A score-based method to improve the quality of emergency gynaecological ultrasound examination

Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery - The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood

OBJECTIVES

Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency.

METHODS

Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves.

RESULTS

Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794-0.879) and high urgency (AUC 0.902, 95 % CI 0.860-0.945).

CONCLUSION

Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion: A Randomized Clinical Trial

Importance

Vacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility.

Objective

To assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy.

Design, Setting, and Participants

The HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio.

Interventions

Surgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286).

Main Outcomes and Measures

The primary outcome was a pregnancy of at least 22 weeks' duration during 2-year follow-up.

Results

The intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, -4.8% [95% CI, -13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups.

Conclusions and Relevance

Surgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases.

Trial Registration

ClinicalTrials.gov Identifier: NCT02201732.

Virtual Compared With In-Clinic Transvaginal Ultrasonography for Ovarian Reserve Assessment

Imaging quality and performance for remote, patient-administered transvaginal ultrasonography are noninferior to in-clinic, ultrasonographer-performed ultrasonography for ovarian reserve assessment with antral follicle count.

To evaluate noninferiority of virtual transvaginal ultrasonography compared with in-clinic ultrasonography for ovarian reserve assessment.

Effects of simulation for gynaecological ultrasound scan training: a systematic review

Introduction

Simulation is a potentially promising solution to some of the challenges in delivering ultrasound training, and in the last decade, research in simulation-based education has rapidly expanded. There have been no prior focused systematic reviews on the effects of simulation on gynaecological ultrasound scan training. The aim of this review was to summarise and critically appraise the available evidence.

Methods

Medline, EMBASE, CINHAL, BNI, PubMed, ERIC, Cochrane Library and ISRCTN Register of Clinical Trials were searched using selected terminology. No language restrictions were applied. The selection criteria were studies of all types that investigated the use of a simulator to teach gynaecological ultrasound. Data evaluating study outcomes, along with methodological details, were extracted in duplicate. The outcomes were classified according to the Kirkpatrick hierarchy and included: patient-related outcomes, such as discomfort; organisational efficiency outcomes, such as examination times; and trainee-related outcomes, such as competence, skill and confidence.

Results

Fourteen studies with 573 participants were included: seven randomised controlled trials, three controlled observational studies and four uncontrolled observational studies. The use of simulation practice in gynaecological ultrasound in addition to standard approaches for teaching is associated with significant improvements in competence, skill and confidence of trainees and reduced patient discomfort, increased perceived patient safety and enhanced confidence in the trainee.

Conclusion

Our findings suggest that simulation in the early stages of training in gynaecological ultrasound is beneficial for the trainee, patients and has organisational benefits through reduced examinations times and need for supervision. Future research needs to confirm these findings in the different settings.

Benefits of using a simulator in the initial training for transvaginal ultrasound examination in gynecologic emergency unit

PURPOSE

Transvaginal ultrasound examination is decisive in Gynecologic emergency unit. This study's aim was to evaluate benefits of using a simulator for initial training of medical student for transvaginal ultrasound examination.

METHOD

A multicenter randomized trial was conducted. Medical student were randomized in two groups: in the intervention group, students took part in a simulation session in addition to the companionship-training while in the control group, they were only trained by companionship. To evaluate their progression, the quality of ultrasound pictures performed in real conditions before (pre-test) and after (post-test) the training by the students of both groups were evaluated and compared. Evaluation was performed according to predefined quality criterias for each ultrasound examination using a score of 20 points. Mean scores of students in both groups were compared for the pre and post-test.

RESULTS

Fifty six medical students were included. Mean scores of the 56 students were significantly better at the post-test than at the pre-test: 10,61/20 [9,62-11, 59] vs 6,35/20 [5,48-7,24], p < 0,001. Mean scores were significantly better at the post-test for students in the intervention group (n = 29) than in the control group (n = 27) 11,79/20 [7,72-10,94] vs 9,33/20 [7,72-10,94], p = 0,01. All the students in the intervention group were satisfied or highly satisfied to take part in this program.

CONCLUSIONS

Using a simulator for medical student was beneficial in the initial training of transvaginal ultrasound examination.

Guidelines for minimal report in gynaecologic sonography: Are they useful for emergency department resident physicians?

OBJECTIVES

This study aimed to evaluate the impact of Collège National des Gynécologues et Obstétriciens Français (CNGOF) guidelines on the minimal sonographic reports generated by emergency department resident physicians.

