Ultrasound Interpretation Research Articles

269: Analysis of Lawsuits Filed Against Emergency Physicians Over Bedside Emergency Ultrasound Examination Performance or Interpretation Over a 20-Year Period

Recent increase in ultrasound (US) use by emergency physicians has led to concern regarding litigation from missed diagnosis on bedside emergency US. We sought to define the extent of lawsuits filed against emergency physicians over bedside emergency US performance and interpretation during the last 20 years nationwide.

Cranial ultrasounds: Are they reliable?

Most newborn intensive care unit centers perform serial cranial ultrasound evaluations early in the course of hospitalization for premature infants and often a follow–up examination is done at 4-6 weeks of age. These evaluations are done to document the presence of intracranial hemorrhage, to guide choice of therapies that may exacerbate risk of further hemorrhage, and to counsel families about neurodevelopmental outcomes. These data are also often used for benchmark comparisons. There have been few studies that investigated the reliability or accuracy of these findings, and yet randomized controlled trials in neonatal patients and interventional studies frequently include presence and degree of intraventricular hemorrhage (IVH) in their outcome data. Hintz et al describe the interobserver reliability and accuracy of the interpretation of cranial ultrasounds in premature infants. The authors took advantage of a large collection of ultrasound examinations performed as part of the NICHD Neonatal Network’s trial on the safety of inhaled nitric oxide. This was an important outcome variable because early case reports had suggested a potential risk of IVH; however, the trial found no differences in the rates of severe IVH or periventricular leukomalacia (PVL) between treated infants and controls. Scans were read by central readers who were board-certified radiologists and employed a structured data instrument. The study demonstrated a high degree of agreement between “local readers” and the central “experts.” This agreement was best for Grades 3 and 4 IVH, less so for periventricular leukomalacia, and poor for milder degrees of IVH. These observations are reassuring but also raise a note of caution. There is a strong association between severe degrees of IVH and poor neurodevelopmental outcome. The strength of those associations is less for milder degrees of bleeding. Given the differences in interpretation between the experts and the home-based readers for milder degrees of IVH, care should be exercised by clinicians in counseling families regarding the association between cranial ultrasound findings and neurodevelopmental prognosis. The study also raises a note of caution for investigators who use cranial ultrasound findings as a study outcome. Future designs should employ strategies to confirm the reliability of the ultrasound findings. Likewise, additional data of this kind on inter-observer reliability of intracranial pathology from computerized tomography or MRI evaluations is needed. All that said, our understanding of the reliability of cranial ultrasound examinations is advanced by this report. Interobserver Reliability and Accuracy of Cranial Ultrasound Scanning Interpretation in Premature InfantsThe Journal of PediatricsVol. 150Issue 6PreviewTo assess interobserver reliability between 2 central readers of cranial ultrasound scanning (CUS) and accuracy of local, compared with central, interpretations. Full-Text PDF

Interobserver Reliability and Accuracy of Cranial Ultrasound Scanning Interpretation in Premature Infants

To assess interobserver reliability between 2 central readers of cranial ultrasound scanning (CUS) and accuracy of local, compared with central, interpretations. The study was a retrospective analysis of CUS data from the National Institute of Child Health and Human Development (NICHD) trial of inhaled nitric oxide for premature infants. Interobserver reliability of 2 central readers was assessed with kappa or weighted kappa. Accuracy of local, compared with central, interpretations was assessed by using sensitivity and specificity. CUS from 326 infants had both central reader and local interpretations. Central reader agreement for grade 3/4 intraventricular hemorrhage (IVH), grade 3/4 IVH or periventricular leukomalacia (PVL), grade of IVH, and degree of ventriculomegaly was very good (kappa = 0.84, 0.81, 0.79, and 0.75, respectively). Agreement was poor for lower grade IVH and for PVL alone. Local interpretations were highly accurate for grade 3/4 IVH or PVL (sensitivity, 87%-90%; specificity, 92%-93%), but sensitivity was poor-to-fair for grade 1/2 IVH (48%-68%) and PVL (20%-44%). Our findings demonstrate reliability and accuracy of highly unfavorable CUS findings, but suggest caution when interpreting mild to moderate IVH or white matter injury.

