Proceedings of the British Medical Ultrasound Society 47th Annual Scientific Meeting 9–11 December 2015, City Hall, Cardiff, UK

The liver and pancreas

T Wells

Morriston & Singleton Hospitals, Swansea, UK

Abstract

This talk begins with a very brief introduction to the physics of CT and MR imaging. It discusses the advantages and disadvantages of CT and MR imaging compared to ultrasound, giving tips for choosing the best modality to further assess a finding on ultrasound. Then follows a review of common liver and pancreatic pathology in a case based format, demonstrating how and when CT and MRI are useful to further assess ultrasound findings.

It covers specifically in the liver: malignant lesions: metastases; hepatocellular carcinoma; cholangiocarcinoma; lymphoma. Benign pathology: focal fat; haemangiomas; adenomas; focal nodular hyperplasia (FNH); hepatitis; cirrhosis; abscesses; cysts including Hydatid (this is Wales!); haemochromatosis.

In the pancreas it covers: adenocarcinoma; neuroendocrine tumours; cystic pancreatic masses – intraductal papillary mucinous neoplasm (IPMN); serous and mucinous cystadenomas; acute and chronic pancreatitis and its complications.

The female pelvis

P Williams

Derriford Hospital, Plymouth, UK

Abstract

This session is aimed at sonographers to help them understand when ultrasound alone is enough and when abnormal ultrasound requires a CT/MR for clarification, also when can US help after an equivocal CT/MR.

The renal tract

E Simpson

Brighton and Sussex University Hospitals, UK

Abstract

This talk aims to give an understanding of CT scans, then covers basic renal protocols and basic CT appearances of common renal pathology, with correlation to ultrasound findings.

Fusion

O Byass

Hull and East Yorkshire Hospitals NHS Trust, UK

Elastography

A Lim

Imperial College, London, UK

Contrast

S Tenant

Derriford Hospital, Plymouth, UK

Abstract

Contrast enhanced ultrasound (CEUS) is now considered routine for the characterisation of liver lesions and robust guidelines have been published regarding its use in other organs. The software to perform these studies is present in most new ultrasound machines. Despite this, take up of CEUS in many imaging departments has been minimal or non-existent. Common perceptions are that it is a difficult skill to master and that other modalities can perform the same task but better.

This talk is intended as an introduction to CEUS for the beginner. It will start with the basics of the technique. It will be pictorially based, illustrating the most useful examinations and the typical imaging appearances of both normality and commonly occurring pathology. It will explain how, in the correct circumstances, CEUS is superior to other imaging modalities. It will hopefully enthuse delegates to adopt the technique in their own departments or to consider expanding their own practice to new areas having seen the benefits CEUS can have in everyday clinical work.

Reproducibility of shear wave elastography liver measurements in healthy volunteers

C Fang, E Konstantatou, O Romanos, GT Yusuf and PS Sidhu

King's College Hospital, London, UK

Abstract

2D shear wave elastography (2D-SWE) (Logic E9, GE Healthcare, Barrington, IL) is a new imaging technique for the non-invasive assessment of tissue stiffness. We assessed the reproducibility of 2D-SWE in quantifying liver elasticity in healthy volunteers, using acoustic radiation force impulse (ARFI) imaging (Acuson S3000; Siemens, Mountain View, CA) as a reference control.

Eleven healthy volunteers were examined twice, by four experienced operators, separated by a one-week interval. Ten 2D-SWE and ARFI measurements, expressed in meters per second, were obtained from deep portions of liver segments 5 and 6 away from vascular structures. Each volunteer was examined on two occasions, with observers blinded to elastography measurements. Inter- and intra-observer agreement was assessed by the Cronbach alpha statistic, with values ≥0.7 considered to be reliable.

Totally 880 2D-SWE and ARFI velocity measurements were recorded from four operators. Mean values ± standard deviation from the four operators ranged between 1.188 ± 0.14 m/s and 1.196 ± 0.15 m/s for 2D-SWE and 1.170 ± 0.23 m/s and 1.207 ± 0.23 m/s for ARFI. Inter-observer agreement between measurements performed in the same subject on the same day for the four observers were similar for 2D-SWE (Cronbach alpha 0.964 and 0.982 for day 1 and 2, respectively) and ARFI (0.966 and 0.971). Similarly, the intra-observer agreements performed in the same subject on different days among the four operators were reliable for 2D-SWE (Cronbach alpha 0.820, 0.884, 0.864, and 0.915, respectively) and ARFI (0.727, 0.917, 0.828, and 0.841, respectively). For both the inter- and intra-observer variability, the Cronbach alpha statistic was ≥0.7, indicating the results were reliable.

This study shows that 2D-SWE is a reliable and reproducible method for elasticity in health volunteers.

Case report: An unusual case of sub capsular liver infarction

A Al-Khatib, B Stenberg and A McNeill

The Newcastle upon Tyne Hospitals, UK

Abstract

A patient was admitted with two month history of weight loss, malaise and obstructive jaundice. On admission, B-mode US and subsequent CT pancreas and MRI liver demonstrated proximal common hepatic duct obstruction due to an enhancing soft tissue growth involving the proximal CHD, proximal cystic duct and gallbladder neck with evidence of infiltration through the hilar fat. The appearances favoured a neoplastic process. The patient proceeded to PTC demonstrating strictured proximal CHD and an internal external drain was inserted. Subsequently the patient underwent extended right hemi-hepatectomy, cholecystectomy and portal vein resection. Histopathology confirmed the diagnosis of moderate-poorly differentiated adenosquamous gallbladder carcinoma. On day 5 post surgery, the remnant left hepatic artery ruptured and an emergency patch repair was performed. A subsequent US Doppler showed intrahepatic arterial flow. However, the clinical picture of the patient and the blood tests were not reassuring. Therefore, a CEUS was performed to assess liver perfusion. This revealed central enhancement in the remaining left lobe, though, there was no enhancement in the peripheral liver parenchyma globally in keeping with peripheral sub capsular infarction.

The applications of ultrasound contrast are ever growing, particularly with regard to the assessment of abdominal organs. Here, we present a case of global sub capsular left liver infarction post a complicated extensive right liver resection and the subsequent use of contrast US in confirming the diagnosis. This pathological process is thought to be due to ischaemia during the hepatic artery rupture, similar to cortical necrosis in kidneys and is more commonly seen in post-transplantation kidneys. It is a safe, easy and efficacious investigative modality to stratify those patients with deteriorating clinical picture despite a reassuring post procedure US liver Doppler.

Urogenital

S Freeman

Derriford Hospital, Plymouth, UK

Abstract

In this talk, cases will be shown and discussed that demonstrate potential pitfalls in urogenital ultrasound including the kidney (infection, normal variants, echogenic masses), bladder (masses, stones and urachal abnormalities) and testis (trauma, torsion, non-malignant masses). The cases presented are intended to share the experience of ultrasound discrepancies from a large teaching hospital with the aim of minimising the chances of you repeating our mistakes in your own practice.

Hepato-biliary ultrasound

P Cantin

Derriford Hospital, Plymouth, UK

Abstract

This talk will discuss possible sources of error in hepato-biliary ultrasound. The importance of good sonographic technique will be emphasised. By reviewing some errors within our own large department, the importance of assessing patient presentation and history while undertaking an ultrasound examination will be described as well as the importance of placing scan findings into clinical context.

Errors of omission

C Gutteridge

Derriford Hospital, Plymouth, UK

Abstract

Where the other two talks in this session look at pitfalls in interpretation, this talk will look at ‘Errors of omission’. There are times when it is appropriate to deviate from the scan that has been requested, taking into account additional information gleaned during your examination. This session will show examples of where using additional information and initiative can allow an alert US practitioner to adapt their study in order to get to the bottom of the clinical problem, thus providing a more useful report.

Ultrasound in acute cholecystitis – Is it as good as we think?

C Miller, J Bell and MJ Weston

Leeds Teaching Hospitals Trust, UK

Abstract

Ultrasound is widely used as a first line investigation for suspected acute cholecystitis, in line with national guidance (NICE). However, this is based on opinion, with the evidence limited to three low powered studies. What is the sensitivity of ultrasound in our practice and how else are patients being diagnosed?

We carried out a retrospective analysis of patients admitted to a large teaching hospital over a three-month period with a diagnosis of acute cholecystitis. The discharge summaries, imaging reports, biochemistry/haematology and histology results were reviewed. The order of imaging and the imaging findings were recorded and the sensitivity of ultrasound was calculated.

A total of 99 cases of acute cholecystitis were identified, of which 74 had an USS as the first line imaging with a sensitivity of 80%. Of the 13 false negative cases, five had a diagnosis confirmed with CT and eight were diagnosed clinically. The five discordant cases were reviewed, with the potential reasons including rapid interim progression, satisfaction of search and operator dependency identified. The remaining cases were diagnosed with CT as a first line investigation (12) or had a previous diagnosis of gallstones and were treated empirically (13).

Our sensitivity is comparable to studies referenced in the national guidance. USS provides an available and safe method of diagnosing acute cholecystitis and should continue as the first line investigation. However, the limitations of ultrasound should be recognised and further investigation should be undertaken if there is clinical suspicion.

Case report: Incidental intussusception on USS; what you need to think about in adults and children?

R Williams

St Georges Hospital, London, UK

Abstract

Outside the realm of the acute paediatric presentation of intussusception, it is not common to see intussusception incidentally on an ultrasound examination. Intussusception is seen in both adults and children with a varied breadth of causative diagnoses that should be considered and excluded in each patient group.

Cases were reviewed whereby incidental intussusception was identified on USS examination; these included both adults and children. Often the patients complained of symptoms of intermittent abdominal pain, meriting further investigation. In all cases, abdominal USS was the first line radiological investigation, often due to radiation protection in young patients. Intussusception was seen in three young adults, a diagnosis of coeliac disease was made. Case images include echogenic abdominal lymph nodes, jejunisation of the ileum and intussusception. Three further paediatric cases of intussusception proved the intussusceptum to be nodal leading points, with Burkitts lymphoma being the final diagnosis.

In the cases discussed the underlying diagnosis and cause of intussusception was coeliac disease (in young adults) and malignancy (in children). This underlines the importance of when an intussusception is witnessed on USS, even if intermittent/transient it is a pertinent finding. It should prompt thought from the operator, alongside possible further investigations. Most operators are aware of the relevance of intussusception found in an adult; malignancy must be excluded and often patients will have a biopsy. These cases highlight malignancy should be considered as a possible, although unusual, cause of intussusception in children. While significant benign disease can also be the cause of adult intussusception.

The joy of research: Is necessity the best mother of invention?

P Wells

Cardiff University, UK

Clinical audit and peer review: Why, when and how?

PC Parker

Hull and East Yorkshire Hospitals NHS Trust, UK

Abstract

There is an increasing need for peer review to be undertaken within clinical ultrasound departments. There is much evidence available to support this and many tools have been described. However, finding an audit tool that is suitable for the dynamic and operator dependent imaging modality of ultrasound can be difficult.

The British Medical Ultrasound Society (BMUS) recommended audit tool has been developed from various peer review tools available. This tool has been tested by a group of ultrasound experts who form the BMUS Professional Standards Group.

The aim of this presentation is to give an overview of audit in everyday clinical practice, how the BMUS recommended tool came about and when its use can change practice. The BMUS recommended audit tool is available to all BMUS members via the BMUS website.

Improving practice from discrepancy meetings

P Rodgers

University Hospitals of Leicester NHS Trust, UK

Abstract

Elevated ALT is frequently associated with hepatic steatosis. Risk factors for raised ALT and steatosis include obesity, excess alcohol consumption, diabetes and chronic medication. The new British Medical Ultrasound Society (BMUS) Guidelines state that US has no value in the management of symptomless patients with raised ALT. Although it is accepted that US is able to diagnose fatty liver, there is no evidence to support the use of US in the management of patients with elevated ALT. Despite this, ultrasound services receive large numbers of referrals for US, most of which simply confirm a fatty liver.

The records of 100 GP and OP referrals for elevated ALT alone were retrospectively examined to establish what proportion had steatosis, what proportion demonstrated other relevant pathology and whether the ALT normalised following management of findings over a period of up to 12 months. The results will be presented.

The obesity epidemic has increased the number of US scans for elevated ALT with consequent pressure on department resources. Eliminating an US scan from the pathway of these patients has considerable potential for resource savings for the health service.

Duty of candour: Facing the facts of error

O Byass

Hull and East Yorkshire, Hospitals NHS Trust, UK

Medical legal issues facing ultrasound practice

A Andrews

Bond Salon, London, UK

Thyroid ultrasound – BTA guidelines and elation (elastography trial)

S Colley

Queen Elizabeth Hospital, Birmingham, UK

Multiparametric ultrasound of the testis: Role of strain elastography

PS Sidhu

King’s College Hospital, London, UK

Abstract

Ultrasound remains the standard for the evaluation of scrotal abnormalities, with B-mode and colour Doppler well established in the diagnosis of intra-testicular lesions. Limitations exist to a full characterization of these lesions, and often malignant and benign lesions overlap. Most intra-testicular lesions are malignant and the surgical management is an orchidectomy. However, newer ultrasound techniques of contrast-enhanced ultrasound (CEUS) and strain elastography (SE), grouped with B-mode and colour Doppler ultrasound under the umbrella term multiparametric ultrasound (MPUS), may be important. These techniques allow assessment of the internal vascularity of the lesion (CEUS) as well as assessment of the blood flow kinetics (enhancement curves) and the lesion stiffness can be ascertained (SE). A more confident diagnosis of the lesion type may allow for testis sparing surgery or ‘watchful waiting’ avoiding orchidectomy.

This lecture will detail current status of MPUS in the assessment of testicular lesions, review the literature and the probable clinical implications.

Physics & clinical applications of microvascular imaging

C Gutteridge

Derriford Hospital, Plymouth, UK

Abstract

A recent development in ultrasound, Superb Microvascular Imaging (SMI – Toshiba Medical Systems) claims to improve sensitivity to very low velocity flow in small vessels by eliminating artefacts from tissue motion. Clinical experience with SMI is still limited and the indications for the use of this new technology and its diagnostic value are not yet clearly established. In this session I will show some examples of where our department have found it most beneficial, having given an overview of the science behind this new development.

Matrix technology

B Stenberg

Freeman Hospital, Newcastle, UK

Abstract

This talk will discuss the principles behind matrix probe design and their advantages and disadvantages, from the conception and early models to recent probe design utilizing more than 9000 elements allowing for rapid near-isovoxel capture and display of data and multiple simultaneous scan planes.

The clinical applications of the matrix technology will also be discussed and how it can increase diagnostic confidence, increase accuracy of measurements, potentially reduce the risk of repetitive strain injury and provide information and data not previously accessible with conventional ultrasound.

The use of SMI in surveillance of endovascular aneurysm repair (EVAR)

B Gorell

University Hospital Wales, UK

Abstract

Endovascular aneurysm repair (EVAR) surveillance is recommended for the detection of endoleaks or aneurysm growth, usually using a combination of colour Doppler ultrasound (CDUS) and computed tomography angiography (CTA). Questions have been raised regarding the sensitivity of CDUS and contrast-enhanced ultrasound (CEUS) has been proposed as an alternative. CEUS is more sensitive than CDUS, but more invasive, costly and carries the potential risks of adverse reactions. Superb microvascular imaging (SMI) is a novel imaging technique developed by Toshiba Medical Corporation which demonstrates improved spatial resolution and low flow capabilities. In this audit, the applicability of SMI in an EVAR surveillance programme was tested.

A retrospective analysis was conducted on 136 patients comparing the success rate in diagnosing endoleaks with CTA, CDUS and SMI. The maximum diameter of the aneurysm sac was measured and the presence of endoleaks on CDUS, SMI and contemporaneous CTA scans was analysed.

Of the 136 patients, 36 also had CTA. Eighteen and 17 patients respectively showed no endoleak on ultrasound (CDUS & SMI) and CTA. Ultrasound failed to demonstrate one endoleak compared with CTA. Eighteen patients were found to have an endoleak on ultrasound (13%). Further analysis showed CDUS alone failed to demonstrate eight of these endoleaks. Of the 18 patients displaying an endoleak on SMI, 12 proceeded to CTA with only eight demonstrating an endoleak. Therefore, SMI detected four more endoleaks than CTA. In addition, two of these four patients with SMI endoleaks had an expanding sac size.

SMI outperformed CDUS and was comparable to CTA for the detection of endoleaks. SMI is a non-invasive technique, with additional cost and safety benefits. The sample size was limited but agrees with trends found with CEUS and CTA in the literature.

Safety of elastography

G ter Haar

Institute of Cancer, Sutton, UK

Abstract

Elastography is rapidly gaining increased acceptance in a number of areas of medical imaging, and comes as a standard mode on many modern ultrasound scanners. It is therefore important that its safety implications are considered seriously.

Changes in tissue stiffness can be interrogated in a number of ways. These are broadly divided into free hand elastography, acoustic radiation force imaging (ARFI) and shear wave elastography. In considering elastography safety it is only necessary to think of concerns introduced over and above those presented by conventional imaging modes. That said, free hand elastography introduces no additional concerns as the impulse needed to form the elastogram comes from mechanical pressure created by the transducer being pushed against the skin surface.

An ARFI pulse sequence consists of both ‘tracking’ beams and ‘pushing’ beams. The tracking beams are conventional B-mode ultrasound beams (A-lines), and the pushing beams produce an “acoustic push pulse” which is transmitted along the same A-line and have higher intensity. These pushes may last 100–500 microseconds, and have a spatial peak, pulse average intensity well in excess of 100 W cm⁻². It has been calculated that temperature rises (which are greatest at the focus of the pushing beam) may be 0.35℃ in soft tissue, ∼8℃ at bone.

Shear wave elastography also uses acoustic push pulses, but because of the ultrafast imaging techniques used to reconstruct the image, the biological effects are likely to be less than with ARFI. These techniques will be discussed, as will be the implications for the relevance of the thermal and mechanical indices displayed.

Inter- and intra-operator reproducibility of acoustic radiation force impulse elastography and factors which affect it

C Watts¹ and J Wilson²

¹Hull and East Yorkshire NHS Trust, UK

²University of Leeds, UK

Abstract

The aim of this research project is to assess intra- and inter-operator reproducibility of acoustic radiation force impulse imaging (ARFI) elastography of the liver and to identify any factors which affect this. Liver disease, which encompasses a wide range of pathological processes, is increasing and is likely to cause significant pressure and cost to the NHS. Accurate and streamlined staging, monitoring and management of liver disease are vitally important, however, invasive testing is not without risk. ARFI elastography is a non-invasive tool which can be used for the assessment of liver fibrosis in addition to abdominal ultrasound and hepatic Doppler assessment and has become a key component in a dedicated service including access to one-stop appointments at the time of consultant appointments in our trust. Whilst the body of evidence relating to the reliability of ARFI elastography of the liver is increasing, as part of a Masters study, a project to assess intra- and inter-operator reproducibility locally and identify any affecting factors has been carried out to add to this body of knowledge.

Using convenience sampling, patients have been recruited at the time of their routine ultrasound appointment as part of consultant care. Three sets of ARFI elastography readings have been acquired by two operators: 17 patients as a non-blinded pilot study and 41 patients as a blinded study. Patient demographics and measurements have been recorded and detailed analysis performed.

Results are still being analysed using statistic programmes to create Bland-Altman plots for all results and whilst this is a small scale study, it is hoped that conclusions can be drawn about both inter- and intra-operator reproducibility but also identify any affecting factors which can affect reproducibility.

Safety of contrast agents in paediatrics

G ter Haar

Institute of Cancer, Sutton

Abstract

Pre-clinical studies have demonstrated a number of biological effects that can be induced by the exposure of contrast microbubbles to a diagnostic ultrasound beam. These arise because these bubbles act as nucleation sites for cavitation, which in turn can lead to microstreaming and/or inertial cavitation. Microvascular damage and premature ventricular contractions have been seen following exposure to diagnostic ultrasound.

Paediatric use of contrast agents does not present significantly different risk than their use in adults, but they are off label for children, and no reference doses or standard protocols exist. Their bio-effects must therefore be carefully documented and understood.

RCR and SCoR equipment standards

NJ Dudley

United Lincolnshire Hospitals NHS Trust, UK

Abstract

The Royal College of Radiologists (RCR) and the Society and College of Radiographers (SCoR) in the United Kingdom (UK) published “Standards for the provision of an ultrasound service”, including equipment standards with application specific limiting values for resolution and penetration. No measurement methods were detailed, so we aimed to develop and test a measurement protocol and explore the theoretical basis of the standards.

In developing a protocol, manual/visual methods were found to be time consuming with a high level of uncertainty with a maximum standard deviation of 14%. Automated measurements were more efficient with a maximum standard deviation of 9%. Current testing methods for axial resolution are not fit for purpose. The final protocol was implemented on four new ultrasound scanners (8 probes). All eight probes failed to meet the standards for axial and lateral resolution and four failed to meet the standard for low contrast penetration. Since application specific standards fail to account for probes of different frequency used for the same application and since no evidence for the standards was provided we have developed new generic standards. A generic standard for penetration was developed based on scanner dynamic range and test object attenuation. Generic standards for resolution were developed from a combination of beam width calculations and direct measurement. The standards were tested on 15 probes, four probes failing to meet the new standards. Only one of the new probes failed to meet the standards.

Automated methods are more efficient and accurate compared with manual/visual methods. New generic standards with a theoretical basis have been proposed. Further work is required to refine standards and evaluation methods and to determine the appropriate relative contributions of objective and subjective methods in equipment selection.

Quality assurance of ultrasound probes

B Segall, A-C Segall

BBS Medical AB, Vätö, Sweden

Abstract

This presentation refers to studies and conclusions performed during 13 years within the area of testing multi brand ultrasound probes in daily use at hospitals in the Nordic countries. It describes the importance of frequently validating ultrasound probe performance for patient safety.

Studies have shown that 35–40% of the ultrasound probes, independent of brand and type, at a non- tested hospital, have defects and need to be attended to.

Common reasons for defective probes include:

– Handling (dropping, transport),

– Wrong gel or cleanser used,

– The performance of an ultrasound probe decreases over time,

– Mistakes during production process.

