Pocket Handheld Ultrasound As a Novel Point-of-Care Imaging Modality to Diagnose Bleeding in Hemophilic Joints
Authors: Zhou Jenny Y , Rappazzo Katherine C. , Volland Lena , Steiner Bruno , Kruse-Jarres Rebecca , Quon Doris V. , Chang Eric Y. , von Drygalski Annette 
Published: October 2019

Abstract
Introduction
Musculoskeletal ultrasound (MSKUS) is being used increasingly for point-of-care (POC) assessment of painful hemophilic joints and has proven to be a critical tool in the evaluation of the presence of hemarthrosis. To date, MSKUS examinations are exclusively performed in the clinic, which often results in delays to definitive diagnosis since patients and caregivers are not always able to undergo or perform a clinical assessment at the time of the event. The use of pocket handheld ultrasound devices, which have primarily been applied for cardiopulmonary and abdominal POC bedside assessments, offers a promising solution to this problem by enabling patients and remote clinics to acquire images for off-site real-time evaluations via tele-transmission. In this study, we evaluated the extent to which the quality of images generated by the handheld ultrasound devices compared to stationary MSKUS and if the image interpretation was similar between various health care providers. The aim is to establish the dynamic potential of this pocket sized device as a cost effective and comparable alternative to the stationary MSKUS.
Methods
A total of 72 typical joint views (36 of the knee, 20 of the elbow and 16 of the ankle) were acquired from healthy volunteers and hemophilia patients at the same session with the stationary GE LogiqS8 and the handheld GE V2scan. Ten different health care providers (7 physicians, 2 physical therapists and 1 nurse), all trained at least in the CME-accredited MSKUS course at the University of California, San Diego, (UCSD), reviewed these images side by side. Information about view, probe placement and tissue compressibility to identify effusions was provided. Each subject was asked to evaluate the following characteristics on a graded scale: (1) similarity of the handheld image to the GE LogiqS8 image, (2) their confidence in identification of major landmarks on the handheld image compared to the GE LogiqS8 image and if an effusion was present, (3) their ability to identify the effusion on both images. The adjudicators were a board-certified radiologist and a senior hematologist trained and experienced in MSKUS. Study procedures complied with rules set forth by the UCSD Human Research Protection Program.
Results
A total of 720 responses were analyzed from the images of normal and hemophilic joints. Among the responses, 87% of images were rated as at least moderately similar to very similar between the handheld device and the stationary ultrasound. In terms of identification, 88% of the responses were rated as at least moderately confident to very confident in the identification of major landmarks on the handheld image. Among a total of 170 responses for effusions, 87% of effusions were identified with both the handheld device and the stationary MSKUS (Table). These percentages were consistent between the different joints with slightly higher rates of correct identification on the handheld device noted in the knee where 100% of effusions were recognized correctly. Representative images depicting an effusion in the lateral recess of the knee acquired simultaneously with the handheld GE V2scan and stationary MSKUS is provided (Figure). There was no significant discrepancy of answers between the types of providers.
Conclusion
The image quality of the handheld pocket device (GE V2 scan) was sufficient to determine major landmarks in joints and to diagnose effusions, with image interpretation comparable between the various health care providers encompassing physicians, nurses, and physical therapists. These findings highlight the potential in the application of this device as a novel POC modality for both patient-performed tele-ultrasound or tele-ultrasound use in remote, resource limited regions for real-time assessments of hemarthrosis. While encouraging, these observations need to be further validated and extended more broadly in future studies.
Table Table.

Disclosures
Kruse-Jarres: Baxalta: Consultancy, Honoraria; Grifols: Consultancy, Honoraria; Roche: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; CSL Behring: Consultancy, Honoraria; Bayer: Consultancy, Honoraria. Quon:Bayer: Consultancy; Biogen: Consultancy, Speakers Bureau; Grifols: Speakers Bureau; Novo Nordisk: Consultancy, Speakers Bureau. von Drygalski:Pfizer: Consultancy, Honoraria, Speakers Bureau; Hematherix LLC: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Consultancy, Honoraria, Speakers Bureau; CSL-Behring: Consultancy, Honoraria, Speakers Bureau; Biogen: Consultancy, Honoraria, Speakers Bureau; Bayer: Consultancy, Honoraria, Speakers Bureau; Baxalta/Shire: Consultancy, Honoraria, Speakers Bureau.