Menstrual Ultrasound

Hi,
I'm very happy to have started a column about ultrasound that appears at AuntMinnie.com. If you bop over there, peruse the selections and sometime type Birnholz into the search list and links to the articles will appear.

The term 'Aunt Minnie' is attributed to Ben Felson, who was an excellent plane film radiologist, and very likely the very best radiology educator  in the history of the specialty. I had the pleasure of meeting him personally  a few times when I was a resident. He was very fond of jokes and humor, and his lectures sparkled with wit. He used the term Aunt Minnie for something you recognize almost instantly on an X-ray film without necessarily having to think  about how you know it - just like knowing that it is your Aunt Minnie when she visits.

The latest article at Aunt Minnie is entitled menstrual ultrasound and it is about the ultrasound exploration of  the dynamics of menstruation and of pathological vaginal bleeding. There is a lot of discussion of the 'hypervascular' myometrium, which is equivalent to diffuse adenomyosis clinically. These images are baseline and energy Doppler views  of the uterus in a woman with vaginal bleeding and pelvic pain. The top image is a shear wave elastogram showing that the myometrium is quite hard with diffuse adenomyosis. A blog treat, since I'm reserving elastography for a future article there. 

 

 Long axis, through a thin endometrium with some liquid blood in the endometrial cavity.  Energy Doppler is monocolor. directional Energy Doppler is multicolored

  transverse views
 

All Images are made with a Supersonic Imagine Aixplorer.

back to blogging

I was very disappointed at the lack of comments about the mystery case. I don't think there are many followers for this blog, but I did e-mail a lot of the so called movers and shakers in OB ultrasound about this case, but as expected, no one seemed willing to make a public mistake, even in an out of the way place like this. Really, guys, when you get to the point where protecting your fragile reputations is more important than learning, you might as well give up.

To be honest, I really didn't expect a lot of correct answers. Most places that do obstetrical ultrasound are mired in a limited set of anatomic issues and act as if a check list a items constitutes a medically acceptable  exam. Consider the issue of selection of major congenital anomalies, where any number of large controlled studies have shown that average performance is really bad. Even if detection rates were very much better, anatomic findings would be relevant in perhaps 5 % of cases. What about the 95% majority of patients? How are they best served? What about the factors that can injure an anatomically "normal" fetus with life long behavioral, intellectual, or motor problems.

The idea is to go beyond an anatomic checklist and a few body measurements to  examining a fetus ultrasonically in exactly the same way that a Pediatrician or, better yet, a Neonatologist would examine a newborn infant. Therein lies the strength and potential of ultrasound.

The challenge case is still open.

Fetal Challange Case

This fetus was seen at 26 weeks GA and again at 28 weeks for a size and dates discrepancy.There was a mild but definite decrease in amniotic fluid volume in both exams. There were no anatomic malformations, growth is normal. The 3D image at 28 weeks was essentially identical to another face view in the earlier exam.

What is the diagnosis?


There is enough information for a relatively specific diagnosis, which will be revealed and discussed after those of you who do OB ultrasound exams make your comments.

Ultrasound Reporting & Photography

Let's link two separate factors: medical imaging is photography and the imaging report is the main marketing tool of the free standing imaging facility.


The first proposition is pretty direct for image forming rather than its inseparable companion,  image interpretation. I'm never surprised at how many of the people I know in the various disciplines of medical imaging  identify their hobby as photography. And, to be sure, the mandatory exposure of residents in Diagnostic Radiology exposes them to a graduate level education in the tech of photography that goes far beyond what the vast majority of professional photographers see or get. Is there really a difference between sunlight or gamma ray photon and  phonon photography at a conceptual level?

I hope you will all visit my light photography website and enjoy the various topic galleries at Visual Jason Photography.

