Younger age is a significant factor for poorer adherence in fracture patients who received low-intensity pulsed ultrasound: A retrospective study.

BACKGROUND: The factors for poor adherence to therapy in patients with postoperative fracture who are treated with low-intensity pulsed ultrasound remain unknown. Therefore, we designed a retrospective cohort study to determine the various factors for poorer adherence to therapy in patients with postoperative fracture who were treated with low-intensity pulsed ultrasound therapy. METHODS: We retrospectively analyzed the data of postoperative patients who underwent low-intensity pulsed ultrasound after fracture surgery from January 2010 to May 2019. The patients were categorized into two groups as follows: group G, including those with a good adherence rate (>72%), and group P, including those with a poor adherence rate (<72%). Factors, such as age, sex, how the rental cost of low-intensity pulsed ultrasound was paid (by the patients themselves or by the insurance company), living (alone or with someone), insurance claim item (fractures within 3 weeks after osteosynthesis or delayed or non-union fractures), low-intensity pulsed ultrasound device-type (earlier- or next-generation), duration of low-intensity pulsed ultrasound use, fracture site (upper or lower limb), frequency of hospital visits (regular or irregular), and employment status (employed/unemployed) were compared between groups G and P. RESULTS: In total, 96 patients (74 and 22 patients in groups G and P, respectively) who underwent low-intensity pulsed ultrasound were included in the study. Univariate analysis revealed that younger patients (P < 0.001) and patients who did not regularly visit the hospital (P = 0.024) were more likely to have poorer adherence to therapy. Multiple logistic regression analysis revealed that age was the only independent, pertinent factor for poorer adherence to therapy (odds ratio, 8.570; 95% confidence interval, 2.770-26.50; P < 0.001), with a cutoff value of 41 years. CONCLUSIONS: Younger age is a significant factor for poorer adherence in patients undergoing low-intensity pulsed ultrasound therapy.

Improving Voice Outcomes After Thyroid Surgery - Review of Safety Parameters for Using Energy-Based Devices Near the Recurrent Laryngeal Nerve.

Technological advances in thyroid surgery have rapidly increased in recent decades. Specifically, recently developed energy-based devices (EBDs) enable simultaneous dissection and sealing tissue. EBDs have many advantages in thyroid surgery, such as reduced blood loss, lower rate of post-operative hypocalcemia, and shorter operation time. However, the rate of recurrent laryngeal nerve (RLN) injury during EBD use has shown statistically inconsistent. EBDs generate high temperature that can cause iatrogenic thermal injury to the RLN by direct or indirect thermal spread. This article reviews relevant medical literatures of conventional electrocauteries and different mechanisms of current EBDs, and compares two safety parameters: safe distance and cooling time. In general, conventional electrocautery generates higher temperature and wider thermal spread range, but when applying EBDs near the RLN adequate activation distance and cooling time are still required to avoid inadvertent thermal injury. To improve voice outcomes in the quality-of-life era, surgeons should observe safety parameters and follow the standard procedures when using EBDs near the RLN in thyroid surgery.

Tightening and Reduction of Unwanted Submental Fat Using Triple-Layer High-Intensity Focused Ultrasound: Clinical and 3-Dimensional Imaging Analysis.

