Use Of Ultrasound Imaging Research Articles

In Response.

We thank Drs Hoffman and Riordan1 for their thoughtful comment on our study.2 While we agree that more research is needed on the treatment of postdural puncture headache (PDPH) with epidural blood patch, it is important to point out that accidental dural puncture is not inevitable and could be prevented through better training and quality assurance. The recent root-cause analysis by Haller et al3 revealed that the absence of skilled assistance during epidural placement (ie, nurse anesthetist) and multiple insertion attempts are associated with an increased risk of PDPH.3 Although the current American Society of Anesthesiologists Task Force on Obstetric Anesthesia Practice Guidelines for Obstetric Anesthesia does not recommend any obstetric team composition for labor epidural placement, the Haller et al3 study suggests that having a skilled assistant to the anesthesiologist during the procedure might reduce the incidence of PDPH. Use of lumbar ultrasound imaging has been shown to decrease the number of epidural placement attempts. Given the heightened risk of major neurological complications associated with PDPH, it is sensible to recommend the use of ultrasound imaging for neuraxial anesthesia in obstetrics, particularly among women with known risk factors for difficult placement, such as difficult anatomical landmark palpation.4 The role of simulation training in acquiring and maintaining technical skills and reducing the number of epidural placement attempts also warrants investigation. Jean Guglielminotti, MD, PhDRuth Landau, MDDepartment of AnesthesiologyColumbia University College of Physicians and SurgeonsNew York, New York[email protected]Guohua Li, MD, DrPHDepartment of AnesthesiologyColumbia University College of Physicians and SurgeonsNew York, New YorkDepartment of EpidemiologyColumbia University Mailman School of Public HealthNew York, New York

Testicular rupture: Simplifying the diagnosis

Objective: To review the use of ultrasound imaging in the diagnosis of testicular rupture and in relation to current guidelines. Methods: Data was retrospectively collected for all patients diagnosed with testicular rupture at a major trauma centre between 2011 and 2018. Data included patient demographics, mechanism of trauma, specific findings on ultrasound and outcomes. On review of ultrasound imaging, specific findings identified include a breach in the tunica albuginea (currently advised in guidelines), heterogenicity and contour loss. Results: Eight patients were identified with average age 37 years old, mechanism of trauma was 50%, 37.5% and 12.5% for motorcycle road traffic collision, sporting injury and workplace injury respectively. A breach of tunica albuginea was identified on ultrasound in 65% of cases, compared with 100% of cases showing contour loss and heterogenicity. Of the 87.5% patients who were managed surgically one needed orchidectomy (and later testosterone replacement). Conclusion: Guidelines have varied on how to use ultrasound imaging in diagnosing a clinically difficult condition. Our case series demonstrates that diagnosing testicular rupture by looking for more easily identifiable characteristics (heterogenicity and contour loss) than currently recommended in the guidelines (breech in the tunica albuginea) will aid diagnosis and patient pathway and improve outcomes. Level of evidence: 5

The presence of helical flow can suppress areas of disturbed shear in parameterised models of an arteriovenous fistula.

Areas of disturbed shear that develop following arteriovenous fistula (AVF) creation are believed to trigger the onset of intimal hyperplasia (IH), leading to AVF dysfunction. The presence of helical flow can suppress the flow disturbances that lead to disturbed shear in other areas of the vasculature. However, the relationship between helical flow and disturbed shear remains unevaluated in AVF. In this study, computational fluid dynamics (CFD) is used to evaluate the relationship between geometry, helical flow, and disturbed shear in parameterised models of an AVF characterised by four different anastomosis angles. The AVF models with a small anastomosis angle demonstrate the lowest distribution of low/oscillating shear and are characterised by a high helical intensity coupled with a strong balance between helical structures. Contrastingly, the models with a large anastomosis angle experience the least amount of high shear, multidirectional shear, as well as spatial and temporal gradients of shear. Furthermore, the intensity of helical flow correlates strongly with curvature (r = 0.73, P < .001), whereas it is strongly and inversely associated with taper (r = -0.87, P < .001). In summary, a flow field dominated by a high helical intensity coupled with a strong balance between helical structures can suppress exposure to low/oscillating shear but is ineffective when it comes to other types of shear. This highlights the clinical potential of helical flow as a diagnostic marker of exposure to low/oscillating shear, as helical flow can be identified in vivo with the use of ultrasound imaging.

