Category Archives: AIUM

Musculoskeletal Ultrasound: Improving Patient Care in Real-Time

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The ability to diagnose and treat musculoskeletal (MSK) conditions with accuracy and efficiency is crucial for both practitioners and patients. Enter musculoskeletal ultrasound, a tool that has revolutionized how we approach these challenges, offering unparalleled real-time imaging and diagnostic capabilities.

Cristy Nicole French, MD, Chair of the AIUM’s Musculoskeletal Ultrasound Community, encapsulates the essence of this powerful technology: “The real-time nature of ultrasound provides the opportunity to interact with the athlete and correlate symptoms with sonographic findings. Patients enjoy this opportunity to ‘share their story’ and often provide critical information to the diagnostic puzzle.” Her words highlight one of the key advantages of MSK ultrasound—its ability to engage patients actively in their care. The immediate feedback loop between the patient’s symptoms and the visual data from the ultrasound helps clinicians piece together the diagnostic puzzle with greater accuracy.

This sentiment is echoed by Humberto Gerardo Rosas, MD, former AIUM Musculoskeletal Ultrasound Community Chair (2019–2021). He emphasizes the indispensable nature of MSK ultrasound in modern medicine: “Musculoskeletal ultrasound has become an indispensable tool in diagnosing and treating musculoskeletal conditions. It provides high-resolution, real-time imaging of the muscles, nerves, tendons, and ligaments, leading to precise evaluations and accurate diagnosis at a fraction of the cost of other modalities. The dynamic capabilities, unique to ultrasound, not only improves the diagnostic accuracy and assessment of the extent of injury but also helps direct more effective and personalized treatment plans. Additionally, it allows for image-guided interventions that afford precise needle placement and medication delivery. For patients, this means quicker, more targeted interventions and better outcomes, making musculoskeletal ultrasound a vital tool in modern sports medicine and orthopedic care.”

The dynamic nature of ultrasound enhances the accuracy of diagnostics and serves as a guide for interventions, ensuring that treatments are effective and tailored to each patient’s unique needs. This level of personalized care, coupled with ultrasound’s cost-effectiveness and convenience, has made it a cornerstone of patient management in MSK medicine.

As we continue to push the boundaries of what is possible in medicine, MSK ultrasound stands out as a prime example of how technology can enhance the human element of care. By offering a window into the body that is both immediate and detailed, it enables clinicians to make informed decisions that lead to better outcomes for their patients. Whether it’s diagnosing a complex injury or guiding a precise intervention, the impact of musculoskeletal ultrasound is profound and far-reaching, cementing its place as an essential tool in the future of healthcare.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in reading more about musculoskeletal ultrasound? Check out these posts from the Scan:

The Next Frontiers of Intestinal Ultrasound for the Assessment of Inflammatory Bowel Disease (IBD): CEUS, SICUS, and Elastography

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In recent years, the utility of intestinal ultrasound (IUS) in diagnosing and managing inflammatory bowel disease (IBD) has gained substantial momentum. The Scan featured a blog post in June 2024 describing the features and uses of IUS for diagnosing and monitoring IBD. That previous article highlighted the many features that can be monitored to assess IBD disease activity and severity right at the bedside using B-mode ultrasound, highlighting that bowel wall thickness (BWT), Doppler signaling (hyperemia), loss of stratification of bowel wall layers (BWS), and peri-intestinal hyperechoic fat are important features of inflammatory on IUS.1 However, adjunct techniques, such as using contrast with ultrasound, may permit better detection of disease complications and activity, particularly in Crohn’s disease, where patients are at risk of developing intestinal strictures (narrowing), bowel perforation, and abscesses. Indeed, these advanced ultrasound techniques push the boundaries of what noninvasive imaging can offer. This blog post delves into three promising techniques—contrast-enhanced ultrasound (CEUS), small intestinal contrast-enhanced ultrasound (SICUS), and elastography—each providing new dimensions to our understanding of IBD and its management.

Contrast-Enhanced Ultrasound (CEUS): Adding Depth to Vascular Assessment

CEUS represents a significant advancement in IUS, particularly in assessing disease activity and vascularization. By injecting a contrast composed of gas-filled microbubbles stabilized by a lipid capsule into the bloodstream, CEUS enhances the visualization of bowel wall vascularity, which is a key indicator of inflammation in IBD. The evaluation relies on the dynamic assessment of the contrast uptake in areas with increased vascular activities, whose intensity can change over time.2 Although visual evaluation can demonstrate areas of activities on CEUS, advanced software is also used to generate time-intensity curves, which measure the signal intensity from the first bubble arrival in the bowel segment of interest and progressive decline in intensity (wash-out) usually over 2 minutes of image capture.3

CEUS can be used in various clinical contexts to monitor Crohn’s disease. The time-intensity curves generated by CEUS are used to calculate the signal’s peak intensity and area under the curve (AUC). Wilkens et al demonstrated that peak intensity and AUC are increased in patients with active disease as compared to controls.4 Further studies have demonstrated promising results in differentiating Crohn’s disease lesions with active inflammation instead of lesions composed predominantly of fibrostenotic tissue.5 Variations in outcomes may be related to the type of contrast used, the quantitative CEUS value of interest analyzed, and the variability in the ultrasound system and analysis software used, which are not standardized between systems.5 However, such findings may be important in predicting response to therapy instead of prioritizing surgical options, as limited data demonstrated higher inflammation quantified by CEUS had a higher response rate to therapies.6

CEUS has emerged as a valuable tool in monitoring complications of Crohn’s disease (CD), particularly in assessing the presence and extent of fistulas and abscesses. By enhancing the visibility of vascular structures and inflammatory activity, CEUS allows for the precise identification and measurement of these complications, which can be challenging to characterize with conventional imaging methods. This enhanced visualization is crucial for guiding clinical decisions, including the need for surgical intervention or adjustments in medical therapy.7

