Category: Ultrasound

Literature Review

In their research, Miller et al. (2012) dwelled on the application of ultrasound in therapeutic treatments and discussed the best ways to minimize side-effect risks and help patients as much as possible. They mentioned that ultrasound had several definite benefits supported by evidence and could be used to increase patient safety when the clinician dealt with chronic pains (Miller et al., 2012). Throughout the research process, the investigators found that the amount of safety information is either insufficient or confusing. Research on the subject of ultrasound therapy revealed that even commercial conflicts might arise throughout the implementation of this kind of treatment. Miller et al. (2012) also highlighted the significance of communicating the safety principles to the patients that were subject to being treated using ultrasound. Their qualitative meta-analysis of the effects of ultrasound on the quality of therapeutic approaches to chronic pains helped find numerous ultrasound methods that can be utilized in different situations. Overall, Miller et al. (2012) proved that the clinical use of ultrasound bears a positive connotation to patient outcomes, and the safety of this method is one of the biggest advantages.

Another research project intended to support the use of ultrasound therapy was conducted by Ulus et al. (2012). In that study, they addressed the short-term impact of ultrasound therapy in the cases where it was necessary to ease the pain or restore physical functions of the patients. Ulus et al.s (2012) study involved several patients (42) with knee osteoarthritis. A researcher that was not involved in the evaluation of the outcomes randomized the sample, and two groups were formed  continuous ultrasound therapy and sham ultrasound therapy.

All of the participants of the study (patients) were subject to receiving 20 minutes of hot packs and at least 15 minutes of specific knee-focused isometric exercises in addition to ten minutes of interferential current (Ulus et al., 2012). The treatment was received throughout three weeks straight (five times per week). The researchers evaluated the data based on the baseline information and the end date. To measure the outcomes, Ulus et al. (2012) used a visual analog scale, a specific osteoarthritis index, Lequesne index, and depression scale. Nonetheless, the study outcomes showed that the application of ultrasound in association with conventional physiotherapy does not have any significant effects on patients with knee osteoarthritis. Instead, it was recommended to apply ultrasound therapy exclusively.

The Gap in Scientific Knowledge

The gap in scientific knowledge is accurately addressed by the authors of the reviewed research study. Their research points at several factors that had not been discussed in the previous literature on the subject of continuous ultrasound. This study is different because Ebadi et al. (2012) dwell on the evidence regarding the effectiveness of physiotherapy practices aimed at treating chronic LBP. Owing to this research project, it turned out that the presence of an effect mitigated the lack of evidence. Therefore, it is safe to say that such findings impact the field of the use of ultrasound for the treatment of chronic pains and prove its efficiency. Ebadi et al. (2012) stated that their research results might bear several practical implications for the healthcare facilities that are keen on finding new treatment methods for patients with chronic back pains.

Research Problem

Within the framework of the research project conducted by Ebadi et al. (2012), the research problem consisted in the fact that the effects of continuous ultrasound were underresearched. The investigators especially became interested in addressing the issue of continuous/ placebo ultrasound therapy and its effect on the patients with NSCLBP. Additionally, Ebadi et al. (2012) saw the problem in investigating the secondary outcomes such as the endurance of lower back muscles and lumbar variety of locomotion.

Research Questions

There was no hypothesis in the study conducted by Ebadi et al. (2012). Still, the research question revolved around the idea that ultrasound might be a useful instrument when dealing with patients suffering from the NSCLBP. The researchers were able to answer this question and provide relevant evidence to support their point of view.

General Methodology

This is mixed research that features both qualitative and quantitative characteristics. The researchers outlined the methodology as follows: 50 patients with NSCLBP took part in the blind placebo-controlled study. To follow the study design, the patients were randomized into two groups  placebo ultrasound (and extra exercises) and continuous ultrasound (with extra exercises as well) (Ebadi et al., 2012). The process of treatment took four full weeks. There were ten treatment sessions with a frequency of three times a week. To randomize correctly, the researchers used opaque taped up envelopes. The latter was arranged by a statistician that created a randomization schedule using a computer. All the envelopes were distributed equally between the subjects of both groups. This study design allowed the researchers to minimize the level of bias and answer the research question because they backed the theoretical findings with statistical data.

Measures/Instruments

To measure the outcomes of the study, Ebadi et al. (2012) used the functional rating index (to address the primary outcome of functional disability) and a visual analog scale (to assess the global pain. There was also feedback data collected using a questionnaire. Throughout their observations, the investigators recorded all the information using electronic data collection forms.

Population and Sampling Plan

There were several inclusion criteria that Ebadi et al. (2012) enumerated in their research article. Those included the presence of NSCLBP and age limit (18-60). On the other hand, there were numerous exclusion criteria: the presence of systemic diseases, previous lower back surgery, specific psychological problems, pregnancy, and fractures (Ebadi et al., 2012). The sample (2 groups, 23 participants each) consisted of the patients coming from three Tehran hospitals. All the study participants were required to sign a consent form and acquire the information regarding the experiment. The information that was presented by Ebadi et al. (2012) may be helpful, but it is not enough to recreate their study. There was no clear rationale for the researchers sampling decisions, but they aligned their project with the expected sample size. There were identified no supporting sources that would justify the sample size decision. Ebadi et al. (2012) were able to conduct the study as is and did not have to review their sampling plans.

Data Collection

To obtain all the necessary electromyographic data, Ebadi et al. (2012) used an 8-channel EMG recorder. After the data acquisition, it was analyzed using the built-in software titled DATA LOG. According to the information presented by Ebadi et al. (2012), the signal was gathered at 1000 Hz and 1000 decibels. All the outcome measures were documented at the starting point, after the end of the study, and one month after the end of the study. According to the information in the article, the author of this submission may claim that there is not enough data available to replicate the study despite a detailed description of the instruments used. One of the missing things is the direct outline of collecting the data, which may be rather important because incorrect study design may cause adverse outcomes in the study participants.

