Sink or Swim? Modifying POCUS Medical Education Curriculum During the Coronavirus Pandemic

Posted on April 6, 2021 by aium1952

Modifying a point-of-care ultrasound (POCUS) medical education curriculum initially designed for 4-year matriculation into a 3-year experience is undoubtedly challenging. This 1-year shortening, combined with the added constraints of mandated social distancing guidelines of the coronavirus pandemic, caused us to search for concrete answers to these new directives that would lead us to either sink or swim in this new ocean of learning.

Claude Bernard, a 19th-century French physiologist, remarked that “it is what we think we know already that often prevents us from learning.” This educational concept was true with our efforts to modify a successful ultrasound in medical education curriculum and transform it into a case-based learning approach for a condensed 18-month pre-clerkship ultrasound curriculum.

How we had conducted ultrasound labs previously would have to be revisited, revised, and revamped to transform the curriculum successfully.

Planning began to modify the ultrasound curriculum for the 18-month pre-clerkship experience approximately 2 years before the pandemic was even on the horizon. In-person meetings were held with fellow faculty to discuss and debate the patient-centered learning course’s mission and goals and where the ultrasound curriculum would be housed. Our discussions took place with ease, and ideas for collaboration easily flowed. Plans were made for in-person, hands-on scanning where students scanned each other, volunteers, or standardized patients, without giving any thought to the physical contact.

There was no thought to the exam rooms’ square footage or how students would enter and exit the ultrasound center. Live introductory lectures at the onset of each lab were planned for 25–30 students to introduce the case and review the scanning techniques and logistics for each lab session. The planning included no discussion of online learning or simulated scanning for students from a remote location. Ultrasound instruction would proceed into the new curriculum with a slight modification to how ultrasound content had been previously delivered.

Then, while finalizing our plans for a start date of August 2020, all in-person instruction was suspended for our institution. It was mid-March, and we had a nearly solidified sketch of the ultrasound lab logistics and learning methods for the inaugural class of the 3-year medical school and the 18-month pre-clerkship curriculum.

Nevertheless, that suddenly changed, and the uncertainty of instructing anyone in-person to do any part of the curriculum was up for discussion. The faculty was mandated to work from home away from the ultrasound center with its hand-held systems, full-size ultrasound machines, and simulation capabilities. Student interactions were reduced to phone calls, emails, and video interactions within online course offerings as each student cohort was scattered throughout the 159 counties of our state.

Learning to conduct curriculum meetings through online platforms filled our days. Trying to accomplish fully online ultrasound electives with a plethora of students and revamp the new ultrasound curriculum within the changing coronavirus guidelines stayed on our minds as we struggled through the spring and early summer.

Nevertheless, we made it!

When the inaugural class of the new pre-clerkship curriculum began, we laid out a plan to keep students, staff, and faculty safe through the 3W’s: wearing a mask, watching physical distance, and hand washing.

Facilities management personnel had surveyed our ultrasound exam rooms and learning spaces and posted how many students could be in each room. Hand sanitation stations and masks were made available for students as they entered the ultrasound center. Signage and arrows were erected to direct students in and out of the ultrasound center in a one-way fashion. An online meeting platform was set up in each exam room for students to hear live instruction before beginning the lab. Instructors utilized a laser point at each room’s door to direct student scanning and maintain social distancing. Students used hand-held ultrasound equipment with image transfer capabilities to obtain images needed to complete their online case-based ultrasound assignments. Although these safety measures were not visualized in our early curriculum planning meetings, the ultrasound curriculum was successfully delivered!

While we did not meet the goal of remote hands-on ultrasound instruction for all ultrasound labs during the pandemic, we learned to conduct in-person ultrasound scanning labs safely and effectively within a new accelerated medical school curriculum. The constraints and trials of a global pandemic did not preclude us from putting aside what we already knew and navigating a new course into the future!

Rebecca J. Etheridge, EdD, RDMS, is an assistant professor at the Medical College of Georgia at Augusta University.

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

What Rheumatologists Really Need for Ultrasound Is…

Posted on March 23, 2021 by aium1952

After I graduated from a Rheumatology fellowship, I was invited to stay on as junior faculty and several years thereafter the ACR (that acronym stands for American College of Rheumatology – I have no idea why most people who are into ultrasound always think it means something else…) developed an educational initiative aimed at bringing MSK US to every Rheumatology training program in the USA.

The ACR began to invite about 20 training programs per year to nominate one faculty member whose journey through the Ultrasound School of North American Rheumatologists (USSONAR) would be subsidized by the College. The idea was that each USSONAR graduate would then start an MSK US training program at his or her home institution, and since there are only about 120 Rheumatology training programs in the USA, the whole process would only take about 6 years. The rate of adoption among training programs was of course not 100%, and there are several key barriers to the development of an ultrasound training program, but at our institution it worked.

I’ve been doing point-of-care MSK ultrasound ever since I completed USSONAR and passed my certification exams, and our institution now has a required half-day MSK ultrasound clinic in which every Rheumatology fellow spends 6 months as part of their required curriculum. While MSK US certification is not required for graduation or to sit for boards, I’m proud to say that so far three of our Rheumatology graduates have opted to sit for the exam and are now ultrasound certified.

The program has been in place for about 7 years now, so it seems a good time to begin reflecting on my impressions of how MSK US fits into a Rheumatology practice, and more importantly some of the ways in which the current off-the-shelf technology doesn’t fully meet our specialty’s needs.

Clearly, MSK US is a major boon to Rheumatology in terms of needle guidance. Our half-day ultrasound clinic has made it possible for us to stop referring hip injections out to Interventional Radiology or Anesthesia-Pain, and I’m hoping that we will soon be able to bring sacroiliac joint injections back in-house as well. Diagnostically, the most common reason a patient is referred to the ultrasound clinic is for disambiguation of the borderline / nebulous case—that patient who endorses symptoms that sound like active inflammation but whose physical exam is benign. Our most common diagnostic referral is to answer the question of whether or not subclinical synovitis is present in the small joints of the hands, and that leads us to the first instance of current MSK US technology being less than a seamless integration into clinical practice and more of a square peg being jammed into a round hole.

