The Value of a Repeat Nasal Bone Evaluation in First-Trimester Screening for Down Syndrome

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First-trimester screening for Down syndrome, a genetic disorder caused by the presence of an extra chromosome, usually involves a combination of maternal blood tests and an ultrasound exam (ie, a combined first-trimester screening [FTS]), which is performed between 11 and 14 weeks of pregnancy.

During the ultrasound exam, the healthcare provider evaluates various markers that can indicate an increased risk of Down syndrome, such as the thickness of the nuchal translucency (a fluid-filled space at the back of the fetus’s neck) and the presence of certain physical features, including the nasal bone. Because research has shown that fetuses with Down syndrome are less likely to have a visible nasal bone on ultrasound than fetuses without the condition, evaluating the nasal bone can help healthcare providers assess the risk of Down syndrome more accurately.

Although visualizing the nasal bone is not a mandatory component of the screening, the inclusion of fetal nasal bone evaluation in the screening improves the clinical performance of the screen for the detection of fetal Down syndrome. Unfortunately, factors such as maternal body habitus (such as increased body mass index [BMI]), poor acoustic windows, unfavorable fetal position, delayed nasal bone ossification, and early gestational age can hinder nasal bone visualization then. In addition, ethnicity may also affect the visualization of the fetal nasal bone as the development of the fetal nasal bone differs between populations. Acknowledging and integrating the differences in facial structure between different racial and ethnic groups can help to promote equity in prenatal imaging and ensure the provision of accurate, personalized risk counseling across patient populations.

Therefore, a recent study aimed to determine if repeat nasal bone evaluation provided a significant improvement in refining the specificity of Down syndrome risk assessment by combined FTS, as well as determine the efficacy of a repeat nasal bone evaluation across various maternal ethnicities.

The study reviewed the medical records of patients who underwent a first-trimester ultrasound evaluation in an American Institute of Ultrasound in Medicine (AIUM)-accredited center between January 2015 and January 2018. The study focused on patients with fetal nasal bone labeled as “absent or hypoplastic” or “unable to be adequately visualized” during the ultrasound. The researchers reviewed the records to assess factors such as patient age, ethnicity, follow-up evaluations, and fetal anomalies. They analyzed the combined FTS results and followed up with patients with abnormal results. They then conducted statistical analyses to compare patient ethnicity and nasal bone visualization on the second exam, as well as to compare patient ethnicity and fetal Down syndrome risk by combined FTS.

The study identified 589 cases (8.7%) of absent or uncertain fetal nasal bone on initial nuchal translucency (NT) ultrasound evaluation among the 6780 total NT ultrasounds performed, with the most frequently represented ethnicities being African American/Caribbean (46.2%) and White (36.8%). Of the total, 125 patients (21.2%) did not complete a repeat nasal bone evaluation, and 105 patients with additional risk factors pursued genetic counseling. Of these patients, 20 pursued chorionic villus sampling (CVS), and 11 of these cases (55.0%) reported abnormal karyotypes. Of the 376 eligible patients who completed a second nasal bone evaluation (exam 2), 82 patients (21.8%) had an absent fetal nasal bone, 26 (6.9%) had an uncertain fetal nasal bone, and 268 (71.2%) had a present fetal nasal bone. White patients were statistically significantly more likely than African American/Caribbean patients to have a present nasal bone on exam 2 (82.9% and 59.2% respectively, P < .0001), as were Asian Indian patients (100% and 59.2%, respectively, P < .0001).

Combined FTS can identify fetuses at high risk for aneuploidy, but it has a relatively high false positive rate. Therefore, proper identification of the absence or presence of the fetal nasal bone during FTS plays a critical role in identifying and counseling patients at increased risk for fetal aneuploidy. The study found that repeat nasal bone evaluation could reduce false positive FTS results, particularly in African American/Caribbean populations.

Even with the widespread use of cell-free DNA screening, combined FTS, including nasal bone assessment, remains an important tool for first-trimester aneuploidy risk assessment.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Follow Your Nose: Repeat Nasal Bone Evaluation in First-Trimester Screening for Down Syndrome” by Kristen A. Miller, MGC, et al. Members of the American Institute of Ultrasound in Medicine (AIUM) can access it for free. Join the AIUM today!

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

Preventing Work-Related Musculoskeletal Disorders Among Ultrasound Operators

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Up to 90% of sonographers and other operators of diagnostic medical sonography report having painful work-related injuries affecting the muscles, nerves, ligaments, or tendons.1 These work-related musculoskeletal disorders (WRMSDs) result from the multiple times a day the operators repeatedly make the same movements and maneuvers while performing ultrasound examinations.2 For the ultrasound operator, the most common locations of WRMSDs include the shoulder, neck, wrist, and hands, and the results of WRMSDs can lead to serious health issues, absenteeism, presenteeism, and even leaving the field of ultrasound altogether.3

The following are some of the critical factors that can lead to the development of WRMSDs:

  • Poor ergonomics, including poor posture and machines with poor ergonomic design.3
  • Poor workflow, including the positions of the machine, bed, and workstation, leads to unnecessary arm abduction and overreaching.3
  • Lengthy exams with an increasing workload and number of exams to be performed during the workday.4
  • Inadequate breaks between examinations in addition to an increasing workload.5
  • Psychological stress and psychosocial factors in the workplace.6
  • Unsupportive or inflexible environments that fail to account for the diverse abilities and experiences of individual operators.7

The Occupational Safety and Health Administration has placed the primary responsibility for protecting workers on the employer.8,9 So, when developing WRMSD prevention protocols, administrators should collaborate with ultrasound operators to create policies that support their safety.10 Such policies should take into account scheduling to limit overtime work and provide breaks, staffing levels to optimize patient care, proper ergonomic equipment and adjustable equipment, and room designs that facilitate proper ergonomics, such as adequate space for patients and equipment. The workplace culture should support wellness and also have transparent policies regarding reporting and tracking of WRMSDs.