BACKGROUND: Unwanted submental fat (SMF) is aesthetically unappealing, but methods of reduction are either invasive or lack evidence of their use. OBJECTIVE: The authors sought to evaluate the safety and efficacy of a novel triple-layer high-intensity focused ultrasound (HIFU) regimen for SMF reduction. METHODS: Forty Korean subjects with moderate/severe SMF were evaluated after receiving a session of triple-layer HIFU treatments (using 3.0-, 4.5-, and 6.0-mm focusing transducers). The objective evaluation based on the 5-point Clinician-Reported Submental Fat Rating Scale (CR-SMFRS) and patients' satisfaction based on the 7-point Subject Self-Rating Scale (SSRS) were determined 8 weeks after treatment. Three-dimensional image analysis was also performed. RESULTS: At the follow-up visit, the proportion of treatment responders defined as subjects with ≥1-point improvement in CR-SMFRS was 62.5%, and the proportion of patients satisfied with appearance of their face and chin (score ≥4 on the SSRS) was 67.5% of the total patients. The results of 3-dimensional analysis were consistent with clinical observations. Only mild and transient side effects were observed for some patients with no serious adverse effects. CONCLUSION: The triple-layer HIFU regimen including the novel 6.0-mm transducer has benefits for tightening and rejuvenation of the area with unwanted SMF, showing reasonable safety profiles.

Transcranial focused ultrasound modulates cortical and thalamic motor activity in awake sheep.

Transcranial application of pulsed low-intensity focused ultrasound (FUS) modulates the excitability of region-specific brain areas, and anesthetic confounders on brain activity warrant the evaluation of the technique in awake animals. We examined the neuromodulatory effects of FUS in unanesthetized sheep by developing a custom-fit headgear capable of reproducibly placing an acoustic focus on the unilateral motor cortex (M1) and corresponding thalamic area. The efferent responses to sonication, based on the acoustic parameters previously identified in anesthetized sheep, were measured using electromyography (EMG) from both hind limbs across three experimental conditions: on-target sonication, off-target sonication, and without sonication. Excitatory sonication yielded greater amplitude of EMG signals obtained from the hind limb contralateral to sonication than that from the ipsilateral limb. Spurious appearance of motion-related EMG signals limited the amount of analyzed data (~ 10% selection of acquired data) during excitatory sonication, and the averaged EMG response rates elicited by the M1 and thalamic stimulations were 7.5 ± 1.4% and 6.7 ± 1.5%, respectively. Suppressive sonication, while sheep walked on the treadmill, temporarily reduced the EMG amplitude from the limb contralateral to sonication. No significant change was found in the EMG amplitudes during the off-target sonication. Behavioral observation throughout the study and histological analysis showed no sign of brain tissue damage caused by the acoustic stimulation. Marginal response rates observed during excitatory sonication call for technical refinement to reduce motion artifacts during EMG acquisitions as well as acoustic aberration correction schemes to improve spatial accuracy of sonication. Yet, our results indicate that low-intensity FUS modulated the excitability of regional brain tissues reversibly and safely in awake sheep, supporting its potential in theragnostic applications.

Efficacy and Safety of High-Intensity, High-Frequency, Parallel Ultrasound Beams for Fine Lines and Wrinkles.

BACKGROUND: Ultrasound energy has been used for cutaneous rejuvenation, including treatment of fine lines and wrinkles. Ultrasound waves of high intensity can induce thermal injury in the dermis, which causes tissue coagulation and remodeling. OBJECTIVE: To examine the safety and utility of a novel ultrasound device that uses high-intensity, high-frequency, parallel ultrasound beams to improve fine lines and wrinkles of the face and neck. MATERIALS AND METHODS: A prospective, multicenter, clinical study investigated the utility of this novel ultrasound device to improve fine lines and wrinkles. Sixty subjects were enrolled for single treatment to the face and neck. RESULTS: Fifty-eight subjects completed the study. The mean age was 58 years, and 87.9% were women. Fitzpatrick skin Types I to VI were represented. Assessments compared 12-week follow-up with baseline. Two blinded reviewers agreed in identifying pretreatment and post-treatment photographs for 78% of subjects. There was significant improvement of 1 to 3 Fitzpatrick Wrinkle and Elastosis Scale units in 86% of subjects. For investigator global improvement scores, 88% of subjects had improvement. Overall, 72% of subjects noted improvement, and the majority were satisfied. There were no device-related adverse events. CONCLUSION: Treatment with a novel ultrasound device that uses high-intensity, high-frequency, parallel ultrasound beams safely improved the clinical appearance of fine lines and wrinkles of the face and neck.

