State of the Art: Contrast Enhanced 4D Ultrasound to Monitor or Assess Locoregional Therapies

Locoregional therapies (LRTs) are an essential management tool in the treatment of primary liver cancers or metastatic liver disease. LRTs include curative and palliative modalities. Monitoring treatment response of LRTs is crucial for maximizing benefit and improving clinical outcomes. Clinical use of contrast-enhanced ultrasound (CEUS) was introduced more than two decades ago. Its portability, cost effectiveness, lack of contraindications and safety make it an ideal tool for treatment monitoring in numerous situations. Two-dimensional dynamic CEUS has been proved to be equivalent to the current imaging standard in the guidance of LRTs, assessment of their adequacy, and detection of early tumor recurrence. Recent technical advances in ultrasound transducers and image processing have made 3D CEUS scanning widely available on most commercial ultrasound systems. 3D scanning offers a broad multiplanar view of anatomic structures, overcoming many limitations of two-dimensional scanning. Furthermore, many ultrasound systems provide real-time dynamic 3D CEUS, also known as 4D CEUS. Volumetric CEUS has shown to perform better than 2D CEUS in the assessment and monitoring of some LRTs. CEUS presents a valid alternative to the current imaging standards with reduced cost and decreased risk of complications. Future efforts will be directed toward refining the utility of 4D CEUS through approaches such as multi-parametric quantitative analysis and machine learning algorithms.

Frontal tangential coronal view two-dimensional ultrasonography in assessment of fetal face [mouth and nose] in comparison with four-dimensional ultrasonography

Background The fetal face reflects strictly the development of the fetal brain during its growth. Four-dimensional (4D) examination permits continuous monitoring of the examined parts of fetal face and surface. The final performance of obstetric sonographic images depends upon multiple factors, such as fetal lie, uterine wall, abdominal wall fat, amniotic fluid, and the number of gestations which may limit the optimum performance of (4D) ultrasound. The two-dimensional (2D) ultrasound is the first choice due to its wide availability, low cost, and real-time capabilities. The tangential view obtained by (2D) ultrasound coronal sections through the face showed the nose, nostril, lips, eye, lens, and hard palate. Results One hundred and sixty fetuses showed straight forwards obstetric examination by both 2D and 4D examinations with identical final reports. While the total number of fetuses with clear images by 2D frontal tangential coronal examination was 191 cases, only 29 cases failed, whereas 170 cases obtained clear images by 4D examination, and 50 cases failed. Both 2D and 4D ultrasound failed to obtain clear images of 19 cases, while 4D failed for 31 cases, and 2D failed for 10 cases. 2D imaging was found to be significantly better than 4D imaging, with a P value of 0.009. Conclusion 2D ultrasound using the frontal tangential coronal view is an essential part of the fetal examination and more superior than 4D ultrasound in assessing facial anatomy and anomalies, as well comparable to 4D ultrasound as regards fascial expression.

Oligohydramnion in the First Half of Pregnancy in the Fetuses with Congenital Abnormalities: Ultrasound Diagnostics and Obstetric Outcomes

Background.Oligohydramnion in the first half of pregnancy, combined with congenital abnormalities in the fetus has objective difficulties in diagnosis. The morphology features and type of defects associated with oligohydramnion, which manifests in the first half of pregnancy, are not sufficiently studied at the present stage. Aims to evaluate the clinical significance of diagnosing oligohydramnion in the first half of pregnancy in women with congenital fetal malformations. Materials and methods.The analysis of the course of pregnancy and perinatal outcomes in 77 women with low water content in combination with congenital malformations of the fetus and 72 patients with a normal amount of amniotic fluid and no congenital malformations of the fetus was performed. The patients of the main group were divided into two subgroups depending on the severity of oligohydramnion: the 1st subgroup (n = 54) patients with severe oligohydramnion and the 2nd subgroup (n = 23) patients with moderate oligohydramnion. The amount of amniotic fluid was determined by 3D/4D ultrasound (1321 weeks of gestation) and the structure of fetal abnormalities associated with oligohydramnion was analyzed. We evaluated perinatal outcomes in women with congenital malformations of the fetus in combination with oligohydramnion and the effect of its severity on the outcome of pregnancy. Results.In the main group (n = 77), fetal abnormalities were detected in patients: urinary system 39 (50.6%), respiratory system 4 (5.2%), heart 1 (1.3%), chromosomal and genetic abnormalities 14 (18.2%), central nervous system 3 (3.9%), osseous system 3 (3.9%), multiple 13 (16.9%). In the main group (n = 77), pregnancy was terminated for medical indications in 47 (61%) cases, in 6 (7.8%) spontaneous miscarriage occurred, in 5 (6.5%) antenatal fetal death. 19 (24.7%) children were born alive, and surgical treatment in the neonatal period was required in 8 (10.4%) cases. In the 1st subgroup (n = 54) in 53 (98.1%) cases, there was a loss of the fetus, in 1 (1.9%) the newborn died on the 9th day. In the 2nd subgroup (n = 23), fetal death occurred in 5 (21.7%) cases, 18 (78.3%) children were born alive, and 8 (44.4%) newborns were operated on in the neonatal period. In the control group, all pregnancies ended with the birth of healthy children. A decrease in ultrasound imaging of internal organs in the fetus was observed when a pregnant woman was obese (BMI more than 35). Conclusions.Oligohydramnion in the first half of pregnancy in combination with fetal malformation should be considered an extremely unfavorable clinical sign for the prognosis of pregnancy and the health of the fetus and newborn. 3D/4D ultrasound scanning allows you to reliably determine oligohydramnion in the first half of pregnancy, and the degree of its severity to assume the nature of complications.

