Predicting Risk of 30-Day Readmission in Heart Failure Patients

Posted on June 13, 2023 by aium1952

Pulmonary congestion is the most frequent cause of heart failure hospitalizations and readmissions. In addition, approximately 20%–25% of heart failure patients aged 65 years and older in the United States are readmitted within 30-days after hospital discharge,^1–5 despite efforts to identify predictors of readmission for acute decompensated heart failure (ADHF), such as laboratory markers, the readmission rates remain high. Lung ultrasound (LUS), however, has been shown to be a valuable tool for assessing pulmonary congestion, providing a reliable assessment based on the presence of B-lines.

A recent study by Cohen et al⁷ evaluated the association between lung ultrasound findings and the risk of 30-day readmission among HF patients, hypothesizing that a higher number of positive B-line lung fields on LUS will indicate an increased risk of readmission. Using a log-binomial regression model in an 8-zone LUS exam from the day of discharge, the researchers assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines, considering a zone positive when ≥3 B-lines were present. According to the results from 200 patients, the risk of 30-day readmission in patients with 2–3 positive lung zones was 1.25 times higher (95% CI: 1.08–1.45), and in patients with 4–8 positive lung zones was 1.50 times higher (95% CI: 1.23–1.82), compared with patients with 0–1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin.

Ultrasound image of a lung with B-lines. The pleural line is indicated by the arrow. Emanating from the pleural line are hyperechoic reverberation artifacts, which are B-lines (indicated by the star), indicating the presence of fluid within the interstitium of the lung.

This study adds to the research on LUS in patients with HF in inpatient or intensive care units and emergency departments, including studies on identifying pulmonary congestion to reduce decompensation in heart failure patients,⁷ the risk of hospitalization or all-cause death was greater in patients with more B-lines at discharge,⁸ and the prognostic value of LUS as an independent predictor of 90-day readmission.^9,10

The study by Cohen et al⁷ expands on the prior research and demonstrates the prognostic importance of more B-lines at discharge for HF patients. Failure to relieve congestion before discharge is associated with increased morbidity and mortality and is a strong predictor of poor outcomes in patients with acute decompensated HF.

By evaluating HF patients with LUS, we may be better able to risk-stratify the severity of asymptomatic pulmonary congestion on discharge and identify patients at higher risk of readmission.

References

Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation 2012; 126:501–506.
Suter LG, Li SX, Grady JN, et al. National patterns of risk-standardized mortality and readmission after hospitalization for acute myocardial infarction, heart failure, and pneumonia: update on publicly reported outcomes measures based on the 2013 release. J Gen Intern Med 2014; 29:1333–1340.
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240–e327.
Tavares LR, Victer H, Linhares JM, et al. Epidemiology of decompensated heart failure in the city of Niter_oi: EPICA -Niter_oi Project. Arq Bras Cardiol 2004; 82:125–128.
Cleland JG, Swedberg K, Cohen-Solal A, et al. The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The study group on diagnosis of the working group on heart failure of the European Society of Cardiology. The medicines evaluation Group Centre for Health Economics University of York. Eur J Heart Fail 2000; 2:123–132.
Cohen A, Li T, Maybaum S, et al. Pulmonary congestion on lung ultrasound predicts increased risk of 30-day readmission in heart failure patients [published online ahead of print February 25, 2023]. J Ultrasound Med. doi: 10.1002/jum.16202.
Araiza-Garaygordobil D, Gopar-Nieto R, Martinez-Amezcua P, et al. A randomized controlled trial of lung ultrasound-guided therapy in heart failure (CLUSTER-HF study). Am Heart J 2020; 227:31–39.
Platz E, Lewis EF, Uno H, et al. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. Eur Heart J 2016; 37:1244–1251.
Gargani L, Pang PS, Frassi F, et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study. Cardiovasc Ultrasound 2015; 13:40.
Coiro S, Rossignol P, Ambrosio G, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail 2015; 17:1172–1181.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Pulmonary Congestion on Lung Ultrasound Predicts Increased Risk of 30-Day Readmission in Heart Failure Patients” by Allison Cohen, MD, et al. Members of the American Institute of Ultrasound in Medicine (AIUM) can access it for free after logging in to the AIUM. Join the AIUM today!

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

Can We Use Ultrasound to Pace the Heart?

