General Medical
Mass forming autoimmune pancreatitis (AIP) mimicking a pancreatic head lesion
Siobhan Alsop
University Hospitals Plymouth NHS Trust
Introduction: This report describes a case of mass-forming autoimmune pancreatitis (AIP) of which I wish to share my learning and experience.
Case: A 57-year-old female was referred for abdominal ultrasound for fatigue, painless jaundice and abnormal liver function tests. She was not tender on assessment. Ultrasound demonstrated a solid pancreatic head mass, isoechoic to the pancreas, with no biliary dilatation. The appearances and presentation were suspicious for malignancy, and consultant review prompted 2-week-wait referral for CT staging. Pancreatitis was not suspected.
CT was negative for cancer but demonstrated enlargement and loss of definition of the pancreatic clefts, suggestive of AIP. Correlation with elevated serum immunoglobulin G4 (IgG4) confirmed the diagnosis. MRI was performed eight weeks later to review response to steroidal treatment, which was unsuccessful. The patient was referred for immunosuppressant control, and will undergo annual imaging surveillance. She experiences ongoing fatigue but is otherwise well.
AIP is an organ-specific manifestation of systemic IgG4 disease, categorised by serum IgG4 elevation1. There can be multiple organ involvement affecting structures such as the kidneys and lungs1. AIP is a mimicker of pancreatic and biliary neoplasia, often presenting with painless jaundice2. The isoechoic appearance of the inflammatory mass and nil duct dilatation may have served a clue to the aetiology, although this can be seen in malignant and inflammatory disease2. Cross-sectional imaging is always indicated for characterisation3 however an awareness of AIP and painless inflammatory masses as differentials for malignancy will enable sonographers to report helpful, differential diagnoses which may alter or improve management and reduce undue patient anxiety.
Conclusion: Sonographers should be mindful that pancreatitis is a complex disease with a range of aetiologies and manifestations beyond gallstones and epigastric pain. Pancreatic masses may be inflammatory in origin and conditions such as AIP are often painless mimickers of malignancy.
References
1. Hara A, Watanabe T, Minaga K, Yoshikawa T, Kamata K, Kudo M. Biomarkers in autoimmune pancreatitis and immunoglobulin G4-related disease. World Journal of Gastroenterology. 2021;27(19):2257-2269. doi:10.3748/wjg.v27.i19.2257
2. Lanzillotta M, Mancuso G, Della-Torre E. Advances in the diagnosis and management of IgG4 related disease. British Medical Journal. 2020;369:m1067. doi:10.1136/bmj.m1067
3. Masood, M. Autoimmune pancreatitis: what we know so far. Journal of Gastroenterology and Hepatology. 2021 Dec 10;6(1):3-10. doi: 10.1002/jgh3.12688. PMID: 35071782; PMCID: PMC8762623.
Put your best ball forward, the rare occurrence of Varicocele Thrombosis
Ciara O’Toole Hutchison
University College Dublin
Background: Varicocele thrombosis is an exceptionally rare cause of acute scrotal pain. A varicocele is described as an irregularly dilated and painful pampiniform venous plexus within the spermatic cord. This rare pathology can be often misdiagnosed on clinical examination due to the non-specific presentation and comparable similarities to other inguinal conditions. This case describes the role of ultrasound in diagnosing varicocele thrombosis in two male patients aged 39 and 24 years old respectively. Both patients were referred for an urgent testicular ultrasound examination.
Ultrasound Findings: B-mode and colour Doppler ultrasound demonstrated hypoechoic tubular structures in the epididymal body and tail. A moderately sized varicocele was detected on the left testicle in both patients, combined with a segment of echogenic material suggestive of a thrombosed varicocele.
Discussion: Varicocele thrombosis is rare and can be difficult to diagnose on clinical examination. Ultrasound is considered the modality of choice for first-line investigation.
Doppler ultrasound confirmed the diagnosis of the left thrombosed varicocele, showing a complete absence of blood flow within a short venous segment in the varicocele, confirmed during the Valsalva technique. Currently, there is no standardised treatment option for varicocele thrombosis and further research is recommended. Conservative treatment is recommended to treat the majority of patients due to the risks of post-surgical complications. However surgical intervention and embolization are considered in patients who are frequently diagnosed with varicoceles where the risk of infertility is high.
Conclusion: Ultrasound plays an essential role in the diagnosis of varicocele thrombosis. It is regularly deemed superior to a physical examination in detecting varicocele thrombosis. Ultrasound is a preferred imaging technique as it is readily available, non-ionizing, and non-intrusive all lending to the patients’ age and allowing for a prompt diagnosis and reducing the impact of further complications.
Ultrasound LI-RADS: Impact of implementing a standardised reporting template for HCC surveillance
Samira Drees, Ruth Reeve
Portsmouth Hospital University NHS Trust
Objectives: Outline introduction of Ultrasound Liver Imaging Reporting and Data Systems (US LI-RADS). Review the impact of introducing US LI-RADS on reporting and imaging of HCC surveillance and management of new observations in patients at risk of HCC.
Method: US LI-RADS is a standardized system for imaging technique, interpretation, reporting and data collection for surveillance ultrasound in patients at risk for developing HCC. US LI-RADS aims to improve communication, patient care, education, and research by including controlled terminology, an illustrative atlas, reporting guidelines and education material. US LI-RADS is composed of categorisation of the visualisation and findings to direct further management.
Quality improvement methodology was utilised to implement US LI-RADS protocols into a single NHS trust, using audits to monitor application and outcomes. Implementation of US LI-RADS was complemented through the model for improvement’s Plan-Do-Study-Act (PDSA) cycles, reviewing acceptability/barriers during implementation. Retrospective audits were conducted.
Results: Initial review of 105 ultrasound scans in 2019 demonstrated US LI-RADS reporting was correctly used in 85% of examinations, with correct images recorded in 100% of examinations. Non-use was identified in non-permanent staff.
In total, 644 ultrasound reports over a 6-month period were reviewed in 2022, 45 reported abnormal findings (US2/3 scores). No US2 lesions progressed to HCC. A total of 52.6 % of US3 lesions were confirmed as cancer (42.1% as HCC, 10.5% other cancers) and the remaining 47.4 % were downgraded following cross-sectional radiology (CT/MRI). Use of US LI-RADS ultrasound surveillance of US2 lesions reduced the demand on cross-sectional radiology. Using US surveillance of US2 lesions, 82% were stable on ultrasound during the review period and 18% of US2s downgraded to US1 (benign) using CT in just one case.
Conclusion: US LI-RADS is well accepted by the radiology team. US LI-RADS is an effective tool that creates a streamlined pathway for HCC surveillance that can correctly identify potential HCC.
The sensitivity of ultrasound in detecting choledocholithiasis compared to other imaging modalities
Amy Dumigan
Portsmouth Hospitals University Trust
Aim: To undertake an audit at a local teaching hospital, assessing the ultrasound accuracy of detecting choledocholithiasis compared to MRI.
Objectives:
Gather data from PACS
Retrospectively screen patients who have had an USS, MRCP and ERCP
Interpret results
Discuss findings
Conclusion and dissemination
Methods: The retrospective cross-sectional analysis identified patients between April 2022 – March 2023 who underwent an ERCP examination on the RIS and were drawn from PACS. The researchers collected information of whether the individual had had an ultrasound examination and when this was conducted, an MRI examination and when this was conducted, alongside the date and results.
The inclusion criteria were patients who had an ERCP for removal of ductal stones. Exclusion criteria were patients who had received prior imaging elsewhere prior to the ERCP.
Results: The search results identified 168 patients who underwent an ERCP for removal of bile duct stones. Of these, 132 patients (78.6%) had a prior ultrasound examination, of which 45 patients (34.1%) were identified as having a diagnosis of choledocholithiasis. There were 86 patients (51.2%) that had an MRI prior to ERCP, whereby a total of 78 patients (90.7%) were confirmed to have choledocholithiasis. There were 75 patients (44.6%) who had an ultrasound followed by an MRI to ascertain a diagnosis of choledocholithiasis. The number of positive cases on ultrasound and MRI totaled 11 patients (14.6%), whilst 57 patients (76%) had a negative ultrasound diagnosis but a positive MRI diagnosis.
Conclusion: Ultrasound is the first line of investigation in assessing the gallbladder and bile ducts however, the detection rate at a local teaching hospital is poor compared to MRI. The use of ultrasound is considered because of its accessibility, tolerability and relatively cheap cost, although the results of this audit suggest that patients would benefit from having an MRI when demonstrating symptoms of choledocholithiasis.
Ultrasound in solid organ transplant assessment
Joshua Eves1, Laura Marsland1, Richard Beese2
1King’s College Hospital
2Queen Elizabeth Hospital
Aim: To present the role of ultrasound (US) in the assessment of solid organ transplants, for both routine, post-operative surveillance, as well as for the investigation of possible complications.
Methods: Pictorial review of post-operative US assessment of both liver and kidney transplants, as well as of common and/or important complications.
Results: The number of solid organ transplants performed in the United Kingdom has almost doubled in the last decade. The most commonly transplanted organs are the kidney and liver.
Transplant grafts are actively monitored following transplant for the entirety of the graft life, as complications, particularly vascular complications, can lead to graft failure. Whilst acute complications are more likely to occur in the days immediately following the procedure, whilst the patient remains in a specialist transplant unit, subacute and chronic complications may well trigger attendance or admission to non-specialist centres.
US imaging, including B-mode and Doppler assessment, is generally first line in assessment of solid organ transplants when there is a need to exclude post-transplant complications and all radiologists and sonographers should be competent and able to do so.
This pictorial review will describe the fundamental requirements for assessment of the post-transplant kidney and liver graft, as well as demonstrate how ultrasound can be used to identify complications in the acute, subacute and chronic setting.
Conclusion: Suspected complications following solid organ transplant may present in a non-specialist setting and US assessment is the first line imaging modality. It is important that all radiologists and sonographers are competent in US assessment in this important clinical context.
Adult ileocolic intussusception - rare cause of epigastric pain
David Johnson
Royal Melbourne Hospital
Adult intussusception is a rare acute medical condition which often presents with non-specific clinical symptoms and poses a challenging imaging diagnosis.
This case report describes an incidental finding of a large ileocolic intussusception of a 21-year-old female presenting with recurrent epigastric pain in a setting of longstanding gastritis.
Initially referred for targeted biliary ultrasound, an extended examination was performed on the basis of the patient’s clinical pain. This identified biliary sludge, distended bowel loops and a 10cm abdominal mass in the midline pelvis. The mass displayed a “target”-like appearance in the axial plane and “pseudo-kidney” characteristics in the long axis.
Subsequent computed tomography confirmed a radiological diagnosis of ileocolic intussusception with likely small bowel ischaemia and associated small bowel obstruction.
Emergency exploratory laparotomy and hemicolectomy identified over 55cm of non-reducible, compromised bowel. Pathological examination diagnosed a 3cm non-cancerous polypoid tumour as the lead-point of intussusception.
Despite hospital-acquired infection with subsequent collection drainage, the patient recovered well within two weeks of diagnosis.
Gynaecology
An ultrasound diagnosis of an ovarian collision tumour
Jennifer Johnson
Mid Yorkshire Hospitals NHS Trust
Background: A 69 year old woman was referred for an urgent ultrasound scan of her pelvis by her General Practitioner (GP) due to a history of left lower abdominal pain for a few months. On examination the GP thought that there was a palpable mass in the LIF. There was no previous imaging of the pelvis available for comparison and the patient was otherwise fit and well.
Case Summary: Ultrasound examination revealed two large cystic lesions arising from the pelvis measuring 19.5cm and 10.5cm diameter respectively. The smaller lesion contained an internal echogenic component with ultrasound appearances typical for a dermoid cyst. The larger lesion contained both cystic and solid components with internal vascularity noted within the solid area. The left ovary appeared normal and separate to these lesions and the right ovary was not seen. A small amount of pelvic free fluid was noted. An upper abdominal survey was unremarkable. The findings were reported as a large cystic lesion with some suspicious features and a possible co-existing dermoid cyst. CT scan confirmed the ultrasound findings with the larger lesion demonstrating borderline to malignant characteristics.
The patient underwent a TAH and BSO. Post-operative histopathology demonstrated two adjacent, but not admixed lesions. The smaller lesion was a benign cystic teratoma and the larger lesion was a Stage 1A malignant Brenner tumour. No further treatment was required.
Collision tumours are uncommon. They represent two histologically distinct lesions within the same organ but no mixing of cell types. Diagnosis can sometimes only be made post-operatively but in this case was suspected from the initial ultrasound scan. This case is even more unusual as Brenner tumours are rare ovarian tumours which are mostly benign with only 2-5% demonstrating malignant change.
The efficacy of ultrasound referral review for non-specific pelvic symptoms in a single NHS Trust
Rebecca Stephenson1, Catriona Hynes2, Pamela Parker1, Shaunna Smith1
1Hull University Teaching Hospital NHS Trust
2Sheffield Hallam University
Background: This service evaluation aimed to establish if Hospital Trust A are safely and effectively managing premenopausal pelvic ultrasound primary care referrals for vague pelvic pain and dysfunctional vaginal bleeding. The aim was to identify 500 R-cancelled referrals that met the study criteria, establish referral to diagnosis timescales either on US, CT or MRI and calculate what percentage had an US detectable pathology to assess the R-cancel process at Trust A against the BMUS (2021) guidelines.
Methods: A retrospective audit of R-cancelled data from September 2021 to August 2022 was extrapolated from a local radiology information system for analysis yielding a total sample size of 45 after exclusions. The data were sub-categorised and percentages for referral to diagnosis timescales and US detectable pathologies were calculated.
Results: Eight (17.8%) of the 45 R-cancelled referrals had an US detectable pathology of varying medical significance, 0% were found to have a malignancy. The average referral to diagnosis timescale was 4.3 months for US, 4.7 months for CT and 1 month for MRI. The mean average referral to diagnosis timescale was 3.3 months with 1% incurring a delay of two weeks referral to diagnosis timescale and 99% had no significant delay.
Conclusion: This service evaluation yielded a small sample size and low percentage of US detectable pathologies which indicates that Trust A has a well-established, safe and effective local R-cancel system in place. A larger audit of sonographer vetting skills specific to premenopausal US pelvis referrals from primary care may further support this. To aid the referrer and provide simplicity to the gynaecology referral criteria, the introduction and development of a Rapid Diagnostic Service at Trust A, specific to gynaecology could be considered in accordance with BMUS (2021) recommendations.
Improving the gynaecology fast track pathway
Catherine Allen, Rajnee Bai, Nikhil Bhuskute, Lesley Walker
Calderdale and Huddersfield Foundation NHS Trust
Aim: The multidisciplinary gynaecology team including ultrasound were tasked with considering new ways of working to embrace the best practice timed pathway (BPTP) for gynaecology fast track referrals to aid faster diagnosis and improve patient experience.
Method: The initial meeting of the clinical and non-clinical teams involved in all aspects of the patient pathway demonstrated a shared vision to improve both patient experience and performance.
Prior to the introduction of the new system of work, patients were either seen in clinic or patients presenting exclusively with postmenopausal bleeding (PMB) were referred from primary care into a one stop clinic. Retrospective audit showed that using ultrasound acquired endometrial thickness measurement, approximately 40% of patients with PMB did not require hysteroscopy after initial ultrasound which resulted in wasted appointments.