Small Intestinal Oral Contrast-Enhanced Ultrasound (SICUS): Expanding the Reach of IUS

While CEUS focuses on enhancing vascular imaging, SICUS takes a different approach by improving the visualization of the small intestine, an area notoriously difficult to image using traditional ultrasound techniques. SICUS is performed in the fasted state and involves the oral administration of a non-absorbable contrast medium, generally a polyethylene glycol solution, that distends the small bowel loops, allowing for better visualization of the bowel wall and lumen. The exam may last 30 to 45 minutes for the contrast to arrive at the areas of interest.8

This technique is particularly valuable in the assessment of small bowel CD, where skip lesions and strictures can be challenging to detect and characterize. SICUS enhances the delineation of these abnormalities, providing a clearer picture of the disease’s extent and severity. Moreover, SICUS can be employed alongside B-mode and CEUS to offer a comprehensive assessment of the small intestine. The combined use of these modalities allows for a more nuanced evaluation of both the inflammatory and structural components of the disease, leading to more informed treatment strategies.9

Elastography: A Noninvasive Window Into Fibrosis

One of the most challenging aspects of managing IBD is differentiating between inflammation and fibrosis, particularly in chronic CD, where long-standing inflammation can lead to fibrotic changes in the bowel wall. Elastography, a technique that measures tissue stiffness, is a promising solution to this issue. By applying mechanical waves to the tissue and measuring the speed at which they propagate, elastography can provide a quantitative assessment of bowel wall stiffness—a surrogate marker for fibrosis.5 Again, this is essential in predicting lesions that would be amendable to medical therapy as opposed to surgery. However, challenges exist in the assessment of the bowel using this technique, as measurements can be affected by peristalsis, and a large body habitus can impede the penetration of the sound waves. Values are not yet standardized between ultrasound systems, making the validation of specific thresholds difficult between centers.5 As research continues to validate its accuracy and reliability, elastography may become a standard tool in the long-term management of IBD.

The Future of IUS in IBD Management

The integration of CEUS, SICUS, and elastography into the IUS toolkit marks a significant step forward in the management of IBD. These advanced techniques not only enhance our ability to diagnose and monitor the disease but also provide critical insights that can tailor treatment strategies to the individual patient.

As we continue to refine these methods and validate their use in clinical practice, the future of IUS in IBD management looks promising. The ability to assess the disease’s inflammatory and fibrotic components in real-time, noninvasively, and with high accuracy will undoubtedly improve patient outcomes and quality of life. However, to move toward more widespread adoption, more training in these techniques will be necessary, and further validation of the data generated is warranted.

In conclusion, the advancements in IUS, particularly with the advent of CEUS, SICUS, and elastography, are poised to transform the landscape of IBD management. These techniques offer a more detailed and nuanced understanding of the disease, enabling us to make more informed decisions that ultimately benefit our patients. As we look to the future, the continued evolution of IUS will undoubtedly play a pivotal role in the quest for better outcomes in IBD care.

Mallory Chavannes, MD, MHSc, FRCPC, FAAP, is an Assistant Professor of Pediatrics in the Division of Gastroenterology, Hepatology, & Nutrition, and is Medical Director of the Inflammatory Bowel Disease Program, at Children’s Hospital Los Angeles.

References:

  1. Novak KL, Nylund K, Maaser C, et al. Expert consensus on optimal acquisition and development of the international bowel ultrasound segmental activity score [IBUS-SAS]: a reliability and inter-rater variability study on intestinal ultrasonography in Crohn’s disease. J Crohns Colitis 2021; 15:609–616. doi: 10.1093/ecco-jcc/jjaa216. PMID: 33098642; PMCID: PMC8023841.
  2. Pecere S, Holleran G, Ainora ME, et al. Usefulness of contrast-enhanced ultrasound (CEUS) in inflammatory bowel disease (IBD). Dig Liver Dis 2018; 50:761–767. doi: 10.1016/j.dld.2018.03.023. Epub 2018 Apr 3. PMID: 29705029.
  3. Merrill C, Wilson SR. Ultrasound of the bowel with a focus on IBD: the new best practice [published online ahead of print August 14, 2024]. Abdom Radiol (NY) doi: 10.1007/s00261-024-04496-1. PMID: 39141152.
  4. Wilkens R, Wilson A, Burns PN, Ghosh S, Wilson SR. Persistent enhancement on contrast-enhanced ultrasound studies of severe Crohn’s disease: stuck bubbles? Ultrasound Med Biol 2018; 44:2189–2198. doi: 10.1016/j.ultrasmedbio.2018.06.018. PMID: 30076030.
  5. Coelho R, Ribeiro H, Maconi G. Bowel thickening in Crohn’s disease: fibrosis or inflammation? Diagnostic ultrasound imaging tools. Inflamm Bowel Dis 2017; 23:23–34. doi: 10.1097/MIB.0000000000000997. PMID: 28002125.
  6. Quaia E, Gennari AG, Cova MA, van Beek EJR. Differentiation of inflammatory from fibrotic ileal strictures among patients with Crohn’s disease based on visual analysis: feasibility study combining conventional B-mode ultrasound, contrast-enhanced ultrasound and strain elastography. Ultrasound Med Biol 2018; 44:762–770. doi: 10.1016/j.ultrasmedbio.2017.11.015. PMID: 29331357.
  7. Pecere S, Holleran G, Ainora ME, et al. Usefulness of contrast-enhanced ultrasound (CEUS) in inflammatory bowel disease (IBD). Dig Liver Dis 2018; 50:761–767. doi: 10.1016/j.dld.2018.03.023. PMID: 29705029.
  8. Losurdo G, De Bellis M, Rima R, et al. Small intestinal contrast ultrasonography (SICUS) in Crohn’s disease: systematic review and meta-analysis. J Clin Med 2023; 12(24):7714. doi: 10.3390/jcm12247714. PMID: 38137782; PMCID: PMC10744114.