The operator also needs to ensure their working space is set up in the best manner possible for preventing WRMSDs during their workday. They can do so by customizing their ultrasound environment to promote proper ergonomic technique.

  1. At the beginning of each examination, the operator should properly position and make adjustments depending upon the body habitus of each patient.11 Reaching movements should be avoided by keeping the operator, machine, bed, and patient as close together as possible and at appropriate heights.
  2. The operator’s head and the screen/monitor should be on the same axis, and the eye-screen distance should be at least 60 cm. The top of the screen should be aligned with the level of the operator’s eyes; then, the top of the screen should be tilted back slightly to encourage proper neck posture.11,12
  3. The operator’s neck should be straight, and neck extension should be avoided.6
  4. The operator should be positioned in order to allow the arm to be in a relaxed position with the upper arm close to the body (minimal flexion, ideally abduction <30 degrees) and the elbow at a 90-degree angle, ie, the forearm should be horizontal to the floor allowing the shoulder to remain in a neutral positionwhenever possible.
  5. A “wearable transducer cable support device,”13 such as a cable brace, can be utilized to reduce arm strain during scanning. Also, the ultrasound transducer cable should not be passed around the operator’s neck as any traction force could result in a poor neck position.11,12
  6. A scanning chair should be equipped with a backrest for lumbar support and adjustable height to mold the lumbar lordosis. Moreover, a seatback inclined between 10° and 20° is recommended. The back should be well supported on the seat. A slight gap should remain between the edge of the seat and the back of the knee, and the body should be on the axis of the screen. The chair should be height adjustable so the operator can be properly positioned relative to the patient and ultrasound system. Exam chairs should not have armrests as they may restrict access to the patient.
  7. Exam tables should be height adjustable to encourage proper positioning by minimizing extended reaching, elevated arms, and wrist deviation, and allowing operators to stand and/or sit while performing procedures.
  8. The ultrasound machine keyboard should be easy to move and adjust.
  9. Removing the transducer from the patient and relaxing the hand to allow for brief micro-breaks during the examination can help reduce muscle strain.
  10. With the exception of point-of-care imaging, portable diagnostic exams should be limited to critically ill patients and those patients who are unable to come to the ultrasound department.

Specific types of ultrasound examinations also bring unique challenges. Some of these challenges are addressed, by specialty, in the AIUM Practice Principles for Work-Related Musculoskeletal Disorder.14

Increased awareness of the magnitude of the problem and local quality improvement (QI) efforts are necessary to ensure that these standards are translated into the successful reduction of WRMSDs among ultrasound operators.

A QI program should include ongoing tracking or logging of the following:

  • Ergonomic education for employees
  • Safety and resource utilization
  • Equipment updates
  • The numbers and types of reported symptoms and/or injuries, and
  • Organizational (ie, policies and practices) changes or updates made to improve employee safety and well-being.

A review of these data, along with a status check on overall workplace culture and worker well-being, should be conducted annually. To do so, a QI team composed of individuals from all levels of the organization (eg, administration, management, staff) should review aggregated data from tracking logs and any annual workplace environment reports to identify and prioritize areas for improvement.

The protection of our frontline workforce is paramount in retaining individuals with valuable skills. This protection requires a change in industry mindset that acknowledges the shared responsibility among both employers and ultrasound operators.

This post was created from the AIUM Practice Principles for Work-Related Musculoskeletal Disorder, which was developed by the American Institute of Ultrasound in Medicine in collaboration and with the expressed support of the American College of Emergency Physicians (ACEP), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR), American Registry for Diagnostic Medical Sonography (ARDMS), American Society of Echocardiography (ASE), Australasian Society for Ultrasound in Medicine (ASUM), Fetal Heart Society (FHS), Intersocietal Accreditation Commission (IAC), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), Perinatal Quality Foundation (PQF), Society of Diagnostic Medical Sonography (SDMS), and Society for Maternal-Fetal Medicine (SMFM). The Practice Principle was developed to expand on the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography”13 to include safety practices for all health care professionals who utilize ultrasound.

