of medical sonography

Transcription

T H E
O F
C A N A D I A N
J O U R N A L
MEDICAL SONOGRAPHY
Volume 4, Issue 1 • Spring 2013
• Professional Practice
• What to Expect When You’re Not Expecting
• Case Study of Myositis Ossificans
• Echocardiography in the United Kingdom
www.csdms.com
Publications Agreement Number 40025049 • ISSN: 1923-0931
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Volume 4, Issue 1 • 2013
Publications Agreement Number 40025049
Contents
5
Volume 4, Issue 1 • 2013
Message from the Editor • Mot du rédacteur en chef
Kim G. Boles, CRGS, CRVS, FCSDMS
EDITOR-IN-CHIEF
Kim Boles
EDITORIAL BOARD
Lianne Broughton, Nanette Denis,
Dal Disler, Cathy Fix, Stuart Gibbs,
Carol Gillis, Chris Harrington,
Wendy Lawson, Verna Maschio,
Vern Parkinson
CSDMS News
7
Professional Practice
Original Articles
14
What to Expect, When You’re Not Expecting: An In-Depth Look into
Professional Liability Insurance
Sheldon Boyde, CRGS
MANAGING EDITOR
Susan Harrison
ART DIRECTOR
16
COPY EDITOR
Susan Harrison
Case Report: Myositis Ossificans
Kathryn McMillan, MRSc
Andrea Mulholland
Reprints
22
Echocardiography in the United Kingdom
Jules Hobson, BSc Hons, HNC, ONC, RCCP, BSE, SCST
PROOFREADER
Scott Bryant
TRANSLATOR
26
Abstract: Systematic Labeling of Twin Pregnancies on Ultrasound
T. Dias, S. Ladd, S. Mahsud-Dornan, A. Bhide, A. T. Papageorghiou,
and B. Thilaganathan
Marie Dumont
ADVERTISING
John Birkby
(905) 628-4309
[email protected]
Book Reviews
27
The Physics and Technology of Diagnostic Ultrasound: A Practitioner’s Guide
Reviewed by Chris Harrington, CRGS, CRCS, CRVS
CIRCULATION COORDINATOR
Brenda Robinson
[email protected]
28
Principles of Vascular and Intravascular Ultrasound
Reviewed by Verna Maschio, BTech, CRVS, CRGS, CRCS
ACCOUNTING
Susan McClung
28
Reviewed by Kim G. Boles, CRGS, CRVS, FCSDMS
GROUP PUBLISHER
John D. Birkby
_______________________________________
For Instructions to Authors, please visit
www.andrewjohnpublishing.com/
CJMS/cjmsinstauthors.html
_______________________________________
The Safe Use of Ultrasound in Medical Diagnosis, Third Edition
Professional Development/Employment Opportunities
8
21
29
30
31
ARDMS
2013 CSDMS Annual Conference and AGM
The Burwin Institute
Sunridge Diagnostic Imaging
Sunridge Diagnostic Imaging
Return undeliverable Canadian Addresses to:
115 King St W., Suite 220, Dundas, ON L9H 1V1
Canadian Journal of Medical Sonography is published four
times a year by Andrew John Publishing Inc., with offices
located at 115 King Street West,Suite 220,Dundas, ON
L9H 1V1.
•••••
We welcome editorial submissions but cannot assume
responsibility or commitment for unsolicited material.Any editorial material, including photographs that are accepted from
an unsolicited contributor, will become the property of
Andrew John Publishing Inc.
The publisher and the Canadian Society of Diagnostic Medical
Sonographers shall not be liable for any of the views
expressed by the authors published in Canadian Journal of
Medical Sonography, nor shall these opinions necessarily
reflect those of the publisher.
www.csdms.com
Cover images (left to right): moose in Kananaskis Country, Alberta;
cascading waterfall in Ontario; Peter Lougheed Provincial Park, Alberta.
Above images (left to right): tulip field, British Columbia; Whytecliff Park,
Vancouver; closeup of a Canadian goose and gosling.
The Canadian Journal of Medical Sonography | Spring 2013
3
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Message from the Editor
T
his issue contains some critical information
on professional liability insurance, along
with an Ontario Coroner’s Advisory. Please take
special note of the coroner’s advisory. Our
Eastern Director Sheldon Boyde has authored
an article on professional liability insurance; all
members should investigate the coverage you
currently have under employer or other group
professional liability policies to ensure that you
have adequate protection as sonographers.
Verna Maschio, Chris Harrington, and I have
reviewed three new reference texts that should be of interest
to many of you. One of our recent graduates, Kathryn
McMillan, has submitted a case study on myositis ossificans.
In endeavouring to produce a well-rounded publication, the
CJMS editorial staff are very committed to presenting a
diverse selection of topics in each issue, providing education
and interest for all sonographers. We work largely in four
subject areas: general ultrasonography, cardiac ultrasonography, vascular ultrasonography, and professional
practice. We would like to add an education section in
upcoming issues. If you are involved in education and
clinical training, please consider contributing an article; it
will assist all educators and those aspiring to become
educators. If you are unsure of what contribution you can
make, please drop me a line to discuss possible topics.
All submissions are welcome, but I would encourage all
echocardiographers and vascular sonographers to consider
contributing to CJMS. Case studies, topics of interest, book
reviews, and original research are needed to support
education, continuing education, and professional growth
for our cardiac sonographer (CRCS) and vascular
sonographer (CRVS) members, our managers, and our
educators.
As the profession continues to advance and expand, we are
continually challenged to provide current and topical
information through CJMS. Advances in contrast
ultrasonography, fusion technology, musculoskeletal
sonography, and point-of-care sonography continue to
www.csdms.com
provide new challenges and opportunities to
Canadian sonographers and the editorial staff.
If you have suggestions on topics you would
like see in upcoming issues or suggestions to
make regarding potential authors you think
would have a valuable educational
contribution to make, please contact me. I
would love to hear from you. And I am more
than willing to pursue special interest topics
and authors on our readers’ behalf.
As promised, this issue includes reviews on
three new reference books that are available. If you are aware
of any new reference texts, software, or e-learning materials
you would like reviewed, please send us a note with the
pertinent source information and we will organize a review
by our Canadian experts. This may assist you in acquiring
additional reference materials for your workplace or
personal reference libraries.
To repeat a previous message, changes have been made by
the CSDMS Board of Directors to the processes at CJMS.
Effective September 1, 2012, vacancies on the editorial board
will be open to all CSDMS members. Editors are selected
based on their special knowledge, experience, and
publication history. References are required. If you are
interested in becoming a member of the editorial board,
please polish your references. We will announce vacancies in
future issues. These positions are for a 2-year term and are
normally only filled once per year.
Effective June 1, 2013, we will have vacancies on the editorial
board for the following: one vascular editor, one cardiac
editor, one generalist editor, and one education editor. Please
send your CV to me if you are interested in a challenging
experience. Applications will be reviewed by the current
editorial board, and recommendations will be forwarded to
the CSDMS Board of Directors for approval. The deadline
for applications is April 15, 2013.
Kim Boles, CRGS, CRVS, FCSDMS
Editor-in-Chief
5
Mot du rédacteur en chef
L
e présent numéro renferme de l’information cruciale à
propos de l’assurance responsabilité civile
professionnelle ainsi qu’un avis du bureau du coroner de
l’Ontario. Je vous invite à en prendre connaissance. Notre
directeur de la région de l’Est, Sheldon Boyde, fait paraître
un article sur l’assurance responsabilité civile
professionnelle; je vous encourage à revoir la couverture
offerte par votre employeur ou groupe professionnel pour
vérifier que vous bénéficiez effectivement de la protection
appropriée en tant qu’échographiste. Verna Maschio, Chris
Harrington et moi avons passé en revue trois nouveaux
ouvrages de référence qui seraient certes utiles à beaucoup
de membres. Kathryn McMillan, diplômée de fraiche date,
propose une étude de cas de myosite ossifiante.
