Abstract

Introduction

     Radiographers can elect to work within many different modalities, one being ultrasound. Within Europe there are differing opinions about how much of a role radiographers should take in relation to the ultrasound examination, particularly report writing. This paper provides findings exploring the radiographer’s views on working within sonography.

Methods

     In 2019 an electronic survey was disseminated to radiographer members by European Federation of Radiographer Societies (EFRS) national radiographer societies, following a pilot study. A mix of closed questions, free text, and scale responses aimed to investigate radiographers’ practice, legal responsibilities, report writing, educational level and experiences of support and mentoring.

Results

     Of 561 radiographers participating, most (92%) reported performing ultrasound scans. Challenges with legislation, medical protectionism and lack of high-quality education restricted other radiographers. On average, the respondents have practiced ultrasound for 13.5 years. A total of 60% had postgraduate education and carried out a wide range of examinations. A full interpretative report, including advice on further investigations is performed by 52%, whilst 22% provide a checklist or descriptive report. Over 55% of radiographers took legal responsibility for the examination and the majority had clear protocols, good mentoring and support in the workplace. Peer review of their work was less common.

Conclusion

     The result shows that in 21 (n = 25) countries radiographers perform ultrasound, however not without challenges. Educational levels range from no formal education or short courses to an MSc in ultrasound. Report writing practice differs across the EFRS countries responding to the survey, as does peer review to enhance skills and clinical practice.

Implications for practice

     National Radiographer societies could review findings to support campaigning for a change in legislation and improvements to educational offerings in ultrasound.

Introduction

     Radiographers perform ultrasound examinations in a number of European countries. They are recognised as an important part of the workforce, particularly as demands on ultrasound and other imaging services increase.1 Ultrasound is predominantly performed by radiologists in Europe, however, due to the shortage of radiologists, providing a qualified ultrasound workforce may become a future challenge in Europe.2,  3,  4,  5,  6,  7,  8,  9,  10,  11 Radiographers educated and trained as sonographers can help overcome this challenge in the future.

     Who should be performing ultrasound examinations? Questions have been raised about who should provide the written ultrasound report and whether this should be the radiographer performing the examination, the radiologist or other professionals.12 Ultrasound is a hands-on investigation, with the written report being the primary communication method and an essential part of the investigation, which is inseparable from sonographic imaging.13 In the United Kingdom (UK) the expectation is that the healthcare professionals performing the examination writes the report, due to dynamic nature of the examination, safety, and best practice.13,14 Besides having the responsibility of writing the examination report, there are other factors affecting radiographers in ultrasound such as educational level, salary, access to new equipment, and psychological support.15 The educational level and training for non-medical ultrasound is variable across Europe.16,17 This is also recognised by the European Society of Radiology (ESR).14 In the United States of America integration of ultrasound education for medical professionals was also found to be extremely inconsistent18 varying from “ad hoc” or “on the job” learning to formal postgraduate qualifications.17 Cultural differences between hospital or country will often determine the preferred educational approach preferred. Still, radiographers writing individual ultrasound reports are highly skilled.17 Hofmann and Vikestad (2013) investigated how radiographers perform in upper abdominal examinations compared to radiologists and found kappa agreement of 0.9.8 Studies have also found radiographer reporting comparable to radiologists in ultrasound and other modalities.19,  20,  21 The knowledge of radiographers’ perspectives, views, experiences and challenges in ultrasound is limited in current literature.

Conclusion

     In general, radiographers perceive sonography as an extension of their role with the addition of new responsibilities and skills. Previous literature supports that an essential component of completing an ultrasound examination is writing the report. Whilst many radiographers responding to this survey practise ultrasound, far fewer have the opportunity to write independent actionable reports. Although numbers were small, the majority of those who do not perform ultrasound would be interested to develop in this area.

     Overall, radiographers have different career, support and educational opportunities to engage in ultrasound practice across Europe. A wide range of clinical ultrasound examinations are undertaken by radiographers, particularly general medical, gynaecology, obstetrics and vascular. The main educational level is postgraduate (EQF level 7), although some radiographers have limited or no formal education and training, which is a concern as ultrasound is such an operator dependent modality. Previous studies suggest that radiographers can provide a safe, effective ultrasound service, but this does require good underpinning education, mentoring, support and on-going audit and peer review of practice.

