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Well-deserved Doctor of Russia (Moscow, 1982)

Pioneer WFUMB and AIUM (Washington, 1988),

Honorary member RASUDM (Moscow, 2007)

Mobile laboratories of combined express-diagnostics

Express diagnostics of thyroid

My decision to pen this article was born as I gazed into the audience at the formal opening ceremony of the 6th Congress of the Russian Association of Medical Ultrasound Examination Professionals – the sheer numbers of those present made me realise how much the ultrasound examination community had expanded over the recent years. Browsing through the exhibition of modern ultrasound equipment, I couldn't help but remember the first devices we once worked with. Changes happened in front of my own eyes – revolutionary, groundbreaking changes.

Many of today's specialists in ultrasound don't even know what A-mode is.

When they work with ultrasound contrasts or perform ultrasound-guided needle biopsy, they don't even fathom that these technologies were introduced in practical diagnostics only very recently, if you look at the long-term, historic scale, yet have since become indispensable.

I would like to tell you, and show you, how ultrasound diagnostics began at the First Central Clinical Hospital under the auspices of the Ministry of Railways. I was fortunate enough to be among the first to embark on this journey, to be a Pioneer (WFUMB, AIUM, Washington, 1988).

Yet, let's start from the beginning.

 

Part One

(from 1960’s to 1970’s)

For many years, I worked at the First Central Clinical Hospital under the auspices of the Ministry of Railways. A flagship of the USSR's ‘railway medicine’, it had been distinguished for its competent, exceptionally qualified staff and cutting-edge equipment. The Hospital had developed into a cluster of advanced healthcare units and many well-known academic departments. Science and practice should be integrated and inseparable – that is exactly the key to progress. And this was how things worked at our Hospital.

Already in early 1960’s, the First Central Clinical Hospital established an ultrasonography diagnostics laboratory. I was the one who managed that process. In addition to traditional radial diagnostics including X-ray and scintigraphy, the Hospital introduced ultrasound examination and thermography.

There are a few points I would like to clarify from the start. Thermography is not among popular modern examination methods nowadays and I believe this is wrong. As my studies once involved comprehensive benchmarking of diagnostic methods among patients with various pathologies, I can claim with certainty that thermography has its own scope of application, and other professionals are gradually returning to this method. For this reason, I will regularly refer to complex diagnostic methods in my article.

Starting with 1962, our Hospital introduced and began to apply ultrasound examination to internal organs, thyroid and breast, as well as soft tissues. We were engaged in active scrutiny of the data collected and their comparison to puncture results, histology data, and pathologic anatomy analysis outcomes (fig. 1-3).

Moreover, our endeavour was to develop a complex diagnostic approach for each individual patient. Back then, we already tried to optimise the set of diagnostic measures for each specific clinical case. For that reason, starting with 1964, we began to actively use telethermographic examination that provided more accurate information about pathophysiological changes in tissues and internal organs using the infrared radiation emitted by the body.

Later we combined this method with ultrasound examination to study thyroid and breast, joint areas, surfaces of the abdominal wall and the lumbar region, as well as blood circulation in limbs, head, and neck [1–15].

I believe that I should first focus on ultrasound diagnostics results related to the organs that this method was hardly applied to at the time.

After a series of laboratory experiments, we discovered that air strata in lungs with the cross-section up to 4.0 cm can be permeated by ultrasound and beyond them, one can detect various morphological features. Thanks to this, we started to examine lungs, the pleural cavity, the oesophagus, the mediastinum, and the pericard [16-21].

We conducted heart examinations to measure its dimensions and detect pathological changes. Our examinations were conducted using ultrasound equipment UZD-4 and UZD-5 as well as one- and two-dimensional sensors operating at the frequency of 1.76 MHz. We managed to measure the dimensions of the heart, the thickness of heart walls, and the size of cavities [18].

Considering the difficulty of visualizing the abovementioned organs, we conducted a series of experiments with animals, which confirmed our hypothesis regarding the efficiency of ultrasound examinations in cases involving chest pathologies.

I would like to share more details about our efforts that established the foundation for a new area in ultrasound examinationsultrasound-guided puncture of various organs and tissues. We conducted the relevant studies in 1968–1970 using Soviet equipment UZD-4 and UZD-5 with two-dimensional scanning sensors and a specially adjusted flat metal strip that moved perpendicular to the longitudinal axis of the sensor. We could trace the exact locations for spot punctures, which we performed successfully [22]. Another area of scientific and practical work that we focused on was sports medicine.

