Ultrasound 2020 - Diagnostics & Therapy: On the Way to Multimodal Ultrasound: Contrast-Enhanced Ultrasound (CEUS), Microvascular Doppler Techniques, Fusion Imaging, Sonoelastography, Interventional Sonography. / Ultraschall 2020 ­ Diagnostik & Therapie: Auf dem Weg zur multimodalen Sonografie: kontrastverstärkter Ultraschall (CEUS), mikrovaskuläre Dopplerverfahren, Fusionsbildgebung, Sono-Elastografie, interventionelle Sonografie.

BACKGROUND: Ultrasound as a non-ionizing imaging procedure is one of the most important diagnostic procedures in everyday clinical practice. The technology is widely used. Due to constant technical innovations, sonographic procedures, such as contrast-enhanced ultrasound (CEUS), sonoelastography, new microvascular Doppler modalities and, as an example of interventional procedures, sonographically controlled microwave ablation (MWA), are becoming increasingly important in diagnostic imaging and interventional medicine alongside CT and MRI. However, this also requires greater expertise, specialization and qualification on the part of users. METHOD: This review article provides information about the range of technical innovations in ultrasound in recent years and describes the underlying technology, the clinical applications, and their diagnostic value. These are presented in the context of the current literature, explaining their advantages and disadvantages and their clinical value. RESULTS AND CONCLUSION: Contrast-enhanced ultrasound (CEUS), microvascular Doppler modalities, fusion imaging and elastography complement B-scan ultrasound and conventional Doppler procedures for various problems. Microwave ablation (MWA) has a firm place as an ablative procedure for local tumor therapy in different organ systems and can be performed under ultrasound guidance. Thanks to new developments, the possibilities of ultrasound are now greater than ever. Knowledge of the technology, indications, and possible applications of newer procedures is essential for adequate patient care. KEY POINTS: · Contrast-enhanced ultrasound (CEUS) allows an increase in sensitivity and specificity in the assessment of parenchymal lesions.. · CEUS allows the microperfusion to be visualized and quantified. For larger vessels, CEUS is an important instrument in diagnosing endoleak after stenting.. · Microvascular Doppler techniques with clutter suppression algorithms allow a more accurate representation of the smallest vessels than regular color or power Doppler.. · Elastography of the liver in diffuse hepatopathies is a noninvasive diagnostic tool to exclude higher grade fibrosis/cirrhosis.. · Microwave ablation (MWA) also offers sonographically controlled ablation of tumors.. CITATION FORMAT: · Kloth C, Kratzer W, Schmidberger J et al. Ultrasound 2020 - Diagnostics & Therapy: On the Way to Multimodal Ultrasound: Contrast-Enhanced Ultrasound (CEUS), Microvascular Doppler Techniques, Fusion Imaging, Sonoelastography, Interventional Sonography . Fortschr Röntgenstr 2021; 193: 23 - 32.

Trends in Diagnostic Point-of-Care Ultrasonography Reimbursement for Medicare Beneficiaries Among the US Emergency Medicine Workforce, 2012 to 2016.

STUDY OBJECTIVE: Point-of-care ultrasonography allows rapid diagnosis in the emergency department. A previous study found that a low prevalence of emergency medicine clinicians received point-of-care ultrasonography reimbursement in 2012 (0.7%). We determine nationwide point-of-care ultrasonography reimbursement patterns for 4 subsequent years. METHODS: We performed a cross-sectional study using 2012 to 2016 data from the Centers for Medicare & Medicaid Fee-for-Service Provider Utilization and Payment Data Part B, defining point-of-care ultrasonographic examinations using Current Procedural Terminology codes. The emergency medicine workforce was defined by emergency medicine, family medicine, internal medicine, critical care, and advanced practice providers who received emergency medicine-specific reimbursements. We compared patterns of point-of-care ultrasonography reimbursement among emergency physicians in 2012 versus 2016 through a 2-sample test of proportions. RESULTS: In 2012, 342 (0.7% of total) emergency medicine workforce clinicians were reimbursed for diagnostic point-of-care ultrasonography versus 801 (1.3%) in 2016. Emergency physicians represented an increasing proportion of the total workforce, increasing from 86.0% (95% confidence interval 82.3% to 89.6%) in 2012 (N=294) to 94.6% (95% confidence interval 93.1% to 96.2%) in 2016 (N=758). From 2012 to 2016, total point-of-care ultrasonography reimbursements increased from 13,697 to 31,717, with significant growth from echocardiograms (4,127 to 14,978), abdominal examinations (3,682 to 7,140), and thoracic examinations (801 to 5,278). CONCLUSION: The proportion of emergency medicine workforce clinicians receiving diagnostic point-of-care ultrasonography reimbursements, as well as the number of point-of-care ultrasonographic studies, more than doubled from 2012 to 2016. Efforts are needed to understand barriers to adoption of point-of-care ultrasonography because only a small proportion of the emergency medicine clinician workforce was reimbursed in any year.

