Prenatal exposure to ultrasound waves impacts neuronal migration in mice

Neurons of the cerebral neocortex in mammals, including humans, are generated during fetal life in the proliferative zones and then migrate to their final destinations by following an inside-to-outside sequence. The present study examined the effect of ultrasound waves (USW) on neuronal position within the embryonic cerebral cortex in mice. We used a single BrdU injection to label neurons generated at embryonic day 16 and destined for the superficial cortical layers. Our analysis of over 335 animals reveals that, when exposed to USW for a total of 30 min or longer during the period of their migration, a small but statistically significant number of neurons fail to acquire their proper position and remain scattered within inappropriate cortical layers and/or in the subjacent white matter. The magnitude of dispersion of labeled neurons was variable but systematically increased with duration of exposure to USW. These results call for a further investigation in larger and slower-developing brains of non-human primates and continued scrutiny of unnecessarily long prenatal ultrasound exposure.

Medical and non-medical protection standards for ultrasound and infrasound

Protection from inappropriate or hazardous exposure to ultrasound is controlled through international standards and national regulations. IEC standard 60601 part 1 establishes requirements for the mechanical, electrical, chemical and thermal safety for all electro-medical equipment. The associated part 2 standard for diagnostic medical ultrasonic equipment sets no upper limits on ultrasonic exposure. Instead, safety indices are defined that are intended to advise users on the degree of thermal and mechanical hazard. At present the display of these safety indices satisfies regulatory requirements in both the USA and Europe. Nevertheless there are reservations about the effectiveness of this approach to protection management. In the USA, there are national regulatory limits on diagnostic exposure, based on acoustic output from clinical equipment in use over 20 years ago. The IEC 60601 part 2 standard for therapeutic equipment sets 3 W cm(-2) as the limit on acoustic intensity. Transducer surface temperature is controlled for both diagnostic and therapy devices. For airborne ultrasound, interim guidelines on limits of human exposure published by the IRPA are now 2 decades old. A limit on sound pressure level of 100 dB for the general population is recommended. The absence of protection standards for infrasound relates to difficulties in measurement at these low frequencies.

The hazards to practitioners of obstetric and gynecological ultrasound

OBJECTIVES

To investigate the specific complaints of physicians and technicians performing obstetric and gynecological ultrasound.

METHODS

This was a cross-sectional retrospective survey. Questionnaires were distributed to members of the Israeli Society of Gynecological Ultrasound, including questions on gender and profession, number and type of scans performed, pain related to profession and any therapy undergone. Statistical analysis included chi-square or Fisher's exact test, Student's t-test, Pearson's correlation coefficient and logistic regression.

RESULTS

Joint pain was reported by 51.7% (30/58) of the technicians compared with 25.3% (19/75) of the physicians (P = 0.002). It was more common in females than in males (P = 0.05) and it was more common among those who performed transabdominal sonography more frequently than they did transvaginal sonography (P = 0.004). There was a significant association between performing transabdominal ultrasound and back pain (P = 0.05). Although females reported pain more frequently, the rate of surgical procedures was higher among males (P < 0.05).

CONCLUSIONS

A technician is 3.5 times more likely to report joint pain than is a physician. Transabdominal sonography is a risk for both joint and back pain. There may be gender differences in pain perception.

Superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse repetition frequency and pulse duration

OBJECTIVE

The purpose of this study was to enhance the findings of an earlier ultrasound-induced lung hemorrhage study (Ultrasound Med Biol 2003; 29:1625-1634) that estimated pressure thresholds as a function of pulse duration (PD: 1.3, 4.4, 8.2, and 11.6 micros; 2.8 MHz; 10-s exposure duration [ED]; 1-kHz pulse repetition frequency [PRF]). In this study, the roles of PRF and PD were evaluated at 5.9 MPa, the peak rarefactional pressure threshold near that of the ED50 estimate previously determined.

METHODS

A 4 x 4 factorial design study (PRF: 50, 170, 500, and 1700 Hz; PD: 1.3, 4.4, 8.2, and 11.6 mus) was conducted (2.8 MHz; 10-s ED). Sprague Dawley rats (n = 175) were divided into 16 exposure groups (10 rats per group) and 1 sham group (15 rats); no lesions were produced in the sham group. Logistic regression analysis evaluated significance of effects for lesion occurrence, and Gaussian tobit analysis evaluated significance for lesion depth and surface area.

