Search

Introduction Musculoskeletal diagnostic ultrasound is an expanding clinical tool and increasingly used at point of care in clinical practice. Criticism around the accuracy of this modality is often attributed to operator dependence. This study evaluated the accuracy of a sonographer’s reporting against shoulder surgery. Methods A musculoskeletal sonographer performed same-day ultrasound scans prior to elective shoulder surgery procedures. The sonographer was blinded to clinical history and previous investigations. A brief physical examination of resisted external rotation and resisted abduction strength was performed prior to scanning. Scan results were reported using British Elbow and Shoulder Society (BESS) reporting criteria. The sonographer attended surgery to gain immediate visual feedback. Sonographic reports and magnetic resonance imaging (MRI) reports were graded (1= complete agreement; 2 = minor discrepancy unlikely to alter patient care; 3 = potentially significant discrepancy; 4 = definite, significant discrepancy) against surgical findings. The accuracy of sonographic reporting was correlated with patients’ body mass index (BMI). Results Fifty-four cases were compared and correlations evaluated. Grade 1 (complete agreement) was reported 87.0% ( n = 47), Grade 2 (minor discrepancy) 9.3% (n = 5) and Grade 3 (potentially significant discrepancy) 3.7% (n = 2). Sonographic reports closely correlated (Grade 1 or 2 scores) with surgical findings in 96% of cases. Conclusions The musculoskeletal sonographic reporting had a high correlation with surgery findings. Ultrasound was more accurate than MRI in reporting full thickness rotator cuff tears. Clinical weakness in resisted external rotation or abduction did not correlate with imaging. Ultrasound was found to be unreliable in detecting rotator cuff tears in participants with a BMI ≥ 35.

Pseudoaneurysms of the superficial temporal artery are rare. They commonly occur after blunt trauma to the frontotemporal region of the head. There have been less than 400 cases of superficial temporal artery pseudoaneurysms reported. We present a case of a patient referred for a pulsatile head mass. Physical examination and color Doppler ultrasound confirmed the diagnosis of a superficial temporal artery pseudoaneurysm (STA PSA). This was treated with ultrasound guided thrombin injection with complete resolution. Anatomical distribution, diagnosis, and treatment of STA PSA are discussed.

Background The use of multiparametric magnetic resonance imaging (mpMRI) within active surveillance of prostate cancer programmes is identified by the UK National Institute for Health and Care Excellence (NICE guideline NG 131 2019) as having a role for monitoring disease. The widespread demands on mpMRI capacity may limit its use in surveillance. It is therefore timely to review the options that modern ultrasound imaging present to this cohort of patients in the monitoring of prostate cancer. Methods Between April and September 2020, 10 databases were searched to recruit studies for the review. Three reviewers evaluated the publications for inclusion. Characteristics including the inclusion criteria for the study cohort, how disease was determined, identification of disease progression, and the modality and mode of imaging used were reviewed. Given the paucity of full text articles, a meta-analysis was not possible. A narrative review was undertaken. Results In total, 12 studies, utilising the range of ultrasound parameters of B-mode, micro-ultrasound, colour Doppler, contrast ultrasound and elastography were included. The review demonstrated that micro-ultrasound offers promise as an imaging tool comparable with mpMRI. However, this is an emerging technology with limited availability. Analysis of the data further demonstrated that by combining the diagnostic features provided by multiple modes reviewed, ultrasound has a role in the diagnostic imaging of patients on active surveillance. Conclusion Providing a multiparametric approach is utilised, stable ultrasound findings may allow for increased intervals between biopsy for men on surveillance. The advent of micro-US offers promise as an imaging modality within an active surveillance pathway but requires further verification.

Background: Because of the large forces and high frequency of throwing, the upper extremity experiences repetitive stresses that lead to acute and chronic adaptations. While the importance of pennation angle and muscle thickness as predictors of muscle force production has been shown in other populations and other joints, there has been little research done that examines these variables in the shoulders of baseball players. Purpose: (1) To examine the chronic effect pitching has on the rotator cuff muscle architecture (pennation angle and muscle thickness) in healthy professional baseball pitchers, and (2) to examine the correlation between muscle architecture and clinical measures of strength and range of motion (ROM). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Twenty-eight healthy professional pitchers were recruited during the 2019 spring training. Internal rotation (IR) and external rotation (ER) strength were measured with a handheld dynamometer and IR and ER ROM were measured with an inclinometer. A diagnostic ultrasound machine was utilized to capture images of humeral retroversion, as well as the pennation angle and muscle thickness of the infraspinatus and teres minor muscles. ImageJ software was used to quantify the pennation angle and muscle thickness. Results: There were no significant differences between the dominant and nondominant arms for ER or IR strength. Also, no pennation angle and muscle thickness differences were found between the dominant and nondominant arms. A weak positive relationship between infraspinatus muscle thickness (superficial and total) and ER strength ( P = .016, R = 0.287 and P = .009, R = 0.316) and a moderate negative relationship between soft tissue glenohumeral internal rotation deficit (GIRD) and the bilateral difference of the teres minor deep pennation angle ( R = −0.477, P = .008) were observed. No other significant relationships were noted. Conclusion: Our results are contrary to current literature as we expected to see a stronger dominant arm, with a larger pennation angle and greater muscle thickness. Interestingly, we found that ER strength was positively related to only the thickness of the infraspinatus muscle, and that soft tissue GIRD was positively related to only the side-to-side adaptation of the pennation angle within the deep portion of the teres minor. This suggests that when posterior shoulder tightness occurs, specifically the architecture of the teres minor muscle is involved. However, the organization to which these players belonged has a very extensive training protocol throughout the year that emphasizes bilateral training during a large majority of the exercises. Therefore, the results may not be generalizable to all professional players.