The soft tissues associated with the small joints of the hands are at very shallow depths, usually under 1 cm in most patients. My very first ultrasound machine was a SonoSite M-MSK, and you adjusted the depth with a pair of pushbuttons. The standard procedure (and I would teach the fellows exactly this) was to start up the machine and then just start tapping the “less depth” button over and over.

Image of a finger joint with a ruler indicating the small height of the joint is less than 2 centimeters.

“Just keep tapping,” I would tell the fellow. “Tap it like you’re playing Space Invaders, and just keep hitting it until the machine starts beeping in protest because the minimum depth has been reached.”

Even at that minimum setting, most ultrasound machines still show a depth of about 2 cm. I often joke with the fellows that this setting would be wonderful if we were trying to look clear through the patient’s hand and figure out what material the cushion on the exam table was made of!

Astute readers will also realize that no matter what the depth on the machine is set to, this puts the target structure (again, usually at a depth of 0.5–1 cm) closer to the probe face than the optimal focal zone distance on many probes—we are giving ourselves a case of technological hyperopia.

A stand-off pad will help keep the tissue at a better focal distance, but these pads can be cumbersome and will make the learning curve for any fellow even steeper than it already is by virtue of obscuring the tactile input, which is integral to the hands-on nature of point-of-care sonography. Ultrasound doesn’t feel like a natural extension of the physical exam with a stand-off pad in the way.

The real solution here is to switch to ultra-high-frequency ultrasound, something in the 50–70 MHz range, where the depth bar at the edge of the monitor is labeled in millimeters instead of centimeters. For small joints, I think this has to be the future of MSK ultrasound. This is why I was interested in the AIUM’s Community on High Frequency Clinical and Preclinical Imaging, and ultimately volunteered to serve among its leadership. Sadly, these UHF machines are expensive and they are often purpose-built for ultra-high-frequency only, meaning that a top of the line Rheumatologic MSK US clinic would need to own two machines, one UHF and one standard.

This won’t fly in most places.

One of the main reasons why the ACR’s vision for an MSK US curriculum in every Rheumatology training program has not been fully realized is the expense involved in acquiring even one machine.

When we are looking at the hands of that patient whose clinical presentation is ambiguous—whose symptoms don’t seem to match their physical exam and in whom occult synovitis is suspected—we are looking for three telltale sonographic signs of the ravages of inflammation: hypertrophy of the synovium, the presence of a joint effusion, and hyperemia from the irritated joint lining struggling to summon blood flow to meet its elevated metabolic demands. The first two are often lumped together under the umbrella of “grayscale findings,” and the hyperemia is of course measured by Doppler.

The second hurdle for MSK US in the field of Rheumatology, then, is that of Doppler sensitivity. We are trying to examine and even semi-quantify the blood flow in capillaries, using equipment designed to measure the jets from regurgitant heart valves. Power Doppler is helpful here, due to its independence from the angle of insonation, but again we end up playing every trick in the book (starting with turning the wall filter off completely, if the machine even allows it) trying to squeeze every iota of signal out of the noise.

I always start the hand exam with a calibration image, in which I capture the blood flow in the pulp of a fingertip. Sometimes, especially in the midst of Chicago winters, you can’t even tell the Doppler is on at all. Currently, there’s nothing to do in that situation other than to comment in the report that Doppler calibration failed and thus the sensitivity of the study for detecting active synovitis (the very thing for which the study was ordered) is significantly compromised.

Taken together, it would seem that perhaps what we really need is for manufacturers to go beyond a blanket “MSK” setting in their machines and offer a true “Rheum” optimization package.

Dr. Mandelin is an academic rheumatologist, registered in MSK ultrasound (RhMSUS) by the American College of Rheumatology and certified in MSK ultrasound (RMSK) by the Alliance for Physician Certification & Advancement. He currently serves the AIUM as secretary of the High Frequency Clinical and Preclinical Imaging Community.

Where do you think MSK ultrasound is headed? Rheumatologists, where else does the technology not quite work in terms of your practice? Comment below or join in the conversation on Twitter, where my handle is @NU_Rheum_MSK_US.

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

POCUS in COVID-19—Clutch or Not So Much?

Posted on March 9, 2021 by aium1952

Health care workers see patients with undifferentiated symptoms day and night in emergency departments, hospitals, and outpatient clinics, so we are hard-pressed to identify symptoms that are NOT part of the constellation of symptoms seen with COVID-19. Practically speaking, any patient we encounter is likely to have one or more of the symptoms, which include incredibly common findings such as fever, chills, cough, shortness of breath, chest pain, headache, myalgias, nausea, vomiting, diarrhea, abdominal pain, and rash!

A Critical Question Exists: How Might Point-of-Care Ultrasound (POCUS) Be Best Utilized in This Pandemic?

While data is still being collected and definite answers may not be attainable, we seek to outline a few scenarios where POCUS may greatly aid every-day patient care.

No Test or Slow Test Scenario

While COVID-19 testing is more available than early in the pandemic, there are still communities in the U.S. and worldwide that lack access to testing or expeditious results. A prior post on AIUM’s The Scan, “My Sonography Experience With COVID-19”, (https://aiumthescan.blog/2020/04/21/my-sonography-experience-with-covid-19/) by Yale Tung Chen, MD, PhD, details common POCUS findings that may aid in diagnosing COVID-19 when tests or test results are not available.¹

POCUS offers greater sensitivity for COVID-19 pneumonia than CXR and is safer (no ionizing radiation) and more cost-effective in comparison to CT imaging of the chest.²

Is This Patient’s Shortness of Breath Due to COVID-19 Pneumonia?

The differential diagnosis of a patient with undifferentiated shortness of breath can be broad. It includes not just COVID-19 pneumonia, but also pulmonary embolism, heart failure, pericarditis, pericardial effusion/tamponade, pneumothorax, and many more.

POCUS can reliably exclude decreased left ventricular ejection fraction, pericardial effusion, and pneumothorax, often rapidly shortening the differential. And POCUS findings of right heart strain may help direct clinicians toward further testing for pulmonary embolism (PE) or the use of thrombolytics in patients in extremis. Detection of a deep venous thrombosis (DVT) may serve as a proxy for diagnosing PE in a patient with shortness of breath or chest pain with a high probability of PE.