References

  1. Evans K, Roll S, Baker J. Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists. A representative sample. J Diagn Med Sonog 2009; 25:287– 299.
  2. Wareluk P, Jakubowski W. Evaluation of musculoskeletal symptoms among physicians performing ultrasound. J Ultrason 2017; 17:154– 159. https://doi.org/10.15557/JoU.2017.0023.
  3. Bowles D, Quinton A. The incidence and distribution of musculoskeletal disorders in final-year Australian sonography students on clinical placement. Sonography 2019; 6:157– 163. https://doi.org/10.1002/sono.12203.
  4. Gibbs V, Young P. A study of the experiences of participants following attendance at a workshop on methods to prevent or reduce work-related musculoskeletal disorders amongst sonographers. Radiography 2011; 17:223– 229. https://doi.org/10.1016/j.radi.2011.02.003.
  5. Baker JP, Coffin CT. The importance of an ergonomic workstation to practicing sonographers. J Ultrasound Med 2013; 32:1363– 1375. https://doi.org/10.7863/ultra.32.8.1363.
  6. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound: can you reduce risk? Ultrasound 2015; 23:224– 230. https://doi.org/10.1177/1742271X15593575.
  7. Chari R, Chang CC, Sauter SL, et al. Expanding the paradigm of occupational safety and health: a new framework for worker well-being. J Occup Environ Med 2018; 60:589– 593.
  8. United States Department of Labor, Occupational Safety and Health Administration. Ergonomics website. https://www.osha.gov/ergonomics. Accessed November 12, 2021.
  9. United States Department of Labor, Occupational Safety and Health Administration. Solutions to control hazards website. https://www.osha.gov/ergonomics/control-hazards. Accessed November 12, 2021.
  10. United States Department of Labor, Occupational Safety and Health Administration. Identity problems website. https://www.osha.gov/ergonomics/identify-problems. Accessed November 12, 2021.
  11. Rousseau T, Mottet N, Mace G, Franceschini C, Sagot P. Practice guidelines for prevention of musculoskeletal disorders in obstetric sonography. J Ultrasound Med 2013; 32:157–164. https://doi.org/10.7863/jum.2013.32.1.157.
  12. BP Bernard (ed). Musculoskeletal Disorders and Workplace Factors; A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. U.S. Department of Health and Human Services July; 1997 DHHS (NIOSH) Publication No. 97B141.
  13. Industry standards for the prevention of work related musculoskeletal disorders in sonography. J Diagn Med Sonogr 2017; 33:370–391.
  14. AIUM practice principles for work-related musculoskeletal disorder [published online ahead of print January 24, 2023]. J Ultrasound Med. https://doi.org/10.1002/jum.16124.

Focused Ultrasound for Brain Tumors: Hope for the Future of GBM

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In John Grisham’s book The Tumor, he tells a story of the typical clinical pathway and trajectory of a patient diagnosed with glioblastoma (GBM), a devastating brain tumor. Then, he sets the stage for a re-imagination of this patient’s clinical course if focused ultrasound were added to his treatment armamentarium. What this could look like is less suffering, longer life expectancy, and cost savings.

Glioblastoma has a 90% mortality rate within 5 years of diagnosis. This disease has lacked any significant improvement in survival in over 30 years, despite scientific advances in many areas, such as molecular subtyping, tailored chemotherapy regimens, and immunotherapy. The current standard-of-care treatment for GBM includes surgical resection, chemotherapy, and radiation.

Focused ultrasound is an emerging therapeutic technology that has the potential to change the treatment landscape and clinical trajectory for a multitude of diseases and conditions, including GBM. The fascinating thing about focused ultrasound is that scientists and clinicians have discovered that the properties of the ultrasound energy can be manipulated in such a way as to induce a variety of different biological effects and mechanisms of action. The technology was initially designed to thermally ablate tissue, but since that time, more than 20 mechanisms of action have been identified.

In GBM, there are three focused ultrasound mechanisms of action that are being employed as an adjunct or complement to traditional therapies: opening of the blood-brain barrier (BBB), sonodynamic therapy (SDT), and radiation sensitization or enhancement (Figure 1).1,2

Figure 1: Focused Ultrasound (FUS) Mechanisms of Action related to brain tumor therapy (A) Blood Brain Barrier Opening (BBBO): In the presence of focused ultrasound, intravenously injected microbubbles oscillate inside the brain’s blood vessels and stretch the tight junctions, allowing therapeutics to diffuse into the targeted region. Not depicted here are the additional mechanisms of sonoporation and increased transcytosis, which also occur with FUS-mediated BBBO. (B) Sonodynamic Therapy: Intravenous injection of a sonosensitizer such as 5-ALA accumulates preferentially inside brain tumor cells. Conversion of the sonosensitizer into an active substrate (ie PpIX) induces tumor cell death. (C) Radiation Sensitization: The proposed mechanism of action involves ceramide-induced endothelial apoptosis, which subsequently enhances radiation by causing vascular disruption. Distortion of the endothelial cell membrane by oscillating microbubbles in the presence of the FUS beam releases ceramide, which then causes platelet aggregation and thrombosis.

The most clinically advanced of these three focused ultrasound mechanisms is BBB opening, which is currently being investigated in numerous clinical trials that combine this technique with delivery of chemotherapeutic agents.3–5 Thus far, safety and efficacy have been confirmed, and I am excited to see additional clinical trial results. SDT clinical trials are also underway and have shown promise. Lastly, using focused ultrasound to enhance radiation is being investigated.

There are also a variety of focused ultrasound devices being investigated for use, from MRI-guided to neuronavigation-guided to implantable devices. Each system offers unique benefits and challenges, which continue to be elucidated through ongoing clinical work.

One more promising frontier for focused ultrasound and GBM is liquid biopsy. Just as focused ultrasound plus microbubbles can disrupt the BBB to allow the passage of therapeutics into the tumor, this method also allows for the leakage of tumor biomarkers into the blood from the tumor, enabling enhanced diagnosis and monitoring methodologies for GBM.6

While this blog post provides a brief overview of focused ultrasound for GBM, it hopefully conveys that the technology is ripe for helping patients live longer, more comfortable lives. The Focused Ultrasound Foundation is on a mission to engage and convene the scientific and medical communities to make this happen as quickly, safely, and effectively as possible so that the fictional character that Grisham described can become a reality.

