JANUARY 2024
Making waves IN SONOGRAPHY RESEARCH
CONTRIBUTORS
Robyn Boman, AFASA Robyn has extensive clinical experience as a general sonographer in metropolitan and rural NSW and qualifications in diagnostic radiography, medical ultrasound, and education. This knowledge has been shared in volunteer outreach ultrasound training projects in Papua New Guinea and Fiji. Her passion for education was evident from the high regard expressed by her students when a lecturing academic with CQU. Robyn is a full-time PhD candidate at Western Sydney University.
Deborah Carmody, AFASA
Peter Esselbach Peter is an MSK Specialist Sonographer at Fowler Simmons Radiology and RadiologySA. He worked for 6 years in Queensland before moving to Adelaide. Peter also holds a physiotherapy degree, working for 20 years as a rehabilitation and musculoskeletal physiotherapist. A qualified Pilates instructor, he enjoys combining both professions to optimise the best outcomes for his patients. Peter has a passion for seeing sonographers prevent and manage any potential MSK injuries.
Joanne King
Deb is the Head of Marketing – Ultrasound for Asia Pacific Japan at Siemens Healthineers with a Master of Medical Sonography focusing on MSK ultrasound (University of South Australia). Deb has worked clinically as a sonographer in Canberra and Brisbane, joining Siemens Healthineers five years ago as Applications Specialist. Deb is passionate about sonographer education, member and past chair of the MSK SIG for over eight years and MSK Stream Co-Coordinator at the ASA2023 Conference.
Joanne brings a wealth of experience and expertise to medical imaging as a dualqualified radiographer (Curtin University, 2007) and sonographer (University of South Australia, 2014). For the past 12 years, Jo has been working in rural and remote Kimberley, WA. She is the manager of the Broome radiology department in clinical and administrative roles and an active member of the ET SIG. Jo stands as a trusted and respected radiographer and sonographer, dedicated to advancing the field and providing exceptional care to patients.
Katrina Dietrich
Ling Lee, AFASA
Kat began as an assistant in nursing before earning her Bachelor of Nursing in 2010. In 2016, Kat graduated from DMU with a Graduate Diploma in Vascular Ultrasound. During COVID, Kat travelled around Australia with her son and greyhound, fulfilling locum assignments. Presently, Kat is the Chief Sonographer at St Vincent’s Vascular Lab, Darlinghurst. Her involvement in the Vascular SIG since 2022 underscores her commitment to learning and continual development.
Ling Lee is a clinical sonographer specialising in maternal-fetal medicine and women’s health. Her role as a clinical educator allows her to participate in training and mentoring student sonographers and fellow sonographers. Her ongoing research focuses on providing better support for the education of future sonographers through a social-psychological lens. She believes research is a vital part of our clinical role and pivotal to the advancement of our profession.
Heath Edwards Heath (B.Med Rad Science, University of Newcastle and Graduate Diploma in Medical Ultrasound, Monash University) is a Senior Radiographer/Sonographer at Brisbane and Women’s Hospital and a vascular sonographer with Queensland Vascular Diagnostics. Heath is a member of the Vascular SIG and a CQU casual tutor. Heath has a specialised interest in MSK and vascular ultrasound. Recently, his focus has been on the role ultrasound plays in managing acute Achilles injuries.
Making waves
Nayana Parange, FASA Nayana is a Professor of Medical Sonography and Professorial Lead (UniSA), qualified in medicine, specialist training in obstetrics/gynaecology, ultrasound, education, and a leading international expert in clinical ultrasound training. Her current research examines the gap in rural, remote and Aboriginal communities in potentially lifesaving ultrasound services and improving their access to antenatal ultrasound services. She is currently examining the impact of training health professionals in remote areas in point-of-care ultrasound.
JANUARY 2024 | 2
CONTRIBUTORS
Emma Rawlings Emma is a paediatric sonographer/ radiographer working in private practice. She has worked in tertiary paediatric centres both in Australia and the UK and has a special interest in paediatric neuroimaging, renal transplants and bowel ultrasound. Emma has been a lecturer at King’s College London and has a strong passion for paediatric ultrasound education and research. She has been a member of the Paediatric SIG since 2017.
Chrissy Thomson, AFASA
Marilyn Zelesco Marilyn is a Western Australian-trained diagnostic radiographer with a postgraduate ultrasound qualification (1991) and Master of Ultrasound (RMIT, 2007). Marilyn has professional awards from the Australian Institute of Radiography, the Australian Sonographers Association and the Australian Society for Ultrasound in Medicine. Marilyn is Lead Sonographer, Fiona Stanley Hospital, Perth, with an interest in hepatic, bowel, male reproductive tract ultrasound, elastography, CEUS, renal transplants, research, education and sonography in Indigenous healthcare.
Chrissy is a cardiac sonographer with 20 years of clinical experience. She is also a sessional academic and the previous Course Coordinator for the QUT Graduate Diploma in Cardiac Ultrasound. Chrissy is a Fellow of the American Society of Echo and a member of the ASA’s Cardiac SIG. She is passionate about guidelines-based education and sonographer training and loves talking ‘All things echo!’
Caterina Watson, AFASA Caterina Watson is a sonographer practising in Western Australia. She also enjoys participating in outreach training programs in the South Pacific Nations. Caterina is a member of the ASA Research SIG, chairperson of ASA Emerging Technologies SIG, and a member of the RANZCR AI Collaboration Committee. Caterina is a PhD candidate at Edith Cowan University.
Craig Winnett Craig has a passion for sharing knowledge and for the advancement of medical ultrasound. A Specialist Sonographer with over 15 years of experience, Craig is dedicated to training and mentoring sonographers. Craig currently works between private practice for I-MED Radiology, The Wesley Hospital and the Princess Alexandra Hospital (Qld Health) in Brisbane. Craig is a tutor for the Central Queensland University Medical Sonography course and a member of MSK SIG.
Making waves
JANUARY 2024 | 3
Contents MUSCULOSKELETAL
raig Winnett – Evaluation of the ulnar nerve with shear-wave C elastography: a potential sonographic method for the diagnosis of ulnar neuropathy
MUSCULOSKELETAL
Deborah Carmody, AFASA – A systematic temporal assessment of changes in tendon stiffness following rotator cuff repair
5
7
RESEARCH ing Lee, AFASA – A typology of reviews: an analysis of 14 review L
9
RESEARCH aterina Watson, AFASA – Analysis of recent Australasian Sonographers C
11
PAEDIATRIC mma Rawlings – Radiological and surgical correlation of pelviureteric E
12
CARDIAC hrissy Thomson, AFASA – Right ventricular to pulmonary C
14
types and associated methodologies
Association (ASA) conference abstracts: How many progress to publication?