Hidradenitis suppurativa: Current understanding, diagnostic and surgical challenges, and developments in ultrasound application.

Hidradenitis suppurativa (HS) is debilitating, costly, chronic disease for which no cure exists and which often precipitates greater health concerns. While we are making advances in understanding, HS remains an area of attention which is evidenced by a 400% increase in research studies involving HS in the past 5years. This includes research regarding the advantages and limitations of ultrasound (US) imaging and its ability to enhance the surgical treatment and medical management of HS. Herein, we describe the diagnostic and surgical obstacles that HS presents, the foremost of which is detection of subclinical information, and perform an in-depth synthesis of current knowledge regarding the use of US imaging to mitigate these obstacles. A comprehensive literature review of US imaging in HS patients and a supplementary review of the current state of HS were conducted. Ultrasound imaging is a powerful tool in the diagnosis, monitoring, clinical management, and preoperative assessment of HS. However, it also has relevant limitations that necessitate additional consideration. Hidradenitis suppurativa is a disabling skin disease that presents a diagnostic and surgical challenge. The invaluable advantages and relevant limitations that US imaging offers are beginning to be understood, leading to standardization and increased implementation. US imaging has the potential to drastically improve patient care and merits further attention.

Applying cuckoo search based algorithm and hybrid based neural classifier for breast cancer detection using ultrasound images

Ultrasound examination is one of the most convenient and appropriate processes used for the diagnosis of tumors that make use of ultrasound images. Ultrasound imaging is a noninvasive modality utilized commonly for the detection of breast cancer, which is a common and dangerous cancer found in women. This paper proposes an approach for the detection of breast cancer using ultrasound images using MKF-cuckoo search (MKF-CS) algorithm and hybrid based neural (H-BN) classifier. In pre-processing, the input images to be diagnosed are pre-processed by ROI extraction using a novel algorithm, four way search. The pre-processed image is allowed to perform segmentation using MKF-CS algorithm. The key features, such as mean, variance, standard deviation, and so on, are extracted in feature extraction and are fed to the proposed H-BN classifier. Based on the training data, H-BN classifier classifies the data into benign or malignant tumor classes, for the detection of breast cancer. To evaluate the performance of the proposed MKFCS-HBN approach, three metrics, such as accuracy, sensitivity, and specificity, are utilized. The experimental results show that MKFCS-HBN could attain the maximum performance with an accuracy of 0.8889, the sensitivity of 1, and specificity of 0.85 and thus, prove its effectiveness.

Segmentation of Femoral Cartilage from Knee Ultrasound Images Using Mask R-CNN.

Segmentation of knee cartilage from Ultrasound (US) images is essential for various clinical tasks in diagnosis and treatment planning of Osteoarthritis. Moreover, the potential use of US imaging for guidance in robotic knee arthroscopy is presently being investigated. The femoral cartilage being the main organ at risk during the operation, it is paramount to be able to segment this structure, to make US guidance feasible. In this paper, we set forth a deep learning network, Mask R-CNN, based femoral cartilage segmentation in 2D US images for these types of applications. While the traditional imaging approaches showed promising results, they are mostly not real-time and involve human interaction. This being the case, in recent years, deep learning has paved its way into medical imaging showing commendable results. However, deep learning-based segmentation in US images remains unexplored. In the present study we employ Mask R-CNN on US images of the knee cartilage. The performance of the method is analyzed in various scenarios, with and without Gaussian filter preprocessing and pretraining the network with different datasets. The best results are observed when the images are preprocessed and the network is pretrained with COCO 2016 image dataset. A maximum Dice Similarity Coefficient (DSC) of 0.88 and an average DSC of 0.80 is achieved when tested on 55 images indicating that the proposed method has a potential for clinical applications.

Gait Phase Identification During Level, Incline and Decline Ambulation Tasks Using Portable Sonomyographic Sensing.

