The Development of a Reporting and Data System Using Ultrasound: My ACR O-RADS Journey

Supervising the development of the American College of Radiology Ovarian-Adnexal Imaging-Reporting and Data System for Ultrasound (ACR O-RADS US)1 has been a journey that has challenged and substantially improved my leadership and management skills.Rochelle F. Andreotti, MD

O-RADS is a quality assurance tool and clinical decision support system for the standardized description of ovarian/adnexal pathology and its management consisting of a lexicon and risk stratification system. It is 1 of 10 Reporting and Data Systems (RADS) sponsored by the American College of Radiology (ACR). The committee was formed in 2015 under the direction of the ACR Ultrasound Commission and Commissioner, Beverly Coleman. I was asked to Chair the committee with Dr. Phyllis Glanc from Toronto, Canada, as Vice-chair.

“The best and the brightest”

O-RADS is an international initiative that has involved extensive collaboration with competing national and international societies. We began in the summer of 2015 developing our mission and membership. Our membership was primarily derived from several major initiatives that prompted our formation. These included the SRU Consensus Statement, a North American initiative helpful in determining management of cystic lesions, the International Consensus, the first collaboration of European and North American management approaches promoting a more conservative, standardized approach while optimizing the referral pattern to a GYN-oncologist when malignancy is suspected and terms and risk stratification models developed by the International Ovarian Tumor Analysis Group (IOTA). It was also highly recommended that the committee consist of members representing national and international related societies who could contribute to and eventually help promote our system. As a result, from the beginning, I was facing highly opinionated, accomplished colleagues so that there would need to be lots of creative thinking to navigate the pathway going forward.

Lumper, not a splitter

I can see the overall picture and am an accomplished problem solver but concentrating on the smaller details is not my forte and I often find them cumbersome. In order to achieve group consensus, the next 2 years that we spent establishing the lexicon was a thought-provoking and prolonged experience in which both of these qualities were essential.

Ergo, I needed to step up my game.

Evaluating quality of evidence using a comprehensive scoring system was an early point of contention, but fairly quickly we were able to come to agreement that scoring articles for quality would not be of much concern in the lexicon phase, although evaluating the quality of the study would be useful if the article added support to the risk management phase.  The method chosen to develop the lexicon became a tedious process of culling evidence-based and frequently used terms from the literature using a survey, then through a consensus process, narrowing down the list to a workable group. Inevitably, since the IOTA terms were the most evidence-based, this became the foundation of the lexicon.

Looking back at other approaches, perhaps there may have been an easier, less time-intensive pathway that would also have led to the same results. Nevertheless, the process taught me that no matter how well thought out a strategy, always be prepared for others who, out of their own desire to work toward the greater good, will complicate the plan.

Let’s keep this as simple as possible

On a similar note to the “lumper” versus “splitter” mindset, we vigorously debated the specific modalities to be included in this system. There was no question that ultrasound (US) as the primary modality and magnetic resonance imaging (MRI) as a problem-solving tool were key. However, would it be prudent to add CT/PET, tools not recommended for these adnexal mass diagnoses, although occasionally demonstrating incidental findings?

Limiting our bandwidth to the two tracks was my recommendation. However, this high-spirited deliberation came close to splintering our fledgling committee, be it not for the ACR staff’s suggestion of a vote that finally put to bed the possibility of a third O-RADS track. The vote left us with the two original parallel US and MRI working groups, preventing much added unnecessary work and anxiety. From this encounter, I learned the value of highly polished social skills.

The European mathematical model and the North American pattern approach- the challenge of working internationally

The relationship of the Ultrasound Working Group of the ACR O-RADS Committee with the IOTA Group has been collaborative but, at times, complicated and contentious. The reasons for this were two-fold. Foremost, the IOTA Group had already developed a set of applicable terms that were evidence-based as well as validated mathematical models to risk stratify lesions and were most interested in expanding their influence. However, these European models, while highly accurate, were less accepted in North America where a pattern-recognition approach is generally more desirable. Since IOTA provided their cohort of over 5900 surgically proven lesions, to support our pattern approach, compromise needed to be reached regarding further incorporation into the O-RADS Ultrasound System.

In the early development of the risk stratification system at our 2017 meeting at ACR headquarters in Reston Virginia, Dr. Dirk Timmerman from Leuven, Belgium, our IOTA representative, first presented to the group a proposal of a dual approach with addition of the IOTA Simple Rules2. After further work using a more generalized pattern approach based upon IOTA data, this was not pursued.

However, later in 2019, we were confronted with the need to incorporate the more accurate, well-validated IOTA ADNEX mathematical model3 into the O-RADS system as an alternate approach. In this way, we were able to obtain acknowledgment from key players representing IOTA with the hope of allowing O-RADS US to be launched internationally in addition to North American acceptance.

With continued use of the system, I have found an extra advantage of incorporating the ADNEX model when evaluating higher risk lesions in that it adds additional specificity to the diagnosis, information greatly appreciated by the gynecologic oncologists.

Impact factor

Any success that I have had in the field of medicine can be attributed to a desire to influence and leave this world, in some way, a little better for it. My hope is that this data system will prove to be something that will make a meaningful contribution and be my legacy to women’s healthcare.

