FASE (Focused Assessment with Sonography for Echinococcosis)
Hands on training course
29Th World Congress of Echinococcosis
August 28-30, 2023
Ultrasound (US) is the technique of choice for the initial diagnosis, in the clinical and field screening settings, and staging of hepatic Cystic Echinococcosis (CE). US alone allows the definition of “Confirmed CE” case when pathognomonic features are clearly visible on US imaging of cysts in liver. For CE screening US has a high sensitivity (100%) and specificity (95.6%). In co-endemic areas, differential with lesions caused by Echinococcus multilocularis (causing alveolar echinococcosis -AE) is also paramount since treatment and prognosis of CE and AE are very different.
Portable US equipment with battery, of good imaging quality and affordable allow performing US screening anywhere. But the main barrier is the shortage of physicians in endemic, often rural and even remote areas with access to US equipment and experience and expertise in the diagnosis of CE. To overcome this shortage, the CE Control Program of Rio Negro Province, Argentina designed in 2000, the FASE (Focused Assessment with Sonography for Echinococcosis) training course, for general/rural physician, without previous experience in US. FASE lasts 2 days and encompasses 20 hours of continuous medical education, with 9 theoretical modules (epidemiologic, clinical, diagnostic and treatment aspects) and 2 practical modules (first group: school children apparently healthy and a second with known patients with CE cysts of different stage). The training is repeated once a year to increase accuracy and at the beginning all lesions suspect for CE are double-evaluated by an experienced physicians, since the rate of false diagnosis is high at the beginning for beginners. Since 2000, we conducted total of 26 courses (19 in Río Negro, 6 in other provinces of Argentina and 1 in Chile) with more than 500 participants. In Rio Negro province, from 1997 to 2017 our trainees carried out 50.718 US scans with 205 positive cases (0.4%). All individuals with cysts confirmed to be CE after expert double-check were managed under protocol according to cyst stage and other features, as per WHO recommendations (active surveillance, antiparasitic treatment or surgery).
US screening for CE in Argentina is focused on schoolchildren but if feasible can be done in general population of some cities/towns. Is essential part of control program. New cases in children means, without any doubt, recent infection and therefore ongoing parasite transmission. Early diagnosis is very important for epidemiological knowledge of infection and for an early, timely, and appropriate treatment to reduce morbidity and mortality. FASE training course can be successfully taught to non-specialists in radiology and has allowed to screen for CE in a large population in remote endemic areas and overcome the barrier of great distances to referral center and the shortage of radiologists in rural areas. Local practitioners are capacitated to treat and follow up locally those patients who are assigned to treatment with albendazole or to ultrasound monitoring only (watch-and-wait approach) and refer only surgical cases to central hospitals. This approach, has spared residents in endemic areas costly travel time and missed work since it avoids unnecessary referral to tertiary centers. Ultrasound for CE screening proved to be an efficacious and low-cost intervention tool for both the community and health care system.
The CE part of the one-day FASE course proposed to accompany the World Congress on Echinococcosis, will be adapted from the Argentinian course, to fit the attendees profile and the hands-on practice will be conducted on known echinococcosis cases. During the course participants will: identify images compatible with CE and measure them; classify the stage of CE cyst according to the consensus WHO-IWGE classification; list possible differential diagnoses and strategies to come to a definitive diagnosis; discuss clinical management options according to WHO recommendations. After the course participants will be able to identify US pathognomonic signs of CE; define a diagnostic plan in case no confirmed diagnosis of CE can be achieved by US only; define a clinical management according to location, stage, size of CE; determine which cases may be treated locally and which should lead to a more complex center and follow up locally by ultrasound scan.
To participate in this course, it is required to be a physician, it is especially aimed at General/Rural Physician of rural areas or countryside. Fundaments of use of US equipment and abdominal anatomy will be provided to participants during practical activities, if at all needed.
It has a maximum quota that is determined by the number of ultrasound scanners with their respective instructors. We consider that for the use of the practice with the ultrasound the relationship should be 5-6 participants / ultrasound.
I. Theoretical: Lectures and case studies.
- Ultrasound diagnosis of abdominal CE and AE
- Differential diagnosis of abdominal CE and AE.