As has long been recognized but is reinforced in the COVID-19 pandemic, the ability to detect these pathologies at the bedside makes POCUS an invaluable tool for patients who are too critically ill to be transported for further diagnostic studies.

POCUS Takes One for the Team, Limiting Healthcare Worker Exposure

Limiting the number of people involved in the hands-on care of a patient with COVID-19 is an important principle in reducing healthcare worker (HCW) exposure.

In another previous post on The Scan, “How the COVID-19 Pandemic Has Changed Your Practice”, Margarita V. Revzin, MD, MS, detailed the time-intensive protocols that are in place to protect both the patients receiving and the HCWs performing ultrasound exams in the radiology department (https://aiumthescan.blog/2020/12/15/how-the-covid-19-pandemic-has-changed-your-practice/).

The ability of POCUS to answer binary clinical questions may help limit the exposure of HCWs who are not part of the primary team for the infected patients. In POCUS, the ultrasound exam is performed by a provider responsible for the comprehensive care of the patient—in essence, one of the HCWs who is primarily caring for the patient. When POCUS is able to definitively answer the clinical question at the bedside, additional imaging studies may be unnecessary, thus reducing the number of consulting providers exposed to a patient with COVID-19.

POCUS as the Great Prognosticator

The lung ultrasound findings of COVID-19 pneumonia precede findings on physical exam and x-ray imaging. Therefore, ultrasound could be used as a screening tool and additional data point in triaging patients and determining if they can be treated as an outpatient or admitted to the hospital.

Studies have suggested that infero-posterior lung POCUS findings are most sensitive for the diagnosis of COVID-19 pneumonia but that anterior lung findings best predict the need for non-invasive ventilation support while hospitalized.³

In addition, calculation of a lung ultrasound score (LUS) may help quantify severity of disease, with higher LUS predicting invasive ventilatory support need, ARDS, and death.⁴

The Future

POCUS is unique. It is the imaging modality that most easily incorporates into telehealth via remote guidance. As the role of POCUS in diagnosis, monitoring, and prognostication in pulmonary disease is better defined, it may play a role in determining care plans for patients seeking care via telehealth while minimizing COVID-19 exposure for both HCWs and patients.^5,6

Furthermore, combining handheld ultrasound devices with novel artificial intelligence algorithms may allow for the automation of diagnosis and monitoring as described in a prior blog post by Alper Yilmaz, PhD, “Using AI and Ultrasound to Diagnose COVID-19 Faster” (https://aiumthescan.blog/2020/08/11/using-ai-and-ultrasound-to-diagnose-covid-19-faster/).

References

Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standardization of the use of lung ultrasound for patients with COVID-19: a simple, quantitative, reproducible method. J Ultrasound Med. 2020 Jul;39(7):1413-1419. doi: 10.1002/jum.15285. Epub 2020 Apr 13. PMID: 32227492; PMCID: PMC7228287.
Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020 May;46(5):849-850. doi: 10.1007/s00134-020-05996-6. Epub 2020 Mar 12. PMID: 32166346; PMCID: PMC7080149.
Castelao J, Graziani D, Soriano JB, Izquierdo JL. Findings and prognostic value of lung ultrasound in COVID-19 pneumonia. J Ultrasound Med. 2020 Sep 16. doi: 10.1002/jum.15508. Epub ahead of print. PMID: 32936491.
Ji L, Cao C, Gao Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care. 2020 Dec 22;24(1):700. doi: 10.1186/s13054-020-03416-1. PMID: 33353548; PMCID: PMC7754180.
Kirkpatrick AW, McKee JL, Volpicelli G, Ma IWY. The potential for remotely mentored patient-performed home self-monitoring for new onset alveolar-interstitial lung disease. Telemed J E Health. 2020 Oct;26(10):1304-1307. doi: 10.1089/tmj.2020.0078. Epub 2020 Jul 10. PMID: 32654656.
Kirkpatrick AW, McKee JL. Re: “Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID-19: A Simple, Quantitative, Reproducible Method”-Could Telementoring of Lung Ultrasound Reduce Health Care Provider Risks, Especially for Paucisymptomatic Home-Isolating Patients? J Ultrasound Med. 2021 Jan;40(1):211-212. doi: 10.1002/jum.15390. Epub 2020 Jul 8. PMID: 32639037; PMCID: PMC7362148.

Jennifer Carnell, Tobias Kummer, and Arun Nagdev are the leaders (2020–2022) of the AIUM Point-of-Care Ultrasound Community. Jennifer Carnell is the Secretary, Tobias Kummer is the Vice-Chair, and Arun Nagdev Arun is the Chair.

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

Dawning of Another Golden Age for Ultrasound

Posted on February 23, 2021 by aium1952

Diagnostic ultrasound is an essential clinician’s tool. And, although it often does not get the attention (such as Nobel Prizes) of its sibling imaging modalities, it is the most utilized imaging modality in the world, depending on the metric.

The reasons why ultrasound is an essential tool are likely obvious to most readers of this blog. Ultrasound is relatively inexpensive, portable, and provides real-time imaging. It can be brought to patients who might otherwise be unable to receive imaging, whether that is because of the condition of the patient or the condition of the world around them. The variety and depth of our communities of practice attest to the robustness of this imaging modality (as does this blog, in its relatively short history). Furthermore, ultrasound imaging is not a static field; new technologies and applications, such as the use of artificial intelligence for COVID-19 diagnosis, are being incorporated on a continual basis.

The American Institute of Ultrasound in Medicine (AIUM) has played a central role in the history and promotion of ultrasound imaging due to its membership. I would argue one of its greatest strengths is that the AIUM provides a home for anyone involved in ultrasound: sonographers, physicians, scientists, academicians, students, private practice providers, and industrial partners. There are a number of other professional societies associated with ultrasound imaging, but none that cover the same breadth of topics and people.

The AIUM has done this, in part, by stepping up to the openings before it. The AIUM has embraced a variety of opportunities to make a difference in the lives of patients, including decades ago with the advent of the ‘modern’ array and continuing to more recent capabilities including bedside POCUS, telehealth, and artificial intelligence.

Is the AIUM ready to continue its role as the preeminent home for all areas of ultrasound? Is it ready to fully embrace the dawning of another golden age for ultrasound – therapeutic ultrasound?

