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April 15, 2011

ARDMS Updates and Headlines in the News:

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Important: ARDMS Examination Information

Revolutionary Tissue Healing Without Surgery

Detailed Teaching Boosts 3D Fetal Ultrasound Performance

Solving the Radiology Gap One Ultrasound at a Time

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Important: ARDMS Examination Information

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Revolutionary Tissue Healing Without Surgery

Platelet Rich Plasma (PRP) has been used in maxillofacial surgery since the 1980s to enhance bone regeneration, bone density and teeth implant survival in women with osteoporosis. Due to its healing properties — PRP consists of plasma that is enriched with concentrated platelets containing white blood cells — it has since gained popularity in dentistry, cardiothoracic surgery, ear, nose and throat medicine, plastic and reconstructive surgery, urology, orthopedic medicine, wound healing and musculoskeletal medicine.

The Science Behind PRP Use

Platelets are known to initiate healing in the body and have the ability to repair collagen. When chronic inflammatory and degenerative changes occur within nonhealing tissues, injecting a concentration of platelets to injured tissues can help release a higher strength of growth factors — the most important of which include epidermal growth factor; platelet-derived growth factor; transforming growth factor beta; insulin-like growth factor; vascular endothelial growth factor and basic fibroblast growth factor. These substances stimulate cell growth, cell migration, new blood vessel growth, differentiation, recruitment and collagen synthesis to facilitate optimal healing. Research has shown the concentration of growth factors in PRP is four to seven times higher than in whole blood.

"When we process PRP in our office, we aim for this ideal concentration of platelets. It is this concentration that releases signals to the body that attract stem cells to the area," said Dr. Pineda. "The presence of stem cells is essential to maximizing the healing environment for injured or degenerated tissue. In essence, you are enhancing the body's ability to heal itself through the use of PRP."

Indications for PRP in Orthopedic and Sports Medicine

Dr. Pineda's interest in PRP began after viewing a program on the Discovery Channel that discussed PRP's application in wound healing and plastic and reconstructive surgery. Because of the positive outcomes documented in these areas, Dr. Pineda believed PRP would be beneficial in the management of musculoskeletal conditions and pursued additional training in musculoskeletal ultrasound in 2006 so she could safely offer PRP to her patients.

At South Texas Arthritis Care Center, Dr. Pineda uses PRP to treat a variety of degenerative and inflammatory conditions that cause chronic pain — including lateral epicondylitis; medial epicondylitis; patellar tendonitis; rotator cuff tendinitis; gluteal and piriformis tendinosis; persistent trochanteric bursitis; iliotibial band syndrome; ligamentous injury or tears such as medial collateral ligament partial tears; patellar tendonitis; chronic ankle sprain and osteoarthritis — in patients whose conditions have not responded to other conservative modalities.

"Patients for whom conservative therapies have failed often face surgery or a life filled with chronic pain if they are not surgical candidates," said Dr. Pineda. "PRP can present a viable alternative to surgery for patients unable to achieve success with conservative methods, including physical therapy, pain medications and cortisone injections. While I would still recommend surgery for some patients, we now have an additional nonsurgical option that will help optimize the healing of tissues."

While larger, prospective and double-blind studies analyzing the effectiveness of PRP in orthopedic patients have yet to be performed, several in vitro and in vivo studies have been performed. Although results of these studies were mixed, the majority of studies showed benefits to using PRP in multiple musculoskeletal conditions and demonstrated that PRP was superior to cortisone injections. A study published in The American Journal of Sports Medicine compared the effectiveness of PRP to administration of corticosteroids in patients with lateral epicondylitis, and results showed that patients who received PRP generally experienced progressive improvement, while patients who received corticosteroids showed continued decline.

PRP Use in Patients With Osteoarthritis

Perhaps one of the most promising indications of PRP use in orthopedic medicine is in the management of mild to moderate osteoarthritis.

"Currently, more than 200,000 hip replacements and 400,000 knee replacements are performed annually due to osteoarthritis," said Dr. Pineda. "By 2030, osteoarthritis is estimated to affect 67 million Americans, so it is vital that we continue to develop effective ways to manage this disease and its impact."

While research is lacking in the area of PRP use in patients with osteoarthritis, according to Dr. Pineda, the rationale behind using PRP lies in the release of certain growth factors — mainly platelet-derived growth factor, transforming growth factor beta and insulin-like growth factor — that promote cartilage maintenance and repair. Furthermore, PRP contains anabolic and anticatabolic bioactive molecules that modify the arthritic process.

"A study performed on porcine chondrocytes showed that PRP stimulated articular chondrocyte proliferation and matrix biosynthesis," said Dr. Pineda. "Several other studies have shown that the potential mechanism of action of PRP in osteoarthritis of the knee is increasing hyaluronic acid production by synovial fibroblasts. Early human studies have also been very promising and has shown PRP use to be safe, but additional research will be required."