KEY POINTS 

– This is a new technique for carpal tunnel release thanks to recent improvement in the quality of ultrasound devices.

– The surgical technique is well described and consists in a wrist approach in a retrograde fashion under strict ultrasound control to transect completely the transverse carpal ligament.

– Outcomes of the first 150 patients, tips and tricks are presented and discussed.

– With a dedicated instrument, this is a safe and well-tolerated procedure, efficient, costless.

Preoperative considerations

     Carpal tunnel syndrome (CTS) is one of the most common neuropathies of the upper limb, and affects mainly manual workers. Its prevalence is approximately 5% of the population, and usually is diagnosed in the last active years (50–60 years old), with an increased incidence in women (4:1). Atroshi and colleagues1 showed that the overall prevalence of neuropathy signs in the median nerve distribution is 14.4% (95% CI, 13.0%– 15.8%).

     They also determined that clinically certain CTS prevalence confirmed by electrodiagnostic tests (4.6% for women and 2.8% for men) was close to or somewhat lower than the true prevalence. CTS diagnosis is clinical, with typical symptoms including paresthesia, pain, and weakness in the median motor nerve distribution, often increasing in intensity at night. Ultrasound (US) and electromyography are used as means of additional evaluation and in poor clinically defined cases, if a differential diagnosis is needed. Once a diagnosis is confirmed, either medical or interventional treatment strategies can be used, the choice depending on the severity of the condition and the patient’s decision. Among accepted severity criteria, authors find permanent amyotrophy of the thenar eminence due to its interrupted median nerve innervation, paralysis of thumb opposition, permanent paresthesia, and all forms of hyperalgesia.2 For severe CTS patients (presence of clinical criteria, activity limitations, presentation of poor prognosis factors, and decreased quality of life) and for those who medical treatment failed, interventional options are preferred.

Discussion

     At the end of the follow-up period, significant recovery of grip strength was observed in the studied population. Additionally, pain and acroparesthesias resolved promptly after surgery, normal activities took less than 2 weeks to resume for a large majority of patients, and no serious complications were observed during the first postoperative month. Procedural subjective satisfaction was high in approximately 98% of operated patients, indirectly reflecting good tolerance and functional results of US-guided release of TCL using a new compact scalpel.

Abstract

KEY POINTS

– The surgical carpal tunnel procedure under sonography prevent intraoperative neurovascular injury.

– The sonography can also be used for carpal tunnel syndrome diagnosis and the surgical release.

– As a low-irradiation imaging technic, sonography can also be used for the trigger finger surgical procedure without skin incision.

– The percutaneous carpal tunnel procedure can be done without tourniquet and prevent from thromboembolism complication.

Introduction

     Carpal tunnel syndrome (CTS) is the most frequent compressive neuropathy.1 In Belgium, in 2018, there were 31,938 carpal tunnel releases (CTRs) performed with an annual direct reimbursement cost of 6,142,052 V. Most patients (64.4%) were women, and the median and average ages were 58 and 59.3 years, respectively. The vast majority of the operations (97.1%) were performed in an ambulatory day clinic.2

     The classical surgical alternatives are Open and Endoscopic Carpal Tunnel Releases (OCTR and ECTR). In 2016, the American Academy of Orthopaedic Surgeons (AAOS) concluded that ECTR offers some benefits as compared to OCTR.3 Sonography is now used more and more in CTS, for the diagnosis,4 but also, by some physicians, during surgery. Already in 1997, Nakamichi suggested using sonography during CTR.4 More recently, sonography has been proposed to guide the release of the transverse carpal ligament (TCL) using various endoscopic devices, or needles permitting sonography-guided percutaneous carpal tunnel release (PCTR). Several cadaveric studies have assessed the efficacy of PCTR.5,6 Lecoq and colleagues reported in their series of 104 specimens, a total release of TCL in all cases. For 61 specimens, the complete release was obtained at first cutting movement.6 In clinics, PCTR has been reported to be safe and could allow quicker return to daily activities and work.7