 

References:

  1. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: A consensus guideline from the ACR Ovarian-Adnexal reporting and data system committee. Radiology 2020;294:168–185.
  1. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. Am J Obstet Gynecol 2016;214(4):424–437.
  1. Van Calster B, Van Hoorde K, Valentin L, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014;349:g5920.

 

Rochelle F. Andreotti, MD, is a Professor of Clinical Radiology and Obstetrics and Gynecology at Vanderbilt University College of Medicine in Nashville, Tennessee.

 

Interested in learning more about using O-RADS? Be on the lookout for the virtual course being held on September 26, 2020, New Approaches to Adnexal Mass Evaluation in North America: The Use of IOTA and O-RADS Systems; registration opens soon. Contact learn@aium.org for more information.

 

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Do It With Heart: Pre-Intubation Point-of-Care Echocardiography for Hemodynamic Optimization

Have you ever wondered why that patient coded after endotracheal intubation? As it turns out, it is not uncommon after critically ill patients are intubated. Approximately 60% of critically ill patients require endotracheal intubation and are at high risk for hemodynamic collapse during this procedure. Prior studies suggest that there is up to a 25% risk of hemodynamic instability even in successful critical care unit intubations. Therefore, it is crucial to prevent peri-intubation hemodynamic instability to avoid poor patient outcomes through hemodynamic optimization prior to endotracheal intubation.

Point-of-care ultrasound has evolved as a simple, portable, and noninvasive tool for assessment of hemodynamic status. It can provide invaluable information about diagnoses and direct resuscitation in critically ill patients. This bedside imaging modality can help determine the etiology of shock, guide appropriate interventions prior to patient decompensation, and assess patient response to management changes. It can also assist in the evaluation of intravascular volume status and fluid responsiveness of critically ill patients.

Endotracheal intubation is especially perilous for a patient with right ventricular failure. Performing this procedure in patients with right ventricular failure can result in catastrophic hemodynamic collapse since the right heart is very sensitive to increases in afterload. Right ventricular failure resulting in hemodynamic collapse is an underappreciated complication of patients undergoing intubation and invasive mechanical ventilation.

Echocardiography during the preparation period of intubation allows for direct and noninvasive visualization of the right ventricle at the bedside and can play a major role in the stabilization of critically ill patients. Pre-intubation echocardiography can prevent hemodynamic deterioration by identifying a failing right ventricle, which is extremely sensitive and unable to compensate for any increase in afterload or decrease in preload from endotracheal intubation. Pre-intubation echocardiography can detect signs of a deteriorating right ventricle (pressure and volume overload) such as right ventricle dilation, bowing of the interventricular septum into the left ventricle, decrease in the size of the left ventricular cavity, and decreased left ventricular filling leading to decreased cardiac output (Figures 1–4). If acute right ventricular failure is identified prior to endotracheal intubation, it can help the physician select appropriate management strategies prior to intubation and avoid hemodynamic instability.

 

With pre-intubation detection of right ventricular failure, different strategies can be implemented prior to endotracheal intubation to avoid hemodynamic collapse. Non-invasive positive pressure ventilation can be an alternative in some cases, which has a less pronounced effect on venous return and preload compared to invasive mechanical ventilation. In the setting of pulmonary embolism (or pulmonary arterial hypertension), inhaled nitric oxide can be used to decrease pulmonary artery pressure through pulmonary vascular dilation. Other strategies to avoid worsening right ventricular failure include administration of vasopressors prior to endotracheal intubation and avoiding intravenous fluid boluses.

Pre-intubation echocardiography is a crucial step in the protocol during endotracheal intubation of critically ill patients to prevent poor patient outcomes. It allows clinicians to approach endotracheal intubation-associated hemodynamic instability in a specific, targeted manner. Integration of pre-intubation echocardiography can vastly improve the management and safety of critically ill patients, in hopes of decreasing the risk of poor outcomes.

 

Srikar Adhikari, MD, MS, FAIUM, is a professor in the Department of Emergency Medicine at the University of Arizona Medical Center.

Interested in learning more about POCUS? Check out the following posts from the Scan:

 

CLEAR!

We all have come upon a machine, unplugged, with old gel caked on a probe or worse (see figures 1 and 2 attached), with the images from the patient from the last exam, labeled on the image that was not closed. Now you have to take time before you can even start YOUR ultrasound exam. It is this variation from machine homeostasis, a steady-state of readiness for the next operator, that was the impetus for CLEAR. How can the last operator help the next operator? CLEAR!Figure 1. Curvilinear probe with left over gel

The 20th-century paradigm for ultrasound was a clinician ordered the exam and the patient went to a suite and a sonographer saved images and videos. That sonographer would clean their own machine between patients as there was one machine for the same operator. Their images were read by the imaging specialist and that person relayed back to the clinician the results of the imaging study. These types of ultrasound exams still occur and are billed differently. We call them comprehensive ultrasound exams or referred ultrasound exams.