Findings

The majority of the findings outlined by Ebadi et al. (2012) revolved around the idea that the patients receiving continuous ultrasound treatment had a higher endurance time rate than their placebo counterparts. Within this research framework, the investigators defined endurance as the ability to sustain mobile activity (which is directly associated with fatigue). The researchers concluded that one of the main predictors of muscle fatigue is the presence of metabolite wastes in the lower back region. Continuous ultrasound was found to increase blood circulation and trigger muscle contraction, which ultimately led to improved low back muscle strength. It may be concluded that Ebadi et al. (2012) successfully answered their original research questions within the framework of the reviewed research study.

Limitations

The most important limitation of the study consisted in the fact that the treating physiotherapist knew everything about the group allocation (Ebadi et al., 2012). This means that the collected data may be biased, and consequently, this may be considered the biggest weakness of this particular study. Another limitation was the number of patients that decided to drop out of the study (approximately 22%) (Ebadi et al., 2012). One of the areas of the study that cannot be improved is the self-reported compliance rate. On the other hand, throughout their future research on the topic, Ebadi et al. (2012) may slightly revise the studys design to be able to observe individual interventions discretely. Bearing in mind the limitations mentioned above, there is a need to redesign the study to obtain valid results.

Future Research

Further research in the area will have to concentrate on the differential effects of various interventions (including those described in Ebadi et al.s (2012) study on NSCLBP patients. Also, the author of this submission believes that future investigation on the topic of NSCLBP should include the measurement of electromyography parameters not included in this research article (for instance, normalized median and mean frequency). This may help the researchers to inspect the impact of these parameters on the patients with NSCLBP. In addition to this, the future research in the area should critically focus on the methodological shortcomings of Ebadi et al.s (2012) study and verify the outcomes in patients with chronic low back pain related to the dose-response.

Site Permission

All of the permissions were granted by the Tehran University of Medical Sciences (including the Ethical Committee and the Research Council). The Netherlands Trial Registry validated the experiment. At the time of the experiment, the site did not have a separate IRB. To obtain all the necessary permissions, Ebadi et al. (2012) asked for informed consent and went through the previous literature.

Participant Contact

The researchers contacted the future participants of the study at the territory of the healthcare facility. After the study was over, all the participants were contacted again to share the outcomes and provide the necessary recommendations. It may be concluded that Ebadi et al. (2012) approached the participants in a correct manner and made them feel safe.

Ethical Considerations

From the studys design, we may learn that the study is in line with all the necessary ethical considerations. The authors did not discriminate against anyone and kept the personal data safe. After the research study was over, Ebadi et al. (2012) carefully analyzed the data and made everything possible not to disclose the study results before validating the obtained information. Overall, the researchers did a great job of protecting the participants from any internal or external adverse influence.

Risk Assessment

The author of this submission did not identify any serious risks that could impact any study participants or examiners. Therefore, the study is within the limits of minimal risk and can be considered reliable. The population that was reviewed in the article could be considered vulnerable. Nonetheless, the level of risk would not differ significantly when the participants were a part of the vulnerable population. The authors of the reviewed study protected their participants by limiting their medication intake and getting used to the specific exercises.

References

Ebadi, S., Ansari, N. N., Naghdi, S., Jalaei, S., Sadat, M., Bagheri, H.,& Fallah, E. (2012). The effect of continuous ultrasound on chronic non-specific low back pain: A single blind placebo-controlled randomized trial. BMC Musculoskeletal Disorders, 13(1), 192.

Miller, D. L., Smith, N. B., Bailey, M. R., Czarnota, G. J., Hynynen, K., & Makin, I. R. S. (2012). Overview of therapeutic ultrasound applications and safety considerations. Journal of Ultrasound in Medicine, 31(4), 623-634.

Ulus, Y., Tander, B., Akyol, Y., Durmus, D., Buyukak1ncak, O., Gul, U.,& Kuru, O. (2012). Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: A randomized doubleblind controlled clinical study. International Journal of Rheumatic Diseases, 15(2), 197-206.

Frame Rate, Line Density, Sector Angle, and Image Depth, and their Interrelationship

According to Gibbs, Cole, & Sassano (2009), Frame rate refers to the number of frames or images that are displayed or projected per second by an imaging device. A sector angle is a central angle that a circle center forms. An imaging depth is a distance between an images’ corresponding scene point and the pinhole of a camera. The camera is often not in harmony with the perception of the depth of a human vision. Line density is the number of acoustic scan lines for every sector in a two-dimensional sector image.

These terms are applied in the working and selection of a diagnostic ultrasound machine and equipment. The images produced by the machine are optimized by the use of focal zones, line density, frame rate, frequency manipulation, and other image processing options. Thus, the terms refer to image processing options applied by a diagnostic ultrasound machine. A diagnostic ultrasound machine is made up of several components, each having a separate function to perform.

Tissue Harmonic Imaging and its advantages and limitations for B-mode imaging

Dogra & Rubens (2003) think that tissue harmonic imaging in the context of ultrasound technology is a signal processing technique whereby an ultrasonic beam is used to insonate body tissues. This insonation helps in the generation of harmonic waves as a result of nonlinear distortion in the pulse-echo cycle’s transmission stage. As time elapses, the ultrasonic sound moves through the tissues of the body nonlinearly.