Author’s note: The Foundation is also enthusiastic about using this technology in a similar fashion for children with diffuse intrinsic pontine glioma (DIPG)/diffuse midline glioma (DMG), and this area has experienced significant growth over the past year. To learn more, visit the Foundation’s webpage dedicated to DIPG/DMG.

References

  1. Roberts JW, Powlovich L, Sheybani N, LeBlang S. Focused ultrasound for the treatment of glioblastoma. J Neurooncol 2022; 157(2):237–247. doi: 10.1007/s11060-022-03974-0. Epub 2022 Mar 10. PMID: 35267132; PMCID: PMC9021052.
  2. Parekh K, LeBlang S, Nazarian J, et al. Past, present and future of focused ultrasound as an adjunct or complement to DIPG/DMG therapy: A consensus of the 2021 FUSF DIPG meeting. Neoplasia 2023; 37:100876. doi: 10.1016/j.neo.2023.100876. Epub 2023 Jan 28. PMID: 36709715; PMCID: PMC9900434.
  3. Bunevicius A, McDannold NJ, Golby AJ. Focused ultrasound strategies for brain tumor therapy. Oper Neurosurg 2020; 19:9–18. doi: 10.1093/ons/opz374
  4. Mainprize T, Lipsman N, Huang Y, et al. Blood-brain barrier opening in primary brain tumors with non-invasive MR-guided focused ultrasound: a clinical safety and feasibility study. Sci Rep 2019; 9:321. doi: 10.1038/s41598-018-36340-0.
  5. Meng Y, Hynynen K, Lipsman N. Applications of focused ultrasound in the brain: From thermoablation to drug delivery. Nat Rev Neurol 2021; 17:7–22. doi: 10.1038/s41582-020-00418-z. 
  6. Meng Y, Pople CB, Suppiah S, et al. MR-guided focused ultrasound liquid biopsy enriches circulating biomarkers in patients with brain tumors. Neuro Oncol 2021; 23:1789–1797. doi: 10.1093/neuonc/noab057.

Lauren Powlovich, MD, MBA(c), serves as Associate Chief Medical Officer at the Focused Ultrasound Foundation (FUSF). She brings together key stakeholders and synthesizes and executes cohesive plans to lead initiatives in the advancement of focused ultrasound for several applications including glioblastoma, neurodegenerative disorders, pediatrics, pain management, and sonodynamic therapy. She is a co-leader of the Research and Education Team, which strategizes on the allocation of FUSF’s resources to best position the field for success. Prior to joining the Foundation, Lauren trained as an anesthesiologist, and she has always been passionate about putting patients first. She continues to have that mindset and works hard to ensure that focused ultrasound reaches patients as efficiently and safely as possible.

How Our Ultrasound Practice Flourished

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My name is Barbara, and I have been an Ultrasound tech for more than 30 years now. Part of my job for the last 25 years has been to get and keep our labs accredited. We recently changed the accrediting body to the American Institute of Ultrasound in Medicine (AIUM). Our initial accrediting body has always been a pleasure to work with, but inside I felt that the AIUM must be more in tune with what our concerns are, being it is strictly ultrasound.

We changed up 2 years ago, and wonderful things started to happen. First, we added more heart views, as, before, only the 4-chamber view was required. We changed that. Many of our younger techs were not proficient with all of the views, so we all pulled together. Our boss let us set up multiple hands-on training sessions from the older, more experienced Sonographers. He let us have as much time as we needed. It was beautiful to watch everyone working together.

Also, as a requirement of our Diagnostic Breast accreditation, every tech in our department got Breast certified; at least 15 techs needed to. Which everyone did willingly. The Radiologist now having to get 15 credits in breast ultrasound, did that willingly too. Everyone was on the same page.

Then what is even more astonishing is our boss came to me and asked if I would set up a quality assurance program. He realized that our exams are so tech-dependent that the techs need a resource to help them grow. And in a busy department, he wanted to make sure they all get what they need to be the best they can be.

As a part of that quality assurance program, management has allowed me to take time in my schedule to review a Sonographer’s ultrasound images. I review at least 30 exams to see a pattern or determine what the sonographer may lack. I then go over my results with the individual tech about image quality, image technique, etc. And, if we noticed the tech may need help in a certain area, we set up a one-on-one or place that tech with a tech that is more experienced to build the less-experienced tech’s confidence and skills.

I am so proud of our management and staff…Thank You, AIUM, for being a catalyst for such good things!!!!

Barbara A. Fennen, RT(M), RDMS, RVT, is a Sonographer at Beebe Healthcare in Rehoboth Beach, DE.

Threading the Needle at UltraCon

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Ultrasound has many advantages when used for interventional procedures such as improved visualization of the anatomy in relation to the needle tip. But acquiring the skills to perform ultrasound‐guided procedures takes time and practice.

And that is why the AIUM has devoted a full-day symposium called “Threading the Needle” to this topic on March 27, 2023, at UltraCon. The symposium provides a comprehensive overview of ultrasound-guided procedures, including:

Instrumentation
The needles and associated instrumentation commonly used in ultrasound-guided procedures will be shared. Important features and variations in equipment will be introduced for all specialties.

