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Time to establish pillars in point-of-care ultrasound
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Ultrasound in Medicine & Biology
there are concerns that it will divert attention and resources in a packed curriculum, the interactive nature of ultrasound training, its direct correlation with anatomy, integration with clinical scenarios, makes it a powerful tool to potentially enhance clinical teaching.
How we create sound for ultrasound imaging is changing - will these changes improve patient care? Kevin Rooker CIVCO Medical Solutions, Coralville, Iowa, USA For more than 5 decades, we have created sound for use in diagnostic imaging by using transducers that utilize piezoelectric crystals. Over time, this has limited advancements in improved detail resolution. Newer technologies have been developed, such as single crystal technology and the use of silicone chips to create sound. These newer technologies allow for virtual beam forming that has led to dramatic increases in overall image resolution, including improvements in temporal resolution (frame rates). Virtual beam-forming significantly improves nearly every aspect of sonographic, anatomic imaging and Doppler motion detection and spectral presentation. These improvements will ultimately improve patient care by enhancing image quality thus leading to better diagnosis and treatments. References: 1. Kremkau, F. W. (2018). The New Paradigm for Understanding, Teaching, and Testing Sonographic Principles. Journal for Vascular Ultrasound, 42(4), 198 202.
Understanding the processes that contribute to a sonographer’s professional identity and role in communication in obstetric ultrasound Samantha Thomas Sydney University, Lidcombe, NSW, Australia Introduction/Aim: Sonography as a profession has developed through the evolution of ultrasound technological advancements over 50 years 1. The traditional role of a sonographer was technical with image taking, similar to radiography, followed later by a sonologist diagnosis and report. However, with the advent of real time scanning a sonographer must now identify, image and diagnose adverse findings whilst performing the scan. A sonographer’s professional identity develops over time 2. Many factors are critical in shaping this identity and it is an ongoing process as a result of multiple discourses with patients, sonologists, sonographers, the social environment, education and other professional interactions 3. Sonographers’ concept of their professional role has changed over time with many believing they are more autonomous and active in patient communication. However, a sonographer’s role within the Australian obstetric model of communication with pregnant patients is ambiguous 4,5. Our aim for the study was to: Explore the role of sonographers in communicating findings directly with pregnant patients Understand sonographers’ perception of their own professional identity Investigate the processes that shape a sonographer’s sense of self Method: An online survey of Australasian Sonographer’s Association members (n=249) with experience in obstetric ultrasound and follow up interviews with six sonographers. Results: Sonographers believe they have an important role in maintaining a pregnant patient’s trust. Open communication about the results at the time of the scan was preferred by most sonographers, however,
Volume 45, Number S1, 2019 there were some sonographers who did not want to take on the responsibility of communication and believed it was the sonologist’s role. The professional culture of medical authority affects a sonographer’s sense of self and professional identity. Most sonographers want empowerment and autonomy in the team. Variations in professional identity varied due to a number of factors which include the sonographer and sonologist relationship, training in how to communicate findings, lack of national policies and guidelines. and critical incidents. Sonographers found communication stressful without support from sonologists and professional bodies. Conclusion: There is confusion within the profession of what a sonographer’s role entails and the sense of their true professional identity. A collaborative approach by professional bodies to break down the barriers of interprofessional tensions will improve acceptance of a sonographer’s important but complex role in obstetric communication.