A straight to test triage pathway was created to provide a streamlined approach, ensuring correct initial test, reduce unnecessary appointments and improve overall patient experience. Ultrasound provided ring fenced appointments for straight to test patients. This was managed within existing radiology provision without any further resources or funding.
The pathway was trialled initially over a 3-month period and is now in its 23rd month, at each review all teams worked together with a flexible approach to fine tune new ways of working. Patient feedback has been monitored throughout via questionnaires.
Results: The number of patients first seen by ultrasound showed initial growth followed by maintenance, wasted hysteroscopy appointments reduced. Day 28 performance increased and has been met consistently since month three of the trial (averaging 99%). Faster diagnosis standard performance from January 2022 has been consistently above 75%.
Conclusion: Creating a model of work using existing radiology provision in conjunction with implementing a multidisciplinary response to the gynaecology referrals has significantly improved the faster diagnosis standard for patients and improved patient experience.
Assessment of the cervix and vagina in the routine transvaginal scan
Angela Clough
Derriford Hospital, University Hospitals of Plymouth NHS Trust
Background: Views of the cervix in a routine transvaginal scan are usually obtained when assessing the uterus appearance and size, and the vagina may be partially visualized in the introitus view. Focused interrogation of these structures however is invaluable in helping to detect a range of pathologies which may be the cause of common presenting symptoms such as dysfunctional bleeding. This poster discusses how and why, to improve imaging of the cervix and vagina and presents images of detectable pathologies.
Discussion: Focused assessment of the cervix should be performed in two planes with optimization of the image depth, field of view and focal zone. A longitudinal view should demonstrate the full length of the endocervical canal, with views of the bladder to help estimate the locations of the internal os and torus. Identifying a normal endocervical canal will generally exclude common pathologies such as cervical polyps, submucosal fibroids and the most common form of cervical cancer, which develops within the canal (exophytic). Although ultrasound is not the first-line test for cervical cancer it can be an unexpected finding, presenting as an endocervical mass. In addition, there are other rare-type cervical cancers, such as small cell cancer, that can be missed in cervical screening and may be detected on ultrasound as isoechoic lesions within the cervical wall (endophytic).
A remaining vaginal stump following hysterectomy for uterine or cervical pathology also requires detailed assessment for possible recurrence. Specific assessment of the introitus view for nodules within the rectovaginal septum is important in suspected deep infiltrating endometriosis. Focal assessment of the cervix and vagina may also help detect cervical and vaginal cysts, adhesions and/or endometriotic nodules within the POD, and incidental bladder/urethral pathology.
Conclusion: Focused assessment of the cervix and vagina is advantageous in the routine scan, with the potential to detect a range of pathologies.
MSK
The ABC of fluid-filled structures around the knee
John Ferrier, Kate Kingston, Samir Paruthikunnan
York and Scarborough Teaching Hospitals NHS Foundation Trust
Aim: Fluid-filled structures present clinically as non-specific soft tissue lumps. The low cost and lack of ionising radiation offered by ultrasound makes it the first line investigation for this presentation. Fluid-filled structures have defined ultrasound characteristics and therefore can be similar in appearance. As such, differentiating the spectrum of fluid-filled structures around a certain joint can be difficult; but is crucial for guiding clinicians and reassuring patients. We aim to outline the differing ultrasound appearances of fluid-filled structures around the knee, with reference to their clinical presentations and expected anatomical locations.
Methods:By presenting cases from our own practice, some with cross-sectional correlation, we outline the anatomical knowledge which contributes to determining the nature and origin of a variety of fluid-filled structures adjacent to the knee joint. This case-based approach allows us to share our experience of creating a differential diagnosis and supporting management of periarticular lesions.
Results: Cases include periarticular bursae and cysts, the knee joint articulation itself as well as its common recesses and outpouchings. We will also cover more complex and rare lesions, which may need further investigation.
Conclusion: Fluid-filled structures are common around the knee, they can appear identical on imaging. With reference to a series of cases, we outline the anatomical and clinical considerations which contribute to differentiating these structures on ultrasound.
When asymmetrical lower limb swelling isn’t a DVT
Kate Kingston, Samir Paruthikunnan, John Ferrier
York and Scarborough Teaching Hospitals
Objective: Asymmetrical lower leg swelling requiring exclusion of deep vein thrombosis (DVT) is an extremely common, almost reflex, ultrasound (US) request with dedicated clinical pathways and daily available scan slots. Our departmental venous Doppler ultrasound scans are sonographer performed, largely protocol driven, with the report mentioning the presence or absence of a Baker’s cyst. When other abnormalities are spotted a dedicated musculoskeletal scan is arranged. We will explore the wide spectrum of pathologies we have encountered when asymmetric lower leg swelling is not caused by a DVT.
Methods: Cases discussed in our pictorial essay were initially referred for a scan to look for DVT as a cause of their leg swelling. Several patients had more than one DVT scan, on occasion, despite the report identifying an alternative possible cause and suggesting further evaluation.
Results: This educational pictorial review will present the wide spectrum of causal pathologies that we have encountered over the past 10 years in patients with unilateral lower limb or calf swelling. Some are commonly seen such as ruptured or haemorrhagic Baker’s cysts, calf muscle tears or haematomas and cellulitis. Accessory muscles, thrombosed popliteal artery aneurysm, abnormal lymph nodes, osteomyelitis and soft tissue infections are less common whilst soft tissue tumours, scurvy, and elephantiasis neuromatosa from diffuse neurofibromatosis are rare. Occasionally, these pathologies caused a distal DVT by external venous compression. Where available we will correlate with cross sectional imaging.
Conclusion: Venous Doppler US scans are commonly performed to rule out DVT in patients with asymmetrical lower limb swelling. In cases with no DVT but significant swelling, other causes may be encountered and where there is high clinical suspicion, should be actively sought.
Set-up of a one stop multidisciplinary shoulder clinic - A quality improvement project
Kate Ashfield
Ultrasound Department, Altnagelvin Hospital, Londonderry, Western Health and Social Care Trust
Objective: Routinely, patients attend an orthopaedic shoulder clinic, and following the consultant’s clinical decision, may be referred for investigation or physiotherapy. Review following the decided intervention, can take many months due to lengthy waiting lists.
Introducing a multidisciplinary one stop shoulder clinic, the first in Northern Ireland, allows patients to receive their ultrasound scan and steroid injection where indicated, physiotherapy advice, then consultant review to decide further management. The project aim was to reduce by 25% the length of time of the patient’s journey for those presenting with a shoulder complaint to orthopaedic clinic, from initial appointment until review including investigations and treatment.
Methods: Reviewing 30 patients who underwent shoulder ultrasound established a baseline average waiting time of 26 weeks. Setting our aim using Quality Initiative guidelines was straightforward, as a specific patient cohort was targeted. Numbers were initially small as the clinic runs only twice every eight weeks. A driver diagram was designed to explore the primary and secondary drivers as well as the change ideas. Plan, do, study, act (PDSA) cycles helped develop the project. The clinic was piloted in a satellite hospital before being implemented across other trust sites.
Results: Wait times reduced from 26 weeks to 5.6 weeks. Shoulder ultrasound appointments reduced from 9.4 weeks to 5.6 weeks. There was a reduction in cannot attend /did not attend rates from 23% to 16%. Physiotherapy patients increased to 88% from 33%. Thirty patients completed a feedback survey with outstanding comments received. In total, 93% of patients responded excellent and 7% responded good to all questions.
Conclusion: Introducing a one stop shoulder clinic reduced patients’ waiting times by 78.46% resulting in a greatly enhanced patient journey, with three separate appointments consolidated into one. Consequently, a financial saving to the trust was made. Due to its success, the clinic was established across other trust sites.
Ultrasound has limited capabilities in assessment of bone tumours: Myth debunked
Louise Fitzgerald
University Hospital Limerick
Background: A 73-year-old male was referred to the ultrasound department after discovering an acute swelling at the region of the jugular notch. The swelling was mildly tender, not well defined, hard and non-mobile. An x-ray of the sternum and chest were performed, neither of which detected any abnormalities. A soft tissue ultrasound of the lump was requested for further assessment.
Ultrasound Findings: Sonographic evaluation illustrated a 5.8cm x 4.7cm x 5.4cm well defined, solid, heterogeneous mass with no retrosternal extension. The mass illustrated multiple prominent blood vessels on colour Doppler and demonstrated high velocity arterial flow on spectral Doppler. The consultant radiologist suggested that this lesion was thymic or nodal in origin and recommended a computed tomography (CT) thorax for additional evaluation.
Discussion: The CT thorax confirmed the presence of a heterogeneous enhancing lesion at the left costosternal joint extending into the manubrium sternum. This lytic lesion was not a soft tissue lesion but of bony origin. Ultrasound permits the evaluation of the bone surfaces only due to the difference in acoustic impedance between soft tissues and the bone cortex. However, in this case, the interruption of the cortex of the bone by the lytic lesion allowed visualisation of the intraosseous mass.
Further CT imaging of the abdomen identified an irregular enhancing lesion at the inferior pole of the right kidney, suspicious for renal cell carcinoma. An ultrasound guided biopsy of the sternal lesion confirmed bone metastases from renal cell carcinoma.
Conclusion: Ultrasound is the modality of choice for the evaluation of palpable soft tissue masses. Indeed, it’s utility should not be underestimated in the assessment of bone lesions. Ultrasound plays a pivotal role in the diagnosis of renal cell carcinoma and the metastatic process; either by identifying thrombus in the renal vein or metastases to the bone.
The clinical utility of emerging ultrasound techniques in the assessment of musculoskeletal soft tissue masses
Cai Sihui, Kho Ying Ying, Ooi Chin Chin, Tan Lee Wei, Tan Eu Jin
Singapore General Hospital
Objectives:
To explore the use of emerging ultrasound techniques, namely Superb Microvascular Imaging (SMI), Strain Elastography (SE) and Shear-wave Elastography (SWE) in the assessment of musculoskeletal soft tissue masses
To highlight the importance in selecting the appropriate assessment tool when assessing musculoskeletal soft tissue masses
To illustrate the sonographic characteristics of benign and malignant lesions using these techniques where available
To present a systematic approach for sonographic evaluation of musculoskeletal soft tissue masses with the incorporation of these techniques as problem solving tools
Methods: Studies performed in the institution were retrospectively reviewed. Appropriate scenarios where these techniques might be feasible would be presented and the potential pitfalls would be discussed.
Results: With the advances of ultrasound technology, SMI, SE and SWE are increasingly used for the assessment of soft tissue masses. SMI utilises adaptive algorithm to remove clutter artefacts while displaying low velocity flow. SMI also enhances visualisation of intra- and peri-lesional minute vessels with slow flow, allowing detection of tumour angiogenesis.
Both SE and SWE provide additional useful information on lesions’ stiffness compared to conventional US and minimise subjective interpretation of lesion hardness/stiffness based on palpation. These emerging techniques value-add to narrow down differential diagnoses as malignant lesions tend to be stiffer than their benign counterparts.
We provide an illustration to guide the application of these emerging techniques. Potential pitfalls or limitations are; excessive transducer pressure, resulting in reduction of SMI signal and increased SWE stiffness values; deep or larger-than-probe-footprint lesions, which limit accurate SE and SWE assessment.
Conclusion: SE, SWE and SMI are excellent adjunctive tools in the diagnostic test of soft tissue masses. Identifying characteristics of aggressive masses, such as intra-lesional vascularity, is important to allow timely clinical management. An effective systematic approach using appropriate technique application in image acquisition can minimise potential pitfalls.
The battle of ultrasound vs X-ray: Diagnosis of a finger fracture
Kerrin Boyle
University College Dublin
Background: Phalangeal fractures are a common pathology seen in the emergency department, however they are typically diagnosed using X-ray and not ultrasound. Ultrasound is useful in the detection of a radiolucent foreign body or a tendon injury post trauma. It is not the modality of choice if a fracture is suspected.
A 29 year old male presented to the emergency department with a swollen and tender left index finger after an injury at work. The patient was referred for an X-ray of their hand which was reported by the radiologist as no bony injury seen. The patient was subsequently discharged from the emergency department. However, the patient represented with an infected and swollen distal phalanx. An ultrasound examination was requested to out rule the presence of a radiolucent foreign body.
Ultrasound Findings: The ultrasound examination revealed a hypoechoic defect in the bony cortex at the tip of the distal phalanx with mild periosteal elevation. This hypoechoic defect demonstrated a sonographic appearance of a double contrast sign in the transverse plane, which is indicative of a fracture. There was also evidence of oedema noted at the distal phalanx. However, there was no sonographic evidence of a foreign body present. These findings represented an undisplaced healing fracture of the distal phalanx of the left index finger which was retrospectively identified on X-ray.
Discussion: A fractured finger is often clinically diagnosed in the emergency department through X-ray. However, ultrasound was an accessory tool in the diagnosis of a missed distal phalanx fracture. Dynamic sonographic imaging of the distal phalanx ensured there was no tendon pathology present or evidence of a radiolucent foreign body.
Conclusion: Ultrasound is not the modality of choice for diagnosing a fracture due to not being readily available. However, it is a beneficial accessory tool when an occult fracture is suspected.
An incidental ultrasound diagnosis of a vein of Galen malformation at 38 weeks and 5 days gestation
Jennifer Johnson, Melanie Harrison
Mid Yorkshire Hospitals NHS Trust
Background: A 26 year old primigravida patient was referred for an ultrasound scan at 38 weeks and 5 days gestation due to a history of reduced fetal movements. Her dating and anatomy scans had been unremarkable and a growth scan performed at 31 + 5 for tailing growth had not shown any abnormalities.
Case Summary: Ultrasound examination revealed that the fetus was in a breech position and an elongated midline cystic structure was seen within the fetal head. This was found to be highly vascular on colour Doppler interrogation with mixed arterial and venous high velocity flow noted. A vein of Galen malformation was suspected.
Following discussion with the local tertiary referral centre, the patient was transferred for repeat scan with fetal medicine. They agreed with our findings and the patient was transferred out of area due to the need for immediate transfer to a national centre of expertise following birth.
A live female was delivered by caesarean section at 39 weeks and 2 days gestation. She clinically worsened during the first week of life and an embolization procedure was performed on day 25. The post-operative period was complicated by a thalamic bleed and intraventricular haemorrhage requiring insertion of a drain, however the patient is now doing well albeit with some right-sided hemiparesis.
Conclusion: A vein of Galen malformation is a rare form of a cerebral arteriovenous malformation and is a defect which occurs early in embryonic development. It is not usually sonographically apparent until the third trimester. Antenatally, they present as a midline cystic structure with arteriovenous flow on colour Doppler, as in this case. Cardiomegaly, fetal hydrops and ventriculomegaly can also occur.
Is there a use for ultrasound in the detection and characterisation of CSDs?
Sarah Leslie, Heather Venables, Rebecca White
University of Derby
Aim: The Caesarean section rate is rising worldwide and with the complications associated with a Caesarean scar defect (CSD), means a subsequent pregnancy can be high risk for these women. The aim of this review is to determine if there is evidence to support the use of ultrasound detection and characterisation of CSDs.
Methods: A small scale literature review was carried out to establish the current evidence base for the performance of ultrasound in identifying CSDs, along with a systematic search of medical databases to identify the most relevant, up to date published material. The results were scrutinised to make sure they would inform the discussion and after applying inclusion/exclusion criteria, narrowed to a final seven papers.