In contrast, a point-of-care ultrasound (POCUS) exam finds the ultrasound equipment more portable and accessible as the price point has lowered. There is usually one machine and multiple operators who use this same machine. In each case that the operator acquires, interprets and uses the information in clinical management at the patient’s bedside without sending them to an imaging suite. The cleanliness of the machine is up to the person who used it last.

Figure 2CLEAR is the acronym and checklist for the components necessary to keep a machine in good working order for patient care. As a provider of emergency medical services and having a strong interest in ultrasound, I have seen the utility of POCUS in the medical setting. It was not called POCUS in the early days, yet machines and operators have been using, and will continue to use, ultrasound for patient care as this movement grows.

CLEAR is about machine homeostasis, ie, getting the ultrasound machine back to a steady-state to be ready for the next patient. The tagline for CLEAR or machine homeostasis is “The last operator is connected to the next operator; YOU may be the next operator.” The message that is intended is leaving the machine in good working order for the next case that needs ultrasound. CLEAR is 5 simple steps to get the machine ready for use and in good working order:

Clean – Clean the machine. In the era of COVID, this might mean twice (in the room, outside the room, and all surfaces)
Locate the machine – Is it in the correct place?
Energize – Is the machine plugged in? Are all the connections tight and working?
Augment supplies – Do you have enough gel, packets, wipes, other supplies?
Remove patient identifiers – Each case should have an accession number and other metadata, which will need to be removed from the machine before the next use. This can usually be accomplished by ending the exam and starting a new exam.

The purpose of CLEAR is to help the operator learn the steps to perform after doing the ultrasound exam.

These can be simplified as:

Clean the machine.
Locate – Put it back to where it is supposed to reside.
Energize – Plug it In!
Augment – Replace supplies, including adding gel for the next person.
Remove – Patient information. End the exam.

The time is not yet here when all patients, or at least all providers, have their own personal ultrasound machine. In the meantime, we share the machine with other doctors and nurses and others. Remember, when sharing ultrasound machines, CLEAR the machine so the next user/operator is ready to go. Our patients will be thankful, as will the next user. You may be the next user! CLEAR the machine.

To read more about CLEAR, check out the article, “CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis,” in the Journal of Ultrasound in Medicine (Prats MINelson BPGold DLBranditz LDBoulger CTBahner DP. J Ultrasound Med. 2019; 38:767–773. doi: 10.1002/jum.14757. Epub 2018 Aug 19).

 

David P. Bahner, MD, FAIUM, FAAEM, FACEP, is Professor and Director of Ultrasound in the Department of Emergency Medicine at The Ohio State University College of Medicine.

Interested in reading more tips for ultrasound use? Check out the following posts on the Scan:

 

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My Sonography Experience With COVID-19

It is been almost 5 weeks since I got infected with SARS-CoV-2 (also known as COVID-19), my life-changing experience.1

The day all started, during my night shift, I started with low-grade fever, chills, and myalgia; I did not doubt for a second that I had to have the test for SARS-CoV-2. That same day, most of my mild COVID-19 patients had these same cold-like symptoms, but some of them did not have a known epidemiological contact. Without time to have any other tests done, laboratory or X-ray, I self-quarantined at home waiting for the result. And finally, it came in the midst of the night; I received the “positive”.

In the morning, as more symptoms started to appear, headache, diarrhea, anosmia, ageusia and dry cough, it was a relief to have my hand-held ultrasound device at home. With the rush, I even left my oximeter, which measures heart rate and blood oxygen levels, in my hospital locker.

There is now growing evidence regarding the imaging findings of COVID-19, but at that time, the only studies were performed via CT scan and X-ray. With my ultrasound probe, I scanned following 8 zones (2 anterior, 2 lateral of both hemithorax) plus posterior lobes. I felt relieved (didn’t last long) to see there was a normal A-line pattern. More relief came when at some point I had a dull but constant right lower abdominal pain with normal appendix and no hydronephrosis on ultrasound.

 

What impresses most about this disease is its dynamic pattern, with sudden changes during the evolution. As my symptoms waxed and waned, so did my lung ultrasound, probably in a different manner than I would have expected. As the disease progressed, I saw all the possible lung findings, from the initial posterobasal scattered B-lines, to small pleural effusions, irregular pleural line, coalescent B-lines, and finally subpleural consolidations, especially in posterior and lateral areas. My personal impression was that I wasn’t feeling worse when I had more B-lines, but when the subpleural consolidations started to appear and spread. Each time I had new subpleural consolidations, there was a worsening in my symptoms coming: more myasthenia, cough, and diarrhea. After the second week, the subpleural consolidations were replaced by coalescent and scattered B-lines. Following that, the irregular pleural line persisted longer.

March 22 still

 

Surprisingly, during the third week, things started to worsen again, and on ultrasound there was a big consolidation appearing in one lobe, that was my sign for a therapy shift towards antibiotics.

My personal feeling is that consolidations are more reliable than just the number of B-lines, and correlated better with my symptoms. Actually, after 3 weeks from the symptom onset, after recovering and testing negative for SARS-CoV-2, I still had several areas with scattered and coalescent B-lines, as well as thickening of the pleural line. We have to be more flexible and take into account other parameters (i.e. oximetry), rather than rely solely on the number of affected areas on ultrasound, to compose the clinical picture, and influence the management.