The peaks present in the pulse waveform move at a faster speed than the troughs. Similar to the compressed sections of the tissues, it is transmitted faster than in areas that have undergone expansion courtesy of the passing pressure wave. The level of such an acoustic signal distortion within a tissue is dependent on the emitted pulse’s amplitude and the distance traveled by the pulse in the tissue (Dogra & Rubens 2003, p. 132).

Tissue harmonic imaging has numerous advantages for B-mode imaging. These benefits include improved cystic resolution and clearing, an aberration of the beam, and a decrease in reverberation. Others are an improved range penetration and axial resolution as a result of high frequencies. Side lobes experience a noise reduction, thereby reducing artifacts and the signal to noise ratio. One limitation is that it leads to substantial degradation of the axial resolution, making it unable to distinguish between tissue planes. Tissue harmonic imaging is most useful clinically for endocardiac visualization, mitral valve visualization, and EF reproducibility (Edelman 2003, p.173).

Assumptions Made by Ultrasound Equipment that give rise to artifacts

The basic assumptions made by ultrasound equipment that gives rise to artifacts are, according to Kohzaki (2003), as follows:

1. The acoustic waves travel in straight lines and are unable to bend under any circumstances (Kohzaki 2003, p. 438).
2. The waves in their lateral extent are infinitely thin since thick or medium waves will not have the same attributes as thin ones (Kohzaki 2003, p. 438).
3. Each interface generates one reflection or echoes only (Kohzaki 2003, p. 438).
4. The returning echo’s intensity is directly proportional to the imaged objects’ scattering strength (Kohzaki 2003, p. 438). This means that as intensity increases, the image’s scattering strength also increases.
5. Sound attenuation and speed are homogenous and are known a priori (Kohzaki 2003, p. 438).
6. Any echo that is detected is a result of the acoustic pulse that was transmitted most recently (Kohzaki 2003, p. 438).

How the Reverberation Artifact is Formed and Areas of the Body where it is Most Prominent

Reverberation artifacts are formed from an object’s multiple reflections if tissue layers’ acoustical impedance is overly different. They are also formed when the detected echo does not run the shortest path of sound as it bounces back and forth between the transducer and the object. Middleton, Kurtz & Hertzberg (2004) think that the body receives sound waves in reverberation artifacts from the transducer skin’s interface.

This artifact is prominent in the liver, skin, and kidney. When the sound waves strike a strong interface, a lot of sounds is reflected in the transducer, leading to a secondary echo being sent into the tissue, forming a series of duplicate, parallel, and ever-deepening interfaces at a depth that is directly proportional to the period that has passed since the signal emission. These artifacts are most common between the skin and the transducer, leading to the formation of the main bang artifact.

A special reverberation case occurs when small gas bubbles act as reflectors, as can be commonly seen in the gastrointestinal tract. As the ultrasound reverberates back and forth amongst the gas bubbles, multiple echoes return to the transducer. Should the gas bubbles be in liquid form, little attenuation would take place, so the echo sequence returning to the transducer over time remains strong (Middleton, Kurtz & Hertzberg 2004, p. 271).

Helpful Artifacts in Diagnosis and Examples

Two artifacts that may be helpful in diagnosis include the imaging and reverberation artifacts. Middleton, Kurtz & Hertzberg (2004) cites examples of imaging artifacts as hypoechoic and anechoic artifacts. Examples of reverberation artifacts are the ring down artifact and the comet-tail artifact. In ultrasound images, artifacts are common, and it is vital to have the ability to recognize them.

An artifact can be ignored once it has been recognized because t s unlikely to have any negative impact on the diagnosis process, or because it is unlikely to lead to a misdiagnosis. In some instances, the artifacts are useful diagnostic signs themselves, as they can provide more information on tissues as well as assisting in highlighting tissues that may be of interest. However, in some cases the artifacts can be misleading, thus making it vital for them to be recognized and minimized, or eliminated if possible (Rumwell & McPharlin 2004, p. 298).

Pre-Processing and Post-Processing

Pre-processing is the process of adjusting or making changes to an image before the scan data is stored in the computer memory. Examples include edge enhancement and log compression. On the other hand, post-processing refers to the process used to adjust an image after storing the scan data in the computer memory. Examples include grayscale assignment, thresholding, black and white inversion, and freeze frame. Controls associated with preprocessing adjust the acquisition and transmission of the ultrasound signals, while its settings control the ultrasound signal formatting to enable its conversion to an electric signal.

Changes made to the controls of preprocessing affect the information that will be accessed by the scanner to create an image, with this formatted information being the basis of image creation. Postprocessing settings affect how the monitor displays the formatted information. In other words, post-processing, defines the ultrasound data’s cosmetic appearance, as displayed on the monitor (Zwiebel & Pellerito 2005, p. 285).

Selecting a High-Frequency Transducer

According to Nyland & Mattoon (2002), the selection of a transducer has been made easy with the emergence of broadband transducers that make it possible for fine-tuning to take place during image optimization. This is unlike in the past were no such tuning was possible. However, proper selection is a critical factor to ensure optimum performance in any ultrasonic gauging application. When selecting a transducer, one also selects the ultrasonic frequency to be applied in examinations. The frequency emitted by a given transducer depends on the piezoelectrical crystals’ characteristics contained in a scan-head.

Frequency change usually requires the ultrasonographer to select a different transducer since either multiple or single crystals produce sound at a certain frequency, depending on the design. Some transducers can operate using multi frequencies. Transducer technology advances now allow for simultaneous imaging of both far-fields and near-fields with different frequencies of sound waves (Nyland & Mattoon 2002). This ensures a maximum possible resolution for a given depth without having to switch transducers. The main objective of a transducer selection is choosing the right resolution and frequency.