junction obstruction in positional anomalies of the kidney in children
artery coupling and outcome in patients with cardiac amyloidosis EMERGING TECHNOLOGIES
oanne King – Point-of-care ultrasound: New concepts J and future trends EMERGING TECHNOLOGIES obyn Boman, AFASA – Artificial intelligence-aided method to detect R
uterine fibroids in ultrasound images: a retrospective study VASCULAR
Katrina Dietrich – Ultrasound examination of venous malformation VASCULAR
Heath Edwards – Contrast-enhanced ultrasound detects type II endoleaks during follow-up for endovascular aneurysm repair
16
17
19
20
WOMEN’S HEALTH ayana Parange, FASA – Late first-trimester ultrasound findings N
21
GENERAL arilyn Zelesco – Diabetes mellitus and the progression of M
23
HEALTH & WELLBEING eter Esselbach – Understanding and appreciating burnout P
25
can alter management after high-risk NIPT result
non-alcoholic fatty liver disease to decompensated cirrhosis: a retrospective cohort study
in radiologists
© Australasian Sonographers Association 2024. Disclaimer: The information in this publication is current when published and is general in nature; it does not constitute professional advice. Any views expressed are those of the author and may not reflect ASA’s views. ASA does not endorse any product or service identified in this publication. You use this information at your sole risk and ASA is not responsible for any errors or for any consequences arising from that use. Please visit www.sonographers.org for the full version of the Australasian Sonographers Association publication disclaimer
Making waves
JANUARY 2024 | 4
MUSCULOSKELETAL
REVIEWED BY Craig Winnett ASA SIG: Musculoskeletal REFERENCE
Evaluation of the ulnar nerve with shearwave elastography: a potential sonographic method for the diagnosis of ulnar neuropathy
Authors: Kim S & Lee GY Journal: Ultrasonography. 2021;40(3): 349-356 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Cubital tunnel syndrome causes neuropathy of the ulnar nerve at the elbow. It is the 2nd most common neuropathy of the arm after carpal tunnel syndrome. Cubital tunnel syndrome occurs at the cubital tunnel of the medial elbow, where compression and/or irritation of the ulnar nerve results. Symptoms of cubital tunnel syndrome include focal pain over the ulnar nerve at the elbow, and numbness and tingling in the 4th and 5th fingers, especially when the elbow is bent. Clinical diagnosis can be aided with nerve conduction and electromyography studies. However, these studies can be painful, cause injury to the nerve and can elicit false negative (normal) results in the early stages of symptoms. Due to its high spatial resolution of nerves, dynamic ultrasound imaging can assess the appearance of the ulnar nerve and assess for signs of irritation or compression of the nerve. Ultrasound is also useful to assess for structural causes of compression and/or irritation to the ulnar nerve at the cubital tunnel, including bony protrusions, accessory muscles and subluxation of the ulnar nerve. A pathological ulnar nerve may demonstrate the following changes seen on ultrasound. These include focal hypoechoic change, thickening of the nerve proximal to the site of compression, alteration of the normal fascicle pattern, perineural oedema and increased intraneural vascularity on colour Doppler. Cross-sectional area (CSA) measurement of the nerve on ultrasound has been shown in previous studies to be useful with a cut-off normal value of 9 mm2. An increase in the area size above 10 mm2 has been linked with positive ulnar neuropathy (with a sensitivity of approximately 60%). Shear-wave elastography (SWE) is a new developing technique and can be used to quantitatively measure the stiffness of soft tissue, including muscles, tendons and masses. The use of SWE to assess the stiffness of nerves is a new area of research. Recent research into the applications of SWE has shown a potential to help with the diagnosis of neuropathies. It has been hypothesised that a swollen neuropathic nerve would have a stiffer, higher SWE measurement compared with a normal nerve. This study aimed to investigate whether SWE could identify increased stiffness of affected ulnar nerves at the cubital tunnel. This study also investigated CSA measurements of the ulnar nerve in relation to the ulnar nerve with neuropathy compared to unaffected ulnar nerves.
HOW THE STUDY WAS PERFORMED The study reviewed 57 patients who had current elbow pain symptoms. The patients underwent an ultrasound scan with B-mode and SWE to examine the ulnar nerves. The study was performed by 2 radiologists using a Samsung RS85 ultrasound machine and a 2-9MHZ linear transducer. The radiologist did not know the patient’s clinical history or the results of the electrodiagnostic studies. The CSA of the ulnar nerves was measured proximal to the cubital tunnel, at the cubital tunnel and distal to the cubital tunnel. The cut-off for normal ulnar nerve CSA of 9 mm2 was used at all points. Ulnar nerves were considered swollen when their CSA was measured above this. SWE was measured using a 5 mm2 area box over the nerve at the same sites where the CSA was measured. Ten of the patients had known ulnar neuropathy confirmed with electromyography. The remaining 47 patients had either symptoms of medial or lateral epicondylitis.
Making waves
JANUARY 2024 | 5
MUSCULOSKELETAL
Evaluation of the ulnar nerve with shear-wave elastography: a potential sonographic method for the diagnosis of ulnar neuropathy
WHAT THE STUDY FOUND Patients with ulnar neuropathy were shown to have significant swelling of the nerve as indicated by an increased cross-sectional area (CSA) of 13 mm2 at the cubital tunnel, compared to 8.7 mm2 for the remaining patients. All patients had a normal CSA measurement of the ulnar nerve (less than 9 mm2) at the proximal cubital tunnel and distal cubital tunnel sites. This study showed that the patients with a pathological ulnar nerve had a normal ulnar nerve CSA measurement proximal and distal to the cubital tunnel. This study went on to demonstrate that patients with ulnar neuropathy had significantly higher measured SWE values at the site of inflammation/irritation of the ulnar nerve at the cubital tunnel. The ulnar neuropathy group had an SWE measurement of 66 kPa, compared to 21–33 kPa for the two other patient cohorts. The study also demonstrated that the ulnar nerve SWE measurements proximal to the cubital tunnel and distal to the cubital tunnel were deemed normal for both the ulnar neuropathy patients and the remaining patients.
SWE seems to be a new, reliable, and simple quantitative diagnostic technique to aid in the precise diagnosis of ulnar neuropathy at the cubital tunnel.
RELEVANCE TO CLINICAL PRACTICE Clinically, CSA measurements of an ulnar nerve at the cubital tunnel are technically non-reliable and subjective due to the tricky anatomy to get a true trans-cross-section of the ulnar nerve consistently without over-measuring the nerve in an oblique view. SWE presents as a possibly more reliable adjunct to the diagnosis of ulnar neuropathy in conjunction with B-mode, colour Doppler and dynamic ultrasound assessment. SWE is showing promising results to be a reliable and simple quantitative diagnostic technique to aid in the diagnosis of neuropathies including the ulnar nerve at the cubital tunnel. A limitation of this study was the small cohort of patients for the data collection. Further study is also needed to investigate if stiffness SWE values do or don’t increase in early neuropathic and chronic neuropathic states of the ulnar nerve. While more research is needed in this field, including establishing normal and abnormal ranges for SWE nerve measurements, the early studies are suggesting that SWE can add quantitative data to aid confidence and increase the sensitivity of ultrasound in the diagnosis of neuropathies, cubital tunnel syndrome, and potentially other sites of nerve entrapment.