As I remarked before, what impresses me most about this disease is the ultrasound dynamism. After having recovered, I still had new areas of thickening of pleural line that appeared in the back (asymptomatic) for the following week (4th), and almost 5 weeks after, I still had one plaque. And after 5 weeks, I am still surprised to have unnoticed findings, such as an asymptomatic pericardial effusion.

As a firm sonobeliever, I found it extremely useful to monitor my disease for sonographic progression and or resolution, and quickly detect complications. After this experience and having returned to work, I would have no excuse to irradiate my patients before scanning them, in the same way I went through.

Definitely, this experience was the best lesson I could have before returning to the trenches.

 

Yale Tung Chen, MD, PhD, is an associate professor at Universidad Alfonso X El Sabio, in Madrid, Spain. He was diagnosed with COVID-19 and shared his symptoms and ultrasound images each day on Twitter @yaletung. Follow his thread at #mycoviddiary.

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan:

The Personal Touch: The importance of human interactions in ultrasound

As I write this, the novel coronavirus COVID-19 is spreading across the globe, inciting fear and anxiety. Aside from frequent hand-washing and other routine precautions, many leaders, officials, and bloggers are advocating for limiting person-to-person contact. This has resulted in cancelation of many professional society meetings, sporting events, and social gatherings, and has stimulated new conversations regarding working from home and virtual meetings. Although these suggestions have many clear benefits (such as the decreased burden of commuting; limiting the spread of infection), there are additional reports describing the impact loss of face-to-face interactions may have on job satisfaction, workflow efficiency, and quality.Fetzer-David-14-2

The current practice of medicine, more than ever, relies on a team approach. No one individual has the time, knowledge, or experience to tackle all aspects of an individual’s care. No one is an island. Unlike many television shows that highlight a single physician performing everything from brain surgery to infectious disease testing, the reality is that we each rely on countless other members of the healthcare team. That practice of medical imaging, ultrasound, in particular, is no different. Whether we work in a radiology, cardiology or vascular, or obstetrical/gynecology practice, the team, and more importantly the relationship between team members, is paramount to an effective and impactful practice.

As a radiologist in a busy academic center, I rely on and value my personal relationship with my team of 50+ sonographers. These relationships have been facilitated by day-to-day, face-to-face interactions, allowing me to get to know the person behind the ultrasound images. These interactions foster an environment of trust. For my most experienced sonographers, my implicit trust ultimately leads to fast, efficient and precise exam interpretations, while for sonographers I rarely work with, my index of suspicion regarding a finding is naturally heightened, impacting my confidence in my diagnosis and thus affecting my interpretation, and ultimately how my report drives patient care.

The trust goes both ways: a strong relationship also fosters honest communication whereby sonographers can come to me with questions or concerns regarding exam appropriateness, adjustments to imaging protocols, and the relevance of a specific imaging finding. The direct interaction provides an opportunity for sonographers, new and experienced, to be provided immediate direct feedback regarding their study—they can learn from me, and often I from them, making us all that much better at the end of the workday.

In addition to trust, open communication allows for users of ultrasound to take advantage of one of the key differentiating features of ultrasound compared to other modalities: the dynamic, real-time nature of image acquisition. Protocol variations can be discussed on-the-fly. Preliminary findings can be shared with the interpreter, and additional images can be obtained immediately, without having to rely on call-backs, inaccurate reports, and reliance of follow up imaging (often by other modalities). This ultimately enhances patient care and decreases healthcare costs. In our practice, we have the ability to add contrast-enhanced ultrasound for an incidental finding, allowing us to make definitive diagnoses immediately, without having to recommend a CT or MRI—this would not be possible if it were not for a personalized checkout process.

We continue to hear about changes in ultrasound workflow across the country: sonographers and physicians, small groups and large, academic and private practices have all considered or have already implemented changes that minimize the communication between sonographer and study interpreter. This places more responsibility on the sonographer to function independently, and minimizes or even eliminates the opportunities for quality control and education. Sonographer notes and worksheets, and electronic QA systems, are poor substitutes for the often more nuanced human interaction. In my experience, these personal encounters enhance job satisfaction, and the lack of it risks stagnating learning and personal drive. There have been many sonographers that have left local practices to join our medical center specifically to take advantage of the sonographer-radiologist interaction we continue to nurture.

Some elements driving these transformations are difficult to change: growing numbers of patients; increasing reliance on medical imaging; medical group consolidation; etc. Many changes to sonographer workflow have been fueled by a focus on efficiency (decreasing scan time, improving modality turn-around times, etc.). Unfortunately, these changes have been made with little regard to how limiting team member communication impacts examination quality, job satisfaction, and patient outcomes; for those of you in a position to address workflow changes, consider these factors. For sonographers yearning for this relationship, do not be afraid to reach out to your colleagues and supervising physicians—ask questions, be curious, and engage with them. Nearly everyone appreciates a human interaction, and even the toughest personality can be cracked with a smile and some persistence. In the end, it is the human interactions and the open and honest communication that not only make us better healthcare providers but happier and healthier human beings.