Background: With recent improvements in transducer strength, image resolution, and operator training, ultrasound (US) provides an excellent alternative imaging modality for the diagnosis of rotator cuff tears. Purpose: To evaluate the diagnostic accuracy of US for partial- and full-thickness rotator cuff tears and biceps tendon tears, compare diagnostic values with those of magnetic resonance imaging (MRI) using arthroscopy as the reference standard, assess longitudinal improvements in accuracy, and compare diagnostic values from operators with different training backgrounds. Study Design: Systematic review; Level of evidence, 3. Methods: The PubMed and Cochrane Library databases were systematically searched for full-text journal articles published between January 1, 2010, and April 1, 2020. The inclusion criteria were studies that evaluated the diagnostic accuracy of US for rotator cuff tears or biceps tendon tears utilizing arthroscopy as the reference standard. The exclusion criteria were studies with Results: In total, 23 eligible studies involving 2054 shoulders were included. US demonstrated a higher median diagnostic accuracy for supraspinatus tendon tears (0.83) and biceps tendon tears (0.93) as compared with subscapularis tendon tears (0.76). US was found to have a higher median accuracy (0.93) for full-thickness supraspinatus tears than partial-thickness tears (0.81). US had superior median sensitivity for partial-thickness supraspinatus tears when performed by radiologists as opposed to surgeons (0.86 vs 0.57). Meta-analysis of the 5 studies comparing US and MRI demonstrated no statistically significant difference in diagnostic sensitivity, specificity, or accuracy for any thickness supraspinatus tears (P = .31-.55), full-thickness tears (P = .63-.97), or partial-thickness tears ( P = .13-.81). Conclusion: For experienced operators, US is a highly sensitive and specific diagnostic modality for the diagnosis of supraspinatus tears and demonstrates statistically equivalent capability to MRI in the diagnosis of both full- and partial-thickness rotator cuff tears.

Background:Arthroscopic rotator cuff repair can be quite complex and time consuming, particularly early in the surgeon’s learning curve.Hypothesis:Patients who have undergone rotator cuff repair with shorter operative times will be less likely to have a rotator cuff retear at 6 months postoperatively.Study Design:Case-control study; Level of evidence, 3.Methods:This study was an analysis of data from 1600 consecutive patients (670 partial-thickness and 930 full-thickness tears) who had rotator cuff repair performed by a single surgeon utilizing an arthroscopic, single-row, knotless inverted mattress suture anchor technique. All patients underwent ultrasound at 6 months postoperatively to determine repair integrity. Moving average analysis was performed for the variables of operative time and case number to evaluate the surgeon’s learning curve.Results:For early cases, the mean operative time was approximately 35 minutes. After approximately 450 cases, the operative time plateaued at approximately 20 minutes. The mean operative time for the cohort (±SEM) was 22 ± 0.3 minutes, and the mean retear rate was 13%. Increased operative time was associated with a retear ( r = 0.18; P < .001). Multiple logistic regression analysis revealed that the variables with the most independent effect on retears were larger tear size (Wald statistic = 36; P < .001), lower case number (ie, less surgeon experience) (Wald statistic = 28; P < .001), older patient age (Wald statistic = 23; P < .001), full-thickness tears (Wald statistic = 13; P < .001), and lower surgeon-rated repair quality (Wald statistic = 8; P = .004). Operative time was not a significant independent factor contributing to retears.Conclusion:Operative time and rotator cuff retear rates decreased as surgical team experience increased. The hypothesis of this study, however, was not supported. The reduced retear rate was not related to a reduction in operative time per se but rather to improved surgical team experience and patient factors, such as improved healing with smaller tears in younger patients.

