Ultrasound has been the greatest imaging modality worldwide for many years by equipment purchase value and by number of machines and examinations. It is becoming increasingly the front end imaging modality; serving often as an extension of the physician's fingers. We believe that at the other extreme, high-end systems will continue to compete with all other imaging modalities in imaging departments to be the method of choice for various applications, particularly where safety and cost are paramount. Therapeutic ultrasound, in addition to the physiotherapy practiced for many decades, is just coming into its own as a major tool in the long progression to less invasive interventional treatment. The physics of medical ultrasound has evolved over many fronts throughout its history. For this reason, a topical review, rather than a primarily chronological one is presented. A brief review of medical ultrasound imaging and therapy is presented, with an emphasis on the contributions of medical physicists, the American Association of Physicists in Medicine (AAPM) and its publications, particularly its journal Medical Physics. The AAPM and Medical Physics have contributed substantially to training of physicists and engineers, medical practitioners, technologists, and the public.
No AccessJournal of Speech and Hearing DisordersThe Forum1 Nov 1964A Standard Definition of Stuttering M. E. Wingate M. E. Wingate University of Washington Google Scholar https://doi.org/10.1044/jshd.2904.484 SectionsAboutPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In Additional Resources FiguresReferencesRelatedDetailsCited by Speech, Language and Hearing (1-17)19 Oct 2023Perceptions and predictors of health-related quality of life among aging adults who stutter: a first glimpseNathan D. 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Maxfield Journal of Fluency Disorders (105778)1 Jun 2020Trait perspective-taking and need for cognition in the formation of stereotypes about people who stutterMaxim Baryshevtsev, Lingzi Zhong, Rachel Lloyd and Matthew McGlone Language, Cognition and Neuroscience35:1 (93-105)2 Jan 2020Processing of self-repairs in stuttered and non-stuttered speechMatthew W. Lowder, Nathan D. Maxfield and Fernanda Ferreira Ulrich Natke and Anke Kohmäscher (2020) Idiopathisches Stottern: Definitionen Stottern10.1007/978-3-662-60942-2_3 Giordano D'Urso, Elena Toscano, Gianpiero Gallo and Andrea de Bartolomeis (2020) Transcranial Direct Current Stimulation in Neurodevelopmental Disorders Non Invasive Brain Stimulation in Psychiatry and Clinical Neurosciences10.1007/978-3-030-43356-7_20 Journal of Speech, Language, and Hearing Research62:12 (4335-4350)18 Dec 2019Group Experiences and Individual Differences in StutteringSeth E. Tichenor and J. 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Maxfield and Fernanda Ferreira American Journal of Speech-Language Pathology28:1 (14-28)21 Feb 2019The Role of Effortful Control in Stuttering Severity in Children: Replication StudyShelly Jo Kraft, Emily Lowther and Janet Beilby Psychiatry and Clinical Neurosciences73:2 (63-69)1 Feb 2019Online cathodal transcranial direct current stimulation to the right homologue of Broca's area improves speech fluency in people who stutterYasuto Yada, Shuta Tomisato and Ryu‐ichiro Hashimoto Clinical Linguistics & Phonetics32:12 (1126-1144)2 Dec 2018An ultrasound investigation of the speech motor skills of stuttering Italian childrenGiovanna Lenoci and Irene Ricci Computers in Biology and Medicine102 (138-150)1 Nov 2018Measuring and monitoring emotional changes in children who stutterAbeer Al-Nafjan, Areej Al-Wabil, Abdulaziz AlMudhi and Manar Hosny American Journal of Speech-Language Pathology27:3S (1180-1194)19 Oct 2018A Phenomenological Analysis of the Experience of StutteringSeth Tichenor and J. 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Zelaya and Bradley S. Peterson The Japan Journal of Logopedics and Phoniatrics58:2 (191-195)Effect of Bi-Mora Frequency in Initial and Final Word Positions on Stuttering Frequency in School-Aged Children Who StutterSaburo Takahashi João Paulo Teixeira, Maria Goreti Fernandes and Rita Alexandra Costa (2017) Automatic Determination of Pauses in Speech for Classification of Stuttering Disorder Design, Development, and Integration of Reliable Electronic Healthcare Platforms10.4018/978-1-5225-1724-5.ch008 Folia Phoniatrica et Logopaedica69:4 (180-189)Speaker and Observer Perceptions of Physical Tension during StutteringSeth Tichenor, Paula Leslie, Susan Shaiman and J. Scott Yaruss Communication Sciences & Disorders21:2 (371-381)30 Jun 2016Self-Reactions of the Public toward People Who Stutter: Age and Sex DifferencesHeeCheong Chon World Neurosurgery90 (703.e7-703.e10)1 Jun 2016New-Onset Stutter After Electrode Insertion in the Ventrocaudalis Nucleus for Face PainAdrian B. 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Bijleveld (2015) Bégaiements et neurologie Les bégaiements10.1016/B978-2-294-74491-4.00005-9 Journal of Special Education Research3:1 (11-14)Differences of Processing Difficulty Between Phrases and Words in School-Aged Children Who StutterSaburo Takahashi and Tomohiko Ito Perceptual and Motor Skills117:1 (193-200)1 Aug 2013Motor Learning Cannot Explain Stuttering AdaptationHorabail S. Venkatagiri, Nuggehalli P. Nataraja and M. Deepthi International Journal of Reliable and Quality E-Healthcare2:3 (62-73)Pause Duration of Disfluent SpeechJoão Paulo Teixeira, Maria Goreti Fernandes and Rita Alexandra Costa The Japanese Journal of Special Education51:1 (31-39)Does Word Length Affect the Frequency of Stuttering? The Transition From Core VowelsSachiyo MATSUMOTO-SHIMAMORI and Tomohiko ITO Revista da Sociedade Brasileira de Fonoaudiologia17:4 (489-494)1 Dec 2012Gagueira desenvolvimental persistente familial: perspectivas genéticasBreila Vilela de Oliveira, Carlos Eduardo Frigério Domingues, Fabíola Staróbole Juste, Claudia Regina Furquim de Andrade and Danilo Moretti-Ferreira Journal of Fluency Disorders37:1 (25-41)1 Mar 2012Factors affecting occupational advice for speakers who do and do not stutterKenneth J. Logan and Elizabeth M. O'Connor The Japan Journal of Logopedics and Phoniatrics53:1 (27-32)Evaluation of Oral Reading in Stuttering Using Phonological AnalyzerNao Yasuda, Kentarou Yoshizawa, Michinari Fukuda, Yumi Yukimoto, Wakana Hata, Yuki Hara, Takashi Masaki and Kouji Yorizumi Journal of Special Education and Rehabilitation13:1-2Incidence of Stuttering in School-Age Children with Down SyndromeNevzeta Salihović, Selma Hasanbašić and Leila Begić Rehabilitación45 (21-26)1 Nov 2011El servicio de rehabilitación de Drassanes en Barcelona ciudad: un modelo integrado en la atención primariaM. Möller, R. Arroyo and M.D. Vega American Journal of Medical Genetics Part A152A:12 (3164-3172)1 Dec 2010 Identification of a microdeletion at the 7q33‐q35 disrupting the CNTNAP2 gene in a Brazilian stuttering case Aline L. Petrin, Célia M. Giacheti, Luciana P. Maximino, Dagma V. M. Abramides, Sthella Zanchetta, Natalia F. Rossi, Antônio Richieri‐Costa and Jeffrey C. Murray NeuroImage52:4 (1495-1504)1 Oct 2010A study of the reproducibility and etiology of diffusion anisotropy differences in developmental stuttering: A potential role for impaired myelinationM.D. Cykowski, P.T. Fox, R.J. Ingham, J.C. Ingham and D.A. Robin Journal of Neurolinguistics23:5 (488-500)1 Sep 2010Dysfluency levels during repeated readings, choral readings, and readings with altered auditory feedback in two cases of acquired neurogenic stutteringVenu Balasubramanian, Kristine L. Cronin and Ludo Max Journal of Fluency Disorders35:3 (246-279)1 Sep 2010Overreliance on auditory feedback may lead to sound/syllable repetitions: Simulations of stuttering and fluency-inducing conditions with a neural model of speech productionOren Civier, Stephen M. Tasko and Frank H. Guenther Clinical Neurophysiology121:9 (1447-1463)1 Sep 2010Neural correlates of semantic activation spreading on the path to picture naming in adults who stutterNathan D. Maxfield, Jessica L. Huffman, Stefan A. Frisch and Jacqueline J. Hinckley Journal of Fluency Disorders35:2 (123-140)1 Jun 2010Five-year longitudinal treatment outcomes of the ISTAR Comprehensive Stuttering ProgramMarilyn Langevin, Deborah Kully, Shelli Teshima, Paul Hagler and N.G. Narasimha Prasad Journal of Communication Disorders42:2 (155-161)1 Mar 2009Communication attitude of Italian children who do and do not stutterSimona Bernardini, Martine Vanryckeghem, Gene J. Brutten, Luisella Cocco and Claudio Zmarich Journal of speech-language & hearing disorders17:4 (19-31)1 Dec 2008The Characteristics of Speech Repetition in Neurogenic Stuttering 신명선 Journal of Fluency Disorders33:3 (180-202)1 Sep 2008Speeded verbal responding in adults who stutter: Are there deficits in linguistic encoding?Neville W. Hennessey, Charn Y. Nang and Janet M. Beilby International Journal of Language & Communication Disorders43:3 (283-299)6 May 2008Investigating factors related to the effects of time‐out on stuttering in adultsDiane E. Franklin, Catherine L. Taylor, Neville W. Hennessey and Janet M. Beilby Journal of Fluency Disorders32:1 (33-50)1 Jan 2007Genetic studies of stuttering in a founder populationJacqueline K. Wittke-Thompson, Nicoline Ambrose, Ehud Yairi, Cheryl Roe, Edwin H. Cook, Carole Ober and Nancy J. Cox International Journal of Language & Communication Disorders41:5 (583-589)1 Jan 2006The Behavior Assessment Battery: a preliminary study of non‐stuttering Pakistani grade‐school childrenMartine Vanryckeghem and Samad A. Mukati Journal of Fluency Disorders31:4 (271-283)Comparing judgments of stuttering made by students, clinicians, and highly experienced judgesShelley B. Brundage, Anne K. Bothe, Amy N. Lengeling and Jeffrey J. Evans American Journal of Speech-Language Pathology14:4 (284-297)1 Nov 2005Differential Diagnosis of Stuttering for Forensic PurposesCarol Hubbard SeeryAmerican Journal of Speech-Language Pathology14:4 (260-273)1 Nov 2005Have Disfluency-Type Measures Contributed to the Understanding and Treatment of Developmental Stuttering?Jóhanna Einarsdóttir and Roger J. Ingham Journal of Fluency Disorders30:4 (307-318)1 Jan 2005A comparative investigation of the speech-associated attitude of preschool and kindergarten children who do and do not stutterMartine Vanryckeghem, Gene J. Brutten and Lynell M. Hernandez BMC Neurology4:11 Dec 2004Morphological brain differences between adult stutterers and non-stutterersLutz Jäncke, Jürgen Hänggi and Helmuth Steinmetz Movement Disorders19:9 (1106-1109)1 Sep 2004Stuttering and gait disturbance after supplementary motor area seizureSun J. Chung, Joo‐Hyuk Im, Jae‐Hong Lee and Myoung C. Lee Contemporary Issues in Communication Science and Disorders31:Spring (80-91)1 Mar 2004Theoretical Perspectives on the Cause of StutteringNicoline Grinager Ambrose Medical Hypotheses62:3 (401-405)1 Mar 2004Slower and incomplete retrieval of speech motor plans is the proximal source of stuttering: stutters occur when syllable motor plans stored in memory are concatenated to produce the utterance motor planH.S Venkatagiri PLoS Biology2:2 (e46)17 Feb 2004What Causes Stuttering?Christian Büchel and Martin Sommer Journal of Fluency Disorders29:1 (3-25)1 Jan 2004Gestural overlap in consonant clusters: effects on the fluent speech of stuttering and non-stuttering subjectsWendy J. Huinck, Pascal H.H.M. van Lieshout, Herman F.M. Peters and Wouter Hulstijn Parkinsonism & Related Disorders9:5 (281-289)1 Jun 2003Tics and developmental stutteringHilda F Mulligan, Tim J Anderson, Richard D Jones, Michelle J Williams and Ivan M Donaldson Neuroscience & Biobehavioral Reviews27:4 (339-347)1 Jun 2003Choral speech: the amelioration of stuttering via imitation and the mirror neuronal systemJoseph Kalinowski and Tim Saltuklaroglu Journal of Communication Disorders36:1 (59-75)1 Jan 2003Second formant transitions in fluent speech of persistent and recovered preschool children who stutterAnu Subramanian, Ehud Yairi and Ofer Journal of Fluency Dec of the in and Journal of Fluency Dec of Journal of Fluency Mar R. of J. Ingham and M. Journal of Speech, Language, and Hearing Aug of Yairi and Nicoline Grinager of Speech, Language, and Hearing Jun on StutteringNicoline Grinager Ambrose and Ehud of Speech, Language, and Hearing Jun Yairi, Nicoline Ambrose and Neuroscience Jun the to stuttering in adults in the Tim and International Journal of Jan and A at Developmental F. Mulligan, Tim J. Anderson, Richard D. Jones, Michelle J. Williams and Ivan M. Donaldson Journal of Speech, Language, and Hearing Aug and of in the Speech of Who K. of Speech, Language, and Hearing Dec and in Scott YarussJournal of Speech, Language, and Hearing Aug of on of K. and Roger J. Ingham Journal of Fluency Nov of the of a stutter with to two of and of N. and J. Journal of Speech, Language, and Hearing Aug for of Treatment for Young Children Who Ingham and Journal of Speech-Language Aug for Young Children Who J. Ingham and Anne K. of Speech, Language, and Hearing Apr the of Scott Yaruss Journal of Fluency Feb of transitions in the speech of stutterers and and International Journal of Jan in is by of Journal of Fluency Disorders21:2 Jun between attitude and fluency of stuttering and childrenMartine Vanryckeghem and Gene J. Brutten Journal of Fluency Jun and of stuttering: A of Gene Journal of Speech, Language, and Hearing Feb of and by in Stuttering K. and Roger J. of Speech, Language, and Hearing Dec of K. and Roger J. Journal of Speech-Language Sep H. of Speech, Language, and Hearing Aug of Positions on the Speech of People Who and of Speech, Language, and Hearing Jun on & in and E. of Speech, Language, and Hearing Apr of K. and Roger J. of Speech, Language, and Hearing Dec of J. Ingham, Anne K. and Journal of Fluency Dec on of and H. Journal of Speech, Language, and Hearing Jun of J. Ingham, Anne K. and L. of Speech, Language, and Hearing Jun and Herman Journal of Fluency Jun treatment for Assessment of stuttering F. Journal of Fluency of stuttering and in the of in children and Ingham Journal of Speech, Language, and Hearing Oct to H. of Speech, Language, and Hearing Oct Can A to H. Journal of Speech-Language Sep of of Speech, Language, and Hearing Aug and Speech and of Speech, Language, and Hearing Jun of L. and Roger J. of Speech, Language, and Hearing Jun Analysis of and for Stuttering K. Roger J. Ingham, Peter Frank and Ingham Journal of Fluency Jan Journal of Speech, Language, and Hearing Oct G. and M. of Speech, Language, and Hearing Aug of in H. D. and Richard F. Journal of Motor Dec Motor of G. Journal of Fluency Oct is stuttering: and E. Journal of Speech and Hearing Aug and of of and and H. of Speech and Hearing Aug is H. Revista de Jan Journal of Fluency Aug and effects of a stuttering in the of a Viswanath Journal of Fluency Aug are E. Behavior Jul of and Treatment of E. A. E. and Peter Journal of Fluency Feb An for a H. Journal of Fluency Oct of stuttering in E. Journal of Fluency Apr between and and and Gene J. Brutten Journal of Fluency Feb to in versus A. and J. Journal of Fluency Apr and and E. Wingate Journal of Fluency Feb effects of of and the of in L. Journal of Fluency Feb and in a R. and L. Journal of Fluency Feb of a Japanese to Revista de Jan de la en de la de la G. Jan by G. Journal of Human Communication Dec A Perceptual Analysis of Speech G. and Bruce E. Journal of Fluency Dec and rate of speech in adult C. and Journal of Fluency Mar and and E. Wingate Journal of Fluency Dec A and Martin R. Journal of Fluency Sep of and in and O. R. and M. Journal of Human Communication Jun of on Perceptual of Treatment A. Journal of Fluency Feb of during Journal of Communication Jul on stuttering in and Journal of Communication Jul in a of adult L. and E. Journal of Fluency (29-37)1 Mar study of and Martin R. and Journal of Communication Mar of the of from on E. and Sep of stuttering by stutterers R. and J. Current in Jun B. Journal of Jan Treatment for Stuttering: A of Speech and E. Journal of Fluency Jan changes in stutterers and during R. Lee and Peter R. Richard and J. Disorders International Handbook of Behavior and Journal of Fluency Sep study of E. Wingate Journal of Fluency Sep and in stuttering and and John M. Journal of Communication Sep of stuttering: and E. Journal of Behavior Mar E. Journal of Fluency Mar by fluent and stuttering children and and Martin R. and of stuttering: and E. Journal of Fluency Dec stuttering and E. and Anne B. Journal of Fluency Dec of stuttering on of J. and David A. Journal of Fluency Sep of to stutteringJay Perceptual and Motor Aug of in Stuttering: A Clinical Study with C. and M. Journal of Fluency Jun and in the speech of Journal of Fluency Jun of speech to the of S. Venkatagiri Journal of Fluency Mar analysis of and and Journal of Fluency Dec analysis of stuttering as a R. Journal of Fluency Jun and The and R. Journal of Fluency Mar and fluency and to Stuttering Journal of Fluency Dec fluency in An and Brutten Journal of Fluency Dec of auditory on the frequency of stuttering M. and M. Behavior Nov effects of speech on stuttering An Journal of Fluency Jun during a in stuttering and and Journal of Fluency Mar Two case studies of stuttering and S. Behavior May of speech with a on the frequency and of in the speech of adult H. and G. Journal of Fluency Jan and of fluent and stuttered R. Journal of Fluency Jan stimulation of the by Lee and Gene J. Brutten Journal of Human Communication Dec Identification and of Stuttering in The D. Journal of Communication Jan analysis of for Behavior Oct analysis of the stuttering and Gene Brutten Journal of Communication Sep among of individual and Martin R. Journal of Communication Jan of in the treatment of R. International Journal of Language & Communication Oct and Roger J. Ingham Behavior Jul of on stutterers and R. and Journal of Communication Mar of and to stuttering A. Journal of the of Speech Dec of a to the Treatment of Stuttering in and Roger J. Ingham and in to Jan in Nov & American
