Abstract
Obstetrics
Placenta accreta spectrum: An audit to assess detection and imaging pathways
Mid Yorkshire NHS Trust, Wakefield, UK
Abstract
A local audit was performed to assess placenta accreta detection rates and imaging pathways. The audit included two years of obstetric scans from November 2016 to November 2018 across three hospital sites at Mid Yorkshire NHS Trust. As per Royal College of Obstetricians and Gynaecologists guidelines 2018 – placenta praevia and accreta (PAS) are auditable conditions and there should be appropriate training for ultrasound staff in the antenatal diagnosis of placenta accreta spectrum. This study aimed to establish if our current imaging pathway was effective in detecting PAS and if any amendments to local protocols were required. Cases were acquired from delivery and surgical notes, (Euroking) as well as reviewing all cases referred for MRI. Imaging through each case obstetric history was evaluated retrospectively to ascertain if correct protocol was followed and if optimal techniques were utilised to exclude PAS. The audit highlighted that: one case of placenta praevia was missed at 20 weeks’ scan; two cases that were high risk for accreta were not detected and resulted in emergency hysterectomy; one case of uterine rupture may not have been avoided but accreta was likely to have been a factor. Three confirmed cases of placenta accreta spectrum were included, of which only one was referred for MRI, where PAS was diagnosed. This case was transferred to the regional tertiary centre for delivery. Learning points from the audit included the importance of bladder filling to assess the uterine/bladder interface. Atypical placenta appearances resulted from T21, chorangiosis and haematoma. A change in the imaging pathway was proposed to give high risk patients a dedicated scan by experienced staff to assess placentation at 24 weeks.
Ultrasound training – What do pregnant women really think?
Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
Abstract
The aim of this study was to assess the experience of pregnant women attending for routine obstetric scans performed by student sonographers. With the demand for obstetric ultrasound scans ever increasing, and the widely recognised shortage of sonographers, we need to change our approach to ultrasound training. At the Rosie Hospital, Cambridge we are exploring new ways of increasing our training capacity for both sonographers and clinicians. As part of this work we wanted to ask women about their experience of participating in ultrasound training. In collaboration with the Trust’s Patient Experience Team, a questionnaire was developed for pregnant women attending for scan with student sonographers. Twenty-nine women were randomly selected and asked to complete questionnaires after attending for a scan with one of our three student sonographers. The data were then collated using Excel and analysed using simple statistics. The qualitative data generated from the questionnaire were assessed for reoccurring themes. Preliminary analysis suggests that 18/20 (90%) women, who responded to this questionnaire, were either impartial or preferred being scanned by student sonographers, while 16/28 (57%) women identified advantages in having scans with student sonographers, stating, for example, ‘more time to see baby’ and ‘a more thorough scan’. Of 29 women scanned, 6 (21%) felt that they were not given an option to accept or decline participating in a training session. Two women surveyed said that they preferred having had a scan without a student sonographer. The results of the questionnaire confirm anecdotal evidence that women do not mind being scanned by students. It did, however, identify an issue with patient consent for participation in training lists which needs to be addressed. Encouragingly, the results suggest that increasing the amount of training undertaken within our department would not impact negatively on women’s experience and they may even see it as advantageous.
A case study of skeletal dysplasia
1National Maternity Hospital, Dublin, Ireland
2School of Medicine, University College Dublin, Dublin, Ireland
Abstract
Routine fetal anatomy examinations are provided in many obstetric units. They mostly provide reassurance to parents and health care professionals by confirming normality. However, in 3% of cases, a fetal abnormality may be identified. Identification of skeletal anomalies is paramount to prenatal diagnoses of osteogenesis imperfecta and lethal cases of skeletal dysplasias. The patient was a 43-year-old woman. She previously had a first trimester miscarriage and a subsequent uncomplicated pregnancy with a term delivery. At 20 + 3 weeks’ gestation she attended for a routine anatomy scan. As this pregnancy had been accurately dated in the first trimester, the first point of concern was the small fetal measurements. All long-bones were short with fixed flexion and minimal movement of the limbs. There was abdominal ascites and wide-set eye orbits. A further examination by a fetal medicine specialist led to a prognosis of thanatophoric dysplasia based on the sonographic features. Thanatophoric dysplasia is the most common lethal dominant skeletal dysplasia resulting from a fibroblast growth receptor FGFR3 gene mutation. Considering this, a poor prognosis was discussed with the parents. A thorough first trimester anatomy screen is not performed routinely in this author’s unit; however, if performed by an appropriately trained operator, up to 40% of lethal and severe malformations may be identified at this stage. Early examinations may identify increased nuchal translucency and/or fetal hydrops, which are common features of skeletal dysplasias in early pregnancy, with most skeletal anomalies identifiable by 14 weeks’ gestation. Whilst usually, anatomy scans are reassuring, sometimes anomalies will be identified. With advances in ultrasound technology and improvements in sonographer skills, more accuracy is being achieved, especially in cases like this where a lethal prognosis and diagnosis is confirmed.
The 18 + 0 to 20 + 6 week fetal anomaly ultrasound scan image review
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Abstract
Our aim as screening support sonographer (SSS) and Deputy SSS was to implement a monthly review of anomaly scan still images obtained by sonographers as per the Fetal Anomaly Screening Programme anomaly scan base menu. By developing an audit tool based on the British Medical Ultrasound Society recommended audit tool, we aimed to provide evidence that still images were to an acceptable standard and to identify any training needs and areas for improvement. An audit tool was devised based on the static images required as per protocol. One study per sonographer per month was reviewed as per the audit tool and each case was assigned a ‘good’, ‘acceptable’ or ‘poor’ score. Results were kept in sonographer individual files for review and feedback given. The monthly image reviews did provide evidence of good clinical practice. This in turn provided valuable feedback for sonographers to demonstrate that competencies were being met. The review was also a good learning tool and revision for sonographers. Where a ‘poor’ score was given, an action plan was implemented. The review also provided evidence of how ultrasound machines were being used in terms of length of examinations, pre- sets used and image quality of different ultrasound machines. Gaps in protocol knowledge were also highlighted, as were common training themes. The audit provides valuable evidence to promote learning, changes in practice, equipment review and scheduling of the test. The frequency of the image review allows for highlighted issues to be resolved quickly. The weakness of the image review is that only images stored can be reviewed, which does not include fetal heart views and it cannot assess other aspects of the scan. Time is also required for review and feedback.
A case of tuberous sclerosis in the third trimester
Ultrasound, Royal Free Hospital, London, UK
Abstract
Tuberous sclerosis is a rare genetic disorder that affects 1 in 6000 births, with an underlining mutation in tuberous sclerosis-1 (TSC1) or TSC2 genes in about 90% of cases. The tumours mostly affect the heart and brain; however, they can also affect kidneys, eyes, lungs and skin. It is found in about 50% of cases of solitary rhabdomyoma after 20 weeks’ gestation and in 90% of cases of multiple rhabdomyomas. The prognosis ranges from mild symptoms of developmental delays to severe abnormalities, depending on presentation. A 38-year-old primigravida with a normal 20-week anomaly scan was referred to the main ultrasound department for a 28, 32, and 36 weeks’ serial growth scans in view of maternal age. During her 36-week growth scan, a solitary hyperechoic lesion was identified within the right ventricle and further referred to the local Fetal Medical Unit Department on suspicion of rhabdomyoma. The patient decided to seek a second opinion at University College London Hospital, where the finding was confirmed and subsequently also underwent a fetal brain MRI, where multiple brain lesions were also identified. After undergoing counselling, the patient opted for fetocide at 38 weeks. The 28- and 32-week growth scans were reviewed, and it was suspected that the rabdomyoma was also present at 32 weeks and could have been detected earlier. Considering strong association of tuberous sclerosis with cardiac rhabdomyomas in the third trimester, with a seemingly normal anomaly scan, a careful examination of the four-chamber view of the fetal heart is recommended. Even though the final outcome was unlikely to be prevented, the value of an earlier diagnosis cannot be underestimated.
Case report: Are we getting our wires crossed? Transposition of the great arteries
1School of Medicine, University College Dublin, Dublin, Ireland
2Letterkenny University Hospital, Letterkenny, Ireland
Abstract
Incidences of congenital heart disease range from 4 to 13/1000 livebirths, with 5–7% related to transposition of the great arteries (TGA). TGA does not pose significant risk in utero; however, it is seen as a neonatal emergency once delivered. A para 20+ lady presented for the second trimester anomaly scan, which was incomplete due to the fetal lie and movements. A follow-up was performed at 32 + 2/40. The pre-set cardiac package for the second and third trimester was selected. Normal situs was confirmed. Using colour Doppler, blood flow appeared to be evenly dispersed through the four chambers of the heart, with an intact ventricular septum. On further assessment, an abnormality was suspected as there was no cross-over of the left and right outflow tracts, with the vessels parallel to each other. The three vessel view was also abnormal. In 98% of cases of TGA, there will be a normal four chamber view. The introduction of extended cardiac views in ultrasound has increased detection rates to 77%. During different stages of this pregnancy, we could see what appeared to be a normal four-chamber view of the heart. Also, it is important to note the ventricular septum was intact. Approximately half of all cases of TGA involve defects of the ventricular septum. The outflow tracts appeared atypical, with no crossing over of the vessels apparent. Alongside this, there was also an abnormal three vessel view. Therefore, TGA was suspected. This diagnosis was confirmed by the fetal medicine specialist, and referral to tertiary centre arranged. Without the extended cardiac assessment, the patient and her care providers would have been oblivious to the complications that lay ahead. With this information, the woman delivered her baby in a tertiary facility and the baby was transferred to a specialist paediatric team for surgery.
Bowel
Case report: An unusual cause of a huge abdominal mass
St James’s Hospital, Leeds, UK
Abstract
A 52-year-old man presented in accident and emergency with left upper quadrant (LUQ)/chest tenderness, swelling and lethargy. The only relevant medical history to these symptoms was that he had been referred to cardiology the previous year. They reported no cardiac symptoms. He reported no weight loss and normal bowel habit. Gastrointestinal stromal tumours (GIST) are rare but represent the most common mesenchymal tumours of the gastrointestinal tract, accounting for approximately 90%. They account for 2–3% of all gastric malignancies and predominantly (50–60% of all cases) arise from the muscularis propria of the stomach. They can be intraluminal, extraluminal or mixed. Current thinking is that size (>5 cm) and mitotic count appear to be the most useful predictors of malignancy. The LUQ swelling revealed a 22 cm, predominantly cystic, well-defined mass occupying most of the left abdomen. There was a small peripheral solid component which showed increased perfusion. The mass was in close contact with the stomach. There was no evidence of invasion into the adjacent organs. No other abnormality was detected. The CT confirmed these findings and also detected a small 1.6 cm aortocaval and small bowel mesentery nodule. Endoscopic ultrasound (EUS) and guided fine needle biopsy found blood and fragments of a moderately cellular spindle cell tumour. Appearances were highly suspicious of a GIST but immunohistochemistry was required to confirm this. Ultrasound identified the potential cause of the mass as a GIST with a differential diagnosis being a renal/adrenal tumour or a mass relating to the tail of the pancreas. The CT scan confirmed the most probable cause of the left abdominal mass was a GIST. EUS and biopsy provided the definitive answer that this was an extraluminal GIST arising from the stomach.
Physics
Measurement of maximum flow velocity in clinical ultrasound scanners using a variety of transducers
1Medical Physics, King’s College London, London, UK
2Medical Physics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Abstract
The use of Doppler ultrasound for quantification of flow velocity is well established in a number of clinical areas. There are many sources of measurement error; hence it is important to assess the accuracy of scanners in clinical use. Our hospital Doppler Quality Assurance (QA) checks highlighted errors in measurement of maximum velocity using certain probes which exceeded our tolerance of ±15% and which could not be adequately explained. The aim of this study was to systematically assess the errors in measurement of maximum velocity in a range of clinical ultrasound scanners and transducers. A commercial Doppler QA flow phantom was used to produce a steady flow of a blood mimicking fluid through a 4 mm diameter tube. A variety of probes (linear, curvilinear, phased array and matrix) on scanners from two manufacturers were assessed using pulsed Doppler modality. Maximum flow velocity was estimated from the sonogram for a range of flow speeds, beam vessels angles, Doppler gain, sample volume depths and sizes. The largest errors were found at large beam vessel angles and, for certain probes only, at small sample volume sizes. Large beam vessel angles (>80°) resulted in overestimation of maximum velocity by up to 170% due to geometrical spectral broadening, with up to 70% overestimation at angles <60°. Certain curvilinear and phased array probes from one manufacturer showed increasing error with decreasing sample volume size (up to 70% overestimation, even with beam vessel angle <50°). This is the first study to report large errors in maximum velocity measurements at small sample volume sizes using certain curvilinear and phased array probes in clinical scanners, to our knowledge, a phenomenon only previously reported using a preclinical scanner with a 40 MHz linear array probe. Errors associated with measurement of maximum velocity using clinical scanners should be characterised and explicable, and requires further investigation.
Investigating the relationship between in-air reverberations and temperature
1Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
2Department of Physics, University of Surrey, Guildford, UK
Abstract
Although many articles have discussed the assessment of reverberation images, there has been limited investigation into the magnitude of the effect temperature has on in-air reverberation images. This work represents an initial investigation into the relationship between reverberations and temperature. In-air ultrasound images were acquired across 14 days using two L12-3 probes on a Philips HD11 ultrasound system with three images being captured during each imaging session. Probe surface temperature measurements were taken using a handheld Hanna Checktemp Q6 thermometer prior to capturing the images. Image acquisition parameters were kept consistent across both probes and throughout all imaging sessions. Image analysis was undertaken to identify the extent of variations between the reverberation images. Images were analysed using an ImageJ v1.47 macro which plotted a vertical line profile through each pixel column across every image. Reverberation profiles were then analysed to identify variations related to temperature changes. Initial results indicate a correlation (R2 = 0.68–0.92) between the areas under the DR curves and temperature. There was a 4.3°C range in probe surface temperatures throughout the 14 days, with the greatest pixel value variation found across a row being 83 pixels (32% pixel value change). The correlation appears to be particularly strong around the multiple minimum and maximum pixel value points of the reverberation pattern (the regions that displayed the greatest pixel value variation). This work has examined the effect of temperature on the reverberation image, which is currently not considered during quality assurance (QA) sessions. This relationship demonstrates that it is important to consider the measurement protocol when setting up a QA programme to minimise the magnitude of the effect. The results of this work indicate the existence of a relationship between temperature and the displayed in-air reverberation image. Further validation is required on different systems and other probe types.
Student session
Case report: Imperforate hymen – The role of ultrasound
1Midlands Regional Hospital, Portlaoise, Ireland
2School of Medicine, University College, Dublin, Ireland
3Health Service Executive, Ireland
Abstract
An 11-year-old female presented to the accident and emergency department of Hospital X. She complained of abdominal pain. The patient was known to be premenarchal. A urine sample was taken and a urinary tract infection was out ruled. The patient was then referred to the ultrasound department to assess for the presence of a pelvic pathology such as a cyst. Greyscale pelvic ultrasound showed both ovaries to be enlarged with multiple internal cysts. There was a centrally located large pelvic cystic lesion identified also. The lesion measured 11 cm × 7 cm × 6 cm. The lesion had a mass effect on the uterus making it difficult to accurately assess the uterus. On colour Doppler investigation, the lesion was avascular. The large, anechoic lesion had no internal septations. It appeared on initial ultrasound examination to originate from the uterus. Following these findings the patient was referred for an MRI examination. A 17 cm × 7 cm well-defined cystic collection between the bladder and rectum was identified on the scan. The patient was diagnosed with an imperforate hymen and subsequently had surgical intervention with 300 ml of menses drained. A follow-up ultrasound of the pelvis demonstrated physiological cysts of the ovaries with a dilated right fallopian tube containing internal echoes. An additional MRI examination confirmed resolution of the previously noted preoperative hydrosalpinx. An adnexal cystic lesion was also noted with presumed endometrial tissue. Imperforate hymen is the most common obstructive disorder to occur in the female reproductive system. Typical presentation includes cyclical abdominal pain with amenorrhea. Patients may also note a pelvic mass or lower back pain. Whilst its incidence is reported, complications such as endometriosis and vaginal adenosis are rare. The current surgical intervention of choice for hymenal malformations such as imperforate hymen is hymenectomy.
Case report: Round ligament varicosities – A rare presentation in pregnancy
1Midlands Regional Hospital, Portlaoise, Ireland
2School of Medicine, University College, Dublin, Ireland
3Health Service Executive, Ireland
Abstract
A 31-year-old female patient at 34 weeks’ gestation presented to the ultrasound department with pain in the left inguinal region accompanied by a swelling. The swelling was reducible upon compression with the ultrasound transducer and became more prominent when the patient stood upright. The patient’s symptoms began at 32 weeks’ gestation and she was referred for a pelvic ultrasound and a lower limb ultrasound. Clinicians were suspicious of an inguinal hernia or a left ileofemoral vein thrombosis. Her blood results showed an elevated D-dimer level. The patient underwent a pelvic and lower limb ultrasound followed by a targeted scan of the region of interest. Greyscale ultrasound displayed a mass in the left iliac fossa containing dilated, anechoic, tubular channels. Colour Doppler identified increased vascularity within these tubular channels that became more pronounced when the patient was scanned in the upright position. There was complete absence of bowel or lymph nodes within the inguinal mass ruling out the possibility of an inguinal hernia. This patient was diagnosed with round ligament varicosities (RLV), a rare presentation which is most commonly associated with pregnant patients. RLV are more commonly detected in pregnancy as there is smooth muscle relaxation causing dilation of the round ligament veins. There is also a raised cardiac output causing increased venous return and leading to engorgement of the vessels and pelvic venous impingement by the gravid uterus. Ultrasound imaging in this patient’s care pathway accurately diagnosed RLV and avoided unnecessary surgical exploration and its associated morbidities. The differential diagnosis of RLV should be considered in the presentation of an inguinal mass, especially in the prenatal patient. Ultrasound imaging provided a dynamic scan allowing the mass to be visualised as the patient was in the upright and supine positions.
Is it me or is it the fetus? – Trusting your instincts as a new practitioner
East and North Hertfordshire NHS Trust, Stevenage, UK
Abstract
Fetal cardiac abnormalities are common with a prevalence of around 8 per 1000 live births1 and are therefore encountered frequently during the 20-week anomaly scan. The impact of finding such an anomaly on both parents and staff should not be underestimated and presents a particularly challenging situation to a newly qualified sonographer. This presentation describes a rare case of double inlet left ventricle as detected during routine screening and offers an insight into my experience as a novice practitioner. I discuss my initial thoughts based on the images obtained during this difficult scan and explain my rationale for making an onward referral to the Fetal Medicine Unit (FMU). The resulting findings from FMU and how they correlated with my findings are revealed as well as the prognosis and actual outcome of the pregnancy. Finally, aspects around preceptorship, clinical confidence and uncertainty are covered. After all, new practitioners have the eternal worry of thinking ‘Is it me or is it the fetus?’ Lessons from the steep learning curve that comes from such situations are shared.