Common faults include:

– Element damage,

– Cable breakage,

– Lens problems, cracks,

– Strain relief.

Studies showed that Biomed Engineers relied either on regular maintenance from the manufacturer or on evaluation of the ultrasound scanners by their own testing protocols. The dynamic range is about 50 dB. This makes it almost impossible for a clinician to detect a few missing elements in the 2D image.

The abstract will describe:

– That it is possible to reduce the frequency of faults by 40% to 10%,

– The clinical impact of defective probes,

– Testing methods,

– Why defects do not show on the image,

– The impact of a few missing elements,

– That for a good Doppler signal, it is very critical that all elements are working,

– Why defects will have even greater importance in elastography mode, pulsed Doppler CFM color flow, CW Doppler,

– Ultrasound industry reactions,

– BioMed Engineers and hospitals are not aware of the problems,

– That clinical studies will have more accurate results if probes are monitored,

– Recommendations for the healthcare sector to bring the fault frequency down. Guidelines, standard for testing, recommended frequency of testing, responsibility.

What sonographers need to know about physics and technology and why

C Oates

Freeman Hospital, Newcastle, UK

Abstract

In using ultrasound, a sonographer is sending energy into the body, obtaining an echo signal back, which is then processed and presented for interpretation as an image or a waveform. The user has a lot of control over what that image looks like, and the processing used, that may affect the quality of the image, and therefore how useful it is for clinical interpretation and making measurements from. As specialist users of ultrasound, who make it their profession for several sessions each week, sonographers should have a good, in depth, knowledge of how ultrasound images are produced; how to interpret them from a physical point of view; and to know what the limitations of ultrasound imaging are. It is also important to understand why machines may differ from one another and what new technologies might be doing.

The level of knowledge and understanding should be at an expert user competency and need not be mathematically intense or highly technical, as a design engineer would need. The concepts and principles needed can be made accessible in teaching through the use of narrative explanation with pictorial diagrams and analogy with commonly understood examples from the everyday world. The key test of successful understanding is whether the sonographer can accurately and clearly explain and answer appropriate questions relating to the physics and technology of ultrasound in their own words and can practically demonstrate proper control of the machine and interpret the images correctly.

What have the physicists ever done for us?

JA Evans

University of Leeds/ Leeds Hospitals NHS Trust, UK

Abstract

At every stage of the development of medical ultrasound, progress has been made only with the key intervention of physical scientists. Probably the first of these was the discovery of the piezoelectric effect by Jacques and Pierre Curie. The subsequent history includes a very long list of people including materials scientists, theoretical and experimental physicists, mathematicians and electronics engineers. The pioneers who were responsible for the invention of the B-scanner, grey scale display, real-time scanning, the various Doppler modes, harmonic imaging, elastography and contrast agents to list but a few, should be recognised for their great contributions. The use of ultrasound in medicine continues to grow at a rapid rate but it might be argued that such fundamental developments have ceased or at least stalled. It follows that the key players now are those involved in applications development such as clinicians and sonographers and that the role of the physicist has come to an end.

It seems that in practice the physicist’s role has gradually petered out. Arguably this is true of the development of any new technology when it reaches the maturity in which it is widely accepted and at least partially automated. However, some fundamental questions arise:

1) Who is going to provide the evidence to ensure value for money and fitness for purpose and how is this to be done?

2) How is the problem with optimisation of display and viewing conditions going to be addressed and by whom?

3) How can the unsatisfactory nature of the evidence base for ultrasound safety be addressed?

4) Is there a need for ongoing QA? How and why?

5) How are therapeutic ultrasound developments such as high intensity focused ultrasound (HIFU) and targeted drug delivery introduced and governed?

The use of texture analysis in diagnosing ovarian masses

R Aldahlawi, ND Pugh and LDM Nokes

Cardiff University, UK

Abstract

Ovarian cancer has the highest mortality rate of all gynaecologic cancers and is the fifth most common cancer in UK women. Amongst various imaging modalities, ultrasound is considered the main modality for ovarian cancer triage. Like other imaging modalities, the main issue is that the interpretation of the images is subjective and observer dependent. Texture analysis has been shown to have potential in the objective assessment of ovarian cancer in a preliminary study.

The aim of this study was to assess prospectively the diagnostic performance of texture analysis in discriminating between benign and malignant adnexal masses and between different types of benign masses. Ultrasound images were collected from participants and transformed to a PC as a bitmap image file (BMP) file for off-line analysis. MaZda software was used to perform the texture analysis. In a preliminary study, two texture analysis features which showed usefulness in differentiating benign from malignant masses (grey-level co-occurrence matrix (GLCM) and wavelet), were applied to masses.¹ Then readings were compared to histology results of participants. p value was calculated for the significance.

Masses were divided into benign, malignant and simple cysts. Benign masses were sub-classified to dermoid, fibroid, endometrioma and suspicious benign masses. Preliminary results showed a significance difference between benign and malignant masses, p = 0.007, p = 0.04 for GLCM and wavelet, respectively. Significance differences were found between the subgroups as well. The results of the full cohort will be discussed and explained.

Miniature transducers for real-time guidance in neurosurgical procedures

R McPhillips¹, Y Jiang², Z Qiu¹, SO Mahboob¹, H Wang¹, C Meggs², G Schiavone³, DR Sanmartin⁴, S Eljamel¹, MPY Desmulliez³, T Button², S Cochran¹ and CEM Demore¹

¹University of Dundee, UK

²University of Birmingham, UK

³Heriot Watt University, UK

⁴Applied Functional Materials Ltd, UK

Abstract

In current neurosurgical practice, guiding interventional tools such as biopsy needles relies predominantly on preoperative MRI or CT imaging. These modalities can be costly, time consuming, and do not account for brain shift which can occur during intervention. Therefore, there is a need for real-time, minimally invasive imaging to guide the procedures. The aim of this paper is to explore the potential for real-time imaging using single element transducers integrated in the tip of a neurosurgical biopsy needle.

Two single element probes were fabricated using advanced microfabrication techniques to overcome the considerable manufacturing challenges, and placed within neurosurgical biopsy needles of 1.8 mm inner diameter. One device has a forward facing transducer at the tip of the needle; the second has a side facing transducer a few mm from the tip. An imaging system was programmed to allow real-time M-mode imaging. Plasticine targets were inserted into the brain of a Thiel embalmed cadaver and a fresh porcine model. The needle probes were inserted and maneuvered manually within both specimens and the M-mode imaging used to guide the needle tip to the target position.

Both fabricated transducers yielded strong signals from the targets within the Thiel embalmed cadaver and porcine brain tissue. The distance between the target and needle tip was changed continuously, and the acquired real-time M-mode images show the change of position of the target relative to the needle. MRI scans obtained of the Thiel cadaver and fresh porcine brain before and after intervention showed there was no significant change in the state of the brain tissue as a result of the experiments.

The M-mode images acquired from the transducers were used to navigate the needle towards the target. These results indicate the potential of miniature micro-ultrasound devices for guiding interventional tools during neurosurgery.

DVT integrated training

ND Pugh

University Hospital of Wales, Cardiff, UK

Abstract

This ever popular practical training session returns for a further year. It includes technique, pathology and reporting advice.

Introduction: Q&A session with faculty.

Lower limb: fem-pop – paired femorals and challenging legs.

Lower limb: calf veins – a magical mystery tour Iliac veins and IVC - practical tips.

Upper limb: arms and neck veins – a pragmatic approach.

Surgical treatments in UTI: The paediatric urologist view

A Abhyankar

Cardiff & Vale University Hospital, UK

The investigation of urinary tract infection in children

W Ramsden

Leeds Teaching Hospitals, UK

Abstract

This talk discusses the important role of ultrasound in imaging children with urinary tract infections, both during the acute episode and afterwards. The role of sonography is situated within overall guidelines for the imaging of children of varying ages with urinary tract infections due to both typical and atypical organisms. Situations where further imaging is required are highlighted, as are important findings which may necessitate specialist referral or long-term follow-up.

Ultrasound of the paediatric renal transplant

J Carmichael

Evelina London Children’s Hospital, UK

Ultrasound of the acute abdomen in children

T Humphrey

Leeds Teaching Hospitals, UK

Abstract

This talk will give guidance on the ultrasound technique and findings in children who present with an acute abdomen. The ultrasound appearances of conditions such as appendicitis and intussusception will be reviewed in conjunction with practical advice on avoiding common pitfalls.

The role of CEUS in paediatric abdominal trauma

M Sellars

King’s College Hospital, London, UK

The role of ultrasound in the diagnosis of paediatric tuberculosis

K Chetcuti

Alder Hey Children’s Hospital, Liverpool, UK

Abstract

Ultrasound is widely available, inexpensive and provides high quality images that allow for rapid diagnosis and ease of assessment for disease progression. These qualities, as well as the fact that ultrasound can be performed at the bedside with hand-carried ultrasound machines, make it appealing for use in low resource environments. Radiology expertise is frequently limited in these settings, however, the relative ease of use of ultrasound makes it available to non-radiologists, who, with basic ultrasound training are able to utilise ultrasound to significantly improve patient management. Ultrasound is generally well tolerated, does not incur any ionising radiation, and seldom requires sedation, making its use particularly attractive to the paediatric cohort.

Point of care ultrasound for the diagnosis of chest tuberculosis (TB) is more accurate in the identification of consolidation, pleural and pericardial effusions and mediastinal lymphadenopathy than auscultation or chest radiography (which is often the only imaging modality available in low resource settings). Although ultrasound imaging of the mediastinum is challenging anatomically, in one study, mediastinal lymphadenopathy diagnosed on ultrasound (later confirmed on computed tomography) was detected in 67% of children who were otherwise deemed to have a normal chest x-ray. Focused assessment with sonography for HIV/TB (FASH) is sensitive for demonstrating signs of extrapulmonary TB that is particularly prevalent in young children.

This presentation will outline the value of ultrasound in the diagnosis of pulmonary and extrapulmonary TB in children with illustrations of the various manifestations of paediatric TB also demonstrated.

Salivary glands – What to look for and how?

N Drage

Dental School, University Hospital of Wales, Cardiff, UK

The larynx – How I do it and why?

T Beale

University College Hospital, London, UK

Abstract

The lecture will start with an introduction on why I started looking at the larynx with ultrasound. I will then demonstrate the technique (sweeps) I use to assess the larynx, highlighting the anatomy that is visible with each sweep. I will concentrate on the ultrasound assessment of squamous cell carcinoma (SCC) of the larynx but will also show a variety of malignant and benign laryngeal pathology and peri-laryngeal pathology including laryngocoeles, vocal cord cysts, benign and malignant cartilage tumours, tracheal stents, thyroglossal remnants, etc.

I hope that by the end of the lecture the laryngeal ultrasound anatomy and technique will be clearer as will the advantages of performing ultrasound in this region. If there is any time remaining I may briefly highlight the advantages of ultrasound in other areas of the head and neck where ultrasound is underutilised, such as the oral cavity and tonsils.

Extra -thyroid masses

S. Colley

Queen Elizabeth Hospital, Birmingham

Abstract

This talk will review the local anatomy of the peri-thyroid region, outlining the tips and key structures that need to be highlighted in order to be able to assess this region when looking for the extra thyroid masses that exist in this region – e.g. parathyroid adenoma, para-tracheal lymph nodes. Common pathology that may present as a “thyroid” mass on ultrasound lists will be covered and presented. Tips and tricks for the ultrasound diagnosis of alternative pathology will be highlighted. The interaction with other imaging modalities is crucial in this region and the factors that influence the decision when to proceed to further imaging are to be discussed. Biopsy in this region can be problematic; tips and problems to avoid will be revealed.

Head and neck ultrasound: The where and now – back to basics?

Rhodri M Evans

Medical Imaging, School of Medicine, Swansea University, Swansea

Abstract

The leaps in technology that have occurred in ultrasound have resulted in a plethora of new techniques, software applications and innovations for the practitioner in the head and neck. As always in medicine, we forget where we were a short time ago and sometimes fail to remember the fundamental lessons we have learnt on the way. Looking back and reviewing where we have come from and asking the question “why?” is important if we are to reinforce and refresh the fundamental knowledge needed and the skills that enhance our practice. As such this talk will take us back to the basics of head and neck ultrasound and identify key areas where retrospection and review will help our current practice. Once we understand the fundamental principles of assessing the neck with ultrasound we can use the new applications now available to us more efficiently. Integration of new technology can then be pragmatic and valuable. This presentation will show the key lessons that I have learnt during my experience and will be presented with a view to question, review and enhance practice in head and neck ultrasound. Hopefully by showing my mistakes and the lessons I have learnt along the way, these tips will allow the practitioner to advance more efficiently along their learning curve and enhance their practice.

Ultrasound – Is anything else needed?

R Rhys

Royal Glamorgan Hospital, Llantrisant, UK

How is the NHS managing demand and the impact on service?

P Rodgers

University Hospitals of Leicester NHS Trust, UK

Walk-in direct access ultrasound service – A means to managing demand?

L Alcock and PC Parker

Hull and East Yorkshire Hospitals NHS Trust, UK

Abstract

Community non-obstetric ultrasound services are well established. With the impetus towards more care being delivered closer to home, the demand for community based services is growing. Non-obstetric ultrasound imaging is an important tool for GPs as it offers a first line investigation for many patients thereby aiding future management plans. Demand for non-obstetric ultrasound is increasing and in our institution there has been an increase in referrals of 5% year on year since 2008. One aspect of the service that has not changed is the DNA rate which runs at 6% despite changes to opening times and appointment booking. Given this high DNA rate, different ways of working and offering appointments have been reviewed. The aim of this pilot study was to offer a walk-in open access service for patients with non-obstetric ultrasound referrals from their GPs with a view to reducing the DNA rate and reducing impact on services within secondary care.

The pilot study ran for eight weeks from 7 April to 31 May 2015. An approximation of required daily capacity was calculated based on previous demand data. Ten appointment slots were allocated per day for this new service. The service was offered at a primary care community hospital. All scans were performed by sonographers experienced in non-obstetric ultrasound in primary care. Local GPs were informed of the pilot study via the East Riding Clinical Commissioning Group. From a patient perspective, the walk-in scheme provided an excellent service. On several occasions, patients with previously unsuspected significant pathology saw their GP, had their ultrasound examination and were reviewed by the GP with a faxed report on the same day.

This presentation outlines the benefits and productivity of this walk-in direct access service. Limitations and disadvantages are also discussed.

How are ISPs managing demand and the impact on service?

I Francis

Medical Imaging Partnership, West Sussex, UK

Education response – What can be done to support service growth?

S Campbell Westerway

Australasian Society for Ultrasound in Medicine (ASUM), Sydney, Australia

SCoR / BMUS profession standards. Implementation and impact on practice

PC Parker

Hull and East Yorkshire Hospitals NHS Trust, UK

Abstract

The 2008 United Kingdom Association of Sonographers (UKAS) Guidelines for Professional Working Practice in Ultrasound have been a much treasured document in most departments. However, the service and profession have developed since the guidelines were first written and this document is in need of review. The British Medical Ultrasound Society (BMUS) Professional Standards Group, working in conjunction with members of the Society of Radiographers, have updated and revised these guidelines and are proud to launch them today at this Annual Scientific Meeting.

The aim of the presentation is to give an overview of the revised guidelines and highlight key developments which will provide useful support for ultrasound practitioners working in the modern healthcare setting.

This house believes outsourcing ultrasound services to independent service providers leads to better service delivery

For – I Francis and Against – P Rodgers

Medical Imaging Partnership, West Sussex, UK

University Hospitals of Leicester NHS Trust, UK

This house believes that undergraduate training of sonographers will relieve the current recruitment and retention staffing issues

For – A Turner and Against – J Wilson

University Hospital North Midlands / Royal Stoke University Hospital, UK

University of Leeds, UK

The acute ovary

A Sanderson

Mid York NHS Trust, UK

Abstract

Acute pelvic pain is a common emergency presentation. It is a nonspecific symptom with a broad range of gynaecological and non-gynaecological causes. Imaging is frequently required to narrow the differential diagnosis and transvaginal ultrasound (TVUS) is the most widely accepted initial imaging modality when a gynaecological cause is considered most likely.

The main differentials in the non-pregnant patient include ruptured or haemorrhagic ovarian cysts, pelvic inflammatory disease, ovarian or adnexal torsion, mal-positioned intrauterine devices and fibroid complications. The clinical presentation and the imaging findings of each condition will be presented with particular emphasis on ultrasound. The ultrasound appearances may be complex and the importance of correlation with the clinical findings will be emphasised. The role of other imaging modalities including CT and MRI will be presented, particularly where used as an adjunct to ultrasound.

Scanning for the IVF patient

S Campbell Westerway

Australasian Society for Ultrasound in Medicine (ASUM), Sydney, Australia

Ultrasound in endometriosis

N Amso

Cardiff University, School of Medicine, UK

3D ultrasound of the uterus

N Kerr

Leeds Hospitals NHS Trust, UK

Abstract

Three-dimensional (3D) transvaginal ultrasound produces a volume of data containing any desired anatomical plane through the uterus. A reconstructed coronal slice through the uterus is rarely obtained with standard 2D ultrasound, but is commonly produced from the 3D volume. This additional view of the uterus has proven to be accurate in the diagnosis and classification of congenital uterine anomalies, aiding in the management of subfertility and pregnancy complications. Another main role of the 3D coronal view includes determining the position of intrauterine devices within the uterus and identifying myometrium perforation. In some cases the 3D coronal view can display thickening and disruption of the junctional zone associated with uterine adenomyosis.

This presentation will explain the basic techniques for obtaining a 3D volume of the uterus and a simple method of manipulating the volumes to produce the reconstructed coronal view. Interpretation of the 3D coronal view of the uterus will be discussed, including how to classify congenital uterine anomalies. The use of 3D transvaginal ultrasound in assessing the position of intrauterine devices, along with case reports on malpositioned intrauterine devices will be included. Finally, the potential benefit of the 3D coronal view of the uterus in the assessment of uterine adenomyosis will be discussed.

3D transvaginal ultrasound is rapidly becoming an essential imaging technique in the diagnosis of congenital uterine anomalies and in determining the position of intrauterine devices. By the end of this presentation delegates should feel confident to obtain and interpret the 3D reconstructed coronal view of the uterus with the objective of implementing 3D transvaginal ultrasound into everyday ultrasound practice.

One-stop postmenopausal bleeding (PMB) clinic – Is it worth it?

A McGuinness

Mid York NHS Trust, UK

Evaluating the indications for pelvis USS with suspected RPOC

S Tangudu

Hull and East Yorkshire NHS Trust, UK

Abstract

A pelvis USS is a very common investigation performed in investigating the cause of an abnormal vaginal bleed or abdominal pain after a delivery to rule out retained products of conception (RPOC). Though the incidence of RPOC is low at 0.4–3.8% it is a very important cause to be ruled out. There is no clear definition, indication and diagnosis on USS and management of RPOC in practice. The false positive rate in the diagnosis on USS is quite high at 28% after a miscarriage and 54% after a term delivery. The risks of evacuation of retained products of conception (ERPC) are well known and are only done as a last resort if conservative or medical management fails. We retrospectively evaluated 80 patients who have had a USS pelvis to rule out a RPOC from January 14 to September 14. The aim of the study was to mainly look at the interpretation of the report by the requesting clinician and the indications for intervention to evacuate the diagnosed or suspected RPOC. The study is underway and will be published soon.

Case report: Cervical cancer

A Harris

City University, London, UK

Abstract

Although deaths from cervical cancer are decreasing in the United Kingdom and survival rates have improved in younger women (aged under 40 years),¹ women over 65 years are at greater risk of cervical cancer if they have not had regular negative smear tests between ages 50–64.² Other risk factors for cervical cancer are human papillomavirus (HPV), smoking, multiple sexual partners, parity, lower age at first pregnancy and immunosuppression.³

A 74-year-old woman was referred by her general practitioner (GP) for an ultrasound scan because of lower urinary tract symptoms (frequency and nocturia). On scan, a large cervical mass was found with extension into the bladder. A follow up MRI scan correlated well with the ultrasound findings.

The most common symptom of cervical cancer is bleeding. In this case, the only symptoms were urinary and non-specific. Risk factors for this patient were smoking, parity (3 children), first child at age 18 years and non-attendance for smear tests since periods had stopped at age 50 years. Smear tests are more difficult to tolerate when postmenopausal and women who have been monogamous may not feel that they are at risk of cervical cancer.²

Case report: A case of hyperreactio luteinalis in early pregnancy complicated by torsion

E Allen, A Appiah, A Hameed, O Nzelu and Y Sana

Kings College Hospital, London, UK

Abstract

Hyperreactio lutenalis refers to moderate to marked cystic enlargement of the ovaries due to multiple benign theca lutein cysts. In 25% cases, it is associated with molar pregnancies or choriocarcinoma. The key differential diagnosis is ovarian malignancy. Typical ultrasound appearance is of multiple thin walled cysts enlarging the ovaries bilaterally.

We describe a case of a 34-year-old multiparous woman who presented to the early pregnancy department with a history of right sided abdominal pain. She was diagnosed with hyperreactio luteinalis and a viable intrauterine pregnancy of six weeks’ gestation. She then presented the next day with symptoms and scan findings suggestive of adnexal torsion. At laparoscopy, diagnosis of torsion and rupture of luteal cysts causing haematoperitoneum of 400 ml was confirmed. De-torsion of the adnexa was performed, conserving the ovary as well as the involved fallopian tube. Follow up ultrasound showed a smaller, less cystic appearance of the ovary and an ongoing pregnancy, with a persistent corpus luteum.

This case highlights the significance of accurate diagnosis and counselling of patients with this condition. An early diagnosis of torsion allowed clinicians to perform surgery to conserve the ovary containing corpus luteum.

Case report: A rare case of post-partum secondary amenorrhoea

B Guruwadayarhalli and N Nunes

West Middlesex University Hospital, UK

Abstract

A 29-year-old lady presented to accident and emergency department (A&E) with secondary amenorrhoea, lower abdominal pain and feeling unwell 10 weeks post ventouse delivery and episiotomy repair. Vulva and vagina were reported to be friable at the procedure. She was breast feeding. The patient’s husband gave a history of difficulty having sexual intercourse and described feeling an obstruction. Patient’s urine pregnancy test was negative.