MATERIAL AND METHODS

This prospective observational study was conducted in the gynaecologic emergency unit of a teaching hospital from November 2016 to May 2017. We analysed sonographic reports generated by residents during gynaecological emergencies before and after training on the minimal report standards. An analysis of the evaluated items was carried out. We also compared residents according to their specialities and seniority.

RESULTS

A total of 240 reports were analysed, 120 before and 120 after the training. Half of the reports concerned women with an early pregnancy while the others concerned women with negative hCG. All residents significantly improved their practice after the training, as shown by the increase in ratings of the evaluated items (38 % before training vs 44.8 % after, p < 0.01). General practitioners had greater improvement (48.1 % of evaluated items), whereas older residents reported fewer items before or after the training (43.5 %) than younger residents. Finally, all residents improved their practice with a conclusion that followed the guidelines in 92.5 % of cases (versus 68.3 % before the training; p < 0.01).

CONCLUSION

Training on the CNGOF minimal sonographic report guidelines significantly improved the emergency sonographic reports generated by residents. Wider dissemination of this training, particularly to young residents, would probably improve the quality of sonographic reports performed at gynaecological emergencies.

A Novel Intelligent Scan Assistant System for Early Pregnancy Diagnosis by Ultrasound: Clinical Decision Support System Evaluation Study

Background

Early pregnancy ultrasound scans are usually performed by nonexpert examiners in obstetrics/gynecology (OB/GYN) emergency departments. Establishing the precise diagnosis of pregnancy location is key for appropriate management of early pregnancies, and experts are usually able to locate a pregnancy in the first scan. A decision-support system based on a semantic, expert-validated knowledge base may improve the diagnostic performance of nonexpert examiners for early pregnancy transvaginal ultrasound.

Objective

This study aims to evaluate a novel Intelligent Scan Assistant System for early pregnancy ultrasound to diagnose the pregnancy location and determine the image quality.

Methods

Two trainees performed virtual transvaginal ultrasound examinations of early pregnancy cases with and without the system. The ultrasound images and reports were blindly reviewed by two experts using scoring methods. A diagnosis of pregnancy location and ultrasound image quality were compared between scans performed with and without the system.

Results

Each trainee performed a virtual vaginal examination for all 32 cases with and without use of the system. The analysis of the 128 resulting scans showed higher quality of the images (quality score: +23%; P<.001), less images per scan (4.6 vs 6.3 [without the CDSS]; P<.001), and higher confidence in reporting conclusions (trust score: +20%; P<.001) with use of the system. Further, use of the system cost an additional 8 minutes per scan. We observed a correct diagnosis of pregnancy location in 39 (61%) and 52 (81%) of 64 scans in the nonassisted mode and assisted mode, respectively. Additionally, an exact diagnosis (with precise ectopic location) was made in 30 (47%) and 49 (73%) of the 64 scans without and with use of the system, respectively. These differences in diagnostic performance (+20% for correct location diagnosis and +30% for exact diagnosis) were both statistically significant (P=.002 and P<.001, respectively).

Conclusions

The Intelligent Scan Assistant System is based on an expert-validated knowledge base and demonstrates significant improvement in early pregnancy scanning, both in diagnostic performance (pregnancy location and precise diagnosis) and scan quality (selection of images, confidence, and image quality).

[Impact of the quality of ultrasound scan performed in gynecological emergencies in the diagnosis of ectopic pregnancy]

OBJECTIVES

There are no recommendations on the way emergency ultrasound should be performed but there are Standardized Acute Female Echography (SAFE) planes with quality criteria for ultrasound scoring. The objective of this study was to evaluate the impact of the quality of ultrasound on the diagnosis of ectopic pregnancy.

METHODS

A retrospective study was conducted in 2016-2017 and included all Ectopic Pregnancies (EP). Clinical, biological and ultrasonographic characteristics were collected, in particular the analysis of ultrasound scans according to the scoring score of standardized planes (total score out of 15). EP diagnosed at first ultrasound and those from Pregnancy of unknown location (PUL) were compared.

RESULTS

Hundred and seventeen patients were included: 45 (38.5%) in the group "EP from PLU" and 72 (61.5%) in the group "EP diagnosed directly". The ultrasound images were significantly better in the "directly diagnosed EP" group than in the "EP from PUL" group: 11.9/15 vs. 10.07/15 respectively (P=0.005). Moreover, in the group "EP from PUL", the images were significantly better on the final ultrasound diagnosing the EP compared to the first ultrasound performed: 11.4/15 vs. 10.07/17 (P=0.04).

