Headlines in the News:
AIUM Announces Accreditation in Musculoskeletal (MSK) Ultrasound (Clicking this link will navigate you away from the NewsWire newsletter.)
Palliative Ultrasound for Home Care Hospice Patients (Clicking this link will navigate you away from the NewsWire newsletter.)
How to Provide Quality Assurance in the Vascular Lab
SonoSite Releases Needle Visualization Package
Association Between Endoscopic Ultrasound Evaluation and Improved Outcomes in Pancreatic Cancer Patients
A new study has found that endoscopic ultrasound (EUS) is associated with improved outcomes in patients with localized pancreatic cancer, possibly due to the detection of earlier cancers and improved stage-appropriate management, including more selective performance of curative intent surgery. This is the first study to analyze a large population-based cancer registry and demonstrate that EUS evaluation is associated with improved pancreatic cancer survival. The study appears in the July issue of GIE: Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy (ASGE).
Pancreatic cancer is common and highly lethal. The only chance of long-term survival in pancreatic cancer is if complete resection (surgical removal) can be performed. The symptoms of pancreatic cancer are non-specific and usually occur late in the course of the disease; less than 20 percent of patients have resectable disease at the time of diagnosis. Endoscopic ultrasound is considered to be one of the most accurate tests for detecting pancreatic masses and for the staging of pancreatic cancer. EUS has proven to have the highest sensitivity in detecting pancreatic tumors, especially when the results of other cross-sectional imaging modalities are inconclusive. It is equivalent and complementary to CT for staging pancreatic cancer and predicting vascular invasion and local resectability.
Endoscopic ultrasound consists of a flexible endoscope which has a small ultrasound device built into the end. The ultrasound component produces sound waves that create visual images of the digestive tract which extend beyond the inner surface lining. EUS can be used to evaluate an abnormality below the surface such as a growth that was detected at a prior endoscopy or by X-ray. EUS is also used to diagnose diseases of the pancreas, bile duct, and gallbladder when other tests are inconclusive, and can be used to determine the stage of cancers. Tissue samples, using a fine needle aspiration technique (FNA), can be obtained in real time with EUS guidance should an abnormality be seen.
"We hypothesized that undergoing EUS was associated with improved overall survival in pancreatic cancer patients, probably related to early pancreatic cancer detection and accurate preoperative staging by EUS and improved stage-appropriate treatment," said study lead author Saowanee Ngamruengphong, MD, Mayo Clinic Arizona, Scottsdale. "In this study, we analyzed the Surveillance Epidemiology and End Results (SEER) - Medicare-linked database to study the association of undergoing EUS with overall survival in a cohort of patients with pancreatic adenocarcinoma and found that EUS is associated with improved survival in pancreatic cancer patients, most probably as a result of improved stage-appropriate management, including more selective performance of curative intent surgery and perioperative adjuvant therapy."
Patients and Methods
Using the SEER-Medicare database, researchers identified a total of 8,616 patients aged 65 and older with primary pancreatic cancer from January 1994 to December 2002 who fulfilled the inclusion and exclusion criteria. The study population was divided into two groups based on whether or not they underwent EUS evaluation. Group I consisted of patients who underwent EUS during the peridiagnostic period, Group II did not undergo EUS. Overall, 610 patients or 7.1 percent, underwent EUS for tumor evaluation and staging.
Results
There were more patients with early-stage disease in Group I than in Group II, 69.3 percent locoregional (localized and regional stage) disease in Group I vs. 36.2 percent in Group II. Curative-intent surgery, chemotherapy and radiation therapy were also performed more frequently in Group I. In patients with locoregional pancreatic adenocarcinoma, the median survival in Groups I and II were 10 months and 6 months respectively. The researchers found that receipt of EUS was an independent predictor of improved survival. Younger age at diagnosis, curative-intent surgery, chemotherapy and radiation therapy were also significantly associated with improved survival.