 I believe the second notion was one that my good friend Dr George Flinn in Tennessee expressed when I started in private practice at the end of 1988 after 20 years in big hospital/academia, where, also, patients tend to have no (or not offered any alternatives) in where they have their imaging studies.The main Harvard associated hospitals never send patients for imaging studies to each other, and there is no phrase in the local language for even expressing the idea of having imaging studies at any of the Tufts or Boston University locations. Perhaps that failure to share resources has something to do local pride of excellence. The situation is much worse in Chicago, where for many years the larger hospitals have formed hospital networks that don't recognize each other's existence, which, from my personal opinion is motivated by economic factors primarily.

From the standpoint of the free standing clinic, what the referring physician gets is a report of the patient's visit. That needs to be coherent, complete, and accurate as well as prepared and sent promptly. We can assume that when there is an urgent issue, the physician involved with an individual exam will contact the referring physician directly. Most of the time the report is e-mailed, faxed, or sent by conventional mail. The referring physician typically has none of the options for reviewing images directly with a Radiologist when everyone is rounding in the same location. For the time being, we will concentrate on the way things have been done for the last 50 years and reserve discussion of some of the free web based PACS systems that are available to private practice Radiologists for a later posting.

What George realized and had been doing in his own practice was a novel way of placing images directly on the reports. What the referring physician needs is to know the interpretation of the Radiologist for the exam, does it answer the clinical question, if not, what should be done next. Placing images on the report is a way of validating the interpretation and expressing visually how an interpretation was made. It also illustrates that the interpretation was made from technically satisfactory images (which has always been a major issue in ultrasound). It is not the images themselves that are important, but what they represent. A report with great images conveys the professionalism of the center doing the study, which is a marketing function when there are multiple locations that appear to provide the same service for patients.

Our own little contribution to this was the thought that when a referring physician sits down to go through all the reports filtering in for their patients, especially those with lesser problems, it may be a little tricky to remember who's who. So, what we do and have done for most of the time we have been in private practice is to photo-identify all of our reports with a closeup of the patient in the upper right hand corner of the report, near the patient's name and identifiers.

21st March, 2011. T, Moon  (11-2146)

Formatting is trivial with a word processor, but you get the idea. About 1 in 12,500 patients will decline the photo-op, which is their privilege. Everyone else likes it, especially my referring physicians, and I find that it helps me to get back into a case whenever  a patient returns for more scanning. Like most Radiologists, I'm primarily visual. The picture above, was made with the same camera that we use for patient photos with some contrast enhancement for impact. Any digital point and click will work well for this application, especially since there is no need for enlargements.Of course no one gets to see those photos who is not designated to receive the report.

I think I saw a short paper in a recent JACR about some clinic at the Massachusetts General Hospital photo-identifying patient reports. Nice innovation, MGH, although about 20 years behind the curve.

Instructive Case - cont'd

I've always wished that I could produce from memory something pithy and perfect and exactly appropriate from Milton, or Shakespeare, or maybe Pope or Shaw, but I can't. However one thing that I can't seem to get rid of is:  This Case, like first love...very instructive, which is from a Charlei Chan movie. Of course almost no one except for some older cruciverbalists remembers Charle Chan or his three movie portrayers and first love tends to hit at an age when instruction and education are impossible. Now that I've used it up, I hope it will vanish from my memory forever.

The question I asked the patient was - Have any relatives who are anemic?  The answer was, "Why yes, my grand mother had sickle cell disease." No one ever asked me that before."

Now let's get into the case itself. There was early intrauterine pregnancy without any unusual pelvic findings. The two pictures are, obviously, the gall bladder (conventional 2D and  a 3D surface reconstruction, in which the anterior part of the gall bladder has been escised revealing the mucosal floor and stone floating just above it.It has been our practice since we started using phased array imaging in 1976 to do a survey of everything visible transabdominally in everyone referred for any type of abdominal or pelvic ultrasound. In the second or third trimesters of pregnancy, we tend to focus on the fetus, but we will a more extensive maternal exam with even the most minimnal of reasons. We don't charge anything extra for our surveys, they only add a minute or two to the exam, they provide a cache of valuable clinical information, establish a baseline should a question come up in the future, and during the process, patient's often volunteer a lot of relevant history, since they perceive that this is a real medical exam.

