Recently we had our half-yearly conference, where academics, industry and user partners come together to talk about the latest developments, challenges and ultrasound solutions across sectors and professions.

The first international speaker, Professor Jan D’Hooge, K.U. Leuven, Belgium, talked about the advantages of speckle tracking in his presentation “Speckle tracking echocardiography: the present and the future”. Speckle tracking echocardiography (STE) is used to provide quantitative and qualitative information on deformation and the motion of cardiac muscles. However, as a relatively new technique, there are some questions about how reliable the data is – are changes over time due to an actual change in the heart muscle (i.e. potential damage), or due to different doctors making the recordings? And can one compare images from two different brands of ultrasound machines (inter-vendor reliability)? Professor D’Hooge has been part of a Task Force aiming to provide quality assurance on inter-vendor reliability (which found that 10% difference is acceptable). Professor D’Hooge also believes machine learning will make diagnostics easier by automated image interpretation.

Speed-of-sound is another ultrasound technique exploiting the acoustic impedance of various tissue – i.e. the speed at which the ultrasound waves are reflected. Dr. Michael Jaeger from the Institute of Applied Physics at the University of Bern, Switzerland, presented his work on computed ultrasound tomography in echo mode (CUTE) in the presentation “Pulse-echo sonographic imaging of speed-of-sound in handheld diagnostic ultrasound”. One of the advantages is that speed-of-sound ultrasound can for example detect liver tissue changes that today’s clinical ultrasound cannot detect. However, there are still challenges with clutter; real-life gives less accurate readings than simulations, and reconstruction in regions of missing data (finding an optimum interpolation strategy).

As a Centre for Research-based Innovation (SFI), CIUS includes partners from the ultrasound industry and end-users. Dagfinn Sætres, General Manager at GE Vingmed Ultrasound, presented the lastest developments on the cSound beamforming platform, which boasts more opportunities for further development by engineers, reduced need for contrast agents, clearer borders colour flow imaging.

Andrew Healey, Chief Scientific Officer at Phoenix Solutions, talked about Phoenix’ Acoustic Cluster Therapy (ACT), which uses microbubbles and nanoparticles do deliver chemotherapy directly to the tumour and releasing it using ultrasound. You can read more about this in the blog post: Microbubbles and focused ultrasound cure tumours in mice.

The final partner presentation was by Halfwave Director of R&D, Petter Norli, who presented the company’s acoustic resonance technology (ART) focusing on monitoring and inspection of land and subsea pipelines and structures, looking for cracks and faults using ultrasound technology.

Furthermore, academic partner University College of Southeast Norway (HSN) represented by Professor Lars Hoff gave an overview over the facilities and capabilities of their laboratories in Horten. NTNU Professor Hefeng Dong gave a talk on Passive Acoustics for Seabed Characterization, and Roy Edgar Hansen from the University of Oslo and the Norwegian Defence Research Establishment (FFI) gave an overview over Seabed Imaging with Synthetic Aperture Sonar.

The seminar also included a speed update session with the following topics:

• Characterising piezoelectric material parameters through a 3D FEM and simulated annealing algorithm, PhD student Marcus Wild, HSN
• Numerical optimisation method of ultrasound transducers, PhD student Kenneth Kirkeng Andersen, HSN
• CustusX – a research platform for ultrasound and image guided treatment, senior researchers Tormod Selbekk and Jon Eiesland, SINTEF
• Nanoparticle-stabilised microbubbles for ultrasound-mediated drug delivery, PhD student Sofie Snipstad, NTNU
• Adaptive clutter filtering in coronary arteries, PhD student Cristiana Golfetto, NTNU
• Model-based regularisation of blood flow measurements, PhD student Thomas Grønli, NTNU
• Prestations of X-FAB, Business Line Manager ing. Ulrich Bretthauer, X-FAB
• Glimoa imaging with PET MRI and its use in ultrasound navigated surgery, Anna Karlberg, PhD student and PET physicists, St. Olavs Hospital

Finally, CIUS’ new Industry Liaison Officer, Svein-Erik Måsøy was presented to the audience. Måsøy will be the contact point between CIUS and its industrial partners.

The second CIUS full-day conference held on 23 November 2016 in Trondheim, attracted near 80 participants representing CIUS researchers, partners, collaborators and international speakers.  The day had a varied programme and ample opportunity for networking across work packages, institutions, and fields of speciality.

Blogger: Kari Williamson

You lie there with gel on your stomach and glance towards the ultrasound screen. There he is, the little one, who will arrive in four-five months’ time. The emotions, questions, the joy, the worry, they all crowd in – and the midwife gives and understanding nod.