- Principles of clinical management allocation and follow-up for CE and AE
- Treatment and follow up of patients under medical treatment.
- Treatment and follow up of patients under surgical or (CE only) percutaneous treatment.
- Pulmonary CE, other less frequent localization.
- Screening: setup, aim, analyzing of results
II. Practical: Hands-on
- Up to 5 participants by each US equipment.
- B mode ultrasound (bidimensional).
- Cases: scan of known patients and collegial discussion.
DURATION AND CREDITS
The duration is 1 day with a total of 10 hours (with final evaluation and endorsed by the Ministry of Health).
It consists of 8 theoretical modules and 2 practical ones.
Fundamentals of the use of ultrasound as a diagnostic tool for screening or population survey (screening) for echinococcosis:
I. GENERAL ASPECTS
Ultrasound is a diagnostic method that:
- Is Harmless (does not use ionizing energy such as X-rays).
- Is non-invasive (important for socio-cultural issues and age group on which we perform it).
- Obtains results immediately.
- Allows storage of images and videos easily shared for second opinions.
- Shows images “live” with positive engagement of the screening participants
- It has no contraindications (except the patient's refusal).
- Is widely used in radiology, cardiology, gynecology, urology, ICU, gastroenterology, endocrinology, ophthalmology, anesthesiology, emergency, general and vascular surgery, sports medicine, etc.
- The point of care use (POCUS) of ultrasound is today, as in its beginnings the stethoscope, a bedside tool that is easy to access and apply to answer clinically-relevant precise questions even by non-radiologists with adequate training.
II. PARTICULAR ASPECTS
Ultrasound in echinococcosis is:
- The available diagnostic method with HIGHEST SENSITIVITY (it replaced serology in screening) for abdominal CE and AE, and with the HIGEST SPECIFICITY for CE
- Relative LOW COST.
- EASY TO LEARN and PRACTICE: the detection of abdominal CE/AE can be taught to non-imaging specialists in a similar way to what the FAST (Focused Assessment with Sonography for Trauma) is taught in trauma-emergency.
- DEPLOYABLE IN THE PERIPHERY, while imaging specialists who perform ultrasound are generally concentrated in tertiary referral centers (highly complex centers) and are not available in rural populations.
- REPEATABLE (positive cases or those with doubts are repeated in a more experienced center) even in vulnerable populations (children, pregnant women etc)
- ABLE TO GUARANTEE continuous follow-up over at the place of diagnosis.
As a result of the implementation of ultrasound for population screening for abdominal echinococcal infections in a systematic way, a LARGE GEOGRAPHICAL COVERAGE has been achieved, allowing the progressive installation of “fixed” ultrasound equipment in the main rural hospitals and portable and “mobile” ultrasound scanners for the areas with lower population density.
8:00 - 8:30. Registration.
|8:30-8:40||Welcome and presentation of faculty and participants|
|8:40-8:55||Ultrasound diagnosis of CE. Leonardo Uchiumi).|
|8:55-9:15||Ultrasound diagnosis of AE. Local: please desigante.|
|9:15-9:35||Differential diagnosis of abdominal CE and AE. Francesca Tamarozzi|
|9:35-10:00||Differential diagnosis of abdominal CE and AE. Local: please designate|
|10:30-10:45||Principles of clinical management and follow-up of CE. Leonardo Uchiumi.|
|10:45-11:00||Principles of clinical management and follow-up of AE Local: please designate.|
|11:00-11:30||Treatment and follow-up of CE under medical treatment. Francesca Tamarozzi.|
|11:15-11:30||Treatment and follow-up of AE under medical treatment. Local: please designate.|
|11:30-12:00||Treatment and follow up of patients under surgical or (CE only) percutaneous treatment. (Leonardo Uchiumi/Local).|
|12:00-12:30||Pulmonary and other less common localization of CE. (Leonardo Uchiumi).|
|12:30-13:100||Set up an US screening: aim and analysis of the results. (Leonardo Uchiumi/Francesca Tamarozzi).|
|14:00-17:00||US practice and discussion of cases|