Pelvic examination was impossible as the patient was very tender and the vaginal introitus appeared completely occluded. Abdominal ultrasound scan revealed a large haematocolpos, haematocervix and haematometra. A trans-perineal scan showed the vagina to be completely occluded about 1 cm from the introitus. A trans-rectal ultrasound scan demonstrated a large haematocolpos and ruled out any further septations or occlusions further up in the vagina. Both ovaries appeared normal. The patient underwent an examination under anaesthesia (EUA) and incision of the occlusion and drainage of the vaginal collection and was discharged home on combined oral contraceptive pills. At follow up two weeks post-operatively, she was still unable to have sexual intercourse and advised to use vaginal dilators to prevent further recurrence. Abdominal pelvic ultrasound scan was essentially unremarkable with complete resolution of haematocolpos and haematometra.

Secondary amenorrhoea due to vaginal obstruction is very rare. Cases of haematocolpos have been described after Stevens – Johnson syndrome¹ and bone marrow transplantation.^2,3 In cases where they occur after bone marrow transplantation, they are thought to represent a manifestation of chronic graft vs. host disease. Cases reported are commonly from Africa. It may occur rarely as a complication of female circumcision⁴ or more commonly from chemical vaginitis.^5,6 Our case was unusual as a post instrumental delivery complication.

Vascular 1 – Carotid

The vulnerable plaque and plaque morphology

ND Pugh

University Hospital of Wales, Cardiff

Stresses and strains in carotid plaque/ elastography

K Ramnarine

University Hospitals of Leicester NHS Trust, UK

Abstract

Technological innovations and developments in diagnostic medical ultrasound have a long history of exploitation in the vascular clinic. Current clinical practice for assessing stroke risk and treatment options is heavily reliant on ultrasound B-mode imaging and Doppler assessment of blood flow velocity to estimate carotid plaque degree of stenosis. Unfortunately, plaque size is not a good predictor of the unstable plaque. This presentation will consider a wide range of ultrasound techniques that have been investigated to help identify the vulnerable carotid plaque, with a particular focus on our experience in Leicester.

Ultrasound techniques include:

• conventional B-mode imaging, utilised for assessment of Greyscale median (GSM), plaque burden, ulceration (surface irregularity), image texture features for tissue characterisation and assessment of dynamic plaque behaviour;

• tissue Doppler imaging (TDI) for plaque wall motion and stress/strain assessment;

• shear wave elastography (SWE) for quantification of tissue stiffness;

• multigate Doppler and vector Doppler for improved blood velocity assessment;

• emboli; contrast agents and others.

Whilst these techniques provide additional information on plaque static characteristics or plaque dynamic behaviour, only some have demonstrated significant clinical benefit. Ultrasound techniques have impressive capabilities and unique advantages compared with competing imaging modalities and technological innovations are on-going. Their implementation into the vascular clinic will benefit patients and the NHS.

Blood flow in carotid plaques / vasa vasorum

E Leen

Hammersmith Hospital & Imperial College, London, UK

Comparison of internal carotid artery stenosis grading by CT angiography and Doppler ultrasound

J Mohajer, K Bryant, ND Pugh and A Gordon

University Hospital of Wales, Cardiff and Vale UHB, UK

Abstract

The 2009 recommendations for reporting carotid ultrasound investigations aimed to improve and standardise UK practice. However, confusion remains as to which measures provide the most accurate diagnosis, particularly around the >50% and >70% stenosis levels. Although not a gold standard, CT angiography is considered reliable for carotid imaging. This study aims to compare the results of CT angiography with the 2009 recommendations and the 2003 Society of Radiologists in Ultrasound (SRU) consensus for carotid ultrasound.

A retrospective evaluation of carotid artery imaging was performed at the University Hospital of Wales, Cardiff. Scan results for 136 patients who had undergone both carotid CT angiography and carotid Doppler imaging were analysed. The ultrasound scans were graded into <50%, 50–69%, 70–89% and 90% stenosis bands, using the 2003 SRU criteria of peak systolic velocity (PSV) and B-mode appearance. Of all, 46 patients had velocity criteria measured for PSV, PSV ratio (PSVR) and St Mary’s ratio, and were also graded using the 2009 UK recommendations. The CT angiography scans were graded using North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. The stenosis grading by CT angiography, and Doppler ultrasound using the 2003 and 2009 recommendations, were compared.

Overall, the ultrasound grading using 2003 SRU criteria matched the CT angiography grading in 93% of cases in the >70% stenosis bands. Doppler grading using SRU recommendations matched the CT angiography grading in around 20% more cases than the 2009 UK recommendations.

There is a degree of variability in the grading of carotid artery disease by CT angiography and Doppler ultrasound. Grading of ultrasound scans using SRU 2003 criteria provided the best correlation with CT. However, CT is not a gold standard and more evidence is needed to improve the reliability of carotid imaging.

Carotid plaque volume: Can it be accurately measured using tomographic (3D) Ultrasound?

S Rogers, J Burrough, S Ball, H Mohammad and C McCollum

University Hospital of South Manchester, UK

Abstract

Current European Society of Vascular Surgery (ESVS) guidelines recommend carotid endarterectomy (CEA) for a symptomatic severe carotid stenosis (>70%; NASCET criteria). However, in asymptomatic patients, the severity of carotid stenosis is a poor predictor of stroke, with a <2% risk of ipsilateral stroke per year for a severe stenosis. The Manchester carotid plaque study group has proven that carotid plaque volume (CPV) – the volume of atherosclerotic disease within the artery or atherosclerotic burden – is significantly higher in symptomatic compared with asymptomatic patients undergoing CEA. We investigated whether CPV can be accurately measured using tomographic (3D) ultrasound and if it is reproducible.

All patients admitted to University Hospital of South Manchester (UHSM) for a CEA were recruited and underwent pre-operative 3D carotid ultrasound by a trained vascular scientist. CPV was measured by two trained observers using a standardised technique. The volume of the endarterectomised plaque was precisely measured using a water immersion technique, based on Archimedes’ Principle, by dividing the suspended weight with the density of the fluid.

CPV measurements by two trained observers have been performed on 40 patients, but results on 10 patients are presented now (3 asymptomatic, 7 symptomatic). The mean CPV was (±SD) 728.9 ± 206.7 mm³. Initial results showed a strong correlation between the CPV measured by 3D ultrasound and the actual CPV, as measured by the immersion technique, with a mean difference (±SD) 99.3 ± 63.7 mm³; RS (10) = 0.82, p < 0.0058. Interrater reliability between the two observers was excellent, with a mean difference (±SD) 22.5 ± 42.4 mm³; RS (10) = 0.92, p < 0.0005. The results on all 40 (or more) will be available by December.

While this sample size is small, tomographic (3D) ultrasound may be used to measure CPV accurately and has excellent reproducibility. The results from paired measurements in over 40 carotid patients will be presented.

Diagnosis and management of May-Thurner syndrome

R Alikhan

University Hospital Wales, Cardiff, UK

Ultrasound assessment of upper limb venous system

T Robinson

Bristol Royal Infirmary, UK

Klippel-Treanaunay syndrome – Comparison of two cases

T Gall

University Hospital South Manchester, UK

Microbubbles – Imaging the peripheral vascular tree – A feasibility study

A Smith, PC Parker, OR Byass and K Chiu

Hull and East Yorkshire NHS Trust, UK

Abstract

Deep vein thrombosis(DVT) is potentially a fatal and debilitating condition causing pulmonary embolism (PE) and post thrombotic syndrome. It affects 1–2% of the population. Ultrasound scan (USS) is the investigation of choice providing a 94% specificity and sensitivity of 95% and 64% in the proximal and distal leg, respectively. Peripheral oedema and obesity may cause suboptimal imaging in many groups. Additionally, patients at high risk of DVT are initiated on anticoagulation, increasing risk of haemorrhage and heparin-induced thrombocytopenia. Both mean multiple attendances to clinics and increased cost. Uncertainty of diagnosis also causes patient anxiety. A method that would improve image specificity and sensitivity would be beneficial to the patient and NHS. We aim to assess the feasibility of utilising Sonovue™ to effectively visualise the deep veins of the lower limb.

Twelve patients with high risk for DVT were selected. A fundamental scan was performed with the patient supine utilising B-mode imaging and a 3–5 MHz probe. Visualisation of the veins was recorded and calf veins measured from the crease of the popliteal fossa. A single bolus 5 ml of Sonovue™ was then administered and the process was repeated. The images were stored on Agfa-Impax.

Results included: a maximum gain in visualisation of 28 cm; improved visualisation to 100% in the proximal lower limb in all candidates; improved visualisation in the calf veins from 54% to 79% (posterior tibial vein (p = 0.01) and peroneal vein (p = 0.03)); combined improved length of visualisation in the calf veins (p = 0.003).

This study demonstrated that contrast enhanced ultrasound (CEUS) is a valid method for visualisation of vessels in the lower limb. CEUS is a potential adjunct to help in the visualisation of the deep veins in difficult to scan patients. Pending further study, we hope to give high risk patients contrast at their initial scan to avoid the need for repeat investigation and to reduce patient anxiety.

Is D-dimer measurement a clinically useful screening test for the assessment of lower limb deep vein thrombosis

P Williams, ND Pugh, R Morris, C Bryant and D Coleman

Cardiff and Vale UHB, UK

Abstract

For the last 25 years, GP patients with suspected deep vein thrombosis (DVT) have undergone first line venous ultrasound scans at the University Hospital of Wales (UHW). Following new NICE guidance, the patient pathway was changed; since July 2013 patients are now referred to a nurse led DVT clinic. Patients undergo an initial Wells score and D-dimer measurement to provide an indication to the likelihood of a positive DVT. Patients with a Wells score of ≥2 are referred for an ultrasound scan, patients with a Wells score of ≤1 have a D-dimer measurement. If the D-dimer is negative, the patient is discharged. If the D-dimer is positive the patient has an ultrasound scan. This approach has the potential to reduce the number of patients requiring an ultrasound scan. However the suitability of the D-dimer test has been questioned due to its high false positive rate.

This retrospective study aimed to determine whether the D-dimer test significantly reduces the number of negative DVT ultrasound scans. Results from patients with a Wells score ≤1 combined with a positive D-dimer were analysed. Results showed that out of 314 patients with a Wells score of ≤1 and a positive D-dimer test only 16 were diagnosed with a positive DVT by ultrasound, a post test probability of 12.4% (87% false positive rate).

D-dimer has a very high false positive rate and therefore does not significantly reduce the number of unnecessary scans performed, considering the additional cost of the D-dimer test and the increased waiting time for the patient.

Case report: Cystic adventitial disease

H Dixon

King’s College Hospital, London, UK

Abstract

Cystic adventitial disease is a vascular condition that mainly affects the popliteal artery and is also most common in men in middle age. Cystic adventitial disease usually presents with symptoms of claudication similar to presentation of popliteal entrapment as it also results in flow obstruction during exercise.

In this case, a 51-year-old male was referred to the DVT clinic complaining of right calf pain with a history of previous DVT. The patient was referred to the vascular lab for a duplex ultrasound to assess for DVT. On attendance at the vascular lab, during clinical history taking, the patient also described claudication symptoms. During the duplex scan a cystic mass was identified in the popliteal fossa adjacent to the popliteal artery. Dynamic studies of the popliteal artery showed the vessel to be patent during flexion of the knee and compressed by the cystic mass on extension of the knee. The patient had a normal resting ankle brachial pressure index (ABPI); however, post exercise testing a reduction in the ABPI value was seen. The vascular laboratory report suggested this was a presentation of cystic adventitial disease and the patient went on to have a CT scan to examine the mass and confirm the diagnosis.

Surgical treatment of cystic adventitial disease was offered to the patient. Surgical intervention involves excision of the cyst and repair of the artery with saphenous vein. The patient declined to have surgery at this stage. This case shows that cystic adventitial disease should be considered in the assessment of younger patients presenting with claudication with normal ABPI values at rest.

Musculature of popliteal fossa for assessment of popliteal entrapment

L Waring

University of Cumbria, UK

Management and treatment of popliteal entrapment

I Williams

University Hospital, Cardiff, UK

Abstract

This presentation will be a discussion around the presentation, investigation and treatment of popliteal entrapment syndrome, which usually presents in young non atherosclerotic patients. Also covered are other rare causes of lower limb ischaemia including popliteal advetitial cysts and iliac endofibrosis.

Colour Doppler ultrasound in the assessment of focal testicular lesions: Influence of lesion size and pattern of vessel distribution in malignant and benign lesions

EC Bartlett, ME Sellars, JL Clarke, SL Sriprasad, GH Muir and PS Sidhu

King's College Hospital NHS Trust, London, UK

Abstract

Increased vascularity is the hallmark of malignancy in focal intra-testicular abnormalities. Colour Doppler ultrasound assessment is reported of limited use in lesions <16 mm. We assessed the capability of colour Doppler in focal testicular abnormalities, to ascertain lesion volume that allows confident lesion vascularisation.

A departmental database identified 135 focal testicular lesions (in 100 patients) examined by a single observer, over a 10-year period, using an Acuson Sequoia 512 and a 15 MHz transducer. Examinations were performed with grey scale and colour Doppler images and video clips recorded. Images were retrospectively reviewed: size/volume, grey-scale features (echogenicity/calcification/ border configuration/cystic change), colour Doppler appearances (presence/absence) and distribution of vessels (linear/criss-cross) were assessed for each lesion. All lesions had histological diagnosis.

The mean age was 37 years (range 1–76 years). The mean lesion volume was 8 ml (range 0.004–142 ml). Histology was: seminoma (n = 54), non-seminomatous germ cell tumour (GCT) or mixed GCT (n = 35), malignant non GCT or metastases (n = 9), benign non GCT (Leydig cell tumour/hyperplasia) (n = 16), ischaemic/inflammatory, post inflammatory/infective lesions or fibrosis (n = 21). Of 54 seminomas, 50 (93%) showed increased vascularity, with criss-crossing intra-lesional vessels; 3 (5%) were hypovascular. One lesion was isovascular to normal testis. No relationship was seen between size and vascularity. Non-seminomatous /mixed GCTs demonstrated a variety of vascular patterns; 29/35 (83%) showed increased vascularity, either criss-crossing or disorganised. No relationship was seen between size and vascularity. Nine focal lesions represented ischaemia and/or infarction or fibrosis. All were avascular. Cystic lesions and abscesses were avascular.

Increased vascularity, with criss-crossing intra-lesional vessels, was demonstrated in 93% of seminomas and in 90% of mixed GCTs with a seminomatous component. Of those 85% of malignant lesions demonstrated increased vascularity. Vascularity was demonstrated in lesions of all sizes. The absence of internal vascularity, in conjunction with typical B-mode findings, correctly prospectively identified benign ischaemic, fibrotic and cystic lesions.

This house believes that we should follow SVT recommendations and measure the PSV, PSV ratio and the St Mary's ratio when assessing the degree of carotid artery stenosis on ultrasound

For – C Oates and Against – ND Pugh

Freeman Hospital, Newcastle, UK

University Hospital of Wales, Cardiff, UK

Ultrasound in acute cholecystitis – Is it as good as we think?

C Miller, J Bell and MJ Weston

Leeds Teaching Hospitals Trust, UK

Does accuracy of ultrasound-guided corticosteroid injection predict outcome in pain and function in subacromial impingement syndrome?

P Raval, N Foster, R Ogollah, A Hall and E Roddy

Keele University, UK

Abstract

Subacromial corticosteroid injection is widely used for treatment of subacromial impingement syndrome (SIS). There is increasing interest in using ultrasound (US) to improve the accurate placement of injections. This study investigated whether accuracy of placement of US-guided subacromial corticosteroid injections influences patients’ outcome of pain and function.

The study method consisted of a secondary analysis of data from a 2 x 2 factorial randomised controlled trial investigating exercise and corticosteroid injection for pain and function in SIS. Video images were reviewed to categorise accuracy of injection into the subacromial bursa into three accuracy groups using pre-defined criteria: 1) not in the subacromial bursa; 2) probably in the subacromial bursa; and 3) definitely in the subacromial bursa. The primary outcome measure was the self-reported Shoulder Pain and Disability Index (SPADI) total score, compared at six weeks and six months. Secondary outcomes included SPADI pain and function subscales and participant global rating of overall change from baseline. A mixed effects model was used to compare accuracy groups’ outcomes at six weeks and six months, adjusted for baseline covariates.

US-guided injection accuracy data were available for 114 participants; with 22 participants in group 1, 21 in group 2 and 71 in group 3. There were no significant differences in mean SPADI scores among the three injection accuracy groups at six weeks (group 2 vs. 1: 8.22 (95% CI −4.01, 20.50); group 3 vs. 1: −0.57 (−10.27, 9.13)) and six months (group 2 vs. 1: 12.38 (−5.34, 30.10); group 3 vs. 1: 3.10 (−11.04, 17.23)). Similarly, no differences between groups were seen in SPADI pain, SPADI function or participant global rating of change.

The accuracy of US-guided subacromial corticosteroid injection in SIS does not influence clinical response, questioning the need for guided injections. Larger, adequately powered studies are required to explore this further.

The use of SMI in surveillance of endovascular aneurysm repair (EVAR)

B Gorell

University Hospital Wales, UK

Abstract

EVAR surveillance is recommended for the detection of endoleaks or aneurysm growth, usually using a combination of colour Doppler ultrasound (CDUS) and computed tomography angiography (CTA). Questions have been raised regarding the sensitivity of CDUS and contrast-enhanced ultrasound (CEUS) has been proposed as an alternative. CEUS is more sensitive than CDUS, but more invasive, costly and carries the potential risks of adverse reactions. Superb microvascular imaging (SMI) is a novel imaging technique developed by Toshiba Medical Corporation which demonstrates improved spatial resolution and low flow capabilities. In this audit, the applicability of SMI in an EVAR surveillance programme was tested.

A retrospective analysis was conducted on 136 patients comparing the success rate in diagnosing endoleaks with CTA, CDUS and SMI. The maximum diameter of the aneurysm sac was measured and the presence of endoleaks on CDUS, SMI and contemporaneous CTA scans was analysed. Of the 136 patients, 36 also had CTA. Of those, 18 and 17 patients, respectively, showed no endoleak on ultrasound (CDUS & SMI) and CTA. Ultrasound failed to demonstrate one endoleak compared with CTA. Of those, 18 patients were found to have an endoleak on ultrasound (13%). Further analysis showed CDUS alone failed to demonstrate eight of these endoleaks. Of the 18 patients displaying an endoleak on SMI, 12 proceeded to CTA with only eight demonstrating an endoleak. Therefore, SMI detected four more endoleaks than CTA. In addition, two of these four patients with SMI endoleaks had an expanding sac size.

SMI outperformed CDUS and was comparable to CTA for the detection of endoleaks. SMI is a non-invasive technique, with additional cost and safety benefits. The sample size was limited but agrees with trends found with CEUS and CTA in the literature.

An audit on ultrasound ‘X’ marking of site for subsequent aspiration or chest drain insertion remote from the radiology department

H Kazi, N Ahmed and A Razack

Hull Royal Infirmary, UK

Abstract

We wanted to assess our local practice of US assessment of pleural effusions and marking of the site for remote aspiration or chest drain insertion (RACD) with review of overall outcome of the procedures and associated complication rates. Our comparative standard was the British Thoracic Society Pleural Procedures Guideline 2010, which suggests that RACD should only be considered in large pleural effusions.

Patients with suspected pleural effusions who were referred for ultrasound assessment and ‘X’-marking of a suitable site between January 2012 and June 2013 were analysed. Parameters assessed included patient demographics, pre-procedure CXR findings, volume of effusion and nature of effusion (simple vs. complex) on ultrasound, presence of loculations and pleural thickening, skin to pleura distance and post-procedure complications.

Of the 109 patients assessed, 72 were deemed suitable for ‘X’-marking while 37 were not marked (28 due to small size, 4 due to loculated /complex effusion and 5 due to unfavourable location). Of the 72 patients, 60 underwent an RACD (19 = pleural aspiration, 41 = chest drains). Pleural aspiration was successful in all patients with no associated complications. Of the 41 drains, three were unsuccessful (drain tip in the subcutaneous tissue outside the pleural cavity in 1 case and kinked in 2 cases). Of the 41, one had a small apical pneumothorax. A common variable in all 4 /41 patients with unsuccessful procedure / complication was the complex nature of effusion or presence of pleural thickening.

Our results indicate that in appropriately selected patients as per guidelines, 'X'-marked RACD may be an acceptable strategy, although ideally real time US guidance should be used. Our data also suggests that 'X'-marking should perhaps be avoided even in large effusions, if there is discernible pleural thickening or loculations/complexity.

Carotid plaque volume: Can it be accurately measured using tomographic (3D) ultrasound?

S Rogers, J Burrough, S Ball, H Mohammad and C McCollum

University Hospital of South Manchester, UK

Abstract

Current European Society of Vascular Surgery (ESVS) guidelines recommend carotid endarterectomy (CEA) for a symptomatic severe carotid stenosis (>70%; NASCET criteria). However, in asymptomatic patients, the severity of carotid stenosis is a poor predictor of stroke, with a <2% risk of ipsilateral stroke per year for a severe stenosis. The Manchester carotid plaque study group has proven that carotid plaque volume (CPV) – the volume of atherosclerotic disease within the artery or atherosclerotic burden – is significantly higher in symptomatic compared with asymptomatic patients undergoing CEA. We investigated whether CPV can be accurately measured using tomographic (3D) ultrasound and if it is reproducible.

All patients admitted to University Hospital of South Manchester (UHSM) for a CEA were recruited and underwent pre-operative 3D carotid ultrasound by a trained vascular scientist. CPV was measured by two trained observers using a standardised technique. The volume of the endarterectomised plaque was precisely measured using a water immersion technique, based on Archimedes’ Principle, by dividing the suspended weight with the density of the fluid.

CPV measurements by two trained observers have been performed on 40 patients, but results on 10 patients are presented now (3 asymptomatic, 7 symptomatic). The mean CPV was (±SD) 728.9 ± 206.7 mm³. Initial results showed a strong correlation between the CPV measured by 3D ultrasound and the actual CPV, as measured by the immersion technique, with a mean difference (±SD) 99.3 ± 63.7 mm³; RS (10) = 0.82, p < 0.0058. Interrater reliability between the two observers was excellent, with a mean difference (±SD) 22.5 ± 42.4 mm³; RS (10) = 0.92, p < 0.0005. The results on all 40 (or more) will be available by December.