Microbubbles and Ultrasound Accelerated Thrombolysis for Peripheral Arterial Occlusions: The Outcomes of a Single Arm Phase II Trial.

OBJECTIVE: Acute peripheral arterial occlusions can be treated by catheter directed thrombolysis (CDT). However, CDT is time consuming and accompanied by the risk of bleeding complications. The addition of contrast enhanced ultrasound and microbubbles could improve thrombus susceptibility to thrombolytic agents and potentially shorten treatment time with a lowered risk of bleeding complications. This article reports the outcomes of the safety and feasibility of this novel technique. METHODS: In this single arm phase II trial, 20 patients with acute lower limb ischaemia received CDT combined with an intravenous infusion of microbubbles and locally applied ultrasound during the first hour of standard intra-arterial thrombolytic therapy. The primary endpoint was safety, i.e., occurrence of serious adverse events (haemorrhagic complications and/or amputation) and death within one year. Secondary endpoints included angiographic and clinical success, thrombolysis duration, additional interventions, conversion, and quality of life. RESULTS: The study included 20 patients (16 men; median age 68.0 years; range, 50.0 - 83.0; and 40% native artery and 60% bypass graft). In all patients, the use of microbubble contrast enhanced sonothrombolysis could be applied successfully. There were no serious adverse events related to the experimental treatment. Duplex examination showed flow distal from the occlusion after 23.1 hours (range 3.1 - 46.5) with a median thrombolysis time of 47.5 hours (range 6.0 - 81.0). The short term ABI and pain scores significantly improved; however, no changes were observed before or after thrombolysis in the microcirculation. Overall mortality and amputation rates were both 2% within one year. The one year patency rate was 55%. CONCLUSION: Treatment of patients with acute peripheral arterial occlusions with contrast enhanced sonothrombolysis is feasible and safe to perform in patients. Further research is necessary to investigate the superiority of this new treatment over standard treatment.

Ultrasonic Bone Scalpel (USBS) Does Not Reduce Blood Loss During Posterior Spinal Fusion (PSF) in Patients with Adolescent Idiopathic Scoliosis (AIS): Randomized Clinical Trial.

STUDY DESIGN: Randomized Clinical Trial. OBJECTIVE: The aim of this study was to compare the efficacy of USBS with standard-of-care surgical instruments during posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS) by evaluating the difference in estimated blood loss per level fused (EBL/level). SUMMARY OF BACKGROUND DATA: PSF surgery for AIS is often associated with high blood loss. Use of an ultrasonic bone scalpel (USBS) has been proposed to reduce blood loss during scoliosis surgery. METHODS: This was a single-blinded (patient-blinded), randomized, controlled superiority trial. We randomized 66 patients with AIS undergoing PSF to the control group (osteotome) or the experimental group (USBS). The primary outcome was intraoperative EBL/level obtained from red blood cell salvage reports. One-year follow-up was available for 57 of 62 (92%) of patients. RESULTS: EBL/level averaged 35 and 39 mL/level in the experimental and control groups, respectively [adjusted mean difference USBS - osteotome -8 mL/level, 95% CI: -16.4 to 0.3 mL/level, P = 0.0575]. There was no difference in curve correction [adjusted mean difference: -1.7%, 95% CI: -7.0 to 3.6%, P = 0.5321] or operative time [adjusted mean difference: -3.55 minutes, 95% CI: -22.45 to 15.46 min, P = 0.7089] between groups. Complications requiring change in routine postoperative care were noted in eight patients: two occurred in patients assigned to the experimental group and six occurred in patients assigned to the control group. CONCLUSION: There was no clinically significant difference in total blood loss, EBL/level, or complications between the two groups. In contrast to reports from other centers, at our high-volume spine center, USBS did not lead to reduced blood loss during PSF for AIS. These results may not be generalizable to centers with longer baseline operative times or higher baseline average blood loss during PSF for AIS.Level of Evidence: 1.

