Clinical Evidence

Sound Judgment Series

The Journal of Ultrasound in Medicine has launched a special series, Sound Judgment, comprised of invited articles highlighting the clinical value of using ultrasound first in specific clinical diagnoses where ultrasound has shown comparative or superior value.

This series will serve as an important educational resource for clinicians, insurers, and educators.

Sound Judgment, Editorial - Levon N. Nazarian, MD, Editor-in-Chief

The Sound Judgment Series, Commentary - Steven R. Goldstein, MD

Sonography in Postmenopausal Bleeding - Steven R. Goldstein, MD

Think Ultrasound When Evaluating for Pneumothorax - Vicki E. Noble, MD

Sonography Should Be the First Imaging Examination Done to Evaluate Patients With Suspected Endometriosis - Beryl R. Benacerraf, MD, and Yvette Groszmann, MD

Sonography of Adenomyosis - Khaled Sakhel, MD, and Alfred Abuhamad, MD

Lung Ultrasound in Evaluation of Pneumonia - Michael Blaivas, MD

Ultrasound-Guided Interscalene Blocks - Andrew Gorlin, MD, and Lisa Warren, MD

Sonography for Surveillance of Patients With Crohn Disease - Kerri L. Novak, MSc, MD, FRCPC, and Stephanie R. Wilson, MD, FRCPC

Sonography as the First Line of Evaluation in Children With Suspected Acute Appendicitis - Leann E. Linam, MD, and Martha Munden, MD

Shoulder Sonography: Why We Do It - Sharlene A. Teefey, MD

Sonographically Guided Enema for Intussusception Reduction: A Safer Alternative to Fluoroscopy - Thomas Ray S. Sanchez, MD, Aaron Potnick, MD, Joy L. Graf, MD, Lisa P. Abramson, MD and Chirag V. Patel, MD

Sonography First for Subcutaneous Abscess and Cellulitis Evaluation - Srikar Adhikari, MD, RDMS, and Michael Blaivas, MD

Sonography in the Treatment of Calcific Tendinitis of the Rotator Cuff - Gregory R. Saboeiro, MD

Use of Sonographic Guidance for Selected Biopsies in the Lung and Superior Mediastinum - Kianoush Ansari-Gilani, MD, Corinne Deurdulian, MD, Nami Azar, MD and Dean A. Nakamoto, MD

Sonography First for Acute Flank Pain? - Christopher L. Moore, MD and Leslie Scoutt, MD

Sonographic Evaluation of Acute Pelvic Pain - Rochelle F. Andreotti, MD and Sara M. Harvey, MD

Musculoskeletal Sonography of the Tendon - Kenneth S. Lee, MD

Caval Sonography in Shock: A Noninvasive Method for Evaluating Intravascular Volume in Critically Ill Patients - Dina Seif, MD, MBA, RDMS, Thomas Mailhot, MD, RDMS, Phillips Perera, MD, RDMS and Diku Mandavia, MD

Use of 3-Dimensional Sonography to Assess Uterine Anomalies - Silvina M. Bocca, MD, PhD, and Alfred Z. Abuhamad, MD

Sonography of Facial Cutaneous Basal Cell Carcinoma: A First-line Imaging Technique - Ximena Wortsman, MD

Other clinical conditions that will be addressed in the series include right lower quadrant pain, pelvic pain, right upper quadrant pain, shoulder pain, among others.

Why Ultrasound First?

Compared to CT and MRI, ultrasound has comparable or superior diagnostic capability in a growing number of imaging scenarios across a clinical spectrum