Résolue à produire une revue solide et pertinente, l’équipe
de rédaction entend publier une sélection de sujets divers,
instructifs et captivants pour les échographistes. Nous
abordons quatre grands sujets : l’échographie générale,
l’échographie cardiaque, l’échographie vasculaire et
l’exercice de la profession. Nous souhaiterions ajouter une
rubrique sur l’éducation dans les prochains numéros. Nous
encourageons ceux qui œuvrent dans les domaines de
l’éducation et de l’enseignement clinique à nous proposer
des articles; ce contenu sera très utile aux éducateurs et à
ceux qui aspirent à le devenir. Si vous n’êtes pas trop certain
sur quoi écrire au juste, envoyez-moi un courriel, nous en
discuterons.
Nous réserverons un bon accueil à toutes les
communications qui nous seront transmises; nous invitons
tout particulièrement les échocardiographistes et les
spécialistes de l’échographie vasculaire à écrire dans les pages
de la revue. Des études de cas, des sujets d’intérêt général,
des critiques de livre et des comptes rendus de recherche
originale viendront appuyer l’éducation, la formation
continue et l’épanouissement professionnel des membres
spécialistes de l’échographie cardiaque (CRCS) et de
l’échographie vasculaire (CRVS), des directeurs de service et
des éducateurs.
Au fil de l’avancement de la profession, nous nous devons
de faire paraître de l’information actuelle et pertinente dans
La Revue. Les percées dans l’échographie de contraste, la
technologie de la fusion, l’échographie de l’appareil
locomoteur et l’échographie au point d’intervention exigent
6
de l’échographiste qu’il se tienne au courant et de l’équipe
éditoriale qu’elle en parle.
N’hésitez pas à me faire part de vos idées, des sujets que vous
aimeriez voir aborder dans la revue ou d’auteurs dont la
contribution serait enrichissante à coup sûr selon vous. Je
serais ravi de savoir ce que vous avez à dire. Et, je suis tout
disposé à traiter de sujets particuliers ou à solliciter des
auteurs pour le compte des lecteurs!
Tel que je l’ai mentionné déjà, vous trouverez ici la recension
de trois nouveaux ouvrages de référence. Si vous voulez
entendre parler de tels ouvrages, que ce soit des textes, des
logiciels de référence ou du matériel de cyberapprentissage
de parution récente, adressez-nous un mot contenant la
source d’information en question. Nous demanderons à des
experts du pays de les examiner. Leur opinion vous sera
certainement utile au moment de vous procurer un ouvrage
de référence à consulter au travail ou d’enrichir votre
bibliothèque personnelle.
Comme je vous l’ai annoncé, le conseil d’administration de
la SCEM a modifié des modalités ayant trait à la RCEM. Au
1er septembre 2012, tous les membres de la Société pourront
poser leur candidature à un poste vacant au comité de
rédaction. La sélection se fonde sur des critères de
connaissances, d’expérience et d’antécédents en matière de
publication et sur l’examen des références figurant sur le
curriculum vitae. Veuillez donc y apporter un soin
particulier si vous souhaitez devenir membre de l’équipe.
Tout poste vacant sera affiché dans la RCEM. Nous tenons
habituellement une seule période de mise en candidature
dans l’année, et le terme est de deux ans à tous les postes.
Au 1er juin 2013, les postes suivants seront vacants : un poste
à la rubrique de l’échographie vasculaire, un à la rubrique
de l’échographie cardiaque, un à la rubrique de
l’échographie générale et un à la rubrique de l’éducation. Si
vous souhaitez vous lancer dans cette aventure passionnante,
faites-moi parvenir votre curriculum vitae. L’équipe de
rédaction examinera les candidatures et communiquera son
choix au conseil d’administration de la Société aux fins
d’approbation. L’échéance de la mise en candidature est le
15 avril 2013.
Kim Boles, CRGS, CRVS, FCSDMS
Rédacteur en chef
www.csdms.com
CSDMS News
Professional Practice
CSDMS and CARDUP have received a letter from the
Maternal and Perinatal Death Review Committee of the
Ontario Coroner’s Office. There was a request to comply
with part one of the committee’s recommendations resulting
from the investigation into a neonatal death.
Committee recommendations:
1. To prenatal ultrasonography providers: Prenatal
ultrasound providers are reminded of the SOGC and
AIUM guidelines requiring full second trimester
morphology assessments and reporting.
2. To obstetrical care providers: Mothers who have suffered
fetal or neonatal loss due to cardiac abnormalities
should be offered fetal echocardiology in subsequent
pregnancies.
It is important for practitioners to recognize that neither the
CSDMS nor CARDUP have the legislated jurisdiction over
diagnostic medical sonographers in Ontario or Canada to
enforce compliance with the coroner’s request.
The CSDMS is publishing the findings and committee
recommendations in their entirety with the consent and
permission of the Ontario coroner to comply with the
CSDMS/CARDUP commitment to the Ontario coroner to
communicate the Review Committee’s recommendations to
Canadian sonographers, reinforcing the usefulness and
importance of the Society of Obstetricians and
Gynaecologists of Canada (SOGC) and the American
Institute of Ultrasound in Medicine (AIUM) practice
guidelines for obstetrical ultrasound.
What Lead to the Committee
Recommendations?
Investigation history:
•
•
•
Primiparous mother in her late 30s
No risk factors identified in the maternal medical or
genetic histories
Infant delivered by emergency caesarean section at 37
weeks’ gestation
Post mortem – findings at autopsy:
•
•
•
Severe fetal hydrops
Dysmorphic facies
Complex congenital heart abnormalities including
ventricular septal defect (VSD) with overriding aorta,
www.csdms.com
•
•
•
•
aortic ring with preductal coarctation, tricuspid and
mitral dysplasia, cardiac hypertrophy, and ventricular
trabeculations with numerous false tendons
Tracheal stenosis
Pulmonary hyperplasia
Normal male karyotype
Positive newborn screen indicated a biotinidase
deficiency, low normal, likely due to “poor sample
integrity”
The boards of directors of CSDMS and CARDUP strongly
recommend that all members and registrants involved in
obstetrical ultrasonography review the clinical practice
guidelines listed below to ensure a thorough understanding
and compliance with professional practice that complies
with SOGC and AIUM guidelines governing a fetal
examination ensuring enhanced maternal and fetal health
and well-being. These guidelines are easily referenced on the
SOGC and AIUM websites.
SOGC Clinical Practice Guidelines
Content of a Complete Routine Second Trimester
Obstetrical Ultrasound Examination and Report
No. 223, March 2009 (Replaces No. 103, May 2001)
This clinical practice guideline has been reviewed by the
Diagnostic Imaging Committee and approved by the
executive and council of SOGC. SOGC acknowledges
advisory input from the Canadian Association of
Radiologists pertaining to imaging guidelines in the creation
of this document.
AIUM Practice Guideline
AIUM Practice Guideline for the Performance of Obstetric
Ultrasound Examinations
Effective October 1, 2007 – AIUM Practice Guidelines –
Obstetric Ultrasound
AIUM is a multidisciplinary association dedicated to
advancing the safe and effective use of ultrasound in
medicine through professional and public education,
research, development of guidelines, and accreditation.
This document was published in conjunction with the
American College of Radiology (ACR) and the American
College of Obstetricians and Gynecologists (ACOG).
It is the professional responsibility of all Canadian
sonographers to maintain awareness of the practice
guidelines for their particular area(s) of practice. This should
7
Profe ssional Pract ice
include institutional, regional, national, and international
standards.
Awareness of and adherence to applicable practice guidelines
helps to ensure that examinations are performed within
accepted safety and practice standards. This will serve to
protect the patients and practitioners. The CSDMS
professional liability policy requires sonographers to practise
within their approved scope of practice and in adherence
with the accepted practice standards of Canadian
sonography. So, the bottom line is this: become informed,
adhere to accepted standards, and protect your patients and
yourself.
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8
www.csdms.com
Profe ss ional Pract ice
www.csdms.com
9
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www.csdms.com
www.csdms.com
11
12
www.csdms.com
www.csdms.com
13
Original Article
What to Expect, When You’re Not Expecting: An In-Depth
Look into Professional Liability Insurance
Sheldon Boyde, CRGS
About the Author
Sheldon Boyde is the Eastern Director for CSDMS. Correspondence may be directed to
[email protected].
T
raditional misconceptions about health care litigation can
often supersede the cold hard reality of potential
malpractice in our current health care system. Doctors are not
the only health care providers who get sued. Conventionally,
doctors were seen as the “central command” around which all
other health care personnel revolved. So, it was reasonable to
assume that any litigation would fall in the laps of central
command. However, in today’s vast network of health care
services, central command lies within our own professional
designations and credentials. As we assume more
responsibility, become more self-reliant, and seek higher levels
of learning, we must also accept a higher risk of litigation.