Introduction Duplex ultrasound is often the sole imaging modality used in diagnosing carotid artery disease. However, the reproducibility and repeatability of scientists in determining the peak systolic velocity and end diastolic velocity of the internal carotid artery and common carotid artery (CCA) is widely debated. Study aim To investigate intra- and inter-operator variability in diagnostic ultrasound of the carotid arteries across a centralised vascular network using a healthy test subject. To identify potential causes of variability and highlight areas for improvement. Methods Fifteen vascular scientists across four hospital Trusts in the Bristol, Bath and Weston vascular network measured the peak systolic velocity and end diastolic velocity of the internal carotid artery and common carotid artery in a subject using a single portable ultrasound machine. A double blind assessment of spectral Doppler images was performed by two vascular clinical scientists for optimal caliper placement, spectral gain and angle correction. Results were compared for intra- and inter-operator variability. Results Initial quality assessment of the Doppler images revealed that three out of 15 scientists produced suboptimal results. Box plot analysis of the common carotid artery and internal carotid artery for each scientist revealed significant variance (ANOVA p Conclusion This study highlights the difficulty in obtaining consistent velocity measurements from a subject. Despite the variability in absolute peak systolic velocity and end diastolic velocity, scientists were generally consistent in obtaining an optimal spectral Doppler trace. Some issues with consistency were, however, identified which were subsequently addressed.

Orthopaedic journal of sports medicine 9(4), 232596712110068 (2021). doi:10.1177/23259671211006826, Published by Sage, London [u.a.]

Background:Portable ultrasound machines are now common, used for point-of-care applications and needle guidance for percutaneous procedures; however, the effectiveness of portable ultrasound in evaluation of the musculoskeletal system has not been fully assessed.Purpose:To prospectively evaluate the use of portable hand-held ultrasound in comparison with conventional cart-based ultrasound in evaluation of the musculoskeletal system.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:In this institutional review board–approved, prospective study, 100 consecutive patients with informed consent were imaged through use of both portable and cart-based ultrasound equipment using 12-5 MHz linear transducers. Agreement in ultrasound diagnosis was documented along with expected clinical changes in management if there was disagreement (definitely no, probably no, uncertain, probably yes, definitely yes). Imaging details of disagreement cases were recorded, and descriptive statistics were calculated.Results:There were 42 male and 58 female patients (mean ± SD age, 53 ± 13 years) imaged over a time period of 20 months. Anatomic areas scanned were the shoulder (n = 30), elbow (n = 11), hand and wrist (n = 15), hip (n = 10), knee (n = 11), foot and ankle (n = 12), and others (n = 11). Scanning with conventional ultrasound revealed abnormality in 92% of patients. Agreement in diagnosis made between portable versus cart-based ultrasound was found in 65% of patients. In the 35% of patients with discordant results, the change in diagnosis resulted in no change in clinical management in 46%, probably no change in 29%, uncertain change in 14%, probable change in 11%, and definite change in 0%. The diagnoses changing management (4%; 4/100) included nondetection of a satellite nodule (n = 1), ganglion cyst (n = 1), hernia (n = 1), and underestimated tendon tear (n = 1).Conclusion:When compared with conventional cart-based ultrasound, a musculoskeletal diagnosis using portable hand-held ultrasound was concordant or was discordant without clinical relevance in 96% (96/100) of patients. Knowledge of benefits and limitations of portable hand-held ultrasound will help determine areas where specific types of ultrasound equipment can be used.

Diagnostic ultrasound is considered to be the gold standard imaging modality for testicular assessment. As a result, it is frequently encountered by general radiologists and sonographers on daily ultrasound lists as well as by radiology residents out of hours. The main strength of diagnostic ultrasound in testicular assessment is that the high-frequency linear transducers utilized reproduce high-resolution images allowing accurate assessment of the testicular parenchyma. The fact that no ionizing radiation is utilized is particularly important as many patients on whom a testicular scan is requested are young or middle aged and the testis as an organ is very radiosensitive. This pictorial review comprises a range of illustrated images of congenital, benign, malignant, infection, polyorchidism and prosthesis-related pathologies collated over a two-year period at our institution.

Background: The importance of meniscal preservation has become widely accepted, and meniscal repair techniques have evolved over recent years. With new techniques come new complications, which are critical to recognize. Purpose: To describe a new complication of foreign body reaction from a nonabsorbable suture anchor associated with improper placement of the all-inside meniscal device. Study Design: Case series; Level of evidence, 4. Methods: This study was a retrospective review of 3 patients who developed pain associated with a foreign body reaction from a misplaced all-inside meniscal device. Results: All patients had a delayed diagnosis (6 months to 8 years) and negative magnetic resonance imaging (MRI). Diagnostic ultrasound identified the misplaced suture with foreign body reaction and was used to guide a diagnostic injection of local anesthetic prior to surgical intervention. Intraoperative ultrasound guidance was utilized to precisely localize and excise the suture material and associated reactive tissue. Conclusion: Foreign body reaction from a misplaced all-inside meniscal device is a previously unreported complication. Diagnosis is challenging as MRI and arthroscopy can be unrevealing. Diagnostic ultrasound was able to identify the foreign body reaction, confirm the diagnosis by facilitating diagnostic local anesthetic injection, and guide surgical excision. Sonographic evaluation should be considered in patients presenting with ongoing knee pain after all-inside meniscus repair.