Teaching Tools
How do you teach others at your institution to perform procedures? The facilitator will provide an overview of best practices with specific examples.

Skills Station
Needle guidance principles will be taught for clinical applications such as IV access, target practice, and more utilizing hands-on models and cutting-edge technologies.

Safety
What are the important safety considerations when performing ultrasound-guided procedures?

Threading the Needle is just one of eight in-depth symposia featured at UltraCon 2023. Check out the Full Schedule to get a sneak peek at everything you could learn.

Another helpful resource about these procedures is the AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures.

Therese Copper, BS, RDMS, is the Director of Accreditation, and Mark Macoit is the Marketing Manager at the American Institute of Ultrasound in Medicine (AIUM).

Why Have UltraCon FOMO When You Can Be a Part of the Transformation of Medical Ultrasound?

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Are you still on the fence about deciding whether or not to attend UltraCon, a reimagined take on the American Institute of Ultrasound in Medicine’s annual meeting? The transformation of the AIUM’s annual ultrasound meeting into UltraCon is an exciting step forward for the field. It will provide a platform to connect professionals, share ideas, and learn from each other. 

Previously, we’ve highlighted the benefits of attending Day 1 and Day 2 of UltraCon, but what about Day 3? Just one look at the UltraCon schedule, and you can tell that this is going to be its busiest day yet! Despite the jam-packed program, there are a ton of amazing professional development opportunities ready for you to explore. On Tuesday, four new symposia will kick off, covering topics from 3D/4D imaging to musculoskeletal sonography. There’s also a shark tank competition, an e-poster kiosk hall, the annual AIUM Awards session, and don’t forget about the William J. Fry Memorial Lecture. 

Let’s dive into the first new symposia, Early Pregnancy Ultrasound: Implications and Impacts on Care. This TED-talk-style forum is a great resource for learning about critical issues in the first trimester, such as providing equitable care in the emergency department and managing life-threatening situations. It has not only valuable information for medical professionals but also provides important insight into how to support patients after Dobbs. Participants can earn up to 1.5 CMEs.

Next, we have Optimizing Outcomes in Prenatal Imaging. During this symposia, participants can increase the quality and patient experience in obstetric imaging with a multidisciplinary approach. A group of specialists will present TED talks on topics such as early trimester issues, health inequities, and maternal/fetal life-threatening situations. Improve imaging outcomes via a perception bias workshop, challenging cases, and using the 3D world to understand ultrasound. Plus, roundtables with industry on image optimization and a special session on understanding the lifecycle of prenatal imaging. Participants can earn up to 3.0 CMEs.

POCUS: Cutting-Edge Uses and Controversies is the third symposium of Day 3. Point-of-care ultrasound (POCUS) is revolutionizing the way clinicians diagnose and treat patients. By providing real-time insights, POCUS offers quick, accurate, and cost-effective diagnosis of clinical problems. From development to bedside, POCUS has changed the game for clinicians worldwide. Are you seeking an engaging and informative symposium to discuss current POCUS advancements in medical ultrasound? Look no further than POCUS: Cutting-Edge Uses and Controversies symposium, which discusses topics such as global health, first-trimester concerns, scan ownership, POCUS workflow, and more. With an array of activities, including lectures, panel discussions, and workshops, this is sure to be a stimulating symposium that will leave you informed and inspired.

Breaking the Sound Barrier: Shaping the Future of Ultrasound is the last symposium of the day. The highly interactive symposium on ultrasound technologies is a great opportunity for clinicians, technologists, researchers, industry, and other stakeholders to learn about the latest advancements in ultrasound technology. This symposium will provide an invaluable platform for experts to share their knowledge and insights on how to utilize ultrasound techniques in clinical settings effectively. Attendees will have a chance to interact with leading professionals from around the world and discuss potential solutions for existing challenges within this field.

Outside of attending the symposia, there are several other interactive activities for participants to engage in. Firstly, the AIUM supports an ePoster program every year where attendees can explore and learn at their own pace through self-guided exploration. Secondly, attendees who have a great ultrasound idea and want to pitch it to industry can submit an application to pitch their ideas to venture capitalists, leaders from the industry, and an IP attorney, for the chance to win a cash prize of $1,000. Lastly, don’t forget to attend the 2023 William J. Fry Lecture given by pioneer in gynecologic ultrasound, Dr. Steven R. Goldstein, entitled “Do You Do POCUS: Why reinvent the wheel?”.  

UltraCon will be the must-attend event of the year for medical professionals who want to stay up-to-date on the latest advancements in ultrasound technology. With a wide variety of engaging sessions and workshops, there’s something for everyone, so avoid getting caught with FOMO. All of this is just what is available on the third day of symposia at UltraCon. Check out the Full Schedule to start planning out your UltraCon journey.

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Ultrasound: A Diagnostic Tool and for Treating Injuries and Diseases

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Now, more than ever, staying up to date on the latest trends and innovations in ultrasound is essential for physicians. This year, the annual meeting of the American Institute of Ultrasound in Medicine (AIUM) is being transformed into UltraCon! This new conference puts you at the center of the conversation where expertise meets interaction and debate. So how can you ensure that you are prepared to take full advantage of this transformative opportunity? 