Posted on September 6, 2022 by aium1952

In a Heartbeat

What would it take to get back a heartbeat?

We hear about cardiovascular diseases (CVDs) all the time, with an estimated 31% of deaths globally¹. It’s not uncommon to hear stories about a close friend who was young and had a heart attack. Perhaps your mom or dad had a stroke or even a neighbor who is having heart rhythm issues.

Every time I think about CVDs, the first thing that comes to my mind is my uncle. He was a healthy man in his 60s, very athletic, he used to swim and participate in marathons all the time. He never smoked, he always had a healthy diet and was active, and bam! One day, he had a stroke. To make the long story short, he ended up having to have a pacemaker implanted. He had a complication due to a pacemaker lead that was dispositioning, which caused a subsequent ischemic stroke.

Don’t take me wrong, pacemakers can be a good solution. However, complications like broken leads for instance can cause unnecessary “shocks” to the user. Complications that may occur during surgery include allergic reactions, infections, vessel damage, and heart tissue punctures.² The weakest link in the pacemaker system, most often leading to complications, is the lead. This poses a question: Can we use an alternative source of energy to pace the heart? Can we use ultrasound as an alternative source of energy? Can we use ultrasound to treat CVDs?

If you would have a choice of another way to “control” the heart, would you do it in a heartbeat?

Cardiac Pacing

Looking back, if there was another way to pace my uncle’s heart and bring him back to a normal life, of course I would do it. Pacemakers work only when needed. If your heartbeat is too slow (bradycardia), the pacemaker sends electrical signals to your heart to correct the beat. The same principle is used if your heart is too fast (tachycardia). The pacemaker has a battery, and it works with electric energy. My goal in the last 10 years or so has been to use ultrasound as an alternative source of energy to pace the heart and to treat cardiovascular diseases.

The first step was to investigate if the ultrasound pulses can increase or decrease the heart rate (HR). Some of my preliminary studies^3-5showed that ultrasound applied to the heart of rats can cause a negative chronotropic effect (or decrease in the heart rate; Figure 1). The ultrasound protocol uses a sequence of different parameters, such as pulse duration (PD), pulse repetition frequency (PRF), etc. The PD is the distance each pulse travels and the pulse repetition frequency is the rate at which the transducer emits the pulses. The pulses must be spaced. This allows enough time between pulses, so the beam has enough time to reach the target and return to the transducer before the next pulse is generated. With a specific sequence, I was able to decrease the heart rate. Voila!

Figure 1: The top image is the baseline before ultrasound application (HR = 322 BPM), then 3 minutes after ultrasound application (HR = 230 BPM), and 15 minutes after (HR = 223 BPM).

But what if I can increase the heart rate using ultrasound pulses? In a recent investigation, I was also able to increase the heart rate with a specific sequence of ultrasound pulses (Figure 2).

Figure 2: HR at various points before, during, or after ultrasound application (points are not linearly spaced). An increase in HR was observed during each increased PRF sequence (1st, 2nd, and 3rd PRF).⁶

Is the Future Wireless?

We are all experiencing changes in gadgets in our daily life, from wireless vacuums to earplugs, chargers, etc. But can we pace the heart without leads? The question remains such as my uncle’s story. He’s still an active guy, but of course he needs to avoid problems like electromagnetic interference (cell phones, metal detectors, etc). Can we have a therapy that uses ultrasound to pace the heart, that is non-invasive, wireless, safe, and feasible? I hope so. Maybe one day I can change this scenario in a heartbeat!

References

1. World Health Organization. Fact Sheets: Cardiovascular Disease. Accessed: July 13, 2020. [Online]. Available: https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

2. Pakarinen S, Oikarinen L, and Toivonen L. Short-term implantation related complications of cardiac rhythm management device therapy: A retrospective single-centre 1-year survey. Europace 2010; 12:103–108. doi: 10.1093/europace/eup361.

3. Coiado OC and O’Brien WD. The negative chronotropic effect in rat heart stimulated by ultrasonic pulses: Role of sex and age. J Ultrasound Med 2017; 36:799–808.

4. Coiado OC and O’Brien WD. The role of the duty factor in ultrasound-mediated cardiac stimulation. J Acoust Soc Am 2014; 136:EL231–EL235.