Current ultrasound education for sonographers is at post-graduate level and it is a service expectation that sonographers are equipped with advanced skills on qualification. The aim of the working party review was to assess the current roles and responsibilities of the sonographers, with a view to determining whether there was an opportunity to introduce a lower band practitioner role within the local hospital ultrasound department as well as the wider ultrasound community. Qualitative data, for the review, were obtained from two sources: (i) a local working party consisting of two ultrasound managers, two sonographers, one consultant radiologist, one line manager and one lecturer in diagnostic imaging and (ii) radiologists of the local department, ultrasound colleagues within the Yorkshire and Humber Strategic Health Authority (SHA), local and national Higher Education Institute and Consortium for the Accreditation of Sonographic Education colleagues. The career structure of sonographers was reviewed with options to introduce a band 6 ultrasound practitioner post in the local radiology department. The level of work expected of sonographers within the local Trust demands advanced skills, currently recognized as Agenda for Change band 7, are utilized on a daily basis. Little opportunity for practitioners to work at a lower grade which would require only technical reports, with no diagnostic opinion, was identified. In conclusion, there is currently no scope for a band 6 ultrasound practitioner within the local radiology department. The review suggests there is a need for an ultrasound practitioner career structure, which is comparable with other professional groups. Such developments will require input and support from clinicians, radiologists, the professional body and the higher education institutions. The review recognizes the need for an ultrasound governance team within individual Trusts to oversee ultrasound provision, reporting and clinical developments.

The wide availability and recent improvement in technology coupled with portability, low cost and safety makes ultrasound the first choice imaging investigation for the evaluation of musculoskeletal diseases. Diagnostic use of ultrasound findings is greatly enhanced by knowledge of the clinical presentation. Conversely, ultrasound skills with its prerequisite anatomical knowledge make the clinical diagnosis more precise and reduce uncertainty in the choice of therapy. Therefore, it is essential for rheumatologists to acquire ultrasonography skills in order to improve patient care. Ultrasound examination provides an excellent opportunity for patient education and to explain the rationale for therapy. This review summarizes the indications for musculoskeletal ultrasound and describes its role in diagnosis, monitoring and prognosis.

Background: Recently, clinicians and researchers started using diagnostic ultrasound to measure humeral torsion as an alternative to radiological assessments in overhead-throwing athletes and other clinical populations. Ultrasound appears to be a reliable, nonradiological alternative, but ultrasound assessment has not been validated against computed tomography (CT), the current gold standard. Purpose: This study aimed to establish the validity of an ultrasound assessment of humeral torsion by comparing data obtained using both ultrasound and CT, the current standard. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Humeral torsion was measured using both ultrasound and CT in 24 collegiate-aged baseball players. Comparisons between the assessments were made using both regression and Bland-Altman plots. Reliability and precision were also established. Results: A strong relationship existed between humeral torsion variables obtained with ultrasound and CT ( R = .797, R2 = .635, P < .001). The ultrasound assessment yielded reliability coefficients ranging from .991 to .997, with approximately 1° of measurement error. The CT method’s reliability coefficients ranged from .805 to .933, with approximately 3.5° of measurement error. Conclusion: There was a strong relationship between humeral torsion obtained with ultrasound and CT, the current standard of assessment. Ultrasound provides a reliable, valid alternative to CT for obtaining an indication of the amount of humeral torsion in the upper extremity.

The goal of this work is to demonstrate the feasibility of using a diagnostic ultrasound system (Siemens Antares™ and CH6–2 curvilinear array) to ablate ex vivo liver with a custom M-mode sequence and monitor the resulting tissue stiffening with 2-D Acoustic Radiation Force Impulse (ARFI) imaging. Images were taken before and after ablation, as well as in 5- s intervals during the ablation sequence in order to monitor the ablation lesion formation temporally. Ablation lesions were generated at depths up to 1.5 cm from the surface of the liver and were not visible in B-mode. ARFI images showed liver stiffening with heating that corresponded to discolored regions in gross pathology. As expected, the contrast of ablation lesions in ARFI images is observed to increase with ablation lesion size. This study demonstrated the ability of a diagnostic system using custom beam sequences to localize an ablation site, heat the site to the point of irreversible damage and monitor the formation of the ablation lesion with ARFI imaging.