Pediatrics (ex: evaluation of suspected appendicitis, intussesception, urinary tract infections)
Emergency/critical care (ex: for timely evaluation of retroperitoneal spaces for bleeding in management of blunt trauma; for evaluating pneumonia, pneumothorax, and shock)
Vascular (ultrasound-guided vascular access is now regarded as standard of care)
Women's medicine (ex: 3D evaluation of uterine anomalies; chronic and acute pelvic pain; postmenopausal bleeding)
Endocrinology (ex: to evaluate neck masses and parathyroid)
Sports/Pain medicine (ex: nerve blocks instead of general surgical anesthesia; to evaluate rotator cuff tears, tendon tears, soft tissue injuries, snapping hip syndrome, effusions)
Rheumatology (ex: diagnosis, aspiration/injection guidance, to track treatment response)
Surgery (ex: ultrasound-guided breast, liver surgical procedures)
Otolaryngology (ex: locate and characterize lesions and for pre-operative identification of abnormal vertebral arteries)
Gastrointestinal (ex: inflammatory bowel disease; malignancy management in the GI tract)
Dermatology (ex: facial basal cell carcinoma; soft tissue infections)
Renal (ex: renal colic)
Chest (ex: pneumothorax, pleural effusion, for early staging of lung cancer)
Cardiovascular (ex: carotid artery, rapid assessment of tamponade)

Using ultrasound first as appropriate improves patient safety.

Using ultrasound first as appropriate can reduce instances of unnecessary patient exposure to radiation.

Ultrasound delivers no ionizing radiation.
- No independently confirmed adverse effects caused by exposure from present diagnostic ultrasound instruments have been reported in human patients in the absence of contrast agents.
Increased number of exposures to CT exams results in increased lifetime risk.
This is a particular concern with the pediatric population.
- Appendicitis: ACR Choosing Wisely Campaign statement: "Don't do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent."
- Inflammatory Bowel Disease: Transabdominal ultrasound is a highly effective modality for detecting inflammatory activity, equal to CT or MR, and ultrasound is safe, noninvasive, with easy repeatability and patient tolerability.
For diagnosing head and neck ailments, radiation exposure is a concern.
- Ultrasound is adequate for diagnosis and assessment of treatment options for most conditions, and preoperatively ultrasound investigation allows a very precise identification of abnormal vertebral arteries.
For renal colic: CT scans are used nearly 80 percent of the time when diagnosing renal colic. Given the fact that renal colic is often a recurrent condition, this magnifies the patient's radiation-related risk. Studies have found that ultrasound provides reliable and noninvasive diagnoses of renal colic in the majority of cases.

Using ultrasound first improves patient outcomes by providing immediate information at the point of care.

Management of blunt or penetrating trauma to evaluate for intraperitoneal hemorrhage, pericardial tamponade, and hemothorax
Rapid evaluation for evidence of abdominal aortic aneurysm.
Rapid evaluation when there is suspicion of pericardial effusion.
Identification pneumothorax and pleural effusion
Ultrasound guidance improves the speed and accuracy of performance of procedures, and reduces complications.

Ultrasound is a cost-effective imaging modality.

Uterine anomalies: 3D transvaginal ultrasound provides visualization and evaluation of the uterine cavity with similar or better accuracy than standard hysterosalpingography in the office setting, with lower cost and morbidity.
Pelvic pain: Endometriosisosis: Transvaginal ultrasound is accurate and effective in detecting endometriosis without the need for MRI.
Rotator cuff tears: An initial screening test with ultrasound, followed by MRI for those patients who required surgery or failed conservative treatment, has been found to be more cost effective than everyone undergoing MRI as the initial evaluation.
Pancreas: Endoscopic ultrasound is better at finding small pre-symptomatic lesions than is MRI and significantly better than CT scans. One ultrasound advantage: it can also be used to collect cells from the pancreatic lesions, secretions from the pancreas, and fluid from cysts to facilitate further study.

Ultrasound has been shown to be an effective educational tool.

In vivo anatomy laboratory: Students are able to study things on live patients that they previously learned about only in cadavers, and can observe the function of living organs, like a beating heart..
Physical examination skills: Students are using ultrasound to enhance their physical examination skills by comparing their findings with ultrasound results at the bedside.
Remote learning: Students training in rural sites can relay ultrasound images to experts hundreds of miles away.

Ultrasound is used throughout the world with great success for diagnosis and management in a variety of medical conditions.