Results

     A total of 141 patients (143 hands) were operated for CTS at Erasme University Hospital in 2019. After exclusion criteria, 116 patients were included in the analysis: 35 men (mean age, 60 years) and 81 women (mean age, 54 years), 75 on the right side and 41 on the left side. Seventy-eight patients were operated by PCTR, 35 by OCTR, and 3 by ECTR. PCTR was performed by one single surgeon experimented in sonography (FM), OCTR and ECTR by multiple hand surgeons. Among the 116 operated patients, 29 were operated under regional anesthesia, 4 under general anesthesia, and 83 (including all PCTRs) under local anesthesia (Table 2). The average operative durations were similar for OCTR (15  8 min) and PCTR (15  6 min), inferior to those of ECTR (29  10 min) (Fig. 1). The same difference was found for the total duration of occupation of the operating room (OCTR, 43  17 min; PCTR, 47  10 min; ECTR, 64  34 min).

Abstract

Background

     Alobar holoprosencephaly (HPE) is easily detected during a first-trimester screening examination, conversely, recognizing the lesser varieties may be difficult even in the second trimester.

Objectives

     To describe the imaging findings of a cohort of fetuses with holoprosencephaly (HPE) and to elucidate the appearances of the different anatomical varieties.

Materials and methods

      We reviewed medical records and stored images of pregnant women referred to our clinic because of a diagnosis or the suspicion of various forms of HPE. We reported the imaging characteristics, the presence of other associated anomalies, magnetic resonance findings, karyotype and autoptic examinations when available.

Results

     Alobar forms show great distortion of normal brain anatomy, with a single ventricle detectable during the first trimester of pregnancy. Extracerebral, face and karyotype abnormalities are often associated. In semilobar and lobar forms the septum pellucidum is typically absent in axial planes, with fused frontal horns, while posterior fossa is often normal. At multiplanar neurosonogram, anomalies involving corpus callosum and cortex development can be detected. Face abnormalities are mild in lobar forms: receding forehead, various degrees of hypotelorism and the presence of a single central maxillary incisor are reported.

Conclusions

     The alobar forms are detectable since the first trimester, with a peculiar single ventricle and extremely frequent extracerebral and karyotype abnormalities. The semilobar and lobar forms are more challenging and the diagnosis is easily missed in a mid-trimester screening exam unless a careful evaluation of both cavum septi pellucidi and frontal horns as well is conducted.

Introduction

     Holoprosencephaly (HPE) is a complex brain malformation characterized by variable degrees of incomplete cleavage of the two hemispheres and the development of midline structures [1–3]. Prognosis is variable but is most frequently dismal. The most severe forms are frequently associated with aneuploidies, trisomy 13 and triploidy in particular, and result in miscarriage or perinatal death; the less severe forms are compatible with postnatal survival but in most cases are associated with delayed neurocognitive and motor development, epilepsy and endocrine disorders due to pituitary deficiency [4–6].

     HPE encompasses a continuum of brain malformations. Classically, three forms with progressive severity have been described: lobar, semi-lobar and alobar. However, there is a broad spectrum of presentation with overlapping findings [7,8]. Thus far, prenatal studies have insisted on the alobar form, the most severe one, which is characterized by typical and very extreme findings [9]. The experience with less severe forms is more limited and the findings that have been described are variable and much more subtle [10–14].

Results

     During the study period fetal HPE was diagnosed in 15 cases; of these 10 (67%) were of the alobar type and 5 of less severe varieties. One case has been previously reported [19].

Alobar HPE Most cases were diagnosed in the late first trimester (median 12 weeks, range 11–16 weeks) and were always referred from screening facilities with a presumptive diagnosis of alobar HPE. The findings were very homogeneous: in all cases, a standard axial view of the head the midline revealed an absence of the midline echo and one single undivided choroid plexus, in association with severe cranio-facial anomalies or a very flat fetal profile (Figure 1) The median week for a referral at our center was 12 weeks (11–16). Nine patients underwent termination of pregnancy with dilatation and curatteage; one patient with discordant twins decided to continue the gestation. The karyotype was obtained in 8/10 cases, and was normal in 2 cases without detectable microarray anomalies; there were 5 cases of trisomy 13, and 1 case of 68, XX. Associated extracerebral anomalies were present in 9 fetuses (Table 1).