Reference
A retrospective clinical audit to determine sonographer compliance with the ‘twice on the couch’ policy
1Northern Lincolnshire and Goole NHS Foundation Trust, Grimsby, UK
2University of Leeds, Leeds, UK
Abstract
The objectives of this audit were first to determine whether two attempts to obtain the nuchal translucency (NT) measurement were undertaken in patients who were referred for the quadruple test, where the NT was not obtained in line with Fetal Anomaly Screening Programme (FASP) guidelines. The second objective was to identify reasons for the failure to obtain the NT measurement. A retrospective clinical audit was undertaken recording the documentation as evidence from obstetric reports or other work based portals to determine whether the ‘twice on the couch’ policy had been followed. One hundred singleton pregnancies (n = 100) were retrospectively sampled with 100% failing to report the ‘twice on the couch’ policy. Further investigation of work-based portals found the policy was adhered to for 75 patients. The main reasons for failing to obtain the NT measurement were fetal position (75%, n = 88/117) followed by increased BMI (19%, n = 22), fetal movements (4%, n = 5) and other anatomical variants (2%, n = 2). The majority of NT measurements took place using the Obstetric Department’s newest ultrasound machine (Canon Aplio 600; 55%, n = 96/175) compared to older machines (Canon Aplio MX, 500; 34%, n = 28; 14% n = 17). Of those patients for whom no evidence could be found, 68% (17/25) were scanned by a sonographer undertaking NT training. Using the FASP image guidance tool, 59% (n = 59) of CRLs were scored poorly, with 29% (n = 29) scored acceptable and 12% (n = 12) scored as good. In those CRLs for which no second attempt could be demonstrated, 68% (17/25) were of a poor standard. Accurate reporting is essential to demonstrate compliance with the guidelines and to support a patient’s future antenatal care. Clearer guidance about the ‘twice on the couch’ policy may help clarify guidelines and local protocols to standardise sonographers’ practice in combined screening. The most appropriate ultrasound machine should be used for the best chance of obtaining the NT and a good CRL, which may reduce attempts and fail rate.
Outcomes of ultrasound-guided transperineal prostate biopsy under local anaesthetic – A safe and tolerable technique?
1Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
2School of Medicine, University of Leeds, Leeds, UK
Abstract
Patients with a clinical suspicion of prostate cancer (PCa) will commonly undergo transrectal ultrasound guided prostate biopsy (TRUS-GB). The evolution of multi-drug resistant bowel flora has increased the rate of sepsis for TRUS-GB. Transperineal biopsy avoids the rectal wall but is overlooked as a primary biopsy method because it usually requires a theatre setting with a general anaesthetic. A transperineal ultrasound guided biopsy using a local anaesthetic (TPB-LA) may offer an alternative approach which can be carried out in an outpatient setting. This systematic review and meta-analysis evaluates the safety and tolerability of TPB-LA. A systematic literature search of the following databases was performed: AMED, EBM Reviews, the Cochrane library, MEDLINE, PubMed, CINAHL, Google Scholar and OpenGrey. The primary outcome is procedure pain, assessed by visual analogue score (VAS). The secondary outcome is biopsy complications. The PCa detection rate is reported for completion. Data extraction and meta-analysis was performed for the eligible studies. A total of 295 articles were identified with 9 studies meeting the inclusion criteria. The pooled VAS pain scores for the stages of the procedure are as follows: probe insertion = 2.65 (95% CI: 1.32–3.99); local anaesthetic administration = 3.12 (95% CI: 2.31–3.92); biopsy sampling = 2.75 (95% CI: 1.90–3.60); overall procedure = 2.73 (95% CI: 1.90–3.55). Haematuria is the most common complication, with rates ranging from 19.8% to 66.7%. No cases of sepsis were recorded. The overall PCa detection rate is 52.73%. TPB-LA is safe with low rates of infectious complications and although other complications are common, they are often self-limiting. TPB-LA is a well-tolerated technique with the majority of patients experiencing mild pain for each stage of the procedure. TPB-LA in an outpatient setting should be considered as a primary biopsy method for PCa detection.
Assessment of the efficacy of the British Thyroid Association’s 2014 guidelines for sonographic assessment of thyroid nodules
1Barts and the London School of Medicine, London, UK
2Radiology, Princess Alexandra Hospital, Harlow, UK
Abstract
We aimed to assess the efficacy of the 2014 British Thyroid Association’s (BTA) guidelines for the sonographic assessment of thyroid nodules as a predictor of neoplasia. We also aimed to investigate whether we performed less fine needle aspirations (FNA) with the new guidelines in place. Finally, we assessed the most common nodule characteristics seen amongst those lesions given an indeterminate grading. Retrospective data were obtained from thyroid scan reports over a 12-month period. The data were categorised into two groups, six months prior to and six months following the introduction of BTA guidelines. The information analysed included the number of nodules found, FNAs performed and neoplasms identified. In the post-guideline introduction group, U-grades and corresponding cytological Thy-grades were recorded. We performed Chi square analysis to compare the number of nodules receiving FNA in each group, as well as how many neoplastic nodules were identified. Within the subgroup of nodules given an indeterminate U3 grade, we reviewed how many nodules displayed each feature set out by the guidelines. In the pre-guideline group, 303 nodules were assessed and 83 (27%) went to FNA cytology. Of these, 23 (28%) were found to be neoplastic. In the post-guideline group, a total of 264 thyroid nodules were identified with 81 (31%) receiving an FNA and 19 (23%) demonstrating neoplasia. Chi square analysis showed no significant differences between the groups. Of 130 of nodules with a BTA grade, 63 (48%) were U3 (indeterminate). Only six U3 nodules were neoplastic. The most common feature seen in U3 nodules was central vascularity. We did not perform fewer FNAs with the new guidelines in place. There was no significant difference in the number of neoplastic nodules identified. A large proportion of nodules were deemed U3 (indeterminate) and most of these were benign.
Case report: Superficial vein thrombosis, not a deep problem?
University College Dublin, Dublin, Ireland
Abstract
A 57-year-old male with a previous medical history of prostate cancer presented to the department for a left lower limb duplex Doppler ultrasound. He had a visibly hardened linear area on the medial aspect of his left thigh. The area had become swollen and inflamed in recent days, raising concern. He had no history of deep vein thrombosis (DVT) but due to his medical history, one could not be ruled out without further investigation. On commencement of scan, the great saphenous vein (GSV) did not completely compress in the transverse plane but the common femoral vein (CFV) did. Following closer examination echogenic material was demonstrated within the GSV. The GSV was interrogated in the longitudinal plane and thrombus was clearly demonstrated. Colour Doppler was applied and there was no flow visualized within the GSV. The curvilinear probe was used to evaluate the extent of the thrombus. The clot was greater than 5 cm in length and less than 3 cm from the saphenofemoral junction, which required urgent treatment. Spectral Doppler with augmentation was used to confirm the patency of the CFV as it was feared that thrombus may be located in the venous system more superiorly. Good compression, augmentation and colour flow were noted throughout the CFV and remaining venous system. The patient was prescribed anticoagulation therapy and was to be reviewed in 3–4 weeks. This was to ensure the clot did not increase in size and propagate into the deep system resulting in a DVT or pulmonary embolism (PE). If anticoagulation therapy is not suitable, the thrombus should be treated surgically. Identifying the size and location of the thrombus in patients with SVT is crucial. Patients with SVT are 4–6 times more likely to later develop a DVT or PE.
Master’s degree (MSc) in medical ultrasound (Direct graduate entry route) – A therapeutic radiographers perspective
University of Cumbria, Lancaster, UK
Abstract
Two-year pre-registration Masters level degrees have been available in the United Kingdom (UK), in nursing, occupational therapy and physiotherapy, since the 1990s. They were introduced to facilitate widening participation in a climate of shortages in the relevant workforces. 1 Much of the literature suggests that these programmes attract older, motivated candidates with a wider academic base who work hard and perform well, ultimately producing high quality clinical practitioners. 2 According to the Society and College of Radiographers, in 2014, 18.1% of sonographer posts in the United Kingdom (UK) were unfilled. 1 In response to the growing sonographer shortages, and the negative impact this is having on ultrasound departments,3,4 new educational solutions have been developed within the UK ultrasound community, 5 which has allowed many with a non-traditional backgrounds to enter the profession. This presentation is a personal account of my pathway into ultrasound, from the perspective of a therapeutic radiographer, and how my background has helped me with the transition.
References
The diagnostic performance of shear-wave elastography (SWE) as a predictor of malignancy in thyroid nodules
1Ultrasound, the York Hospital, York, UK
2Medical Imaging, University of Leeds, Leeds, UK
Abstract
The purpose of this systematic review and meta-analysis is to assess if shear-wave elastography (SWE) can be an accurate diagnostic predictor of malignancy in thyroid nodules. Potential studies were searched for in OVID Medical Database, PubMed, Cochrane Library, University of Leeds Library and Opengrey.eu online. There were 11 eligible studies found. The major study characteristics such as sensitivities, specificities, false positive rates and false negative rates were extracted. Study quality was assessed using the CASP checklist for diagnostic test accuracy. All 11 studies were suitable for both qualitative and quantitative review. There were 2301 patients involving 3039 thyroid nodules identified, of which 1291 were malignant. A significant level of heterogeneity between the studies was found with the acceptance of the Higgins test (p > 0.05) and a random effects model was used thereafter for statistical calculations. The summary log diagnostic odds ratio = 2.68, the area under the curve = 0.85 ± 0.07. SWE is an accurate diagnostic predictor of malignancy in thyroid nodules when used under the correct conditions and within its limitations, suggesting a useful role in everyday clinical practice, most likely as an imaging adjunct where malignancy is clinically suspected. Further research in larger, international studies is advised, considering limited literature on this topic.
Should the velocity pulse trace of the main portal vein be measured as well as colour Doppler when screening cirrhotic livers for portal hypertension
University of Derby, Derby, UK
Abstract
There are conflicting opinions among academics on which method should be used for optimal assessment of the portal vein in cirrhotic patients. Thus, the author decided to conduct a literature review to examine the diagnostic value that Doppler ultrasound provides. The author systematically directed a literature search strategy; using pertinent search terminologies collectively used with Boolean logic terms and truncated search terms ensuring the search attains the most relevant results. The general consensus from the literature is that the portal flow velocity will be markedly lower in cirrhotic livers evidencing hepatofugal flow. However, Kok et al.1 state that due to the velocity values of healthy patients and cirrhotic patients alike changing so considerably, it is difficult to determine an ‘absolute value of portal flow velocity’. Furthermore, the literature states that additional external influences including the body position of the patient determine the value. Iranpour et al.2 agree, stating that many inherent and external parameters affect the calculated velocity trace which results in misinterpretation. These authors clarify that the accumulation of a valid velocity value is strongly operator dependent. Iranpour et al.2 expand suggesting that misplacement of the angle of insonation and ill-positioning of the sample volume lead to false results. Moreover, altering the beam-flow angle over 60° against the flow of direction results in false-positive data. The reviewed literature explains Doppler ultrasound is essential in the imaging pathway for cirrhotic livers. However, calculating a velocity trace of the main portal vein is divisive. Velocity tracing is hindered by its susceptibility to external influences and inherent variables within patients themselves. To conclude, further research examining the variation of the sonographer’s adjustment of the sample volume as well as the angle indicator would generate a consensus of these scanning parameters, increasing the reliability of a velocity trace.
References
Case report: Splenic artery aneurysm
HEM Clinical Ultrasound Service Limited, Sittingbourne, UK
Abstract
A splenic artery aneurysm (SAA) is defined as a focal dilatation of the splenic artery, measuring more than 1 cm in diameter. They are typically saccular in nature and are the third most common intra-abdominal aneurysm, subsequent to aortic and iliac aneurysms. 1 The true prevalence remains controversial, with estimates varying widely from 0.2% to 10.4% in the general population. 2 As with all aneurysms the main concern is rupture, which has a mortality rate of between 25% and 40%. 3 A 70-year-old female presented with urine frequency, query incomplete bladder emptying. There was no other past medical history of note. The scan revealed a 14 mm anechoic, rounded structure adjacent to the splenic hilum. Colour Doppler demonstrated arterial flow towards the spleen and a rounded area of turbulence arising from the side of the vessel. SAAs are increasingly being detected incidentally during ultrasound examinations. Nevertheless, small or multiple aneurysms may be difficult to visualise; therefore, ultrasound practitioners must be vigilant when assessing the abdominal vasculature. SAAs typically appear on ultrasound as rounded vascular lesions at the splenic hilum. However, occasionally they are more proximal in location along the splenic artery, which are often more challenging to visualise. When SAA is suspected, ultrasound practitioners should consider the following questions to assess the likelihood of rupture: (1) is the aneurysm greater than 2 cm? 4 (2) Is the patient pregnant?5,6 (3) Is the patient symptomatic? 3 (4) Is the patient a liver transplant recipient? 7 If the answer is yes to any of these questions an urgent vascular referral should be considered.
References
Gynaecology
Translabial ultrasound for the localisation of midurethral sling mesh
1Ultrasound CS Partners Medical Ltd, Marlow, UK
2Oxford Gynaecology and Pelvic Floor Centre, Oxford, UK
Abstract
Polypropylene midurethral slings have been a widely used surgical treatment for stress urinary incontinence. However, short- and long-term complications have been reported, including visceral injury and chronic pain, as well as vaginal and lower urinary tract mesh erosion. Serious complications affect 10% of women within five years of the procedure and may be more common with transobturator slings. 1 Complete sling excision can be associated with resolution of pain. 2 Around 3% of women who undergo these procedures will receive a sling excision within 10 years. 3 However, there is no validated imaging modality for localisation of the tape. Here we summarise our experience in identification of sling mesh position using 3D trans-labial ultrasound. This was a prospective study of patients presenting for possible tension-free vaginal tape (TVT) surgical removal between July 2016 and February 2019. Fifty-three women were examined with successful imaging on 100% of patients. TVT was visualised as an echogenic net-like structure between the urethra and vagina. The integrity, shape, distance from urethral lumen and the relationship to vagina were noted. Of the 53 women in the inclusion period, TVT mesh was successfully identified in 100%. In 43 the TVT was in a single piece, in 10 in two or more pieces. In 29 TVT was measured <4.1 mm distal from urethral lumen. In four the mesh appeared to be within the urethral lumen, subsequently confirmed by cystoscopy. In 11 the TVT was irregularly shaped, in 3 TVT fragments were imaged and localised prior to surgery. Translabial ultrasound is a valid, reproducible, first-line technique to visualise TVT mesh, significantly contributing to pre-surgery discussion and laparoscopic guidance, being very useful at identifying possible mesh remnants within the vagina after previous partial removal. However, scan findings need to be interpreted carefully based on symptoms and surgical history.
References
Case report: Grossly normal pelvic scan
Royal Free Hospital, London, UK
Abstract
Cervical cancer is one of the most preventable types of cancer in developed countries with a cervical screening program. This type of cancer is usually slow growing and exclusively caused by human papillomavirus virus. A 47-year-old nulliparous woman attended accident and emergency (A&E), presenting with menorrhagia and pelvic pain. She was found to be anaemic and required a blood transfusion. She reported attending the A&E departments of several NHS hospitals for the past two years for the same symptoms. No records of recent smear tests were found. The patient was scanned in the acute gynaecology department, and the ultrasound showed marginally increased vascularity of the cervix, and negative sliding sign of the ovaries. The left ovary was normal in size; however, it appeared somewhat solid-looking. The rest of the study appeared grossly normal. Considering the presentation of non-mobile ovaries, endometriosis was suspected, and additional assessment of the pelvic floor with bladder and ureters was obtained. Several hypoechoic lesions that were suspected to be deep infiltrating endometriosis were found, with involvement of the bladder, uterovesicle pouch and the left ureter; left renal hydronephrosis was noted. The study was extended to CT and MRI, which suggested bladder invasion and invasion to the lower uterine corpus and proximal upper third of the vagina. There was also involvement of the left ovary and right ureteric involvement and on the CT scan there was evidence of mediastinal lymphadenopathy but no lung lesions. The cervical biopsy confirmed a moderately differentiated squamous cell carcinoma, with diagnosis of stage IV cervical cancer. She was offered palliative chemotherapy and left ureteric stenting. The case study highlights the importance of developing advanced skills in pelvic floor assessment.
A case study of haematometra
1Fetal Assessment Unit, National Maternity Hospital, Dublin, Ireland
2School of Medicine, University College Dublin, Dublin, Ireland
Abstract
Regular cervical screening has been paramount in the detection of early stage cervical disease. Programmes for follow-up and treatment have been satisfactory. However, with any sort of invasive treatment or surgery, damage to the cervix may occur and effects may include cervical stenosis. Haematometra is a rare but potential comorbidity of cervical stenosis, where uterine contents collect within the cavity, unable to pass through the cervix causing amenorrhagia, pain and occasionally infection and damage to the uterus. A 37-year-old woman presented to her GP and the casualty department of a women’s hospital concerned with abdominal pain and bloating. Past gynaecological and obstetric history included, in chronological order, an early miscarriage, a spontaneous vaginal delivery, Cone biopsy for CIN3 (completely excised) and a low segment caesarean section for failure to dilate/cervical stenosis. She had amenorrhagia since the last delivery, despite stopping breastfeeding five months previously. A pelvic ultrasound was ordered and performed both transabdominally and transvaginally (with consent). The uterus was found to be enlarged and the uterine cavity filled from fundus to external cervical os with homogenous avascular echoes consisting of a ‘ground glass’ appearance. There was no evidence of the same within the vagina. A diagnosis of haematometra was made. Treatment was surgical cervical dilatation and suction removal of the haemorrhagic materials. Whilst screening and treatment for cervical disease has been instrumental in women’s health, the comorbidities of treatment cannot be overlooked. Whilst it is not common, in cases of cervical stenosis it may be necessary to implement a thorough surveillance policy for antenatal and postnatal care. Accurate history taking and thorough knowledge of pelvic anatomy when performing a pelvic ultrasound examination are integral for a timely and concise diagnosis.
Professional Issues
An analysis of adverse incidents within ultrasound in 2018
Clinical Quality, InHealth, High Wycombe, UK
Abstract
It is inevitable in health care that adverse events and incidents will occur. There are many reasons why an adverse event can happen, including equipment failure, poor communication, unsafe procedures, etc. One of the primary causes, also, is human error. We encourage all staff to report adverse incidents in order that systems can be put in place to guard against a repeated event. Staff are encouraged to document all incidents and near misses on our online portal. Their line-managers and relevant members of the clinical quality team receive notification of new incidents. All new incidents are discussed at a dedicated weekly meeting so that relevant action can be taken and learning can be shared. This audit looks at those incidents reported within the ultrasound team in an 11-month period, from 1 January 2018 to 21 November 2018. All incidents were analysed and classified in to 1 of 15 subgroups. It was found that 65% of the incidents reported fell into just four of the groups. These groups included booking errors, reporting queries, patient pathway delays and clinic cancellations. In the time-period analysed, approximately 74,338 ultrasound scans were performed, and there were 133 reported incidents, giving a 0.17% incident reporting rate. The current incident reporting target is 0.6% of all patients seen. Therefore, the ultrasound reporting rate for the period audited was considerably lower. Further work is needed to engender a culture within ultrasound to encourage staff to report more frequently to create a culture of learning and of safety.