Clinical practice involves measuring quantities for a variety of purposes, such as aiding diagnosis, predicting future patient outcomes, and serving as endpoints in studies or randomized trials. Measurements are almost always prone to various sorts of errors, which cause the measured value to differ from the true value; accordingly, studies investigating measurement error frequently appear in this and other journals. The importance of measurement error depends upon the context in which the measurements in question are to be used. For example, a certain degree of measurement error may be acceptable if measurements are to be used as an outcome in a comparative study such as a clinical trial, but the same measurement errors may be unacceptably large to make measurements usable in individual patient management, such as screening or risk prediction. In the past 20 years many papers have been published advocating how studies of measurement error should be analyzed, with a paper by Bland and Altman1 being one of the most cited and well known examples. There has been much controversy concerning the choice of parameter to be estimated and reported, and consequently confusion surrounding the meaning and interpretation of results from studies investigating measurement error. In this paper we first distinguish between the general concepts of agreement and reliability to aid researchers in considering which are relevant for their particular application. We then review the statistical methods that can be used to investigate and quantify agreement and reliability, dealing separately with the different types of measurement error study, while emphasizing the largely common techniques that should be used for data analysis. We reiterate that the judgment of whether agreement or reliability are acceptable must be related to the clinical application, and cannot be proven by a statistical test. We highlight the fact that reliability depends on the population in which measurements are made, and not just on the measurement errors of the measurement method. We discuss the advantages of method comparison studies making at least two measurements with each measurement method on each subject. A key advantage is that the cause of a correlation between paired differences and means in the so-called Bland–Altman plot can be determined, in contrast to when only a single measurement is made with each method. Throughout the paper, we try to emphasize that calculated values of agreement and reliability from measurement error studies are estimates of parameters, and as such we should report such estimates with CIs to indicate the uncertainty with which they have been estimated. We restrict our attention to measurements of a continuous quantity; alternative methods are required for categorical data2. One difficulty in the measurement error field is the number of different terms used to describe studies of measurement error. The terms ‘agreement’, ‘reliability’, ‘reproducibility’ and ‘repeatability’ are used with varying degrees of consistency in the medical literature. We first make clear the distinction between the statistical concepts of agreement and reliability3. Agreement quantifies how close two measurements made on the same subject are, and is measured on the same scale as the measurements themselves. Two measurements of the same subject may differ for a number of reasons, depending on the conditions under which the measurements were made. In a method comparison study there will be differences because of inherent variability in each of the measurement methods, as well as potentially a bias between the measurements from the methods. If the measurements are made by different observers or raters, differences may be due to biases between the observers. Agreement between measurements is a characteristic of the measurement method(s) involved, which does not depend on the population in which measurements are made, unless bias or measurement precision varies with the true value being measured. One popular way of quantifying agreement is to estimate the 95% limits of agreement, as proposed by Bland and Altman1. These limits are defined such that we expect that, in the long run, 95% of future differences between measurements made on the same subject will lie within the limits. If reliability is high, measurement errors are small in comparison to the true differences between subjects, so that subjects can be relatively well distinguished (in terms of the quantity being measured) on the basis of the error-prone measurements. Conversely, if measurement errors tend to be large compared with the true differences between subjects, reliability will be low because differences between measurements of two subjects could be due purely to error rather than to a genuine difference in their true values. The reliability parameter is also known as an intraclass correlation (ICC), as it equals the correlation between any two measurements made on the same subject. Reliability takes values between zero and one, with a value of one corresponding to zero measurement error and a value of zero meaning that all the variability in measurements is due to measurement error. As a dimensionless quantity, it is arguably quite difficult to interpret, and deciding what value constitutes sufficiently high reliability is often made in a subjective fashion. Repeatability of measurements refers to the variation in repeat measurements made on the same subject under identical conditions4. This means that measurements are made by the same instrument or method, the same observer (or rater) if human input is required, and that the measurements are made over a short period of time, over which the underlying value can be considered to be constant. Variability in measurements made on the same subject in a study can then be only to errors due to the measurement refers to the variation in measurements made on a subject under conditions4. The conditions may be due to different measurement methods or being measurements being made by different observers or raters, or measurements being made over a period of time, within which the of the could The first of study we is a study, in which we investigate and quantify the of measurements made by a single instrument or method, and in which the conditions of measurement constant. The of study we is a method comparison study, in which measurements are made two measurement methods on a of The of two different methods means that this is a study, but the method comparison is used as it the conditions under which measurements have been made. In contrast to a study, bias may between measurements made by two different methods, and their measurement errors may have different The of study we is one in which measurements are made by different observers or this is a of As with method comparison biases may between and their measurement may As we discuss Measurements with observers or if in quantifying the measurement error of the particular observers in study, the same methods should be used as for a method comparison In to investigate the of a study for an make at least two measurements subject under identical This means that the measurements must be made by the same measurement method, or the same observer or The is to then quantify the agreement and reliability of measurements made by that particular method or If the differences between two measurements made on a subject are in the long we expect the difference between two measurements on a subject to differ by than the on 95% of estimate the we can a of to the data the repeat measurements made on can be in all statistical variability in data that which can be to differences between and that to within For a study, the are defined by the subjects under and this must be in the statistical used. The estimates how much variation in measurements can be to differences in the or values of subjects, with the measurement error. the results in estimates of the and (or the corresponding which are the The estimate of the can be used in the to an estimate of the We with a study by the of measurements of made by one observer from The estimated meaning that the difference between any two future measurements made by that particular observer on a particular are estimated to be than on 95% of is to that the of observer may be because of differences in the and of observers. the calculated is an it is to a for it to indicate how it has been estimated. A may be by statistical but in the we review how a 95% for the can be a can be used to a for the by the limits by If the for the is by the limits must first be to a for the The that the measurement errors are of the true and that the of the errors is the of values. the of errors with the true value being measured. This should be by paired differences between measurements their the so Bland–Altman We this in the context of a method comparison study the and describe how such errors can often be with by making a variability in measurement of the on the differences between measurements being This can be by a or plot of the paired differences in measurements on each subject. made in the of the for the is that the measurement errors are If this is in the may be to The reliability of a measurement method is often of when measurements are to be used to between subjects or of For example, if we have a choice of two measurement methods that could be used to an outcome in a clinical or study, the method with reliability will statistical to differences between for a In this we describe how measurements from a single method can be used to estimate the reliability in a we discuss the of reliability to measurement methods Reliability in method comparison and different observers in The same as can be used to estimate statistical will the estimated which is the of we can the estimates of the and the Agreement and to estimate the For the data of an estimated of This means that of the variability in measurements of the estimated to be due to genuine differences in between with the being due to errors in the measurement and the observer the measurements were all made by one the reliability may be to as As with the the calculated is an and a 95% should be statistical a but in the we review the of a 95% for the For the data of the estimate of a 95% of to we the same to estimate reliability as we describe for agreement, the same of 95% CIs for the estimate on of the true values. The reliability of a measurement method depends upon the of the population in which the measurements are made. the of reliability Agreement and we that the of true values in the measured by the the value of agreement between repeat measurements is a characteristic of the method or instrument the of measurement errors is the of true reliability depends on the of measurement errors and the true in the population in which measurements are made. The is with a a method for measuring has a of which does not with the underlying value being measured. we a study to estimate the reliability, and we from a population in which the in true is 20 This a reliability or of we our subjects from a in which the of true values is the same as the variability of the error. In this the reliability is to If studies report only an estimate of the reliability (ICC), can only make of the estimate if the population in which the to such measurements has We that report estimates of and in to the In this can whether the measurement method will be sufficiently for their application, in which the between subjects may be we a measurement method or in clinical we must that the measurements it are to by the measurement method that measurements made with the method are the method. If the measurements from the two methods are sufficiently close and the of a patient on their basis be the the method could the method in clinical because the method is or to The as to what constitutes depends on how the measurements are to be used. If the two measurements are made on the same or we can quantify their investigate and quantify the agreement between measurements made by two methods, we must at a a of subjects the measurement method and the proposed method. The data from such a study of of measurements from each with the the measurements from the two measurement methods. we making two measurements on each subject each method because the one measurement method is the most common we by analysis. The first to such a is to plot the The plot is of measurements from the method from the method (or If measurements were from we expect the to lie on the of the of can be used to if there is if data are the than this that the method on the measurements on the of for this plot and report a statistical for whether the of the plot from the of As by Bland and in a paper in this we expect the to have a than one if the method on the any measurement and so a of the that the true is to one is not a it the same as a plot with the of of the between the measurements from two methods is often by the difference in a measurements from the two methods the of their as first by and this is to as the Bland–Altman and is frequently in of measurement error We the plot an from the literature. measurement in with and measured and also by We have their plot of differences means and it is as only data from the in measured by and by their from study by the and the each with 95% The plot the difference between calculated and the of two values. not their plot or of results to indicate which measurements were from is to be and always the same measurement from the The the of the paired from zero an estimate of the bias between the two methods. which measurements have been from which to which method, on measurements. The indicate the estimated limits of agreement their which we describe The plot can be used to the differences between measurements made by the two methods. The variability of the differences between the two methods how well the methods If the variability of the paired differences is the of and there is between the difference and we can quantify the agreement between the methods by the limits of the of the limits of agreement, we how the for limits of agreement may be and how they can be on we expect the difference in as measured by the two methods to lie between and for 95% of future measurements. is to that the limits of agreement calculated in this are just and as with any of estimate it is to quantify and report how the limits are estimated of 95% The estimated limits of agreement indicate how large the between the measurements will be on 95% of The whether the methods sufficiently well must then be made depending on the context in which the measurements will be used. In contrast to the which bias between the limits of agreement method this The of the paired differences whether on one method to or measurements to the measurements of the method, which we to as a bias between the methods. In the data in from there of a bias between the two methods, because the difference between the methods close to at We can a statistical to whether there is of bias by a of the differences paired of the measurements from each we the that the true of the differences is corresponding to bias between the methods. For the data in this that there of a bias between and made The limits of agreement method that the of the differences is the of measurements. this will not be the In frequently the of the differences will with the In this for small values the limits of agreement will be than for values the limits will be of the plot of differences from the study by that the variability of the differences may be when the value being measured is The of the paired differences the of the means it for the This can often be by of the measurements of the two If the difference in the of the measurements results in we can the limits of agreement and CIs for the limits in the the difference of two is to the of the we can all the estimates made on the scale by of the limits of agreement to the of one measurements to the For the data in the of the difference in measurements with