مرکزی صفحہ Ultrasound (Maney Publishing) Abstracts from the 50th Annual Scientific Meeting of the British Medical Ultrasound Society, 4–6...
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Abstracts Abstracts from the 50th Annual Scientific Meeting of the British Medical Ultrasound Society, 4–6 December 2018, The Point, Emirates Old Trafford, Manchester, UK Day 1 Tuesday 4 December Gynaecology Ultrasound features of immature ovarian teratoma: Case series and review of literature SA Idle and JA Ross Early Pregnancy and Acute Gynaecology, King’s College Hospital, London, UK Abstract The aim of this case series was to characterise immature ovarian teratomas (IOT) using grey-scale and Doppler ultrasonography to increase the detection rate and awareness of these tumours. This has not been achieved to date. This is a multicentre retrospective case series review. Patients with a confirmed histological diagnosis of IOT, from 2006 to 2018 at King’s College Hospital and St George’s Hospital London, ultrasound scans were retrieved and described according to IOTA criteria. Eight patients were identified in total with a mean age of 26 years old (range 13–35). Presenting symptoms included abdominal mass, pelvic pain and/or amenorrhoea. Half of the patients had a previous mature ovarian teratoma (three ipsilateral, one contralateral). The cysts were large (median 115 mm), fast growing unilateral cysts with a single, peripheral, predominantly solid component arising from the cyst wall. The solid component was hyperechoic with multiple foci of fibrosis and numerous small cysts. The cystic component typically formed less than 75% of the lesion and the cyst fluid was of low-level echogenicty. Subjective assessment of vascularity of the solid part of the tumours varied between scores of 0–2. Tumour markers in this cohort showed a raised serum a-fetoprotein level in 42% of patients. IOT are rare, rapidly growing ovarian cysts that typically have a large predominantly solid, poorly or moderately vascularised component. Ultrasound 2019, Vol. 27(2) NP1–NP52 ! The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1742271X19840271 journals.sagepub.com/home/ult This component i; s typically less cystic than the multilocular ‘honeycomb’ nodules of mucinous borderline tumours and much larger than the small papillary projections seen in serous and sero-mucinous borderline tumours. The hyperechoic sebaceous material that is pathognomonic of dermoid cysts was not a typical feature. The images and features described should facilitate the presumptive preoperative diagnosis in patients who present with ovarian cysts in their twenties, particularly in women with a history of a previous dermoid cyst. Review of the outcomes of pregnancies of unknown location in a District General Hospital R Phillips1 and T Blacker2 1 Health and Applied Science, University of the West of England, Bristol, UK 2 Radiology, Royal United Hospital Trust, Bath, UK Abstract Pregnancy of unknown location (PUL) is a common diagnostic challenge. Correct management of PUL is crucial to reduce unnecessary intervention as well as to aid the timely detection of ectopic pregnancies. Furthermore, over-surveillance with repeated scans may result in unnecessary anxiety for the woman as well as increased workload for the Early Pregnancy Assessment Clinic (EPAC). The rationale for this review was prompted by an anecdotal observation that the frequency of PUL incidents had increased within our unit, resulting in multiple scans for the woman before a final diagnosis was made. The purpose of this review was to identify any local factors that may influence the management of women with a PUL and standardise the care received by these women. A retrospective data collection was carried out between January and June 2018, reviewing women attending an EPAC with the initial diagnosis of a PUL. The data collected included the diagnosis at NP2 the first scan and all of the subsequent scans and BHCg results if available. The ultrasound results were then grouped into five categories based on their sonographic findings and the final outcomes recorded. One hundred and sixteen women presented to the EPAC, with 49 (42%) diagnosed initially with PUL; of these, 20% were presenting at a gestation of six weeks or less. On average, each woman had 2.3 scans per pregnancy, with three women having four scans. There were two ectopic pregnancies missed in the review period. These cases were evaluated and areas of improvement identified. Local guidelines need to be regularly reviewed and implemented. Teaching sessions need to be facilitated to enable correct interpretation of images and reporting by sonographers and the interpretation of these reports by EPAC nurses and medical staff. A repeat review is planned to monitor changes in practice. Case report: C-section scar sausage A McGuinness Ultrasound Mid Yorkshire Hospitals NHS Trust, Wakefield, UK Abstract In the last five years, the author’s trust has seen a significant increase in the number of scans performed for complications of lower segment Caesarean section (LSCS) operation scars. These include haematomas, seromas, abscesses, dehiscence and endometiotic deposits. This case study describes several cases of abnormal lesions seen on the anterior myometrium in the region of a previous LSCS scar found in patients complaining of abnormal uterine bleeding and pain. The lesions have ultrasound appearances of soft tissue but have no significant vascularity and are described as ’sausage-shaped’. The sonographers have reported unknown aetiology and therefore questioned the significance of these ’lesions’ and have recommended that the patients have further imaging and in some cases referred the patient to a gynaecologist. In all cases, the patients have undergone repeat transvaginal ultrasound scans or magnetic resonance imaging. The lesions appear to have benign features and have been reported as being of no clinical significance, and not the cause of the patients’ symptoms. There has been an increase of LSCS scar complications; however, the findings described are incidental, asymptomatic and benign and do not require further imaging or follow-up and do not appear to be the cause of the patient’s symptoms. However, the significance in future pregnancies needs further evaluation. Ultrasound 27(2) Case report: A presentation of post-menopausal pyometra S Hopkins1,2, C Curran2, M Moran1 and Therese Herlihy1 1 School of Radiography, University College Dublin, Dublin, Ireland 2 Radiology, Our Lady of Lourdes Hospital, Drogheda, Ireland Abstract Pyometra, the accumulation of pus in the endometrial cavity, is a relatively uncommon gynaecological presentation. It is more common in elderly postmenopausal women and there is an associated risk of a malignant cause. A 73-year-old lady was referred to the emergency department via her GP following an episode of foul smelling vaginal discharge of sufficient quantity to soak through her clothing. The patient is para 10, all vaginal deliveries. Bloods and biochemistry were normal. Speculum examination proved difficult. She was referred for a pelvic ultrasound scan. The trans-abdominal pelvis ultrasound demonstrated a markedly distended endometrial cavity, measuring 11.2 cm 6.5 cm 7.3 cm, the content of which was echogenic and motile, highly suggestive of pus. The myometrium appeared thin, most likely due to atrophy and distension, but was otherwise unremarkable. Interrogation with power and colour Doppler demonstrated no vascularity within the uterine cavity and no solid intrauterine masses were identified. Neither ovary was identified but no adnexal masses were seen. The patient declined a transvaginal scan. The patient underwent a hysteroscopy and 400 ml of foul smelling pus was drained from the endometrial cavity. A contrast-enhanced CT of the thorax, abdomen and pelvis was performed post-hysteroscopy which demonstrated a residual collection within the endometrial cavity but was negative for any evidence of malignancy. Pelvic MRI yielded no additional information. Endometrial curettings were sent for histology which showed florid endometritis but no evidence of malignancy. Following a course of antibiotics, the patient proceeded to a total abdominal hysterectomy with bilateral salpingectomy and oophorectomy which on histology demonstrated chronic endometritis but no evidence of malignancy. Trans-abdominal pelvic ultrasound clearly demonstrated the presence and size of the pyometra. CT and MRI helped rule out a malignant cause and pathology confirmed its benign aetiology. Abstracts NP3 Head and Neck Professional Issues Case report: Metastatic parotid and thyroid masses from renal cell carcinoma Preceptorship in practice C Kirkpatrick Radiology, United Lincolnshire Hospitals Trust, Lincoln, UK Abstract A 75-year-old female presented to the Head and Neck One Stop Clinic in November 2017 with a palpable right parotid lump and left anterior neck. She had a previous medical history of renal cell carcinoma (RCC) in 2013. There are very few cases in the literature of parotid metastasis from RCC or thyroid metastasis from RCC. This case presents and discusses an even more uncommon finding of thyroid and parotid metastases in the same patient, and possibly but unconfirmed histologically, submandibular gland (SMG) metastasis. Imaging findings and patient management are discussed. The findings included a 25 mm 16 mm right parotid lesion, which was visible and palpable, with a differential diagnosis given as a pleomorphic adenoma. The thyroid gland was enlarged due to the presence of multiple large nodules, the largest in the left lobe measuring 35 mm 27 mm. This had U3 features in line with BTA guidelines. There was also a 9 mm hypoechoic lesion in the left SMG gland which was too small to characterise on ultrasound. Contrast-enhanced CT showed a 3 cm, well-defined, strongly enhancing mass superficially within the right parotid gland and a similar enhancing mass within the left submandibular gland measuring approximately 10 mm. There was a benign goitre within the left lobe of thyroid with no significant tracheal compression. Contrastenhanced MRI of the neck showed a well-defined mass involving the right parotid gland (probable pleomorphic adenoma) and a left thyroid nodule measuring about 3 cm in diameter. Cytology and histology tests revealed the following. An ultrasound guided fine needle aspiration (FNA) of the thyroid was classified as Thy3a. An ultrasound (US) guided FNA of the parotid gland showed a possible primary salivary gland malignancy. An ultrasound guided FNA of an SMG lesion was non-diagnostic. MDT recommended parotid and thyroid lesion US guided biopsy. A US guided 18 G core biopsy of the right parotid lesion and left thyroid nodule revealed profiles consistent with metastatic RCC. This is a rare presentation of renal cell carcinoma metastases in the head and neck. H Brown School of Health, Radiography, Birmingham City University, Birmingham, UK Abstract In recent years, we have seen the advent of several different educational entry routes into the sonography profession, all designed to reduce the national shortage of sonographers. How do we ensure that these newly qualified sonographers are supported into practice, to become confident, autonomous and competent practitioners working within a defined scope of practice? Preceptorship is a widely acknowledged and accepted developmental process in nursing and midwifery, with national and regional frameworks to support the transition of newly qualified staff into their first professional post and beyond. Historically, allied health professionals have not had the same access to these programmes with the concept of preceptorship varying across individual departments, from some with very structured and defined levels of support, including, education, mentorship, clinical supervision leading to audit of scanning and reporting and a final sign off of competence, through to others operating on a ‘sink or swim’ philosophy. Nursing has a high attrition rate in the early post-registration period, largely cited as being due to burnt out. A contributing factor is the disparity between the individual’s expectations of the role and the demands of the post; this leads to stress and ultimately burnt out. With all of the work done by professional organisations to increase the sonography workforce and training capacity, it is vital that we do not lose staff in this way. We must ensure that newly qualified sonographers are supported into practice and that they are safe, confident, caring practitioners who can provide a high quality safe service to patients. This talk explores