Clinical viability of powered lower-limb assistive devices requires reliable and intuitive control strategies. Stance and swing are the main phases of the gait cycle across different locomotion tasks. Hence, a reliable method to accurately identify these phases can decrease sensing complexity and assist in enabling high-level control of assistive devices. Ultrasound (US) imaging has recently been introduced as a new sensing modality that may provide a solution for intuitive device control. US images of the rectus femoris and vastus intermedius muscles were collected in humans during level, incline, and decline ambulation tasks. Five low-level static (i.e. time-independent) features of US images were measured with respect to a reference image, including correlation coefficient, sum of absolute differences, structural similarity index, sum of squared differences, and image echogenicity. Time-derivatives of the static features were also calculated as temporal features. Support vector machine classifiers were trained using these static features to identify the gait phase both dependent and independent of the ambulation tasks. The results indicate an accuracy of 88.3% in identifying the gait phases for task-independent classifiers when trained using only the static features. Performance of the classifiers improved significantly to 92.8% after using the temporal features (p $\lt0.01)$. The algorithm was efficient and the average processing speed was faster than 100 Hz. This study is the first demonstration on use of US imaging to provide continuous estimates of ambulation phase, and on multiple surfaces. These findings suggest task-independent approaches may reliably identify the main phases of the gait cycle. Advancements in this area of study may provide simpler intuitive strategies for high-level assistive device control and increase their clinical relevance.

Cranial Suture Measurement by 2-point Method in Ultrasound Screening of Craniosynostosis.

Background:Diagnostic imaging for craniosynostosis currently relies entirely on radiation images, but it has been estimated that a risk of cancer from diagnostic x-rays may exist. Use of ultrasound imaging has been reported, but very little has been written on normal findings of the cranial suture. Also, ultrasound diagnostic methods have not been established. To obtain images for the diagnosis of abnormal sutures in craniosynostosis, we investigated the normal ultrasonographic appearance of the suture. To establish screening methods for craniosynostosis, we prepared a 2-point method for simple evaluation and confirmed its usefulness.Methods:Ultrasonography was performed in infants with normal head, deformational plagiocephaly, and craniosynostosis. We focused on the measurement indices and decided on the order for making our observations. Furthermore, we developed an evaluation method (2-point method) and recorded our finding in a useful table.Results:We could clearly judge whether the cranial suture was patent or closed and were able to measure the suture width. Even for 2-year-old children, the width of the sutures at the points measured exceeded the echocardiographic resolution. By using the 2-point evaluation method, all the sutures could be inspected in about 2 minutes. Sensitivity was 100% and specificity was 95.1%.Conclusions:Our present studies showed that normal or abnormal suture can be clearly distinguished by ultrasound. By evaluating the fixed points instead of the whole line, it was possible to shorten the inspection time. Ultrasound screening by applying the 2-point method is very useful.

Animate! Breathing new life into an old pedagogy: Human embryology teaching reenvisioned

The teaching of human embryology is as ancient as that of human anatomy itself. Over the centuries up to the present time, embryology pedagogy has evolved from enlisting the dissection of fetal cadavers and use of two‐dimensional (2D) sketches and diagrams, to the modern technologies of 2D and 3D animations, CT scans of embryos and fetuses with 3D rendering of the images, and the use of ultrasound imaging. These techniques seek to balance accurate portrayal of embryonic structures with the cognitive load associated with learning the concepts presented using these images, and their value as learning adjuncts for students. This paper discusses the rationale, pedagogical basis and implementation of narrated 2D animations of embryonic development, which present the early stages of human life in accessible cartoon‐like sequences. In response to the demand from curriculum leaders at the University of British Columbia (UBC) medical school for high‐quality, simplified yet accurate rendition of early embryonic development, we have developed the first of a series of 2D animations, which presents key embryonic processes during the first 12 weeks of life contemporaneously. First and second year MD students at UBC will have access to these animations as adjuncts to the embryology components of the MD Undergraduate pre‐clerkship program. The animation was developed using Adobe Animate® software during approximately 300 hours of programming. Audio design, recording and editing were completed with Adobe Audition®, After Effects® and Adobe Premiere Pro®. In evaluating the animation, students rated it highly for visual appeal and helpfulness to learn basic embryology, while providing useful comments on how it may be improved.Support or Funding InformationSouthern Medical Program, UBC Faculty of MedicineThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Regional and total muscle mass, muscle strength and physical performance: The potential use of ultrasound imaging for sarcopenia