RESULTS

For lesion occurrence and sizes, the main effect of PRF was not significant. The interaction term, PRF x PD, was highly significant, indicating a strong positive dependence of lesion occurrence on the duty factor. The main effect of PD was almost significant (P = .052) and thus was included in the analysis model for a better fit.

CONCLUSIONS

Compared with the findings from a PRF x ED factorial study (J Ultrasound Med 2005; 24:339-348), a function that considers PRF, PD, and ED might yield a sensitive indicator for consideration of a modified mechanical index, at least for the lung.

Sustained endemicity of Burkholderia cepacia complex in a pediatric institution, associated with contaminated ultrasound gel

OBJECTIVE

To determine whether contaminated ultrasound gel is the source of intermittent outbreaks of nosocomial infection due to Burkholderia cepacia complex in patients without cystic fibrosis since 1992.

DESIGN

A prospective clinical and in vitro study of all in-use bottles of ultrasound gel, as well as a retrospective analysis of archived bacterial strains, were performed. Handling of gel for clinical purposes throughout the hospital was evaluated. Gel and archived clinical isolates of B. cepacia complex were speciated to genomovar level and characterized by pulsed-field gel electrophoresis, and the pulsed-field gel electrophoresis patterns were compared.

SETTING

The Hospital for Sick Children, a 300-bed, tertiary care, pediatric academic health sciences center in Toronto, Canada.

PATIENTS

All patients without cystic fibrosis from whom B. cepacia complex was recovered at the Hospital for Sick Children since 1992.

RESULTS

No standardized protocol for storage or handling of ultrasound gel was found. Gel from 39% of bottles grew either B. cepacia (genomovar I) or Burkholderia stabilis (genomovar IV). These isolates had pulsed-field gel electrophoresis patterns identical to 2 of the 7 clinical pulsed-field gel electrophoresis types that are responsible for 88% of clinical isolates.

CONCLUSIONS

Contaminated ultrasound gel contributed to nosocomial infection due to B. cepacia complex in this institution over the course of 10 years. Suggested guidelines for the handling of ultrasound gel are provided.

Effect of repeated transvaginal ultrasound-guided follicle aspiration on fertility in mares

OBJECTIVE

To determine whether performance of transvaginal ultrasound-guided follicle aspiration (TVUFA) repeatedly in mares adversely affects their fertility.

DESIGN

Historical prospective study.

ANIMALS

23 mares that had never undergone TVUFA and 59 mares that had undergone TVUFA on 1 to 11 occasions.

PROCEDURE

Mares were classified into 4 groups according to the number of TVUFA procedures previously performed on the ovary in which ovulation occurred at the time of insemination as follows: group 1, 0 TVUFAs (control group, n = 23 mares); group 2, 1 or 2 TVUFAs (40 mare-cycles); group 3, 3 or 4 TVUFAs (21 mare-cycles); and group 4, 5 to 11 TVUFAs (13 mare-cycles). Each ovary and its associated number of TVUFAs were considered separately; therefore, some of the mares that underwent TVUFA were represented in > 1 group (1 mare was included in group 2 twice [once for each ovary]), and the sample size in groups 2, 3, and 4 was denoted as mare-cycles. Fertility was assessed as pregnancy rates in cycles in which mares were inseminated with fresh or cooled semen from 1 fertile stallion.

RESULTS

There were no significant differences in pregnancy rates among groups 1, 2, 3, and 4 (83%, 90%, 81%, and 85%, respectively).

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that repeated performance of TVUFA (as many as 11 times) had no detectable adverse effect on fertility in mares. This finding is clinically important for situations when TVUFA is performed on fertile mares, whether for oocyte collection or other purposes.

[On influence of ultrasound on health state of doctors working on ultrasound diagnostic devices]

The authors presented data of studies on immune state, intestinal microflora, BP and pulse rate in accordance with physical exertion in doctors working on ultrasound diagnostic devices and internists having no contact with ultrasound, as well as output ranges of ultrasound diagnostic devices used by doctors.