5. Coiado OC, Buiochi E, and O’Brien W. Ultrasound-induced heart rate decrease: Role of the vagus nerve. IEEE Trans Ultrason Ferroelectr Freq Control 2015; 62:329–336.

6. Coiado OC, Yerrabelli RS, Christensen AP, Wozniak M, Lucas A, O’Brien WD Jr. Positive chronotropic effect caused by transthoracic ultrasound in heart of rats. JASA Express Lett 2021; 1:08200.

Dr. Coiado, PhD, is a Teaching Associate Professor in both the Carle Illinois College of Medicine and the Bioengineering Department at the University of Illinois at Urbana-Champaign. At Carle Illinois College of Medicine, she acts as the Director of Student Research and Discovery Learning. Her research interests focus on cardiovascular studies, acoustics, bioinstrumentation, and education.

Interested in reading more about vascular ultrasound? Check out these resources:

JUM article by Coiado et al: The Negative Chronotropic Effect in Rat Heart Stimulated by Ultrasonic Pulses: Role of Sex and Age
JUM article by Coiado et al: Therapeutic Ultrasound in Cardiovascular Medicine
From the Scan: Ultrasound in Central Vein Assessment – The Importance of Knowing
From the Scan: The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound
From the Scan: How to Obtain Focused Cardiac Ultrasound Images

Duplex Ultrasound in Arterial Disease in Patients With Critical Limb Ischemia

Posted on March 8, 2022 by aium1952

Critical limb ischemia (CLI) is the most severe manifestation of peripheral arterial disease (PAD) and presents with severe, chronic rest pain or ischemic skin lesions (ulcer or gangrene). It is the major cause of amputation of ischemic limbs in the United States; the annual incidence of CLI is 500 to 1000 cases per million people. Revascularization by endovascular or open surgical technique is recommended, depending on the severity of the disease.

Many imaging modalities can identify an arterial lesion that is a candidate for endovascular or open surgical technique. Angiography is the gold-standard diagnostic test but it is a high-risk, invasive, and costly procedure (Figure 1).

**Figure 1.** Aorto-iliac angiography showing acute ischemia involving the right common iliac artery (arrows).

Computed tomography angiography (CTA), using multidetector computed tomography (MDCT) technology and magnetic resonance angiography (MRA), is highly accurate in diagnosing PAD, equivalent to angiography. CT acquisition is rapid and less prone to motion artifacts than MRA is, but its disadvantage is exposure to doses of radiation and the use of iodinated contrast to enhance the vessel visualization. Also, CTA produces streak artifacts from heavy calcification or metallic materials, resulting in a limited evaluation of vascular patency (Figure 2).

**Figure 2.** CTA image of lower extremities at the onset of acute limb ischemia. The arrow indicates the short-segment occlusion of terminal aorta and bilateral common iliac arteries.

MRA produces an image without contrast or interference from calcium, but its disadvantages are it is time-consuming and expensive, it cannot be performed on patients with metallic devices or on patients who might experience claustrophobia from a closed area, and it might produce false-positive results (Figure 3).

**Figure 3.** MRA in a patient with pain in the left leg while walking and when resting. The arrowhead indicates stenosis in the distal part of the left common iliac artery.

Duplex ultrasound is widely available for the screening and diagnosis of vascular lesions. It is safe without risk of radiation exposure, easily repeatable, relatively cost-effective, and causes minimal discomfort. Several studies have shown that duplex ultrasound has good sensitivity, specificity, and diagnostic agreement with angiography in assessment of lower-extremity arterial disease in critical limb ischemia. The peak systolic velocity (PSV) quantified by spectrum analysis from spectral pulsed-wave (PW) Doppler ultrasound was the most common criterion used for diagnosis and categorizing the severity of the disease in most previous studies. The duplex scanning protocol begins with B-mode and color Doppler ultrasound to identify the lesion and assess blood flow before sampling the Doppler signal by spectral PW Doppler ultrasound. The waveform feature analysis (triphasic or monophasic, acceleration time, spectral broadening, turbulence, or direction) and velocity measurement can be obtained at the proximal, distal, and overall points of the lesion when suspicion of abnormality exists. Using mutual interpretation of the findings from B-mode, color, and spectral PW Doppler ultrasound (waveform analysis and velocity measurement) is the key concept of using duplex ultrasound for the diagnosis of vascular disease and PVD (Figure 4).