Results: The review showed that ultrasound was the first line imaging tool to assess a CSD and that the length, depth, width, residual myometrial thickness (RMT) and anterior myometrial thickness (AMT) are the ultrasound measurements that should be taken to assess a CSD. This will aid the gynaecologist in their decision of how to manage any complication as there are no current management guidelines. A thin RMT and AMT, with increased length, depth and width measurements, characterise a CSD. An RMT of 2cm and a scar depth of 0.5cm are the cut off values to define a large CSD, with a highly significant relationship (p<0.0001) demonstrated between large CSDs and prolonged menstruation. CSD detection rates in symptomatic women were reported at 80.9% (p<0.05).
Conclusion: TVUS can detect CSDs in both pregnant and non-pregnant women, however with the serious complications associated with a defect, it is of benefit to be aware before a subsequent pregnancy, to reduce the risk of CSP. It is vital that CSD awareness is raised amongst sonographers and gynaecologists, and that they know how to assess and report them.
Obtaining first trimester two-dimensional (2D) anatomical views with the aid of three-dimensional (3D) ultrasound volumes
Jayne Lander, Jehan Karim, Aris Papageorghiou
University of Oxford
Objectives: To assess whether fetal anatomy can be examined using 2D image slices extracted from a 3D volume taken at this gestation.
Methods: This was a prospective observational study of women attending a routine first trimester ultrasound scan between November 2021 and April 2022. A routine 2D first trimester scan was performed, followed by a 3D volume of the entire fetus, starting in the sagittal plane. If successfully obtained, the 3D volume was uploaded to GE 4D view software. Each 3D volume was examined in multiplanar view to assess whether 2D images of diagnostic quality could be extracted for the axial head, facial profile, stomach, cord insertion, bladder, bilateral hands and feet, crown-rump length (CRL) and nuchal translucency (NT).
Results: In total, 81 participants were prospectively recruited. A successful 3D volume was obtained for 94% of participants. It was possible to diagnostically evaluate the following structures using only the 2D image slices obtained from the 3D volume: CRL (88%), NT (72%), head (93%), facial profile (80%), stomach (62%), cord insertion (86%), bladder (22%) bilateral hands (97%), bilateral feet (93%).
Conclusions: A single 3D volume has the potential to provide information on key anatomical structures within minutes. With appropriate training, extraction of 2D images from this volume at 11-14 weeks allows evaluation of major anatomical structures in the first trimester, reducing time pressures on ultrasound departments, and may provide additional benefit in reducing the rate of repetitive strain injuries for sonographers. Future studies should aim at optimising 3D acquisition, taking into account more difficult to extract anatomies; and examine whether this could be a useful alternative to 2D imaging rather than an adjunct.
A comparison of SMFMS and ISUOG criteria in the prediction of infants with features of growth restriction
Christopher Owen1, Naomi Griffiths1, Philip Owen2
1NHS Scotland
2Greater Glasgow and Clyde Health Board
Correctly identifying a fetus with growth restriction (FGR) remains challenging. Unlike small for gestational age (SGA) fetuses, there is no widely adopted antenatal criteria to diagnose FGR. It is well documented that most adverse outcomes are in growth restricted rather than SGA fetuses.
Our objective was to compare the test performances of one?. Published consensus-based ultrasound criteria (ISUOG) and 2. Published SMFMS ultrasound criteria in the diagnosis of malnourished newborns.
Methods: Both ISUOG and SMFMS criteria were applied to previously described prospectively collected data from 269 low-risk pregnancies undergoing serial EFW, umbilical artery Doppler and neonatal anthropometric measurements. The ISUOG criteria are 1. Estimated Fetal Weight (EFW) <3rd centile or two?. Two out of three from EFW <10th centile, EFW crossing >50 centiles or umbilical artery pulsatility index (PI) >95th centile. The SMFMS criterion is EFW<10th centile. Neonatal malnourishment (preceding FGR) was determined by a skinfold thickness measurement (SFT) <10th centile. Test performance is reported as sensitivity, specificity, PPV, NPV, +LR and –LR.
Results: ISUOG - Sens 57%, spec 84%, PPV 33%, NPV 93%, LR+ 3.6, LR - 0.51
SMFMS - Sens 68%, spec 78%, PPV 30%, NPV 95%, LR+ 3.1, LR- 0.41
Discussion: There are no published comparisons of the ISUOG and SMFMS criteria of FGR in the prediction of malnourished newborns. The test performances of both criteria are similar and modest with low LR+ results. As with most tests in obstetric practice, both criteria are useful in ruling out growth restriction (high NPV).
A limitation of our study is our inability to calculate the cerebroplacental ratio, a metric included in the ISUOG criteria, so there remains the possibility that our study has underestimated the potential of the ISUOG criteria.
Is the difference in mean sac diameter (MSD) and crown-rump length (CRL) a reliable predictor of an adverse pregnancy outcome?
Anne Kayley-Burgess, Rebecca White
Derby University
Aim: This narrative review intended to ascertain whether ultrasound measurements of CRL and MSD could be used to reliably predict adverse perinatal outcome should sufficient disparity be noted between measurements. In doing so, the researchers hoped to inform national and local policy to support sonographers and clinicians with the reporting and management of pregnancies most at risk of miscarriage.
Methods: A search was carried out using AMED, EMBASE, SCOPUS and Science Direct databases. These results were reviewed; many were rejected as they only considered single parameter studies. Papers were chosen which considered combined parameters and were published within the last six years. The final review generated three papers.
Results: All papers reviewed stated that a difference of <5mm between the MSD-CRL was a reliable indicator of early pregnancy loss. However, one paper that concurred with these results added that combined parameters were not a better indicator than the current single parameters already stated by NICE.
Conclusion: Early diagnosis of pregnancy loss is complex. The objective of a sonographer’s investigation is to provide a timely and reliable diagnosis to inform their reports and guide further management. Current guidelines, based on single parameters, have not been changed for the past ten years, with very few studies considering the relationship between parameters in combination as a predictor of outcome. Further primary research is therefore required to determine whether combined parameters may be a more accurate tool for diagnosis.
Patient expectation should be managed to ensure appropriately timed scans. Further education is also required for clinical staff and general practitioners to better support, counsel and signpost patients appropriately.
Physics
Stricter Mechanical Index limits are not being observed
Jasmine Lister, Prashant Verma
Sheffield Teaching Hospitals NHS Foundation Trust
Aim: This audit aimed to assess local compliance to the stricter MI limits imposed on lung and eye ultrasound examinations by professional bodies (MI < 0.7 and MI < 0.23, respectively), and the associated guidance.
Method: Study descriptions for lung (US thorax and pleural cavity) and eye (US eye left/right/both) ultrasound examinations were queried on PACS across the radiology and A&E department. The maximum MI across each study was noted alongside the pre-set, transducer, frequency, acoustic power and imaging mode. For studies with more than one transducer and/or pre-set, the maximum MI and associated parameters were noted per each variation. The station number was recorded for future investigation of pre-set values should any MI or imaging parameters have exceeded the specified limits. The maximum, minimum, range and modal values were calculated across both departments for each examination type, along with a tally of pre-set choice.
Results: In A&E (n=33), 45% of examinations had an MI > 0.7, nine of which had used a dedicated lung pre-set. In contrast, 90% of examinations in radiology (n=55) had an MI > 0.7, of which there were no examinations using a dedicated lung pre-set.
In A&E, only one instance (5%, n =19) of ultrasound on the eye was performed with a suitable MI, which used a dedicated orbit pre-set. Of the remaining 18 examinations, 21% studies were performed using a dedicated orbital pre-set and 61% utilised colour Doppler. No eye examinations were performed in radiology, due to the trust having a dedicated ophthalmological ultrasound service.
Conclusion: Both lung and eye ultrasound examinations have exceeded the limits imposed by professional bodies. The pre-sets in both radiology and A&E require revision, along with potential retraining of staff to understand the safety considerations that arise when scanning these anatomical sites. A wider, multisite audit is advisable due to discovery of ineffectual pre-sets.
Shear wave elastography imaging performance of a range of scanners: A comparative study using the Leicester-St Thomas’ Elastography Pipe Phantom
Emma Barton1, Patricia Amata2, Simone Ambrogio1, Carmel M Moran3, Emma Chung4,5,6, Fiammetta Fedele1, Kumar V Ramnarine1
1Guy’s and St Thomas’ NHS Foundation Trust
2The Christie NHS Foundation Trust
3Centre for Cardiovascular Science, University of Edinburgh
4King’s College London
5University of Leicester
6University Hospitals of Leicester NHS Trust
Introduction: Although clinical applications of elastography imaging techniques are expanding rapidly, the performance assessment and routine quality assurance of elastography scanners is limited. The aim of this study was firstly to develop custom image processing software to enable the quantification of all colour elastography map pixel values and second to assess and compare the elastography imaging performance of different ultrasound scanners.
Methods: We used the Leicester-St Thomas’ Elastography Pipe (L-STEP) phantom to acquire longitudinal and transverse images of six soft cryogel pipes with diameters ranging 1 - 6.5 mm which were embedded at 45° within a stiff agar tissue mimic. Shear wave elastography (SWE) images were acquired using optimised settings and linear probes on scanners from six different manufacturers. Custom MATLAB software was developed to quantify the RGB pixel values and extract the Young’s Modulus (YM) data. Our custom software was validated by subjective comparison with the displayed colour map and by quantitative comparison of region of interest (ROI) values obtained using the scanner measurement tools. Line profiles were taken along longitudinal sections of the cryogel pipes and at a tangent to them as well as horizontal and vertical line profiles of transverse pipe sections.
Results: Performance parameters including resolution, accuracy, variance/reproducibility, depth dependence, sensitivity and the L-STEP summative performance index were compared between scanners. Line profiles enabled quantification of full width half maximum (FWHM) pipe diameter estimates and the gradient near the soft-pipe/stiff-background interface which demonstrated potential as novel performance metrics. Similarities and differences between scanners were effectively highlighted and will be presented.
Conclusion: Our image processing software enables analysis of elastography images and is more versatile than options currently available on scanners. The L-STEP phantom was able to quantify a number of image performance parameters and helped to assess and to compare the performance of different scanners.
Ultrasound Imaging and the Ring Vortex Phantom: Initial Experience
Alana Matthews1, Jasmine Lister2, Prashant Verma2, John Fenner1
1University of Sheffield
2Sheffield Teaching Hospitals NHS Foundation Trust
Aim: The ring vortex complex flow phantom is a prototype device designed to challenge and assess quantitative flow imaging technologies. Its use of the ring vortex as its reference flow offers predictable, reproducible and stable vortical dynamics along with flow complexity and well-characterised velocities at the sub-mm scale. This study explored the performance of established clinical ultrasound techniques (B-mode and PW Doppler) in the context of the flow phantom.
Methods: Using a GE LOGIQ E9 scanner and 9L-D probe, ring vortex flows seeded with 10μm-diameter polyamide particles were imaged in B-mode. Five different ring speeds were investigated, ranging from 5cm/s-26cm/s. Ten rings were generated at each speed. Cine loops were analysed to determine the translational speeds of the rings and compared to experimental recordings, with further comparison to Laser-PIV benchmark datasets. Intra-ring velocities were measured using PW Doppler with a 1mm gate, positioned down the ring’s length in increments of 2mm. Five measurements were taken for each gate position, with maximum velocities averaged. These values were compared to benchmark Laser-PIV datasets.
Results: Analysis of B-mode images produced values which lay consistently within 10% of both real-time recordings and previously collected Laser-PIV measurements. Measurements of PW Doppler maximum velocities also correlated well to benchmark values across the length of the ring vortex, with higher velocities observed at the vortex cores.
Discussion and Conclusion: This phantom has previously established itself as a dependable flow reference, operating to within tolerances of 10%. The B-mode analysis confirmed anticipated correlation with the test object. PW Doppler traces mirrored benchmark measurements, with the expected biphasic signature observed at the vortex cores. The clear visualisation of the vortices invites further measurements, where future work will include cross-manufacturer and cross-transducer studies, and expansion to more state-of-the-art technologies.
Quantifying the effect of slice thickness on the imaging performance of ultrasound scanners
Scott Inglis1, David Roddy2, Stephen Pye2, Carmel Moran2
1NHS Lothian
2University of Edinburgh
Objective: The resolution integral (R) is a technique combining resolution at different depths into a single figure-of-merit. Overall imaging performance is quantified by calculating R using the Edinburgh Pipe Phantom (EPP), which contains nine anechoic pipes of diameters (d) between 0.4-7.9mm [1]. The depth (L) over which each pipe is visualised is plotted against 1/d, and the area under the curve is equal to R. From this curve, the depth of field (LR) and the characteristic resolution (DR) are calculated. LR is the length of the region of optimum imaging, and DR is the typical resolution within this region.
Aim: To develop a method for calculating R only in the slice thickness (ST) dimension (R(ST)), and compare results with R measured using the EPP (R(EPP)).
Methods: A slice thickness phantom (CIRS ATS538NH) was used to obtain continuous profiles of ST versus depth for three curvilinear (Siemens 4C1 and 6C1, GE C1-5-D), two linear (GE 9L-D, Siemens 18L6HD) and three multi-row linear transducers (Siemens 14L5 and 9L4, GE ML6-15-D). Assuming that a pipe cannot be imaged if a beam’s ST is wider than its diameter, L equals the depth range over which the ST is less than d. Values of L were obtained from which R(ST), DR(ST) and LR(ST) were calculated.
Results: R(ST) values (range 26 to 41) were 25-60% of the R(EPP) values, and were similar to single-element transducers (previously reported range 22 to 37). There was no clear relationship between R(EPP) and R(ST) but LR and DR were strongly correlated: r=0.99 and 0.86 respectively.
Conclusion: Slice thickness is an important limiting factor in the quality of grey scale ultrasound imaging. The performances of the clinical transducers tested, including three modern multi-row transducers, were similar to single element transducers in the slice thickness dimension.
Ultrasound QA in Northern Ireland: Experiences and challenges faced during a new service roll out
Joyce Joy, Cormac McGrath, Adam Workman
Belfast Health & Social Care Trust
Background: The Regional Medical Physics Service in Northern Ireland (NI) started a new ultrasound physics support service in 2019. This abstract summarises the experiences and challenges faced during the roll out. A few cases of repetitive faults on similar probes are presented. Cases of unusual faults and experiences with interactions with manufacturers are discussed further.
Methods: NI has five main healthcare trusts and there are 22 hospitals with specific radiology departments. An up-to-date inventory of all ultrasound scanners which belonged to any screening programmes such as BSP, AAA and Fetal Anomaly and of all radiology scanners was established and acceptance and baseline testing was initiated on these scanners.
Results and Discussion: Approximately 35% (39/111) of all probes tested had faults. In total, 70% (7/10) of a particular probe from Manufacturer A were found to be faulty and needed replacement. Cable fault, shattered crystal and increased number of drop outs were some of the major faults repeatedly noticed. Several probes of a similar kind from Manufacturer B were rejected due to similar damage to the surface coating making it impossible to clean adequately, hence presenting a cross contamination risk. Rare faults such as variation in the lens thickness, axial bandings, improper functioning of speckle reduction imaging, washed out appearance of images were also noticed.