Making waves
JANUARY 2024 | 6
MUSCULOSKELETAL
REVIEWED BY Deborah Carmody, AFASA ASA SIG: Musculoskeletal REFERENCE
A systematic temporal assessment of changes in tendon stiffness following rotator cuff repair
Reviewer: Authors: Lisa Hackett, Ryan S Ting, Patrick H Lam, George AC Murrell Journal: J Ultrasound Med. 2023;42: 1799-1808 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Rotator cuff disorders are a common cause of shoulder pain and discomfort, and surgical repair of the rotator cuff is one of the most common upper limb surgeries performed. There is a high incidence of retear after surgical repair of the rotator cuff, prompting the need to understand the healing process and material changes in the tendon. Shear-wave elastography (SWE) can be used to quantify tissue stiffness. Bone is a stiff structure and has high shear-wave velocity and low shear-wave displacement. Tissues such as muscle bellies or adipose tissues are less stiff and have low shear-wave velocity and high shear-wave displacement. Tendon stiffness is in between bone and adipose tissue. The stiffness of uninjured tendons should be greater than those of tendinopathic tendons. The paper aimed to evaluate whether there were changes in time (over one year) in supraspinatus tendons post arthroscopic rotator cuff repair in terms of: • stiffness (using SWE) • thickness • the relationship between tendon stiffness and thickness
HOW THE STUDY WAS PERFORMED The supraspinatus tendon of 50 participants who had surgically repaired rotator cuff tendons (single-row inverted mattress arthroscopic repairs) was sonographically assessed using longaxis B-mode imaging and acoustic radiation force imaging (ARFI) SWE (at three regions: adjacent to, 3 mm medial and 6 mm medial to the tendon footprint, all 2 mm posterior to the long head of biceps brachii tendon). Participants were assessed at six time points by a single sonographer: 1, 6, 12, 24 and 52 weeks, postoperatively.
Making waves
JANUARY 2024 | 7
MUSCULOSKELETAL
A systematic temporal assessment of changes in tendon stiffness following rotator cuff repair
WHAT THE STUDY FOUND The study found several significant findings: • T he stiffness of the supraspinatus tendon increased in the lateral tendon 24 weeks following primary arthroscopic rotator cuff repair before stiffness increased at the medial tendon and continued to improve out to 52 weeks post-op. • T he repaired tendon became 11% thinner in the first 6 weeks post-surgery and that tendons that were less stiff 1 week postoperatively were more likely to be thinner 6 weeks postoperatively. This finding that tendon thickness decreased from 1 to 6 weeks postoperatively was consistent with our hypothesis that the repaired supraspinatus tendon takes 6 weeks to heal to the bone, before becoming stiffer over time.
Evidence of rotator cuff tendon healing on postoperative ultrasound is characterised by increased echogenicity with increased fibrillar pattern and echotexture.
RELEVANCE TO CLINICAL PRACTICE Understanding the changes in tendon stiffness and thickness can aid in patient management and rehabilitation planning. The observation that tendons may stretch and thin out in the initial 6 weeks post-surgery highlights the importance of careful postoperative monitoring and early intervention if necessary.
Making waves
JANUARY 2024 | 8
RESEARCH
REVIEWED BY Ling Lee, AFASA ASA SIG: Research REFERENCE
A typology of reviews: an analysis of 14 review types and associated methodologies
Authors: Maria J Grant & Andrew Booth Journal: Health Information & Libraries Journal. 2009; 26: 91-108 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED With an increased number of systematic reviews added to the medical library and information literature as a result of evidence-based practice (EBP), a wide variety of terminology has been adopted to describe the methods in performing such reviews, such as review of the evidence, comprehensive review, literature review, overview and systematic review. The diversity of such terminology is confusing. As outlined in its objective, the study aims to describe and analyse the most common types of reviews, a total of 14, using examples from health and health information domains that have contributed to the library and information science (LIS) sector.
HOW THE STUDY WAS PERFORMED The authors practised literary warrant by examining the vocabulary used in the searched literature to determine the most commonly used terminology. Then, by adopting a framework called Search, Appraisal, Synthesis and Analysis (SALSA), each review type was analysed to describe its specific characteristics to differentiate it from others, including its perceived strengths and weaknesses. An example was provided to appreciate the characteristics of different review types.
WHAT THE STUDY FOUND A total of fourteen (14) review types and associated methodologies were mapped against the SALSA framework and were clearly summarised in a table. The review types are as below: 1. Critical review 2. Literature review 3. Mapping review/systematic map 4. Meta-analysis 5. Mixed studies review/mixed methods review 6. Overview 7. Qualitative systematic review/qualitative evidence synthesis 8. Rapid review 9. Scoping review 10. State-of-the-art review 11. Systematic review 12. Systematic search and review 13. Systematised review 14. Umbrella review The study identified, in the process of classifying reviews by various authors, that there is significant incoherence and overlapping among the supposed different review types. The authors stated the only sensible way to differentiate each review type is by applying the SALSA framework to identify the unique features of each review type, followed by direct comparison and emerging precedent, due to a lack of agreement in defining and standardising review types internationally.
Making waves
JANUARY 2024 | 9
RESEARCH
A typology of reviews: an analysis of 14 review types and associated methodologies The typology presented in this study serves as a baseline to assist LIS workers (librarians, information professionals, etc.) in commissioning and developing reviews. Furthermore, it assists them in appraising and interpreting reviews to uphold an evidence-based library and information practice, as well as to further support the practice of others in the wider healthcare domain.
RELEVANCE TO CLINICAL PRACTICE The rise in incorporating review articles to guide our clinical practice as sonographers to ensure evidence-based practice (EBP) is apparent. Equipping ourselves with critical appraisal skills, such as the SALSA framework, is beneficial to assist us in interpreting and utilising review articles effectively to keep our clinical practice updated. From the research perspective, this typology helps guide us in designing and performing reviews. It is worthwhile to engage LIS workers, such as librarians and information professionals, for their excellent skills in extracting, identifying and reviewing health information reviews, especially in the initial stage of developing research, such as data collection and the review development process.
Making waves
An agreed typology of reviews is crucial to the advancement of EBP of LIS workers themselves while providing valuable support to health practitioners in the upholding of EBP in healthcare.
JANUARY 2024 | 10
RESEARCH
REVIEWED BY Caterina Watson, AFASA ASA SIG: Research REFERENCE
Analysis of recent Australasian Sonographers Association (ASA) conference abstracts: How many progress to publication?
Author: Jo-Anne Pinson Journal: Sonography. 2020; 7: 148–153 Open Access: No (article accessible to ASA members in Sonography journal) READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Sonographer training requires accomplishment in clinical skills and an accredited course of postgraduate study. Knowledge interpretation and critical thinking are developed during this period. The conference abstract is another tool to hone these professional skills. This study was the first known analysis of the ASA conference abstract to publication rate. It compares this rate to similar allied health and radiology conference abstract publication rates. This metric can be used as a benchmark for future studies to gauge research shifts within the Australian sonography profession.