Does Interactive Ultrasound Intervention Relieve Minor Depressive Symptoms in Pregnancy? A Randomized Controlled Trial

BackgroundPerinatal depression, especially minor depression, is common during pregnancy and is likely to continue into the postpartum period. It impairs the mother’s health, infant’s neurodevelopment, and the mother-infant relationship. Screening for perinatal depression is recommended; however, there is no uniform alignment of how to treat depressive symptoms while simultaneously supporting the mother-infant relationship. Ultrasound screenings might be potential as an intervention method because it has shown to improve maternal-fetal attachment among pregnant women. Our aim is to develop a 4 dimensional-based (4D) interactive ultrasound intervention and test whether it relieves minor depressive symptoms and improves maternal-fetal attachment. Previous studies show that supporting the mother-infant relationship aids in relieving maternal depression. Until now, few studies have combined pregnancy ultrasound and psychological support. MethodsA controlled randomized setting was designed to assess whether interactive 4D-ultrasound intervention would decrease maternal depressive symptoms, strengthen maternal-fetal attachment, and mother-infant relationship. A sonographer and a psychologist specialized in infant mental health conduct the interventions. The focus of the session is to jointly observe the behavior of the fetus according to the mothers’ wishes. Altogether, 100 women scoring 10-15 in Edinburgh Pre/-Postnatal Depression Scale (EPDS) and with singleton pregnancy will be recruited using a web-based questionnaire. Half of the participants will be randomized to the intervention group and will receive three interactive ultrasound examinations. The primary outcome is the change in the mean EPDS score. EPDS measurements will be done at three time points: before and after the intervention and four to five months after delivery. The secondary outcomes are maternal representations that will be assessed using the Working Model of the Child Interview (WMCI) and prenatal attachment that will be assessed using the Maternal Antenatal Attachment Scale (MAAS) questionnaire. The postnatal mother-infant interaction will be assessed with the Parent-Child Early Relational Assessment (PCERA) and Maternal Postnatal Attachment Scale (MPAS). DiscussionUltrasound is widely used during pregnancy. The interactive approach is unique and it would be feasible as part of routine screenings and maternity clinic visits. Intervention decreasing depression and simultaneously supporting maternal-fetal attachment could be a valuable addition in treating minor depression among pregnant women. Trial registrationRegistered on January 5th 2018, ClinicalTrials.gov NCT03424642. https://clinicaltrials.gov/ct2/show/NCT03424642

Applications of Advanced Ultrasound Technology in Obstetrics

Over the years, there have been several improvements in ultrasound technologies including high-resolution ultrasonography, linear transducer, radiant flow, three-/four-dimensional (3D/4D) ultrasound, speckle tracking of the fetal heart, and artificial intelligence. The aims of this review are to evaluate the use of these advanced technologies in obstetrics in the midst of new guidelines on and new techniques of obstetric ultrasonography. In particular, whether these technologies can improve the diagnostic capability, functional analysis, workflow, and ergonomics of obstetric ultrasound examinations will be discussed.