POCUS training in low resource settings (Ghana) focusing on sustainability
Angela Booth1, Pascal Kangberee2, Papa Kojo Mbroh2, Davidson Iroko3
1University of Salford
2Cape Coast Teaching Hospital, Ghana
3School of Medicine, University of Health and Allied Sciences, Ho, Ghana
Introduction: The World Health Organisation acknowledges ultrasound as an important tool globally but recognises the need for education and training (Buscarini et al, 2013) and low resource settings are ideal for point of care ultrasound (POCUS) (Davis and Alade, 2021).
The aim of training in low-resource settings should ensure sustainability and not rely on expensive visits by overseas instructors. Many projects have attempted to train large numbers of practitioners in short time periods and not include education of future trainers (Dreyfuss et al, 2020).
Project outline: The University of Salford (UoS) in conjunction with Worldwide Radiology (WWR) started a POCUS training project in 2020 in Ghana with sustainability as a core priority.
2023 is the 3rd year of delivery and in 2022, the second year of delivery alongside the POCUS training, we started a “Train the Trainer” and three doctors who had completed the full course from the first cohort were selected to become trainers/assessors within our project.
They received teaching on mentorship, training, failing to fail, assessing and giving feedback from an experienced UoS staff member and who was on site in Ghana.
The three doctors were observed delivering teaching sessions and given verbal feedback. The university staff member observed them performing a formative and summative clinical assessment on one of the new cohort and giving feedback. They were then given feedback on their technique and discussed the final conclusions.
Conclusion: All three were moderated and there was no discrepancy between the decisions of the University moderator and the three new trainers. These three trainers are now being successfully used in year-3 and another three trainers are being “trained” so in year-4 there will be six moderated trainers to work within the UoS and WWR joint project and reduce the need for United Kingdom based staff to attend.
Undergraduate POCUS teaching: A survey of prevalence and attitudes in the UK
Catriona Farrell, Ingeborg Welters
Liverpool University
Aim: The advent of hand-held ultrasound devices has caused a surge of interest in POCUS. Until now, POCUS in the UK has principally been taught in the postgraduate setting. We investigated use of, and attitudes to undergraduate POCUS teaching in the UK.
Method: Google survey distributed within a network of undergraduate clinical skills leads at 36 UK medical schools via email over a tenweek period in 2023.
Results: Seventeen of thirty-six medical schools responded (47%). A total of 9/17 (52%) currently teach POCUS, 4/8 institutions started teaching POCUS in 2022. Total time spent on POCUS teaching is 5-6 hours in two institutions, 3-4 hours in three institutions, and 2 hours in three institutions. Teaching includes hands-on sessions, lectures, and demonstrations. Topics include vascular access (7/9), FAST (5/9), echocardiography (4/9), abdominal aortic aneurysm (4/9), pneumothorax (3/9), renal (3/9), ascites (2/9), lung (2/9), bladder (1/9) and pleural effusions (1/9).
Teaching is delivered by radiologists, anaesthetists, emergency, acute and critical care physicians, cardiologists, and non-medical clinical skills staff. Only two medical schools formally assess POCUS, one with a practical scanning assessment. Observation of POCUS in a clinical context was reported by one institution only.
A total of 14/17 (82%) of respondents are interested in developing undergraduate POCUS teaching. Barriers include lack of experienced teachers (13/17), time constraints (12/17), lack of a formal curriculum (10/17), limited access to equipment (10/17). 10/17 respondents regard POCUS skills as very beneficial to students’ future careers. 13/17 view POCUS as very integral to future clinical practice. 3/8 institutions who don’t currently teach POCUS have plans to.
Conclusion: Although POCUS teaching to undergraduate medical students is increasing in the UK, provision is patchy, without consistency of topics taught. Lack of time, standardised curriculum, resources, and skilled teachers are all barriers. It is thought likely that POCUS will form part of the clinical practice of tomorrow’s doctors. POCUS teaching at medical schools is markedly time-limited, and unlikely to result in competence.
The use of ultrasound in palliative care
Charles Middleton1, Richard Beese1, Thomas Hanton2
1Queen Elizabeth Hospital
2York Hospitals
Introduction: Hospice and palliative care refer patients for ultrasound diagnosis and ultrasound intervention.
Methods: We present cases in which we have used ultrasound to benefit patient care in these difficult situations. For example, placement of drains for malignant pleural and peritoneal fluid for symptom relief. We present a pictorial overview of the use of ultrasound in palliative care and a review of the literature.
Conclusion: In certain clinical situations ultrasound has proven of great benefit to palliative care patients.
Postgraduate medical ultrasound student perceptions and experiences of academy model clinical ultrasound training in Scotland
Diane Dickson, Morgyn Sneddon
Glasgow Caledonian University
Aim: The National Ultrasound Training programme (NUTP) is a new initiative based within the NHS Scotland Academy, Golden Jubilee National Hospital, to support clinical ultrasound training and boost training numbers in response to workforce decline and increased demand on service. NHS Scotland Health boards are being supported through funding of trainees from Scottish Government, directed by the NHS Recovery Plan 2021-2026.
Clinical training is a key component in the development of ultrasound competency and is traditionally heavily supported by NHS board clinical staff in their role as mentor/practice educator. This study will explore the perceptions and experiences of the first cohort of students who undertake clinical training within the newly established NUTP. Identifying potential opportunities and challenges, this study will provide evidence-based recommendations for any future enhancements.
Methods: Up to six, 60-minute, semi-structured, one-to-one Microsoft Teams interviews with NUTP trainees will be performed between June and September 2023. Open-ended questions to explore perspectives, barriers and facilitators will be audio-recorded and transcribed verbatim with participants invited to verify the transcript to establish rigour. Interpretative phenomenological analysis using inductive coding derived from the data’s lower order themes will be employed to explore data within and across participants.
This study was reviewed by the School of Health and Life Sciences Psychology, social work and allied health sciences departmental committee and given ethical approval on 13/04/2022 under the following approval code: HLS/PSWAHS/21/213
Results: The NUTP is supporting nine students from six Scottish NHS boards. Two interviews have been scheduled and recruitment is ongoing. Demographic service data and qualitative key findings and any future recommendations will be available for conference presentation.
Conclusion: Conclusions will be based on results following data collection and analysis.
Retention of sonographers: an exploration of sonographers’ experiences/perceptions and how these impact their intent to stay working within the NHS
Kirsty Cutt
York & Scarborough Teaching Hospitals Foundation Trust
Background: The sonographer vacancy rate is currently 12.6%. The demand for sonographers is rising due to the increasing imaging demand. Maintaining the current sonography workforce is essential. The Society and College of Radiographers (SCoR) 2019 Ultrasound Workforce UK Census found sonographers are more likely to leave their posts than other radiographers. The SCoR ranks sonographer retention as a top research priority.
Aims:
To determine whether sonographers are considering leaving roles in the NHS before expected retirement age.
To identify factors that influence sonographers to leave roles in the NHS before expected retirement age.
To identify characteristics of workplaces linked with sonographers’ intent to remain working within the NHS.
To determine if there are different themes that emerge between sonographers in the early stages of their careers compared to late career stage sonographers.
To use the study findings to make recommendations to improve retention of sonographers within the NHS at local and national levels.
Methods: This is an empirical mixed methods study. Data were collected through an online questionnaire. Participants were recruited using social network sites using snowball sampling. Inclusion criteria of participants included sonographers and student sonographers who have experience working in the NHS.
Results: Ninety-two participants’ responses were analysed. 11 sonographers who work solely in the NHS (15% of NHS sonographers) were under 55 years old and considering leaving ultrasound. A negative workplace culture is linked with a higher intention to leave. Regular feedback, ability to seek advice and CPD is linked to a positive workplace culture. Only 7% of participants are fulfilling all four pillars of advanced clinical practice; clinical practice, research, leadership and education. 78% agree that opportunities for career progression make a good working environment.
Conclusion: Local solutions exist which could improve sonographers’ intent to stay working within the NHS.
Delivering ultrasound training in non-acute settings: measuring impact
Morag Stout1, Claire Lindsay2
1NHS Education Scotland
2NHS Scotland Academy
Objective: To determine the impact a National Ultrasound Training Programme (NUTP) has on workforce and service delivery by qualitative assessment from learners, mentors, managers and patients.
Methods: Learners attended a new National Ultrasound Training Programme. Whilst the academic component of their training was unchanged, they attended a National Waiting Times Hospital for five, 1-week blocks of training over the academic year. Learners were taught knobology, practical scanning and reporting. Feedback was obtained from learners at the start and end of the programme via a survey. Mentors were interviewed halfway through the academic year and surveyed at the end of the year. Service managers were also surveyed to capture any potential impact on acute sites. All patients were invited to complete a patient satisfaction survey.
Results: Eleven learners from six health boards attended NUTP. Feedback was globally outstanding with praise for training in a relaxed, supportive, unhurried environment. All felt more confident after attending and felt their training had accelerated as a result. Mentors were content with the programme. They believed the quality of training was excellent and it took pressure off their sites. All will be keen to use the programme again. One mentor commented that more information about the programme would have been useful prior to commencement. Managers had a similar response to mentors and some commented that not having to convert some lists to training lists impacted on patient turnaround and eased pressure on mentors. To date, over 4000 scans have been performed at NUTP. Patient feedback has been tremendous, with over 2000 responses reporting 100% patient satisfaction.
Conclusion: Results demonstrate NUTP has been extremely well received by learners, mentors, managers and patients. The training has accelerated and enhanced learning whilst easing pressure on acute sites and reducing waiting times.
Service pressure in diagnostic ultrasound: “doing more” is not the answer. Improving efficiency whilst protecting sonographers’ wellbeing
Morag Stout1, Claire Lindsay2
1NHS Education Scotland
2NHS Scotland Academy
Objective: To modernise administration processes in imaging departments to minimise “did not attend” (DNA) rates so as to maximise efficiency whilst avoiding the practice of overfilling ultrasound lists.
Method: Patient focused booking commenced in Ultrasound in January 2023. Patients receive an invitation to call to arrange an appointment within 72 hours. In March 2023, two questions were added to the invitation letter to avoid unnecessary scanning and/or duplication of work. Patients were asked to inform administration staff if they had already had a scan (ultrasound or other modality) or had surgery since the original request was submitted.
A survey was developed and sent to 14 Health Boards to consider administration processes around outpatient ultrasound booking and their associated DNA rates. Information around use of text confirmation(s), patient focused booking and short notice cancellation lists was collected and correlated with DNA rates.
Results: Introduction of patient focused booking in January 2023 showed DNA rates to reduce from 6.6% in September 2022 to 4.8% in February 2023. Introduction of two questions regarding interim imaging and/or surgery in March 2023 resulted in DNA rates reducing to 3.8% in May 2023.
In total, 11/14 boards responded to the survey. One board used patient focused booking and five used text reminders. Four used a short notice cancellation list. DNA rates varied from < 4% to 12% with an average rate of 7.3%. A clear association was identified between lower DNA rates and use of text reminders. However, this was strongly evident when coupled with patient focused booking.
Conclusion: Patient focused booking as described has been shown to be extremely effective in reducing DNA rates. This requires investment in administration staff but will without doubt save money whilst protecting staff.
What are sonographers’ perceptions on their practice and future of the sonography profession?
Andrew Lee1, Catriona Hynes2
1Sheffield Teaching Hospitals NHS Foundation Trust
2Sheffield Hallam University
Introduction: There is a shortage of sonographers within the UK and sonographers commonly complete postgraduate training in medical ultrasound before independent practice. New models of direct-access education introduced alongside a sonographer career framework aim to provide professional structure aligning with other allied health professions (AHP). Direct-access undergraduate education is a change from postgraduate training routes. Previous research has identified scepticism and reluctance to embrace change.
The title “sonographer” is not protected, and a high proportion of sonographers maintain statutory registration via primary AHP registers such as HCPC. Entrants to sonography through direct-access are ineligible to be statutorily registered which has implications on eligibility for advanced clinical practice.
Aim: What are sonographers’ perceptions on their practice and future of the sonography profession?
Methods: A qualitative study was undertaken, using semi-structured interviews to gain an understanding of current perceptions sonographers hold on issues facing the profession.
Results: Sonographers consider undergraduate entry, professional identity and practice, registration, and service delivery as key issues. Perceptions relating to undergraduate entry suggest a positive outlook focused on effective implementation rather than reluctance. Participants view the absence of professional registration as a hindrance for those unable to register as an existing AHP. This has led to concerns regarding a two-tier workforce because only registered professions can hold an Advanced Clinical Practitioner (ACP) title.
Participants noted sonographers have varying levels of awareness and engagement with the ACP four pillars of practice. They also identify service and workforce pressures as an issue, hindering progression within the profession.
Conclusion: There is a growing optimism towards new career frameworks, as they may provide benefits such as supporting experienced sonographers to develop as ACPs and enhancing their status and recognition within the profession. Statutory registration and service pressures remain a concern and sonographers look to leaders of the profession to consider solutions.
Is simulation-based education an acceptable method of education to safely and ethically develop sonographers’ advanced non-technical skills?
Beverley C. Scragg, Angela Booth, Colin P. Griffin
University of Salford
Simulation-based education (SBE) is a recommended component of medical education. SBE is a recognised method of teaching both technical skills and non-technical skills in an evidence-based manner, which can improve patient outcomes (HEE, 2016). It is also recognised that SBE in healthcare education is good ethical practice, as it traditionally does not involve learning skills on patients (BMA, 2003). Students have been using imaging-based simulators for many years and this is well-established in education.
Sonographers increasingly undertake complex tasks autonomously, and the BMUS Preceptorship and Capability Development Framework for Sonographers identifies key capabilities that includes enhanced communication skills, complex decision making, governance and safety (BMUS 2022).
The University of Salford, in partnership with GE HealthCare, have opened The Centre for Medical Imaging (CMI), which lends itself well to SBE.
Accordingly, we have introduced SBE into sonography education to explore the merits of this method in teaching non-technical skills such as adaptability, decision-making and governance, along with preparing the student sonographer to break bad news, counsel patients and de-escalate conflict situations, along with scope to explore the concept of giving results. The SBE equipment in place include animatronic mannequins that are directed to react, and interact, with the students which offer the ability to work through a “real-life” simulated experience within the CMI.
Students co-created the curriculum, identifying issues that they wanted to examine in the sessions.
We describe a pilot study, whereby we evaluate what impact, if any, SBE has on the student sonographer’s technical and non-technical skills. We use a non-experimental design to survey the students and use thematic analysis to answer the primary question: Is SBE an acceptable method of education to safely and ethically develop sonographers’ advanced non-technical skills?
The impact of virtual site visits on sonography program accreditation
Catherine Rienzo
Society of Diagnostic Medical Sonography
Introduction: While programmatic and institutional accreditation remains the vital components of quality education, the associated costs of a site visit can be high, especially when the technology is available to accomplish this process virtually. In the wake of the COVID-19 global pandemic, it also became evident that a virtual site visit was the only viable means to accredit diagnostic medical sonography programs, given safety concerns for site visitors.
Methods: The study followed a mixed method, quasi-experimental design. These virtual site visits include all learning concentrations (e.g., general sonography, adult cardiac sonography, and vascular technology) along with programs offering a multi-concentration educational program (i.e., combinations of any of the listed learning concentrations).
This research was based on three quantitative questions and a fourth qualitative question.
Results: The data analyses confirmed the McEwan and Walsh theory that the virtual accreditation site visit is a viable option given the many possibilities of communication technologies available today. This cost-saving alternative has the potential to reshape the rigorous accreditation process while saving educational institutions the expense of the on-site visit, which the program directors noted.