The limits of agreement on the scale are to the of with 95% limits of agreement for the of to The 95% CIs can be calculated on the scale to the which measurements were made by which method, we cannot whether the is for measurements by to by or a plot of the of the measurements by the two methods to their a with the estimated 95% limits of agreement and their 95% This that the of a for the paired differences is of measured by and by of on data published by the and the each with 95% to can also be used to try to For example, estimate limits of agreement paired differences in measurements as a of the of the two measurements. The key is that a should be used which that are and have the of is for there to be an between the paired differences and of this is in a study by the agreement between as measured and the calculated in We have the data from their Bland–Altman plot of the difference between the and the and it in There to be a between the paired differences and differences between measured by and by from study by correlation the and the each with 95% We can a statistical to the for a whether the correlation between the paired differences and means from zero or by of the differences the The is known as in the context of the of measurements from two methods, which for the data in is for an between paired differences and how should we than for the difference as a of the we should be to the cause of the A between the paired differences and means when the of measurements from one method from the of measurements from the other method. There are at least two of an between paired differences and The first is that there is between the difference in measurements from the two methods and true value being the bias between methods over the of true values. The is that the of the two methods This will in the of bias if a method has or measurement errors than the method. This is and when a or measurement method is compared with a If the cause of the correlation is and we were to plot the paired differences the true value being there be The between the Bland–Altman plot and a plot true values because the paired means measurement errors, in contrast to the true values. as by and with only one measurement method we cannot which of two is the we must make an that the of the two methods are so that the correlation is to or that the two are and that there in between bias and true value we may have a of For the of we with the from by that the correlation is due to a difference in the of the two methods. A correlation between differences and means will when the method with measurement error is from measurements of the method with error. For the data in the correlation is the errors than the measured by which and to the measured by as the true that such measurements were to an that there is we can 95% limits of agreement, as by because the limits of agreement method does not that the two are In to from the data whether bias is we must make at least two measurements with each method on each subject. This study has often been but is we describe how such studies can be to whether a correlation between paired differences and means is due to bias between the methods with two measurements from each As reliability may be a parameter with which to two different measurement methods. estimate each reliability, we must make at least two measurements of each subject with each of the two methods. The repeat measurements from each method can then be as two studies estimates of each reliability, which can be advantage of reliability to measurement methods is that it can be used to methods when their measurements are on different or as the reliability is a dimensionless reliability depends on the of the true values in the population Reliability depends on population it is that reliability are compared only if they have been estimated from the same report a single reliability estimate from method comparison studies in which it that only a single measurement subject method is appear that the estimates are a as The that there are biases between measurements within subjects, and that the are for all measurements measurements are from two different methods, of may be bias may between the methods and their may If is the is and the estimates of within and between subject are estimates of different The reliability estimate then has a different interpretation from the We the estimate from the to data from two different measurement methods. As making two measurements with each method an of whether bias between the methods is or whether the measurement error the measurements from each method can be separately as two the methods estimates of the and reliability for each method. The Bland–Altman plot of paired differences means can be by the of a two measurements from each method in of the single As with the Bland–Altman plot on a single measurement from each method, an correlation between differences and means could be due to bias or a difference in measurement error between the methods. We describe a to whether any bias between measurements made by a method with the as measured by the method. We by the of the two measurements made the method and we by the measurement made on subject by the measurement method. A plot of can then be used to investigate whether the bias between the and methods with the as measured by the method. is that is rather than because the a to the common measurement error in and is for the same that paired differences between measurements from two methods the measurements from one method is in method comparison between values of and that the bias between the methods with the true value as measured by the method. A statistical of this can be by a for with as the The for the that the in this from zero the of the of If of bias with true value is we may be in the at which the bias between the methods We can estimate this by the estimate from the by our estimate of the This quantity is an estimate of the in bias method for a in the true value as measured by the method. The choice to is We could have and have a different and estimate of the at which the bias This choice is because we will two different and because it means the is The underlying is a of and as such can be for The is to and for measurements are made by observers or measurements made by two different observers are than are two measurements made by the same as with two methods, measurements from two observers may differ due to bias between the observers observer and their measurement errors may also have different For example, measurements from an observer can make measurements will have a than made by a If measurements in the future are to be made by different we to describe and quantify the differences between such measurements in to whether differences are genuine or may be due to measurement error. As with a method comparison study, the way to study this is for each observer to make at least two measurements of a of The of such a study and the of statistical that are should be by whether in a particular of or whether we are in a population of observers or If future measurements are to be made by a of the measurement error study should each of observers making measurements of a of subjects, with at least two measurements observer subject. We can then the same methods as for method different observers as different measurement methods. If each observer two or measurements on each we can whether there is bias or bias between observers. We can the bias of future measurements (in by measurements the corresponding estimated We can also estimate and reliability for each the may be of to which observers are and if differences in reliability can be related to observer such as of or If we are to that biases between observers are we can a so-called to such a for a subject and observer The estimates indicate the and for bias between observers. such can be to the measurement error to differ between observers. The observers in a measurement error study can often be considered as a of observers from a population of observers may be used in future studies or clinical In this we are not in the particular observers in the measurement error study, but only in the that they the population of observers. In this it is that a number of observers is used in the measurement error For example, if the measurement error study only two can be the population of because we have a of just the observers in the measurement error study are considered a from the population of we such a study a that the observer as a We a with subject and observer a estimates of the and the measurement error to be the same for different The variability in measurements due to or biases between the observers. such estimates one can the of the difference in two made by the same observer or by two different observers. the is the will be than the This is because biases between observers to make measurements from different observers it is difficult to distinguish between subjects on the basis of measurements made by two different observers than if the subjects been measured by the same In this paper we have distinguished between the concepts of agreement and parameter is to the as they describe different of the measurement The choice of what to report in a particular study should be by how measurements are to be used in the and also by the fact that may to a measurement method in a different We have the fact that the reliability of a method depends not only on the of the measurement errors but on the of true values in the population in which measurements are made. As measurement techniques potentially may be used in a variety of clinical and different it is to report estimates of and We have which methods we are for the of method comparison and studies with measurements made by different observers or In we not a single reliability should be used for method comparison If the reliability of two methods are to be each reliability should be estimated by making at least two measurements on each subject with each measurement method. We have how an between paired differences and means may not be by bias between two methods. an may also be by a difference in the measurement error but with only one measurement subject method it is not to which of is the comparison studies should make at least two measurements subject method. This an of the of any between paired differences and means for measurements made by the two methods, and also the and reliability of each method to be estimated. measurements an observer or measurement error studies must an number of observers if in making a population of observers. we results for the of CIs for two in the in which two measurements are from each
No AccessJournal of Urology1 Jun 1990Prostate Cancer Detection in a Clinical Urological Practice by Ultrasonography, Digital Rectal Examination and Prostate Specific Antigen William H. Cooner, B.R. Mosley, Charles L. Rutherford, Jeff H. Beard, Harry S. Pond, William J. Terry, Todd C. Igel, and Donald D. Kidd William H. CoonerWilliam H. Cooner More articles by this author , B.R. MosleyB.R. Mosley More articles by this author , Charles L. RutherfordCharles L. Rutherford More articles by this author , Jeff H. BeardJeff H. Beard More articles by this author , Harry S. PondHarry S. Pond More articles by this author , William J. TerryWilliam J. Terry More articles by this author , Todd C. IgelTodd C. Igel More articles by this author , and Donald D. KiddDonald D. Kidd More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)40211-4AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail The prostate cancer detection rate from screening by digital rectal examination and tactilely guided prostate biopsy is approximately 1.7%. Among 1,807 men a detection rate of 14.6% was achieved in a clinical urological practice by physician-conducted prostate ultrasonography, digital rectal examination and determination of serum prostate specific antigen. Results are presented in 5-year increments as well as for the group as a whole. The possible benefit to be derived from an improved detection rate is undetermined. Recommendations are made regarding the clinical use of these diagnostic modalities. © 1990 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byKryvenko O, Epstein J and Cote R (2018) Do Black NonHispanic Men Produce Less Prostate Specific Antigen in Benign Prostate Tissue or Cancer Compared to White NonHispanic Men with Gleason Score 6 (Grade Group 1) Prostate Cancer?Journal of Urology, VOL. 196, NO. 6, (1659-1663), Online publication date: 1-Dec-2016.Riedinger C, Womble P, Linsell S, Ye Z, Montie J, Miller D and Lane B (2018) Variation in Prostate Cancer Detection Rates in a Statewide Quality Improvement CollaborativeJournal of Urology, VOL. 192, NO. 2, (373-378), Online publication date: 1-Aug-2014.Crawford E, Rove K, Trabulsi E, Qian J, Drewnowska K, Kaminetsky J, Huisman T, Bilowus M, Freedman S, Glover W and Bostwick D (2018) Diagnostic Performance of PCA3 to Detect Prostate Cancer in Men with Increased Prostate Specific Antigen: A Prospective Study of 1,962 CasesJournal of Urology, VOL. 188, NO. 5, (1726-1731), Online publication date: 1-Nov-2012.Baden J, Adams S, Astacio T, Jones J, Markiewicz J, Painter J, Trust C, Wang Y and Green G (2018) Predicting Prostate Biopsy Result in Men With Prostate Specific Antigen 2.0 to 10.0 ng/ml Using an Investigational Prostate Cancer Methylation AssayJournal of Urology, VOL. 186, NO. 5, (2101-2106), Online publication date: 1-Nov-2011.Mishail A, Shahsavari M, Kim J, Welliver R, Vemulapalli P and Adler H (2018) Deficits in Urological Knowledge Among Medical Students and Primary Care Providers: Potential for Impact on Urological CareJournal of Urology, VOL. 180, NO. 5, (2140-2147), Online publication date: 1-Nov-2008.Thompson I, Ankerst D, Etzioni R and Wang T (2018) It's Time to Abandon an Upper Limit of Normal for Prostate Specific Antigen: Assessing the Risk of Prostate CancerJournal of Urology, VOL. 180, NO. 4, (1219-1222), Online publication date: 1-Oct-2008.Bruno J, Armenakas N and Fracchia J (2018) Influence of Prostate Volume and Percent Free Prostate Specific Antigen on Prostate Cancer Detection in Men With a Total Prostate Specific Antigen of 2.6 to 10.0 ng/mlJournal of Urology, VOL. 177, NO. 5, (1741-1744), Online publication date: 1-May-2007.Andriole G, Marberger M and Roehrborn C (2018) Clinical Usefulness of Serum Prostate Specific Antigen for the Detection of Prostate Cancer is Preserved in Men Receiving the Dual 5α-Reductase Inhibitor DutasterideJournal of Urology, VOL. 175, NO. 5, (1657-1662), Online publication date: 1-May-2006.Makarov D and Carter H (2018) The Discovery of Prostate Specific Antigen as a Biomarker for the Early Detection of Adenocarcinoma of the ProstateJournal of Urology, VOL. 176, NO. 6, (2383-2385), Online publication date: 1-Dec-2006.Uzzo R (2018) RENAL CELL CARCINOMA: UROLOGISTS IN A NEW ERAJournal of Urology, VOL. 174, NO. 5, (1723-1724), Online publication date: 1-Nov-2005.DATTA M, DHIR R, DOBBIN K, BOSLAND M, MELAMED J, BECICH M, ORENSTEIN J, KAJDACSY-BALLA A, PATEL A, MACIAS V and BERMAN J (2018) PROSTATE CANCER IN PATIENTS WITH SCREENING SERUM PROSTATE SPECIFIC ANTIGEN VALUES LESS THAN 4.0 NG/DL: RESULTS FROM THE COOPERATIVE PROSTATE CANCER TISSUE RESOURCEJournal of Urology, VOL. 173, NO. 5, (1546-1551), Online publication date: 1-May-2005.EMILIOZZI P, SCARPONE P, DePAULA F, PIZZO M, FEDERICO G, PANSADORO A, MARTINI M and PANSADORO V (2018) The Incidence of Prostate Cancer in Men With Prostate Specific Antigen Greater Than 4.0 Ng/Ml:: A Randomized Study Of 6 Versus 12 Core Transperineal Prostate BiopsyJournal of Urology, VOL. 171, NO. 1, (197-199), Online publication date: 1-Jan-2004.MATLAGA B, ESKEW L and McCULLOUGH D (2018) Prostate Biopsy: Indications and TechniqueJournal of Urology, VOL. 169, NO. 1, (12-19), Online publication date: 1-Jan-2003.KARAZANASHVILI G and ABRAHAMSSON P (2018) Prostate Specific Antigen and Human Glandular Kallikrein 2 in Early Detection of Prostate CancerJournal of Urology, VOL. 169, NO. 2, (445-457), Online publication date: 1-Feb-2003.Bozeman C, Carver B, Eastham J and Venable D (2018) Treatment Of Chronic Prostatitis Lowers Serum Prostate Specific AntigenJournal of Urology, VOL. 167, NO. 4, (1723-1726), Online publication date: 1-Apr-2002.CAREY J and KORMAN H (2018) TRANSRECTAL ULTRASOUND GUIDED BIOPSY OF THE PROSTATE. 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Volume 143Issue 6June 1990Page: 1146-1152 Advertisement Copyright & Permissions© 1990 by The American Urological Association Education and Research, Inc.MetricsAuthor Information William H. Cooner More articles by this author B.R. Mosley More articles by this author Charles L. Rutherford More articles by this author Jeff H. Beard More articles by this author Harry S. Pond More articles by this author William J. Terry More articles by this author Todd C. Igel More articles by this author Donald D. Kidd More articles by this author Expand All Advertisement PDF downloadLoading ...
