 1 out of every 33,000 moles that is malignant, while weeding out those that are not.

Once skin cancer is diagnosed, the treatment depends on depth penetration, possibly involving facial nerves, muscles around the eye and nasal bone or ear cartilage. Verified superficial tumors are treated topically or by low dose non-scarring radiation. Many cancers provoke a benign local immune response or coexistent inflammatory reaction that simulates a much larger area of malignancy, and cicatrix accompanies the healing response. 4D imaging combined with optical microscopy (RCM (reflectance confocal microscopy) or OCT (optical coherence tomography)) defines the true border during surgery, sparing healthy tissue, resulting in smaller excisional margins and less scar formation.

 

Do you have any tips on incorporating ultrasound in cancer imaging? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Robert Bard, MD, DABR, FASLMS, currently runs a private consulting practice in New York City. He authored Image Guided Dermatologic Treatments, Image Guided Prostate Cancer Treatment, and DCE-MRI of Prostate Cancer and is a member of multiple leading international imaging societies. Since 1972, Dr. Bard has pioneered digital imaging technologies as alternatives to surgical biopsies for dermatologic and solid organ neoplastic disease.

Sonography and the Seeds of Education in Underserved Rural Clinics

How many of us began our sonography journey thinking about the number of callbacks that we would log per shift, the number of patients that we would scan in an 8-hour day, or, even worse, the number of career-ending ailments that we would amass? Zero; we didn’t. tammySterns_2017

We saw ultrasound as a way to contribute to something bigger than ourselves.

The complex, yet simplistic, science of sound drew us to the field. Looking at the screen and seeing the images come to life was fascinating, and being the first to see presenting pathology while shedding light on the diagnosis mesmerized us. The thought that even after 20 or 30 years in the profession we would encounter images of structures that we’d never seen before was enticing, and the opportunity to be a life-long leaner was thrilling.

Patient interaction and our role in their medical experience appealed to us. Not too much, not too little, but just the right amount of patient care time that allowed us to interact with them and leave a positive imprint on their journey. We imagined we would sit by their bedsides, walk them casually back to the exam rooms, and listen as they shared.

Our patients would come first.

Instead, too often, we found ourselves in the middle of a never-ending battle between cost-effectiveness and patient satisfaction reports. We logged more hours of callbacks than we ever thought possible, sometimes having difficulty even finding the correct key to open the ultrasound office door. We strived to create the profession that we had imagined within the confines of the variables that we’d been given. We did the best that we could, often to the detriment of our own bodies.

And, somewhere along the way, we forgot the wonder of our profession.

About 10 years ago, I had the opportunity to participate in my first overseas medical trip. A group of physicians and a few sonographers, with portable machines strapped in backpacks, were intent on sharing sonography with some of our peers an ocean away. It was during this trip that I saw the purest form of ultrasound come to life. We had one of the simplest of machines and the most basic of lectures and yet they came from miles to learn. The patients sat all day in the heat waiting for the opportunity to have an ultrasound scan. I witnessed ultrasound identifying and explaining pain that had existed for years. I saw tears of relief, joy, and despair as people received answers that changed their lives.

A few years later, I was able to return to the same place. I fully expected to find that they had not utilized our lessons on sonography to their fullest. Instead, our previous pupils greeted us with dog-eared textbooks, mastered skills, and the desire to know more! The seeds of education that we had planted had flourished as they realized the potential ultrasound held for their rural clinics. It offered the ability to quickly investigate and diagnose and you could see the wonder of ultrasound that we had once experienced reflected in their eyes.

Seven years ago, my family and I had the opportunity to move to a developing country. Living in the second-poorest country in the western hemisphere with limited medical availability, I now see every day the wonder of our profession come to life. All the benefits of ultrasound that we learned as students, that are often taken for granted, are the benefits that allow lives to be changed every day.

Portability – I can scan in a makeshift clinic, under a tree in a field, or in someone’s handmade shelter while they lay on the floor.

Inexpensive – Portable machines are relatively inexpensive and diagnostically sound, making them perfect for short-term trips or as gifts to native physicians.

Quick – Within minutes, we can scan and find answers to problems that have hindered the livelihood of those who are sick and in pain. One of my first patients was an OB patient who had been in labor for several days without any progress. A quick scan revealed placenta previa.

Relatively Safe – Without the worry of radiation and chemicals, ultrasound, when utilized by those who are qualified, provides a safe method of imaging.