The field of therapeutic ultrasound has a rich history stretching back decades. What separates the current era from the past is the combination of technological advancements made and the pairing of these technologies with dedicated clinicians. Furthermore, the field has been accelerating as it learns from past successes to create future ones. One of the most notable initial advances was the use of ultrasound thermal ablation of uterine fibroids, which has been available to women in the United States since 2004. A number of companies have subsequently obtained FDA clearance, the European CE mark, or other equivalent regulatory approval for their ultrasound thermal ablation devices, enabling the treatment of a wide range of conditions.

In the past decade, reimbursement has also become available for ultrasound treatment of bone metastases and essential tremor. Most importantly though, the pipeline is rich with dozens of potential applications and hundreds of clinical trials. Importantly, the mechanism of action by which ultrasound can have a therapeutic effect has grown beyond thermal ablation, with clinical trials in blood-brain barrier disruption, ultrasound-mediated drug delivery, and mechanical tissue ablation (just to name a few).

The AIUM already has a number of our basic-scientist and clinician-scientist members making great contributions, particularly within the Basic Science & Instrumentation and Therapeutic Ultrasound Communities of Practice. However, to remain the preeminent home for all areas of ultrasound, we will need engagement from the entire broad and rich swath of expertise that our full membership community has to offer. There are important questions to answer, and I do not pretend to know the answers. I am confident, though, in the ability of our community to answer them. A few of the important questions for us to consider are:

Just as there has been great opportunity in bringing together ultrasound imaging expertise across medical fields, do we see similar opportunity in being a home to bring together ultrasound therapy expertise across different medical fields?
How do we make our society a welcoming place for therapeutic ultrasound clinicians who might not have the deep background in diagnostic ultrasound that is common of current AIUM members?
How do we integrate our existing imaging expertise in helping to advance therapy, through treatment planning, guidance, and monitoring?
How do we break down some of the silos between our existing communities, particularly the more discovery-oriented communities and the more practice-oriented communities?
As we have played an important role in establishing standards, guidelines, and practice parameters in ultrasound imaging, should we do the same for therapeutic ultrasound?

The fundamental question, however, is: do we want to remain to be the American Institute of Ultrasound in Medicine, or do we want to be the American Institute of Ultrasound Imaging in Medicine?

Kevin Haworth (Twitter: @kevinhaworth) is an Associate Professor of Internal Medicine at the University of Cincinnati in Ohio.

What’s Your Dialogue?

Posted on February 9, 2021 by aium1952

Ultrasound image of a uterus showing the crown rump length of the fetus is 0.34 centimeters.

Beneath the paper drape of the “2:30 OB Confirmation” lies your next patient. Despite the application of the ultrasound study performed, a variety of stressors wreak havoc on a patient’s mental state prior to examination. The impact of what we say and how we say it, or the very lack of it, can shape a person’s view of testing, staff, or even healthcare as a whole. Yet, how much of an emphasis in ultrasound training is placed on effective communication? Especially in obstetrics where early pregnancy loss is prevalent, a blank stare at the monitor and averted eyes feels disconnected and insensitive. Let’s ask ourselves:

How do we, as ultrasound providers, communicate with our patients?
Do we attempt to provide comfort or empathy when needed?
How important is this interaction to our patients?

We owe it to quality patient care to take a deeper dive.

In settings where our patients show fear, stress, or grief, what’s your dialogue?
How should it look and sound?

Perhaps your patient, waiting nervously under the drape, presents with a poor OB history. Performing an ultrasound examination should encompass more than the stoic mechanical bedside manner. We should engage with the person behind the diagnosis code.

We see it often in OB. Despite reassurances of last week’s scan and normally-rising labs post early spotting, the patient leaves her appointment only to consult Dr. Google where she absorbs every related link about bleeding in pregnancy from previa to placental abruption. It’s been the L O N G E S T week of her life, and she’s sure fate will deliver yet another D&C instead of the child she desires. Miscarriage is the kind of trauma that leaves a woman emotionally scarred and fearful that history will repeat itself. It’s imperative we contemplate the real trepidation some patients feel for their examinations—and act accordingly.

For the brief time a patient resides in our care, we sonographers control the environment. We drive the equipment, manage the time, and guide our patients. It is completely within our power to greet them with warmth and direct eye contact, to adopt a caring tone in our explanations, to ensure comfort in our care, and to assure answers for their questions—where we can.

It’s a fine balancing act, isn’t it? …A tightrope walk between what we sonographers can share with an inquiring patient and what we cannot. Though protocols vary, we all surely must learn what information we are allowed to impart. Precisely how we convey it is up to us. After all, our patients must disrobe before a perfect stranger who is not their physician; in turn, we must overcome the propensity for a swift robotic contest against the clock to be more attentive. We may not manage a patient’s care, but for a short time, we are a patient’s provider and caregiver. The interchange with our patients is as much an integral part of our job as is concise reporting.

Effective patient communication should be a cornerstone of every curriculum and commence as early as learning sagittal versus transverse. Every veteran sonographer who relishes the confidence of cultivated skill and experience began the same way. Typically, navigating this technology for most students requires a long learning curve to perform it well and accurately. It’s quite easy for the initial focus to lie with capturing textbook images, not connecting with the patient. Learning appropriate and competent dialogue is as imperative as exam protocol. The new sonographer must observe and mimic this personal interaction before the first steps beyond the classroom.

Conversely, the skillful sonographer, buried in the demands of a hectic patient load, may lose the tendency over time to prioritize this communication. Juggling the demands of a full schedule with urgent add-ons and after-hours call, we sometimes end up fanning the flames of burnout where a slide into the hurried robotic pace of patient-in, patient-out feels unavoidable. Don’t lose sight of the importance of your work and who depends on you. Every patient you scan lies on your table, and your’s alone. We are each responsible for the level of quality care we provide.

Now, examine your own daily patient interactions. Are they mechanical and rushed? Or do you take the time to employ earnest conversation? Do you attempt to allay fears or offer an empathetic tone when needed? Do you extend the care you would want, need, and expect if on the receiving end of healthcare? I challenge each of you to put forth the very same degree of consideration you’d like for your mother, your sister, your daughter, yourself…if the white coat fear was your own, if the anxiety of a test result was your own, if the pregnancy loss was your own. The appreciation our patients show can mystifyingly renew a sense of purpose in our work today and fuel our career tomorrow.