**Figure 4.** Duplex ultrasound of the right common femoral artery (CFA). The color Doppler imaging (color box) showed totally occluded CFA in a critical limb ischemia.

Dr. Akram Asbeutah, PhD, DMU-ASUM, ASAR, ASA, FAIUM, SVU, AIR, ASRT, RT(R) ARRT, is a Clinical Associate Professor in the Department of Radiologic Sciences at the Faculty of Allied Health Sciences, Kuwait University/Adjunct, Monash University-Melbourne, Australia.

Sudden Cardiac Death in Young Athletes

Posted on February 8, 2022 by aium1952

Sudden cardiac death is very rare in young athletes (<35 years of age), however, it is the most common medical cause of death in the athletes. There are tests, commonly performed as a preparticipation screening, to detect the abnormal heart rhythms that lead to SCD, however, the tests can also have false-positive results and can miss some heart abnormalities.

There are no current standards for what needs to be included in athlete preparticipation screening but personal and family histories, physical examination (PE), and 12-lead electrocardiography (ECG) are most commonly used. Would ultrasound help to increase the efficacy of the screening?

Point-of-care ultrasound (POCUS) provides real-time bedside images that can assist in clinical decision making by potentially identifying dilated cardiomyopathy, aortic root dilatation, and coronary artery anomalies, which history, PE, or ECG frequently miss.

In a recent study to determine whether POCUS would be a beneficial adjunct to the preparticipation screening, the researchers found that although POCUS would have resulted in a 4-fold decrease in referrals, that was based on older studies using now outdated ECG guidelines. The 2017 guidelines greatly reduced the number of false-positives results, so adding POCUS as an adjunct would not create such a large decrease anymore.

POCUS did identify one primary diagnosis, left ventricular noncompaction, which was not identified by any other part of the screening. So, although the value of a POCUS adjunct may not be in reducing false-positives, it’s value may be in identifying anatomic anomalies.

Read the full article on the study by Cassels M, Moulson N, Reganin J, et al, in “Point-of-Care Ultrasound as a Component of Preparticipation Screening of Athletes: A Systematic Review” in the Journal of Ultrasound in Medicine (J Ultrasound Med 2019; 38:3123–3130. doi: 10.1002/jum.15021).

Interested in learning more about ultrasound for athletes? Check out the following resources from the American Institute of Ultrasound in Medicine (AIUM):

Post on the Scan: The Role of Musculoskeletal Ultrasound in Sports Injuries

Post on the Scan: Ultrasound-Guided Musculoskeletal Injections

JUM Article With CME: Using Ultrasound Measurement of the Achilles Tendon in Asymptomatic Runners to Assist in Predicting Tendinopathy

The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound

Posted on December 17, 2019 by aium1952

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, 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.

Novice to Competence to Understanding Our Role as POCUS Educators

Posted on December 3, 2019 by aium1952

Nights at the VA medical ICU could get lonely sometimes. When the hubbub of the day had drawn down and the critical care fellows had gone home, the work in the ICUs slowed. Headshot_kevin piro

I figured that I would make use of the time that had seemingly stopped. I grabbed the ultrasound and went to scan and chat with a friendly gentleman whom I had admitted the previous night. It became readily apparent that I was still a struggling learner at this point in my training. There was something that looked like cardiac motion, but not resembling anything like the diagrams and videos I had looked at on my own. It was an uncomfortable place to be.

I imagine that is where a lot of people get frustrated and stop, especially when they don’t have someone to encourage and nurture their continued practice. I had a different luxury. Just a few weeks prior, I had received an inquiry about participating in a new general medicine POCUS fellowship at Oregon Health & Science University, and I was instantly sold on its potential. Here was a chance to carve out a new path and to invest in a skill that offered me a skillset that could improve my patient care. And I knew that I would have the benefit of POCUS experts literally holding my hand as I learned the skill. What a luxury!

So, I kept scanning in the ICU prior to my fellowship. You know what I found? Patients are much more forgiving than we might imagine them to be. Most understand that hospitals are frequently places of learning and like to be engaged in the process and, as I stumbled through my next few exams, I was reminded of my Dad’s words of encouragement, “the only difference between you and an expert is that they have done it once or twice.” So I kept at it. I was terrible the next times too. But, it got easier and I felt less intimated with each scan I performed. By the time I hit fellowship, I was already moving in the right direction.