Time to establish pillars in point-of-care ultrasound Carolynne J. Cormack,1 Anthony M. Wald,2 Peter R. Coombs,1,3 Leah Kallos,1 Gabriel E. Blecher4,5 1 Monash Imaging, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia, 2 Monash Heart, Monash Health, Clayton, VIC, Australia, 3 Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, VIC, Australia, 4 Monash Medical Centre, Emergency Program, Monash Health, Melbourne, VIC, Australia, 5 Monash Emergency Research Collaborative, School of clinical sciences at Monash Health, Monash University, Clayton, VIC, Australia Point of Care Ultrasound (PoCUS) has evolved rapidly over the past two decades and been adopted by many medical specialities, none more so than emergency and critical care physicians. There are significant benefits in both rapid bedside ultrasound diagnosis and safe procedural guidance. It is, however, our opinion that comprehensive and collaborative PoCUS frameworks are essential to ensure the highest standards of clinical quality and safety. Emphasis is frequently placed upon PoCUS education without adequate governance, infrastructure, administration and quality assurance processes put in place to support this education. We propose five essential pillars of PoCUS based upon experience establishing a collaborative PoCUS program for emergency and critical care physicians in a sizeable tertiary teaching hospital network. The five pillars are defined as governance, infrastructure, administration, education and quality. References: 1. Kendall J, Hoffenberg S, Smith R. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med 2007;35(5):126 30. 2. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364: 749 57. 3. Stawicki SP, Bahner DP. Modern sonology and the bedside practitioner: evolution of ultrasound from curious novelty to essential clinical tool. Eur J Trauma Emerg Surg 2015; 41: 457 60. 4. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside physical examination: inspection, palpation, percussion, auscultation, and insonation. JAMA Cardiol 2018; 3: 346 50. 5. ACEP Policy Statement. Ultrasound guidelines: emergency, pointof- care and clinical ultrasound guidelines in medicine. Ann Emerg Med 2017; 69: e27 54. 6. Strony R, Marin J, Bailitz J, Dean A, Blaivas M, Tayal V, et al. Systemwide clinical ultrasound program development: an expert consensus model. WestJEM 2018; 19(4): 649 53.
Abstracts 7. Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. Perspectives on Safety 2018. Available from: https://psnet.ahrq.gov/perspectives/perspective/251/safety considerations-in-building-a-point-of-care-ultrasound-program?q= moore+program. Accessed 27-August-2018. 8. Cormack C, Coombs P, Guskich K, Blecher GE, Goldie N, Ptasznik R. A collaborative model for training and credentialing point of care ultrasound: six year experience and quality outcomes. JMIRO 2018; 62: 330 6.
SESSION 14I: PAEDIATRICS Thoracic US - Technique and pathology Christoph F. Dietrich, Dagmar Schreiber-Dietrich Caritas Krankenhaus Bad Mergentheim, Uhlandstr. 7, 97980 Bad Mergentheim The value of ultrasound techniques in the examination of the pleura and lungs has been underestimated over the recent decades, which is especially true for children. However, a variety of pathologies of the chest wall, pleura, and lungs result in altered tissue composition, providing sufficient access and visibility for ultrasound examination. Ultrasound of pleura and lungs can be noninvasively imaged repeatedly without radiation exposure for the pediatric patient. Ultrasound is thus particularly valuable in the follow-up of disease, differential diagnosis, and detection of complications. The use of CEUS in children has not been comprehensively described. However, there are reports that suggest that CEUS may improve the diagnostic confidence of grey scale US supplemented by colour and power Doppler imaging in differentiating consolidated lung from cavitating pneumonia in children, and better delineating the extent and contents of associated para-pneumonic fluid collections. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can safely be performed under realtime ultrasound guidance. In this presentation, an overview is given presenting not only the benefits and indications but also the limitations of pleural and pulmonary ultrasound. References: 1. Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365. 2. Sidhu PS, Cantisani V, Deganello A, Dietrich CF, Duran C, Franke D, Harkanyi Z, et al. Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement. Ultraschall Med 2017;38:33-43. 3. Dietrich CF, Goudie A, Chiorean L, Cui XW, Gilja OH, Dong Y, Abramowicz JS, et al. Point of Care Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol 2017;43:49-58.
Blueberries vs melons paediatric and adolescent breast ultrasound Sara Kernick Tutor Sonographer, Royal Childrens Hospital, Melbourne, VIC, Australia Ultrasound of the paediatric breast is requested for many reasons. Knowledge of the normal developmental appearance of the breast is important to allow differentiation from pathology this can obviate the need for unnecessary, potentially damaging interventions. Paediatric and adolescent breast pathologies differ greatly to adult pathologies in type and incidence. Ultrasound can, with clinical correlation, assist greatly in the differentiation and diagnosis of many pubertal conditions.