So, what’s your dialogue?

Sandra M. Minck, RDMS, is the creator of UltrasoundUnwrapped.com and @ultrasound_unwrapped on Instagram, a resource for accurate ultrasound information for expectant parents. She is the author of Ultrasound Unwrapped: A Pregnancy Image Guide, soon to be published.

Interested in learning more about communicating with patients? Check out the following posts from the Scan:

Dermatologic Ultrasound: Skin Deep Knowledge

Posted on January 26, 2021 by aium1952

According to the recent European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound,¹ dermatologic ultrasound is the application of ultrasound to the diagnosis of skin and appendages (hair and nails) diseases, as well as their healthy state, and cosmetic alterations.

This application was born as a necessity to answer challenges in dermatology that could not be addressed with superficial exploration methods such as clinical inspection, wood lamp, or dermoscopy, which mainly offer 2D views of the skin. The possibility of adding a third dimension (depth) and even a 4^th one (with Doppler or dynamic explorations) with ultrasound makes dermatologic ultrasound a new way to go from guessing what’s happening below the surface to “seeing” what is really happening.

Ultrasound follow-up of intralesional glucantime injection in a cutaneous leishmaniasis. a) Clinical before treatment, b) B-mode before treatment, c) Color Doppler before treatment, d) Clinical after 3 injections, d) B-mode after 3 injections, d) Color Doppler after 3 injections.

During my years of clinical practice incorporating ultrasound in dermatology, I have heard some questions that always seem to arise in meetings. These are some of them:

What are the technical requirements for quality dermatologic ultrasound?

Although equipment with 70 MHz can be helpful to elucidate very concrete aspects of skin pathology, most questions and clinical situations in dermatology can be addressed today with high-quality conventional equipment above 15 MHz with color Doppler.

Apart from high-quality equipment, having a deep knowledge of dermatology, basic ultrasound, and its physical principles is the key to performing appropriate explorations in dermatologic ultrasound.

Which are the main fields of dermatologic ultrasound?

The fields at the forefront of dermatologic ultrasound are skin oncology, inflammatory skin diseases, and cosmetic dermatology.

How can dermatologic ultrasound help us dermatologist in skin oncology?

Skin cancer is the most frequent cancer in the human body. Most malignant skin tumor prognosis and treatment rely on depth and structural invasion, therefore, dermatologic ultrasound is an essential tool compared with MRI or CT in these kinds of evaluations, mainly because of its higher resolution and availability.

Is dermatologic ultrasound helpful in inflammatory skin diseases?

Deep inflammatory skin diseases such as hidradenitis suppurativa and morphea and sclerosing diseases usually do not have clear superficial expression. Dermatologic ultrasound is a key tool for in-depth evaluation of the inflammatory state of these diseases and is a guide for treatment and follow-up.

What are the main applications of dermatologic ultrasound in cosmetic dermatology?

Detection of dermal fillers and the complications and adverse reactions of these medical devices is essential in the management of a responsible cosmetic dermatology practice. Dermatologic ultrasound can also be an excellent tool for skin aging evaluation and anti-aging treatment evaluation.

Who is the AIUM and how can I learn Dermatologic Ultrasound from the AIUM?

The American Institute of Ultrasound in Medicine (AIUM) is the only scientific society that hosts a very active Dermatologic Ultrasound Community, which was funded in 2015 by Ximena Wortsman together with Orlando Catalano (present vice-chair of the community), Fernando Alfageme (present chair of the community and author of this post), and Claudia Gonzalez (secretary).

This community and their members are very active in AIUM meetings, hosting several scientific and didactic sessions, and has also produced some reference papers in dermatologic ultrasound.

The AIUM has hosted several sessions and workshops in AIUM meetings in the last 5 years with the collaboration of the dermatologic ultrasound community, although a need for structured teaching and learning is still necessary for those who are interested in this subspecialty.

Dermatology is an amazing application for ultrasound and it will be key in the near future for high quality, personalized skin medicine to foster the best, responsible care for our patients.

Fernando Alfageme, MD, is a Dermatologist and Chair of the Dermatologic Ultrasound Community (AIUM) as well as Codirector of the Ultrasound Learning Centre (Dermatology) at EFSUMB.

Reference

Alfageme F, Wortsman X, Catalano O, et al. European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound. Ultraschall Med. 2020 May 7. Online ahead of print. doi: 10.1055/a-1161-8872.

The Role of Musculoskeletal Ultrasound in Sports Injuries

Posted on January 12, 2021 by aium1952

Approximately 20% of the U.S. population engaged in sports or exercise on a daily basis from 2010–2019.¹ As expected, exercise and sports-related injuries are common, not only in the elite athlete but also in the general population. These injuries frequently lead to sport participation absence (SPA) and often, contact with the health care system. Although history and physical examination are the primary tools of diagnosis, musculoskeletal ultrasound (MSK US) has become the “stethoscope” for evaluation of sports medicine patients.

Even though MSK US has been widely used in Canada and Europe for years, the dramatic utilization increase in the United States has only occurred over the last two decades.^{2, 3} Between 2003 and 2015, there was a 347% increase in total MSK US volume within the Medicare population.³ The growth in subspecialties such as physical medicine and rehabilitation, rheumatology, and sports medicine has outpaced the growth in radiology. This Point-of-Care Ultrasound (POCUS) by clinicians may help facilitate diagnosis, expedite treatment planning, and reduce patient wait time and number of visits by offering one-stop clinics.

POCUS can be quite useful to evaluate sports injuries. Propelled by advances in technology, the advent of compact, portable, and more affordable ultrasound machines may facilitate prompt diagnosis of sports injuries on the field and in the training room. 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. They also appreciate the immediate findings the physician may be able to provide at the time of imaging. In fact, most patients actually prefer ultrasound to MRI.⁴ Other unique advantages of MSK US for sports imaging are the ability to easily assess the contralateral side as a control and the capability for dynamic imaging. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies.⁴ Sports clinicians often encounter a treatment gap for a substantial percentage of young, active patients with a strong desire to return to activity, yet for whom conservative measures have failed and surgery is not indicated. Fueled by media coverage of the treatment of high-profile professional athletes, the field of orthobiologics has exploded in recent years. Ultrasound can provide target localization during administration of a wide array of injectable agents (prolotherapy, autologous whole blood, and platelet-rich plasma) in addition to image-guided peritendinous corticosteroid injections, tendon needling or fenestration, and even percutaneous ultrasonic tenotomy (Tenex).