When I started my POCUS fellowship, I was fortunate to work with all sorts of supportive colleagues that allowed me to continue to grow. Where I had struggled to build a foundation on my own, colleagues collected from internists, sonographers, and EM physicians provided me with the scaffolding. They provided me with lessons. “Remember, air is the enemy of ultrasound” and “ultrasound does not give you permission to turn your brain off. It is a problem-solving tool.” They entertained clinical application questions. They gave back when I leaned in. These colleagues were an amazing support network and would help me construct the mosaic that I teach from now.

A few months into the fellowship, I could complete a competent exam comfortably. It came together one day for me when I completed a Cardiovascular Limited Ultrasound Exam (CLUE) on a pleasantly demented older man, who had shortness of breath likely representing heart failure. As I looked at his lungs, taking stock of the bilateral B-lines and pleural effusions that confirmed his diagnosis, I discussed and showed the findings with his daughter.

“This makes so much sense now!” she remarked. The lightbulb went on for her as I democratized her father’s clinical information. The lightbulb came on for me too as I had a sense of satisfaction of both feeling confident in my diagnosis, but also being better able to teach and engage a family in their medical care. My transformation from novice to competency was mostly complete.

Now, a little more than 2 years removed from my fellowship, I have a little more perspective on the road from novice to competency, not only from my personal experience but also from my opportunity to network with an amazing group of enthusiastic (IM) POCUS educators.

These educators are largely trained by their own curiosity, their attendance at POCUS CME courses, or by latching onto experts from peripheral medical departments. In essence, these educators are pulling themselves up by their own bootstraps in a time when there is a distinct scarcity of POCUS educators within Internal Medicine, which can leave the supposed “all-knowledgeable” physician in an uncomfortable place of vulnerability. They have shared the angst that POCUS is a particularly challenging skill to learn due to its humbling nature – we may not know how badly we were hearing murmurs as medical students, but I bet most learners can guess by looking at a picture how poorly they are doing when they are scanning. It was a feeling I shared back in the ICU as a resident, but our experiences diverged when I had mentors who invested in me learning this valuable skill.

But, these physicians who learned POCUS independently are now at the next, even harder, part. As new leaders, we must reach behind us and pull up the trainees, whether that be by creating the next POCUS fellowship, starting or improving a residency POCUS program, or simply training your fellow colleague. We are tasked with making new learners feel supported and encouraged, and to make this technology accessible in fields where POCUS is not the standard of care. We need to foster these learners’ growth so that they can arrive at their own lightbulb moment and so they keep scanning on the ICUs in the effort to improve the care they deliver.

What was your defining moment in your decision to go into ultrasound? Have you had a unique learning experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

Kevin M. Piro, MD, participated in and helped build a point-of-care ultrasound fellowship at Oregon Health & Science University (OHSU), becoming only the second general medicine-focused ultrasound fellowship in the nation. Dr Piro is now a hospitalist at OHSU.

Pioneering Ultrasound Units

Posted on October 8, 2019 by aium1952

If you think your ultrasound machine is out-dated, imagine if you still had to use these from as long ago as the 1940s.

1940s

Ultrasonic Locator
Dr G. D. Ludwig, a pioneer in medical ultrasound, concentrated on the use of ultrasound to detect gallstones and other foreign bodies embedded in tissues. During his service at the Naval Medical Medical Research Institute in Bethesda, Maryland, Dr Ludwig developed this approach that is similar to the detection of flaws in metal. This is A-mode in its operation and was Dr Ludwig’s first ultrasonic scanning equipment.

Locator

1950s

Ultrasonic Cardioscope
Designed and built by the University of Colorado Experimental Unit, the Cardioscope was intended for cardiac work.

Ultrasonic Cardioscope

1960s

Sperry Reflectoscope Pulser / Receive Unit 10N
This is an example of the first instrument to use an electronic interval counter to make axial length measurements of the eye. Individual gates for the anterior segment, lens, and vitreous compartment provided accurate measurement at 10 and 15 MHz of the axial length of the eye. This concept was the forerunner of all optical axis measurements of the eye, which are required for calculation of the appropriate intraocular lens implant power after cataract extraction. This instrument, which includes A-mode and M-mode, was developed by Dr D. Jackson Coleman and Dr Benson Carlin at the Department of Ophthalmology, Columbia Presbyterian Medical Center.