While our immunity to potential litigation may be somewhat
weakened by this change, we can certainly strengthen our
ability to cope by obtaining our own professional liability
insurance.
Perhaps the biggest falsehood regarding professional liability
insurance involves the question, why do we need it if our
employer has institutional professional liability coverage?
While this may be true, you need to dive deeper into any
coverage provided by your own particular institution’s liability
policy; you will immediately find that the interests of the
employer are often selfishly based on its own financial wellbeing and not on any protection of you. Why, then, would you
place your career, personal assets, and professional integrity
and reputation in the hands of an entity that does not hold
your professional, financial, and familial interests as its
number one priority? Litigation can be professionally and
financially disabling. It can leave you emotionally drained and
in permanent disconnect from your family and professional
surroundings. If your employer holds its own interests above
yours and a litigation suit threatens your well-being, who has
your back? Your personal liability insurer does!
14
The facts about having your own professional liability
insurance are quite simple. The language used in the liability
policies can be challenging to understand, but this is one of
the major reasons why having your own liability policy
works in your favour; it’s tailored to your specific professional
needs and scope of practice!
The benefits of having a professional liability policy, in my
mind, supersede any disadvantage of its cost:
•
•
•
•
•
It is mobile, meaning it follows you wherever you go
and is not employer specific. You can work anywhere in
Canada and always be covered, no matter who you work
for.
It is tailored to your own profession, meaning that the
policy is created specifically for you as a sonographer
and encompasses all sonographic activities that fall
within your scope of practice.
It is not based on a “shared limit of liability” like your
employer’s policy is. You would not know, based on
your employer’s limit, how much would be available to
defend your claim. If your employer has exhausted its
limit on other claims, you are left with the shortfall if
extended litigation costs or damages are incurred. These
costs and damages are often sought from your personal
assets such as your house, vehicle, etc.
In the CSDMS professional liability program, our
insurance provider has made changes to the wording to
ensure that the professional services covered are defined
as “those services rendered by the insured, while acting
within the scope of the insured profession as a
diagnostic medical sonographer including duties
customary to the practice.”
The scope of practice and insured professional services
www.csdms.com
B oyde
are defined and determined by the profession – not the
employer, and not the insurer. They are tailored
specifically to your role as a sonographer, regardless of
your discipline of practice.
In an employer’s policy, covering all members of the health
care and support team, the insurer may not know exactly all
the services legally provided by the practitioner that require
coverage. The exclusions in an employer’s policy need to be
closely monitored to ensure that the coverage provided to
diagnostic medical sonographers is not affected by the policy
wording and limitations in place.
Professional liability insurance, like any other insurance, is
there when we need it. It’s probably one of only a few
purchases that we make in our lifetime that we hope we
never to have to use. We never expect to get sued; oftentimes
a claim is not made against a direct act of omission or error
on your part, but against a single event somewhere in a chain
of events. Why take the chance? Would you honestly feel
comfortable sitting down at a discovery session during a
lawsuit, knowing the only one in the room who knows what
a transducer looks like is you? Would you feel unnerved
about explaining common knowledge sonographic events
to someone who thinks we take baby pictures all day long?
This is ultimately what happens under a general policy
insurance program like the one your employer has. It is
general, not specific. Under a general policy, the only true
exclusion will probably be your employer’s involvement, and
the only true inclusion will likely be you alone.
We must recognize that all diagnostic results of our
profession are based on specifics and expertise in our field.
A generalized policy does not work in a field of specifics.
That’s why we have our own policy. A policy tailored to our
needs, created for sonographers and overseen by
sonographers. A policy that knows and speaks our language
and fully encompasses our scope of practice. Professional
liability insurance is not for everyone, but should be for
every sonographer across Canada. I encourage you to review
in detail the coverage provided by the CSDMS professional
liability policy, which can be found on the CSDMS website.
Become informed, and protect yourself and your financial
well-being.
Growing the field of
Medical Sonography!
www.csdms.com
www.csdms.com
15
Original Article
Case Report: Myositis Ossificans
Kathryn McMillan, MRSc
About the Author
Kathryn McMillan is a recent graduate of McMaster University, in Hamilton, Ontario.
Correspondence may be directed to [email protected].
M
yositis ossificans is a rare benign condition that involves
the ectopic deposition of bone and fibrous tissue
adjacent to or in the muscle.1 It is also known as heterotopic
ossification and ectopic ossification. Myositis ossificans can
form spontaneously but usually results from damage such as
trauma or surgery to the muscle. The most common location
is in the high thigh and hips, although other possible sites
include the upper arm, calf, and the sole of the foot.2 Presented
below is a case study involving myositis ossificans, followed by
an explanation of the findings.
Case Report
A 20-year-old female presented to the emergency room with
severe leg pain. She immediately underwent radiography of
the femur and magnetic resonance imaging (MRI) of the
spine; both showed normal results except for mild knee
effusion (Figure 1). Two days later, the patient revisited the
emergency room with severe leg pain; however, at that time,
she was unable to bear weight on her leg. Sonography was
ordered to rule out deep vein thrombosis (DVT), but no DVT
was present. The sonographer asked the patient to show the
area of pain, which was the left thigh, and found an ill-defined
intramuscular, vascular mass measuring 3.5 × 3.8 × 2.5 cm
(Figure 2). The mass appeared heterogeneous with decreased
echogenicity. Computed tomography (CT) was performed 3
days later to stage the primary mass, but the CT scan results
appeared normal. An MRI was completed 2 weeks later, whose
results suggested osteosarcoma or a non-occlusive clot in the
common femoral vein (Figure 3).
The patient again returned to the emergency room, 3 days after
the MRI was performed, this time with excruciating pain, left
thigh swelling, and an inability to move her left leg.
Sonography was again performed; no DVT was present,
16
although dramatic changes to the mass were apparent. The
mass then contained large calcifications, and the internal
echogenicity could no longer be seen due to the shadowing of
the calcifications (Figure 4). Musculoskeletal biopsy was
attempted, which showed significant peripheral mineralization,
edema in the muscle lesion, and that the lesion was hard. The
stiffness of the lesion was significant, and the biopsy needle was
bent during the procedure. The radiologist suggested that the
mass was an extracranial osteosarcoma but noted that it could
also be myositis ossificans.
A week later, radiography of the femur was performed that
showed rapid onset of mineralization in the left thigh with a
zonal pattern appearance. It had more prominent
mineralization peripherally than centrally, which suggested the
diagnosis of myositis ossificans (Figure 5). A bone scan was also
completed showing intense focal increased activity which is
compatible with soft tissue mineralization, also consistent with
myositis ossificans.
Types of Myositis Ossificans
There are four different categories of myositis ossificans:
myositis ossificans post traumatica, fibrodysplasia ossificans
progressive, myositis ossificans associated with paraplegia,
and myositis ossificans circumscripta.3 Myositis ossificans
post traumatica (PTMO) is the type seen most commonly
(60–75%) and occurs after a direct blow to the body or from
repeated minor trauma.1 Ossifications are formed from the
embedding of periosteal cells into the muscles from the
direct blow, or they can be caused by bone growth occurring
within a hematoma.
The “genetic type” of myositis ossificans is called
fibrodysplasia ossificans progressive. This type involves bone
morphogenetic protein 4 (BMP-4), which causes ectopic
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McMil lan
Figure 1. Radiograph of the
left leg at the patient’s first
visit to the emergency room.
Figure 2. Ultrasonogram of lesion in left leg, obtained during the
patient’s second visit to the emergency room.
Figure 4. The second sonogram, showing a calcified lesion in left leg.
bone formation within the first decade of life.4
Paraplegia can also cause this pathology, due to the constant
pressure on a patient’s immobilized joint. Myositis ossificans
occurring while a patient is immobilized in bed for a reason
other than paraplegia is also grouped with myositis ossificans
associated with paraplegia.
Myositis ossificans circumscripta involves a reparative process
when the body is trying to respond to trauma, inflammation,
or infection.5 An inflammatory response causes connective
tissue cells to turn into osteogenic precursors, later creating
bone.