With the development of high-frequency transducers, MSK US has equal diagnostic accuracy to magnetic resonance imaging (MRI) for evaluation of many superficial tendon and ligament abnormalities. In the current era of cost containment, the utilization of MSK US as an alternative to other more expensive imaging modalities may represent an effective way to save healthcare dollars.^{5, 6} However, many issues related to accuracy, observer variability, and high-quality training need to be considered, aside from pure economics, to ensure that MSK US is ethically and adequately performed in the best interest of patient care.

As any of us who have picked up a transducer know, some of the most significant disadvantages of ultrasound are the relatively long learning curve and inherent operator dependence. These challenges are compounded in MSK US by the complex anatomy, pathology, and terminology not often included in general ultrasound education programs. Dedicated training and standardized technique can minimize these limitations. Many subspecialty residency and fellowship programs have recognized the necessity of standardized, high-quality training and have strategically designed curricula to become proficient in the core competencies of MSK US.

In recent years, quantitative ultrasound methods, such as shear-wave elastography (SWE) and contrast-enhanced ultrasound, have emerged as an adjunct tool to standard B-mode imaging in the evaluation of various structures throughout the body. In particular, SWE has seen an exponential increase in the number of musculoskeletal applications. Shear-wave elastography can assess tissue stiffness by applying a mechanical stress that generates shear waves, which then travel through the tissue at a speed proportional to its stiffness. By quantifying mechanical and elastic tissue properties, SWE may provide important information about pre-clinical injuries in musculoskeletal tissues as well as tissue healing after injury. Although SWE is FDA-approved on most ultrasound platforms, its use for clinical imaging in musculoskeletal ultrasound has lagged behind research due to lack of standardization in study protocols, techniques, and outcomes measures. Nonetheless, SWE has a promising role in the future of ultrasonography in sports medicine and may help practitioners to better estimate injury severity and individualize the retraining plan for the injured athlete.

References

Hauret KG, Bedno S, Loringer K, Kao TC, Mallon T, Jones BH. Epidemiology of Exercise- and Sports-Related Injuries in a Population of Young, Physically Active Adults: A Survey of Military Servicemembers. Am J Sports Med. Nov 2015;43(11):2645-53. doi:10.1177/0363546515601990
Sharpe RE, Nazarian LN, Parker L, Rao VM, Levin DC. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. J Am Coll Radiol. Feb 2012;9(2):141-6. doi:10.1016/j.jacr.2011.09.008
Kanesa-Thasan RM, Nazarian LN, Parker L, Rao VM, Levin DC. Comparative Trends in Utilization of MRI and Ultrasound to Evaluate Nonspine Joint Disease 2003 to 2015. J Am Coll Radiol. Mar 2018;15(3 Pt A):402-407. doi:10.1016/j.jacr.2017.10.015
Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol. Jun 2008;190(6):1621-6. doi:10.2214/ajr.07.3385
Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. Mar 2008;5(3):182-8. doi:10.1016/j.jacr.2007.07.016
Bureau NJ, Ziegler D. Economics of Musculoskeletal Ultrasound. Curr Radiol Rep. 2016;4:44. doi:10.1007/s40134-016-0169-5

Dr. Cristy French (Twitter: @cristy_french) is an Associate Professor in the Division of Musculoskeletal Radiology at Penn State Health Milton S. Hershey Medical Center. She is the Director of Musculoskeletal Ultrasound as well as the Musculoskeletal Fellowship Director.

Complications of Cosmetic Fillers

Posted on December 29, 2020 by aium1952

Dermatologic Ultrasound—The first modality of choice in the diagnosis and management of complications due to the use of cosmetic fillers

Each day, the use of exogenous materials for aesthetic purposes (known as fillers) is more common. Recent data from the American Society of Plastic Surgery (ASPS) confirmed that it is the second most common noninvasive medical procedure, followed by the use of botulinum toxin.

It has been described that the ideal filler material must meet certain characteristics: be cosmetically effective, not allergenic or induce immunologic reactions, not carcinogenic, not teratogenic, not migrating, biocompatible, biodegradable, and injectable. When used routinely, the technique and the results should be reproducible. Finally, in addition to what is described, it must be cost effective.

Unfortunately, a substance that meets all of these characteristics does not yet exist and, therefore, it is possible that with the use of cosmetic fillers, multiple complications may appear, from very simple to severe disfigurement, irreversible sequelae, and even blindness or hemiparesis. To make the scenario even more difficult, complications can occur with medically approved substances such as hyaluronic acid or with substances not medically approved for cosmetic use such as silicone in oil.

Fillers can be injected by qualified physicians or nonphysicians and constitute a problem of malpractice. In my country, Colombia, this has become such a complex scenario, the complications derived from all these types of products and procedures have been considered a public health problem, and the situation may not be different in other countries of the world.

In many cases, complications can appear early or late, even many years after the filler application, and patients may not remember or even deny the use of them. Their clinical presentation is diverse and imprecise and can simulate multiple dermatologic pathologies. In this complex scenario, the precise diagnosis of these complications represents a clinical and imaging challenge.

Some diagnostic modalities, such as magnetic resonance imaging (MRI), have been used for the characterization of exogenous materials, mainly due to their excellent spatial anatomic resolution but, it is unable to establish precisely the type of substance injected. Although there are silicone suppression sequences, which in theory would allow differentiation of this substance from other types of fillers, the truth is that other types of fillers can have an appearance similar to silicone in MRI, which manifests as “silicone like”, being indistinguishable from each other or with multiple inflammatory skin conditions.

Computerized axial tomography does not have any indication in the identification of these types of substances and positron emission tomography (PET)-CT is not recommended for the evaluation of injectable material because the increase in metabolic activity is not specific and can be seen in patients with or without complications caused by the injection of the fillers.

High-resolution dermatologic ultrasound with linear transducers from 14- to 22-MHz has proven to be a very precise diagnostic tool to differentiate the type of filler injected and the complications derived from them, avoiding misdiagnosis and the use of unnecessary biopsies. Substances such as hyaluronic acid, calcium hydroxyapatite, silicone, polymethylmethacrylate, and polycaprolactone, among others, have a unique and characteristic ultrasound appearance that allows them to be easily differentiated from the others.

