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CHAPTER 1 Earth in Space and Time The Early Solar System In


Earth in Space and Time The Early Solar System In recent decades, scientists have been able to construct an everclearer picture of the origins of the solar system and, before that, of the universe itself. Most astronomers now accept some sort of “Big Bang” as the origin of today’s universe. Just before it occurred, all matter and energy would have been compressed into an enormously dense, hot volume a few millimeters (much less than an inch) across. Then everything was flung violently apart across an ever-larger volume of space. The time of the Big Bang can be estimated in several ways. Perhaps the most direct is the backcalculation of the universe’s expansion to its apparent beginning. Other methods depend on astrophysical models of creation of the elements or the rate of evolution of different types of stars. Most age estimates overlap in the range of 12 to 14 billion years. Stars formed from the debris of the Big Bang, as locally high concentrations of mass were collected together by gravity, and some became large and dense enough that energy-releasing atomic reactions were set off deep within them. Stars are not permanent objects. They are constantly losing energy and mass as they burn their nuclear fuel. The mass of material that initially formed the star determines how rapidly the star burns; some stars burned out billions of years ago, while others are probably forming now from the original matter of the universe mixed with the debris of older stars. Our sun and its system of circling planets, including the earth, are believed to have formed from a rotating cloud of gas and dust (small bits of rock and metal), some of the gas debris from older stars (figure 1.1). Most of the mass of the cloud coalesced to form the sun, which became a star and began to “shine,” or release light energy, when its interior became so

developing planets incorporated much larger amounts of lowertemperature minerals, including some that contain water locked within their crystal structures. (This later made it possible for the earth to have liquid water at its surface.) Still farther from the sun, temperatures were so low that nearly all of the materials in the original gas cloud condensed—even materials like methane and ammonia, which are gases at normal earth surface temperatures and pressures. The result was a series of planets with a variety of compositions, most quite different from that of Earth. This is confirmed by observations and measurements of the planets. For example, the planetary densities listed in table 1.1 are consistent with a higher metal and rock content in the four planets closest to the sun and a much larger proportion of ice and gas in the planets farther from the sun (see also figure 1.2). These differences should be kept in mind when it is proposed that other planets could be mined for needed minerals. Both the basic chemistry of these other bodies and the kinds of ore-forming or other resource-forming processes that might occur on them would differ considerably from those on Earth, and may not have led to products we would find useful. (This is leaving aside any questions of the economics or technical practicability of such mining activities!) In addition, our principal current energy sources required living organisms to form, and so far, no such life-forms have been found on other planets or moons. Venus—close to Earth in space, similar in size and density— shows marked differences: Its dense, cloudy atmosphere is thick with carbon dioxide, producing planetary surface temperatures hot enough to melt lead through runaway greenhouse-effect heating (see chapter 10). Mars would likewise be inhospitable: It is very cold, and we could not breathe its atmosphere. Though its surface features indicate the presence of liquid water in its past, there is none now, and only small amounts of water ice have been found. There is not so much as a blade of grass for vegetation; the brief flurry of excitement over possible evidence of life on Mars referred only to fossil microorganisms, and more-intensive investigations suggested that the tiny structures

in question likely are inorganic, though the search for Martian microbes continues. Earth, Then and Now The earth has changed continuously since its formation, undergoing some particularly profound changes in its early history. The early earth was very different from what it is today, lacking the modern oceans and atmosphere and having a much different surface from its present one, probably more closely resembling the barren, cratered surface of the moon. Like other planets, Earth was formed by accretion, as gravity collected together the solid bits that had condensed from the solar nebula. Some water may have been contributed by gravitational capture of icy comets, though recent analyses of modern comets do not suggest that this was a major water source. The planet was heated by the impact of the colliding dust particles and meteorites as they came together to form the earth, and by the energy release from decay of the small amounts of several naturally radioactive elements that the earth contains. These heat sources combined to raise the earth’s internal temperature enough that parts of it, perhaps eventually most of it, melted, although it was probably never molten all at once. Dense materials, like metallic iron, would have tended to sink toward the middle of the earth. As cooling progressed, lighter, low-density minerals crystallized and floated out toward the surface. The eventual result was an earth differentiated into several major compositional zones: the central core, the surrounding mantle, and a thin crust at the surface (see figure 1.3). The process was complete well before 4 billion years ago. Although only the crust and a few bits of uppermost mantle that are carried up into the crust by volcanic activity can be sampled and analyzed directly, we nevertheless have a good deal of information on the composition of the earth’s interior. First, scientists can estimate from analyses of stars the starting composition of the cloud from which the solar system formed. Geologists can also infer aspects of the earth’s bulk composition from analyses of certain meteorites believed to have formed at the same time

The planets of the solar system vary markedly in both composition and physical properties. For example, Mercury (A), as shown in this image from a 2008 Messenger spacecraft flyby, is rocky, iron-rich, dry, and pockmarked with craters. Mars (B) shares many surface features with Earth (volcanoes, canyons, dunes, slumps, stream channels, and more), but the surface is now dry and barren; (C) a 2008 panorama by the Mars rover Spirit. Jupiter (D) is a huge gas ball, with no solid surface at all, and dozens of moons of ice and rock that circle it to mimic the solar system in miniature. Note also the very different sizes of the planets (E). The Jovian planets—named for Jupiter—are gas giants; the terrestrial planets are more rocky, like Earth. Sources: (A) NASA image courtesy Science Operations Center at Johns Hopkins University Applied Physics Laboratory; (B) NASA; (C) Image courtesy NASA/JPL/Cornell; (D) NSSDC Goddard Space Flight Center; (E) NASA

A chemically differentiated Earth. The core consists mostly of iron; the outer part is molten. The mantle, the largest zone, is made up primarily of ferromagnesian silicates (see chapter 2) and, at great depths, of oxides of iron, magnesium, and silicon. The crust (not drawn to scale, but exaggerated vertically in order to be visible at this scale) forms a thin skin around the earth. Oceanic crust, which forms the sea floor, has a composition somewhat like that of the mantle, but is richer in silicon. Continental crust is both thicker and less dense. It rises above the oceans and contains more light minerals rich in calcium, sodium, potassium, and aluminum. The “plates” of plate tectonics (the lithosphere) comprise the crust and uppermost mantle. (100 km ≈ 60 miles

as, and under conditions similar to, the earth. Geophysical data demonstrate that the earth’s interior is zoned and also provide information on the densities of the different layers within the earth, which further limits their possible compositions. These and other kinds of data indicate that the earth’s core is made up mostly of iron, with some nickel and a few minor elements; the outer core is molten, the inner core solid. The mantle consists mainly of iron, magnesium, silicon, and oxygen combined in varying proportions in several different minerals. The earth’s crust is much more varied in composition and very different chemically from the average composition of the earth (see table 1.2). As is evident from this table, many of the metals we have come to prize as resources are relatively uncommon elements in the crust. Crust and uppermost mantle together form a somewhat brittle shell around the earth. The heating and subsequent differentiation of the early earth led to another important result: formation of the atmosphere and oceans. Many minerals that had contained water or gases in their crystals released them during the heating and melting, and as the earth’s surface cooled, the water could condense to form the oceans. Without this abundant surface water, which in the solar system is unique to Earth, most life as we know it could not exist. The oceans filled basins, while the continents, buoyant because of their lower-density rocks and minerals, stood above the sea surface. At first, the continents were barren of life. The earth’s early atmosphere was quite different from the modern one, aside from the effects of modern pollution. The first atmosphere had little or no free oxygen in it. It probably consisted dominantly of nitrogen and carbon dioxide (the gas most commonly released from volcanoes, aside from water) with minor amounts of such gases as methane, ammonia, and various sulfur gases. Humans could not have survived in this early atmosphere. Oxygen-breathing life of any kind could not exist before the single-celled blue-green algae appeared in large