HOW THE STUDY WAS PERFORMED Between 2015 and 2017, 605 abstracts were identified in the Sonography special issue ASA conference abstracts publication. This was reduced to 297 Australian abstracts. Excluded abstracts included invited plenary speakers (35), international and workshop abstracts (133), and incomplete conference abstracts (140). Australian abstracts were traced in peer-reviewed journals using the following search criteria: author, research institute, date of publication, comparable data or methodology, and conclusion equivalent to conference abstract. Published conference proceedings, grey literature and white papers were not considered journal publications.
WHAT THE STUDY FOUND From 297 abstracts, 59 abstracts resulted in the publication of full texts. These publications were distributed over 29 journals and had more than 430 citations (average 7.4 citations/publication). Sonography journal published the full text for 32.2% of the 59 abstracts.
Future research could focus on clinicians’ reasons why they do not publish. Implementation of programs to improve clinicians’ ability to publish would add value to the health service in terms of evidence, recognition and patient outcomes.
Over three years, the ASA conference abstract to publication rate was 19.9%. This figure was within range for emergency ultrasound conference abstracts, which had a publication rate of 22.8%. Radiology conferences have been reported to have a publication rate of 44.9%, considerably higher than abstract publication rates for allied health bodies. Of the accepted ASA abstracts, 11.8% were from non-metropolitan areas. The average number of accepted poster abstracts was 16.0 ± 7.0. The average number of accepted oral presentation abstracts was 83.0 ± 17.0. Duplication of data was examined in multiple conference abstracts and different conference years. The replication rate for ASA Sonography special issue abstracts was reported to be 2.7%.
RELEVANCE TO CLINICAL PRACTICE Some presentations may never be intended for publication but are used for gaining presentation experience or conference funding. ASA conference presenter professions (not plenary speakers) included sonologist, radiologist, cardiologist, surgeon, obstetrician, and gynaecologist. A more relevant abstract to publication metric might be found with the presenter professions focusing on sonographer, educator, researcher, and allied health professional. This may reveal a truer reflection of research participation in the sonography profession. Gauging a profession’s research participation can inform the research culture. Identifying the uptick in research activity has been an interesting trend noted in the other allied health groups of emergency medicine and radiography. For example, radiography has reported annual increases in the number of doctoral awards, publications and citations. This has been interpreted as growth in research participation. This study is a snapshot of Australian research presented at ASA conferences between 2015–2017. A repeat study may provide evidence for a similar trend in the Australian sonography profession.
Making waves
JANUARY 2024 | 11
PAEDIATRIC
REVIEWED BY Emma Rawlings ASA SIG: Paediatric REFERENCE
Radiological and surgical correlation of pelviureteric junction obstruction in positional anomalies of the kidney in children
Authors: Meshaka R, Biassoni L, Leung G, Mushtaq I, Hiorns M Journal: Pediatric Radiology 2022 Dec; 53:544–557 Open Access: No READ THE FULL ARTICLE HERE
PURPOSE OF THE PAPER Meshaka et al. have compiled this review with the primary aim of discussing the anatomical, radiological and surgical correlations of congenital pelviureteric junction (PUJ) obstruction in the context of the normal kidney and a spectrum of renal abnormalities including hyper-rotation (also described as renal malrotation), failed renal ascent, fusion anomalies and accessory crossing renal vessels. They also supply technical tips on how to identify altered anatomy sonographically and provide correlation with MR urography, scintigraphy and postoperative imaging where indicated. The main learning objective is to understand the role of imaging in the preoperative assessment of PUJ obstruction with emphasis on the radiological appearances of a non-standard PUJ obstruction which may preclude the child from a successful pyeloplasty.
WHAT THE PICTORIAL REVIEW DESCRIBED Background PUJ obstruction is the congenital narrowing of the urinary tract at the junction of the renal pelvis and ureter and is the most common cause of paediatric upper urinary tract obstruction. The authors describe the normal physiology of renal ascent and rotation. Failure of ascent results in fusion anomalies, and ectopic or partially ascended kidneys (including parachute kidney). Hyper-rotation (or malrotation) most commonly describes the posterior or lateral facing renal pelvis (or any deviation from the normal 90-degree rotation). As ascent and rotation are contemporaneous, abnormalities can coexist in a non-standard PUJ obstruction, which may require an altered surgical approach. PUJ obstruction in anatomically normal kidneys PUJ obstruction may be intrinsic or extrinsic, with kinking of the PUJ, adhesion bands or overlying vessels. The authors describe an ultrasound protocol and describe circumstances in which scintigraphy or MR urography may be indicated. Measurement of the AP renal pelvis is included, with > 10 mm correlating strongly with the presence of uropathy and > 15 mm identifying the need for pyeloplasty (> 90% sensitivity and specificity). PUJ obstruction in kidneys with a posterior or lateral facing renal pelvis This morphological arrangement results from excessive or reverse rotation of the kidney and is caused by the inferior pole of the kidney compressing the PUJ as the proximal ureter courses over it to find its normal position anterior to the psoas muscle. Failure to detect this configuration has significant surgical implications as conventional pyelopasty is less likely to be successful therefore increasing the likelihood for further surgical intervention. PUJ obstruction in renal ectopia and fusion anomalies Ultrasound of an obstructed pelvic, parachute, horseshoe or cross-fused ectopic kidney should aim to determine the position of the pelvis exiting the kidney and the level of obstruction to inform surgical planning. The authors suggest that it is also important to understand the preoperative appearances in these cases, as postoperative follow-up imaging often fails to follow the expected post-pyeloplasty course in terms of improving renal pelvic dilatation (the renal pelvis commonly remains markedly dilated despite relief of the functional obstruction).
Making waves
JANUARY 2024 | 12
PAEDIATRIC
Radiological and surgical correlation of pelviureteric junction obstruction in positional anomalies of the kidney in children
Crossing vessel PUJ obstruction Accessory renal arteries may cross the PUJ leading to extrinsic compression and obstruction (up to 5% of cases). If an accessory vessel is identified, the level of the obstruction should be scrutinised to see if it correlates with extrinsic compression. Surgically, a vascular hitch procedure is performed to relocate the accessory vessel, negating the need for a pyeloplasty. (NB: No stent or anastomosis will be identifiable on postoperative imaging.) The authors provide a tabulated suggested sonographic protocol for the preoperative assessment of PUJ obstruction in children, including key considerations. Operators are encouraged to consistently report renal position, pelvic exit and accessory renal vessels to help inform the surgical approach.
RELEVANCE TO CLINICAL PRACTICE
Operators are encouraged to report renal position, pelvic exit and accessory renal vessels, any of which could contribute to obstruction.
PUJ obstruction is the most significant cause of paediatric upper urinary tract obstruction and causes up to 30% of antenatally detected pelvicalyceal dilatation. Obstruction can lead to stasis, recurrent infection, calculi, scarring and eventual loss of renal function, and the timing of surgical intervention depends on the severity. Ultrasound plays a vital role in preoperatively assessing the PUJ obstruction, monitoring and postoperative assessment. This article is extremely helpful in guiding the operator to thoroughly assess the PUJ obstruction and to provide as much detail as possible to inform surgical planning.