In a previous post, we highlighted how you could explore new, exciting, and current technologies in ultrasound; identify the different approaches to diagnostic ultrasound; and determine which ultrasound techniques can help you advance your practice at “Can You Do That With Ultrasound?” on day one at UltraCon (March 25–29, 2023). Day two at UltraCon offers attendees more opportunities to deepen their understanding of ultrasound—both as a diagnostic tool and in treating injuries and diseases—through two additional symposiums: “Optimizing Ultrasound Image Quality” and “Ultrasound Diagnoses You Can’t Miss.”

Optimizing Ultrasound Image Quality

Optimizing ultrasound image quality and, ultimately, patient care is at the heart of this symposium. As a healthcare professional, you will be well-equipped to succeed at this task with knowledge gained through key topics such as physics, knobology, and Doppler, as well as improving patient/probe position. You will benefit from roundtable discussions that cover image reviews and quality assurance—useful topics that can help move one step closer to improving patient outcomes. Earn 5 CMEs for learning about ultrasound technology advancements, advancing your image acquisition techniques, and finding ways to improve image quality. This symposium is sure to contribute to providing better patient care!

This symposium will feature a total of 8 engaging and interactive sessions for attendees to participate through in groups:

  • “Physics: So Easy it Hertz,” led by Frederick Kremkau, PhD, FAIUM. How does ultrasound work? It’s all about physics. Knowing the role physics plays will help you avoid artifacts.
  • “Know Your Knobs,” led by Elena S. Sinkovskaya, MD, PhD. To even get an ultrasound image, you must know how your machine works, how to make fundamental adjustments, and how to make optimal use of B-mode. Glossary handout included.
  • “Elements of Scanning,” led by Margaret R. Lewis, MD. Improve your ultrasound diagnostics by understanding optimal patient and transducer positioning techniques, equipment quality assurance, and more.
  • “Demystifying Doppler,” led by Tracy Anton, MD. What is Doppler ultrasound? How does it work? How do I select the correct equipment? How do I interpret the results? Learn all this and more by attending.
  • “Just Images Roundtable,” led by Mishella Perez, BS, RDMS, RDCS, FAIUM, and Yvette S. Groszmann, MD, MPH. Learn what you can do to improve image quality across specialties, including OB, GYN, MSK, POCUS, and Vascular.
  • “Echoes of the Past to the Voices of the Future,” led by Frederick Kremkau, PhD, FAIUM. Attend this session to understand how prior advancements in ultrasound technology have established the scaffold for the possibilities of the use of diagnostic ultrasound in the present and the future.
  • “Ultrasound Quality Assurance Roundtable,” led by Timothy Canavan, MD, MSc, FAIUM, Therese Cooper, BS, RDMS, David Jones, MD, FAIUM, Anita Moon-Grady, MD, and Aubrey Rybyinski, MD. Understanding the role of accreditation and continuous QA is essential to ensuring the best outcomes for patients. Hear from a panel of experts to better guide your practice and get answers to your questions.
  • Image Quality Trivia: Test your ultrasound knowledge during this fun, quiz-style game where the entire audience participates. Topics include OB, fetal echo, GYN, physics, MSK, and general imaging.

Ultrasound Diagnoses You Can’t Miss

Ultrasound diagnoses are a crucial part of maintaining top-level medical care. Ultrasound experts from various disciplines meet in this symposium to share their expert knowledge and experience, allowing participants to stay on top of the imaging findings and avoid any form of misdiagnosis. During the symposium, a multispecialty expert panel will create an interactive discussion for the attendees to apply their learning to real clinical scenarios. And what’s more? You can earn up to 5.75 CMEs just by attending this “Ultrasound Diagnoses You Can’t Miss” symposium!

This symposium will feature a total of 17 engaging and interactive sessions for attendees to participate in where subspecialty discussion, breakout opportunities, and rapid case reviews will take place.

UltraCon is an incredible opportunity for medical ultrasound practitioners who want to stay up-to-date on all things related to medical ultrasound technology. From interactive debates to resource handouts, exhibitor sandboxes, and focus groups—this event has something for everyone! Come prepared with an open mind and get ready to connect with experts from around the world while learning about the exciting new possibilities that are transforming the field of medical ultrasound today! Don’t miss out—All of this is just what is available on the second day of symposia at UltraCon. Check out the Full Schedule to get a sneak peek at everything you could learn.

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Where to Find What’s New in Ultrasound and Education

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As the use of ultrasound is expanding at a greater rate than ever, both as a diagnostic tool and in treating injuries and diseases, keeping up-to-date on all of the changes can be a struggle. In an upcoming symposium, however, you can explore new, exciting, and current technologies in ultrasound. Identify the different approaches to diagnostic ultrasound and determine which ultrasound techniques can help you advance your practice at “Can You Do That With Ultrasound?” on March 26, 2023, at UltraCon.

This symposium is an exciting new approach to discovering the technical advancement of ultrasound and applications across all subspecialties with collaborative interactions and networking opportunities to enhance the experience. It will begin with a discussion with John Pellerito, MD, Luis O. Tierradentro-Garcia, MD, Emile Redwood, MD, and John K. Hill of three abstracts with cutting-edge content regarding assessing cerebral blood flow in neonatal hydrocephalus, analyzing gene expression, and robotics-assisted transabdominal cerclage in pregnancy.

