Answer
Answer
-
Thanks for the question, Royal Darwin!
We got a very enthusiastic response from the group which I'm sure will help.
Every member of the group is in agreement that retrograde flow must be demonstrated in the ovarian veins for them to be labelled incompetent. This is in keeping with the latest classification by the American Vein & Lymphatic Society (Meissner et al 2021).
That isn’t to say diameter isn’t important. The above paper found >70% positive predictive value for reflux in ovarian vein with diameters ranging from 0.5-0.8cm. In actual practice, the overall experience of the vascular SIG is that ovarian veins with a diameter >0.5cm are often incompetent.
As far as protocol is concerned, having the patient well hydrated is definitely the way to go. Patients can be scanned in the supine position – if views of the ovarian veins are equivocal then scanning patient in a semi recumbent or erect position can help.
As part of this scan, you’ll also want to rule in/out left renal vein (Nutcracker)and left common iliac vein compression (May Thurner) as well as performing a full assessment of the IVC and bilateral iliac veins to assess for patency, flow direction and waveform.
One of the SIG members suggested this would be a great topic for a travelling workshop in Darwin – would that be of interest to you?
Thanks
Vasc SIG
Answer
-
There are no specific measurements for the lateral ventricles at the 12-13 week scan. Instead, Using a subjective approach to assess ventricular anatomy. This is consistent with current research as no systemic approaches are currently used.
Ventriculomegaly and its prognosis is highly dependent on the underlying cause. It may be associated with both chromosomal and non chromosomal causes. Development may occur later in the pregnancy just as ventriculomegally may resolve as the pregnancy progresses.
Currently, suspected isolated ventriculomegaly at the 12 - 13 week scan requires further investigation by fetal neurosonography or tertiary referral.
Attached are some relevant articles.
Answer
-
Thank you for your question.
This is a very tricky scenario. ASA has no "standpoint" on the topic.
However, we would suggest speaking to your radiologist who is reporting and following your local guidelines.
A strategy to approaching these requests would be to speak to your patient, let them know what normal practice is and ensure your ask them if you can check FHR.
We cannot do anything without patient consent. If the patient declines any imaging of the fetus, please ensure you are clear on your worksheet and document that the patient declined.
Answer
-
Thanks for your question regarding GCA. It brought with it a unanimous answer from three members of the vascular SIG. The points made where that there are no official guidelines for assessing for GCA in Australia and yes, the axillary artery should definitely be included as part of the study as GCA has been well documented in this vessel.
Its more the Rheumatology space that investigates GCA - please find the attached paper from EULAR.
Thanks
Vasc SIG
Answer
-
Sorry , for the delay but after asking around I haven't found a supplier of vertical arm slings. All the best
Answer
-
Hi, apologies for the delayed response.
We fast for HCC screens for the usual 4 hours to reduce bowel gas, but also if they are going to have a liver elastography as well. Non fasting artificially increases elastography values.
No answers found
Answer
-
Certificate of Capacity is issued by the nominated treating doctor (NTD) once the person has reported the problem to management and a WorkCover insurance claim has been raised.
You should report incapacity to your management?
ASA has no advise on examples of Certificate of Capacity as such. Light duties are prescribed once the person has sought medical advice and reported through the proper channels.
A hand therapist may help via a thumb brace for support. Cortisone injection also may be of benefit if synovitis is present in the thumb joints. Best to seek advice from a GP or physio.
No answers found
No answers found
No answers found
Answer
-
Hi Matt,
I am making sure that this thread is working.
Your question: Is there anyway you could provide me with details on the nurse training that was provided for cannulation? Were there any medico-legal issues you had to navigate in terms of sonographers actually being able to needle in Victoria?"
The training is fairly informal. We do a short session on cannulation theory, and practising with a phantom, and then do some supervised cannulations, and then get assessed. For ultrasound guided cannulation it is also a short session with one of the radiologist. It is not very involved, and no medico-legal issues, and in fact radiographers can do an ultrasound guided cannulation short course. We are happy for you to ring us at RMH if you want any more information.
-
Hi Matt, it was probably myself talking about cannulation . Some Sonographers can cannulate at RMH , and have done a short course with the nursing educators, then a few supervised cannulations before they are signed off to do it themselves . This is very easy . We usually have our nurses do it though, as this gives us time to chat to the radiologist and prepare the contrast . Let us know if you have any more Ceus queries .