The researchers noted that improved survival related to undergoing EUS in this study is likely due to many factors because EUS is purely a diagnostic imaging modality and carries no direct therapeutic impact. Therefore EUS evaluation may help identify patients who would most likely benefit from undergoing attempts at curative resection. On the other hand, EUS evaluation might help to identify patients with advanced or metastatic pancreatic cancer who would not benefit from curative resection and therefore avoid the morbidity and mortality related to unnecessary surgery.
Researchers also looked at sociodemographic and geographic factors with undergoing EUS evaluation and found in multivariate analysis that younger age, white race, being married, locoregional disease, living in the Midwest region, and more recent year of diagnosis were significant predictors of undergoing EUS. The rate of EUS use in the study patients increased from .6 percent in 1994 to 13.1 percent in 2002. Although EUS evaluation is still performed in a minority of patients with pancreatic cancer, there is an increasing trend in the use of EUS in these patients. This may reflect increasing availability with dissemination of EUS technology from select academic centers to the community.
In an accompanying editorial, Bryan G. Sauer, MD, MSc, and Vanessa M. Shami, MD, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, stated that they believe the study "provides further evidence of the value of EUS in pancreatic cancer. Although EUS is not currently used to treat cancer, its association with improved survival is most likely a surrogate for multiple factors that improve survival, such as earlier detection of cancer; more accurate staging; and multidisciplinary, stage-appropriate treatment. We believe that individuals with localized pancreatic masses should undergo EUS for diagnostic and staging purposes, so that stage-appropriate treatment can be pursued. Furthermore, we anticipate earlier detection of pancreatic cancer through improved imaging and effective screening."
Article written by staff at medicalnewstoday.com and adapted for the purposes of this newsletter.
How to Provide Quality Assurance in the Vascular Lab
Quality assurance (QA) in the vascular ultrasound laboratory can be a laborious process, and not much fun. But this crucial task isn't just about generating statistics; it's what you do with that knowledge that counts, according to an expert on ultrasound QA.
"When you do gather data, it's really important to use it," said Cindy Weiland, RVT, RRT, director of accreditation and quality assurance monitor for the Intersocietal Accreditation Commission (IAC). She shared her thoughts on QA for vascular labs during a talk at the recent Leading Edge in Diagnostic Ultrasound conference in Atlantic City, NJ.
A comprehensive QA program includes several components, such as quality control of equipment; quality assurance for assessing compliance with standards, policies, and procedures, as well as documenting accuracy and outcomes; and continuous quality improvement, according to Weiland.
In developing a QA program, it's important to first identify the quality indicators, which is what you want to assess in the laboratory, she said. Quality indicators may relate to:
- Structure (the overall organization)
- Process (how exams are performed)
- Outcome of care (statistical analysis of desirable and undesirable results)
Once the indicators are established, thresholds need to be identified. Thresholds are defined as a percentage of acceptable deficiency; they may be defined for numerous indicators such as test accuracy, waiting time, and scheduling time, Weiland said.
The data collection process will make use of sources such as medical records, lab reports, surgical reports, other imaging modalities, and questionnaires. Data worksheets can be used to organize this information, she said. A number of software programs are available to help with this task.
The time frame and volume of data to be collected also need to be defined.
"If you're in a huge lab where you do 20,000 patients in a year, tracking every single positive patient may not be the best thing," Weiland said. "If at all possible, in a perfect world, the best thing to do would be to track anybody that was going to have any sort of follow-up exam or surgery. But if you're in a huge lab, you may say, 'OK, we want to track 100 a year.' Then again, if you're in a very small lab, it's really important probably to take note of any patient that you feel might have some sort of follow-up."
Some examples of QA logs can be downloaded from the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) website, according to Weiland.
Data analysis
Lab data should include figures on sensitivity (the probability that the test will be positive when disease is present), specificity (the probability that a test will be negative when disease is absent), and accuracy (the number of correct findings regardless of whether disease is present or not), Weiland said.