Making waves
JANUARY 2024 | 13
REVIEWED BY
CARDIAC
Chrissy Thomson, AFASA ASA SIG: Cardiac REFERENCE
Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis
Authors: Tomasoni D, Adamo M, Porcari A, Aimo A, Bonfioli G, Castiglione V, et al. Journal: European Heart Journal Cardiovascular Imaging. 2023;24: 1405–1414 Open Access: No READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Right ventricular to pulmonary artery (RV-PA) coupling relates to the ability of the RV to increase contractility to match RV afterload (pulmonary arterial pressures). When RV contractility cannot rise to match RV afterload, RV-PA uncoupling occurs, resulting in RV dysfunction and RV failure. This study aimed to (1) investigate the prognostic value of the echocardiographic assessment of RV-PA coupling in patients with cardiac amyloidosis (CA), and (2) whether this measurement could provide superior prognostic information compared to the stand-alone measurements of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP).
HOW THE STUDY WAS PERFORMED A retrospective evaluation of echocardiographic studies was performed on consecutive patients diagnosed with immunoglobulin light chain (AL) or transthyretin (ATTR) CA from 2011 to 2021. A total of 283 patients were included in the analysis, with 63% of the study population being male, and a median age of 76 years. RV-PA coupling was measured using the TAPSE/PASP ratio. TAPSE was measured from an RV-focused apical four-chamber view. The PASP was measured using the equation: 4 x [TR peak velocity]2 + [estimated right atrial pressure*] *Based on inferior vena cava collapsibility and size. Other standard measurements were included for analysis and were stratified by the TAPSE/ PASP ratio. These included left and right ventricular size, wall thickness and function, and atrial size. Measurements were performed according to recommendations by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. The primary endpoint for the study was the composite of all-cause death or heart failure (HF) hospitalisation, with a secondary endpoint being all-cause death. Data was collected using electronic health records, chart review and patient reporting.
WHAT THE STUDY FOUND The median value of the TAPSE/PASP ratio across the 283 patients was 0.45 mm/mmHg. Patients with TAPSE/ PASP < 0.45 mm/mmHg were older, had a higher prevalence of ATTR-CA, presented with lower systolic blood pressure, had more severe symptoms and had higher rates of atrial fibrillation. In addition, these patients had greater ventricular wall thickness, poorer LV systolic and diastolic function, greater RV dilatation, poorer RV function, and more dilated atria.
Figure 3 from the article demonstrated patients with TAPSE/PASP < 0.45 mm/mmHg reached the primary endpoint of all-cause death or HF hospitalisation more frequently than those with TAPSE/ PASP > 0.45 mm/mmHg, with an approximately twofold risk.
Making waves
JANUARY 2024 | 14
CARDIAC
Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis The optimal cut-off for predicting the prognosis of the primary endpoint was found to be 0.47 mm/mmHg, according to receiver operator curve (ROC) analysis. It was also found that while the stand-alone TAPSE and PASP measurements were significantly related to the study endpoints, the TAPSE/PASP ratio < 0.45 mm/mmHg provided a more comprehensive assessment of right heart performance and prognostic information than either TAPSE or PASP alone (see Table 4 in original article).
RELEVANCE TO CLINICAL PRACTICE Stand-alone measurements of TAPSE and PASP are currently routine inclusions in an echocardiographic study. An additional, simple calculation of the TAPSE/PASP ratio will provide clinicians with additional prognostic information in patients with cardiac amyloidosis, enabling closer monitoring of those patients found to be at higher risk of death and hospitalisation.
Making waves
The TAPSE/PASP ratio was more effective than TAPSE or PASP in predicting prognosis.
JANUARY 2024 | 15
REVIEWED BY
EMERGING TECHNOLOGIES
Joanne King ASA SIG: Emerging Technologies REFERENCE
Point-of-care ultrasound: New concepts and future trends
Authors: Yaoting Wang, Huihui Chai, Ruizhong Ye, Jingzhi Li, Ji-Bin Liu, Chen Lin, Chengzhong Peng. Journal: Advanced Ultrasound in Diagnosis and Therapy, 2021, 5(3): 268-276 Open Access: Yes
WHY THE STUDY WAS PERFORMED
READ THE FULL ARTICLE HERE
‘Point-of-care ultrasound (POCUS): New concepts and future trends’ provides a comprehensive overview of the current state of POCUS and its prospects. The paper effectively covers the historical background, clinical applications, and recent advancements in the field.
HOW THE STUDY WAS PERFORMED The paper starts with exploring key concepts related to POCUS, including its historical background, technological advancements and clinical applications. The authors provide a comprehensive overview of the different POCUS techniques, such as acute and critical care, ultrasound-guided procedural and musculoskeletal applications, highlighting their respective benefits and limitations. Furthermore, the paper discusses the emerging trends and future directions in the field of POCUS. The paper explores the integration of artificial intelligence and machine learning algorithms to enhance image interpretation and improve diagnostic accuracy. The authors also touch upon the potential role of POCUS in resource-limited settings and telemedicine applications, providing a glimpse into the broader impact of this technology. The organisation of the paper is logical and well-structured. The sections flow smoothly, allowing the reader to understand the concepts progressively. The authors provide ample references to support their statements and include relevant figures and illustrations to aid comprehension.
POCUS can provide reliable essential information and participate in the entire clinical diagnosis and treatment process.
WHAT THE STUDY FOUND The paper successfully emphasises the importance of this technology with a wide range of clinical applications and its potential impact on patient care. The discussion effectively covers the historical development of POCUS and brings the reader up to speed with recent advancements in technology. On a side note – it was refreshing to see the ultrasound technology developments set out in a schematic diagram (Figure 1) and to wonder what advances will occur in the next decade or two.
Figure 1: Schematic diagram of US technology developments
The exploration of future trends in POCUS, particularly the integration of artificial intelligence, is a notable aspect of the paper. This aspect highlights the potential for further advancements and the role of POCUS in improving healthcare outcomes. However, a more extensive discussion on the ethical considerations and potential limitations and challenges of these technologies would have enhanced the paper’s impact.
RELEVANCE TO CLINICAL PRACTICE The advancements in emerging technologies not only help with improving image quality but are also important to meeting the increasing requirements of various clinical specialties. Overall, this paper demonstrates that POCUS and emerging technologies have the potential to impact various medical specialties, improve patient outcomes, and enhance the efficiency of healthcare delivery by providing immediate diagnostic information at the point of care.
Making waves
JANUARY 2024 | 16
EMERGING TECHNOLOGIES
REVIEWED BY Robyn Boman, AFASA ASA SIG: Emerging Technologies REFERENCE
Artificial intelligence-aided method to detect uterine fibroids in ultrasound images: a retrospective study
Authors: Tongtong Huo, Lixin Li, Xiting Chen, Ziyi Wang, Xiaojun Zhang, Songxiang Liu, Jinfa Huang, Jiayao Zhang, Qian Yang, Wei Wu, Yi Xie, Honglin Wang, Zhewei Ye & Kaixian Deng Journal: Sci Rep. 2023;13, 3714 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED This study was performed to assess the effectiveness of an artificial intelligence (AI) program for the detection of uterine fibroids from transabdominal (2–7 MHz) and transvaginal (5–7 MHz) ultrasound images. The study aimed to analyse if the use of the AI program could assist junior sonographers in detecting uterine fibroids and compare the findings to the detection rate of senior sonographers. The ability of the senior sonographer was the ground truth for the AI program analysis.