Gallstones are highly prevalent, making this one of the commonest intended or unexpected ultrasound imaging findings.In this case we have a young (slender) woman (not a lot of subcutaneous fat to be seen) with a single, larger stone that floats in bile at the distal end of the gall bladder (not the dependent neck region with the patient supine). There is no acoustic shadowing, gall bladder volume is normal, and the wall is thin and delicate.

Typical cholesterol stones are typically preceeded by progressine chronic focal cholecystitis with puntate scarring showing up as reflective patches in the submucosa and as distinct ridging, usually transverse to the axis of the gallbladder) in 3D cutaway views of anterior or posterior lumenal surfaces. The posterior surface, here is absolutely smooth and pristine. All of which suggests that this stone is most likely due to chronic intermittent episodes of hemolysis.  An additional finding was a splenic accessory, next to a slightly rounded tip of a normal sized spleen with a uniform sonic architecture.

The 'incidental' finding now makes us think of Sickle trait or one of the sickle trait variants.Aside from the frequency of renal papillary necrosis and wel described renal concentrating issues in older patients with sickle trait, there is always the worry that episodes of sickling can occur whenever and wherever there may be hypoxia. The prototype and tragic example is sudden death during exercise in black military recruits, which received a lot of attention in the 1980's leading to recognition of this problem and steps for its prevention. Dancers, like this patient, often have workouts that put to shame what a lot of professional athletes can indure. 

There is a really great article about sickle trait by Dr John Kark of the Howard University School of Medicine that you may find really instructive by clicking here.

Interlude: A way to look at the role of ultrasound

John Knowles, presidential adviser and head of Massachusetts General Hospital (when I was a lowly serf there) told me some 30+ years ago that it's a lot easier to prevent disease than to treat it. I treasure the memory of the interaction, although he might have been stingier with his prescient platitudes if he knew that I would soon deviate from my original interest Cardiology.

What I have seen over and over again is that a lot of people are reluctant to have diagnostic exams and how relieved they are when there is a simple, fixable explanation (like pelvic adhesions in a woman afraid of ovarian cancer) or, better, yet, when they exam can show that something really appears to be normal.This is, actually, the main role of ultrasound in obstetrics. There is always maternal anxienty, it gets worse with each pregnancy, typically least first time around and peaking with the third child, eventhough some 90+ % of unselected groups of pregnant women traversing the first trimester in peace, will have 'normal' children close to term.

The great developmental pediatrician HFR Prechtl in a massive body of work, slipped in a paper maybe 15 years ago about  scoring 'wellness' in exams rather than abnormalities.I recall his referring to that as 'optimality testing'. There have been lots of  studies with  'quality of life' as an end point, which is very closely related  and which also provide a set of statistical tools for coping with this type of subjective variable.

I think it is about time that we all got involved in studies which show how a lot of our exams promote patient happiness by eliminating the worries about specific problems. In many ways this is an unique property of ultrasound, which can be used widely, cheaply, and without any compromise in patient safety. In places where ultrasound is trusted, there is also reduced demand upon and improved utilization of CT and MRI, but that is another matter entirely. The tools are there, and after focusing on pathology for so long, a look at the flip side might be refreshing. If you think about it, a negative exam is even better for prevention than finding an early indication of a problem requiring some behavioral modification of pre-emptive drug therapy.

An Instructive Case

The patient is a 21 year old female Afro-American dancer referred with intermittent pelvic pains about 2 weeks after conception.

What should you ask her?



What ultrasound industry marketing people need to know about Radiologists and other physicians.

Most physicians spend a lot of time improving their medical skills and tend not to know the distinctions between sales, marketing, and promotion within the larger multinational companies that dominate the ultrasound market.

