Italian chapter of the International Society of cardiovascular ultrasound expert consensus document on training requirements for noncardiologists using hand-carried ultrasound devices

Hand-carried ultrasound devices (HCDs), also named personal use echo, are pocket-size, compact, and battery-equipped echocardiographic systems. They have limited technical capabilities but offer some advantages compared with standard echocardiographic devices due to their simplicity of use, immediate availability at the patient's bedside, transportability, and relatively low cost. Current HCDs are considered as screening tools and are used to complement the physical examination by cardiologists. Many noncardiologic subspecialists, however, have adopted this technologic advancement rapidly raising the concern of an inappropriate use of HCD by health professionals who do not have any specific training. In keeping with the mission of the International Society of Cardiovascular Ultrasound to advance the science and art of cardiovascular ultrasound and encourage the knowledge of this subject, the purpose of this Expert Consensus document is to focus on the training for all health care professionals considering the use of HCD. Accordingly, this paper summarizes general aspects of HCD, such as technical characteristics and clinical indications, and then details the specific training requirements for noncardiologists (i.e., training program, minimum case load, duration, and certification of competence).     

Novel application of four-dimensional sonography with B-flow imaging and spatiotemporal image correlation in the assessment of fetal congenital heart defects

Aims: To evaluate the role of four‐dimensional (4D) ultrasound with B‐flow imaging and spatiotemporal image correlation (STIC) in the evaluation of normal fetal heart and congenital heart disease during pregnancy. Methods: Volume data sets of the fetal heart were acquired with automated transverse and longitudinal sweeps of the anterior chest wall. We studied 31 normal fetuses and 28 fetuses with congenital heart disease (6 with double‐outlet right ventricle, 5 with complete transposition of great arteries, 8 with tetralogy of Fallot, 3 with right aortic arch, 2 with persistent left superior vena cava, 3 with truncus arteriosus communis, and 1 with interruption of aortic arch) at gestation ages ranging from 18 to 39 weeks using transabdominal 4D B‐flow sonography with STIC (4D BF‐STIC). Results: Four‐dimensional BF‐STIC demonstrated dynamic angiographic features in both normal and abnormal fetal hearts. Four‐dimensional BF‐STIC images could not be obtained in two normal fetuses at 18.9 and 35.6 weeks because of the high fetal heart rate and inappropriate fetal position. Of the other 29 fetuses all extracardiac vessels such as aorta, pulmonary artery, ductus arteriosus, inferior vena cava, and ductus venosus could be detected on reconstructed images. In seven normal cases, a 4D image was recorded to allow simultaneous visualization of all four pulmonary veins. In the 28 fetuses with cardiac anomalies, 4D sonography with B‐flow imaging and STIC detected the “digital casts” of the outflow tracts, great arteries, and veins draining into the heart. These results demonstrate spatial relationship among these structures which provide important anatomical information. Conclusion: Four‐dimensional BF‐STIC provides a means of real time three‐dimensional evaluation of fetal extracardiac hemodynamics in the second and third trimesters. This novel technique assists in the evaluation of fetal cardiac hemodynamics and may play an important role in future fetal cardiac research and in the identification of anatomical features of different congenital cardiac anomalies. (Echocardiography 2012;29:614‐619)     

High resolution sonography in the evaluation of the peripheral nervous system in polyneuropathy – a review of the literature

Clinical, laboratory and electrodiagnostic studies are the mainstay in the diagnosis of polyneuropathy. An accurate etiological diagnosis is of paramount importance to provide the appropriate treatment, prognosis and genetic counselling. High resolution sonography of the peripheral nervous system allows nerves to be readily visualized and to assess their morphology. Ultrasonography has brought pathophysiological insights and substantially added to diagnostic accuracy and treatment decisions amongst mononeuropathies. In this study the literature on its clinical application in polyneuropathy is reviewed. Several polyneuropathies have been studied by means of ultrasound: Charcot–Marie–Tooth, hereditary neuropathy with liability to pressure palsies, chronic inflammatory demyelinating polyneuropathy, Guillain‐Barré syndrome, multifocal motor neuropathy, paraneoplastic polyneuropathy, leprosy and diabetic neuropathy. The most prominent reported pathological changes were nerve enlargement, increased hypo‐echogenicity and increased intraneural vascularization. Sonography revealed intriguingly different patterns of nerve enlargement between inflammatory neuropathies and axonal and inherited polyneuropathies. However, many studies concerned case reports or case series and showed methodological shortcomings. Further prospective studies with standardized protocols for nerve sonography and clinical and electrodiagnostic testing are needed to determine the role of nerve sonography in inherited and acquired polyneuropathies.     