The frequency should be capable of penetrating the required depth for a particular examination. Other factors to consider in selecting a transducer to affect its ability to separate adjacent structures and image resolution. They include the ultrasonic pulse length, the resolution, and the beam diameter of the video monitor. The sonographer usually cannot alter these parameters at the time of examination with a certain transducer. However, the focal point can be altered with a dynamic or selective focusing on the latest ultrasound equipment (Galiuto, Basdano, Fox, Sicari, & Zamorano 2011). Ultrasound imaging technology is based on the pulse-echo principle.

This, in essence, point to the fact that transducers do not produce continuous sound and instead produce it in pulses. The image is formed after each pulse, from the echoes reflected by the transducer. Thus, an appropriate time must be allowed for the return of all the echoes before the transducer being pulsed again. About three echoes are emitted in each pulse when the crystal is pulsed before a backing block within the transducer dampens the vibration (Nyland & Mattoon 2002 p. 2).

The crystal frequency is inherent, and scanner controls cannot change it. It is vital to put several factors into consideration. These factors include part temperature and geometry, and the material under measurement. Evolution in technology has led to a reduction in transducer size and aperture. Smaller transducers require fewer acoustic windows than large ones and are easier to use than the latter. High-frequency transducers are required for a fine resolution imaging of shallow structures, such as children’s hearts and cardiac apex for adults (Galiuto, Basdano, Fox, Sicari, & Zamorano 2011, p. 4).

Factors Affecting the Near Field and Far Field Length of an Ultrasound Beam

According to Middleton (2002), one of the factors affecting the near-field and far-field length of an ultrasound beam is the size and shape of the ultrasound source. The ultrasound source size affects the width of the beam, the Fresnel zone length, and the divergence angle beyond the near-surface. Fresnel zone length is given in the below equation.

D =

In the equation, D is the Fresnel zone length, r the transducer radius and ϒ is the ultrasound beam wavelength. The breadth of the beam is more or less equal to the transducer diameter.

Inferring from the above equation, the Fresnel zone length increases rapidly as the width of the beam or diameter of the transducer is increased. Moreover, a rapid reduction in the Fresnel zone length is seen to lead to a decrease in the transducer diameter. Beam frequency is a factor known to affect both the far-field and near-field length of any ultrasound beam (Middleton 2002).

Now ϒ= v/f where ultrasound velocity is represented by v, while beam frequency is represented by f.

From D =

Substituting D =

From this equation, it can be seen that the Fresnel zone length increases as the frequency of the beam is increased. Additionally, the angle of divergence that is beyond the near field diminishes with an increase in frequency. The improved image resolution is thus not the only effect of higher frequencies but also increases the useful near field length (Middleton 2002).

Another factor that could significantly affect an ultrasound beam’s far-field and near-field lengths is how the ultrasound beam is focused. The ultrasound beam shape can be changed to varying extents through the application of different focusing methods. One of them is the crystal element shape whose crystal element can be suitably shaped by a concave curvature to focus on the ultrasound beam. This method is an internal focusing one, as it is affected by the crystal itself.

The focusing degree is dependent on the crystal curvature extent. Another focusing method is the use of acoustic lenses made from materials that propagate ultrasound at different velocities from those found in soft tissues. It can be applied in focusing the beam through refraction. The lens’ curvature will be concave, with the focusing degree, to a great extent, depending on the curvature radius. The ultrasound beam can also be focused using a concave mirror, with the focusing degree once again dependent on the curvature radius (Middleton 2002, p. 382).

References

Dogra, V & Rubens, DJ 2003, Ultrasound Secrets. Elsevier Health Sciences. New York.

Edelman, SK 2003, Understanding Ultrasound Physics, Esp, New York.

Galiuto, L, Basdano, L, Fox, K, Sicari, R & Zamorano, JS 2011, The EAE Textbook of Echocardiography, Oxford University Press, London.

Gibbs, V, Cole, D & Sassano, A 2009, Ultrasound Physics and Technology: How, Why and When. Elsevier Health Sciences, New York.

Kohzaki, S, Tsurusaki, K, Uetani, M, Nakanishi, K, & Hayashi, K 2003, The aurora sign: an ultrasonographic sign suggesting parenchymal lung disease’, British Journal of Radiology, vol 76, no, 2, pp 437- 443.

Middleton, WD 2002, General and Vascular Ultrasound: Case Review. Elsevier Health Sciences, New York.

Middleton, WD, Kurtz, AB, Hertzberg, BS 2004, Ultrasound: the requisites. Mosby, New Jersey.

Nyland, TG & Mattoon, JS 2002, Small Animal Diagnostic Ultrasound, Elsevier Health Sciences, New York.

Rumwell, C & McPharlin, M 2000,Vascular technology: an illustrated review, Davies Pub, New York.

Zwiebel, WJ & Pellerito, JS 2005, Introduction to vascular ultrasonography, Saunders, New York.

The Topic and Problem Driving the Research

The use of technology is often regarded as an important aspect of clinical practice. Healthcare professionals have to utilize technology to provide high-quality healthcare services. However, many practitioners lack the necessary skills and knowledge since the educational system (both formal education and on-job training) fails to keep up with the development of technology (Bergsland, Elle, & Fosse, 2014). It is vital to develop various training programs to help healthcare professionals to utilize technology effectively. The focus of this research is the evaluation of the effectiveness of the training program aimed at encouraging surgeons to resort to ultrasound color doppler-guided surgery when treating chronic insertional Achilles tendinopathy. Alfredson and Isaksson (2014) note that this type of surgery and examination has proved to be effective as it leads to a shorter healing period and patients’ satisfaction. At that, it is important to make sure that surgeons can use the corresponding devices to ensure the effectiveness of the method.