HOW THE STUDY WAS PERFORMED This study was a noninterventional and retrospective study of the efficacy of an artificial program to identify uterine fibroids. The fibroids were all sonographically and pathologically identified. The training of the algorithm used 3870 ultrasound images in total. There were 2020 images with uterine fibroids (n = 667, mean age = 42.5 years ± 6.23) and 1850 normal images (n = 570, mean age = 39.2 years ± 5.3). A deep convolutional neural network, which is based upon a deep learning algorithm, used 3382 after exclusions to create the AI program. The ground truth was established by sonographers with more than ten years of clinical experience for the confirmation of observed fibroids. The testing of the efficacy of the AI program was divided into four combinations with each category using averaged results. The sonographers were junior sonographers (n = 4) with 5 or fewer years of experience and senior sonographers (n = 4) with 10 or more years of experience. The two levels of experience were compared against the AI program. Additionally, the junior sonographers and AI program combined were compared against the senior sonographers.
WHAT THE STUDY FOUND The study demonstrated there was an improvement in the detection of uterine fibroids using the AI program compared to the detection rate of junior sonographers. There was also an improvement in the detection of uterine fibroids for AI-assisting junior sonographers compared to junior sonographers with no assistance from the AI program.
The proposed DCNN detection system can identify the presence of fibroids in ultrasound images, and it can also serve as a learning tool for junior sonographers to learn to correctly differentiate uterine fibroids.
Incidentally, there was no statistical difference between the findings of the junior sonographers. Additionally, there was no statistical difference between the senior sonographers identifying uterine fibroids with or without the assistance of the AI program. With the use of the AI program, the junior sonographers demonstrated the same efficacy as the senior sonographers without AI. The area under the curve (AUC) defines the characteristic performance of the testing. Junior sonographers demonstrated an AUC of 0.87 while the senior sonographers, AI program alone and AI program combined with junior sonographers, were all 0.95. These results demonstrate the effectiveness of the AI program tested as a teaching tool.
Making waves
JANUARY 2024 | 17
EMERGING TECHNOLOGIES
Artificial intelligence-aided method to detect uterine fibroids in ultrasound images: a retrospective study
RELEVANCE TO CLINICAL PRACTICE The development of this AI program has been demonstrated to be an effective tool in assisting junior sonographers to improve their ability to detect uterine fibroids. The AI program has the potential to improve detection rates while assisting junior sonographers in the process of identifying uterine fibroids (Table 1). Table 1. Comparison between the DCNN model and ultrasonographers with different levels of seniority
PPV positive predictive value, NPV negative predictive value, AUC area under the receiver operating characteristic curve. P*1 value for junior ultrasonographers (averaged) compared to DCNN. P*2 value for senior ultrasonographers (averaged) compared to DCNN. P*3 value for DCNN + junior ultrasonographers (averaged) compared to junior ultrasonographers (averaged). P*4 value for DCNN + junior ultrasonographers (averaged) compared to senior ultrasonographers (averaged).
Making waves
JANUARY 2024 | 18
VASCULAR
REVIEWED BY Katrina Dietrich ASA SIG: Vascular REFERENCE
Ultrasound examination of venous malformation
Authors: H Kim & N Labropoulos Journal: Ann Phlebology. 2022; 20(1): 24-29 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED The authors discuss venous malformations (VM) and present an ultrasound protocol for performing a malformation study. As VM can be complex and extensive, Kim and Labropoulos successfully simplify and break down the topic for experienced vascular sonographers. The authors stress the importance of differentiating between varicose veins (VV) and VM to appropriately guide management. Other imaging modalities are briefly mentioned, highlighting the typical US limitations – operator dependency and anatomy complexity.
HOW THE STUDY WAS PERFORMED Kim & Labropoulos review case studies from patients diagnosed with venous malformations and discuss the ultrasonic features of several examinations. The authors include clinical as well as ultrasonic images, focusing on specific imaging features indicative of venous malformations. The article presents several differing malformations (size, location, depth, anatomical relationships) with similar ultrasonic findings assisting in the arrival of a VM diagnosis. Other imaging modalities were also discussed.
WHAT THE STUDY FOUND The article presents a case in the utility of ultrasound to differentiate between VM and VV, which has clinical implications for patient management. The clinical cases discussed further demonstrate the importance of ultrasound in conjunction with other imaging modalities for diagnosing and characterising venous malformations. Specific ultrasonic features such as low to very low flow, minimal reflux (if present), as well as the presence of muscular or bony involvement, are indicative of venous malformations. Importantly, the identification of phleboliths within the vascular structures is another definitive feature. The authors found that ultrasound can delineate the extent and anatomical characteristics of venous malformations in many cases, aiding in treatment planning and decision-making. Furthermore, the study discussed the advantages of ultrasound over other imaging modalities in terms of accessibility, cost-effectiveness, and real-time evaluation. Despite its limitations in visualising deeper structures compared to MRI or CT scans, ultrasound is a valuable initial imaging tool due to its non-invasive nature and ability to provide dynamic imaging, allowing for the assessment of hemodynamic changes within the malformation.
The natural history and prognosis of VVs and VM are different, and the discrimination of both diseases is critical for devising management strategies.
RELEVANCE TO CLINICAL PRACTICE This article serves as an important reminder to the reader that the most common type of congenital vascular malformations is venous malformations. Ultrasound can be a reliable imaging modality for the diagnosis and characterisation of VM, which is crucial for guiding treatment strategies. This article briefly discusses the pathogenesis of VM, provides a protocol for ultrasound examination as well as presents ultrasonic imaging findings of clinical cases. The authors provide a list of distinguishing features comparing VM and VV, which is helpful for vascular sonographers who will be exposed to VM. Vascular ultrasound is useful in diagnosing and characterising these malformations, allowing for prompt and accurate diagnosis, facilitating early intervention and appropriate management planning. The accessibility and cost-effectiveness of ultrasound make it a practical first-line imaging modality in assessing patients with suspected venous malformations. Real-time imaging and dynamic assessment of blood flow within the malformation assist clinicians in monitoring changes over time and evaluating treatment response. US avoids exposure to the articular in the younger patient cohort.
Making waves
JANUARY 2024 | 19
VASCULAR
REVIEWED BY Heath Edwards ASA SIG: Vascular REFERENCE
Contrast-enhanced ultrasound detects type II endoleaks during follow-up for endovascular aneurysm repair
Authors: L Johnsen, J Hisdal, T Jonung, A Braaten, G Pedersen Journal: J Vasc Surg. 2020;72(6): 1952-1959 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Endovascular aneurysm repair (EVAR) requires lifelong follow-up due to the potential for major complications. Surveillance of EVAR using computed tomography angiography (CTA) leads to increased radiation dose and exposure to nephrotoxic contrast agents. This study was performed to investigate the sensitivity of contrastenhanced ultrasound (CEUS) versus CTA, post EVAR, concerning the detection of an endoleak.