the concept and purpose of preceptorship, including types of activities and models of preceptorship, showing the benefits of this important period in supporting the newly qualified workforce into independent practice. It examines the benefits of preceptorship to the workforce, the service and the service user whilst acknowledging some of the challenges of supporting preceptorship in the busy workplace. NP4 Ultrasound 27(2) Vascular A retrospective analysis of the growth rate of common iliac artery aneurysms A Dhanji-Lakha Barts Health NHS Trust, London, UK Abstract The objective of this analysis was to determine the prevalence and growth rate of common iliac artery aneurysms (CIAA) in patients attending a regional vascular laboratory. An audit of clinical reports of patients attending a regional vascular laboratory to undergo an aorto-iliac duplex scan (USS) was undertaken retrospectively. Expansion rate of aneurysms was studied in patients who had >2 USS scans; data were recorded at 6 and/or 12 monthly intervals up to five years. Patient age, initial CIAA diameter, bilateral/unilateral CIAA and coinciding aortic diameter were recorded to determine if these specific risk factors were associated with CIAA growth rates. Pearson’s correlation coefficient was used to determine the strength of association between variables. Of 1060 patient records, 995 were suitable for review; 21.6% (215/995) of patients had a CIAA. Isolated CIAA accounted for 17.2% (37/215). Mean CIAA growth was 1.5 mm/year. There was a strong correlation between CIAA diameter vs. time from diagnosis (R ¼ 0.820; p ¼ 0.004). Data showed that the smaller the initial CIAA diameter (15–20 mm), the more rapid the growth rate (R ¼ 0.9145; p ¼ 0.001). An initial CIAA diameter greater than 30 mm was not significantly correlated with growth rate. No impact of unilateral/bilateral CIAA on growth rate was identified. In the presence of an AAA measuring >50 mm (R ¼ 0.305; p ¼ >0.05) CIAA growth is less predictable. AAA diameter < 50 mm did not correlate significantly with CIAA growth rate (p ¼ >0.05). These data will enable development of a CIAA surveillance protocol. Outcomes after deep vein thrombosis: Resolution, recurrence, reflux and PTS 1 2 M Bonfield , F Cramp and J Pollock deep vein thrombosis (DVT). Whether this is important for longer term outcomes is unclear. Some patients may recover fully after DVT whilst others are left with chronic symptoms grouped under the umbrella term post-thrombotic syndrome (PTS). The objective of this study was to examine the natural history and response to the treatment of DVT and assess associations between baseline or follow-up characteristics and the longer term outcomes: resolution, recurrence, venous incompetence and PTS. A total of 171 consecutive participants with a first episode of acute DVT were followed up at defined intervals for up to two years. Ultrasound was used to examine changes in thrombus and venous function. PTS was assessed using the Villalta score. Possible predictors of outcome after DVT were analysed using multivariate logistic regression. DVT remained unresolved when prescribed anticoagulation treatment ceased in 34% of cases and 27% remained unresolved at two years post-diagnosis. Recurrent DVT during follow-up was detected in 15%, new venous incompetence developed in 28% and PTS developed in 30%. Following adjustment for confounding, distal DVT and cases with lower thrombus burden were significantly more likely to resolve. The development of venous incompetence was associated with proximal DVT and treatment with heparin and warfarin rather than Rivaroxaban. Women were more likely to develop PTS than men. PTS was also associated with being overweight, residual DVT, not using compression stockings, superficial venous incompetence and deep venous incompetence when combined with superficial incompetence. No significant associations were found with treatment duration, smoking, hypertension, provocation status, pre-existing incompetence, superficial thrombophlebitis, symptoms duration, thrombus evolution pattern or recurrence. This study provides information that could potentially inform better patient information and lifestyle advice, risk stratification for PTS and more tailored treatment for DVT which could be assessed through future research. BMUS Young Investigator 2018 2 1 Vascular Science, University Hospitals Bristol NHS Foundation Trust, Bristol, UK 2 Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK Abstract Evidence indicates that there is variability in thrombus resolution and residual venous function after Nonlinear effects in modern diagnostic ultrasound imaging equipment with high working frequencies E Jafarzadeh1, MH Amini2 and AN Sinclair1 1 Mechanical Engineering, University of Toronto, Toronto, Canada 2 Acoustics, FujiFilm VisualSonics Inc., Toronto, Canada Abstracts Abstract Diagnostic ultrasonic imaging systems with operating frequencies in excess of 30 MHz are emerging for clinical use to improve the image resolution. Until recently, limitations in hydrophone technology prevented the study of nonlinear effects in such highfrequency systems. Nonlinear effects are of great importance since they can increase the amount of heat deposited locally into biological tissue and thereby raise some serious safety concerns. The objective of this paper is to evaluate the level of nonlinearity, which consists of nonlinear wave propagation and nonlinear behaviour of the transducer, and the associated consequences for modern equipment with high working frequency. To this end, a very broad band hydrophone was used to capture the pressure field of a commercial linear array imaging system working at 50 MHz, in the range of 1.2 to 8 MPa peak-to-peak pressure at the focal point in water. Strong higher order harmonics were measured even at the lower end of this pressure range. Under high-pressure conditions, the amplitude of the second harmonic was only 1.5 dB smaller than that of the fundamental component; calculations indicate that the rate of heat deposition associated with the second harmonic is approximately 2.5 times that of the fundamental component. This implies that nonlinear effects (nonlinear wave propagation and nonlinear behaviour of the transducer) cannot be ignored for high-frequency systems in terms of thermal bio-effects. In addition, an amplitude-dependent down-shift in the overall spectrum of the fundamental component is introduced as another consequence of nonlinearity for high-frequency systems. The down-shift is due to the frequency dependence of the nonlinear effects which can lead to a noticeable decrease in lateral imaging resolution. A significant amount of down-shift (up to 35% of the central frequency of the fundamental component) was observed for the investigated 50 MHz system. The quality of ultrasound training for first year radiology trainees and the impact on the ultrasound department N Ellerby1, S Mcneill2, S Chawla1 and J Webb2 1 2 Mersey School of Radiology, Liverpool, UK Aintree University Hospital, Liverpool, UK Abstract First year radiology trainees (ST1) generally enter training with no ultrasound experience. They need to be competent in on-call scans to answer clinical questions by the end of that same year. We looked at NP5 the quality of training for ST1s across the Northwest deanery and the impact on the US departments facilitating this training. A questionnaire was emailed to all ST1s in the Northwest deanery. A customised questionnaire was also conducted with ultrasound department managers in the Northwest. The questionnaires included questions on number of lists, number of patients per list, background of trainers, measures to facilitate training and rating of the quality of training on a scale of 1–5, as well as free text comments. There were responses from 76% of ST1s, with an average of 1.2 lists per week, 64% having six or more patients per list. Different sonographers led in 32% of the sessions, 32% were consultant radiologist led, 18% were with both a consultant and a different sonographer and one had no list. The average rating of ultrasound training was 3.7. Of the trainees, 36% had both increased time slots and reduced patient lists, whilst 46% had no provisions to facilitate training. Comments included: a disparity between sonographer training and ST1 training, cancellation of lists and lost scanning time due to patient and trainers’ cancellations and absences. The ultrasound manager’s questionnaire revealed that departments had 1–3 ST1s, and all had trainee sonographers. Average rating of ST1s training was 3.5, whilst sonography training rating was 4.5. Comments discussed the need for dedicated lists, but the inability to provide them due to the impact upon backlogs. Ultrasound training for ST1s is variable despite time pressure to become competent. Staff shortage and backlog pressures impact upon training. Dedicated lists with a dedicated ultrasound tutor responsible for trainees learning would improve US training. UltrasoundEd N Alsafi1 and A Alsafi2 1 Radiology, The Hillingdon Hospital NHS Trust, London, UK 2 Radiology, Imperial College Healthcare NHS Trust, London, UK Abstract Social media has become an integral part of daily life with 38 million users in the UK alone and the average user being logged-in for 135 minutes per day. Social media has become increasingly used to disseminate learning in a variety of fields but particularly in medicine. A number of Instagram accounts are now solely dedicated to education in Radiology. The aim of this study was to assess the current use of Instagram in disseminating ultrasound education. An Instagram NP6 search using the hashtags: #Ultrasound and #Radiology were conducted and the content of the posts classified into social and academic. The results were then compared. There are 461,884 #Ultrasound posts compared with 243,011 #Radiology posts. From the first 30 #Ultrasound posts retrieved, 3 were educational and 27 were social. The social posts predominantly relate to announcements of pregnancy. In comparison 21/30 #Radiology posts are educational while 9 were classified as social. There are a number of educational radiology and ultrasound accounts on Instagram. While the educational radiology posts are relatively easy to find, those for ultrasound are buried within a sea of social posts. We propose the adoption of the hashtag #UltrasoundEd to separate educational ultrasound posts and make them easier to identify. This is in order to allow the rapid free dissemination of ultrasound education. Social media can be an excellent tool for education. Instagram is an ideal platform for this as it is image based. The use of a standardised hashtag (#UltrasoundEd) for ultrasound education will help easily identify relevant educational posts. Vastus lateralis’ stiffness: A supersonic shear wave elastography study R Santos1 and PA da Silva2 1 Medical Imaging and Radiotherapy Department, Coimbra Health School, Polytechnic Institute of Coimbra, Portugal 2 Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa, Portugal Abstract Supersonic shear image (SSI) is an ultrasound elastography method that offers a direct quantitative measure of tissue stiffness based on the velocity of shear waves. The potential of this technique is enormous and has enabled researchers in many fields. The purpose of this study was to assess changes in Vastus Lateralis’s shear modulus with knee position and after a session of maximal isometric and isokinetic Concentric and Eccentric contraction and to analyse the relationship between Vastus Lateralis’s shear elasticity and submaximal knee extension torque with SSI. Sixteen subjects were submitted to acute changes in Vastus Lateralis’s stiffness associated with passive stretching, performance of short but intense contractile activity, and muscle isometric contractions that were investigated by means of SSI. The results demonstrated an acute increase of around 10% in Vastus Lateralis’s shear modulus as a result of performing maximal isometric, concentric, Ultrasound 27(2) and eccentric contractions. The shear modulus of the Vastus Lateralis also increased when the knee moved. Finally, a linear relationship between the shear modulus and the level of isometric muscle contraction was observed. SSI proved to be a good method to investigate muscle mechanical property changes associated with muscle function. These results emphasise an objective and quantifiable muscle ultrasound evaluation for studying muscle adaptation and function, in general. The Stacked-Ellipse algorithm: A novel 3D uterine segmentation tool for enabling adaptive radiotherapy for cervical cancer S Mason1, I