At South Texas Arthritis Care Center, the majority of patients who have received PRP injections for the management of osteoarthritis have reported less pain and increased functionality. Dr. Pineda has also found that injecting PRP into multiple areas of the knee has helped to improve knee biomechanics and stability.

"In my practice, I have seen that PRP therapy can be very successful in appropriate candidates," said Dr. Pineda. "However, patients with severe osteoarthritis, those who have extensive comorbid disease, those who are taking long-term medications that impair healing or those with lifestyle factors, such as smoking, that inhibit healing are generally considered poor candidates."

Patient Candidacy

Athletes — including Hines Ward, wide receiver for the NFL's Pittsburgh Steelers, and Tiger Woods — have brought public attention to the use of PRP in recent years. However, Dr. Pineda explains that PRP use should not be limited to athletes.

"Although everyone's healing process is different, and it is reasonable to expect that younger, healthier patients will respond more favorably, PRP should not be limited to high-performing athletes or young patients," said Dr. Pineda. "PRP is also beneficial for the hard worker who develops chronic pain due to work-related or repetitive injuries, the weekend warrior, the older patient who is trying to remain active despite chronic pain and the stay-at-home parent who works 24 hours a day to manage a home and children."

To ensure candidacy and help patients develop reasonable expectations regarding outcomes following their injections, Dr. Pineda screens patients before administering PRP.

Preserving Safety During a PRP Procedure

At South Texas Arthritis Care Center, Dr. Pineda performs all PRP injections using ultrasound guidance, which helps improve the safety and efficacy of the procedure."Injecting PRP using ultrasound guidance optimizes the efficacy and accuracy of PRP because I can more easily identify arteries, veins, nerves and other key structures in order to avoid injury or damage," said Dr. Pineda. "Using ultrasound guidance helps me to more accurately diagnose injuries to muscles, ligaments and joints, and also enables me to guide the needle into the specific target area."

When compared to X-ray, MRI and CT scanning, musculoskeletal ultrasound boasts several advantages, including better resolution of soft tissue, convenient in-office availability, no exposure to ionizing radiation and the ability to perform a dynamic study, which enables physicians to observe the injured area while the patient is in motion.

"In a study comparing the accuracy of soft-tissue aspiration, the group in which ultrasound guidance was used had an accuracy rate of 97%, while the blind group had an accuracy rate of 32%," said Dr. Pineda. "Ultrasound guidance was compared to fluoroscopy in another study looking at the accuracy of piriformis injections and had a 97% accuracy rate compared to a 30% accuracy rate in patients in whom fluoroscopy was used.

View the article online

Article written by staff at mednews.com and adapted for the purposes of this newsletter.

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Detailed Teaching Boosts 3D Fetal Ultrasound Performance

Providing detailed instruction to maternal-fetal medicine physicians can improve the quality of fetal facial 3D ultrasound images, according to research published in the April edition of the Journal of Ultrasound in Medicine.

In a study that compared the performance of physicians who had received detailed instruction on 3D ultrasound volume manipulation to those who had instruction only on basic principles, researchers found that those with detailed instruction yielded significantly higher fetal profile and parallel-plane palate scores.

"Teaching physicians in a standardized way may help improve the use of [3D ultrasound] in clinical practice," said the team led by Dr. Gladys Ramos, of the University of California, San Diego.

While volume sonography has been explored for diagnosing a number of fetal abnormalities, clinical implementation has been challenging for a number of reasons, including training limitations, according to the researchers. As a result, the study team sought to determine whether systematic instruction would help teach maternal-fetal medicine physicians with minimal 3D ultrasound experience how to display a diagnostic fetal profile and palate from 3D volumes (Journal of Ultrasound in Medicine).

The researchers recruited 10 physicians and randomly assigned them to two groups. Both groups were initially instructed on basic principles of 3D ultrasound volume manipulation using the 4D View program; the second group also received detailed, step-by-step 3D procedures on how to obtain the fetal profile.

Physicians in the first group (group A) were asked to display the fetal profile in five preselected fetal volumes, including one fetus with abnormalities. After receiving detailed instruction, group B physicians then also displayed the fetal profile in the same five volumes. After the initial round of scanning, both groups were combined into one group and received the same detailed instruction provided previously to group B. Then the physicians were asked to review an additional five volumes.

In a later session, the researchers divided the physicians back into their respective groups and performed a similar exercise, this time for the display of the fetal palate in three-orthogonal-plane and parallel-plane images. Two experienced sonologists then reviewed all of the images in a blinded fashion for accuracy and clinical utility.

Group B turned in significantly higher fetal profile and parallel-plane palate scores than group A (p < 0.001). However, no significant difference was found between the groups for displaying the three-orthogonal-plane image of the palate or after additional training for either group, according to the researchers.

In other findings, the researchers did not detect a significant difference in mean display time between the groups. Evaluation time for abnormal profiles was longer than for normal profiles (p = 0.02).