Trends in Retina Specialist Imaging Utilization from 2012 to 2016 in the United States Medicare Fee-for-Service Population.

PURPOSE: To characterize temporal trends and regional variance in retinal imaging utilization in the United States Medicare fee-for-service population from 2012-2016. DESIGN: Cross-sectional, retrospective database analysis. METHODS: This study addresses office or operating-room based retinal imaging. Our study population included retina specialists, defined as ophthalmologists performing either intravitreal anti-vascular endothelial growth factor injections or posterior segment laser photocoagulation and no neodymium-doped yttrium aluminum garnet laser capsulotomy. We recorded fundus photography, optical coherence tomography (OCT), intravenous fluorescein angiography (IVFA), indocyanine-green angiography, and ophthalmic ultrasound (B-scan) billed in the Medicare fee-for-service population from 2012-2016. Imaging obtained on any platform or device was eligible for inclusion (eg, posterior pole imaging vs ultrawidefield imaging). The main outcome measure was the relative utilization of retinal imaging modalities. RESULTS: National relative utilization of OCT increased from 61.5% in 2012 to 70.5% in 2016 (P < .001), while IVFA fell from 20.9% to 15.1% over the same interval (P < .001). Fundus photography decreased from 14.6% in 2012 to 11.7% in 2016 (P < .001). By 2016, the Midwest region had the highest relative utilization of OCT (75.2%) and lowest of IVFA (12.0%), while the West region had the lowest OCT (68.4%) and highest IVFA (17.0%). CONCLUSIONS: Among retina specialists, OCT usage increased while the utilization of fundus photography and IVFA has declined. The Midwest region had the highest utilization of OCT and lowest of IVFA.

Ultrasound assessment of gastric emptying time after a standardised light breakfast in healthy children: A prospective observational study.

OBJECTIVES: Current guidelines recommend 6 h of fasting for solids before anaesthesia. However, prolonged fasting may lead to discomfort, hunger, thirst, misbehaviour and lipolysis. To prevent this, a more liberal fasting regimen has been empirically implemented in our children's hospital, allowing a shorter fasting time of 4 h for a standardised light breakfast. AIM: The aim of this study was to determine the gastric emptying time after a standardised light breakfast in healthy children. DESIGN: A prospective observational noninterventional study. METHODS: After fasting overnight, the children had a standardised light breakfast. Before and afterwards, ultrasound examinations of the gastric antrum were performed hourly to determine the gastric antral area (GAA), which is a surrogate parameter for gastric volume in children in the right lateral position (RLP). Demographic data and fasting times are presented as mean ±â€ŠSD (range) and GAA as median (interquartile range). RESULTS: Twenty-two children aged 7.8 (2.5 to 13.6) years volunteered for this study. After fasting overnight [735 ±â€Š120 (467 to 930) min], the initial GAA was 3.06 (2.35 to 4.03) cm in RLP. After the light breakfast, GAA in RLP initially increased and decreased subsequently. After 4 h, GAA in RLP was lower than the initial value (median of differences -0.54, 95% confidence interval -1.00 to -0.07, P < 0.05). Correlation between GAA in RLP and fasting time was significant (r = -0.62, P < 0.0001). Using a linear regression model, the calculated mean gastric emptying time after the standardised light breakfast was 211 min for GAA = 3.06 cm. CONCLUSION: The study showed a mean gastric emptying time of less than 4 h after a standardised light breakfast in children. These results encourage our current clinical practice and support the efforts towards a more liberal fasting regimen for light meals in paediatric anaesthesia. TRIAL REGISTRATION: German Registry of Clinical Studies (DRKS-ID: DRKS 00013893).