White2, M Baker3, C Behrens3, S Lalondrelle2, JC Bamber1 and EJ Harris1 1 Institute of Cancer Research, Sutton, UK Royal Marsden NHS Foundation Trust, Sutton, UK 3 Department of Oncology, Herlev Hospital, Herlev, Denmark 2 Abstract The purpose of this work was to enable adaptive radiotherapy (RT) for cervical cancer whereby the beam aperture conforms to the target. It is essential to know the shape and position of the uterus with respect to the treatment room isocentre. Although it is possible to visualise the uterus with 3D transabdominal ultrasound (3DTAUS), there is an unmet clinical need of fast 3D uterine segmentation for the purpose of US-guided RT. The Stacked-Ellipse (SE) algorithm was developed using a training set of 5 patients to semi-automatically segment the uterus on 3DTAUS, and evaluated on an independent cohort of 10 patients. The uterus of 15 patients was scanned with 3D US (5 MHz centre frequency) using the ClarityÕ System (Elekta Ltd) at multiple time points during treatment, resulting in a dataset of 49 images. The uterus was manually contoured on each 3DTAUS. Five uterine contours from the Herlev cohort comprised the training set for parameterising the uterus as a series of stacked ellipses. The SEalgorithm was validated on the remaining 44 US images in the RMH cohort using the manual contours as the gold-standard. The SE-algorithm uses a manually initialised slice in the sagittal plane to provide a series of 2D elliptical initialisation contours in semi-axial planes along the length of the uterus. Each 2D elliptical initialisation contour is deformed according to image features in the semi-axial planes of the US images such that it conforms to the uterine boundary, regularised to smooth the contour and Abstracts correct for outliers, and projected into 3D. The median (interquartile range (IQR)) Dice Similarity Coefficient and mean-surface-to-surface-distance between the SE-algorithm and gold-standard was 0.80 (0.03) and 3.3 (0.2) mm, respectively, which is within the range of reported interobserver contouring variability. The SE-algorithm could be implemented in adaptive RT to precisely segment the uterus on 3DTAUS. Student Education Session Undergraduate student clinical experience H Rzeskiewicz Faculty of Health, Birmingham City University, Birmingham, UK Abstract The introduction of new educational routes into sonography has provided new challenges to clinical teaching methods. Clinical departments are under increasing pressure with growing patient volumes, staff shortages and now longer training programmes. It is essential that both students and clinical departments are supported throughout the training period. This is an account of my experience as an undergraduate sonography student across multiple west midlands NHS trusts, discussing what has worked well and the challenges faced. Areas of comment will include supervision, hands-on scanning, interesting cases, report writing and social wellbeing. Qualified healthcare practitioner promoted to student: An interpretive phenomenological analysis of the impact of job characteristics on motivation for the student sonographer C Rogers Royal Bournemouth Hospital, Bournemouth, UK Abstract A current national shortage of sonographers is causing severe service delivery issues, and figures show that the problem is getting worse. Ultrasound imaging is a frontline diagnostic tool in the detection of many pathologies including cancer. This study proposes, with the application of psychological theory of work motivations, to explore the lived experiences of student sonographers entering the post from a radiography background. Since Kramer’s seminal paper in NP7 1974, which highlighted ’transition shock’, there has been a huge body of work produced by the nursing field exploring and analysing the transition from student nurse to qualified practitioner. There is yet to be any research done in the allied health professions field, specifically concerning the unique pathway from transitioning from a qualified radiographer to student sonographer. Hackman and Oldham’s job characteristic model, building on Herzberg’s motivation-hygiene theory, states that there are five job characteristics that are essential to engage higher order needs for employees: autonomy; task identity; task significance; task variety and feedback. A qualitative interpretive phenomenological analysis methodology using semi-structured, open ended interview schedules was developed. Four participants, enrolled on a CASE approved training course in the UK, aged 24–30 were recruited as a purposive sample. Data were transcribed verbatim. The validity of this study was demonstrated against Yardley’s four broad principles: sensitivity to context; commitment and rigour; transparency and coherence; impact and importance. Interpretative phenomenological analysis demonstrated three master themes in the data: ‘I want to be the expert’ – evolving professional identity; ‘being bottom of the pile’ – adjusting to a new position; ‘It’s not remotely standardised’ – differing practices and training. The findings suggest that themes in the lived experience of participants are congruent with the five factors detailed in the theoretical framework. These links may offer insight for sonography departments on the broader motivational factors impacting current sonography students. Ultrasound guided procedures: What are the barriers surrounding interventional practice for sonographers? H Mohamed Chelsea and Westminster Hospital, London, UK Abstract The main aim of this study is to identify the barriers of ultrasound-guided interventional practice for sonographers in England. The radiographer/sonographer role development has been driven by a shortage of radiologists and the need to maintain an effective diagnostic service. The demand for radiology examinations has risen over recent years due to the increasing population. The participants involved in this study were qualified sonographers in England. Between 6 February 2018 and 13 March 2018, a self-selecting questionnaire was available online which consisted of 32 closed-ended questions NP8 Ultrasound 27(2) and 3 open-ended questions. Conventional descriptive statistics were presented in the form of frequency histograms, and qualitative responses were then amalgamated, split and analysed thematically. A total of 202 responses were obtained from the online questionnaire. The number one ranked barrier for ultrasound-guided interventional practice was staff shortages, with many expressing that radiologists are a large barrier. This study has found 29% of those who perform interventions will retire within five years. It was identified that average ages of those performing intervention were between 44 and 55. There is a significant difference between regions in seeking and performing intervention (p ¼ 0.02). Various key trends relating to the barriers were identified, which include personal preference, salary, education, training, costs, negative perceptions of other professionals, auditing, protocols, CPO and medico-legal issues. Other barriers such as prescribing issues, part-time working, training waiting lists and no demand have also been highlighted by the study. Participants who undertake ultrasoundguided intervention were positive about teaching others. Generalisation of these results is limited due to the number of responses. This research has uncovered the attitudes of those who perform interventions. These findings should be acted upon by introducing a change in practice, a larger-scale study including the whole of the UK would be useful. haematomas and hydrocephalus; this is due to permanent friction between the multiple bone fragments of the skull and vascular fragility. In this case study, the role of ultrasound, as a first line investigation in a case of subdural collection, is evaluated. The head circumference has increased and due to the complex background, a cranial ultrasound scan was requested. The diagnosis was a subdural collection on ultrasound; the patient underwent a CT scan postUS to further evaluate this; however, CT did not add any more information. Neonatal neuroimaging sonography is a very useful initial screening modality for evaluating the neonatal brain, especially in premature babies and babies that have multiple comorbidities and restrictions with imaging. The recent advances in technology, appropriate training and rigorous scanning technique have shown that neonatal neurosonography can be diagnostically accurate and useful as an initial modality for clinical management. Added to this, ultrasound is cheaper than cross-sectional modalities, does not require sedation and there is no ionisation radiation involved. Case report: Neonatal neurosonograhy case study of subdural collection Abstract Deep vein thrombosis (DVT) is a frequent medical condition, which can become fatal if a patient develops a pulmonary embolism (PE). This case is of a 57year-old lady who presented to the emergency department complaining of pain and swelling of her left leg. The patient also had associated shortness of breath and abnormal menstrual bleeding with no associated cause or explanation. The ultrasound examination incorporated a B-mode and colour Doppler assessment of the left leg veins. The external iliac vein, common femoral vein, femoral vein and superficial veins were all patent, compressible and showed augmented flow. The distal popliteal and peroneal veins did not compress and an echogenic area with minimal blood flow was seen within the distal peroneal vein. This echogenic matter indicated a DVT of the distal veins when compression technique was applied. The patient then proceeded to have a transabdominal and transvaginal ultrasound to investigate the abnormal bleeding. The transvaginal ultrasound on both B-mode and power Doppler indicated a cervical lesion. Following the ultrasound examination, the patient became A Kadrou Birmingham Children’s Hospital, Birmingham City University, Birmingham, UK Abstract Baby X was seven months old at the time of the cranial ultrasound and had been an ’in-patient’ at a specialist paediatric hospital since birth. During pregnancy, mum was offered a termination as the foetus was diagnosed with osteogenesis imperfecta (OI) type 2 and had already sustained numerous fractures while in utero. The patient’s survival until today makes this a rare case. Osteogenesis imperfecta is an inherited rare collagenous disease characterised by different degrees of low bone mass and an increased susceptibility to fractures and bone deformities. OI type 2 is lethal in the perinatal period and in the most severe form, patients are at a high risk of dying due to lung hypoplasia. Neurological complications of children with OI involve chronic subdural collections/haematomas, acute intracranial Case report: Deep vein thrombosis – Always look at the bigger picture T Herlihy Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland Abstracts increasingly unwell and a computed tomography examination was performed. This concluded that the patient had a PE and anticoagulant medication was administered. The patient’s respiratory symptoms subsided following this. A pelvic magnetic resonance imaging examination was performed confirming the presence of a malignant cervical mass and the patient was scheduled for surgical removal of the lesion. This case study demonstrates an unusual outcome following ultrasound evaluation of lower limb DVT and the associated cause. Ultrasound played an essential role in the diagnosis of a calf DVT. As no other risk factors for DVT were present, the abnormal menstrual bleeding needed to be rapidly investigated and the cervical mass found on the pelvic ultrasound provided a rapid diagnosis and aided patient management. Case report: Pyogenic flexor tenosynovitis as a result of a foreign body and the role of ultrasound A Kadrou Birmingham Children’s Hospital, Birmingham City University, Birmingham, UK Abstract Boy X was referred from his GP to the plastic hand surgeons at a specialist children’s hospital. The history given verbally from the patient was that posttrauma, his right index finger had been swollen and tender for nearly two months. He visited his local hospital where he had plain radiographs the same day as the trauma, but as no evidence of a foreign body was seen, he was discharged from the hospital and visited his GP a week later as the swelling and pain continued. The GP referred the patient to hand surgeons at a specialist paediatric hospital for an expert opinion. ’Boy X’ was seen in the hand clinic where the plastic surgeon felt that an ultrasound scan would be a good first line of investigation