The Problem of Forced Insurance Coverage on Prenatal Ultrasound

On January 2007, the government announced its policy "Total Care of Pregnancy and Delivery; National Responsibility on Pregnancy and Delivery." While the policy is welcome, there are currently two problems with the plan. First, there is no provision for high-risk pregnancy. Second, the government's plan to cover the expenses on prenatal ultrasound is limited to payments for obstetrics only. The reasons why the government should not be so hasty in forcing its plan to cover current co-payment on prenatal ultrasound are the followings: first, physicians' techniques in making proper ultrasound images and doctors' abilities of ultrasound image interpretation cannot be standardized. Second, the types of ultrasound are diverse: conventional ultrasound, level II ultrasound, 3D ultrasound, doppler ultrasound, portable ultrasound, etc. Third, ultrasound fees are also charged by radiology, internal medicine, and other clinical fields. It raises a question of fairness if the government covers ultrasound expenses for obstetrics and gynecology alone. Lastly, the current medical fees are computed only by the Health Insurance Review Agency (HIRA) without consultation with medical suppliers. Furthermore, there is no systematic principle for estimating medical fees. The Korean Society of Obstetrics and Gynecology proposes alternative plans: "Total Care of Pregnancy and Delivery" should include support for high-risk pregnancy, support for prenatal care fees except those for sonography, and payments of cash bounties to mothers upon delivery of their babies. After sufficient government budget is secured, harmonious arrangements between the government and the clinical fields that use ultrasound should be made for the systematic computation of ultrasound fees.

P11.16: Prenatal diagnosis of uterine rupture in a patient with previous Cesarean section: lack of per‐operative correlation

We describe here the case of a patient with previous Cesarean section presenting at 32 weeks' a clinical suspicion of uterine rupture. Ultrasound examination was realized by our tertiary care center referee. We observed a complete disruption of the myometrial wall in the uterine scar zone. A Cesarean delivery was decided, and despite a careful examination of both sides of the uterine wall before and after hysterotomy, no dehiscence was seen. Ultrasound examination of Cesarean scar has been described as a new technique for risk prediction of uterine rupture. Its reproducibility has not been clearly established. This case raises the question of ultrasound interpretation accuracy in the evaluation of previous uterine scar.

Liver fibrosis identification based on ultrasound images captured under varied imaging protocols

Diagnostic ultrasound is a useful and noninvasive method in clinical medicine. Although due to its qualitative, subjective and experience-based nature, ultrasound image interpretation can be influenced by image conditions such as scanning frequency and machine settings. In this paper, a novel method is proposed to extract the liver features using the joint features of fractal dimension and the entropies of texture edge co-occurrence matrix based on ultrasound images, which is not sensitive to changes in emission frequency and gain. Then, Fisher linear classifier and support vector machine are employed to test a group of 99 in-vivo liver fibrosis images from 18 patients, as well as other 273 liver images from 18 normal human volunteers.

73: Ultrasonographic Appearance of the Uterine Cavity One Year Following Novasure Endometrial Ablation

