A Collaborative Approach to Ultrasound

Conventionally, the main users of ultrasound have been radiologists, obstetricians and cardiologists. The last decade, however, has seen a rapid introduction of ultrasound equipment and applications into almost every field of medicine. “From internists, gastroenterologists to vascular surgeons, emergency physicians to hospitalists, rheumatologists and orthopedists and even podiatrists and chiropractors, everyone is using ultrasound. Recently, I saw some handheld machines that have been introduced for use by nurses and medical students. And even in the veterinary field, ultrasound has been widely accepted,” says Dr. Barry Goldberg, Director of the Diagnostic Ultrasound Division, Department of Radiology, at Thomas Jefferson University Hospital (TJUH).

With so many specialties sharing an interest in ultrasound, Goldberg has recognized the advantages of working together. Under the umbrella of the Ultrasound Research and Education Institute (JUREI), TJUH’s radiologists teamed up with its obstetricians, perinatologists, vascular surgeons, gastroenterologists, cardiologists and emergency physicians. “That’s the key rather than working independently,” Goldberg points out.

The advantages of a collaborative approach to ultrasound are obvious, believes Goldberg. “We have a joint agreement between, for example, the vascular surgeons and us, so our technologists are one group. Our machines are used more efficiently. If there is a problem case, we can consult each other. If, on the other hand, we had separate centers there’d be an increase in expenses to the hospital because each group would have to buy separate ultrasound machines. They would have to hire separate schedulers and sonographers and would have separate forms, separate billing and so on. The concept of centralization, coming together for a common usage of equipment, is always advantageous,” he stresses.

Three-dimensional imaging

Goldberg had the opportunity to start working with ultrasound from its very beginning. “Back then it was just little spikes, then it became two-dimensional imaging without gray scale. Then it became gray scale, then color was added, then power,” he recalls. The biggest revolution, he adds, has been the computerization of ultrasound.

“What we’re seeing is significant improvement in image quality through the introduction of new crystal technologies and new computer technologies that allow us to better focus the beam, eliminate noise and produce higher quality images. The major breakthrough has been the ability to collect a volume of ultrasound resulting in three-dimensional imaging. We’ve seen a lot of success in obstetrics. It’s three-dimensional in real-time, so seeing motion of the heart and of the fetus, and having a volume that we can then manipulate to maximize information, is beginning to revolutionize ultrasound,” Goldberg relates enthusiastically.

Most of the machines available today, he points out, use a mechanical movement of the transducer. “But we’re beginning to see electronic arrays of some 3000 small crystals. We’re working towards 10,000 crystals in which you will have high resolution, three-dimensional real-time imaging that will be equivalent to the best image quality of the current two-dimensional imaging. That’s going to be a major revolution which will happen, hopefully, within the next five years,” Goldberg predicts.

Elastography

The computer’s power in analyzing ultrasound signals is also increasingly taken advantage of. In elastography, for example, ultrasonic imaging is used to detect or classify tumors by using stiffness or strain images of soft tissue. “There is a correlation between malignant masses, which tend to be harder or firmer, and benign masses, which are much softer. Some of the results have been very promising in terms of helping to differentiate types of tumors, and even work in the future by looking at, for instance, the liver and how much fibrosis there is in cases with hepatitis and cirrhosis. So that’s a whole new area. Some machines are clinically available now, and more are coming down the line.”

A third area has been the development of ultrasound contrast agents over more than the past decade. “These are little bubbles of gas, smaller then red blood cells, that are highly reflective,” explains Goldberg, adding: “They’re a thousand times more reflective than one blood cell. It allows you to see vascularity similar to what you get when you have CT or MRI with contrast, but at a much lower price. These agents have already been approved for detection and characterization of masses in Europe, Canada and most recently in Japan, China and Latin America. In the US, we’ve been a little bit slower because the FDA is perhaps more concerned than others about safety, although results have shown them to be as safe, if not safer, than the contrast agents used in CT or MR. We expect over the next several years to see approval in the US. And companies are already developing newer agents.”