While this sample size is small, tomographic (3D) ultrasound may be used to measure CPV accurately and has excellent reproducibility. The results from paired measurements in over 40 carotid patients will be presented at the meeting.

Reliability of elastography measures of the Achilles tendon

C Payne

University of Brighton, UK

Abstract

Elastography provides a direct, real-time assessment of tissue elasticity and is valuable in tumour tissue differentiation, used for detection and diagnosis of many cancers and liver fibrosis. Its value in musculoskeletal imaging is less well defined. The purpose of this study was to determine the reproducibility and repeatability of two common types of elastography, compression (CE) and shear wave elastography (SWE), in depicting the mechanical properties of the in vivo Achilles tendon.

Data from CE and SWE were collected from eight healthy participants at the relative tendon mid-point in two blocks including five consecutive measurements taken in a one hour period and one measure taken every day for a five day period.

For CE, all coefficient of variation (CV) scores were above 53%, correlations indicated no correlation to weak correlations, and intra-class correlation coefficient (ICC) values were all in the poor category. For SWE, CV scores were 3.70–7.37%, correlations ranged from 0.15 to 0.85 and ICC ranged from 0.34 to 0.89. No significant differences were noted with respect to protocol or time, no significant differences were found in transverse data for foot position, but significant differences were shown between fixed and relaxed foot positions for longitudinal scanning (p = 0.003). ICC between two separate operators was 0.70 for transverse and 0.80 for longitudinal scanning.

Given the wide variation in CE results, it was deemed to have a low level of reliability for depicting mechanical properties of the Achilles tendon and not applicable for this particular purpose. In comparison, SWE was shown to be reproducible and repeatable at depicting and quantitatively assessing the mechanical properties of the human Achilles tendon. There was no additional benefit to securing the foot during SWE examination and there is a high level of agreement between different operators.

Comparison of internal carotid artery stenosis grading by CT angiography and Doppler ultrasound

J Mohajer, K Bryant, ND Pugh and A Gordon

University Hospital of Wales, Cardiff and Vale UHB, UK

Abstract

The 2009 recommendations for reporting carotid ultrasound investigations aimed to improve and standardise UK practice. However, confusion remains as to which measures provide the most accurate diagnosis, particularly around the >50% and >70% stenosis levels. Although not a gold standard, CT angiography is considered reliable for carotid imaging. This study aims to compare the results of CT angiography with the 2009 recommendations and the 2003 Society of Radiologists in Ultrasound (SRU) consensus for carotid ultrasound.

A retrospective evaluation of carotid artery imaging was performed at the University Hospital of Wales, Cardiff. Scan results for 136 patients who had undergone both carotid CT angiography and carotid Doppler imaging were analysed. The ultrasound scans were graded into <50%, 50–69%, 70–89% and 90% stenosis bands, using the 2003 SRU criteria of PSV and B-mode appearance. Of all, 46 patients had velocity criteria measured for peak systolic velocity (PSV), PSV ratio (PSVR) and St Mary’s ratio, and were also graded using the 2009 UK recommendations. The CT angiography scans were graded using NASCET criteria. The stenosis grading by CT angiography, and Doppler ultrasound using the 2003 and 2009 recommendations, were compared.

Overall, the ultrasound grading using 2003 SRU criteria matched the CT angiography grading in 93% of cases in the >70% stenosis bands. Doppler grading using SRU recommendations matched the CT angiography grading in around 20% more cases than the 2009 UK recommendations.

There is a degree of variability in the grading of carotid artery disease by CT angiography and Doppler ultrasound. Grading of ultrasound scans using SRU 2003 criteria provided the best correlation with CT. However, CT is not a gold standard, and more evidence is needed to improve the reliability of carotid imaging.

The work being undertaken nationally by Health Education England to address the current sonography workforce crisis

Kevin Moore

Health Education England, UK

The future of sonographic education and the University of Cumbria’s experience of developing a graduate entry two-year accelerated MSc in Clinical Ultrasound

G Bolton

University of Cumbria, UK

The role and value of focused ultrasound courses in meeting service delivery demands

G Dolbear

Canterbury Christ Church University, UK

Come fly with me and become a sonographer!

C Oates

Freeman Hospital, Newcastle, UK

Abstract

With a national shortage of trained sonographers there is a need to train sonographers as quickly as possible. One option currently being introduced is direct graduate entry by those with no previous health service experience. For all trainees, a particular bottleneck in training is the need for one-to-one hands-on training to master scanning and achieve the necessary competencies to scan. This can place a high demand on a department that may have limited staff and a heavy workload. The number of trainees they can cope with is limited. Consequently, the time taken for a trainee to begin to gain some confidence in scanning is often prolonged because they have to fit learning to scan into busy clinic schedules.

This paper draws inspiration from the airline industry to propose a novel model for the initial training of sonographers. Would-be pilots have to master a set of practical and theoretical skills that may be compared with the physical and mental complexity of sonography. The basic training of an airline pilot to gain their commercial pilot’s licence is 12 weeks. The full theory and experience will take longer, but at that stage they can fly a commercial plane. This paper proposes an intensive 12-week training programme for sonographers that will take someone from zero experience to a point where they can operate a scanner and be able to scan an abdomen, recognising and obtaining clinical views of normal anatomy and simple pathology. During this time they would gain 250 hours of hands-on scanning time using simulators and real patients. It requires a dedicated trainer to train students on a 2:1 basis. At the end of this period, the trainees would immediately begin to be useful to a department and could move onto a more advanced phase of recognising pathology straight away.

The Northern Regional Simulation Centre – Experiences so far!

S Richards

Teesside University, UK

The role and value of ultrasound simulation in formative and summative assessment

V Gibbs

University of the West of England, Bristol, UK

Head & neck integrated training

R Evans¹ and R Rhys²

¹Morriston Hospital, Swansea, UK

²Royal Glamorgan Hospital, Llantrisant, UK

Abstract

The anatomy of the head and neck will be taught through a series of standard sweeps through the neck. The neck will be systematically covered outlining the key structures that need to be identified, starting with the submental triangle and ending with the larynx. Tips and pitfalls will be highlighted allowing a comprehensive scanning technique of the neck to be mastered under the guidance of the faculty.

Quality and practical governance practical workshop

PC Parker¹ and NJ Dudley²

¹Hull and East Yorkshire NHS Trust, UK

²United Lincolnshire Hospitals NHS Trust, UK

Abstract

Medical imaging departments and services are increasing being scrutinised. With the advent of the RCR Imaging Services Accreditation Scheme (ISAS) and Care Quality Commission (CQC) inspections specifically reviewing imaging services there has never been a greater need for robust governance and quality processes and documentation. The aim of this workshop is to give advice and practical experience in the key aspects of governance and quality measures in ultrasound. The British Medical Ultrasound Society (BMUS) QA guidelines will be presented and there will be an opportunity for delegates to gain experience and confidence in undertaking these tests with a team of experts. The latest in infection control guidance will be presented as well as an overview of governance requirements for your ultrasound service.

Governance in ultrasound, what, why, how, and when?

PC Parker

Hull and East Yorkshire NHS Trust, UK

QA – What, why, how and when?

NJ Dudley

United Lincolnshire Hospitals NHS Trust, UK

Microbial issues for ultrasound imaging

S Campbell Westerway

Australasian Society for Ultrasound in Medicine (ASUM), Sydney, Australia

Improving the routine detection of foetal cardiac anomalies

O Uzun

Cardiff and Vale UHB, UK

Foetal Anomaly Screening Programme update

P Pandya

University College Hospital, London, UK

Screening for serious foetal cardiac anomalies – Friend or foe?

T Chudleigh

Addenbrooke’s University Hospitals NHS Trust, Cambridge, UK

The impact of training and policy on the increased detection rate of cardiac anomalies in the foetus: The Welsh experience

J Kennedy¹, E Kealaher¹ and O Uzun²

¹Cardiff University, UK

²Cardiff & Vale UHB, UK

Abstract

Congenital heart disease is a leading cause of congenital defect-related death in childhood with improved antenatal detection of cardiac abnormalities, especially those of the outflow tracts, being key in improving outcomes. Due to wide acceptance that additional views of the heart improve diagnostic accuracy, from 2001 various training programmes were undertaken in Wales culminating in the mandatory inclusion of outflow tracts as part of the foetal anomaly scan in 2010. This study was undertaken to assess detection rates of outflow tract anomalies in each period, and the current status of training requirements. Retrospective analysis of cases in South Wales from 2001 to 2013 was undertaken via departmental (n = 2958) and national (CARIS – n = 5420) databases. A training needs analysis questionnaire was undertaken to assess current sonographer foetal echo training requirements.

During 2001–2009 the mean number of outflow tract anomalies detected per year was 14.4 whereas during the period 2010–2013 it was 21.2 (p = 0.008). The mean referrals per year for these two periods was 196.2 and 208, respectively (p = 0.65). The rate of antenatal detection of outflow tract abnormalities during these periods also increased (47% vs. 70%, p = 0.0005). Detection rates peaked in 2011 reaching 80.6% before dipping to 70% and 66% in 2012 and 2013 respectively. 60% (n = 41) of sonographers described themselves as very competent at the examination of outflow tracts. However, 77% (n = 30) of these still professed a need for further training updates.

The detection rate of outflow tract anomalies throughout South Wales has improved substantially. A major increase is seen after the initial training programme, and continues with the All Wales training programme and subsequent mandatory implementation of outflow tract examination policy. It has, however, shown a decreasing trend since the cessation of training, indicating that successful screening policies must be combined with continuing structured training programmes.

Case report: Accreta - How confident can you be?

P McTigue and A McGuinness

Mid Yorks NHS Trust, UK

Abstract

This is a case study of an interesting case of morbidly adherent placenta (Accreta). A 34 years patient (BMI 47) attended for a dating scan with a previous history of C section. Our department had been exploring the equipment requirements for assessing placenta accreta and whether specialist training, high frequency linear probes or both were necessary to confidently rule this condition out. This case was influential at a local level and occurred at a time when evidence and experience from this case was used to develop obstetric protocols and placental assessment pathways in the Trust.

There was some difficulty performing all of her scans due to body habitus. The initial dating scan highlighted evidence of accreta at 16 weeks GA. Subsequent scans contradicted this finding before it was finally agreed that it was a case of accreta after USS at 29 weeks and MRI at 31 weeks. To obtain a better appreciation of what the scans represent, a sonographer will be present during planned C-Section on 13 August 2015 as well as the obstetric and vascular teams. It is expected that intra-operative sonography will be necessary to plan incision sites due to maternal body habitus and anterior placenta. At least five sonographers performed or assisted scans on this patient and this has benefitted them and the wider department.

This case explores some of the difficulties sonographers face in obstetrics in a condition which is becoming more prevalent. Expectations of higher diagnostic confidence in assessing accreta is an issue with many sonographers today as higher quality imaging has led to some ambiguity over what to look for and how. Ultrasound signs of accreta, present at 16 weeks, were highlighted in this case but this may not have been detected in following scans and potentially resulting in an unfavourable outcome.

A pictorial review of scar endometriosis of the caesarean section and its presentation as mimics of acute abdominal emergencies

J Furaide, R Mohanty, M Funi, H Butt, A Ashfaq and L Khalid

London Northwest Hospitals NHS Trust, UK

Abstract

Scar endometriosis represents endometriosis occurring in a Caesarean section scar. Its incidence is 0.03–0.6%. Most patients have cyclical pain (up to 70%), which is usually intermittent and associated with the menstrual cycle. It is caused by implantation of endometrial stem cells at the surgical site at the time of surgery. Sonography shows non-specific subcutaneous nodule having relatively irregular borders, a heterogeneous echotexture with internal scattered hyperechoic echoes surrounded by a hyperechoic ring of variable width, and vascularity may be present. CT demonstrates well-defined soft tissue nodule with heterogeneous post-contrast enhancement and streakiness in the surrounding tissue. MRI is the most sensitive imaging modality, accurately locates the lesion in relation to a previous C Section scar, with signal characteristics similar to that of background endometriosis.

This presentation aims to briefly demonstrate some of the presentations of scar endometriosis on abdominal ultrasonography and other imaging modalities, address the disease and aid in recognition between them. It reviews imaging-based cases from our institution, emphasising how to differentiate between incidental findings and real pathology causing symptoms.

Abdominal sonography is the first line investigation/ screening tool when a female presents with acute abdominal pain because of easy access and no radiation risk. Most of the time scar endometriosis may be asymptomatic, however, it can become symptomatic. The dilemma arises whether we can safely class it as scar endometriosis and rule out any possibility of soft tissue sarcoma. It can be concluded that the diagnosis by ultrasonography is mostly dependent on clinical presentation and history. However, MRI is more specific but can cause delay in the diagnosis and subsequent management. Moreover, biopsy is always saved for obscure cases after discussing the issue with multidrug therapy (MDT).

From praevia to accreta – Challenges in placental scanning

G Attilakos

UCH London, UK

Abstract

Placenta accreta can be described as a “modern” disease with a dramatic increase in incidence over the last few years. The lecture will explore the diagnosis and management of this serious clinical problem. According to the RCOG guideline, the main diagnostic ultrasound criteria on greyscale are:

• Loss of the retroplacental sonolucent zone,

• Irregular retroplacental sonolucent zone,

• Thinning or disruption of the hyperechoic serosa–bladder interface,

• Presence of focal exophytic masses invading the urinary bladder,

• Abnormal placental lacunae.

The main diagnostic ultrasound criteria with colour Doppler are:

• Diffuse or focal lacunar flow,

• Vascular lakes with turbulent flow (peak systolic velocity over 15 cm/s),

• Hypervascularity of serosa–bladder interface,

• Markedly dilated vessels over peripheral subplacental zone.

Early suspicion or diagnosis is important because it allows more time for pre-operative planning. Multidisciplinary input prior to delivery is extremely important.

Challenges and pitfalls in scanning the foetal CNS

A McEwan

Queen’s Medical Centre, Nottingham, UK

Skeletal dysplasias

R Liebling

St Michael's Hospital, Bristol, UK

Foetal surgery – A realistic challenge?

R Wimalasundera

UCH London, UK

Case-based discussions in foetal medicine

T Overton

St Michael's Hospital, Bristol, UK

Shoulder ultrasound training – A comprehensive approach to supporting the trainee sonographer and their trainer

M Smith

Cardiff University, UK

Abstract

Diagnostic ultrasound of the shoulder is recognised as being one of the most technically challenging aspects of musculoskeletal ultrasound to master. It has a steep learning curve and makes gaining competency a time-intensive training process for both the trainee and their trainer. This talk will present a training, assessment and feedback package developed within the framework of a Consortium for the Accreditation of Sonographic Education approved post-graduate ultrasound course and published in the journal “Ultrasound” earlier this year.

The package comprises: (i) a shoulder diagnostic ultrasound scan protocol with definition of findings, differential diagnosis and pro forma for recording scan findings, (ii) an assessment form for performance of shoulder diagnostic ultrasound scans with assessment criteria and (iii) a combined performance assessment and scan findings form, for each tissue being imaged. The package was developed using medical education principles and provides a mechanism for trainees to follow an internationally recognised protocol. Supplementary information includes the differential diagnostic process used by an expert practitioner, which can otherwise be difficult to elicit. The package supports the trainee with recording their findings quickly and consistently and helps the trainee and trainer to explicitly recognise the challenges of scanning different patients or pathologies. It also provides a mechanism for trainers to quantify and trainees to evidence their emerging competency. As well as being used in shoulder ultrasound training, the package and its principles could be adapted for other musculoskeletal regions or other ultrasound disciplines.

As well as presenting the training package, it is hoped that this talk will stimulate discussion regarding the challenges of sonographer training and potential solutions that the ultrasound community can develop.

The mystery of rotator cuff pathology – Diagnosis and management

T Matthews

University Hospital of Wales, Cardiff, UK

Abstract

It is not clear who first described the rotator cuff of the shoulder, and that lack of clarity continues today in terms of understanding its pathology and subsequent dysfunction and treatment. It is not infrequent that patients are encountered with significant degeneration but are asymptomatic and unaware of their condition, and others, with what appears to be identical pathology, suffer with intractable pain and debilitating dysfunction. Initial treatment often includes anti-inflammatory cortisone injections for a non-inflammatory condition!? Surgical treatment has concentrated on honing techniques together with the continuous pursuit of “failsafe” implants despite the knowledge that the pathology usually determines the outcome rather than the procedure!?

Thankfully three dimensional imaging of the rotator cuff has remained one of the few relatively stable pillars in its management with high diagnostic accuracy levels, for both MRI and ultrasound, although not without their limitations. Understandably there is an increasing trend for musculoskeletal practitioners to take up ultrasound assessment of the shoulder as an adjunct to their clinical evaluation and provide a “one stop shop” diagnostic clinic. So what is the point in providing accurate imaging assessment of a structure, the integrity of which and the extent of pathology seen, does not predict the eventual outcome?

Don’t forget you can move it!

M Maybury

Heart of England NHS Trust, UK

Abstract

The presentation uses a mix of live scanning and PowerPoint presentation to remind musculoskeletal (MSK) sonographers that ultrasound is a dynamic imaging modality, which can be used to answer a number of questions not necessarily answered by taking standard views. The use of motion, in combination with basic orthopaedic tests can highlight tears and subluxations in various MSK structures which may be difficult to visualise with a standard MSK ultrasound examination. The presentation highlights some of these tests used in the examination of both the upper and lower limbs, and the rationale behind when to use dynamic movement testing in a standard MSK ultrasound examination.

Scanning lumps and bumps – When should the alarm bells ring?

S Davies

Morriston Hospital, Swansea, UK

Integration of musculoskeletal ultrasound imaging into patient assessment

S Innes

University of Essex, UK

Abstract

A diverse range of professionals have expressed interest in musculoskeletal ultrasound, (MSKUS) in the last decade. Existing literature has emphasised the requirement for all clinicians to receive adequate training but has not fully explored these professionals’ educational experiences or motivations to use the modality. The process of integrating MSKUS imaging findings into patients’ assessment process has also rarely been discussed in literature.

The professional group physiotherapists were chosen as the basis for a mixed-methods doctorate study. The initial quantitative study involved a questionnaire that was distributed via several professional channels and explored each professional’s interest and education in MSKUS: 75 responses were received. A purposeful sampling strategy was followed to identify a group of subjects for the second qualitative stage of the study; in-depth interviews. Eleven clinicians were interviewed to explore their personal experiences of accessing education and the role of MSKUS in their practice. The interview data was analysed thematically.

A number of themes were identified in the analysis; several themes related to clinical reasoning and the integration of MSKUS into practice. The role of MSKUS in relation to holistic clinical reasoning models including the biopsychosocial approach was raised by many subjects. Clinicians highlighted the need for a comprehensive knowledge of musculoskeletal medicine and pain physiology to support discussions with patients when there was an absence of tissue-based findings on imaging.

MSKUS was reported to be a valuable imaging modality by the subjects in the study. They placed significance on communication between the scanning clinician and the patient to ensure imaging findings were placed within a multidimensional assessment. MSKUS services are offered by a wide variety of professional groups. This specific professional group integrated the imaging findings with a biopsychosocial approach and raised concerns about the impact of poor communication on the patients' experience and potential clinical outcome.

Does accuracy of ultrasound-guided corticosteroid injection predict outcome in pain and function in subacromial impingement syndrome?

P Raval, N Foster, R Ogollah, A Hall and E Roddy

Keele University, UK

Abstract

Subacromial corticosteroid injection is widely used for treatment of subacromial impingement syndrome (SIS). There is increasing interest in using ultrasound (US) to improve the accurate placement of injections. This study investigated whether accuracy of placement of US-guided subacromial corticosteroid injections influences patients’ outcome of pain and function.

The study method consisted of a secondary analysis of data from a 2 x 2 factorial randomised controlled trial investigating exercise and corticosteroid injection for pain and function in SIS. Video images were reviewed to categorise accuracy of injection into the subacromial bursa into three accuracy groups using pre-defined criteria: 1) not in the subacromial bursa; 2) probably in the subacromial bursa; and 3) definitely in the subacromial bursa. The primary outcome measure was the self-reported Shoulder Pain and Disability Index (SPADI) total score, compared at six weeks and six months. Secondary outcomes included SPADI pain and function subscales and participant global rating of overall change from baseline. A mixed effects model was used to compare accuracy groups’ outcomes at six weeks and six months, adjusted for baseline covariates.

US-guided injection accuracy data were available for 114 participants; with 22 participants in group 1, 21 in group 2 and 71 in group 3. There were no significant differences in mean SPADI scores among the three injection accuracy groups at six weeks (group 2 vs. 1: 8.22 (95% CI −4.01, 20.50); group 3 vs. 1: −0.57 (−10.27, 9.13)) and six months (group 2 vs. 1: 12.38 (−5.34, 30.10); group 3 vs. 1: 3.10 (−11.04, 17.23)). Similarly, no differences between groups were seen in SPADI pain, SPADI function or participant global rating of change. The accuracy of US-guided subacromial corticosteroid injection in SIS does not influence clinical response, questioning the need for guided injections. Larger, adequately powered studies are required to explore this further.

Ultrasound-guided dry needling and injection of the deep layer for plantar fasciitis: Results in our patients group and review of literature

M Thavendran, T Akbari, H Ali, R Mohanty, M Johnson and A Sahu

London Northwest Hospitals NHS Trust, UK

Abstract

Plantar fasciitis is a disorder resulting in pain in the heel and bottom of the foot. Aetiology of plantar fasciitis is still not clear. Risk factors include overuse such as from long periods of standing, an increase in exertional activities, prolonged standing and high BMI. There are several modalities of treatment including corticosteroids injection, extracorporeal shockwave therapy (ESWT), plantar iontophoresis and dry needling (+/− injection). Plantar iontophoresis involves anti-inflammatory substances such as steroid and acetic acid applied topically to the foot and transmitting these substances through the skin via electric current. Dry needling involves repeatedly passing a fine needle through the abnormal fascia under local anaesthesia. This is done to stimulate an inflammatory response followed by formation of reparative tissue, which strengthens the tendon.