Answer
-
Thank you for your question.
There are many reasons why a formal ultrasound may be requested in cases of suspected FDIU.
National, and many international guidelines on management of stillbirth state that evaluation following a stillbirth include fetal autopsy, gross and histologic exam of the placenta, umbilical cord and membranes, and genetic studies. A formal scan could assist with confirming FDIU on a high resolution machine, identifying location of placenta, fetal position (which can help the Ob/Gyns plan delivery), identifying gross features such as oligohydramnios/polyhydramnios/skeletal or any other anomalies in the fetus/placenta that may not be identified at bedside ultrasound, as this can help guide further investigations. It may also help identify other causes, such as IUGR. The thought of an autopsy can be very distressing to parents, so not all parents are willing to go through the autopsy, hence maximizing info through ultrasound may be helpful for future management.
There have a rare number of instances (particularly in cases where imaging was difficult eg. obesity, or where TV scanning was not performed), where fetal heart motion was missed or vice versa. Clinicians sending these referrals may want to eliminate any trace of doubt and share the burden of responsibility. Additionally, it is often requested by the patient and their partner to also be in no doubt about the findings.
As discussed in the below article point of care ultrasound 'should not be considered a substitute for formal diagnostic ultrasound'. Point of care ultrasound in obstetrics: https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/ajum.12133
No answers found
Answer
-
Thank you for your question.
There are numerous useful resources available online:
https://onlinelibrary.wiley.com/doi/full/10.1002/jum.16129
We do not currently have a protocol for endometriosis, however some practices use a checklist, which may include looking for endometriosis markers on a transvaginal examination, (if clinically indicated) which includes:
Adenomyosis, endometriomas, question mark sign (fixed uterine anteversion and/or retroflexion), site specific tenderness, ovarian mobility, fixed/kissing ovaries(fixed together), fallopian tube distortion, the sliding sign(rectum glides freely over cervix), posterior cul-de-sac obliteration and deep infiltrating endometriosis nodules in anterior and posterior compartments.
The ASA is currently investigating hands-on training options.
Answer
-
have found these 2 articles that may assist the enquirer in regards to differentiating punctate calciifcations versus colloid ring down artifact. Modern equipment does minimise artifacts in some settings, but my advice would be for us to direct this sonographer to their specific manufacturer in order to modify their specific equipment settings. Hope this helps - Marilyn
https://www.sonographers.org/secureassets/872673aa-102e-ee11-9122-0050568796d8/kjr-24-22-thyroid.pdf
Answer
-
Hello Gayle
The cardaic SIG has had a hard think about your issues and drafted this reply to you. Please not, this is NOT legal advice not work related advice. This is a group of sonographers putting our collective thoughts down to support a fellow cardiac scanner.
Best wishes
Anthony Wald
SIG Cardiac chair
Answer
-
Hey Jared, a completely valid question. It's always hard when a radiologist contradicts what your line thinking has always been.
The other members of the SIG group who contributed to this answer and myself broadly agree with you in the sense that raised velocities in the coeliac axis during full expiration can be associated with MALS.
One of our SIG members documents if there is significant PSV difference between inspiration and expiration in the Coeliac artery even if the PSV is slightly under 350cm/s, as getting the correct Doppler angle in the Coeliac axis can sometimes be difficult.