Sperry Reflectoscope Pulser

Sonoray Model No. 12 Ultrasonic Animal Tester (Branson Instruments, Inc.)
This is an intensity-modulated B-mode unit designed exclusively for animal evaluations. The instrument is housed in a rugged aluminum case with a detachable cover that contains the cables and transducer during transportation. The movable transducer holder on a fixed-curve guide was a forerunner of mechanical B-scan ultrasonic equipment.

Sonoray Animal Tester

Smith-Kline Fetal Doptone
In 1966, pharmaceutical manufacturer Smith Kline and French Laboratories of Philadelphia built and marketed a Doppler instrument called the Doptone, which was used to detect and monitor fetal blood flow and the heart rate. This instrument used the continuous wave Doppler prototype that was developed at the University of Washington.

Smith Kline Fetal Doptone

Smith-Kline Ekoline 20
Working in collaboration with Branson Instruments of Stamford, Connecticut, Smith-Kline introduced the Ekoline 20, an A-mode and B-mode instrument for echoencephalography, in 1963. When B-mode was converted to M-mode in 1965, the Ekoline 20 became the dominant instrument for echocardiography as well as was the first instrument available for many start-up clinical diagnostic ultrasound laboratories. The A-mode was used in ophthalmology and neurology to determine brain midlines.

Ekoline 20

University of Colorado Experimental System
Developed by Douglas Howry and his team at the University of Colorado Medical Center, this compound immersion scanner included a large water-filled tank. The transducer moved back and forth along a 4-inch path while the carriage on which the transducer was mounted moved in a circle around the tank, producing secondary motion necessary for compound scanning.

1970s

Cromemco Z-2 Computer System (Bioengineering at the University of Washington)
This color-Doppler prototype, introduced in 1977, was the computer used for early color Doppler experiments. Z2 “microcomputers” were used for a variety of data acquisition and analysis applications, including planning combat missions for the United States Air Force and modeling braking profiles for the San Francisco Bay Area Rapid Transit (BART) system during actual operation.

Cromemco Z-2 Computer System

ADR-Model 2130
ADR of Tempe, Arizona, began delivering ultrasound components to major equipment manufacturers in 1973. Linear array real-time scanners, which began to be manufactured in the mid-1970s, provided greater resolution and more applications. Grayscale, with at least 10 shades of gray, allowed closely related soft tissues to be better differentiated. This 2-dimensional (2D) imaging machine was widely used in obstetrics and other internal medicine applications. It was marketed as an electronic linear array, which was faster and more repeatable without the need for a water bath as the transducer was placed right on the skin.

ADR Model 2130

Sonometrics Systems Inc, NY BR-400V
The first commercially available ophthalmic B-scanner, this system provided both linear and sector B-scans of the eye. The patient was examined in a water bath created around the eye by use of a sterile plastic ophthalmic drape with a central opening. Both A-scan and B-scan evaluations were possible with manual alignment of the transducer in the water bath. The instrument was developed at the Department of Ophthalmology, Columbia Presbyterian Medical Center by Dr D. Jackson Coleman, working with Frederic L. Lizzi and Louis Katz at the Riverside Research Institute.

Sonometrics Systems Inc, NY BR-400V

Unirad GZD Model 849
Unirad’s static B-scanner, allowing black-and-white anatomic imaging, was used with a scan arm and had similar controls as those used today, including processing, attenuation compensation, and gain.

1980s

American Flight Echocardiograph
This American Flight Echocardiograph (AFE) is a 43-pound off-the-shelf version of an ATL 400 medical ultrasonic imaging system, which was then modified for space shuttle compatibility by engineers at the Johnson Space Center to study the adaptations of the cardiovascular system in weightlessness. Its first journey to space was on the space shuttle Discovery in 1985 and its last on the Endeavour in 1992. The AFE generated a 2D cross-sectional image of the heart and other soft tissues and displayed it in video format at 30 frames per second. Below, Dr Fred Kremkau explains more about it.

To check out even more old ultrasound machines, visit the American Institute of Ultrasound in Medicine’s (AIUM’s) An Exhibit of Historical Ultrasound Equipment.

How old is the ultrasound machine you use now? What older ultrasound equipment have you used? Did it spark your desire to work with ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Connect_digital_graphics_E-NEWSLETTER

The AIUM is a multi-disciplinary network of nearly 10,000 professionals who are committed to advancing the safe and effective use of ultrasound in medicine.