followed by a magnetic resonance imaging (MRI) scan to rule out the unknown aetiology of the right index finger pain and swelling. The radiology department was able to offer the ultrasound scan immediately following the outpatient appointment on the same day. The ultrasound scan showed a 3 mm foreign body within the tendon sheath of the flexor tendon with evidence of tenosynovitis. ‘Boy X’ felt his symptoms began after an incident in which he fell into a rose/thorn bush. The patient then went for an MRI scan two days later where the foreign body was not seen. Ultrasound is a proven unique modality in the detection and localisation of foreign bodies as well as NP9 in diagnoses of associated complications, including pyogenic flexor tenosynovitis as in this case. It is quicker and cheaper than any other imaging modality, non-invasive with no known side effects and it is easily repeatable. Metastatic endometrial carcinosarcoma C McFadyen Ultrasound, The University of Cumbria, Lancaster, UK Abstract Endometrial carcinoma is one of the most invasive malignancies of the female reproductive system. Statistics from Cancer Research (2015) state that uterine malignancy is the fourth most common cancer in females. Approximately 9300 new cases of uterine cancer were diagnosed in the United Kingdom in 2014, with the majority occurring in the endometrium. Endometrial carcinosarcoma has an increased tendency to metastasise early, with the liver being reported as an atypical metastatic site. A nulliparous 64-year-old female presented to the one stop post-menopausal bleeding clinic following recurrent episodes of vaginal bleeding. The patient declined transvaginal ultrasound; therefore, an endometrial thickness of 5 mm was obtained transabdominally, prompting further investigation. Hysteroscopy examination revealed the presence of a 30 12 7 mm endometrial polyp, which pathology results concluded to be comprised of carcinosarcoma. An abdominal and pelvic Computed Tomography scan revealed no further presence of disease. The patient underwent an abdominal hysterectomy, bilateral oophorectomy, omentectomy and removal of the para-aortic and pelvic lymph nodes. A follow-up appointment was arranged within six months’ time. Five months after initial diagnosis, the patient presented to clinic with fatigue and right-sided abdominal pain. An ultrasound scan revealed a 12 cm heterogeneous mass within the right lobe of the liver. A pathological specimen concluded the mass was a metastatic component of carcinosarcoma. The patient received palliative chemotherapy, but unfortunately passed away five months after presenting with right upper quadrant pain. Following recommendations from Nice Guidelines (2015) regarding post-menopausal bleeding, in which an urgent appointment is arranged within two weeks, one stop clinics ensure diagnostic tests and interventions are carried out in a timely manner. Further cross-sectional imaging is paramount following a diagnosis of endometrial NP10 carcinoma, in order to assess the extent of disease and construct treatment plans. Ultrasound 27(2) The use of ultrasound to support palliative care in a hospice setting J Eastman Day 2 Wednesday 5 December Saint Francis Hospice, Havering-Atte-Bower, UK General Medical Abstract This study is a retrospective audit of 341 scans carried out by the author (an experienced sonographer) over a five-year period in an adult hospice. The World Health Organisation describes palliative care as ‘an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’. Ultrasound imaging is a valuable resource that has been widely used in hospitals for many years. Its usage has been to slow to develop in hospices despite improvements to the cost of machines and their accessibility. It can help clinicians make what are often difficult management decisions at a crucial point in a patient’s life. This talk presents a review of the experience of establishing the provision of an ultrasound scanning service in an adult hospice setting. Over the course of five years, 341 scans were carried out on 305 patients, with an age range of 25 to 96. Indications for scans included suspected urinary retention, DVT, and assessment of abdominal ascites or pleural fluid. A wide range of pathologies were found, from disease progression to gallstones accounting for pain. The author offers practical suggestions for scanning in these challenging but rewarding circumstances. The author has been able to demonstrate that a hospice-based ultrasound service is achievable, effective and safe. Clinicians value the greater certainty available with the use of sonography when signs and symptoms are subtle or complex, while patients appreciate not having to travel for imaging. Case report: Ultrasound diagnosis of possible scrotal filariasis – Mobile mega sperm a differential R Mahmood and C Amadi Ultrasound, Queen’s Medical Centre, Nottingham, UK Abstract Filariasis (lymphatic filariasis) is primarily caused by a bite to the skin by an infected mosquito, which allows the invasion of filarial nematodes (roundworms) transferring themselves to the lymphatic system, where they nest and multiply. Research has shown that about 120 million people are currently infected, of which 65% are in the Southeast Asia and 30% in Africa. This disease has demonstrated a life span of about 15 years and has been found to cause swelling of the limbs and male genitalia which results in both physical and social disabilities. Although there is low prevalence of this disease in Europe, it is not uncommon for people who travel to endemic regions, to contract this disease. Therefore, there is a need to bear this in mind while clerking patients during scan. Ultrasound appearances demonstrate bulky, dilated and ectatic lymphatic channels of the epididymis with associated mobile, echogenic foci (live filarial worms) representing the typical ‘filarial dance sign’, exhibiting ‘to and fro’ movements in an appropriate clinical context. However, there is a fine line between the sonographic appearance of the filarial dance sign and post-vasectomy entrapped mobile mega sperm cells. Therefore, with high prevalence of vasectomy in the UK (21% of men of reproductive age compared to the rest of the world) an accurate patient clinical history is vital in distinguishing between the two, ensuring exclusion and paving the way to explore other possible differentials in such cases. The case to be presented describes the differential diagnosis of mobile echogenic foci along the right epididymal body over the region of maximum tenderness with the patient’s long travel history to parts of India and Kenya. The multiparametric sonographer A Hunter, P Parker and O Byass Ultrasound, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK Abstract Sonographer role development has been well established within the local ultrasound service for many years. The year 2001 saw the training of the first sonographer within this Trust to undertake transrectal ultrasound-guided prostate biopsy procedures Abstracts (TRUS). The service has expanded and there is now a well-established team of six sonographers performing TRUS. Changes in prostate cancer pathways, coupled with cancer targets, have led to increased pressure to innovate and improve the service provided in terms of turnaround times, reduced infection rates and increased diagnostic biopsy yield. To this end, fusion guided TRUS (fTRUS) was developed in 2015 to aid targeting specific lesions identified on multiparametric MRI (mMRI). This fTRUS service has been developed, and is now provided, predominantly by two of the TRUS sonographers. Demand for prostate imaging and biopsy has risen recently in light of increased publicity due to high-profile celebrities being diagnosed with prostate cancer. In addition, there is a move towards pre-biopsy MRI given the benefits of targeted biopsy. These changes have resulted in increased demand for radiologist skills at a time when there are significant recruitment issues and pressures from other service areas. Given that fTRUS requires an understanding and interpretation of mMRI to ensure the correct area is targeted during the biopsy procedure, the sonographers providing this local service began to develop such skills. A solution for increasing fTRUS and mMRI demand has been to formalise the sonographer’s skill development into an in-house mMRI reporting training programme. Using radiologists’ reports as the gold standard, the sonographer reporting skills have been assessed. Integrating prostate MRI reporting by sonographers into practice has demonstrable benefits to patient care and contributes to the delivery of a sustainable, safe and timely pathway. The role and benefits of the multiparametric sonographer are described in this presentation. Early post-operative ultrasound for renal transplant: What not to miss K McFeely1, T Davies1, M Murphy1 and C Gutteridge2 1 Radiology, Peninsula Radiology Academy, Plymouth, UK 2 Radiology Derriford Hospital, Plymouth, UK Abstract Ultrasound (US) is the preferred imaging modality for evaluation of renal transplants in the immediate post-operative period and long-term follow-up. This is namely due to its accessibility, inexpensive and non-invasive qualities. Furthermore, patients can remain monitored on the hospital ward with the scanning performed portably if necessary. Upwards of 3300 renal transplants were performed in the UK NP11 in the last financial year, 1009 living, 1404 donation after brain death (DBD) and 934 donation after circulatory death (DCD) with an estimated 5000 or more patients on the waiting list.1,2 At Derriford Hospital, as the tertiary referral centre for the South West, a total of 57 renal transplants were performed within the same time period: 17 living, 18 donation after brain death (DBD) and 22 donation after circulatory death (DCD). Twenty-one patients (39%) underwent renal ultrasound prior to hospital discharge. If there are concerns in the early post-operative period, ultrasound may be used to evaluate and diagnose complications. The principal aim is to identify those complications which may benefit from urgent surgical intervention. These include renal vein thrombosis, renal artery thrombosis, arterial kink and large perinephric collections. This paper demonstrates typical post-surgical sonoanatomy and identifies common early complications of renal transplant that can be depicted sonographically and are essential not to miss. References 1. NHS Blood and Transplant. Transplant activity report. Bristol: NHS Blood and Transplant, 2018, www.organdonation.nhs.uk/ supporting-my-decision/statistics-about-organ-donation/transplant-activity-report/ (accessed 13 March 2019). 2. Give a Kidney. Why we need more altruistic kidney donors. London: Give a Kidney, 2018, www.giveakidney.org/why-weneed-more-donors/ (accessed 13 March 2019). Sonographic appearances of mid- and long-term renal transplant complications T Davies1, K McFeely1, M Murphy1 and C Gutteridge2 1 Radiology, Peninsula Radiology Academy, Plymouth, UK 2 Radiology, Derriford Hospital, Plymouth, UK Abstract Ultrasound (US) is the preferred imaging modality for evaluation of renal transplants in the immediate post-operative period and long-term follow up. This is namely due to its accessibility, inexpensive and non-invasive qualities. Upwards of 3100 renal transplants were performed in the UK in the last financial year. An estimated 5000 or more patients remain on the waiting list.1,2 During the mid and late postoperative period and at routine follow-up, ultrasound may be used to evaluate the transplant and diagnose complications. It is important to understand that different complications occur at different stages NP12 following a transplant. The complications seen at this stage are often managed medically, or with the assistance of interventional radiology. These include rejection, peri-nephric collections, vascular stenosis, ureteric stenosis, renal calculi, malignancy and recurrence of original pathology. In this imaging review, we aim to demonstrate typical post-surgical sonoanatomy and identify common mid and late urological, vascular and neoplastic renal transplant complications seen in the follow-up period. References 1. NHS Blood and Transplant. Transplant activity report. Bristol, NHS Blood and Transplant, 2018, www.organdonation.nhs.uk/ supporting-my-decision/statistics-about-organ-donation/transplant-activity-report/. 