Study Objective1) To prospectively evaluate the appearance of the uterine cavity in patients who had a NovaSure endometrial ablation for dysfunctional bleeding at least one year post ablation. 2) To correlate the findings of the ultrasound with the bleeding patterns (amenorrhea or degree of bleeding) and findings obtained during hysteroscopy in order to better understand ultrasound image interpretation in patients post NovaSure ablation.DesignProspective, single arm study.SettingSacred Heart Hospital, University of Montreal, Canada.PatientsFifty randomly selected patients with a history of NovaSure endometrial ablation with at least 12 months follow-up.InterventionTransabdominal and endovaginal ultrasound performed by experienced radiologist. Diagnostic hysteroscopy and endometrial biopsy.Measurements and Main ResultsDegree of menstrual bleeding and satisfaction with the NovaSure endometrial ablation was recorded. Ultrasonographic evaluation of the uterine cavity post ablation is feasible and when combined with diagnostic hysteroscopy can be used to predict and evaluate patients who present with abnormal bleeding. Adequate understanding of the specifics in appearance of the uterine cavity post-ablation is imperative due to a potential misinterpretation of the ultrasonographic image of the endometrial stripe with the fibrotic layer that is formed post ablation. Homogeneity of the endometrial line should also be taken into account when deciding to pursue the investigation with endometrial sampling and hysteroscopic evaluation.ConclusionEvaluation of the endometrium 12 months post NovaSure ablation is a good method of evaluation for sound development of the course of treatment in patients presenting with post-ablation bleeding. Study Objective1) To prospectively evaluate the appearance of the uterine cavity in patients who had a NovaSure endometrial ablation for dysfunctional bleeding at least one year post ablation. 2) To correlate the findings of the ultrasound with the bleeding patterns (amenorrhea or degree of bleeding) and findings obtained during hysteroscopy in order to better understand ultrasound image interpretation in patients post NovaSure ablation. 1) To prospectively evaluate the appearance of the uterine cavity in patients who had a NovaSure endometrial ablation for dysfunctional bleeding at least one year post ablation. 2) To correlate the findings of the ultrasound with the bleeding patterns (amenorrhea or degree of bleeding) and findings obtained during hysteroscopy in order to better understand ultrasound image interpretation in patients post NovaSure ablation. DesignProspective, single arm study. Prospective, single arm study. SettingSacred Heart Hospital, University of Montreal, Canada. Sacred Heart Hospital, University of Montreal, Canada. PatientsFifty randomly selected patients with a history of NovaSure endometrial ablation with at least 12 months follow-up. Fifty randomly selected patients with a history of NovaSure endometrial ablation with at least 12 months follow-up. InterventionTransabdominal and endovaginal ultrasound performed by experienced radiologist. Diagnostic hysteroscopy and endometrial biopsy. Transabdominal and endovaginal ultrasound performed by experienced radiologist. Diagnostic hysteroscopy and endometrial biopsy. Measurements and Main ResultsDegree of menstrual bleeding and satisfaction with the NovaSure endometrial ablation was recorded. Ultrasonographic evaluation of the uterine cavity post ablation is feasible and when combined with diagnostic hysteroscopy can be used to predict and evaluate patients who present with abnormal bleeding. Adequate understanding of the specifics in appearance of the uterine cavity post-ablation is imperative due to a potential misinterpretation of the ultrasonographic image of the endometrial stripe with the fibrotic layer that is formed post ablation. Homogeneity of the endometrial line should also be taken into account when deciding to pursue the investigation with endometrial sampling and hysteroscopic evaluation. Degree of menstrual bleeding and satisfaction with the NovaSure endometrial ablation was recorded. Ultrasonographic evaluation of the uterine cavity post ablation is feasible and when combined with diagnostic hysteroscopy can be used to predict and evaluate patients who present with abnormal bleeding. Adequate understanding of the specifics in appearance of the uterine cavity post-ablation is imperative due to a potential misinterpretation of the ultrasonographic image of the endometrial stripe with the fibrotic layer that is formed post ablation. Homogeneity of the endometrial line should also be taken into account when deciding to pursue the investigation with endometrial sampling and hysteroscopic evaluation. ConclusionEvaluation of the endometrium 12 months post NovaSure ablation is a good method of evaluation for sound development of the course of treatment in patients presenting with post-ablation bleeding. Evaluation of the endometrium 12 months post NovaSure ablation is a good method of evaluation for sound development of the course of treatment in patients presenting with post-ablation bleeding.

STATIC AND REAL-TIME 3D SONOGRAPHY OF THE TEMPOROMANDIBULAR JOINT

Purpose: The specificity, sensitivity and accuracy of 2D temporomandibular joint (TMJ) sonography for the assessment of disk dislocation vary considerably in the literature. This difference may depend upon the quality of the ultrasound equipment, the frequency, observer experience and interpretation. Therefore static and real-time 3D sonography was introduced to assess additional information from a third dimension.