Mocci G, Migaleddu V, Cabras F, et al. SICUS and CEUS imaging in Crohn’s disease: an update. J Ultrasound 2017; 20:1–9. doi: 10.1007/s40477-016-0230-5. PMID: 28298939; PMCID: PMC5334271.

The Growing Role of Ultrasound in Addressing Complications in Aesthetic Medicine

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A patient we’ll call Janet contacted our clinic in a state of distress. What began as a seemingly benign bruise a day after her chin and jawline filler injections spread to her cheek and forehead. Subsequently, her eyelids became bruised and edematous, and purple marks appeared on her temple, tracing the path of her arteries. When she sought help from the clinic that administered the injections, the doctor was unavailable. It took days before she was finally diagnosed with vascular occlusion and began treatment, which included hyperbaric oxygen therapy, aspirin, hyaluronidase injections, and even Viagra to improve blood flow. Yet, the sinister purple marks continued to spread, and the areas remained exquisitely painful. With a growing sense of alarm, she reached out to our office.

In aesthetic medicine, few situations are true emergencies. Even with vascular occlusion, like in Janet’s case, there’s typically a treatment window of 2–3 days. However, by the time Janet reached us, that critical period had elapsed, and we found ourselves in a race against time to prevent ischemic tissue damage. Fortunately, our clinic is well equipped for such emergencies, armed with a high-resolution ultrasound device and years of experience.

Filler-related vascular occlusion, with the pain of ischemia, and subsequent treatments, along with the looming threat of facial necrosis and the anxiety over uncertain outcomes, can be a daunting experience for both practitioners and patients. In these situations, ultrasound becomes invaluable. Its ability to provide real-time visualization of affected vessels and the occlusive filler enables precise, ultrasound-guided hyaluronidase injections that dissolve the filler, improve arterial spasm, and restore blood flow. Once the occlusion is treated, Color Doppler can demonstrate immediate improvement in blood flow, correlating with clinical recovery and providing reassurance to both patients and medical practitioners.

Janet’s ultrasound exam revealed several areas of blockage along the facial arteries, with adjacent filler deposits. We found areas of decreased blood flow along the jaw, in her cheek, in the temple, and at the mandibular angle, with large deposits of anechoic hyaluronic acid filler adjacent to them. We also discovered and treated severely decreased flow in the facial vein, which likely explained the unusual periorbital edema and ecchymosis. You can see one area of compromised blood flow in Figure 1.

Figure 1

We treated these areas with ultrasound-guided hyaluronidase injections, as depicted in Figure 2.

Figure 2

By the following day, Janet’s condition had shown marked improvement, and the pain had subsided. Improved blood flow in both the facial artery and facial vein can be seen in Figure 3.

Figure 3

Over the last several years, we have witnessed an exponential increase in the number of aesthetic treatments. However, as we keep pushing the envelope to improve our patients’ results and the longevity of our treatments, we face a growing number of complications, including overfilled faces, filler malposition and migration, lumps, chronic edema, and vascular complications such as vascular occlusion, and even stroke and blindness. Vascular occlusion, one of the most dreaded filler complications, has been the main impetus behind the introduction of ultrasound into aesthetic medicine.

This process could not have come at a better time. The use of ultrasound offers a blend of opportunities and challenges that are reshaping our profession. From mastering facial anatomy and adopting safer injection techniques to managing complications more effectively, aesthetic practitioners can harness the power of ultrasound to advance their practice and patient care, refine techniques, enhance safety, and improve patient outcomes.

References:

  1. Desyatnikova S, Schelke L. Treatment of filler-related vascular occlusion using handheld portable ultrasound device. J Cosmet Dermatol 2022; 21:3166–3168. doi: 10.1111/jocd.15125.
  2. Desyatnikova S, Barrera P. High-resolution ultrasound for diagnosis and treatment of filler-related septal necrosis. Plast Reconstr Surg Glob Open 2024; 12:e5630. doi: 10.1097/GOX.0000000000005630.
  3. Choi SY, Shin SH, Seok J, Yoo KH, Kim BJ. Management strategies for vascular complications in hyaluronic acid filler injections: A case series analysis. J Cosmet Dermatol 2023; 22:3261–3267. doi: 10.1111/jocd.15990.
  4. Schelke LW, Velthuis P, Kadouch J, Swift A. Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers. J Am Acad Dermatol 2023; 88:79–85. doi: 10.1016/j.jaad.2019.07.032.

Stella Desyatnikova, MD, is a double board-certified facial plastic surgeon, with over 20 years’ experience. She is the founder of The Stella Center for Facial Plastic Surgery and the Ultrasonos Aesthetic Ultrasound Training Center in Seattle, WA. She is a leading authority in aesthetic ultrasound research and education, committed to expanding education and awareness of ultrasound use to optimize safety of aesthetic procedures. Her research is focused on filler injectable safety and facial ultrasound applications. She is the Secretary-elect of the Dermatology Community of the American Institute of Ultrasound in Medicine (AIUM). She is also an International Expert Board Member of the Complications in Medical Aesthetics Cooperative (CMAC) and a member of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

Interested in learning more? Check out the online Advanced Dermatologic Ultrasound Course on September 7–8, 2024, with renowned faculty including Stella Desyatnikova, MD.

Understanding the Basics of Medical Ultrasound Safety in Musculoskeletal Ultrasound

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Musculoskeletal ultrasound (MSK US) is an invaluable diagnostic tool that provides real-time, dynamic imaging of muscles, tendons, ligaments, joints, and soft tissues. Its advantages include being non-invasive, relatively low-cost, and free of ionizing radiation. However, to maximize its benefits and ensure patient safety, it is crucial for practitioners to understand and apply certain fundamental principles, including ALARA (As Low As Reasonably Achievable) and the Mechanical Index (MI). Here, we provide an overview of these concepts and other essential information for new users of MSK US.