Ultrasound in the Age of Telehealth, Telemonitoring, Telemedicine, Robots, and Kimonos

Posted on March 28, 2017 by aium1952

Today, there is online access to almost everything; groceries, a video chat with your grandmother across the globe, step-by-step instructions on how to fix your lawnmower, and a virtual doctor to help with pain in your abdomen. The healthcare applications of the internet have exploded in recent years with digital health and telemedicine assuming one of the highest growth areas for start-up entrepreneurs. The expansion of telehealth resources (IT infrastructure/capabilities) has allowed telemedicine to extend to isolated, inaccessible, remote spaces (maybe even your living room). And telehealth has gone beyond just a video chat with incorporation of sensing technologies including cameras, digital stethoscopes, and ultrasound.
Kat and Scott

Ultrasound imaging in austere locations is not just about access to an ultrasound system; it requires both the ultrasound operator, and the interpreter, to have specific knowledge, competency, and ultimately accountability about the quality of the examination, and the diagnosis it helps to provide. Our NASA-sponsored research team has shown that novice ultrasound operators can acquire diagnostic quality ultrasound images after a short training period with remote tele-ultrasound guidance in a space medicine environment. The astronaut operators were able to perform terrestrial standard abdominal, cardiovascular, and musculoskeletal ultrasound examinations with modest remote guidance oversight; zero gravity specific exams of the eyes, spine, and sinus were also completed. Importantly, the astronaut crewmembers quickly became more autonomous during their 6-month mission in space and were able to self-direct image acquisition.

But a major challenge with tele-ultrasound is operator training. William R. Buras, Sr, Director, Life Sciences at Tietronix Software Inc, and his team are making an augmented reality user interface for ultrasound scanning using a wearable heads-up display with imbedded guidance to improve ultrasound competency. This innovative Houston team is being funded by a NASA grant.

Unfortunately, when it gets to real-world practicality, neither the ultrasound machine nor the examination is intuitive. A team in Canada led by Dr Andy Kirkpatrick are working on a sustainable ultrasound solution using both remote ultrasound system operation and telemonitoring. They investigated the ability of non-trained firefighters to perform ultrasound in Edmonton being guided from Calgary. “We found that by using just-in-time–training with motivated firefighters, the remote examiner guiding the firefighters was 97% correct in determining the presence of a simulated hemo-peritoneum. Ironically, while this trial design also attempted to examine the utility of remote ultrasound knobology control, the firefighters were so good at the task that the remote knobology control became less of a relevant problem” said Dr Kirkpatrick.

To reduce the challenges of novice ultrasound operators, at team in France, led by Dr Phillipe Arbelle, linked a robot-coupled ultrasound device with a remote operator. The distant clinician can move the ultrasound probe with a joystick to acquire the ultrasound images. His concept has been implemented in a French ultrasound device, SonoScanner, that the European Space Agency will begin investigating on the International Space Station.

Similar work in robotic ultrasound is being done in Australia, where a team is building a robotic ultrasound machine that can perform abdominal ultrasound.

Have you seen the guy in a kimono buying a car? Online resourcing is indeed pants-optional. But if you plan on telemonitoring be suitably dressed.

Alien

What other areas have come a long way when it comes to ultrasound? What areas are poised to be next? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Kathleen M Rosendahl-Garcia, BS, RDMS, RVT, RDCS, is a NASA contractor working for KBRWyle and is a senior scientist and clinical sonographer in the Space Medicine division working under the Human Health and Performance Contract. Scott Dulchavsky, MD, PhD, is the Roy D. McClure Chairman of Surgery and Surgeon-in-Chief at Henry Ford Hospital in Detroit, and Professor of Surgery, Molecular Biology and Genetics at the Wayne State University School of Medicine. He is also a principal investigator for NASA and heads a project teaching astronauts how to use medical ultrasound in space.

Why I Love Credentials

Posted on November 22, 2016 by aium14750

My name is Mike. I am many things, including a veteran, a business man, a coach, and a sonographer. And while the “things” I am change over time, one thing has remained the same: I am a student! This is thompson most evidenced by the 8 professional credentials I currently hold.