 

David Fetzer, MD, is an assistant professor in the Abdominal Imaging Division, as well as is the Medical Director of Ultrasound in the Department of Radiology at the UT Southwestern Medical Center.

 

Interested in reading more about communication? Check out the following posts from the Scan:

Ultrasound in Central Vein Assessment – The Importance of Knowing

Thorough vascular assessment prior to any intravascular device insertion is of paramount importance – for both clinician and patient. It guides the clinician to evaluate the current state of vessel health, determining suitability of the veins, and to follow a pre-determined pathway that will lead to the best decision for the patient. The assessment phase alone in vascular access procedures highlights a number of important underlying anatomical structures, as there are frequently variances amongst many patient groups and it provides a platform to perform a thorough assessment of the vascular structures to evaluate vessel health, viability, size, and patency, including the location of other important and best-avoided anatomical structures – prior to performing any procedures. The success in complication-reduction alone drives the importance of patient safety and improved patient- and device-related outcomes, not to mention patient satisfaction and comfort.

Its use for assisting the proceduralist are many:

  • pre-procedural ultrasound assessment of the vascular anatomy provides a rational choice of the venous access most likely to be associated with an optimal clinical outcome;
  • real-time, ultrasound-guided puncture and cannulation of the vein reduces the risk of failure and/or damage to the surrounding structures;
  • ultrasound scan after the venipuncture allows an early/immediate detection of puncture-related complications such as pneumothorax or local hematoma;
  • ultrasound-based tip navigation verifies the proper direction of the guidewire and/or the catheter during its progression into the vasculature;
  • transthoracic echocardiography allows proper ultrasound-based tip location;
  • ultrasound is also useful for detection of late complications such as catheter-related venous thrombosis, tip migration, or fibroblastic sleeve.

A simple yet systematic approach to vessel assessment is the RaCeVA (Rapid Central Vein Assessment), a process manifested as a quick and highly effective process for performing vessel assessment in a compelling and methodical approach. It allows a systematic approach to exclude venous abnormalities such as thrombosis, stenosis, external compression, and anatomical variations of size and shapes; it also allows a full anatomic evaluation for optimum site selection and the best insertion approach for the patient. It also has many advantages: it takes only 30–40 seconds for each side, it is easy to teach, easy to learn, and it is a useful guide for a rational choice of the central vein to be accessed, in terms of patient safety and cost-effectiveness, since it helps the operator to choose the most favorable puncture site and the optimal insertion site, with an overall improvement of the clinical outcomes and patient satisfaction.

RaCeVA - table

The RaCeVA Steps

Important considerations include the following:

  1. size of the vein (internal diameter/caliber)
  2. depth of the vein (depth of target vessel from skin surface)
  3. respiratory variations (influence of respiratory cycle on vein diameter)
  4. compression by artery (influence of arterial pulsation on vein diameter)
  5. proximity to non-venous structures that must not be damaged (pleura, nerve, artery)
  6. exit site location – convenience/appropriateness in terms for best care and maintenance
Image 1

Overview of RaCeVA steps highlighting ultrasound transducer scanning points – courtesy of the author.

Utilization of the RaCeVA protocol throughout both pre- and post- device insertion stages offers multiple advantages: “before” (to define the anatomy and the best target vessel), “during” (with real-time techniques of ultrasound-guided venipuncture: short-axis in-plane, short-axis out-of-plane, long-axis in-plane), and “after” cannulation (to detect or rule out complications such as pneumothorax, malpositions, local hematoma).

 

As a tool, RaCeVA is designed (a) to teach the different ultrasound-guided approaches to the central veins, (b) to help the operator to scan systematically all possible venous options, and (c) to guide the operator in choosing the most appropriate vein to be accessed, on a rational and well-informed basis. Optimal training is mandatory, through formal programs and hands-on sessions that imply using vascular simulation phantoms – the latter being especially important for practitioners to perform repeated ultrasound-guided vascular cannulations without posing serious risks for patients and ultimately successfully transferring this practice to patients.

 

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Timothy R. Spencer, RN, DipAppSc, BHSc, ICCert, APRN, VA-BC™, is Director of Global Vascular Access, LLC, in Scottsdale, Arizona.

 

To Treat or Not to Treat – That is the Question!

What if your newborn has a patent ductus arteriosus?

Some might ask, what is a ductus arteriosus?

During fetal development, a patent ductus arteriosus (PDA, see Figure) is important for diverting well-oxygenated blood returning from the placenta past the fluid-filled lungs and directly into the systemic circulation in order to perfuse organs.

Blood Flow with Patent Ductus Arteriousus

A patent ductus arteriosus allows for diverting aortic blood to flow into the lungs and thus pressurize the pulmonary circulation as well as allow for deoxygenated blood to enter into the aortic arch if the flow is reversed. Very low birth weight infants are prone to this condition and choice of appropriate treatment is in question. Image provided by Blausen.com.(4)

In full-term newborns, the PDA closes within two days of birth by means of vasoconstriction and anatomic remodeling.(1) Or it doesn’t. In 65% of premature infants born at 30 weeks’ gestation or less, the PDA fails to close within the first 7 days.(2, 3) Therefore, the pulmonary and systemic circulations remain connected. Consequently, blood is shunted away from the general systemic circulation to the lungs and can lead to severe flow-related problems such as central nervous system ischemia and hemorrhage, necrotizing enterocolitis, and renal failure. Such a Patent Ductus Arteriosus (PDA) leads to the ultimate question of to treat or not to treat? The two schools of thought in neonatology are watchful waiting, treating with nonsteroidal anti-inflammatory drugs (NSAID) or an invasive procedure to close the ductus.