Photoacoustic monitoring of oxygenation changes induced by therapeutic ultrasound in murine hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is a highly vascular solid tumor. We have previously shown that ultrasound (US) therapy significantly reduces tumor vascularity. This study monitors US-induced changes in tumor oxygenation on murine HCC by photoacoustic imaging (PAI). Oxygen saturation and total hemoglobin were assessed by PAI before and after US treatments performed at different intensities of continuous wave (CW) bursts and pulsed wave (PW) bursts US. PAI revealed significant reduction both in HCC oxygen saturation and in total hemoglobin, proportional to the US intensity. Both CW bursts US (1.6 W/cm2) and the PW bursts US (0.8 W/cm2) significantly reduced HCC oxygen saturation and total hemoglobin which continued to diminish with time following the US treatment. The effects of US therapy were confirmed by power Doppler and histological examination of the hemorrhage in tumors. By each measure, the changes observed in US-treated HCC were more prevalent than those in sham-treated tumors and were statistically significant. In conclusion, the results show that US is an effective vascular-targeting therapy for HCC. The changes in oxygenation induced by the US treatment can be noninvasively monitored longitudinally by PAI without the use of exogenous image-enhancing agents. The combined use of PAI and the therapeutic US has potential for image-guided vascular therapy for HCC.

Application of low-intensity pulsed therapeutic ultrasound on mesenchymal precursors does not affect their cell properties.

Ultrasound is considered a safe and non-invasive tool in regenerative medicine and has been used in the clinic for more than twenty years for applications in bone healing after the approval of the Exogen device, also known as low-intensity pulsed ultrasound (LIPUS). Beyond its effects on bone health, LIPUS has also been investigated for wound healing of soft tissues, with positive results for various cell processes including cell proliferation, migration and angiogenesis. As LIPUS has the potential to treat chronic skin wounds, we sought to evaluate the effects produced by a conventional therapeutic ultrasound device at low intensities (also considered LIPUS) on the migration capacity of mouse and human skin mesenchymal precursors (s-MPs). Cells were stimulated for 3 days (20 minutes per day) using a traditional ultrasound device with the following parameters: 100 mW/cm2 with 20% duty cycle and frequency of 3 MHz. At the parameters used, ultrasound failed to affect s-MP proliferation, with no evident changes in morphology or cell groupings, and no changes at the cytoskeletal level. Further, the migration and invasion ability of s-MPs were unaffected by the ultrasound protocol, and no major changes were detected in the gene/protein expression of ROCK1, integrin ß1, laminin ß1, type I collagen and transforming growth factor ß1. Finally, RNA-seq analysis revealed that only 10 genes were differentially expressed after ultrasound stimulation. Among them, 5 encode for small nuclear RNAs and 2 encode for proteins belonging to the nuclear pore complex. Considering the results overall, while the viability of s-MPs was not affected by ultrasound stimulation and no changes were detected in proliferation/migration, RNA-seq analysis would suggest that s-MPs do respond to ultrasound. The use of 100 mW/cm2 intensity or conventional therapeutic ultrasound devices might not be optimal for the stimulation the properties of cell populations. Future studies should investigate the potential application of ultrasound using variations of the tested parameters.

The effectiveness of high intensity laser therapy in the patients with lumbar disc herniation: A protocol of randomized placebo-controlled trial.