"A systematic approach using clinical volumes provided maternal-fetal medicine physicians experience with practicing and training on personal computer workstations with a 'gamelike' atmosphere that stimulated the learner's interest and motivation for competition," the authors wrote. "An improved understanding of the importance of symmetry of the face was obtained from manipulating the volumes; this information is useful for both 2D and 3D evaluation of the face."

"We believe that additional practice (> 10 volumes) manipulating volumes is needed to consistently obtain adequate palate images using both three-orthogonal-plane and parallel-plane displays," said the team led by Dr. Gladys Ramos, of the University of California, San Diego.

View the article online

Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.

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Solving the Global Radiology Gap One Ultrasound at Time

After deciding to specialize in radiology in his second year of medical school, University of California, San Diego medical student and avid volunteer Benjamin Johnson came to a disheartening realization about his chosen specialty—radiology is one of the specialties least engaged in medical outreach and humanitarian efforts. Undeterred, Johnson scoured the internet for opportunities to wed his specialty with his passion.

He learned that access to imaging in the developing world is severely lacking. According to the World Health Organization, two-thirds of the world population lacks access to radiology.

At its most basic level, radiology requires three inputs: an acquisition device, a means to transmit or view images and diagnostic review. Indeed, developments in imaging and network technologies, specifically the diffusion of low-cost, portable ultrasound systems and ubiquity of cellular phones and networks, offer fresh hope for developing nations. The missing ingredient, surmised Johnson, seemed to be diagnostic expertise.

After more than a year of searching, the medical student located Rad-Aid, a global network assisting developing countries to implement and optimize radiology and health imaging service, and Imaging the World (ITW), a nonprofit that integrates technology, volunteers and education to bring medical expertise and high quality healthcare to remote and underserved areas worldwide.

In May, Johnson will embark on his second trip to Uganda to work on an ITW-developed teleradiology project that offers ultrasound imaging to pregnant women residing in rural regions of the country. Johnson paints a stark picture. "One in 22 Ugandan women die during childbirth, most frequently due to bleeding that could have been prevented by ultrasound scanning." A mere 35 radiologists practice in the country, which has a population of 30 million.

According to Johnson, radiology has lagged behind other specialties in outreach efforts, because in addition to expertise, it requires a large initial investment in imaging infrastructure, followed by the costs of training staff to maintain and operate the equipment. "ITW's model takes advantage of the falling costs and increasing portability of modern ultrasound units to address those challenges. It also takes advantage proliferation of cellular networks to perform outreach without ever traveling overseas."

"The model is really clever. It uses volumetric ultrasound imaging to remove the need for an expert sonographer on the front end of image collection," he explained. During a five-week volunteer stint in the summer of 2010, Johnson trained local Ugandan midwives and healthcare workers in Kamuli to perform basic ultrasound scans that capture volumetric cine-loops based on external anatomy. (Pre-set acquisition parameters are programmed into the system.)

In the model, a local healthcare worker identifies a pregnant woman who might benefit from ultrasound scanning and performs a basic five-sweep scan. At the end of the scan, the cine loops are compressed and transmitted over cellular networks back to a PACS in the U.S., where volunteer radiologists interpret the DICOM datasets.

The minimalist scans do not provide the diagnostic fidelity of a scan performed by a trained sonographer, Johnson admitted. However, the protocols suffice to diagnose the basic complications associated with the country's high maternal death rate, such as placenta previa.

Reporting is equally bare bones. That is, a standardized template sends a text message to the local clinic, categorizing results from 0 (normal) to 10 (STAT). For urgent and emergent cases, radiologists send relevant images and a detailed report to a hospital, so local physicians have the information needed for follow-up and tertiary care.

During the pilot phase last summer, the team completed an image quality validation and determined the viability of the model. In fact, the key requirements for success are quite simple and include a compact ultrasound system and DICOM compatibility.

The primary challenge as the project heads into its second year, said Johnson, is the cost of the ultrasound system. "Once the model has been set up, the main cost is the machine. The diagnostic expertise is back-loaded to the U.S. where people can provide volunteer expertise." Other costs include the wireless router and a netbook computer to run the software that compresses the cine loops.

This summer, Johnson and his ITW colleagues plan to test a new ultrasound system to determine if it provides image quality to meet established diagnostic standards. He noted that the model is not specific to Uganda and could be deployed nearly anywhere across the globe.

"Johnson's work can really make a difference," summed Dolores H. Pretorius, MD, professor of radiology and director of imaging at the University of California, San Diego center for fetal care and genetics. "The results are quantifiable. The participating clinic in Uganda has seen a significant increase in visits during the first six months since the program was implemented. Those visits provided proper diagnosis and care to women with urgent medical needs in order to hopefully prevent catastrophic injury to the mother and fetus at delivery."

View the article online

Article written by staff at healthimaging.com and adapted for the purposes of this newsletter.

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