Abstract

     Ultrasound is an imaging modality that is highly operator dependent. This article reviews the challenges in learning how to perform obstetric sonography, as well as the processes necessary to acquire expert performance skills in sonography. Simulation-based education and learning, and the value of medical simulation are also discussed. Ultrasound simulators are an effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. We review evidence that simulation can improve performance in obstetric ultrasound examination, review current simulators, and discuss the current problems/gaps in ultrasound simulation. Optical positioning ultrasound simulation is a novel high-fidelity simulation learning system, which addresses many of these problems/gaps and is introduced for the first time here.

Introduction

     Ultrasound imaging is integral to the practice of obstetrics, as it allows comprehensive anatomic and physiologic evaluation of the fetus and maternal pelvic organs [1]. Therefore, ultrasound examinations are recommended for all pregnant women [2–4]. Over the years, there has been an overall increase in the utilization of obstetric ultrasound in the U.S., with women receiving on average 4–5 sonographic examinations per pregnancy [5]. Yet, there is substantial variability in the sensitivity of routine sonography to detect fetal anomalies [6–8]. In a review of 36 studies that included more than 900,000 fetuses, an overall sensitivity of only approximately 40% for detecting fetal anomalies was noted [9]. Although the sensitivity of obstetric sonography depends upon gestational age at screening, type of congenital anomaly, selection of pregnant women, etc. the level of training and expertise of the sonologist is crucial to examination performance [10].

Conclusions

     Ultrasound examinations are recommended for all pregnant women. Yet, sonography is a highly operator-dependent modality that is challenging to master. Simulator training is a reliable tool to assess learners, and improves healthcare education and practice, as well as patient safety. There is broad consensus on the value of integrating simulation into ultrasound education and training programs. Ultrasound simulators are an innovative and effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. Moreover, teaching occurs in a controlled and safe environment, where skills can be practiced repetitively, and without patient anxiety and medicolegal concerns. Simulation-based training also allows trainees to practice a systematic approach to ultrasonography before the start of clinical training. Optical positioning ultrasound simulation is a high-fidelity simulation learning system which can address many of the current problems/gaps in ultrasound simulation, due to its unique characteristics.

Abstract

Objectives

     To compare hydrocolonic sonography with histopathology for diagnosing children with symptoms highly suggestive of Hirschsprung disease (HD).

Methods

     In this prospective study, patients presenting refractory constipation highly suggestive of HD underwent hydrocolonic sonography with retrograde infusion of saline into the colon. The dilated segments, narrowed segments, luminal diameter ratio, transition zone (TZ), thickening, and blood perfusion of the upstream bowel were evaluated. The sensitivity and specificity of combined and single parameters were determined in comparison with biopsy.

Results

     One hundred and three children were included in this study; 49 were confirmed to have HD. The luminal diameter ratio showed superiority over other parameters. An area under the curve (AUC) of 0.969 (95% confidence interval [CI]: 0.936–1.000) and a cutoff value of 1.51 were established by receiver operating characteristic (ROC) curve analysis of the luminal diameter ratio (sensitivity: 89.8%; specificity: 96.3%). By combining the luminal diameter ratio as the major criterion with two minor criteria, hydrocolonic sonography showed the same sensitivity (91.8%) and better specificity (96.3% vs 87%) than contrast enema, but this difference was not statistically significant (p = 0.063). Consistency analysis showed a kappa value of 0.825 (p < 0.001), indicating excellent agreement between hydrocolonic sonography and contrast enema.

Conclusions

     Hydrocolonic sonography is a valuable diagnostic tool with both high sensitivity and specificity for HD diagnosis, allowing morphological and vascular assessments of the colon, and correlates well with contrast enema. In the appropriate setting, hydrocolonic sonography may be an alternative screening method for HD in a large group of children with constipation.

Introduction

     Hirschsprung disease (HD) is a common congenital disorder with a global incidence of approximately 1 in 5000 in newborns [1–4]. HD is characterised by an absence of ganglion cells of the submucosa and myenteric nerve plexus in the distal bowel (usually localised to the rectosigmoid region), which causes the afected bowel to lose its peristaltic ability and leads to dilation of the upstream colon, resulting in refractory constipation. HD is classifed according to the length of the aganglionic section into short-segment (confned to the rectosigmoid region), long-segment (extending beyond the rectosigmoid region), total colonic (entire colon and terminal ileum), and total intestinal (most of the intestines are involved) HD [5]. An operation is recommended once the diagnosis has been established [6].