S75
AI augmented 3D ultrasound for hip dysplasia Jeevesh Kapur Assistant Professor, National University Hospital, Diagnostic Imaging, Singapore Developmental dysplasia of the hip (DDH) is a congenital deformity occurring in »3% of infants. If hip dysplasia is diagnosed early simple corrections using a soft cast are sufficient but if missed it can lead to premature osteoarthritis and might require surgical intervention. More than one-third of hip replacement procedures in the less than sixty age-group can be attributed to undiagnosed hip dysplasia. Early and accurate diagnosis of hip dysplasia reduces medical costs resulting from multiple surgeries and repeated hospital visits. DDH is currently diagnosed by 2D ultrasound scanning and physical examination of the hip joint. However, current methods used for hip dysplasia diagnosis have limitations mainly due to 1) high variability in manual interpretation, 2) lack of complete visualization of the hip from 2D ultrasound and 3) lack of medical expertise in remote health care centers. Clinical studies have also shown that 2D alpha angle measurements vary in 50% of infants with minor changes in probe orientation. Recent studies show that using 3D ultrasound can reduce the need for follow-up by one-third in comparison to 2D ultrasound. Artificial Intelligence (AI) based techniques have recently shown promise in automatically interpreting 2D and 3D hip ultrasound images. AI also enables quick computation of novel indices like the rounding index that quantifies roundedness of the hip joint. These measures can be combined with conventional measures (like the alpha angle) to provide higher diagnostic accuracy. Overall, AI-based computer-aided diagnosis (CAD) systems could potentially eliminate interobserver variability and significantly reduce expert time in hip dysplasia examination.
US evaluation of the child and adolescent with gynaecological problems Kate Stone Consultant Sonologist, Mercy Hospital for Women, Heidelberg, VIC, Australia This talk will focus on the approach to imaging in this group of patients. The role of ultrasound, its limitations and important considerations in this group of patients will be discussed.
SESSION 15A: MSK & RHEUMATOLOGY Scanning the wrist for ligament injuries Le-Anne Grimshaw Sonographer, Castaways Beach, QLD, Australia To understand the pathology which may occur following an injury to the wrist, this presentation will review the anatomy and biomechanics of this joint. The biomechanics of wrist injuries are as follows Weightbearing injuries which may be sustained weightlifting or in gymnastics where there is increased axial loading or where the wrist is extended and radially deviated, may result in volar carpal ligament injuries. Twisting injuries during wrestling and again gymnastics where there is excessive pronation or supination of the wrist may affect the TFCC. Impact injuries such as a fall onto the outstretched hand - FOOSH can result in scapho-lunate, lunotriquetral and or palmar radiocarpal ligament rupture, a TFCC tear or a strain of the dorsal radiocarpal ligament. (Anderson, Read, 2008)
Ultrasound in Medicine & Biology
there are concerns that it will divert attention and resources in a packed curriculum, the interactive nature of ultrasound training, its direct correlation with anatomy, integration with clinical scenarios, makes it a powerful tool to potentially enhance clinical teaching.
How we create sound for ultrasound imaging is changing - will these changes improve patient care? Kevin Rooker CIVCO Medical Solutions, Coralville, Iowa, USA For more than 5 decades, we have created sound for use in diagnostic imaging by using transducers that utilize piezoelectric crystals. Over time, this has limited advancements in improved detail resolution. Newer technologies have been developed, such as single crystal technology and the use of silicone chips to create sound. These newer technologies allow for virtual beam forming that has led to dramatic increases in overall image resolution, including improvements in temporal resolution (frame rates). Virtual beam-forming significantly improves nearly every aspect of sonographic, anatomic imaging and Doppler motion detection and spectral presentation. These improvements will ultimately improve patient care by enhancing image quality thus leading to better diagnosis and treatments. References: 1. Kremkau, F. W. (2018). The New Paradigm for Understanding, Teaching, and Testing Sonographic Principles. Journal for Vascular Ultrasound, 42(4), 198 202.