Figure 1.3 A chemically differentiated Earth. The core consists mostly of iron; the outer part is molten. The mantle, the largest zone, is made up primarily of ferromagnesian silicates (see chapter 2) and, at great depths, of oxides of iron, magnesium, and silicon. The crust (not drawn to scale, but exaggerated vertically in order to be visible at this scale) forms a thin skin around the earth. Oceanic crust, which forms the sea floor, has a composition somewhat like that of the mantle, but is richer in silicon. Continental crust is both thicker and less dense. It rises above the oceans and contains more light minerals rich in calcium, sodium, potassium, and aluminum. The “plates” of plate tectonics (the lithosphere) comprise the crust and uppermost mantle. (100 km ≈ 60 miles) Crust (continents = granitic) (ocean crust = basalt) Mantle (iron-rich silicates) Core (iron and nickel) Uppermost mantle Mantle Lithosphere Continental crust Oceanic crust Mantle continues downward 0 100 km Crust 200 km Table

Most Common Chemical Elements in the Earth WHOLE EARTH CRUST Element Weight Percent Element Weight Percent Iron 32.4 Oxygen 46.6 Oxygen 29.9 Silicon 27.7 Silicon 15.5 Aluminum 8.1 Magnesium 14.5 Iron 5.0 Sulfur 2.1 Calcium 3.6 Nickel 2.0 Sodium 2.8 Calcium 1.6 Potassium 2.6 Aluminum 1.3 Magnesium 2.1 (All others, total) .7 (All others, total) 1.5 (Compositions cited are averages of several independent estimates.) mon22959_ch01_001-020.indd 5 6 Section One Foundations 4.5 billion years ago Precambrian

animals took to the air with the development of birds about 150 million years ago, and by 100 million years ago, both birds and mammals were well established. Such information has current applications. Certain energy sources have been formed from plant or animal remains. Knowing the times at which particular groups of organisms appeared and flourished is helpful in assessing the probable amounts of these energy sources available and in concentrating the search for these fuels on rocks of appropriate ages. On a timescale of billions of years, human beings have just arrived. The most primitive human-type remains are no more than 4 to 5 million years old, and modern, rational humans (Homo sapiens) developed only about half a million years ago. Half a million years may sound like a long time, and it is if compared to a single human lifetime. In a geologic sense, though, it is a very short time. If we equate the whole of earth’s history to a 24-hour day, then shelled organisms appeared only about 3 hours ago; fish, about 2 hours and 40 minutes ago; land plants, 2 hours ago; birds, about 45 minutes ago—and Homo sapiens has been around for just the last 6 seconds. Nevertheless, we humans have had an enormous impact on the earth, at least at its surface, an impact far out of proportion to the length of time we have occupied it. Our impact is likely to continue to increase rapidly as the population does likewise. 1.2 Geology, Past and Present Two centuries ago, geology was mainly a descriptive science involving careful observation of natural processes and their products. The subject has become both more quantitative and more interdisciplinary through time. Modern geoscientists draw on the principles of chemistry to interpret the compositions of geologic materials, apply the laws of physics to explain these materials’ physical properties and behavior, use the biological sciences to develop an understanding of ancient life-forms, and rely on engineering principles to design safe structures in the presence of geologic hazards. The emphasis on the “why,” rather than just the “what,” has also increased. The Geologic Perspective Geologic observations now are combined with laboratory experiments, careful measurements, and calculations to develop theories of how natural processes operate. Geology is especially challenging because of the disparity between the scientist’s laboratory and nature’s. In the research laboratory, conditions of temperature and pressure, as well as the flow of chemicals into or out of the system under study, can be carefully controlled. One then knows just what has gone into creating the product of the experiment. In nature, the geoscientist is often confronted only with the results of the “experiment” and must deduce the starting materials and processes involved. Another complicating factor is time. The laboratory scientist must work on a timescale of hours, months, years, or, at most, decades. Natural geologic processes may take a million or a billion years to achieve a particular result, by stages too slow even to be detected in a human lifetime (table 1.3). This understanding may be one of the most significant contributions of early geoscientists: the recognition of the vast length of geologic history, sometimes described as “deep time.” The qualitative and quantitative tools for sorting out geologic events and putting dates on them are outlined in appendix A. For now, it is useful to bear in mind that the immensity of geologic time can make it difficult to arrive at a full understanding of how geologic processes operated in the past from observations made on a human timescale. It dictates caution, too, as we try to project, from a few years’ data on global changes associated with human activities, all of the long-range impacts we may be causing. Also, the laboratory scientist may conduct a series of experiments on the same materials, but the experiments can be stopped and those materials examined after each stage. Over the vast spans of geologic time, a given mass of earth material may have been transformed a half-dozen times or more, under different conditions each time. The history of the rock that ultimately results may be very difficult to decipher from the end product alon

Geology and the Scientific Method The scientific method is a means of discovering basic scientific principles. One begins with a set of observations and/or a body of data, based on measurements of natural phenomena or on experiments. One or more hypotheses are formulated to explain the observations or data. A hypothesis can take many forms, ranging from a general conceptual framework or model describing the functioning of a natural system, to a very precise mathematical formula relating several kinds of numerical data. What all hypotheses have in common is that they must all be susceptible to testing and, particularly, to falsification. The idea is not simply to look for evidence to support a hypothesis, but to examine relevant evidence with the understanding that it may show the hypothesis to be wrong. In the classical conception of the scientific method, one uses a hypothesis to make a set of predictions. Then one devises and conducts experiments to test each hypothesis, to determine whether experimental results agree with predictions based on the hypothesis. If they do, the hypothesis gains credibility. If not, if the results are unexpected, the hypothesis must be modified to account for the new data as well as the old or, perhaps, discarded altogether. Several cycles of modifying and retesting hypotheses may be required before a hypothesis that is consistent with all the observations and experiments that one can conceive is achieved. A hypothesis that is repeatedly supported by new experiments advances in time to the status of a theory, a generally accepted explanation for a set of data or observations. Much confusion can arise from the fact that in casual conversation, people often use the term theory for what might better be called a hypothesis, or even just an educated guess. (“So, what’s your theory?” one character in a TV mystery show may ask another, even when they’ve barely looked at the first evidence.) Thus, people may assume that a scientist describing a theory is simply telling a plausible story to explain some data. A scientific theory, however, is a very well-tested model with a very substantial and convincing body of evidence that supports it. A hypothesis may be advanced by just one individual; a theory has survived the challenge of extensive testing to merit acceptance by many, often most, experts in a field. The Big Bang theory is not just a creative idea. It accounts for the decades-old observation that all the objects we can observe in the universe seem to be moving apart. If it is correct, the universe’s origin was very hot; scientists have detected the cosmic microwave background radiation consistent with this. And astrophysicists’ calculations predict that the predominant elements that the Big Bang would produce would be hydrogen and helium—which indeed overwhelmingly dominate the observed composition of our universe. The classical scientific method is not strictly applicable to many geologic phenomena because of the difficulty of experimenting with natural systems, given the time and scale considerations noted earlier. For example, one may be able to conduct experiments on a single rock, but not to construct a whole volcano in the laboratory, nor to replicate a large meteorite impact (like that of figure 1.5) to study its effects. In such cases, hypotheses are often tested entirely through further

observations or theoretical calculations and modified as necessary until they accommodate all the relevant observations (or are discarded when they cannot be reconciled with new data). This broader conception of the scientific method is well illustrated by the development of the theory of plate tectonics, discussed in chapter 3. “Continental drift” was once seen as a wildly implausible idea, advanced by an eccentric few, but in the latter half of the twentieth century, many kinds of evidence were found to be explained consistently and well by movement of plates—including continents—over earth’s surface. Still, the details of plate tectonics continue to be refined by further studies. Even a well-established theory may ultimately be proved incorrect. (Plate tectonics in fact supplanted a very different theory about how mountain ranges form.) In the case of geology, complete rejection of an older theory has most often been caused by the development of new analytical or observational techniques, which make available wholly new kinds of data that were unknown at the time the original theory was formulated. The Motivation to Find Answers In spite of the difficulties inherent in trying to explain geologic phenomena, the search for explanations goes on, spurred not only by the basic quest for knowledge, but also by the practical problems posed by geologic hazards, the need for resources, and concerns about possible global-scale human impacts, such as ozone destruction and global warming. The hazards may create the most dramatic scenes and headlines, the most abrupt consequences: The 1989 Loma Prieta (California) earthquake caused more than $5 billion in damage; the 1995 Kobe (Japan) earthquake (figure 1.6), similar in size to Loma Prieta, caused over 5200 deaths and about $100 billion in property damage; the 2004 Sumatran earthquake claimed nearly 300,000 lives; the 2011 quake offshore from