This is how many of us imagine the experience of the first ultrasound consultation offered to all pregnant women in Norway at week 18. There is a lot of technological and medical research and innovation behind this half-hour consultation, but what about the human aspect? What about the pregnant woman and her partner? How do they experience this meeting?

This is what midwife Liv Øyen at NTNU and the National centre for foetal medicine at St. Olavs Hospital has looked at in more detail. After nearly 30 years as a midwife and around 14 years as an ultrasound-teacher, the meetings with pregnant women and their partners have been many. And some central questions have emerged:

• What is the pregnancy ultrasound all about?
• How should it be done? How should it be communicated?
• What do the pregnant women themselves think about this offer at week 18?

Medical and personal

The pregnancy ultrasound is primarily for medical reasons. The information brochure from the Norwegian Directorate of Health on pregnancy ultrasound, says that the consultation is a check-up on the foetus and the uterus to gain information about the age of the foetus, the number of foetuses, the location of the placenta and the foetus’ anatomy and development.

But if you ask expecting parents about the pregnancy ultrasound, this is not their main concern. Of course they want to know if everything is ok medically, but it is the experience of seeing their child for the first time that they talk about. There is actually a new life in there, and someone is about to become a parent.

Øyen has interviewed eight pregnant women for her master thesis, and the responses indicate that they wish for the midwife to acknowledge the impact of this first visual meeting. They also want a dialogue – not just a monologue of technical and medical data. In short, they want to be met as human beings, as a family.

This may sound difficult to achieve in a mere 30-minute consultation, but Øyen does not believe it actually takes much. The key is to see the persons coming in through the door and make them feel acknowledged.

This is something Øyen wishes to bring into the ultrasound training for midwives by introducing theories such as Tor-Johan Ekeland’s on therapeutic communication. The theory states that communication and information are not the same thing – in order to really communicate, there has to be a relationship in place.

Øyen’s aim is therefore to educate compassionate midwives who see the couples coming through the door and focus on the person rather than just the technology. “The most important thing is to create a bond between mother, father and child. This is the pivotal point,” one of the women in the survey said.

It is after all call pregnancy CARE.

Ultrasound is something most people know about, but did you know that some of the greatest achievements in the history of ultrasound happened in Trondheim? In May former and current ultrasound researchers gathered to celebrate milestones, birthdays – and to look into the future, towards 2025.

Highlights from Trondheim include:

• 1976: The PEDOF prototype is made (the first ultrasound apparatus measuring blood flow velocity).
• 1982: Cardiologist Liv Hatle and engineer Bjørn Angelsen publish the book “Doppler Ultrasound in Cardiology”, which is the first book of methods in the field.
• 1993: 3D ultrasound is developed for brain tumours. A collaboration between neurosurgeon Geirmund Unsgård and the technologists at the university.
• 2009: VScan – handheld ultrasound is a reality.

Most people know ultrasound through gynaecology and obstetrics – who hasn’t seen ultrasound images of babies? Professor and section chief at NTNU and St. Olavs Hospital, Sturla Eik-Nes, depicted the development in ultrasound from 1960 when the foetus was shown as lines on a graph, to coloured 3D images in 2000.

Ultrasound photos of a baby in 1960, 1970, 1990 and 2000.

But the images are not there simply to look at the unborn baby, they are also of great medical importance. In the 80s one could measure the blood flow velocity of the baby using ultrasound, the blood flow between mother and placenta, and the blood flow between placenta and the baby. This made it possible for example to give blood transfusions to the baby in the womb.

Ultrasound has also been a crucial factor in making the foetus and unborn baby a patient with its own rights and specialists.

Diagnosis and surgery – via ultrasound

Bjørn Angelsen draws parallels between the development of ultrasound and the moon landing project.

Ultrasound is not only used in gynaecology and obstetrics – another important area is cardiac diagnosis and surgery. It can be used to look at aneurisms on the aorta, and to see if the blood flows correctly through the heart.

During heart surgery one can use ultrasound probes to measure the blood flow velocity in blood veins, whereas visual ultrasound can be used to for example show the location of plaque in blood veins, which can cause stroke or heart attacks.

Trondheim was also the scene of the world’s first 3D ultrasound guided brain operation in 1997, two years after the establishment of the National Centre for 3D Ultrasound at NTNU and St. Olavs Hospital. Last year, the centre expanded to become the National Centre for Ultrasound and Image Guided Therapy.

Ultrasound as treatment

Something that may come as a surprise to those outside the medical sphere is that ultrasound can be used for more than looking at things inside the body or measuring blood flows – in the future we could also see it used in active treatment.