Fat or Fiction

Purpose: Hepatic steatosis (or fatty liver) is common in the United States and frequent in patients with chronic hepatitis C (CHC), where it may lead to disease progression and hinder response to HCV therapy. Therefore, it is important to recognize fatty liver. Liver biopsy confirms the degree of fat, inflammation and fibrosis, but is invasive. Hepatic ultrasound is well-tolerated, non-invasive and provides good information. It is commonplace to trust the results of an ultrasound suggesting fatty liver, but there are conflicting reports on its accuracy. Therefore, we retrospectively examined liver biopsies and compared the histologic results to the ultrasound interpretations. We selected patients with chronic liver disease, primarily CHC, in order to evaluate the accuracy of ultrasound in identifying fatty liver in a typical clinical setting. Methods: Liver biopsies were reviewed on 131 patients who had a random liver biopsy performed for evaluation of chronic liver disease (89% had CHC). The biopsies were graded for fat (grades 0–3), inflammation (grades 0–4) and fibrosis (stages 0–4). Ultrasound interpretations were grouped into 3 categories- ‘normal’, ‘fatty liver’ and ‘non-specific’, and then compared to histologic results. Results: A ‘normal’ ultrasound interpretation was correct in excluding significant fat (grades 2–3) 95.8% of the time, but 25% had some fat (grades 1–3) on biopsy, representing false negatives. Furthermore, 37.5% had significant fibrosis (stages 2–4) and 8.3% had significant inflammation (grades 2–4). A ‘fatty liver’ interpretation was only correct in identifying some fat on biopsy in 36.4% and significant fat in 11.4%, yielding many false positives. In addition, 47.7% had significant fibrosis and 18.2% had significant inflammation. A ‘non-specific’ interpretation was associated with 25.6% significant fat, 53.8% significant fibrosis and 23.1% significant inflammation. The sensitivity of ultrasound for detecting fat ranged from 32.0–88.2 and the specificity ranged from 40.4–65.4, depending on the degree of fat on biopsy and the sonographic interpretation considered to be significant. Conclusions: Ultrasound is inaccurate for diagnosing hepatic steatosis in patients with chronic liver disease; echogenic alterations are more likely to be the result of fibrosis or inflammation in this setting. Therefore, in patients with chronic liver disease, the ultrasound diagnosis of fatty liver is more ‘fiction’ than ‘fat’.

Ultrasound Image Transmission Via Commercially Available Camera Phones for Emergency Ultrasound Interpretation

Study Objectives: Emergency physicians (EPs) who are newly credentialed in emergency ultrasound (US) and still are acquiring experience may encounter unfamiliar findings during routine US examinations. The ability to have real time consultation regarding image findings is highly desirable. We sought to compare high resolution thermal printer ultrasound images and images recorded and transmitted via commercial camera cell phones for potential use in distance over-reading by emergency departments utilizing ultrasound.

Do emergency medicine physicians perform ultrasound and conventional radiography in the emergency department? Recent trends from 1993 to 2001

To examine trends in emergency medicine physicians' participation in diagnostic ultrasound and conventional radiography from 1993 to 2001. The nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 1993 and 1996 through 2001 were examined to determine the total number of ultrasound and conventional radiography examinations performed in emergency departments, except for ophthalmic ultrasound and supervision or interpretation claims. Ultrasound examinations were categorized as general, vascular, breast, echocardiography, and obstetrical. Conventional x-ray examinations were categorized as chest, skeletal, abdomen, and gastrointestinal fluoroscopy. The total volume and overall share of the two modalities and nine aforementioned categories were calculated for each year for radiologists, emergency medicine physicians, other nonradiologists, and multispecialty groups using the Medicare provider and location-of-service codes. The total volume of ultrasound examinations performed in emergency departments increased from 134,533 in 1993 to 355,889 in 2001 (+164.5%). Emergency medicine physicians performed 760 (0.6%) of the examinations in 1993 and 1160 (0.3%) in 2001. Radiologists performed 87,377 (64.9%) in 1993 and 257,479 (72.3%) in 2001, other nonradiologists (primarily cardiologists performing echocardiography and vascular surgeons performing vascular ultrasound) performed 40,501 (30.1%) in 1993 and 76,649 (21.5%) in 2001, and multispecialty groups performed 5895 (4.4%) in 1993 and 20,601 (5.8%) in 2001. The total volume of conventional radiography examinations increased from 5,120,608 in 1993 to 8,054,771 (+57.3%) in 2001. Emergency medicine physicians performed 243,705 examinations (4.8%) in 1993 and 167,968 (2.1%) in 2001, radiologists performed 4,558,933 (89.0%) and 7,478,659 (92.8%), other nonradiologists performed 113,848 (2.2%) and 99,627 (1.2%), and multispecialty groups performed 204,122 (4.0%) and 308,517 (3.8%). The largest volume of examinations performed by radiologists and emergency medicine physicians in emergency departments in 2001 was in chest radiography, with radiologists performing 3,765,209 and emergency medicine physicians performing 98,851. The largest volume for other nonradiologists in emergency departments in 2001 was in echocardiography; they performed 53,943 of these examinations. Emergency medicine physicians perform a very small percentage of all ultrasound and conventional x-ray examinations performed in emergency departments, with their share decreasing over the 8-year period. The fact that the participation of emergency medicine physicians in ultrasound imaging and conventional radiography in emergency departments is limited and has been decreasing makes their claim of substantial participation highly questionable.