The radiologist in the case study above believed that this
patient suffered from PTMO, although the patient could not
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Figure 3. The second magnetic resonance
image obtained.
Figure 5. A second radiograph, showing rapid
onset of mineralization in the left thigh.
recall any previous trauma. However, she did say she had
suffered from abuse as a child.
The pathogenesis of PTMO is the same as a standard
inflammatory response for hematoma formation. Soft tissue
necrosis causes the body to send out histiocytes, which have
properties similar to phagocytes to clear the wound.5 After
this initial response, fibroblasts and undifferentiated stromal
cells migrate to the connective tissue. Mesenchymal cells later
become osteoblasts, causing ossification from the periphery
of lesion to the centre.5
Signs and Symptoms
Myositis ossificans is seen most commonly in males between
17
Cas e Re por t: Myosit is Oss ificans
Figure 6. Left, The early stage of myositis ossificans, where Figure 7. Magnetic resonance image of the thigh showing a lesion in the enlarged left
no lesion is evident on the radiograph. Right, A later stage leg.
– now the lesion can be seen.
Figure 8. Left, Sonogram of the early stage of myositis ossificans post traumatica. Right, The same lesion at a later stage.
the ages of 20 and 30 years.6 Common signs and symptoms
may include pain, edema, swelling, tenderness, an ecchymosis,
a palpable mass, and a decreased range of motion.2 During
the early stage of the disease, the lesion is soft and painful and
swelling occurs. Once matured, the lesion becomes firm and
is most commonly a painless mass, although pain can persist.7
the periphery. Between the 4th and 6th weeks, the lesion
begins showing ossification along the peripheral rim. This is
often described as a shell around the lesion.1 Maturity is
reached when the calcifications progress from the periphery
to the centre, forming bone. Complete maturity is achieved
in approximately 5–6 months.1
Stages of Myositis Ossificans
Differential Diagnosis
Myositis ossificans often occurs in the muscle belly with no
interruption of the muscle fibres. In the early stage of myositis
ossificans, the centre of the lesion has decreased echogenicity
and the outer portion is hyperechoic with an ill-defined rim.
There is vascularization, but there is no calcification. In
approximately the 3rd week, calcifications begin to appear on
Differential diagnosis for myositis ossificans includes
hematoma, abscess, metastases, lymphoma, and sarcomas.8
Osteosarcomas can be difficult to differentiate because both
have persistent pain, swelling, and rapid growth. Early myositis
ossificans is commonly confused with fibrosarcoma upon
biopsy because both appear as undifferentiated tissue.7 Biopsy
18
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McMil lan
of mature myositis ossification shows mature lamellar bone,
allowing differentiation from osteosarcoma, which includes
osteoids and tumour cells. On a radiograph, myositis
ossification appears separate from bone, whereas osteosarcoma
has a direct connection with the periosteum, allowing for
differentiation of the two.6 Another way to differentiate is to
look at the makeup of the lesion. Osteosarcoma’s central zone
is made of mature bone while the periphery is highly mitotic
cells that are primitive and cellular, compared to myositis
ossificans, which has a central zone composed of immature
and mitotic cells and a dense periphery with mature bone
formation.7 In the case of myositis ossificans, swelling remains
within the muscle at all times.
Plain Film Radiography
Plain film radiography is not effective at visualizing the early
stage of myositis ossificans – the lesions often appear normal
(Figure 6).1 However, at 1–2 weeks after formation has begun,
faint bone formation in the periphery can be seen; and after
3–4 weeks, mineralization in the periphery is evident (see
Figure 6). After approximately 2 months, bone deposits form
and visualization of myositis ossificans on plain film
radiography is possible.1 Radiographs can assist in determining
the size, density, and location of lesion and can even help
differentiate the condition from osteosarcoma.1 Abnormalities
are seen by radiography after the onset of symptoms.
Computed Tomography
CT is also useful in diagnosing mature myositis ossificans. The
main benefit of CT is the demonstration of the zonal patterns
of ossification with decreased attenuation at the centre. CT
allows for the identification of a clear location of the lesion
and separation of the mass from adjacent cortex, which assists
in surgical resection.1
Magnetic Resonance Imaging
MRI is the most sensitive imaging technique for early, small
lesions before the onset of calcifications; however, it lacks
specificity.1 Within 8 weeks of onset, MRI can show diffuse
edema disproportionate to the lesion, which helps
differentiate it from neoplastic lesions.1 Intermediate lesions
on MRI appear as irregular areas of decreased signal intensity
entering and surrounding the lesion (Figure 7). Mature
lesions seen on MRI are well defined and inhomogeneous.1
The drawback with MRI is the inability to view soft tissue
calcifications.
Sonography
Sonography is highly sensitive in the early stages of myositis
ossificans and is effective at detecting calcific deposits in soft
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tissues in the mature stage. A benefit with sonography is the
ability to perform serial studies on the same patient at short
intervals. Because of this, you can see the progression of the
calcific deposits in the lesions.1 Sonography can assist in
diagnosing myositis ossificans because you can view that the
lesion is intramuscular without affecting muscle fibres. This
feature can help differentiate myositis ossificans from
osteosarcoma, which is attached to bone.
The edge of the lesions are seen clearly on sonograms, which
assists in finding the precise location for resection: the
periphery of myositis ossificans lesions is the first to calcify,
and on sonograms, calcifications shadow completely.
Therefore, sonography is ideal for guiding the excisions of a
lesion.1 Sonography is inexpensive, available, non-invasive,
and non-ionizing, making it a preferred modality in
musculoskeletal imaging.
Results from Case Study
In the case study discussed above, the thigh was the affected
region, and this is the most common place for myositis
ossificans to occur. The muscle affected was the vastus lateralis
of the quadriceps. The average length of a myositis ossificans
lesion is 3.0–9.3 cm; this patient’s lesion measured 4.75 cm in
the mature stage.9 The early stage of myositis ossificans was
detected by sonography, when it had been missed by plain
film radiography. If the sonographer had not inquired about
the location of the patient’s pain and checked the lesion, the
condition would not have been detected. This shows the
importance of listening to patients and taking a thorough
history.
The case study demonstrates the early stage of myositis
ossificans, as was evidenced by a decreased echogenicity and
hyperechoic rim (it was not calcified) (Figure 8).
Calcifications were seen with sonography on the periphery of
the lesion in the later stage (see Figure 8). This shows the value
of sonography when diagnosing myositis ossificans because
it allows you to view the lesion in both early and later stages.
Histology
Viewing myositis ossificans microscopically is a major factor
in diagnosing this condition. Early stages of myositis ossificans
appear as degenerated and necrosed damaged muscle cells.9
It is mostly cellular, with fibroblastic tissue resembling
granulation tissue (seen in one case study). Mature myositis
ossificans appears mineralized, and bone formation occurs.9
Treatment
When a blunt trauma occurs, the individual should
immediately apply ice and compression to the injured area,
elevate it, and rest. Twenty-four to 48 hours of immobilization
19
Cas e Re por t: Myosit is Oss ificans
is then recommended, followed by rehabilitation to prevent
injury. If the person affected does not follow this regimen, he
or she is at risk of developing myositis ossificans. A patient
with myositis ossificans is recommended to begin physical
therapy once pain free. This should begin with early
mobilization and passive range-of-motion exercises, and
slowly progress to a full physical therapy program. Myositis
ossificans is rare and can spontaneously resolve.5 Nonsteroidal
anti-inflammatory drugs should be given, including
corticosteroids and indomethacin.10 These have been proven
to decrease the risk of myositis ossificans formation in
patients undergoing hip arthroplasty. Radiotherapy may be
given to high-risk patients who are experiencing severe pain
with decreased range of motion and who are not surgical
candidates.5
Excision of myositis ossificans can be performed but only to
treat symptoms: persistent pain, impaired movement creating
functional disability (e.g., decreased range of motion and
strength), or impingement on a vital structure such as a
nerve.10 Only completely ossified, mature myositis ossificans
can be surgically excised.9 If the lesion is not completely
ossified, it is still vascularized and is much more likely to
reoccur.5
Conclusion
This case study is unique since patients with myositis
ossificans do not usually present for diagnostic imaging until
calcifications have occurred in the lesion. In this case, early
and late stages were viewed in multiple modalities. The early
diagnosis was osteosarcoma, which almost resulted in surgery
to remove her leg. Myositis ossificans must be suspected if the
lesion does not resolve in 2 weeks, is slow to heal, and worsens
with time.2 Myositis ossificans is a rare but a clinically
significant pathology.