Plastic Surgeon-Led Ultrasound.

BACKGROUND: Portable high-frequency ultrasound is a useful adjunct to a plastic surgeon's practice. With a short learning curve, this patient-friendly imaging modality has a variety of uses that aid patient management/treatment plans. The authors describe clinical cases and review the literature regarding ultrasound performed by the surgeon. METHODS: The Sonosite S-Nerve machine with the L25X transducer was used (depth, 4.3 cm). Clinical cases that ordinarily would have been referred to the radiology department were taken from the day-to-day practice of the senior author (M.G.). The clinical scenarios ranged from acute presentations to planned elective settings. RESULTS: Ultrasound was a useful adjunct in a variety of applications, ranging from acute hand trauma visualizing neurovascular bundles and tendons, to elements of reconstructive breast surgery such as fat grafting over an implant and scar release. The ultrasound machine was also used for determination of the depth and size of collections such as seromas to facilitate drainage, for identification of lymph nodes before transfer, and for acute presentations of conditions ranging from undiagnosed swelling to foreign body localization. CONCLUSIONS: The portable ultrasound machine has become an invaluable tool in the senior author's practice. In a short time and with a short learning curve, the authors' unit identified numerous applications for its use. From a patient perspective, it is noninvasive/nonpainful and has no deleterious radiation effects, and treatment plans can be enacted without delay. It is highly recommended that surgeons become familiar with this imaging modality and assimilate it into their daily practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France.

OBJECTIVE: Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011. METHODS: We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone. RESULTS: Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS. CONCLUSION: Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Back to the future: forget ultrasound and focus on clinical assessment in rheumatoid arthritis management.

Ultrasound (US) unquestionably improves many aspects of rheumatoid arthritis (RA) diagnosis and management, but no consensus has been reached regarding the optimal US methodology that should be used, and high levels of standardisation have not yet been attained. Current evidence from two randomised controlled trials does not support the US in directing treatment decisions. A return to the endorsement of clinical assessment and the adoption of T2T strategies aiming at ACR/EULAR remission still represent the standard of care for RA and should be pursued through appropriate educational programmes. Thus, for now, the major application of sonography in arthritis should have a focus on diagnostic and especially differential diagnostic aspects.

Comparative Trends in Utilization of MRI and Ultrasound to Evaluate Nonspine Joint Disease 2003 to 2015.

PURPOSE: MRI and ultrasound (US) are effective diagnostic tools to evaluate extremities. In this study, we analyze utilization trends in musculoskeletal (MSK) US and MRI from 2003 to 2015 within the Medicare population. METHODS: Our data sources were the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2003 to 2015. They cover all Medicare fee-for-service enrollees (37.5 million in 2015). Current Procedural Terminology codes for nonvascular, nonspine joint MRI and extremity US were selected and volumes within these codes were determined. Medicare's physician specialty codes were used to identify provider specialty. We accounted for the 2011 code change that created both complete and limited US examinations. RESULTS: Total Medicare joint MRI volume increased from 738,509 in 2003 to 1,131,503 in 2015 (+53%), although there was little change after 2007. Radiologist MRI share in 2015 was 93%, followed by orthopedic surgeons at 5%. Total MSK US volume grew from 96,235 in 2003 to 429,695 in 2015 (+347%). Radiologists' market share of US decreased from 65% in 2003 to 37% in 2015, with nonradiologists now representing a majority of ultrasound examinations. Multiple nonradiology subspecialties also exceed radiology in volume of complete ultrasounds. CONCLUSION: The potential negative impact of MSK US on MSK MRI volume is likely overestimated because MRI volume has remained stable. MSK ultrasound is increasingly utilized outside radiology. If radiologists want to maintain their market share as MSK imaging leaders, more emphasis should be placed on increasing their involvement and expertise in MSK US.