The effects of residual temperature rise on ultrasound heating

In recent theoretical studies, the temperature rise produced by diagnostic ultrasound was estimated by solving the Bioheat Transfer Equation (BHTE) but ignoring the initial temperature rise. The temperature rise was determined in our study by the BHTE including an initial temperature rise. We discuss how the initial temperature rise occurs during an ultrasound examination, and how the initial temperature rise affects subsequent ultrasound heating. We theoretically show that the temperature rise produced by the ultrasound examination (exposure time of 500 s) in a tissue sample having an initial temperature rise was higher than that in a tissue sample with no initial temperature rise that was exposed to ultrasound (exposure time of 1200 s). The theoretical results for these two cases were 5.64 degrees C and 3.58 degrees C, respectively. In our experimental study, the highest temperature rise was measured in the presence of an initial temperature rise as in the theoretical study under the same exposure conditions. Mean temperature rises for tissue without an initial temperature rise and for tissue with an initial temperature rise were 2.42 +/- 0.13 degrees C and 3.62 +/- 0.17 degrees C, respectively. Both theoretical and experimental studies show that unless the initial temperature rise produced by the first ultrasound examination decreases to 0 degrees C, the next ultrasound examination on the same tissue sample may cause the temperature rise to be higher than expected.

Delayed stimulatory effect of low-intensity shockwaves on human periosteal cells

We investigated the effect of shockwaves on cells explanted from normal human periosteum to study the potential mechanisms of their responses and to determine suitable treatment settings. The cells were subjected to one shockwave treatment with systematic combinations of energy intensities (range, 0.05-0.5 mJ/mm) and number of shocks (range, 500-2000) whereas control cells received no treatment. The immediate effect on cell viability and the long-lasting effect on proliferation, viable cell number at Day 18, and mineralization at Day 35 were assessed. We observed an immediate dose-dependent destructive effect of shockwaves. Energy intensity and number of shocks contributed equally to viability. Total energy dose (intensity x number of shocks) was a better reference for determining the shockwave effect. We also found a long-term stimulatory effect on proliferation, viable cell number, and calcium deposition of human periosteal cells. At the same total energy dose, low-intensity shockwaves with more shocks (0.12 mJ/mm at 1250 shocks) were more favorable for enhancing cellular activities than high-intensity waves with fewer shocks (0.5 mJ/mm at 300 shocks). These findings document some of the biochemical changes of periosteal cells during shockwave treatments.

Incidence of cardiac arrhythmias with therapeutic versus diagnostic ultrasound and intravenous microbubbles

OBJECTIVE

The purpose of this study was to determine the type of arrhythmias induced with therapeutic versus diagnostic transthoracic low-frequency ultrasound (TLFUS) transducers in the presence of intravenous microbubbles.

METHODS

Intravenous perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles were infused or given as a bolus injection while TLFUS was applied in the standard parasternal and apical views with either a 1-MHz therapeutic ultrasound transducer or high-mechanical-index diagnostic ultrasound (1.7 MHz).

RESULTS

Significantly more ectopy was produced by the therapeutic transducer, especially at higher-intensity settings in the continuous wave mode after bolus injections of PESDA (P < .001 compared with lower intensities and lower continuous infusion rates). Six patients (15%) had either clinical supraventricular tachycardia or nonsustained ventricular tachycardia after intravenous PESDA with therapeutic TLFUS. In comparison, diagnostic high-mechanical-index ultrasound produced only isolated ventricular ectopy and no sustained ventricular arrhythmias.

CONCLUSIONS

Intravenously injected microbubbles and low-frequency therapeutic transducers operating at longer duty cycles and wide beam widths have the capability of eliciting clinically important arrhythmias in patients at high risk for such events.

Adverse effects associated with SonoVue®use

Conventional ultrasonography (US) has limited accuracy in the detection and characterisation of solid focal liver lesions (FLL). Contrast-enhanced ultrasound (CEUS) significantly improves the diagnostic performance of US in the assessment of FLL. Rare reports of serious adverse events have been reported with CEUS. The rates of adverse reactions reported from the use of ultrasound contrast agents seem comparable to, or lower than, those observed for other imaging modalities that use contrast agents such as computed tomography and magnetic resonance imaging. Improved diagnostic results and diagnostic confidence achieved in conventional CEUS studies of the liver and during the investigational use in the intraoperative CEUS exploration appear to justify the use of this promising modality.

Progress in medical ultrasound exposimetry

Biomedical applications of ultrasound have experienced tremendous growth over the past 50 years. Early work in thermal therapy and surgery soon was followed by diagnostic imaging and Doppler. Because patient safety was an important issue from the beginning, the study of methods for measuring exposure levels, and their relationship to possible biological effects, paralleled the growth of the various therapeutic and diagnostic techniques. The diverse conditions of use have presented a range of exposure measurement challenges, and the sensors and techniques used to evaluate ultrasound fields have had to evolve as new or expanded clinical applications have emerged. In this paper some of the more notable of these developments are presented and discussed. Topics covered include devices and techniques, methods of calibration, progress in standardization, and current problem areas, including the effects of nonlinear propagation. Some early methods are described, but emphasis is given to more recent work applicable to present and future uses of ultrasound in medicine and biology.