Late or early complications such as the development of dermatopathies, hypersensitivity reactions, migration of the filler material, inflammatory and noninflammatory nodules, can also be characterized with dermatologic ultrasound and the differentiation of these complications from diseases such as morphea, sarcoidosis, or cutaneous lymphoma that they may have an identical clinical presentation can be adequately performed by ultrasound. The study must be carried out by personnel with specific training and follow the suggested guidelines for the use of dermatologic ultrasound.

During my almost 10 years dedicated exclusively to dermatologic ultrasound, I have diagnosed many cases with all these types of complications related to the use of filler material, cases with mild complications or devastating stories of patients with sequelae that will mark your life forever. In all of them, ultrasound has provided valuable information with which my clinical colleagues, Dermatologists and Plastic Surgeons, have assertively managed their patients.

Bibliography

Worstman X. Identification and complications of cosmetic filler: sonography first. J Ultrasound Med 2015 Jul; 34(7):1163–1172. DOI: 10.7863/ultra.34.7.1163.
.Cavallieri F. Adventages of sonography in fillers and complications. In Image Guided Dermatologic Treatments. Switzerland. Springer 2020. pp93–102.
González C. High resolution ultrasound of soft tissues for characterization of fillers and its complications. Rev Colomb Radiol 2019; 30(1): 5064–5068
Worstman X, Alfagame F, Roustan G, Arias-Santiago S, Martorell A, Catalano O, Scotto M, Zarchi K, Bouer M, González C, Bard R, Mandava A, Gattini D. Guidelines for performing dermatologic ultrasound examinations by the DERMUS group. J Ultrasound Med 2016; 35: e111–e114.

Claudia Gonzalez, MD, is a radiologist at IDIME in Bogotá, Colombia, and is Secretary of the Dermatologic Ultrasound AIUM Interest Group, High Resolution Dermatological and MSK Ultrasound.

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

How the COVID-19 Pandemic Has Changed Your Practice

Posted on December 15, 2020 by aium1952

Coronavirus disease 2019 (COVID-19, also known as SARS-CoV-2) was declared an official pandemic by the World Health Organization (WHO) on March 11, 2020, with infections reported in all countries around the world. As of today, November 12, 2020, there have been almost 53 million cases of COVID-19 reported worldwide, with over 1.3 million COVID-19-associated deaths.

This pandemic is severe, and the mortality and morbidity associated with this disease cannot be overstated. Although most infected patients are either asymptomatic or experience mild symptoms, a significant number end up in serious or critical condition. This is the patient population that develops a number of complications that affect all body systems, and this group of patients should be very closely monitored in the hospital setting.

Radiology professionals play a significant role in the diagnosis of infected individuals, identification of complications that are not apparent on physical exam or laboratory analysis, and the follow-up imaging assessment of known COVID-related complications. Given that this virus is highly contagious, it became very apparent that safe methods for patient assessment had to be designed and implemented. Ultrasound serves as a first-line imaging modality for evaluation of a number of COVID-19 pathologies and related complications, including evaluation of pulmonary, hepatobiliary, renal, gastrointestinal, and cardiac manifestations. It is the modality of choice in the pediatric population and in pregnant patients. Moreover, ultrasound plays a critical role in the evaluation of patency of peripheral and central vascular systems, including both the arterial and venous circulation as well as solid organ perfusion.

Due to the highly contagious nature of COVID-19, our routine ultrasound radiology practice had to undergo dramatic changes in order to ensure proper infection prevention. We accomplished this through the establishment of control measures and good hygiene practices that were shown to limit spread of COVID‐19 and protect patients, sonographers, and physicians. In addition to following specific guidelines (established at the beginning of the pandemic by the ACR and the SRU) for cleaning and disinfection of ultrasound equipment and use of personal protective equipment (PPE), we also incorporated our own changes that we found to be beneficial in preventing spread of the infection and limiting staff exposure.

At our institution, all patients are considered to be SARS-CoV-2 persons under investigation (PUI), including those without respiratory or digestive symptoms, and appropriate safeguards are taken while performing examinations.

Given the fact that transmission of SARS-CoV-2 occurs primarily through respiratory droplets, fomites, and possibly aerosols, we emphasize the use of portable ultrasound imaging at the patient’s bedside whenever feasible, with the radiology staff wearing appropriate PPE, including an N95 mask, gloves, protective eyewear or an overlying face shield, and a disposable gown.We request that all patients wear surgical masks during the examination.

Equipment must be disinfected after every exposure to COVID-19 positive or suspected positive patients. According to the Centers for Disease Control and Prevention (CDC), surfaces need to be either washed with soap and water or decontaminated using a low-level or intermediate-level disinfectant such as iodophor germicidal detergent solution, ethyl alcohol, or isopropyl alcohol. Vendors should be contacted to determine the safest disinfectant for each piece of equipment. Radiology technologists should perform sanitizing procedures while remaining in full PPE.

It is uncertain how long the air within an examination room remains infectious. Contributing factors likely include the size of the room, the number of air exchanges per hour, the length of time the patient was in the room, type of filters installed in the room, and whether an aerosol-generating procedure was performed. Use of air exchange measures vary depending on the availability of equipment. At our institutions, a 20-minute downtime is mandated for disinfection of the air in an examination room.

The keyboard and monitor of the ultrasound equipment are covered with a plastic drape or cover, and only the required probes are utilized during specific examinations. External transducers require low-level disinfection between procedures, while internal transducers require a single-use transducer cover and high-level disinfection between patients. It should be noted that products that are alcohol-based should be avoided when cleaning keyboards and track balls. If possible, a dedicated machine should be utilized for COVID-positive or suspected-positive patients. The machine should be cleaned with an EPA-approved disinfectant for viral pathogens, by a technologist in full PPE.