Possible concerns are multifactorial. Intervention risks side effects from medications and procedural complications. Watchful waiting risks diminished blood and oxygen supply to the brain and abdominal organs. Quantifying blood flow and oxygen supply in these fragile humans is nearly impossible, especially since most of them are actually very low birth weight babies (VLBW, i.e. <1,500 grams). They are tiny.

In rare cases, clinicians use MRI to image and quantify PDA and carotid flow. That, however, requires specialized facilities in which the neonates can remain in their protective incubators while being in the magnet.

Imagine you could use ultrasound to assess not only the PDA but also the blood flow to the brain and the abdomen. Ultrasound is the ideal modality as it is non-ionizing, can be used at the bedside and is already a part of neonatal care. Yet, assessing blood flow quantitatively using 2D pulsed-wave ultrasound has been a challenge in and of itself. It not only requires user-selected angle correction as well as lumen diameter measurements but also neglects flow outside of the 2D image plane. Others may use simple velocity measurements or surrogate markers, but those do not represent flow.

A possible solution has been proposed by our group at the University of Michigan (UM). It is using 3D ultrasound to employ Gauss’ Theorem to quantify flow. While high-frequency ultrasound is excellent for VLBW babies, imaging a 1-mm diameter PDA lumen may still be a challenge. The UM team has previously shown the benefits of 3D color flow for quantification of blood flow. We hypothesize that even a PDA lumen could be assessed accurately, despite its challenging diameter. In addition, if successful, clinicians should be able to measure flow in the PDA within 6 seconds after obtaining a cross-sectional color flow image of the PDA with minimal to no user dependence. This presupposes a 2D matrix array capable of recording 5 color flow volumes per second.

In an American Society of Echocardiography (ASE) and AIUM co-sponsored investigation (E21 and EER funding), we will assess the effects of PDAs before and after treatment. Baseline blood flow for cardiac output, total brain blood flow, blood flow to the small intestines, and renal blood flow will be determined in full-term healthy neonates. An inter- and intraoperator variability study will be employed to warrant scientific rigor and target an end-organ flow estimation with <10% variation for test-retest and <10% between operators. Blood flow measurements in VLBW cohorts scheduled for intervention will yield estimates before and after intervention and thus provide insight in the predictive value for this method.

The ultimate goal is that 3D ultrasound will help caregivers to determine if adequate flow to end organs exists and if intervention is required. Furthermore, stable and unstable VLBW cohorts can possibly be differentiated by their flow to end organs and through the PDA. Thus, answering the question of whether to treat or not to treat.

Principle Investigators: Oliver D. Kripfgans, Ph.D. and Jonathan M. Rubin, M.D., Ph.D.
Co-Investigators: Gary Weiner, M.D. and Marjorie C. Treadwell, M.D.

References:

  1. Deshpande P, Baczynski M, McNamara PJ, Jain A. Patent ductus arteriosus: The physiology of transition. Semin Fetal Neonatal Med 2018;23(4):225–231. doi: 10.1016/j.siny.2018.05.001
  2. Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol 2012;36(2):123–129. doi: 10.1053/j.semperi.2011.09.022
  3. Egbe A, Uppu S, Stroustrup A, Lee S, Ho D, Srivastava S. Incidences and sociodemographics of specific congenital heart diseases in the United States of America: an evaluation of hospital discharge diagnoses. Pediatr Cardiol 2014;35(6):975–982. doi: 10.1007/s00246-014-0884-8
  4. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

 

Oliver D. Kripfgans, PhD, FAIUM, is a Research Associate Professor in the Department of Radiology at the University of Michigan. Jonathan Rubin, MD, PhD, FAIUM, is a Professor Emeritus in the Department of Radiology at the University of Michigan.

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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A Major Boon for Physical Therapy

As a second-year physical therapy (PT) student, I was first introduced to ultrasound for musculoskeletal conditions in 2009.

I was immediately intrigued.Headshot

I continued to dabble in musculoskeletal ultrasound (MSKUS) for a couple of years but never really with a focus on becoming good or great at the skill, more on the emphasis of becoming more knowledgeable and comfortable with human anatomy (ie, looking at muscle pennate structure, fibrillar patterns of tendons and ligaments, and identifying what they were).

Then, in 2011, I sought out a mentor for MSK ultrasound whom I had known since PT school, Wayne Smith, who is also a physical therapist with 40 years of experience. Wayne has been doing MSKUS since 2000 and in 2011 was working at Andrews Institute with Josh Hackel in the physical therapy department.