The continued examination of potential biological effects of ultrasound and their relationship to clinical practice is a key element in evaluating the safety of diagnostic ultrasound. Periodically, the American Institute of Ultrasound in Medicine (AIUM) sponsors conferences bringing experts together to examine the literature on ultrasound bioeffects and to develop conclusions and recommendations related to diagnostic ultrasound. The most recent effort included the examination of effects whose origins were thermal or nonthermal, with separate evaluations for potential effects related to fetal ultrasound. In addition, potential effects due to the introduction of ultrasound contrast agents were summarized. This information can be used to assess risks in comparison to the benefits of diagnostic ultrasound. The conclusions and recommendations are organized into five broad categories, with a comprehensive background and evaluation of each topic provided in the corresponding articles in this issue. The following summary is not meant as a substitute for the detailed examination of issues presented in each article but rather as a means to facilitate further study of this consensus report and implementation of its recommendations. The conclusions and recommendations are the result of several rounds of deliberations at the consensus conference, subsequent review by the Bioeffects Committee of the AIUM, and approval by the AIUM Board of Governors.

Gas-filled microbubbles are used as contrast agents in diagnostic ultrasound imaging. A preclinical, acute toxicity study of 2 surfactant-stabilized ultrasound contrast agents (ST68 and ST44) was conducted. Subjects were 104 Sprague-Dawley rats (experimental doses, 0.1, 0.2, 0.8, and 1.0 mL/kg; control, 1.0 mL/kg saline) that were studied for 14 days after contrast; clinical signs, weight, blood, and urine were evaluated. Histopathology was performed following euthanasia. Of the 40 animals receiving ST44, 4 died prematurely and a dose dependency was demonstrated ( P = .011), whereas in the ST68 groups only 1 death occurred (no dose dependency; P = .48). Only the weight of rats injected with ST44 varied significantly ( P = .0003). This dependency was also found for 3 of 5 urine parameters and 4 of 36 blood parameters ( P < .05). For ST68, only 1 urine parameter showed significance ( P < .0001). Giant cell infiltration in the lungs was significantly higher than controls in the ST44 0.1 mL/kg and the ST68 0.8-1.0 mL/kg groups ( P < .01). It is concluded that the prudent choice for future nonrodent, toxicology studies and potentially for human clinical trials is ST68 (given the deaths in the ST44 groups).

Microbubbles and cavitation are playing an increasingly significant role in both diagnostic and therapeutic applications of ultrasound. Microbubble ultrasound contrast agents have been in clinical use now for more than two decades, stimulating the development of a range of new contrast-specific imaging techniques which offer substantial benefits in echocardiography, microcirculatory imaging, and more recently, quantitative and molecular imaging. In drug delivery and gene therapy, microbubbles are being investigated/developed as vehicles which can be loaded with the required therapeutic agent, traced to the target site using diagnostic ultrasound, and then destroyed with ultrasound of higher intensity energy burst to release the material locally, thus avoiding side effects associated with systemic administration, e.g. of toxic chemotherapy. It has moreover been shown that the motion of the microbubbles increases the permeability of both individual cell membranes and the endothelium, thus enhancing therapeutic uptake, and can locally increase the activity of drugs by enhancing their transport across biologically inaccessible interfaces such as blood clots or solid tumours. In high-intensity focused ultrasound (HIFU) surgery and lithotripsy, controlled cavitation is being investigated as a means of increasing the speed and efficacy of the treatment. The aim of this paper is both to describe the key features of the physical behaviour of acoustically driven bubbles which underlie their effectiveness in biomedical applications and to review the current state of the art.

Ultrasound is a widely used modality for both therapy and diagnosis in medicine and biology. Currently, in the field of medical diagnosis, ultrasound is responsible for about one in five of all diagnostic images. The physical characteristics of medical ultrasound, along with its behaviour as it interacts with biological tissues, are described in this tutorial. The role of ultrasound in therapeutic and diagnostic applications is briefly described. In view of the importance of ultrasound as a medical imaging modality, the basic technological building blocks utilized in diagnostic ultrasound scanners are also described. Many of these topics are the subjects of other papers in this special issue where they are dealt with in more detail.

This is an account of a two week introductory programme in abdominal ultrasound run at and by the University of Salford (UoS) in the UK, jointly planned and delivered by four European institutions, and funded as an ‘intensive programme’ by the EU Lifelong Learning Programme, in order to promote development of education and practice in diagnostic ultrasound throughout the EU member countries. The course syllabus was embedded within existing modules at UoS. Each partner institution was asked to supply a cohort of students and a teacher to assist with delivery of the programme: 30 students from the four institutions attended the course. The course did not in any way confer or imply any measure of clinical competency and this was clear to all participants. The success of the course proves the value of international healthcare education and brings us a step closer to harmonisation of ultrasound education and practice across Europe.