     The diagnosis is based on symptoms, contrast enema, rectal suction biopsy, and full-thickness rectal biopsy. Contrast enema is the imaging modality of choice for HD, with sensitivity ranging from 76 to 88.9% and specifcity from 84.2 to 98% [7–9]. With regard to contrast enema, patients are exposed to radiation; therefore, parents may have safety concerns. Rectal biopsy, despite being radiation-free, is invasive, sometimes requires anaesthesia, and is not widely accepted by parents. Over 80% of patients who undergo biopsies have normal ganglionic biopsies [10, 11]. In our centre, the negative biopsy rate is 74%. Therefore, there is a clear need for a noninvasive, safe, and highly sensitive diagnostic method to increase the positive rate of rectal biopsy. Ultrasound (US), although noninvasive and radiation-free, has limitations for the evaluation of HD: difuse intraluminal gas precludes the detailed evaluation of the colon wall. Second, the rectosigmoid region is the most commonly involved region in HD, and identifcation of this region by trans-abdominal US is challenging due to its deep location.

Results

Patient’s characteristics

     Between February 2019 and May 2020, 139 consecutive children met the inclusion criteria; however, 33 patients were subsequently excluded for contrast enema performed at another hospital, 2 were excluded because of fnal diagnoses of post-necrotising enterocolitis stenosis, and 1 was excluded for a fnal diagnosis of the Currarino syndrome. The fnal analysis was performed on 103 patients (median age, 6 months; interquartile range, 3–20 months). There were 41 (39.8%) girls and 62 (60.2%) boys.

     According to the rectal biopsy, the absence of ganglion cells was found in 49 patients. In 4 of these, no abnormal fndings of HD were observed on contrast enema (two of them had abnormal hydrocolonic sonography); therefore, a repeat biopsy was subsequently performed, with aganglionosis confrmed in all 4 cases. Thus, 49 patients were diagnosed with HD (43 cases were short-segment disease and 6 were long-segment disease) and 54 cases were ruled out (Fig. 4). There was no signifcant diference regarding age in the HD and non-HD groups (Mann–Whitney test; U=276.000; p=0.756). The HD group had a greater proportion of males (73.5% vs 48.1%, p=0.009).

Purpose: In this study, we used time-driven activity-based costing to increase efficiency in our ultrasound-guided breast biopsy practice by understanding costs associated with this procedure. Methods: We assembled a multidisciplinary team of all relevant stakeholders involved in ultrasound-guided breast biopsies, including a radiologist, a lead technologist, a clinical assistant, a licensed practical nurse, and a procedural support assistant. The team mapped each step in an ultrasound-guided breast biopsy from the time of scheduling a biopsy to patient checkout. We completed on average 20 time observations of each step involved in these biopsies from a provider’s perspective. Using capacity cost rate, we calculated the cost of all resources including personnel, supply, room, and equipment costs. Several costly steps were identified in the process, which led to the intervention of changing our overlapping biopsy times to staggered biopsy times. Time observations for each step and cost calculations were repeated postintervention. Results: Our postintervention data showed that the total time spent by the radiologist in an ultrasound breast biopsy decreased by 28%, accounting for 56% of the total cost in comparison with 63% pre-intervention. The radiologist’s wait time decreased by 38%, accounting for 28% of the total cost in comparison with 35% pre-intervention. Our total cost of the procedure decreased by 20%, and the personnel cost decreased by 25%. Conclusions: Time-driven activity-based costing is a practical way to calculate costs and identify non-value-added steps, which can foster strategies to improve efficiency and minimize waste.