Conclusion: A future study of this kind could be enhanced by using a larger sample size than the 28 programs that participated in this study.
Take home message: In an era of cutting costs and maximizing efficiency while still upholding the integrity of the programmatic accreditation, the virtual site visit does maintain the effectiveness and efficiency of the accrediting process.
Evaluation of a sonography high intensity foundation training programme
Heather Venables, Rebecca White, Gillian Coleman, J. P. Mayes, Emma Hyde, Nang-Tege Ekumah, Elle Whyke
University of Derby
Aim: Early skills development in ultrasound can be a steep learning curve, with some experiencing conceptual difficulties that are challenging to address in a busy clinical setting. Despite this, approaches to practical training have been largely unchanged over several decades. While national debate continues, pressure on clinical departments is unrelenting. To support training across specialties and at scale, it is imperative that all early-stage ultrasound skills development is moved out of the clinical department and is achievable within a short timescale. This pilot study evaluates the effectiveness of a high intensity campus-based training programme on early skills development.
Methods: Using an active learning approach, SHIFT (Sonography High Intensity Foundation Training) combines core theory with highly structured practical sessions and computer-based simulation activities that aim to enable trainees to develop the hand-eye coordination required for ultrasound image capture, to build familiarity and understanding of equipment controls and recognition of normal ultrasound appearances.
For an initial cohort of ST1 radiology trainees (n=23), post-course qualitative feedback and reflection on learning was captured through use of a ’Listening Rooms’ methodology to explore trainee peer-to-peer reflections on their experience. Thematic analysis was undertaken by independent research assistants (not faculty).
Results: The study used a collaborative approach to building a better understanding of the impact of high intensity training on trainee experience, understanding and confidence. We present initial findings, interpreted from a learner perspective.
Conclusion: Highly structured, supported learning in a low-pressure environment results in rapid development of conscious competence in core skills and increased trainee confidence. This enables specialist trainees to enter clinical placement with minimal disruption to service delivery, and reduced impact on supervising staff. This approach may provide a useful alternative approach to early-stage ultrasound training across specialties.
Student and Trainees
Ultrasound users in non-traditional ultrasound Departments: An insight into those who use ultrasound for diagnostic purposes within a clinical setting
Sahra Deane
Kings College London
Background: It is important to acknowledge and highlight those who use ultrasound diagnostically within a clinical setting that may not be as well known to the majority of healthcare professionals. Understanding their training requirements could also help produce training and certification to solidify users’ knowledge and encourage more to gain training in ultrasound for their respective areas of specialty.
Aim: This study aims to feature some of the different healthcare professionals who use ultrasound for diagnostic purposes, as well as delving into the training processes for them, and whether the level of training available for them is sufficient for their practice.
Methods: Interviews with some of the healthcare professionals identified outside of the traditional imaging departments were undertaken in order to learn more about their typical practice as well as their training and any further requirements they may have.
Results: Based on the data collected from NHS Trusts within the South-East of England, which included 28 Trusts, 34% of ultrasound systems within their database belonged to those outside of the traditional ultrasound departments. When interviewing healthcare professionals 100% stated that they would be interested in obtaining certification of ultrasound training. Some themes were picked up during the interviews as to how these professionals undertook their ultrasound training, and whether they would recommend the use of ultrasound to others in their specialty.
Discussion: From the results, it is clear that there are far more ultrasound users than most would expect within an NHS Hospital. One thing that is important to highlight is the discrepancy in departments across the NHS that do offer ultrasound services. Acknowledging their method of training and mode of obtaining continued professional development is varied therefore certification would potentially be beneficial to ensure ultrasound users are competent and confident in all aspects of ultrasound in their field.
Initial operator experiences using a prototype ultrasound system for cavitation enhanced drug delivery to solid tumours
Jessica Thorne
Oxford University Hospitals NHS Foundation Trust
Background: Recent years have seen the development of new technologies using ultrasound to facilitate cancer treatment. This article focuses on initial operator experiences when trialling a prototype ultrasound drug delivery system, the SonoTran platform, manufactured by Oxsonics therapeutics.
Completion of phase 1 safety testing in the 1st in-human investigation into Cavitation Enhanced Drug Delivery to liver metastases from colorectal cancer provides an opportunity to explore initial operator experiences when using the system for patient treatment. Four trained operators of varying professional backgrounds were involved in the trial.
Aim: The aim of this study is:
To demonstrate the practical steps required for the SonoTran operator.
To offer operator insights into sonographic workforce requirements of this technology in the future.
Methods: All operators trained to use the system clinically to date (n=4) were asked to complete a brief questionnaire on their professional experience and confidence levels when using the device. Follow up interviews were recorded and transcribed to extract common themes.
Results: The participants comprised two radiologists (one registrar, one consultant), one clinical oncologist and one consultant sonographer. (n= 4)
Successful imaging and targeting of the tumour were related to patient factors, tumour position, and prototype image quality. Clearly identifying the target lesion using the SonoTran prototype was reported as the biggest challenge for the operator. Cavitation and the systems workflow were both rated highly.
Discussion: All participants agreed that high level ultrasound skills are required for detecting target tumours on the prototype. Specialist sonographers would be well equipped to compliment the multi-disciplinary team involved in delivering cavitation enhanced drug delivery.
Image quality in renal scanning and identification of perinephric fat stranding for early detection of chronic kidney disease
Chelsea Scott
Kings College University London
Background and motivation: Previous MRI and CT imaging of patients with suspected chronic kidney disease suggests that the presence of perinephric fat stranding (PFS) provides a reliable early marker for increased risk of CKD, however, whether PFS is routinely reported on ultrasound and the incidence of PFS in younger individuals at risk of CKD has not yet been explored.
Aim: This quality improvement study aimed to explore whether reporting of perinephric fat stranding (PFS) using ultrasound could be useful as a potential screening tool for early detection of CKD through establishing the prevalence of PFS in working age patients (aged 25-55 years) referred for a scan of the kidneys.
Methods: A single-centre retrospective image review audit was designed and reported considering the Standards for Quality Improvement Reporting Excellence guidelines (SQUIRE, 2016). Ultrasound images of the kidneys were reviewed by the author using a modified version of the BMUS Peer Review tool to assess image and reporting quality against best practice guidelines, with a special focus on the detection and reporting of PFS. All cases of PFS, and a random sample of 10% of scans, were also reviewed by 3 other experienced sonographers.
Results: Of a total of 140 renal ultrasound images, 6 (4.3%) were confirmed to include PFS; 3 of these had undergone blood tests confirming normal creatinine levels (50-98µmol/L); one had normal eGFR (>90mL/min/1.73m2) and the remaining two had mildly reduced eGFR (85 and 86mL/min/1.73m2). Best practice guidelines were adhered to in most examinations and 96.4% of images were rated either good or excellent quality. However, none of the 6 cases of PFS had been reported as part of the original scan.
Discussion: This study highlights a need for a greater awareness of PFS amongst sonographers as PFS appears to be underreported. Our study confirmed that PFS is sometimes present in patients with normal kidney function.
Nephrocalcinosis: A review of how we assess and report it on ultrasound
Mayurun Ramadas, Gorsey Leung
Great Ormond Street Hospital for Children
Objective: Nephrocalcinosis is an infrequently encountered Paediatric diagnosis, which makes recognising and diagnosing it a challenge1. Worsening nephrocalcinosis can lead to end stage renal failure2. Consequently, early diagnosis can facilitate reversibility and/or limit disease progression depending on the underlying cause3. Our objective was to audit ultrasound reporting methods of nephrocalcinosis at our UK Paediatric Hospital. We aim is to share our findings to increase consistency and reliability of nephrocalcinosis reporting.
Methods: We audited and evaluated over 2000 ultrasound examinations for nephrocalcinosis at our UK Paediatric hospital performed over five years. We assessed consistency and accuracy of reports and liaised with clinical teams on how the reports impacted clinical management.
Results: Diagnosis and description of cases pertaining to mild and moderate nephrocalcinosis were variable and inconsistent. Severe cases were consistently reported. Terminology to describe nephrocalcinosis grading was found to be broad and subjective by clinicians. Inconsistency of reporting was deemed in part due to complexity of perception and subjectivity of terminology.
Conclusion: Our results demonstrate a lack of consistency with subjective use of terminology when reporting mild to moderate nephrocalcinosis – cases with a larger scope for management. Terminology should be clearly defined and easily applicable. This will increase interobserver consistency when reporting nephrocalcinosis and in turn facilitate meaningful impact on the treating clinician’s understanding of disease progression which aids management.
1. Dickson.F and Sayer. J 2020, ‘Nephrocalcinosis: A review of monogenic causes and insights they provide into this heterogeneous condition’ International journal of molecular sciences vol 21 pp 369-385
2. Priante. G, Ceol. M, Terrin. L, Gianesello. L, Quaggio. G, Del Prete. D and Anglani. F 2017, Understanding the pathophysiology of nephrocalcinosis, updates and advances in nephrolithiasis- Pathophysiology, genetics and treatment modalities, Layron Long, Intech Open DOI: 10.5772/intechopen.69895
3. Monet-Didailler C, Chateil JF, Allard L, Godron-Dubrasquet A, Harambat J. Nephrocalcinosis in children. Nephrol Ther. 2021;17(1):58-66. doi:10.1016/j.nephro.2020.12.001
Developmental Dysplasia of Infant Hips (DDH); is there any correlation between high birthweight in females and incidence of DDH identified in ultrasound screening?
Innocent Onu1, Marcos Katchburian1, A. H Turner2
1Maidstone and Tunbridge Wells Hospital NHS Trust
2Anglo European College of Chiropractic
Introduction: Developmental Dysplasia of the Hip (DDH) refers to a spectrum of pathologic hip conditions, ranging from hip instability, subluxation, dislocation and/or acetabula malformation. DDH is the most common congenital abnormality in infants and it is of public health concern as it could result in a lifelong disability if the diagnosis is not made within the first few weeks of life.
Aim: To analyse the hip ultrasound findings in macrosomia (>4kg birthweight) female infants to find out if there is any correlation between high birthweight in females and incidence of DDH detected in ultrasound screening.
Method: This research was conducted retrospectively using a cross sectional descriptive research design. One sample T test, Spearman’s correlation and 95% confidence intervals analysis were carried out and displayed in tables and charts.
Result: The population size of this study was 720, those that met the inclusion criteria was 681; this gave rise to 1,362 hips as both hips were scanned. The modal age was 5 weeks, constituting 42.1% (n=287). The analysis revealed a total of 64.5% (n = 878) Graf type I -mature hips, 26.5% (n = 361) type 2a – immature hips, 4.0% (n = 55) type 2b – mildly dysplastic hips, 3.7% (n = 51) type 2c – moderate-severe dysplastic hips, 0.5% (n = 7) type D -decentring hips and 0.7% (n = 10) type III – decentred hips. There was no Graf Type IV hip found. 22 (3.2%) subjects had bilateral hip dysplasia; 57 (8.3%) subjects had dysplastic right hips and 66 (9.7%) subjects had dysplastic left hips. This brought the total number of dysplastic hips to 123(9.0%) and number of individual subjects with dysplastic hips to 101 (14.8%).
Conclusion: There is high incidence of DDH in macrosomia female infants detected in ultrasound screening with prevalence rate of 140.3 cases per 1000 macrosomia babies.
Brain tissue motion in acute ischaemic stroke
Jennifer Nicholls1, Andrea Lecchini-Visintini2, Emma Chung3
1University of Leicester
2University of Southampton
3King’s College London
Background: It has long been known that the brain pulsates in synchrony with the cardiac cycle, however, existing literature is heavily focused on motion of the healthy brain. This is the first case study presenting the effect of acute ischaemic stroke on brain tissue motion.
Case Summary: A 63-year-old man presented to a UK emergency department with symptoms of headache, left sided weakness and slurred speech. He presented approximately 5 hrs post-onset of symptoms with a blood pressure of 157/66 mmHg and National Institute for Health Stroke Scale (NIHSS) score of 14, suggestive of moderate injury. The patient consented to participate in the Brain Tissue Velocimetry (Brain TV) for Emergency Assessment of Acquired Brain Injury study to allow measurement of brain tissue motion using a non-commercial transcranial tissue Doppler ultrasound prototype. As part of this study, he also received a brain magnetic resonance imaging scan and physiological monitoring (heart rate, blood pressure and end-tidal CO2). Pairs of left and right brain tissue pulsation measurements were taken from 2 positions on the head at 55 and 77 hrs post-onset.
The MRI confirmed a large right middle cerebral artery (MCA) infarct (102 x 45 mm in area), adjacent to the posterior body of the right lateral ventricle, with local mass-effect and reduced flow in the distal right MCA branches. No obvious differences in brain motion were noted between the affected and unaffected hemispheres on MRI.
Ultrasound tissue motion measurements from the right forehead position at 55 hrs and 77 hrs post-onset, and from the right temporal position at 55 hrs post-onset, were 4.1 to 13.5 µm lower than equivalent measurements for the unaffected hemisphere.
This case suggests that brain tissue motion is reduced on the affected stroke side compared to the un-affected side in acute ischaemic stroke.
Day 2
Young Investigator
Introduction of a paperless ultrasound quality assurance system; a service improvement project
Alice Bevan
Somerset NHS Foundation Trust
Aim: Following a Quality Standard for Imaging assessment, an identified mandatory action was that a quality assurance (QA) and cleaning programme compliant with professional and legal standards was required as existing paper processes were recognised to have major limitations.
Methods: Initial training in undertaking effective QA was provided by clinical technologists, followed by the creation of bespoke online training. QA presets were installed on all machines. A schedule for daily, weekly and monthly QA was agreed. Initial implementation was in November 2021 with biannual audit and occasional sonographer-led service review using survey.
The existing clinical reporting system is used to document QA tasks undertaken against a clearly fictional patient name, unique to each machine, making a bespoke task-logging system unnecessary. QA tasks are allocated time by booking an appointment for the fictional patient ensuring QA time is ring-fenced in the working schedule.
Results: Two process audits in February and August 2022 recorded compliance of 66% and 63% respectively, however there was a large range between staff professions, with lower compliance on machines used primarily by radiologists.
User surveys showed the processes and procedures were well understood. Sonographer compliance barriers included lack of time, partly due to overbooking of patients, forgetfulness and a lack of management buy-in. Following procedure revisions, subsequent audit in February 2023 showed significant improvement to 79% compliance but with radiologist machine compliance still low at 32%. Scheduling changes are being implemented to resolve this through making the process sonographer-led.
Conclusions: The system described is cost-neutral, fully auditable and permanently electronically recorded. Its implementation has made QA and cleaning an integral part of daily workflow. It has allowed accurate and timely identification of faults and improved sonographer knowledge of equipment. Regular audit identifies where processes can be continuously improved.
POCUS - Game changer in resuscitation
Divya Lovelin Regina Rajaiah
York Teaching Hospital
Introduction: Point of care ultrasound (POCUS) is a rapidly evolving technology and a definite game changer that has the potential to revolutionize the field of resuscitation. By providing real-time cardiac and pulmonary images POCUS can help emergency physicians to identify and correct the life threatening cardiac/pericardiac arrest situations more quickly and accurately.
In this presentation, we will discuss the use of POCUS in resuscitation. We will review the evidence supporting the use of ultrasound in different resuscitation scenarios, and we will discuss the practical applications of POCUS in cardiac/pericardiac arrest scenarios.
