USEFUL

USEFUL: Ultrasound Exam for Underlying Lesions Incorporated into Physical Exam
Jon Steller, MD, Bianca Russell, MD, Shahram Lotfipour, MD, MPH, Graciela Maldonado, MD, Tim Siepel, MD, Halsey Jakle, MD, Stacy Hata, BS, Alan Chiem, MD, RDMS, John Christian Fox, MD, RDMSDisclosures
Western J Emerg Med. 2014;15(3):260-266.

ABSTRACT

Introduction: The Ultrasound Screening Exam for Underlying Lesions (USEFUL) was developed in an attempt to establish a role for bedside ultrasound in the primary and preventive care setting. It is the purpose of our pilot study to determine if students were first capable of performing all of the various scans required of our USEFUL while defining such an ultrasound-assisted physical exam that would supplement the standard hands-on physical exam in the same head-to-toe structure. We also aimed to assess the time needed for an adequate exam and analyze if times improved with repetition and previous ultrasound training.

Methods: Medical students with ranging levels of ultrasound training received a 25-minute presentation on our USEFUL followed by a 30-minute hands-on session. Following the hands-on session, the students were asked to perform a timed USEFUL on 2–3 standardized subjects. All images were documented as normal or abnormal with the understanding that an official detailed exam would be performed if an abnormality were to be found. All images were read and deemed adequate by board eligible emergency medicine ultrasound fellows.

Results: Twenty-six exams were performed by 9 students. The average time spent by all students per USEFUL was 11 minutes and 19 seconds. Students who had received the University of California, Irvine School of Medicine's integrated ultrasound curriculum performed the USEFUL significantly faster (p< 0.0025). The time it took to complete the USEFUL ranged from 6 minutes and 32 seconds to 17 minutes, and improvement was seen with each USEFUL performed. The average time to complete the USEFUL on the first standardized patient was 13 minutes and 20 seconds, while 11 minutes and 2 seconds, and 9 minutes and 20 seconds were spent performing the exam on the second and third patient, respectively.

Conclusion: Students were able to effectively complete all scans required by the USEFUL in a timely manner. Students who have been a part of the integrated ultrasound in medicine curriculum performed the USEFUL significantly faster than students who had not. Students were able to significantly improve upon the time it took them to complete the USEFUL with successive attempts. Future endpoints are aimed at assessing the feasibility and outcomes of an ultrasound-assisted physical exam in a primary care setting and the exam's effect on doctor-patient satisfaction.

Introduction

Records of Hippocratic physical examinations, influenced by the Egyptian, Cretan and Babylonian exams taught before them, included: careful history taking, inspection, palpation, and direct auscultation, and are a tradition that has continued on for thousands of years.[1] It is a great model, yet it is one that has seen few technological advances. Progress was made with the invention of the stethoscope by Laennec in 1816, and was further improved upon by Leyton, Kerr, Bowles, Rappaport, Sprague and Littmann. As newer stethoscopes improved the diagnostic sensitivity and specificity of auscultation, they were implemented into the physical examination. For Ramsay once wrote of Dr. Leyton in the British Medical Journal in 1916, "In spite of careful inquiry into the history of cases and in spite of the many accurate methods of investigation which are nowadays at our command, we cannot invariably form a perfectly definite opinion as to the cause of a patient's symptoms. Any new instrument, therefore, which can help us in our decisions should be of real use to the profession."[2] While his message encourages progress, utilization of new tools in medicine requires a detailed examination of risks and benefits. In modern medicine, we struggle to balance the cost of innovation, time constraints, management of incidental and benign exam findings, patient satisfaction, and managed health care. Our skepticism and curiosity of medical advances drive the use of the scientific method to investigate such developments before they are accepted and implemented by the community of physicians—before they can drive progress.

Over the years, various uses of bedside ultrasound have been adopted by specialties including emergency medicine, obstetrics and gynecology, and trauma. While its use in those fields has been rigorously studied in clinical settings and is the preferred first-line imaging modality for assessment of many of the organs in the abdomen and pelvis,[3] little has been reported on its role in an outpatient primary care setting and this has inspired us to consider the possible role of ultrasound as an addition to the standard physical exam. Given the recent affordability and improved image quality of bedside ultrasound units, we believe bedside ultrasound could be the new figurative stethoscope.

With this first paper, our primary endpoints were to examine the feasibility and time requirements of a medical student-performed ultrasound-assisted physical exam, termed the Ultrasound Screening Exam for Underlying Lesions (USEFUL), wherein students with varying levels of expertise would be evaluated on their ability to correctly and efficiently image individual organs from head to toe. We also sought to define our ultrasound-assisted physical exam for further medical student education and for clinicians interested in integrating ultrasound into their physical exams. Aware of the time restraints for physicians in outpatient clinics, we determined six minutes or less would be an acceptable length for a USEFUL and hoped this would be a reasonable goal. The USEFUL was developed by students and faculty interested in establishing a role for bedside ultrasound in the primary and preventive care setting with the hope that, in the future, an ultrasound-assisted physical exam that would take approximately six minutes might supplement the standard hands-on physical exam.

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US ELASTOGRAPHY for VARICOSE VEINS of LOWER EXTREMITIES

Aims and objectives

To assess a feasibility of ultrasound elastography for monitoring of conservative therapy of the varicose veins of lower extremities with a drug containing micronized purified flavonoid fraction (MPFF).

Ultrasound elastography, as a technique evaluating the elastic properties (stiffness) of tissues, was carried out after standard ultrasound examination. The elasticity of biological tissue describes its ability of reversible deformation, i.e. the property to exert mechanical resistance when the force is applied and to regain the original shape after removal of force. Elastography image is a graphical representation of the displacement of tissue layers under the influence of several cycles of compression/decompression of the investigated vein by sensor. The received echo signal is processed by the device, and the color-coded information on the displaceability of the studied tissue layers is displayed.

The dense tissue is indicated in blue, the tissue with moderate elasticity - in green and yellow-green, and softer tissue - in red.

According to our data, the unaltered vein has a soft-elastic structure of the vessel wall/perivasal tissues complex, which is uniformly encoded in green or yellow-green. The width of soft-elastic limbus around the vein is determined by the size of the vessel, as well as the presence of abnormalities. During the USEG of veins and adjacent tissues we evaluated the area of perivasal tissues on the posterior wall of the vessel at the moment of maximal decompression, which has a homogeneous elasticity, as well as the width of perivasal zone of tissue elasticity (Figures 1a, 1b). The vein is coded in red as the softest structure because of the presence of liquid component and formed elements that can move and, therefore, determine a high degree of relative elasticity of the tissue.

Conclusion

The study has shown that the changes identified using the ultrasound elastography are more pronounced in the vessels of large diameter. Intact veins of lower extremities have a homogeneous image of elastogram, suggesting about unaltered histological structure of these tissues. In the presence of varicose transformation, the heterogeneous elastography pattern reflected, probably, the disturbance of histological regularity of tissues surrounding the vessel.

The therapy with MPFF was associated with a trend to normalization of elastographic image of vessel, which relates to the reduction of the severity of aseptic inflammation and normalization of cellular structure, and, therefore, the physical properties of the studied tissue.

The obtained data confirm the feasibility of ultrasound elastography for identification of the objective markers of treatment response to MPFF in varicose disease.