True, my exam room isn’t exactly ergonomically correct and there are times that chickens and roosters run underfoot. I’ve had to prop the machine on a rock and scan in the brightest sun of the day. But I’ve also witnessed a mother’s face when she sees her baby for the very first time without me having to operate under the time constraints of efficiency. I’ve held a father’s hand as he realized that the pain he’s had for years isn’t the cancer he so greatly feared but a simple fix. I’ve scanned at the bedside of a daughter who lay dying without any medical options, and I fall more and more in love with our profession every single day.

Experience the wonder of ultrasound again.

If given the opportunity, I encourage you to participate in a medically related trip or volunteer opportunity. You will see firsthand how our profession and our images impact the world one life and one scan at a time. You don’t have to move permanently as we did to a developing country. Opportunities also abound in your local community from volunteering your time as a clinical instructor to scanning for local centers. Expand your horizons and allow yourself to experience the wonder of ultrasound again.

 

How have you seen ultrasound incorporated into medical care in other nations? Do you have an ultrasound story to tell? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Tammy Stearns, MS, RT(R), RDMS, RVT, FSDMS, is Director of Women’s Ministry and Sonographer for Project H.O.P.E. in Managua, Nicaragua. She is also the President of the Society of Diagnostic Medical Sonography and an adjunct professor of Diagnostic Medical Sonography at Adventist University in Orlando, Florida, and a sonographer consultant for Heartbeat International.  She is also the author of “Know Hope” and “Living Worthy”.

The Research Sonographer

Research sonography is not a common term when talking with fellow sonographers. There is no specialty exam or formal training involved. I would like to say research fell into my lap, but I was determined to learn as much as possible about ultrasound research in my earliest days. As a student at Thomas Jefferson University, I spent a lot of time hanging around the Research Institute. During my first job at UCSD, I started volunteering with the contrast ultrasound research team. I volunteered my lunch breaks and came in early before my shift at 7 am.  An opportunity opened to work on 2 simultaneous CEUS clinical trials as a research coordinator/sonographer. Looking back, I had no idea what I was doing but I knew I was up for the challenge.IMG_1175

Together with help from my mentors, we created a research sonography position. I asked A LOT of questions. I learned how to write research protocols and submit for IRB (Institutional Review Board) review. The clinical trial monitors were gracious enough to teach me source documentation and the regulatory aspect. When the clinical trials ended, I spent nearly 10 years at Philips learning the medical device side of ultrasound. Eventually, I followed my passion and went back to clinical research when an opportunity opened at the FDA as a contractor; and now I am pursuing my master’s in clinical research management-Regulatory Science. Opportunities are always created if you follow the instincts that drive you.

The first hurdle is funding a research position. Whether funded by a clinical trial or applying for grant money, the process can be laborious. Sometimes a lapse between awards can occur but, in general, the budget is stretched so there is no loss in coverage. Every year, the project or position can be up for financial renewal. Planning for the next financial award is always on the horizon. Therefore, research sonography jobs usually hire for short-term employment, unless a Radiologist you are working with has grant money for a project. I recognize this path is not a stable one, not nearly as long-term as a departmental position would be.

Some crave the stability of 10–20 years ahead with one employer. I think the Research Sonographer is one that likes to accept challenges; is interested in science, research, and development; and has a yearning to think outside the clinical box and challenge the status quo in a way clinical sonography does not present itself. But this is not for everyone.

There are differences in clinical and research ultrasound. The investigators’ research protocol is the imaging parameters that will be followed, not The Standards, CPT codes, or departmental protocol. I ascertain this as a challenge; once you have the transducer and start driving, it is difficult to not diagnose and document images in an orderly fashion. Instead, we are examining a hypothesis and proving specific aims. There is a shift in cognitive thinking that needs to occur. Setting up a controlled environment with repetitive imaging to prove a hypothesis is imperative. It is most important to re-create the same controlled imaging environment on all subjects and then analyze the data off-line.

How does one become a research sonographer? Situations arise that are different in every corner of the country. Align with a research-based physician, coordinator, or mentor, at a university hospital or outpatient center that performs research. Start on a small project, volunteering your time and evaluate the differences. You may find research is not at all interesting for your personality type. Search for clinical trials in need of a sonographer, usually posted on on-line ultrasound job boards. A good website to search for on-going or upcoming trials is http://www.clinicaltrials.gov. Search for clinical trials that involve sonography, ie, fertility, where the exam times are usually early morning before the volunteers go to work. Remember research sonography is not the same as performing an entire pelvic exam. The sponsor will only want images on what the protocol states, so exam times and ergonomics are reduced. You might be measuring the bladder volume or the volume of an ovary, in total. Align with a mentor that will help you carve out your path, follow your instincts, and seek out opportunities that will lead in your direction.