Getting it right first time – How collaborative working can improve patient gynaecological pathways
Radiology, Worcestershire Acute NHS Trust, Worcester, UK
Abstract
As the pressure on ultrasound services rises with the increasing demand for scans and adhering to national targets, this inevitably results in an increase in waiting times for patients. Within our Trust we were seeing a steady rise in requests for gynaecology scans which contributed to 45% of all ultrasound requests received from local GPs. In 2018, we embarked on a collaborative review of gynaecology services with the local clinical commissioning groups (CCGs) and Gynaecology Team within the Trust, to review the patient pathways and ensure there was an emphasis on ‘getting it right first time’. During sessions with the GPs it was quickly identified that they wanted guidance and often used the ultrasound scan as a way to be directed along the most appropriate pathway. A CCG task group supported by the gynaecologists and Radiology were then able to develop guidance for the common gynaecological conditions. Following this, many of the traditional reasons GPs would have sent the patient for an ultrasound scan were removed in favour of gynaecological referral for other examinations such as hysteroscopy or routes of treatment suggested. To support this new guidance, a training day was provided for GPs and a robust vetting protocol developed by Radiology to match the new guidance. This has ensured that all unsuitable requests are returned to the GP detailing the correct pathway which should be followed. Although this journey has not been simple, there are many benefits to the patient pathway and experience, including reduced waiting times and specialist referral early in the pathway if required.
Head and Neck
Ultrasound of the eye in accident and emergency
Queen Elizabeth Hospital, London, UK
Abstract
High frequency ultrasound is an extremely useful examination of the anatomy and pathology of the chambers and accessories of the eye. Ultrasound can be used as an extension of the clinical and ophthalmic examination of the eye. Ultrasound has the advantage in examining the eye when ophthalmic and clinical exam cannot be performed such as in cataracts and trauma. We demonstrate the use of ultrasound in a pictorial review of common eye conditions that present to accident and emergency.
Musculoskeletal
Audit: Sonographic report correlation against surgical findings during elective shoulder surgery
East Sussex Healthcare Trust, Hastings, UK
Abstract
Diagnostic ultrasound examination is an expanding clinical tool used to help inform clinical practice. The popularity of this modality appears to be coming from non-radiological professions. 1 This diagnostic tool has proven to be as accurate as MRI in detecting rotator cuff pathology. Criticism around the accuracy of this modality is often attributed to operator dependence. The aim of this audit was to offer assurance in sonographic shoulder report scanning, interpretation (description, report writing) and improve practice, if required. A sonographer performed an ultrasound scan on the morning of surgery. The sonographer was blinded to the patient’s history and previous investigations. The sonographer’s scan results were reported using the British Elbow and Shoulder Society criteria for report writing. 2 The sonographer attended surgery to gain immediate visual feedback. The sonographic report was scored by the orthopaedic surgeon, using criteria by Riley et al. 3 The sonographer’s reports had a high degree of correlation with findings during surgery. Accuracy and confidence of sonographic reporting improved throughout the data collection. Ultrasound in the hands of this sonographer was found to be more accurate than MRI in reporting full thickness tears of the rotator cuff. Musculoskeletal ultrasound appears a relatively cheap and accurate modality in the detection of rotator cuff pathology, which can aid surgical planning.
References
Case report: Primary lung tumour invading the chest wall on ultrasound
Radiology Department, Sheffield Teaching Hospitals, Sheffield, UK
Abstract
Soft tissue masses are commonly encountered in primary care, with the vast majority being benign abnormalities such as a lipoma or epidermoid cyst. Lung cancers account for around 20% of all cancer deaths and the chest wall is involved in around 5% of primary lung tumours. This case study reports on a primary lung tumour invading the chest wall that was originally detected on ultrasound in a male patient aged 67 who was a smoker. The patient presented to their GP with a three-month history of an increasing lump on the left upper chest wall. The patient was referred by the GP for a soft tissue ultrasound scan and a lipoma was suspected. The ultrasound scan demonstrated a hypoechoic and hypervascular soft tissue mass, extending out of the chest into the subcutaneous tissues and starting to erode the overlying rib. The appearances were highly suspicious of a malignancy. The patient was sent for a chest X-ray, which confirmed an opacity in the left upper zone, and referred to the chest multidisciplinary team. A staging CT scan confirmed the ultrasound appearances of a primary lung cancer with nodal metastases. The patient had an ultrasound-guided biopsy confirming the diagnosis of a squamous cell carcinoma. The patient subsequently had an upper lobectomy with a combination or radiotherapy and chemotherapy. Tumours of the chest wall are varied and are divided into benign and malignant tumours, and those that arise from the rib cage. Primary lung tumours are uncommonly seen on ultrasound and this case highlights the ultrasound imaging features.
Young Investigator 2019
Ultrasound assessment of colonic inflammatory bowel disease – A retrospective review
Furness General Hospital, Barrow-in-Furness, UK
Abstract
Although there is increasing appreciation of the value of ultrasound in inflammatory bowel disease (IBD), most focus has been on small bowel and ileal Crohn’s disease. The role of ultrasound in colonic IBD is less well evaluated. The objective of this study was to review the accuracy of ultrasound in a mixed population referred for ultrasound assessment for possible IBD. We carried out a retrospective review of three years (2016–2018) of patients referred for ultrasound evaluation of possible IBD. Inclusion was based on patients who had undergone colonic ultrasound assessment performed as part of the routine scan and who underwent full optical colonoscopy within three months of the ultrasound procedure. All scans were performed by one operator. Correlation was made between the endoscopic findings, histology and the ultrasound report. Distal rectosigmoid disease was not included in the ultrasound assessment. Ultrasonic identification of colonic inflammatory disease was made on the basis of colonic wall thickening, particularly involving mucosa and submucosa, increase in vascularity, ulceration and change in the pericolonic fat. Sixty patients were identified. The male:female ratio was 28:32 and the age range 16–86 years. There were 14 cases of Crohn’s colitis, 5 of ulcerative colitis (UC) and 1 unclassified colitis. There were 16 true positives, 39 true negatives, 1 false positive and 4 false negatives. Overall sensitivity was 80%, specificity 97.5%, positive predictive value 94.12% and negative predictive value 90.7%. Analysis of false negative cases noted one had superficial endoscopic changes but equivocal histology, one had mild UC, one had undergone a recent steroid course and one in retrospect was abnormal on image review. Ultrasound may be more useful than hitherto appreciated in colonic IBD. It appears to be particularly useful in Crohn’s colitis and may offer a useful adjunct to other imaging, especially in patients who are unable to undergo full optical colonoscopy.
Visualising sub-millimetre intrahepatic vascular structures in patients with fatty liver disease and hepatocellular carcinoma
Imperial College Healthcare NHS Trust, London, UK
Abstract
Intrahepatic vascular changes, through neoangiogenesis and arterialisation of existing vascular structures, are key in the progression of fatty liver disease (FLD) and hepatocarcinogenesis. These changes occur early in pathogenesis, are associated directly with the oxidative stress that drives FLD, and are present before signs of fibrosis. A means to assess these changes shows potential as a biomarker, particularly in the context of early detection of hepatocellular carcinoma (HCC), by identifying those patients most at risk without relying on measures of fibrosis, and drug development, as vascular changes are likely to occur before amelioration of fibrotic processes. At present it is challenging to examine small intrahepatic vascular structures (IHVS) non-invasively. Our aim was to develop a reliable method for visualising sub-millimetre IHVS in patients with FLD and/or HCC, of sufficient quality for image analysis. One hundred twenty-five participants underwent abdominal ultrasound Doppler imaging of hepatic parenchyma before and after Sonovue injection, using an Aplio 500 system (Canon Medical Systems Europe, Zoetermeer, the Netherlands). Liver stiffness measurements were obtained from all participants; histology data were available for 30 participants. Rotational, rigid (affine) and non-rigid motion correction was applied to a subset of imaging and the most suitable method was reviewed based on improvement of visualisation of IHVS on maximum intensity projections. While non-enhanced Doppler imaging could visualise small vascular structures in some cases, contrast enhanced ultrasound (CEUS) was required for the majority of cases and in particular those with significant attenuation due to FLD. Motion correction was not required for any cases, due to the ability to collect multiple videos within a single contrast volume, but rigid motion correction could improve image quality. We were able to reliably assess intrahepatic vascular structures with sufficient quality for image analysis using a CEUS enhanced Doppler technique.
New design for a portable diagnostic power meter for use in hospitals
National Physical Laboratory, Teddington, UK
Abstract
Output acoustic power is an important parameter in the assessment of diagnostic probes as it relates to the safety indices and can indicate transducer malfunctioning or degradation. Measurement of acoustic power is commonly made using radiation force balances. The high sensitivity to noise and vibration of these devices makes them difficult to use outside of laboratory environments. We have developed a device based on the pyroelectric effect, i.e. the ability of a material to generate a voltage when heated or cooled. The sensor has dimensions of 80 mm × 65 mm and is made of a 28 µm thick polyvinylidene fluoride (PVDF) element, covered by a 9 µm protective PVDF layer. It is backed with a highly acoustically absorbing material to maximize temperature elevation. The sensor is angled at 60° to avoid standing waves and is embedded in an enclosure covered by acoustically absorbing material. The response of the sensor and the electronics is tuned to show a sharp rise in pyroelectric voltage when the transducer is switched on (proportional to applied power) and a sharp decrease when the transducer is switched off. We present the results from four sensors, tested at four different frequencies from 1 to 15 MHz and different transducer-sensor separations to evaluate effects of attenuation in water. The measured sensitivity values were consistent among the four sensors with values around 85 mV/W. Sensitivity variation with frequency is within ±10% and is expected to be compensated for by calibration. Distance compensations must be applied for frequencies above 5 MHz due to attenuation in water. The device shows promising results. A new version is under development that will embed reading electronics, providing a portable and self-standing tool for acoustic power measurements in hospitals, potentially down to a few mW.
Towards a standard test phantom for magnetic resonance guided high intensity focused ultrasound (MRgHIFU)
1Medical Physics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
2National Physical Laboratory, Teddington, UK
Abstract
Magnetic resonance guided high intensity focused ultrasound (MRgHIFU) effectively ablates tissues by targeting the region of interest (ROI) and allows real-time monitoring of the temperature rise and assessment of the treatment effectiveness. Standards for characterisation of HIFU acoustic fields are well established; however, the correlation between exposure parameters, tissue heating and therapeutic effectiveness is uncertain. The lack of universally accepted treatment planning and calibration protocols is limiting clinical acceptance. The aim of this study is to develop a standard test phantom which is suitable for performance assessment and quality assurance (QA) of HIFU systems. A phantom consisting of 3D printed bone-equivalent disks, IEC agar based tissue mimic (TMM) and eight fine wire type-K thermocouples placed in strategic positions was manufactured. The phantom was sonicated with a Sonalleve MR-HIFU (Philips, Eindhoven, Netherlands) using different acoustic powers, cell sizes and ROIs. Sonications were performed on TMM and bone-equivalent regions both far from the thermocouples and on the thermocouples. MR-thermometry estimates were unreliable near the thermocouples due to imaging artefacts and temperature estimates from coronal, sagittal and transverse MRI-thermometry planes differed by up to 40%. The maximum MRI-thermometry temperature estimate was within 5% of the corresponding thermocouple measurement. Treatment powers of 40 and 70 W for 16 seconds exposures resulted in peak temperature increases of 10.2°C and 22°C in TMM, respectively. An acoustic power of 40 W in the bone-mimic resulted in a peak temperature increase of 26°C, comparable to 24.7°C found in previous studies with ex-vivo lamb legs. There was good agreement between maximum temperature estimates from MRI-thermometry and thermocouple measurements. Further tests are required to confirm the suitability of the test phantom for supporting calibration, QA, training, optimisation and validation of MRgHIFU procedures, thereby ensuring safe and effective HIFU treatments.
New technologies for clinical and preclinical research into ultrasound therapy and imaging
OptimUS: An open source general purpose ultrasound simulation platform
1University College London, London, UK
2Pontificia Universidad Catolica de Chile, Santiago, Chile
3University of Cambridge, Cambridge, UK
Abstract
The clinical deployment of ultrasound therapies is hindered by challenges in treatment planning based on numerical models. For realistic clinical scenarios, simulation methods that employ volumetric meshes require several hours/days to run on a computer cluster. The wider clinical adoption and translation of therapeutic ultrasound will be greatly facilitated by the ability to produce fast and accurate patient specific simulations, with minimal computational overheads. For ultrasound scientists involved in preclinical research and for manufacturers of ultrasonic equipment, the ability to use open source software to rapidly visualise pressure fields in complex media bears significant advantages. OptimUS is a general purpose open source ultrasound research platform which uses a multi-domain boundary element formulation to calculate and visualise ultrasonic fields in complex media. It features an easy-to-use Python front-end. OptimUS works by discretizing only the contours of the different tissue types thus considerably reducing computational overheads. Compounding this with efficient preconditioners and matrix compression techniques, the interactions of incident ultrasonic fields with multiple tissue domains may be accurately computed within a realistic clinical timeframe, and with no staircasing or numerical dispersion effects. Constrained optimisation techniques provide the possibility to focus through scatterers such as bone and to reduce scattering at boundaries where there is significant contrast in tissue properties. OptimUS also provides a simple framework for modelling complex ultrasonic sources such as array transducers, as well as planar and bowl transducers. Convergence tests demonstrate that, with meshes involving four elements per wavelength, the solvers used in OptimUS produce results within 5% of the analytical solution to the problem of a single sphere object impinged by a plane wave. Calculations on anatomical meshes show that the presence of tissue heterogeneities and strong scatterers such as bone can lead to substantial aberration of the focus, lensing effects and a reduction in peak pressures.
Acoustic and thermal characterisation of polyvinyl alcohol (PVA) hydrogels as tuneable tissue phantoms for high-intensity focused ultrasound (HIFU) treatment
1Institute of Cancer Research, London, UK
2ETH Zurich, Zurich, Switzerland
Abstract
High intensity focused ultrasound is a promising non-invasive cancer therapy. For experiments and simulations, tissue mimicking materials that can be easily adjusted to resemble different tissues are required. Polyvinyl alcohol (PVA) hydrogels are promising, cheap and non-toxic candidate phantom materials. PVA hydrogels with concentrations from 5% to 20% w/w, ±5% w/w cellulose, were investigated. Ten per cent PVA gels were also analysed as a function of cellulose content (2.5–10% w/w), and PVA molecular weight (PVAlow: 31,000–50,000 g/mol, PVAstandard: 85,000–124,000 g/mol, PVAhigh: 146,000–186,000 g/mol). Six-millimetre thick sheets of hydrogel were produced by crosslinking polymer solutions in three freeze–thaw cycles. The 5.5 cm diameter disks were cut and acoustic properties (attenuation coefficient, speed of sound) were investigated using the finite amplitude insertion method (frequency: 2.5 MHz) in a temperature-dependent measurement (20–45°C). Thermal properties (specific heat capacity, thermal conductivity) were measured using a Hot Disk system. Some gel formulations were excluded due to visible heterogeneity (5% PVAstandard with cellulose), or entrapped air bubbles (20% PVAstandard with cellulose, PVAhigh). PVA molecular weight controlled sample stiffness and mechanical stability upon heating. Sound speed was independent of the sample’s cellulose content, but attenuation increased linearly. Molecular weight dependence is presented. Neither adding cellulose, nor using different molecular weight PVA had a significant influence on thermal properties. PVA standard hydrogels were the most suitable for tissue mimics since these gels are reproducible, stable over a large temperature range, and their acoustic properties can be tuned by the cellulose content.
Prediction of pelvic tumour coverage by magnetic resonance guided high-intensity focused ultrasound (MRgHIFU) from referral imaging
1Therapeutic Ultrasound, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
2MRI Unit, The Royal Marsden NHS Foundation Trust, London, UK
3Cancer Research UK, Cancer Imaging Centre, Division of Imaging and Radiotherapy, The Institute of Cancer Research, London, UK
Abstract
Triaging is required to determine whether a patient’s pelvic tumour is suitable for magnetic resonance-guided high intensity focused ultrasound (MRgHIFU). Currently, clinicians assess patient suitability by examining MR planning images obtained with patients lying on the MRgHIFU bed in a clinician-determined ‘suitable’ treatment position. Software automation of the triaging process using pre-existing (typically supine) referral imaging may improve the patient workflow. Software-based triaging requires accurate prediction of the treatable tumour volume. This requires segmentation of acoustic obstructions (e.g. bone), organs at risk (e.g. rectum), and the target tumour. Once the ideal treatment orientation has been determined, tumour accessibility (the proportion of tumour volume reachable with the focus) can be evaluated after accounting for the effect of body deformation in the new position. Tumour treatability can be evaluated via simulation of acoustic propagation, and the resultant thermal bioeffects. In a first step towards automated triaging, software designed to predict tumour accessibility has been developed and tested. DIXON 3 D MRI datasets were acquired for five volunteers and three patients (NCT02714621). Referral and treatment images of all subjects lying supine on the Achieva® MR bed and at an incline on a Sonalleve® V2 MRgHIFU treatment bed, respectively, were obtained. Referral datasets were registered to treatment datasets manually. Body outline was segmented automatically. Bones were segmented manually. Organs-at-risk and bowel gas were ignored for volunteers and manually segmented for patients. Tumours were segmented manually by a radiographer. The accessible tumour volume (patients) or soft tissue volume (volunteers) was quantified in both (registered) referral and treatment datasets using an exhaustive search method, after taking into account acoustic coupling limitations and the expected body deformation, and the results compared. The accessibility prediction methodology from referral images shows promise and triage software development can proceed.
Acknowledgements
Research supported by Koninklijke Philips (Amsterdam, Netherlands) and Profound Medical (Mississauga, Canada).
A controlled study of proliferation and prostaglandin E2 up-regulation in pre-osteoblasts stimulated by low-intensity pulsed ultrasound
1Centre for Medical and Industrial Ultrasonics, University of Glasgow, Glasgow, UK
2Biomedical Engineering, University of Strathclyde, Glasgow, UK
Abstract
Low intensity pulsed ultrasound (LIPUS) is an established treatment for non-healing fractures. Past in vitro studies suggest LIPUS stimulates integrin mechanotransduction pathways in osteoblasts, such as cyclo-oxygenase-2 and prostaglandin-E2 (PGE2). 1 One barrier to understanding LIPUS mechanisms is that ultrasound exposure is not always adequately characterised. We designed an experimental setup allowing full control of the acoustic field. Pre-osteoblast cells were exposed to LIPUS at 45 kHz and 1 MHz, with mechanical index (MI) up to 0.2. Potential healing effects were assessed by cell proliferation and up-regulation of PGE2 compared to controls. Ten custom-built, acoustically transparent culture vessels (biocells) were seeded with MC3T3-E1 cells (25,000 cells cm−2). After 24-hours incubation, media was refreshed and each biocell placed in a tank of sterilised water at 34 ± 1°C. Two transducers (45 kHz; 1 MHz) delivered LIPUS for 20 minutes with pulse width 200 µs, repetition rate 1 kHz and Ml 0 (control), 0.05, 0.15 or 0.2. Field mapping was conducted before exposure using 0.5 mm or 2 mm needle hydrophone (Precision Acoustics). PGE2 concentration in the media 20-hours post-exposure was measured by ELISA kit (Abcam). Proliferation was quantified by counting viable cells pre- and post-exposure using fluorescence microscopy. To maximise sample size, cell counts were undertaken in the centre, at maximum MI, and off-centre, at lower local MI. After exposure to 1 MHz LIPUS, cell proliferation and PGE2 concentration peaked at 0.1 MI. 45 kHz results were prone to variation but PGE2 and proliferation increased at 0.2 MI, suggesting 45 kHz LIPUS may be more effective at higher MI. We hypothesise that variation across frequencies is due to the shorter rise time of the 1 MHz pulse, producing a step change in radiation force: a mechanism of interest in mechanotransduction pathways. This, along with MI > 0.2 at 45 kHz is the focus of future work.