The main mechanisms by which ultrasound can induce biological effects as it passes through the body are thermal and mechanical in nature. The mechanical effects are primarily related to the presence of gas, whether drawn out of solution by the negative going ultrasound pressure wave (acoustic cavitation), a naturally occurring gas body (such as lung alveoli), or deliberately introduced into the blood stream to increase imaging contrast (microbubble contrast agents). Observed biological effects are discussed in the context of these mechanisms and their relevance to ultrasound safety is discussed.

Diagnostic ultrasound manufacturers are advancing the technology of sonographic systems, providing superior image quality and improving the diagnostic confidence for both sonographers and radiologists. Real-time adaptive filters (RTAFs) are perhaps the least known among the advanced signal processing techniques available on most modern sonography machines, which is further complicated by the fact that RTAF appears under various trademark names. Despite the different proprietary names, RTAFs generally employ a postprocessing mathematical algorithm to real-time imaging that improves contrast resolution by reducing noise and artifacts while simultaneously enhancing the edges and smoothing the tissue texture of structures. This technique may be applied across a wide variety of clinical examinations and may not yet be completely understood and appreciated by sonographers. This review aims to educate readers on how RTAFs work, supported by examples of their benefit to image quality. In particular, the authors describe the effectiveness of using RTAF for superficial structures (thyroid, abdominal wall), deep structures (abdomen, pelvis), and dynamic examinations, including musculoskeletal and vascular applications.

Ultrasound is widely used in small animal veterinary medicine for the investigation of cardiac disease and abdominal disorders. However, non-abdominal non-thoracic ultrasound in dogs and cats currently has a much more minor role in routine diagnostic work-ups. This article, based on a presentation given to the annual BMUS meeting in 2007, aims to provide some insight into the use of diagnostic ultrasound in evaluating the small parts of small patients.

Aim: The on-screen Mechanical Index (MI), was recorded from eight diagnostic ultrasound machines used for cardiac scanning of neonates. The objective of the study was to compare values of MI used in neonatal cardiac scanning with those recommended by the British Medical Ultrasound Society safety guidelines. Methods: The eight scanners were based at Sheffield Teaching Hospitals NHS Trust (STH), Sheffield Children's Hospitals NHS Trust (SCH) and Leeds Teaching Hospitals NHS Trust (LTH). Two methods of recording the MI value were used. At the Sheffield sites the on-screen safety index was obtained from archived patient studies saved on the Trust PACS. At the Leeds site the on-screen safety index was recorded from the scanner when it was switched on to its default neonatal or paediatric pre-sets with the appropriate transducer connected. Results: Data from clinical examinations at the Sheffield sites show that on average the MI values, for cardiac scanning, in B-mode and colour/pulsed wave Doppler mode were 1·1±0·3 and 1·3±0·3 respectively. The maximum values of MI recorded during clinical cardiac examinations were 1·6 for B-mode and 1·7 for colour/pulsed wave Doppler mode. Data from the Leeds site recorded default MI values, using appropriate transducers with neonatal and paediatric presets. One scanner from the Leeds site defaulted to an MI value of 1·9 in colour/pulsed Doppler mode with a neonatal preset. All the MI values are well above BMUS guideline recommendations for neonates when lung tissue is present within the ultrasound beam. Conclusions: The implication of these results is that neonates undergoing cardiac ultrasound examinations, were regularly exposed to MI values at least four to six times that recommended by BMUS guidelines (MI

Background: The purpose of this study was to introduce a novel operative technique and to evaluate the clinical outcomes in a cohort of patients with missed or neglected Achilles tendon ruptures. Methods: Fifteen consecutive patients with missed complete Achilles tendon ruptures and 5-cm or larger gaps had reconstruction with V-Y lengthening and flexor hallucis longus tendon transfer through a single incision. The patients were evaluated at an average of 106 weeks after surgery. At the time of followup, all patients were assessed with regard to their self-reported level of satisfaction and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Ankle strength and active range of motion were evaluated using Biodex® (Biodex Medical Systems, Shirley, NY) isokinetic dynamometry. In addition, seven patients were evaluated using diagnostic ultrasound. Results: We found a 7.7 N-m (–22.3%) loss of plantarflexion torque at 60 degrees/sec and a 3.5 N-m (–13.5%) loss of plantarflexion torque at 120 degrees/sec, as well as a 5 degrees loss of active range of motion. AOFAS scores were all good to excellent, with an average score of 94.1 of 100. All patients were satisfied with their outcomes (rated good or very good). Excellent exposure of the Achilles tendon repair was obtained with ultrasound. Conclusions: For patients with missed or neglected Achilles tendon rupture with a rupture gap of at least 5 cm, operative repair using V-Y lengthening and flexor hallucis longus tendon transfer through a single incision technique achieved a high percentage of satisfactory results.