ALARA Principle

The ALARA principle stands for “As Low As Reasonably Achievable” and is a cornerstone of safe ultrasound practice. It emphasizes minimizing the patient’s exposure to ultrasound energy while still obtaining the necessary diagnostic information.

Key Strategies to Apply ALARA:

1. Optimize Scanning Parameters: Use the lowest possible settings for power, gain, and exposure time that still yield diagnostic quality images. Avoid unnecessary Doppler applications, which use higher energy levels.

2. Adjust the Probe Position and Angle: Efficient probe manipulation can improve image quality without increasing power output. Use proper ergonomics to maintain consistent and effective contact with the patient’s skin.

3. Limit Scan Duration: Conduct scans efficiently to minimize exposure time. Pre-plan the examination to focus on areas of interest and avoid prolonged scanning.

By adhering to the ALARA principle, practitioners ensure that ultrasound procedures are both effective and safe.

Mechanical Index (MI)

The Mechanical Index (MI) is a parameter used to evaluate the potential for mechanical bioeffects, such as cavitation, which can occur during ultrasound procedures. It is calculated based on the peak negative pressure of the ultrasound wave and the frequency of the ultrasound.

Understanding MI Values:

  • Low MI (<0.3): Safe for sensitive tissues; minimal risk of cavitation.
  • Moderate MI (0.3–0.7): Generally considered safe for routine diagnostic imaging.
  • High MI (>0.7): Increased risk of mechanical bioeffects; should be used with caution and justified by clinical need.

To maintain patient safety, it is essential to monitor and adjust the MI, especially during prolonged or intensive scans.

Thermal Index (TI)

Another crucial parameter in MSK US is the Thermal Index (TI), which estimates the potential for tissue heating. The TI is influenced by the duration of the ultrasound exposure and the intensity of the ultrasound beam.

Categories of TI:

  • TIS (Soft Tissue): Applies to imaging of soft tissues and abdominal organs.
  • TIB (Bone): Relevant for imaging near bone structures.
  • TIC (Cranial): Pertains to imaging the fetal skull or neonatal head.

For MSK US, TIB is the most relevant as it applies to imaging around bones and joints. Maintaining an appropriate TI helps prevent thermal damage to tissues.

Essential MSK US Techniques

1. Probe Selection: Use the appropriate probe for the area being examined. High-frequency linear probes (7–15 MHz) are commonly used for superficial structures like tendons and muscles, while lower-frequency probes are better for deeper structures.

2. Patient Positioning: Proper patient positioning is crucial for optimal imaging. Ensure the area of interest is accessible and the patient is comfortable to avoid movement that can degrade image quality.

3. Image Optimization: Adjust the depth, focus, gain, and time-gain compensation (TGC) to enhance image quality. Clear visualization of the anatomy is essential for accurate diagnosis.

4. Dynamic Examination: Utilize the dynamic nature of ultrasound to assess the movement and function of musculoskeletal structures. Real-time imaging can help identify abnormalities that static imaging may miss.

5. Documentation: Capture and store high-quality images and clips of the relevant findings. Proper documentation supports clinical decisions and facilitates communication with other healthcare providers.

Conclusion

Performing musculoskeletal ultrasound requires a solid understanding of key safety principles, such as ALARA and MI, as well as technical skills in image optimization and patient positioning. By adhering to these guidelines, practitioners can ensure safe and effective use of MSK US, providing valuable insights into musculoskeletal conditions and enhancing patient care.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in learning more about the basics of ultrasound? Check out these resources from the American Institute of Ultrasound in Medicine:

The Sonographer Scope of Practice: what you need to know

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Why is it important to read the Sonographer Scope of Practice?

  • A scope of practice clearly articulates the activities and processes healthcare professionals can perform.
  • A scope of practice limits the activities of a healthcare professional based on specific education, training, and competency requirements based on regulations, standards, and laws.
  • Very few states regulate the education, competency, and certification of sonographers.
  • The Sonographer Scope of Practice is our guiding document that describes the boundaries of our profession.

This year (2024), the Society of Diagnostic Medical Sonography (SDMS) released the latest revision of the Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer (The Scope) which encompasses the changes and growth in technology and the expansion in the roles of sonographers. I was excited to represent the American Institute of Ultrasound in Medicine (AIUM) in this revision process, and glad that the AIUM Board of Governors voted again to continue to support The Scope.

This comprehensive document sets forth the most current standards and expectations for sonographers, emphasizing patient care, safety, and the evolving role of sonographers in healthcare.

I asked colleague Jaime Taylor-Fujikawa, RDMS, RDCS, why she feels The Scope is important. Her first reason was because it is not stagnant. She stated that “the sonographer profession continues to expand and evolve, and The Scope has changed with the times.” Jaime is a sonographer of 21 years, a long-time member of the AIUM, and she lives in 1 of only 4 states that requires licensure of sonographers. She has taken certification exams in OB, Adult Echo, Pediatric Echo, and Fetal Echo.

Did you know that though certification of sonographers is considered the standard of care, it is still considered voluntary except in those states that require licensure?

The sonographer is defined as an individual who performs diagnostic exams and procedures, acquiring images and other pertinent information to provide to the interpreting physician. Sonographers do not practice independently and function as a delegate of the physician. In brief, we

  • Follow written policies, protocols, and guidelines.
  • Apply principles of safe use (ALARA) for the patient, ourselves, and the healthcare team.
  • Commit to ongoing education to increase competence with increasing advancements.
  • Acquire appropriate training and experience in examinations and specialty areas in which they perform.