[Patient safety in diagnostic ultrasound II--ultrasound guided interventions]

New digital ultrasound techniques simplify the documentation of ultrasound images and allow better comparison with respect to different image modalities. New vascular imaging modes including contrast enhanced power Doppler and 3D power Doppler allow for the detection of very small vessels and leakages. B-flow, a recently introduced digital substraction technique is advancing the detection of residual blood flow in high-grade stenosis without vibration artifacts. Modern contrast agents allow to perform ultrasound guided intervetion such as biopsies and ablation therapies with improved accuracy. This way, the risk for complications can be significantly reduced.

Contrast-aided diagnostic ultrasound does not enhance lung metastasis in a mouse melanoma tumor model

OBJECTIVE

The purpose of this research was to test the hypothesis that contrast-aided diagnostic ultrasound (CADUS) could exacerbate the metastatic spread of mouse melanoma tumor cells to the lungs.

METHODS

The melanoma cell lines B16 and B16-D5 (metastatic specifically to lung) were implanted on a hind leg of female C57/bl6 mice. Growing tumors were scanned by 1.5-MHz diagnostic ultrasound in a 37 degrees C water bath. Four hundred image frames were triggered at a 1-Hz rate with 4 retro-orbital injections of an ultrasonographic contrast agent at dosage of 10 microL/kg at 100-second intervals. Sham-treated mice received 400 frames of ultrasonography followed by the contrast agent with the ultrasound off. The primary tumor was surgically removed 1 day after ultrasound administration. Lungs were removed and evaluated blind after 2 weeks of bleaching in Fekete solution.

RESULTS

Three experiments were performed. The first experiment involved scanning sham and CADUS groups of 20 mice each with B16 tumors; B16 metastasis was not enhanced. The second experiment repeated this test with the D5 cell line; the metastasis enhancement was marginally significant for average number (0.3 and 3.2; P = .06) and incidence (3 and 9 of 19; P = .08) in mice without tumor recurrence. Finally, a third experiment was performed to clarify ambiguous results in the second experiment and consisted of 2 groups of 40 mice each. In this larger experiment, the results were essentially equal for the sham and CADUS groups.

CONCLUSIONS

Overall, the results do not support the hypothesis of CADUS-enhanced metastasis.

Characteristics of the audio sound generated by ultrasound imaging systems

Medical ultrasound scanners use high-energy pulses to probe the human body. The radiation force resulting from the impact of such pulses on an object can vibrate the object, producing a localized high-intensity sound in the audible range. Here, a theoretical model for the audio sound generated by ultrasound scanners is presented. This model describes the temporal and spectral characteristics of the sound. It has been shown that the sound has rich frequency components at the pulse repetition frequency and its harmonics. Experiments have been conducted in a water tank to measure the sound generated by a clinical ultrasound scanner in various operational modes. Results are in general agreement with the theory. It is shown that a typical ultrasound scanner with a typical spatial-peak pulse-average intensity value at 2 MHz may generate a localized sound-pressure level close to 100 dB relative to 20 microPa in the audible (< 20 kHz) range under laboratory conditions. These findings suggest that fetuses may become exposed to a high-intensity audio sound during maternal ultrasound examinations. Therefore, contrary to common beliefs, ultrasound may not be considered a passive tool in fetal imaging.

Sonography and MRI of the shoulder: comparison of patient satisfaction

OBJECTIVE

MRI and sonography are both used to evaluate patients with painful shoulders. This study was conducted to compare patients' perceptions and satisfaction with both tests.

SUBJECTS AND METHODS

One hundred eighteen patients with shoulder pain and a clinically suspected rotator cuff tear underwent both MRI and sonography and filled out satisfaction surveys after both tests. Patients were asked the following questions: Did the test cause pain? If it did, they were asked to grade the pain on a scale of 1-10 (1, minimal pain; 10, severe pain). Did the test take too long? Would they be willing to undergo the test again? How would they grade their overall satisfaction with the test (1, poor; 2, fair; 3, good; 4, very good; and 5, excellent)? Which test did they prefer if both were equally accurate?