No AccessJournal of Urology1 Apr 1967Ultrasonic Studies of the Bladder Joseph H. Holmes Joseph H. HolmesJoseph H. Holmes View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)63094-5AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1967 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited by Semproni F, Iacovacci V and Menciassi A Bladder Monitoring Systems: State of the Art and Future PerspectivesIEEE Access, 10.1109/ACCESS.2022.3221816, VOL. 10, (125626-125651) Nasrabadi M, Tabibi H, Salmani M, Torkashvand M and Zarepour E (2021) A comprehensive survey on non-invasive wearable bladder volume monitoring systemsMedical & Biological Engineering & Computing, 10.1007/s11517-021-02395-x, VOL. 59, NO. 7-8, (1373-1402), Online publication date: 1-Aug-2021. 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Watanabe H, Mishina T and Ohe H (1983) Staging of bladder tumors by transrectal ultrasonotomography and U.I. OctosonUrologic radiology, 10.1007/BF02926762, VOL. 5, NO. 1, Online publication date: 1-Dec-1983. Thornbury J, Wicks J and Eckel C (1983) Imaging methods for evaluating the adult bladder and urethra: An overviewSeminars in Roentgenology, 10.1016/0037-198X(83)90033-0, VOL. 18, NO. 4, (250-254), Online publication date: 1-Oct-1983. POSTON G, JOSEPH A and RIDDLE P (1983) The Accuracy of Ultrasound in the Measurement of Changes in Bladder VolumeBritish Journal of Urology, 10.1111/j.1464-410X.1983.tb03322.x, VOL. 55, NO. 4, (361-363), Online publication date: 1-Aug-1983. Hakenberg O, Ryall R, Langlois S and Marshall V (2018) The Estimation of Bladder Volume by SonocystographyJournal of Urology, VOL. 130, NO. 2, (249-251), Online publication date: 1-Aug-1983. RAVICHANDRAN G and FELLOWS G (1983) The Accuracy of a Hand-held Real Time Ultrasound Scanner for Estimating Bladder VolumeBritish Journal of Urology, 10.1111/j.1464-410X.1983.tb07073.x, VOL. 55, NO. 1, (25-27), Online publication date: 1-Feb-1983. Bree R and Silver T (1982) Nongynecologic bladder and perivesical ultrasoundUrologic Radiology, 10.1007/BF02924038, VOL. 4, NO. 1, (135-145), Online publication date: 1-Dec-1982. Robinson J (2012) The lower urinary tract.British Journal of Clinical Pharmacology, 10.1111/j.1365-2125.1982.tb01864.x, VOL. 13, NO. 6, (761-773), Online publication date: 1-Jun-1982. Henriksson L and Maršál K (1982) Bedside ultrasound diagnosis of residual urine volumeArchives of Gynecology, 10.1007/BF02111664, VOL. 231, NO. 2, (129-133), Online publication date: 1-Mar-1982. Szabó V, Sóbel M, Pajor L and Balogh F (1981) Ultrasonic measurement of residual urine: a method requiring no catheterInternational Urology and Nephrology, 10.1007/BF02081935, VOL. 13, NO. 4, (345-351), Online publication date: 1-Dec-1981. Gutsche H, Brunkhorst R, Müller-Ott K, Niedermayer W, Attallah A, Stahl R, Sack K, Marre R, Schulz E, Fuchshofen-Röckel M, Romen W, Röckel A, Richter E, Brunner H, Essers U, Mann H, Roth W, Riegger G, Haasis R, Thomae U, Lotz N, Boos W, Hermann M, Bachmann W, Haslbeck M, Winterberg B, Knoll O, Lison A, Gottschalk I, Samtleben W, Baltzer J, Gurland H, Ludwig-Köhn H, Henning H, Matthaei D, Sziedat A, Scheler F, Zilker T, Bottermann P, Hales C, Ley H, Scheidhauer K, Wanner C, Hörl W, Stepinski J, Heidland A, Müller-Berghaus G, Kniepert W, Glöckner W, Sieberth H, Molzahn M, Pommer W, Krause P, Müller G, Wernet P, Baldwin W, Es L, Wagner K, Neumayer H, Schultze G, Schwietzer G, Schudrowitsch L, Ruf W, Kreusser W, Andrassy K, Wietasch A, Koderisch J, Ritz E, Zimmermann S, Schirmer K, Gläser M, Tschöpe W, Deppermann D, Mehnert H, Leber H, Münzel U, Rawer P and Schütterle G (1981) Nephrologie Verhandlungen der Deutschen Gesellschaft für innere Medizin, 10.1007/978-3-642-47092-9_12, (640-722), . Szabó V, Sóbel M, Bégrádi J and Balogh F (1980) Diagnostic ultrasound in rulogyInternational Urology and Nephrology, 10.1007/BF02082466, VOL. 12, NO. 4, (291-309), Online publication date: 1-Dec-1980. Kornhuber H, Widder B and Christ K (1980) The measurement of residual urine by means of ultrasound (Sonocystography) in neurogenic bladder disturbancesArchiv f�r Psychiatrie und Nervenkrankheiten, 10.1007/BF00365737, VOL. 228, NO. 1, (1-6), Online publication date: 1-Mar-1980. Rise M, Bradley W and Frohrib D An Ultrasonic Bladder-Volume SensorIEEE Transactions on Biomedical Engineering, 10.1109/TBME.1979.326464, VOL. BME-26, NO. 12, (709-711) Bradley W, Rise M and Frohrib D (1979) Clinical use of biocompatible ultrasonic bladder volume sensorUrology, 10.1016/0090-4295(79)90510-7, VOL. 14, NO. 3, (300-302), Online publication date: 1-Sep-1979. Harada K, Igari D, Tanahashi Y, Watanabe H, Saitoh M and Mishina T (1977) Staging of bladder tumors by means of transrectal ultrasonographyJournal of Clinical Ultrasound, 10.1002/jcu.1870050606, VOL. 5, NO. 6, (388-392), Online publication date: 1-Dec-1977. TEELE R (1977) ULTRASONOGRAPHY OF THE GENITOURINARY TRACT IN CHILDRENRadiologic Clinics of North America, 10.1016/S0033-8389(22)02544-1, VOL. 15, NO. 1, (109-128), Online publication date: 1-Apr-1977. Green W and King D (1976) Diagnostic ultrasound of the urinary tractJournal of Clinical Ultrasound, 10.1002/jcu.1870040118, VOL. 4, NO. 1, (55-64), Online publication date: 1-Feb-1976. H�nig R (1976) Ultrasonic diagnosis in pediatrics The state of the art of ultrasonic diagnosis in pediatrics today Part IIPediatric Radiology, 10.1007/BF00975353, VOL. 4, NO. 3, (175-185), . HARRISON N, PARKS C and SHERWOOD T (1975) Ultrasound Assessment of Residual Urine in ChildrenBritish Journal of Urology, 10.1111/j.1464-410X.1975.tb04061.x, VOL. 47, NO. 7, (805-814), Online publication date: 1-Dec-1975. Carson P, Wenzel W, Avery P and Hendee W (1975) Ultrasound imaging as an aid to cancer therapy-IInternational Journal of Radiation Oncology*Biology*Physics, 10.1016/0360-3016(75)90020-6, VOL. 1, NO. 1-2, (119-132), Online publication date: 1-Oct-1975. Piiroinen O and Rauramo L (1975) Oral contraception and uterine size-ultrasonic studyAmerican Journal of Obstetrics and Gynecology, 10.1016/0002-9378(75)90181-7, VOL. 122, NO. 3, (349-351), Online publication date: 1-Jun-1975. Jankowiak Z (2018) The Determination of the Residual Urine Volume on the Basis of the Excretory Cystograms and Mathematical FormulaUrologia Journal, 10.1177/039156037404100602, VOL. 41, NO. 6, (547-552), Online publication date: 1-Dec-1974. Kobayashi T, Osamutakatani , Hattori N and Kimura K (1974) Echographic evaluation of abdominal tumor regression during antineoplastic treatmentJournal of Clinical Ultrasound, 10.1002/jcu.1870020210, VOL. 2, NO. 2, (131-141), Online publication date: 1-Jun-1974. JACOBS J (1972) Ultrasound as a Diagnostic Tool Advances in Biomedical Engineering, 10.1016/B978-0-12-004902-8.50009-0, (219-285), . Barnett E and Morley P (1971) Ultrasound in the investigation of space-occupying lesions of the urinary tractThe British Journal of Radiology, 10.1259/0007-1285-44-526-733, VOL. 44, NO. 526, (733-742), Online publication date: 1-Oct-1971. Damascelli B, Cascinelli N, Livraghi T and Veronesi U (1968) Preoperative approach to thyroid tumours by a two-dimensional pulsed echo techniqueUltrasonics, 10.1016/0041-624X(68)90135-2, VOL. 6, NO. 4, (242-243), Online publication date: 1-Oct-1968. Damascelli B, Lattuada A, Musumeci R and Severini A (2018) Comparison of Ultrasound and Radiography in the Diagnosis of Abdominopelvic MassesTumori Journal, 10.1177/030089166805400401, VOL. 54, NO. 4, (267-289), Online publication date: 1-Jul-1968. Volume 97Issue 4April 1967Page: 654-663 Advertisement Copyright & Permissions© 1967 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph H. Holmes More articles by this author Expand All Advertisement PDF downloadLoading ...
Diagnostic ultrasound is the safest medical imaging modality for the exposed patient and this has contributed to it being established as the method of choice for fetal examinations. The clinical benefits of obstetric ultrasound are generally recognized and, for about three decades, one or more ultrasound examinations during pregnancy have been offered to millions of pregnant women worldwide. A number of follow-up studies of children exposed to ultrasound in utero provided reassuring evidence that prenatal ultrasound examination does not cause adverse effects with regard to malformations, childhood malignancy, neurological abnormalities or abnormal growth1. The reported weak association between prenatal ultrasound exposure and non-right-handedness2 needs further evaluation but does not refute the fact that there is at present no evidence which would contradict the safe use of ultrasound in pregnancy. This was supported by a recently published prospective study demonstrating that multiple ultrasound examinations during pregnancy did not have any adverse effect on the postnatal growth, behavior and neurological development of children followed up to the age of 8 years3. However, high-energy ultrasound can induce biophysical effects when passing through tissue, for example, thermal effects and mechanical stress, causing cavitation. Consequently, some authorities, such as the Food and Drug Administration (FDA) in the USA, set upper limits for the output from ultrasound equipment: the estimated in-situ intensity must not exceed 720 mW/cm2. In Europe, no such general regulation of the output levels is given. It is the user's responsibility to control the output energy and to use the equipment in a safe manner. In order to facilitate ultrasound safety assessment, in the early 1990s, the American Institute of Ultrasound in Medicine and National Electrical Manufacturers Association introduced the 'output display standard' (ODS) using biophysical indicators for real-time display of safety information during scanning. The FDA adopted the ODS and issued regulations demanding the ODS information to be provided by the manufacturers. The definitions of these biophysical indicators and the requirements for their display are now included in an International Standard4. The ODS indicators comprise two types of biophysical index: the thermal index (TI) and mechanical index (MI)5. The indices are calculated for the given machine settings on the basis of tissue models and their acoustic properties. The TI is an estimate of the tissue temperature rise in degrees centigrade (°C), which might be possible under 'reasonable worst-case conditions'. For particular examination situations, three types of TI have been defined: soft tissue (TIS) and bone tissue (TIB) thermal index, and TI for cranial examinations (TIC). The MI attempts to indicate the probability of non-thermal effects occurring within the tissue. According to the ODS, for equipment that can at certain machine settings produce output energy giving TI or MI ≥ 1.0, the indices should be displayed if they exceed 0.4. The MI and TI are only rough estimates of possible effects and should not be understood as giving more than guidance to the operator. Nevertheless, the ODS is considered at present to be the best way of providing safety information. Several national and international professional bodies—societies of medical ultrasound—issue regularly statements with recommendations for the safe use of diagnostic ultrasound. The safety statements can be found in the official publications6 and on the websites of the societies (Table 1). Practically all safety statements recommend the use of ODS. Often, especially for use in pregnancy, the ALARA (as low as reasonably achievable) principle is suggested. The British Medical Ultrasound Society (BMUS) published more detailed recommendations regarding the exposure time of the fetus/embryo at various levels of TI7. In an attempt to survey the knowledge among ultrasound users of some safety aspects of diagnostic ultrasound, a questionnaire was distributed to professionals using ultrasound for fetal examinations. The questionnaire was answered by the participants and faculty members of six postgraduate courses in obstetric ultrasound, Doppler ultrasound and fetal echocardiography given in Sweden, Norway and Austria in 2003. Furthermore, in Sweden, the questionnaire was distributed to the staff meeting participants of two major obstetric ultrasound units and of one unit for fetal echocardiography, and at a meeting of the Working Group for Ultrasound of the Swedish Society of Obstetrics and Gynecology. In total, 199 questionnaires were anonymously answered by doctors (n = 145), sonographers (n = 22) and midwives trained in ultrasound (n = 32). All of them were using diagnostic ultrasound on a daily or weekly basis. The respondents were from nine European countries. In none of the countries is formal certification for the use of diagnostic ultrasound, in pregnancy or otherwise, required. The doctors who answered the questionnaire were specialists in obstetrics and gynecology (including some of the internationally recognized experts in fetal ultrasound), pediatric cardiology, radiology or clinical physiology. The respondents were not informed about the questionnaire in advance and they had a limited time to answer the 16 questions, typically 10–15 min. The questions concerned explanation of the safety indices and their relation to various ultrasound modes, i.e. real-time B-mode, M-mode, three-dimensional (3D), spectral Doppler, color and power Doppler ultrasound. The respondents were also asked which ultrasound system they used most often and where on the system the information on TI and MI was displayed (e.g. in the top right corner of the screen, in a separate window, etc.) Furthermore, the respondents had to indicate how they adjust the output energy level on their own machine. For all questions, there was the optional answer 'Don't know'. The complete list of questions is provided as supplementary material in the online version of the journal (Appendix S1). Table 2 summarizes the answers to the most important questions. About one-third of the ultrasound experts were able to define the abbreviations TI and MI. For the subclasses of the TI, the correct answer was found in only 3–8% of cases. Of those who knew what the TI and MI meant, only two-thirds and one-third of respondents, respectively, were able to give a simple explanation of the indices. In 49% of questionnaires, the Doppler modes were correctly ranked as generally producing higher ultrasound exposure than the imaging modes (B-mode, 3D). Some 28% of the respondents correctly indicated where on their own machine the information on safety indices is displayed. However, not all of them knew how to control the output energy level. For all items in the questionnaire there were no significant differences in the results between the three categories of respondents (i.e. physicians, sonographers and midwives). The results of the questionnaire were anything but encouraging and they indicated that the users, who are supposed to be responsible for controlling exposure of the fetus to ultrasound, had a very poor knowledge of the basic safety aspects of ultrasound. This was surprising, as, without exception, the respondents were experts and were very frequently using ultrasound for fetal examinations. It can be presumed that the level of knowledge is still lower among clinicians without special interest in diagnostic ultrasound who are routinely using ultrasound for examinations of pregnant women. Among non-professionals that use fetal ultrasound for non-medical commercial purposes, no understanding of the safety issues whatsoever can be expected. The questionnaire was distributed among European ultrasound users only and the results may not be representative of those obtained from obstetricians and radiologists performing fetal ultrasound in other parts of the world (e.g. the USA and Japan). However, as there is no requirement for obstetric ultrasound certification in these countries either, a better level of knowledge of ultrasound safety would not be anticipated. The information gained from the questionnaire indicates that the laudable initiative of BMUS to give TI limits for the use of diagnostic ultrasound in pregnancy remains without practical impact. The majority of the expert users did not know where to find and how to interpret information on the safety indices on the systems they used and, in addition, they were not able to control the energy output. The manufacturers are not responsible for the ultrasound output energy levels of their systems when used for obstetric or other purposes. Their obligation is to follow the ODS and to provide information on safety indices when the ultrasound energy might give a TI or MI of 1.0 or higher. They are expected to inform the purchaser of their equipment about how to find and use this information. Unfortunately, the quality of the information given in the user manuals varies greatly among the manufacturing companies, even if it has substantially improved over the years. Similarly, the knowledge about safety aspects among sellers and application specialists varies greatly. Considering the above points, the promotion of modern ultrasound equipment aimed at the lay public, as practised by some large manufacturing companies, has to be judged as unfortunate, since it might indirectly support the non-medical use of fetal ultrasound without proper respect being paid to the safety aspects. When analyzing the possible causes of the poor knowledge of safety aspects among expert users, several factors should be taken into account. First, there is the possibility of insufficient information being provided and the possibility of teaching quality being poor. There is plentiful literature on the subject, including the abovementioned safety statements, tutorials and reviews, published by professional organizations. Our own society, ISUOG, has a committee on bioeffects and safety of ultrasound, publishing safety statements and comments on urgent questions that arise. There is also an agreement that all courses on obstetric and gynecological ultrasound approved by ISUOG should include a lecture or seminar on safety issues. Similarly, the scientific program of annual ISUOG world congresses should contain an activity dealing with the problem of ultrasound bioeffects and safety. Thus, various sources of information are provided and are quite easily accessible. However, the questions of ultrasound safety are often perceived by the users as difficult to understand or even boring. For the same reason, the safety sessions at the congresses are usually not well attended and the impact of teaching activities is uncertain. Clinicians often refer to the basic thesis that ultrasound is safe for fetuses and, consequently, that it is unnecessary to spend time and energy acquiring the complicated information on physics