Correlation matrices allow for comparison of ultrasound findings with other imaging studies. If no other imaging studies were performed, correlation of ultrasound findings with surgical reports can also be determined, according to Weiland.
"It's good to know that the surgical outcome or surgical findings correlated well with the [ultrasound] exam," she said. Tracking clinical outcome takes a lot of work, but can be of value in situations such as tracking venous patients, she noted.
Peer review can also be a valuable process. Physician review can encompass exam findings, report content, and adherence to diagnostic criteria. This can be overseen by a medical director or technical director, or somebody who has a good grasp of proper protocols and diagnostic criteria, Weiland said.
The same process could be performed for a technologist review, covering image and waveform quality, following protocols, and performance of technically correct exams, she said. These findings need to be communicated to staff on an ongoing basis, according to Weiland.
"This can be awkward, but everybody has to be open to being wrong on occasion," she said. "When you find things that are wrong, don't put your head in the sand. It's of use and can be rather detrimental if something happens with a patient when you know something isn't being done correctly, and you haven't done anything about it."
Peer review worksheet examples can also be downloaded from the ICAVL's website, she said. The data should be used to develop corrective action plans, Weiland said.
"If you go through and see that things are not correlating because some of the physicians aren't following the criteria, then you make a plan," she said. "Like we're going to look at these reports routinely for the next four months, and we're going to come back and look at the correlation again to see if it changes."
Regular QA meetings are a good idea and offer a good learning experience, she said. Meeting minutes should be taken. All staff should be involved, and people should be held accountable, Weiland said. QA should also be an ongoing process.
"If you apply for accreditation, you know you're going to have to do it," she said. "You shouldn't wait for three years and rush back to try and collect data for the last three years, because if you've been missing something for three years now, you're really doing a disservice to yourself and to your patients. So if you can do it where you're doing it every quarter or at least every six months, it makes it less of a painful process and really does help enhance everything that you're doing with your lab."Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.
SonoSite Releases Needle Visualization Package
SonoSite Inc. released a software upgrade for some of its ultrasound models to help anesthesiologists better view needles that can often appear invisible during pain-relieving sticks called nerve blocks.
The technology, dubbed Enhanced Needle Visualization, runs on algorithms the Bothell, Wash.-based company said its engineers spent two years developing.
According to SonoSite, the "lost needle phenomenon" is a well-known drawback of some ultrasound-guided anesthesiology procedures, especially peripheral nerve blocks, where doctors have to deliver needles at steep angles to numb pain in limbs, often during surgeries.
"If the doctor of any kind, in this case an anesthesiologist, wants to put a needle down near a target which is deep, they insert the needle next to the probe and they aim deep into the body," Kevin Goodwin, CEO of SonoSite, stated. "That needle travels in parallel with the probe and the probe beam. As it heads towards the target, the doctor cannot tell where the needle is and therefore, it's very difficult to do nerve blocks or other injections that are deep in the body where you're trying to pinpoint the location of your medicine," he said.
Goodwin said the new Enhanced Needle Visualization tool could potentially save customers money because it can eliminate the need for echogenic needles in several cases and drastically improve throughput.
"It's been an absolute home run for us with customers," said Goodwin. "Doctors are now able to understand that they could do more procedures with greater confidence, with greater accuracy and less time."
The software upgrade is currently available for SonoSite's HFL50 and HFL38 transducers, the company said.
"This is going to eliminate any difficulties I have with accurately visualizing the shaft of the needle and it will decrease the time it takes to perform a steep needle procedure," Dr. Mimi Lee, an anesthesiologist based in Marin, Calif., said in a statement.
Goodwin said that there is much evidence that needle injection accuracy is a major problem in the industry. In some cases in the last year, orthopedic injection accuracy rates were off by as much as 30 percent, explained Goodwin.
SonoSite plans to expand Enhanced Needle Visualization to other procedures in the near future, said Goodwin.
Article written by staff at dotmed.com and adapted for the purposes of this newsletter.