Comparative increases in utilization rates of ultrasound examinations among radiologists, cardiologists, and other physicians from 1993 to 2001

Purpose To ascertain changes in the utilization rates of diagnostic ultrasound among radiologists, cardiologists, and other physicians in recent years. Methods and materials The nationwide Medicare Part B databases for 1993 and 2001 were searched in all ultrasound Current Procedural Terminology 4 codes, except for ophthalmic ultrasound and supervision and interpretation codes. Ultrasound examinations were categorized as general, vascular, breast, obstetric (very low in the Medicare population), and echocardiography. Using the Medicare physician specialty codes, utilization rates per thousand Medicare beneficiaries per year were calculated for radiologists, cardiologists, and other physicians for all codes in the five aforementioned categories. Results Radiologists performed 24% of all ultrasound examinations in 2001. The overall utilization rate of ultrasound examinations among radiologists increased from 132.9 per thousand Medicare beneficiaries in 1993 to 166.3 in 2001, a 25% increase. Among cardiologists, the rate increased from 190.3 in 1993 to 356.1 in 2001, an 87% increase. The vast bulk of these examinations were echocardiograms, but cardiologists also had some involvement in vascular ultrasound. Among other physicians, the rate increased from 116.9 in 1993 to 167.0 in 2001, a 43% increase. The areas of greatest involvement by these other physicians were echocardiography, vascular ultrasound, and general ultrasound. Of the five ultrasound categories, echocardiography had by far the highest volume. Conclusion Nonradiologist physicians utilize ultrasound at much higher rates than radiologists, primarily reflecting the influence of echocardiography. Between 1993 and 2001, the ultrasound utilization rate grew over 3 times as rapidly among cardiologists as among radiologists; the rate among other physicians grew almost twice as rapidly as it did among radiologists. This raises the concern that self-referral may be leading to higher utilization and costs.

D-Dimer as a Screening Tool for Ultrasound Examination for Diagnosis of Deep Vein Thrombosis

Ultrasound (US) examinations have become the standard for evaluation of deep venous thrombosis (DVT). Evaluation for a possible DVT constitutes more than 40% of the daily ultrasound examinations performed at St. John's Regional Health Center. Of the US examinations performed for DVT, 80% are negative. The addition of D-dimer testing to the diagnostic algorithm has the potential to make the diagnosis of DVT in outpatients more convenient and economical. Ultrasound examination and interpretation is expensive. This project was to evaluate the D-dimer determination as a screening tool to indicate the need for US evaluation for DVT. The focus of this evaluation was the negativity of the D-dimer as a predictor of a normal venous examination. This study found that with a negative D-dimer result, more than 90% of the venous examinations were negative for DVT.

Ultrasound screening of the lambdoid suture in the child with posterior plagiocephaly.

The child with posterior plagiocephaly may have positional molding or unilateral lambdoid synostosis. Molding responds to conservative treatment, lambdoid synostosis requires surgical reconstruction. CT is diagnostic, but uses ionizing radiation, may need sedation, and the incidence of lambdoid fusion is only 2-3%. The purpose of this prospective study was to evaluate ultrasound as a screening test of lambdoid sutural patency using CT as the reference standard. In total, 41 children having head CT examinations were enrolled over 6 months. Of those, 29 were referred for abnormal head shape and suspected synostosis, of whom two had lambdoid fusion; 12 were referred for indications not related to head shape and found to have a normal study. Ultrasound scanning and interpretation of the lambdoid sutures was performed blinded to the CT reference standard. The lambdoid suture was read as patent or fused if a hypoechoic gap could or could not be seen between the hyperechoic calvarial bones, respectively. The mean sensitivity and specificity of ultrasound in distinguishing a patent from fused lambdoid suture by three blinded pediatric radiologists was 100% and 89%, respectively. Sonography of the lambdoid sutures shows excellent preliminary promise as a screening test of lambdoid sutural patency.