Ultrasound-guided vascular access has been shown to improve success rates while reducing iatrogenic injury, number of needle passes, and infection rates. Additionally, it may improve patient comfort and satisfaction.
Nerve block: Ultrasound-assisted peripheral nerve blocks for surgical anesthesia and postoperative analgesia have been found to be superior to general anesthesia as they provide effective analgesia with few side effects and can hasten patient recovery.
Ultrasound-guided surgery:
- Its use to remove tumors from women who have palpable breast cancer is much more successful than standard surgery in excising all the cancerous tissue while sparing as much healthy tissue as possible.
- With ultrasound-guided surgery, the need for major hepatectomies is much less likely, which results in improved quality of life and independence for these patients.
Triage: Easy to move around, ultrasound is a great asset for rapid imaging in mass casualty situations, including military. Because it's a real time modality, ultrasound diagnostic information is available immediately, which supports rapid decision-making.
Patient care in remote regions: Lightweight, portable ultrasound systems can easily be delivered to remote regions, including the International Space Station where it is the only imaging modality, so is playing an important role in astronaut safety and medical research.
Facial basal cell carcinoma: Ultrasound can be useful to plan BCC surgery; it can recognize lesions, layers of involvement and vascularity patterns in a non-invasive way.
Sports injuries: At the Olympics and other sports events, portable ultrasound units are being used to bring imaging to injured athletes instead of vice versa, which helps coaches and physicians determine whether an injured athlete can return to the field of play.
Endoscopic ultrasound: Produces detailed images of the gastrointestinal tract and adjacent organs, including the pancreas, liver, bile duct, and mediastinal space.
- Combining endoscopic ultrasound with fine needle aspiration offers powerful diagnostic capabilities that can help optimize malignancy management in the GI tract and inform appropriate treatment paths for the patient, including chemotherapy, radiation, or palliation.
Cardiac assessment: An ultrasound scan of the carotid artery significantly improves prediction of heart attack risk prediction, improving patient management strategies.

Continuing developments in ultrasound hold promise for valuable new ultrasound contributions to patient care.

Ultrasound elastography may mean fewer invasive procedures. The technique augments hand palpation to provide more information about tissue structures, and the digital information obtained from the exam can be stored for comparison at follow-up exams for increased diagnostic confidence in patient management decisions.
Photo-acoustic ultrasound holds promise for an accurate, cost-effective alternative to x-ray-based DXA scans for assessing osteoporosis.
High-frequency ultrasound holds tremendous promise for lower-cost disease diagnosis and treatment monitoring techniques. With the use of HIFU:
- Doctors could determine a tumor's response to therapy very early on in treatment.
- Make earlier, better-informed decisions about treatment efficacy and whether to continue prescribed plan or develop a different one.
- Improve patients' quality of life.
- Support other research by offering fast feedback on the effectiveness of trail therapies
- Reduce the need for invasive procedures and surgeries.

Ultrasound is underutilized.

Need to raise public awareness of ultrasound's advantages and many applications.
Need to educate medical community and patients as to clinical scenarios where ultrasound is an appropriate alternative to CT or MRI.

Selected References

Abramowicz JS, Barnett SB, Duck FA, Edmonds PD, Hynynen KH, Ziskin MC. Fetal Thermal Effects of Diagnostic Ultrasound. J Ultrasound Med 2008; 27:541-559.

Abuhamad AZ. Ultrasound outreach and the crisis in Haiti. J Ultrasound Med 2010; 29:673Ð677.

Benacerraf BR, Groszmann Y. J Ultrasound Med. 2012 Apr;31(4):651-3. Sonography should be the first imaging examination done to evaluate patients with suspected endometriosis.

Bioeffects Committee of the American Institute of Ultrasound in Medicine. American Institute of Ultrasound in Medicine Consensus Report on Potential Bioeffects of Diagnostic Ultrasound: Executive Summary. J Ultrasound Med 2008; 27:503-515.

Blaivas M, Tsung JW Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation. J Ultrasound Med. 2008 May;27(5):785-9.

Bobadilla F, Wortsman X, Mu–oz C, Segovia L, Espinoza M, Jemec GB. Pre-surgical high resolution ultrasound of facial basal cell carcinoma: correlation with histology. Cancer Imaging. 2008 Sep 22;8:163-72.