ObjectiveTo evaluate the relationship between the regional and total muscle mass, muscle strength and physical performance, and also to investigate the affected muscles, their strength and physical performance with aging. MethodsA total of 145 healthy subjects were included for the cross-sectional descriptive study. Demographic data were obtained, and body composition was consecutively assessed by anthropometric methods, bioelectrical impedance analysis and ultrasound (muscle thickness, fascicule length and pennation angle). Functional status was assessed using hand grip strength and gait speed measurements. ResultsAbdominal and thigh muscles were thinner and triceps muscle was thicker in older subjects when compared with younger ones. Age and grip strength were significant predictors for physical performance. Gait speed, grip strength and regional muscle measurements decreased with age at higher rates (26–28%), skeletal muscle mass index was affected at a lower rate (15%). ConclusionsLow muscle strength and regional muscle measurements should be used to confirm the diagnosis of sarcopenia.

Spontaneous Penile Tumescence by Sparing Cavernous Tissue in the Course of Malleable Penile Prosthesis Implantation

IntroductionSpontaneous penile tumescence after penile prosthesis implantation has been sporadically reported in the literature. AimTo preserve residual erectile function of patients’ spontaneous penile tumescence by sparing cavernous tissue in the course of malleable penile prosthesis implantation. MethodsOverall, 92 patients were randomized into 2 equal arms; patients undergoing conventional malleable penile prosthesis implantation, and patients undergoing the cavernous tissue–sparing technique. 1 month after surgery, these patients underwent penile duplex examination to assess the maximal cavernous tissue thickness around the implant cylinders. Additionally, they were asked about the occurrence of any spontaneous or arousal-induced penile tumescence. Main Outcome MeasuresPostoperative changes were compared with the preoperative ones. ResultsThe mean maximal cavernous tissue thickness was shown to be significantly higher in the cavernous tissue–sparing group compared with the conventional surgery group (5.2 ± 0.8 mm vs 2.2 ± 1.04 mm, P < .01). In the cavernous tissue–sparing group, 41 of 46 patients (89.13%) reported having a significantly higher incidence of residual penile tumescence vs 7 of 46 patients (15.2%) in the conventional surgery group (P < .001). The postoperative penile girth was significantly higher in the cavernous tissue–sparing group than in the conventional surgery group (11.16 ± 1.1 cm vs 10.11 ± 1.15 cm, P < .001). Clinical ImplicationsThis study provides a step-by-step approach to maintaining post-implantation penile tumescence and preserving penile girth in a reproducible manner. Strengths & LimitationsThis is the first study to demonstrate the benefits of implanting a penile prosthesis while the penis is in a pharmacologically induced tumescent state. It is also the first to make use of ultrasound imaging in assessing postoperative corporal tissue. The main limitations are the short postoperative follow-up period and the non-blinding of measurements. ConclusionIt could be concluded that the cavernous tissue–sparing technique is a reproducible technique that has the added value of preserving residual erectile function in the form of retained postoperative penile tumescence and preserved penile girth.Zaazaa A, Mostafa T. Spontaneous Penile Tumescence by Sparing Cavernous Tissue in the Course of Malleable Penile Prosthesis Implantation. J Sex Med 2019;16:474–478.

The use of ultrasound imaging in rheumatology- our experiences to-date

Background This presentation is designed to demonstrate the value ultrasound imaging brings to Rheumatology and diagnosis. The development and implementation of rheumatologic ultrasound training in Australia will be discussed. Reporting and identifying bony changes and the articular surface of the bone is essential in ultrasound. Understanding what “synovitis” is and its ultrasound appearance in this presentation will be thoroughly discussed in detail. Ultrasound is used extensively in Europe and is a valuable imaging tool used in diagnosis of rheumatoid changes within the hands, knees, elbows and joints. It is important, as a sonographer, to report the correct information relating to auto immune disease and have an understanding of such diseases. Hopefully, a very informative and new presentation. Key points • Identifying “synovitis” • Why use Power Doppler (PD) – what does that tell us • “bony” changes • Joint capsule changes • Protocol to follow • Imaging of the Dorsal wrist – assess synovium with colour (PD) • Radio-carpal joint • Ulnar styloid • Comment on common extensor tendons and retinaculum • MCPJs • PIPJs • Bony cortex • Joint capsule Inflammatory arthritis - overview • In the RA wrist synovium appears hypo-echoic with a thickened synovial wall. • Wrist “fat “is echogenic in comparison to normal tissue and may give the appearance of “clumped” tissue. • Power Doppler imaging (PD) is used to determine if the disease is “active”. • This presentation is very common and the patient usually presents with NO PAIN. • Patient presents with “stiffening” of the hands in the morning. • One or two joints maybe tender. • OA - joints appear swollen. • RA – joints are destroyed and disfigured. • Decreased ROM. • Bone erosions are identified reliably with ultrasound and demonstrated in both the longitudinal and coronal plane.