Several research projects are looking into direct drug delivery to sick organs by combining nanoparticles or micro-bubbles with ultrasound. The idea is to attach medicines or drugs such as chemotherapy to nanoparticles or micro-bubbles. When these reach the target area, ultrasound waves are applied to help these particles across from the blood veins into the sick organ or tissue, resulting in targeted treatment.

Ultrasound through the crystal ball

The ultrasound technology itself is still under development. Technicians here in Trondheim and across the world work on projects to improve image quality, make ultrasound easier to use, increase the levels of automation, and to reduce costs.

They are exploring whether today’s, and the future’s, computer technology could utilise more of the data coming from ultrasound images than humans are able to.

Stay tuned in to #NTNUMedicine to learn more about some of these projects!

An exhibition about ultrasound can be visited in Medical Museum at St. Olavs Hospital in October.

Happy birthday!

• 75 years: Kjell Arne Ingebrigtsen
• 60 years: Kjell Kristoffersen, Hans Torp, Arne Grip
• 50 years: Department of Physical Electronics
• 40 years: Doppler signals from the aorta
• 30 years: IREX/Vingmed Meridian (Grand Plan, Sys. I)
• 20 years: Digital beamformer, Sys. V)
• 10 years: 4D ultrasound, electronic transducer

In premature children the causes are often a combination of several risk factors; whereas in infants born at full term, it could be the child’s inherent abilities to withstand unfortunate events at birth that cause some children to develop CP and others not.

In addition there seems to be a correlation between high prevalence of CP and low neonatal death rates in some Norwegian counties.

“There could be several explanations for this,” says PhD candidate Magne Stoknes at the Department of Laboratory Medicine, Children’s and Women’s Health (LBK), NTNU. One explanation could be that more children that already have a brain injury before birth are saved that otherwise would not have survived.

“Survival rates were higher in smaller counties, but these counties also had a higher prevalence of CP, which could suggest that the distance to hospital may be of some relevance. But we cannot say for certain whether the correlation is due to differences in quality or external factors.”

Individual factors.

When looking at the risk factors present during pregnancy and around birth in children with CP, there are no clear factors that can be singled out, and often there are different combinations of risk factors. It is also not clear when in the pregnancy CP occurs:

“The background for a child developing brain injury leading to cerebral palsy is complex. There are probably several risk factors that independently or combined contribute to a process that leads to brain injury, and these risk factors operate together in a certain order of events (so-called causal pathways).

“In addition some children seem to be more vulnerable to the various combinations of risk factors, so that there are different combinations of risk factors leading to CP in individual children,” Stoknes explains.

Still a puzzle

The research nevertheless offers a new piece to a larger puzzle, but there are still many pieces left to be found before we with certainty can say something about why some children develop CP and how this could be prevented.

Stoknes says the research team now wishes to continue with larger studies that look even closer at how different risk factors come together to contribute to brain injury which again causes CP.

The studies

Stoknes’ research is based on three studies. The first study which looked at low birth weight at full term included 400,488 Norwegian children born in the period 1996-2003, where 36,604 had low birth weight. Of these 104 did not live and 69 developed CP.

The second study, which looked at how risk factors were combined, included 176,979 children born in the period 1996-98, where 241 developed CP.

In the last study where the share of neonatal deaths was compared with the prevalence of CP in surviving children, the researchers used data from 468,443 children born in the period 1996-2003, where 1020 were diagnosed with CP.

Viva

Magne Stoknes will defend his thesis “Novel Approaches to the Study of Risk Factors for Cerebral Palsy” on 8. April 2013 at 12.15 in ØHA11 at NTNU.

The trial lecture will take place at 10.15.

Publications

• Cerebral palsy and neonatal death in term singletons born small for gestational age. Stoknes M et.al.
• The effects of multiple pre- and perinatal risk factors on the occurrence of cerebral palsy. A Norwegian register based study. Stoknes M et.al.

Pocket-sized ultrasound (Vscan) in use. (Photo Geir Mogen/NTNU)

“Our models may be used to identify high-risk patients in order to provide a basis for a meaningful informed consent; for making decisions on whether or not to recommend surgery; and to weight between risk and benefit for an individual patient,” says PhD candidate Yunita Widyastuti at the Department of Laboratory Medicine, Children’s and Women’s Health (LBK) at NTNU.

The three models for predicting heart problems (cardiac dysfunction), prolonged need for respirator treatment (mechanical ventilation) and length of intensive care unit (ICU) stay, are said to be more accurate for Norwegian patients than previous models. This is because they were developed using patient data from approximately 5000 heart patients operated at St. Olavs Hospital in Trondheim over the period 2000-2007.