We looked into our practice of percutaneous dry needling and injection as a novel treatment for this condition. Thirty-two patients with sonographically – confirmed plantar fasciitis were analysed after their treatment. All were symptomatic for >4 months and have failed alternative conservative treatments like foot wear with gel pads, NSAIDS, topical application and physiotherapy. Ultrasound-guided dry needling was performed by two dedicated musculoskeletal radiologists. Sonographic assessment of the plantar fasciia thickness and neovascularity was undertaken in the procedure. Pain scores were obtained before and after the procedure for four weeks.

Out of 27 patients 22 plantar fascia were successfully treated and rest are still being followed in the long term. Our combined therapeutic intervention led to a significant improvement in pain scores and most of the patients >85% are satisfied with their outcome. Percutaneous dry needling and injection of the deep layer under ultrasound guidance promises to be an alternative treatment. Patients prefer this treatment as surgery has a longer recovery process and is more invasive with higher risks attached.

Clinical governance in Point of Care ultrasound – Challenges in developing a Point of Care Service

G Morgan

Prince Charles Hospital & Royal Glamorgan Hospital, Cwm Taf Health Board, UK

Abstract

The Clinical Musculoskeletal Assessment and Treatment Service (CMATS) provides the provision of advanced conservative care and may prevent surgical intervention or inform and prepare for appropriate surgical pathways. The use of Point of Care (POC) diagnostic and interventional musculoskeletal ultrasound within the CMATS service may assist and inform patient pathways without the potential delay with traditional models. However, POC musculoskeletal ultrasound is still an emerging field. Setting up a POC musculoskeletal ultrasound service within the CMATS model provided many challenges. This presentation aims to illustrate the development of a POC service along principles of prudent healthcare from the ground up, and highlights the challenges met along the way.

Advanced groin ultrasound: Difficult hernias, post op recurrence and alternative diagnoses

P Mullaney

University Hospital of Wales, Cardiff, UK

Abstract

The diagnosis of groin hernias is a significant technical and clinical challenge for the ultrasound operator. Inguinal anatomy is complex and visualisation of vital anatomic landmarks can be difficult. A decreasing clinical experience of non-specialist referrers and the evolving epidemic of obesity in the population are resulting in an increasing reliance on imaging to confirm and characterise groin hernias. In addition, an increasing number of patients are referred after previous hernia surgery. The presence of an indwelling mesh repair and post-operative scarring represent a significant challenge to the diagnosis or exclusion of hernia recurrence. This talk aims to present a simple, reproducible method for the ultrasound assessment of groin hernias. Defining anatomic landmarks will be highlighted and reasons for their non-visualisation will be discussed. The ultrasound appearances of post-operative patients will be reviewed including mesh repairs, and ways to increase diagnostic yield in this challenging patient group will be emphasised. Finally, the differential diagnosis of groin pathology and alternative imaging techniques will be discussed.

US guided MSK injections – The evidence?

P Wardle

Royal Glamorgan Hospital, UK

Abstract

Ultrasound-guided musculoskeletal injections are widely employed in nearly all radiology departments in the UK. The demand on these services is continuing to increase but their role is occasionally questioned. The presentation will discuss the variety of interventions that are currently practiced, focusing on a few examples with relevant evidence and reflection.

Ultrasound-guided interventions in the foot and ankle

A Carne

Royal Surrey County Hospital, NHS Foundation Trust, UK

Ultrasound in the diagnosis and assessment of RA

R Thompson

Aintree Hospital, Liverpool, UK

Abstract

Early diagnosis and prompt treatment to suppress inflammation is vital to prevent joint damage in rheumatoid arthritis (RA). Ultrasound and MRI are more sensitive than clinical examination in detecting synovitis. Clinic based ultrasound is a valuable tool in the diagnosis, assessment of prognosis and response to treatment of patients with RA. Every rheumatology unit should have ready access to an ultrasound machine and a trained person able to use it.

Comparison between vertical on printed paper with horizontal on screen measurements for the assessment of developmental dysplasia of the infant hip

D Walden

Salisbury Hospital, UK

Abstract

Developmental dysplasia of the hip (DDH) describes a problem with hip joint formation in children. The location of the problem can be either the hip joint (femoral head), the socket of the hip joint (the acetabulum) or both. Abnormal hip development or developmental dysplasia of the hip is the commonest problem found in a baby’s musculoskeletal system.

The author describes the Graf technique for the assessment of DDH. This assessment is based on the appearance of the acetabulum in a coronal neutral position and describes measurements of the acetabular slope (alpha angle). The first measurement technique involves printing out the images on thermal paper and drawing the appropriate lines. The alpha angles of both hips are then calculated in the vertical plane using a sonometer and classified using the Graf method. The second technique involves plotting the relevant lines on screen in the horizontal plane using electronic callipers and using the hip tools pre-set. The author's research compared scans of the alpha angle performed using these two methods on the same group of infants. The research showed that there was a high level of agreement between the values obtained using the manual (vertical plane) and computer aided (horizontal plane) methods for the critical alpha angle. Of all, 87.5% of the scans performed with the two methods were in agreement.

The high level of agreement between the two methods leads the author to conclude that the computer based method should be adopted leading to a more efficient, less wasteful, and more reproducible examination.

Impact of time of day on measures of Achilles tendon stiffness using shear wave elastography

C Payne

University of Brighton, UK

Abstract

There is a noted lack of systematic reports with regard to the mechanical properties of tendon structures, and whether stiffness alters throughout the course of a normal day. Morning stiffness is a commonly reported symptom in patients with Achilles tendinopathy. This is the first study to directly assess whether stiffness of the human in vivo Achilles tendon and wider gastrocnemius-soleus complex alters throughout a day, as measured using shear wave elastography (SWE).

Fifteen healthy men and women (mean ± SD) 27.7 ± 4.1 years, height 176.1 ± 7.7 cm and weight 71.3 ± 7.1 kg were measured at 08:00, 12:30 and 17:00. Shear wave elastograms were taken at varying points in the gastrocnemius-soleus complex. To assess transducer orientation, four different measures were taken of medial and lateral gastrocnemius muscles on the dominant side. All measures were taken with a Siemens ACUSON S3000™ HELX EVOLUTION Ultrasound System (Siemens Medical Solutions, USA).

No significant differences (p > 0.05) were seen over the three measured time points in the shear wave velocity of participants dominant musculo-tendinous junction (p = 0.114), mid soleus muscle (p = 0.223), (p = 0.648) or lateral gastrocnemius muscle (p = 0.159) or non-dominant Achilles tendon (p = 0.143). Possible trends were noted for alterations in shear wave velocity of dominant Achilles tendon and the junction of soleus and gastrocnemius muscles (p = 0.094, ${\eta }_p^2$ = 0.16 & p = 0.050, ${\eta }_p^2$ = 0.19, respectively). Results obtained from four different transducer orientations were significantly different from each other for medial (p ≤ 0.001, ${\eta }_p^2$ = 0.56), and lateral gastrocnemius muscles (p = 0.001, ${\eta }_p^2$ = 0.53).

The results demonstrate that time of day does not significantly alter the stiffness of the Achilles tendon and wider gastrocnemius soleus complex in normal subjects. This still needs to be evaluated in pathological tendons. Significant alterations were noted with different probe orientations, therefore orientation should be standardised when assessing results from pennate muscles.

Reliability of elastography measures of the Achilles tendon

C Payne

University of Brighton, UK

Abstract

Elastography provides a direct, real-time assessment of tissue elasticity and is valuable in tumour tissue differentiation, used for detection and diagnosis of many cancers and liver fibrosis. Its value in musculoskeletal imaging is less well defined. The purpose of this study was to determine the reproducibility and repeatability of two common types of elastography, compression (CE) and shear wave elastography (SWE), in depicting the mechanical properties of the in vivo Achilles tendon.

Data from CE and SWE were collected from eight healthy participants at the relative tendon mid-point in two blocks including five consecutive measurements taken in a one hour period and one measure taken every day for a five-day period.

For CE, all coefficient of variation (CV) scores were above 53%, correlations indicated no correlation to weak correlations, and intra-class correlation coefficient (ICC) values were all in the poor category. For SWE, CV scores were 3.70–7.37%, correlations ranged from 0.15 to 0.85 and ICC ranged from 0.34 to 0.89. No significant differences were noted with respect to protocol or time, no significant differences were found in transverse data for foot position, but significant differences were shown between fixed and relaxed foot positions for longitudinal scanning (p = 0.003). ICC between two separate operators was 0.70 for transverse and 0.80 for longitudinal scanning.

Given the wide variation in CE results, it was deemed to have a low level of reliability for depicting mechanical properties of the Achilles tendon and not applicable for this particular purpose. In comparison, SWE was shown to be reproducible and repeatable at depicting and quantitatively assessing the mechanical properties of the human Achilles tendon. There was no additional benefit to securing the foot during SWE examination and there is a high level of agreement between different operators.

The use of diagnostic imaging in Rugby World Cup year: WRU National Team doctor’s perspective

G Davies

Welsh Rugby Union, UK

Abstract

WRU team Doctor & Consultant Sports Physician, Dr Geoff Davies, will give an overview of his use of imaging in the build-up and during the eventful 2015 Rugby World Cup (RWC). His use of ultrasound in relation to other imaging modalities will be discussed. An interesting array of injuries sustained during this period will be presented.

iDirisha Project: Tele-Radiology and education - Maternal health benefits in East Africa

I Francis

Medical Imaging Partnership, UK

Abstract

iDirisha is an overseas development project that is planning to use satellite technology to support UN development goals in Sub- Saharan Africa. The project’s focus is to reduce maternal death in rural areas by healthcare capacity building through education and development of local health care workers to allow intervention where appropriate. The opportunity to be part of this development to educate and empower healthcare benefits through increased access to ultrasound services will be discussed.

Asian (Indonesia, Philippines & Nepal) outreach

S Campbell Westerway

Australasian Society for Ultrasound in Medicine (ASUM), Sydney, Australia

Image review session

This interactive session is aimed at sonographers and radiology registrars wishing to refine their general ultrasound observational skills and knowledge.

Is patient preparation still necessary for an ultrasound of the abdomen or pelvis?

M Roddie

Imperial College Healthcare NHS Trust, UK

Abstract

Patient feedback to imaging departments and on internet forums makes it clear that preparation for imaging tests can be distressing and uncomfortable. Although bowel purgation and dietary restriction for colonic imaging tests scores most highly in terms of patient discomfort and embarrassment, the requirement to attend appointments for pelvic or renal tract ultrasonography with a full bladder comes a close second. This is particularly difficult for patients who have lower urinary tract symptoms.

The GI radiology community has made great strides in producing more acceptable preparation regimes for CT imaging of the colon with the introduction of faecal tagging, electronic colon cleansing and reduced purgation. The distress caused to much greater numbers of patients undergoing prolonged fasting and bladder filling regimes (largely drawn up in the 1970s) for routine ultrasonography, however, has been largely ignored despite published evidence that it does not improve diagnostic quality and is therefore unnecessary in most patients.

This presentation will review evidence that questions current practice and propose the argument that patients having ultrasonography of the abdomen and pelvis require no specific preparation other than, at most, a suggestion that they do not empty their bladder in the hour before their appointment.

What is normal lymph node ultrasonically?

K Satchithananda

King's College Hospital NHS Foundation Trust, London, UK

Abstract

The understanding of the morphology and functional anatomy of lymph nodes allows ultrasound to be used to image and aid management decisions in both malignant and inflammatory conditions. Ultrasound allows lymph nodes to be mapped in relation to the pathological nidus (sentinel node imaging) and also to try to distinguish pathological nodes so that they can be targeted for histological/cytological examination.

We will review how the use of grey scale characteristics with advanced functions such as colour Doppler, resistance index (RI), B-Flow imaging, elastography and contrast enhanced imaging can help to increase our accuracy in differentiating malignant from non-malignant nodes with ultrasound imaging.

What to do with GB polyps and wall thickening

T Higginson

Queen Alexandra Hospital, Portsmouth, UK

Advanced MSK hands-on workshop

A Hall

Keele University/The Royal Wolverhampton NHS Trust, UK

Abstract

This workshop is intended for those with sound knowledge of ultrasound instrumentation and basic MSK scanning techniques, who are extending their scope of practice.

Fundamentals of MSK hands-on workshop

A Hall

Keele University/The Royal Wolverhampton NHS Trust, UK

Abstract

This workshop is aimed at those with sound knowledge of ultrasound instrumentation but little or no experience in MSK U/S scanning.

Is there a relationship between ultrasound scanning ability (sonography) and visuospatial perception or psychomotor ability?

E Chapman

Scanavia Ltd, Edinburgh, UK

Abstract

Getting the right people for training presents challenges for recruiters. Trainee selection for ultrasound training programs may be enhanced through the identification of potential evaluations that could be implemented at the selection stage. Competent sonography includes a unique combination of skills including visuospatial perception and psychomotor skills not yet defined. Little is known about the relationship between these abilities and scanning ability. This feasibility study explored possible relationships.

A sample of 30 experienced sonographers and 30 trainees before and after training were administered five visuospatial perception tests, two psychomotor tests and an Obstetric Structured Assessment Test (OSAT) to evaluate scanning ability. The two psychomotor tests employed measured dexterity for gross movement of arms, hands, and fingers, fingertip dexterity and hand to eye coordination or speed and accuracy of hand movement.

No significant relationship between trainees’ visuospatial ability or psychomotor abilities and scanning abilities were found. The results for visuospatial perception tests suggested that three of the tests were influenced by sonography training so they were not measuring innate skills. However, two of the tests were not influenced by training therefore they may measure the innate skills of sonographers and therefore may be useful to identify those trainees who may benefit from more intense training and support. The ranges of scores for each of the eight tests for the profession of sonography were established including a measure of dexterity for gross movement of arms, hands, and fingers and fingertip dexterity for this particular group, adding to the current body of knowledge in this area. Performance on the OSAT combining all the skills required for sonography pre-training gave the best indication of post training scanning performance so this may be a useful tool for initial assessment of potential trainees; however, abilities require further investigation.

One year, one consultant sonographer and 10,000 ultrasound examinations

A McGuinness

Mid Yorkshire Hospitals NHS Trust, UK

Abstract

At the author's Trust, all newly qualified sonographers have a six-month probationary period and during that time all the non-obstetric examinations they perform are double reported. Historically this was undertaken by consultant radiologists, but over the last five years the number of radiologists with a special interest in ultrasound has diminished and in this Trust, the role has been transferred to a consultant sonographer.

Since 2013, nine newly qualified staff have been appointed at this Trust and between 1 April 2014 and 31 March 2015 the consultant sonographer double reported almost 10,000 examinations. This presentation will outline the issues encountered and discuss the potential pros and cons associated with this change in roles.

A breakdown of the examinations will be provided and examples of common issues and discrepancies will be discussed along with the methods used for mentoring and ensuring these newly qualified sonographers achieve and maintain competency in independent reporting.

Direct entry ultrasound – Changing the face of ultrasound training

S Smart, L Waring and G Bolton

University of Cumbria

Abstract

There is a well-documented crisis within the ultrasound workforce in the UK due to a shortage of qualified sonographers in addition to increased workloads because of expanding services and working hours. This is leading to increasing difficulties for many NHS Trusts in meeting the demands on ultrasound departments. There have been many consultations over the last 10–15 years on this issue, and it is clear that there is no quick fix for this problem. However, failure to address this current crisis will mean a number of risks will continue to exist and further manifest themselves. Several models of sonographic education have been proposed offering both long-term and short-term solutions to the issue and the University of Cumbria through close consultation with their local stakeholders have spent the last 12 months developing a full time Direct Access MSc in Medical Ultrasound Programme to run in conjunction with the traditional part time route open to current healthcare practitioners.

Following a sonography workforce meeting held in Manchester in November 2014 in which Health Education North West (HENW) highlighted the local issues with sonographer shortages, the University of Cumbria arranged a stakeholder meeting aimed at discussing the development of an additional training route that would welcome applications from non-healthcare based applicants. Following this meeting it was decided that the University would look to develop a full time direct access MSc in medical ultrasound. Throughout the development process, continued close consultation with the local stakeholders was maintained. In spring 2015 HENW commissioned a report which investigated the findings arising from in-depth interviews with 20 ultrasound department leads throughout the North West of England including participants from both the NHS and independent sectors from Merseyside, Greater Manchester, Lancashire and Cumbria. The issues under investigation included current staffing status, preferred model of education and Health and Care Professions Council (HCPC) issues.

The stakeholder consultations and commissioned report highlighted the region’s desire for action on this issue and reassured the faculty team that the programme would be welcomed and well supported within the region. It also helped to secure some funding for the course. The investment of time into discussing and researching the views of the local stakeholders is vital to ensure the programme and resultant sonographers are fit for purpose. It is hoped that this new and innovative course will over time help to support the current ultrasound education provision and help to ease the current crisis. The national shortage in the sonography workforce has led to development of the Direct Entry MSc by the University of Cumbria. The process has involved close liaison between the University of Cumbria and their stakeholder in order to ensure the needs of the local area are met by the programme.

An innovative approach to ultrasound training

S Anderson

Norfolk and Norwich University Hospitals Foundation Trust, UK

Abstract

There is a requirement for us as health education providers to deliver innovative approaches to teaching, learning and assessment. This is in response partly to government guidance, a challenging economic climate and the time-poor society we inhabit. Ultrasound is a widely used diagnostic tool with transvaginal ultrasound (TVUS) being performed on most gynaecological investigations in our institution. This is in keeping with a survey of many institutions in the United Kingdom performed in 2015. TVUS is an intimate examination meaning that training has to be given great consideration. In view of all these facts, it was decided that training for the radiology specialist trainees in TVUS needs to be updated. Until recently this has been entirely clinical based and somewhat fragmented.

A TVUS simulator has been chosen to aid our trainees with the acquisition of the skills they require. This is a haptic device which provides kinaesthetic and tactile sensation resulting in high physical fidelity. The simulation session will be structured to include various activities aiming to encourage group interaction, reinforce anatomy and link theory to practice. Assessments will be completed before commencing departmental training. Results of workplace based assessments that have been always performed at the end of each ultrasound block will be compared to previous cohorts to determine whether the simulator use has improved results. As this will be a new method of ultrasound education for our institution, comprehensive feedback will be sought.

The use of technology for medical education has rapidly developed over recent years. As a result of increasing pressures to integrate this technology into our training, there is a growing interest in the use of simulation. Can simulation training replace initial ultrasound training?

Quantifying the impact of increasing ultrasound workload on patient waiting times using multiple time series analysis: An NHS Trust experience

B Olisemeke¹, K Hemming² and A Girling²

¹Heart of England NHS Foundation Trust, UK

²University of Birmingham, UK

Abstract

The demand for diagnostic imaging is increasing;¹ waiting times are increasing as well. Increased waiting times are thought to result from a mismatch between demand and capacity.² Increased waiting times for diagnosis are associated with poorer outcomes.³ There is as yet no assessment of the quantitative impact of increasing ultrasound workload on waiting times. Our study attempts to fill that gap.

Workload and waiting time data were retrieved from the radiology information system (RIS), from November 2008 to September 2013. We used a structural vector autoregressive (SVAR) model to describe the relationship between workload and waiting times. The workload and waiting time values were log-transformed to stabilise variance.⁴ A total of 314,667 patient episodes were recorded within the study period. An increasing trend was noted for both workload and waiting times. Five clinical specialties generated over 70% of the ultrasound workload: General Practice (37%), General Surgery (14%), General Medicine (9%), Gynaecology (8%) and Urology (6%). The mean weekly workload increased by 32% from 936 (SD 102) to 1240 (SD 135) over the study period. The median weekly waiting time increased by 46% from 13 (IQR 2) to 19 (IQR 5) days within the study period. The orthogonalised impulse response function (IRF) computed from the SVAR model suggested that a 1% increase in workload is associated with a 0.7% (CI 0.43, 1.02) increase in the median weekly waiting times.

Our results suggest that a 1% increase in ultrasound workload might lead to a 0.7% increase in waiting times. Five clinical specialties were responsible for over 70% of ultrasound workload. Targeted demand-management interventions within the Trust should pay particular attention to these five clinical specialties.

Peer review audit of independent reporting sonographers 2013–2015

K Lomas and S Riley

Bradford Teaching Hospital Foundation Trust, UK

Abstract

This poster illustrates the methods and results of an on-going peer review audit of image quality and reporting accuracy introduced in April 2013 in Bradford Teaching Hospitals NHS Foundation Trust, following a scheme of work implemented in 2011 to increase the number of sonographers with capacity to independently report. The aim of the audit was to ensure that high standards of reporting and image quality are maintained.

All sonographers able to independently report (SIR) gynaecology and general medical ultrasound were included. Ten scans every month for each SIR were peer reviewed for image quality and agreement with the report. The review was performed by another SIR and a grade of agreement allocated to the examination report and the quality of images. Grades of agreement were: 1. total agreement; 2. minor changes unlikely to alter patient care; 3. potentially significant discrepancy; and 4. definite, significant discrepancy likely to have adverse consequences for patient care. Image quality was graded as: 1. good quality; 2. satisfactory; and 3. poor.

Audit findings were distributed to each sonographer. Cases of Grade 3 or 4 agreements were discussed with the sonographer and an addendum added to the report where necessary. Comparison of results from two yearly audit cycles April 2013–March 2014 and April 2014–March 2015 showed an overall increase in reporting agreement and image quality.

Accident and emergency ultrasound – Does it provide effective patient management and financial efficiency in the NHS?

SR Chunilal

Royal Bolton Hospital, UK

Abstract

Accident and emergency ultrasound (A&E US) is an examination performed at the bedside that may assist in the assessment of a patient’s symptoms and answer focused questions. The aim is to improve patient management and reduce costs to benefit the organisation. A retrospective audit of patients referred for a US scan through an A&E US service has been undertaken, in order to evaluate the efficiency and discuss the value of the service. Utilising the patient information systems, all patients that presented in A&E between 1 January 2012 and 31 July 2014, and consequently had an US scan in A&E, were identified. There were 304 patients included in this study. Data and information were obtained via the patient information systems currently used at the Trust. An Excel spreadsheet was composed encompassing all of the collected data and costs and times were calculated using the figures.