I have found that after being in the field of ultrasound for more than 2 decades, credentialing and continuing education can distinguish the enthusiastic sonographer from the merely competent one. With the introduction of more focused credentials such as musculoskeletal, breast, pediatric, phlebology, and advanced cardiac subspecialties, sonographers can now stand out from the crowd in terms of awareness and competency while at the same time being on the cutting-edge of the latest techniques and literature.

Acquiring a new credential, or even just studying for the registry examination, requires you to learn valuable new knowledge that may impact the way you treat and diagnose patients. For example, while I was preparing for the RPhS registry, multiple sources recommended a pneumatic compression device to augment venous flow while a patient is standing as an alternative to the patient performing the Valsalva maneuver in order to induce and record venous reflux. For me, this method has helped me better evaluate for this condition with less strain on the patient while eliminating communication barriers that may exist. If I hadn’t been preparing for that exam, I probably would never have learned this technique.

While some credentials are necessary for certain jobs, multiple credentials prove to existing and future employers that you take your profession seriously and you don’t settle for the minimum standard. I am not saying you need to get multiple credentials. If your professional interest does not reach beyond one credential, that is fine, but few ultrasound labs today only perform only one specialty. Echocardiography labs and vascular labs are growing together as cardiovascular labs, and many departments are requiring a more comprehensive knowledge in ultrasound. Credentialing yourself to the highest degree may get you the new job you pursue or secure the one you have. While increased pay is always a motive, sometimes the satisfaction of being able to set yourself apart from others in the field can be just as rewarding.

Some sonographers have the position that if the credential doesn’t come with a pay raise, it’s not worth it. With reimbursement cuts and higher credentialing standards being proposed by private and government payors, my opinion is that keeping your job is a pay raise.

Why do you hold the credentials you have? What are your go-to resources? What book would you like to see written? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Mike Thompson, MPH, RDMS, RDCS, RVT, RPhS, RVS, RCS, RCCS, is Owner of Diagnostic Resources in Perry, Georgia.

How to Obtain Focused Cardiac Ultrasound Images

Posted on August 2, 2016 by aium14750

My first exposure to handheld ultrasound was as a first-year medical student. I was assigned to a cardiology clinic with an attending that pioneered handheld ultrasound examinations. Watching him move from patient to patient and use ultrasound to simultaneously diagnose and teach inspired me to learn how to use ultrasound and incorporate it into my practice.

Parasternal long axis demonstrating a dilated left ventricle.

As a budding cardiologist, examining and triaging patients with handheld ultrasound is a part of my daily work. Although handheld ultrasound and the stethoscope differ vastly in their technology, at the bedside, both are limited by the user’s interpretation of the examination findings. I have found when using handheld ultrasound, as with the stethoscope, perhaps the most important tool is “between the ears.”

The “Introduction to Focused Cardiac Ultrasound” set of lectures provide an overview to focused cardiac ultrasound views and a guide to obtain them. The main goal is to develop an understanding of the scope of focused cardiac ultrasound and to “get the heart on the screen” when scanning. The first lecture focuses on the parasternal long axis and subcostal views of the heart. In practice these views will often be the most helpful and accessible. The second lecture reviews the parasternal and subcostal views and introduces the apical views of the heart. Each lecture includes sample diagnoses.

My rationale for reviewing all the basic views of the heart is to provide a broad survey of all the windows and probe orientations. When a formal cardiac echo is ordered, these are the views and windows obtained by the sonographer. In practice with handheld ultrasound, one or two of these views can be utilized to answer the question at hand. Based on patient positioning and body habitus, however, certain windows may provide a better view of the heart.

My hope in sharing all the views in the second lecture is to not overwhelm the learner but rather provide a strong foundation in understanding the anatomical relationships of the ventricles and atria in the body and see how one window builds off the next. The views in this lecture are directly applicable to structured bedside ultrasound examinations, such as the “CLUE examination.”

At our home institution, we utilize these lectures in a continuously rolling small-group lecture series for our medical students and house staff. The cardiology fellow leads the lecture and the hands-on scanning portion, rotating every third week on the step-down cardiology unit. Overall the feedback has been positive with many of the trainees spreading the skills to other rotations. We are happy to share this resource and welcome feedback.

What resources are invaluable to you? What tools do you use to continually learn? Where do you find the information you need? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Colin Phillips, MD, is Fellow, Division of Cardiovascular Disease at Beth Israel Deaconess Medical Center.

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