2. Give a Kidney. Why we need more altruistic kidney donors. London, Give a Kidney, 2018, www.giveakidney.org/why-weneed-more-donors/. Case report: Splenic artery pseudoaneurysm, a rare complication of pancreatitis A Hurleston Ultrasound, Stockport NHS Foundation Trust, Stockport, UK Abstract Splenic artery pseudoaneurysm is a rare finding associated with chronic pancreatitis, acute pancreatitis, pancreatic pseudocyst or abdominal trauma. Formation of a splenic pseudoaneurysm is thought to be attributed to digestion of the splenic artery by pancreatic enzymes; the artery wall weakens, forming a pseudoaneurysm. A 79-year-old male was referred to ultrasound with known liver cirrhosis as part of a routine six monthly hepatoma screening. The patient had a history of chronic pancreatitis and a cholecystectomy six years ago. The ultrasound examination revealed an incidental, ill-defined complex mass in the left upper quadrant which measured 58 mm in diameter with turbulent arterial flow noted on colour Doppler. A follow-up CT scan confirmed a giant pseudoaneurysm arising from the splenic artery sited within a thick walled pseudocyst; there was no evidence of acute contrast extravasation to suggest rupture. The remainder of the pancreas showed progressive atrophy and calcification in keeping with chronic pancreatitis. The splenic vein was occluded as a consequence of previous pancreatitis with upper abdominal venous collaterals noted along with secondary gastric varices. Due to a high risk of rupture, the patient was referred to Ultrasound 27(2) hepatobiliary vascular specialists. A follow-up CT several weeks later demonstrated a heterogeneous structure within the tail of the pancreas, most likely a combination of necrosis and chronic pseudocyst with the comment that the previously reported splenic artery pseudoaneurysm had spontaneously thrombosed. This case was an incidental finding; patients usually present with bleeding or abdominal pain. Almost half of patients who present have a concomitant pseudocyst. Embolization is one method of choice for treatment, alternatively surgical or conservative management. Ultrasound has the benefit of being readily available, a real-time dynamic assessment with no contrast required and relatively low cost. MSK Case report: Sonographic evaluation of sciatic nerve damage in a symptomatic patient following pellet shotgun injury G Constantinescu, MH Ho and R Ahluwalia Kings College Hospital NHS Foundation Trust, London, UK Abstract The aim of this investigation was to accurately determine the level and extent of sciatic nerve injury in a victim of pellet gunshot assault to the left lower limb. Upon initial plain film and CT assessment to exclude bone and vascular trauma, high resolution, sonographic evaluation of the right sciatic nerve was performed. Two dedicated MSK Radiologists performed high-resolution ultrasound evaluation of the sciatic nerve for the patient. Although the sciatic nerve remained in continuity (no nerve transection seen), at least three pellets were identified within the nerve sheath in the upper and mid-left thigh. Sonographic assessment of sciatic nerve for pellet injury is relatively fast, accurate and reliable and has significant advantages over modalities such as plain film, CT and MRI evaluation, which cannot precisely identify the relationship between pellets and nerve. The sonographic evaluation is also noninvasive. Abstracts Professional Issues Isle of Wight peer review D Beare Diagnostic Imaging, Isle of Wight Healthcare NHS Trust, Newport, Isle of Wight, UK Abstract Sonographer is not a protected title recognised by the HCPC at present, but there is continuing work to change this. Once this happens, there is likely to be a more robust expectation for review and regulation of work practices within the ultrasound profession. There remains no national requirement for regulation of sonography practice within a very diverse group of ultrasound practitioners. There is, however, a need for practicing sonographers to regularly audit the quality of their work, identify any potential errors and plan CPD and training needs around the outcomes. The BMUS Peer Review Toolkit was launched at the BMUS conference in Cardiff in 2015. The Toolkit was introduced into practice on the Isle of Wight in January 2016. There was early enthusiasm to use the toolkit to benchmark our work but it has been difficult to maintain the process for a number of different reasons. We have also found that the toolkit and peer review process have had some unexpected and sometimes adverse effects on our practice and throughput. We have continued to use the toolkit and adapted our practice in some areas as a result of the outcomes. The toolkit provides a benchmark for assessing the quality of imaging and reporting but does not include a review of professional practice outside of these processes. We believe that a full QA review should include all of these processes, so we have added systems to include these to our overall QA programme. Are we doing enough to protect patients? J Burnage JB Imaging Solutions, Manchester, UK Abstract Whose responsibility is it to ’police the practitioners’? Every one of us has colleagues we would want to scan us if we were in need and it is highly likely that everyone of us also has a list of colleagues (past or present) whom we would not want to scan us. But what are we doing about it? How are we protecting patients from people who we wouldn’t have scanning our friends and family? What are employers/managers/ commissioners/providers doing to ensure that those NP13 performing ultrasound are doing what their CV/ references/agency say they can do and to a level deemed acceptable? Where are lines of accountability drawn and who draws those lines? Breathing a sigh of relief when we ’get rid of’ a poor performer is understandable but it is also unacceptable to do nothing else. I believe that the health and safety of patients is being compromised and until the industry as one puts strategies in place to ensure that information is shared, we are all complicit in the harm that comes from turning a blind eye. Veterinary Hepatic diseases differentials in dogs and cats M Lobacz Radiology, Davies Veterinary Specialists, Higham Gobion, UK Abstract Differential diagnosis divided for focal or multifocal disease: differentiation of hepatocellular carcinoma with hepatocellular adenoma cannot be done alone with ultrasound; CT contrast is needed. Hepatocellular carcinoma: central (79%), marginal enhancement (93%) in the arterial phase; cyst like lesions (93%); capsule formation (93%) and hypoattenuation in portal (86%) and equilibrium phase (93%). Hepatic adenoma: diffuse enhancement pattern during the arterial phase 57% which was also found in nodular hyperplasia 60% but never in hepatocellular carcinoma; contrast retention more frequent than other groups; nodular hyperplasia: isoattenuation in the equilibrium phase, likely to have capsule structure 20%. Target lesions were associated with malignancy in 67% instances. However, may represent benign nodular hyperplasia, pyogranulomatous hepatitis, cirrhosis, chronic active hepatitis and others. Haematoma: The internal appearance changes as it ages. Acute haemorrhage <24 hours old is echogenic; within the first week haematoma becomes more hypoechoic and better defined, with a mixture of solid and fluid components. Over the next several weeks, the haematoma becomes increasingly less distinct as fluid is resorbed and spaces are filled with granulation tissue. Acute abdomen in case of liver lobe torsion may mimic hepatic mass, it is hypoechoic or mixed echogenicity, use Doppler – absent or reduced blood flow. Left lateral liver lobe predisposed in large breed dogs. Diffuse liver diseases: hepatic congestion due to right sided insufficiency such as: (1) NP14 Cardiac tamponade causing increased pressure within the CVC ¼ > hepatic veins appear dilated, the liver is enlarged and diffusely hypoechoic; (2) Caudal vena cava obstruction. Hepatomegaly due to the endocrine diseases: hyperadrenocorticism, hypothyroidism, diabetes mellitus, hepatitis and due to neoplasia. Linear branching mineral opacities in canine liver may be due to the previous cholangiohepatitis – incidental finding – predisposed CKCS. Biliary tract diseases: Gallbladder wall thickening: cholecystitis, oedema, cystic mucosal hyperplasia, rarely neoplasia. Gallbladder mucocele suspected rupture – to cut or not to cut? All depends on the clinical presentation of the patient. Clinical signs, although sometimes absent, include abdominal pain, inappetence, fever, vomiting and icterus. Predisposition with hyperadrenocorticism. Distention of the intrahepatic biliary tracts indicates biliary obstruction >7 days long. Small animal musculoskeletal ultrasound O Taeymans Diagnostic Imaging, Dick White Referrals, Six Mile Bottom, UK Abstract Ultrasound is very suitable for examining musculoskeletal structures. It is too often forgotten as a complementary imaging modality to radiographs, and instead should be considered as a logical next step before resorting to using more expensive imaging modalities. Most musculoskeletal applications require a high-frequency (>10 MHz) linear transducer. Very superficial structures may require the use of a stand-off pad to display these structures at a greater image depth, where image resolution is better. Most common indications are evaluation of the tendons surrounding the shoulder (biceps, supraspinatus and infraspinatus), soft tissue abscesses, and foreign bodies. Other tendinous structures that are commonly evaluated are the psoas muscle insertion, the gastrocnemius origin, the common calcaneal tendon insertion, the abductor pollicis longus, patellar ligament and the abdominal wall. Joint effusion, synovial proliferation, joint neoplasia, myositis and muscle tumours can also be evaluated, whereby ultrasound can further assist in obtaining samples for cytology/histology or guide the injection of steroids. Despite not being able to travel through healthy bone, ultrasound can be very helpful in assessing pathologically affected bone. Monitoring fracture healing by differentiating fibrous vs. bony callus formation and assessing Ultrasound 27(2) vascularisation of the callus, diagnosing osteomyelitis, bone tumours, as well as detecting small osteophytes not detectable on radiograph are occasionally performed. Less rewarding results have been reported for the diagnosis of hip dysplasia, avascular necrosis of the femoral head, medial coronoid pathology, osteochondrosis of the shoulder and tarsal joints, as well as assessing cranial cruciate ligaments, articular cartilage and menisci. What difference has ultrasonography made in veterinary anaesthesia M Drozdzynska Veterinary Anaesthesia, Dick White Referrals, Six Mile Bottom, UK Abstract In the last few years, the use of ultrasound increased significantly in the field of veterinary anaesthesia. For many loco-regional anaesthesia techniques, ultrasonography serves as a useful alternative or complementary technique to the use of peripheral nerve stimulator. Due to direct visualisation of targeted nerves, it allows for local anaesthetic dose reduction, increased block precision and reduced risk of nerve damage. Furthermore, ultrasonography allowed to develop completely new group of loco-regional anaesthesia techniques called intrafascial/compartmental bocks. They facilitate predictable anaesthetic spread via use of anatomical fascias. Due to hypoechoic character and superficial location of most fascias these blocks are classified as low-risk and easy to master loco-regional techniques. The serratus plane block designed for thoracic wall procedures and transversus abdominis plane block for abdominal procedures will be presented as an examples. Finally, ultrasonography is currently used for peripheral nerve/plexuses catheter placement which due to the use of differential block phenomenon, allows for more effective management of acute postoperative pain. Overall, ultrasonography due to improvement and widening the spectrum of available loco-regional anaesthesia techniques facilitates the way towards opioid-free analgesia in veterinary profession. Prevalence and clinical significance of the medullary rim sign identified on ultrasound of feline kidneys A Ferreira, R Marwood, T Maddox and J Mortier University of Liverpool, Liverpool, UK Abstracts Abstract The medullary rim sign (MRS) is a recognised ultrasonographic (US) feature of feline kidneys that has been identified in normal and diseased kidneys. The objectives of this study were to determine the prevalence of the MRS in a population of cats from a referral hospital and identify if the presence, or any specific US features, of the MRS are associated with renal disease. Renal US images from 661 cats were reviewed and cases with an MRS identified. An equal number of time control cases without