Ultrasound for kidney access in percutaneous nephrolithotomy: a contemporary review.

Nowadays percutaneous nephrolithotomy (PCNL) is the standard of care for renal staghorn calculus or large (>20 mm)pelvic or caliceal stones, as well as for the failure of other treatment options.This review aims to evaluate the contemporary use of ultrasound imaging in PCNL, by comparing it to conventional fluoroscopy,reviewing data regarding the complication and success rate of nephrostomy tract creation and stone free rate (SFR), aswell as data concerning the learning curve for these procedures and cost indicators.The evidence acquired shows that the ultrasound guided access (USGA) is a comparable method with the classic fluoroscopicguided access (FGA), with a similar safety profile, with a significant reduction in radiation exposure, up to radiationfree complete PCNL. USGA PCNL seems to lead to decreased bleeding and need for transfusion, especially when the Dopplermode is used, and also to a slightly higher SFR than conventional FGA PCNL. USGA PCNL reduces the overall costs of theprocedure by about 30% and can be safely learnt and performed by urologists. For an experienced endourologist, familiar withFGA PCNL, the learning curve for shifting to USGA PCNL is of approximately 20 procedures.

Automated patient-specific transperineal ultrasound probe setups for prostate cancer patients undergoing radiotherapy.

The use of ultrasound imaging is not widespread in prostate cancer radiotherapy workflows, despite several advantages (eg, allowing real-time volumetric organ tracking). This can be partially attributed to the need for a trained operator during acquisition and interpretation of the images. We introduce and evaluate an algorithm that can propose a patient-specific transperineal ultrasound probe setup, based on a CT scan and anatomical structure delineations. The use of this setup during the simulation and treatment stage could improve usability of ultrasound imaging for relatively untrained operators (radiotherapists with less than 1yr experience with ultrasound). The internal perineum boundaries of three prostate cancer patients were identified based on bone masks extracted from their CT scans. After projection of these boundaries to the skin and exclusion of specific areas, this resulted in a skin area accessible for transperineal ultrasound probe placement in clinical practice. Several possible probe setups on this area were proposed by the algorithm and the optimal setup was automatically selected. In the end, this optimal setup was evaluated based on a comparison with a corresponding transperineal ultrasound volume acquired by a radiation oncologist. The algorithm-proposed setups allowed visualization of 100% of the clinically required anatomical structures, including the whole prostate and seminal vesicles, as well as the adjacent edges of the bladder and rectum. In addition, these setups allowed visualization of 94% of the anatomical structures, which were also visualized by the physician during the acquisition of an actual ultrasound volume. Provided that the ultrasound probe setup proposed by the algorithm, is properly reproduced on the patient, it allows visualization of all clinically required structures for image guided radiotherapy purposes. Future work should validate these results on a patient population and optimize the workflow to enable a relatively untrained operator to perform the procedure.

Updates on ultrasound research in implant dentistry: a systematic review of potential clinical indications.