A Focused Breast Skills Workshop Improves the Clinical Skills of Medical Students

Purpose. The aim of this study was to determine the effectiveness of a focused breast skills workshop for teaching clinical skills to third-year medical students. Methodology. One hundred twenty-four third-year medical students involved in the surgical core clerkship were randomly assigned to two groups. Group 1 ( n = 67) participated in a 2-h focused breast skills workshop. Group 2 ( n = 57) received “traditional” ambulatory teaching for a period of 4 h in the breast clinic. The focused workshop consisted of a series of encounters concentrating on mammogram and ultrasound interpretation, physical examination skills, lump detection, and workup of a breast mass. Both groups received a didactic core curriculum lecture from surgical faculty. All students completed a satisfaction rating scale and a subset of students completed a pre- and postencounter self-efficacy rating scale on several aspects of breast skills. Student's t test was used to compare the groups in the areas of clinical skills as evidenced by performance on the breast-specific items on the end of the clerkship Objective Structure Clinical Examination and student satisfaction as evidenced by their response on a satisfaction rating scale. ANCOVA (controlling for preencounter self-efficacy rating) was used to compare the change scores between pre- and postencounter self-efficacy ratings. Results. Students in Group 1 performed significantly higher than the students in Group 2 in the areas of clinical examination skills ( t = −2.99, P < 0.05); in sensitivity ( t = −5.82, P < 0.05) and specificity ( t = −7.27, P < 0.05) in the examination of breast models; and with their satisfaction with the encounter ( t = 10.72, P < 0.05). Students in Group 1 also demonstrated a higher level of confidence in their breast skills at the end of the clerkship than students in Group 2 ( F = 6.22, P < 0.05). Conclusions. The focused breast skills workshop is more effective than the traditional ambulatory setting for teaching clinical breast examination skills. This setting also demonstrated the development of higher confidence in breast skills than the traditional ambulatory setting.

Hand and wrist sonography.

Although the anatomy of the hand and wrist is complex and the pathologic conditions encountered are diverse, many of the disease processes are localized, and in many situations, the clinical question is specific and limited. Because of this, ultrasound has always been an attractive imaging modality for evaluation of hand and wrist problems. Unfortunately, intrinsic difficulties in ultrasound image acquisition and interpretation have slowed the acceptance of hand and wrist sonography. Recently, however, new developments in high-resolution transducers and signal processing have dramatically improved image quality and scanning flexibility. For this reason, hand and wrist sonography is now more widely accepted and is taking its place along side other traditional modalities such as radiography, computed tomography, magnetic resonance imaging, and arthrography. Specific situations in which ultrasound offers definite benefits include evaluation of tendon inflammation and rupture, evaluation of palpable masses or suspected occult masses, and evaluation of suspected foreign bodies. Analysis of the median nerve is also possible and in the future, may have a role in patients with carpal tunnel syndrome.

Bedside Ultrasonography at Emergency Department - “New Kids on the Block” and “Echoes of Future”

Bedside ultrasonography is increasingly being performed by emergency physician in Hong Kong. Nearly every Accident and Emergency department in Hong Kong is equipped with an ultrasound machine. Ultrasonographic examination is a powerful clinical tool as it is non-invasive, safe, reliable and inexpensive. It has a high diagnostic accuracy in an experience hand. The practice of performing ultrasonography by local emergency physician is just at the early stage. This article aims to review the characteristic, scope and limitation of bedside ultrasonography at emergency department setting. The issue of training and certification, cost effectiveness and medico-legal implication of this tool is also discussed. The goal of bedside ultrasonography program in Hong Kong is to provide round the clock ultrasound examination and interpretation by well-trained and qualified emergency physician. Establishment of the scope of emergency ultrasound examination and implementation of quality improvement audit on the services is necessary. Training and research in the area of ultrasound imaging should be encouraged. With the maturation of our specialty and the effort of our local emergency physicians, bedside emergency ultrasonography will soon emerge as the “Echoes of the future”.