Cross sectional area reference values for sonography of peripheral nerves and brachial plexus

ObjectiveUltrasound measurements of the cross sectional area (CSA) variability have been recently introduced to quantify pathological changes in peripheral nerves (PN).MethodsReference values from 75 healthy subjects and their correlation to age, height, weight and sex are reported.ResultsThe mean values in PN were: (1) intranerve CSA-variability: median 1.05 (SD ± 0.13), ulnar 1.53 (SD ± 0.51), fibular 1.33 (SD ± 0.37), tibial 1.39 (SD ± 0.39), (2) internerve CSA-variability 1.76 (SD ± 0.37), (3) intraplexus CSA-variability 1.52 (SD ± 0.37), (4) side-to-side difference ratio of the CSA-variability: median 1.21 (SD ± 0.04), ulnar 1.2 (SD ± 0.25), fibular 1.19 (SD ± 0.23), tibial 1.28 (SD ± 0.24) and brachial plexus 1.19 (SD ± 0.23). CSA did not correlate with height in PN, but correlated with weight in the ulnar nerve [Guyon’s canal, r = 0.411, p = 0.0237, elbow r = 0.409, p = 0.0248]. Significant changes between sex were found only in the ulnar (Guyon’s canal, p = 0.0265), fibular (popliteal fossa, p = 0.0336) and sural nerve (p = 0.048). CSA decreased with age in the median (axilla, p = 0.0236), and radial nerve (spiral groove, p = 0.0037) and increased in the tibial nerve (ankle, p < 0.0001).ConclusionsThe CSA reference values reported seem to correlate at certain sites with age, weight and sex but not with height.SignificanceThe new CSA variability measures may be helpful in investigating pathologies of the PN.     

The mechanisms of human ejaculation – a critical analysis

The current mechanism for human ejaculation is a two-part model consisting of a postulated “pressure chamber” created in the prostatic urethra by initial closure of both distal and proximal sphincters with secretions loaded in by adrenergic-mediated smooth muscle contractions of the vas deferens and capsules of the internal genital organs. The pressure build up is claimed then to “trigger” the intermittent relaxation/contraction of the distal sphincter and activate the contractions of the striated pelvic musculature, especially that of the bulbocavernosus, which forcefully expels the semen along the urethra by powerful, rhythmical spurts. A number of difficulties with this model are examined critically against experimental findings which indicate that the so-called pressure chamber is unlikely to be the valid trigger for ejaculation. The most recent finding of a specialised group of lumbar sacral neurons in the spinal cord of rat that function as the spinal ejaculation generator is more likely to be the “trigger” for ejaculation but confirmation that these cells also exist in the human cord is waiting.     

术中超声实时导航在大脑半球肿瘤切除术中的应用

目的比较术前MR图像与术中超声图像对手术指导的差异,评价术中B超的应用价值。方法回顾性分析26例应用术前1.5T场强MRI及术中超声辅助切除的大脑半球肿瘤患者,对比两种方法对肿瘤血供的探测能力和对肿瘤边界大小的判断能力的差异。结果对肿瘤的血供判断方面,术中B超有探测能力强,实时、随时探测的术中指导能力;对肿瘤的大小边界判断方面,术中B超判断边界与MR图像无统计学差别,虽然图像清晰度不及MR图像,但由于其实时探测能力而在手术中更具实时指导的优越性。结论对于大脑半球肿瘤,术中超声辅助切除能有效提高无创探查效率,减少神经损伤,及早控制肿瘤供血,指导肿瘤全切。     

Novel imaging approaches in adult asthma and their clinical potential

Currently, imaging in asthma is confined to chest radiography and CT. The emergence of new imaging techniques and tremendous improvement of existing imaging methods, primarily due to technological advancement, has completely changed its research and clinical prospects. In research, imaging in asthma is now being employed to provide quantitative assessment of morphology, function and pathogenic processes at the molecular level. The unique ability of imaging for non-invasive, repeated, quantitative, and in vivo assessment of structure and function in asthma could lead to identification of ‘imaging biomarkers’ with potential as outcome measures in future clinical trials. Emerging imaging techniques and their utility in the research and clinical setting is discussed in this review.