CONCLUSION

The evaluation of quality of ultrasound scan using a standardized scoring system shows an impact in the diagnosis of ectopic pregnancies.

Gynecological emergency ultrasound in daytime and at night: differences that cannot be ignored

Background

Ultrasonography, the preferred adjunct examination method and the differential diagnostic tool for gynecologic emergency, can reflect the change pattern of gynecological diseases in daytime and at night. The purpose of this study was to analyze the diseases through gynecological emergency ultrasound in daytime and at night and to evaluate the day–night difference in the accuracy of ultrasound diagnosis.

Materials and methods

Retrospective analysis was performed on the 2016 clinical data of the patients who had undergone gynecological emergency ultrasound at The First Affiliated Hospital of Guangxi Medical University, and the results of the ultrasound diagnosis were compared with the clinical diagnosis.

Results

The following categories of gynecologic emergency diseases during the daytime and at night have significant statistical differences in the constituent ratio (P<0.001); ectopic pregnancy, intrauterine pregnancy, acute pelvic inflammatory disease, no organic lesion in uterine and adnexa; while the constituent ratio of abortion and trophoblastic diseases, ovarian tumor, uterine and endometrial lesions, was no statistical difference during the daytime and at night (P>0.05). The overall coincidence rate of ultrasound diagnosis was 96.3% (daytime, 97.9%; night, 86.4%). The coincidence rates of ectopic pregnancy ultrasonography diagnosis in daytime and at night were 96.4 and 75.4%, respectively; the difference was statistically significant (P<0.001).

Conclusion

Since the different constituent ratio of disease between daytime and night gynecological emergency ultrasound was significantly different, and the diagnostic accuracy of ultrasound at night was low; hence, the ultrasound doctor at night should pay attention to improve the accuracy of diagnosis and the ability of differential diagnosis of ectopic pregnancy, and it is suggested that some suspected cases during the night should be reexamined again in the daytime to eliminate the errors resulted from subjective factors.

Improving the quality of transvaginal ultrasound scan by simulation training for general practice residents

Background

Ultrasonography (US) is an essential tool for the diagnosis of acute gynecological conditions. General practice (GP) residents are involved in the first-line management of gynecologic emergencies. They are not familiar with US equipment. Initial training on simulators was conducted.

The aim of this study was to evaluate the impact of simulation-based training on the quality of the sonographic images achieved by GP residents 2 months after the simulation training versus clinical training alone.

Methods

Young GP residents assigned to emergency gynecology departments were invited to a one-day simulation-based US training session. A prospective controlled trial aiming to assess the impact of such training on TVS (transvaginal ultrasound scan) image quality was conducted. The first group included GP residents who attended the simulation training course. The second group included GP residents who did not attend the course. Written consent to participate was obtained from all participants. Images achieved 2 months after the training were scored using standardized quality criteria and compared in both groups. The stress generated by this examination was also assessed with a simple numeric scale.

Results

A total of 137 residents attended the simulation training, 26 consented to participate in the controlled trial. Sonographic image quality was significantly better in the simulation group for the sagittal view of the uterus (3.6 vs 2.7, p = 0.01), for the longitudinal view of the right ovary (2.8 vs 1.4, p = 0.027), and for the Morrison space (1.7 vs 0.4, p = 0.034), but the difference was not significant for the left ovary (2.9 vs 1.7, p = 0.189). The stress generated by TVS after 2 months was not different between the groups (6.0 vs 4.8, p = 0.4).

Conclusion

Simulation-based training improved the quality of pelvic US images in GP residents assessed after 2 months of experience in gynecology compared to clinical training alone.

Quality assessment of pelvic ultrasound for uterine myoma according to the CNGOF guidelines

INTRODUCTION

French guidelines regarding the minimum criteria for gynaecological ultrasound were given in a recent report in 2016, by the French National College of Obstetricians and Gynaecologists (CNGOF). An accurate report is essential for the optimal care of women, especially those presenting myomas. The goal of this study was to evaluate the quality of gynaecological ultrasound reports for women with type 0 to 2 uterine myomas, referring to the items contained in the French guidelines.

MATERIALS AND METHODS

A retrospective descriptive study was conducted from reports of ultrasounds performed in private offices and in the gynaecologic department of a hospital, between June 2014 and June 2016 (before the report of CNGOF). These reports involved women who underwent hysteroscopic resection of myoma(s). A search of validated items was conducted for all of the reports, and the missing items were analysed. The different types of practitioners and between hospital and private medical offices were also compared with Chi-square tests.