Introduction

With increasing health care costs and evolving payment models, it is more critical than ever that medical providers maximize value by increasing efficiency and decreasing costs. Although value is difficult to define in health care, Porter’s widely cited definition of value is outcomes achieved relative to costs (outcomes/cost) [1]. To enhance value, one must improve outcomes or decrease cost. Although there has been a significant focus on improving patient outcomes in the recent past through regulatory and financial incentive models, there has been scant emphasis on decreasing cost. To decrease cost, one must be able to evaluate the true cost of a medical process or procedure. Calculating the cost of a medical process or procedure is challenging because various shareholders in the health care arena often define costs differently. Health care policy makers may refer to cost as the money paid to providers for medical services, and providers may define their costs by their reimbursement, but these are not necessarily the costs incurred by the health care system for a medical process or procedure [2,3]. Not knowing true costs prevents one from truly decreasing costs, which can have substantial negative downstream consequences such as the inability to adequately negotiate reimbursement in a bundled payment model.

Introduction

Materials and methods

Results

Conclusion

References

Abstract

Objective
Ventriculomegaly is one of the most common anomalies encountered at obstetric ultrasound and it necessitates follow up. Fetal magnetic resonance imaging (MRI) can be used to confirm the ultrasound diagnose or to detect additional anomalies. Aim of this study is to assess follow up and management of fetal ventriculomegaly shown by ultrasound, and to evaluate additional diagnostic contribution of MRI. Study Design
This study was conducted retrospectively including 89 patients who had fetal MRI subsequent to ultrasound diagnose of ventriculomegaly in between 2011-2017. Medical records of patients were investigated and accompanying anomalies, congenital infection, chromosomal examination, degree and progression of ventriculomegaly, neonatal imaging and diagnose, and neurodevelopmental findings on follow up were evaluated. Patients were classified in two groups as isolated and nonisolated ventriculomegaly, and subgroups mild, moderate, severe were formed according to their findings. SPSS 23.0 programme was used for statistical analysis.
Results
Ultrasound and following MRI was performed in a range of 18-35th gestational weeks, diagnoses were isolated ventriculomegaly for 56 patients and nonisolated ventriculomegaly for 33 patients. Progression and neurodevelopmental delay was higher in severe nonisolated ventriculomegaly group. There was not significant contribution of MRI in the follow up of isolated ventriculomegaly (p < 0.001), and diagnostic imaging findings declined in neonatal period with proceeding normal neurodevelopment in 92.7% of patients followed with diagnosis of isolated ventriculomegaly.
Conclusion
When isolated ventriculomegaly is detected, ultrasound performed by an experienced team is mostly sufficient. MRI can be used in suspicious cases or when ventriculomegaly progresses.

Introduction

In obstetric follow up, ultrasound is the main imaging tool to monitor fetal growth and development. Technologic development and increased experience in ultrasound practice in recent years has allowed ultrasound imaging for both routin purposes and detailed fetal investigation to provide better information in management of the patient [1]. However, beyond major anomalies that can be exactly shown by detailed obstetric ultrasound including fetal neurosonogram, suspicious findings that necessitate to be clarified in the proceeding visits can also be encountered. One suchlike finding involves lateral ventricle measurement which is an important part of central nervous system evaluation. According to ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) guidelines, measurement of atrial width at the level of glomus of the choroid plexus, perpendicular to the long axis of ventricle, using the inner edges of the lateral walls is recommended for ventricular measurement, and
10 mm is described as ventriculomegaly [2]. Ventriculomegaly, prevalance of which is reported to be 0.3–2%, may be unilateral or bilateral [3]. Furthermore, mild, moderate or severe forms which are defined due to measured width of lateral ventricle may be seen, although the exact definition concerning cut-off values varies at different studies [4,5]. Ventriculomegaly may regress or progress during follow up, it may also accompany other cranial or extracranial anomalies. Whether serious fetal anomalia is doubted, fetal magnetic resonance imaging (MRI), which is especially helpful for assessment of central nervous system anomalies, can be used to confirm the ultrasound diagnose or to detect additional anomalies [6]. Aim of this study is to assess follow up and management of fetal ventriculomegaly shown by detailed obstetric ultrasound, and to evaluate additional diagnostic contribution of MRI on this process.