Ultrasonography has shown promising diagnostic value in dental implant imaging research; however, exactly how ultrasound was used and at what stage of implant therapy it can be applied has not been systematically evaluated. Therefore, the aim of this review is to investigate potential indications of ultrasound use in the three implant treatment phases, namely planning, intraoperative and post-operative phase. Eligible manuscripts were searched in major databases with a combination of keywords related to the use of ultrasound imaging in implant therapy. An initial search yielded 414 articles, after further review, 28 articles were finally included for this systematic review. Ultrasound was found valuable, though at various development stages, for evaluating (1) soft tissues, (2) hard tissues (3) vital structures and (4) implant stability. B-mode, the main function to image anatomical structures of interest, has been evaluated in pre-clinical and clinical studies. Quantitative ultrasound parameters, e.g. sound speed and amplitude, are being developed to evaluate implant-bone stability, mainly in simulation and pre-clinical studies. Ultrasound could be potentially useful in all three treatment phases. In the planning phase, ultrasound could evaluate vital structures, tissue biotype, ridge width/density, and cortical bone thickness. During surgery, it can provide feedback by identifying vital structures and bone boundary. At follow-up visits, it could evaluate marginal bone level and implant stability. Understanding the current status of ultrasound imaging research for implant therapy would be extremely beneficial for accelerating translational research and its use in dental clinics.

Incorporation of Clinically‐Based Ultrasound Workshops in a 1st Year Medical Anatomy Course

Ultrasound (US) is quickly becoming an increasingly common tool in point‐of‐care medical practice (commonly called “the new stethoscope”). To better prepare our students for this environment, the Arizona College of Osteopathic Medicine (AZCOM) has developed and is implementing a 4‐year, longitudinal, integrated, US curricular experience. The initial phase (1st year courses) includes a major US component in gross anatomy. The gross anatomy series is two regional, dissection‐based courses with eight exam units (four per course) over two quarters. The US component to the gross courses includes increased use of US images in lectures as well as eight, clinically‐based, hands‐on US workshops; one for each exam unit. Modifications in the lecture schedule made inclusions of the workshops credit‐hour neutral. The exam units and associated US workshops (in italics) are: Back/Scapular—lumbar puncture; Upper Extremity—carpal tunnel syndrome; Thorax—4‐view cardiac assessment; Abdominal—biliary colic; Posterior Abdominal wall/Pelvis/Perineum—AAA, FAST; Lower Extremity—plantar fasciitis, calcaneal tendonitis, tarsal tunnel syndrome; Head and Neck I—ocular and thyroid exams; Head and Neck II—carotid stenosis. The US workshops are designed for students to visualize the relevant anatomy of a common, point‐of‐care clinical scenario on living subjects. Student assessment is in the form of oral “check‐out” quizzes in the workshops and US‐based questions in the written and practical portions of the unit exams. Overall performance on US questions in the first four exams was below the exam averages (77% v. 83%), but with a marked upward trajectory of the US question performance (69%, 62%, 76%, 89%). Practical exam questions showed a similar trajectory, but with lower averages. A Likert scale survey—first of a series as part of an ongoing four‐year study—was given at the end of the first quarter (4 exam units) to assess student opinions regarding US in the anatomy course. The non‐incentivized response rate was 146/279. Students overwhelmingly (90+%) feel US training is an important part of the curriculum that should begin as early as possible. For each workshop a strong majority agreed that it improved their comprehension of both the anatomy of the region scanned (87%, 92, 91, 92) and the regional clinical concerns (91%, 94, 93, 93). A majority of students also agreed that the US workshops led them to do some form of further research of the clinical concerns (65%, 64%, 74%, 71%). These preliminary results are very encouraging. Another survey will be taken at the end of the winter quarter, but current indications are that the utilization of US workshops in the AZCOM gross anatomy course has been a valuable addition.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users.

IntroductionCase management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests.MethodsThe study consisted of a retrospective chart review of ED and inpatient visits in our hospital’s ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management.ResultsThe study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant.ConclusionCase management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.

Clinical assessment and brain findings in a cohort of mothers, fetuses and infants infected with ZIKA virus