Why the Issue Is Interesting and Why the Study Needs to Be Implemented

It is possible to employ various techniques and methodologies to evaluate the effectiveness of the intervention. Quantitative studies can provide the researcher with generalizable data that can help assess whether the intervention is effective. This type of study can also equip the researcher with quantifiable data that will show the exact number (or percentage) of people who benefit from the training program (Cockerham, 2015). However, the evaluation of a training intervention can also benefit from the focus on certain qualitative aspects. People’s opinions and attitudes are as important as some statistical data since they help identify people’s motivation and commitment.

For instance, it is essential to explore the way trainees see the program, its effectiveness, and its relevance to their working setting. It is possible to explore some factors that may affect the trainees’ engagement. Motivation is one of such aspects to examine. Howe, Smajdor, and Stöckl (2012) note that resilience is another important factor that has a considerable impact on trainees’ performance. It is important to understand the trainees’ attitude towards an intervention to make it more efficient through aligning it with expectations, hopes, and some peculiarities of learners.

It is crucial to carry out a qualitative study that will unveil opinions of surgeons concerning the training intervention addressing the use of technology (associated with the ultrasound color doppler-guided surgery). The research should focus on such elements as the trainees’ motivation, expectations, and their overall attitude towards technology. To implement an in-depth analysis of these aspects, it is necessary to employ qualitative research methods.

Overview of the Study

The purpose of the study is to examine the opinions of the trainees attending a training course concerning the use of technology. It is necessary to note that the training program in question will involve new surgeons who will be encouraged to participate though they will be able to refuse to take part in it. To implement the qualitative study, it is possible to use a random sampling technique. Five trainees can take part in the research. The intervention program is the focus of the study, so it is but natural to use a case study research design. Holloway and Wheeler (2013) note that the case study “is a way of exploring a phenomenon or several phenomena in context” (p. 250). Thus, this research design will allow the researcher to identify the participants’ attitudes and opinions.

The research questions can be formulated as follows:

1. What are the participants’ views on the use of technology in their clinical practice?
2. How effective is the intervention as seen by the participants?
3. What are the participants’ expectations?
4. What motivates the participants to take part in the training program?

The case study research design is characterized by the use of several data collection methods. Observation and interviews are common tools to collect data (Holloway & Wheeler, 2013). It is possible to use these methods. As to the observation, the researcher will observe two training sessions. All the training sessions will be digitally recorded, but the researcher will choose two of them randomly. The participants will know that the training sessions will be recorded, and they will provide their written consent concerning this matter. During the observation, the researcher will pay attention to the participants’ input during class discussions, their performance, and their questions or arguments (if any). These data will help the researcher to examine the participants’ engagement and motivation during the training sessions.

As far as interviews are concerned, it is vital to encourage the participants to share their views openly and provide detailed answers. To achieve this goal, semi-structured interviews will be utilized. When using this method, the researcher crafts a number of guiding questions, but they can be adjusted, and new questions can be asked during the interview (Holloway & Wheeler, 2013). This tool creates an atmosphere of a conversation, and participants tend to be more relaxed while the researcher may focus on aspects of particular concern. The guiding questions will address such areas as the use of technology, motivation, the training program’s effectiveness, and expected outcomes. The participants’ accounts will be transcribed with the help of the corresponding software. The transcripts will be analyzed, and the researcher will identify the most recurrent themes and patterns.

To obtain more information and unveil more opinions and attitudes, it is also possible to employ focus group discussions. Wilkinson (2016) notes that this data collection tool is quite common in medical research, and it enables the researcher to address aspects that could be missed during interviews. Participants often have quite different views on certain issues, and they provide more details and arguments to support their viewpoints. In this study, the researcher will design the guiding questions for the focus group discussions based on the analysis of the interviews. The researcher will pay specific attention to contrasting views to encourage the participants to provide more arguments to support their ideas. The major focus of these discussions will be the effectiveness of the training program. At that, the participants’ expectations, motivation, and opinions concerning the use of technology will also be discussed. The discussions will also be digitally recorded (and the participants will sign written consent forms). The records will be transcribed and analyzed. The most recurrent themes and patterns will be examined.

Conclusion

On balance, it is possible to note that the qualitative study described can help evaluate the effectiveness of the training program. The use of the case study design is beneficial as it allows the researcher to collect a wealth of data. The researcher will focus on such aspects as the participants’ motivation, expectations, and opinions concerning the use of technology in the clinical setting.

References

Alfredson, H., & Isaksson, M. (2014). Ultrasound and color doppler-guided surgery for insertional Achilles tendinopathy-results of a pilot study. Open Journal of Orthopedics, 4(1), 7-14.

Bergsland, J., Elle, O., & Fosse, E. (2014). Barriers to medical device innovation. Medical Devices: Evidence and Research, 7, 205-209.

Cockerham, W. (2015). Medical sociology. New York, NY: Routledge.

Holloway, I., & Wheeler, S. (2013). Qualitative research in nursing and healthcare. Ames, IA: John Wiley & Sons.

Howe, A., Smajdor, A., & Stöckl, A. (2012). Towards an understanding of resilience and its relevance to medical training. Medical Education, 46(4), 349-356.

Wilkinson, S. (2016). Analysing focus group data. In D. Silverman (Ed.), Qualitative research (pp. 83-101). Thousand Oaks, CA: SAGE.