This is but a brief overview of The Scope. A few areas that were added/expanded included

  • The role of the advanced practice sonographer (under physician supervision)
    • As an evolving role for those with higher levels of education, training, and experience,
    • Which may be identified with advanced job titles such as ultrasound practitioner, advanced cardiac sonographer, advanced sonographer, and/or with an advanced certification (currently there is only 1 advanced certification available)
  • The use of contrast, which has been expanded and is now woven strategically throughout the document with more succinct guidelines of the sonographer’s role.
  • The expansion of safety principles to increase focus on prevention of work-related musculoskeletal disorders (WRMSD) to encourage
    • Maintenance of an environment to avoid injuries,Implementation and participation in programs designed to reduce WRMSD, and
    • Reporting signs and symptoms of WRMSD.

A few areas of The Scope are outlined here, and it contains an overarching theme of essential commitment (from sonographers) to professional growth and development and adherence to our professional standards, regulations, and accreditation standards that guide our actions to serve our patients competently and safely. The Scope compels us to

  • Treat all patients with kindness, compassion, dignity, and respect.
  • Perform examinations only with a medical order.
    • Exceptions for educational programs, in-service training, CME activities, research
  • Perform only those examinations for which we are educated, trained, experienced, and competent, and (where applicable) certified.
  • Adhere to the scope of practice and other professional documents.

In the absence of licensure, it is imperative that sonographers follow The Scope and that employers hire certified sonographers so that patients can receive quality ultrasound examinations and excellent patient care.

Do you work with a sonographer? Are they certified? Do you know their areas of certification? You can find the complete Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer here https://www.sdms.org/about/who-we-are/scope-of-practice.

Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM, is currently an Adjunct Faculty at AdventHealth University. She has taken certification exams in Abdomen,
OB/Gyn, Pediatric Sonography, Breast, Fetal Echo, and Vascular Technology. She
has been a member of AIUM since 1989 and has served on the AIUM Board as 2nd
Vice President, and most recently co-chaired the Practice Principles on
Work-Related Musculoskeletal Disorders.

Harnessing Sound to Heal: The Transformative Power of High-Intensity Focused Ultrasound

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In the evolving landscape of medical technology, where the boundaries between science fiction and clinical practice blur, one innovative treatment stands out for its profound potential to change lives: High-Intensity Focused Ultrasound (HIFU). As a leader in both the academic and practical application of this technology, I’ve witnessed firsthand its transformative power and the hope it offers to patients worldwide.

HIFU represents a groundbreaking approach to treatment, utilizing the precise application of sound waves to target and treat a variety of medical conditions, without the need for invasive surgery. This technology harnesses the energy of ultrasound waves, concentrating them on a specific point within the body. At this focal point, the ultrasound energy induces a therapeutic effect, such as destroying tissue in tumors or stimulating cellular responses that promote healing, without harming surrounding tissues.

The implications of HIFU are vast and varied. In oncology, it offers a non-invasive alternative to traditional surgeries, significantly reducing recovery times and associated risks. For patients with uterine fibroids, prostate cancer, or kidney stones, HIFU provides a treatment option that is not only effective but also preserves quality of life by minimizing side effects and hospital stays.

Beyond its current applications, ongoing research, including projects financed and led by our team at the Focused Ultrasound Foundation, is exploring the potential of HIFU to deliver targeted gene therapies and to treat neurological conditions such as Parkinson’s disease, ALS, Alzheimer’s and epilepsy. The ability of HIFU to cross the blood-brain barrier—a longstanding obstacle in neurology—opens new avenues for treating diseases previously deemed intractable.

The journey of HIFU from a promising concept to a validated medical treatment underscores the importance of interdisciplinary collaboration and innovation. It is a testament to the power of combining physics, engineering, biology, and medicine to overcome challenges and push the boundaries of what is possible in patient care.

However, the path forward requires more than just scientific breakthroughs. It necessitates a concerted effort among researchers, clinicians, policymakers, and patients to ensure that these advances are accessible to those who need them most.

As we stand on the brink of a new era in medical treatment, the promise of HIFU exemplifies the potential of technology to not just treat disease, but to transform lives. It compels us to reimagine the future of medicine as one where the scalpel is replaced by sound waves, where treatment is as precise as it is noninvasive, and where the healing power of innovation knows no bounds.

Dr. Frederic Padilla is the Director of Applied Physics Research at the Focused Ultrasound Foundation and a Visiting Professor at UVA School of Medicine.

An Invaluable Tool in Your Practice: Musculoskeletal Ultrasound

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Musculoskeletal ultrasound (MSK US) has emerged as a powerful tool that is advancing pediatric sports medicine. Its noninvasive nature, real-time imaging capabilities, and portability make it invaluable for injury assessment and treatment planning. Let’s delve into some key points:

  • Utility in Sports Medicine: The American Medical Society for Sports Medicine (AMSSM) developed a recommended MSK US curriculum for sports medicine fellows in 2010 to help guide programs towards adequate training during their fellowship to meet the requirements of competency outlined by the American Institute of Ultrasound in Medicine (AIUM) Training Guidelines for the Performance of MSK US Examination. This was later revised in 2015 and it was where the term “sports ultrasound” was first introduced to reflect the use of ultrasound by sports medicine physicians for both musculoskeletal and non-musculoskeletal indications.  Since then, sports US has become nearly ubiquitous in sports medicine clinics, training rooms, and at sporting events across the country. Finally, in 2017, ultrasound training was formally added to the Accreditation Council for Graduate Medical Education (ACGME) core program requirements for sports medicine fellowships, including pediatric-based programs.
  • Pediatric Considerations: Skeptics may argue that ultrasound isn’t necessary for evaluating musculoskeletal (MSK) complaints in children, assuming they don’t experience the same amount of pathology as adults. However, as a pediatric sports medicine physician with a decade of ultrasound experience, I can attest that children do encounter similar MSK issues. Children exhibit both common MSK conditions (like tendinosis, ligament tears, muscle injuries, effusions, and fractures) and unique ones related to their growing skeletons (like osteochondral defects, Salter Harris injuries, apophysitis, and avulsion fractures). MSK US can play a role in evaluating all of these conditions at the point of care. 
  • Beyond Pediatric Sports Medicine: MSK Ultrasound is a valuable tool that extends beyond pediatric sports medicine as well. It is widely used in rheumatology clinics, where it helps diagnose conditions like synovitis, arthritis, and enthesitis. Emergency physicians can quickly identify joint effusions and dislocations, full-thickness tendon tears, and fractures, influencing acute management decisions. General pediatricians can benefit from MSK ultrasound, too, and this is not just ordering ultrasounds to rule out hip dysplasia in infants. Simple questions—like distinguishing between solid versus cystic soft tissue masses and assessing joint effusions—can guide primary care clinicians. When families seek answers about their child’s condition and treatment options, especially “How can we get them back to sports safely?” time is of the essence and point-of-care ultrasound (POCUS) becomes even more important!
  • Interventional Possibilities: While the volume of procedures may not match clinics focused on older athletes, there are still opportunities for the pediatrician. US guidance opens the door to injections of not only joints and their recesses but also within tendon sheaths, bursa, and perineural spaces. Therapeutic injections have their obvious role in successful treatment of pathologic conditions, but diagnostic injections can also play a crucial role, especially for patients with chronic pain. Precise targeting using ultrasound ensures accurate delivery of anesthetic injectates that can help inform the clinician of the etiology of pain, which often goes undiagnosed for years in the more challenging patient scenarios.         
  • Safety and Efficiency: Sonologists with diagnostic expertise can now confidently guide needles to precise locations, minimizing risks. Unlike radiography, which involves radiation exposure, ultrasound is radiation-free. This safety aspect is crucial, especially when discussing imaging options with pediatric patients and their families. For example, repeating radiographs or imaging contralateral sides for comparisons may be unnecessary if the pediatric clinician has POCUS in their toolbox.   

In summary, MSK ultrasound is a versatile tool that empowers clinicians across pediatric specialties to make informed decisions and provide better patient care. I challenge you to take advantage of all the great MSK US resources available through the AIUM and ask yourself how you could start incorporating this tool into your practice.

Drew Duerson, MD, RMSK, is a Sports Medicine physician in the Division of Sports Medicine at Nationwide Children’s Hospital. He is also a clinical associate professor of Pediatrics at the Ohio State University. Drew is a board-certified Pediatrician with a certificate of added qualification in Sports Medicine. He also holds a POCUS Musculoskeletal certification from the Alliance for Physician Certification and Advancement. 

Drew.Duerson@nationwidechildrens.org

@pedsmskusdoc

Drew Duerson, MD, RMSK

Interested in reading more about MSK ultrasound? Check out these on-demand webinars from the American Institute of Ultrasound in Medicine (AIUM):

Advancing Inflammatory Bowel Disease Management: Harnessing Intestinal Ultrasound for Screening and Monitoring

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Inflammatory bowel disease (IBD) encompasses a group of chronic inflammatory conditions of the gastrointestinal tract, primarily including Crohn’s disease and ulcerative colitis. The rate of patients affected by these conditions has been growing in the last decades, with an estimated 2.39 million Americans living with this diagnosis in 2020.1 About 25% of those affected are children.2 Active inflammation in the context of IBD increases the risk of disease complications, such as requiring surgery and developing colon cancer. However, symptoms have been shown to not accurately correlate to intestinal inflammation and ongoing bowel damage.3,4 Therefore, the assessment of disease activity relies on invasive techniques, such as colonoscopy and cross-sectional imaging (ie, Computer Tomography Enterography and Magnetic Resonance Enterography), which are costly and laborious tests. Repeated imaging using these techniques is important to assess for the complete reversal of inflammation, termed mucosal healing, which was shown to lead to much better long-term outcomes.5

Intestinal ultrasound (IUS) has emerged as a valuable technique for screening patients with concerning symptoms of IBD and monitoring individuals with known disease. It has the advantages of being feasible at the bedside in the gastrointestinal clinic, noninvasive, painless, requiring no preparation from the patient, and not exposing the patient to ionizing radiation. IUS has been used for monitoring disease activity for many years in Europe and is now being rapidly adopted in the United States.

IUS Features of Intestinal Inflammation

IUS is generally performed using a high-frequency linear transducer to visualize the intestinal wall and surrounding structures in real-time and a curvilinear low-frequency transducer to assess for disease complications, often located in the pelvis. The thickness of the bowel wall, which comprises layers such as the mucosa, submucosa, and muscularis, measures under 3mm in healthy adults, but this measurement increases in the setting of inflammation.6 Bowel layers can be distinct or more disturbed depending on disease severity. Other important features include the presence of abnormal increased Doppler signals in and along the bowel wall, which are usually absent in healthy patients and progressively more prominent in diseased bowel. Furthermore, peri-intestinal fat can be increased in the presence of disease. Examples of these IUS features are illustrated in Figure 1.

Figure 1A
Figure 1B

Screening With IUS

One of the key advantages of IUS in IBD management is its ability to screen for the presence of disease in patients with nonspecific symptoms that could be due to IBD. By visualizing the thickness of the intestinal wall, the presence of bowel wall edema, and the extent of inflammation, ultrasound can help identify active disease and assess its severity. Indeed, a study demonstrated that IUS could distinguish between patients with Irritable Bowel Syndrome (IBS) or functional symptoms and patients with new or flaring IBD.7,8 The use of IUS by trained providers can help with resource allocation and expedite invasive testing in the right patient without delays, and avoid unnecessary invasive investigation in patients who do not require it.