RESULTS

A total of 138 reports were analysed; 71 were performed in private offices and 67 were performed in the gynaecologic unit of the hospital. Many items were missing in the reports, with disparities between the type of institution (private offices or hospital) and the speciality of practitioners (radiologists or gynaecologists). Specific items regarding myomas, such as the International Federation of Gynaecologists and Obstetricians (FIGO) classification or measurement of the posterior wall, were more often missing in reports from radiologists (89.7% and 79.5%, respectively) than in reports from gynaecologists (21.2% and 34.3%, respectively) (P<0.05). A significant difference was also observed for these data between private offices' reports and hospitals' reports. Items relative to ultrasound structures, such as the appearance of myomas or associated abdominal effusion, were more frequently missing in gynaecologists' reports (88.9% and 49.5%, respectively) compared to radiologists' reports (56.4% and 12.8%, respectively) (P<0.05).

CONCLUSIONS

Certain items are present in all the reports, while others are insufficiently mentioned. These inequalities can be explained in part by the type of practice; however, methods to overcome these difficulties must be developed. Information campaigns to educate professionals on the minimum reporting and training conducted jointly by radiologists and gynaecologist surgeons might improve reports and improve the care of women.

[Feasibility and diagnostic value of hysterosonography performed in bleeding time in the exploration of abnormal uterine bleeding]

OBJECTIVES

The aim of our study is to evaluate the feasibility, safety and diagnostic value of hysterosonography performed in an emergency setting among patients consulting for active abnormal uterine bleeding.

MATERIALS AND METHODS

In this prospective study, we included 216 patients visiting our emergency department for abnormal uterine bleeding. All patients had a transvaginal ultrasound with doppler study and an hysterosonography. Secondly, the patients, in whom we diagnosed a suspected organic lesion, were addressed to an endoscopic or surgical procedure with pathological examination. Initially, we evaluated the feasibility and the safety of hysterosonography and secondly, we compared the two techniques (EEV and hysterosonography), sensitivity, specificity, LHR+and LHR-.

RESULTS

The hysterosonography was performed in 98.1 % of patients and its realization has resulted in an additional period of 1.2minutes on average (extreme: 6-12) compared to ultrasound. The tolerance of the hysterosonographic examination was very good in 73.5 % of patients and good in 23.1 % of them. For the 167 patients who had been diagnosed with presumed organic lesions, pathological examination found an endometrial hyperplasia in 34.7 % of cases, polyps in 40.1 % of cases, sub-mucosal fibroids in 11.3 % of cases, endometrial cancer in 0.7 % of cases and other lesions in 13.2 % of cases. The diagnostic value of hysterosonography was superior to ultrasound in the detection of polyps (AUC: 0.894 vs 0.778, P=0.003) and fibromas (AUC: 1.000 vs 0.716, P=0.001) while the two methods showed no significant difference in the detection of hyperplasia.

CONCLUSION

The purpose of our study was to focus on a particular context of use of the hysterosonography consisting on hemorrhagic period and on its realization in the emergency room. We were able to demonstrate that hysterosonography is compatible with the emergency situation as to its feasibility and its diagnostic value and that its realization would contribute to the sorting of patients to guide them immediately to a surgical or endoscopic procedure if necessary.

Randomized Clinical Trial of Virtual Reality Simulation Training for Transvaginal Gynecologic Ultrasound Skills

OBJECTIVES

To compare the impact of virtual reality simulation training and theoretical teaching on the ability of inexperienced trainees to produce adequate virtual transvaginal ultrasound images.

METHODS

We conducted a randomized controlled trial with parallel groups. Participants included inexperienced residents starting a training program in Paris. The intervention consisted of 40 minutes of virtual reality simulation training using a haptic transvaginal simulator versus 40 minutes of conventional teaching including a conference with slides and videos and answers to the students' questions. The outcome was a 19-point image quality score calculated from a set of 4 images (sagittal and coronal views of the uterus and left and right ovaries) produced by trainees immediately after the intervention, using the same simulator on which a new virtual patient had been uploaded. Experts assessed the outcome on stored images, presented in a random order, 2 months after the trial was completed. They were blinded to group assignment. The hypothesis was an improved outcome in the intervention group. Randomization was 1 to 1.