Understanding the processes that contribute to a sonographer’s professional identity and role in communication in obstetric ultrasound Samantha Thomas Sydney University, Lidcombe, NSW, Australia Introduction/Aim: Sonography as a profession has developed through the evolution of ultrasound technological advancements over 50 years 1. The traditional role of a sonographer was technical with image taking, similar to radiography, followed later by a sonologist diagnosis and report. However, with the advent of real time scanning a sonographer must now identify, image and diagnose adverse findings whilst performing the scan. A sonographer’s professional identity develops over time 2. Many factors are critical in shaping this identity and it is an ongoing process as a result of multiple discourses with patients, sonologists, sonographers, the social environment, education and other professional interactions 3. Sonographers’ concept of their professional role has changed over time with many believing they are more autonomous and active in patient communication. However, a sonographer’s role within the Australian obstetric model of communication with pregnant patients is ambiguous 4,5. Our aim for the study was to: Explore the role of sonographers in communicating findings directly with pregnant patients Understand sonographers’ perception of their own professional identity Investigate the processes that shape a sonographer’s sense of self Method: An online survey of Australasian Sonographer’s Association members (n=249) with experience in obstetric ultrasound and follow up interviews with six sonographers. Results: Sonographers believe they have an important role in maintaining a pregnant patient’s trust. Open communication about the results at the time of the scan was preferred by most sonographers, however,
Volume 45, Number S1, 2019 there were some sonographers who did not want to take on the responsibility of communication and believed it was the sonologist’s role. The professional culture of medical authority affects a sonographer’s sense of self and professional identity. Most sonographers want empowerment and autonomy in the team. Variations in professional identity varied due to a number of factors which include the sonographer and sonologist relationship, training in how to communicate findings, lack of national policies and guidelines. and critical incidents. Sonographers found communication stressful without support from sonologists and professional bodies. Conclusion: There is confusion within the profession of what a sonographer’s role entails and the sense of their true professional identity. A collaborative approach by professional bodies to break down the barriers of interprofessional tensions will improve acceptance of a sonographer’s important but complex role in obstetric communication.
Time to establish pillars in point-of-care ultrasound Carolynne J. Cormack,1 Anthony M. Wald,2 Peter R. Coombs,1,3 Leah Kallos,1 Gabriel E. Blecher4,5 1 Monash Imaging, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia, 2 Monash Heart, Monash Health, Clayton, VIC, Australia, 3 Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, VIC, Australia, 4 Monash Medical Centre, Emergency Program, Monash Health, Melbourne, VIC, Australia, 5 Monash Emergency Research Collaborative, School of clinical sciences at Monash Health, Monash University, Clayton, VIC, Australia Point of Care Ultrasound (PoCUS) has evolved rapidly over the past two decades and been adopted by many medical specialities, none more so than emergency and critical care physicians. There are significant benefits in both rapid bedside ultrasound diagnosis and safe procedural guidance. It is, however, our opinion that comprehensive and collaborative PoCUS frameworks are essential to ensure the highest standards of clinical quality and safety. Emphasis is frequently placed upon PoCUS education without adequate governance, infrastructure, administration and quality assurance processes put in place to support this education. We propose five essential pillars of PoCUS based upon experience establishing a collaborative PoCUS program for emergency and critical care physicians in a sizeable tertiary teaching hospital network. The five pillars are defined as governance, infrastructure, administration, education and quality. References: 1. Kendall J, Hoffenberg S, Smith R. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med 2007;35(5):126 30. 2. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364: 749 57. 3. Stawicki SP, Bahner DP. Modern sonology and the bedside practitioner: evolution of ultrasound from curious novelty to essential clinical tool. Eur J Trauma Emerg Surg 2015; 41: 457 60. 4. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside physical examination: inspection, palpation, percussion, auscultation, and insonation. JAMA Cardiol 2018; 3: 346 50. 5. ACEP Policy Statement. Ultrasound guidelines: emergency, pointof- care and clinical ultrasound guidelines in medicine. Ann Emerg Med 2017; 69: e27 54. 6. Strony R, Marin J, Bailitz J, Dean A, Blaivas M, Tayal V, et al. Systemwide clinical ultrasound program development: an expert consensus model. WestJEM 2018; 19(4): 649 53.
Abstracts 7. Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. Perspectives on Safety 2018. Available from: https://psnet.ahrq.gov/perspectives/perspective/251/safety considerations-in-building-a-point-of-care-ultrasound-program?q= moore+program. Accessed 27-August-2018. 8. Cormack C, Coombs P, Guskich K, Blecher GE, Goldie N, Ptasznik R. A collaborative model for training and credentialing point of care ultrasound: six year experience and quality outcomes. JMIRO 2018; 62: 330 6.