O-181 4D ultrasound guided embryo transfers statistically improve live birth rates - A randomised controlled trial

Study question Does the use of 4D ultrasound to guide embryo transfers improve live birth rates in comparison to the clinical touch technique? Summary answer 4D ultrasound guided embryo transfers (4DUS) result in significantly higher live birth rates (LBR) in comparison to those performed using the clinical touch technique (CTT)(41%vs28%). What is known already A previous Cochrane review showed ultrasound guided embryo transfers (ET) improve pregnancy outcomes in comparison to CTT; however there was a large degree of heterogeneity between the studies and the largest study in the review showed no difference between ultrasound guidance and CTT. A further study demonstrated no difference in ongoing pregnancy rates between 2D vs 3D ultrasound guided embryo transfers, however this study did not use LBR as an endpoint and did not report on procedure duration/difficultly, both of which are known to impact ET success rates. Study design, size, duration This was a prospective, open labelled randomised controlled trial comparing superiority between two techniques for ET (4DUS vs CTT). A total of 320 (n = 160/group) patients were recruited using computer generated randomisation that were centrally distributed in consecutive sealed opaque envelopes between July 2018 to December 2019. Main outcomes were clinical pregnancy rate (CPR) and LBR. Following the procedure, participants completed a survey based on their comfort and satisfaction. Participants/materials, setting, methods Inclusion criteria included single blastocyst transfer and a normal uterine cavity. Participants were recruited and randomized on the day of ET. Those allocated to the CTT group, had their embryo transferred without ultrasound, depositing the embryo 6cm from the external os. Those in the 4DUS group had their ET using transvaginal 4D ultrasonography and had their embryos deposited at the maximal implantation point (MIP). Main results and the role of chance Results were available from a total of 295 women (8% attrition rate, CTT n = 153; 4DUS n = 142)). No demographic differences between the two groups (CTT and 4DUS) were noted including age (p = 0.05), BMI (p = 0.29), duration of infertility (p = 0.94), type of infertility (p = 0.68) or embryo quality (p = 0.89). All the 4DUS and 95% of the CTT group were performed by the same practitioner. The 4DUS resulted in significantly higher CPR (50% vs 36% p = 0.015, OR 1.78 (1.12-2.84)) and LBR (41%vs 28%, p = 0.021, OR 1.77 (1.09-2.87)). There were no statistically significant differences between miscarriage (p = 0.494), pregnancy of unknown location (p = 0.141) or ectopic pregnancy rates (p = 0.958) between the two groups. The 4DUS process took significantly longer time compared with the CTT procedure (15.7 vs 10.2 minutes respectively, p < 0.01). The results of the survey showed no statistical difference between patient comfort (p = 0.17) or satisfaction (p = 0.08) between the groups however there were significantly more positive comments in the 4DUS (p < 0.01). In the 4DUS group there was no difference in mean endometrial thickness (P = 0.186) or endometrial volume (p = 0.836) between pregnant and non-pregnant patients. Limitations, reasons for caution Due to the nature of this trial we were unable to blind the participants due to the obvious differences between the methods. Wallace catheters were used for the CTT and Kitazato catheters for the 4DUS, whilst a methodological weakness; previous meta-analysis has not shown any difference between different soft catheters. Wider implications of the findings LBRs, when utilizing 4DUS, are significantly higher than the current UK average (41%vs22-23%) and significantly higher than CTT. 4DUS allows for superior imaging of the uterine cavity, tailoring the embryo deposition point specifically to the patient. Further RCTs are required to confirm that 4DUS is the superior technique for ET. Trial registration number ISRCTN79955797 ,IRAS 202857

Cost Benefit dan Effectiveness Investasi Alat Kesehatan Berteknologi Tinggi di Instalasi Radiologi

<p><em>One of the important components supporting the effort to cure patients is medical devices. Hermina Mekarsari Hospital type C classification seeks to meet services in accordance with service standards. Preliminary monitoring data found that the CT - Scan examination room facilities in the Radiology Installation have not been used as intended. This is because the medical equipment investment process is not optimal, the financial sector is not involved, so no investment analysis is conducted. The research objective was to analyze the investment feasibility and investment planning process of two CT-Scan and 3D / 4D ultrasound medical devices in Radiology Installation. Research is an empirical study with quantitative methods. The aim is to obtain more in-depth information about the planning process for high-tech and expensive medical equipment. A total of 6 informants as parties involved in the investment process. The results of the study for CT-Scan and 3D / 4D ultrasound, based on NPV calculations are positive, IRR values are lower than the interest rates used, CBR values are more than 1, and PI values are more than 1. It was concluded that from the analysis of financial aspects for investment in both medical devices is worth the investment. It is recommended that hospitals immediately hold the two medical devices in 2020 or 2021.</em></p>