Are you a research sonographer? Share your experience. Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Karen Alton, BS, RDMS, RVT, is a graduate student at Arizona State University, an owner of Karen Alton Consulting, LLC, and is an Ultrasound Imaging Research contractor at the US Food and Drug Administration.

The Buzz in Orlando

From the moment you stepped foot inside the Hilton Bonnet Creek Resort, you knew this was going to be a different kind of AIUM Convention. Maybe it was the new venue. Maybe it was all the new offerings. Maybe it was the excitement about connecting and reconnecting with colleagues from around the world.IMG_7012

Whatever it was, it caused a buzz in Orlando.

If you were in Orlando, we hope you felt the same. If you were unable to make it this year, here are a few of the highlights (you can see and learn even more if you search #AIUM19 on your favorite social media site):

 

IMG_7019 copyNew Offerings—Each year, the AIUM and the Annual Convention Committee look to enhance and improve the event. This year was no exception. To get the juices flowing, attendees could participate in a morning exercise class that varied each day. We added the Recharge Lounge where attendees could relax and charge up their devices. We partnered with the International Contrast Ultrasound Society on a one-day educational event. And we enhanced the Meet-the-Professor sessions.

SonoSlam—In its fourth year, 24 teams battled it out for the coveted Peter Arger Cup. The University of Connecticut’s team, PoCUS Maximus, came out on top–and defended their title! Save the date for next year—March 21 in New York City! Big thanks to headline sponsor Canon.

 

 

Social Media—From Instagram to Twitter to Facebook, Convention attendees were very active on social media at #AIUM19. And, for the first time, there was a takeover! Kristy Le, a recent RDMS graduate, took the reigns of our social accounts to give her perspective on the AIUM Convention! Search #AIUM19 to get her take!Twitter_AIUM19

Kristys Takeover

Networking–It’s not an AIUM event if there isn’t networking. IMG_6998 copyThis year there were even more opportunities to make new contacts and reconnect with colleagues from around the world. From the morning workouts to the Presidential Reception. From Community meetings to the Welcome Reception. From the intimate Meet-the-Professor sessions to the Exhibit Hall breaks. You almost couldn’t help but expand your network.

Global Plenary—AIUM President Brian Coley, MD, hosted the Plenary session that featured a lecture on reducing workplace injuries from Kevin D. Evans, PhD, RT, RDMS, RVS, FSDMS, FAIUM, Professor at The Ohio State University College of Medicine. This talk launched a series of sessions and events at the AIUM Convention that focused on ergonomics. The entire Plenary Session is available on the AIUM Facebook Page.

Fun Activities—Not only was #AIUM19 educational, it was also fun. Buttons_IMG_1967_EDITEDThis year attendees could participate in morning exercise classes (yoga, jogging, bootcamp); do a scavenger hunt with the AIUM app (Congrats to Julie Abe, MD, from Brazil for winning the free #AIUM2020 registration); collect specialty-specific buttons (Congrats to Joanne Richards, RT, RDMS, RT on winning the smartwatch for collecting at least 15 buttons); and participate in Industry Symposia.

 

Sold-out Exhibit Hall—This year’s exhibit hall was the most exciting and active it has ever been. There were more new companies at this year’s event than ever, making the exhibit hall vibrant and exciting! IMG_7035New product releases, special offers, and cool giveaways created a buzz we haven’t seen in years. Plus, there was cake! Thanks to all the exhibitors!

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

James A. Zagzebski, PhD–William J Fry Memorial Lecture Award
Steven R. Goldstein, MD, FAIUM—Joseph H. Holmes Clinical Pioneer Award
Keith A. Wear, PhD, FAIUM—Joseph H. Holmes Basic Science Pioneer Award
Kevin David Evans, PhD, RT, RDMS, RVS, FAIUM—Distinguished Sonographer Award
Michael Blaivas, MD, MBA, FAIUM, FACEP—Peter H. Arger, MD Excellence in Medical Student Education Award
Bryann Bromley, MD, FAIUM—Carmine M. Valente Distinguished Service Award
Liat Gindes, MD—AIUM Honorary Fellow
Tammy Stearns, MS, RT(R), RDMS, RVT, FSDMS—AIUM Honorary Fellow