a MRS were collected and compared in a retrospective case-control study. Medical data retrieved included age, weight, sex, breed, biochemical results, urinalysis results and final clinical diagnoses. US images and reports were reviewed and the MRS presence, thickness, intensity, symmetry, changes on repeat US scans as well as additional renal US findings were recorded. Associations between independent variables and the MRS were examined with conditional and unconditional logistic regression. In the 661 reviewed cases, 243 (36.8%; 95% CI: 33.1–40.1) showed a variation of the MRS; thin and thick medullary rims were identified in 133 (54.7%) and 110 cases (45.3%) respectively. A thick MRS in the presence of additional renal findings (loss of corticomedullary definition, pyelectasia and reduced size) was associated with renal disease (P ¼ 0.03). The presence of a thin rim only, was associated with an absence of renal insufficiency, although this was not a significant association. There was an association between the presence of MRS and a final diagnosis of feline infectious peritonitis (P ¼ 0.045). Hypercalcemia was not associated with the presence of MRS (P ¼ 0.52). The MRS is a common finding in cats. Based on these results a thin MRS is usually a nonspecific finding not associated with renal insufficiency or hypercalcemia. A thick MRS in combination with other US findings is associated with renal disease. New Technologies for Clinical and Preclinical Research Opening the blood–brain barrier with an implanted ultrasound device for increasing the penetration of carboplatin into the brain: Preclinical and clinical results C Lafon1, M Canney2, A Idbaih3 and A Carpentier3 1 LabTAU INSERM, Lyon, France 2 Carthera, Paris, France 3 Pitié Salpêtrière Hospital Paris APHP, Paris, France NP15 Abstract The blood–brain barrier (BBB) limits the penetration of most drugs into the brain. Pulsed ultrasound in combination with injected microbubbles can transiently disrupt this BBB to increase the passage of drugs to brain tissue. An implantable unfocused ultrasound source operating at 1 MHz, SonoCloud, was used to repeatedly disrupt the BBB in patients with recurrent glioblastoma (GBM) prior to carboplatin chemotherapy. The goal of the presentation will be to describe recent pre-clinical work on carboplatin activity in glioma models as well as an update on the clinical work. Experiments were first performed in a primate model in order to assess the carboplatin chemotherapy distribution after BBB disruption. Then, efficacy of combined carboplatin and BBB disruption was evaluated on mice bearing orthotopic human GBM xenografts. A first-in-man clinical trial at the University Hospital Pitié Salpêtrière, APHP, Paris, France was conducted. GBM patients with tumor recurrence had surgery to implant the SonoCloud device. It was then operated monthly in a < 10 minute procedure in conjunction with IV administration of carboplatin and microbubbles. Patients were monitored clinically and T1w contrast-enhanced MR images were used to visualize BBB disruption. BBB disruption resulted in a significant local increase of Carboplatin concentrations in the primate model and an increase in survival in GBM mouse models. Twenty-five patients were included in the study and 85 sonications were performed. BBB disruption was visible on MRI and depended on the applied ultrasound pressure. No carboplatin-related neurotoxicity was observed and only minor related adverse events were observed. Pulsed ultrasound with the SonoCloud device was well-tolerated and may increase the effectiveness of drug therapies in the brain. Future work will aim at improving the efficacy of the treatment by sonicating larger volumes of brain. Clinical trial information: NCT02253212. Non-linear acoustic emissions from therapeutically driven contrast agent microbubbles JH Song and P Prentice CavLab, Medical and Industrial Ultrasonics, University of Glasgow, Glasgow, UK Abstract Non-linear emissions from microbubbles introduced to the vasculature for exposure to focused ultrasound are routinely monitored for assessment of NP16 therapy and avoidance of irreversible tissue damage. Yet the bubble-based mechanistic source for these emissions may not be well understood. In this presentation, dual-perspective high-speed imaging at 210,000 frames per second (fps), and shadowgraphically at 10 Mfps, is used to observe cavitation from microbubbles flowing through a 500 mm polycarbonate capillary, exposed to focused ultrasound of 692 kHz at therapeutically relevant pressure amplitudes. The acoustic emissions are simultaneously collected via a broadband calibrated needle hydrophone system. The observations indicate that periodic bubble-collapse shock waves dominate the non-linear acoustic emissions, including subharmonics at higher driving amplitudes. Contributions to broadband noise through variance in shock wave amplitude and emission timings are also identified. Possible implications for in vivo microbubble-cavitation detection, mechanisms of therapy and the conventional classification of cavitation activity as stable or inertial are discussed. Development of a 1-D linear phased ultrasonic array for intravascular sonoporation A Moldovan1, S Cochran2 and A Gachagan1 1 2 University of Strathclyde, Glasgow, UK University of Glasgow, Glasgow, UK Abstract Sonoporation is a minimally invasive targeted drug delivery technique that relies on high-power ultrasound to cavitate microbubbles (MBs) in the proximity of cells. The therapeutic purpose is to increase the cells’ permeability to exogenous agents and thus improve the efficacy of drugs in the treatment of various pathologies. External hepatic sonoporation is particularly difficult because of the ribs, which lead to heat deposition through ultrasound attenuation and beam scattering. Liver movement during patient respiration and the surrounding fat layer are other complications. The objective of the current work is to design an 11-Fr catheter transducer that overcomes these issues by providing sonoporation intracorporeally from within a larger hepatic vein. The transducer is a 1-D linear phased array made of 1–3 piezocomposite material. The active materials investigated are ceramic (PZT-5H) and single-crystal (PMN-29%PT and 26%PIN-PMN-32%PT) and are coupled with a polymer filler (EpoFix, Struers, UK). The array behaviour was simulated using finite element modelling (FEM) (PZFlex, Onscale, Cupertino, CA, USA) and its performance was improved through Ultrasound 27(2) a parametric sweep of volume fraction and aspect ratio. The monitored output was peak negative pressure (PNP) which is related to cavitation threshold and sonoporation efficiency. Two operating frequencies were investigated: 1.5 MHz, limited by transducer thickness compatible with catheter diameter, and 3.0 MHz, approximate MB resonance. The number of array elements is 24 for the lower frequency array and 32 for the higher frequency one. The array elevation is 2.4 mm and the length is approximately 10 mm. A total of six transducer arrays are currently being prototyped using the dice and fill method. The wiring of the transducers is achieved with a flexi circuit applied on the back of the array using conductive paint while the front of the transducer is grounded with a single electrode. A microballoon-filled epoxy backing is present to provide transducer robustness. The parametric sweeps showed that one pillar per element in the array length direction achieves the lowest PNP for all cases. Electrical impedance simulations related reduced array elevation to lateral reflections and a decrease in overall performance. The two single crystal active materials proved to have similar efficiency but were 33% better than the ceramic. PNP at the focal point of the arrays was around 4 MPa at 1.5 MHz and 17 MPa at 3.0 MHz for an excitation signal of 200Vpp. A single element transducer was designed and manufactured for model validation and sonoporation tests. The impedance measurements of the manufactured transducer indicate that the electrical resonance frequency aligns well with the model, but the coupling coefficient is reduced. Pressure maps in water show the beam shape is similar to the model and the PNP is half that of the model which is attributed to FEM assumptions of perfect electrical matching and higher piezoelectric coupling coefficients. Future work will involve finalising the array fabrication and characterisation. The transducers will be tested for cavitation efficiency using high-speed video imaging and passive acoustic mapping. Sonoporation tests will be performed in vitro and a liver phantom will be used for pressure and temperature measurements. Finally, the transducer will be implemented in a catheter. Abstracts NP17 QUANTuM: A CSO Knowledge Transfer Partnership focusing on quality assurance in MR-guided high-intensity focused ultrasound 1 2 1 Experimental variation in the measurement of ultrasound fields E Martin and B Treeby University College London, London, UK 2 F Fedele , B Zeqiri , D Butler , P Miloro , D Sinden2, Il Shahzad1, L Monzon1, H Abbas1, F Bosio1, M Thanou3 and A Gangi1 1 Guy’s and St Thomas NHS Foundation Trust, London, UK 2 Ultrasound and Underwater Acoustics, National Physical Laboratory, Teddington, UK 3 King’s College London, London, UK Abstract MR-guided high-intensity focused ultrasound (MRgHIFU) is a novel therapy that exploits MR guidance to deliver targeted sustained ultrasound heating to cancerous lesions.1,2 In the UK, the procedure has so far been NICE approved only for prostate cancer and benign tumours (fibroids), but has the potential to treat most cancer lesions and be used for neurological diseases and palliative care.1–4 Treatment protocols and quality assurance procedures in place for such therapies are far behind those of other established techniques, such as radiotherapy. This lack of robust and standardised procedures is contributing to limit the diffusion of this therapy. In July 2018, Guy’s and St Thomas NHS Foundation Trust and National Physical Laboratory set up a 12 months NHS Knowledge Transfer Partnership, supported by the Chief Scientific Office (CSO), BMUS, the Institute of Cancer Research (ICR), Therapy Ultrasound Network for Drug Delivery and Ablation Research (ThUNDDAR), and the Institute of Physics and Engineering in Medicine (IPEM) and collaborators at King’s College London. The aim of the collaboration is to develop Quality Assurance and Treatment planning for MRgHIFU (QUANTuM) and facilitate dissemination of the procedure in UK. This is a report on the first five months of collaboration, and the longer term plan, including both scientific and system leadership developments. References 1. ter Haar G and Coussios C. High intensity focused ultrasound: physical principles and devices. Int J Hyperthermia 2007; 23: 89–104. 2. Giles S. MRgHIFU for pain palliation of bone metastases. In: 12th UK Therapeutic Ultrasound Interest Group, National Physical Laboratory, Teddington, May 2015. 3. NICE Interventional Procedure Guidance 424. Treating localised prostate cancer using high-intensity ultrasound in a targeted area of the prostate. London: NICE, 2012. 