I've met quite a few marketing executives over the years, many of them are admirable as individuals, but none of them has really understood physicians or our needs. A few of the sharper marketeers moving through the ultrasound realm during the last decade know this is true and they have focused much of their attention on technologists, whom they perceive as doing a lot of the exams and influencing purchases, although they are not responsible (legally or ethically) for the content of the exams themselves.

Medicine has been reinventing itself for the last few centuries. We are finally getting to understand the astoundingly complex nature of diseases as genetic pathways that are activated, blocked, subverted, or altered; new therapies are being devised based on the understanding of these pathways, and the relatively recent onset and progressive development of statistical methods are indicating what works diagnostically and how treatment should be started, bridging the divide between populations of people and the individual patient. There are also economic forces that have to be addressed when trying to provide optimal care for the entire population. I would assume that most physicians, like me, would say that middle of the road care for everyone is better than fabulous care for just a few, and that given time and a working system, mediocre will become uniformly excelllent.

Internal medicine may have begun as a specialty around the time and through the teachings of William Osler and his disciples. Osler mainly championed critical, scientific thinking, and a lot of skepticism, applied to the patient evaluation. Perhaps the main goal was to sift out from available information whether one was dealing with a systemic condition (i.e. involving  an organ system and having consequences for the entire body) or something localized and hence the classic caricatures of the scholarly internest analyzing data (including drug responses) and  the surgeon who fixes something physically and decisively.

Anyway, there is always that question that pervades every diagnostic patient encounter: is there an  occult systemic process or is the problem localized. For a long time, there were few lab tests and limited imaging procedures. There was little or no preventive medicine, and common conditions were found late in their courses when little could be done. With the notable exception of screening chest films (once an integral part of every hospital admission for any cause), imaging studies tended to be restricted to limited questions.

We now have lots of very specific blood and body fluid lab tests, and, of course, everyone is tending to rely more and more on newer forms of imaging to do the traditional job of the Internest, determining what is going on inviolate deep inside the body. Ultrasound is often marketed in a disease-centric way, not as a general diagnostic tool. The consequence of this approach is that it emphasizes the older notion ofcofirming suspicions of advanced pathology rather than identifying earlyforms of disease without external signs.

Now here is the real  issue: every radiologist no matter what the imaging task, labors under the worry about the basic question of  systemic vs local disease. Sometimes, we have to accept the word of the referring physician that problems are just local (like a broken finger in a healthy person), but the basic diagnostic burden is still always there, whether we see the patient directly or work through agents like technologists or nurses. This is not a frivolous matter, because the Radiologist, like all other physicians, knows that if he misses any clue to a systemic or more immediately life endangering process, then that inattention will harm the patient. With experience, this burden becomes greater, and part of maturation as a physician is in coping with this responsibility in daily practice. It tends to make us a little humble to our patients (which doesn't mean loss of  confidence, since it is essential to believe that you can help in order to do so), forgiving of each other, and, to be honest, somewhat arrogant towards those who are trying to sell us something who don't know about this aspect of our work.

It's a good idea to think of physicians that you are encountering in a business setting a little like talking to an armed FBI agent. That person demands a lot of respect and an understanding that they are not too far removed from life and death issues and apply a knowledge base and set of experiences that are appropriate to those tasks. You should, of course, try to involve imaging physicians as early in instrument development as possible, instead of  at the end when your company is already committed to a specific type of implementation.Alternatively, you should think of the physician you are approaching exactly the way that you interact with your own physician.

A lengthy intro to this blog about diagnostic ultrasound

When I had my graduate and postgraduate medical education (on the East Coast mid 1960's-1970's) there was NO public medical advertising, and the rare times when anyone sought to advertise, the assumption was that physician, clinic, or hospital had to be failing financially,  probably, because they weren't very good at what they did. In the 1980's, some of the larger hospitals that were failing financially, began to advertise heavily on radio, TV, magazines, and newspapers trying to capture new patient visits or referrals for their extended professional resources. For some places, that worked very well and has become established now as part of the daily background. In some practice areas, like infertility, back pain, and anything cosmetic, smaller clinics and even private practitioners allocate a lot of funds for local promotions.