20
References
1.
Parikh J, Hyare H, Saifuddin A. The imaging features of
post-traumatic myositis ossificans, with emphasis on
MRI. Clin Radiol 2002;57(12):1058–66.
2. Sodl JF, Bassora R, Huffman GR, et al. Traumatic myositis
ossificans as a result of college fraternity hazing. Clin
Orthop Relat Res 2008;466(1):225–30.
3. Kusuma S, Lourie GM, Lins RE. Myositis ossificans of the
hand. J Hand Surg 2009;24(1):128–30.
4. Olmsted EA, Kaplan FS, Shore EM. Bone morphogenetic
protein-4 regulation in fibrodysplasia ossificans
progressiva. Clin Orthop Relat Res 2003;408:331–43.
5. Beiner JM, Jokl P. Muscle contusion injury and myositis
ossificans traumatica. Clin Orthop Relat Res
2002;403(2):110–9.
6. Fletcher CDM, Unni KK, Mertens F. World Health
Organization Classification of Tumours. Pathology and
Genetics of Tumours of Soft Tissue and Bone. Lyon:
IARC Press; 2002.
7. Kumar V, Abbas AK, Fausto N. Robbins and Cotran
Pathologic Basis of Disease, 7th edition. Philadelphia
(PA): WB Saunders Company; 2004.
8. Damron TA, Morris C, Rougraff B, et al. Diagnosis and
treatment of joint-related tumors that mimic sportsrelated injuries. Instr Course Lect 2009;58:833–47.
9. Abate M, Salini V, Rimondi E, et al. Post traumatic
myositis ossificans: sonographic findings. J Clin
Ultrasound 2011;39(3):135–40.
10. Ben Hamida KS, Hajri R, Kedadi H, et al. Myositis
ossificans circumscripta of the knee improved by
alendronate. Joint Bone Spine 2004;71(2):144–6.
www.csdms.com
Reprint
Echocardiography in the United Kingdom
Jules Hobson, BSc Hons, HNC, ONC, RCCP, BSE, SCST
About the Authors
Jules Hobson has been practising echocardiography since 1989. He served in the Royal Army
Medical Corps (British Army) as a clinical physiologist from 1988 to 2010. During that time,
he provided clinical physiology services including echocardiography and, in later years,
almost exclusively at various military and national health secondary care facilities. Services
provided over a 22-year period were overseas or within the United Kingdom and included
military operations within field hospitals such as Operation Telic in Iraq/Kuwait. He
currently works at Total Cardiology in Calgary, Alberta, as a cardiac ultrasonographer.
Correspondence may be directed to [email protected].
W
hen I was asked by Josh Fraser to write an article for eInterface, I wondered how I could benefit the readers
of this informative journal. I decided that my background may
provide an interest to those who may be thinking of taking a
sabbatical to the UK while working as an echocardiographer
or to those who may like to compare the Trans-Atlantic
working practices.
Apart from the obvious differences like driving on the right
in Canada, steering wheel on the left, and spending virtually
no time at all in traffic. Being able to cross London in 20
minutes stress free! Apart from that, there may be some
differences in how you scan or how a clinic is expected to run.
I don’t have diverse exposure or experience in Canadian labs
so I thought it best to talk about the reality over there and let
you the reader make your own comparisons.
So if you are thinking of going over the pond to England,
Scotland, Northern Ireland, or Wales this article may be a
useful read. Please read it as a guide and not an authority.
Some Useful Contacts
•
•
•
•
cardiac-output.co.uk/ – Cardiac Output is a publication
furnished with employment opportunities and includes
contact information for agencies that provide
employment.
www.bsecho.org/ – British Society of Echocardiography
is the accreditation society in Britain and can provide
information to potential applicants on required
qualifications.
www.bhf.org.uk/ – British Heart Foundation can
provide additional professional information and job
listings.
www.bcs.com/ – British Cardiovascular Society can
•
•
provide additional professional information and job
listings.
www.physiologicalmeasurements.com/ – Physiological
Measurements LTD. can provide additional professional
information and job listings.
www.canadianaffair.ca/ – Canadian Affair is a travel
company that provides relocation information and
assistance.
Where Are the Jobs?
There are different ways of acquiring a position within a lab;
they are broadly speaking as follows:
•
•
•
Agency employment
Bank staff
Part-time/full-time or casual employment
They will be in the following establishments:
•
•
•
Secondary care facility (hospital based)
Primary care facility (family doctors)
Private clinic
An application for a position as an echocardiographer will
usually require an accreditation qualification with the BSE
(British Society of Echocardiography). Although ARDMS and
or CARDUP would be advantageous, today I am not aware of
any employer that does not state the BSE accreditation or
equivalent as a prerequisite in their recruiting criteria. That is
not to say that someone who clearly has experience and holds
ARDMS or equivalent will be precluded. The web can assist
you by providing additional contacts and employment
This article was originally published in the Fall 2012 issue of the CSDMS e-newsletter e-Interface.
22
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H obs on
information with great links through the sites mentioned
above.
Agency Work
The drawback to agency work is that it can be short
term/temporary and at unpredictable locations. In addition
you may be required to show insurance coverage; however,
you can acquire this indemnity cover through the BSE. The
plus side is that it is good pay and keeps you moving so you
experience more diversity and clinical mix. You get to learn
more dialects, accents, and culture, even if you only move 20
miles down the road.
The agency will manage your administrative needs including
pay.
Primary/Secondary and Private Care Work
A primary/secondary care facility or private clinic will hold
interviews for vacancies directly.
Pay
Through the agency, pay is 40 pounds per hour which is $60
in today’s exchange rate. The agency takes its cut and gives
you that hourly rate. You can expect less from other
employers.
An experienced echocardiographer at a hospital-based clinic
will probably be paid about $50–55 an hour. Expect to be paid
more in London due to increased living expenses, known as
London weighting. So, if you secure a job as an
echocardiographer in Harley Street then pay may be as much
as $70 an hour.
Reports
All echocardiograms must have full reports complementing
the acquired images. The cardiac ultrasonographer is
responsible for the final report sent out to the referring
physician. If this is a family doctor it should be written in a
way that is non technical and useful for the GP (general
practitioner/family doctor). Irrespective of referrer, all reports
should be semi diagnostic in format and not just a technical
descriptor. Essentially the sonographer is the final reporter.
Only very occasionally will the cardiologist follow on with a
further report. This is one of the big differences between
British and North American sonographers.
Scan Times
When the government changed the working business
practices of the NHS and introduced fund holding, some time
ago, it had an impact on costings and consequently money
saving. The intention to create more efficiency with financing
and resources through fund holding has had a detrimental
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effect ultimately on patients. They seem to suffer from the
effects of this due to “fund rationing” driven by nonmedically-trained budget holders who find unethical ways to
save money. The BSE recommends a 45 minute scan time to
include complete report and for the most part this is adhered
to; however, there are clinics that will still run 25-minute slots
for echocardiograms. Although this increases the fundholder’s
revenue it compromises quality for speed which affects
ultimately both patient care and sonographer reputation. So
be aware scan times can be inappropriately reduced for
unethical reasons and you probably will not get a say in the
matter. So good luck with that!
18-Week Waiting List Initiative
In addition the new waiting list initiative of 18 weeks from
referral to treatment now means that all patients referred must
have their diagnostic tests complete within 6 weeks. This
usually means most facilities set a 2-week period for
echocardiograms to be complete. This additional pressure
that service providers are under again increases the chances
of reduced time slots for echocardiogram investigations. If the
providers fail to meet the government set deadlines they face
fines and potential loss of status of awards like foundation
trust titles. This consequently affects budget premiums when
finances are awarded annually. Managerial financial pressure
cascades down to increase the volume of completed tests to
reduce fines and retain budget supply. This affects the patient
and sonographer because the answer to achieve this is to
reduce time slots for investigations. The divisional managers
that control these concepts try to find different ways to assist
with this waiting list bottleneck and have introduced weekend
and evening clinics. So this can provide more work for agency,
casual, or bank staff. In some diagnostic services like
biomedical science a 24 hour, 7 days per week working
practice is the only answer to adhere to the 18-week initiative.