Soon after starting the training, Wayne and I collaborated with my PT clinic owner to help create a physical medicine model combining physiatry with physical therapy; MSKUS was a large piece of this model.

We quickly realized how powerful MSKUS had become and that it had turned into a gatekeeper and point-of-care diagnostic tool. MSK ultrasound is a great adjunct to evaluating a patient at time zero and in the hands of qualified physical therapists with requisite training. MSKUS allowed the clinic to execute and expedite patient plan of care by immediately cutting out unnecessary imaging studies (MRI mainly), streamlining physical therapy plans, aiding the physician with percutaneous-ultrasound-guided needle procedures, and/or immediate referral for surgical consult or advanced imaging if needed.

At this time, the RMSK exam was not on my radar so the training was piecemeal; I made the most out of my time to train with Wayne every 6 weeks while practicing and reading Jon Jacobsen’s Fundamentals of Musculoskeletal Ultrasound book.

In 2014, I took on a part-time trial with an orthopedic surgeon performing MSKUS in his office as well as physical therapy services consisting of evaluation, therapeutic exercise, and home exercise prescription. This business model became very successful and super-charged my learning in MSK ultrasound because I was now able to get feedback not only with other imaging studies, such as MRI, but I was then able to synergize findings in surgery that were based on the MSKUS imaging studies (ie, bursal sided rotator cuff tear vs intrasubstance). This feedback was very valuable and accelerated my learning curve. This orthopedic clinic is now an AIUM-accredited diagnostic center in MSK ultrasound within the state of Arizona.

In the medical model or in a stand-alone outpatient physical therapy practice, incorporating orthopedic physical therapy evaluation, MSK ultrasound evaluation combined with exercise prescription is a very powerful visit for the patient. It cuts out unnecessary imaging, saving the patient money and additional timely medical visits as well as expediting the patient’s plan of care. I’ve since incorporated this business model to many other physician offices in the greater Phoenix area.

Incorporating MSKUS into physical therapy has been a major boon for the profession and for the medical community in general.

My workweek now consists 100% of performing MSKUS scans, teaching at A.T. Still University (Mesa), starting up an online MSKUS training program, and mentoring physical therapists, athletic trainers, general sonographers, and radiology technicians in the field of musculoskeletal ultrasound in their preparation to take the RMSK or RMSKS certification exam.

Interested in reading more about how ultrasound can change physical therapy? Check out Carrie Pagliano’s post, Real-time Ultrasound in Physical Therapy.

Colin Thomas Rigney, PT, DPT, OCS, RMSK, is the Director of MSK Ultrasound for Physicians United as well as a member of both the Residential and Post-Professional Doctor of Physical Therapy Degree Faculty at A.T. Still University in Mesa, Arizona, teaching courses on Radiology and Imaging for Physical Therapy students.

 

Have you incorporated musculoskeletal ultrasound in your physical therapy practice? What benefits have you experienced? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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POCUS: A Holiday in the Sun

Getting started with point-of-care ultrasound (POCUS) is like taking a vacation in Bali, Bermuda, or the Bahamas.  Let’s say you’ve landed in an exotic destination and plan to rent a car to explore the island. After collecting your keys, what’s next? Jump in the vehicle and peel off to the beach? Of course not – you’ll take a minute to consider the controls of your car, where you’re going, and how you’ll get there. POCUS is no different from a dream island visit.

Mackenzie headshot 2

In an unfamiliar vehicle, it’s normal to become acquainted with the controls. You want to know how to turn on the car’s lights and wipers and position the mirrors and windows appropriately. There’s a direct analog in performing a POCUS study. The operator has to select the correct transducer and examination preset before getting started. If it’s a machine you’re not familiar with, you need to take a moment to locate essential controls such as depth and gain. Even if the machine is familiar, you need to optimize those settings to ensure you can obtain quality images, just as you would with the mirrors in your car.

It’s also second-hand nature to adjust a car for comfort. The seats and steering wheel need to be positioned so you have a comfortable trip, and the climate settings arranged for passenger comfort. For a successful POCUS scan, the same steps should happen. Both the operator and the patient should be comfortable and positioned correctly. That means adjusting the bed, lowering the side rails, and placing the patient and machine where you can obtain adequate images while ensuring no one has to be a contortionist.

Taking a car on the road on unfamiliar roads can be stressful, and more so if you’re not used to driving on the left. If driving on the opposite side of the road is unfamiliar, it’s smart to visualize how you will be oriented on the road and during turns before heading out on the road. Successful POCUS users have the same habit: they understand where the indicator marker is on both the screen and the transducer before acquiring images. Failing to do so leads to confusion and a breakdown of pattern recognition, just as driving on the left might.

With the car and orientation controls sorted, you’re still not going to fire up the engine yet. Most travelers take a moment to figure out where they’re headed, with a GPS or map. The sonologist needs to take the same step, remembering the focused question they’re trying to answer with the POCUS study, and what they need to see to be satisfied. While you might be happy to ramble aimlessly in a car, POCUS scans should stay focused.