Conclusion: The use of POCUS in resuscitation is still evolving, but the evidence to date is very promising. Barriers to POCUS use appear not to stem from physicians doubting its utility. Instead, under-confidence with POCUS skills and practical barriers to operating the machine emerged as key. Acquiring good hands-on experience and the confidence to perform POCUS in the chaotic resuscitation scenarios are the key towards effectiveness and best outcomes of POCUS.
Gallbladder polyps: To follow or not to follow, that is the question
Nazanin Babazadeh, Nehan Khalid, Shaunna Smith, Sandra Wee Ping Ngu, Pamela Parker
Hull University Teaching Hospital NHS Trust
Background: Polypoid lesions of the gallbladder are commonly detected findings on abdominal ultrasound scans. The vast majority of these are not malignant but rather benign cholesterol, inflammatory or adenomyomatosis polyps. Therefore, it is essential to determine an appropriate follow-up pathway that allows early diagnosis of such diseases to ensure early treatment whilst aiming to minimise the overall impact on waiting times in a busy department.
Objectives:
To determine if the follow up of gallbladder polyps alters patient management
To determine if the patients were being followed up in accordance to the local guidelines
To determine the incidence of malignancy in the gallbladder polyps
Methods: Retrospective study using the hospital database. Time period: 2.5 years (January 2021- July 2023). Inclusion criteria: all patients who underwent US abdomen and pelvis. Exclusion criteria: if inaccessible imaging, e.g. initial scan done in another trust.
Results: In total:
65/100 patients had a GB polyp found incidentally
35/65 were symptomatic
61/100 had yearly follow-up as they were either asymptomatic or < 10mm
24/61 were followed up as per guidance
24/61 were not followed up appropriately
13/61 are awaiting follow-up
39/100 referred to UGI team of which 10 underwent cholecystectomy - 1 was malignant, 9 were benign.
*Note, there are 400 more cases to be reviewed that will be included in the final analysis.
Conclusion: The follow-up of gallbladder polyps is a lengthy process with a significant impact on the patients’ mental health as well as added strain onto a stretched department. The results of our study concluded that a large proportion of polyps being followed up were benign with only one positive diagnosis of malignancy thus far. Therefore, it is clear that our Trust’s local practice needs to be reviewed and amended in accordance to the latest literature in the interest of the patient.
Assessment of thermal index compliance in clinical ultrasound examinations
Sam Butler
University Hospitals of North Midlands NHS Trust
Introduction: The Thermal Index (TI) is a critical metric for monitoring potential heating risks in ultrasound examinations. This study aims to analyse adherence to thermal index guidelines in clinical ultrasound exams, focusing on the thermal index in soft tissue (TIS) and thermal index with bone (TIB).
Methods: Clinical ultrasound images acquired at a single NHS trust over a period of five working days were analysed using a custom MATLAB script. TI values were extracted from DICOM headers and where necessary supplemented with optical character recognition for missing values. Time at each TI value (imaging interval) was calculated as the time between consecutive images assuming a constant TI. These values were compared to thermal index guidelines provided by the British Medical Ultrasound Society (BMUS).
Results: The analysis included 570 obstetric and 962 non-obstetric exams, comprising 3,754 obstetric images and 18,401 non-obstetric image intervals. All imaging events and intervals adhered to recommended BMUS limits for the thermal index in soft tissue (TIS); however, breaches of the guidelines were observed for thermal index with bone (TIB). In the obstetric scans, 22 image intervals across 21 patients exceeded the TIB limits (0.46% of TIB intervals and 3.22% of patients). For non-obstetric scans, two image intervals across two patients surpassed the TIB limits (0.02% of intervals and 0.50% of patients).
Conclusion: Most ultrasound exams demonstrated compliance with BMUS guidelines for thermal index, except for breaches in the obstetric TIB limits. All breaches were associated with the use of pulsed-wave Doppler.
The effect of dead transducer elements on pulsed Doppler and imaging performance
Daniel Wyatt1, Nicholas Dudley1, Joel Clayton1, Siân Curtis2
1Multi-Medix
2University Hospitals Bristol and Weston NHS Foundation Trust
Aim: It has been suggested that as few as two dead transducer elements can affect Doppler performance. We aimed to determine the effect of one to five dead elements on Doppler velocity estimates, using a flow phantom, and on B-mode imaging performance using a tissue mimicking test object (TMTO).
Methods: Transducer pin connections were mapped for a high frequency linear array using an electronic probe tester. Doppler spectra and B-mode images were obtained using a flow phantom and a TMTO respectively for the transducer with all elements functioning, then with 1, 2, 3, 4 and 5 consecutive elements disabled by cutting pins in the connector. Images were obtained with targets centred on the dead elements, and also offset with dead elements laterally placed in the transmit beam over the relevant targets. Spectral velocities were measured using the scanner’s automatic tracing function and B-mode resolution and anechoic target visibility were assessed by software analysis.
Results: There were no significant effects of dead elements on measured velocity. Lateral resolution deteriorated more markedly with an asymmetric transmit beam than with the defect centred on the targets, e.g. full-width-half-maximum rose from a baseline of 0.63+/-0.03 mm, for a target at 10 mm depth, to 0.74 mm (centred) and 0.81 mm (offset) with five dead elements. Anechoic target visibility showed a more marked downward trend with the transmit beam defect centred on the targets.
Conclusion: Up to five consecutive dead elements had no significant effect on velocity measurement, but resolution and anechoic target visibility deteriorated.
Therapy in Ultrasound Network for Drug Delivery and Ablation Research
Multi-modal confirmation of thermosensitive liposome delivery to the brain after FUS-induced blood-brain barrier (BBB) opening for the treatment of glioblastoma
Paul Cressey1, Chris Payne2, Antonios Poulopoulos2, Maya Thanou1
1King’s College London, Institute of Pharmaceutical Sciences
2Surgical & Intervention Engineering
Introduction: Glioblastoma is an extremely aggressive brain tumour and currently has limited effective treatment options, with median survival of only 14 months.1 This low survival is attributed to the blood brain barrier (BBB) especially in early-stage glioblastoma.2 In this study, we formulated imageable drug loaded thermosensitive liposomes (iTSL-SM/CC) and tested their efficacy against U87 in vitro and in vivo (subcutaneous). In addition, we performed focused ultrasound (FUS)-induced BBB opening to deliver the iTSLs into non-tumour-bearing mice. Liposome uptake was determined and quantified in vivo and ex vivo using MRI and near-infrared fluorescence (NIRF) respectively.
Methods: FUS-induced BBB opening was performed in mice either with or without administration of iTSLs. Mice were also administered iTSLs without BBB opening. FUS parameters: Pressure = 450 kPa, cycles = 500, PRF = 5, pulses = 600. SonoVue microbubbles (3 ml/kg) were administered i.v. simultaneously to sonication. iTSLs (7 ml/kg) were administered i.v. 10 minutes after sonication. T1-weighted MRI was performed in a 9.4-T magnet 2 and 4 hours after BBB opening, to allow time for iTSLs to accumulate in the brain for optimal T1 contrast. NIRF imaging was also performed on perfused and excised mouse brains after the final time point. In addition, the ability of iTSL-SM/CC to suppress tumour growth was investigated with single treatments against U87-MG subcutaneous xenograft tumours (10 mg/kg SN38, 42 oC, 10 min).
Results/Discussion: iTSLs were successfully formulated with both gadolinium and NIRF lipid conjugates. iTSLs were also loaded with SN-38 (1.11 mg/ml) and carboplatin (0.84 mg/ml) (iTSL-SM/CC). iTSL-SM/CC (10mg/kg SN-38) treatment caused an increase in survival when administered alone and a significant effect when combined with FUS (42 °C, 10 min). MRI and NIRF imaging confirmed localized increased uptake of iTSLs where FUS-induced BBB opening was performed (yellow arrows), compared to the contralateral control side. Localised uptake was also confirmed compared to mice without BBB opening. These results suggest that MRI/NIRF-tagged drug loaded liposomes are suitable drug carriers for the treatment of glioblastoma using FUS-induced BBB opening.
Acknowledgements
Special thanks go to all involved at King’s College London. In addition, we would like to thank Innovate UK, King’s College London, FUS foundation and Little Princess Trust for funding.
References
1. S. Mohammed, et al., Reports of Practical Oncology and Radiotherapy, 2022, 27, 1026–1036.
2. J. N. Sarkaria, et al., Neuro Oncol, 2018, 20, 184–191.
Mechanisms of Therapeutic Ultrasound on Biomimetic Models of Cancer
Silva, D, Cheema, U, Gélat, P.
UCL Centre for 3D Models of Health and Disease, Division of Surgery and Interventional Science, Charles Bell House, University College London
Introduction: Therapeutic ultrasound has shown promise in treating various cancer types, overcoming the invasive and systemic side effects of conventional cancer therapies. Low-intensity ultrasound (LIUS) has been proposed to selectively eradicate cancer cells, but the underlying mechanism remains unknown. This project aims to characterise this phenomenon.
Methods: Two-dimensional (2D) monocultures of MCF-7 and MDA-MB-231 breast cancer cells were sonicated at varying acoustic intensities (0.1−0.5 W.cm-2) and excitation time parameters (1−10 minutes). To recapitulate in vivo conditions, cancer cells were also seeded into 3D collagen hydrogels. 2D monocultures of healthy Human Dermal Fibroblast and MCF-10A breast cells were sonicated at varying acoustic intensities (0.1−0.5 W.cm-2) to determine distinguishing biological responses. To establish the influence culturing plates have on ultrasound propagation, the acoustic wave propagation software OptimUS was used to solve this through six-well plate models at a frequency of 500 kHz.
Results: At 1 MHz frequency, 20% duty cycle, 100 Hz pulse repetition frequency, a significant drop in cancer cell viability was observed at an intensity of 0.5 W·cm-2 and over a 10-minute excitation time. Healthy cells sonicated with the same parameters demonstrated no distinguishing effects. Sonication of breast cancer cells seeded in 3D collagen hydrogels revealed no effect in cell viability. OptimUS identified that the culturing plate materials significantly alter the acoustic field.
Conclusion: Under specific ultrasound parameters, LIUS sonication in 2D monocultures induced identical biological responses in breast cancer and healthy cells lines, with the underlying mechanism still unidentified. Translating this to 3D culture, breast cancer cells seeded in collagen hydrogels resulted in no biological response. This could suggest that a more in vivo representative orientation provides a protective environment from the effects of ultrasound. OptimUS highlighted the issues of near-field sonication. Going forward, the information obtained from these results will advise the design of a platform suitable to carry out LIUS in vitro.
Single cell analysis of tumour infiltrating leukocytes in boiling histotripsy-exposed orthotopic pancreatic tumours
Petros Mouratidis, Gail ter Haar
The Institute of Cancer Research, London
Background: Pancreatic ductal adenocarcinoma is a disease with a dismal prognosis and 5-year survival rates of < 1%. Advances in our understanding of the biology and aetiology of pancreatic cancer have not resulted in the identification of treatments that could significantly improve survival rates for patients. Boiling histotripsy is an ultrasound-based physical modality that can induce acoustic cavitation and emulsify solid tumours, including pancreatic. But the modulation of the immune system to these treatments is unknown. The aim of this study was to use whole transcriptome (single cell RNA-seq) techniques to investigate this response.
Methods: Syngeneic pancreatic orthotopic KPC tumours (KrasLSL.G12D/+; p53R172H/+; PdxCre tg/+) were grown in the pancreas of immune-competent murine C57BL/6 subjects. Tumours were exposed to boiling histotripsy (P- = 17 MPa, duty cycle = 1 %, 25 repeats, f = 1.5 MHz, lesions every 1mm) (VIFU 2000 platform). Acoustic cavitation was monitored using 2D high frequency (14 MHz) B-mode ultrasound imaging during treatment and was quantified using a weakly focused polyvinylidene fluoride, broadband (0.1 to 20 MHz) passive cavitation detector after treatment. The effects of the treatments on tumour infiltrating immune cells were investigated with single-cell analysis (BD Rhapsody platform) 24 hours after treatment, and bioinformatic analysis was performed using R Studio. Animal survival was also assessed.
Results: More than 30 distinct immune cell populations were identified in the pancreatic tumours, including various subsets and significant numbers of CD8 and CD4 T lymphocytes, macrophages, neutrophils and B cells. Heatmap analysis showed distinct expression signatures between sham-exposed and histotripsy-exposed immune populations. Surprisingly, initial analysis of immune cell abundance shows an increase of cell types associated with an adaptive immune cell response (for example CD8 T cells), and a decrease in those immune cells associated with innate immunity (for example neutrophils) in histotripsy exposed tumours compared to sham-exposed. Also, boiling histotripsy treatment of pancreatic tumours approximately doubled the survival of subjects compared to sham-exposed subjects.
Conclusion: These results show that the use of boiling histotripsy significantly improved the survival of subjects carrying pancreatic tumours and initiated an adaptive immune response.
A Comparative Study of Experimental and Simulated Ultrasound Beam Propagation Through Cranial Bones
Alisa Krokhmal, Bradley Treeby, Eleanor MartinUniversity College London
Transcranial ultrasound therapies are currently under development for various medical applications, with accurate targeting being a critical aspect for their implementation. Ensuring precise delivery of ultrasound waves to the intended area of the brain is essential for the effectiveness and safety of these treatments. This study investigates the accuracy of numerical calculations for focused ultrasound beam propagation through cranial bones, utilizing the k-Wave toolbox. The aim was to evaluate the accuracy of simulation of ultrasound propagation through ex vivo human skulls and their potential use in medical interventions.
The methodology included measuring holograms of four skull specimens at frequencies ranging from 270 kHz to 1 MHz in degassed water, utilizing both quasi-continuous and pulsed modes. The open-source k-Wave toolbox was employed for simulations, using both an equivalent-source hologram and a bowl source with parameters best matching the experimental pressure distribution observed in free field. The skull geometry and medium properties were obtained from clinical CT scans of the skulls.
Results indicated that although attenuation and sound speed values derived from CT scans may inaccurately reflect the actual values in the skull, they can still yield high accuracy in modelling. Simulations predicted the position and volume of the focal zone to within 2 mm and 27% on average, respectively, and the amplitude of acoustic pressure to within 15% on average. Notably, simulations performed with a bowl source with a uniform distribution of pressure amplitude and phase achieved accuracy comparable to hologram sources when radii of curvature and aperture diameters were optimized for each frequency.
This research highlights the potential of k-Wave simulations of trans-skull propagation of focused ultrasound beams for planning of therapeutic interventions in the human brain.
AI integrated treatment planning and feedback for ultrasound-guided High Intensity Focused Ultrasound (USgHIFU) therapy of thyroid nodules
Lewis Howell1, Tze Wah2, James Chandler1, James McLaughlan1
1University of Leeds
2Leeds Teaching Hospitals Trust
Ultrasound-guided High Intensity Focused Ultrasound (USgHIFU) is a non-invasive and non-ionising technology for ablation of tissue. For benign thyroid nodules, HIFU can provide symptomatic and cosmetic relief through tumour volume reduction. In the UK, the National Institute for Health and Care Excellence (NICE) found that HIFU is safe for treating benign thyroid nodules, but current evidence on its efficacy is limited, emphasising a need for further research. At present, the efficacy of USgHIFU for thyroid nodules is operator-dependent, treatment planning is laborious, and treatment duration is long. Our research uses Artificial Intelligence (AI) to streamline treatment planning and guidance of a co-robot assisted USgHIFU system.