At that time, we could not find any research dedicated to ultrasound diagnostics of locomotor injuries occurring in the course of sports activities.

In 1967–1968, we conducted a series of research activities with sportsmen, who suffered various kinds of soft tissue injuries including contusions, spraining, bursting or rupture of muscles and ligaments, rupture of hill tendons, tendopathy and peritendinitis, as well as chronic synovitis [23].

Until 1964, the method applied most commonly was the so-called “A-mode” (“A” referring to amplitude), which was a one-dimensional method and could be applied to measure the size of different organs or foreign-tissue lesions as well as distinctive macrostructure changes in organs.

Starting with 1965, we began to broadly implement the “B-mode” (two-dimensional), which propelled ultrasound examination to its current strong position in medical diagnostics in the modern medicine.

To my mind, we should pay special attention to the areas of ultrasound diagnostics that triggered the step change in the approach applied by clinicians to patient treatment and advanced medicine to the new stage of development.

We published a number of articles on various types of ultrasound diagnostics (oesophagus, biliary tracts, thyroid, neck tumours, pneumonia, serous effusions, thromboembolism of the pulmonary artery, as well as other research areas) [2, 6, 16–21, 24–27] (fig. 4–7).

At the same time, we started to apply ultrasound examination in paediatrics since there was a children’s department at our Hospital and we believed that quick and painless examination of children was one of the top priorities [1].

All these articles developed jointly by a team of specialists caused a certain reaction in the community of researches and practitioners.

Our laboratory broadly applied complex diagnostics based on thermography and ultrasound in such areas as breast tumour diagnostics, liver and kidney diseases, as well as carotid artery and aorta lesions [3–6, 28–32].

I believe that we should focus on the series of experiments that we held in 1970 dedicated to clinical testing of the first Soviet ultrasound apparatus for complex scanning called Obzor-100, laboratory type [31, 33] (fig. 8). We compared our results of liver, spleen, thyroid, lung, and heart examinations to the outcome of radioisotope scanning, X-ray, and ultrasound examinations by UZD-4 and UZD-5 performed in parallel with complex ultrasound examinations by Obzor-100 as well as to surgical data. The clinical testing of the new equipment confirmed its wide scope of diagnostic applications and high technical accuracy.

During the Global Electrotechnical Congress held in Moscow in 1977, our echography lab was exhibited as a medical centre performing complex examinations (biological ultrasonic scanning and thermography) to diagnose various diseases. At the plenary session, we presented a report on the application of this complex in the diagnostics of breast diseases [5].

In 1977, ultrasound-guided fine-needle aspirations were supplemented with urgent cytological examinations.

In 1973, Meditsina Publishing Company issued a book titled “Radioisotope scanning, ultrasound examinations, and heat imaging in hospitals” by T. P. Makarenko, Yu. N. Bogin, A.V. Upyrev, and A.V. Bogdanov. One of the sections in the book was dedicated to ultrasound diagnostics [6].

In 1979, a monograph titled “Ultrasound diagnostics for liver and spleen diseases” by Yu. N. Bogin and G. M. Sokolova was added to list of books recommended as teaching guides for doctors specializing in hepatic and spleen diseases by the Scientific Council of the Central Medical Refresher Institute [32].

We developed and published a sonographic classification for normal liver and hepatic lesions [32, 34].

In addition to the scientific and practical efforts, the staff of the ultrasound examination laboratory were also engaged in training of new specialists in ultrasound diagnostics and telethermography and actively promoted relevant methods in medical periodicals such as Meditsinskaya Gazeta and Gudok, as well as at various conferences and symposia.

 

Part Two

(from 1980’s to 1990’s)

These decades were marked by widespread implementation of Doppler technologies and complete revamping of ultrasound equipment at hospitals. The scope of capabilities in ultrasound diagnostics was significantly expanded.

Taking into account the high professional level of specialists in functional diagnostics and their willingness to take an active part in ultrasound examinations of the cardiovascular system, we conducted theory and practice training in fundamentals of ultrasound examinations for them and provided them with an opportunity to get involved with this extremely important area of medicine.