Performing an ultrasound of the gall bladder only

Patient preparation

The examiner introduces himself to the patient. The relevant clinical information regarding the patient should be confirmed. The examination area should be checked (Bisset, 2002). The examiner explains to the patient how the procedure will be performed and how much time is necessary to finish the examination. Verbal consent is obtained from the patient. The patient should be dressed appropriately for the procedure and feel entirely comfortable (Ultrasound of the gallbladder 2012).

A brief medical history is taken, and the following details are obtained: if the pain is present, its location and duration are verified; the presence of any nausea or vomiting should be noted; any history of the abdominal disease or abdominal surgery is discussed; any current medications are discussed; any recent tests or imaging procedures are clarified with the patient (Block 2004; Ultrasound of the gallbladder 2012).

It should be ensured that the patient is nil per os (NPO) before the procedure. The patient has explained the technique of breathing during the ultrasound scanning. The patient is asked to lie face up on the examination bed. The patient should feel comfortable, and if necessary, his or her position should be adjusted with the help of pillows or foam wedges (Ultrasound of the gallbladder 2012).

Equipment

The ultrasound machine, gel warmers, power beds should be prepared in advance to start the examination. The work of the computer system, sonographer’s worksheet, and the printer should be checked. The bed should be prepared (linen, cloths, towels).

The next stage is to select the transducer’s frequency and perform the survey. It is essential to choose the right subcostal or the right intercostal positions for the survey. While surveying the gallbladder area, it is necessary to identify the anatomical landmarks. The healthy gallbladder is oval and echo-free. It is located on the inferior part of the liver. It is required to refer to the sonographic landmark of the gallbladder. Scanning the gallbladder, the examination of the neck, fundus, and the gallbladder wall is realized. It is possible to scan transversely through the gallbladder, covering the fundus to the neck. Finally, the thickness of the gallbladder wall should be measured. The presence of any gallstones can be noted.

The image shows definite gall bladder disease. A positive Murphy sign is usually the indicator of acute cholecystitis. Ultrasound imaging helps investigate the gall bladder disease sensitively. It is possible to observe the changes in the gall bladder, which are characteristic for the acute cholecystitis. It is typical for the gall bladder, which is consistent with gallstones to have the acoustic shadow, which can be easily observed with the help of ultrasound. Gall stones observed in the gall bladder of the patient affect the significant inflammation of the gall bladder’s mass. Gall stones are specific disorders in the gastrointestinal tract, which cause the pain and change the function of the gall bladder. Thus, referring to the image, it is possible to observe the distended gall bladder, multiple gall stones, the significant thickening of the gall bladder wall, which is rather oedematous. The pericholecystic fluid can also be observed. These signs in connection with a positive Murphy sign are the indicators of the acute cholecystitis.

Real-time’ techniques used to assist with the diagnosis

Computed Tomography (CT) can be used along with ultrasound since CT can detect other pathologies in the abdomen if they are present. In the case of acalculous acute cholecystitis (AAC), the use of hepatobiliary scintigraphy is debatable, and it may be used with a high clinical suspicion when the usage of ultrasound is more appropriate. Although this technique has a high sensitivity in diagnosing AAC, it cannot provide the necessary specificity. This problem can be avoided with using of morphine-augmented scintigraphy.

Nevertheless, CT and magnetic resonance imaging (MRI) is considered as useful adjuncts to ultrasound because of providing accurate real-time images and results (Yusoff, Barkun & Barkun 2003). Ultrasound is more effective than the mentioned techniques for the initial diagnosing of cholecystitis. CT and MRI can be used as additional methods.

Patients with the above pathology often clinically present with jaundice

Jaundice

When the level of bilirubin in the blood is abnormally high, then people’s sclera and skin become rather yellow. This process and condition are known as jaundice. Clinically, jaundice becomes obvious when the serum bilirubin level becomes more than 2.5mg/dL (Smeltzer et al. 2010).

‘Indirect’ and ‘direct’ bilirubin, and their functions in detecting liver diseases

Bilirubin is present in red blood cells. It can be harmful because it is a breakdown product. The terms ‘indirect’ and ‘direct’ bilirubin describe the way according to which bilirubin can react to testing dyes being conjugated or direct and unconjugated or indirect. Direct bilirubin reacts to the reagents when they are added directly to the blood. To make the unconjugated bilirubin react, it is necessary to add some alcohol. Thus, indirect bilirubin cannot react independently (Stocksley, 2001).

Patients who have Mirizzi syndrome may also present with jaundice as well as having a gall bladder

Mirizzi Syndrome

Mirizzi syndrome is the hepatic duct obstruction. The obstruction is usually by calculus, and it is impacted in Hartmann’s pouch (Yusoff, Barkun & Barkun 2003). This condition often leads to significant complications because surgery is necessary to diagnose and treat the syndrome. There are four types of the syndrome (Yusoff, Barkun & Barkun 2003).

Mirizzi syndrome is a potential cause for acute cholangitis

Acute cholangitis

Acute cholangitis can be defined as a systemic infectious disease. The symptoms are caused by acute inflammation and infection in the bile ducts. It is possible to observe the combination of biliary obstruction and bacterial growth (Mosler, 2011).

Differences between acute cholangitis and primary sclerosing cholangitis

Acute cholangitis differs from sclerosing cholangitis significantly. Primary sclerosing cholangitis (PSC) can be defined as chronic cholestatic liver disease. It is typical for intra and extrahepatic bile ducts (Worthington & Chapman 2006).

Comparison of the possible sonographic appearances between these two pathologies

(Smeltzer et al. 2010).

