Surgeon eye lens dose monitoring in interventional neuroradiology, cardiovascular and radiology procedures.

PURPOSE: This study investigated the radiation dose to surgeon eye lens for single procedure and normalised to exposure parameters for eight selected neuroradiology, cardiovascular and radiology interventional procedures. METHODS: The procedures investigated were diagnostic study, Arteriovenous Malformations treatment (AVM) and aneurysm embolization for neuroradiology procedures, Coronary Angiography and Percutaneous Transluminal Coronary Angioplasty (CA-PTCA), Pacemaker and Implantable Cardioverter-Defibrillator implantation (PM-ICD), Endovascular Aortic Repair (EVAR) and Fenestrated Endovascular Aortic Repair (FEVAR) for cardiovascular and electrophysiology procedures. CT-guided lung biopsy was also monitored. All procedures were performed with table-mounted and ceiling-suspended shields (0.5 mm lead equivalent thickness), except for FEVAR and PM-ICD where only a table mounted shield was present, and CT-guided lung biopsy where no shield was used. Dose assessment was performed using a dosemeter positioned close to the most exposed eye of the surgeon, outside the protective eyewear. RESULTS: The surgeon most exposed eye lens median Hp(3) equivalent dose for a single procedure, without protective eyewear contribution, was 18 µSv for neuroradiology diagnostic study, 62 µSv for AVM, 38 µSv for aneurysm embolization, 33 µSv for CA-PTCA, 39 µSv for PM-ICD, 49 µSv for EVAR, 2500 µSv for FEVAR, 153 µSv for CT-guided lung biopsy. CONCLUSIONS: In interventional procedures, the 20 mSv/year dose limit for surgeon eye lens exposure might be exceeded if shields or protective eyewear are not used. Surgeon eye lens doses, normalised to single procedures and to exposure parameters, are a valuable tool for determining appropriate radiation protection measures and dedicated eye lens dosemeter assignment.

Improving patient waiting time of centralized front office service in a regional hub hospital using the discrete event simulation model.

BACKGROUND: Today, hospital rankings are based not only on basic clinical indicators, but even on quality service indicators such as patient waiting times. Improving these indicators is a very important issue for hospital management, so finding a solution to achieve it in a simple and effective way is one of the greatest goals. OBJECTIVES: The aim of this article is to evaluate the use of a discrete event simulation model to improve healthcare processes and reduce waiting time of patients and hospital costs. METHODS: The case study proposed in this paper is the reorganization of non-clinical front office operation for the patients (i.e. booking of exams, delivering medical reports, etc.) of the Careggi University Hospital of Florence, to optimize the utilization of the human resources and to improve performances of the process. RESULTS: The development and validation of the model was made according to an analysis of real processes and data, pre and post implementation of model outcomes. The new organization shows a decrease of waiting times from an average value of 10 minutes and 37 seconds to 5 minutes and 57 seconds (-44%). CONCLUSIONS: This paper shows that discrete event simulation could be a precise, cost-limited tool to optimize hospital processes and performance.

Effect of vessel curvature on Doppler derived velocity profiles and fluid flow.

Side-branches and curvatures in the arterial tree yield deviations from the axial oriented velocity. Velocity or volume flow estimates based on the assumption that flow is axially oriented are of limited value at these sites. This article evaluates information obtainable by using a multigate Doppler ultrasound (US) instrument used with curved phantoms, which resemble the human coronary arteries. The comparison of experimental velocity data with data provided by an accurate computational fluid dynamics (CFD) method shows differences in the range of 4 to 11% for four curvatures with different radii. Multigate data are also used to estimate the volume flow in the curved segments at different experimental conditions. An error lower than 15% is obtained, to be compared with a 24% error obtained by assuming a parabolic velocity profile. In particular, it is shown that the residual error is not related to the small deviation of the velocity vectors from the axial direction due to the presence of secondary velocity components, which are found to be of magnitude less than 10% with respect to the axial velocity component.

A real-time chirp-coded imaging system with tissue attenuation compensation.