and techniques of ultrasound. Is this a reasonable conclusion? Do safety committees push an issue that is of only academic interest? It does not seem to be the case. The data indicating lack of any adverse effects on human fetuses are based mainly on older studies that used ultrasound equipment producing low intensities. It has been shown that the output intensities of commercially available equipments have significantly increased over the years and that they can reach levels many times higher than those used 10 years ago8. New modalities producing higher intensities (e.g. harmonic imaging and Doppler ultrasound) are now widely available. In a study recording the levels of safety indices and their time course during standard examinations of high-risk pregnancies, including examinations of the uterine and fetal circulation with Doppler ultrasound, the TI values were found to exceed 1.5 and even 2.0 on several occasions during the examination9. Even if there is a considerable margin of safety, this warrants awareness of safety issues among users, especially among those examining embryos and fetuses susceptible to external physical factors. The fact that routine ultrasound examination of the fetus is being offered to practically all pregnant women, the majority of them without complications or risk factors, makes the prudent use of ultrasound still more important. The responsibility for safe use of ultrasound has been transferred to the user and it is up to the operator to balance the risk of not making a correct diagnosis against the minimal risk of ultrasound exposure. As a support to user's decision making, the ODS was designed to provide the necessary information. Theoretically, it is an excellent concept. The question is whether it has attained its goal. To utilize the information provided, a certain level of knowledge is necessary. The questionnaire described above indicates clearly that this prerequisite has not been fulfilled: not only did the users not show a reasonable understanding of the ODS principle; they were unable to control the output energy levels of their own equipment. Moreover, even if the users were to be fully informed, the ODS has practical limitations, especially for obstetric application. During the examination of a moving embryo/fetus, the operator has to concentrate fully on scanning and optimization of the image. Usually, switching between the various modes (e.g. B-mode, color Doppler and spectral Doppler), in addition to changing the settings, leads to a change in the safety index values. Thus, a continuous monitoring of the ODS values is necessary for full control of the output levels. Such monitoring is not practically possible, as the diagnostic quality of the examination would suffer. Conclusively, the ODS does not seem user-friendly; it provides hardly any useful guidance in obstetric examinations where the output control and guarantee of the safe ultrasound use is more important than in most other applications of diagnostic ultrasound. Deane and Lees9 proposed a graphical display of temporal changes in safety indices for monitoring of output levels and exposures. Certainly, an automatic recording of the output levels during fetal examination would enhance the awareness of the users, provided that they understand the ODS principles. Considering the above facts, I believe that some other ways of regulating the output levels, at least for the use of ultrasound in pregnancy, should be sought. Recently, there has been debate as to whether there should be an upper intensity limit for diagnostic ultrasound10. I do not think that removing upper intensity limits would be beneficial for obstetric ultrasound. Due to the favorable physical conditions during pregnancy (the fetus being surrounded by amniotic fluid, the absence of gas in the uterus), quite low intensities are usually required to obtain an image or Doppler signal of excellent quality. Thus, relatively low output limits should be sufficient in most instances. Naturally, the operator must be able to exceed the limits if this is necessary to achieve a diagnosis, for example, in cases of oligohydramnios or maternal obesity. However, in such situations the equipment should automatically alert the operator. In summary, there are no confirmed biological effects of diagnostic ultrasound on patients including fetuses. Nevertheless, because of the potential of adverse effects at high energy levels, informed use and proper control of output levels is mandatory. It seems that the ODS has failed to provide a practically useful platform, at least when applied to obstetric examinations. In addition to improved training and teaching of operators, new ways of output regulations should be sought which would facilitate the safe use of ultrasound. The following material is available from the Journal homepage: http://www.interscience.wiley.com/jpages/0960-7692/suppmat/index.html (restricted access) Appendix S1 Safety aspects of diagnostic ultrasound. Anonymous questionnaire used to survey the knowledge among ultrasound users of some safety aspects of diagnostic ultrasound. This article contains supplementary material available via the Internet from the Journal http://www.interscience.wiley.com/jpages/0960-7692/suppmat/index.html Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
You have accessJournal of UrologyAdult urology1 Jun 2007Guideline for the Management of Clinically Localized Prostate Cancer: 2007 Updateis accompanied byQuantifying the Impact of Prostate Volumes, Number of Biopsy Cores and 5α-Reductase Inhibitor Therapy on the Probability of Prostate Cancer Detection Using Mathematical Modeling Ian Thompson, James Brantley Thrasher, Gunnar Aus, Arthur L. Burnett, Edith D. Canby-Hagino, Michael S. Cookson, Anthony V. D’Amico, Roger R. Dmochowski, David T. Eton, Jeffrey D. Forman, S. Larry Goldenberg, Javier Hernandez, Celestia S. Higano, Stephen R. Kraus, Judd W. Moul, Catherine M. Tangen, and Prostate Cancer Clinical Guideline Update Panel Ian ThompsonIan Thompson Financial interest and/or other relationship with Mission Pharmacal, AstraZeneca and National Institutes of Health. More articles by this author , James Brantley ThrasherJames Brantley Thrasher Financial interest and/or other relationship with Medidiom and Abbott. More articles by this author , Gunnar AusGunnar Aus Financial interest and/or other relationship with Bok Medical. More articles by this author , Arthur L. BurnettArthur L. Burnett Financial interest and/or other relationship with Pfizer, Lilly ICOS and Guilford/MOI Pharma. More articles by this author , Edith D. Canby-HaginoEdith D. Canby-Hagino More articles by this author , Michael S. CooksonMichael S. Cookson Financial interest and/or other relationship with Sanofi-Aventis, GlaxoSmithKline, Envisioneering Medical Technologies, Aeterna Zentaris Solvay, Photocure, National Institutes of Health and GTX. More articles by this author , Anthony V. D’AmicoAnthony V. D’Amico More articles by this author , Roger R. DmochowskiRoger R. Dmochowski Financial interest and/or other relationship with Indevus, Watson Pharmaceuticals and Bard. More articles by this author , David T. EtonDavid T. Eton More articles by this author , Jeffrey D. FormanJeffrey D. Forman More articles by this author , S. Larry GoldenbergS. Larry Goldenberg More articles by this author , Javier HernandezJavier Hernandez More articles by this author , Celestia S. HiganoCelestia S. Higano More articles by this author , Stephen R. KrausStephen R. Kraus Financial interest and/or other relationship with National Institute for Diabetes and Digestive and Kidney Diseases, Pfizer, Atellas, Novartis and Ortho McNeil. More articles by this author , Judd W. MoulJudd W. Moul Financial interest and/or other relationship with AstraZeneca, Pfizer, Sanofi-Aventis and GlaxoSmithKline. More articles by this author , Catherine M. TangenCatherine M. Tangen More articles by this author , and Prostate Cancer Clinical Guideline Update Panel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2007.03.003AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction In December 1995, the AUA published the Report on the Management of Clinically Localized Prostate Cancer.1 The document was the culmination of six years of work by 17 clinicians and scientists and required the evaluation of 12,501 scientific publications with the detailed extraction of information from 165 papers that met the rigorous criteria of the panel of experts (Appendix 1 on-line). The Panel noted that a lack of evidence precluded specific recommendations for optimal treatment of an individual patient, which patients should be offered all treatment options, and that patient preferences should guide decision making. Since 1995, approximately 2,600,000 men2 in the United States have been diagnosed with prostate cancer, and nearly 375,000 men3,4 have lost their lives to this disease. In addition, the National Cancer Institute4 has spent $2.1 billion on prostate cancer research and as of November 2005, approximately 28,111 scientific papers concerning prostate cancer have been published in peer-reviewed medical journals (OVID Search, December 31, 1995 to October 23, 2005; key word: prostatic neoplasms). At the same time, mortality rates from prostate cancer have been declining: 34,475 men died in 1995 compared with an estimated 30,350 in 2005.4 Several pivotal RCTs related to prostate cancer treatment have been completed, including a chemoprevention study,5 along with studies demonstrating prolongation of life in men with hormone-refractory metastatic disease6,7 and improved outcomes in men with nonmetastatic disease.8–35 With the use of new and combined treatments, the frequency and variety of complications have differed from those previously reported. Advances have been made in prostate cancer imaging, biopsy methodology, in understanding causative factors and disease, in treatment-related QOL and in predicting the behavior of individual tumors using risk strata. Despite these advances, no consensus has emerged regarding the optimal treatment for the most common patient with prostate cancer: the man with clinically localized stage T1 to T2 disease with no regional lymph node or distant metastasis (T1 to T2N0-NxM0). Of the 234,460 men in the United States diagnosed with prostate cancer annually, 91% have localized disease.36 For these men and their families, the bewildering array of information from scientific and lay sources offers no clear-cut recommendations. Understanding this challenge for patients with newly diagnosed localized prostate cancer and the explosion in research and publications, the AUA re-impaneled the Prostate Cancer Clinical Guideline Panel (Appendix 2 on-line) for the purpose of reexamining and updating its analysis of treatment options. We herein report the results of a 5½-year effort to update the 1995 Guideline. The online version of this Guideline, which can be accessed at http://www.auanet.org/guidelines/, contains appendixes that include additional documents used in the conduct of the analysis and the graphics detailing the Panel’s findings. Context A contemporary man with localized prostate cancer is substantially different from the man with prostate cancer of 20 years ago. With the advent of PSA screening beginning in the late 1980s and the dramatic increase in public awareness of the disease, the average new prostate cancer patient has generally undergone multiple prior PSA tests and may even have experienced one or more prior negative prostate biopsies. When the cancer is detected, it is in a substantially earlier stage, often nonpalpable clinical stage T1c with, perhaps, one to several positive biopsy cores. The typical patient usually is very familiar with his PSA history and has a history of multiple visits to either his primary care provider or urologist. The most common patient will likely have Gleason score 6 or 7 disease, reflecting the most common current grading category and the fact that contemporary uropathologists assign this score more often than in the past when this group of tumors was frequently diagnosed one or two scores lower.37 The average patient of today also will more commonly have serum PSA levels in the 4 to 10 ng/mL range, and often in the 2.5 to 4.0 ng/mL range. In many cases, the patient’s PSA history will include sufficient data to allow a prediagnosis PSA velocity or doubling time to be calculated. Generally, the treating physicians will personalize the patient’s risk based on serum PSA level, highest/worst Gleason score, clinical stage, and burden of disease (either number or percent of biopsy cores with cancer). Following diagnosis, today’s patient will oftentimes be better informed and consequently request a second opinion by other physicians including other urologists or such specialists as radiation and medical oncologists. Many centers offer multidisciplinary clinics where the patient can consult with urologists, and with radiation and medical oncologists at one location. After considering the options and gathering several opinions, a patient and his family will choose among active surveillance, interstitial prostate brachytherapy, EBRT, and RP with treatment generally commencing two to three months after diagnosis. Aside from this complex decision, where the evidence basis for action has been suboptimal, patients now also are faced with subtle but important technical decisions such as choosing the type of surgery (eg open vs laparoscopic/robotic prostatectomy), the type of radiotherapy (eg conformal vs intensity modulated), the type of brachytherapy isotope, or whether a combination (eg brachytherapy and EBRT) of therapies should be used. Minimal data currently are available for the following interventions: high-intensity focused ultrasound, cryotherapy, high-dose rate interstitial prostate brachytherapy, and primary hormonal therapy. Conclusions regarding outcomes of these treatments cannot be made. It is in this very changed environment that we present the 2007 AUA Prostate Cancer Clinical Guideline Panel report. Definitions and Terminology The reader desiring a greater degree of information regarding the terminology used herein is directed to Appendix 3 on-line, which provides a glossary of terms important to a full understanding of the management options of localized prostate cancer. Screening Tests Clinically localized prostate cancer generally causes no symptoms. Slowing of the urinary stream, arising at night to void, and increased urinary frequency are common symptoms associated with aging but often are unrelated to the presence of prostate cancer. It is for this reason that early detection tests have been developed to identify prostate cancer while it remains confined to the prostate. The two most commonly used tests are a serum PSA level and a DRE.38,39 PSA Prostate specific antigen is a protein produced by cells within the prostate, and in men PSA can be measured in the blood. While higher blood PSA levels often are noted in men with prostate cancer, PSA elevation is not specific for prostate cancer. At present, a higher PSA test value is the most common reason why prostate cancer is detected in the United States. DRE A DRE is an examination by a physician using a gloved finger placed into the rectum to feel the surface of the prostate. The region of the prostate adjacent to the rectal wall is where tumors commonly develop; hard regions or asymmetry may indicate the presence of prostate cancer. Prostate Biopsy Although a higher PSA value or abnormal DRE may raise the suspicion of prostate cancer, detection requires confirmation with a prostate biopsy. At the time of biopsy, several small cores of tissue are removed from the prostate and are then examined by a pathologist to determine if cancer is present. Tumor Characteristics Tumor grade Tumor aggressiveness can be determined by the pathologist’s examination of the microscopic pattern of the cancer cells. The most commonly used tumor grading system is the Gleason grading.40,41 This system assigns a grade for each prostate cancer from 1 (least aggressive) to 5 (most aggressive) based on the degree of architectural differentiation of the tumor. Tumors often show multiple different grade “patterns” within the prostate or even a single core biopsy. To account for this, the Gleason score is obtained by assigning a primary grade to the most predominant grade present and a secondary grade to the second most predominant grade. An exception to this is in the case where the highest (most aggressive) pattern present in a biopsy is not either the most predominant or second most predominant pattern; in this situation, the Gleason score is obtained by combining the most predominant pattern grade with the highest grade. The Gleason score is then displayed as, for example, 3 + 4 where 3 would be the most common pattern of tumor and 4 the second most common pattern (or highest pattern) of tumor seen in the core. Given that the individual Gleason value can range from 1 to 5, the added values (Gleason scores or “sums”) can range from 1 + 1 to 5 + 5 or from 2 to 10. Generally, Gleason scores of 2 to 4 are uncommon; as a result, the majority of detected tumors range from 5 to 10. Occasionally, if a small component of a tumor on prostatectomy is of a pattern that is higher than the two most predominant patterns, then the minor component is added as a tertiary grade to the report (eg 60% pattern 3, 35% pattern 4, and 5% pattern 5 should be reported as 3 + 4 with tertiary grade 5). High-grade cancer With each increase in tumor score (eg from Gleason 5 to 6), there is an increase in tumor aggressiveness. High-grade cancer commonly refers to the most aggressive of tumors, generally Gleason scores of 8 to 10 (the most aggressive group), but also can include Gleason 7 tumors. Tumor stage Tumor stage refers to the degree to which the tumor has involved the prostate gland or has spread. As with other tumors, prostate cancers that involve only a small portion of the prostate are more successfully treated than those that have extended throughout the gland. Similarly, tumors that remain confined to the prostate are also more successfully treated than those that have extended beyond the confines of the gland. Finally, tumors that have spread to sites remote to the prostate (eg metastatic disease in lymph nodes or bone) have the poorest outcomes. The AJCC has established a system of tumor staging (Appendix 4 on-line).42 For the purposes of this guideline, the Panel chose to only examine treatment options for the most common group of patients diagnosed today: the patient whose tumor is confined to the prostate. Using the AJCC nomenclature, these