Next, with images and clinical histories, you will be able to review cases and discuss how each specialty group would approach the systems using different ultrasound techniques and instrumentation. Jon Jacobson, MD, Humberto Rosas, MD, Margarita Revzin, MD, MS, FSRU, FAIUM, Misty Blanchette Porter, and Stephanie Gisele Midgley, MD, will facilitate the discussion on state-of-the-art scanning techniques and innovative technology. Following that, John Pellerito, MD, will assist you with networking and crowdsourcing the answers to your questions. Then, industry representatives, expert clinicians, and expert researchers will also take questions.

Another symposium, “Everyone Can Be an Effective Ultrasound Educator” will also be happening that same day. Filled with practical and effective strategies and techniques to improve your teaching skills, Todd D. Zakrajsek, PhD, the keynote speaker, will share his thoughts on the foundational aspects of learning and relatively easy ways to teach while considering the diversity of learners today, as well as dispel learning myths and traps that hinder the learning process.

This symposium will feature a total of 8 engaging and interactive sessions for attendees to rotate through in groups:

  • “Active Learning, Learning by Doing,” led by Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM, Rebecca J. Etheridge, EdD, RDMS, and Sara Durfee, MD, will show you how to apply creative and meaningful activities designed to enhance the teaching and learning environment.
  • “Case-based Teaching: Let’s Have a Shared Learning Experience,” led by Iryna Struk, MS, RDMS, RDCS, RVT, and Jennifer Cotton, MD, will offer strategies for using case-based learning (CBL), an established approach used across disciplines where learners apply their knowledge to real-world scenarios, promoting higher levels of cognition.
  • “Good Job. Keep It Up. Effective and Ineffective Feedback Strategies in Ultrasound Education,” led by Creagh Boulger, MD, Lauren D. Branditz, MD, and Christine M. Schutzer, RT, BS, RDMS, will review the literature and techniques for effective feedback and assessment.
  • “Designing Virtual Lectures: A Necessary Challenge,” led by Kevin J. Haworth, PhD, Petra Duran Gehring, MD, RDMS, and Jacob Avila, MD, will review concepts in lecture design to increase student learning.
  • “Gaming: Trendy Buzz Word or Effective Educational Tool?” led by Creagh Boulger, MD, and Rachel Liu, MD, will be a hands-on activity to solve your needs in education and how you can apply gaming as an effective, evidenced-based strategy for assessment, learning, and engagement.
  • “Old School, New School, Best School,” led by Linda Zanin, Jennifer Cotton, MD, Lee Shryock, and Michelle Haines, will help you determine which new and exciting technologies are worth the investment and how you can integrate them into your curriculum.
  • “Social Media and Education,” led by Kevin J. Haworth, PhD, and Chris Fox, MD, discusses ways in which social media can be used to improve teaching and learning.
  • “The Impact of Emotional Intelligence in Education,” led by Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM, David Bahner, MD, and Hilary L. Davenport, DO, will provide tools that can help strengthen students’ emotional intelligence, which can positively impact relationships, academic success, and work performance.

In addition, this symposium includes “Learn From Our Learners,” in which former and current students (Creagh Boulger, MD, and Jennifer Cotton, MD) will share things that have worked well, experiences that have not worked well, and ideas they have for ways ultrasound can be better utilized in education.

All of this is just what is available on the first day of symposia at UltraCon. Check out the Full Schedule to get a sneak peek at everything you could learn.

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

Ultrasound Education in United States Medical Schools

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Although nearly every medical specialty uses ultrasound, medical schools are inconsistently integrating ultrasound education into their curriculum. According to a 2019 study (by Nicholas et al) of United States Accredited Medical Schools (USAMS),1 although integration of ultrasound into curricula has increased since a prior study in 2014 (by Bahner et al),2 ultrasound instruction is still inconsistent.

In the fall of 2019, researchers contacted 200 allopathic and osteopathic USAMS for the Nicholas study.1 Of those schools, 168 (84%) responded and, of those, 122 (72.6%) indicated they have an ultrasound curriculum.

Of the medical schools that responded, 46 (23%) indicated they did not have ultrasound curriculum. 1

Although this study did not look into why they did or did not have the curriculum, some barriers clearly still remain to incorporating it, such as those mentioned in a 2016 study by Dinh et al3: lack of funding, lack of trained faculty, and lack of curricular space.

According to the Nicholas study, it seems as though some of the schools (42) work around the lack-of-funding barrier by having volunteers as faculty. Only 35 (20.8% of those who responded) compensate their faculty and, of those, 22 (13.1%) are compensated monetarily.1 And when schools can’t afford their own ultrasound machines, some have found other means, such as borrowing hospital ultrasound equipment. 3 Other means of helping to distribute the cost of starting up a program include gradually adding classes, using near-peer teaching, and self-directed asynchronous learning using online resources and simulators.3 

As medical students who have learned about ultrasound have reported that it improves their understanding of anatomy and physical examination skills, and more specialties adopt this technology, students need to learn about it before they need to use it in clinical practice.1

Although more schools keep adding ultrasound to their curricula, it is not yet nationwide, and many who have succeeded had to struggle to make it happen. It is imperative that USAMS receive the funding and support they need to train medical students in the safe and effective use of ultrasound.

