Transient intussusception - What the sonographer needs to know.

Intussusception is typically considered an acute emergency; however, the increased utilisation of medical imaging has revealed that intussusceptions can also be transient, asymptomatic and possibly physiologic. Sonographers should be aware of three categories of intussusceptions: (i) persistent intussusceptions resulting in acute abdomen and requiring urgent intervention, (ii) transient symptomatic intussusceptions which may be amenable to a 'wait-and-see' strategy and (iii) transient asymptomatic intussusceptions which almost always involve the small bowel. In particular, the incidental discovery of enteroenteric intussusceptions in children should not be confused with acute pathology. In adults, sonographers should be mindful of the frequent presence of pathological lead points and further investigations may be warranted. In this literature review, we provide an overview of transient intussusceptions, highlight important differences between children and adults and describe sonographic appearances of various intussusceptions and their mimics.

The value of evaluating the abdominal aorta in patients <50 years of age presenting for abdominal ultrasound.

INTRODUCTION: Practitioners of US routinely include a survey of the abdominal aorta during abdominal US in accordance with international guidelines. Such practice is of uncertain value in younger patients. METHODOLOGY: This study was a retrospective review of 2000 abdominal US examinations which included visualisation of the aorta in patients <50 years of age. Patient demographics and referral details were recorded, and US images and reports were reviewed for the presence of aortic and periaortic pathology. RESULTS: The most common indications for US were abdominal pain (1337, 44%), deranged liver function tests (453, 15%), nausea and/or vomiting (229, 8%), elevated inflammatory markers (146, 5%), pancreatitis (134, 4%) and pyrexia (127, 4%). Fewer than half (977, 49%) of the reports contained a comment regarding the aorta. Aortic pathology was reported in 2 (0.1%) cases. Both were reported as aortic ectasia and both represented a false-positive diagnosis. One male patient had a known abdominal aortic aneurysm with endovascular aortic repair. No new aortic aneurysms were found. All cases of atherosclerotic disease were ignored, and none were reported. Periaortic pathology was encountered on 1 patient, but this was known. No case of new periaortic pathology was detected. CONCLUSION: Routine and indiscriminate imaging of the abdominal aorta during abdominal US in patients <50 years of age is not evidence based. No new case of abdominal aortic aneurysm or new para-aortic pathology was detected, all cases of atherosclerosis were ignored, and two false-positive diagnoses of aortic ectasia were made.

Experimental Investigation of Suitable Cutting Conditions of Dry Drilling into High-Strength Structural Steel.

Dry machining is one of the main ways to reduce the environmental burden of the machining process and reduce the negative effect of the cutting fluid and aerosols on operators. In addition, dry machining can reduce overall machining costs and, in the case of large workpieces, reduce the extra work associated with removing residual cutting fluid from the workpiece and adjacent area. For high-strength structural steel products, it is typical to drill holes with larger diameters of around 20 mm. Therefore, this work is devoted to the investigation of the dry drilling process carried out on a workpiece made of S960QL steel with a helical drill with a diameter of 21 mm. The aim was to find suitable cutting conditions for dry drilling with regard to process stability and workpiece quality. An experiment performed with a coolant served as a comparison base. A dry drilling experiment was performed with cutting speeds from 30 to 70 m·min-1 and feeds from 0.1 to 0.3 mm·rev-1, and with the results of this experiment, the same experiment with flood cooling was performed. During the drilling process, spindle torque values were recorded using the indirect spindle current recording method. The macroscopic chip morphology was studied to understand the cutting process. The chip thickness ratio was measured, as well as the maximum diameter of spiral chips. On the final workpiece, the qualitative and dimensional parameters of the holes were evaluated, such as the diameter, cylindricity and surface roughness, depending on the change in the cutting conditions and cutting environment. Evaluation of the obtained data led to the following conclusions. When drilling the S960QL material, there is only a very small increase in the drilling torque during dry drilling compared to drilling with cutting fluid. The increase in friction demonstrated by the chip thickness coefficient is significant. The influence of the environment on the dimensional accuracy showed a tendency for a slight increase in the holes' diameters during dry machining. In comparison, the cylindricity of the dry-drilled holes shows a lower deviation than the holes drilled with cutting fluid. The surface roughness of the holes after dry drilling is affected by the increased friction of the outgoing chips, despite the resulting parameters being very good due to the drilling technology standards. This work provides a comprehensive view of the dry drilling process under defined conditions, and the results represent suitable cutting conditions to achieve a stable cutting process and a suitable quality of drilled holes.