The AIUM also recognized the life and achievements of these individuals who were inducted into the Memorial Hall of Fame:

Michael L. Manco-Johnson, MD
Terry J. DuBose, MS, RDMS, FAIUM, FSDMS
Donald Baker

Up and Comers—In addition to our national awards, the AIUM also recognizes its New Investigators. This year’s winners and runners-up are:

Basic Science
Winner—Viktor Bollen, Postdoctoral Fellow, University of Chicago for “A Comparison Of Thrombus Dissolution Efficacy With Single And Multiple-Cycle Histotripsy Pulses In Vitro.
Runner-Up–Lakshmanan Sannachi, PhD, Postdoctoral Fellow, Department of Physical Sciences, Sunnybrook Health Sciences Centre for “Quantitative Ultrasound Texture-Derivative Methods Combined with Advanced Machine-Learning for Therapy Response Prediction: Method Development and Evaluation.”

Clinical Ultrasound
Winner—Misun Hwang, MD, Assistant Professor of Radiology, Children’s Hospital of Philadelphia, University of Pennsylvania for “Quantitative Detection of Brain Injury with Contrast-Enhanced Ultrasound in Neonates and Infants.”
Runner-Up–Michal Fishel Bartal, Maternal Fetal Medicine Fellow, McGovern Medical School, University of Texas at Houston (UTHealth) for “Validation of 3D Power Doppler Volume Analysis in Patients with 2D Ultrasound Suspected Morbidly Adherent Placenta.

Convention attendees say that the reason they attend this event is because of the multi-specialty nature of the AIUM. This event brings together physicians, sonographers, scientists, students, and others from at least 20 specialties–all focused on medical ultrasound! No other event–or professional society–does this. To all of those who joined us in Orlando, thanks and we hope you were able to take back some contacts, a lot of information, and resources to improve patient care. For everyone else, we hope to see you in New York City for AIUM2020.

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Physics of Ultrasound

Snell’s Law [in-class demonstration]

The concept that sound reflects and propagates in varied angles is an abstract concept that many students struggle to understand. I review this concept by providing an in-class demonstration that makes this less abstract and something that can be seen with glasses of liquids.

Evans_Fig 1

 

If speed 1 < speed 2, then the incident angle < transmitted angle.

The difference in the stiffness and resulting propagation speeds helps to explain why the straw appears to be “broken” when you look through the side of the glass of water. The angle of transmission is measured against the vertical black line drawn on the glass of water. This helps to illustrate the 30-degree oblique incidence vs. the increased angle of transmission. A real-world example would be the change in imaging of a needle in a fluid-filled structure.

Example:

The propagation speed of sound through air is 900 m/sec while the propagation speed of sound through water is 1200 m/sec. To figure out the change in the angle of transmission, we form a ratio that will allow us to arrive at a percentage of change. So, 900/1200 = .75 and, therefore, that ratio of change from air to water in the glass is 100 – 75 = 25%. To figure out the angle, take 30 times .25 = 7.5 degrees. Therefore, 30 + 7.5 = 37.5 degree angle of transmission.

Now, consider a different glass of liquid as part of this demonstration by viewing a glass of Karo syrup.

Evans_Fig 2

This time, the glass is filled with Karo syrup, which is stiffer and denser than the water, and the transmitted angle is greater due to the increased ability to travel quickly in the second media.

 

If speed 1 < speed 2, then the incident angle < transmitted angle.

Example:

The propagation speed of sound through air is 900 m/sec while the propagation speed of sound through Karo is 1500 m/sec. To figure out the change in the angle of transmission, we form a ratio that will allow us to arrive at a percentage of change. So, 900/1500 = .60 and, therefore, the ratio of change from air to Karo syrup in the glass is 100 – 60 = 40% gain. To figure out the angle, take 30 times .4 = 12 degrees. 30 + 12 = 42 degree angle of transmission. The real world example for this is noting a speed propagation artifact.

A final demonstration can be a glass that has 1/3 air, 1/3 vinegar, and 1/3 cooking oil. Do not forget to add a straw so that several bends in the straw are noted by viewing through the side of the glass.

 

 

Kevin D. Evans, PhD, RT (R) (M) (BD), RDMS, RVS, FSDMS, FAIUM, is Chair and Professor of Radiologic Sciences and Respiratory Therapy at The Ohio State University in Columbus, OH.