HOW THE STUDY WAS PERFORMED The study included 79 men and 13 women with each patient scheduled for paired CTA and CEUS appointments at 1 month, 6 months, 12 months, and 24 months, post EVAR.
High sensitivity and specificity as well as avoidance of radiation and nephrotoxic contrast agents are advantages.
Altogether, 233 paired CEUS and CTA examinations were performed. Data was missed due to patient limitations: renal failure leading to the inability to perform CTA, inability to be transported for follow-up due to worsening health condition, and patient death. The results from the CEUS were blinded from the operator performing the CTA and vice versa. The results from previous paired examinations in the same patient were also unavailable when a new follow-up examination was being conducted.
WHAT THE STUDY FOUND Of the total 233 paired examinations, CEUS detected 39 of the 48 endoleaks detected on CTA. Two false positives were noted, with the overall sensitivity of CEUS 81.3%. All the endoleaks detected in this study population were type II. The 9 endoleaks missed on CEUS were defined as small type II endoleaks on the CTA reports, with no increase in aneurysm sac or intervention required. Patient body mass index (BMI) was a limiting factor with the false positive rate substantially higher with increased BMI as depicted in the graph below: Although CEUS seems to be able to detect endoleaks with high precision, this study showed that the missed endoleaks on CEUS are overrepresented in the patient group with high BMIs.
RELEVANCE TO CLINICAL PRACTICE High sensitivity and specificity as well as the avoidance of radiation and nephrotoxic contrast agents are advantages of CEUS vs CTA in follow-up post EVAR.
Fig 3. Percentage of false-negative endoleaks using contrast-enhanced ultrasound (CEUS) and the relation to body mass index (BMI).
The number of patients undergoing EVAR, as are younger patients, is growing globally. This study has proven the ability of CEUS to detect endoleaks with high precision and it should have a role in EVAR follow-up. Incorporating CEUS into EVAR surveillance with CTA recommended for patients with increased BMIs should be a consideration.
Making waves
JANUARY 2024 | 20
WOMEN’S HEALTH
REVIEWED BY Nayana Parange, FASA ASA SIG: Women’s Health REFERENCE
Late first-trimester ultrasound findings can alter management after high-risk NIPT result
Authors: F Scott, M-E Smet, J Elhindi, R Mogra, L Sunderland, A Ferreira, M Menezes, S Meagher, A McLennan Journal: Ultrasound Obstet Gynecol. 2023; 62: 497-503 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Non-invasive prenatal testing (NIPT) is a screening test in pregnancy performed typically around 10–11 weeks of pregnancy to determine the risk of genetic abnormalities in the fetus. This test analyses cell-free DNA (cfDNA), which is principally from the maternal haemopoietic cells and the cytotrophoblast. NIPT sensitivity and specificity are the highest for Trisomy 21. The detection rates are also high for Trisomy 18 and Trisomy 14; however, positive predictive values (PPV) for these are lower as these anomalies are less prevalent and have a greater degree of placental mosaicism. The false positive cfDNA is most often due to placental mosaicism although other contributing factors include maternal factors such as malignancy, fibroids, and mosaicism. Late first-trimester ultrasound (LFTU) scan for the assessment of fetal anatomy and nuchal translucency (NT) is performed closer to 13 weeks’ gestation and is useful for characterising structural anomalies in keeping with the specific genetic abnormality identified by the high-risk NIPT, thus potentially increasing the PPV of NIPT. Conversely, an unremarkable ultrasound may decrease the NIPT’s PPV. This study aimed to evaluate the impact of a detailed LFTU on the PPV of a high-risk NIPT for various aneuploidies.
HOW THE STUDY WAS PERFORMED This was a retrospective study of data for all women with a singleton pregnancy undergoing prenatal invasive diagnostic testing from 3 tertiary providers of obstetric ultrasound from 2 major cities in Australia over 4 years, each using NIPT as a first-line screening test. Data collection included pre-NIPT ultrasound, NIPT results, LFTU findings, placental serology, and later, ultrasound findings. Pre-NIPT ultrasound information included fetal, number, viability, and gestation. Where structural abnormalities or enlarged NT were identified, genetic counselling ensued to help determine if NIPT was undertaken or bypassed in favour of chorionic villus sampling (CVS). All LFTUs were performed by Fetal Medicine Foundation-accredited sonographers. LFTU was classified as normal when the fetus displayed appropriate growth and appeared structurally normal with no sonographic aneuploidy markers evident. When structural abnormalities and/or enlarged NT (> 3.00 mm) were identified, invasive testing was offered, even with a low-risk NIPT result. Statistical analysis was completed in Stata SE Version 14.2. Hypotheses were conducted at a significance level of 0.05 with a two-sided alternative.
WHAT THE STUDY FOUND Amniocentesis and chorionic villus sampling (CVS) were performed on 2657 patients, 51% of whom had prior NIPT, with 612 (45%) returning a high-risk result. The LTFU findings significantly altered the PPV of the NIPT result for trisomies 13, 18 and 21, monosomy X (MX) and rare autosomal trisomies (RATs), but not for the other sex chromosomal abnormalities or segmental imbalances (> 7 Mb). An abnormal LFTU increased the PPV close to 100% for trisomies 13, 18 and 21, MX and RATs. The magnitude of the PPV alteration was highest for the lethal chromosomal abnormalities. If the LTFU was normal, the incidence of confined placental mosaicism (CPM) was highest for those with an original high-risk T13 result, followed by T18, then T21. After a normal LFTU, the PPV for trisomies 21, 18, 13 and MX decreased to 68%, 57%, 5% and 25% respectively.
Making waves
JANUARY 2024 | 21
WOMEN’S HEALTH
Late first-trimester ultrasound findings can alter management after high-risk NIPT result
STRENGTHS AND LIMITATIONS OF THE STUDY The strengths of this study include its broad representation from multiple centres, the large population screened with NIPT, mostly as a first-line screening method, the large number undertaking Genome-wide NIPT, the use of microarray analysis in all cases, the quality of the ultrasound equipment and the sonographers in a specialised obstetric ultrasound service. Weaknesses of the study include the older maternal age seen in a private ultrasound service, which may not be representative of the general obstetric population, the limited numbers of certain chromosomal abnormalities and the absence of ultrasound information from later gestations, as many confirmed genetic abnormalities resulted in termination of pregnancy. Most of the pregnancies had a pre-NIPT ultrasound, which could be considered as both a strength and a weakness of the study, as ideally an ultrasound should be performed before collecting blood for a NIPT but some cases with anomalies identified on the pretest ultrasound elected to bypass NIPT in favour of CVS, which could cause some inadvertent selection bias in the study.
RELEVANCE TO CLINICAL PRACTICE
A more accurate PPV of a high-risk NIPT result after a late first-trimester scan may facilitate counselling regarding invasive testing and can be reassuring for those with normal late first-trimester ultrasound who opt to wait for amniocentesis to avoid a mosaic result on chorionic villus sampling.