4. NICE Interventional Procedure Guidance 413. Magnetic resonance image guided transcutaneous focused ultrasound for uterine fibroids. London: NICE, 2011. Abstract Measurement-based simulation of ultrasound fields is important for accurate prediction of in situ exposure levels in both ultrasound therapy and diagnosis. To ensure the simulations are accurate, thorough experimental validation is required. Sources of error can arise from both the model and measurement, and must be understood in order to determine the level of agreement between the model and the measurement. This talk discusses sources of error in measurements of acoustic pressure arising from properties of the source, measurement equipment and data processing. The variation in repeated measurements of ultrasound fields, as well as comparison of measurements of ultrasound fields made with a range of hydrophones is presented and the implication for model validation is discussed. A new protocol for in vitro study of low intensity pulsed ultrasound J Savva, M Lucas and H Mulvana Medical and Industrial Ultrasonics, School of Engineering, University of Glasgow, Glasgow, UK Abstract Clinical trials have shown that low intensity pulsed ultrasound (LIPUS) stimulates healing of fractured bone.1 Numerous in vitro studies investigated LIPUS effects by measuring cellular markers of bone regrowth, such as Prostaglandin E2 (PGE2).1 However, comparison of results is difficult because the acoustic field is often inadequately characterised or affected by the set-up. In addition, mechanical bioeffects are the most likely mechanism of LIPUS stimulus,1 implying peak negative pressure (p) is the best indicator of LIPUS dose. But the LIPUS field is usually defined by intensity (ISATA). This pilot study tested a robust and repeatable protocol for in vitro investigation of LIPUS, with a new definition of dose based on p. Custom-built ‘biocells’ were seeded with MC3T3-E1 osteoblasts (50,000 cells/cm2) and incubated overnight. The biocells consisted of circular 3D-printed frames (VeroGrayTM) bounded by 6 mm-thick Mylar (Goodfellow, UK) forming an acoustically transparent window and cell growth surface. Cells and media were injected via self-sealing septa (Merck, UK). A purpose-built transducer (Ferroperm NP18 Ultrasound 27(2) PZT27, 25 mm diameter) was driven with a LIPUS pulse (frequency 1 MHz, pulse width 200 ms, repetition rate 1 kHz) to produce maximum peak negative pressures (p^ ) up to 500 kPa at 100 mm from the front face. Beam patterns were measured with a 0.5 mm needle hydrophone (Precision Acoustics, UK). The average LIPUS dose was estimated by averaging p across the biocell window area (p , SA). Transmission measurements through the biocell window confirmed the acoustic field was not altered. After incubation, biocells were filled with media and mounted so the cell layer was 100 mm from the transducer. They were then exposed to 20 minutes LIPUS (p^ ¼ 0 kPa to 500 kPa) in a tank of sterilised water at 37 2 C. After exposure, all but 5 ml of media was removed and the biocells incubated for 20 hours. PGE2 concentration in the media was measured by enzyme-linked immunosorbant assay (Abcam AB133021) and microplate reader (Tecan, AT). PGE2 up-regulation was significantly enhanced at p^ ¼ 100 kPa (p , SA ¼ 21 kPa), corresponding to ISATA close to that of typical LIPUS fields. To date, the ultrasound exposure method has only been repeated once, but the results give early confidence in the methodology. However, cell adhesion was an issue and future work will focus on developing the method to improve this, plus the robustness of the ‘biocell’ frames and tank temperature variation. Cell proliferation will also be considered. The final method will enable a controlled investigation of optimum LIPUS fields, focussing on low frequency, to provide quantitative assessment of how ultrasound can promote bone healing at frequencies representative of commercial ultrasonic osteotomy devices. advantages of machine learning is that it can be effective when the data are acquired without a carefully controlled experimental design, when there is variability between experimental setups, or in the presence of complicated nonlinear interactions. However, a robust algorithm requires the selection and extraction of a number of features. A feature is an individual measurable property or characteristic of the phenomenon being observed. Ideally, features should be independent, informative and discriminating, encapsulating all the required information about a system. The majority of the literature on cavitation detection has been based on statistical methods, typically using integrated broadband noise as the dominant feature for determining the thresholds at which inertial cavitation is likely to occur. There is an increasing recognition of the need for standardisation in both the detection and the reporting of cavitation activity. In this talk a number of features, extracted from both time- and frequency-domain information from both continuous and pulsed exposures in water are described and a classification algorithm presented. The advantages and disadvantages of the features and the experimental consequences of attempting to capture all the possible features is discussed, as well as possible extensions to the include models which can distinguish between types of cavitation, or attempt to predict quantities from a given exposure. Reference JF Aubrey 1. Padilla F, Puts R, Vico L, et al. Stimulation of bone repair with ultrasound. In: Escoffre JM and Bouakaz A (eds) Therapeutic ultrasound. Basel: Springer International Publishing, 2016, pp. 385–427. Institut Langevin, Paris, France Machine learning for cavitation detection D Sinden National Physical Laboratory, Teddington, UK Abstract This talk presents some work in progress on applying techniques from machine learning to cavitation detection. Machine learning can be used to find generalizable predictive patterns from a training data set. This predictive capability aims at forecasting unobserved outcomes, without necessarily knowing how a system fully works. Indeed, one of the Modulating brain activity with focused ultrasound: Feasibility, challenges and recent breakthroughs Abstract Transient ultrasonic neuromodulation has been demonstrated in rodents,1,2 non-human primates3 and humans.4 Transcranial ultrasonic brain therapy at frequencies higher than 500 kHz requires adaptive focusing to compensate for the aberrations induced by the skull bone. Nevertheless, challenges remain, such as how to illicit sustainable effects, and how to precisely target deep seated targets in human brains (Lee et al.4 was limited to cortical stimulation). We will show here that the effects of ultrasonic neuromodulation can be extended to 30 minutes by optimizing the ultrasonic parameters. Moreover, we will present a novel low-cost technique to focus ultrasound beams deep into human brains. Transcranial focusing is currently achieved by using multi-element arrays driven by a dedicated Abstracts multi-element electronics. A growing number of elements were used to improve the focusing: 64 elements in 2000,5 300 in 2003,6 1024 in 20137 and with more to come. We will present some of the salient results obtained pre-clinically and clinically with such multielement transcranial devices. Nevertheless, we will show that comparable transcranial focusing can be achieved with a novel approach in rupture with the current trend. It consists in a single-element covered with a 3D silicone acoustic lens of variable and controlled thickness. Similar lenses have been introduced in the past to perform single or multiple focusing patterns in homogenous propagating media8 but recent 3D printing and milling capabilities make tailor-made 3D lenses a feasible option for transcranial adaptive focusing.9 References 1. Younan Y, Deffieux T, Larrat B, et al. Influence of the pressure field distribution in transcranial ultrasonic neurostimulation. Med Phys 2013; 40: 082902. 2. King RL, Brown JR, Newsome WT, et al. Effective parameters for ultrasound-induced in vivo neurostimulation. Ultrasound Med Biol 2013; 39: 312–331. 3. Wattiez N, Constans C, Deffieux T, et al. Transcranial ultrasonic stimulation modulates single-neuron discharge in macaques performing an antisaccade task. Brain Stimul 2017; 10: 1024–1031. 4. Lee W, Kim H, Jung Y, et al. Image-guided transcranial focused ultrasound stimulates human primary somatosensory cortex. Sci Rep 2015; 5: 8743. 5. Clement G, Sun J, Giesecke T, et al. A hemisphere array for noninvasive ultrasound brain therapy and surgery. Phys Med Biol 2000; 45: 3707–3719. 6. Pernot M, Aubry JF, Tanter M, et al. High power transcranial beam steering for ultrasonic brain therapy. Phys Med Biol 2003; 48: 2577–2589. 7. Lipsman N, Schwartz ML, Huang Y, et al. MR-guided focused ultrasound thalamotomy for essential tremor: a proof-of-concept study. Lancet Neurol 2013; 12: 462–468. 8. Fjield T, Silcox CE and Hynynen K. Low-profile lenses for ultrasound surgery. Phys Med Biol 1999; 44: 1803–1813. 9. Maimbourg G, Houdouin A, Deffieux, et al. 3D-printed adaptive acoustic lens as a disruptive technology for transcranial ultrasound therapy using single-element transducers. Phys Med Biol 2018; 63: 025026. NP19 Abstract The clinical benefit of immunotherapy has not yet been realised in pancreatic cancer, which is characterised by a low antigenicity and dense stroma profile. Focused ultrasound (FUS) can be used in the treatment of solid tumours, either by inducing necrosis (using ablative temperatures), or by creating cavitation which results in mechanical disruption of the stroma. Both of these processes may regulate the immune response and make the tumours more susceptible to immunotherapeutic treatments. In this study, pancreatic tumours have been exposed to pulsed FUS and co-treated with immune checkpoint inhibitors (ICI) to explore whether control of the tumour growth can be achieved. Syngeneic orthotopic KPC pancreatic tumours (KrasLSL.G12D/þ; p53R172H/þ; PdxCre tg/þ) were grown in immunecompetent murine C57BL/6 subjects (>15 weeks old). Tumours were exposed to pulsed FUS using the small animal Alpinion VIFU 2000 Therapeutic ultrasound platform. Pulsed FUS exposure parameters were designed to result in cavitation (power ¼ 200 W, duty cycle ¼ 1 %, pulse repetition frequency ¼ 1 Hz, 25 repeats) in the target tissue. A combination of anti-CTLA4 and anti-PD-1 antibodies were administered intraperitoneally three days before treatment, and every three days thereafter. Tumour growth was estimated using high-frequency ultrasound imaging, and with callipers at the time of culling. Pulsed FUS treatment of pancreatic tumours resulted in cell and collagen depleted regions in the tumours, associated with an extensive rearrangement of the extracellular matrix. No skin damage was observed. Combination of a single pulsed focused ultrasound treatment with administration of ICIs resulted in improved control of tumour growth relative to the monotherapies and sham exposures. Additional results for the systemic and localised abundance of immune cells will be presented. Frequency optimisation for opening the blood–brain barrier A preclinical study of the combinatorial effects of pulsed focused ultrasound and immune checkpoint inhibitors in pancreatic cancer B Treeby1, E Martin1, James Choi2 and A Hurrell3 P Mouratidis, M Costa, I Rivens and G ter Haar Abstract Significant advances have been made in the development of therapeutic agents for the treatment of neurodegenerative diseases, psychiatric illnesses and brain cancers. However, the blood–brain barrier (BBB) presents a major impediment to the delivery Joint Department of Physics, The Institute of Cancer Research: Royal Marsden NHS Foundation Trust, Sutton, UK 1 University College London, London, UK mperial College London, London, UK 3 Precision Acoustics, Dorchester, UK 21 NP20 of larger molecules into the interstitial fluid of the brain, which severely limits the clinical efficacy of these agents. There is now well-established evidence that ultrasound can reversibly and selectively disrupt the BBB. One remaining challenge in the transcranial application of ultrasound is that the skull can lead to significant attenuation and aberration of the transmitted waves, which affects the quality of the ultrasound focusing, and thus the targeting and specificity of the BBB opening. This can be overcome using lower frequency ultrasound waves (below 500 kHz); however, this increases the presence of standing waves, which can have a similarly deleterious effect on treatment specificity. The purpose of this ThUNDDAR-funded pilot study is to carefully examine the interplay between the ultrasound drive parameters and the transmission loss, aberration and standing waves caused by the skull. In this presentation, we report preliminary results from the study. Non-bubble mechanisms of sonothrombolysis C Everbach University of Oxford, Oxford, UK Abstract Sonothrombolysis or ultrasound-accelerated thrombolysis is the dissolving of blood clots with ultrasound (and often microbubbles). Exogenous microbubbles, under appropriate conditions, can greatly accelerate sonothrombolysis, but there is also evidence that endogenous microbubbles form during clotting. Overpressure experiments show that about half of the acceleration due to ultrasound persists in the absence of bubbles. What is the mechanistic basis of this effect? Based on fundamental physical and biochemical mechanisms, the presentation will highlight outstanding problems with understanding the non-bubble components of sonothrombolysis. Photoacoustic imaging with photothermal therapy and gold nanorods for a new approach to lung cancer management O Knights1, T Carpenter1, D Cowell1, S Freear1 and J McLaughlan1,2 1 School of Electronics and Electrical Engineering, University of Leeds, Leeds, UK 2 Leeds Institute of Medical Research, University of Leeds, St. James’s University Hospital, Leeds, UK Ultrasound 27(2) Abstract Plasmonic gold nanorods (AuNRs) show potential for use in a range of cancer diagnostics and therapeutics when combined with photoacoustic imaging (PAI) and/or