It was found that a breach of the 4 hour A&E waiting target was not caused by a delay in US response times. All scans were performed within 1 hour of the request time. The cost of an A&E attendance plus an A&E US scan was considerably lower than that involving any number of nights stay on a ward; maximum possible cost that could be incurred is £789,792 for 304 patients over three years. The costs incurred were greater when a computed tomography (CT) scan was performed instead of US; the total additional cost of having a CT scan as opposed to an ultrasound scan in A&E equated to between £10,196 and £21,663 over the three years. A&E US positively assists in the efficient and safe management of patients and provides efficiency for the Trust in terms of timeliness and financial benefits.

Security of patient data when transferring ownership of ultrasound systems

J Moggridge

University College London Hospitals, UK

Abstract

Loss of patient data can cost an NHS Trust up to £500,000. Although ultrasound systems generally archive to picture archiving and communication system (PACS), their archiving workflow will typically involve storage of images to an internal hard disk before it is transferred onwards. Deleting records from the local system will delete entries in the database and from the file allocation table or equivalent but, as when deleting files from a PC, files can be recovered. Great care is taken with disposal of PC media from a healthcare organisation to prevent data breaches but ultrasound systems are routinely returned to lease companies, sold on to third parties or donated to charity without such controls.

In this project, we tried three methods of hard disk erasure on nine ultrasound systems being decommissioned. We used the typical method of full reinstallation of system software (including wiping of archive partition); the manufacture’s own disk wiping service; and open source disk wiping software. We then attempted to recover data using open source recovery tools. All methods successfully deleted all patient data as viewable from the ultrasound system and from browsing the disk from a PC. However, jpeg images with patient details and digital imaging and communications in medicine (DICOM) headers with full examination details could be recovered following the reinstallation method. No files could be recovered using the manufacturer’s service or the disk wiping software.

The typical method of reinstalling an ultrasound system’s software will not prevent patient data from being recovered. When transferring ownership, care should be taken that an ultrasound system’s hard disk has been cleaned to a sufficient level with guidance from the manufacturer as to what method is appropriate, particularly if the scanner is to be returned with approved parts and in a fully working state.

Why your ultrasound scan may not show everything we would like to see

C Oates¹ and P Taylor²

¹Freeman Hospital, Newcastle, UK

²Royal Victoria Infirmary, Newcastle, UK

Abstract

Poor visualisation is a problem sonographers often face. This limits their ability to make clear observations and accurate measurements. Within the realm of obstetric ultrasound, the need to see the developing organs and make fine measurements, such as nuchal translucency, is crucial. Where poor visualisation prevents this, the reasons must be noted in the scan report. From the expectant mother’s point of view, they may see the report of a sub-optimal scan and interpret it as blaming them for being overweight, when that is not how they perceive themselves, or they may blame the sonographer for not being up to the job. There is anecdotal evidence that such comments have been shared on Facebook. There are sound physical reasons why there may be poor visualisation and it was thought that by explaining the reasons to expectant mothers, they may understand and not blame themselves or the sonographers.

A poster was designed to explain the two main causes of poor visualisation in simple basic language. The position the baby is lying in and a type of fatty tissue that distorts the sound beam in the way “wobbly” bathroom glass distorts light. The poster was displayed in the obstetric ultrasound waiting room. A questionnaire was used to obtain feedback on whether the patients found the poster helpful. A leaflet that can be given to patients to take away has also been developed.

Pulsatility and resistivity indices of the uterine artery in pregnancy: Comparison of magnetic resonance imaging and Doppler ultrasound

R Hawkes, D Lomas and G Harrison

Cambridge University Hospitals NHS Foundation trust, UK

Abstract

Doppler ultrasound is used to predict pre-eclampsia and intrauterine growth restriction using the uterine artery pulsatility index (PI) and resistivity index (RI) as markers of increased resistance to blood flow in the placenta. MRI is routinely used for identifying placenta accreta, however, there is limited research into placental blood flow. Early studies found identification of the uterine arteries difficult and evaluation of flow impossible. The aim of this work was to identify the uterine arteries on MRI, measure RI and PI, and compare these results with same day Doppler ultrasound.

Thirty-five normal singleton pregnancies at 28–32 weeks underwent Doppler examination, followed by a phase contrast MRI study. Doppler ultrasound recorded the RI and PI of each artery. Vessels meeting set criteria on MRI were identified as likely uterine arteries and in-house flow analysis was used to measure RI and PI. Exclusions were made if an artery was not identified or motion artefact occurred. Results were compared with ultrasound using Bland Altman statistics. At MRI, 76 arteries were identified. After exclusions, 69 vessels in 34 patients were available for analysis. Bland-Altman analysis demonstrated a relatively small bias for the results. It proved possible to identify uterine arteries in the majority (80%) of patients and obtain a flow profile and a PI and RI value similar to the ultrasound. This is the first report of PI and RI being successfully measured using MRI and results compare well with the reference standard ultrasound.

This study demonstrates that the uterine arteries can be identified at MRI in a majority of healthy pregnancies in the early third trimester, with a small measurement bias when compared with same day Doppler US measurements. Future studies involving patients with abnormal Doppler findings are needed to further validate this MR based technique.

Caesarean scar ectopic: Sonographic findings and management dilemmas

H Hughes^1,2, C Mulcahy¹ and M Moran²

¹National Maternity Hospital, Dublin, Ireland

²University College Dublin, Dublin, Ireland

Abstract

The last decade has seen an increase in caesarean section rates with a concomitant rise in the incidence of caesarean scar ectopics. The prevalence is thought to be one in 2000 pregnancies. Greater awareness of the common sonographic presentations of caesarean scar ectopic at different gestational ages may improve detection rates. Hysterectomy and termination of pregnancy can be a life saving measure. However, the use of methotrexate or expectant management can be advantageous to reduce morbidity and preserve future fertility if detected at an earlier gestation. Four cases identified in an Irish tertiary referral centre over four years demonstrate the differing presentations of caesarean scar ectopic and the management dilemmas discussed in the setting of Irish legislation in relation to termination of pregnancy.

Ultrasound presentation:

Case 1 – A six week pregnancy identified within the caesarean scar with no embryo seen. Expectant management was successful.

Case 2 – A live seven week pregnancy with significant trophoplastic flow on vascular Doppler, managed with methotrexate, conserving fertility.

Case 3 – A live pregnancy at 14 weeks gestation. In this case, surgical management was the treatment choice (hysterectomy and termination of pregnancy).

Case 4 – Presentation of substantial antepartum haemorrhage with a live pregnancy in the caesarean scar at 16 weeks, resulting in hysterectomy and termination of pregnancy.

The management of a caesarean scar ectopic pregnancy particularly in later gestations posed significant ethical dilemmas in a country where termination of pregnancy is only permissible where a significant threat to the mother’s life exists. Information obtained from ultrasound images facilitated clinical decision making regarding management.

The knowledge of the ultrasound presentation of caesarean scar ectopic is an essential skill of all obstetric sonographers for accurate diagnosis of this dangerous complication in the current climate of high rates of caesarean section delivery.

Case report: Caesarean scar ectopic pregnancy: A waiting game?

C Conneely^1,2, MC Moran², A DeTavernier¹ and Keane³

¹Portiuncula Hospital, Ballinasloe, Co. Galway, Ireland

²University College Dublin, Ireland

³University Hospital Galway, Co. Galway, Ireland

Abstract

We present the case of a caesarean scar ectopic pregnancy (CSEP) from initial presentation, diagnosis and management to complete resolution. The patient presented to the Accident and Emergency Department at six weeks gestation with lower abdominal pain and a positive pregnancy test. This immediately raised the suspicion of a possible ectopic pregnancy. A prompt referral was made to the early pregnancy unit (EPU) where transvaginal scanning (TVS) coupled with serum biochemistry were integral to her care and management.

Initially a transabdominal ultrasound scan (TAS) was performed, however, due to limited views of the uterus, we proceeded to a TVS. The familiar sonolucent, circular gestational sac was observed, however, it appeared to be abnormally implanted adjacent to the more echogenic scar tissue of a previous caesarean scar. A yolk sac and embryo were also present, no cardiac pulsations were detected. The endometrial thickness nearer the fundus was assessed, measuring 15.5 mm, while the ovaries and adnexa appeared normal. Initially, the possibility of an incomplete miscarriage could not be out-ruled. However, serial TVS in conjunction with serum BhCG tests confirmed a CSEP. In view of the location of the ectopic pregnancy, methotrexate was deemed the most prudent management option. This was repeated as per Royal College of Physicians of Ireland guidelines when the BhCG levels failed to decrease as desired.

Consultation with peers endorsed the need for a ‘hands-off’ approach to this lady’s care. Hence, there ensued a period of 21 weeks of repeated TVS combined with serial BhCG to monitor this pregnancy to its conclusion. Transvaginal ultrasound imaging was the optimum tool for monitoring this case, utilised to support serial blood data, thus enabling the provision of conservative care for this woman, and minimising the risk of potential morbidity.

Sonographic soft markers in the second trimester: Subtle indicators or significant findings?

K Mc Carthy^1,2, G Gallagher¹ and M Moran²

¹Letterkenny General Hospital, Co Donegal, Ireland

²Diagnostic Imaging, School of Medicine, University College Dublin, Ireland

Abstract

Advances in obstetric ultrasound expertise over recent years mean that the once controversial area of aneuploidy detection is becoming a popular topic for sonographers worldwide. Improvements in ultrasound resolution now mean that subtle anatomic variations referred to as “soft markers” are more detectable, often leaving practitioners in a dilemma regarding referral for further testing and follow up care pathways. When combined with laboratory testing and risk assessment tools, early detection of these soft markers can provide a rationale for the diagnosis and management of chromosomal abnormalities.

The literature is abundant with information defining soft markers and the inclusion criteria varies throughout institutions; however, the majority of sources have a classification list comprising – choroid plexus cyst, echogenic intracardiac foci, echogenic bowel, pyelectasis, shortened femur, single umbilical artery, mild ventriculomegaly and talipes. This poster presents a visual analysis of these particular soft markers providing a critique for recognition and standard for ultrasound diagnosis. Referral for further management will depend on institutional guidelines and client preference, however, the majority of settings advocate further investigations if two or more anatomic variations are noted on ultrasound.

Although amniocentesis remains the most accurate diagnostic test in the detection of aneuploidy, recent advances in the field of non-invasive prenatal screening of maternal cell free DNA boast significant results without the added risks to the fetus. Information regarding these tests in Ireland is readily available; nonetheless current provision of this investigation remains a personal cost to the client. In relation to ultrasound diagnosis the inclusion of the nasal bone length as part of the detailed anomaly scan is also advocated, particularly in the diagnosis of Down syndrome.

Investigating the possible relationship between post-surgical adhesions, reported pain and scar tissue quality following Caesarean section using transabdominal ultrasound

K Spens

Greenwich University, London, UK

European School of Osteopathy, Maidstone, UK

Abstract

Caesarean section is an increasingly popular procedure in the UK with post-surgical adhesions cited as a major complication and the leading cause of secondary infertility in women. The use of transabdominal ultrasound for assessment of quality of scar tissue and adhesions following C-section is limited. This study’s aim was to determine the association between these surgical adhesions and perceived clinical symptoms.

In this observational causative study, women who had undergone between 1 and 3 transverse lower-segment Caesareans were included. Women with existing gynaecological conditions, who had undergone previous abdominal/pelvic surgery or who were pregnant were excluded. Two transabdominal ultrasound techniques were performed; visceral slide and adhesion criteria. Visceral slide facilitated dichotomisation into positive adhesions (<1 cm movement) and negative adhesions (>1 cm movement). Scar tissue quality of the Caesarean sample was assessed using patient and observer scar assessment scale (POSAS); these were scaled 1–10 over 6 scales and dichotomised into low (1–5) and high (6–10) quality. Clinical symptoms were collated with a questionnaire using numerical rating scales (NRS), 6 scales (0–10) were dichotomised into low (0–5) and high (6–10) categories. The relationship between adhesions and symptoms was explored using Fishers Exact test. Twenty-two participants aged 29–47 (mean 35.27(±5.37)) were recruited: 91% had one Caesarean; 4.5% had two; 4.5% had three Caesareans. Reduced visceral slide was found to have an association with pelvic pain (p < 0.043) and scar pain (p < 0.004) within the study population. All other symptoms were not significantly associated with adhesion type.

Transabdominal ultrasound in the detection of post-operative Caesarean adhesions showed significant associations to aspects of pain symptomology. A comprehensive adhesion assessment needs to be developed to improve effective long-term treatment and management of post-operative adhesions. The study design requires minor modification for validation and inter-rater reliability, before a larger scale study is performed.

Case report: Ovarian prolapse 17 years after abdominal hysterectomy: A very rare case

S Tangudu

Hull and East Yorkshire NHS Trust, UK

Abstract

Vault dehiscence and adnexal prolapse after hysterectomy is a very rare event with an incidence of 0.03–1.2%. Though rare case reports of small bowel, omentum, fallopian tube, appendix have been reported in the literature, a case of ovarian prolapse 17 years after hysterectomy is not yet been published. The risk of vault dehiscence post hysterectomy is more commonly associated with robotic or laparoscopic hysterectomy.

We present a case of a 51-year-old lady who presented to the gynaecology department with history of vaginal discharge for few weeks. She had a history of abdominal hysterectomy 17 years ago for a benign disease and one of her ovaries was removed. On speculum examination, there was a mass at the vaginal vault. An USS pelvis showed a 17 x 36 x 48 mm mass of ovarian origin with a heterogeneous component. This mass was likely causing degree of irritation of the cyst wall and causing the vaginal discharge. She then went on to have a laparotomy and left oophorectomy with an uneventful recovery. The histology of the ovary showed a borderline mucinous tumour of FIGO stage 2a.

The use of transvaginal US in confirmation of Essure coil placement

G Miles, P Scott and P Cantin

Derriford Hospital, Plymouth, UK

Abstract

Since European approval for use in 2001, the Essure uterine tubal occlusion device is being increasingly used for patients requesting permanent sterilisation. Its popularity amongst practitioners and patients is growing given the lack of general anaesthetic and incision and relatively quick hysteroscopic insertion time. The flexible nickel coil is inserted into each fallopian tube hysteroscopically. Each coil incites a local fibrotic reaction which leads to tubal occlusion. The device is not, however, considered functional until imaging confirmation has been obtained approximately three months post insertion.

Since 1 July 2015 the Food and Drug Administration in the USA has approved the use of transvaginal ultrasound (TVUS) in the confirmation of Essure coil placement. Previously a plain abdominal radiograph and hysterosalpingiography were required. The use of TVUS negates the need for exposure to either radiation or contrast dye. It is clearly essential, however, that appropriate placement is determined accurately to avoid unwanted pregnancy. We therefore present a review of the essential salient features to identify on ultrasound scanning and a selection of imaging potential pitfalls to avoid as well as some of the recognised complications.

Case report: Ultrasound of a twisted teratoma

Y Green^1,2, M Walsh² and T Herlihy¹

¹University College Dublin, Ireland

²Mater Misericordiae University Hospital, Dublin, Ireland

Abstract

This poster discusses the case of a 30-year-old female who attended our Accident and Emergency (A&E) department. She presented with sudden onset of severe left lower quadrant (LLQ) pain. She was exquisitely tender on palpitation and blood tests revealed leucocytosis. The emergency team assessing her requested a pelvic ultrasound scan to rule out a tubo-ovarian abscess, an ovarian torsion or least likely an acute appendicitis.

A trans-abdominal (TA) pelvic ultrasound scan was performed. Immediately, a large fluid filled structure which resembled a full bladder extended across the screen. The uterus and right ovary appeared normal with an enlarged oedematous left ovary visualised (9.5 cm x 6 cm). Upon closer inspection it became apparent that the fluid filled structure, which initially was believed to be the bladder, was in fact a large cyst. It contained both solid and cystic components and arose from the left ovary. There was a small amount of free fluid within the Pouch of Douglas and a complete lack of vascularity within the left ovary despite optimisation of settings. With a definitive diagnosis of ovarian torsion made, a trans-vaginal (TV) scan was deemed unnecessary. The patient was immediately referred for gynaecological review and scheduled for theatre that day. During the laparoscopic surgery it was observed that the ovary had a necrotic appearance. A left sided salpingo-oophrectomy was performed. Post-op histological assessment of the removed cyst confirmed it to be a dermoid cyst. An ovary containing a large dermoid cyst, such as this, is predisposed to torsion due to the increase in mass.

This case demonstrates the classic sonographic characteristics of ovarian torsion. It proved the usefulness of ultrasound in completing the clinical picture to arrive at a diagnosis of ovarian torsion.

Case study: Simply a ureterocele – On transabdominal pelvic ultrasound

M Kingston^1,2, L Carpenter² and T Herlihy¹

¹University College Dublin, Ireland

²The Adelaide and Meath Hospital incorporating the National Children's Hospital, Dublin, Ireland

Abstract

This case study describes an incidental finding of a ureterocele while performing a pelvic ultrasound on an lady with pelvic pain. A ureterocele is an uncommon finding in adults and most found at this stage are asymptomatic. Characterisation of a ureterocele and the identification of any related pathology is important for patient management. This poster describes the sonographic appearances of a simple ureterocele. It shows the benefits of transabdominal ultrasound imaging and the importance of renal imaging in the diagnosis and characterisation of ureteroceles.

A 48-year-old female attended the ultrasound department with a referral from her GP. She complained of pelvic pain which was slightly worse on the left side. Transabdominal and transvaginal ultrasound of the pelvis was performed, followed by a renal ultrasound. The ovaries and uterus appeared normal. On transabdominal ultrasound, a tubular structure was identified in the left adnexa which represented a moderately dilated distal ureter. On examination of the bladder, a ureterocele measuring up to 3 cm was identified within. Real time imaging allowed visualisation of its expansion and contraction. Colour Doppler was used to observe ureteric jets of urine within the bladder and to therefore rule out obstruction. Imaging of the left kidney revealed no duplex system and no significant collecting system dilatation. No other complications of the ureterocele were identified. The dilated distal ureter was also identified on transvaginal ultrasound. Urology opinion was recommended as the patient’s pain was predominantly on the left side.

In this case, it was found that the dilated distal ureter and the associated ureterocele were best visualised on transabdominal ultrasound. Pelvic and renal ultrasound led to a diagnosis of a simple ureterocele with no apparent complications.

Case report: Ultrasound: Turning inflammation into information! The role of ultrasound in the imaging of pelvic inflammatory disease

E Maughan

University College Dublin, UK

Abstract

This poster documents the case of a 33-year-old female presenting to the Emergency Department at our institution, with sudden onset of acute right iliac fossa (RIF) pain. Physical examination revealed tenderness in the right lower abdomen with adnexal tenderness on vaginal examination. A full blood work-up disclosed leukocytosis and an elevated inflammatory marker, C-reactive protein. A negative serum β-hCG excluded an obstetric aetiology. As result of abnormal blood test values and physical symptoms, the patient was immediately referred for a pelvic ultrasound scan to out rule ovarian or appendiceal pathology.

The initial transabdominal (TA) survey exposed an abnormality in the right adnexa, which prompted a transvaginal scan (TV) for more thorough investigation. An axially positioned uterus and adjacent ovaries appeared normal, however, a well-circumscribed structure was identified opposing the right ovary in the right adnexa. TV ultrasound illustrated the distinctive ‘cog-wheel’ sign characterised by thickening of endosalpingeal folds that is associated with acute pelvic inflammatory disease. An additional feature confirming acute disease included hypereamia of the structural wall by colour Doppler. A distended fallopian tube with low-level internal echoes suggestive of a pyosalpinx further reinforced the diagnosis. The patient was treated conservatively with intra-venous (IV) anti-biotic therapy. Laboratory examination confirmed bacterial vaginosis of the lower genital tract. Furthermore, a polymerase chain reaction (PCR) test excluded Neisseria gonorrhoea or Chlamydia trachomatis as the source of the infection.

Ultrasound proved valuable in narrowing the alternative diagnosis and assessing the extent of disease in this young reproductive female. The early diagnosis and initiation of antibiotic therapy reduced the threat to wellbeing by preventing the onset of long-term sequelae including: infertility, increased risk of ectopic pregnancy and chronic pelvic pain.

Renal cancer metastases to the thyroid: Case studies, review of literature and new thyroid ultrasound signs

S Colley, E Mcloughlin and A Aziz

Queen Elizabeth Hospital Birmingham, UK

Abstract

Renal cell carcinoma (RCC) is an unpredictable tumour that can metastasise to uncommon sites, occurring both at the time of original diagnosis or many years later. RCC metastasis to the thyroid gland is a rare but recognised occurrence and is considered one of the more common neoplasms to metastasise to the thyroid gland with a number of cases described in the literature. Metastasis into a thyroid neoplasm – tumour-to-tumour metastasis – is extremely rare with renal cell carcinoma also being the most common associated neoplasm.

We present two cases of metastatic RCC to the thyroid gland, and believe our cases have merit as they demonstrate markedly different clinical presentations, and both describe new thyroid ultrasound signs – a ‘nodule within a nodule’, and a ‘pulsatile thyroid nodule’. These unique ultrasonographic findings are previously undescribed in the medical literature to the best of our knowledge.

Specific imaging findings characterising renal cell metastases in the thyroid gland have not previously been described, with diagnosis usually based upon pathology – especially in the setting of ‘tumour-to-tumour metastasis’. We present the first case of a tumour-to-tumour metastasis described on pre-operative imaging, with pathological correlation following thyroidectomy.

Thyroid ultrasound: Correlation between U grading, fine needle aspiration result and histology

D Thorley and G Johnson

Tameside General Hospital, Manchester, UK

Abstract

Thyroid nodules are common, occurring in up to 70% of the population on ultrasound scan. Of these only a small proportion will contain a malignancy. Given this, a good way to determine which nodules need further investigation is required. Ultrasound has always been the gold standard imaging for thyroid nodules, with a number of different features being looked at to suggest the possibility of malignancy. More recently the British Thyroid Association in their 2014 guidelines introduced the U grade for ultrasound with the intention of simplifying reporting and making it easier to decide if further investigation with fine needle aspiration (FNA) cytology is required.