Reference
Interleaving passive acoustic mapping with compounded diverging-wave imaging for high intensity focused ultrasound treatment monitoring
1School of Electronics and Electrical Engineering, University of Leeds, Leeds, UK
2Leeds Institute of Medical Research, University of Leeds, St. James’s University Hospital, Leeds, UK
Abstract
Ultrasound-guided high intensity focused ultrasound (HIFU) therapy could provide a low cost and convenient approach for real-time feedback. It, however, currently can only provide limited information on the formation of thermal lesions. Cavitation activity can play an important role during HIFU exposures that can lead to heating enhancement and/or asymmetric lesion formation. Thus, monitoring its progression during exposures, through interleaved passive acoustic mapping (PAM) and high frame rate imaging (HFR) could provide valuable temporal and spatial information of this phenomenon. As HFR imaging needs to be interleaved with the HIFU exposure, minimising the imaging time is necessary to ensure maximum heating efficiency. Compounded diverging-wave imaging by phased-array was confirmed as the optimal HFR modality and a suitable compromise between HIFU duty cycle (95%) and HFR acquisition time was demonstrated with minimal impact on thermal lesion formation. During exposures, PAM can be performed to complement HFR imaging. In this study, several time-domain PAM beamformers were assessed; these included time exposure acoustics, Capon beamforming (CB), robust Capon beamforming (RCB), Eigenspace robust Capon beamforming (E-RCB) and Wiener E-RCB (WE-RCB). It was shown that WE-RCB provided improved signal-to-noise ratio (SNR) (2 ± 0.2 dB higher than E-RCB). However, RCB without ‘DC components’ outperforms WE-RCB in terms of point spread function size, SNR, axial and lateral resolution, without the need to combine more computationally complex techniques such as Eigen-space and Wiener. Moreover, the results demonstrate that ‘X-type’ artefacts, common to PAM images, are not only originating from interactions between bubble clusters but also from DC components. In order to achieve real-time feedback, the PAM algorithms will be implemented on field programmable gate arrays. Finally, a systematic ultrasound guided HIFU treatment system including HFR, PAM and US temperature mapping techniques could be developed to provide meaningful feedback on ablation progress for clinical guidance.
A thermochromic tissue mimicking material (Th-TMM) for high intensity focused ultrasound and hyperthermia procedures
1Guy’s and St Thomas’ NHS Foundation Trust, London, UK
2National Physical Laboratory, Teddington, UK
Abstract
Measurement of temperature rise due to acoustic exposure provides important information on targeting accuracy, effectiveness and safety of high intensity therapeutic ultrasound and hyperthermia procedures. A thermochromic tissue mimicking material (Th-TMM), both ultrasound and magnetic resonance compatible, is proposed in this study. Th-TMM samples were manufactured by freezing/thawing four times a solution of PVA (10 wt%), glycerol (8 wt%), benzalkonium chloride (0.5 wt%) and a thermochromic ink (5 wt%) (LCR Hallcrest). The samples were divided in three groups. Group A was immersed in a temperature-controlled water bath to assess the sensitivity in the range of interest (40–65°C). Measurements of speed of sound and attenuation were carried out on Group B. Group C was sonicated in a water tank with a 2 MHz high intensity focused ultrasound (HIFU) transducer, at 20 W (acoustic power), for exposure times ranging from 20 to 60 seconds, in continuous wave. The samples in Group A provided appreciably different shades of magenta colour when immersed in water with temperature ranging from 45°C to 65°C. The speed of sound and attenuation of the Th-TMM were 1560 ± 10 m s−1 and 0.13 f 1 .5 ± 10% dB cm−1 MHz−1.5, where f is frequency. The spatial distribution of the temperature increase and focus shape after the HIFU exposures show that the region of interest (ROI; temperature greater than 45°C) is bigger for longer exposures. Th-TMM melting occurs for exposures longer than 30 seconds. A Th-TMM sensitive to a temperature range relevant to HIFU and hyperthermia procedures has been manufactured and tested. Further experiments are needed to optimise the acoustic properties, to quantify the temperature distribution within the ROI, to determine cavitation thresholds and to cross-reference the results with independent measurement methods (such as MRI-thermometry). Overall, early experiments showed the material has great potential and can be used in test objects.
Elucidation of biological mechanisms of clinically viable low frequency (20 kHz) ultrasound applicator for chronic wounds therapy
1Drexel University, Philadelphia, PA, USA
2University of Glasgow, Glasgow, UK
Abstract
The primary goal of this work was to investigate the biological mechanisms of action underlying the clinical pilot study success of a novel, wearable ultrasound applicator that we previously showed can reduce healing time of chronic wounds by 60% in a pilot study of eight diabetic patients. Chronic wounds cost $25 billion annually in the US alone and a reduction of healing time directly reduces healthcare costs. Macrophages are critical in inflammation and have been shown to respond to external mechanical stimuli. Chronic inflammation has been implicated as a potential source of poor healing of chronic wounds. In contrast to commercial ultrasonic debridement systems, a light-weight (<20 g) ultrasound applicator prototype operating at 20 kHz was developed. Its peak acoustic output pressure amplitude is limited to 55 kPa, corresponding to a spatial peak temporal peak intensity of 100 mW cm−2, which is below the inertial cavitation threshold; hence, in the verified absence of temperature elevation, the tissue–ultrasound interaction is dependent on radiation force alone. A custom-curated panel of 227 genes was analyzed 24 hours after exposing THP-1 macrophages in vitro with the clinical applicator (n = 3). Student’s t-test with Benjamini–Hochberg correction was applied for statistical significance. Preliminary gene analysis showed eight genes (CD163, FOXQ1, CD80, CCL8, DEFB3, IL 15, NIMA, CSF3, FPR1) were significantly (p < 0.05) downregulated. These genes are responsible for functions related to recruitment, activation, proliferation and differentiation of immune cells indicating a decrease in inflammatory macrophage associated genes. Macrophage gene regulation appears to be a potential chronic wound healing mechanism activated by this therapeutic ultrasound applicator. A down regulation of these inflammation associated genes could indicate a less inflammatory macrophage after ultrasound treatment. Understanding the effects of therapeutic ultrasound on macrophage behaviour may lead to personalized wound care treatments’ procedures.
Demonstration of the ability to use microbubbles combined with low pressure focused ultrasound to induce cavitation in orthotopic pancreatic tumours
The Institute of Cancer Research, London, UK
Abstract
High intensity focused ultrasound (HIFU) can be used for the treatment of solid tumours by creating cavitation which results in mechanical disruption of their tumour microenvironment. Pancreatic tumours which are characterised by a dense stroma should be particularly prone to these acoustic cavitation effects. Our pilot preclinical studies have shown that treatment of pancreatic tumours with pulsed HIFU (pHIFU) can result in biological and immunological anticancer effects. The application of these pHIFU exposure parameters in a clinical setting is, in parts, hindered by the high acoustic pressures (>10 MPa) required, which are considered to be neither practical nor safe for the patient. The aim of this study was to investigate the feasibility of combining pHIFU with cavitation enhancing agents (microbubbles) to induce acoustic cavitation in pancreatic tumours at clinically relevant low rarefactional pressures. Syngeneic orthotopic pancreatic KPC tumours (KrasLSL.G12D/+; p53R172H/+; PdxCre tg/+) were grown in immune-competent murine C57BL/6 subjects. Subjects were injected intravenously with 100 µl of microbubbles, and tumours were exposed to pHIFU (peak negative pressures = −17.6 to −2.7 MPa, duty cycle = 1%, pulse repetition frequency = 1 Hz, 25 repeats, f = 1.5 MHz) using the small animal AIpinion VIFU 2000 therapeutic ultrasound platform. Acoustic cavitation was monitored during pHIFU bursts using a weakly focused polyvinylidine fluoride, broadband (0.1 to 20 MHz) passive cavitation detector. Data recording was controlled and processed using custom-written Matlab software. Tumours were imaged using 2D high frequency (14 MHz) B-mode ultrasound (E-Cube 9, Alpinion, USA). Results showed that broadband and half harmonic emissions were detected at peak negative pressures as low as −3 MPa when microbubble contrast agent was injected immediately before the pHIFU treatment. These results suggest that the use of microbubbles could reduce the pressure threshold needed for the induction of acoustic cavitation during pHIFU treatment of pancreatic tumours.
General Medical and Paediatrics
Case report: Abdominal distension in children
1Radiology, Peninsula Radiology Academy, Plymouth, UK
2Radiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
Abstract
Peritoneal mesothelioma is strongly associated with asbestos and metal fibres exposure, an occupational hazard, and it predominantly affects middle aged to older males (50 to 70 years). Rarely, in 1–2 cases per million, does it arise as a primary neoplasm from the peritoneum. Patients may be asymptomatic or present with abdominal distension, nausea and vomiting, abdominal pain, weight loss and/or malaise. A 13-year-old girl presented with six weeks of rapid abdominal distension with no change in bowel habit. Her appetite was fine and she felt well and active. She had had chicken pox and was post-menarche. There was no family history of any medical conditions. On examination, her abdomen was tense but non-tender. There was no palpable mass or peripheral lymphadenopathy, and no signs of anaemia or jaundice. Trans-abdominal ultrasound revealed extensive ascites with low level echoes throughout. Around the liver, there was multiple subcapsular moderately echogenic lesions indenting the liver surface. No intrahepatic lesion and normal gallbladder was noted. There was a large lobulated solid pelvic mass with some internal heterogeneity and a more discrete left sided cystic structure containing multiple peripheral solid nodules. Uterus and ovaries were not identified. Further cross-sectional imaging with MRI was acquired. Peritoneal biopsy confirmed the diagnosis of malignant epithelial mesothelioma. Immunohistochemical marker and genomic profiling were also performed. Treatment options include cytoreductive surgery, intraperitoneal chemotherapy and systematic chemotherapy. Malignant deposits follow flow of peritoneal fluid and gravity into dependent pelvic spaces and up into right subphrenic spaces. Psychosocial support for the patient, sibling and family is vital in the overall management of paediatric oncology patients.
Case report: Rare urachus abnormality – Inflammatory myofibroblastic tumour (IMT)
Radiology, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
Abstract
Inflammatory myofibroblastic tumour (IMT) is an infrequent, locally aggressive, benign soft tissue tumour with uncertain malignant potential, originally reported in the lungs by Brunn1 with subsequent occurrences in the digestive system. It is rare in the urinary system, being first discovered in the bladder by Roth. 2 An urachal IMT is extremely rare and challenging to diagnose. Urachal remnants represent rare congenital anomalies resulting in a failure of the obliteration of the allantois at birth which connects the dome of the bladder to the umbilicus. Awareness and recognition of urachal anomalies and knowledge of IMT is important to distinguish whether the tumour originates from the bladder or the urachus, because the surgical treatment options are completely different. An eight-year-old male presented for abdominal ultrasound with a 3/52 history of frank haematuria, dysuria, pyrexia, ‘flu like’ symptoms and constipation, but no history of urinary tract infection, trauma or surgery. On physical examination, he was pale and thin. Laboratory results indicated raised inflammatory markers, i.e. C-reactive protein and erythrocyte sedimentation rate. Ultrasound assessment revealed a large well defined, mixed echo, vascular mass at the umbilicus extending into the dome of the urinary bladder raising the suspicion of a urachal malignant neoplasm. The normal obliteration of the urachus after birth terminates in the midline umbilical ligament. Incomplete regression results in several anomalies. Recognition is required because of increased potential for infection and neoplastic differentiation, with ultrasound being the primary investigative tool in classifying and characterisation of the type of anomaly. Awareness and understanding of the urachal anatomy, embryology and the entity of the urachal IMTs is a prerequisite for timely and accurate diagnosis.
References
Ultrasound diagnosis of biliary obstruction: Are the recommended cut-off criteria of common bile duct diameter and liver function testing safe?
1Radiology, Hull and East Yorkshire Hospitals Trust, Hull, UK
2Leeds Teaching Hospitals Trust; Leeds, UK
Abstract
Transabdominal ultrasound (TAUS) including measurement of the common bile duct (CBD), and liver function tests (LFTs), are the recommended initial investigations into suspected biliary pathology, but estimates of test specificity are average. Recent guidelines propose increasing the normal limit of CBD diameter and combining elevated LFTs, including elevated bilirubin as alternative diagnostic criteria. The objectives of this study were to determine and compare diagnostic accuracies of current and alternate criteria for diagnosis of biliary pathology using magnetic resonance cholangiopancreatography (MRCP) as the reference standard. A retrospective service evaluation was conducted on 508 eligible subjects between September 2013 and August 2018. All subjects received TAUS and laboratory blood analyses followed by MRCP for investigation into suspected biliary pathology. Ultrasound, MRCP and laboratory findings were collected by retrospectively applying the current and alternate diagnostic criteria to the study cohort. Sensitivity and specificity with confidence intervals were calculated for both criteria by populating 2 × 2 contingency tables. Of the 508 subjects, reference standard MRCP identified 328 with complex biliary pathology, 79 with simple gallstones, and 101 with no abnormality. Application of the current diagnostic criteria correctly identified the target condition in 256 subjects with 72 incorrectly identified as negative. Application of the alternate diagnostic criteria correctly identified 227 subjects as positive with 101 incorrectly identified as negative. Sensitivity and specificity were 78% (CI 73–82%) and 44% (CI 37–52%) respectively for the current diagnostic criteria, and 69% (CI 64–74%) and 67% (CI 59–74%) respectively for the alternate diagnostic criteria. The alternate diagnostic criteria yielded greater specificity but inferior sensitivity when compared to the current criteria used in daily practice. Increased false negative diagnoses are unacceptable due to the risk of infectious morbidity associated with undiagnosed biliary obstruction. The alternate diagnostic criteria should be considered unsafe for clinical use.
Case report: Incidentalomas – Point of care ultrasound and haemangiomas
1Obstetrics and Gynaecology, Mater Dei Hospital, Msida, Malta
2Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Abstract
Internationally, point of care ultrasound (POCUS) is a developing modality. POCUS examinations are carried out by medical and non-medical clinicians, from many disciplines. They have varying degrees of ultrasound (US) experience and education. This focussed examination may detect incidentalomas. The aim of this case report is to demonstrate the role of POCUS in the management of a patient with focal liver lesion (FLL) incidentalomas. A 24-year-old woman was referred to an urologist and a same-day kidney POCUS clinic due to a gynaecologist’s suspicion of urinary tract endometriosis. She had symptoms of urgency, dysuria during the menstrual cycle, altered bowel habit and weight loss. A POCUS examination was done by a trainee sonographer (obstetrician) and supervised by an expert non-medical sonographer/lecturer. The findings were: normal kidneys and bladder. Four solid FLLs were identified. The largest, in segment II/III measured 3.5 cm and had mixed echotexture. The other three lesions measured between 1 and 2.9 cm. The conclusion was atypical haemangiomas; needs further characterization. An US specialist (Consultant Radiologist) confirmed the POCUS findings. Magnetic resonance imaging was requested. This agreed with the POCUS and the specialist’s findings of haemangiomas. The patient was reassured and discharged. POCUS equipment is relatively cheap and compact. It provides same-day access to imaging with the potential of reducing anxiety, repeat visits and costs. POCUS is a rule-in examination and not a definitive diagnostic examination. FLL incidentalomas may be identified. These include haemangiomas, focal nodular hyperplasia, focal steatosis, adenomas and malignancy. POCUS clinicians should refer the patient with unexpected pathology to specialists (radiologists and non-medical sonographers) in medical imaging departments. POCUS and specialist US services should complement each other for the benefit of the patient.
The utility of ultrasonography in the diagnosis of testicular torsion – A systematic review
Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
Abstract
Although ultrasound is a valuable tool in establishing a diagnosis for acute scrotum patients, its role in detection of testicular torsion remains controversial and has historically been reliant on colour Doppler ultrasound alone. This review aims to assess the value of combined B-mode and colour Doppler ultrasound features in the detection of testicular torsion in acute scrotum patients. A thorough literature search through several electronic databases, grey literature and hand searching was conducted to identify relevant literature which met the inclusion criteria of this review. Relevant articles were systematically reviewed and data from included studies were extracted, tabulated and analysed. The included studies demonstrated strong agreement on the value of ultrasound as a triage tool in acute scrotum patients. Sole reliance on colour Doppler ultrasound features showed potential for false-negative results, whereas several B-mode appearances were found to be good indicators for testicular torsion and showed high sensitivity and specificity values. Where B-mode and colour Doppler ultrasound features were combined, sensitivity towards testicular torsion detection increased, with three studies achieving 100%. However, all studies recommended correlation with clinical examination findings and that any investigations should be conducted within appropriate time to avoid delays to treatment. Several limitations in methodology of the included studies, such as small sample populations, lack of information on the ultrasound operators and selective tabulation of data were noted. Ultrasound, utilising the combination of B-mode and colour Doppler, is a useful and reliable adjunct to clinical examination in the detection of testicular torsion in acute scrotum patients, especially in indeterminate and low suspicion cases. However, a larger scale primary study is required to further validate the results of this review due to limitations in methodology of included studies.
Professional Issues
Current ultrasound practice in Europe: A European Federation of Radiographer Societies (EFRS) Survey of National Radiographer Societies
1European Federation of Radiographer Societies, Middleburg, the Netherlands
2School of Health Sciences, City, University of London, London, UK
3Lillebaelt Hospital, Denmark and University of Southern Demark, Denmark
4Radiology Technician Teaching and Research, University of Applied Sciences, Vienna, Austria
5Inholland University of Applied Science, the Netherlands
6Coimbra Health School, Polytechnic Institute of Coimbra, Coimbra, Portugal
Abstract
A survey of the European Federation of Radiographer Societies’ (EFRS) national radiographer societies was carried out to collate information and opinions about ultrasound practice across the wider European countries. A SurveyMonkey questionnaire was developed and sent by e-mail to 54 European, Baltic and Asian countries’ radiographer societies. A range of questions were used including free text options, to expand on specific topic areas. Responses were received from 27 countries, with 40 individual responses from radiographer societies. Radiologists perform ultrasound examinations in 39 (97.5%) countries, followed by ‘specialised medical doctors’ in 32 (80%) countries. Radiographers perform ultrasound examinations in 13 (48%) countries and had limited involvement in 3 (11%) countries, leaving 41% of countries with no radiographer involvement in ultrasound. Common reasons for radiographers not undertaking ultrasound examinations were professional resistance or legislation preventing it and limited educational provision specifically for ultrasound. Where education was available, focused courses predominated (39%) and post graduate ultrasound courses (35%). The UK was the only country to have a dedicated BSc (Hons) programme specifically for ultrasound education. Fully independent interpretative reporting by radiographers was uncommon (4%). The majority provide descriptive or checklist reports, which are finalised or written by a radiologist. Indemnity insurance was provided by 25% of radiographer societies for radiographers performing ultrasound examinations; one highlighted that it was secondary insurance to support employers’ primary insurance. The findings were varied, with some countries fully engaged with radiographers performing ultrasound examinations. A few were trying to develop the role and others had a range of barriers to expanding radiographers’ involvement into ultrasound. Barriers were explored in the survey and the findings can be used to assist countries who want to develop the sonographer role for radiographers, to overcome some of the challenges and provide safe, high quality patient care.