Patients with primary sclerosing cholangitis are at increased risk of developing cholangiocarcinoma

The classification of cholangiocarcinomas

It is possible to determine four types based on their anatomical location. Cholangiocarcinomas may be classified as intra and extrahepatic. Moreover, it is possible to determine the extrahepatic type (Blechacz, 2008). The first type is based on the involvement of the common hepatic duct distal to the biliary confluence; the second type is the involvement of the biliary confluence; the next two types are the involvement of the biliary confluence along with the right hepatic duct and involvement of the biliary confluence along with the left hepatic duct; and the last type is the involvement of the confluence with the right and left hepatic ducts (Blechacz & Gores, 2008).

Further subclassification is based on their macroscopic appearance. Extrahepatic cholangiocarcinomas are classified as sclerosing, nodular, and papillary. Intrahepatic cholangiocarcinomas are classified as periductal infiltrating, mass forming, intraductal, and mass forming and periductal infiltrating (Blechacz et al. 2011).

The aetiology of cholangiocarcinoma

It is possible to concentrate on such risk factors as primary sclerosing cholangitis and hepatobiliary flukes (Opisthorchis viverrini and Clonorchissinensis) which can be ingested from the undercooked fish and hepatolithiasis. Other risk factors associated with the aetiology of cholangiocarcinoma include biliary malformations (Caroli’s disease), Hepatitis C, cirrhosis, biliary enteric drainage procedures in the presence of recurrent cholangitis, substances like thorotrast and dioxins (Blechacz & Gores, 2008).

The prognosis of cholangiocarcinoma

The prognosis of cholangiocarcinoma is often poor. Surgery is the only curative therapy. Nevertheless, the aetiology and molecular pathogenesis of cholangiocarcinoma are better understood now than in the past. Also, with improvement in diagnostic abilities, it is possible to diagnose patients at the earlier stages, and therefore, it is possible to cure the disease. A 5-year survival rate can be obtained with liver transplantation plus neoadjuvant chemoradiotherapy in highly selective patients with unresectable perihilar cholangiocarcinomas (Blechacz & Gores, 2008).

The possible differential diagnoses for cholangiocarcinomas

The possible differential diagnoses for cholangiocarcinomas are hepatocellular carcinoma (HCC), ampullary carcinoma, pancreatic carcinoma, choledocholithiasis and cholangitis.

Patients with cholangiocarcinomas may present with altered blood tests

Cholangiocarcinomas are the transformations in bile ducts that is why blood tests, as well as liver function tests of the patients with cholangiocarcinomas, often represent the elevated levels of bilirubin. The levels of alkaline phosphatase and gamma-glutamyl transpeptidase are also often increased. Thus, blood tests are altered, and they represent high levels of cholestasis. It is also possible to use the CA19-9 marker as the test for cancer antigens to confirm the diagnosis because it is usually elevated. However, it is essential to pay attention to the non-specific markers of malignancy which can be altered. They are the reduced levels of albumin and haemoglobin which should be tested with other techniques to confirm the results (Lau & Lau 2012).

Patients with choledochal cysts may present with recurrent acute cholangitis and are also at increased risk of developing cholangiocarcinomas

Choledochal cyst

Choledochal cysts are congenital bile duct anomalies which appear as cystic dilatations of the biliary tree. They depend on the specific extrahepatic or intrahepatic biliary radicles. Choledochal cysts are classified into five major types. Type I and IV are subclassified into types IA, IB, IC, IVA and IVB (Keir 2007).

The aetiology of choledochal cysts

The aetiology of choledochal cysts is not very clear. Babbitt’s theory of cysts has gained a lot of popularity. According to this theory, the abnormal pancreaticobiliary duct junction (APBDJ) matters. The mix of the pancreatic and biliary juices can activate the pancreatic enzymes which cause inflammation of the biliary duct wall. This process leads to dilation (Singham et al., 2009).

There is also an opinion that adult cysts with distal obstruction can lead to fusiform lesions (Bluth 2001). Choledochal cysts can be associated with colonic atresia, duodenal atresia, imperforate anus, pancreatic arteriovenous malformation, and multiseptate gallbladder (Singham et al. 2009).

References

Bisset, K 2002, Differential diagnosis in abdominal ultrasound, Elsevier, India.

Blechacz, B 2008, ‘Cholangiocarcinoma’, Clininc Liverer Diseases, vol. 12 no. 4, pp. 131-150.

Blechacz, B & Gores, G 2008, ‘Cholangiocarcinoma: advances in pathogenesis, diagnosis and treatment’, Hepatology, vol. 48 no. 1, pp. 308–321.

Blechacz, B, Komuta, M, Roskams, T, & Gores G 2011, ‘Clinical diagnosis and staging of cholangiocarcinom’, Gastroenterology & Hepatology, vol. 2 no. 8, pp. 512-522.

Bluth, E 2001, Ultrasound: a practical approach to clinical problems, Thieme, USA.

Block, B 2004, The practice of ultrasound, Thieme, USA.

Keir, L 2007, Medical assisting, Cengage Learning, USA.

Lau S & Lau W 2012, ‘Current therapy of hilar cholangiocarcinoma’, Hepatobiliary Pancreatic Diseases International, vol. 11 no. 1, pp. 12-7.

Mosler, P 2011, ‘Management of Acute Cholangitis’, Gastroenterology, vol. 7 no. 2, pp. 121–123.

Singham, J, Yoshida, E, & Scudamore, C 2009, ‘Choledochal cysts’, Journal of Surgery, vol. 52 no. 5, pp. 12-18.

Smeltzer, S, Bare, B, Hinkle, J, & Cheever, K 2010, Brunner and Suddarth’s textbook of medical-surgical nursing, Lippincott Williams & Wilkins, USA.

Stocksley, M 2001, Abdominal ultrasound, Cambridge University Press, USA.