SESSION 14I: PAEDIATRICS Thoracic US - Technique and pathology Christoph F. Dietrich, Dagmar Schreiber-Dietrich Caritas Krankenhaus Bad Mergentheim, Uhlandstr. 7, 97980 Bad Mergentheim The value of ultrasound techniques in the examination of the pleura and lungs has been underestimated over the recent decades, which is especially true for children. However, a variety of pathologies of the chest wall, pleura, and lungs result in altered tissue composition, providing sufficient access and visibility for ultrasound examination. Ultrasound of pleura and lungs can be noninvasively imaged repeatedly without radiation exposure for the pediatric patient. Ultrasound is thus particularly valuable in the follow-up of disease, differential diagnosis, and detection of complications. The use of CEUS in children has not been comprehensively described. However, there are reports that suggest that CEUS may improve the diagnostic confidence of grey scale US supplemented by colour and power Doppler imaging in differentiating consolidated lung from cavitating pneumonia in children, and better delineating the extent and contents of associated para-pneumonic fluid collections. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can safely be performed under realtime ultrasound guidance. In this presentation, an overview is given presenting not only the benefits and indications but also the limitations of pleural and pulmonary ultrasound. References: 1. Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365. 2. Sidhu PS, Cantisani V, Deganello A, Dietrich CF, Duran C, Franke D, Harkanyi Z, et al. Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement. Ultraschall Med 2017;38:33-43. 3. Dietrich CF, Goudie A, Chiorean L, Cui XW, Gilja OH, Dong Y, Abramowicz JS, et al. Point of Care Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol 2017;43:49-58.
Blueberries vs melons paediatric and adolescent breast ultrasound Sara Kernick Tutor Sonographer, Royal Childrens Hospital, Melbourne, VIC, Australia Ultrasound of the paediatric breast is requested for many reasons. Knowledge of the normal developmental appearance of the breast is important to allow differentiation from pathology this can obviate the need for unnecessary, potentially damaging interventions. Paediatric and adolescent breast pathologies differ greatly to adult pathologies in type and incidence. Ultrasound can, with clinical correlation, assist greatly in the differentiation and diagnosis of many pubertal conditions.
S75
AI augmented 3D ultrasound for hip dysplasia Jeevesh Kapur Assistant Professor, National University Hospital, Diagnostic Imaging, Singapore Developmental dysplasia of the hip (DDH) is a congenital deformity occurring in »3% of infants. If hip dysplasia is diagnosed early simple corrections using a soft cast are sufficient but if missed it can lead to premature osteoarthritis and might require surgical intervention. More than one-third of hip replacement procedures in the less than sixty age-group can be attributed to undiagnosed hip dysplasia. Early and accurate diagnosis of hip dysplasia reduces medical costs resulting from multiple surgeries and repeated hospital visits. DDH is currently diagnosed by 2D ultrasound scanning and physical examination of the hip joint. However, current methods used for hip dysplasia diagnosis have limitations mainly due to 1) high variability in manual interpretation, 2) lack of complete visualization of the hip from 2D ultrasound and 3) lack of medical expertise in remote health care centers. Clinical studies have also shown that 2D alpha angle measurements vary in 50% of infants with minor changes in probe orientation. Recent studies show that using 3D ultrasound can reduce the need for follow-up by one-third in comparison to 2D ultrasound. Artificial Intelligence (AI) based techniques have recently shown promise in automatically interpreting 2D and 3D hip ultrasound images. AI also enables quick computation of novel indices like the rounding index that quantifies roundedness of the hip joint. These measures can be combined with conventional measures (like the alpha angle) to provide higher diagnostic accuracy. Overall, AI-based computer-aided diagnosis (CAD) systems could potentially eliminate interobserver variability and significantly reduce expert time in hip dysplasia examination.
US evaluation of the child and adolescent with gynaecological problems Kate Stone Consultant Sonologist, Mercy Hospital for Women, Heidelberg, VIC, Australia This talk will focus on the approach to imaging in this group of patients. The role of ultrasound, its limitations and important considerations in this group of patients will be discussed.
SESSION 15A: MSK & RHEUMATOLOGY Scanning the wrist for ligament injuries Le-Anne Grimshaw Sonographer, Castaways Beach, QLD, Australia To understand the pathology which may occur following an injury to the wrist, this presentation will review the anatomy and biomechanics of this joint. The biomechanics of wrist injuries are as follows Weightbearing injuries which may be sustained weightlifting or in gymnastics where there is increased axial loading or where the wrist is extended and radially deviated, may result in volar carpal ligament injuries. Twisting injuries during wrestling and again gymnastics where there is excessive pronation or supination of the wrist may affect the TFCC. Impact injuries such as a fall onto the outstretched hand - FOOSH can result in scapho-lunate, lunotriquetral and or palmar radiocarpal ligament rupture, a TFCC tear or a strain of the dorsal radiocarpal ligament. (Anderson, Read, 2008)