Simultaneous measurement of multiple hemodynamic parameters is of high importance for the understanding of tissue function and disease progression. Hemodynamic responses are normally produced in response to physical or organ activity, environmental changes as well as neural activity to guarantee proper oxygen delivery to tissues [1,2]. Majority of cardiac and vascular disorders are similarly related to systemic hemodynamic dysfunction, so that hemodynamic measurements are essential in their timely diagnosis and treatment monitoring [3]. Color Doppler ultrasound (US) has arguably become the gold standard for mapping the distribution of blood flow. Handheld US scanners are extensively employed in the clinics for diagnosing blood clots, defects in heart valves, blockage in arteries and numerous other conditions [4]. Owing to its unique capability for non-invasive label-free mapping of the distribution of oxy- and deoxyhemoglobin deep in living tissues, multi-spectral optoacoustic tomography (MSOT) has recently found widespread use in preclinical imaging applications [5,6] and is undergoing rapid clinical translation in various point-of-care diagnostic applications, such as melanomas [7,8], inflammatory bowel (Crohn’s) disease [9], breast abnormalities [10], thyroid cancer [11,12] or peripheral vascular diseases [13]. Efficient integration between MSOT and US in a hybrid handheld scanner is expected to further accelerate clinical translation of MSOT and significantly enhance imaging performance of the stand-alone systems by simultaneously delivering their highly complementary contrasts. While a number of possible hybridization approaches have been previously suggested [14–18], such an efficient combination is inherently challenged by the fundamentally different excitation and image formation strategies behind the two modalities. Recently, a hand-held probe based on a multi-segment detector array combining linear and concave segments with different inter-element pitch has been reported [19,20]. The different parts of the array provide optimized performance for each modality, hence enabling accurate multi-modal optoacoustic and pulse-echo US imaging. The linear segment may additionally be exploited for other US modes, such as Doppler US. Here we adopted the multi-segment array approach in order to achieve multi-modal MSOT, pulse-echo US and color Doppler imaging in a hand-held mode. The experimental performance of the multi-modal approach is further showcased by imaging the carotid artery region of a healthy volunteer, where Doppler US is commonly used for the detection of vascular abnormalities, such as stenosis or intraluminal turbulence [21].

Obstetric 0stula (OF) is a devastating condition that occurs when women experience prolonged obstructed labor. ,e soft tissues of the pelvis undergo tissue necrosis, resulting in an abnormal communication between the vagina and the bladder and/or rectum. Women with OF continually leak urine and/or feces from their vagina until they are surgically repaired [1]. Many women with OF develop secondary infertility or amenorrhea, although some become pregnant again, before or after surgical repair. For those who do become pregnant, their pregnancies are often associated with high rates of preterm birth and spontaneous abortion, particularly in the second trimester [2–4]. ,e reasons for this are not well understood, although experts have hypothesized that women with OF have higher rates of preterm birth because of severe cervical damage and avulsion that occur during prolonged obstructed labor, which leads to cervical insu@ciency [5]. In extreme cases, 0stula surgeons have noted that patients have no identi0able cervical tissue [1, 6, 7]. A case series of 22 OF patients found that, on vaginal exam, 40% of patients had a normal cervix, 23% had cervical erosion, 18% had only a cervical dimple, 14% had a nonidenti0able cervix (because it was bound to the pubic symphysis), and 5% had a “harelip” defect of the anterior cervix. On transabdominal ultrasound, 68% had a normal-appearing cervix and 9% had anterior cervical defects [7]. No published study has assessed the use of endovaginal ultrasound to evaluate the cervix in OF patients. Cervical length measurement is often performed during pregnancy to assess for short cervix, which is associated with preterm birth [8]. Women found to have a short cervix due to structural weakness of the cervix, as in the case of prior cone biopsy or a Mullerian duct anomaly, may bene0t from ¨ placement of a prophylactic cerclage [9–11]. No published studies have examined the use of prepregnancy cervical length as a predictor for preterm birth in women at risk for having a short or abnormal cervix. ,e cervix lengthens during the 0rst trimester of pregnancy, so pregnant women generally have longer cervices than nonpregnant women [12, 13]. ,e prepregnancy cervical length may have some predictive value, particularly in women with prior cervical trauma or surgery. For OF patients, pregnancy is uncommon, and they interface with the health care system infrequently. It is more practical to assess their pelvic anatomy by ultrasound at the time of their repair. If OF patients are found to have compromised pelvic anatomy, this could result in counseling on future pregnancy risk or potential interventions to prevent early pregnancy loss or other complications.