Honshu, Japan, killed over 15,000 people and caused an estimated $300 billion in damages. The 18 May 1980 eruption of Mount St. Helens (figure 1.7) took even the scientists monitoring the volcano by surprise, and the 1991 eruption of Mount Pinatubo in the Philippines not only devastated local residents but caught the attention of the world through a marked decline in 1992 summer temperatures. Efforts are underway to provide early warnings of such hazards as earthquakes, volcanic eruptions, and landslides so as to save lives, if not property. Likewise, improved understanding of stream dynamics and more prudent land use can together reduce the damages from flooding (figure 1.8), which amount in the United States to over $1 billion a year and the loss of dozens of lives annually. Land

slides and other slope and ground failures (figure 1.9) take a similar toll in property damage, which could be reduced by more attention to slope stability and improved engineering practices. It is not only the more dramatic hazards that are costly: On average, the cost of structural damage from unstable soils each year approximately equals the combined costs of landslides, earthquakes, and flood damages in this country. It is worth noting that as scientists become better able to predict such events as earthquakes and volcanic eruptions, new challenges arise: How certain should they be before a prediction is issued? How best to educate the public—and public officials—about the science behind the predictions and its limitations, so that they can prepare/respond appropriately? What if a prediction is wrong? Such issues will be examined in later chapters. Our demand for resources of all kinds continues to grow and so do the consequences of resource use. In the United States, average per-capita water use is 1500 gallons per day; in many places, groundwater supplies upon which we have come to rely heavily are being measurably depleted. Worldwide, water-resource disputes between nations are increasing in number.

As we mine more extensively for mineral resources, we face the problem of how to minimize associated damage to the mined lands (figure 1.10). The grounding of the Exxon Valdez in 1989, dumping 11 million gallons of oil into Prince William Sound, Alaska, and the massive spill from the 2010 explosion of the Deepwater Horizon drilling platform in the Gulf of Mexico were reminders of the negative consequences of petroleum exploration, just as the 1991 war in Kuwait, and the later invasion of Iraq, were reminders of U.S. dependence on imported oil. As we consume more resources, we create more waste. In the United States, total waste generation is estimated at close to 300 million tons per year—or more than a ton per person. Careless waste disposal, in turn, leads to pollution. The Environmental Protection Agency continues to identify toxic-waste disposal sites in urgent need of cleanup; by 2000, over 1500 so-called priority sites had been identified. Cleanup costs per site have risen to over $30 million, and the projected total costs to remediate these sites alone is over $1 trillion. As fossil fuels are burned, carbon dioxide in the atmosphere rises, and modelers of global climate strive to understand what that may do to global temperatures, weather, and agriculture decades in the future. These are just a few of the kinds of issues that geologists play a key role in addressing

The earth is a dynamic, constantly changing planet—its crust shifting to build mountains; lava spewing out of its warm interior; ice and water and windblown sand and gravity reshaping its surface, over and over. Some changes proceed in one direction only: For example, the earth has been cooling progressively since its formation, though considerable heat remains in its interior. Many of the processes, however, are cyclic in nature. Consider, for example, such basic materials as water or rocks. Streams drain into oceans and would soon run dry if not replenished; but water evaporates from oceans, to make the rain and snow that feed the streams to keep them flowing. This describes just a part of the hydrologic (water) cycle, explored more fully in chapters 6 and 11. Rocks, despite their appearance of permanence in the short term of a human life, participate in the rock cycle (chapters 2 and 3). The kinds of evolutionary paths rocks may follow through this cycle are many, but consider this illustration: A volcano’s lava (figure 1.11) hardens into rock; the rock is weathered into sand and dissolved chemicals; the debris, deposited in an ocean basin, is solidified into a new rock of quite different type; and some of that new rock may be carried into the mantle via plate tectonics, to be melted into a new lava. The time frame over which this process occurs is generally much longer than that over which water cycles through atmosphere and

oceans, but the principle is similar. The Appalachian or Rocky Mountains as we see them today are not as they formed, tens or hundreds of millions of years ago; they are much eroded from their original height by water and ice, and, in turn, contain rocks formed in water-filled basins and deserts from material eroded from more-ancient mountains before them (figure 1.12)

Chemicals, too, cycle through the environment. The carbon dioxide that we exhale into the atmosphere is taken up by plants through photosynthesis, and when we eat those plants for food energy, we release CO2 again. The same exhaled CO2 may also dissolve in rainwater to make carbonic acid that dissolves continental rock; the weathering products may wash into the ocean, where dissolved carbonate then contributes to the formation of carbonate shells and carbonate rocks in the ocean basins; those rocks may later be exposed and weathered by rain, releasing CO2 back into the atmosphere or dissolved carbonate into streams that carry it back to the ocean. The cycling of chemicals and materials in the environment may be complex, as we will see in later chapters. Furthermore, these processes and cycles are often interrelated, and seemingly local actions can have distant consequences. We dam a river to create a reservoir as a source of irrigation water and hydroelectric power, inadvertently trapping stream-borne sediment at the same time; downstream, patterns of erosion and deposition in the stream channel change, and at the coast, where the stream pours into the ocean, coastal erosion of beaches increases because a part of their sediment supply, from the stream, has been cut off. The volcano that erupts the lava to make the volcanic rock also releases water vapor into the atmosphere, and sulfur-rich gases and dust that influence the amount of sunlight reaching earth’s surface to heat it, which, in turn, can alter the extent of evaporation and resultant rainfall, which will affect the intensity of landscape erosion and weathering of rocks by water. . . . So although we divide the great variety and complexity of geologic processes and

Chapter 3: Project Design and Methodology Introduce this chapter by describing how

Dear writer, please see the PDF file You previously finished a business research paper for me; this is the Business Assignment Help Chapter 3: Project Design and Methodology

Introduce this chapter by describing how the project outcome will improve the quality of health care for the patient population. This section should report how the project is rooted in quality improvement from the outset of the improvement initiative. Then, in no less than three substantive paragraphs, discuss the differences between research, evidence-based practice, and quality improvement. Include what makes them each unique and how one leads the other. Please support your discussion with scholarly citations.


The “Purpose” section of Chapter 3 should be two or three paragraphs long. It should (a) reflect on the problem statement, (b) identify how the project will be accomplished, and (c) explain how the project will contribute to the field. The section begins with a declarative statement, “The purpose of this project is….” which is based on your problem statement from Chapter 1. Included in this statement are also the project design, population, variables to be investigated, and the geographic location. Further, the section clearly defines the dependent and independent variables, relationship of variables, or comparison of groups (comparison versus intervention) for quantitative analyses. Keep in mind that the exact purpose statement (i.e., copy paste what is here) in this chapter is restated in the abstract and Chapter 5. This purpose statement aligns to the PICOT components from previous courses. Use the following template for structuring your purpose statement: The purpose of this quality improvement project is to determine if the implementation of _________________ (whose research are you translating or what clinical practice guidelines) would impact ______________(what) _______________________ among ___________(population). The project was piloted over an eight-week period in a (rural, urban, or directional (eastern, western, …)________ (state) ________ (setting i.e., primary care clinic, ER, OR).

Project Planning and Procedures

Introduce this section with three to five sentences. Include why project planning was initiated and how it helped the team to think systematically. This section addresses the overall concept of the project planning procedure.

Interprofessional Collaboration

This section should be three or four paragraphs long. The first paragraph should outline why organizational support is imperative when improving patient outcomes. Include what organizational support will be required for your quality improvement project. Ensure to use a transitional statement between this section and the next.

The second paragraph will summarize the organizational support you are receiving from the stakeholders at the project site. In this paragraph, identify both the internal and external stakeholders from within the organization. What are their roles and how will this ensure sustainability of the project in the future?