tumors are clinical stage T1 (normal DRE) or T2 (abnormal DRE but no evidence of disease beyond the confines of the prostate), N0 to Nx (no evidence of spread to regional lymph nodes or regional lymph nodes were not assessed), and M0 (no evidence of metastatic spread). Initial Evaluation and Discussion of Treatment Options with the Patient Standard. An assessment of the patient’s life expectancy, overall health status, and tumor characteristics should be undertaken before any treatment decisions can be made. [Based on review of the data and Panel consensus.] Life Expectancy and Health Status Life expectancy, rather than patient age, is a major factor to consider in treatment selection. Thus, the Panel did not specify a chronological age cutoff point for the patient to whom this Guideline applies. When a man’s life expectancy is relatively long, localized prostate cancer can be a cause of morbidity and mortality. At an advanced patient age or when life expectancy is relatively short, competing hazards for mortality reduce the chance that a man will experience disease progression or die from prostate cancer (Appendix 5 on-line).10,43 The patient’s overall health status is the sum of all conditions and includes both patient and family history as well as the present state of the patient’s well-being and the degree of any coexistent disease. There are two reasons to evaluate overall health status prior to deciding on an intervention: (1) overall health status influences life expectancy, and (2) overall health status may affect patient response to adverse events resulting from particular interventions. In the management of prostate cancer, urinary, sexual, and bowel functions are important to consider when choosing a therapy. Tumor Characteristics Tumor characteristics, including PSA level and such changes as velocity and doubling time,44,45 Gleason score, and tumor stage are predictive of cancer outcomes. Using PSA, Gleason score, and tumor stage, risk strata have been defined that are significantly associated with PSA recurrence and cancer specific mortality.46 Therefore, these risk strata have been used as the basis for the current data analysis and treatment option specifications. Because of the differences in outcome by risk group for a given treatment, the Panel opted to develop treatment recommendations based on these risk strata. The size (volume) of the prostate gland may impact the treatment choice in some situations and, thus, requires consideration prior to instituting therapy. Risk Strata Risk stratification schemes have been developed based on the PSA level, biopsy Gleason score, and 2002 AJCC clinical T-category that are associated with the risk of PSA failure and prostate cancer specific mortality following RP, EBRT, or interstitial prostate brachytherapy.47 While variations on this system exist, for the purpose of this report the following scheme was used: • Low risk: PSA ≤10 ng/mL and a Gleason score of 6 or less and clinical stage T1c or T2a • Intermediate risk: PSA >10 to 20 ng/mL or a Gleason score of 7 or clinical stage T2b but not qualifying for high risk • High risk: PSA >20 ng/mL or a Gleason score of 8 to 10 or clinical stage T2c Treatment Options Watchful waiting and active surveillance The great disparity between cancer incidence and mortality indicates that many men may not benefit from definitive treatment of localized prostate cancer. Autopsy studies have shown that 60% to 70% of older men have some areas of cancer within the prostate.48,49 This can be compared with the 15% to 20% of men diagnosed with prostate cancer during their lifetime and with the 3% lifetime risk of death from prostate cancer.36 Men who choose not to undergo immediate therapy may opt for continued followup under a program of WW or active surveillance. Watchful waiting, as studied in RCTs,10,19,50 is based on the premise that some patients will not benefit from definitive treatment of the primary prostate cancer. The decision is made at the outset to forgo definitive treatment and to instead provide palliative treatment for local or metastatic progression if and when it occurs. Options for local palliation could include transurethral resection of the prostate or other procedures for the management of urinary tract obstruction, and hormonal therapy or radiotherapy for palliation of metastatic lesions. In contrast to WW, a program of active surveillance is based on the premise that some, but not all, patients may benefit from treatment of their primary prostate cancer. A program of active surveillance has two goals: (1) to provide definitive treatment for men with localized cancers that are likely to progress and (2) to reduce the risk of treatment-related complications for men with cancers that are not likely to progress. An ideal regimen for active surveillance has not been defined but could include periodic physical examination and PSA testing or periodic repeat prostate biopsies to assess for sampling error of the initial biopsy as well as for subsequent progression of tumor grade and/or volume. Active surveillance currently is under study in non-randomized trials in Canada, the United Kingdom, and the United States.51–53 A multicenter randomized trial of active surveillance vs immediate intervention was to have opened in the United States in 2006. Which patients are suitable candidates for active surveillance? Patients with lower risk tumors (low Gleason score, PSA level, and clinical stage) could be candidates for this treatment strategy. Several studies have shown that patients with lower grade, localized prostate cancer have a low risk for clinical progression within the first 10 to 15 years after the diagnosis.37,51,54–56 Thus, this treatment strategy may be best suited for men with a shorter life expectancy. Generally, patients with high-grade tumors have a relatively poor prognosis and are not suitable for active surveillance but, as will be noted in this report, often have poor outcomes with any therapy. Under special conditions, some patients with a longer life expectancy may opt for active surveillance as their primary management. This may include patients with very small areas of cancer in their biopsy or patients who, at the time of diagnosis, are reluctant to accept the side effects of potentially curative therapies. If the tumor shows evidence of progression (eg increased grade, volume, or stage) while the patient still has a reasonable life expectancy, curative treatments (eg surgery or radiation) can be initiated.53 This can be a difficult clinical decision since signs of progression must be identified before the cancer evolves to a stage (or grade) where therapy is no longer curative. Currently, providing evidence-based recommendations for when to intervene in patients with a long life expectancy are not possible since markers of disease progression are poorly validated. Most reports describe a clinical strategy that includes PSA level and DRE with a periodic repeat prostate biopsy along with an option of more active therapy if or tumor grade or progression In this Guideline the Panel used the to to a program initial treatment for the patient with localized cancer. As noted this program and its may be different based on patient and tumor characteristics and is from WW in which a degree of may be used and in which treatment is generally if or symptoms prostate brachytherapy interstitial prostate brachytherapy as a treatment has been since the patients were to the for an open at which time of After the of this were identified by at the Cancer and, in the late a was developed as a definitive treatment for localized prostate Patients with clinically localized prostate cancer are candidates for interstitial prostate brachytherapy, but with to which risk are offered this will use this treatment option for disease only while will both and to a study is to assess prostate and to determine the number of and the isotope, and the for the The are a under of or or with for each Treatment include different in combination with hormonal therapy and/or of the most important factors in predicting the of an is An is defined as one in which or more of the prostate gland at of the radiotherapy radiotherapy has been for the treatment of prostate cancer since the with the radiation at that time Since has been In the late with the first improved the to the of treatment improved the of treatment more of the prostate, and lymph this better of the adjacent to such as the and small The with for the early work in radiation As a of these changes in the 1980s and radiation were increased from the then typical of to to In the the advent of intensity radiotherapy and radiotherapy either with or the of markers treatment The resulting and provide in local tumor and in late For men considering EBRT, the evaluation commonly at a serum PSA level, and biopsy with Gleason the number of positive the number of cores and the presence or of or tertiary grade. staging and is for patients with a Gleason score or a PSA level >20 ng/mL prior to and medical for not present an for a patient radiotherapy is as a curative treatment for prostate cancer in men who not have a history of bowel disease such as disease, or a history of prior The results of RCTs have the use of and or hormonal therapy. As a result, hormonal therapy often is for men with Gleason score 7 cancer or higher or a PSA level in of 10 ng/mL in with can be to to using a conformal radiation and at with a of no more than 10 at the prostatic rectal include a for treatment and either a intensity or radiotherapy using a or For the RCTs a benefit of For patients in the RCTs have shown either hormonal therapy and or to should be For patients with advanced or high-grade disease (Gleason score RCTs have shown two to three years of hormonal therapy to at for years and is common for the assessment of the prostatectomy prostatectomy is a in which the prostate gland and the of the are prostatectomy may be using a or or by using a or on tumor characteristics and the patient’s either or RP is commonly can be with RP and is generally for patients with higher risk of Generally, patients RP will be for one to three after Patients with medical or complications may a longer of Patients are from the with an for one to two to the Because the prostate gland is removed with RP, the major benefit of this is a cancer in patients in whom the prostate cancer is In where the prostate cancer is of a high grade, when the tumor has spread of the prostate or when the tumor is not the prostate may not that all the cancer is the patient at risk for hormonal therapy may be with the of providing of prostate cancer for patients in whom definitive treatment with surgery or radiation is not possible or The of should be from the use of RP or radiation or RP or radiation hormonal therapy. from the a
HomeCirculationVol. 83, No. 1An updated coronary risk profile. A statement for health professionals. Free AccessAbstractPDF/EPUBAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessAbstractPDF/EPUBAn updated coronary risk profile. A statement for health professionals. K M Anderson, P W Wilson, P M Odell and W B Kannel K M AndersonK M Anderson Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. , P W WilsonP W Wilson Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. , P M OdellP M Odell Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. and W B KannelW B Kannel Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. Originally published1 Jan 1991https://doi.org/10.1161/01.CIR.83.1.356Circulation. 1991;83:356–362 Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hespe C, Giskes K, Harris M and Peiris D (2022) Findings and lessons learnt implementing a cardiovascular disease quality improvement program in Australian primary care: a mixed method evaluation, BMC Health Services Research, 10.1186/s12913-021-07310-6, 22:1, Online publication date: 1-Dec-2022. Lemke E, Vetter V, Berger N, Banszerus V, König M and Demuth I (2022) Cardiovascular health is associated with the epigenetic clock in the Berlin Aging Study II (BASE-II), Mechanisms of Ageing and Development, 10.1016/j.mad.2021.111616, 201, (111616), Online publication date: 1-Jan-2022. 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Disouza J, Patil K, Kakade P and Patravale V (2019) Dietary Fibers and Nutraceuticals in Prevention of Hypertension Nutraceutical and Functional Foods in Disease Prevention, 10.4018/978-1-5225-3267-5.ch007, (192-232) Charles‐Schoeman C, DeMasi R, Valdez H, Soma K, Hwang L, Boy M, Biswas P and McInnes I (2019) Risk Factors for Major Adverse Cardiovascular Events in Phase III and Long‐Term Extension Studies of Tofacitinib in Patients With Rheumatoid Arthritis , Arthritis & Rheumatology, 10.1002/art.40911, 71:9, (1450-1459), Online publication date: 1-Sep-2019. Sánchez-Acevedo M, Acosta-Chí Z, Sabino-Moxo B, Márquez-Domínguez J and Canton-Croda R (2019) Big Data Analysis for Cardiovascular Diseases Coronary and Cardiothoracic Critical Care, 10.4018/978-1-5225-8185-7.ch004, (60-77) Plante T, Juraschek S, Zakai N, Tracy R and Cushman M (2019) Comparison of Frequency of Atherosclerotic Cardiovascular Disease Events Among Primary and Secondary Prevention Subgroups of the Systolic Blood Pressure Intervention Trial, The American Journal of Cardiology, 10.1016/j.amjcard.2019.08.028, 124:11, (1701-1706), Online publication date: 1-Dec-2019. Nakas G, Bechlioulis A, Marini A, Vakalis K, Bougiakli M, Giannitsi S, Nikolaou K, Antoniadou E, Kotsia A, Gartzonika K, Chasiotis G, Bairaktari E, Katsouras C, Triantis G, Sionis D, Michalis L and Naka K (2019) The importance of characteristics of angina symptoms for the prediction of coronary artery disease in a cohort of stable patients in the modern era, Hellenic Journal of Cardiology, 10.1016/j.hjc.2018.06.003, 60:4, (241-246), Online publication date: 1-Jul-2019. Buettner R and Schunter M (2019) Efficient machine learning based detection of heart disease 2019 IEEE International Conference on E-health Networking, Application & Services (HealthCom), 10.1109/HealthCom46333.2019.9009429, 978-1-7281-0402-7, (1-6) Albarqouni L, Doust J, Magliano D, Barr E, Shaw J and Glasziou P (2019) External validation and comparison of four cardiovascular risk prediction models with data from the Australian Diabetes, Obesity and Lifestyle study, Medical Journal of Australia, 10.5694/mja2.12061, 210:4, (161-167), Online publication date: 1-Mar-2019. Liu Y, Li Q, Chen S, Wang X, Zhou Y, Tan N and Chen J (2018) A Simple Modified Framingham Scoring System to Predict Obstructive Coronary Artery Disease, Journal of Cardiovascular Translational Research, 10.1007/s12265-018-9837-6, 11:6, (495-502), Online publication date: 1-Dec-2018. 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More than with any other imaging modality, the medical use of ultrasound is highly operator-dependent. The potential for diagnostic error is magnified by the ongoing development of increasingly sophisticated equipment with extended applications. A gap is appearing between the sophistication of the most advanced machines and techniques and the skills of those expected to use them and interpret the images produced, due to a lack of training. Whilst many obstetricians and gynecologists in training attend courses addressing the finer points of, for example, cardiac Doppler, central nervous system posterior fossa imaging or three-dimensional endometrial visualization, relatively few are willing to attend courses on basic theoretical and practical ultrasound techniques. There are a few exceptions, for example in Scandinavia, where basic courses are mandatory. Are there steps missing in the training of doctors in the specialty? The impression we have is that there exists a relatively small number of talented and skilled ultrasound practitioners seeking to hone their skills ever more precisely, whilst many perfectly competent clinicians are perhaps less enthusiastic and more fearful of ultrasound as they have simply not been taught the basics. The answer should be yes. Modern obstetrics and gynecology practice is virtually impossible without the use of ultrasound. That does not mean that all obstetricians and gynecologists need to be experts in ultrasound. Certain aspects of the specialty require specific skills that are more important than ultrasound—for instance, gynecological oncology and urogynecology require surgical expertise, whilst maternal medicine requires specific medical knowledge. Nevertheless, it is clearly desirable for all obstetricians and gynecologists to have been trained robustly in basic sonographic skills so that their scanning in antenatal and gynecological clinics and on the labor ward is both safe and reproducible. Moreover, in order to gain maximum clinical benefit and to achieve optimal use of resources, there is a need for all ultrasound operators to have appropriate skills to perform and interpret ultrasound examinations. The European Board and College of Obstetrics and Gynaecology (EBCOG) has developed guidelines for basic education in obstetrics and gynecology (approved in June 2005). For ultrasound, the basic competence levels are defined only in broad terms. With respect to obstetric ultrasound, the trainee should have ‘detailed theoretical knowledge of the normal and abnormal anatomy of the fetus, placenta and amniotic fluid compartment, estimation of gestational age, fetal biometry, fetal growth and behaviour, [and] of the evaluation of fetal and uteroplacental blood flow’1. In gynecological ultrasound the trainee should have ‘detailed theoretical knowledge of ultrasonic aspects of normal pelvic anatomy; gynaecological disease; infertility and ultrasound guided invasive procedures’1. In addition, each trainee should have a log book listing 200 antenatal obstetric scans and 100 gynecological scans2. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) is more detailed in its minimum training recommendations for the practice of medical ultrasound3. For Level 1 (basic competence level) in gynecological ultrasound, EFSUMB recommends that trainees should perform a minimum of 300 examinations under supervision and keep an illustrated log book of 20 documented cases. They should receive a minimum of 20 hours of theoretical tuition, preferably at the beginning of the training period. For Level 1 in obstetric ultrasound the recommendations are that the trainee performs a minimum of 500 examinations under supervision, producing a log book listing the types of examinations, and receives 30 hours of theoretical tuition3. In 1996, ISUOG (the International Society of Ultrasound in Obstetrics and Gynecology) Education Committee produced the most ambitious proposal in their ‘Update on proposed minimum standards for ultrasound training for residents in Ob/Gyn’4. This document describes the contents of a basic theory course and required practical skills. It recommends that for certification a trainee should have 100 hours of supervised scanning including 100 gynecological and 200 obstetric scans. A log book with 30 cases with ultrasound images (including 15 fetal anomalies) should be included. Theoretical (multiple choice or written exam of three or four cases) and practical (transvaginal and fetal anomaly scan—30 min for both) examinations were recommended. ISUOG may decide to update this proposal, but in the meantime its Clinical Standards Committee has provided practical advice in the form of guidelines for individual types of exam. The difficulty in creating consistency in training standards throughout Europe has led to the separate and independent development of ultrasound training approaches in individual countries. We have, through contact with colleagues in other countries, performed an informal survey comparing ultrasound training in obstetrics and gynecology in some European countries. The results are presented in Table 1, which demonstrates that European countries differ in their formal definitions and requirements for basic obstetric and gynecological ultrasound training. Theoretical knowledge is taught in basic and intermediate ultrasound courses. Some countries test the theoretical knowledge in course exams, whilst in the UK, membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) requires an ‘overall’ exam including all subject areas, of which only a small fraction will include ultrasound. Some do not assess theoretical knowledge among trainees at all. Whilst most systems require formalized theoretical teaching, ‘hands-on’ practical supervision is rarely formalized. Yet, this is the most critical aspect of basic training. Most hands-on supervision for trainees is probably ad hoc in an opportunistic, unstructured way in clinics and wards, rather than being arranged in advance with clear educational goals. Log books and check lists are frequently used to document a certain number of scans, and the quality of images can be checked by a supervisor. However, achieving a particular number of scans does not equate to a certain level of competence. We suggest that four aspects should be discussed and decided upon: This has been proposed previously by EBCOG, EFSUMB and ISUOG. However, a problem is that definitions vary and do not seem to be implemented uniformly in European countries (Table 1). In the UK, basic ultrasound training for obstetric ultrasound (though not gynecological ultrasound) has recently become mandatory and comprises two modules. The goal of training is that each trainee should be able to carry out a dating scan at 8–12 weeks and to undertake some aspects of late pregnancy scanning, for example amniotic fluid index assessment, fetal presentation, placental site and aspects of basic fetal biometry. While these may appear to be modest goals for basic training, they are a marked improvement: now all UK trainees will be expected to achieve at least basic competence. Training must be offered and standards maintained, for which a robust assessment process is critical. However, the assessment process in European countries is variable (Table 1) and only a few countries have nationally applied assessment guidelines or tools. There are specific national considerations. In the UK, for example, objective and reproducible assessments are evidenced by RCOG (Royal College of Obstetricians and Gynaecologists) workplace-based assessments, which may be completed by medical or non-medical training supervisors. These include Objective Structured Clinical Examinations (OSCEs), Case Based Discussions (CBDs) and mini-CEXs (Clinical Examinations). Web-based resources to support trainers are available on the RCOG website5, along with the RCOG curriculum, assessment tools and information6. Both sonographers and obstetricians/gynecologists may, where appropriately qualified, perform assessments7. This is important because in the UK, the majority of obstetric ultrasound examinations are carried out by sonographers. Indication for ultrasound investigations, the sonographic appearance of normal anatomy in the standard planes, the correct settings of an ultrasound system as well as safety issues can easily be taught in conventional ways (lectures, books, videos), but the practical usage of an ultrasound system and, in particular, handling of the ultrasound probes (positioning, insonation angle) and adjustments for fetal movements and positional changes must be taught on a one-to-one basis. Once these basic abilities have been mastered, however, there are some other potentially useful educational tools: Online lectures. Several societies and dedicated individuals offer educational lectures on the Internet, ranging from basic to very advanced topics. ISUOG, for example, offers the contents of several ultrasound courses, covering both obstetric and gynecological topics, in full-media format (audio and video). While many of these lectures cover advanced topics, some also address concepts such as the fetal cardiac screening exam. These lectures are available for all members from ISUOG's website (www.isuog.org). In several European countries, trainees are able to access the ISUOG website through a free membership program. Multimedia-based self-study, using offline material (CD ROM). CD ROMS have been produced by various authors, including ISUOG, who offer an educational series of CD ROMS, some produced jointly with The Fetal Medicine Foundation, London (downloadable from ISUOG's website). Ultrasound simulators. Ultrasound simulators in basic obstetric and gynecological ultrasound training have been studied, but only sparsely, and their applicability for basic training has been disputed8, 9. However, once basic abilities (use of the ultrasound system, handling of the probes, acquisition of standard images) have been achieved by a trainee, there may be a possible role for digitally preserved pathological specimens both in basic and advanced training10, 11. EBCOG has representatives from all European countries and could agree on a structure for basic and intermediate ultrasound training, allowing harmonization between different European countries. The potential for putting together a joint course curriculum and for combining and sharing existing teaching material and expertise between the national societies is unarguable. ISUOG has come a long way in advanced women's imaging education, arranging well-attended, high-quality conferences, producing a top-ranked journal and providing a large and growing body of media-rich lectures and other tools on its website. The focus so far has, however, been on developing the skills of already competent ultrasound practitioners. We therefore suggest that the time is right to team up in order to craft a basic training program for ultrasound in obstetrics and gynecology that is geared towards residents' training. Without doctors being taught the basics, they are unlikely to become confident and competent advanced ultrasound practitioners. It is unrealistic to expect an overall and unified European ultrasound training scheme, though with increasing movement of doctors and patients within Europe this might be desirable. But there is no reason why a template for basic, intermediate and advanced training, both theoretical and practical, cannot be developed jointly between national bodies and supranational organizations. How this training is provided and assessed will differ from country to country, but a template may at least guide national societies to improve ultrasound education for all obstetricians/gynecologists. This will be rewarded by safer and more confident clinical management of patients in both obstetrics and gynecology. The Authors are very grateful to Kurt Biedermann, Gianluigi Pilu, Ann Tabor, Lil Valentin, Klaus Vetter and Yves Ville for provision of information used in the construction of Table 1 of this article.
In order to demonstrate the growth of the medical image registration field over the past decades, this paper presents the number of journal publications on this topic since 1988 until 2002. In a similar manner, trends in topics within the field of medical image registration are detected. Publications on computed tomography (CT) and magnetic resonance imaging (MRI) are rather constant through the years. Positron emission tomography (PET) and single photon emission computed tomography (SPECT), on the other hand, seem to loose ground to newly emerging functional imaging techniques, such as functional MRI (fMRI) whereas an increase in interest in registration of ultrasound (US) images was observed. Two topics in image registration that are currently considered hot are intraoperative and elastic registration. Although the interest in intraoperative registration strongly increased in the late 1990s, there seems to be a slight relative decrease in recent years. On the other hand, elastic registration has become a popular topic, reaching the highest numbers so far in 2002.
The role of Doppler in the assessment of fetal and placental blood flow is well-established1. However, as exemplified by the large variability of results published in the literature, its role in the evaluation of uterine and ovarian hemodynamics is not so clearly defined. Velocimetric indices such as pulsatility index and resistance index have been shown to provide useful information on uterine perfusion and angiogenesis in the ovarian follicle and certain cancers, but have not been adopted to any significant degree into clinical practice. Because of the advantages of power Doppler compared with conventional two-dimensional color Doppler2, some investigators have advocated its use for blood flow mapping3, 4. However, this technique only provides information on the ‘vascular map’ of a given region of interest and assessment relies largely on the subjective impression of the examiner. The advent of three-dimensional (3D) power Doppler ultrasound has begun a new era in tissue and organ vascularization research. Using this technique, we can now assess a virtually reconstructed vascular tree within a volume of interest5 and can ‘objectively’ determine its vascularization by calculating indices using the specially designed VOCAL™ software (GE Medical Systems, Zipf, Austria)6. Objective and non-invasive quantification of vascularization of a given tissue volume holds much promise, particularly because this method has proved to be highly reproducible between observers (thereby overcoming one of the main limitations of conventional Doppler ultrasound)7-9. Since the pioneering study of Pairleitner et al.6 in 1999, more than 100 papers have been published analyzing the role of 3D power Doppler ultrasound in almost all areas of obstetrics and gynecology, including placental and fetal vascularization10, 11, reproductive medicine12, 13, gynecological endocrinology14, gynecological oncology15-17, breast pathology18 and the pelvic floor19. Despite this abundance of literature on the application of 3D power Doppler ultrasound, it seems that so far few have stopped to ask what we are measuring. Calculation of the three 3D power Doppler ultrasound vascular indices, the vascularization index (VI), flow index (FI) and vascularization flow index (VFI), is based on and related to the total and relative amounts of power Doppler information within the volume of interest. VI denotes the ratio of color-coded voxels to all voxels within the volume and is expressed as a percentage, FI represents the mean power Doppler signal intensity from all color-coded voxels and VFI is the simple mathematical relationship derived from multiplying VI by FI and dividing the result by 1006. Both FI and VFI are unitless and are expressed as a numerical value ranging from 0 to 100. The indices are thought to reflect the number of vessels within the volume of interest (VI), the intensity of flow at the time of the 3D sweep (FI), and both blood flow and vascularization (VFI)6. Although our knowledge about what these indices are actually measuring is limited, most examiners involved with the use of power Doppler are aware that several factors affect the power Doppler signal20, 21. Yet, studies evaluating how machine settings affect measurements are scanty22. In this issue of the Journal, three papers make a significant contribution to the understanding of what these indices are measuring and how machine settings affect the measurements23-25. All three studies were performed in an in-vitro setting using a flow phantom experiment. In the first study by Raine-Fenning et al.23, the authors evaluated the relationship of VI, FI and VFI values with vessel number, flow rate, attenuation and ‘erythrocyte’ density. They found a positive linear relationship between VI and VFI and all these factors except attenuation, which showed a negative relationship. In other words, with increasing number of vessels, volume flow or erythrocyte density, VI and VFI values increase. In the case of VI, these findings are particularly interesting. VI actually quantifies the number of color-coded voxels, which does not necessarily mean the number of vessels. However, in this phantom study, the authors found a correlation between the number of color-coded voxels and ‘number of vessels’. This finding is in agreement with preliminary data from in-vivo studies that showed that VI correlates positively with microvessel density count as assessed by immunohistochemical techniques26. In contrast, the further the object under investigation is from the transducer, the lower the values obtained. This is of clinical relevance, because the route—transvaginal or transabdominal—should be taken into account when performing the calculations, as should the distance between the probe and the object under investigation. However, Raine-Fenning et al. found that FI showed a ‘more complex cubic relationship that is not always logical’. This could indicate that FI is less predictable than VI and VFI. For example, they discovered that VI and VFI increase steadily with an increasing number of vessels, while FI reached a peak with three vessels and decreased thereafter. Additionally, as the authors themselves proved, a greater distance from the transducer to the furthest ‘vessels’ in the phantom decreased the signal intensity, leading to an overall decrease of the power Doppler signal. In their second paper, Raine-Fenning et al.24 demonstrate that machine settings and speed of acquisition affect significantly all three 3D power Doppler ultrasound indices. These findings could be anticipated because it is well known that machine settings affect the power Doppler signal20, 21. A potential weakness of their study is that it used an ultrasound machine from the old Voluson series, the Voluson 530, which did not have the power Doppler sensitivity of equipment in current use. However, in my opinion, this fact does not invalidate their results. In fact, in the third study, by Schulten-Wijman et al.25, the more modern Voluson 730 Expert was used and the principal study findings, that machine settings affect VI and FI calculation, were similar. An interesting additional finding is that ‘measured VI’ overestimated ‘actual VI’ even with different machine settings by up to 44 times! The concept of ‘actual VI’, as described by the authors in the paper, could be misleading but they are probably right. The VI is just a ratio between colored and total voxels and, since voxels are actually small cubes that occupy a predetermined volume, in my opinion, the VI is in fact the ratio between the volume of colored voxels and the volume of the total voxels. However, what I cannot understand is how they obtained those results because, assuming that all colored voxels within the tube are detected by the machine, the VI should be as high as the ‘actual VI’, but never higher. The experimental set-up in this study used a single tube, simulating one vessel, and it remains to be seen whether this finding could be extrapolated to true tissue vascularization where multiple vessels exist. Notwithstanding, this fact should be taken into consideration when measuring the VI in a single vessel, such as the uterine, umbilical, or fetal middle cerebral artery. Schulten-Wijman et al. also propose that the term ‘flow index’ be replaced by ‘power index’, a suggestion that I would endorse, because what we are actually measuring is mean power Doppler signal intensity. Although it should be acknowledged that phantom studies for assessing Doppler systems have certain limitations27, 28, and that the authors of these three studies used somewhat exaggerated machine settings that are not usually used in clinical practice, the results they report are relevant for at least two reasons. First, they provide evidence that machine settings affect VI, FI and VFI calculations. The primary consequence of this should be that all future papers published using this method should report the machine settings used and even the maximum depth of the objects evaluated when performing investigations. Furthermore, these results should prompt us to reach a consensus about which machine settings should be used, at least in the research situation, in order to allow meaningful comparison among studies. To the best of my knowledge, only the 3D Ultrasound Group from the Spanish Society of Ultrasound in Obstetrics and Gynecology has documented recommendations about machine settings to be used for research29 and, in my opinion, the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) should formulate a proposal for standardized settings to be used worldwide. Second, these studies have shown how VI, FI and VFI indices are not related equally to the number of vessels and volume flow. This implies that the most appropriate index to use might be different depending on the clinical setting. For example, for analyzing tumor vascularization, VI may be preferred because in clinical practice oncologists and pathologists already use the mean vessel density (i.e. the number of vessels as a measure of tumor vascularization), the amount of flow being less relevant. However, when volume flow is the target of investigation, for example in maternal–fetal and reproductive medicine, it may be that FI is more useful. I believe that we are a long way from clearly defining the role of 3D power Doppler ultrasound indices in clinical practice. However, steps such as those reported in this issue of the Journal are important for the scientific understanding of this technology.