This is an extract from the Journal of medial ultrasound that backs that point up a bit that they suggested we steer your way. The study isn't the most recent but the principal still stands - Median Arcuate Ligament Syndrome 2003
''The median arcuate ligament is found at the T12-L1 level and bridges the crura of the diaphragm just anterior to the aorta. In patients with the median arcuate ligament syndrome, the celiac artery is compressed by the median arcuate ligament with expiration. With inspiration, the celiac artery descends in the abdominal cavity, resulting in a more vertical orientation of the celiac artery, which often relieves the compression. With the patient in the erect position, the celiac artery descends farther in the abdominal cavity, resulting in an even more vertical orientation of the celiac artery and relief of compression by the ligament''
Below is another extract from a much more recent publication which details some other nuances to be aware of that another member thought might be useful
Pellerito, John S., and Joseph F. Polak. Introduction to Vascular Ultrasonography. Seventh edition. Philadelphia, Pennsylvania: Elsevier, 2020. Print. Revxin Chapter 26 p 547-581
A potential pitfall for celiac artery stenosis is the median arcuate ligament (MAL) syndrome. The MAL is a fibrous band that extends from the diaphragmatic crura on either side of the aortic hiatus. The MAL usually passes just superior to the celiac artery. In some people, however, the MAL passes along the anterior margin of the celiac artery and may cause celiac artery compression during expiration. During the examination, the examiner may observe a characteristic change in the appearance of the celiac artery during different phases of the respiratory cycle. On expiration, the celiac artery assumes a hook-like appearance because of compression of the vessel by the ligament, and on inspiration, the artery takes a neutral, non-compressed course. With pulsed Doppler, mechanical compression of the celiac artery by the MAL is detected as increased PSV during expiration. On inspiration, a normal PSV is observed. Therefore inspiratory and expiratory velocity measurements should be obtained whenever MAL syndrome is suspected. Chronic compression of the celiac artery by the MAL may produce a fixed stenosis of the celiac artery with an elevated PSV that persists during inspiration.
This member (like myself) doesn't use a particular PSV but looks for the hook appearance in expiration, and a change in velocity. If a change with inspiration/expiration can't be produced you can also get them to stand which lower the mesentery and relieve the compression.
General consensus is that the radiologist has it backwards :)
Majority of credit for this answer goes to Dan Rae and Donna Oomens.
Hope this helps.
Answer
-
Sorry it's taken a while to get back to you.
The answer is a bit multi-faceted. In regards to forearm fistulae you are completely right, retrograde radial artery flow beyond the anastomosis is perfectly normal in instances where the palmer arch is intact, and depending on where you read this retrograde distal radial flow can make up to 25% of the overall volume flow. Some papers even suggest that in some fistulas the retrograde flow alone is actually sufficient to provide effective dialysis.
Being that you mostly see upper arm AVFs you are likely exposed to a higher proportion of patients with distal ischemia due to a higher prevalence of this symptom in this variety of AVF. This is because brachial artery anastomoses tend to be larger which create lower vascular resistance, that pull more blood through the fistula and away from the hand, which is a problem that’s compounded by the fact that this is the only inflow artery to the forearm, as opposed to a RCAVF where only one of three arteries to the hand is affected.
We also need to discuss the differentiation between steal and steal syndrome. Most BCAVF will demonstrate physical steal whether that’s a bit of bi-directional flow in the brachial artery beyond the anastomosis or a retrograde radial/ulnar artery. This can be totally asymptomatic but becomes steal syndrome when symptoms of ischemia are present which is, like you say, a purely clinical diagnosis.
These symptoms can often be worse during HD which for sonographers obviously isn’t great because we can’t scan them during this period to see if there is any haemodynamic change. In answer to your actual question though - the only useful information we can provide via ultrasound is the status of the fistula (functional? Volume flow? Stenoses?),forearm arteries (all patent?) and the palmer arch (intact?).
Hope this helps
-
Hi Lauren,
We had a good chat about your question in our SIG meeting last night. It's a great question and we aim to get back to you with a full answer with reference papers by the end of next week.
Thanks for posting and feel free to ask any other vascular related questions.
Matt
Disclaimer: by using this service you recognise that the information provided is general in nature; it does not constitute professional advice. Any views expressed are those of individual(s) and may not reflect ASA’s views. The ASA does not endorse any product or service identified. You use any information provided at your sole risk and the ASA is not responsible for any errors or for any consequences arising from that use.
Thank you for your question.
The guideline is specifically for patients in the mid trimester scan, ie. morphology. In the guideline a specific subgroup for third trimester patients was not included, as there is limited clinical value in performing CL measurements after 24 weeks. Therefore a CL measurement (either TV or TA) is not required in third trimester, unless specifically requested by the referring doctor or as per your radiologist.
If a patient presents to you in third trimester (these would usually be surveillance), to have a CL assessment at the request of the referrer, it is usually appropriate to do a TV scan, as long as it is not contraindicated (ie. Preterm labour).