In early 1980’s, our laboratory started to cooperate with leading manufacturers of medical equipment. We collaborated most closely with two global giants in this area, Siemens from West Germany producing ultrasonic diagnostic equipment and AGA (Agema) from Sweden making heat imaging equipment. We received an opportunity to share experience with foreign hospitals using this equipment by presenting our reports to them and learning about their work. One of the greatest opportunities that we got was a chance to hold four international conferences on ultrasound and heat imaging diagnostics organised by our Hospital and supported by these two companies (1981, 1982, 1988, and 1991). In addition, we got a chance to perform clinical testing of state-of-the-art equipment produced by those companies in our laboratory.

Still focusing primarily on complex diagnostics, we conducted research in the areas where we thought this approach would be most appropriate.

In 1979, we summarised the first results of applying complex ultrasound, thermography, and aspiration biopsy diagnostics for breast diseases. Our sample included 4,520 women [5, 7, 15, 35]. Urgent fine-needle aspiration biopsy was performed using needles with the internal diameter of 1 mm. The tested complex of diagnostic methods proved efficient. 432 of those women had a surgery. The accuracy of our diagnostics was 92% for breast cancer (173 cases) and 93% for benign tumours (259 cases) [7, 12, 15, 35].

We were inspired by the results and continued to apply complex diagnostics to thyroid examination. The resulting accuracy rate of complex diagnostics reached 90% [8, 11, 12, 14].

In 1980–1984, we used some of the best ultrasound and heat imaging equipment available at the time to examine kidneys of 2,250 sick and 75 nearly healthy people aged from 8 to 88. The accuracy rate of our ultrasound diagnostics reached 90%. We studied the following ultrasound scans: healthy kidneys, kidney cysts, multicystic kidneys, kidney tumours, acute paranephritis, transplanted kidneys, acute glomerulonephritis, acute pyelonephritis, chronic pyelonephritis, and bladder stone disease. When necessary, we also applied telethermography – primarily in cases of inflammatory processes or foreign tissue lesions [9, 13].

In 1987, we analysed the results of our study of adrenal glands held in 1980–1986 covering a sample of 760 people including 76 with suspected pathology of adrenal glands. During the diagnostics, we measured the size of adrenal glands, examined their internal ultrasound structure and interface with nearest organs. The accuracy rate of our diagnostics based on the results of surgeries was 80% [10].

We developed a methodology to calculate the mass of internal organs of living people, which was supposed to facilitate more accurate estimation of medicine dosages and procurement of more objective clinical symptoms [36].

In 1990–1991, ultrasound diagnostics and telethermography were first applied in veterinary medicine [27, 37].

To sum up the results, it is necessary to supplement the above data with productive work that we completed. In total, we examined 156 thousand patients, trained 273 doctors in ultrasound diagnostics and telethermography as well as complex diagnostics (theory and practice training), and published 117 scientific research papers, including those published in the USA, Spain, Italy, and West Germany.

Considering the findings of complex diagnostics combining ultrasound examination with other methods, together with Era Association, we designed and equipped two mobile laboratories (a bus and a trailer) for complex express diagnostics (fig. 9, 10). The express diagnostics included clinical examination, thermography, ultrasound and cytological examination.

The need to design and equip mobile laboratories for complex express diagnostics emerged after the tragic events at the Chernobyl Nuclear Power Plant and the resulting demand for mass examination of thyroid and other organs of people living in areas affected by the explosion.

Considering the fact that there are many remote towns and villages in Russia that have no equipment to perform proper examination of patients, such complexes of modern equipment with a wider scope of application (digital photofluorography units, mammography units, etc.) could be of great help and bring modern healthcare services to the country’s population.

Our ultrasound laboratory actively demonstrated its achievements at two international exhibitions, Boltintsa-90 and Boltintsa-91. Both times we received honorary diplomas .

Already in early 1990’s, we developed software for training and practice in order to coach our staff engaged at mobile complex diagnostics laboratories. The software called Diagnost was recorded on a CD. This was a real breakthrough for that period of time.

Under my academic guidance, six students received their degree of PhD in Medical Sciences. We also have several patents for inventions [38, 39].

Many specialists from Western countries visited our laboratory to get acquainted with its achievements, including our colleagues from Eastern European countries, North America, Australia, and Asia. I personally led the classes and practical training for our guests who were often accompanied by representatives of various ministries and government agencies.

To conclude, I would like to say that thanks to the new developments, modern ultrasound technologies have a wide scope of diagnostic applications. I hope this method will continue developing and improving to eventually reach the level of histological and cytological research.

 

I would like to express my gratitude for assistance in the course of developing the present article to Marina Rybakova and Lidiya Suvorova