plasmonic photothermal therapy (PPTT). Generally in PPTT, continuous wave (CW) lasers are used to destroy cancerous tissue through bulk heating. However, in order to add a diagnostic component through PAI, a pulsed wave (PW) laser is needed. If PPTT can be achieved using PW lasers then combined theranostic applications with the same laser system is possible. Additionally, AuNRs can be many different sizes but exhibit equivalent surface plasmon resonances (SPRs) so the size may be significant in the efficacy of these modalities. Endobronchial ultrasound (EBUS) is routinely used as part of the patient pathway in order to stage and guide needle biopsies of suspected cancerous regions. EBUS, if combined with nanorods, PPTT and PAI could present a new approach to both identify and treat lung cancer, one of the deadliest forms of cancer, without the need for surgical intervention and/or, radio or chemotherapy. A tuneable 7 ns PW laser was used to irradiate AuNR solutions at their specific SPRs across a fluence range of 1–40 mJ cm2 to determine AuNR melting thresholds. The photoacoustic (PA) emissions from AuNRs with four different lateral widths (10, 25, 40 and 50 nm) across a range of equivalent concentrations were measured, and their PA emission amplitudes calculated via a technique similar to PA image reconstruction. These were also imaged in a pre-clinical photoacoustic system, the inVision MSOT 128 to provide direct comparison. The four AuNR sizes were used for PPTT in a lung cancer cell line (A549), irradiated for 5 minutes with the same PW laser (fluence below the melting threshold) as well as a CW laser (1.5 W/cm2) for comparison. The results indicate that larger AuNRs produce stronger PA signals but are more prone to melting compared with the smallest AuNRs (10 nm), suggesting that AuNR size has a significant effect on PA response. The PPTT efficacy of the four AuNR sizes on an A549 cell line was determined and the temperature profile monitored via a thermal imaging camera. These results suggest that a PW laser can achieve increased cell death without bulk heating. An inhouse diagnostic ultrasound imaging system was used to mimic EBUS in tissue mimicking phantoms demonstrating the potential to use PAI with this established imaging modality. Abstracts NP21 A technique for predicting HIFU acoustic intensity using only electrical measurements Development of an experimental platform for rapid prototyping of UmTDD methods C Adams1, T Carpenter1, D Cowell1, JR McLaughlan1,2 and S Freear1 R Domingo-Roca1, JC Jackson2 and H Mulvana1 1 School of Electronics and Electrical Engineering, University of Leeds, Leeds, UK 2 Leeds Institute of Medical Research, University of Leeds, St. James’s University Hospital, Leeds, UK Abstract Acoustic intensity (AI) is the most common way to control the volume of thermally formed lesions. It can be measured accurately using a radiation force balance (RFB) or estimated using hydrophone measurements. Whilst RFBs are the gold standard, their expense obstructs new researchers from accurately calibrating their HIFU exposures. Both measurements are performed with the transducer in water (i.e. free field), which are then converted into in situ parameters through the application of various models of attenuation. Thus, the introduction of a technique for monitoring acoustic output in real time would greatly benefit treatment planning and the clinical use of HIFU. The peak excitation voltage may be used as a control, but it requires calibration and is not immune to variances in transducer manufacturing or differing excitation circuitry. In this study, it was found that a current probe could be used to predict AI. In the frequency domain, voltage and current waveforms were multiplied to find electrical power. The real components of the power were numerically integrated and a conversion efficiency of 80% was presumed to predict the acoustic power. To find acoustic intensity, the focal volume was approximated using the transducer dimensions. This technique was tested by lesioning ex vivo chicken breast at three Als (700, 1000 and 1400 W/cm2) using a switched circuit and a linear amplifier. Compared with using an RFB, the AI and lesion volume were the same (p 0.05) irrespective of the hardware used when using the described technique. Using only voltage to predict AI produced significantly different intensities and lesion sizes (p 0.05). The results show that it is possible to predict AI without using an RFB. This may make HIFU research more accessible to new researchers and be useful for characterising large multi-element transcranial arrays quickly. 1 Medical and Industrial Ultrasonics, School of Engineering, University of Glasgow, Glasgow, UK 2 Centre for Ultrasonic Engineering, Department of Electronic and Electrical Engineering, University of Strathclyde, Glasgow, UK Abstract Ultrasound has been shown to trigger drug release1 and enhance the uptake of low- and high-weight molecules in cells and tissues.2,3 Although ultrasound itself can induce biological effects, ultrasound-mediated targeted drug delivery (UmTDD) uses microbubbles (mB) to enhance ultrasound effects UmTDD can reduce cytotoxic drug dose, improve local drug delivery, and reduce suffering in cancer treatments. Although ultrasound interaction with blood vessels and mBs has been thoroughly studied, the mechanisms and efficiency of UmTDD in real systems remains unclear, limiting the utility in vitro systems to optimise UmTDD protocols. Developing UmTDD protocols appears to be an extremely challenging task given all the parameters to take into consideration in real systems, being capillary size, shape and morphology the most important features, as they play a relevant role in mB flow and behaviour, directly affecting UmTDD efficiency. Furthermore, experimental testing of UmTDD presents high ethical costs due to the use of animal testing.4,5 In this work we present a new approach to control all the relevant parameters for UmTDD treatments from micro-computer tomography (mCT) data . This approach uses the stereolithography (STL) 3D-printing technique (allowing 3D-printing microchannel widths down to 200 mm) to develop capillary phantoms based on the real systems obtained from the mCT scans, which can further be used to develop controlled protocols allowing a deeper and more detailed study of the phenomena involved in UmTDD with minimal animal use. References 1. Rapoport NY, Christensen DA, Fain HD, et al. Ultrasound-triggered drug targeting of tumors in vitro and in vivo. Ultrasonics 2004; 42: 943–950. 2. van Wamel A, Bouakaz A, Bernard B, et al. Radionuclide tumour therapy with ultrasound contrast microbubbles. Ultrasonics 2004; 42: 903–906. 3. Tachibana K, Uchida T, Tamura K, et al. Enhanced cytotoxic effect of Ara-C by low intensity ultrasound to HL-60 cells. Cancer Lett 2000; 149: 189–194. NP22 4. Raymond SB, Treat LH, Dewey JD, et al. Ultrasound enhanced delivery of molecular imaging and therapeutic agents in Alzheimer’s disease mouse models. PLoS ONE 2008; 3: e2175. 5. Yoon Yl, Kwon Y-S, Cho H-S, et al. Ultrasound-mediated gene and drug delivery using microbuble-liposome particle system. Theranostics 2014; 4: 1133–1144. Day 3 Thursday 6 December Obstetrics Ultrasound 27(2) cases of stillbirth. The national congenital anomaly reporting is now online; this will allow us to improve our reporting and identification of cases. The next step is to set up a local database which will allow more regular comparison with national standards. Challenges to professional autonomy: Australian sonographers’ experiences in communicating adverse outcomes to pregnant patients Antenatal diagnosis of congenital heart disease over a two-year period in an NHS tertiary referral centre S Thomas, K O’Loughlin and J Clarke V White1, G Coleman1 and A Mahendru2 Abstract Unlike the United Kingdom, Australia is yet to formalise the sonographer practitioner role allowing for independent reporting and communication with patients. This research explored the role of Australian sonographers in communicating adverse outcomes in obstetric ultrasound. Advances in ultrasound imaging place sonographers as the frontline practitioner with patients expecting to know scan results immediately. Communicating adverse outcomes is often left to the sonographer, who may feel unsupported and conflicted in deciding whether to convey this information to the patient. Members of the Australasian Sonographer’s Association qualified to perform obstetric ultrasound completed a survey (n ¼ 249) seeking their views and practices on reporting an adverse outcome. Both quantitative and qualitative data were derived from the 33-item instrument. The majority of participants reported that conveying an adverse outcome should be part of the sonographer role, however, they acknowledged the difficulty of doing this without recognition of their professional status and autonomy, and acknowledged that it was, to some degree, dependent on the diagnosis. Most agreed they would communicate a definitive diagnosis such as ‘no fetal heart beat’, whereas it was more difficult with a fetal abnormality. Policy and protocols recognising the professional status of sonographers and providing a supportive framework for their practice are needed so that all stakeholders (patients, sonographers, radiologist/ sonologist) understand and accept the sonographer role. This should occur irrespective of the type of practice or location so patients can expect uniformity. The United Kingdom model of the sonographer practitioner with independent and autonomous reporting and communication could be a starting point for Australia’s sonographers. 1 Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK 2 Feto-Maternal Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK Abstract Antenatal detection of congenital heart defects (CHD) allows parents to make decisions about pregnancy outcomes and improves neonatal morbidity and mortality. By auditing all the cases of CHD detected antenatally, we can ensure we are meeting national standards for detection and management of CHD. This would help us to improve detection rates as well as identify areas of improvement in the management of these women. We carried out a retrospective audit of CHD cases diagnosed antenatally between January 2016 and December 2017. Patient demographics, cardiac views recorded, time-frames for diagnosis and pregnancy outcome were compared against FASP standards, the East Midlands Network referral pathway and national CHD data. Twentythree cases of CHD were identified with 87% defined as severe. The mean maternal age was 28 years with 57% being nulliparous. None of the women had any medical problems and the average BMI was 24.8 kg/ m2. There was 100% compliance with the FASP cardiac views, which were completed by 23 weeks’ gestation; 74% were live births, 17% ended in termination of pregnancy and one baby was stillborn. The mean birthweight was 2486 g with a mean gestational age at delivery of 36 weeks and 5 days. As per the regional referral pathway, 100% patients were reviewed by paediatric cardiology; 26% of cases had associated genetic causes. The screening service in this trust is meeting FASP and regional standards with regard to CHD in the majority of cases. There is inconsistent reporting of undiagnosed serious CHD at birth and in the immediate neonatal period or in Faculty of Health Sciences, University of Sydney, Sydney, Australia Abstracts To FASP or not to FASP? Investigating the impact of storing only FASP recommended anomaly images on patient recall rate C Sampson and G Coleman Ultrasound, Nottingham University Hospitals NHS Trust, Nottingham, UK Abstract Anomaly scans are conducted at Nottingham University Hospitals (NUH) according to the national Fetal Anomaly Screening Programme (FASP) guidelines. Historically, imaging of the anomaly scan followed locally set guidelines which included storing a minimum of 23 images to PACS. A retrospective audit of anomaly scan recalls showed that the departmental recall rate was 20% in January and 22% in February 2018; however, for some sonographers, this was much higher, with the highest recall rate of a sonographer being 93%. The ultrasound clinical specialists worked with individual sonographers with the highest recall rates. It was found that scan technique was good; however, several sonographers were recalling patients if they could not achieve all of the specified images. Some sonographers were also storing up to 70 images per anomaly scan. Consultation with the obstetricians and foetal maternal medicine specialists was undertaken and an agreement was made to trial a new way of working within