Diagnostic ultrasound is generally considered to provide images without causing any significant biological effects in the tissues being visualized. If, however, the energy used is increased sufficiently, ultrasound can kill cells instantaneously, and causes thermal necrosis. High intensity focused ultrasound beams are being used to destroy masses in deep-seated tissues without damage to the intervening, overlying structures. This new technique is being investigated for use in the treatment of cancer of the prostate, liver, kidney, breast and bone.

Diagnostic Ultrasound has a well recognized role in the evaluation of patients across the spectrum of clinical practice. Technological advances have improved image quality, while making the functionality and ease of use better. This has resulted in more compact systems becoming available at more affordable prices. Over the past 10 years there has been an increase in the development of the point of care application of this skill, in particular at the bedside by clinicians looking to complement their traditional forms of patient assessment. This has been most evident in some of the acute specialist practices, such as Emergency Medicine, and other critical care practices, as well as some out-patient and primary care environments. In this article we describe some of the training and educational challenges inherent in the development of imaging skills by non-traditional practitioners. We describe an innovative post-graduate award (Postgraduate Certificate) that has been specifically designed to provide a suitable educational structure for clinicians wishing to develop focused ultrasound skills. In particular we concentrate on the experience of the first cohort of students from Emergency Medicine who have completed the course successfully. We describe the experience related to the development of the course and the lessons learned from its provision. We argue that there is an increasing need for such courses across the spectrum of clinician ultrasound at the bedside and we look forward to further evaluation in the years ahead.

The temperature rises at the surface of diagnostic ultrasound transducers in air and in contact with a tissue-equivalent phantom have been compared. Twenty-five transducers from seven different manufacturers were studied in imaging and pulsed Doppler modes. Comparisons were made between the temperature rise at 200 s 'in air' and 'on phantom' using two standard tissue mimicking materials (TMMs). Temperature rises in contact with the phantom (ΔTp) were always lower than those in air (ΔTa). Using a phantom that included a 1·5-mm silicone rubber layer to mimic the skin, the relative temperature rises ΔTp/ΔTa varied from 43 to 87 % with an average of 60%. The two TMMs gave comparable temperature rises despite their different compositions. Relative temperature rise depended slightly on frequency (2·5% MHz−1) and was higher on average in imaging mode than in pulsed Doppler mode. Linear relationships were observed between temperature rise and acoustic power, and relative temperature rise and silicone rubber thickness (∼11.5% mm−1). The phantoms gave rise to broadly similar temperature rises to those on skin, although the 1·5-mm silicone rubber skin-mimic layer may give a slight over-estimate of temperature rise for some transducers.

Background Rotator cuff tears are associated with significant morbidity. Ultrasound scanning in the diagnosis and evaluation of cuff tears has been shown to be highly sensitive and specific. However, it is hypothesized that ultrasound may not be such a precise modality in the setting of a district general hospital. Materials and Methods The present study identified all patients in a 1-year period who underwent shoulder arthroscopy and who had also undergone a preceding ultrasound scan. Tables (2 × 2) were drawn up to compare findings and calculate sensitivity, specificity and predictive values. Results Eighty-five patients were identified with a total of 59 (69%) cuff tears detected at surgery. Overall, the sensitivity and specificity of ultrasound was 66% and 54%, respectively. This equated to an overall accuracy of 62%. The positive predictive value was 76% and the negative predictive value was 41%. Discussion The results obtained in the present study demonstrate disappointingly low sensitivity, specificity, positive and negative predictive values, as well as accuracy, for the use of ultrasound scanning in the assessment of the rotator cuff. This has implications not only for the diagnostic process, but also in terms of theatre time logistics. It is suggested that a regular multidisciplinary team meeting is held to discuss imaging and consideration of magnetic resonance imaging as an alternative modality in this setting.

The safety committee of the British Medical Ultrasound Society has drawn up guidance that is intended to encourage best practice in determining and reporting the exposure conditions used in ultrasound bio-effect studies among researchers. The guidance addresses diagnostic and therapeutic applications of ultrasound, and is intended for bio-effects researchers, review boards of ethical and funding committees, and the editors and reviewers of scientific journals.

We carried out a four-month pilot study of telemedicine for the delivery of training and diagnostic ultrasound services for general practitioners (GPs). Two health centres and a district general hospital were linked using ISDN (128 kbit/s) and PC-based videoconferencing units. Sixteen videoconferencing sessions were conducted, with 64 patients scanned over the ISDN link for a range of clinical conditions. Nine cases of pathology were demonstrated and confirmed by a consultant radiologist. A total of 229 images were transmitted using the store- and -forward facility, of which 194 (85%) images were of diagnostic quality and 35 (15%) were regarded as non-diagnostic. Allowing for sampling error, we would expect 79–89% of stored images to provide diagnostic information at a 95% confidence level. A total of 115 store- and-forward images (SAFI) were randomly selected and compared with hard-copy images (HCI) for technical quality. There was a significant difference in the quality of images. The results show that SAFI are far superior to HCI, traditionally used by clinicians for making primary diagnosis and that the superior quality of the SAFI improved diagnostic accuracy. This pilot study showed a high degree of confidence in videoconferencing for training GPs to carry out ultrasound clinics, enhancing their ability to make accurate diagnoses, and providing them with immediate access to second and higher opinion.