The third and fourth paragraphs should include the characteristics of the team that conducted the intervention (for instance, type and level of training, degree of experience, and administrative and/or academic position of the personnel leading workshops) and/or the personnel to whom the intervention was applied should be specified. Often the influence of the people involved in the project is as great as the project components themselves. Explain the role of a project manager of this quality improvement project and how a project manager influences and facilitates the team and the project. Include your responsibilities and duties using third person without referring to yourself. Next, describe the role and responsibilities of the team members in your project.

Project Management Plan (list required resources—delete this parenthetical note)

This section should be two to three paragraphs long. This section details the step-by-step plan for the project’s implementation. Include that the project starts with IRB approval and ends at data analysis. Every change that could have contributed to the observed outcome should be noted. Each element should be briefly described. Refer to the project timeline completed in DNP-840A (ATTACHED) (see Appendix C). The plan should include a complete procedure and outline of the education that will provide to the staff. Explain where the education was derived from (typically the instrument/tool/evidence-based intervention) and discuss how it will be deployed. Refer to the Educational Plan in Appendix D. Describe how or why you are qualified to teach this information to the staff. Include if you required additional outside resources to implement the education. Describe your procedure in such a way that your reader could follow the same steps and get the same results.

The project was initiated after receiving approval for ABC University’s Institutional Review Board. (see Appendix E) This Appendix will become Appendix A once your project has been evaluated by the HIJK institutional review board and an outcome letter issued.


This section should be one or two paragraphs. What is required to make your project successful? Do you have adequate staff and time to educate the healthcare providers (nurses, doctors, mid-levels, tech, medics, etc.) on the evidence-based intervention? Do you need supplies or technology for support? As the project manager can you do the education or is there a cost to bring someone in (is this addressed in your budget)? Refer to the budget completed in DNP-840A (ATTACHED) as an appendix (see Appendix F). Remember having a balanced budget is imperative in today’s healthcare so as you show expenses, there should be some reference to anticipated improved revenue. Is the project designed in a way to ensure realistic implementation of the project? Support your discussion with scholarly citations.

Setting and Sample Population

This section discusses the total population, project population, and project sample based on the geographical setting of the project site. A description of the sample is essential for other clinicians to apply your findings to their settings.


In one paragraph, introduce this section by providing a broad description of the project site. Describing the organization in which in intervention took place in detail is necessary to assist readers in understanding whether the intervention is likely to “work” in the local environment (consider what the organization’s public description is on their website). This includes the description of the community, its makeup, and current services. Include additional information as needed, such as information about the location, practice type, teaching status, system affiliation, patient population (i.e., number of patients in a given time frame), size of the organization, staffing, and relevant processes in place. Follow the broad overview of the organization with a more focused overview of the specific area of practice (i.e., ER, OR, or ICU).

Population and Sample

The discussion of the sample includes the proper terminology specific to the type of sampling method used for the project. This section should be three to four paragraphs long and include the following components:

The characteristics of the total population and the project population from which the project sample (project participants) is drawn. Describe the characteristics of the project population and the project sample.

Clear definitions and differentiation of the sample versus the population for the project. Describe the project population size and project sample size and justify the project sample size (e.g., power analysis) based on the selected design.

Details on the sampling procedures, including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population. If subjects withdrew or were excluded from the project, you must provide an explanation of why.

The informed consent process, confidentiality measures, project participation requirements, and geographic specifics.

How the intervention answers the evidence-based question(s).

Data Collection Procedures

This section should be three or four paragraphs in length. This section details the entirety of the process used to collect the project data and describes the sources from which the data will be obtained. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. Data should include descriptive or demographic data of the project sample and outcome data. Describe who/and from where data are obtained.

Instrumentation or Data Source

The first paragraph should include a description of data sources including any instrumentation. This paragraph should address the procedures for data collection, including how each instrument or data source was used, how and where data were collected (including demographic data), and how data were recorded. If survey/instruments are used, then their validity and reliability must be explained, including the psychometric data, using relevant scholarly citations. Refer to the instrument in Appendix G. Include permission to use the tool in Appendix H. If an instrument was not used for data collection, then explain the reliability and validity of the data source (e.g., reliability and validity of the EHR). If other instruments or sources of data are needed, provide evidence in the appendices. (see Appendix I).


The second paragraph should include an explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable). It should also include a description of the procedures for project sample selection and how the data for the participants were grouped (e.g., comparison versus implementation).

Data Integrity and Storage

The third paragraph should include how the data integrity will be managed throughout project implementation. Include the description of how the final analysis data collection set and data dictionary were created and if any data manipulation was required. It should also provide a description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analysis used.

Data Management

The fourth paragraph should provide a detailed description of the relevant data collected for each project question. It should also detail how the raw data were organized and prepared for analysis. Include any methods for data cleansing. There should also be a description of the procedures adopted to maintain data security, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed following the project site’s policy. What data management errors were anticipated during the data collection period? Include how errors in data collection and entry will be discovered early and remedied. Support your discussion with scholarly references.

Potential Bias and Mitigation

In this section, you will describe the potential biases that may impact your project (proposal stage) and biases that did impact your project (finished manuscript). In addition, you will explain how these biases were mitigated to ensure the validity of the project. This section should be at least four paragraphs long.

You should explain at least five potential biases that are related to (a) the project methodology, (b) the project design, (c) the sampling procedures, (d) data collection, and (e) data interpretation. For each bias, you need to (a) clearly define what the bias is/was, (b) clearly explain how the bias may have been present in your project, and (c) explain how you mitigated this bias. Your discussion should be supported with scholarly citations.

Please note, you will need to personalize the possible biases based on the project you conducted. For example:

If my project employs an internet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation!


When conducting a quality improvement project, it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used.

Ethical Considerations

This section should be one paragraph and summarize the ethical aspects of implementing an intervention and analyzing the data. This section should include a description of the procedures for protecting the rights and well-being of the project sample as well as the staff completing the intervention. The key ethical issues that must be addressed in this section include:

How any potential ethical issues will be addressed.

Ethical issues are related to the project and the sample population of interest, institution, or data collection process.

Anonymity, confidentiality, privacy, lack of coercion, and potential conflict of interest.

The key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions.

Include a statement that the project has undergone a formal ethics review by the LMNOP IRB. Select the following statement that best aligns with your IRB determination and embed it in your paragraph (see Appendix E):

Quality Improvement: This project was reviewed by the Institutional Review Board at ABC University, and was determined not to be human subjects research. As such, this project did not require IRB review.

Exempt/Expedited: This project was reviewed by the Institutional Review Board at ABC University, and was determined to be exempt/expedited. As such, this project was approved.


This section summarizes the key points of Chapter 3 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 4 followed by a description of the remaining chapters. This section should be two paragraphs long.


Atherton K. N. (2020). Project Five Wishes: promoting advance directives in primary care. Journal of the American Association of Nurse Practitioners, 32(10), 689–695.

Barry, H. (2018, December 01). Advance care planning increases execution of advance directives and surrogate decision-maker assignment. American Association of Family Practitioners,

Bernard, C., Tan, A., Slaven, M. et al. (2020) Exploring patient-reported barriers to advance care planning in family practice. BMC Fam Practice 21, 94.

Bond, W. F., Kim, M., Franciskovich, C. M., Weinberg, J. E., Svendsen, J. D., Fehr, L. S., & Asche, C. V. (2018). Advance care planning in an accountable care organization is associated with increased advanced directive documentation and decreased costs. Journal of Palliative Medicine, 21(4), 489-502.

Caldwell, A., Cunningham, M.J., Baker, J.N. (2020). Advance Care Planning. In: Mazur, K., Berg, S. (eds) Ethical Issues in Pediatric Hematology/Oncology . Springer, Cham.

Carlon, K (2016). A Swot Analysis for your nursing career.

Cuellar De la Cruz, Y., & Robinson, S. (2017). Answering the call to accessible quality health care for all using a new model of local community not-for-profit charity clinics: A return to Christ-centered care of the past. The Linacre Quarterly, 84(1), 44-56.

Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: model and guidelines. 4th ed. Indianapolis, IN: Sigma Theta Tau International

Dixon, J., Karagiannidou, M., & Knapp, M. (2018). The effectiveness of advance care planning in improving end-of-life outcomes for people with dementia and their

careers: A systematic review and critical discussion. Journal of Pain and Symptom Management, 55(1), 132-150.e1

Epstein, A. S., OReill, E. M., Shuk, E., Romano, D., Li, Y., Breitbart, W., & Volandes, A. E. (2018, August). A randomized trial of acceptability and effects of values- based advance care planning in outpatient oncology: Person-centered oncologic care and choices. Advance Care Planning in Oncology, 56(2), 169-177.

Fleuren, N., Depla, M.F.I.A., Janssen, D.J.A. et al. (2020) Underlying goals of advance care planning (ACP): a qualitative analysis of the literature. BMC Palliat Care 19, 27

Green, M. J., Schubart, J. R., Whitehead, M. M., Farace, E., Lehman, E., & Levi, B. H. (2015). Advance Care Planning Does Not Adversely Affect Hope or Anxiety Among Patients With Advanced Cancer. Journal of Pain and Symptom Management, 49(6), 1088-1096.

Huber, M. T., Highland, J. D., Krishnamoorthi, V. R., & Tang, J. W. Y. (2018). Utilizing the electronic health record to improve advance care planning: A systematic review. American Journal of Hospice and Palliative Care, 35, 532-541.

Howard, M. (2018, April). Barriers to and enablers of advance care planning with patients in primary care. Canadian Family Physician, 64(4), e190-e198. Retrieved from

Hui, D., Nooruddin, Z., Didwaniya, N., Dev, R., De La Cruz, M., Kim, S. H., Kwon, J. H., Hutchins, R., Liem, C., & Bruera, E. (2014). Concepts and definitions for “actively dying,” “end of life,” “terminally ill,” “terminal care,” and “transition of care”: a systematic review. Journal of pain and symptom management, 47(1), 77–89.

Iglesias K, Busnel C, Dufour F, et al. (2020) Nurse-led patient-centered intervention to increase written advance directives for outpatients in early-stage palliative care: study protocol for a randomized controlled trial with an embedded explanatory qualitative study BMJ Open 2020;10:e037144.

Institute of Medicine. (2015). Dying in America: Improving quality and honoring individual preferences near the end of life. National Academies Press (US).

Isola, S., & Al Khalili, Y. (2021). Protected Health Information. In StatPearls [Internet]. StatPearls Publishing.

Jackson, T., Hobson, K., Clare, H., Weegmann, D., Moloughney, C., & McManus, S. (2020). End-of-life care in COVID-19: an audit of pharmacological management in hospital inpatients. Palliative Medicine, 34(9), 1235-1240.

Kang, H. (2021). Sample size determination and power analysis using the G* Power software. Journal of educational evaluation for health professions, 18.

Lume, H. D., Barnes, D. E., Katen, M. T., Shi, Y., Boscardin, J., & Sudore, R. L. (2018). Improving a Full Range of Advance Care Planning Behavior Change and Action Domains: The PREPARE Randomized Trial. Journal of pain and symptom management, 56(4), 575–581.e7.

Lyon, M. E., Jacobs, S., Briggs, L., Cheng, Y. I., & Wang, J. (2013). Family-centered advance care planning for teens with cancer. JAMA pediatrics, 167(5), 460–467.

Miller, B., (2017) “Nurses in the Know: The History and Future of Advance Directives” OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 3.

Myers, J., Cosby, R., Gzik, D., Harle, I., Harrold, D., Incardona, N., & Walton, T. (2018).

Provider tools for advance care planning and goals of care discussions: A systematic review. American Journal of Hospice and Palliative Care, 35(8), 1123-1132. 10.1177/1049909118760303

Nouri, S. S., Barnes, D. E., Shi, Y., Volow, A. M., Shirsat, N., Kinderman, A. L., Harris, H. A., &Sudore, R. L. (2021). The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer. Cancer, 127(19), 3631–3639.

Prakash B. (2010). Patient satisfaction. Journal of cutaneous and aesthetic surgery, 3(3), 151–155.

Rao, J. K., Anderson, L., Lin, F. C., & Laux, J. (2014). Information for CME Credit — Completion of Advance Directives Among U.S. Consumers. American Journal of

Preventive Medicine, 46(1). doi:10.1016/s0749-3797(13)00608-9.

Selman, L., Lapwood, S., Jones, N., Pocock, L., Anderson, R., Pilbeam, C., Johnston, B., Chai, D., Roberts, N., Short, T., & Ondruskova, T. (2020). Advance care planning in the community in the context of COVID-19. The Centre for Evidence-Based Medicine. community-in-the-context-of-covid-19/

Splendore, E., & Grant, C. (2017). A nurse practitioner–led community workshop.

Journal of the American Association of Nurse Practitioners, 29(9), 535-542.

doi:10.1002/2327 -6924.12467

Sudore, R., Heyland, D., Lum, H., Rietjens, J., Korfage, I., Ritchie, C., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Lorenz, K., Howard, M., Green, M. J., Simon, J. E., Feuz, M. A., & You, J. (2018). Outcomes that define successful advance care planning: A Delphi panel consensus. Journal of Pain and Symptom Management, 55(2), 245-255.

Sudore, R. L., Schillenger, D., Katen, M. T., Shi, Y., Boscardin, J., Osua, S., & Barnes, D. E. (2018). Engaging diverse English- and Spanish-speaking older adults in advance care planning: The PREPARE randomized clinical trial. JAMA Internal Medicine, 178(12), 1616-1625. https:// doi:10.1001/jamainternmed.2018.4657

Troost, E., Roogen, L., Goossens, E., Moons, P., De Meester, P., Van De Bruaene, A., & Budts, W. (2019). Advance care planning in adult congenital heart disease: Transitioning from repair to palliation and end of life. International Journal of Cardiology, 279, 57-61.

US Department of Health and Human Services [HHS]. (2016). Office for Human

Vandervoort, A., Houttekier, D., Stichele, R. V., Van der Steen, J. T., & Van den Block, L. (2014, March 10). Quality of dying in nursing home residents dying with dementia: does advance care planning matter? A nationwide postmortem study. PLoS ONE, 9(3).

Watson, J. (1999). Nursing: Human science and human care: A theory of nursing. Jones & Bartlett Learning Research Protections.

Appendix A

SWOT Analysis

Figure 1
SWOT Analysis for Quality Improvement Project

Appendix B

Literature Evaluation Table

Learner Name: Treasure Dooker

Instructions: Use this table to evaluate and record the literature gathered for your DPI Project. Refer to the assignment instructions for guidance on completing the various sections. Empirical research articles must be published within 5 years of your anticipated graduation date. Add or delete rows as needed.

PICOT-D Question: In adult cancer patients, would the translation of research conducted by Lume et al., on the implementation of PREPARE For Your Care online clinical tool used in conjunction with current practice utilizing the easy-to-read advance directive increase the number of completed advance directives in an urban New York outpatient Cancer Center within 8 weeks?

Table 3 Primary Quantitative Research – Intervention (5 Articles)

Table 4
Additional Primary and Secondary Quantitative Research (10 Articles)

Table 3: Theoretical Framework Aligning to DPI Project

Nursing Theory Selected

APA Reference – Seminal Research References

(Include the GCU permalink or working link used to access each article.)

Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project

Watson’s Philosophy and Science of Caring theory

Watson, J. (1999). Nursing: Human science and human care: A theory of nursing. Jones & Bartlett Learning.

The ten Caritas processes make an ideal framework for educating patients on new topics, especially difficult to talk about ideas such as preparing for one’s declining health or end of life (Watson, 1979).

Change Theory Selected

APA Reference – Seminal Research References

(Include the GCU permalink or working link used to access each article.)

Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention

Johns Hopkins Nursing Evidence-Based Practice Model

Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: model and guidelines. 4th ed. Indianapolis, IN: Sigma Theta Tau International

The John Hopkins Nursing Evidenced Based Practice model (JHNEBP) model has

been applied in quality improvement studies to arrive at the most appropriate outcome

for addressing a clinical concern. Problem-solving interventions are vital tools for any

organization and are practical even in the healthcare system. The JHNEBP focuses on

improving the quality of care provided by a nurse practitioner. The interventions are

scanned through the problem, evidence, and the transition phases, to arrive at a care

plan that is most appropriate for a particular setting based on evidence.

Table 5
Clinical Practice Guidelines (If applicable to your project/practice)

APA Reference –
Clinical Guideline

(Include the GCU permalink or working link used to access the article.)

APA Reference –
Original Research (All)

(Include the GCU permalink or working link used to access the article.)

Explanation for How Clinical Practice Guidelines Align to DPI Project





Appendix C

Project Timeline

Appendix D

Plan for Educational Offering

Appendix E

QRST Institutional Review Board Outcome Letter

Appendix F

Project Budget

Appendix G

Data Collection Tool for Evaluation (Use the name of the tool here)

Appendix H

Place the Permission to Use the Tool Here

Appendix I

Other Data Collection Tool and/or Permissions

Application Author, Year Type of study Population characteristics and sample size Objectives


Author, Year

Type of study

Population characteristics and sample size



Main findings

Renal perfusion

Bergmann –Koester et al (2004)

Prospective research

N = 10 (20 kidneys).

Healthy volunteers

Evaluation of different techniques of contrast-enhanced phase inversion ultrasound to visualize renal perfusion.

Comparison of contrast-enhanced phase-inversion ultrasound with B-mode or Doppler mode techniques.

CEUS was performed on 20 kidneys with different mechanical index levels and frame rate.

Analysis was done using software algorithm for time-resolved perfusion and compared to single-image analysis.

High mechanical index to destroy microbubbles and low frame rate (0.5 images/second) were optimal to depict renal perfusion.

‘’Renal perfusion can be visualized using contrast-enhanced phase-inversion ultrasound. For depiction of bigger vessels, it is equal to B-mode ultrasound or Doppler mode techniques; however, it is superior for visualization of renal parenchymal perfusion’’.

Hans-Peter (2012)

Prospective cohort study

Scleroderma patients (n=14), median age = 43.5, mean disease duration =6.1 yrs

Healthy controls (n=12), median age = 49.5 yrs

Age and sex matched

Assess renal perfusion in scleroderma patients (renal damage is common in scleroderma).

Sonovue was infused and destroyed using Siemens Sequoia.

ROI: renal parenchyma, interlobular artery and renal pyramid

ROI were analyzed using quantitative contrast software CUSQ 1.4.

Time to maximal (TmE), maximal enhancement (mE) and maximal enhancement relative to maximal enhancement of the interlobular artery (mE%A) were calculated for each ROIs.

Renal perfusion could be assessed in scleroderma patients using CEUS.

‘’ There was a linear correlation between the TmE in the parenchyma and the GFR assessed by MDRD that was close to stastical significance. (P=0.8)”.

Bellomo et al. (2013)

Prospective research

12 patients at high risk of AKI planned for cardiac surgery.

Inclusion : Age above 70 years, pre-existing renal impairment (preoperative pCr (>120 umol/L), NYHA Class ¾ or LVEF <35%, valvular surgery, redo cardiac surgery or insulin-dependent type 2 diabetes mellitus.

‘’Establishe CEU’s feasibility, safety, reproductibility and potential diagnostic value in the assessment of renal cortical perfusion in the peri-operative period in cardiac surgery patients.

CEUS using IU22 ultrasound system and Snovue was done before the operation, on ICU arrival and the day following the admission.

Hemodynamic parameters were obtained peri-operatively.

A dedicated softward (Sonotumor) was used to export video sequences and two independent radiologist blinded to patient and time performed the analysis.

The software generates a perfusion index (PI) which is proportional to perfusion at a ROI.

‘’All 36 renal CEUS studies, including 24 in the immediate post-operative period could be performed and were well tolerated’’”.

‘’Correlation between readers PI was excellent.’’

‘’IN patients at risk of AKI, CEUS-derived parameters suggest a decrease in renal cortical perfusion in the 24 hours following cardiac surgery’’.

(Further studies with larger sample size are required to establish whether there is a correlation between changes in microvascular cortical flow

And markers of renal function)) pour la discussion/resultat.

Bertolotto et al. (2017)


Retrospective observational study

Patients with renal function impairment presenting with acute renal failure (ARF) of suspicious vascular origin.


Evaluate the usefulness of CEUS in the detection of renal perfusion abnormalities in patients presenting with ARF of suspicious vascular origin.

CEUS using sulphur hexafluoride-filled microbubble contrast agent was performed over a 8 year period to rule out vascular causes of ARF.

Detection rate of vascular abnormalities were calculated and compared to the detection rate of color Doppler ultrasound.

‘’ The detection rate of infarction was significantly higher (p=0.0002) compared to color Doppler ultrasonography.

‘’CEUS showed high detection rate of renal perfusion abnormalities in patients with ARF’’.

JI et al. (2022)

Yan, Z. H. A. N. G., Yinghong, X. U. E., & Donghui, J. I. (2022). The Evaluation of Renal Blood Perfusion after Atherosclerotic Renal Artery Stenosis by rTCEUS. IMAGING SCIENCE AND PHOTOCHEMISTRY, 40(3), 464.

Prospective observational study

Patients with severe atherosclerotic RAS, defined as ARAS 70%, who received angioplasty and percutaneous transluminal angioplasty and stenting (PTRAS)

N = 31

‘’Explored the value of real-time CEUS in evaluating renal blood perfusion after percutaneous transluminal renal angioplasty and PTRAS’’.

All patients underwent color-coded duplex ultrasound sound (CCDS) and realt-time CEUS before and after PTRAS.

TIC was derived before and after PTRAS and perfusion parameters were analyzed.

‘’ The peak intensity (PI) and rising slope (S) of the curve after PTRAS were significantly higher than those before PTRAS (P<0.05), while the peak time (TTP) and mean transit time (MTT) were significantly lower than those before PTRAS (P<0.05)’’.

Other parameters (i.e ΔAUC) did not correlate.

‘’Parameters obtained by rTCEUS have a great value in evaluating the changes of renal blood flow in patients with severe renal artery stenosis after PTRAS’’.

Friedersdorff et al. (2022)


Healthy kidney donors

N= 30 (60 kidneys)

Identify relationship between kidney function and perfusion determined by CEUS.

Comparison of CEUS perfusion parameters with established methods of kidney function evaluation (DTPA and eGFR).

DTPA was determined for the measurement of the total kidney function, while MAG3 scintigraphy was used for the assessment of the split renal function.

CEUS was performed using Sonovue one day before nephrectomy.

Kidney perfusion parameters was quantified with a TIC using VueBox postprocessing tool.

‘’Mean signal intensity (MeanLin) had the strongest correlation ..wtih EGF and total kidney function)’’.

‘’Signal intensity parameters as opposed to time dependent parameters had the strongest correlation, which were similar for preoperative total kidney function, preoperative split kidney function and postoperative kidney.

No correlation was made between DTPA (reference method) and MeanLIn. However, when stratified by weight, a significant correlation is detected (r=-0.409, p =0.001).

Results suggest a possible association between CEUS intensity parameters and kidney function in normal-weight individuals.

More research is required.

Selby et al. (2022)


Cross-sectional observational study

Healthy volunteers (≥ 18 yrs, no kidney disease, hypertension or diabetes and no known hypersentivity to the CA (SonoVue).

N= 10

Median age = 39 yrs

Assess intra-subject and inter operator repeatability of CEUS-derived cortical perfusion parameters.

2 CEUS scan within a 2 week period.

Using Sonovue and using a Philips iU22 ultrasound machine (with contrast-specific software

5destruction/reperfusion sequences were captured. One phase association was performed to derive perfusion parameters.

Analysis was performed using VueBox® Gastrointestinal (GI)I Perfusion Package. VueBox yielded time-intensity curves and parametric images.

Repeatability was evaluated using intra-class correlation (ICC).