Suffice to say that combined with the government set
demands and the lack of supply of trained cardiac
sonographers nationally and locally, the discerning amongst
you should have no problem securing a position as a scanner.
Radiography and Cardiac Ultrasound
It may also be worth bearing in mind that unlike North
America, in the UK the cardiac ultrasonography field is
devolved from the radiography sector. The UK radiographers
are not involved with any type of cardiac ultrasound and it is
undertaken and administered by cardiac specialized
departments only.
Machine Types
You will probably run into the following ultrasound
23
Echocardiography in the Unite d Kingdom
machines: Phillips; IE 33; CX 50; HP 5500, 7500; GE; Vivid
Series; Siemens; Acuson; Cypress.
Reporting Packages
Some labs may still use the machine for analysis and
measurement, and still provide handwritten reports.
However, most places use the following digitally networked
reporting packages: Prism, EchoPAC, McKesson Cardiology,
Horizon Cardiology, Hand written (measure on machine).
Working with the Echo Companies
Siemens, Phillips, and GE are always looking for application
specialists to demonstrate their products around the country.
BSE Accreditation
You can find detailed information on accreditation and reaccreditation procedures at the BSE website. However, in
general to attain Adult Trans Thoracic Accreditation with the
BSE a candidate will successfully complete the following:
•
•
•
Written examination, multiple choice of ultrasound
physics and cardiac pathology in addition to an
echocardiogram video reporting section.
Log book complete with 250 cases of specified
pathologies. Majority being in the valve disease and LV
dysfunction categories. Each case must be written up as
a full report.
Video submission of 5 specific pathologies containing
full study data set and optimal image processing. Full
reports are to be attached for each study.
BSE – British Society of Echocardiography
The British Society of Echocardiography (BSE) was formed
in 1990 to promote the study and advancement of cardiac
ultrasound imaging and Doppler techniques, through
professional representation, education, and quality
benchmarking.
It is recognized in the UK and around the world as being the
preeminent organization representing the interests of
echocardiography and echocardiographers.
Having over 2,600 members, it is the largest of the
professional groups affiliated to the British Cardiovascular
Society. It also has functional links to the European
Association of Echocardiography and the European Society
of Cardiology. Although originally intended to cater primarily
for the United Kingdom and the Republic of Ireland, the
society now has members in over 30 other countries in
Europe, the Middle and Far East, North and South America,
and Africa.
Two scientific meetings are held each year: one in the summer,
24
in conjunction with the British Cardiovascular Society’s
annual conference, and the other, the BSE Annual Meeting,
in the autumn.
The society has a major interest in education and training of
physicians and echocardiographers. It has published training
guidelines and members can undertake a formal accreditation
programme of written examinations and documented clinical
experience. There are specialist options for adult transthoracic, trans-oesophageal, critical care and community
echocardiography. These accreditations are accepted as
evidence of competence by employers and those responsible
for organizing higher medical training in cardiology. In order
to encompass continuing rapid advances in ultrasound
technology and clinical applications, there is a need for
continuing professional education. This is being addressed
through a programme of regular re-accreditation.
Members receive regular BSE publications containing articles
on topical professional matters, details of meetings and
training courses, reports of overseas meetings, news items, job
vacancies, etc.
The society is a registered charity and is administered by a
president and an elected council. Members are required to
subscribe to the society's rules and code of professional
conduct.
Summary
In summary, be prepared to be the last stop between the
report and the referrer. That means adapting your report
writing between family physicians and consultants. And don’t
be surprised if echo slot times wax and wane between
different labs, as budget controllers face different pressures.
ARDMS or equivalent should be adequate to secure a position
as an echocardiographer, but have the breakdown of the
accreditation ready just in case an employer has not heard of
the qualification. Although work visas are not covered here
you can find out more at this UK government website. Enjoy
the culture, history, and diversity. And please remember you
Canadians are extremely polite, nice people, so be prepared
to stay that way.
If you have any specific questions or queries please drop me
a line at [email protected].
The Scan
Cardiac ultrasound labs within the UK subscribe to the
minimum data set required by the BSE education council, this
is outlined below and at the BSE website (TTE Minimum
Data Set: http://www.bsecho.org/tte-minimum-dataset/).
1. Overview
It is recommended that any study is accompanied by a
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H obs on
statement regarding the image quality achieved: good/fair/poor.
2. Identifying Information
The images acquired should be clearly labelled with patient
identifiers, including the following: patient name, a second
unique identifier such as hospital number or date of birth,
and identification of the operator such as initials.
3. ECG
An ECG should be attached ensuring good tracings to
facilitate the acquisition of complete digital loops. Loops
should be examined and adjusted accordingly in order to
ensure a clear representation of the image acquired.
4. Height/Weight/Haemodynamic Variables
Qualitative and quantitative evaluations of chamber size and
function are major components of every echocardiographic
examination. Chamber dimensions may be influenced by
age, gender, and body size. Therefore, consideration should
be given to the use of referenced ranges indexed to height or
body surface area. Additionally, velocities measured using
Doppler should take account of pulse rate and blood
pressure. No recommendation is made to the routine use of
indexed measurements but facilities should be available to
sonographers to measure height, weight, pulse rate, and
blood pressure at the time of an echocardiogram.
List of Abbreviations
Views
PLAX
PSAX
A4C
A2C
A5C
SC
SSN
ALAX
parasternal long axis
parasternal short axis
apical four chamber
apical two chamber
apical five chamber
subcostal
suprasternal
apical long axis or apical three
chamber
Modality
PW
CW
CFM
TDI
pulsed wave Doppler
continuous wave Doppler
colour Doppler
tissue Doppler imaging
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5. Duration
The average time required for performance and reporting of
a fully comprehensive transthoracic echocardiogram (TTE)
following these recommendations is considered to be 40–45
minutes, although it is understood that some studies may
take longer whilst others may take less time. The time taken
for a standard TTE should include time to complete a
report, and should also take into account the time taken for
patient preparation.
6. Report
No standard TTE is complete until a report is released and
is made available to the referring individual. The majority
of studies performed in a department should be reported
immediately on completion and a report available on
discharge of a patient from the echocardiography facility.
It is recognized that there are times when a review of images
and further consideration is required, for example when the
individual performing the scan does not hold proficiency
accreditation and the scan requires review prior to release,
although this should be done as soon as possible.
7. Chaperones
A standard TTE is not considered an intimate examination
but performance still requires patient sensitivity. Chaperones
should not usually be required for standard TTE but for all
TTE studies, patients should be offered a gown.
sinotubular junction
Measurement and Explanatory STJ
LVIDd/s
left ventricular
Text
LV
left ventricle
LA
left atrium
MV
mitral valve
AV
aortic valve
Ao
aorta
LVOT left ventricular outflow tract
RV
right ventricle
RA
right atrium
PV
pulmonary valve
RVOT right ventricular outflow tract
L/R PA left/right pulmonary artery
RL/RU/
LL/LUPVright lower/right
upper/left lower/left upper
pulmonary vein
TV
tricuspid valve
IVC
inferior vena cava
IVSd/s
LVPWd
PHT
RVd
VTI
PHT
RWMA
TAPSE
MAPSE
internal dimension
in diastole and systole
interventricular septal width
in diastole and systole
left ventricular posterior wall
width in diastole
pressure half-time
right ventricular cavity
diameter in diastole
velocity time integral
pressure half-time
regional wall motion
abnormality
tricuspid annular plane
systolic excursion
mitral annular plane systolic
excursion
25
Reprint
Abstract: Systematic Labeling of Twin Pregnancies
on Ultrasound
R
ecently, CSDMS Eastern region board director Sheldon
Boyde was doing some CME reading and found a very
valuable article that he felt would be beneficial to our
generalist members. Published in the International Society of
Ultrasound in Obstetrics and Gynecology (ISUOG) journal,
“Systematic Labeling of Twin Pregnancies on Ultrasound,”
by T. Dias, S. Ladd, S. Mahsud-Dornan, A. Bhide, A. T.
Papageorghiou and B. Thilaganathan, originally appeared in
Ultrasound in Obstetrics and Gynecology, Volume 38, Issue 2,
pages 130–133, August 2011 (DOI: 10.1002/uog.8990).