Ultrasound morphological patterns of testicular tumours, correlation with histopathology.

INTRODUCTION: Ultrasound (US) plays a key role in the detection of testicular tumours. However, reliable characterisation of testicular tumours with US is difficult. The purpose of this study was to investigate the morphological patterns of testicular tumours as seen on modern US imaging and correlate these with histology. METHODS: The imaging features of 50 testicular tumours were analysed and compared with histology. The US appearance was categorized into 15 distinct morphological patterns. RESULTS: Patient's age ranged from 0.5 to 85 years. Of the 50 tumours in our series, 49 were malignant. Nearly half of the malignancies were seminomatous germ cell tumours (SGCTs). Tumours ranged in size from 10 to 130 mm with considerable overlap of size between tumours of different histological type. Even small (10 mm) tumours in our cohort were malignant. SGCTs demonstrated a narrower range of morphological appearances than non-seminomatous germ cell tumours (NSGCTs). Calcification was common in both SGCT and NSGCTs. Multicomponent cystic-solid appearance was only seen in NSGCTs. CONCLUSION: The differentiation of testicular tumours with US continues to be challenging. In this paper, we have demonstrated the diverse morphological patterns of testicular neoplasms and have proposed the study of tumour morphological features as a promising research direction.

Do radiologists need to review abdominal ultrasound examinations reported as 'normal' by the sonographer?

INTRODUCTION: Sonographers demonstrate a high standard of diagnostic performance and work with a considerable degree of professional independence. In Australasia, sonographers typically generate a preliminary report which is reviewed by the radiologist who issues a final report. The aim of this study was to determine whether radiologist's review is required in cases reported as normal by the sonographer. METHODS: This study was a retrospective review of 1000 abdominal US examinations considered normal by sonographers that were subsequently reported by radiologists. Any findings reported by radiologists that were not reported by sonographers were analysed and separated into errors or discrepancies according to commonly accepted definition. RESULTS: The 1000 abdominal examinations included 244 complete abdominal, 200 hepatobiliary, 506 urinary tract and 50 other abdominal examinations. Patients' age ranged from < 1 to 94 years (mean = 35 years, median = 32 years). US examinations were performed by any one of 14 sonographers with 1-21 years (mean = 6 years, median = 7 years) of clinical experience. Two diagnostic errors were made by sonographers and two errors by radiologists. In no single case did the radiologist uncover a case of an acute or serious illness, illness requiring admission or urgent clinical review, nor did the radiologist identify the cause for the presenting symptoms. Eighteen discrepancies were found, but these were of trivial nature and most were rated by specialist clinicians as irrelevant. CONCLUSION: Sonographers are accurate in distinguishing normal abdominal US examinations. The involvement of a radiologist in a second reading of normal abdominal US examinations is unnecessary.

Visualisation of focal renal lesions on ultrasound: A review of 518 lesions with contrast CT correlation.