RESULTS

The mean score was significantly greater in the simulation group (n = 16; mean score, 12; SEM, 0.8) than the control group (n = 18; mean score, 9; SEM, 1.0; P= .0302).

CONCLUSIONS

The quality of virtual vaginal images produced by inexperienced trainees was greater immediately after a single virtual reality simulation training session than after a single theoretical teaching session.

Operative hysteroscopy versus vacuum aspiration for incomplete spontaneous abortion (HY-PER): study protocol for a randomized controlled trial

Background

Incomplete spontaneous abortions are defined by the intrauterine retention of the products of conception after their incomplete or partial expulsion. This condition may be managed by expectant care, medical treatment or surgery. Vacuum aspiration is currently the standard surgical treatment in most centers. However, operative hysteroscopy has the advantage over vacuum aspiration of allowing the direct visualization of the retained conception product, facilitating its elective removal while limiting surgical complications. Inadequately powered retrospective studies reported subsequent fertility to be higher in patients treated by operative hysteroscopy than in those treated by vacuum aspiration. These data require confirmation in a randomized controlled trial comparing fertility rates between women undergoing hysteroscopy and those undergoing vacuum aspiration for incomplete spontaneous abortion.

Methods

After providing written informed consent, 572 women with incomplete spontaneous abortion recruited from 15 centers across France will undergo randomization by a centralized computer system for treatment by either vacuum aspiration or operative hysteroscopy. Patients will not be informed of the type of treatment that they receive and will be cared for during their hospital stay in accordance with standard practices at each center. The patients will be monitored for pregnancy or adverse effects by a telephone conversation or questionnaire sent by e-mail or post over a period of two years. In cases of complications, failure of the intervention or diagnosis of uterine cavity disease, patient care will be left to the discretion of the medical center team.

Discussion

If our hypothesis is confirmed, this study will provide evidence that the use of operative hysteroscopy can increase the number of pregnancies continuing beyond 22 weeks of gestation in the two-year period following incomplete spontaneous abortion without increasing the incidence of morbidity and peri- and postoperative complications. The standard surgical treatment of this condition would thus be modified. This study would therefore have a large effect on the surgical management of incomplete spontaneous abortion.

Trial registration

ClinicalTrials.gov Identifier: NCT02201732; registered on 17 July 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0900-1) contains supplementary material, which is available to authorized users.

Impact of accreditation training for residents on sonographic quality in gynecologic emergencies

OBJECTIVES

To assess the impact of an educational intervention based on an original accreditation training program on the quality of emergency sonography performed by obstetrics and gynecology (Ob/Gyn) residents.

METHODS

We conducted a prospective before-after study on residents who performed bedside standardized sonographic examinations as first-line investigations in patients seen at our gynecologic emergency department. In both periods, the residents followed a 1-hour class taught by a board-certified Ob/Gyn sonography expert (opinion leader) and received a written standardized imaging protocol. An accreditation training process was implemented for the new residents at the beginning of the second period: 5 complete sonographic examinations were required for each resident, and facilitated feedback from the opinion leader was performed using a dedicated sonographic quality score. During both periods, all consecutive sonograms were collected and stored. The primary outcome was the sonographic quality score. A mixed model for repeated measures was used to compare scores in both periods from 20 consecutive sonographic examinations performed by 5 residents who were different in each period.

RESULTS

The mixed model analysis showed an increase in quality scores in the post-accreditation training compared to the pre-accreditation training period (estimated coefficient ± SD, 4.13 ± 0.51; t = 8.16). The sonographic examination order also had a significant effect in both periods (estimated coefficient ± SD, 0.11 ± 0.03; t = 3.99).

CONCLUSIONS

An accreditation training process including facilitated feedback from a local opinion leader improved the quality of sonographic examinations performed by Ob/Gyn residents in women presenting to a gynecologic emergency department.

Multi-Institution Validation of an Emergency Ultrasound Image Rating Scale-A Pilot Study

BACKGROUND

As bedside ultrasound (BUS) is being increasingly taught and incorporated into emergency medicine practice, measurement of BUS competency is becoming more important. The commonly adopted experiential approach to BUS competency has never been validated on a large scale, and has some limitations by design.

OBJECTIVE

Our aim was to introduce and report preliminary testing of a novel emergency BUS image rating scale (URS).