Ultrasound interpretation of hydronephrosis is improved by a brief educational intervention

Nineteen emergency medicine (EM) physicians (14 residents and 3 attendings) from an EM residency program which teaches ultrasound as part of the curriculum, were asked to rate 40 ultrasound scans showing different degrees of kidney hydronephrosis, first solely on the basis of their prior knowledge and experience. One week later, after a brief 15 minute lecture on a new objective method to read degrees of hydronephrosis, the same EM physicians were again asked to rate the 40 ultrasounds. One month later, to assess retention of the method, the same physicians were asked to read the same scans using the objective method presented 1 month prior. The three readings were compared with each other, and then each with a gold standard established for the study. Agreement of the group regarding scan interpretation improved and was maintained after the educational intervention (multirater kappa + .19, .32, and .32 for the three tests administered). When the differences between each week's readings and the gold standard were assessed, differences decreased with each successive test, and were statistically significant with the third test ( P = .029). We conclude that our brief educational intervention improves agreement among physicians in readings of ultrasound scans and also significantly increases accuracy in readings when compared with a gold standard.

Intraoperative, Laparoscopic, and Endoluminal Ultrasound

This is an interesting and potentially useful book. It clearly occupies a niche, but it is not unique. There are other recent texts on interventional ultrasound, and ultrasound in surgery, with similar content. As the title suggests, the current text covers a broad range of topics in the use of ultrasound in surgery. There are two chapters that may be of value to neurosurgeons (brain and spinal canal), as well as chapters dealing with urologic topics including ultrasound of the genitourinary system, and endoluminal ultrasound of the prostate. Three chapters deal with intraoperative ultrasound of the gastrointestinal tract (liver, pancreas, and biliary system). Two other chapters discuss laparoscopic ultrasound and endoluminal ultrasound of the gastrointestinal tract. In addition, there are brief chapters on the use of ultrasound in thoracic surgery and surgery of the breast. In keeping with the text’s broad scope, there is also a chapter on intraoperative vascular ultrasound. This breadth of coverage probably enhances the value of the text for the radiologist/ultrasonographer, but diminishes its value for the practicing surgeon. I believe this is by design because the former group seems to be the intended audience. Although the book is devoted to “surgical” ultrasound, 20 of the 21 authors are radiologists and one is a gastroenterologist; no surgeons contributed to the chapters. There is, furthermore, no chapter on ultrasound principles, nor a basic science review of ultrasound physics; it is assumed that the reader already has a good knowledge of ultrasound techniques and interpretation. This makes the book less suited for the physician who uses ultrasound occasionally, or the clinician who wants to learn about the use of this modality in his practice. Some chapters have excellent descriptions of techniques to insure high-quality ultrasound studies, but the book is not a substitute for formal training in ultrasonography. Several chapters are quite comprehensive, with good coverage and plenty of references, including the chapters on intraoperative ultrasound of the liver, intraoperative vascular ultrasound, and endoluminal ultrasound of the rectum and anus. Other chapters are disappointingly brief, with very cursory coverage. In particular, coverage of intraoperative ultrasound of the pancreas and the breast and endoscopic ultrasound of the gastrointestinal tract would have benefited from expansion. Regardless of the extent of coverage of specific topics, this book should win an award for the highest quality image reproduction among medical textbooks. Although ultrasound images are notoriously “fuzzy,” those selected for inclusion in this text are remarkably clear and crisp. Occasionally, specific ultrasound findings were discussed, but corresponding images were not provided. Nonetheless, this is not an atlas of ultrasound findings, and does not pretend to be. Most surgeons will not want to buy this book, but it certainly deserves shelf space in their hospital or medical school library. The surgeon who is already familiar with ultrasound and uses this modality may want to add this book to his or her personal collection, after comparing it with one of the other available texts on surgical ultrasound to be certain of buying the one that will be most useful in his or her practice.

Breast Sonography

Ultrasonography (US) is well established as the most useful adjunctive breast imaging modality. While the traditional role of ultrasonography has been to differentiate between cystic and solid breast masses, recent advances in ultrasound technology and interpretation have the potential to expand greatly the role of this modality in the evaluation of breast disease. This paper reviews the current status of sonography as used in clinical practice and examines recent progress in equipment, technique, and interpretation of breast ultrasonography.