INTRODUCTION: Conventional ultrasound (US) is a common imaging investigation of the kidneys; however, the current diagnostic performance of US in the visualisation of focal renal lesions is unknown. METHODS: This study was a retrospective sequential review of 518 focal renal lesions (FRLs) in 200 patients aged 50 years or older who received an US of the kidneys followed by contrast-enhanced computed tomography (CECT). RESULTS: Patient's age ranged from 50 to 94 years. The majority were hospital inpatients. 518 FRLs were identified on CECT ranging from 3 to 165 mm (median 8 mm). The majority of FRLs (96.1%) were benign. The visualisation rate of FRLs on US was size-dependent: <5 mm, 10.2%; 5-9 mm, 22.3 mm; 10-14 mm, 48.0%; 15-19 mm, 82.1%; and 20-24 mm, 100%. The visualisation of simple cysts was 49.1% and hyperdense lesions 81.8%. Follow-up was available on 58% of lesions. Benign lesions generally remained stable. Seven patients had concerning heterogeneous hyperdense masses on CECT, and US had visualised six of these (85.7%). CONCLUSION: Visualisation of FRLs is size-dependent. High rate of visualisation is achieved once the lesion exceeds 15 mm in size. Small FRLs are associated with a low rate of visualisation on ultrasound; however, they are rarely concerning. Hyperdense lesions on CECT that carry high suspicion of malignancy are associated with a high rate of US visualisation.

How to set-up and perform contrast-enhanced ultrasound.

Contrast-enhanced ultrasound (CEUS) is an important part of current ultrasound imaging practice. Sonographers, radiologists and other sonologists should consider CEUS as a standard tool in the diagnostic toolbox of ultrasound and utilise it liberally to solve a wide range of imaging problems whilst reducing the need to resort to CT or MRI. Setting up a CEUS service is within easy reach of all motivated practitioners. The initial process requires assessment of the demand for CEUS, ensuring staff readiness, preparing administrative processes and obtaining CEUS supplies. The CEUS examination includes gaining informed consent, ensuring authorisation to administer contrast agent (preferably by means of a standing order), conventional pre-scan of the area of interest, insertion of a peripheral IV cannula, preparation of the contrast agent, initiation of the contrast imaging mode, administration of the contrast agent, performance of the examination and aftercare. A number of other important considerations are discussed including cannulation and IV certification, scopes of practice for sonographers performing CEUS, contrast dosing, scheduling, training, interpretation, reporting and quality control.

The value of surveying the kidneys during pelvic ultrasound examinations.

INTRODUCTION: Pelvic ultrasounds are commonly performed for various clinical indications in female patients presenting to the hospital. A survey of the kidneys is routinely included as part of the examination, but there is limited justification for their inclusion in the assessment of every female presenting for a pelvic ultrasound. METHOD: We examined the utility of surveying the kidney ultrasound during pelvic ultrasonography by reviewing the records of 1009 pelvic ultrasound examinations in 1000 women. RESULTS: In total, 46 incidental findings were identified, but 91% of these were clinically inconsequential. Only four patients had incidental findings of high clinical priority requiring specialist treatment. Of these, two patients were symptomatic and had urinary tract obstruction due to stones. The other two patients harboured asymptomatic renal cell carcinomas. The overall incidence of renal incidental findings of high clinical priority in asymptomatic patients was two in 1009 examinations (1999 kidneys). CONCLUSION: Indiscriminate uncritical screening of the kidneys in women presenting for pelvic ultrasound is not evidence-based and represents a low-yield examination with extremely low rate of incidental findings of clinical significance.

Do current Philips ultrasound systems exceed the recommended safety limits during routine prenatal ultrasounds?

BACKGROUND: Biological safety of ultrasound is a complex and nuanced subject that is poorly understood by ultrasound users. Little is known about the acoustic output and thermal index levels during the routine use of modern ultrasound machines in prenatal scanning. METHODOLOGY: This study was a retrospective review of thermal index (TI) values encountered during 300 prenatal ultrasound examinations (100 in each trimester) performed on any one of 13 Philips Epiq 7 or Epiq 5 systems, representing approximately 106.5 h of real-time scanning. The TI levels were compared to three international guidelines on the biological safety of ultrasound. RESULTS: The routine use of current Philips systems was associated with low TI levels. Of the 300 examinations reviewed, virtually all were compliant with the BMUS and Nelson safety guideline. Whether the examination was compliant with the WFUMB guideline is open to interpretation. The highest level of TI encountered was 1.1. In no instance did the TI level incur into the 'not recommended' range or into a range where specific user action was required to reduce the TI within 1 min. The most frequent action associated with TI > 0.7 was the use of M-mode to document the fetal heart rate. In the four instances where TI peaked at 1.1, 3 were associated with the use of M-mode and one with B-mode. Spectral Doppler was not implicated in high TI levels. These results are surprising and open up a range of opportunities for future study.