Vascular
Case report: Paediatric deep vein thrombosis – Out-ruling all potential causes
1University College Dublin, Dublin, Ireland
2University Hospital Galway, Galway, Ireland
Abstract
Deep vein thrombosis (DVT) events are rare in children in comparison to adults. However, DVT is becoming an increasingly common complication, particularly among hospitalised children. This case presents a six-year-old male with a background of spina bifida and limited mobility admitted with left lower limb swelling, increased leg temperature and skin discolouration. The paediatric team ordered a lower limb Doppler ultrasound (US) as they queried the presence of a DVT. B-mode, colour and spectral Doppler US assessment of the left leg veins was performed. The external iliac vein, common femoral vein, proximal to mid femoral vein were all patent, compressible and showed augmented flow. The mid femoral vein to popliteal vein were non-compressible with absent flow, consistent with DVT. The patient received anti-thrombotic treatment but with progressive symptoms, a serial follow-up US scan was performed three weeks after the initial diagnosis showing resolution of the DVT. The US findings of a resolved DVT led to a query over the initial cause of the DVT and of the progressing symptoms. Femur radiographs revealed a longstanding distal femur fracture with extensive callous bone formation and soft tissue swelling. The combination of patient immobility and bone trauma meant that this patient was at a particularly high risk of developing a DVT, thus highlighting the importance of out-ruling all potential causes of DVT when diagnosed in children. Ultrasound plays an important role in both the diagnosis of paediatric DVT and follow-up of its resolution. However, consistency in scanning approach and reduced interscan variability is crucial to improve confidence in US findings. Paediatricians should have a very high index of suspicion for DVT, especially in hospitalised children. It is also important to out-rule all potential causes of DVT in children when an US diagnosis is made.
Upper limb Doppler ultrasound: A dual site study analysing clinical outcomes and indications
Hull and East Yorkshire Hospitals Trust, Hull, UK
Abstract
The aims of this study were to: assess the accuracy and appropriateness of information provided by clinicians on deep vein thrombosis (DVT) requests to guide justification; analyse the outcome data in positive scans for dual sites; and monitor follow-up imaging relating to the symptoms associated with the initial presentation. Data were collected between 1 January 2018 and 31 December 2018 including both inpatient and outpatient scans during this period, of patients aged 16 and above. Each patient record was assessed for indication of scan, past medical history, ultrasound result, relevant follow-up imaging and patient demographics. These were input into an anonymised database for analysis. Ninety-two patients had ultrasound Doppler studies during 1 January 2018–31 December 2018 (54% female, 46% male). Mean age was 61 years, with a range of 16–92 years. Indications for the scan were: 4 patients had clinical documentation of cellulitis; 88 patients had swelling and pain in the affected limb; 6 patients did not have a documented D-dimer (7%); 29 had positive findings; 1 had thrombophlebitis. The remaining 28 (30%) had deep vein thrombosis (stenotic vs. occlusive). Of these 28, the most prevalent location was in the subclavian vein (10 patients 36%). Four of these extended into the external jugular vein, two were occlusive and one extended into the axillary vein. Of note, four patients had brachial DVTs (14%), two of which were secondary to peripherally inserted central catheter line insertions. Four patients had follow-up, two of which were CT venograms to analyse the venous occlusions. Upper limb ultrasound is a useful tool in analysing venous occlusive disease in the acute setting. Our study highlights its effectiveness with only four patients continuing to have follow-up imaging. The most prevalent documented area of thrombus burden in our study was the subclavian vein.
Use of ultrasound guidance in peripheral venous cannulation
Emergency Department, Chesterfield Royal Hospital, Chesterfield, UK
Abstract
The aim of this study was to evaluate the use of ultrasound guidance in peripheral venous cannulation (PVC) in the emergency department. This was based on a review of the literature surrounding the use of ultrasound guidance in PVC. PVC is a routine procedure in emergency medicine allowing vital fluids and medications to be given to patients. Cannulation can be difficult to achieve in certain groups of patients, such as intravenous drug users, patients with raised body mass index and patients with circulatory shock.1,2 With the rising prevalence of obesity, 3 the number of patients with difficult venous access is likely to rise. Ultrasound is widely used to aid PVC in patients with difficult venous access. 4 Two meta analyses demonstrated with statistical significance that ultrasound guided PVC was more successful than traditional cannulation techniques.5,6 Research has shown that potential advantages of using ultrasound include reduced number of cannulation attempts and reduced time to complete the procedure. 7 However, some studies have shown that there were no significant differences in these parameters. 6 Central venous catheters can be used in patients with difficult venous access; these, however, are a resource intensive intervention and not without risk. 8 Studies show that ultrasound guided PVC has been associated with reduced number of central venous catheter insertions, 8 and can be easily taught to junior doctors and emergency nurse practitioners.2,9 Ultrasound guidance can improve success rates of PVC in those with difficult venous access,2,5,6,8,9 and is an alternative technique with a lower risk profile compared to central venous cannulation. 9 As a consequence of this review, the induction programme for the new cohort of junior doctors at Chesterfield Royal Hospital Emergency Department will include training in the use of ultrasound guided venous access.
References
Is there value in repeating lower limb Doppler ultrasound (sonovenograms) for suspected deep vein thrombosis, without clinical reassessment? – A pilot study
Leeds Teaching Hospitals NHS Trust, Leeds, UK
Abstract
Lower limb deep venous thrombosis (DVT) causes significant morbidity, 1 and is difficult to identify clinically. 2 At our centre, we assess for DVTs using sonovenograms. The National Institute for Health and Care Excellence (NICE) recommends repeat sonovenogram 6–8 days following an initial negative scan, if the Wells Score ≥2 and D-dimer >230 ng/ml. 3 Anecdotal accounts from sonographers and radiologists indicate some returning patients in whom symptoms have improved. We thereby question justification for rescanning without clinical reassessment. Our aim was to ascertain: the frequency of positive repeat scans; risk factors making positive repeat imaging more likely; and whether we should introduce repeat clinical assessment and D-dimer before rescanning. This was a pilot study, covering one month (October 2018), with the view to extend to a year (January 2018–January 2019). Patients with two scans within six weeks (negative for DVT on initial scan) were selected. We retrospectively analyse data from the Trust’s ultrasound database, the Radiology Information System (CRIS) and the Trust’s electronic patient records system (PPM+). Of 83 patients (29 M, 54 F; age range 18–94), one had a positive repeat sonovenogram (1.2%). The request conveyed clinical reassessment had occurred, which was unusual, and D-dimer increased (232–241) – the sole case where D-dimer was repeated (1.2%). There were no risk factors identified; although, a Bakers’ Cyst was diagnosed on the first scan. Preliminary data suggest positive yield following an initial negative sonovenogram is low (1.2%) and repeating the test is of questionable value. Perhaps a more targeted reassessment would be preferable – particularly as, anecdotally, the positive study involved both clinical and D-dimer reassessment. However, a larger study is required to ascertain the role of clinical reassessment, before proposing its introduction into standard clinical practice.
References
Case report: Evaluating the role of ultrasound in the diagnosis of bilateral persistent sciatic arteries
Radiology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
Abstract
Peripheral vascular disease (PVD) affects 13% of the population aged over 50 in the western world and can be divided into two main groups: organic and functional. Other less common causes to include in the differential diagnosis in younger patients are Buerger’s disease and anatomical variants such as duplication of the superficial femoral artery and persistent sciatic arteries (PSAs). PVD is a major cause of morbidity and mortality globally. Symptoms vary from cold extremities, intermittent claudication, to acute and critical ischaemia. All of these have a significant financial burden on critical healthcare resources. This case report evaluates the role of ultrasound in the diagnosis of bilateral PSAs. A 16-year-old female was referred by her GP to the vascular clinic presenting with bilateral intermittent claudication. On examination, missing dorsals pedis pulses were noted bilaterally. No previous imaging was available and the patient was referred for a lower limb Doppler ultrasound. Initial ultrasound scanning demonstrated no evidence of diseased vessels causing the patient’s pain, but unusual arterial anatomy. Both superficial femoral arteries tapered to the distal thigh, where collaterals were demonstrated. Following the scan a diagnosis of persistent bilateral sciatic arteries was made. Ultrasound, due to its many advantages, is usually the first line imaging investigation to assess the peripheral arteries. In this case ultrasound was able to demonstrate that there was no evidence of any organically diseased vessels, but an anatomical variant causing the patient’s symptoms. However, it was unable to demonstrate the overall view of the lower limb vasculature, the origin of the PSA, or provide all information to classify the sub type in view of any potential treatment or surgery. Although ultrasound is useful in the diagnosis of PSA, it lacks the ability to assess the whole of the peripheral circulation.
Analysis of carotid referral practice at a hyperacute stroke unit (HASU)
Northwick Park Hospital, London, UK
Abstract
From the National Vascular Registry data, rates of carotid endarterectomies (CEAs) performed nationally are decreasing yearly. Our unit represents one of eight hyperacute stroke unit in London and we had experienced a similar reduction in CEA rates. We examine our referral process to identify the number of carotid duplexes performed in 2018, ascertain the pick-up rate for CEA and determine if all appropriate patients were referred for vascular input. A retrospective analysis was performed of all duplexes performed at our centre in 2018. This was cross-referenced with electronic patient records and physical notes. A total of 1209 carotid duplex scans were performed during the study interval, with 114 patients (9.4%) identified with significant (>50%) ICA stenosis. Of these, 34 patients (29.8%) underwent CEA. Ten patients who were not referred and had ICA stenoses of 50–59% as measured using the NASCET criteria. Two patients with no electronic documentation were referred to the vascular outpatient clinic. We identified that 12 patients with symptomatic stenoses were not referred to vascular surgery for inpatient assessment, which would represent up to a 35% increase in CEA activity. We recommend closer collaboration between stroke and vascular teams to identify patients who would benefit from CEA.
Veterinary
Case report: Left atrial rupture – Echocardiographic diagnosis: an interesting case
Cardiology, Northwest Veterinary Specialists, Runcorn, UK
Abstract
A left atrial rupture was diagnosed in a dog with advanced myxomatous mitral valve disease that experienced a sudden onset collapse episode after intense exercise. Two-dimensional echocardiography showed the presence of pericardial fluid, myxomatous mitral valve disease, severe mitral regurgitation and presence of organized echogenic material originating from the wall of the left atrium, extending adjacent to the left ventricular free wall within the pericardial space, suggestive of a thrombus. Supportive treatment, with oxygen, furosemide and pimobendan, was started. The dog’s state of health improved on treatment and was discharged after one day. The patient is alive at the time of writing.
Poster Exhibition 2019 Bowel
Ascites: In neonates, children and adults
Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
Abstract
Ascites is the abnormal accumulation of intraperitoneal fluid. This may be due to an intra-abdominal source or an important sign of an underlying systemic condition. In order to successfully treat ascites, it is important to accurately diagnose the cause. Ultrasound is very sensitive in detecting small volumes of fluid in the recesses. It may also help differentiate the nature of the ascites as simple fluid is anechoic, whereas complex fluid with exudative, haemorrhagic, or neoplastic components may have particulate debris, layered appearance and septations. There is a large differential diagnosis for the presence of ascites, which is different for neonates, children and adults. Through a series of cases, this presentation aims to demonstrate that ultrasound is a reliable imaging modality in the detection and characterisation of ascites and is central in making crucial clinical decisions with regard to guiding the need and timing of further imaging and definitive management.
Colonic diverticulitis: Is transabdominal ultrasound comparable to computed tomography in diagnosis?
Nottingham University Hospitals NHS Trust, Nottingham, UK
Abstract
Colonic diverticulitis (CD) occurs when mucosal protrusions (diverticula) from the colon wall become infected and inflamed. Its prevalence increases with age. Uncomplicated cases can be treated conservatively but complications such as large abscesses, fistulas or perforation may require urgent interventional or surgical management. The Society and College of Radiographers/ British Medical Ultrasound Society guidelines (2019)1 list diverticulitis among the bowel conditions where ultrasound can and should contribute in diagnosis. However, in the author’s institution, patients with suspected diverticulitis are referred directly for only a computed tomography (CT) scan. The objective of this study was to determine if the value of trans-abdominal ultrasound is comparable with CT in diagnosing CD. Several databases were searched using keywords derived from the research question. The results were limited to peer-reviewed articles in English and published between 2008 and 2018. The three most relevant articles which met the inclusion criteria were selected for critical appraisal. (1) Min et al. 2 discovered no significant difference between the sensitivity of ultrasound (89.04%) results alone and the net sensitivity (97.26%) of both ultrasound and CT (p = 0.101). The most common form of CD included in this study was uncomplicated. (2) Van Randen et al. 3 demonstrated a higher sensitivity for CT (81%), compared to ultrasound (61%) although this study did not differentiate between complicated and uncomplicated diverticulitis. (3) In Nielsen et al., 4 ultrasound misdiagnosed 79% of patients presenting with a complicated diverticulitis while ultrasound and CT results were consistent in 83% of the patients with uncomplicated diverticulitis. Ultrasound can effectively diagnose only uncomplicated diverticulitis. CT is more accurate in detecting complicated forms of diverticulitis. Misdiagnosing a complicated diverticulitis has serious implications on patient outcomes and management. This review supports local practice in the use of CT as the main imaging modality for suspected cases of CD. Ultrasound can be utilized where CT is contraindicated.
References
Inflammatory bowel disease in dog and human bowel, a comparison
Ultrasound, Royal Devon and Exeter NHS Trust, Exeter, UK
Abstract
Ultrasound of the small intestine has become a routine investigation in small animals, becoming more common as with humans due to improved imaging. Ultrasound can provide information on bowel wall thickness, layering of the wall, peristalsis and luminal contents. Canine intestinal ultrasound plays an important role in the recognition, diagnosis and monitoring of many gastroenterological diseases and is becoming increasingly important in the management of inflammatory bowel disease (IBD). IBD is an irritant disease that results in inflamed cells within the gastrointestinal wall. Suggestions for the cause are hypersensitivity to certain foods, bacteria, parasites or other foreign element. There is thickening of the bowel. Also two patterns of increased mucosal echogenicity have been reported: hyperechoic striations and hyperechoic speckles. Hyperechoic speckles within the mucosa are a sensitive parameter for determining the presence of inflammatory disease and may represent chronic changes that may require a longer period of time to resolve. Normal jejunum/ileum wall thickness is 3–3.8 mm and 1.5 mm for the large intestine. In humans, bowel wall thickness is the most common indicator for the detection of inflammatory activity within the intestine. Wall thickness of the alimentary tract differs by region and depends on the degree of distension and contraction and probe compression. Common cut-off values are 2 mm for wall thickness of the small intestine and 3–4 mm for the large intestine, although there is no standardization. Loss of layering is an indicator of active inflammation. In conclusion, transferring skills between canine and human imaging show similarities of disease.
General Imaging
Point of care ultrasound in the assessment of volume status: Glass half full or glass half empty?
St George’s University Hospitals NHS Trust, London, UK
Abstract
The objective of this study was to evaluate the use of point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) in the assessment of volume status. A review was carried out of literature regarding the value of IVC ultrasound in predicting response to fluid challenge. Estimation of intravascular volume status is vital in assessment of the acutely unwell patient. It has been shown that clinical judgement alone is a poor predictor of this, and thus POCUS of the IVC has been investigated as a surrogate marker. Several studies have shown ultrasound measurement of maximal IVC diameter and collapsibility index to predict hypovolaemia and fluid responsiveness. It has been successfully taught to medical residents within 4 hours, and appears to have good inter-rater reliability. The technique has become commonplace in emergency departments across the UK, yet the validity remains unclear. A number of studies have refuted the claim that IVC collapsibility can predict fluid responsiveness in both spontaneously breathing and ventilated patients. Furthermore, IVC diameter has been shown to vary dependent on sampling location and anatomical differences. This leads to a significant rate of false negatives, whereby radiological hypervolaemic/euvolaemic patients actually remain fluid responsive. A recent meta analysis suggested there was a moderate level of evidence that POCUS of the IVC can identify hypovolaemic patients, but concluded further research was necessary before it could be used with confidence in the ED. Lee et al. 1 provide a useful algorithm of how POCUS can practically be used to guide fluid resuscitation. We conclude that POCUS can be a useful tool to guide fluid resuscitation, but results should be interpreted with caution and used alongside clinical judgement. Further research in this area is required.
Reference
Combined prospective and retrospective assessment of haematoma formation post percutaneous ultrasound non targeted transthoracic liver biopsy: A single centre study
Hull University Teaching Hospitals NHS Trust, Hull, UK
Abstract
The aims of this study were: (1) to assess the frequency of haematoma formation post ultrasound guided liver biopsy, and the sequelae; and (2) to consider whether we can change the current standard in our hospital to combine all cases to one single medical day unit. An audit tool was created to collect data regarding indications for a liver biopsy, the number of attempts made, the number of cores taken and if there were any immediate post procedural complications. Four months of data were used. Two and a half months of data were used retrospectively and any follow-up in terms of scans or admissions following complications of the biopsy noted. One and a half months of data were collected prospectively by a radiology registrar using a portable ultrasound scanner to assess for haematoma formation 2–4 hours post procedure. Thirty-one patients were included in this audit (10/31 male; 21/31 female). Ten were assessed prospectively and 21 were assessed retrospectively using online patient records and the picture archiving and communication system to note any follow-up scans. In terms of indications for biopsy, the two most common were for non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (32% of patients), and for metastatic disease seen on previous scans (26%). The number of cores taken varied from 1 to 4 in a single sitting. No patients had any immediate post procedural complications (pain, hypotension, vasovagal, perforation). No scanned patients had a haematoma. One patient had significantly deranged clotting and received 4 units of fresh frozen plasma prior to the biopsy. Eleven patients underwent further imaging: five for tumour staging; two for routine? fibrosis ultrasound; one? ascites (2 months post biopsy); one computed tomography of kidneys, ureters and bladder; one magnetic resonance cholangiopancreatography – gall bladder calculus (?medication related). In conclusion, we had excellent post biopsy haematoma rates; although a small sample, results are encouraging; there is scope for reshaping services and improving our patient pathway, which is currently being analysed.
Case report: A series of unfortunate events – Epididymo-orchitis complicated by testicular abscess, necrosis and rupture
1Diagnostic Imaging, University College Dublin, Dublin, Ireland
2Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
Abstract
Acute epididymo-orchitis is the inflammation of both the epididymis and the testis and is a common cause of acute scrotum in male adults. Testicular infections are typically treated with antibiotics with little to no morbidity. However, in rare cases progression to complications such as abscess formation, testicular infarct and rupture may occur. The following case follows the care pathway of one such patient and examines the role of ultrasound in diagnosis and treatment planning. A 47-year-old male presented with severe right testicular pain and associated swelling and induration of the scrotum. The patient was being treated for epididymitis at the time of presentation. An ultrasound was requested to assess the testes to determine a cause for the pain. The ultrasound scan demonstrated epididymitis, a scrotal collection inferior to the right testicle as well as no intra-testicular flow concerning for testicular torsion or infarct due to infection. Exploratory surgery found no torsion and the testicle was deemed viable. A drain was inserted to treat the collection. A post drain removal ultrasound scan demonstrated a focal abscess, testicular necrosis and possible rupture of the inferior pole which was confirmed intraoperatively and histologically. A successful orchidectomy was performed. Ultrasound enables rapid and accurate diagnosis of testicular disease such as epididymo-orchitis, as reflected in this case. Acute scrotum is a common presentation. However, awareness of rare complications such as abscess formation, testicular infarct and rupture is paramount for positive patient prognosis.