This work demonstrates the application of Deep Learning (DL) to segment anatomical structures in ultrasound images of thyroid phantoms. DL networks were dually optimised for both segmentation speed and accuracy, achieving an inference framerate of 27FPS and a mean Dice Similarity Coefficient of 85%. This was implemented in real-time, using a point-of-care ultrasound system, allowing automatic delineation of key structures and tissue types in the treatment area. Using tracked ultrasound, segmentation masks are applied in the 3D reconstruction of patient-specific anatomy, defining the target volume and safety margins automatically. Registration of the imaging guidance system and co-robot arm allows real-time feedback during therapy, enforcing margins and ensuring conformance with the treatment plan.
Importantly, segmentation of tissue in the acoustic path also allows us to estimate the path-specific attenuation and thus calculate the heating effects, enabling fast approximation of the thermal dose with Physics Informed Neural Networks (PINNs). Applying Deep Reinforcement Learning (DRL) then allows optimisation of the locations, durations, and intensity of HIFU exposures. This reduces the necessity for long cooling times between exposures by leveraging the flexibility provided by the co-robot arm to improve on simplistic raster scanning approaches.
Methods proposed in this work provide new opportunities for the treatment of thyroid nodules and could eventually be applied to other challenging tumour sites such as those of the liver, pancreas, and kidney. Ultimately, we hope this will increase USgHIFU’s accessibility as a cost-effective alternative to surgery, improving patient outcomes and representing part of a paradigm shift towards minimally-invasive treatments and AI in medicine.
Ultrasound hyperthermia as radiosensitiser on a preclinical glioblastoma model
Gianni Durando, Federica Vurro (co-first), Fabio Saba, Piero Miloro, Ivory M. Aoife, Raphaela de Melo Baesso, Antonello E. Spinelli
National Physical Laboratory
Hyperthermia is the process of raising tissue temperatures to levels that do not cause necrosis (generally 40–45 °C) for a prolonged time. Hyperthermia has been used as a stand-alone treatment or in combination with other therapies such as radiotherapy or chemotherapy. Ultrasound is a good candidate to produce hyperthermia in localised areas, without affecting surrounding tissues.
We have designed and characterized a heat delivery system for ultrasound hyperthermia able to generate and maintain constant temperature for application to superficial tumours on mouse models. The system consists of a 3.57 MHz HIFU transducer, a coupling interface and two fine wire thermocouples, which allow closed loop control on the ultrasound power to keep the temperature constant in the target area.
To study the effect of hyperthermia as radiotherapy enhancer, the system has been tested on Glioblastoma xenograft nude mouse model, for a total of 15 mice divided in control group (C), Radiotherapy Only (RT) and Radiotherapy plus Hyperthermia (RT+HT). Measurement of tumour growth was performed over a period of 21 days after treatment, after which the mice were sacrificed and immunohistochemical analysis was performed.
Both calliper and bioluminescence measurements showed an improved response in the RT+HT group, both in the days after treatment (tumour growth 0.5 vs 1.5 in control group) and at sacrifice (1.5 vs 3.5). The results support the evidence that Hyperthermia acts as a radiosensitizer and that the proposed setup and protocol can be used to quantify this effect on mice models.
An in vitro platform to treat cancer spheroids with heat and radiation
Petros Mouratidis, Ian Rivens, Gail ter Haar
The Institute of Cancer Research, London
Background: Hyperthermia has been used in the treatment of cancer due to its properties as radio and chemosensitizer, and to stimulate the immune system. High intensity focused ultrasound (HIFU) can heat tissue in a non-invasive and non-ionizing manner, even in deep parts of the body. Traditionally the biological effects of HIFU have been investigated in vivo where a uniform heating effect can be achieved more easily than in vitro. This is because there is a lack of in vitro systems that can mimic both the biological and physical properties of tissues and which are compatible with HIFU heating. In this study, we present a new system based on holographic lenses coupled to a HIFU transducer to sonicate 3D spheroids to a uniform thermal dose. The effects of HIFU and non-HIFU-induced heating on the response (size and viability) of spheroids to radiation treatments were compared.
Methods: The exposure system can treat cancer spheroids contained in an International Electrotechnical Commission (IEC) tissue-mimicking phantom with multiple wells, each holding a single tumour spheroid, with real-time temperature and thermal dose monitoring. Glioma U87-MG cancer spheroids were exposed to combinations of HIFU or thermal cycler-induced thermal doses (TIDs) of 0-240 CEM43 and radiation of 0-16 Gy. The size and viability of the spheroids were determined using the Celigo microscope and Cell Titer Glo assays respectively.
Results: The use of acoustic holograms designed for uniform thermal dose created a region of uniform hyperthermia, with differences in thermal dose received by each spheroid < 18%. Exposing U87-MG spheroids to an ultrasound-induced thermal dose of 120 CEM43 shrank them by 15% and decreased their growth and metabolic activity more than seen in those exposed to a thermocycler-induced heating. Additive cytotoxic effects in combination with radiation (2 and 6 Gy) were also seen.
Conclusion: The use of acoustic holograms to modify a HIFU transducer to deliver ultrasound hyperthermia accurately controlled thermal dose delivery to 3D therapeutic targets. Spheroid data showed that thermal and non-thermal mechanisms were implicated in the response of cancer cells to non-ablative ultrasound heating.
Acknowledgements
The authors would like to thank Diana Andres, Noé Jiménez, and Francisco Camarena (Universitat Poltècnica de València) for their help exposing spheroids in gel phantoms.
Safety considerations for FUS therapies in the spinal cord: acoustic and thermal simulations coupled with a historical investigation of spinal cord exposure thresholds
Rui Xu, Bradley E. Treeby, Eleanor MartinUniversity College London
The development of focused ultrasound (FUS) therapies for the brain has sparked interest in similar spinal cord treatments. The spinal cord is encapsulated by the vertebral canal, placing bone within 1 cm of any spinal cord target. Safety exposure thresholds specific to the spinal cord have not yet been established and should consider the proximity of bone to the focus and the sensitivity of spinal cord tissue.
We reviewed fifteen pre-clinical spinal cord ablation studies, encompassing sixty-three parameter combinations and found a clear relationship between spinal cord damage, spatial peak time-averaged intensity, and treatment time. This relationship was utilized to define a ’possible damage’ threshold, spanning multiple animal models, source frequencies, and sonication modes. Nine spinal cord neuromodulation studies were identified, and damage was only observed well above the threshold. However, the thermal risks associated with spinal cord neuromodulation should not be underestimated. Twenty microbubble-mediated FUS blood-spinal cord barrier opening (BSCBo) studies were identified. The addition of microbubbles resulted in damage above and below the threshold. The only group consistently achieving BSCBo without damage implemented a pressure feedback control algorithm based on microbubble emissions.
Translating these pre-clinical results to the human scale can be facilitated with simulation, e.g. via the simulation of heat deposition patterns and by aiding in beamforming microbubble emissions. We simulated FUS propagation through the spine using k-Plan, spine CTs, and spine acoustic and thermal properties. Simulations to investigate the effect of array position on spine heating and focal aberration revealed acoustic windows to the spinal cord. A simulation study for a neuromodulatory pulse train (fifty 0.1 s pulses at 500 kHz, 0.33 Hz pulse-repetition frequency, 548 kPa free-field pressure amplitude) found large inter-subject and inter-positional variability in target pressures (90–320 kPa) and peak heating (0.4–3.8°C) values, highlighting the need for individualized treatment planning.
Day 3
General Medical and Paediatrics
Ultrasound in cases with abnormal LFTs: quality of referrals and a need for report standardisation
Morag Stout, Damien Leith
NHS Education Scotland
Objective: To evaluate the practice and terminology used in outpatient US scans for abnormal liver function tests (LFTs) across Scotland.
Methods: Eleven Health Boards provided data for a total of 515 patients undergoing ultrasound investigation for abnormal LFTs. A standard data collection tool gathered information on patient demographics, clinical history, organs assessed, report content and terminology used.
Results: Male to female ratio of 1:1.1. Mean age was 57.1 and a range of 18-93. 78% of referrals came from primary care and 22% secondary care (16% gastro/hepatology). 77% of scans were performed by sonographers, 21% radiologists (10% SPR) with 2% from radiology unspecified. Clinical history was often inadequate with most requests omitting detail around the specific pattern of abnormal LFTs. Thirteen descriptors for parenchymal abnormality were recorded. Terminology used was aligned to local Radiology Training Programme Deaneries. Which organs and structures were described on reports was inconsistent. Parenchyma was described in 92% of reports but size and contour were described in just 64% and 57% of reports respectively. Of note, reports often failed to comment on the presence (or absence) of signs of fibrotic change.
Conclusion: Analysis showed referrals had insufficient clinical history and/or no clinical question and subsequent ultrasound reports were unhelpful. Parameters reported were not influenced by the clinical history. There was a significant variance in terminology used. When fatty infiltration was described, reports were largely inadequate to risk stratify. When features were suggestive of cirrhosis, the word was only used in 11% of cases and referral to gastro/hepatology in <5%. With most scans referred from primary care, there were potential missed opportunities to diagnose cirrhosis. The group recognised the need for standardised ultrasound referral and reporting in cases of abnormal LFTs.
A preliminary experience in the role of new liver tools in the assessment of steatosis
Andrea Mould, Marilyn Zelesco, Steven Abbott, Christopher Welman
Fiona Stanley Hospital, Murdoch, Australia
Hepatic steatosis is the accumulation of more than 5 % fat in the liver. It is the most prevalent histopathological finding in the western population. The gold standard for the degree of hepatic steatosis is biopsy, however there are risk factors, costs and intolerance.
The objective of the study was to evaluate if a novel on-cart ultrasound tool of hepatic parenchyma Attenuation Index (ATI) was comparable with non-targeted liver biopsy results.
A comparison of ATI values provided by Canon Medical Systems Ltd of steatosis grading; mild (0.67-0.74) moderate (0.75-0.89) and severe (>0.89) to give a degree of steatosis with the Brunt scale pathologists use for grading steatosis (none, S1, S2, S3).
We recruited 151 patients referred for non-targeted liver biopsy with the following indications: Non-alcoholic fatty liver (NAFL) (69), abnormal liver function tests (LFTs) (31), autoimmune hepatitis (AIH) (27), and miscellaneous (21). Patients were recruited over a four-year period, and each had ATI assessment within a month of biopsy. Patients were of varying ages (19-83), BMIs (15-57), intercostal tissue thicknesses (8 - 64 mm), and genders (F 103, M 46). Recorded ATI values varied from 0.36 to 1.2 dB/cm/MHz.
Results: Mean ATI values for histological steatosis grading of none, mild, moderate and severe steatosis was 0.6, 0.72, 0.85 & 0.88 respectively. Using manufacturer criteria, ATI sensitivity for detection of steatosis was 84% and specificity 81%. In particular, ATI demonstrated excellent stratification in the differentiation of S0, S1 and S1/2 respectively. However, demarcation between S2 and S3 was limited.
Conclusion: As NAFL is the leading cause of hepatic dysfunction globally, a non-invasive and cost-effective assessment tool is required. Ultrasound assessment, such as ATI, may fulfil this purpose.
Contrast enhanced ultrasound (CEUS) for indeterminate renal lesions - What are you waiting for?
Jamie Wild, Steven Kennish
Sheffield Teaching Hospitals
Renal lesions are frequently detected incidentally during diagnostic imaging, being present on 13% - 27% of diagnostic tests (Rübenthaler et al, 2016). The most common renal lesions encountered are benign simple cysts which are easily characterised on conventional ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). More complex cysts with proteinaceous or haemorrhagic content can be indistinguishable from solid relatively hypovascular tumours, however non-fat containing renal lesions that appear solid should generally be considered as highly suspicious for malignancy. Traditional imaging methods such as CT can sometimes demonstrate indeterminate imaging features such as borderline enhancement necessitating the need for long-term surveillance and may even lead to unnecessary biopsy or surgical interventions (Mittal and Sureka, 2016).
Possessing a greater sensitivity and specificity in both demonstrating vascular flow in hypovascular solid lesions and excluding vascular flow in benign cysts than conventional imaging, CEUS is an excellent problem-solving tool for renal lesion characterisation allowing for much greater confidence when deciding on discharge, biopsy/surgery, or further imaging follow-up (Sidhu et al, 2018).
It is the opinion of the authors that the adoption of CEUS for evaluating indeterminate renal lesions is currently underutilized on a national scale. This presentation aims to describe the necessary steps for implementing a CEUS service for indeterminate renal lesions. Additionally, the findings of a local CEUS service are presented, emphasizing the diagnostic benefits of CEUS in cases where conclusive imaging wouldn’t have been otherwise possible.
By highlighting the use of CEUS, this presentation aims to raise awareness about the potential of CEUS in transforming the evaluation of indeterminate renal lesions. The presentation looks to underscore the importance of integrating CEUS into more routine clinical practice including the multidisciplinary team (MDT) meeting, ultimately leading to more accurate diagnoses, reduced surveillance, minimising unnecessary biopsies and surgeries and reducing patient anxiety.
Our experience of transitioning to ultrasound as the first line investigation for suspected midgut malrotation
Gorsey Leung, Riwa Meshaka, Tom Watson
Great Ormond Street Hospital for Sick Children
Objective/Aim: Ultrasound is established in hospitals across Europe, North America and Australia, as the first-line imaging test for investigation of suspected midgut malrotation/volvulus in neonates presenting with bilious vomiting. In the UK, fluoroscopy, in the form of an upper gastrointestinal contrast series (UGI), remains the gold standard imaging test. This descriptive study aims to share the experience of a UK paediatric hospital making the transition to an ultrasound-first protocol.
Methods: In October 2021, we included an abdominal ultrasound as part of our standard of care for all children under 1 year presenting to our institution with a clinical suspicion of malrotation/volvulus. In March 2023, we performed an audit of these cases. The level of experience of the operator, detection rates by ultrasound (US), use of fluoroscopy, the findings and surgical outcome were compared and documented.
Results: The search yielded 70 eligible cases between October 2021-March 2023. 48/70 (69%) had both US and UGI: 32/48 (67%) US first, 16/48 (33%) UGI first. 15/70 (21%) had US only and 7/70 (10%) UGI only. All positive findings were detected by US. The findings over time demonstrated improving visualisation of the duodenum with decreasing reliance on fluoroscopy, both by the radiology team and surgeons.
Ultrasound was also able to detect alternative pathologies including intussusception, haematocolpos, haemochromatosis, internal hernia, choledochal cyst and distal intestinal volvulus without malrotation.
UGI was able to detect duodenal atresia (1), duodenal web (1) and gastric outlet obstruction (1), which were not demonstrated on US.
Conclusion: We report a positive initial experience in transitioning to an ultrasound-first protocol for the investigation of midgut malrotation/volvulus in infants presenting with bilious vomiting.
Ultrasound of the appendix
Erin Nugent
Alberta Health Services Foothills Medical Centre, Calgary, Canada
Evaluation of the appendix in an acute abdomen has historically relied on imaging methods such as CT. However, amid concerns about ionizing radiation, ultrasound is an excepted and reliable method for the evaluation of the appendix. In light of this fact, it is crucial to provide sonographers with the skill set and techniques required to aid the radiologist in making an accurate diagnosis.