‘’Interoperator repeatability was excellent for all perfusion parameters’’.

‘’Time-based variable (mTT) has a good repeatability (ICC: 0.71) and iis likely the most reliable measure … to assess changes in perfusion over time. The large intra-individual variability in intensity-based measures (AI) seen in some patients (ICC : 0.5) suggest that parameter may not be suitable for this purpose’’.

Renal stenosis

Wu et al. (2020)


Retrospective research

Patients with suspected renal artery stenosis

Exclusion criteria; Patients with nephrectomy, renal tuberculosis, renal aneurysm and anomalous origin of the renal artery.

N= 63 (total 122 renal arteries)

Mean age = 57.3 +/- 6.7 yrs

Evaluate the accuracy of CEUS in grading renal artery stenosis.


DSA, DUS and CEUS was performed for all patients in the research

Digital substraction angiography (DSA) was used as the gold standard and comparator

Sonovue was used.

Accuracy of the grading was assessed using the area under the receiver operating characteristic (ROC) curves and compared between groups.

Stenosed renal arteries were grade 1 to 4 using the stenosis rate equation (1- (X/R) x 100%.

X: minimum diameter of stenosed region

R: maximum diameter of stenosed region.

‘There was no significant difference in grading renal artery stenosis between CEUS and DSA (X2= 0.643, P=0.424).

Sensitivity, specificity, accuracy, PPV, NPV were

88.9%, 87.8%, 88.5%, 93.5%, and 80.0%, respectively. Higher than DUS.

The kappa consistency was 0.749 (good consistency = 0.61-0.80).

‘CEUS can enhance the flow visualization of renal artery stenosis, and it showed a good consistency with the gold standard DSA. As a noninvasive, nonradiative, nontoxic, accurate, and cost-effective technique, CEUS may represent the method of choice in grading renal artery stenosis.’

Wang et al. (2022)


Prospective observational study

Inclusion criteria;

1.Patients who were diagnosed as unilateral or bilateral RAS via CEUS and latter by DSA. 2. Patients who did not undergo CTA, MRA or DSA before CEUS.

Exclusion criteria; incomplete clinical data

N= 40 (0.6 M, 0.4, F), 80 renal arteries

Median age (60.98 +/- 17.81)

Average BMI 24.20 +/- 3.61 kg/m’2

Evaluate the accuracy, role and limitations of CEUS in the investigation of suspected RAS and its limitations.

CEUS using a Samsung RS80A ultrasound scanner and Sonovue as the CA was performed to assess the the renal artery followed by DSA.

ROC curves were derived and the diagnosis performance of the presence and dregree of stenosis using CEUS was compared to DSA results.

CEUS was accurate to diagnose the presence (sensitivity= 96.4%, specificity = 95.8%) and the degree of severity of RAS and was consistent with DSA.

Misdiagnosis were usually in mild to moderate stenosis cases.

The addition of CEUS to hemodynamic indicators (i.e. Doppler ultrasound) can help improve the diagnosis of RAS.

Operator’s standardized examination (i.e. duration of investigation and professional training) was shown to be an important predictor for the accuracy of the diagnosis of RAS.

Wang et al (2022)

Prospective monocentric observational study

Patients with renal artery stenosis and CKD (n=60).

Mean age = 64.4 +/- 18.0 yrs

‘’Compare the sensitivity and specificity of CEUS for diagnosis of RAS in CKD patients, using DSA and CTA as the gold standards.’’

Assess the value of CEUS in the follow-up post renal artery revascularization.

CEUS was done using Sonovue as a CA to evaluate stenotic renal arteries; then, DSA or CTA was performed to verify the accuracy of CEUS in the diagnosis of renal artery stenosis.

CEUS was performed for a median follow-up time of 5.0 month.

Results showed that CEUS had a good consistency (kappa = 0.776), was accurate, specific and specific. In addition, no difference were found in the accuracy of CEUS to diagnose Tayasu RAS compared to atherosclerotic RAS.

Furthermore, they concluded that CEUS ‘’is a reliable tool for follow-up surveillance after renal artery revascularization’’.

‘’ CEUS examination is a credible alternative for diagnosing moderate and severe RAS in patients with CKD’’

Acute kidney injury (AKI)

Chen et al. (2019)

Prospective observational

Patient who developed sepsis (n= 90)

Inclusion criteria included met the diagnostic criteria for sepsis and ≥ 18-years-old .

Exclusion criteria : 1) kidney transplantation, renal benign/malignant tumor, and vascular disease before admission 2) severe heart failure within 72h 3) patient gave up halfway, 4) pregnant women, lactating women, patient with mental disabilities 5) poor results of CEUS.

Assess the usefulness of CEUS and other indicators of renal function (i.e serum creatinijne and blood urea nitrogen (BUN)) in the early diagnosis of septic AKI.

Patients were divided into an AKI group (n=24) and a non-AKI group based on renal function and urine output in the 48h following sepsis diagnosis.

On the 7th day, the non-AKI group was subdivided again into an AKI and non-AKI subgroup based on the same criteria.

CEUS was performed using Sonazoid and an offline software was used to form a TIC and CEUS quantitative parameters.

Differences of the indicators in various subgroups were compared using X2 test.

Peak intensity and wash in slope were lower in the AKI group than those in the non-AKI group (P< 0.05.

Sensitivities of CEUS parameters WIS and PI (100% and 100%) were higher than the sensitivity of Scr (56.76%), but they had lower specificities (71.70% and 75.47%) than Scr (100%) for the diagnosis of septic AKI.

‘’The combination of Scr, PI and WIS can improve the diagnostic accuracy of septic AKI.’’

Shin et al. (2020)

Prospective observational cohort study

Patient with a clinical diagnosis of AKI (varying degree of severity), KDIGO guidelines (serum creatinine).

Exclusion criteria;
≤18 yrs, contraindication to CA (history of cardiac shunt, respiratory disorders or hypersentivitiy).

N = 48 (25% prerenal, 71% intrinsic, 2% post renal, 1% intrinsic and postrenal).

Mean age = 60.65 ± 16.14 years

To evaluate CEUS-driven parameters as predictors for renal outcome including KDIGO AKI stage, initiation of renal replacement therapy (RRT),AKI recovery and CKD progression) in patients with AKI.

All patients underwent CEUS with a Philipps Iu22 at the occurrence of AKI

Sonovue was used.

3 similar size region of interest (ROI) from the renal cortex and medulla were chosen. Time-intensity curves (TIC) were extracted using computer assisted program. For every ROI, the analysis was repeated 3 times and the mean value was used for comparison. ROC was used to evaluate performance of various perfusion parameters.

‘’None of the TIC parameters showed stastically significant difference between patients with intrinsic, prerenal or renal AKI’’”

Primary outcome: Initiation of RTT was precited by cortical MTT (OR= 1.07) and RT (1.20).

Secondary outcome = AKI recovery was predicted by cortical WIS (OR= 76.23) and medullary PI (OR=125) and CKD prediction was predicted by medullary PI (O.78 and AUC.

‘’By evaluating renal microperfusion, CEUX may be used as a supplemental tool to estimate severity of renal dysfunction and to predict renal outcomes after AKI.

Chronic Kidney Disease (CKD)

Li et al. (2018)

Prospective observational study

CKD patients (proven by pathology ), n=275

Healthy adults, n=30

‘’ Assess the severity of renal pathology in patients with chronic kidney disease (CKD) using contrast-enhanced ultrasonography (US)’’.


CEUS was performed and US parameters were derived.

Patients were classified in categories of various CKD severity based on renal pathology findings.

Analysis was performed using logistic correlation and ROC curves.

“ Peak intensity was associated independently with the severity f renal pathology in patients with CKD’’.

PI less than 13.87 dB has a sensitivity and specificity of 72.5% and 64.0, respectively.

There may be a potential role for CEUS in the evaluation of disease severity, follow-up and treatment guidance of CKD.

Re nal transplant

Stefanczyk et al. (2011)

Prospective observational study

Kidney allograft recipients

N= 63 (31 F, 32 M)

Recipients were further divided into an early good function (EGF) and delayed graft function (DFG).