To assess how well the U grading system reflects final results obtained from FNA or histology a retrospective study was performed to assess U grade, FNA result where applicable and when available, final histology. The study period was for four months from April 2014 to July 2014. Initial patient lists were obtained from both histology and radiology. The lists where combined and then reviewed. Patients who had undergone ultrasound but no thyroid nodules were excluded, as were those under 18 years of age. For each patient, the ultrasound images were reviewed by a consultant sonographer and assigned a U grade, the FNA results were also collected using the Royal College of Pathologists Thy classification. Histology, where available, was recorded as either benign or malignant.

Within each U grade the percentage of each Thy category will be assessed, along with final histology to determine whether there is any correlation between the grading systems. Additionally the percentage of FNAs performed in the U2 category will be looked at, as will patients determined to have a U3 or above nodule who did not receive an FNA. This will determine whether the U grade will reduce the number of FNAs performed.

Comparison between vertical on printed paper with horizontal on screen measurements for the assessment of developmental dysplasia of the infant hip

D Walden

Salisbury Hospital, UK

Abstract

Developmental dysplasia of the hip (DDH) describes a problem with hip joint formation in children. The location of the problem can be either the hip joint (femoral head), the socket of the hip joint (the acetabulum) or both. Abnormal hip development or developmental dysplasia of the hip is the commonest problem found in a baby’s musculoskeletal system.

The author describes the Graf technique for the assessment of DDH. This assessment is based on the appearance of the acetabulum in a coronal neutral position and describes measurements of the acetabular slope (alpha angle). The first measurement technique involves printing out the images on thermal paper and drawing the appropriate lines. The alpha angles of both hips are then calculated in the vertical plane using a sonometer and classified using the Graf method. The second technique involves plotting the relevant lines on screen in the horizontal plane using electronic callipers and using the hip tools pre-set.

The author's research compared scans of the alpha angle performed using these two methods on the same group of infants. The research showed that there was a high level of agreement between the values obtained using the manual (vertical plane) and computer aided (horizontal plane) methods for the critical alpha angle. Of all, 87.5% of the scans performed with the two methods were in agreement. The high level of agreement between the two methods leads the author to conclude that the computer-based method should be adopted leading to a more efficient, less wasteful and more reproducible examination.

Spinoglenoid notch – A relatively under imaged area in ultrasound

S McGarry and R Botchu

Royal Orthopaedic Hospital Birmingham, UK

Abstract

Shoulder examination is one of the most commonly performed examinations of musculoskeletal ultrasound. This is a cost effective, dynamic and patient friendly method to image a shoulder. Generally used to evaluate the integrity of the rotator cuff and assess for tears, tendinopathy and impingement, a complete examination should include assessment of the Spinoglenoid notch. A systematic methodology should be followed to identify the underlying pathology. Spinoglenoid notch is easy to identify and examine by ultrasound and should be a part of the routine shoulder examination. We present the technique to examine this and present few pathologies.

Ultrasound-guided intervention in the foot and ankle: A pictorial guide of tips and techniques

D Roberts, S Kamath and K Mukherjee

University Hospital of Wales, UK

Abstract

Ultrasound can be key in the diagnosis and management of musculoskeletal pathologies in the foot and ankle. The high-resolution images created with the high-frequency linear transducer, enable the practitioner to accurately visualise the soft tissue structures of the foot and ankle. Ultrasound-guided injections are commonplace, and the real time nature of ultrasound can result in precise, targeted injections.

We present a pictorial guide of how we perform various foot and ankle ultrasound guided interventions. We aim to aid those that will be, or those that have recently started to perform these potentially quality of life changing procedures. The ultrasound-guided interventions displayed will include Morton’s neuroma injection, small joint injection, plantar fasciitis injection, tenosynovitis injection, as well as hydrodissection for refractory Achilles tendinosis.

Severity scoring for quadriceps tendon tears on ultrasound-aiding recognition of the more severe, traumatic disruptions of the quadriceps tendon in the DGH setting

G Constantinescu¹, A Tindall², J Smith¹, S Morgan MS¹, K Gulati² and Chettiar¹

¹Darent Valley Hospital NHS Trust, UK

²Lewisham & Greenwich NHS Trust, UK

Abstract

Ultrasound (US) examination is the first line modality to investigate/detect tears of the quadriceps tendon (QT) following trauma in many district general hospital (DGH) imaging departments in the UK. The severity of the US detected QT partial tears is often difficult to quantify and is frequently underestimated. We attempted scoring the tear severity using the observed tear of the QT and indirect signs such as patella tendon (PT) buckling and the size of the posttraumatic haematoma (PTrH).

A total of 27 consecutive cases of suspected QT tears were studied by three dedicated musculoskeletal (MSK) radiologists, in two, large DGHs within a 15 months’ interval. Of all, 22 were male patients (n1 = 22) and five female patients (n2 = 5). The age range was 16–57 years. We recorded the presence/ absence of PT buckling, the severity of the QT tear (percentages as <50%, >50% but <80% tears, and >80% tears) and the presence/severity of PTrH (grading of haematomas recorded as mild, moderate and severe). Feedback was obtained from all operated patients.

Twenty patients had significant QT tears (50% or more of the QT fibres). Nineteen patients underwent surgical repair of the ruptured tendon. Thirteen surgically treated patients had buckling of the PT and associated severe partial tears of the QT. Four patients had no PT buckling, but had severe tears and two patients presented equivocal PT buckling, but had severe QT partial tears (this subgroup of 6 patients also had MRI evaluation). All operated patients had variable sized (usually moderate or large) haematomas in the suprapatellar bursa.

The buckling of the PT and moderate-, and large size PTrH are seen in a large proportion of patients with post-traumatic QT disruption. Although not sufficiently specific and/or sensitive alone, the combination of these features could be used to score objectively the QT disruption and select the patient sub-group requiring surgery.

Ultrasound detected coracoid-tip pathology – A less common cause of anterior shoulder pain

G Constantinescu¹, R Singh MS¹ and Gulati²

¹Darent Valley Hospital NHS Trust, UK

²Lewisham & Greenwich NHS Trust, UK

Abstract

A variety of causes and/or processes related to bone and soft tissues structures around the shoulder joint can generate pain. Relatively uncommon pathological processes of the short head of the biceps and the coracobrachialis tendons, at the coracoid process, are less frequently evaluated, but can be a source of localized anterior shoulder pain.

Within an 18 months’ interval, among the patients referred to our imaging department with anterior shoulder pain, we evaluated eight patients (n = 8) for localized tenderness on the coracoid process. The evaluated patients had limitation of motion caused by pain. Most patients had jobs involving lifting. The small cohort included five female (n1 = 5) and one male (n2 = 3) patients. All patients were reviewed in the department at three months following their first assessment.

We detected significant tendinopathy of the short head of biceps in six patients (6), whereas two patients presented tendinopathy of both short head of the biceps-, and coracobrachialis tendons. No tendon tear was seen. The Doppler flow map showed prominent new vessel formation in the affected areas of the tendons, just below their insertions at the coracoid process. The rotator cuff tendons were normal and no impingement was present. All patients underwent US-guided radiological therapeutic intervention via a combination of fenestration and steroid injections, followed by physiotherapy, with good short-term improvement.

Coracoid-based, well localized, anterior shoulder pain may result from proximal tendinopathy of the short head of biceps and/or coracobrachialis tendons. The tendons demonstrate abnormal Ultrasound features. The tendinopathy showed response to minimal, ultrasound guided radiological intervention. There is limited experience and relatively few published data with regard to coracoid process tendinous insertion pathology. In our experience this area (coracoid process tip) is often under-investigated on both US and MRI and these findings highlight the need for more dedicated and targeted evaluation.

A pictorial review of de Quervains tenosynovitis following pregnancy and recommendations of preventive measures during postnatal period

T Akbari, H Ali, M Thavendran, R Mohanty, M Johnson and A Sahu

London Northwest Hospitals NHS Trust, UK

Abstract

De Quervain's tenosynovitis is an inflammatory condition characterised by localised tenosynovitis of the first extensor compartment of the wrist. It is associated with occupational risk factors, repeated strain injury, during and after pregnancy. It happens due to performing rapid repeated activities. Activities involving grasping, pulling and pushing are considered at increased risk. Repeated postures with a thumb base doing abduction and extension is considered at risk.

The aim of this poster is to review the presentation of de Quervain's tenosynovitis in females during the post-partum period and to suggest precautionary measures to avoid it as a perinatal care advise. Ultrasound was used as the imaging modality of choice followed by guided injections for symptomatic cases. We focus on the review of imaging-based cases from our institution. We highlight the clinical presentations of patients with a problem in their wrist and later mimics de Quervain’s tenosynovitis. Emphasis will be put on the best way to distinguish between incidental findings and real pathology bringing on symptoms. We give sonographic and MRI findings of de Quervain’s tenosynovitis and pictorial demonstrations of preventive measures as a learning tool.

We propose that certain positions of the wrist while holding the baby may predispose or trigger this condition. We recommend mothers to modify their activities such as avoiding repetitive movements and sustained positions. For example carry things with a shoulder bag instead of the hands, adopt a breastfeeding position and position baby's head by the forearm instead of on the hands, etc. In the UK, we provide a lot of guidance regarding antenatal, perinatal and post-natal care for the welfare of the mother and the baby and we would like to give a message here regarding this particular clinical condition, which can make a difference in outcome by making little changes.

Hydrodilatation for the frozen shoulder

Y Mei Koay, S Rymaruk, M Stott, N Phillips, R Braham, M Mubashar and W Bhatti

University Hospital of South Manchester, UK

Abstract

Adhesive capsulitis (frozen shoulder) causes severe pain and stiffness of the glenohumeral joint. It has a 3–5% incidence rate in the general population. It is often self-limiting, but symptoms may last up to three years. Treatments include analgesia, steroid injections, regular physiotherapy, manipulation under anaesthesia and surgical release. Our department routinely perform ultrasound-guided hydrodilatation for the frozen shoulder, a method which involves distending the shoulder capsule using a mixture of steroid, long-acting local anaesthetic and saline solution. We audited the outcomes of orthopaedic patients who have undergone ultrasound-guided shoulder hydrodilatation within an 11-month period.

We carried out a retrospective review of patients who have undergone hydrodilatation within an 11-month period. Their clinical letters were then reviewed for outcome following intervention.

A total of 63 patients were referred by the orthopaedics teams for shoulder ultrasound-guided hydrodilatation. Of these, 39 patients had clinic letters before and after the procedure with interpretable data. Seven patients underwent further procedures to relieve their symptoms, and one patient had a repeat intervention. Of all, 84% of the patients reported an improvement in their symptoms, with up to 25° of external rotation improvement. The discharge rate of patients post-hydrodilatation was 46%.

Ultrasound-guided shoulder dilatation offers a high success rate, which is comparable to the current literature. It carries a relatively lower health risk to the patient, compared to the surgical release method. We recommend that a larger cohort of patients for a re-audit, with a standardised scoring system, e.g. Oxford test, at appointments to allow a better outcome assessment of improvement.

Comparison of radiological and histopathological diagnosis in the soft tissue sarcoma MDT from 01 April 2013 to 30 January 2014

Y Al-Radhi and D Taylor

Hull and East Yorkshire NHS Trust, UK

Abstract

Imaging plays a vital role in the characterization of soft tissue lesions. The purpose of this study is to determine the accuracy of radiological characterization of soft tissue lesions, the frequency of specific diagnoses, anatomical location and the age distribution in a soft tissue sarcoma multidrug therapy (MDT) setting in our trust. This was a retrospective, unblinded study. It involved retrospective data analysis of 64 patients who were referred to the soft tissue sarcoma MDT from 01 April 2013 to 30 January 2014 and had US/MRI and histopathological biopsy. Radiological characterization was categorized into benign, malignant and indeterminate.

Of those, 54 (84%) were characterized as definite benign / malignant. Meanwhile, 10 cases (16%) were characterized as indeterminate. Diagnostic accuracy of all lesions, benign and malignant, is 82%. There were 15 (23%) sarcoma cases of which 14 (94%) were correctly characterized. Of those, 4 (6%) benign cases were overdiagnosed as possibly malignant. The spectrum of diagnoses included: Schwannoma (4.6%), haemangioma (3.1%), gout tophi (1.6%), sarcoma (23%), lipoma (31%), leiomyoma (1.6%), giant cell tumours (6.2%), hibernoma (1.6%), endometriosis (3.1%), cyst (10.9%), nodular fasciitis (1.6%), tissue necrosis (3.1)%, fibromatosis (1.6%), myopericytoma (1.6%), desmoid tumour (1.6%) and none found (2%).

Radiological characterization of soft tissue lesions is accurate and reliable despite the challenging large number of pathological possibilities. Sarcoma represents 23% of our cohort, although it is a rare diagnosis, reflecting the effectiveness of using imaging characterization as a triaging tool in soft tissue sarcoma MDT.

Study looking at the reliability of using elastography as an indicator of liver fibrosis

S Tangudu, PC Parker and L Corless

Hull and East Yorkshire NHS Trust, UK

Abstract

Elastography is a non-invasive, ultrasonographic method for determining the degree of liver fibrosis. It is the most commonly used method in assessing liver fibrosis, especially in Europe. It uses a 5-MHz ultrasound transducer probe mounted on a vibrator. The vibrator emits painless vibrations of 50 Hz frequency and an amplitude of 2 mm. This leads to an elastic shear wave propagating through the skin and the subcutaneous tissue to the liver. The shear wave velocity is directly related to the stiffness of the tissue.

Elastography has been implemented in our Trust as part of the hepatology assessment for patients with liver disease. The hepatologists have adopted this assessment method in preference to liver biopsy and since introducing the technique over 1500 examinations have been undertaken. The aim of this study is to review the reliability of using shear wave elastography as an indicator of liver fibrosis. The propagating shear wave velocity has been correlated with other clinical markers and the ultrasound features of hepatic fibrosis. These include liver appearance, platelet count: spleen ratio and liver function tests. A retrospective study of 100 patients who had elastography done is currently being undertaken. All patients attended a one-stop hepatology and ultrasound clinic between 1 January 2015 and 28 February 2015. The results are currently being analysed.

SonoVue (sulphur hexafluoride microbubbles) clinical re-audit

A Al-Khatib, A McNeill, B Stenberg and T Hoare

The Newcastle upon Tyne Hospitals, UK

Abstract

SonoVue is an ultrasound contrast agent consisting of sulphur hexafluoride microbubbles that improves display of the blood vessels, thus allowing more specific characterisation of liver lesions. NICE guidelines recommend the use of SonoVue to characterise focal liver lesions in an adult with cirrhosis, investigate potential liver metastases as well as characterise incidentally detected indeterminate focal liver lesions on unenhanced ultrasound at the same appointment. The purpose of this audit was to review current practice and identify potential aspects of service improvement.

We carried out a retrospective review of contrast-enhanced ultrasound scans (CEUS) performed in the period November 2014–April 2015, collected from the picture archiving and communication system (PACS) database in two screening centres. Suitability for CEUS was determined using locally developed work flow guidelines. Standards used were local guidelines based on NICE suggestions: when an incidental liver lesion is detected, a CEUS is performed as a “same-day appointment” or within seven days if this is unavailable. A total of 43 CEUS were identified. Average age was 52 years (range 22–83). There was an overall 77% compliance rate with the seven day local guidelines. Delay in CEUS was in the range 2–9 weeks. The spectrum of diagnoses included haemangioma, liver metastasis, hepatocellular carcinoma, focal nodular hyperplasia (FNH) and other benign conditions.

The department performance of CEUS to further characterize liver lesions and conform to local and NICE guidelines is to a good level although there is room for further improvement in care delivery. Good staff satisfaction has been perceived regarding the current “Focal liver lesion ultrasound pathway” flowchart. CEUS has proved to be a very efficient and robust way of quickly characterizing liver lesions by confirming or ruling out benignity, expediting patient care.

Renal transplant USS; Are we doing it correctly and uniformly in a transplant centre?

R Williams

St Georges Hospital, London, UK

Abstract

Kidney transplantation is evidenced to improve quality of life and be of financial value for the greater health economy. Following Organ Donation Taskforce recommendations in 2008, there was an increase of 50% in deceased organ and living donor transplants. Imaging evaluation is essential to a recipient’s care pathway, with USS usually the main modality from initial post-operative to surveillance period. Early diagnosis/intervention of complications is vital to limit risk and optimise long-term function. Review of transplant cases in recent discrepancy meetings prompted discussion on operator variability.

Renal transplant USS cases July 2014–November 2014 were evaluated. All cases were assessed on optimisation and accuracy of five parameters relating to Doppler display / measurements.

1. Position of resistive indices (RIs) (interlobular vessels),

2. Quality of spectral trace (2/3 of display),

3. Scale settings on colour Doppler imaging (between 20 and 30 cm/s),

4. Spectral gate size (within main transplant artery),

5. Angle correction when measuring peak systolic velocity – PSV (below 60°).

Errors in parameters can compromise quality of display, under/overestimate complications.

Over five months, 60 ultrasound studies (portable and departmental) from 30 renal transplants were evaluated. These included post-operative, early and late follow-up surveillance imaging. Angle correction for PSV was the most incorrectly measured parameter at 22 cases (37%). Quality of trace was incorrect in 22% (13 cases). Both RIs and gate size were incorrect in 10 cases (17%) and there were scale setting errors in four cases, (7%). For patients with over four USS (5 patients), further imaging with nuclear medicine was carried out.

Renal transplant USS can prove challenging; knowledge of technical parameters is crucial. Both missing pathology and inappropriate ‘overcalling’ in transplants are important. Vascular flow rates were overestimated alongside poor quality traces with little attempt at optimisation. Interpretation may lead to invasive inappropriate investigation. Clear operator education is imperative to provide accurate safe services.

Targeted fusion biopsy: The way forward in investigating suspected prostate cancer

H Joshi, PC Parker and OR Byass

Hull and East Yorkshire Hospitals NHS Trust, UK

Abstract

Prostate cancer is the commonest cancer in men in the UK, affecting approximately 42,000 new patients a year. Commonly, clinically suspected cancer would be investigated and diagnosed through a route of clinical examination, prostate-specific antigen (PSA) levels, prostate biopsy and MRI examination under the two week wait (2WW) pathway. Failure to meet the 2WW target is often due to MRI unavailability, where appointment times can be as long as six weeks. In our centre, we have developed a protocol where patients deemed to be at high risk of prostate cancer are offered the MRI scan first. If prostate cancer remains clinically suspected, a focused fusion trans-rectal ultrasound (TRUS)-guided biopsy is offered in order to obtain targeted histology samples. As MRI is offered prior to biopsy, there is no requirement for a time lag between the two investigations. We implemented the new protocol in February 2015 and collected prospective data on all targeted fusion TRUS biopsies performed to date. Data collection included MRI findings, time to TRUS biopsy from MRI and histology results. In all cases, both targeted and non-targeted biopsies were performed.

Between February 2015 and June 2015, 21 targeted fusion biopsies were performed. Patients underwent fusion TRUS biopsy as quickly as three days following their MRI study. Quantitative analysis of the histology results is currently not available due to the low numbers of cases obtained. The data at present shows targeted biopsy samples to have equal or higher Gleason scores and an increase in the proportion of the sample being histologically malignant compared to non-targeted samples. Our early experience in targeted TRUS prostate biopsy has shown to be positive. Patients can undergo TRUS biopsy quickly following MRI which improves the patient pathway and we are obtaining more accurate Gleason scores allowing clinicians to formulate a more focused treatment plan.

Colonic diverticulosis and diverticulitis: An ultrasound perspective

Y Mei Koay, R Magennis, S Sukumar and V Rudralingam

University Hospital of South Manchester, UK

Abstract

Ultrasound is often the primary imaging modality used to investigate the cause of abdominal pain and a broad range of gastrointestinal symptoms in patients. It is therefore important that the operator has a fundamental understanding of the ultrasonographic appearance of common underlying gastrointestinal tract-related diagnoses, such as acute diverticulitis. Acute diverticulitis is caused by inflammation of colonic diverticula. This results from an impacted faecolith within a diverticulum, with resultant surrounding inflammation and micro-perforation. Clinical presentation is usually a combination of acute lower abdominal pain, pyrexia and rectal bleeding. Diverticula are localised sac-like out-pouching arising from the colonic wall. In the absence of clinical symptoms, this is referred to as diverticulosis. It is estimated 5% of people have diverticula by the time they are 40 years and up to 50% by 80 years old. Up to 25% will develop acute diverticulitis.

With a systematic approach using both the curvilinear and high-resolution linear transducer, ultrasound can demonstrate the hallmarks of diverticulosis and acute diverticulitis. Trans-vaginal ultrasound can also be used to assess the pelvic colon. The findings seen in acute diverticulosis include a thickened colonic wall notably with hypertrophy of the muscularis propria layer and presence of diverticula. In acute diverticulitis, there is surrounding hyper-echoic inflamed fat centred on a segment of colonic diverticulosis, accompanied with localised tenderness. Doppler ultrasound may show hyperaemia. Complications such as abscess and fistula can be demonstrated. Typical features are diagnostic of acute uncomplicated diverticulitis and, where inconclusive, can triage the need for further imaging with CT.

The poster highlights the imaging findings of colonic diverticulosis and acute diverticulitis. Given the low risk and ability for dynamic assessment of the bowel on ultrasound, an awareness of the findings is crucial to prevent unnecessary morbidity.

Ascites: It's all about the fluid!

C Footitt¹, V Rudralingam² and B Layton¹

¹Royal Bolton Foundation Trust, UK

²University Hospital South Manchester, UK

Abstract

The excess accumulation of intra-peritoneal fluid, referred to as ascites, is an important clue to a significant underlying illness. This may be due to a pathological event within the peritoneal cavity or secondary to an underlying systemic condition. Ascites is broadly classified into transudate and exudate based on protein content with a potential wide range of underlying differential diagnosis.