BACKGROUND: There is no consensus in existing literature on the pulse power, application time, frequency and the dose of energy of laser therapy for the patients. Therefore, we conducted this research for the assessment of safety and efficiency of ultrasound and high-intensity laser therapy (HILT) in the lumbar disc herniation (LDH) patients. METHODS: Our present research was approved by the institutional review board in the West China-Guangan Hospital. All the participants would acquire the written informed consent. From December 2020 to December 2021, we will conduct a prospective evaluation via a senior surgeon for 1 hundred LDH patients who plan to undergo the conservative treatment at our hospital. In this research, the inclusion criteria contained: the patients with lumbar disc herniation diagnosed by lumbar MRI; the patients with no history of trauma or congenital abnormalities; and the patients with sufficient psychological ability to understand and then answer the questions raised in assessment scale. The participants were randomly divided into the control group or HILT group after performing the examination of baseline. The main outcome was the pain score of visual analog scale. The other results contained the adverse effects, back range of motion as well as functional scores. CONCLUSIONS: We assumed that the HILT is as effective as the ultrasound therapy in treating pain for LDH. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5975).

Nonsurgical Treatment of Postpartum Lower Abdominal Skin and Soft-Tissue Laxity Using Microfocused Ultrasound With Visualization.

BACKGROUND: Microfocused ultrasound with visualization (MFU-V) is a well-established treatment modality for skin tightening. There is a paucity of evidence for its use in body treatments, such as the lower abdomen. OBJECTIVE: To investigate the effectiveness and safety of MFU-V in treating lower abdominal skin and soft-tissue laxity in postpartum women. METHODS: The lower abdomen of 20 female patients between 6 and 24 months postpartum are treated with MFU-V using 1.5-, 3.0-, and 4.5-mm transducers. Data are prospectively collected and analyzed at 3 and 6 months using subject-reported and investigator-reported outcome measures. One additional patient underwent planned abdominoplasty 6 weeks after MFU-V treatment with tissue assessed intraoperatively and histologically. RESULTS: There was a mean improvement of 1.0 and 1.3 grades at 6 months using the investigator-reported and patient-reported skin laxity scale, respectively (p < .001). Patient-reported outcomes and satisfaction survey showed consistent improvement at 6 months. Histological examination of pretreated tissue showed increased total collagen, increased number and thickness of fibrous septae, and no change in fat cells within pretreated tissue compared with the control. No significant adverse events were recorded. CONCLUSION: MFU-V is an effective and safe treatment modality for lower abdominal skin laxity in postpartum patients.

From Anatomy to Functional and Molecular Biomarker Imaging and Therapy: Ultrasound Is Safe, Ultrafast, Portable, and Inexpensive.

Ultrasound is the most widely used medical imaging modality worldwide. It is abundant, extremely safe, portable, and inexpensive. In this review, we consider some of the current development trends for ultrasound imaging, which build upon its current strength and the popularity it experiences among medical imaging professional users.Ultrasound has rapidly expanded beyond traditional radiology departments and cardiology practices. Computing power and data processing capabilities of commonly available electronics put ultrasound systems in a lab coat pocket or on a user's mobile phone. Taking advantage of new contributions and discoveries in ultrasound physics, signal processing algorithms, and electronics, the performance of ultrasound systems and transducers have progressed in terms of them becoming smaller, with higher imaging performance, and having lower cost. Ultrasound operates in real time, now at ultrafast speeds; kilohertz frame rates are already achieved by many systems.Ultrasound has progressed beyond anatomical imaging and monitoring blood flow in large vessels. With clinical approval of ultrasound contrast agents (gas-filled microbubbles) that are administered in the bloodstream, tissue perfusion studies are now routine. Through the use of modern ultrasound pulse sequences, individual microbubbles, with subpicogram mass, can be detected and observed in real time, many centimeters deep in the body. Ultrasound imaging has broken the wavelength barrier; by tracking positions of microbubbles within the vasculature, superresolution imaging has been made possible. Ultrasound can now trace the smallest vessels and capillaries, and obtain blood velocity data in those vessels.Molecular ultrasound imaging has now moved closer to clinic; the use of microbubbles with a specific affinity to endothelial biomarkers allows selective accumulation and retention of ultrasound contrast in the areas of ischemic injury, inflammation, or neoangiogenesis. This will aid in noninvasive molecular imaging and may provide additional help with real-time guidance of biopsy, surgery, and ablation procedures.The ultrasound field can be tightly focused inside the body, many centimeters deep, with millimeter precision, and ablate lesions by energy deposition, with thermal or mechanical bioeffects. Some of such treatments are already in clinical use, with more indications progressing through the clinical trial stage. In conjunction with intravascular microbubbles, focused ultrasound can be used for tissue-specific drug delivery; localized triggered release of sequestered drugs from particles in the bloodstream may take time to get to clinic. A combination of intravascular microbubbles with circulating drug and low-power ultrasound allows transient opening of vascular endothelial barriers, including blood-brain barrier; this approach has reached clinical trial stage. Therefore, the drugs that normally would not be getting to the target tissue in the brain will now have an opportunity to produce therapeutic efficacy.Overall, medical ultrasound is developing at a brisk rate, even in an environment where other imaging modalities are also advancing rapidly and may be considered more lucrative. With all the current advances that we discuss, and many more to come, ultrasound may help solve many problems that modern medicine is facing.