In ultrasound imaging, pulse compression methods based on the transmission (TX) of long coded pulses and matched receive filtering can be used to improve the penetration depth while preserving the axial resolution (coded-imaging). The performance of most of these methods is affected by the frequency dependent attenuation of tissue, which causes mismatch of the receiver filter. This, together with the involved additional computational load, has probably so far limited the implementation of pulse compression methods in real-time imaging systems. In this paper, a real-time low-computational-cost coded-imaging system operating on the beamformed and demodulated data received by a linear array probe is presented. The system has been implemented by extending the firmware and the software of the ULA-OP research platform. In particular, pulse compression is performed by exploiting the computational resources of a single digital signal processor. Each image line is produced in less than 20 µs, so that, e.g., 192-line frames can be generated at up to 200 fps. Although the system may work with a large class of codes, this paper has been focused on the test of linear frequency modulated chirps. The new system has been used to experimentally investigate the effects of tissue attenuation so that the design of the receive compression filter can be accordingly guided. Tests made with different chirp signals confirm that, although the attainable compression gain in attenuating media is lower than the theoretical value expected for a given TX Time-Bandwidth product (BT), good SNR gains can be obtained. For example, by using a chirp signal having BT=19, a 13 dB compression gain has been measured. By adapting the frequency band of the receiver to the band of the received echo, the signal-to-noise ratio and the penetration depth have been further increased, as shown by real-time tests conducted on phantoms and in vivo. In particular, a 2.7 dB SNR increase has been measured through a novel attenuation compensation scheme, which only requires to shift the demodulation frequency by 1 MHz. The proposed method characterizes for its simplicity and easy implementation.

Transverse Doppler spectral analysis for a correct interpretation of flow sonograms.

The classic Doppler equation predicts that scatterers moving transversely to the ultrasound beam yield a zero frequency shift in the received echoes. An original theoretical approach, which has been developed in the last few years, has demonstrated that any focused beam leads to the generation of a Doppler spectrum with a nonzero bandwidth even for a transverse flow orientation. Based on this new theory, it is shown here that "transverse" Doppler spectral analysis can also be usefully applied in vivo. Experimental results obtained by observing normal and diseased carotid arteries at 90 degrees show that the information obtained with this approach is complementary to that provided by the mean frequency alone, which is given by the classic Doppler equation.

Application of autoregressive methods to multigate spectral analysis.

Multigate analysis is known to be capable of detecting accurate blood velocity profiles from human vessels. Experimental systems so far presented in the literature use time-domain frequency estimations and, more recently, the fast Fourier transform (FFT) for real-time analysis of Doppler signals from multiple range cells. This experimental study is aimed at evaluating the application of an autoregressive (AR) method (Burg algorithm) to multigate Doppler analysis. Both in vitro and in vivo results were collected with a commercial Duplex scanner coupled with a prototype multigate unit developed in our laboratory. The same multigate signals are, thus, processed according to both the FFT and the Burg algorithms. The related spectral and maximum frequency profiles are reported and statistically compared. AR, implemented with the Burg algorithm, is demonstrated to be a way to perform multigate spectral analysis with reduced spectral variance, suitable for maximum velocity profile extraction through a simple threshold.

Selective transmission of a focused Doppler ultrasound beam through a plastic layer.

Laboratory test objects are widely used in Doppler ultrasound (US). Although the acoustic properties of in vitro materials are usually known, they are unlikely to match each other, or their in vivo counterparts, exactly. We conducted theoretical and experimental studies of a focused ultrasound beam as it passes from one fluid, through an intervening plastic layer at an oblique angle, and then into a different fluid. Dual mode propagation may occur (i.e., both longitudinal and shear waves can propagate in the plastic layer). Our calculations show that the power transmitted by either mode drops very rapidly to zero at certain critical angles. A range of angles of incidence exists within a focused beam and this, combined with the highly angle-dependent power transmission behaviour, can produce major distortions of Doppler data. These may persist even when the beam axis is not oriented exactly at the critical angle. The total power transmitted depends on all the wave speeds, may involve mode conversion, and is a very complicated function of the angle of incidence. This study reports a practical method for the calculation of power transmission though a plastic layer, and shows how the resulting power vs. angle graph can be used to avoid artefacts in in vitro Doppler studies.

Improved blood velocity estimation using the maximum Doppler frequency.

In vessels whose diameter is smaller than the length of the range cell or measurement volume, the maximum blood velocity is often calculated from the maximum frequency of the Doppler spectrum, using the classical Doppler equation. It is shown that the accuracy of this procedure is significantly improved at large beam-to-flow angles, if a correction for transit time broadening is made. This finding is based on the demonstration that the maximum frequency of the Doppler spectrum depends only on the maximum velocity passing through the measurement volume, but in a manner which is a function both of the Doppler shift frequency as well as the transit time broadening associated with the passage of scatterers through the beam width.

Clinical evaluation of a new anti-aliasing technique for ultrasound pulsed Doppler analysis.