Of course, this assumes that renting a car is the best way to get around the island. Maybe you’d be better served by a taxi, bus, or boat. Or maybe after seeing the rental vehicle, you decide the car can’t accommodate your plans. In the same vein, not all clinical questions can be answered with POCUS. An alternative imaging modality or comprehensive ultrasound may be the test you need, and it’s OK to change your mind and decide you need something else after you perform the scan.

POCUS is rewarding and helps both clinicians and patients, but isn’t always easy. Think of POCUS like the start of a vacation, and you may find your studies are easier, and a bit closer to a holiday in the sun.

 

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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David Mackenzie, MDCM, is an emergency physician at Maine Medical Center, in Portland, Maine. Follow Dr Mackenzie on Twitter @mackendc.

The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound

Peripheral Vascular Disease (PVD) in the United States affects approximately 8 million to 12 million patients a year; some experts in the field believe this number may be underestimated. The disease is associated with significant cardiovascular morbidity and mortality, with a high rate of fatal and non-fatal cardiovascular events, such as myocardial infarction, stroke, renal failure, limb amputations, abdominal aortic aneurysms, pulmonary embolus, and progressive ischemic end-organ dysfunction. The reduction in quality of life from global vasculopathy in many patients can thus be significant.

George Berdejo

George Berdejo, BA, RVT, FSVU

Prompt and accurate diagnosis of these disease processes is of utmost importance and high-quality vascular ultrasound plays an essential role. In fact, vascular ultrasound and the role of the vascular ultrasound professional has evolved and expanded rapidly and is at the core of modern vascular disease care in the United States and is emerging around the world.

Vascular ultrasound can be seen at the intersection of imaging, physiology, physiopathology, interventional medicine, and surgery and is utilized widely by healthcare providers from many specialties, including but not limited to vascular technologists and other subspecialty sonographers, vascular surgeons, vascular interventional radiologists, vascular medicine physicians, cardiologists, radiologists, and other vascular specialists with an interest in vascular disease.

At the core of any thriving vascular surgery practice is high-quality vascular ultrasound imaging. Duplex vascular ultrasound (DU) is used to evaluate all of the major vascular beds outside of the heart. The use of duplex ultrasonography for the study of vascular disease is firmly established but is also rapidly expanding. Thanks to continued improvements in the performance of ultrasound devices, vascular ultrasound can be used to perform a greater range of assessments in a noninvasive manner in some cases excluding the need for more invasive, expensive, contrast-based imaging modalities.

The recent proliferation of “less and minimally invasive” endovascular options currently available and offered to patients with various vascular disease processes has mandated better, less invasive, preferably noninvasive methods, to diagnose the disease that is being treated. Advances in technology have increased the diagnostic capabilities of vascular ultrasound and its role not only in diagnosis but also in planning and performing interventions and in patient follow-up and surveillance after intervention. Indeed, vascular ultrasound has become the standard “go-to” diagnostic imaging technique prior to most vascular interventions and has certainly emerged as the imaging technique of choice for following patients after most vascular interventions.

Endograft Evaluation. Duplex vascular ultrasound has emerged as the standard of care for surveillance after endovascular repair of abdominal aortic aneurysms. A major complication of this procedure is endoleak (persistent or recurrent flow within and pressurization of the residual aneurysm sac). This results in persistent risk of aneurysm rupture and potential death. Ultrasound assessment allows imaging and Doppler interrogation of deep structures and low-flow detection capabilities needed in patients with low-volume/low-velocity endoleak. Duplex vascular ultrasound, in good hands, has supplanted computed tomographic angiography as the primary surveillance technique in these patients. In addition, DU allows for the ability to resolve the deep structures of the abdomen to measure aneurysm sac size.

Hemodialysis Access Mapping and Surveillance. Higher frequency, better resolution, smaller footprint transducers that are currently available provide the high-resolution images that are needed to assess the veins and arteries of the upper extremity in order to plan the optimal access sites and also to provide the surveillance often needed postoperatively in order to maximize the life of the access and the quality of life for the dialysis patient.

Lower Extremity Vein Reflux Testing. Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. An estimated 40 percent of people in the United States have CVI. The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. Duplex ultrasound is integral in the evaluation, treatment and follow-up of these patients. Absent the appropriate equipment, the initial duplex reflux scan is among the most physically challenging, labor-intensive scans performed in vascular ultrasound. These exams account for 20%–25% of all the ultrasound scans performed in our practice.

Lower Extremity Arterial Mapping. Our philosophy regarding the practical evaluation of patients with known peripheral arterial disease who require intervention includes the use of duplex ultrasound as the primary first-line imaging modality precluding the use of more expensive, invasive, and nephrotoxic diagnostic arteriography in most patients.

Vascular ultrasound is now being used by increasing numbers of specialists who are employing both traditional and newer cutting-edge methods and techniques to improve patient care and management and who are dedicated to the delivery of quality care to their patients.

The future is bright for both vascular ultrasound and the vascular sonography professional!

 

Do you have any tips for performing vascular ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

 

 

George Berdejo, BA, RVT, FSVU, is Director of Vascular Ultrasound Outpatient Services at White Plains Hospital in White Plains, New York. He is the Chair of the AVIDsymposium (www.AVIDsymposium.org) and is the current Chair of the Cardiovascular Community of the AIUM.