Ultrasound image optimisation: The differential diagnosis of testicular lesions
Leeds and West Yorkshire Radiology Academy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Abstract
Testicular lesions encompass a broad spectrum, for which treatment strategies range from a ‘leave-alone’ approach, to aggressive, early surgical intervention. Since ultrasound is the preferred (and often only) modality of choice for imaging the testes, it is crucial to ensure that as unequivocal a diagnosis as possible is reported to the referrer. The practitioner-dependent nature of ultrasound has an impact on diagnosis and treatment. We present a selection of testicular lesions, seen in the ultrasound department of a busy tertiary centre, as a series of self-contained miniature case presentations. These are: (1) a 59-year-old male with tuberculous epididymitis; (2) a 31-year-old male with a testicular epidermoid tumour; (3) a 79-year-old male with a hyper vascular scrotal wall mass; and (4) a 49-year-old male with multiple testicular abscesses. A brief clinical background is given for each case, followed by annotated images. For each case, a particular emphasis is put on the imaging optimisation used when interrogating the findings. This is to impact on our increased diagnostic confidence, conclusion and patient management recommendations. The improper use of ultrasound scanner presets and settings can have an effect upon the image quality. This will have a significant impact on the scrotal image interpretation. We were able to exploit the characteristics of each lesion by making proper use of image optimisation; employing techniques such as color and power Doppler; varying the focal zones position and making use of artefacts such as posterior acoustic enhancement and shadowing. This is to form clear and sensible diagnoses and recommendations, which if incorrect, would have had significant patient management implications.
Sonographer led contrast enhanced ultrasound service: Is there more we can offer?
Hull University Teaching Hospitals NHS Trust, Hull, UK
Abstract
A contrast enhanced ultrasound (CEUS) service has been delivered in our institution since 2004. The service started primarily assessing incidental focal liver lesions. Previous audit of the CEUS service in 2008 demonstrated concordance between CEUS and secondary imaging in 88% with a discrepancy rate of 12%. CEUS in lesions of >10 mm was recommended at that time. The advent of increasing numbers of non-contrast renal CT, and the development of CT colonoscopy, has seen an increase in the need to characterise incidental lesions. The service has developed into a sonographer led service delivered by two experienced sonographers and has changed emphasis in recent years. The CEUS service, however, is still largely dependent upon radiologists’ and clinicians’ experience of CEUS and not delivered as a planned pathway for incidental findings. This is despite the 2012 NICE guidance and the EFSUMB guidelines of 2017 and 2018 which all advocate the use of CEUS as a first line investigation. The aim of this audit was to evaluate the current CEUS findings with any secondary imaging with a view to establishing a defined pathway which incorporates this technique as a primary investigation in the characterisation of incidental lesions. All CEUS examinations of incidental lesions performed in 2017 (207) were reviewed and compared with previous and subsequent imaging. CEUS findings and any secondary imaging tests were scored as benign, malignant or indeterminate. 83% of CEUS examination were characterised as benign, 11% malignant and 6% were indeterminate. Forty-six per cent of cases had secondary imaging; there was agreement between primary and secondary imaging in 92%. There were discrepancies in 8% (5) of cases which are discussed in this poster. CEUS is a useful and accurate imaging tool for the characterisation of incidental lesions and a defined imaging pathway has been developed accordingly.
Sonographer led extracorporeal shockwave lithotripsy (ESWL)
Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
Abstract
Extracorporeal shockwave lithotripsy (ESWL) is used in the treatment of urinary tract calculi; it uses high energy shock waves to fragment the stone so the smaller fragments can easily pass. This negates the need for surgical intervention. In recent years, ESWL has become known to be a minimally invasive, low risk and highly successful treatment choice for managing renal and ureteric calculi. With new advancements in lithotripsy technology, ultrasound imaging is now being readily used to aid in targeting renal stones and maintaining the focus during treatment; the main aim being to increase the accuracy of stone treatment and the efficacy of ESWL. In view of the new 2019 NICE guidance on treatment, this method is set to take precedence in the treatment of acute urinary tract calculi. This poster gives an insight into this advancing treatment method and our experience as sonographers delivering this service to the patients of Bradford and Airedale.
Combining prostate specific antigen density and adapted transrectal ultrasound prostate biopsy technique: Can the clinical significant cancer yield be improved?
Hull University Teaching Hospitals NHS Trust, Hull, UK
Abstract
Traditional extended core technique deployed for transrectal ultrasound guided prostate biopsy (TRUS Bx) procedures results in a high yield of prostate cancer detection. However, there are a number of patients with a negative but raised or rising prostate specific antigen (PSA). Using the traditional technique, biopsies are usually taken from the peripheral rather than anterior region of the prostate. Consequently, tumours originating from the anterior/apical region may be under-sampled and it is known that up to 30% of cancer is situated in this region. 1 – 3 However, sampling the anterior zone can increase the level of pain the patient experiences during the procedure, frequently to an unacceptable level. 4 It has been noted that men with a PSA density (PSAd) >0.19 have a significant risk of clinically significant cancers, 5 and suggested that combining PSAd with an abnormal digital rectal exam may lead to improved detection if the TRUS Bx technique is adapted. 6 The aim of this study was to evaluate if an adapted TRUS Bx technique in men with a PSAd of >0.15 improves clinically significant cancer yield at first TRUS Bx. TRUS Bx technique was adapted for all patients with a PSAd of >0.15 attending for TRUS from 1 June 2018 to 28 February 2019. The biopsy technique was recorded and compared with the subsequent histology results. One hundred fifty men had the adapted technique TRUS Bx. Fifty-eight (39%) were found to have clinically significant cancer. In 10 of these (17%) clinically significant cancer was detected in the cores taken from the anterior or apex of the prostate only but in none of the other standard cores. This initial study has demonstrated that using an adapted extended core TRUS Bx technique in men with a PSAd >0.15 increases the yield of clinically significant cancer.
References
Fusion guided transrectal ultrasound prostate biopsy: Does targeted biopsy following multi parametric magnetic resonance imaging (mpMRI) result in a more accurate detection of significant prostate cancer?
1Hull University Teaching Hospitals NHS Trust, Hull, UK
2Health and Social Care Research, University of Teeside, Middlesborough, UK
Abstract
The aim of this study was to ascertain whether the introduction of a new diagnostic pathway for prostate cancer using targeted fusion guided transrectal (fTRUS) biopsy following MRI has resulted in a more accurate detection of significant prostate cancer. A service evaluation, using retrospective secondary data of men on a new suspected prostate cancer pathway who had fTRUS and a subsequent prostatectomy, was undertaken comparing the histology from the fTRUS biopsy with the histology from the prostatectomy. The fTRUS target biopsy sample population comprised 40 men who were aged 70 or less and had a persistent sciatic artery of 10 or less. A comparator sample of 40 men of the same demographic who had undergone standard biopsy and prostatectomy prior to the new pathway was selected. Anonymised histology data were provided by the pathology department. The diagnostic outcomes for each man were established and the data analysed descriptively. Characteristics of the tests, including sensitivity and specificity, were calculated and compared with results from current literature. fTRUS target biopsy achieved a diagnostic accuracy rate of 92% compared to 77% with standard biopsy. There were also fewer false positives and false negatives in the fTRUS target group. The results confirm that fTRUS target biopsy following MRI has increased the accuracy of detecting significant cancer.
Slowly but surely: Contrast enhanced ultrasound (CEUS) for indeterminate renal lesions
Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Abstract
A review of prospectively collected data was undertaken to assess the diagnostic utility of contrast enhanced ultrasound (CEUS) performed for patients with renal lesions deemed indeterminate on conventional greyscale ultrasound, pre and post contrast CT and MRI. A prospective record of patient identification number, demographics, previous imaging, CEUS diagnosis, complications, subsequent histopathology and follow-up was accrued since the introduction of CEUS as a problem-solving tool for assessing indeterminate renal lesions at our institution in November 2017. Evaluation to determine whether CEUS provided additional diagnostic value over conventional imaging using histopathology, discharge or imaging follow-up schedules as references was undertaken. Twenty patients underwent CEUS to evaluate 22 indeterminate renal lesions from 09 November 2017 to 23 May 2019. All patients were thought to have Bosniak 2F/3 cysts or possibly solid hypo-vascular lesions on prior imaging. Eight of 21 lesions were deemed to be solid hypo-enhancing tumours on CEUS and histopathology from biopsy and/or resection confirmed 4 papillary renal cell carcinomas (pRCC), 1 oncocytic papillary renal tumour and 1 oncocytoma. Confirmatory histopathology was not obtained in one patient with two solid lesions, one in a transplant kidney and the other in a native kidney because the patient died of unrelated factors. Four lesions were found not to enhance on CEUS allowing for discharge. Twelve of 21 lesions (57%) were categorised as either malignant or benign allowing for definitive management such as surgery or discharge. Nine (43%) lesions were categorised as either Bosniak 2F/3 cysts necessitating imaging follow-up. CEUS has a valuable role as a problem-solving tool for renal lesions deemed indeterminate on conventional imaging. It guides whether to biopsy/resect, follow-up or discharge patients in all cases. Solid renal tumours diagnosed on CEUS tend to be hypo-vascular pRCC because characteristic microvascular enhancement (slowly but surely) has not been detected with conventional imaging.
Ultrasound imaging of the right-side upper abdomen: Revisiting lying compared to standing erect with gastric filling!
1Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
2Obstetrics and Gynaecology, Mater Dei Hospital, Msida, Malta
Abstract
The purpose of the technical tip is to showcase the role of assessing the patient’s right side upper abdomen with ultrasound in the standing erect position with gastric filling, compared to the supine position. Patients with suspected pathology were scanned fasting; first examined in the supine position without gastric filling. They then drank 200 ml of water (gastric filling). Patients were reassessed in a standing erect position. Images of patients with/out pathology in the supine and erect positions will be showcased. The standing erect and gastric filling intervention demonstrated improved visualisation and diagnostic confidence for gallbladder, lower end common bile duct and pancreas pathology, compared to the supine without gastric filling. In our experience, scanning the right upper quadrant and the epigastrium in a standing erect position following gastric filling water load is a useful and complimentary non-invasive technique. This should be considered before recommending alternative imaging modalities. The complimentary techniques may either obviate the need for referral for magnetic resonance imaging or computed tomography. This revisited intervention may enable a more effective and efficient patient pathway for diagnosis and therapeutic management. The use of one imaging modality on one day has a potential impact: for benefit to the patient by reducing anxiety; and reducing the workload burden on medical imaging services.
Ultrasound in adult patients with difficult peripheral intravenous access: Education intervention for clinicians
1Leeds Teaching Hospitals NHS Trust, Leeds, UK
2Emergency Medicine, Mid-Yorkshire NHS Trust, Leeds, UK
Abstract
The primary aim of this systematic review was to evaluate, in patients over the age of 18 years with difficult peripheral intravenous (PIV) access, the efficacy and efficiency of ultrasound guided PIV compared to the traditional ‘landmark technique’. The secondary aim was to evaluate the ultrasound guided PIV access educational interventions used, to aid continuing professional development, for medical and non-medical clinical practitioners. A literature search was undertaken using seven databases. Search terms were selected by an initial literature search. A PRISMA chart, quality assurance, data extraction, data analysis and synthesis were done. Five randomized studies were included in the review. Heterogeneity in ultrasound equipment, probes, technique, and practitioner education and experience were found. Two studies showed conflicting results for the time taken to gain PIV access using ultrasound. Two studies showed success rates of 88.6% and 96% using ultrasound. One of five studies (20%) stated the length of education and experience of the practitioner doing ultrasound guided PIV access. The clinicians who did the ultrasound procedures included anaesthetists and anaesthesiologists, emergency department physicians and technicians, and nurses. Limited robust evidence to demonstrate, in patients with difficult access, the efficacy and efficiency of ultrasound guided PIV access was demonstrated. Poor data on the type of the ultrasound education intervention was demonstrated. Ultrasound guided PIV access guidelines need to be established. The introduction of a new algorithm for the role of ultrasound guided PIV access requires in-depth clinical and academic education of medical and non-medical clinicians. A large prospective multi-centre randomized controlled trial is required to confirm the effectiveness and efficiency of the educational intervention for ultrasound guided PIV access.
Gynaecology
Case report: Cervical cancer – The role of ultrasound from diagnosis to treatment
Radiology, Hull University Teaching Hospitals NHS Trust, Hull, UK
Abstract
Despite a well-established screening programme which aims to prevent cervical cancer by treating pre-cancerous disease, data from 2014 to 2016 reveals that around 3200 new cases of cervical cancer are detected each year, with peak incidence in females aged 24–29. With presenting symptoms including unusual vaginal bleeding and pain, symptoms that can be attributed to many different gynaecological conditions, ultrasound will likely be one of the initial diagnostic tests performed to investigate. Referred by her GP for ultrasound, a 42-year-old patient presented with symptoms of abdominal pains, nausea, vaginal discharge and dysmenorrhoea. There was no relevant gynaecological history. However, the patient was not up to date with smear tests. A trans-vaginal scan revealed an ill-defined, hyper-vascular lesion in the anterior wall of the cervix with associated endometrial canal distension. Urgent referral to the gynaecology team was made and an adenosquamous cancer of the cervix was confirmed, following MRI assessment of the pelvis and a biopsy of the cervix with a predicted International Federation of Gynecology and Obstetrics (FIGO) staging of 2b. This patient has undergone combined treatment of chemotherapy, with external beam radiotherapy and intra-uterine brachytherapy. Three intra-uterine brachytherapy treatments have been given with trans-abdominal ultrasound guidance. This has been particularly important in this case for correct applicator placement given the risk of perforation due to the steeply anteverted position of the uterus on insertion. Whilst minimising the complications of uterine perforation, correct dosage to the treatment site is given, thus avoiding unnecessary higher doses to surrounding tissues. This case study is an example of the role of ultrasound not only in the initial detection of a FIGO stage 2b cervical cancer, but how it can aid in the successful placement of intrauterine brachytherapy applicators to positively contribute to the overall treatment.
Has ultrasound the sensitivity and specificity to make an accurate diagnosis of adnexal torsion?
1College of Health and Social Care, University of Derby, Derby, UK
2Emergency Gynaecology and Early Pregnancy, Nottingham University Hospitals NHS Trust, Nottingham, UK
Abstract
The Gynaecology Triage Unit at NUH NHS Trust operates 24/7, with the majority of women presenting with acute pelvic pain that may not necessarily be associated with early pregnancy. Adnexal torsion (AT) is sometimes considered to be a possible cause of acute pelvic pain and has a prevalence of 2.7–3%. Although low, its misdiagnosis has far reaching consequences beyond future fertility. Sonographers seem to be of the opinion that ultrasound (US) cannot really be used to accurately diagnose AT, due to its perceived lack of sensitivity and specificity. The author has a strong desire to review the accuracy of these opinions. AT is sometimes also described as ovarian torsion. However, the broader terminology is becoming the term of choice in more recent publications, as torsion can occur with or without tubal involvement. A literature search strategy was planned using PICO to identify key terms to search and then MeSH terms were employed for the time period between 2008 and 2018. Results provided insight into why AT is challenging to identify, and awareness relating to stages of the process of torsion. Specific clinical signs and US imaging hallmarks could be used in conjunction, and as US may not be the first imaging undertaken in an emergency, results were compared with computerised tomography (CT) and magnetic resonance imaging (MRI). Key hallmarks combined with clinical information could lead to early accurate surgical intervention and safer patient outcomes, as well as prevent unnecessary surgery. Use of this practical poster placed within the emergency gynaecology department and in-house dissemination for wider learning, could support both the sonography and emergency gynaecology teams to be better informed of US identifiers and clinical signs which may be indicative of AT.
Hysterosalpingo-contrast sonography and the subtle secondary signs of tubal patency
Radiology, Our Lady’s Hospital, Navan, Ireland
Abstract
One in six couples is affected by subfertility, classified as the failure to conceive after 12 months of regular, unprotected vaginal intercourse. Female problems are responsible for 70% of cases with tubal factors contributing to 20% of these cases. Tubal patency testing is therefore an essential first step in assessing the subfertile patient. Hysterosalpingo-contrast sonography is an all-inclusive screening test, evaluating the myometrium, endometrium, ovaries, tubal structure and patency. A variety of pelvic conditions which may be the cause for infertility can be illustrated. It is a well-tolerated procedure and an excellent alternative to hysterography (HSG) and laparoscopy. There is no ionizing radiation used. This is especially important in situations where fallopian tubes may momentarily spasm, thus, prolonging the examination time while waiting on the spasm to resolve. In addition, the risks of contrast reactions that may occur with HSG are eliminated. There is no general anaesthetic involved, an obvious advantage over laparoscopy. Our Ultrasound Department services a local population of 184,135. It is a two-room department servicing inpatients, outpatients, Emergency Department, Medical Assessment Unit and GP patients. In 2011, a dedicated HyCoSy service was established for this region, offered two days per week to assess tubal patency. In cases where tubal patency is confirmed, we have noted subtle secondary sonograpic findings. These include: free fluid containing echogenic bubbles indicating peritoneal spillage; echogenic rim around the posterior uterus; echogenic rim around the ovaries with subsequent loss of sonographic detail of ovarian tissue. Current literature portrays ultrasound appearances of tubal patency. However, the author found no publications about the more unusual secondary sonographic signs described. This pictorial review aims to share, demonstrate and increase awareness of these findings.
Case report: A case of uterine arteriovenous malformation – Ultrasound appearances
Ultrasound, Manchester Fertility, Cheadle, UK
Abstract
Uterine arteriovenous malformation (UAVM) is a rare gynaecological condition which can be life threatening when presenting with severe vaginal bleeding. Arteriovenous malformations are abnormal communications between arteries and veins in a tissue without the presence of an intervening capillary network. A 29-year-old female presented to the clinic following recent termination of pregnancy at 15 weeks’ gestation for foetal abnormalities. The patient was experiencing painless prolonged vaginal bleeding eight weeks post-surgical evacuation. The transvaginal ultrasound examination revealed marked enlargement of the anterior myometrial wall with dilated vessels. The endometrium was visualised separately but was distorted posteriorly. UAVM was suspected and a referral was made to the gynaecological assessment unit at her local hospital. Unfortunately, the scan findings at the hospital were ambiguous and retained products of conception (RPOC) was misdiagnosed. The patient underwent hysteroscopy and dilation and curettage which resulted in a complication of excessive blood loss requiring blood transfusion. Over time, the patient’s symptoms subsided and conservative management was recommended. Within eight weeks of the initial diagnosis of UAVM, the ultrasound examination revealed full resolution. The diagnosis of UAVM is challenging not only given the rarity of the condition but because they may present similarly to, or in conjunction with, other pregnancy related pathologies, such as RPOC, postpartum endometritis, as well as gestational trophoblastic disease. Accurate differentiation from other uterine pathology is critical as procedures such as hysteroscopy or dilation and curettage should be avoided in cases of UAVM as there is a risk of causing profuse bleeding and even death. This poster aims to highlight the importance of consideration of UAVM and to demonstrate the characteristic ultrasound presentation.