Clinical evaluation of a new method of Doppler spectral analysis is discussed in this paper. According to this method, which basically involves a proper reformatting of the data provided by a conventional spectrum analyser, the frequency range usually considered in pulsed systems is considerably extended. This has been demonstrated even in extreme clinical conditions, corresponding to tight stenosis in major arteries. Details of materials and methods employed in this evaluation are included. Examples of experimental results are reported, along with a discussion about some possible applications of the new technique.

An FFT-based flow profiler for high-resolution in vivo investigations.

Pulsed Doppler spectral analysis is a well-established diagnostic technique in the assessment of arterial diseases. Because of hardware limitations, its use has been so far restricted to the analysis of a single sample volume located along the ultrasound beam axis. In this paper, we discuss the operation of a newly developed multigate instrument capable of performing, in real time, 64-point fast Fourier transforms of Doppler signals sampled from 64 different range cells. The new instrument is capable of accurately detecting the actual blood flow behavior in major human vessels. Significant examples of velocity profiles obtained in real time from carotid arteries in healthy subjects are reproduced here for the first time. Multigate extension of spectral analysis is demonstrated to be a suitable means for detailed in vivo investigation of blood flow dynamics.

On the interaction between ultrasound and contrast agents during Doppler investigations.

Knowledge of interaction mechanisms between ultrasound (US) and contrast agents (CA) suspended in blood is important for a correct interpretation of clinical investigation results. Experiments performed in different laboratories have shown that, as a consequence of primary radiation force, CA tend to move away from the US transducer. Accordingly, Doppler spectra produced by particles suspended in moving water turn out to be significantly altered from what is theoretically expected. The purpose of this paper is twofold. First, an original model describing the bubble dynamics as the outcome of the balance between US radiation force and fluid drag force is validated for the case in which bubbles are suspended in blood. The high fluid viscosity is shown to prevent significant bubble deviations from the unperturbed fluid streamlines so that, in large vessels, a residual spectral distortion may exist only at the highest intensity levels permitted by current regulations. Finally, the relative importance and differences between the effect of primary radiation force and streaming mechanisms that, in principle, could lead to similar effects, are discussed.

A tracking FFT processor for pulsed Doppler analysis beyond the Nyquist limit.

A tracking procedure for processing ultrasound pulsed Doppler signals with instantaneous frequencies beyond the Nyquist limit is discussed. It is based on the observation that the frequency translation required to properly reconstruct an aliased spectrum can be achieved by means of a simple reordering of data provided by a digital fast Fourier transform (FFT) unit. The amount of reordering is automatically derived by the computed value of a spectral parameter, e.g., the mean frequency. The procedure has been tested by introducing some modifications at the output of an FFT unit included in a conventional pulsed Doppler system. As a result, the dynamic evolution of the full Doppler spectrum and related mean frequency can be followed in real time over an extended range. In vitro and in vivo experiments, as well as quantitative measurements carried on with test signals are presented.

Real-time identification and archiving of micro-embolic Doppler signals using a knowledge-based DSP system.

Identification of micro-emboli in the cerebral circulation using transcranial Doppler ultrasound provides valuable clinical information, but, currently, embolic signal detection and analysis are significantly limited because they mainly rely on costly off-line analysis by human experts. In this study, a reliable, high-resolution, real-time automated system for the detection and archiving of embolic signals was designed and implemented using expert system theory and modern DSP technology. Preliminary tests were conducted to evaluate the functions and the performance of the system using data from ten carotid endarterectomy patients and two normal volunteers. Using the widely accepted 7 dB threshold for human reliability and a human expert, majority-decision gold standard, the real-time system reached sensitivity and specificity of 93.6% and 99.3%, respectively, which were close to the results obtained by three human experts under ideal laboratory conditions (90.1% and 99.8%, 98.4% and 99.9%, 98.9 and 99.9%). The new system has the potential to be used either as a bedside monitoring and signal acquisition device, or as a laboratory investigation tool.

Quantitative analysis of Doppler spectrum modifications yielded by contrast agents insonified at high pressure.

In this report, the authors consider the modifications yielded in the Doppler spectrum when acoustic fields of increasing intensities are applied to encapsulated gas bubbles. Their in vitro experimental results show that the spectrum bandwidth is nearly proportional to the incident acoustic pressure, when its amplitude is maintained below about 200 kPa. At higher pressure levels, it even may happen that, in a steady, unidirectional flow (which should generate only positive Doppler frequencies), the Doppler spectrum is enlarged up to the point that negative Doppler shifts also are produced. Possible explanations in terms of either radiation force or streaming are discussed for this asymmetrical bandwidth enlargement.

Doppler spectra from contrast agents crossing an ultrasound field.