Efficacy of the Decalcification of Heavily Calcified Femoral Bifurcation Lesions Using a Cavitron Ultrasonic Surgical Aspirator.

BACKGROUND: In the current diabetes era, severe calcified femoral bifurcation lesions extending to the external elastic lamina are sometimes experienced and are technically challenging during conventional endarterectomy. We previously reported an alternative method, a decalcification technique with a Cavitron Ultrasonic Surgical Aspirator (CUSA), for calcified lesions. This study aimed to clarify the efficacy of CUSA decalcification technique. METHODS: A total of 26 limbs treated with CUSA decalcification from 2014 to 2017 were enrolled and evaluated hemodynamically with ankle-brachial index (ABI) and morphologically with computed tomography angiography (CTA). ABI was measured every 6 months, and CTA was performed early after surgery and then annually thereafter. Curved planar reformation images and cross-sectional multiplanar reconstruction images obtained by CTA were used to measure the cross-sectional area of the common femoral artery (CFA). Then, the time courses of the ABI and CFA areas were analyzed. RESULTS: The operative indication was claudication in 80.8%, rest pain in 7.7%, and tissue loss in 11.5% of the cases. A concomitant profundaplasty was performed in 34.6% of the cases. One case of an intraoperative arterial wall perforation was experienced as a procedure-related complication. Hemodynamic success rate was 96.2% (preoperative ABI: 0.37 ± 0.28, postoperative ABI: 0.75 ± 0.15, P < 0.0001) and technical success rate was 100.0% (preoperative CFA area: 4.1 ± 5.9 mm2, postoperative CFA area: 46.1 ± 17.0 mm2, P < 0.0001), with clinical improvement achieved in 95.8% of cases. Primary and secondary patency rates of the CFA were 100.0% at 2 years postoperatively, and the reintervention-free rate for the ipsilateral limb was 88.5% at 2 years postoperatively. Over a median follow-up period of 28.0 months (range, 12.3-67.0 months), the restenosis rate of CFA was 7.6%, when restenosis was defined as a >50% decrease in cross-sectional area. CONCLUSIONS: CUSA decalcification is a safe and effective alternative method to treat heavily calcified femoral lesions with a good patency rate and a low restenosis rate.

Predictors of Treatment Response Following Ultrasound-Facilitated Catheter-Directed Thrombolysis for Submassive and Massive Pulmonary Embolism: A SEATTLE II Substudy.