Goldberg himself has been working on an agent that has the ability to detect tumors in lymph nodes. “This looks like a potential major breakthrough. We’ve been working on this in animal models and we hope in the next several years to apply this to human use in many areas, like breast, skin and colon cancer,” he says.

The future of ultrasound

FDA approval of ultrasound contrast agents and the availability of multi-crystal, three-dimensional real time ultrasound probes to produce high resolution 3D ultrasound will lead to a considerable increase in the quality of ultrasound imaging. Goldberg predicts: “This will become very competitive with CT and MRI with contrast. And this can be important because in the developing world, which is probably 80 percent of the population, it is difficult to support CT, PET or MR equipment. But it’s much easier to support ultrasound equipment. The addition of elastography and miniaturization, which is allowing machines to become smaller to bring it to the bedside or anywhere, will lead to a significant surge in the utilization of ultrasound. So at this point, we’re waiting for all these things to come together to really make a significant impact on the future of ultrasound.”

Knowing how to use ultrasound correctly, believes Goldberg, is key. “That’s always the dilemma. You can buy a machine, but if you don’t know how to use it properly, are you really helping the patient?” He will concentrate his efforts on educating physicians and paramedical personnel who will increasingly have access to ultrasound equipment but may not have spent enough time to learn how to use and interpret it properly. “You wouldn’t want to have somebody driving a car who did not how to use it. Unfortunately, that happens and you see the results. The result of misdiagnoses is harmful to patients. So we’re hoping to expand our education efforts with emphasis on establishing ultrasound education centers in developing countries. We’re donating education materials and equipment. And I am the medical advisor for a website called ‘www.sonoworld.com’ created to provide free education in ultrasound.”

In terms of his own research efforts, Goldberg is most excited about the work he’s been doing in the field of sentinel lymph node detection. “If we are able to find additional nodes that the surgeons haven’t removed we can take them out and, hopefully, increase the longevity of cancer patients. That’s one of my dreams.”

About Barry Goldberg

Dr. Barry Goldberg has been the Director of the Diagnostic Ultrasound Division, Department of Radiology, at Thomas Jefferson University Hospital (TJUH) since February 1977 and has twelve staff physicians, seven cross-sectional imaging fellows and an ultrasound physicist. Goldberg is also the Founder and Director of the Jefferson Ultrasound Research and Education Institute (JUREI), which is recognized as the only center for continuing education in general ultrasound by the World Health Organization.

The Leading Edge in Ultrasound

‘Leading Edge’ is the annual educational conference of the Jefferson Ultrasound Institute. The conference provides updates on the major specialty areas and overviews of the hot topics in diagnostic ultrasound. The Leading Edge program has established a reputation for excellence since its debut in 1980. The program is designed to meet the educational and CME needs of physicians, sonographers, vascular technologists, nurse midwives and other participants. The major themes that will be covered in the 2008 Leading Edge program include women’s imaging, vascular imaging and Doppler, a physics refresher course, pediatric ultrasound, musculoskeletal ultrasound and contrast agents and the ‘requisites’ program. The newest addition to 2008 will be an elastography tutorial and a fetal nuchal translucency credentialing program.

Global Ultrasound Equipment Donation Foundation (GUEDF)

GUEDF’s mission is to provide donated ultrasound equipment to needy clinics, hospitals and teaching facilities in emerging and developing countries around the world. The Foundation’s program and activities consist of the solicitation of contributions of equipment; selection of needy sites; distribution of equipment; determining knowledge level of potential equipment users; and training of equipment users. GUEDF works closely with other non-profit organizations including JUREI, Assist International (AI), the Radiology Outreach Foundation (ROF) and the International Certification and Education Accreditation Foundation (ICEAF).

www.SonoWorld.com
SonoWorld is dedicated to the mission of bringing free or low-cost educational materials and information to the global ultrasound community. Dr Barry Goldberg, Head of the Medical Advisory Board, and its members from around the world are widely recognized for their contributions to clinical ultrasound, education, research, training and industry, and for their commitment to quality education.