When contrast agents are injected in a fluid, it is implicitly assumed that they move at the same velocity as the fluid itself. However, a series of in vitro tests performed by using air-filled microbubbles suspended in distilled water, have shown that the Doppler spectrum generated in this case may be notably different from that obtained from non-resonating scatterers. In this paper, we show, through a simple simulation model, that the actual movement of microbubbles may be predicted as the result of the complex balance between two forces: the ultrasound radiation force, which tends to move the particles along the sound beam direction, and the fluid drag force, which tends to move the particles along the fluid stream. The contrast agents turn out to be displaced only during the passage of the ultrasound burst; during the remaining time, they are maintained at the fluid velocity by the drag force. Based on the total particle displacement estimated between consecutive pulses, a series of Doppler spectra corresponding to different intensity levels was computed. This series was shown to be in excellent agreement with the experimental spectra obtained in vitro using Levovist (Schering AG, Berlin, Germany) particles suspended in distilled water flowing at a steady rate.

Invariance of the Doppler bandwidth with range cell size above a critical beam-to-flow angle.

For a sound beam impinging on a blood vessel, with a range cell much smaller than the vessel diameter, it is known that the breadth of the echo Doppler spectrum is proportional to the velocity of the flow through the range cell. As the range cell is lengthened to include a greater range of velocities, the spectrum is expected to widen proportionately. It is shown theoretically, and confirmed experimentally, that if the beam-to-flow angle is greater than a critical value, the Doppler spectrum bandwidth is independent of the length of the range cell, and depends only on the maximum velocity encompassed by it. This happens because for angles greater than the critical, the narrow spectra produced by lower velocity flows near the vessel walls are contained within the broader spectrum produced by the higher speed flow near the vessel axis. The critical angle is the angle at which the flow axis is normal to one of the beam edges.

Blood flow images by a SAW-based multigate Doppler system.

Multigate operation of an ultrasound pulsed Doppler flowmeter, providing Doppler frequency detection in a number of adjacent sample volumes, is capable of displaying the instantaneous blood velocity distribution along the cross section of a sonified vessel. Real-time serial Doppler processing of 32 range cells has been implemented in a novel system using fast spectral analysis based on surface-acoustic wave (SAW) dispersive filters. The basic architecture and first in vitro experiments were reported previously. The in vivo application of the system is described here, and images of human carotid artery and jugular vein are presented. Appropriate display formats are introduced to use the great amount of information known on spatial and temporal behavior of flow profiles. Digital postprocessing of spectral Doppler data allows velocity profiles to be displayed at selected times to correlate spatial and temporal evolution. A color code can be used to represent different velocity strengths. The potential application of the system to two-dimensional (2-D) flow imaging is discussed.

Experimental proof of Doppler bandwidth invariance.

A line flow of scatterers crossing the sound field produced by a focused circular transducer at uniform velocity originates a quasi-triangular Doppler spectrum. It is known that the spectrum shape and width depend on the line flow to beam axis angle, as well as on the transducer geometry. It has recently been theoretically predicted that this spectrum width is independent of the flow line location in the sound field. Experimental verification of the new theorem, based on the use of a thread phantom operated at various orientations, ranges, and offsets, with respect to the ultrasound transducer, is presented. The tests were made with a computerized pulsed Doppler system designed to perform optimal real-time spectral analysis of data obtained in this application. The prototype system and the experimental procedure adopted for demonstrating in vitro the invariance of the Doppler spectral bandwidth are described.

Synchronous dynamic focusing for ultrasound imaging.

An approach to dynamic focusing of ultrasound linear array scanners is presented, leading to the unique capability of implementing a focus that continuously tracks the return signal along the penetration depth. An electronically variable lens is obtained by a heterodyning process, in which the phases of echo signals at the array elements are equalized by mixing with suitable reference oscillations. These are generated by control of a single voltage-controlled oscillator, whose frequency is properly varied in synchronism with the delay of signal from different depths. The technique has been experimentally demonstrated by modifying the focusing processor of a conventional echographic linear scanner. Superior performances have been obtained with respect to fixed-focus operation mode. The image quality results are comparable with those of multizone-focus operation mode, in which the focus is varied over more transmit/receive cycles at the expense of lower frame rate.

PSpice modelling of ultrasound transducers: comparison of software models to experiment.

This paper presents a complete PSpice model of an ultrasound single-element transducer, including electrical and mechanical matching as well as the focusing lens. By using this model, it is possible to obtain a relation between the electrical driving source and the acoustic velocity on the transducer surface. This boundary condition then allows the acoustic field to be calculated by numerical methods. Experimental data obtained with two different transducers are in good agreement with results predicted by the related models.