One of the primary changes that we implemented within our ultrasound division is the utilization of abbreviated protocols while imaging COVID-19 patients. We found that abbreviated protocols are useful and sufficient for the diagnosis of most COVID-19-related pathologies and complications, and are usually able to provide answers to the questions posed by referring clinicians. We strongly believe that abbreviated protocols have allowed us to decrease technologists’ exposure to the infection and the amount of time spent during imaging exams. When performing ultrasound examinations, we focus only on the area of interest and acquire cine clips rather than still images during the exam. It has also been shown that post processing of images, including image labeling and parameter optimization, significantly decrease the amount of time spent on scanning.

Lastly, it is important to recognize that not every patient benefits from imaging. We carefully review requests for imaging studies with the patient providers and try to weigh the benefits of imaging against the risk of exposure. The guiding principle to keep in mind is that studies don’t need to be performed unless patient management is going to be affected by the imaging findings.

The ultrasound workforce provides a valuable clinical service but is particularly vulnerable because of the prolonged close physical contact between staff and patients. Hopefully, this blog post will serve as a resource to help practitioners improve safety and minimize exposure risk during the performance of ultrasound examinations.

From top left: Basilic vein thrombosis, chest wall hematoma, gallbladder sludge, internal jugular vein occlusion, lung consolidation with air bronchograms, lung interstitial edema with B lines, popliteal artery occlusion, and urinary bladder clot.

Lung US annotated B lines and pleural thickening.

For additional reference:

Revzin MV, Raza S, Warshawsky R, D’Agostino C, Srivastava NC, Bader AS, Malhotra A, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 1: Viral Pathogenesis and Pulmonary and Vascular System Complications”. RadioGraphics 2020 Oct;40(6):1574–1599. doi: 10.1148/rg.2020200149 Monograph Issue.
Revzin MV, Raza S, Srivastava NC, Warshawsky R, D’Agostino C, Malhotra A, Bader AS, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations.” Radiographics 2020 Nov–Dec;40(7):1866–1892. doi: 10.1148/rg.2020200195.

Margarita V. Revzin, MD, MS, FSRU, FAIUM, is an Associate Professor of Diagnostic Radiology in the Department of Radiology and Biomedical Imaging at Yale University School of Medicine, in New Haven, Connecticut.

Interested in learning more about ultrasound and COVID-19? Check out the following posts from the Scan:

Shear Wave Elastography and Diffuse Liver Disease

Posted on December 1, 2020 by aium1952

Diffuse liver disease is a worldwide problem. The causes are several, with non-alcoholic fatty liver disease (NAFLD), alcoholic liver disease, and viral B or C hepatitis being the most frequent. No matter what the cause is, the chronic inflammation of the liver and the cellular death lead to liver tissue scarring, namely liver fibrosis, that may progress to cirrhosis with its complications.

Staging liver fibrosis is important for the management and prognosis of diffuse liver disease. For decades, liver biopsy has been the reference standard for the staging of liver fibrosis.

Shear wave elastography (SWE) is a method able to assess the tissue stiffness by applying a mechanical stress that induces the generation of shear waves, which then propagates into the tissue with a speed that is proportional to the stiffness of the tissue. The shear waves are generated by a body-surface compression, as in transient elastography (TE), or by the push-pulse of a focused ultrasound beam, as in acoustic radiation force impulse (ARFI) techniques.

The speed of the shear waves is related to the stiffness: they travel faster in stiffer tissue. Using a formula and making some assumptions, it is possible to convert the speed into units of stiffness, ie kilopascals.

A fibrotic tissue is harder (stiffer) than a normal tissue, and an increase of fibrosis is coupled with an increase of the stiffness. Therefore, there is a close positive relationship between fibrosis and stiffness.

TE is an SWE technique performed with the FibroScan system (Echosens). This system has a probe with a tip at the end and a button on the lateral part of it. By pushing the button, the tip compresses the body surface and this deformation propagates into the liver as shear waves. An ultrasound beam tracks the shear wave speed and sends information back to the software of the system. The final reading is in kilopascals. The FibroScan quantifies the stiffness but doesn’t assess the morphology of the liver.

The ARFI techniques are implemented in ultrasound systems that are used for other diagnostic purposes when a patient with diffuse liver disease is evaluated. In fact, using an ultrasound system, it is possible to study the organ’s morphology with B-mode, the hemodynamics with Doppler, and to characterize focal liver lesions with contrast agents. ARFI techniques make use of the energy of the ultrasound beam to generate the shear waves whose speed propagation is assessed in m/s: higher the speed stiffer the tissue.

ARFI techniques include point shear wave elastography (pSWE) and two-dimensional shear wave elastography (2D-SWE). pSWE measures the stiffness in a small and fixed region of interest whereas with 2D-SWE the stiffness is obtained over a large field of view and a color-coded image, from which the stiffness value is gotten, is displayed on the monitor of the ultrasound system. The shear wave speed can be converted into kilopascals; the ultrasound systems generally provide both speed values in m/s and stiffness values in kilopascals.

The stress is made directly into the liver; therefore, the examination can be performed also in patients with ascites.

All the published studies have shown that the ARFI techniques have accuracy similar to or higher than FibroScan for the staging of liver fibrosis. Over the last years, the assessment of liver stiffness with SWE techniques, either TE or ARFI, has increasingly been used as a means to noninvasively staging liver fibrosis. Currently, guidelines have accepted that SWE techniques can safely replace liver biopsy in several clinical scenarios. SWE can safely be used also in children. It is feasible in children of all ages and has many pediatric applications in the setting of chronic liver disease.

Bibliography

Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the Society of Radiologists in Ultrasound Liver Elastography Consensus Statement. Radiology 2020; 296:263–74.
Ferraioli G, Wong VW, Castera L, Berzigotti A, Sporea I, Dietrich CF, Choi BI, Wilson SR, Kudo M, Barr RG. Liver Ultrasound Elastography: An Update to the WFUMB guidelines and recommendations. U Med Biol 2018; 44:2419–2440.
Ferraioli G. Review of liver elastography guidelines. J Ultrasound Med 2019; 38:9–14.
Ferraioli G, Barr RG, Dillman JR. Elastography for pediatric chronic liver disease: a review and expert opinion. J Ultrasound Med 2020; doi: 10.1002/jum.15482

Giovanna Ferraioli, MD, FAIUM, is a researcher at Medical School University of Pavia, Italy. She’s the lead author of WFUMB guidelines on liver elastography, co-author of the SRU consensus, and of several international guidelines on elastography.

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