The ICU model, although fairly accurate, is less useful however, as the length of stay in intensive care tends to depend on hospital policy.

All three models are based on similar heart-related variables as previous models, but the variables are weighted differently making them more accurate for Norwegian patients, Widyastuti explains.

Viva

Yunita Widyastuti will defend her thesis “Risk factors for common complications following adult heart surgery” at 12.15 on 13. December, 2012, in the MTFS Auditorium at NTNU.

A trial lecture titled “The impact of blood product transfusion on mortality and morbidity after cardiac surgery” will be held in the same place at 10.15 am.

Related publications

• Length of intensive care unit stay following cardiac surgery: is it impossible to find a universal prediction model? Widyastuti Y, et.al.
• Preoperative and intraoperative prediction of risk of cardiac dysfunction following open heart surgery. Widyastuti Y et.al.
• Pre-operative and intraoperative determinants for prolonged ventilation following adult cardiac surgery. Widyastuti Y, et.al.

“This is an interesting find, and it is probably caused by a mix of environment and genetics,” says PhD candidate Gry Børmark Hoftun.

“When we looked at teenagers with divorced parents, we saw a stronger association between pain experienced by teenagers and pain in the parent with whom they lived. For example: In teenagers living with their mother, there was a strong association between pain experienced by the mother and pain experienced by the teenager, but there was no clear association with father’s pain.”

This last finding indicates that environment is of great importance. That is, parents can act as role models for their children – pain is something the teenagers learn.

“These findings are useful when examining or treating children with chronic, unspecified pain. It is important to make the parents aware of this association and that children learn behaviour patterns from their parents. In other words, it is important not to focus too much on their own or their children’s pain. One should rather promote the use of distraction techniques,” Hoftun says.

Nearly half experience chronic pain

Nearly half (44%) of the 7373 teenagers who responded to the pain related questions in the health study Ung-HUNT 3 said they experience chronic, unspecific pain – that is, chronic pain with no obvious medical cause.

Most of these said they had pain in more than one location, and 80% said the pain affected leisure activities and every-day life.

This is important knowledge, not least to reassure parents worrying that children with chronic pain suffer from serious disease. Most often this is not the case – it is in fact quite common that children and teenagers experience pain, and it is usually due to factors other than serious illness.

Girls more affected than boys

There are also many more girls than boys suffering from chronic pain. As many as 54% of the girls say they suffer from pain, as opposed to only a third of the boys. But is it really the case that girls experience more pain than boys?

“The girls do report more pain for unknown reasons, but it could have something to do with gender roles – whereas boys are supposed to be ‘tough’ and handle pain, girls talk more about it and share more with their friends. Sex hormones may also have an impact, as several studies have shown that the difference between boys and girls arises when they hit the teens – and it has been shown that sex hormones affect pain paths differently,” Hoftun explains.

“At the same time both anxiety and depression are more common among girls, and these are also associated with chronic pain.”

Possible causes?

The researchers also looked into other factors associated with chronic pain.
“What show the greatest association with pain among teenagers are symptoms of anxiety and depression,” Hoftun says.

She warns, however, that this specific study cannot say whether anxiety and depression cause chronic pain, or whether pain over longer periods leads to anxiety and depression. There is some support for the first hypothesis though in other studies.

“We also saw that being overweight, smoking and alcohol are strongly associated with pain,” she says.

This is knowledge which could prove useful when meeting teenagers who are referred to hospital for chronic, unspecified pain. At the same time as asking the teenagers about smoking and alcohol, one can make them aware of the connection. This could then be a starting point for treatment and to promote a healthy lifestyle.

In addition, one needs to focus on mental health and offer help if there is suspicion of anxiety or depression, or other mental problems.

Does it pass?

It would be interesting to follow-up the teenagers from HUNT 3 to see how many of these still suffer from chronic pain as adults, and to see what characterised these during their teens, Hoftun concludes.

Viva

Gry Børmark Hoftun will defend her thesis Chronic Non-Specific Pain in Adolescence Prevalence, Disability, and Associated Factors – Young-JHUNT and HUNT 3, 2006-2008, at 12.15 on Friday 30. November in the Auditorium at MTFS.

She will hold a trial lecture at 10.15 in the same place.

Related publications

• Chronic idiopathic pain in adolescence–high prevalence and disability: the young HUNT Study 2008. Hoftun GB et al.
• Factors associated with adolescent chronic non-specific pain, chronic multisite pain, and chronic pain with high disability: the Young-HUNT Study 2008. Hoftun GB et al.
• Association of Parental Chronic Pain With Chronic Pain in the Adolescent and Young Adult Family Linkage Data From the HUNT Study (link not yet available).