The abstract is reprinted here by permission of ISUOG and
their publisher Wiley, and the full article can be accessed at
the following link: http://onlinelibrary.wiley.com/doi/
10.1002/uog.8990/pdf.
Additionally, ISUOG and Wiley have advised us that this
article was selected article for a Journal Club feature in
Ultrasound in Obstetrics and Gynecology. As such, there is
also a set of slides and discussion points for the article freely
available online: http://onlinelibrary.wiley.com/journal/
10.1002/%28ISSN%291469-0705/homepage/uog_journal_
club_2011.htm (under August).
We would like to thank ISUOG for their generous cooperation in permitting the reprint of this abstract, as well
as Oliver Stirrup, the ISUOG editorial coordinator, and Paul
Cumine, Ultrasound in Obstetrics and Gynecology publishing
manager at Wiley, for their help and co-operation. We
sincerely hope all CSDMS members will derive benefit from
the recommendations the article contains.
We believe that this inter-professional co-operation will
further emphasize the continuing need for examination
guidelines that will assist all practitioners to order
appropriate diagnostic examinations and receive necessary
details from the final diagnostic reports. This will help to
ensure increased patient safety while making more effective
use of healthcare dollars.
Systematic Labeling of Twin Pregnancies on
Ultrasound
Results: A total of 416 twin pregnancies were seen during the
study period. At the 11–14-week scan 90.9% of twins were in
lateral orientation while the remainder were oriented vertically.
None of the vertically oriented twin pairs but 32 (8.5%) of the
laterally oriented twin pairs changed their presenting order
between the first and the last ultrasound scan prior to delivery.
There were 108 discordant-sex twins scanned in the third
trimester, of which the birth order changed in 20.3% that were
delivered by Cesarean section and in 5.9% of those delivered
vaginally.
Conclusion: The study demonstrates that antenatal labeling
of twins according to laterality or vertical orientation is
reliable. The technique ensures continuity of biometric
assessment from serial scans at each visit, and as such should
be adopted as the preferred method of twin labeling.
Furthermore, the use of orientation for antenatal labeling of
twins rather than assignment of a number based on proximity
to the cervix, precludes any misconception regarding which
twin will be born first and ensures that parents and
pediatricians are aware of the significant likelihood of a
peripartum switch.
T. Dias, S. Ladd, S. Mahsud-Dornan, A. Bhide,
A. T. Papageorghiou, and B. Thilaganathan
ABSTRACT
Objective: Correct labeling of twin fetuses is needed for
consistency in assigning and interpreting longitudinal scan and
prenatal screening/diagnostic results. The aim of this study was
to describe a standard method of twin labeling in the first
trimester of pregnancy and to assess the robustness of such a
technique in predicting the presenting twin in subsequent
scans and at delivery.
Methods: This was a retrospective first-trimester study of all
twin pregnancies assessed by ultrasonography at our center
between 2000 and 2010. The fetus contained in the gestational
sac closer to the maternal cervix was designated as Twin 1 and
the relative orientation of the fetuses to each other was then
defined as either lateral (left/right) or vertical (top/bottom).
In discordant-sex twins, their sex and presenting order on the
final scan prior to delivery were documented and compared
with the sex and birth order at delivery.
26
www.csdms.com
Book Reviews
Professor Robert Gill, PhD, is an Australian electronic engineer who has worked
extensively in diagnostic sonography for 30 years. His primary focus is Doppler
ultrasound. Recently retired, Professor Gill has written The Physics and
Technology of Diagnostic Ultrasound: A Practitioner’s Guide to help medical
professionals obtain a good understanding of ultrasound physics and
technology. His target audience is students enrolled in formal training
programs, and the book competes directly with texts such as Sonography
Principles and Instruments, by Kremkau, Ultrasound Physics and Instrumentation,
by Miele, and Ultrasound Physics and Instrumentation, by Hykes and Hedrick,
among others.
Professor Gill’s book is well organized and easy to read. There are 12 chapters,
starting with an introductory overview to basic mathematical concepts and
ending with a final chapter on new developments such as three-dimensional
sonography and elastography. Professor Gill’s writing is clear and concise, and
his explanations are easily understood. These are definitely strengths of the book.
Robert Gill
Key points are highlighted throughout each chapter within blue text boxes.
High Frequency Press, Sydney, Australia, 2012
There are ample graphics accompanying the text, and these are well designed,
ISBN: 9780987292100
colourful, and clear. The ultrasound images are also of high quality.
142 pages, soft cover
The balancing act with which all textbook writers struggle is deciding on the
amount of detail to provide. On one side, too little detail results in a good
introductory text but may not meet the needs of students preparing for local or
national examinations. On the other, too much detail may overwhelm students and prevent them from obtaining a good
understanding of fundamental concepts.
How well does Professor Gill’s book strike this balance? I suggest that this text comes very close to meeting that objective, but
tends toward being an introductory text. This book would serve very well in that role or, perhaps even better, as a refresher
text that could be used by practising sonographers within a clinical department. Indeed, the title, A Practitioner’s Guide,
suggests this role. At 142 pages, the amount of detail that can be provided is necessarily limited, and the author clearly admits
this.
While almost all major topics are covered, students in an ultrasound program would need more emphasis on key topics and
more in-depth explanation of those topics. Students would also benefit from more exercises and detailed answer keys. Professor
Gill does provide “Suggested Activities” at the end of each chapter, but these are somewhat limited and the answer keys do
not provide any explanation. In addition some topics are not covered at all. For example, picture archiving and communication
system (PACS), which is used almost universally these days, is not explained; nor is there any significant discussion of digital
terminology. In the chapter on hemodynamics, important concept of a tardus parvus waveform is not explored. The final
chapter does cover newer concepts such as elastography, but, again, this is done in a very cursory manner. While there are
numerous ultrasound images within the book, students would benefit from more examples, particularly to support concepts
in the earlier chapters such as the importance of frequency, attenuation, impedance mismatch, etc.
In summary, I enjoyed Professor Gill’s book and view it as a welcome addition to the current crop of ultrasound physics texts.
As an introductory or refresher text, it is superb; and depending on the program and the circumstances, it may well be a good
text for use within a formal program. This could certainly be the case if the program were able to supplement the information
in the text with more detail and emphasis. Indeed, according to the publisher’s website (www.ultrasoundbook.net), several
Australian ultrasound programs including those at Charles Sturt University and the University of South Australia have already
adopted the book as a prescribed or recommended course textbook. It will be interesting to see if that trend will continue in
North America.
Chris Harrington, CRGS, CRCS, CRVS
Program Coordinator, Ultrasound Training Program
Health Sciences Centre
Winnipeg, Manitoba
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27
B ook Re vie w
Stuart J. Hutchison, Katherine C. Holmes
Saunders, an imprint of Elsevier Inc., 2012
ISBN: 978-1-4377-0404-4
320 pages
A limited number of vascular sites in Canada are credentialed with Intersocietal
Accreditation Commission (IAC) Vascular Testing (formerly ICAVL), and one of
the major deficiencies in sites performing vascular studies is the absence of a
standardized approach and technique to these examinations. Stuart Hutchison and
Katherine Holmes’s goal in writing Principles of Vascular and Intravascular
Ultrasound was to present structured, thorough techniques and protocols to
vascular sonographers and clinicians.
Practical information, tips, and hints are presented on all areas of vascular
sonography including peripheral arterial and venous, cerebrovascular, and
abdominal studies. A unit covering intravascular sonography has even been
included. Each chapter contains practical key points and “scanning pearls” to assist
the sonographer in producing quality images while avoiding artifacts. Techniques
are well outlined, and scanning protocols and diagnostic criteria are summarized
in both table format and point form within their related chapter. IAC Vascular
Testing standards for accreditation are summarized. Disease entities are discussed
and characterized, and plenty of high-quality anatomy and sonographic images are
included to illustrate and reinforce material covered in each chapter.
Each chapter is presented in a consistent format, making this text an excellent quick
reference guide for anyone performing and/or teaching vascular sonography;
however, students may find the information on each topic too abbreviated as they
often require fuller explanations for understanding.