The DFG subgroup was further diagnosed with biopsy into the cause of the DFG either acute rejection (AR) or acute tubular necrosis (ATN).

Mean age = 49 +/-/ 16 yrs.

Evaluate the usefulness of CE-US in the early post-transplant (72-120 hours post-op) .assessment of graft perfusion and the determination of the cause of delayed graft function (DFG).

Ultrasound examinations including B-mode, Color-Doppler and pulse wave were performed. In addition, RI measurements were performed at the level of the segmental arteries

Afterwards, patients underwent CE-US with Sonovue (2.4 mL) as the CA and local perfusion was assessed using a TIC.

TIC of the ROIs were compared to the hemodynamic flow parameters.

‘’ A delay of contrast medium inflow strongly indicates DFG’’.

‘’There was significantly longer inflow time of the contrast medium to the cortex and renal pyramids in patients with AR than in ATN recipients’’.

‘’US-CE may be a valuable tool in the determination of the cause of DGF’’.

Stefancyk et al. (2013)

Prospective observational study

Patient who underwent kidney transplantation

N = 180

Investigate the ability of CEUS to detect graft parenchyma perfusion disturbances (GPPD) in the postoperative period.

Compare the visualization of ischemic foci by CEUS with real-time US (B mode) with color and power Doppler (US-CD/PD) and B-flow ultrasound.

Patients were investigated using B+US-CD/PD/B-flow and CEUS in the immediate postoperative period and follow-up examinations were carried out up to 6 months postoperatively.

Number and size of ischemic foci were compared between the two acquisition protocols.

CE-US revealed more GPPDS and was more precise in detecting them. In addition, ischemic foci were better visualized using CE-US compared to B+US-CD/PD/B-flow,

The authors recommend CE-US as routine diagnostic procedure in the early postoperative period following kidney transplantation.

He et al. (2015)

Prospective observational study

Selgas et al. (2016)

Prospective observational study

Patien/t who underwent a kidney transplantation. (deceased/living donor ; 86 %/11%)

N= 79

Age at transplantation : 52.1 +/- 14.4 yrs

DFG = 12.5%, acute rejection 10.1%

‘’Describe the natural history of cortical capillary blood flow (CCBF) over time under diverse conditions of kidney transplant, to explore the influence of donor conditions and recipients events, and to determine the capacity of CCBF for predicting renal function in the medium term’’.

Real-time contrast enhanced sonography (RT-CES) was performed in all patient after 48h, 5-7 days, and 1, 3 and 12 months post-transplantation.

At first, B-mode sonography and Doppler scan were performed.

Afterwards, CEUS was done using sulphur hexafluoride/Sonovue. Initial infusion was performed at 4 mL1min and optimal contrast visualization was achiev ed at 30-60 sec.

Quantification of renal cortical perfusion was done with CUSQ 1.4.

3 ROI: 2 in the renal cortex proximal to transducerren and 1 in the cortex contralateral

The CCBF of each patient was calculated as the mean of the 3 selected ROIs.

CCBF was significantly lower at 48h and day 7 when compared to 1 and 3 months.

Over the first year,brain-death donor age and rejection episode had an inverse relationship with the CCBF.

Compared to brain-death donors, living donors had higher mean CCFF levels at each examination point.

‘’ RT-CES is a non-invasive tool that can quantify and iteratively estimate cortical microcirculation’’.

‘’The first week is the most difficult period for interpreting CCBF results. However, from then on especially after the first month, CCBF could reflect the graft’s actual vascular capacity and reserve. (..) CCBF defined better than level of serum creatinine the graft function status at medium-term’’.

Araujo & Suassuna (2018)

Prospective observational study

Two groups; 1. Patients who underwent kidney transplantation and had a short-term postoperative period follow-up (). This group was divided based on the need for dialysis (early graft function early graft function [EGF] and delayed graft function [DGF]). N = 29

2. Patients who underwent kidney transplantation and had a long-term postoperative period follow –up as outpatient (≥ 90 days).
This group was divided into creatinine tertiles. N = 37

All patients were on immunosuppression therapy and given steroids.

‘’ To build a time-intensity curve (TIC) using CEUS in non-immunological DGF (defined as the need for dialysis within 1 week) to understand the utility of CEUS in early transplantation.’’.

CEUS examination was performed using a convex transducer (Aplio 400) with Sonovue as the CA.

3 ROIs: segmental artery, medullary pyramid and subcapsular cortex.

An inbuilt TIC software was used to derive a TIC and various perfusion parameters calculated including the time to peak (TTP) and the rise time (RT).

‘’It was not possible to differentiate EGF and DGF (excluding acute rejection) patients using TTP and RT derived from TIC analysis performed in three kidney territories (segmental artery, cortex and medulla). (..) These results seem to support that some approaches to increase renal blood flow in DGF are useless’’. This study points out that blood flow reduction may not be the cause of non-immunological DGF; therefore, CEUS would be useless in this case.

However, clear differences were found between the early and late groups. In fact, the largest difference was in between the whole early group and the lowest tertile of the late group (stable renal function). The RT and TTP differences pointed out that there may be blood shunting in renal dysfunction.

Haematomas inpost renal transplant patients

Steganczyk et al. (2012)


Prospective observational study

Patients who underwent a deceased donor kidney transplantation and were suspected to have an haematoma around the kidney between based on a standard B examination done in the early post-operative period (1-3 days).

N = 16 (7F, 9M)

Mean age = 48.3 +/- 9.9

Each patient were on standard triple immunosuppressive therapy.

Evaluate and compare the size and echogenicity of perirenal haematomas in patients with kidney transplantation, which were assessed with both standard B examination followed by CE-US.

Following standard B examination, suspected patient of having a perirenal haematoma underwent CE-US with Sonovue as the CA (2.4 mL/examination.

TIC curves were derived.

2 ROI: renal parenchyma and areas identified during standard US as haematomas.

‘’Dyanamic data loops allowed the acquision of identical kidney cross-sections and enabled measuring the echogenicity and thickness of the abnormalities at the same location.

The echogenicity was 6.2 x greater CE-US when compared to routine B examination. Furthermore, the size of the haematomas was larger in 62% of lesions detected with CE-US. In both cases, it was stastically significant.

CE-US allowed for a more detailed assessment of haematomas during the early-post operative period.

Ureteral patency

Fetzer et al. (2020)

Prospective cohort study

Patients who have undergone a percutaneous nephrolitomy and are on their first postioperative day.

N= 73 (81 examinations

As part of a quality improvement study, assessing the performance of CEUS for the evaluation of ureteral patency. Evaluate hospital resource use.

Patients underwent both CEUS using Lumason (sulphur hexafluoride lipid type A) and fluoroscopic anterograde nephrostogram in the first postoperative day.

Lumason was injected using an indwelling nephrostomy tube.

‘’Ureteral patency was confirmed by intravesical ultrasound (US) contrast.’’

Fluoroscopy was the reference standard

‘’Sensitivity and specificity were 96% and 57%, respectively. (..) the relatively low specificity may have resulted from false negative results in fluoroscopy’’.

The hospital costs, resource use, portability, lack of ionizing radiation were all advantages of CEUS compared to fluoroscopy.

The only disadvantage noted compared to fluoroscopy was the lower levels of comfort noted by some patients.

Vesicourethral anastomosis leakage


Damiano et al. (2013)

Prospective observational study

Patients who have undergone radical retropubic prostatectomy (RRP)


Investigate the diagnostic accuracy of transrectal CEUS and transrectal ultrasound (TRUS) to detect vesicourthral extravasation after RRP and to assess the strength of the vesicourethral anastomosis (VUA).

Use conventional cystography (CG) as a reference .

CG, TRUS and CEUS were performed sequentially, but the examiner was blinded to the result of the previous tests.

CEUS was performed by emptying and then refilling the bladder with NaCl and Sonovue (1:10) as the CA.

‘’No stastically significant difference in detection of vesicourethral extravasation was found amount the three tests (p=0.472)’’.

‘’TRUS amd CEUS are able to provide information on the integrity of the VUA that is comparable with that of CG.’’