Congenital Zika virus (ZIKV) infection can be detected in both the presence and absence of microcephaly and manifests as a number of signs and symptoms that are detected clinically and by neuroimaging. However, to date, qualitative and quantitative measures for the purpose of diagnosis and prognosis are limited. Main objectives of this study conducted on fetuses and infants with confirmed congenital Zika virus infection and detected brain abnormalities were (1) to assess the prevalence of microcephaly and the frequency of the anomalies that include a detailed description based on ultrasound and magnetic resonance imaging in fetuses and ultrasound, magnetic resonance imaging, and computed tomography imaging postnatally, (2) to provide quantitative measures of fetal and infant brain findings by magnetic resonance imaging with the use of volumetric analyses and diffusion-weighted imaging, and (3) to obtain additional information from placental and fetal histopathologic assessments and postnatal clinical evaluations. This is a longitudinal cohort study of Zika virus-infected pregnancies from a single institution in Colombia. Clinical and imaging findings of patients with laboratory-confirmed Zika virus infection and fetal brain anomalies were the focus of this study. Patients underwent monthly fetal ultrasound scans, neurosonography, and a fetal magnetic resonance imaging. Postnatally, infant brain assessment was offered by the use of ultrasound imaging, magnetic resonance imaging, and/or computed tomography. Fetal head circumference measurements were compared with different reference ranges with <2 or <3 standard deviations below the mean for the diagnosis of microcephaly. Fetal and infant magnetic resonance imaging images were processed to obtain a quantitative brain volumetric assessment. Diffusion weighted imaging sequences were processed to assess brain microstructure. Anthropometric, neurologic, auditory, and visual assessments were performed postnatally. Histopathologic assessment was included if patients opted for pregnancy termination. All women (n=214) had been referred for Zika virus symptoms during pregnancy that affected themselves or their partners or if fetal anomalies that are compatible with congenital Zika virus syndrome were detected. A total of 12 pregnant patients with laboratory confirmation of Zika virus infection were diagnosed with fetal brain malformations. Most common findings that were assessed by prenatal and postnatal imaging were brain volume loss (92%), calcifications (92%), callosal anomalies (100%), cortical malformations (89%), and ventriculomegaly (92%). Results from fetal brain volumetric assessment by magnetic resonance imaging showed that 1 of the most common findings associated with microcephaly was reduced supratentorial brain parenchyma and increased subarachnoid cerebrospinal fluid. Diffusion weighted imaging analyses of apparent diffusion coefficient values showed microstructural changes. Microcephaly was present in 33.3-58.3% of the cases at referral and was present at delivery in 55.6-77.8% of cases. At birth, most of the affected neonates (55.6-77.8%) had head circumference measurements >3 standard deviations below the mean. Postnatal imaging studies confirmed brain malformations that were detected prenatally. Auditory screening results were normal in 2 cases that were assessed. Visual screening showed different anomalies in 2 of the 3 cases that were examined. Pathologic results that were obtained from 2 of the 3 cases who opted for termination showed similar signs of abnormalities in the central nervous system and placental analyses, including brain microcalcifications. Congenital microcephaly is not an optimal screening method for congenital Zika virus syndrome, because it may not accompany other evident and preceding brain findings; microcephaly could be an endpoint of the disease that results from progressive changes that are related to brain volume loss. Long-term studies are needed to understand the clinical and developmental relevance of these findings.

The Use of Ultrasound Imaging in the External Beam Radiotherapy Workflow of Prostate Cancer Patients.

External beam radiotherapy (EBRT) is one of the curative treatment options for prostate cancer patients. The aim of this treatment option is to irradiate tumor tissue, while sparing normal tissue as much as possible. Frequent imaging during the course of the treatment (image guided radiotherapy) allows for determination of the location and shape of the prostate (target) and of the organs at risk. This information is used to increase accuracy in radiation dose delivery resulting in better tumor control and lower toxicity. Ultrasound imaging is harmless for the patient, it is cost-effective, and it allows for real-time volumetric organ tracking. For these reasons, it is an ideal technique for image guidance during EBRT workflows. Review papers have been published in which the use of ultrasound imaging in EBRT workflows for different cancer sites (prostate, breast, etc.) was extensively covered. This new review paper aims at providing the readers with an update on the current status for prostate cancer ultrasound guided EBRT treatments.

Current Uses of Ultrasound Imaging in Musculoskeletal Rehabilitation.

The term Rehabilitative Ultrasound Imaging (RUSI) refers to the use of ultrasound imaging by physiothera-pists. Ultrasound is used by physiotherapists to evaluate the morphology of muscles and other associated soft tissues not only at rest but also for a dynamic assessment of those structures during physical activities and tasks. RUSI is most commonly utilized as part of a biofeedback mechanism, which shows good efficacy in lower back pain treatment. Several possibilities have been also described for clinically adapting this method in the rehabilitation of the shoulder and knee and postoperative improvement of tendons. RUSI is a novel method with a high clinical potential to support physiotherapeutic therapies.