Imaging Utilization for the Diagnosis of Appendicitis in Stand-Alone Children's Hospitals in the United States: Trends and Costs.

OBJECTIVE: To describe the imaging utilization patterns for the diagnosis of appendicitis among children's hospitals in the United States over the last 10 years (2005-2014). METHODS: All patients with a primary discharge diagnosis of appendicitis included in a large administrative database of 45 pediatric institutions in the United States between 2005 and 2014 were selected. Demographics, imaging utilization, and costs were described. RESULTS: In all, 96,786 children with appendicitis (59% boys, 41% girls; mean age: 9.9 years) were studied. The average length of stay decreased from 5.0 days in 2005 to 3.4 days in 2014 (P < .01). The percentage of patients undergoing CT increased between 2005 and 2007 from 59.1% to 62.6%, respectively, followed by a decrease from 62.6% to 32.7% in 2014 (r2 = 0.93). Radiograph utilization decreased from 14.2% in 2005 to 3.6% in 2014 (r2 = 0.93), and ultrasound and MRI increased from 25% and 0.03% in 2005 to 61% and 1.0% in 2014 (r2 = 0.97 and 0.64), respectively. The mean total hospital costs increased from $11,700 in 2005 to $16,500 in 2014; imaging costs increased only slightly from $3,205 to $3,259. The imaging fraction of hospital costs decreased from 27.5% to 19.8%. CONCLUSION: There has been a significant decrease in utilization of CT and radiographs for the management of appendicitis in children, and ultrasound has continued to increase. Imaging costs have remained stable in comparison to rising hospital costs, generating a drop in the fraction of costs related to imaging.

Reflections on ultrasound image analysis.

Ultrasound (US) image analysis has advanced considerably in twenty years. Progress in ultrasound image analysis has always been fundamental to the advancement of image-guided interventions research due to the real-time acquisition capability of ultrasound and this has remained true over the two decades. But in quantitative ultrasound image analysis - which takes US images and turns them into more meaningful clinical information - thinking has perhaps more fundamentally changed. From roots as a poor cousin to Computed Tomography (CT) and Magnetic Resonance (MR) image analysis, both of which have richer anatomical definition and thus were better suited to the earlier eras of medical image analysis which were dominated by model-based methods, ultrasound image analysis has now entered an exciting new era, assisted by advances in machine learning and the growing clinical and commercial interest in employing low-cost portable ultrasound devices outside traditional hospital-based clinical settings. This short article provides a perspective on this change, and highlights some challenges ahead and potential opportunities in ultrasound image analysis which may both have high impact on healthcare delivery worldwide in the future but may also, perhaps, take the subject further away from CT and MR image analysis research with time.

Changing Abdominal Imaging Utilization Patterns: Perspectives From Medicare Beneficiaries Over Two Decades.

PURPOSE: To assess changing utilization patterns of abdominal imaging in the Medicare fee-for-service population over the past two decades. METHODS: Medicare Physician Supplier Procedure Summary master files from 1994 through 2012 were used to study changes in the frequency and utilization rates (per 1,000 Medicare beneficiaries per year) of abdominal CT, MRI, ultrasound, and radiography. RESULTS: In Medicare beneficiaries, the most frequently performed abdominal imaging modality changed from radiography in 1994 (207.4 per 1,000 beneficiaries) to CT in 2012 (169.0 per 1,000). Utilization rates of abdominal MR (1037.5%), CT (197.0%), and ultrasound (38.0%) all increased from 1994-2012 (but declined briefly from 2007 to 2009). A dramatic 20-year utilization rate decline occurred for gastrointestinal fluoroscopic examinations (-91.9% barium enema, -80.0% upper gastrointestinal series) and urologic radiographic examinations (-95.3%). Radiologists were the dominant providers of all modalities, accounting for >90% of CT and MR studies, and >75% of most ultrasound examination types. CONCLUSIONS: Medicare utilization of abdominal imaging has markedly changed over the past two decades, with overall dramatic increases in CT and MRI and dramatic decreases in gastrointestinal fluoroscopic and urologic radiographic imaging. Despite these changes, radiologists remain the dominant providers in all abdominal imaging modalities.