Bocca SM, Oehninger S, Stadtmauer L, Agard J, et al. A study of the cost, accuracy, and benefits of 3-dimensional sonography compared with hysterosalpingography in women with uterine abnormalities. J Ultrasound Med 2012; 31:81Ð85.

Chiou SY, Lev-Toaff AS, Masuda E, Feld RI, Bergin D. Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. J Ultrasound Med. 2007 Oct;26(10):1289-301.

Church CC, Carstensen EL, Nyborg WL, Carson PL, Frizzell, LA, Bailey MR. The Risk of Exposure to Diagnostic Ultrasound in Postnatal Subjects: Nonthermal Mechanisms. J Ultrasound Me; 2008; 27:565-592.

Currie GP, McKean ME, Kerr KM, Denison AR, Chetty M. Epub 2011 May 5. Endobronchial ultrasound-transbronchial needle aspiration and its practical application. QJM. 2011 Aug;104(8):653-62.

Fujii Y, Hata J, Futagami K, et al. Ultrasonography improves diagnostic accuracy of acute appendicitis and provides cost savings to hospitals in Japan. J Ultrasound Med 2000; 19:409Ð414.

Goldstein SR. Sonography in postmenopausal bleeding. J Ultrasound Med. 2012 Feb;31(2):333-6.

Hoppmann RA, Rao VV, Poston MB, et al. An integrated ultrasound curriculum (iUSE) for medical students: 4-year experience. Crit Ultrasound J 2011; 3:1Ð12.

http://www.nysora.com/peripheral_nerve_blocks/ultrasound-guided_techniques/3063-ultrasound_assisted_nerve_blocks.html

Kehl S, Kalk AL, Sven Eckert S, et al. Assessment of lung volume by 3-dimensional sonography and magnetic resonance imaging in fetuses with congenital diaphragmatic hernias. J Ultrasound Med 2011; 30:1539Ð1545.

Miller DL, Averkiou MA, Brayman AA, et al. Bioeffects Considerations for Diagnostic Ultrasound Contrast Agents. J Ultrasound Med 2008; 27:611-632.

Noble, VE. Think ultrasound when evaluating for pneumothorax. J Ultrasound Med. 2012 Mar;31(3):501-4.

O'Brien WD Jr, Deng CX, Harris GR, et al. The Risk of Exposure to Diagnostic Ultrasound in Postnatal Subjects: Thermal Effects. J Ultrasound Med 2008; 27:517-535.

Royse C. Ultrasound education in anaesthesia: turning the tables on convention. Ann Card Anaesth 2008; Jul-Dec;11(2):77-9.

Sakhel K, Abuhamad A. Sonography of Adenomyosis. J Ultrasound Med 2012 May;31(5):805-808.

Sani FM, Sarji SA, Bilgen M. Quantitative ultrasound measurement of the calcaneus in Southeast Asian children with thalassemia: comparison with dual-energy x-ray absorptiometry. J Ultrasound Med 2011; 30:883Ð894.

Singh P, Mukhopadhyay P, Bhatt B, et al. Endoscopic ultrasound versus CT scan for detection of the metastases to the liver: results of a prospective comparative study. J Clin Gastroenterol 2009; 43:367Ð373.

Stratmeyer ME, Greenleaf JF, Dalecki D, Salvesen KA. Fetal Ultrasound: Mechanical Effects. J Ultrasound Med 2008; 27:597-605.

Ultrasound evaluation of acute abdominal emergencies in infants and children. Radiologic Clinics of North America - Volume 42, Issue 2 (March 2004)

Yasufuku K, Nakajima T, Motoori K, et al. Comparison of Endobronchial Ultrasound, Positron Emission Tomography, and CT for Lymph Node Staging of Lung Cancer. CHEST September 2006 vol. 130 no. 3 710-718.

Declaring 2013 The Year of Ultrasound will raise public awareness and advance the use of ultrasound to promote patient safety and reduce unnecessary economic burden.