This new blog was prompted by an ad that I heard today while waiting for a news updates on Libya and Japan. It was from a larger, specialized medical group that kept going on about the latest and most advanced TECHNOLOGY, which was why patients should just flock to them. I have to say that I'm a little tired of every place claiming this distinction. And as a Radiologist, I tend to chuckle at how all visual ads, like TV or brochures, always seem to have some mandatory MRI ( or, the much older, CT) images to illustrate the claim. What I think rankles most is that it is the skill and experience of the users of the TECHNOLOGY that need to be 'best' for this all to work, nor is there any way for individual patients to really know about this when they are trying to decide where to go for a test or procedure. Most people rely on their primary doctor to select where a test ought to be done and that person may be limited to the self interest of their own institution or network.

I have been subspecialized in ultrasound, essentially since the field began here in the US. So, I've kind of seen it all. I am very proud of the technical advances that have been almost continuous during that time, and I have even had a little to do with some of those improvements myself. There was a big jump in equipment performance in 1983 with the commercial release of Computed Sonography - more about that in later posts. It ushered in what I think of as the golden age of Ultrasound, because there was a relatively small group of ultrasound physician specialists who were trying to find out how this method could be best utilized medically on its own and relative to all other diagnostic tools.

Computed sonography began what I might refer to as the beam former approach to image reconstruction. The end point was that images had less noise than earlier kinds of equipment: diagnoses were broader, faster, and more reliable than ever before in all applications.

As computing capabilities became faster (and cheaper) beam former technology and its partner, transducer design, improved, and many manufacturers began to produce lower cost equipment, although with performance features and clinical utility were typically inferior to what might be achieved with the "best" equipment used expertly. All it might take to avail oneself of ultrasound in a practice, would be to buy a unit, buy a technologist to run it, or attend a short training course. This is admirable in a practice 50+ miles from anywhere, but it's a little dubious in urban or suburban areas with  lots of local medical resources. Smaller units are often designated as point of care equipment. Most emergency room services have point of care ultrasound devices, and some  ER physicians now have fellowship training, although most of the clinical work in this area tends to be focused on limited issues and resembles work of the 1980's. I suppose an emergency facility getting on site ultrasound for the first time can advertise latest technology (for them), meaning newest.

I do realize that facility advertising has everything to do with the facility and essentially really not much to do with the people who work there. I assume, that any physician is always trying to do the best he or she can all of the time. That is an entirely separate issue from using capital equipment purchases promotionally.

Obstetrics is the field which has taken made the most use of point of care ultrasound imaging. The good thing is that a lot of  fetuses get looked at who would not have had the opportunity otherwise. The bad thing is that most of those millions of exams annually are with low performance equipment, done by personnel with limited imaging education and restricted clinical goals. Perhaps, because our society tends to indulge in  lawsuits, particularly when something appears to go wrong in pregnancy, an unique concept transpired when many Obstetrics facilities wrested this form of imaging from Radiology departments in their institutions which was to identify levels of exam for non-Radiologists, A level I exam is supposed to convey one that is utterly basic, including a short set of mandatory imaging items.  Imagine this, for the first time in the history of medicine, practitioners thought that it is OK to request or to do a study that is identified as limited, inexpert, or incomplete in any way. The justification is thrugh admitting that the study not as good or complete as one might get somewhere else. Of course, places doing limited exams cannot usually claim 'latest technology', on the other hand there are many instances of such places promoting their 3D fetal portrait capabilities, eventhoug this does not change the scope of the exam itself.

The intention of this blog is to expand upon the interfaces between patient, examiner, and equipment, unearth some of the trends that have led us to where we are now (definitely not another golden age from the patient's standpoint), and then get into a few of the real technical advances happening now that may revitalize the use of this amazingly powerful diagnostic tool. Maybe, we will get to a point where pointless touting of 'The Latest Technology' will be identified for what it is.