References

    1. Nicholas E, Ly AA, Prince AM, et al. The current status of ultrasound education in United States medical schools. J Ultrasound Med 2021; 40:2459–2465. https://doi.org/10.1002/jum.14333.
    2. Bahner D, Goldman E, Way D, Royall NA, Liu YT. The state of ultrasound education in U.S. medical schools: results of a national survey. Acad Med 2014; 89:1681–1686.
    3. Dinh VA, Fu JY, Lu S, Chiem A, Fox JC, Blaivas M. Integration of ultrasound in medical education at United States medical schools: A National Survey of Directors’ experiences. J Ultrasound Med 2016; 35:413–419. https://doi.org/10.7863/ultra.15.05073.
    4. Tarique U, Tang B, Singh M, Kulasegaram KM, Ailon J. Ultrasound curricula in undergraduate medical education: a scoping review. J Ultrasound Med 2018; 37:69–82. https://doi.org/10.1002/jum.14333.

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

    Pick-Up-and-Go Block Bags for Fascia Ilaca Blocks

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    Ultrasound-guided regional anesthesia is a mainstay of multimodal pain control and is becoming an increasingly important part of emergency medical care. Regional anesthesia allows for maximal analgesia while minimizing the adverse effects of opioids, such as respiratory depression and sedation. The fascia iliaca block is one such procedure that provides regional anesthesia in the Emergency Department (ED) for proximal femur fractures and hip fractures.1 This plane block is performed by depositing a moderate volume of local anesthetic, usually bupivacaine, into the potential space between the fascia iliaca and the iliopsoas muscle. The procedure provides analgesia in the distribution of the femoral nerve, as well as the obturator nerve and lateral femoral cutaneous nerve. 1 Patients who receive this procedure experience improved pain scores and a reduction in the need for opioid medication.2–5 The use of preoperative regional nerve blocks, specifically including older patients with hip fractures, is supported by 2022 American Association of Orthopedic Surgeon guidelines.5,6

    At Rutgers New Jersey Medical School, we developed a teaching paradigm for the fascia iliaca block, with an online didactic session followed by a hands-on simulated skills session offered to faculty and residents (Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model).

    Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
    Figure 1A
    Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
    Figure 1B

    Later in the year, we performed a quality assurance project in order to determine what barriers existed to performing this block, in order to maximize the number of eligible patients that received this valuable procedure. We found that the fascia iliaca block was performed about 16% of the time when indicated (Figure 2).

    A bar graph indicating that, of those who received a nerve block, 87 were for hip/femur fractures (~3-4 per week), 16% (95CI: 10% to 25%) received the block, and 90% (95CI: 82% to 95%) completed the survey.
    Figure 2. Percentage of eligible patients who received the block.

    The most common reason for the block not being performed was the perceived lack of time during a busy clinical shift (Figure 3), which was a factor that was present in more than ¾ of missed opportunities.7 We theorized that this limitation came from a combination of the time required to obtain consent from the patient, gather supplies, coordinate with the admitting Orthopedics service, and ultimately perform the procedure.

    A bar graph indicating the number and strength of each agreement for each response.
    Figure 3. Reasons that the block was not performed.

    To address this barrier, we created ready-made pick-up-and-go nerve block kits containing all the necessary materials for performing ultrasound-guided nerve blocks in the ED (Figure 4). These kits include sterile gloves, ultrasound probe covers, sterile drapes, spinal needles, syringes, IV tubing, nerve block reference materials, and a consent form. We placed the kits in a centralized location in the ED for ease of access.

    Figure 4A. A collection of nerve block kits ready for use.
    Figure 4B. Contents of a nerve block kit.

    As a result of this intervention, we have anecdotally noted an increased number of procedures performed, with a complete analysis forthcoming. As our program increases the scope and scale of regional anesthesia procedures offered to patients, the nerve block kits will hopefully eliminate a barrier to performing nerve blocks and thus facilitate the deliverance of high-quality patient-centered analgesia to the largest number of patients possible.

    References

    1. Chesters A, Atkinson P. Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Emerg Med J 2014; 31(e1):e84–e87. doi:10.1136/emermed-2013-203073.
    2. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015; 16:1188–1193. doi:10.5811/westjem.2015.10.28270.
    3. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM 2016; 18:37–47. doi:10.1017/cem.2015.75.
    4. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med 2012; 43:692–697. doi:10.1016/j.jemermed.2012.01.050.
    5. Kolodychuk N, Krebs JC, Stenberg R, Talmage L, Meehan A, DiNicola N. Fascia iliaca blocks performed in the emergency department decrease opioid consumption and length of stay in patients with hip fracture. J Orthop Trauma 2022; 36:142–146. doi:10.1097/BOT.0000000000002220.
    6. O’Connor M, Switzer J. AAOS Clinical practice guideline summary: Management of hip fractures in older adults. J Am Acad Orthop Surg 2022; 30(20):e1291–e1296. doi: 10.5435/JAAOS-D-22-00125.
    7. Alsharif P, Muckey E, Lu H, et al. Emergency department workflow limits the utilization of fascia iliaca blocks for hip and femur fractures. Academic Emergency Medicine 2022; 29(S1). https://doi.org/10.1111/acem.14511.

    Peter Alsharif MD, Marwa Ali MD, Helen Lu MD, Robert James Adrian MD, Annette Mueller MD MBA, Ilya Ostrovsky MD, and Stephen Alerhand MD, are from the Department of Emergency Medicine at Rutgers New Jersey Medical School in Newark, New York.