Monitoring Disease Progression and Treatment Response

In addition to screening, IUS can have a central role in monitoring response to treatment. Although there is a growing armamentarium of treatments for IBD, no single treatment has led to endoscopic remission rates higher than about 40–50%.9 Repeat ultrasound examinations can track changes in the thickness of the intestinal wall and complications over time. This real-time feedback allows for the timely optimization of treatment strategies, with subsequent improvement in patient outcomes. This proactive approach to objective evaluation of disease activity and continuous optimization of therapies, named the treat-to-target approach, has been demonstrated to improve long-term complication-free remission.5,10 Moreover, ultrasound can detect complications such as strictures, abscesses, and fistulas, guiding treatment decisions and surgical planning.

Advantages of IUS

Several factors contribute to the growing popularity of IUS in IBD management:

  1. Noninvasive: IUS does not require the insertion of instruments into the body, minimizing patient discomfort and reducing the risk of complications.
  2. Radiation-free: Unlike CT scans, which involve ionizing radiation, ultrasound uses harmless sound waves, making it safe for repeated examinations by professionals, including in pregnant women and children.
  3. Real-time imaging: IUS provides immediate feedback, allowing healthcare providers to assess disease activity and complications on the spot.
  4. Cost-effective: Compared to other imaging modalities, IUS is relatively affordable, potentially increasing patient accessibility in various healthcare settings.

Conclusion

Intestinal ultrasound (IUS) has emerged as a valuable tool in the screening and monitoring of inflammatory bowel disease. Its noninvasive nature, lack of radiation exposure, real-time imaging capabilities, and cost-effectiveness make it an attractive option for healthcare providers and patients alike. By incorporating IUS into the diagnostic algorithm for IBD, clinicians can improve the accuracy of diagnosis, optimize treatment strategies, and enhance patient outcomes.

In the ever-evolving landscape of IBD management, IUS stands out as a versatile and effective imaging modality, offering valuable insights into disease activity and treatment response. As research continues to elucidate its utility and refine its techniques, IUS is poised to play an increasingly prominent role in the personalized care of individuals living with IBD.

References:

  1. Lewis JD, Parlett LE, Jonsson Funk ML, et al. Incidence, prevalence, and racial and ethnic distribution of inflammatory bowel disease in the United States. Gastroenterology 2023 Nov; 165(5):1197–1205.e2. doi: 10.1053/j.gastro.2023.07.003. Epub 2023 Jul 20. PMID: 37481117; PMCID: PMC10592313.
  2. Abraham BP, Mehta S, El-Serag HB. Natural history of pediatric-onset inflammatory bowel disease: a systematic review. J Clin Gastroenterol 2012; 46:581–589.
  3. Modigliani R, Mary JY, Simon JF, et al. Clinical, biological, and endoscopic picture of attacks of Crohn’s disease. Evolution on prednisolone. Groupe d’Etude Thérapeutique des Affections Inflammatoires Digestives. Gastroenterology 1990; 98:811–818. doi: 10.1016/0016-5085(90)90002-i. PMID: 2179031.
  4. Jharap B, Sandborn WJ, Reinisch W, et al. Randomised clinical study: discrepancies between patient-reported outcomes and endoscopic appearance in moderate to severe ulcerative colitis. Aliment Pharmacol Ther 2015; 42:1082–1092. doi: 10.1111/apt.13387
  5. Ungaro RC, Yzet C, Bossuyt P, et al. Deep remission at 1 year prevents progression of early Crohn’s disease. Gastroenterology 2020 Jul; 159(1):139–147. doi: 10.1053/j.gastro.2020.03.039. Epub 2020 Mar 26. PMID: 32224129; PMCID: PMC7751802.
  6. Novak KL, Nylund K, Maaser C, et al. Expert consensus on optimal acquisition and development of the international bowel ultrasound segmental activity score [IBUS-SAS]: a reliability and inter-rater variability study on intestinal ultrasonography in Crohn’s disease. J Crohns Colitis 2021; 15:609–616. doi: 10.1093/ecco-jcc/jjaa216. PMID: 33098642; PMCID: PMC8023841.
  7. Novak KL, Jacob D, Kaplan GG, et al. Point of care ultrasound accurately distinguishes inflammatory from noninflammatory disease in patients presenting with abdominal pain and diarrhea. Can J Gastroenterol Hepatol 2016; 2016:4023065. doi: 10.1155/2016/4023065. Epub 2016 Apr 20. PMID: 27446838; PMCID: PMC4904691.
  8. St-Pierre J, Delisle M, Kheirkhahrahimabadi H, et al. Bedside intestinal ultrasound performed in an inflammatory bowel disease urgent assessment clinic improves clinical decision-making and resource utilization. Crohns Colitis 360 2023 Sep 21; 5(4):otad050. doi: 10.1093/crocol/otad050. PMID: 37809033; PMCID: PMC10558199.
  9. Cholapranee A, Hazlewood GS, Kaplan GG, Peyrin-Biroulet L, Ananthakrishnan AN. Systematic review with meta-analysis: comparative efficacy of biologics for induction and maintenance of mucosal healing in Crohn’s disease and ulcerative colitis controlled trials. Aliment Pharmacol Ther 2017 May; 45(10):1291–1302. doi: 10.1111/apt.14030. Epub 2017 Mar 22. PMID: 28326566; PMCID: PMC5395316.
  10. Colombel JF, Panaccione R, Bossuyt P, et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet 2017 Dec 23; 390(10114):2779–2789. doi: 10.1016/S0140-6736(17)32641-7. Epub 2017 Oct 31. Erratum in: Lancet 2018 Dec 23; 390(10114):2768. PMID: 29096949.

Mallory Chavannes, MD, MHSc, is an Assistant Professor of Pediatrics in the Division of Gastroenterology, Hepatology, & Nutrition, and is Medical Director of the Inflammatory Bowel Disease Program, at Children’s Hospital Los Angeles.