RESULTS

Sonography caused pain above the baseline in 39 patients, with an average pain score (mean +/- SD) of 5.4 +/- 2.3, and MRI caused pain above the baseline in 40 patients, with an average pain score of 6.1 +/- 2.7 (p = 0.36). Two patients thought the sonography examination took too long, and 28 patients though the MRI examination was too long (p < 0.001). The average satisfaction level for sonography was 4.3 +/- 0.7 and for MRI, 3.6 +/- 1.2 (p < 0.001). The satisfaction score was higher for sonography in 54 patients, higher for MRI in 13 patients, and the same for both in 50 patients (p < 0.001). All patients were willing to repeat the sonography, but 10 patients were unwilling to repeat the MRI (p = 0.002). Ninety-three patients preferred sonography, eight patients preferred MRI, and 17 patients had no preference (p < 0.001).

CONCLUSION

Most patients with shoulder pain prefer sonography to MRI.

Excess risk thresholds in ultrasound safety studies: statistical methods for data on occurrence and size of lesions

Concerns about the safe use of clinical ultrasound (US) at diagnostic pressure levels (below a mechanical index, or MI, = 1.9) have stimulated considerable research in US risk assessment. The objective of the present study was to develop probability-based risk thresholds for US safety studies, to present statistical methods for estimating the thresholds and their standard errors and to compare these methods with the analysis based on a piecewise linear ("hockey stick") model. The excess risk at exposure level x > 0 was defined as the relative increase in the probability of a lesion at that level compared with the background probability of a lesion at exposure x = 0. The risk threshold was then defined as the exposure level at which the excess risk exceeded a specified level (e.g. 5% or 50%). Thus, given pressure-dependent estimates of the excess risk, the thresholds were estimated by solving the risk equation to obtain the pressure at which the target level of excess risk occurs. Threshold estimates of this type have been developed extensively in the literature for incidence (presence or absence) data. Only recently, however, have excess risk threshold estimates been derived for data in which lesion size (depth, surface area) is measured if present and a zero is recorded if the lesion is absent. Tobit regression was used to estimate pressure-dependent percentiles of the size distribution, and the excess risks were estimated from the tobit probability of a positive-valued response. The tobit model provides a well-established approach to modeling data constrained to be nonnegative. Solving the risk equation for the tobit model leads to risk threshold estimates that incorporate the information on size of observed lesions. Results using these probability-based risk estimates were compared with results for a piecewise linear ("hockey stick") model, which has also been used in the US safety literature, although it does not explicitly address the nonnegativity constraint in the sampling model. The comparisons were carried out for data from two previously published studies, from different laboratories, on US-induced lung hemorrhage. The thresholds derived from logistic regression of lesion occurrence and tobit regression of lesion size were quite consistent with each other and within sampling error. The hockey stick thresholds, defined as the exposure level at which the piecewise linear model for the probability of the expected size of a lesion bends upward, corresponded to quite different excess risk values for incidence (lesion occurrence) compared with size (lesion surface area or depth), although these methods have been developed previously for both types of data. The use of probability-based excess risk thresholds is recommended to obtain consistent incidence vs. size thresholds and to ensure that the thresholds are well-defined and interpretable independent of the details of the statistical model.

Perforation of a pancreatic pseudocyst induced by abdominal sonography

A fifty-year-old man complained of abdominal pain, nausea, loss of appetite, postprandial vomiting and loss of weight. Abdominal sonography revealed a chronic calcifying pancreatitis with a tubular stenosis of the common bile duct, dilatation of the pancreatic duct and multiple pancreatic duct stones. Distal of the pylorus there was an intramural pseudocyst, which had led to the obstruction of the duodenal lumen. Shortly after the ultrasound examination abdominal pain increased. In addition, an elevation of serum lipase levels was noted, but reclined rapidly the next day and was normalized a few days later. The patient was well the next morning, the symptoms of gastric retention disappeared and he had a good appetite. A CT of the abdomen two days later showed the chronic pancreatitis but could not confirm the pseudocyst and a subsequent repeat sonography revealed only a remnant of the pseudocyst. In conclusion it can be assumed that the intramural pseudocyst ruptured when pressure was applied with the ultrasound transducer to displace interfering colonic gas. Although it cannot be advised as a treatment measure for a pseudocyst, regression of a pseudocyst due to emptying into the gastrointestinal tract has to be expected.