In summary, this is an excellent reference book for any site performing vascular
studies: well-organized, concise, and clearly written. However, the highlight of this
book is definitely the superior images, illustrating so many of the vascular findings
and pathologies discussed.
Verna Maschio, BTech, CRVS, CRCS, CRGS,
Vascular Instructor
NAIT Diagnostic Medical Sonography Program
The Safe Use of Ultrasound in Medical Diagnosis, Third Edition, is published by the
British Institute of Radiology with the cooperation and support of the British
Medical Ultrasound Society, the European Federation of Societies for Ultrasound
in Medicine and Biology, and the National Physical Laboratory (UK).
The very best place to start with this review is simply to reprint the preface Dr. Gail
ter Haar MA, PhD, DSc, has written as it certainly best describes the aims of this
new reference text and the actual results that have been achieved.
Edited by Gail ter Haar
British Institute of Radiology, 2012
ISBN: 978-0-905749-78-5
166 pages
28
It is an oft observed fact that safety sessions at congresses are seldom well attended,
and that the sneaky insertion of a lecture on a safety-related topic into specialist
session may be regarded by some as the opportunity for a coffee break, but the fact
remains that the safe use of diagnostic ultrasound is the responsibility of the person
conducting the scan. In order for appropriate judgements to be made, the
practitioner must be knowledgeable about the hazards and risks involved in
performing an ultrasound examination, and this book aims to provide this basic
knowledge. Leading world experts in the fields of ultrasound physics, biology,
standards and epidemiology have contributed chapters, written at a level that is
intended to be accessible to everyone, whatever their background. Each chapter is
extensively referenced to allow readers to delve deeper into a topic of interest if
they so wish.
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B ook Re v ie w
Ultrasound has an unprecedented safety record, but that
does not mean that we can be cavalier about its use. What
is evident from information presented in this book is that
there are many gaps in our knowledge about ultrasound
safety. Many of the studies on which we base our
information and recommendations have been carried out
in animal models whose relevance to the human is not
fully understood, ultrasound exposure conditions which
have little relevance to diagnostic ultrasound pulses, or on
scanners that are no longer in common clinical use. While
this is useful information, it must always be interpreted
with care.
It must be remembered that “absence of evidence of harm
is not the same as absence of harm” (Salvesen et al., 2011).
It is never possible to prove a negative; all we can do is to
use increasingly more sensitive tests and assays. It is for
these reasons that professional societies continue to
support committees whose remit is to inform and educate
users about the safe use of ultrasound, so that ultrasound
imaging can continue to enjoy its reputation as a
technique whose benefits far outweigh any potential risk.
The Safe Use of Ultrasound is a well-written book that,
although quite detailed, is suitable for all members of the
ultrasound community. There are excellent sidebar notes on
each page that simplify the concepts discussed without the
detail contained in the body of the text. These allow for
quick reference to the subject matter as you proceed through
the book. Diagrams, illustrations, and tables are well
referenced in the text and help to clarify the information
discussed. An exceptional list of references follows each
chapter, allowing the reader to further explore topics or
garner valuable explanations of material that is not well
understood. While the material will stretch some, it is well
presented in a logical format with rational subject
development, leading the reader to understand the
standards, methods, guidelines, and recommendations that
are discussed.
As I am an older sonographer, I think I had lost a firm touch
with many of the issues raised, along with parts of the
foundational physics that so many of us tend to forget over
time. Of particular interest to me as a vascular sonographer
was the chapter on non-thermal effects of ultrasound with
the introduction of ultrasound contrast agents. This gave
me pause to think about our examination protocol,
examination duration, and machine settings.
Well highlighted is the need for new research, knowledge,
and due diligence on the part of all practitioners in view of
the changes and advancements in technology such as multicrystal probe technology, colour pulsed Doppler, tissue
www.csdms.com
harmonic imaging, pulse coding, and contrast-enhanced
imaging, to mention a few. Many answers to questions and
the foundations for many new questions and potential
research are developed in this text. The information causes
us to ask, are the old safety measurements, assumptions on
the generally accepted safety of the modality, and the current
safety measures recommended and employed adequate to
protect our patients?
Many sonographers young and old will find themselves
feeling the way I did about forgotten or neglected machine
safety concerns. This is a good eye opener and very
interesting reading for all practitioners. It will make you
think and closely reflect on your own daily practices. That
can only be a good thing.
I highly recommend this text to all members of the
sonography community.
Kim G. Boles, CRGS, CRVS, FCSDMS
Editor-in-Chief
Canadian Journal of Medical Sonography
EDUCATION FOR THE MEDICAL
PROFESSION SINCE 1985
“STUDY WHILE YOU WORK”
HOME STUDY COURSES
IN
GENERAL ULTRASOUND
BREAST SONOGRAPHY
MUSCULOSKELETAL
ECHOCARDIOGRAPHY
VASCULAR TECHNOLOGY
*MOST COURSES ARE WORTH 30 CME CREDITS*
www.burwin.com
1-877-625-5297 (Central Time)
1-800-322-0737 (Atlantic Time)
29
SUNRIDGE DIAGNOSTIC IMAGING
Barrie L. Steed MD // David Lyons MD // Shaunna Menard MD
2133 - 36 Street NE - Calgary AB T1Y 5S3
P. 403. 568. 7676
w w w . S D I u l t r a s o u n d . c o m
F. 403. 568. 7677
CALGARY - ALBERTA
4 Day Work Week - Full Time hours by extended hours daily.
We are an office practice dedicated solely to diagnostic sonographic imaging. We are
staffed with three enthusiastic radiologists dedicated to the excellence of sonographic
diagnosis.
This is a practice with a wide diversity of exams. Along with general ultrasound exams, we
serve as an emergent/urgent imaging center which expands the level of pathology
encountered. We do extensive vascular work including pre and post op surveillance for the
vascular surgeons of Calgary. We specialize in musculoskeletal and MSK intervention
including alcohol sclerosis for plantar neuromas.
The highest level of sonographic diagnostic excellence occurs with exceptional radiologist
supervision, education and staff compatibility. We foster a staff of technologists and
radiologists that are cordial, enthusiastic, and enjoy a team environment. Our highest
priority is in patient comfort and in contributing to an accurate final diagnosis.
We are looking for a technologist who has an eager attitude to learn and work as a team
member; who can confidently perform routine abdomen, pelvic, obstetric and small part
exams. Any skill in vascular and musculoskeletal exams is welcomed but not a
prerequisite. Opportunity to expand skills through onsite teaching and, support for other
learning. we have 12 ultrasound machines with new Siemens Sequoia 2000, GE Logiq E9.
lf you love ultrasound, you should love our practice.
e-mail Dr. Steed - [email protected]
SUNRIDGE DIAGNOSTIC IMAGING
Barrie L. Steed MD // David Lyons MD // Shaunna Menard MD
P. 403. 568. 7676
w w w . S D I u l t r a s o u n d . c o m
2133 - 36 Street NE - Calgary AB T1Y 5S3
F. 403. 568. 7677
DEDICATED VASCULAR SONOGRAPHER REQUIRED Calgary
Required by a dedicated OFFICE ultrasound practice. Never on call.
ENJOY a 4 Day Work Week with Full Salary by extended hours daily 7:00 to 4:30. Choose
to work extra hours on Fridays. Benefits are competitive.
3 RADIOLOGISTS Dedicated to ultrasound with intense RAD SUPERVISION
We perform outpatient pre and post op Vascular Surveillance for the Peripheral Vascular
Surgeons of Calgary
VASCULAR STUDIES
Endostents and other Vascular Stents, all varieties of Grafts, Carotids, Thoracic Outlet and
Popliteal lmpingements, Arm A-V Fistulas; Renal, Celiac and Superior Mesenteric Artery
Stenosis; Leg Insufficiency Studies, Arm and Leg artery and vein exams, Variety of
Exertional Compartment Syndromes, Groin Pseudo Aneurysms and Fistulas.
We examine Pre and Post Transplant Renal and Liver exams and TIPS Surveillance.
All performed on - Siemens Sequoia 2000, GE Logiq E9, ATL 5000. Onsite training for less
familiar studies. lmportant to us is the willingness of staff members to associate and
communicate well with one another. Our small practice nurtures a comradery and sense
of belonging.
ARDMS or CARDUP registration with active status is required. RVT not a
requirement.

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