Ultrasound: A New Approach to Treating Addiction

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Addiction is a complex and multifaceted condition that affects millions of individuals worldwide. Traditional treatments, such as behavioral therapy and medication, have varying levels of success. However, recent advancements in medical technology have opened new avenues for treating addiction, one of which involves the use of ultrasound. Although still being studied, this noninvasive technique is showing promise in helping individuals manage and overcome addiction by targeting specific areas of the brain involved in addictive behaviors.

To appreciate how ultrasound can be utilized in treating addiction, you need to understand the neurological underpinnings of addiction. Addiction often involves the brain’s reward system, particularly areas like the nucleus accumbens and the prefrontal cortex. These brain regions are responsible for the pleasurable sensations associated with substance use and the subsequent cravings and compulsive behaviors.

When an individual consumes an addictive substance, it triggers the release of dopamine, a neurotransmitter associated with pleasure and reward. Over time, the brain’s chemistry and circuitry can become altered, making it difficult for the individual to experience pleasure without the substance and leading to a cycle of dependency.

Ultrasound, traditionally used for imaging purposes, has found a new role in neuromodulation—altering nerve activity through targeted delivery of stimuli. Focused ultrasound (FUS) is a technique that uses sound waves to target specific areas of the brain with high precision. This method can modulate neural activity without the need for invasive procedures or pharmaceuticals.

How It Works

  • Targeting Specific Brain Regions: Ultrasound waves are precisely focused on brain areas implicated in addiction. This targeting can help modulate the activity of neurons in these regions, potentially reducing cravings and compulsive behaviors associated with addiction.
  • Noninvasive and Safe: One of the significant advantages of ultrasound therapy is its noninvasive nature. Unlike deep brain stimulation, which requires surgical implantation of electrodes, ultrasound therapy involves no incisions or physical alterations to the brain.
  • Adjustable: The effects of ultrasound neuromodulation can be adjusted by changing the frequency and intensity of the sound waves. Additionally, the treatment can be halted without lasting damage if any adverse effects occur.

Recent studies and clinical trials have explored the potential of ultrasound in treating various forms of addiction. For example, a study (see the report by the Washington Post) being conducted at the University of Virginia has demonstrated that FUS could modulate brain activity in regions associated with drug cravings. Participants who received focused ultrasound treatment showed a reduction in cravings and an improved ability to manage their addiction.

The application of ultrasound in addiction treatment is still in its early stages, but the preliminary results are promising. As technology advances and our understanding of the brain’s role in addiction deepens, ultrasound could become a cornerstone in the arsenal against addiction.

Future research will likely focus on optimizing the parameters of ultrasound therapy, such as determining the most effective frequencies and durations of treatment. Additionally, long-term studies are needed to assess the sustained benefits and potential risks of this approach.

Ultrasound therapy represents a new development in the field of addiction treatment. By offering a noninvasive, adjustable, and effective method for modulating brain activity, ultrasound has the potential to change the way we approach addiction. As research continues to unveil the full capabilities of focused ultrasound, it may provide new hope for individuals struggling with addiction, leading to more effective and accessible treatments.

The journey to overcoming addiction is challenging, but with innovations like ultrasound therapy, there is renewed optimism for those seeking to reclaim their lives from the grip of addiction.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

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Burnout, the Force Propelling Sonographers Away From Their Calling

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Amidst the bustling corridors and resonant discussions of the 2024 AIUM Ultracon conference, a groundbreaking revelation emerged from the forefront of medical imaging research. Shedding light on the intricate interplay between Work-Related Musculoskeletal Disorders (WRMSDs) and the often-overlooked specter of sonographer burnout, the collaborative inquiry of my colleagues and I sought merely to confirm existing associations but ultimately challenged entrenched assumptions. What materialized from our investigation was a surprising insight: burnout, eclipsing the physical strains of the profession, emerges as the predominant force propelling sonographers away from their calling. This revelation, underscored by the poignant narratives of our colleagues, beckons us to embark on a journey that redefines our understanding of occupational health and demands a holistic approach to safeguarding the well-being of every sonographer.

Professional research informs us that WRMSDs can cause a sonographer to leave the profession and that both WRMSDs and burnout share similar root causes. The intent of our research was to forward the discussion on WRMSDs, by determining if there is an association between the two conditions; an association we did find: burnout was the reason for a sonographer to consider leaving the profession, not a WRMSD. That eye-opening finding reshaped how we viewed our research results. What if the profession, instead of focusing on education and engineering as the way to prevent WRMSDs, looked closer at the psychosocial causes of WRMSDs? 

We were happy to see so many stakeholders, such as radiologists and administrators, express concern for sonographer burnout. While it was gratifying to find so much support from our colleagues, we were saddened by the many sonographers who spoke with us about their own experiences with burnout. During Ultracon, sonographers came up to us and expressed their thoughts of leaving the patient care environment, or that burnout was the reason they had already changed jobs. They voiced concern that pizza parties were viewed as solutions when what they really need is meaningful change to the work and professional culture that prioritizes profits and throughput over people. Sonographers are suffering in silence, and simply want to know someone cares for their well-being.  

How can we move forward knowing that burnout is an issue for the profession and that it is also a factor related to the WRMSD epidemic? Larger research studies are needed on sonographer burnout for us to fully understand not only the scope of the problem but also its root causes.

We encourage other researchers to look at sonographer burnout as a single issue in addition to exploring its relationship to WRMSDs. If we hope to attract young, talented people to pursue a sonography career, we need to show that the career is worth it to them. It is up to us, sonologists, administrators, and sonographers, to work together to ensure that our profession supports the whole sonographer, mind, and body. 

Jennifer Bagley, MPH, RDMS, RVT, FAIUM, FSDMS, is a professor and sonography program director for the College of Allied Health at the University of Oklahoma Health Sciences in Oklahoma City, Oklahoma. She also currently serves on the AIUM Board of Governors.

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