Ultrasound appearance of uterine vascular lesions: Pictorial review
Department of Diagnostic Imaging and Intervention, KK Women’s and Children’s Hospital, Singapore, Singapore
Abstract
Uterine vascular lesions are rare but potentially life-threatening lesions. In patients with vaginal bleeding, a pregnancy related event and prior instrumentation, diagnosis of vascular lesions such as arteriovenous malformation (AVM), pseudoaneurysm and direct arterial injury may be considered. Ultrasound (US) is the initial imaging modality for evaluation of abnormal bleeding. Angiography is performed in cases requiring therapeutic embolization. We report three cases where recognition of the US appearance of these lesions led to early diagnosis and appropriate treatment. Case report 1: a 38-year-old woman presented with bleeding after Caesarian section. US showed a mass composed of tubular structures and marked vascularity in the endometrium. CT angiography showed a vascular mass at the uterine fundus. Angiography confirmed left uterine artery pseudoaneurysm which was then embolised. Follow-up US showed resolution of the vascular mass. Case report 2: a 22-year-old pregnant woman with no prior instrumentation presented with heavy bleeding. US showed a mass in the endometrium with cystic spaces, intense vascularity and elevated peak systolic velocity. Angiography showed AVM and the patient underwent therapeutic embolization. Case report 3: a 17-year-old woman with prior termination of pregnancy presented with irregular bleeding. US demonstrated a mass with tubular cystic spaces with arterial and venous flow in the endometrium extending into the anterior myometrium. Angiography confirmed right uterine artery pseudoaneurysm with AVM. Uterine vascular lesions often manifest as a mass containing cystic spaces or tubular structures in the endometrium and/or myometrium on grey scale US. Colour Doppler US plays a significant role in demonstrating vascularity of these lesions. Differential diagnoses include retained products of conception, gestational trophoblastic disease and subinvolution of placental bed. Angiography confirms the diagnosis and therapeutic embolization may be performed.
Head and Neck
The abnormal neck node: A sonographers’ guide
Imaging, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Abstract
When performing head and neck ultrasound, abnormal lymph nodes are often identified as a cause for neck lumps. The presence of an abnormal lymph node will usually only form part of the clinical picture and once found will begin a process of further investigation. With the nasopharynx and oropharynx unable to be appreciated with ultrasound and due to the complexities of the lymphatic drainage system, the primary pathology may not be in the immediate vicinity. Also with the changes in disease process with the increase in human papillomavirus positive head and neck cancers, it can often lead to multiple imaging investigations being requested to ensure that the all areas are thoroughly assessed. This poster is a sonographers’ guide to head and neck lymph nodes and how location can indicate the possible primary diagnosis. This reference guide will give a visual representation of the common locations of spread for different head and neck cancers to support sonographers in performing a comprehensive scan which will help with the planning of the patient pathway.
A pictorial case review of the sonographic findings of facial lumps in adults
Radiology, Eastbourne District General Hospital, Eastbourne, UK
Abstract
Facial lumps are an infrequently encountered, but important clinical presentation with a wide spectrum of differentials ranging from benign surveillable lesions to malignant pathologies. High resolution ultrasound is not only the first line, but often the only imaging modality used and accurate diagnosis based on sonographic findings is key to directing appropriate management. We present a pictorial review of histologically confirmed cases in adults presenting with a cheek mass, who are referred for ultrasound assessment. The review covers a broad spectrum of both benign and malignant pathologies with description of salient sonographic features that allow accurate diagnosis. CT/MR correlation has been included where available. The benign diagnoses include abscesses, epidermoid cysts, mucocoeles, vascular malformations and benign tumours. More rare diseases such as IgG-4 disease and nodular fasciitis are also depicted. Examples of malignant conditions covered include primary presentations of lymphoma, mucoepidermoid cancer and spindle cell carcinoma and metastatic disease to the face from a number of primary malignancies. Bony lesions and those involving the parotid gland have been excluded. Facial lumps tend to be superficial and are readily amenable to high resolution ultrasound assessment. The primary role of ultrasound is to provide anatomical detail, information regarding the vascularity of a lesion and accurate initial characterisation. It also guides the need for further cross-sectional imaging in larger/more extensive or potentially malignant lesions and is subsequently used to direct percutaneous needle biopsy to establish a tissue diagnosis. We present several histologically confirmed cases of facial lumps, detail the imaging findings and potential differential diagnoses.
The role of new ultrasound technology in head and neck management
Radiology, Tameside and Glossop Integrated Care NHS Trust, Ashton-under-Lyne, UK
Abstract
This is a retrospective and prospective study performed in the one stop head and neck clinic to evaluate the potential of micro vascular imaging. All scans are performed by one of the team of sonographers, consisting of one consultant radiographer and two advanced practitioners. The ultrasound machine used is the Canon 450. This study primarily assesses the use of micro vascular imaging in lateral neck investigations. It will investigate its efficacy in determining squamous cell carcinoma and also infective lymphadenopathy. Micro vascular imaging can detect established vascularity in lymph nodes in cases where colour Doppler can only give a glimpse of vascular presence. In our study, we intend to explore whether, alongside the characteristic appearances on ultrasound, the presence/absence of established vascularity seen on micro vascular imaging can improve diagnosis. Some early results are described. A working hypothesis is: can the use of micro vascular imaging alter the care pathway with regard to reducing the role/necessity of core biopsy or even excision biopsy?
Crucial sonographic features of extrathyroidal extension: A pictorial review
Division of Radiological Sciences, Singapore General Hospital, Singapore, Singapore
Abstract
Extrathyroidal extension (ETE), a feature associated with papillary thyroid carcinoma (PTC), describes the extension of the primary tumour beyond the thyroid capsule and its invasion into adjacent structures. Among the suggested risk factors for patients with PTC, ETE has been identified as one with significant prognostic implications. This is attributed to its association with greater morbidity and mortality due to higher risk of incomplete surgical excision. Sonography is the first-line imaging modality for assessing thyroid nodules, and allows preoperative evaluation of ETE, which in turn facilitates surgical planning of thyroid cancers. This didactic exhibit aims to improve the diagnostic confidence of ultrasound practitioners in recognizing ETE by describing the important sonographic features of ETE and reviewing possible pitfalls which may cause misinterpretations. The Radiology Information System database was searched and thyroid ultrasound examinations performed in Singapore General Hospital between January 2016 and June 2019 were retrospectively reviewed. Serial static images of ultrasound studies that demonstrate histology proven ETE, as well as studies with false positives and negatives of ETE were collected. A pictorial review with actual case illustrations on thyroid nodules is presented to describe the pertinent sonographic features of ETE. These include capsular abutment by the nodule, bulging of the normal thyroid contour, and loss of the echogenic capsule. Where available, cases demonstrating false positive and false negative of ETE in sonography were also presented to enhance ultrasound practitioners’ awareness of possible ultrasound pitfalls which may lead to wrong diagnoses. It is imperative for ultrasound practitioners to recognize ETE, as this will facilitate timely diagnosis and management, which is in turn critical in ensuring good patient outcome.
Musculoskeletal
Case report: Abdominal wall lumps, not always a hernia!
Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
Abstract
An abdominal wall lump is a bulge or swelling, which can be located anywhere within the abdomen. The most common causes are hernias and commonly these patients are referred from primary care for imaging to confirm the clinical diagnosis. Ultrasound is the first line imaging modality for abdominal wall masses. This case study reports on a patient who presented to their GP with a six-month history of a pelvic pain with a lump on the lateral aspect of a caesarean section. The patient was referred by the GP for an abdominal wall ultrasound scan to exclude a hernia. The abdominal wall scan detected an intramuscular mass in the rectus muscle. As the lump was painful and under the caesarean section scar, an endometrial deposit was suspected. The patient had an MRI scan, which was indeterminate and the patient was referred to the local sarcoma multidisciplinary team. An ultrasound guided biopsy confirmed the diagnosis of an endometrial deposit and the patient had this subsequently excised. Abdominal wall endometriosis can occur following a caesarean section, with the classic presentation of a mass that increases in size and becomes painful during menses. Despite this, differential diagnoses include malignancies such as a sarcoma, metastatic disease or fibromatosis and benign abnormalities including a suture granuloma, hernia or abscess. As such, an ultrasound guided biopsy is required to provide a definitive diagnosis.
Review of bone pathology detected with ultrasound
Radiology, Peninsula Radiology Academy, Plymouth, UK
Abstract
We aim to review the imaging findings and clinical history of cases with bone pathology detected or diagnosed on ultrasound often unexpected or incidentally. This is a retrospective review of our imaging database and saved cases. We present ultrasound findings for pathology including osteochondromas, osteomyelitis, fractures and osteosarcoma. A wide range of bone pathology can present and mimic soft tissue disease for which ultrasound is often used as the first line investigation. Familiarity with the potential pathology and its ultrasound appearances may help instigate timely further investigation and treatment.
Ultrasound guided percutaneous trigger finger release: A recent, one-year experience in our centre
1Radiology, Kings College Hospital, NHS Foundation Trust, London. UK
2Radiology, Barts and Royal London Hospitals NHS Foundation Trust, London, UK
Abstract
The aim of this study is to highlight the benefits and limitations of this simple, outpatient technique in musculoskeletal radiology practice. Stenosing tendinosis/tenosynovitis (trigger finger/trigger thumb) is a relatively common cause of pain and disability presenting in general practice, rheumatology, and orthopaedic clinics. It presents with pain, popping, catching feeling and limited finger movement. Significant thickening of the A1 flexor tendon pulley thus restricting its motion causes it. It can be primary or associated with conditions such as diabetes, gout, repetitive finger stress, etc. Forty-one (n = 41) patients with signs and symptoms of trigger finger were referred to our service within a one-year period (1 January 2018–31 December 2018). Ultrasound (US) evidence of A1 pulley thickening was present in all cases. Thirty-one (n1 = 31) were females and 10 (n2 = 10) males. The age range at presentation varied between 22 and 71 years (median age 46.5). Eight (k1 = 8) patients presented with trigger thumb, 33 (k2 = 33) with trigger finger. Seventeen (p1 = 17) patients had predisposing conditions (diabetes, gout). Twenty-four (p2 = 24) had no predisposing conditions. Nine (p3 = 9) patients showing minimal A1 pulley thickening were not included in the study. Radiological, US guided percutaneous A1 tendon pulley release was performed in all 41 selected patients. No complications occurred in the interval. Thirty-five (r1 = 35) patients responded very well following A1 pulley release, with no need for further intervention at six months follow-up. Four (r2 = 4) patients returned for a second release procedure (all 4 diabetics). Two (r3 = 2) patients failed to respond and were referred for surgery. Radiological, US guided percutaneous A1 pulley release is a very good alternative treatment in the vast majority of referred patients where conservative treatment fails. It is fast reliable, and devoid of complications in most cases. Diabetic patients tend to respond less well. A small number of patients with significant A1 pulley fibrosis will require surgery. We further aim to study the additional benefit of corticosteroid injection to prevent pulley scarring.
Nevi analysis by ultrasound
Medical Imaging and Radiotherapy, Coimbra Health School, Polytechnic Institute of Coimbra, Coimbra, Portugal
Abstract
Ultrasonography, including B mode and elastography, is a non-invasive imaging technique, free of ionizing radiation and represents an excellent tool in the diagnosis of different skin changes. The purpose of this study was to evaluate and characterize the nevi by ultrasound elastography. The study included 66 participants aged between 18 and 70 years. Participants who had scars and/or tattoos in the study area were excluded. After informed consent, all participants answered personal and sociodemographic questions, such as age, ethnicity, sun exposure, use of sunscreen, among others. Then, the selected nevi were photographed, and ultrasound was performed on different areas of the skin with elastography on the nevi. According to rule ABCDE, the signs were normal and, through elastography, it was possible to verify that there was predominance of green colour, which is compatible with intermediate stiffness. It was possible to verify that the assessed nevi were normal, being concordant with the predominance of green colour in elastography. Ultrasound elastography was shown to be a good method for the evaluation of nevi.
Primary bone tumours: Rare but not to be missed
1North Bristol NHS Trust, Bristol, UK
2Withybush Hospital, Hywel Dda Trust, Haverfordwest, UK
Abstract
We present two cases of primary bone tumours that have presented to sonographer lists in the past 12 months. It is expected that a general radiologist will see two or less cases of osteogenic sarcoma in a working lifetime; primary bone tumours are rare and account for 0.2% of all malignant tumours in adults. Whilst undoubtedly rare and unusual, a diagnosis of osteogenic sarcoma or Ewing’s sarcoma may well present as a soft tissue mass on a general ultrasound list. We present the features to look for on ultrasound plus the actions that should be instigated if a primary bone malignancy is suspected. A 14-year-old girl presented to accident and emergency with a history of thigh pain and swelling. She was referred for ultrasound with the clinical question? haematoma. An 18-year-old male student was referred for ultrasound via his GP with a three-month history of intermittent swelling of the left forearm, with the clinical question? repetitive strain injury. The following learning points arose from these cases: (1) always ensure when imaging soft tissue masses that the underlying bone is assessed; (2) always assess any soft tissue mass with colour flow and ensure that this is recorded; (3) look at soft tissue margins – sarcomas may often have well defined margins, whereas osteomyelitis and haematomas will be ill-defined; (4) look at underlying bone cortex – signs to look out for are Codman triangle, spiculated cortex, soft tissue tumour arising from an area of bone destruction with displacement of soft tissues and possible preservation of the fat plane; (5) when malignancy is suspected, ensure radiographs are taken immediately if none are available; (6) ensure that senior review and urgent discussion occurs with a radiologist and that MRI is organised.
Obstetrics
A multi-disciplinary team approach to fetal anomalies
Bradford Hospitals NHS Trust, Bradford, UK
Abstract
This poster aims to inform delegates about how Bradford’s Multi-Disciplinary Team work closely together at a weekly meeting to improve the quality of care given to women found to have a fetal abnormality at scan. Our team includes obstetric consultants with a special interest in fetal medicine, sonographers, screening co-ordinators, neonatologists with a special interest in palliative care, and the palliative care team at a local children’s hospice. We meet once a week to discuss fetal abnormalities found the previous week and update any outcomes from previously diagnosed pregnancies.
Chorionic bumps: A potential pitfall in early pregnancy ultrasound
Stockport NHS Foundation Trust, Stockport, UK
Abstract
Chorionic bumps are described as being an irregular, convex bulge into the chorio-decidual surface of a gestation sac and most likely represent a haematoma. They are most commonly seen within the first trimester and can differ greatly in size and appearance, occasionally mimicking an embryo. Chorionic bumps are thought to affect approximately 4–7 per 1000 pregnancies and are often found incidentally. Research is currently very limited and the significance of this finding in relation to pregnancy outcome is unclear. The aim of this poster is to demonstrate the varying appearances of chorionic bumps and highlight this as a potential pitfall in early pregnancy ultrasound.
The Fetal Anomaly Screening Programme: Data collection and improvement methodology to raise standards – A case study
Ultrasound, University Hospitals Plymouth NHS Trust, Plymouth, UK
Abstract
National guidelines by the Fetal Anomaly Screening Programme (FASP) state that detection rates should be 75% and above for cleft lips during the anomaly scan performed at 18–20+6 weeks’ gestation. We undertake annual audits to assess our adherence to this target. In 2017, our detection rate fell below the standard to 50%. We wanted to improve our detection rate for and prevent further missed cleft lips and adhere to the FASP targets. This poster describes the methodology used in identification of areas where practice could be improved and plan-do-study-act (PDSA) methodology in making improvement where necessary. Robust collection of outcome data was central in identifying areas of practice requiring improvement, together with a communication and education strategy for ultrasound staff in achieving improvements where necessary. Yearly audit of fetal anomaly detection outcomes for 2018 demonstrated that all cleft clips were detected prenatally at the 18–20+6 weeks’ scan. The conclusions from the work were: (1) robust collection of outcome data is central to ensuring quality of service in relation to screening for fetal abnormality; (2) a clear strategy for improving areas of practice which fall below national standards is important; (3) this use of PDSA methodology enabled our department to demonstrably improve diagnostic standards for pregnant women in our institution.
Four unusual case studies of the fetal thorax
Royal United Hospital, Bath, UK
Abstract
It is estimated that in 2–3% of UK live births, there is a significant congenital anomaly. 1 Early antenatal detection not only gives access to appropriate counselling for parents but also to timely treatment pathways.2,3 Fetal Anomaly Screening Programme (FASP) aims to identify potential fetal anomalies out of an otherwise healthy population through a combination of biochemical and ultrasound markers. One of the components for the FASP anomaly scan is standardised screening for cardio-thoracic anomalies. Whilst four of the more common cardiac anomalies are audited, there are many different cardio-thoracic anomalies detectable during the 20-week anomaly scan.2,4 This poster describes four rare cardio-thoracic anomalies detected during the 20-week anomaly scan at the Royal United Hospital, Bath: aortic tunnelling; supraventricular fibrillation; a rhabdomyoma; and absent right lung. Each case is reported alongside FASP protocols with ultrasound findings and follow-up investigation, together with prognoses and literature studies on the anomalies. Ultrasound technique is discussed alongside common pitfalls and some potential differential diagnoses. Antenatal diagnosis is important in the management of major cardio-thoracic anomalies. In some cases, prenatal treatment can offer the best prognosis. For other cardio-thoracic anomalies, early detection will enable multi-disciplinary teams to schedule postnatal treatment. Furthermore, a timely diagnosis allows parents and families to adjust expectations, become involved in decisions and prepare for treatment.5,6
References
Looking through the keyhole at megacystis
1Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
2Maternity Department, St Luke’s General Hospital, Kilkenny, Ireland
Abstract
Megacystis is a sonographic finding of a bladder that measures large for gestational age. The global incidence is approximately 0.38% with male fetuses predominantly affected. The fetal kidneys produce urine from around 10 weeks’ gestation, and from 10 to 14 weeks the normal sagittal diameter of the bladder is <7 mm. A 37-year-old primigravida had a routine ultrasound at 12 weeks where a megacystis was identified. The ultrasound demonstrated a fetal bladder measuring 22 mm × 16 mm ×15 mm. A large cord cyst was also noted. However, there was no evidence of bladder exstrophy at cord insertion site, ruling out both a patent urachus and allantoic cyst. Fetal stomach and kidneys were identified and the fetal bowel appeared echogenic. Following referral to Fetal Medicine the chorionic villus sampling result showed normal chromosomes, with no other abnormalities detected. A scan at 16 weeks showed severe oligohydramnios, fetal growth restriction and a bladder diameter of >40 mm, with a keyhole appearance. The continued pressure from a hyperextended bladder can cause irreparable damage to the kidneys. Megacystis, if severe in the first trimester, can often lead to renal failure, with a combination of renal failure, oligohydramnios and the effect of the large bladder leading to pulmonary hypoplasia. In the absence of chromosomal abnormalities and the appearance of the fetal bladder, the findings in this case were suggestive of posterior urethral valve with a poor prognosis expected. The couple attended for a termination of pregnancy at 17 weeks’ gestation. However, prior to the procedure it was noted that the fetal heart had already stopped and there was a subsequent miscarriage.
Thinking outside the sac: Adnexal masses in obstetric ultrasound
London North West University Healthcare NHS Trust, London, UK
Abstract
The aims of this study were: (1) to review adnexal masses seen on routine obstetric ultrasound cases to determine the value of reporting ultrasound characteristics in assessing the risk of malignancy; (2) to examine the value of scanning and accurate reporting with follow-up scans and adequate referrals to aid patient management and exclude the risk of malignancy. A pictorial review was conducted on interesting cases with adnexal masses on routine obstetric ultrasound and subsequent scans. The International Ovarian Tumor Analysis (IOTA) criteria were used to determine the risk of malignancy in each case to evaluate subsequent management, including a conservative approach and post-partum planning/intervention. Three cases were reviewed and scored via simple IOTA rules to classify masses as benign/malignant. In the first case, an 8 cm multiseptated cyst was seen on NT scan with some loculations and no vascularity. This grew to 20 cm at 36 weeks’ gestation. The size added an ‘M’ characteristic, so MRI was performed. It was reported as a large multiseptated cyst with no solid/papillary projections and features of a benign cyst. Histology confirmed a mucinous cystadenoma. In Case 2, bilateral cysts with solid components measuring 8 and 4 cm were seen on nuchal scan with differential of dermoid cysts. MRI confirmed bilateral dermoid with ‘B’ features which were monitored monthly. In Case 3, a 20-cm collection in POD with septations at dating scan was followed up and reviewed with patient history – peritoneal thickening consistent with previous imaging which was result of TB several years earlier. The management of adnexal masses discovered in pregnancy is contentious. Application of IOTA criteria is beneficial. Observation is reasonable if asymptomatic and the sonographic features indicate a benign etiology. The majority of adnexal masses in pregnancy are incidentally discovered on routine prenatal ultrasound examination. Accurate application of IOTA criteria in serial scanning appears to be useful to determine the increased risk of malignancy.