BACKGROUND: Little is known about which factors predict improvement in clinical and imaging parameters among patients undergoing catheter-directed thrombolysis for submassive or massive pulmonary embolism. The identification of such predictors may allow for more appropriate patient selection for ultrasound-facilitated catheter-directed thrombolysis. METHODS: We conducted a retrospective cohort analysis of patients from the SEATTLE II trial (Prospective, Single-Arm, Multi-Center Trial of EkoSonic Endovascular System and Activase for Treatment of Acute Pulmonary Embolism) to identify clinical characteristics that independently predict pulmonary artery pressures, right ventricular-to-left ventricular (RV/LV) diameter ratio, and modified Miller angiographic index following ultrasound-assisted catheter-directed thrombolysis. Eligible patients had submassive or massive pulmonary embolism and an RV/LV diameter ratio ≥0.9 on chest computed tomography. Multivariable linear regression was used to identify independent clinical predictors of each outcome. RESULTS: One hundred fifty patients with massive (n=31) or submassive (n=119) pulmonary embolism were enrolled. Mean (±SD) baseline and postprocedure RV/LV diameter ratio, pulmonary artery systolic pressure, and modified Miller Score were 1.59 (±0.39) and 1.14 (±0.2), 51.45 (±16.0), and 37.47 (±11.9), and 23.0 (±5.7) and 15.7 (±5.9), respectively. The multivariable model adjusted R2 for absolute change in RV/LV ratio, pulmonary artery systolic pressure, modified Miller Score was 0.71, 0.57, and 0.43, respectively. After adjusting for age, gender, and baseline RV/LV ratio, pulmonary artery systolic pressure, and modified Miller Score, patients with higher body mass index, renal or hepatic dysfunction, active smoking, or a higher baseline heart rate showed less improvement. CONCLUSIONS: Patients with more life-threatening pulmonary embolism may derive the greatest benefit from ultrasound-assisted, catheter-directed thrombolysis.

Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia.

BACKGROUND: Ultrasound-enhanced catheter-directed thrombolysis (UET) using the Ekosonic® Endovascular System device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting. METHODS: We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALEs; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications. RESULTS: A total of 32 patients (mean age 67.4 ± 14.9 years; 25% women) underwent UET for acute limb ischemia between 2014 and 2018. The Rutherford Acute Limb Ischemia Classification was Rutherford (R) 1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 ± 11.3 hr, and mean tissue plasminogen activator dose was 24.5 ± 15.3 mg. MALEs occurred in 16.7% of patients within the first 30 days and 38.9% experienced a MALE by 1 year. Limb salvage at 30 days and 1 year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30 days and 37.5% of patients within 1 year. Overall mortality was 6.2% at 30 days and 13.5% at 1 year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in preoperative to postoperative ankle-brachial index (0.31 ± 0.29 vs. 0.78 ± 0.34, P < 0.001) and number of patent tibial runoff vessels (1.31 ± 1.20 vs. 1.96 ± 0.86, P < 0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%). CONCLUSIONS: UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in-line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared with that of traditional methods.

Ultrasound-Accelerated, Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism: Single-Center Retrospective Review with Intermediate-Term Outcomes.

PURPOSE: To evaluate ultrasound-accelerated, catheter-directed thrombolysis (CDT) for treatment of acute submassive pulmonary embolism (PE). MATERIALS AND METHODS: This single-center, retrospective study included patients who underwent CDT for acute submassive PE (N = 113, 52% men/48% women) from 2013 to 2017. Baseline characteristics included history of deep venous thrombosis (12%), history of PE (6%), and history of cancer (18%). Of cohort patients, 88% (n=99) had a simplified PE severity index score of ≥ 1 indicating a high risk of mortality. RESULTS: A technical success rate of 100% was achieved with 84% of patients having bilateral catheter placements. Average tissue plasminogen activator (tPA) therapy duration was 20.7 hours ± 1.5, and median tPA dose was 21.5 mg. Three patients (2.6%) experienced minor hemorrhagic complications. Mean hospital length of stay was 6 days. Mean pulmonary arterial pressure decreased from 55 mm Hg on presentation to 37 mm Hg (P < .01) 1 day following initiation of thrombolytic therapy. All-cause mortality rate of 4% (n = 4) was noted on discharge, which increased to 6% (n = 7) at 6 months. At 6-month follow-up compared with initial presentation, symptom improvements (93%), physiologic improvements (heart rate 72 beats/min vs 106 beats/min, P < .01), oxygen requirement improvements (fraction of inspired oxygen 20% vs 28%, P < .01), and right ventricular systolic pressure improvements by echocardiography (30 mm Hg vs 47 mm Hg, P < .01) were observed. CONCLUSIONS: CDT for acute submassive PE was associated with low complications and mortality, decreased right ventricular systolic pressure, high rates of clinical improvement, and improved intermediate-term clinical outcomes.