Comprehension of right lower quadrant anatomy, particularly bowel anatomy, is a cornerstone of successful appendix scanning. The presentation will discuss appendiceal location and reflect on anatomical variations that can affect it. Techniques will be presented to guide sonographers in localising the cecal pole, a critical step in ultimately finding the appendix. Common pathologies of the appendix will also be discussed.
At a large Canadian tertiary care centre, the past decade has seen an exponential increase in ultrasounds for the appendix. This corresponds directly with increased confidence in ultrasound’s ability to quickly and accurately assess the appendix. Not only can these patients be quickly referred for the appropriate treatment, ultrasound can rule out appendicitis by visualising a normal appendix, preventing unnecessary surgery.
Providing sonographers with the tools to confidently scan the appendix makes an enormous contribution to patient care. Ultrasound is free of ionizing radiation and is unparalleled in spatial and temporal resolution, making it the ideal modality for patients of all demographics.
Finding and assessing the abnormal and normal appendix on ultrasound is not only possible but highly probable with the correct tools.
Professional Issues
Towards understanding patient and sonographer experience of diagnostic ultrasound imaging reports
Charlie Rogers1, Jane Chudleigh1, Soph Willis2, Steve Gillard3
1King’s College London
2Birmingham City University
3City, University of London
Background: Medical ultrasound diagnostic imaging reports serve as the primary means of communication between medical professionals and patients. With recent changes allowing patients access to their digital records, more patients are reading these imaging reports. However, the presence of medical jargon can lead to confusion, miscommunication, reduced patient involvement, and increased anxiety. In the UK, ultrasound scans are primarily conducted by sonographers who interpret the imaging data during the scan to inform their reports.
Aim: The aim of this research project is to gain a comprehensive understanding of the experiences of both sonographers and patients regarding diagnostic ultrasound imaging reports. The goal is to co-design interventions that address their priorities for improvement.
Methods: The research project will consist of six stages, combining the traditional Experience Based Co-Design (EBCD) method and Interpretive Phenomenological Analysis (IPA) within the co-discovery phase. This study is part of a PhD research and the initial findings are yet to be fully completed and shared.
Results: Patients now have increased access to their health records through Electronic Patient Record Systems, but delays in granting accelerated access occurred due to the COVID-19 pandemic and opposition from the GP Committee England. Simply sharing health information without considering patients’ experiences may overwhelm them, especially with complex medical terminology, potentially impacting their health negatively.
Conclusion: Ultrasound imaging reports contain vital information but can also confuse and prompt further information-seeking from patients. Sonographers’ knowledge can improve understanding and mitigate harm from changes in patient access to reports.
As health record access widens, providers must consider patients’ ability to manage and understand the information. Many adults find health information too complex, particularly those from minority or low-income backgrounds. Low health literacy links to adverse outcomes, increased hospital use, and higher mortality, which may extend to imaging reports with complex terms and measurements.
BSc (Hons) Medical Ultrasound, direct entry undergraduate education for sonographers
Anushka Sumra
Birmingham City University
The United Kingdom (UK) is in the midst of a workforce shortage with an exponential demand for ultrasound services. It is a well-documented concern that there is a national shortage of sonographers as reported by the Migration Advisory Committee (MAC). These factors directly impact the training of ultrasound students.
In 2019 it was recorded that in the UK there were approximately 3000 ultrasound practitioners working. Due to sonography being an unregulated profession, the most accurate number is unknown.
For those individuals wishing to pursue a profession in sonography, there are a number of defined pathways available, namely, BSc (Hons), postgraduate study and short stand-alone ultrasound courses (focused courses). In order to address the education, clinical shortfalls and provide a greater volume of skilled students, there must be focused effort by the education bodies to provide a wider and more varied pathway, without depleting other struggling professions such us radiography, midwifery, nursing or physiotherapy. The introduction of the innovative new direct entry course has ensured that a new generation of professionals are both attracted to the profession and set on a structured education pathway, resulting in a diverse workforce needed to address the constraints present in today’s system.
Employability and personal experiences from the graduates will be highlighted from the first ever BSc (Hons) Medical Ultrasound Degree. We present the outcomes of the direct entry BSc (Hons) Medical Ultrasound plus PgCert Medical Ultrasound (preceptorship) programme graduates.
Developing the next generation of sonography leaders
Catherine Rienzo
Society of Diagnostic Medical Sonography, USA
Introduction: Our nonprofit organisation provides various programs that benefit the sonography community and the patients they serve. In 2020, an exciting new program was developed that invites a cohort of students and recent graduates to be mentored as future leaders in the sonography profession. This 6-month Emerging Leaders Program is completed virtually and combines self-study, live presentations, and collaborative discussions on various leadership and sonography career topics. It is designed to engage each participant in meaningful dialogue and projects related to the future of the profession and leadership volunteerism. The experience culminates with the selection of one cohort participant to receive a grant to attend the Society of Diagnostic Medical Sonography (SDMS) board of directors meeting and the SDMS Annual Conference.
Results: This Emerging Leaders Program is vital to the volunteer organisation because it aims to identify leadership potential, as evidenced by the alum community volunteering for various positions within the organisation. The participants provide a written summary of their experience and how they plan to apply their leadership skills.
Conclusion: The program offers an emerging leader the opportunity to participate in the decision-making process and network with luminaries in the field. It also aids the organisation by providing additional input and perspective on emerging issues and trends in sonography education.
Take home message – The Emerging Leaders Program cultivates sustainability for the organisation’s growth strategy.
Impact on sonographer vetting with implementation of a decision algorithm
Rina Pindoria
London North West University Hospital Trust
The algorithm ensures patients receive the correct scans/referral and reduce vague ultrasound requests. The additional rejections mean waiting times of genuine requests will reduce. Algorithms can be built into requesting systems and reduce burden of vetting in future or move to automated vetting thus improving workforce.
This included a guidance for sonographers in onward management and referral advice with certain pathologies (e.g., ovarian cysts). The standardised reporting templates keep reporting/referral consistent while avoiding excessive rescans such as ovarian cysts/fatty live and ensure vague requests are rejected for additional information to provide optimal care/reduce RSI from typing and voice recognition errors.
The algorithm was built with close collaboration of CCG and GP partners. Expert advice was sought with each subspecialty group and clear contact points/emails were shared.
Vetting statistics at one trust pre/post decision algorithm showed more rejected scans with the main changes:
Post-menopausal bleeding requests redirected to rapid access gynaecology clinic, leading to one-stop PMB clinic
Improved relations with secondary care clinics
Fewer rescans for small benign ovarian cysts. More patients reassured
MSK patients directed to secondary care pathways/specialist care
Lumps/bumps assigned new soft tissue code
Clearer pathways for suspected cancer (haematuria)
Patients seen face-face with clinical examination first
Collaboration with GP group & CCG pathways - autonomy and consistency with GPs on board
Results/impact on activity:
Reduction in MSK referrals: 14% to 8%
Renal US referrals reduced (13% to 4%) after vetting algorithm
23% more rejections of abdominal requests. Abdo/renal (as one exam): 26% more rejections
10% more rejections the first year
This algorithm can remove vague requests and guide those who may benefit from onward referral in primary care. The sonographers felt comfortable with rejecting scans and referencing reasons. This will allow building the options/clinical questions onto the requesting platforms to avoid frustration/delays for clinicians in primary care.
Taking part in the BMUS Preceptorship Endorsement Scheme pilot
Sharon Watty
Guys and St Thomas Hospital
Background: Preceptorship is described as a structured period of support to ensure the smooth transition to develop skilled, confident, autonomous healthcare professionals (DoH, 2010). Preceptorship has therefore become a desirable process to undertake within many ultrasound departments.
BMUS launched a Preceptorship and Capability framework for Sonographers in July, 2022, which provided a welcome framework to strive towards. In March 2023, our ultrasound department was invited to take part in a pilot for BMUS preceptorship endorsement scheme.
We share our experience in taking part and gaining BMUS preceptorship endorsement.
Summary: Whilst preceptorships are typically aimed towards newly qualified staff, it was both interesting and challenging to consider how we apply the same framework of preceptorship to three defined training routes which sonographers experience throughout a career.
New starters
Transitioning sonographer (upskilling, new roles, new banding)
Newly qualified
The endorsement scheme enabled us to critically reflect on our current documentation and evidence of support, such as induction packages and quickly identified how we already provide many of the essential criteria defined for a successful preceptorship.
Taking part in the scheme allowed us to recognise what we already do well. This was reinforced when a survey of staff experiences of preceptorship at our Trust was undertaken. These results were promising showing overall staff satisfaction and also highlighted some gaps particularly for those who were transitioning. We have since developed a Sonographer Competency and Training Framework, and standardised and improved various documents. We also had a QSI visit who acknowledged the achievement from BMUS.
Poor experiences during any transitional period are undesired and can negatively impact career progression and retention. A good preceptorship is one way to ensure sonographers can enjoy a long and satisfying career. The endorsement scheme is a worthwhile way to ensure this is undertaken to a high standard.
Physics
Assessment of thermal index compliance in clinical ultrasound examinations
Sam Butler
University Hospitals of North Midlands NHS Trust
Introduction: The Thermal Index (TI) is a critical metric for monitoring potential heating risks in ultrasound examinations. This study aims to analyse adherence to thermal index guidelines in clinical ultrasound exams, focusing on the thermal index in soft tissue (TIS) and thermal index with bone (TIB).
Methods: Clinical ultrasound images acquired at a single NHS trust over a period of five working days were analysed using a custom MATLAB script. TI values were extracted from DICOM headers and where necessary supplemented with optical character recognition for missing values. Time at each TI value (imaging interval) was calculated as the time between consecutive images assuming a constant TI. These values were compared to thermal index guidelines provided by the British Medical Ultrasound Society (BMUS).
Results: The analysis included 570 obstetric and 962 non-obstetric exams, comprising 3,754 obstetric images and 18,401 non-obstetric image intervals. All imaging events and intervals adhered to recommended BMUS limits for the thermal index in soft tissue (TIS); however, breaches of the guidelines were observed for thermal index with bone (TIB). In the obstetric scans, 22 image intervals across 21 patients exceeded the TIB limits (0.46% of TIB intervals and 3.22% of patients). For non-obstetric scans, 2 image intervals across two patients surpassed the TIB limits (0.02% of intervals and 0.50% of patients).
Conclusion: Most ultrasound exams demonstrated compliance with BMUS guidelines for thermal index, except for breaches in the obstetric TIB limits. All breaches were associated with the use of pulsed-wave Doppler.
Automated image processing of ultrasound quality assurance (USQA) images
Madalina Negoita, Simone Ambrogio, Emma Barton, Grace Aneju, Fiammetta Fedele, Kumar Ramnarine
Guys and St Thomas’ NHS Foundation Trust
Background/introduction: The benefit of performing routine ultrasound quality assurance is widely appreciated to help assess scanner performance and maintain optimum diagnostic images of patients. However, not all NHS hospitals perform comprehensive USQA tests in accord with guidelines from professional bodies, partly due to limited resources, qualified staff and time. The aim of this study was to develop a user-friendly image processing software to automatically analyse test object images and produce the final USQA report.
Methods: An in-house MATLAB software was developed to analyse B-mode images of in-air reverberation and test-objects used during a routine USQA. The software is vendor independent and can accommodate a wide range of probes including linear, curvilinear, phased array and endocavity probes. The software produces the report of the QA assessment in accord with current guidelines from professional bodies.
Results: At the scanner, each probe is separately assessed for noise level, cyst targets and callipers as measured on screen. Offline analysis of the B-mode images automatically determines the reverberation depth and beam uniformity then, low contrast penetration depth, resolution and callipers as determined by the software. The images and graphs are displayed in the certificate. For the curvilinear probe, the shape of the beam is tracked to allow determining the reverberation depth and uniformity. The USQA process on a typical scanner with three probes is fast (20 minutes) and can be performed by a novice.
Conclusion: An automated software was developed for USQA which can be used by a novice to determine the quality of the images produced by the probes and scanner. The software can also be used with a frame-grabber to produce the QA report at the end of the assessment.
The effect of dead transducer elements on pulsed Doppler and imaging performance
Daniel Wyatt1, Nicholas Dudley1, Joel Clayton1, Siân Curtis2
1Multi-Medix
2University Hospitals Bristol and Weston NHS Foundation Trust
Aim: It has been suggested that as few as two dead transducer elements can affect Doppler performance. We aimed to determine the effect of one to five dead elements on Doppler velocity estimates, using a flow phantom, and on B-mode imaging performance using a tissue mimicking test object (TMTO).
Methods: Transducer pin connections were mapped for a high frequency linear array using an electronic probe tester. Doppler spectra and B-mode images were obtained using a flow phantom and a TMTO respectively for the transducer with all elements functioning, then with 1, 2, 3, 4 and 5 consecutive elements disabled by cutting pins in the connector. Images were obtained with targets centred on the dead elements, and also offset with dead elements laterally placed in the transmit beam over the relevant targets. Spectral velocities were measured using the scanner’s automatic tracing function and B-mode resolution and anechoic target visibility were assessed by software analysis.
Results: There were no significant effects of dead elements on measured velocity. Lateral resolution deteriorated more markedly with an asymmetric transmit beam than with the defect centred on the targets, e.g. full-width-half-maximum rose from a baseline of 0.63+/-0.03 mm, for a target at 10 mm depth, to 0.74 mm (centred) and 0.81 mm (offset) with five dead elements. Anechoic target visibility showed a more marked downward trend with the transmit beam defect centred on the targets.
Conclusion: Up to five consecutive dead elements had no significant effect on velocity measurement, but resolution and anechoic target visibility deteriorated.
Seven years of ultrasound probe failures from a monthly QA programme
Jasmine Lister, Prashant Verma, Andrew Lee, Mariusz Grocki
Sheffield Teaching Hospitals NHS Foundation Trust
Objective/Aims: This audit aims to identify whether a monthly QA programme is effective at identifying probe failures, prior to their manifestation as a detrimental fail-related artefact in a clinical image.
Methods: Probe failures were identified from monthly QA reports (2017 – 2023), and their date of removal from the local equipment database. Patient images for each probe failure from PACs were cross-compared against their associated monthly in-air reverberation QA images, to identify any matching fail-related artefacts. If present, the first patient potentially affected by the fail-related artefact was found. The patients’ images were presented to the lead sonographer to determine whether the fail-related artefact may have changed the patient pathway and why.
Results: Most failures were identified in monthly QA, primarily occurring one week prior to QA. Crystal drop-out and physical damage made up over two-thirds of the failure modes suggesting poor probe care is a leading cause for failure. Across probes failed for image quality reasons, around half showed a fail-related artefact clinically. Fail-related artefacts presented as either, or a combination of, shadowing, enhancement, and noise variation within the clinical images. Of these, many may have led to a different diagnosis following sonographer review. These instances were attributed to artefact location and extent versus potential sonographer inexperience.
Conclusion: Monthly QA is a snapshot, and so is not sufficient to identify all faults before they have the potential to affect clinical images. However, due to constraints in the current workforce more frequent QA is not viable. Therefore, it is proposed to move to a more frequent (daily/weekly) automated QA approach, such as the in-air reverberation uniformity analysis proposed by Horssen et al (2017). Additionally, improved communication between clinical and scientific teams is required to streamline the reporting of issues and accidents to the QA team, as and when they are arising.