Scanxiety: Can we reduce anxiety in primigravida patients attending for the fetal anomaly scan
South Eastern Health and Social Care Trust, Belfast, UK
Abstract
The Royal College of Obstetricians and Gynaecologists (RCOG) state that women must be fully aware of the objectives of the anomaly scan and this should be as explicit as possible so that they can make a decision with their partner on whether to proceed or not. The lack of information surrounding the scan could be contributing to patient anxiety and thus adding extra stress for sonographers undertaking these examinations. Through performing a quality improvement programme using qualitative and quantitative data we aimed to reduce patient anxiety by 10% for primigravida patients attending for the anomaly scan. A patient video was produced which so far, we believe, is the first of its kind in the UK. Our results to date have shown that for the majority of patients their anxiety is reduced after watching the video prior to the scan. The patient video includes a comprehensive description of the scan, detailing screening and its limitations, but at the same time ensuring that patients are aware regarding the positive experiences that an anomaly scan can provide. We can see from results thus far that social media can be used to facilitate a programme to improve public knowledge and perspectives regarding the fetal anomaly scan. Our aim once the study is complete is for patients to access the video prior to attending for the scan, by uploading using a QR code available at the time of the first appointment.
Knowledge of pregnant Portuguese women on obstetric ultrasound
Medical Imaging and Radiotherapy, Coimbra Health School, Polythechnic Institute of Coimbra, Coimbra, Portugal
Abstract
Obstetric ultrasound is part of prenatal care as a diagnostic test, allowing the identification of fetal abnormalities early, through the evaluation of pre-established parameters and when performed at the recommended gestation time. The perception and knowledge of Portuguese pregnant women on obstetric ultrasound diagnosis is something not yet studied and essential for the effectiveness of diagnosis and follow-up of pregnancy, as well as it is essential that pregnant women have an active participation in the change of the National Health Plan in Portugal, revision and extension to 2020. The purpose of this study was to evaluate the knowledge and perception of pregnant women on diagnostic ultrasound. The study was conducted using a questionnaire to 198 pregnant women whose pregnancy surveillance was performed in Portugal. The study was carried out from October 2018 to March 2019. Data were recorded and analysed using Statistical Package for Social Science (SPSS), version 25. The mean age of pregnant women was 30.6 years ± 5.0 (range, 18 to 43 years). The level of knowledge of pregnant women on diagnostic obstetrical ultrasound was rated as Insufficient (1%), Adequate (14.6%), or with a good level of knowledge (84.3%). However, there are specific questions that presented a high rate of incorrect answers. Regarding the expectations regarding obstetric ultrasound diagnosis, 61.6% of the participants considered that more ultrasounds should be performed during pregnancy, especially during the second and third trimesters of pregnancy. Of all, 79.3% of participants indicated that they would like to have more information on obstetric ultrasound available mainly through health professionals and childbirth preparation classes. Most pregnant women demonstrated knowledge regarding the purpose of diagnostic obstetrical ultrasound but less knowledge of the parameters it evaluates. It is an important time for pregnant women being most interested in having more information available on obstetric ultrasound diagnosis.
Paediatrics
Neonatal cranial ultrasound: A systematic approach, tips and common pathologies
Great Ormond Street Hospital for Children, London, UK
Abstract
Great Ormond Street NHS Hospital, London (GOSH) is a quaternary paediatric referral centre which sees a wide variety of patients and pathologies. Ultrasound is frequently used at GOSH to investigate the cranial contents and is particularly useful for identifying any abnormalities within the first few months of life and until the anterior fontanelle closes. It is an effective, non-invasive technique with high sensitivity and specificity. The pitfalls, however, are that it is highly operator dependent and requires a good and established knowledge of technique and anatomy, and confidence in usage of the equipment. This educational poster shows our ultrasound scanning techniques and protocols used to enhance imaging and reduce inter-observer variability. It demonstrates the variety of clinical presentations requiring specialist cranial imaging. Common abnormalities which present, including vein of Galen, ventriculomegaly and its follow-up, sagittal sinus thrombus and corpus callosum cysts are demonstrated. Scanning technique with tips, and the variety of pathologies encountered are presented as a pictorial review. Cranial pathology is a commonly encountered entity. However, it can often be met with a degree of trepidation when ultrasound is used as an imaging modality. We show the techniques employed at a quaternary paediatric centre alongside both normal anatomy and examples of pathology.
Ultrasound of the paediatric transplant kidney: Scanning technique and complications
Great Ormond Street Hospital for Children, London, UK
Abstract
End stage renal disease is uncommon in paediatrics, accounting for only 10 children per million each year. Despite these figures, Great Ormond Street is the largest paediatric renal transplantation centre in the UK, on average undertaking 26 transplants each year with the figures exponentially increasing. This leads to a demand of up to 62 ultrasound studies per month requiring the ultrasound team to have experience in providing high quality imaging studies. The technically complex interpretations for the immediate and long-term follow-up are essential and the multi-disciplinary team input relies on ultrasound as the main non-invasive imaging modality to evaluate the transplant kidney, enabling assessment of the anatomy and vasculature with minimal distress to the already delicate patient. It is therefore important for the ultrasound practitioner to have a thorough understanding of the technique to provide consistency for these regular follow up investigations. This educational poster provides information and imaging correlation of the normal renal graft anatomy and varying appearances. It shows the spectrum of post-surgical complications, which includes an AV fistula, post-biopsy haematoma, renal artery stenosis, peri-nephric collection and recurrent native renal disease. We apply a systematic approach to achieve an effective ultrasound technique. Our aim is to increase confidence in the assessment of the paediatric transplant patient with techniques that can also be applied to the adult population.
Concordance of ultrasound and magnetic resonance imaging in the vascular workup of patients undergoing renal transplantation
Radiology, Great Ormond Street Hospital for Children, London, UK
Abstract
Patients with end-stage renal disease are at risk of vascular thrombosis, either due to their underlying condition or as a result of treatment and years of lines for haemodialysis. Pre-operative vascular assessment helps to identify anomalous or occluded vessels, which then influences the operative approach. The aim of this study is to compare the consistency of ultrasound (US) and magnetic resonance (MR) imaging in the vascular assessment of paediatric patients undergoing renal transplantation. We carried out a retrospective review of patients transplanted at our institution from 2013 to 2018, comparing results of patients who had US and MR within four months of each other. The imaging findings were compared to the gold standard of the intraoperative findings. Patients were retrospectively stratified into high and low clinical risk groups. One hundred thirty-seven transplants were performed, 85 of which had pre-operative workup with US only. Twenty-two patients were worked up with MR only. Thirty patients had workup with US and MR. All went on to successful transplantation. There was concordance between US and MR in 17 patients (55%); 11 of these had a normal US and MR and 1 patient showed an occluded external iliac vein which was confirmed on MR. The US was equivocal in 10 cases (32%), and of these 8 went on to have an abnormal MR and 2 a normal MR. Seventy-one per cent of the low-risk group had normal US and MR. In the high-risk group, 46% were normal on US and MR. No low risk patients went on to have an abnormal MR. We conclude that US is an excellent screening tool in paediatric patients undergoing workup before renal transplantation and is a reliable technique to identify abnormalities. High and low risk stratification is essential in identifying patients likely to have vascular complications. MR is beneficial for patients with clinical concerns and ambiguous findings.
Ultrasound of urachal anomalies in children: A pictorial essay
Department of Diagnostic Imaging and Intervention, KK Women’s and Children’s Hospital, Singapore, Singapore
Abstract
The urachus connects the dome of the bladder to the umbilical cord in foetal life. This connection usually involutes at birth. Urachal anomalies occur when the urachus persists beyond birth. These anomalies may cause severe morbidity and mortality due to complications such as infection and malignancy. These anomalies often present in childhood and ultrasound is often the first and only modality needed to diagnose these lesions. The purpose of this poster is to illustrate the sonographic features of these anomalies and their complications. Four types of urachal anomalies may occur and these are: the patent urachus, where the entire communication between the umbilicus and the urachus has not involuted; the urachal cyst, which is a fluid-filled dilation of the mid-urachus; the umbilical-urachal cyst, which is a blind focal dilatation of the umbilical end of the urachus; and the vesicourachal diverticulum, which is a blind focal dilatation of the bladder end of the urachus. The sonographic features of these lesions and their complications are shown. After reviewing this poster, the reader will be familiar with the normal embryological development of the urachus and the sonographic characteristics of these anomalies and complications. The reader will be able to diagnose these anomalies early, helping to optimize an appropriate treatment plan.
Case report: Ultrasound diagnosis of Burkitt lymphoma presenting as ileo-colic intussusception
Department of Diagnostic Imaging and Intervention, KK Women’s and Children’s Hospital, Singapore, Singapore
Abstract
Idiopathic ileo-colic intussusception is a frequent cause of abdominal pain in children less than five-years of age. Ileo-colic intussusception occurring in adolescents should raise the suspicion of a pathological lead point which rarely may be due to Burkitt lymphoma. We present a case of a 15-year-old boy where the diagnosis of Burkitt lymphoma was suspected on the initial ultrasound. The objective of this case report is to highlight the ultrasound findings that led to the early diagnosis of Burkitt lymphoma which positively impacted the management and prognosis of this patient. A 15-year-old boy presented with increasing frequency of abdominal colic over a period of four months. Physical examination detected a mass in the epigastric region. Abdominal x-ray showed the presence of a soft tissue density over the epigastric region. Ultrasound revealed an ileo-colic intussusception containing a large soft tissue lead point with diffuse asymmetrical ileal wall thickening and surrounding lymph node enlargement. These findings led to a suspicion of Burkitt lymphoma and a decision was made not to proceed with an air enema reduction which would normally have been performed in idiopathic and uncomplicated cases of ileo-colic intussusception. A confirmatory CT scan and laparoscopic examination were performed instead. Laparoscopy confirmed the presence of an irreducible ileo-colic intussusception and biopsies of the enlarged lymph nodes confirmed the diagnosis of Burkitt lymphoma. The patient underwent chemotherapy. Follow-up CT showed the ileo-colic intussusception to be still present but the lead point and lymph nodes to be much smaller in size. This case highlights the importance of recognizing a lead point within an ileo-colic intussusception and the findings of Burkitt lymphoma within bowel. These findings in an adolescent should strongly raise the suspicion of Burkitt lymphoma.
Professional Issues
Return to sonography
London North West University Healthcare NHS Trust, London, UK
Abstract
There is paucity of information about the practical aspects of ‘Return to Sonography’. We considered retraining a sonographer who had not practised for 20 years and wished to return for obstetric scanning, to determine the feasibility, process required and length of time for retraining. Health and Care Professions Council requirements for re-registration are for 60 days of training. This should include a mixture of hands on learning, self-learning and lectures. We appreciated that the ‘hands on learning’ aspect would be the most challenging, but would be enhanced by access to our simulator. Completion of Fetal Anomaly Screening Programme online courses was a prerequisite. Following the initial practical sessions with dating and growth scans, anomaly scans were introduced with the objective of completing all four levels of City University competencies for obstetric scanning. The availability of a simulator for practice and online modules proved invaluable, combined with the interactions with the PGC/D students in our academy. After the initial month of training lists, service pressures forced us to revert to normal service lists with their inherent challenges. We started with an optimistic target of retraining in three months, but realised that six months were more realistic. At times, both the trainee and trainers were frustrated with a plateau in the progress. We were all delighted that level four competency was achieved in six months. The sonographer is now employed on a part-time basis, with the initial three months as a consolidation period. ‘Return to sonography’ is a daunting process, particularly after a lengthy break. We should not underestimate the demands of the practical aspects and reliance based on the good will, hard work and motivation of both the trainee and trainers. Furthermore, the stress on the trainee must be taken into account, with retraining ideally taking place in a dedicated environment.
Ultrasound Academy, the way forward in ultrasound training
The Ultrasound Academy, Central Middlesex Hospital, London North West University Healthcare NHS Trust, London, UK
Abstract
The national shortage of sonographers and increasing demand for ultrasound services have inspired the London North West University Healthcare NHS Trust Radiology Management to create a new approach to sonographer training – the first of its kind, The Ultrasound Academy, which opened at Central Middlesex Hospital in September 2017. The objective of this poster is to present a new, pioneering way of training sonographers in order to reduce the shortage of sonographers and produce highly competent sonographers. The students at the Academy have the opportunity to train in a hospital-based, state-of the art learning environment, where they are able to use the ultrasound simulator, student workshops, high quality ultrasound machines and dedicated student ultrasound rooms and extended scanning slots to reduce the pressure of training on those who undertake ultrasound examinations. The student sonographers benefit from ongoing on-to-one support. The Academy has teamed up with City University and Samsung to enable the students to learn in the best possible circumstances. The Ultrasound Academy has provided training for eight students at PGDip and PGC levels. The Ultrasound Academy seems to be the new and effective way of ultrasound training to tackle the shortage of sonographers in the UK.
I don’t understand: Setting communication standards in ultrasound
Clinical Quality, InHealth, High Wycombe, UK
Abstract
Effective communication is essential in all aspects of healthcare. Ensuring that patients understand the process of their appointment, and what will occur, has a positive impact on the efficiency of the appointment; the quality of the scan; the experience of the patient and is critical to informed consent. There are three basic forms of communication: verbal, written and body language. This project was instigated following an analysis of all ultrasound related complaints over a 12-month period. It was discovered that 58% of complaints were communication related. A project was begun to improve the communication skills of all clinical staff involved in the ultrasound service. This was accomplished with a series of practical workshops and reflective practice. This poster looks at the different ways that we all communicate with our patients, to raise awareness and perception of communication and how to improve those skills. We should think about our responses to patients and reflect on how patients perceive us. We need to assess how complaints may occur and also think about informed consent.
Diagnostic thoracic ultrasound imaging: An exploration of respiratory physiotherapists’ interest and use in clinical practice – A national survey
1Blackpool Teaching Hospital NHS Foundation Trust, Blackpool, UK
2Cardiff University, Cardiff, UK
3University of Essex, Colchester, UK
Abstract
Thoracic ultrasound (TUS) is an imaging modality used to assess the lung and has enhanced accuracy compared to chest radiography. This ability to accurately assess pulmonary pathologies would be a useful skill for respiratory physiotherapists to possess. Physiotherapists do not routinely learn to perform TUS; however, they are now beginning to learn TUS as autonomous practitioners. The aim of this study was to explore the use of TUS by respiratory physiotherapists through a national UK-wide questionnaire. A questionnaire comprising of open/closed questions was distributed at three national study days and via a newsletter containing a link to the questionnaire. The questionnaire was open for a six-week period between July and August 2018. A total of 133 questionnaires were completed and returned. Of the 133 respondents, 23% (n = 31) reported that they used TUS imaging in clinical practice with 76% (n = 101) reporting that they did not. The most common roles of TUS in practice were to: enhance the ability to differentially diagnose respiratory pathologies, aid respiratory assessment and support clinical reasoning. Of the 133 respondents, 44% (n = 58) reported that they had undertaken training in TUS imaging and 56% (n = 75) reported that they had not. The most common factors identified regarding TUS implementation were mentor availability, team support, ultrasound machine availability/cost, time pressures, evidence based support for its use and availability/cost of training. The majority of responses for all factors were predominantly negative with the exception of ‘team support’ which was more evenly balanced between positive and negative. This survey has provided an understanding of TUS practice amongst respiratory physiotherapists in the UK. The survey results demonstrated the barriers that inhibit current practice and highlighted the importance of mentors to support professional progression. There was a good understanding by all respondents regarding the clinical application of TUS.
Vascular
Feasibility of using portal vein pulsatility index for risk stratification in patients with non-alcoholic fatty liver disease
1Aintree University Hospital, Liverpool, UK
2Royal Liverpool and Broadgreen Hospital, Liverpool, UK
Abstract
The aim of this study was to establish the feasibility of stratifying risk of progression of non-alcoholic fatty liver disease (NAFLD) to steatohepatitis/cirrhosis by the non-invasive means of calculating portal vein pulsatility index (PVPI). We retrospectively reviewed portal vein flow (PVF) and calculated PVPI in a cohort of 62 patients referred for Fibroscan with either clinically or biopsy confirmed diagnosis of NAFLD, and compared it to the Fibroscan grading of fibrosis and liver biopsy where available. Of the 62 patients, only 28 patients who underwent ultrasound had adequately documented colour and spectral Doppler PV assessment. There were technical shortcomings also of the documented PVF. These included: lack of optimisation of angle of PV insonation, wall filter, colour velocity, and spectral velocity scale; inadequate length of trace; no caliper measurement of flow velocity; too large gate size with consequent sampling of hepatic arterial flow instead of PVF. A value of 0.48 ± 0.31 was used as normal PVPI in accordance with the literature; just one patient in our cohort had increased PVPI. No correlation with Fibroscan grading of fibrosis was present. Of the seven patients who had liver biopsy, three had no adequate PVF assessment; in all those remaining, mild/moderate fibrosis on biopsy corresponded to a normal PVPI. We have organised a teaching session for ultrasound staff on significance and correct technique of PVF assessment, and we have planned to prospectively measure PVPI in a new cohort of NAFLD patients, applying correct ultrasound technique. PVPI has been reported to have the potential to become a useful prognostic index for patients with NAFLD. We found inadequate documentation of PVF preventing accurate PVPI measurement in our cohort of patients. We have planned a prospective PVPI comparison with Fibroscan after a teaching session on correct PVF technique.
A single-trust service evaluation to identify if the ankle brachial pressure index test alone can accurately diagnose peripheral arterial disease without a duplex ultrasound in primary care referred patient
Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
Abstract
Non-invasive lower limb assessment for patients with suspected peripheral arterial disease (PAD), including those with diabetes, is commonly performed using arterial duplex ultrasound (DUS) and ankle brachial pressure indices (ABPIs). To improve the pathway for these patients and reduce scan time, Trust A has proposed to remove the DUS from the examination if the ABPI is within normal range. The aim of this study was to investigate whether ABPIs can provide reliable, diagnostic results for PAD unaccompanied by a lower limb arterial DUS in primary care referred patients. The secondary aim was to determine whether patient diabetic status had an effect on the reliability of ABPIs. A retrospective service evaluation was performed. Consecutive patients were identified between 1 September 2017 and 28 February 2018 at one National Health Service Trust. Cohen’s kappa, McNemar’s χ2, and diagnostic accuracy tests were performed on the study population and diabetic and non-diabetic subgroups. Significance was set at p < 0.05. Ethical approval was granted by Trust A and the University of Leeds. One hundred thirty-six cases were identified. Using DUS as the reference standard the results demonstrate ‘good’ to ‘very good’ agreement between ABPIs and DUS in the study population (K = 0.768) and non-diabetic cases (K = 0.813). For diabetic patients the agreement was ‘moderate’ (K = 0.416) and the sensitivity of ABPIs was 40% indicating a reduced performance by ABPIs in this patient group. DUS provides invaluable information for the diagnosis of PAD in GP referred patients both diabetic and non-diabetic. Therefore, DUS is important and required in the diagnosis of PAD and cannot be justifiably removed.