A study of efficacy and safety of high-intensity focused ultrasound for the treatment of melasma in Asians: A single-blinded, randomized, split-face, pilot study.

BACKGROUND: A recent report suggested potential of high-intensity focused ultrasound in improving UVB-induced hyperpigmentation in patients with Fitzpatrick skin type IV, but reports regarding its efficacy in other hyperpigmented conditions including melasma are lacking. OBJECTIVES: To investigate efficacy and safety of high-intensity focused ultrasound for the treatment of melasma in Asians. METHODS: Each side of the face of 25 melasma patients was randomized to receive 3-monthly sessions of high-intensity focused ultrasound treatment or serve as control. Lightness index, Melasma Area and Severity Index of malar area (MASIm ) by blinded dermatologists, self-evaluated improvement and satisfaction scales by patients, and side effects were assessed every 4 weeks for 20 weeks. RESULTS: Twenty-one patients with Fitzpatrick skin type III and IV completed the study. There was a greater reduction of relative lightness index and MASIm after treatment in high-intensity focused ultrasound-treated side. However, there were no statistically significant differences between both sides. More than 50% improvement on treatment side was rated in 11 patients (52.4%). Side effects were minimal. None had worsening of melasma. CONCLUSIONS: High-intensity focused ultrasound may be an adjuvant for treatment of melasma. Further studies with larger sample size and proper parameter settings are recommended to determine its efficacy.

Outcome Measures for Acute Submassive Pulmonary Embolisms at a Community-Based Hospital Using Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis.

PURPOSE: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. MATERIALS AND METHODS: This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. RESULTS: Our study showed greater differences (P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. CONCLUSIONS: Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.

Influence of Radial Pressure Wave Therapy (RPWT) on collagenase-induced Achilles tendinopathy treated with Platelet Rich Plasma and Autologous Adipose Derived Stem Cells.

Tendinopathy treatment poses a current challenge for sport medicine due to unique physiology and biomechanics of tendons. The goal of this work was to compare the efficacy of the addition of the radial pressure wave therapy (RPWT) treatment to injection of autologous Adipose Derived Stem Cells (ADSCs) or Platelet Rich Plasma (PRP) in the therapeutic procedure for collagenase induced Achilles tendinopathy in sheep. 14 sheep (aged 5 and 6 years, Polish Mountain Sheep breed, weight 60-70 kg) were injected bacterial collagenase type 1A-S (Clostridium histolyticum, C-5894, Sigma Aldrich, Poznan, Poland) bilaterally to Achilles tendons. Subsequently, the animals were injected with PRP (7 sheep) or ADSCs (7 sheep) to previously induced tendinopathy foci. Left limbs of all the animals were additionally treated with RPWT focused above the tendinopathy origins. Treatment progress was controlled by ultrasound scans, and tendon samples were taken on the 126th day of the experiment. Tendon samples taken from the sheep treated with RPWT+ADSCs showed lower cellularity and the highest number of thick collage fibers. Samples taken from the sheep treated with RPWT+PRP showed an elevated rate of neovascularization. Addition of the RPWT to ADSCs injections in the treatment of induced Achilles tendinopathy in sheep resulted in good quality of the tissue regeneration. Dual therapy with RPWT+PRP injection can lead to neovascularization in the tendon tissue.