Medicare Utilization of Vascular Ultrasound From 1998 to 2013: Continued Growth in Both Radiologist and Nonradiologist Imaging.

PURPOSE: The aim of this study was to assess national trends in the utilization of vascular ultrasound (VUS) and changing relative specialty roles in examination interpretation. METHODS: Service-specific claims data for VUS studies were identified using Medicare Physician Supplier Procedure Summary Master Files for the period from 1998 to 2013. Longitudinal national utilization rates were calculated using annual Medicare enrollment data for 1998 to 2012. Procedure volumes by specialty group and site of service were analyzed. RESULTS: Total annual claims for VUS studies for Medicare fee-for-service beneficiaries increased from 4,422,360 to 8,599,677 (+94.5%) between 1998 and 2013. Per 1,000 beneficiaries, overall utilization rose from 145.93 in 1998 to 264.26 in 2012 (+81.1%). However, this peaked in 2009 at 270.43 and has been slowly declining each year since. Overall market share decreased from 43% to 41% for radiology and increased from 10% to 16% and from 9% to 17% for vascular surgery and cardiology, respectively. Compound adjusted growth rate increases were 4.2% for radiology, 7.8% for vascular surgery, and 8.7% for cardiology. CONCLUSIONS: Utilization of VUS in the Medicare population increased from 1998 through 2009 but has been declining ever since. Although radiology has maintained the dominant market share over time, relative growth by cardiology and vascular surgery has outpaced that by radiology.

From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment.

Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.

Musculoskeletal ultrasound in rheumatology in Korea: targeted ultrasound initiative survey.

AIM: In collaboration with the Targeted Ultrasound Initiative (TUI), to conduct the first study in Korea to investigate current practices in ultrasound use among Korean rheumatologists. METHODS: We translated the TUI Global Survey into Korean and added questions to better understand the specific challenges facing rheumatologists in Korea. To target as many rheumatologists in Korea as possible, we created an on-line version of this survey, which was conducted from March to April 2013. RESULTS: Rheumatologists are in charge of ultrasound in many Korean hospitals. Rheumatologists in hospitals and private clinics use ultrasound to examine between one and five patients daily; they use ultrasound for diagnosis more than monitoring and receive compensation of about US$30-50 per patient. There are marked differences in the rates of ultrasound usage between rheumatologists who work in private practice compared with tertiary hospitals. Korean rheumatologists not currently using ultrasound in their practice appear eager to do so. CONCLUSION: This survey provides important insights into the current status of ultrasound in rheumatology in Korea and highlights several priorities; specifically, greater provision of formal training, standardization of reporting and accrual of greater experience among ultrasound users. If these needs are addressed, all rheumatology departments in Korea are likely to use ultrasound or have access to it in the future.

Failure of gastroenterologists to apply intestinal ultrasound in inflammatory bowel disease in the Asia-Pacific: a need for action.

Intestinal ultrasound (IUS) is a cheap, noninvasive, risk-free procedure that is significantly underutilized in the diagnosis and management of patients with inflammatory bowel disease (IBD) in the Asia-Pacific region. More cost-effective methods of monitoring disease activity are required in light of the increasing global burden of IBD (especially in Asia), the advent of personalized medicine, and the rising cost of healthcare. IUS is a prime example of a technique that meets these needs. Its common clinical applications include assessing the activity and complications of IBD. In continental Europe, countries such as Germany and Italy use this imaging tool as the standard of care and have integrated it into management protocols. There are formal training programs in these countries to train gastroenterologists in IUS, and it is used in an outpatient setting during patient consultations. Barriers to its use in the Asia-Pacific region include lack of experience and research data, and there are few established centers with active training programs. These concerns can be addressed by investing more in IUS service provision and by increasing allocation of resources toward local research and training. Increased uptake of IUS will ultimately benefit patients with IBD.