Accurate prediction of delivery date in canine and feline allows a better management of parturition, reducing the loss of neonates. This review evaluates the most common methods adopted to accurately predict the day of delivery: determination of ovulation and hormonal assays, first appearance of embryonic/foetal structures using ultrasound or radiography, echographic measurement of extra-foetal and foetal structures, or evaluation of foetal flux and heart rate. Determination of ovulation and hormonal assays at the time of breeding and close to pregnancy term is widely used to predict parturition in dogs (Concannon et al. American Journal of Veterinary Research 44, 1983, 1819; Hayer et al. Journal of Reproduction and Fertility, Suppl. 47, 1993, 93; Hase et al. Journal of Veterinary Medical Science, 62, 2000, 243; Kutzler et al. Theriogenology, 60, 2003a, 1187). In cats, some studies have been carried out, but no hormonal parameters for accurate prediction of parturition have been described so far (Buff et al. Journal of Reproduction and Fertility, Suppl. 57, 2001, 187; De Haas van Dorsser et al. Biology of Reproduction, 74, 2006, 1090; DiGangi et al. Journal of the American Veterinary Medical Association, 237, 2010, 1267; Dehnhard et al. Theriogenology, 77, 2012, 1088). Many studies suggested that gestational timing can be obtained by observation using ultrasound or radiography of specific structures in relation to the time of appearance during gestation (Concannon and Rendano American Journal of Veterinary Research, 44, 1983, 1506; Rendano et al. Veterinary Radiology, 25, 1984, 132; Shille and Gontarek Journal of the American Veterinary Medical Association, 187, 1985, 1021; Davidson et al. Veterinary Radiology, 27, 1986, 109; England et al. Journal of Small Animal Practice, 31, 1990, 324; Yeager et al. American Journal of Veterinary Research, 53, 1992, 342; Zambelli et al. Theriogenology, 57, 2002a, 1981; Zambelli et al. Journal of Feline Medicine and Surgery, 4, 2002b, 95; Zambelli and Prati 2006; Lopate Theriogenology, 70, 2008, 397; Davidson and Baker Topics in Companion Animal Medicine, 24, 2009, 55). Ultrasonographic measurement of extra-foetal and foetal structures is a common and accurate method for the prediction of parturition day during pregnancy, when specific formulae are used depending on the ultrasonographic parameter, the species and, in canines, the size of the bitch (Shille and Gontarek Journal of the American Veterinary Medical Association, 187, 1985, 1021; England et al. Journal of Small Animal Practice, 31, 1990, 324; Luvoni and Grioni Journal of Small Animal Practice, 41, 2000, 292; Luvoni and Beccaglia Reproduction in Domestic Animals, 41, 2006, 27; Lopate Theriogenology, 70, 2008, 397; Michel et al. Reproduction in Domestic Animals, 46, 2011, 926; Beccaglia and Luvoni Reproduction in Domestic Animals, 47, 194, 2012). Recent studies demonstrated that in dogs, the imminence of parturition could be predicted by evaluating foetal flux and foetal heart rate by ultrasound (Gil et al. Theriogenology, 82, 2014, 933; Giannico et al., Animal Reproduction Science, 154, 2015, 105). For an accurate prediction of parturition date, the combination of different methods is desirable.
BACKGROUND: Any form of screening aims to reduce disease-specific and overall mortality, and to improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. To better inform individual patient decision-making and health policy decisions, we need to consider the entire body of data from randomised controlled trials (RCTs) on prostate cancer screening summarised in a systematic review. In 2006, our Cochrane review identified insufficient evidence to either support or refute the use of routine mass, selective, or opportunistic screening for prostate cancer. An update of the review in 2010 included three additional trials. Meta-analysis of the five studies included in the 2010 review concluded that screening did not significantly reduce prostate cancer-specific mortality. In the past two years, several updates to studies included in the 2010 review have been published thereby providing the rationale for this update of the 2010 systematic review. OBJECTIVES: To determine whether screening for prostate cancer reduces prostate cancer-specific mortality or all-cause mortality and to assess its impact on quality of life and adverse events. SEARCH METHODS: An updated search of electronic databases (PROSTATE register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CANCERLIT, and the NHS EED) was performed, in addition to handsearching of specific journals and bibliographies, in an effort to identify both published and unpublished trials. SELECTION CRITERIA: All RCTs of screening versus no screening for prostate cancer were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: The original search (2006) identified 99 potentially relevant articles that were selected for full-text review. From these citations, two RCTs were identified as meeting the inclusion criteria. The search for the 2010 version of the review identified a further 106 potentially relevant articles, from which three new RCTs were included in the review. A total of 31 articles were retrieved for full-text examination based on the updated search in 2012. Updated data on three studies were included in this review. Data from the trials were independently extracted by two authors. MAIN RESULTS: Five RCTs with a total of 341,342 participants were included in this review. All involved prostate-specific antigen (PSA) testing, with or without digital rectal examination (DRE), though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 45 to 80 years and duration of follow-up from 7 to 20 years. Our meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). The methodological quality of three of the studies was assessed as posing a high risk of bias. The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were assessed as posing a low risk of bias, but provided contradicting results. The ERSPC study reported a significant reduction in prostate cancer-specific mortality (RR 0.84, 95% CI 0.73 to 0.95), whilst the PLCO study concluded no significant benefit (RR 1.15, 95% CI 0.86 to 1.54). The ERSPC was the only study of the five included in this review that reported a significant reduction in prostate cancer-specific mortality, in a pre-specified subgroup of men aged 55 to 69 years of age. Sensitivity analysis for overall risk of bias indicated no significant difference in prostate cancer-specific mortality when referring to the meta analysis of only the ERSPC and PLCO trial data (RR 0.96, 95% CI 0.70 to 1.30). Subgroup analyses indicated that prostate cancer-specific mortality was not affected by the age at which participants were screened. Meta-analysis of four studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.96 to 1.03). A diagnosis of prostate cancer was significantly greater in men randomised to screening compared to those randomised to control (RR 1.30, 95% CI 1.02 to 1.65). Localised prostate cancer was more commonly diagnosed in men randomised to screening (RR 1.79, 95% CI 1.19 to 2.70), whilst the proportion of men diagnosed with advanced prostate cancer was significantly lower in the screening group compared to the men serving as controls (RR 0.80, 95% CI 0.73 to 0.87). Screening resulted in a range of harms that can be considered minor to major in severity and duration. Common minor harms from screening include bleeding, bruising and short-term anxiety. Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence. Harms of screening included false-positive results for the PSA test and overdiagnosis (up to 50% in the ERSPC study). Adverse events associated with transrectal ultrasound (TRUS)-guided biopsies included infection, bleeding and pain. No deaths were attributed to any biopsy procedure. None of the studies provided detailed assessment of the effect of screening on quality of life or provided a comprehensive assessment of resource utilization associated with screening (although preliminary analyses were reported). AUTHORS' CONCLUSIONS: Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.
STUDY OBJECTIVES: The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established. METHODS: The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included. RESULTS: A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles). CONCLUSION: There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.
BACKGROUND: The applications of artificial intelligence (AI) processes have grown significantly in all medical disciplines during the last decades. Two main types of AI have been applied in medicine: symbolic AI (eg, knowledge base and ontologies) and nonsymbolic AI (eg, machine learning and artificial neural networks). Consequently, AI has also been applied across most obstetrics and gynecology (OB/GYN) domains, including general obstetrics, gynecology surgery, fetal ultrasound, and assisted reproductive medicine, among others. OBJECTIVE: The aim of this study was to provide a systematic review to establish the actual contributions of AI reported in OB/GYN discipline journals. METHODS: The PubMed database was searched for citations indexed with "artificial intelligence" and at least one of the following medical subject heading (MeSH) terms between January 1, 2000, and April 30, 2020: "obstetrics"; "gynecology"; "reproductive techniques, assisted"; or "pregnancy." All publications in OB/GYN core disciplines journals were considered. The selection of journals was based on disciplines defined in Web of Science. The publications were excluded if no AI process was used in the study. Review, editorial, and commentary articles were also excluded. The study analysis comprised (1) classification of publications into OB/GYN domains, (2) description of AI methods, (3) description of AI algorithms, (4) description of data sets, (5) description of AI contributions, and (6) description of the validation of the AI process. RESULTS: The PubMed search retrieved 579 citations and 66 publications met the selection criteria. All OB/GYN subdomains were covered: obstetrics (41%, 27/66), gynecology (3%, 2/66), assisted reproductive medicine (33%, 22/66), early pregnancy (2%, 1/66), and fetal medicine (21%, 14/66). Both machine learning methods (39/66) and knowledge base methods (25/66) were represented. Machine learning used imaging, numerical, and clinical data sets. Knowledge base methods used mostly omics data sets. The actual contributions of AI were method/algorithm development (53%, 35/66), hypothesis generation (42%, 28/66), or software development (3%, 2/66). Validation was performed on one data set (86%, 57/66) and no external validation was reported. We observed a general rising trend in publications related to AI in OB/GYN over the last two decades. Most of these publications (82%, 54/66) remain out of the scope of the usual OB/GYN journals. CONCLUSIONS: In OB/GYN discipline journals, mostly preliminary work (eg, proof-of-concept algorithm or method) in AI applied to this discipline is reported and clinical validation remains an unmet prerequisite. Improvement driven by new AI research guidelines is expected. However, these guidelines are covering only a part of AI approaches (nonsymbolic) reported in this review; hence, updates need to be considered.
UNLABELLED: Ultrasound, which is a safe and non-invasive diagnostic modality that uses more and more advanced imaging techniques, has become the first-choice examination in various diseases. It is more and more often used in the general practitioner's office to supplement physical examination and interview. AIM: The aim of this paper is to review the Polish medical literature pertaining to the usage of ultrasound imaging in general practice as well as to present advantages, disadvantages and utility associated with conducting ultrasound examinations by general practitioners based on selected publications. MATERIAL AND METHODS: The analysis involved 15 articles found in Polish medical literature published in 1994-2013 in 9 medical journals. These publications were obtained using various data bases, such as Polish Medical Bibliography, Google Scholar as well as websites of "Lekarz Rodzinny" and "Ultrasonografia." RESULTS: Of 15 available publications, 5 papers present the usage of ultrasound imaging by a primary care physician for general purposes, 4 discuss the usage of abdominal scans, 3 - imaging of the neck and lymph nodes, 1 - lungs, and 2 discuss its usage for specific disease entities. In over 70% of the papers, the financial aspect associated with the usage of this modality in general practice is mentioned. More than a half of the publications draw attention to the possibility of using point-of-care ultrasound examinations. Advantages of ultrasonography most often mentioned by the authors include: good effects of screening, safety, short duration and low cost. The authors of eight publications also indicate disadvantages associated with ultrasound imaging used by a general practitioner. CONCLUSIONS: In the Polish literature, there are relatively few papers on the role of ultrasonography in the office of a primary care physician. This modality is more and more often becoming a tool that helps primary care physicians to establish diagnoses, accelerates the initiation of treatment and directs the further diagnostic process.
Ultrasound training and education in medical schools is rare, and the foci of current ultrasound curricula are limited. There is a significant need for advanced ultrasound training models in medical school curricula to reduce educational burdens for physician residency programs and improve overall physician competency.The authors describe and evaluate the advanced ultrasound training program developed at The Ohio State University College of Medicine (OSU COM). The OSU COM program is a longitudinal advanced ultrasound curriculum for fourth-year medical students pursuing specialties that require frequent use of focused ultrasound. One hundred fifty student participants have completed the yearlong program to date. Participants engage in didactic lectures, journal club sessions, hands-on training, teaching and patient-modeling activities, and complete a final project. Experienced Ohio State University Medical Center faculty are recruited from specialties that frequently use ultrasound (e.g., emergency medicine, internal medicine, obstetrics-gynecology). A multimodal instructional assessment approach ensures that ultrasound training yields experience with cognitive, behavioral, and constructive learning components. The authors discuss the benefits of the program as well as its challenges and future directions.The advanced ultrasound training program at OSU COM demonstrates a novel approach to providing ultrasound training for medical students, offering a feasible model for meeting training guidelines without increasing the educational requirements for residency programs.
Ultrasonography (renamed from the Journal of Korean Society of Ultrasound in Medicine in January 2014), the official English-language journal of the Korean Society of Ultrasound in Medicine (KSUM), is an international peer-reviewed academic journal dedicated to practice, research, technology, and education dealing with medical ultrasound, Aims and Scope:Ultrasonography (renamed from the Journal of Korean Society of Ultrasound in Medicine in January 2014), the official English-language journal of the Korean Society of Ultrasound in Medicine (KSUM), is an international peer-reviewed academic journal dedicated to practice, research, technology, and education dealing with medical ultrasound.It is published four times per year: January 1, April 1, July 1, and October 1. Original articles, topical reviews, pictorial essays, and notable case reports are published in Ultrasonography covering state-of-the-art content. Ultrasonography also serves as a medium for cooperation among physicians and specialists from around the world who are focusing on various ultrasound technology and disease problems.
Ultrasonography (renamed from the Journal of Korean Society of Ultrasound in Medicine in January 2014), the official English-language journal of the Korean Society of Ultrasound in Medicine (KSUM), is an international peer-reviewed academic journal dedicated to practice, research, technology, and education dealing with medical ultrasound, Aims and Scope:Ultrasonography (renamed from the Journal of Korean Society of Ultrasound in Medicine in January 2014), the official English-language journal of the Korean Society of Ultrasound in Medicine (KSUM), is an international peer-reviewed academic journal dedicated to practice, research, technology, and education dealing with medical ultrasound.It is published four times per year: January 1, April 1, July 1, and October 1. Original articles, topical reviews, pictorial essays, and notable case reports are published in Ultrasonography covering state-of-the-art content. Ultrasonography also serves as a medium for cooperation among physicians and specialists from around the world who are focusing on various ultrasound technology and disease problems.
Ultrasonography (renamed from the Journal of Korean Society of Ultrasound in Medicine in January 2014), the official English-language journal of the Korean Society of Ultrasound in Medicine (KSUM), is an international peer-reviewed academic journal dedicated to practice, research, technology, and education dealing with medical ultrasound, Aims and Scope:Ultrasonography (renamed from the Journal of Korean Society of Ultrasound in Medicine in January 2014), the official English-language journal of the Korean Society of Ultrasound in Medicine (KSUM), is an international peer-reviewed academic journal dedicated to practice, research, technology, and education dealing with medical ultrasound.It is published four times per year: January 1, April 1, July 1, and October 1. Original articles, topical reviews, pictorial essays, and notable case reports are published in Ultrasonography covering state-of-the-art content. Ultrasonography also serves as a medium for cooperation among physicians and specialists from around the world who are focusing on various ultrasound technology and disease problems.