The clinical ultrasound report: Guideline for sonographers.

The reporting roles of sonographers in Australasia vary considerably. A large number of sonographers already routinely produce formal reports, while others are moving into clinical ultrasound roles where reporting is expected. This article summarises the best practice in reporting of ultrasound examinations based on international literature and addresses key topics including report structure, clinical content, style and language. Numerous examples and sample phrases are provided and common pitfalls are discussed.

The clinical implications of adopting new criteria for the grading of internal carotid artery stenosis.

INTRODUCTION: A patient's eligibility for carotid endarterectomy (CEA) is determined primarily by the degree of carotid stenosis detected on duplex ultrasound. The Australasian Society for Ultrasound in Medicine (ASUM) criteria are widely used to grade carotid stenoses in many practices throughout Australasia. METHODS: We sought to investigate the potential impact on the grading of carotid artery stenosis if practitioners switched from the ASUM criteria to the United Kingdom's joint recommendation (UKJR) criteria by reviewing 100 patients with a haemodynamically significant carotid artery stenosis. RESULTS: We found agreement between the criteria in 100% of cases for stenoses <50%, in 80% of cases for stenoses 50-69%, in 89% of cases for stenoses ≥70% and in 100% of cases for stenoses ≥80%. While there was variation in grading of stenoses in 16% of cases, reclassification resulted in no change in the number of patients eligible for CEA. The UKJR guideline enabled more precise categorisation of haemodynamically significant stenosis into deciles. DISCUSSION: Because the UKJR guideline is more comprehensive, we believe that adopting this guideline would enable the ultrasound practitioner to grade carotid stenoses more precisely, better understand the nuances of carotid duplex imaging and more successfully navigate and interpret complex carotid examinations, without impacting the number of patients eligible for CEA.

The diagnostic performance of ultrasound in the detection of ectopic pregnancy.

BACKGROUND: Accurate diagnosis of ectopic pregnancy is essential in reducing maternal mortality and morbidity. Transvaginal ultrasound (TVUS) is the accepted imaging modality of choice for the diagnosis of ectopic pregnancy (EP). AIMS: To assess the effectiveness of transvaginal ultrasound (TVUS) in the detection of EP in consecutive women presenting for ultrasound to a radiology department with a clinical suspicion of EP. METHODS: Retrospective analysis of 585 women presenting for TVUS over a 2.5-year period was performed. Women were classified as having a confirmed EP on the basis of surgery and histology. Women with a suspected EP who were treated medically or expectantly were also included. RESULTS: Eighty-seven women had a confirmed EP and 29 women had a suspected EP. The sensitivity and specificity of ultrasound for the detection of confirmed EP was 88.5% and 96.5% on the initial TVUS and 93.1% and 95.7% with an additional rescan. CONCLUSION: TVUS in the radiology setting of a tertiary hospital has excellent diagnostic performance for the detection of EP.

Retrospective audit of patients presenting for ultrasound with suspicion of appendicitis.

Purpose: To assess the ultrasound performance on patients presenting to Waikato hospital ultrasound department with a clinical suspicion of appendicitis. Method: This was a retrospective audit of 309 patients presenting to our department within business hours with clinical suspicion of appendicitis between September 2012 and March 2014. The patients were evaluated by operators of mixed experience. The scan reports, surgical reports, histology and discharge summaries were reviewed. Results: The overall sensitivity of ultrasound on detecting appendicitis was 50%, the specificity was 98.5%. The positive predictive value and the negative predictive value were 84% and 92.6% respectively. The appendix was visualised in 14% of the true positive cases. When the appendix was visualised, the sensitivity and specificity of ultrasound was 95.2% and 69.2% respectively. Conclusion: The sensitivity of ultrasound to appendicitis was lower than that commonly reported in the literature, but on a par with a recent audit from another tertiary hospital in New Zealand.