Traditionally, computed tomography (CT) has been regarded as the imaging modality of choice to demonstrate ascites and diagnose the underlying cause. However, ultrasound (US) can reliably detect small volumes of fluid and is a useful first line imaging modality for clinical triage. For instance, in the emergency setting, the detection of a trace of free fluid in the dependant aspect may be the earliest indicator of an acute abdomen needing surgery. US can quantify the volume of ascites and aid the decision process for fluid drainage. US is superior to CT at qualitative assessment of fluid. In general, simple fluid is anechoic whereas complex fluid may appear particulate, layered or with septations, typically from an inflammatory or neoplastic cause. On CT, both have a uniform hypo-dense appearance and are often indistinguishable. Given US in comparison to CT is safe, relatively inexpensive and readily available, it is a valuable tool in the assessment of ascites.

Hence, once ascites is detected on US, it is imperative for the operator to have a systematic approach to attempt to provide an underlying diagnosis. Common diagnosis includes portal hypertension from underlying liver cirrhosis, carcinomatosis or peritonitis. Through a series of cases, this poster aims to increase awareness and reaffirm the role of US in the assessment of ascites.

A pictorial review of focal splenic lesions on sonography with review of literature and their correlation

M Funi, J Furaide, H Butt, A Ashfaq, L Khalid, R Mohanty and A Sahu

London Northwest Hospitals NHS Trust, UK

Abstract

The spleen is rarely the primary site of a malignant disease. The incidence of focal splenic lesions ranges from 0.1% to 0.2%. The ratio of benign versus malignant focal splenic lesions is 1:3. The benign splenic lesions are often solitary but the malignant lesions (lymphoma, metastasis) are more frequently multiple and grow at rapid pace. The solitary metastasis is usually very rare. Cysts are the most common benign disease of the spleen. Congenital cysts account for 64.7%, post¬traumatic cysts 11.6% and dermoid cysts for 5.8%. Amongst these lesions, true cysts account for 21%, angiomas 14%, calcification and infarctions 9%, pseudocysts 8%, lymphomas and abscesses 7%, and metastases 4%. The ability of ultrasound to depict focal or multiple splenic lesions depends on several factors such as the size of the lesions and their appearances.

This poster looks briefly at some of the presentations of focal splenic lesions. Ultrasound is the preferred first line imaging modality to locate these benign and malignant splenic lesions. We present a pictorial review of focal splenic lesions cases from our institution. We highlight some of the clinical presentations and incidentally detected focal splenic lesions. Emphasis is placed on how to differentiate between incidental findings and real pathology causing symptoms.

Our aim is to provide the range of splenic lesions in order to remind about common and rare lesions seen in clinical practice. Contrast enhanced ultrasound (CEUS) helps to differentiate benign and malignant lesions with sensitivity and specificity of 90% and 100%, respectively. The use of ultrasound-guided fine needle aspiration (FNA) biopsy of other abdominal masses has been accepted as a common diagnostic procedure, however, other modalities or core biopsy may be required for inconclusive lesions.

Anomalies associated with horseshoe kidney

L Khalid, J Furaide, H Butt, A Ashfaq, R Mohanty, A Rafique and A Sahu

London Northwest Hospitals NHS Trust, UK

Abstract

Horseshoe kidneys are found in approximately one in 400–500 adults and are more frequently encountered in males (M:F 2:1). The vast majority of cases are sporadic, except for those associated with genetic syndromes. It is the most common type of renal fusion anomaly. They render the kidneys susceptible to trauma and are an independent risk factor for the development of renal calculi and transitional cell carcinoma of the renal pelvis. Horseshoe kidneys are frequently associated with other genitourinary and non-genitourinary malformations, and are also seen as part of a number of syndromes. Most of them are asymptomatic and they are usually identified incidentally.

We aim to briefly demonstrate incidental congenital anomalies associated with horseshoe kidney detected on ultrasonography and later confirmed on different imaging modalities. We will focus on the review of imaging-based cases from our institution. We would highlight the clinical presentations of patients with horseshoe kidney and emphasis will be placed on how to differentiate between incidental findings and real pathology causing symptoms. We suggest looking for skeletal anomaly, cardiovascular anomaly, anorectal malformation, CNS anomaly, genitourinary anomaly like hypospodia, undescended testis, bicornuate uterus, ureteral duplication, and chromosomal abnormalities like Downs syndrome, trisomy 18, Turner syndrome (60%). Of those, 50% patients present with caudal ectopia, vesicoureteral reflux or hydronephrosis secondary to pelviureteric obstruction.

We suggest that if we find horse shoe kidney on abdominal ultrasound, we should try to look for these other associated anomalies. If these are looked for carefully during initial radiological scans, then we can make a difference in early the detection of other medical problems in future and in the outcome of the patient.

Case report: A hard nut to crack – A case of the rare Nutcracker Syndrome

A Isherwood, P Parker, O Byass and A Myatt

Hull and East Yorkshire Hospitals Trust, UK

Abstract

The nutcracker phenomenon refers to the compression of the left renal vein, usually between the superior mesenteric artery (SMA) and the aorta. If combined with symptoms such as haematuria, loin pain or varicocoele, it is known as the nutcracker syndrome. Venous compression results in left renal hypertension and the rupture of small venules into the collecting system. The condition can present at any age though there is a correlation with low BMI. Although rare, it is thought to be an underdiagnosed cause of persistent haematuria and Doppler ultrasound can be helpful in the diagnosis.

A 23-year-old gas fitter with low body fat density presented to the haematuria clinic for persistent frank haematuria, worse on exercise and heavy lifting. Initial renal ultrasound showed structurally normal kidneys, as did CT which also excluded renal calculi. Cystoscopy revealed that blood was entering the urinary bladder from the left ureteric orifice only. Left ureteroscopy failed to demonstrate any abnormality and there was no arteriovenous malformation apparent on renal artery angiography. Review of the CT images indicated that the proximal left renal vein was dilated towards the renal hilum but became compressed as it passed between the superior mesenteric artery (SMA) and the aorta consistent with nutcracker phenomenon. Follow up Doppler ultrasound confirmed the anatomical findings of venous impingement and an increased resistive index (RI) in the left kidney during increased abdominal pressure (RI reduced on the right). A diagnosis of nutcracker syndrome was made.

This gentleman underwent significant investigation before the diagnosis of nutcracker syndrome was made. Doppler ultrasonography is thought to have a high specificity for nutcracker syndrome and can be utilised as an initial imaging technique in those in whom it is clinically suspected.

Emphysematous pyelonephritis

N Fitzgerald^1,2, K Buckley² and T Herlihy¹

¹University College Dublin, Dublin, Ireland

²Cork University Hospital, Cork, Ireland

Abstract

This poster documents the transition of a 45-year-old woman through the hospital from entering Accident and Emergency to diagnosis and intervention. She presented with neutropenic sepsis, fever and flank pain. She had a history of horseshoe kidney, acute myeloid leukaemia and was 101 days post bone transplant. She was referred for a renal ultrasound scan. Moderate hydronephrosis within the right kidney was seen on the ultrasound scan, as well as echogenic debris within some of the calyces. Non dependant echogenic shadowing foci (dirty shadows) within the calices were seen which were suspicious for air. No discrete calculus was identified. Diagnostic considerations included emphysematous pyelonephritis/ emphysematous pyelitis. The findings were discussed with the radiologist and an urgent CT scan was requested. The CT scan demonstrated multiple locules of air within the collecting system with perinephric fat stranding. Emphysematous pyelonephritis was diagnosed. The findings were discussed with the Haematology and Urology team.

The patient commenced IV antibiotics for 10 days and had a nephrostomy tube inserted for one week to resolve the infection. The patient’s urine cultures were investigated which were positive with Escherichia coli which caused the infection. It was believed that the patient developed this infection as she was immunosuppressed (101 days post bone marrow transplant). Having a horseshoe kidney also left her susceptible to infection.

Ultrasound proved to be successful in demonstrating the “dirty shadows” which is a typical feature seen with emphysematous pyelonephritis. It is an important ultrasound finding as emphysematous pyelonephritis can be potentially life threatening if left untreated due to septic complications. Thus, early detection enabling quick intervention is crucial.

Performance assessment of a shear wave elastography imaging system using the Leicester (Elastography) Pipe Phantom

K Ramnarine¹, P Ummur², R Shah¹, H Charadva¹ and A Khetia¹

¹University Hospitals of Leicester NHS Trust, UK

²University of Leicester, UK

Abstract

The imaging performance of conventional greyscale ultrasound scanners can be assessed by test objects and phantoms such as The Edinburgh Pipe Phantom. The purpose of this study was first to develop a new test phantom to assess the performance of emerging elastography imaging modalities, and second to demonstrate its application by assessment of a shear wave elastography imaging system.

Analogous to The Edinburgh (B-mode) Pipe Phantom, The Leicester (Elastography) Pipe Phantom has been developed which consists of five soft pipes (made of PVA cryogel of diameters from 1 to 13 mm), surrounded by a block of stiffer agar-based tissue mimicking material (TMM). This was used to assess the imaging performance of a shear wave elastography (SWE) scanner with L15-4 linear array probe (Supersonic Imagine, Aix en Provence, France). Longitudinal and transverse sections of each soft pipe were imaged at different depths and at different scanner settings.

The Leicester (Elastography) Pipe Phantom was able to quantify a number of image performance parameters and help determine optimum scanner settings. The Young’s modulus of the surrounding agar TMM was measured as approximately 280 kPa compared to the largest cryogel pipe of approximately 70 kPa. A number of features or artefacts of SWE imaging were also highlighted and will be presented. Examples include: penetration depth through the agar TMM block (4.5, 4 and 3.5 cm for Penetration, Standard and Resolution optimisation settings respectively), and through different pipe diameters; resolution performance assessment capability; effect of pipe depth and diameter on Young’s Modulus estimates within a 2 mm region of interest measurement circle. Interesting artefacts were visualised in prototype phantoms, related to scatter concentration and scanner settings. The Leicester (Elastography) Pipe Phantom was able to demonstrate interesting artefacts and features of SWE imaging and quantify performance aspects of a SWE scanner.

Investigating unwanted nerve damage in regional anaesthesia with micro-ultrasound imaging

A Chandra¹, P Felts¹, R Eisma¹, G Corner¹, C Demore¹ and G McLeod²

¹University of Dundee, UK

²Ninewells Hospital, UK

Abstract

Regional anaesthesia (RA) is used to deliver anaesthetic around peripheral nerves via a needle to perform nerve blocks for many surgical procedures. RA offers quick patient recovery, lower cost and improved pain management. Peripheral nerve stimulation and ultrasound imaging are used for guiding the needle, but there remains a considerable (10%) chance of nerve damage mainly caused by the needle penetrating the nerve. The aim of this paper is to identify the fascicles (bundles of nerve fibres) using micro-ultrasound imaging (frequencies greater than 30 MHz), validate these findings with histology, and identify changes in the nerve caused by the needle penetration.

The nerve specimens used were dissected from Thiel embalmed human cadavers and fresh cadavers. Micro-ultrasound images of the nerves were obtained by scanning the specimens with high frequency (30 MHz and 40 MHz) transducers. The nerve specimens were fixed and stained for histological processing. RA needles were inserted into the nerve to simulate the clinical problem, and 3D micro-ultrasound images acquired with needles in place and after removal.

The micro-ultrasound imaging was able to visualise the substructures of the nerve showing fascicles of size, 0.5 mm diameter and greater. Statistical analysis of the fascicle dimensions along the length of the nerve was done. The anatomical structures were found to be similar in both micro-ultrasound and histology images. The position of needles within the nerves, and fascicles split by inserted needles were easily visualised in the micro-ultrasound images. The micro-ultrasound results were validated with histology demonstrating its use for studying the morphology of peripheral nerves. The needle insertion pilot study indicated that there is mechanical damage caused when the needle was inserted within and without the fascicles.

High frequency measurement of the speed of sound and attenuation of small animal soft tissue

A Rabell¹, SD Pye², T Anderson¹ and CM Moran¹

¹University of Edinburgh, UK

²NHS Lothian, Royal Infirmary of Edinburgh, UK

Abstract

Commercially available ultrasonic test phantoms are manufactured from tissue-mimicking materials (TMMs) and are used to calibrate, assess and quantify the performance of clinical ultrasound scanners. The properties of the TMMs used in these phantoms are based on IEC recommendations based on the acoustic properties of clinical soft tissue obtained at frequencies 2–10 MHz (speed of sound (SoS) = 1540 ± 15 m s⁻¹ and attenuation = 0.5 ± 0.05 dB cm⁻¹MHz⁻¹). Currently, our lab is developing a high frequency performance test phantom manufactured from a new TMM, the acoustic properties of which will mimic small animal soft tissue at the higher frequencies (15–40 MHz) which are most routinely used to ultrasonically scan these animals.

The aim of this work was to determine the magnitude of the speed of sound and attenuation of small animal soft tissue. Within 5 minutes of euthanasia, 10 fresh, non-perfused mouse livers and kidneys were extracted, sliced (∼2 mm thick) and immersed in a PBS tank maintained at 37℃. A high frequency ultrasound scanner Vevo 770 (Visualsonics, Inc) was used to collect the RF data in the frequency range of 12–35 MHz. The acoustic power output from the transducer probe was set at 10% corresponding to a peak negative pressure of 1.0 MPa.¹

Initial measurements from five livers showed a mean SoS of 1617 ± 22.3 m s⁻¹. The measured liver attenuation values (uncompensated for the PBS) were found to vary with frequency as 0.0122f²+ 0.577f (R²= 0.99). The SoS results obtained from liver were outside the recommended values provided by the IEC 2001 guideline (1540 ± 15 m s⁻¹) for low frequency (2–10 MHz). Nevertheless our results were in good agreement when compared with measurements undertaken in human and bovine liver at low frequency (1–7 MHz) by Bamber and Hill² where the SoS was found to be 1614.3 ± 16.1 m s⁻¹.

Paediatrics

Case report: GIST presenting as cystic mass in a child

J Coates

Leeds Teaching Hospital Trust, UK

Abstract

We present a case of an eight year old who was referred by his GP for investigation of a left upper quadrant mass. Ultrasound showed a large complex cyst which was proven to be a gastro intestinal stromal tumour (GIST) after excision.

An eight-year-old boy presented to his GP with a cough and fatigue. On examination a left upper quadrant mass was noted and an urgent referral made for abdominal ultrasound. The ultrasound demonstrated a large left-sided complex cystic mass. The lesion was further assessed with an MRI scan which confirmed a large complex cystic mass, containing haemorrhage. On referral to a regional paediatric surgical centre the child underwent laparotomy and a 1 kg mass was excised from his stomach. This was found to be a GIST on histological examination.

Paediatric GIST is a very rare diagnosis, accounting for between 1% and 2% of all patients diagnosed with GIST. The majority of these patients are female and it usually starts in the stomach. When compared with adult GIST they tend to be slower growing and less aggressive and patients are less likely to show certain genetic mutations. Imaging findings are variable, depending on size, location and amount of cystic change, haemorrhage and necrosis.

Neonatal cerebral Doppler – What it is for (and what it isn't)

JR Fernandez Alvarez, L Mahoney, B Reulecke and H Rabe

Brighton & Sussex University Hospitals NHS Trust, UK

Abstract

Cranial ultrasound is the most common sonographic investigation in neonatal intensive care. Cerebral Doppler sonography has become a valuable additional modality in the assessment of the new-born brain. Its clinical application is increasingly extending, providing even information about organ systems outside the brain. We aim to review and illustrate the current and future role of cerebral Doppler ultrasonography in new-borns.

We searched the literature using the terms “neonates”, “sonography”, “ultrasound”, “Doppler” and “brain”. We also reviewed imaging textbooks and cross-referenced with our literature search looking for applications of cerebral Doppler sonography in the management of sick or premature new-borns. We use partly our own images from our tertiary referral neonatal unit to illustrate the findings.

Cerebral Doppler sonography helps assessing congenital and acquired brain problems directly and indirectly involving the brain vessels. In term infants with hypoxic-ischemic injury, the arterial flow pattern and resistance index are abnormal. Assessment of the arteries can help predict severity of brain injury and neurodevelopmental outcome. In preterm infants, cerebral autoregulation is very primitive. Hypo-/hypercapnia can alter cerebral blood flow to the extent that the risk of brain injury is increased. Similarly poor cardiac output or significantly low blood pressure can be reflected in abnormal Doppler traces in the brain. The flow pattern and resistance index in the cerebral arteries can help determine the clinical significance and guide the management of a patent ductus arteriosus. Ischemic and venous infarctions as well as vein thrombosis can easily be seen using colour Doppler in addition to pulsed wave Doppler. Cerebral Doppler ultrasonography is a valuable addition to the standard B-mode assessment of the neonatal brain. It has the potential to help assess the severity of a clinical problem remote to the brain, guide clinical management and predict outcome in certain conditions.

Sonographic determination of splenic volume in children with sickle cell anaemia in steady state

N Irurhe, YI Caleb, FO Olowoselu, C Esezobor and E Temiye

Lagos University Teaching Hospital, Nigeria

Abstract

Accurate, non-invasive assessment of splenic volume is used in the clinical management of patients with these diseases. Previously, techniques for measuring splenic size have relied on nuclear scintigraphy and computerized tomography. However, ultrasonography (US) is now the imaging modality of choice because it does not use ionizing radiation; in addition, it is sensitive, cheap and readily available. The purpose of the study is to determine the splenic volume in children with sickle cell anaemia in steady state.

The subjects were 200 children with sickle cell anaemia in steady state attending the paediatric sickle cell clinic and 200 age and sex matched controls (normal children) attending the general paediatric outpatient clinic. All patients were scanned at the Radiology department of the Lagos University Teaching Hospital by transabdominal ultrasonography. Calculations of the splenic volume were based on measurement of splenic length (L) width (W) and thickness (T) as obtained on two images placed side by side on the monitor utilizing the standard ellipsoidal formula (L x W x T).

The relationship between age and sex of the subjects ranging from 1 to 15 years old (mean 7.9 and 8.1 years) were analysed. Splenomegaly was observed in 113 (56.5%) of the patients. Fifteen (7.5%) had autosplenectomy. The mean splenic volume in the patients ranged between 36 and 331 cm³ compared with 21–239 cm³ in the controls. There was no gender variation in both groups and no significant correlation between splenic volume and the frequency of blood transfusion. However, a strong correlation between age and splenic volume was established. This study has provided standard values of normal splenic volume in sickle cell anaemia children in our environment. It has also confirmed the age and sex related changes in the spleen.

Lung ultrasound: Time to inflate our skills?

C Williams and K Barton

University of Portsmouth, UK

Abstract

Lung ultrasound (LUS) is now an accepted extension of the focused assessment with sonography in trauma (FAST) examination and is routinely used in this setting for the detection of both haemo- and pneumothoraces. In addition, a recent review by Lichtenstein¹ concluded that LUS is a suitable replacement for chest x-ray and, in many cases, computed tomography (CT), not only for trauma patients but also in the critical care setting. LUS has also been shown to detect the following diseases of the pleura: pneumonia, pulmonary oedema, pulmonary embolism, asthma and chronic obstructive pulmonary disease with a 90–100% sensitivity and specificity range.² This technique enables rapid diagnosis and treatment as it can be performed at the bedside avoiding the hazards involved in patient transfer. In addition, it is repeatable, non-invasive, inexpensive and can provide an excellent opportunity for procedural guidance. LUS is relatively easy to learn and could be a valuable adjunct in the assessment of many inpatients, yet despite its many uses and advantages LUS currently remains underused, with sonographers receiving little or no training in this technique.

This poster provides a basic how to guide with relevant images detailing both technique and image interpretation. Topics covered will include indications, patient position, probe type, machine settings and basic scanning technique along with relevant normal and abnormal images.

Facilitating the use of ultrasound scanning in general medical practice in the National Health Service

D Lukey

HIG (Healthcare Innovations Group) Ltd, UK

Abstract

The purpose of this study was to determine the feasibility of promoting ultrasound scanning in general medical practice across the UK as an additional GP skill. Although ultrasound training has been offered to GPs for the past two decades, there are very few GPs who have undergone training and an even smaller number who regularly practice the skill. The aim of the research was to determine why so few GPs have taken up training and to assess whether anything could be done to promote the service if there was sufficient enthusiasm amongst students, trainees and GPs.

The major component of the research was quantitative in nature, i.e. in the form of questionnaires to assess the opinions of GPs, GP trainees, medical students, radiologists/ sonographers and commissioners. The second part was the structured interviews conducted with providers of equipment and an academic at a medical school. The final component was the unstructured interviews/discussions with members of the focus group.

The enthusiasm of the GPs, trainees and students was evident from the findings of the survey (43% positive – 25 respondents). The commissioners (50% positive – 2 respondents) would have to be persuaded to view GP USS as a worthwhile investment on the evidence of fewer cases referred to hospital for USS and fewer patients attending A&E. The career sonographers, in particular the latter (33% positive – 6 respondents), would require considerable persuasion in order to convince them of the non-threatening nature of GP USS. The providers of equipment (100% positive – 3 respondents) showed considerable interest in the undertaking.

The introduction of GP USS would require a change in culture, a veritable paradigm shift, but it can be hoped that on the evidence presented such a change is not only possible, but desirable, if not inevitable.

Interventional ultrasound techniques replacing surgery in breast radiology – Considerations, benefits and pitfalls

J Lee, S Bhuva and M Bhattacharyya

Oxford University Hospitals NHS Trust, UK

Abstract

Advances in technology have significantly improved ultrasound-guided interventions in breast radiology. With real-time ultrasound-guided core biopsy and vacuum-assisted excisions biopsy, the sonographer is now not only able to diagnose, but also to treat, breast lesions with increasing accuracy. This approach has led to a significant reduction in surgical biopsies and excisions. New guidelines and training requirements for ultrasound-guided interventions in breast radiology have also been released. Knowledge of the appropriate considerations, benefits and pitfalls of ultrasound-guided intervention in breast radiology will enable the sonographer to communicate confidently with the patient, optimise the ultrasound-guided intervention, and to enhance the patient’s clinical pathway.

We present:

1) Considerations and technique of ultrasound-guided intervention in breast radiology, including appropriate case selection and current guidelines;

2) Advantages, including an analysis of its accuracy, potential cost-savings and impact on the patient’s clinical pathway;

3) Pitfalls and training requirements for the sonographer;

4) A few cases to illustrate how the clinical context influences the ultrasound-guided interventional procedure.