METHODS

Gallbladder BUS was selected as the test case. Twenty anonymous BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six training sites across the United States. Each reviewer rated the BUS sets using the pilot URS that consisted of three components, with numerical values assigned to each of the following aspects: Landmarks, Image Quality, and Annotations. Reviewers also decided whether or not each BUS set would be "Clinically Useful." Kendall τs were calculated as a measure of concordance among the reviewers.

RESULTS

Among the 13 attendings, image review experience ranged from 2-15 years, 5-300 scans per week, and averaged 7.8 years and 60 images. Kendall τs for each aspect of the URS were: Landmarks: 0.55; Image Quality: 0.57; Annotation: 0.26; Total Score: 0.63, and Clinical Usefulness: 0.45. All URS elements correlated significantly with clinical usefulness (p < 0.001). The correlation coefficient between each attending reviewer and the entire group ranged from 0.48-0.69, and was independent of image review experience beyond fellowship training.

CONCLUSION

Our novel URS had moderate-to-good inter-rater agreement in this pilot study. Based on these results, the URS will be modified for use in future investigations.

Evaluation and comparison of current fetal ultrasound image segmentation methods for biometric measurements: a grand challenge

This paper presents the evaluation results of the methods submitted to Challenge US: Biometric Measurements from Fetal Ultrasound Images, a segmentation challenge held at the IEEE International Symposium on Biomedical Imaging 2012. The challenge was set to compare and evaluate current fetal ultrasound image segmentation methods. It consisted of automatically segmenting fetal anatomical structures to measure standard obstetric biometric parameters, from 2D fetal ultrasound images taken on fetuses at different gestational ages (21 weeks, 28 weeks, and 33 weeks) and with varying image quality to reflect data encountered in real clinical environments. Four independent sub-challenges were proposed, according to the objects of interest measured in clinical practice: abdomen, head, femur, and whole fetus. Five teams participated in the head sub-challenge and two teams in the femur sub-challenge, including one team who tackled both. Nobody attempted the abdomen and whole fetus sub-challenges. The challenge goals were two-fold and the participants were asked to submit the segmentation results as well as the measurements derived from the segmented objects. Extensive quantitative (region-based, distance-based, and Bland-Altman measurements) and qualitative evaluation was performed to compare the results from a representative selection of current methods submitted to the challenge. Several experts (three for the head sub-challenge and two for the femur sub-challenge), with different degrees of expertise, manually delineated the objects of interest to define the ground truth used within the evaluation framework. For the head sub-challenge, several groups produced results that could be potentially used in clinical settings, with comparable performance to manual delineations. The femur sub-challenge had inferior performance to the head sub-challenge due to the fact that it is a harder segmentation problem and that the techniques presented relied more on the femur's appearance.

Routine ultrasound examination by OB/GYN residents increase the accuracy of diagnosis for emergency surgery in gynecology

Introduction

Diagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain.

Methods

A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both.

Results

Emergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%.

Conclusions

First-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.

Standardization of fetal ultrasound biometry measurements: improving the quality and consistency of measurements

OBJECTIVE

To assess whether a standardization exercise prior to commencing a fetal growth study involving multiple sonographers can reduce interobserver variation.

METHODS

In preparation for an international study assessing fetal growth, nine experienced sonographers from eight countries participated in a standardization exercise consisting of theoretical and practical sessions. Each performed a set of seven standard fetal measurements on pregnant volunteers at 20-37 weeks' gestation, and these were repeated by the lead sonographer; all measurements were taken in a blinded fashion. After this the sonographers had hands-on practice and feedback sessions on other volunteers. This process was repeated three times. Measurement differences between sonographers and the lead sonographer, expressed as a gestational-age-specific Z-score, between the first and third scans were compared using the Wilcoxon signed ranks test, and variance was assessed using Pitman's test. Interobserver agreement was also assessed using the intraclass correlation coefficient (ICC), and all images were scored for quality in a blinded fashion.

RESULTS

At baseline the level of agreement and image scoring were high. A significant reduction in the differences between sonographers and the lead sonographer were seen for fetal biometry overall (head circumference, abdominal circumference and femur length) between the first and third scans (median Z-scores, 0.46 and 0.24; P = 0.005), and a reduction in the variance was also observed (P < 0.001). The ICCs for measurement pairs for every fetal measurement showed a clear trend of increasing ICC (better agreement) with consecutive training scan sessions, although no improvement in image scores was seen.

CONCLUSION

Even for experienced sonographers, a standardization exercise before starting a study of fetal biometry can improve consistency of measurements. This could be of relevance for studies assessing fetal growth in multicenter sites.