The applications of color Doppler and power flow imaging for laparoscopic intraoperative ultrasonography (LIOU) are discussed. Basic principles concerning Doppler, color Doppler imaging (CDl), and power flow (PF) are briefly reviewed, and a number of representative examples of imaging are provided. LIOU is progressively gaining importance, not only for screening of the biliary tract, but in particular, for staging laparoscopy in patients with gastrointestinal cancer. The CDI technology that was developed relatively quickly is now in widespread use in diagnostic ultrasound, particularly for vascular surgery. CD options are no longer restricted to the expensive high-end ultrasound scanners, but are available in the majority of modest duplex systems with limited additional costs. Ongoing developments in ultrasound technology have resulted in the introduction of an alternative option to mean frequency-based CD ultrasound, ie, the PF. There are several advantages that emanate from the combination of B-mode ult...

Much work has been done on ultrasound phantoms foe biopsy and anatomic training of physicians and sonographers. Artifacts observed during scans in vivo also have been described. The authors' purpose in this article is to describe the construction and perdormance of phantoms designed to demonstrate ultrasound image artifacts for teaching purposes. Phantom images exhibiting ringdown, range errors, reverberation, and multipath artifacts produced by scanning intrauterine devices, shotgun pellets, and other objects are illustrated.

Although diagnostic ultrasound has been widely applied for various clinical conditions and diseases, its clinical effectiveness remains less well defined. Technology assessment can be applied to ultrasound and includes several criteria such as techologic capability, range of possible uses, diagnostic accuracy, impact on health care providers, therapeutic impact, and patient outcome. A review of each of these criteria is provided to raise sonographer awareness as to the need for further reserch in this area.

Background: The importance of meniscal preservation has become widely accepted, and meniscal repair techniques have evolved over recent years. With new techniques come new complications, which are critical to recognize. Purpose: To describe a new complication of foreign body reaction from a nonabsorbable suture anchor associated with improper placement of the all-inside meniscal device. Study Design: Case series; Level of evidence, 4. Methods: This study was a retrospective review of 3 patients who developed pain associated with a foreign body reaction from a misplaced all-inside meniscal device. Results: All patients had a delayed diagnosis (6 months to 8 years) and negative magnetic resonance imaging (MRI). Diagnostic ultrasound identified the misplaced suture with foreign body reaction and was used to guide a diagnostic injection of local anesthetic prior to surgical intervention. Intraoperative ultrasound guidance was utilized to precisely localize and excise the suture material and associated reactive tissue. Conclusion: Foreign body reaction from a misplaced all-inside meniscal device is a previously unreported complication. Diagnosis is challenging as MRI and arthroscopy can be unrevealing. Diagnostic ultrasound was able to identify the foreign body reaction, confirm the diagnosis by facilitating diagnostic local anesthetic injection, and guide surgical excision. Sonographic evaluation should be considered in patients presenting with ongoing knee pain after all-inside meniscus repair.

An in vitro system has been set up to study the possible genetic effects of diagnostic ultrasound (US) on the developing fetus. Amniotic cells were cultured by the in situ technique. Well established clones were exposed to US for various lengths of time using a linear array transducer within a sound transparent apparatus. Cells were then grown in the presence of 5-bromo-2'-deoxyuridine and processed for scoring the number of sister chromatid exchanges (SCE) as the cytogenetic endpoint. There was no linear relationship between the SCE frequency and the duration of US exposure. Variance analysis showed that only interindividual variability was a significant component of total variation. Neither the main effect of treatment nor the interaction effect were statistically significant. The data suggest that US delivered from a diagnostic unit to actively growing cultured fetal cells in a system closely mimicking the conditions of US exposure during amniocentesis does not induce SCE.

Thermal and mechanical indices are acoustic output descriptors that provide a means of assessing the potential for biologic effects from exposure to diagnostic ultrasound. Models and assumptions used in the estimation of acoustic output indices are discussed with illustrative diagrams. The defining equation for each index is presented. Safety guidelines based on the index values are reviewed.

Photographic recording of representative images from a diagnostic ultrasound examination documents clinical findings. Geometric distortion can be introduced into the hardcopy image by the image-recording device. Size, shape, and relative positions of structures are not accurately portrayed. Illustrative examples of distortion produced by improperly adjusted hardcopy cameras are presented. Testing methods for distortion are described.