Systemic sclerosis (SSc) is an autoimmune connective tissue disease with multiple phenotypic presentations, driven by the interplay of autoimmunity and vasculopathy with excessive dermal and internal organ fibrosis. Microvascular damage is a hallmark in the pathogenesis of SSc, most often manifested clinically by Raynaud’s phenomenon, skin ulcers, and pulmonary arterial hypertension (PAH) [1, 2]. Skin ulcers represent a major challenge in SSc, affecting up to 58% of SSc patients and may involve multiple fingers and both hands. Skin ulcers are painful and have a major impact on SSc-related hand disability. SSc patients with digital ulcers (DU) have limited wrist and hand mobility, increased global and hand disabilities, and decreased health-related quality of life compared to those without active DU [3]. Ultrasound (US) is a non-invasive, low-cost, reliable method that has been increasingly used for measuring joint inflammation and damage in rheumatology [4]. It is promising in evaluation of joints and tendons in SSc patients [5]. Additionally, US has been reported to support the assessment of skin thickness in SSc patients [6]. However, there are no previous reports using ultrasonography to evaluate skin ulcers in SSc patients. Clinical assessment of skin ulcers by visual examination is commonly associated with limited ability to assess the depth of the ulcer, the degree of tissue loss, the presence or absence of underlying calcinosis, and whether the ulcer is infected or not. Skin ulcer is defined histologically as a break in the epithelial integrity of the skin which may extend to deeper structures [7]. Recently, a preliminary clinical definition of skin ulcer in SSc has been developed [8]. US scanning of skin ulcers may provide a unique opportunity to better define and assess skin ulcers. To date, there has been no sonographic characterization of SSc-related skin ulcers. The availability of an objective US image of skin ulcers in SSc may have utility in clinical trials to objectively assess ulcer morphology, extent, severity, and response to treatment. It may also be useful to define and measure skin ulcers in the clinical setting. The purpose of our study was to preliminarily evaluate the ability of ultrasound (both gray scale (GS) and power Doppler (PD)) to define the morphology and extent of cutaneous ulcers in SSc patients.

In surgeries involving the anterior abdominal wall, the role of abdominal wall block is increasing as a part of multimodal analgesic method for postoperative pain control. Rectus sheath block (RSB) is a simple and easily applicable abdominal wall block. Local anesthetic is deposited between the rectus muscle and its posterior sheath, which blocks the anterior cutaneous branches of the lower thoracic spinal nerves (T7–T12). This technique was introduced in 1899 and used for surgical anesthesia and muscle relaxation, but has been neglected due to the development of neuromuscular blocking agents [1]. Smith et al. demonstrated a reduction in postoperative pain in patients who received bilateral rectus sheath block (BRSB) during diagnostic laparoscopy compared to a control group [1]. The subsequent development of ultrasound (US)-guided nerve block has led to the rise of US-guided BRSB (US-BRSB), which has been investigated in the context of various abdominal procedures, including pediatric umbilical hernia repair and myomectomy, with both pain-reducing and opioid-sparing efects [2–6]. Several trials have examined the efects of transversus abdominis plane (TAP) block, which represents another classical type of anterior abdominal wall block, during laparoscopic surgery [7–10]. The results of these trials revealed benefcial efects of TAP block on pain reduction and opioid usage, but these efects were relatively small and observed only during the early postoperative period. Multi-port laparoscopic surgery typically involves three to four incisions. The umbilical or periumbilical incision, into which a laparoscope is usually inserted with a large-bore trochar, requires peritoneal and fascial closures, whereas the other incisions can be closed with skin sutures (that may or may not be subcutaneous). We thought that, because the umbilical incision represents the most painful incision site, and because RSB focuses on the midline, RSB may be useful in decreasing the pain caused by umbilical incision. Furthermore, because the distribution of RSB can extend to the anterior superior iliac spine (ASIS), it might be possible to reduce pain from other port incisions as well [11, 12]. Few studies have been published on RSB during laparoscopic surgery [5, 13], but the available results demonstrate lower pain scores during the early postoperative period (up to 10 h).