Late first-trimester ultrasound in the setting of a high-risk NIPT result when performed by welltrained sonographers provides valuable information altering the PPV for many chromosomal abnormalities. This information helps guide pregnancy management and prenatal diagnostic testing decisions.
Making waves
JANUARY 2024 | 22
GENERAL
REVIEWED BY Marilyn Zelesco ASA SIG: General REFERENCE
Diabetes mellitus and the progression of nonalcoholic fatty liver disease to decompensated cirrhosis: a retrospective cohort study
Authors: James O’Beirne, Richard Skoien, Barbara Leggett, Gutner F Hartel, Louisa G Gordon, Elizabeth Powell, Patricia Valery Journal: Med J Aust. 2023; 219: 358-365 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE ARTICLE WAS PUBLISHED Diabetes mellitus, obesity, and components of the metabolic syndrome are risk factors for the progression of non-alcoholic fatty liver disease (NAFLD) to decompensated cirrhosis, but their contributions to risk have not been examined in Australia.
INTRODUCTORY TEXT About five million Australians have non-alcoholic fatty liver disease (NAFLD), and the number is projected to rise to seven million by 2030. NAFLD can progress to adverse hepatic diseases, such as cirrhosis and its complications, including hepatocellular carcinoma. Shared risk factors such as obesity and diabetes mellitus mean that people with NAFLD are also at risk of extrahepatic complications, including major adverse cardiovascular events and cancer. The article assessed the incidence of decompensated cirrhosis and associated risk factors in people hospitalised with non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) with or without cirrhosis. It was a retrospective cohort study of linked Queensland Hospital Admitted Patient Data Collection, Queensland Registry of Births, Deaths, and Marriages, and Queensland Cancer Register data. Participants were Queensland residents aged 20 years or older admitted to Queensland hospitals with NAFLD/NASH from 1 July 2009 to 31 December 2018.
CORE TEXT The article focused on data extracted from analysing patients of all hospitalisations in Queensland from 1 July 2007 to 31 December 2019, aged at least 20 years with diagnoses of NAFLD or NASH (non-alcoholic steatotic hepatitis). After exclusions, 8006 patients were included in the analysis (10,082 admissions), including 4632 women (58%) and 2514 people with diabetes mellitus. Follow-up information was available for a median of 4.6 years, during which 351 people (4.4%) progressed to decompensated cirrhosis. Of the 1106 people with cirrhosis at the index admission, 32.4% had progressed to decompensated cirrhosis within 10 years, the median time to decompensation was 2.5 years. Of the 6900 people without cirrhosis, 4.5% had progressed to decompensated cirrhosis within 10 years, and the median time to decompensation was 4.1 years. Diabetes mellitus was the most frequent other medical condition at the index admission of people who progressed to decompensated cirrhosis. Of the 486 people with cirrhosis and diabetes mellitus, 10.5% progressed to decompensated cirrhosis within 12 months and 37.1% within 10 years. Compared with people without cirrhosis or diabetes, the risk of progression was greater for people with cirrhosis and diabetes mellitus or cirrhosis only. NAFLD often progresses to decompensated liver disease, and several factors are associated with this outcome. Progression to decompensation was more frequent among people with NAFLD/NASH who had diabetes mellitus but not cirrhosis at the index admission than for those who had neither cirrhosis nor diabetes mellitus. Other factors, such as age, hypertension, extrahepatic cancer, and history of major adverse cardiovascular events, also influenced the risk of progression. Further, the effect of these factors was cumulative; the risk of progression to decompensation was 13 times as high for people aged 50 years or more who had diabetes mellitus, a history of major adverse cardiovascular events, and hypertension than for people with none of these risk factors.
Making waves
JANUARY 2024 | 23
GENERAL
Diabetes mellitus and the progression of non-alcoholic fatty liver disease to decompensated cirrhosis: a retrospective cohort study
RELEVANCE TO CLINICAL PRACTICE This article reinforces concerns about the future burden of NAFLD-related liver disease in Australia. Healthcare use and costs are high for people with decompensated cirrhosis because of the required investigation and management of liver-related complications, long hospital stays, and high re-admission rates. Given the greater risk of progression to cirrhosis decompensation for people with NAFLD/NASH who also have diabetes mellitus, identifying those with advanced fibrosis and providing appropriate treatment to avert disease progression is vital. This is where hepatic ultrasound with shear-wave elastography and fat quantification software will become an increasingly important non-invasive tool.
Making waves
… given the greater risk of progression to cirrhosis decompensation in people with diabetes mellitus, identifying advanced fibrosis for averting disease progression is vital …
JANUARY 2024 | 24
HEALTH AND WELLBEING
REVIEWED BY Peter Esselbach ASA SIG: Health and Wellbeing REFERENCE
Understanding and appreciating burnout in radiologists
Authors: Christopher Bailey, Allison Bailey, Anna McKenney and Clifford Weiss Journal: RadioGraphics 2022: 42:E137-E139 Open Access: Yes READ THE FULL ARTICLE HERE
WHY THE STUDY WAS PERFORMED Burnout is on the increase in radiology with 49% of respondents in a recent survey reporting burnout. Burnout is a risk factor for mental illness, including major depressive disorder, and anxiety disorders. It is therefore important to understand what burnout is and how to recognise it in ourselves and our colleagues. We also need to be aware of how we might mitigate risk factors for burnout in radiology.
HOW THE STUDY WAS PERFORMED Data from Medscape’s 2022 National Physician Burnout and Depression Report was collated and examined to answer 3 questions: What drives burnout in radiologists? When does burnout become a clinical concern? How can we mitigate risk factors for burnout in radiology?
WHAT THE STUDY FOUND The top 5 factors contributing to burnout in physicians are: too many bureaucratic tasks; lack of respect from administrators, employers, colleagues, and staff; too many hours at work; lack of autonomy over one’s life; insufficient salary; and frustrations related to the use of electronic medical records. Burnout is considered a depressive syndrome and can be associated with significant functional impairment and a reduction in one’s quality of life. Changes in mood, energy, interest and motivation should not be dismissed and may be an indication for assessment by a mental health professional. Mitigation involves creating a workplace culture that is accepting and supportive of individual wellbeing. Addressing social isolation in radiology may involve providing structure and protected time for both mentorship and informal social interactions. On an individual level, this could involve stress reduction strategies like mindfulness or exercise, but these interventions are insufficient in isolation. Radiology practices should provide education on recognising the signs of burnout and facilitate access to appropriate mental health resources.
Burnout is a risk factor for mental ill health and can affect interpersonal dynamics in multiple social domains. Burnout is also a risk factor for significant mental illness including major depressive disorder, anxiety disorders, and substance use, particularly in those with predispositions for these conditions.
RELEVANCE TO CLINICAL PRACTICE Burnout in radiology and with sonographers is a significant and increasing issue. We need to be aware of the signs and symptoms and understand the factors that contribute to this syndrome. Sonographers can implement some of the strategies suggested in this article to help combat burnout in radiology practices.
Making waves
JANUARY 2024 | 25