Ultrasound of the gallbladder. 2012. Web.

Worthington, J & Chapman, R 2006, ‘Primary sclerosing cholangitis’, Journal of Rare Diseases, vol. 1 no. 4, pp. 22-29.

Yusoff, I, Barkun, J, & Barkun, A 2003, ‘Diagnosis and management of cholecystitis and cholangitis’, Gastroenterology, vol. 10 no. 12, pp. 1145–1168.

Introduction

Contrast-enhanced ultrasound (CEUS) is now gaining popularity as a key a tool for demonstration and detection of focal liver lesions. It has replaced the normal medical ultrasound as an imaging technique. A normal medical ultrasound as an imaging technique has generally been the gold standard diagnostic imaging technique for the liver across the world.

Its pros lie in its affordability and availability. However, one of its major pitfalls is its reliability in demonstrating focal lesions despite the advent of Doppler. This has often been a major challenge because of the grey scale appearances of the sonograms causing blurring patterns. Small lesions with diameters >1cm and iso-echoic lesions too pose great difficulty in this diagnostic modality.

The sensitivity is poor with a false-negative rate of > 50 % (Wernecke et al 1991, p. 731). In addition, inaccessibility to the eighth of the liver is a major setback in detecting lesions in the segment.

With the advent of Doppler ultrasound, more insight in the diagnosis of liver lesions has been added by the use of the arterial patterns whose abnormality may be characteristic of certain pathology e.g. the spoke wheel pattern observed in focal nodular hyperplasia.

Contrast enhanced ultrasound involves intravenous injection of contrast media (microbubbles) prior to the ultrasound procedure. The microbubbles remain in the systemic circulation for a given duration of time during which ultrasonic waves are directed to the anatomic site of organ pathology. An echo is then reflected by the microbubbles which are then converted into contrast-enhanced image by the ultrasound system.

The operator needs to familiarize himself with the ultrasound equipment and its ‘contrast’ settings, which is dependant on the type of machine. The contrast agent is prepared according to instructions provided. 20 ml of normal saline should be given following the administration of the contrast. An intravenous cannula is placed away from the side of ultrasound examination.

A stop-watch in the machine is used for accurate interpretation of the phase of imaging (Arterial, venous and late phases). Scanning is then done for a period of at least 5 minutes. The examination may be video recorded for later review. Still images are also taken at points to help highlight the pathology.

Some focal lesions in the liver not demonstrable on ultrasound may not be suitable for demonstration with contrast agents. Small lesions <1 cm, may be difficult to characterize especially when deep within parenchyma, generally.However, liver metastases, even those < 0.5 cm, are normally demonstrated using slow infusions through the liver in the later portal-venous phase or the late phase.

The characterization of focal liver lesions forms a key element in the majority of radiological practices. Although the normal medical ultrasound imaging is useful for the identification of focal liver lesions, accurate demonstration and characterization of a lesion is often difficult even with the use of colour Doppler (Nino-Murcia et al., 1992, p. 1195).

Microbubble contrast enhanced ultrasound (CEUS) has proven diagnostic accuracy in focal liver lesions (Bleuzen et al., 2006, p. 40). It can also be used to augment other imaging modalities like plain abdominal X-ray, contrast enhanced ultrasound guided percutaneous biopsy and B-mode ultrasound. It does not use ionizing radiation and is non-invasive unlike angiography or biopsy. It is well tolerated, affordable and relatively time efficient.

Table 1: The quoted sensitivity and specificity for the detection and demonstration of some common liver lesions using microbubble contrast (Source: Berry & Sidhu 2004, p. 96).

The contrast agents used consist of gas-containing microbubbles in a shell. The shell is made of a carbohydrate or protein (albumin) and measures around 10 mm in diameter. Once injected, the microbubbles greatly increase the back scatter because of their resonant frequency which falls within the range of the medical ultrasound (Harvey et al., 2001, p. 675).

This literature review looks at the applications of contrast-enhanced ultrasound in the demonstration and characterization of focal liver lesions. Benign, malignant and traumatic focal lesions of the liver have been cited with specific characteristics that define their pathology in the contrast enhanced ultrasound.

It also describes the use of contrast enhanced ultrasound guided percutaneous biopsy that has improved the precision and accuracy in the histological diagnosis of focal liver lesions. In addition, the review points out the major gains made by the advent of CEUS, its demerits and their possible solutions.

Contrast‐Enhanced Ultrasound of Benign Focal Lesions

Focal liver benign lesions that can be detected by Contrast Enhanced Ultrasound include Hepatic cysts which occur in up to 18% of patients in a study by Bleuzen and Tranquart (2004). They are frequently due to a developmental anomaly of the bile ducts.

They pose little clinical significance and appear as well defined hypo-reflective regions on ultrasound. Differential diagnosis of such a lesion would be a small haemangioma. The use of contrast reveals hypo-enhancing throughout all phases in a simple cyst unlike what is seen in a haemangioma. All the Arterial, Venous and Late phases show iso-enhancing on CEUS.

Focal fatty infiltrations may occur primarily or may be secondary to Budd–Chiari syndrome, portal vein thrombosis or Porto-arterial shunts. They are demonstrated as focal areas of reduced reflectivity or discrete areas of hyper-reflectivity on ultrasound.

This could appear like malignant liver lesion. They however have a geometric pattern of appearance, normal vascularity and proximity to the portal vein. CEUS shows such lesions to be iso-enhancing with the surrounding parenchyma. All the phases (Arterial, Venous and Late phases) show iso-enhancing.

Haemangiomas are second to benign cysts as the most common benign liver neoplasm. They occur in up to 20% in an autopsy series described by Karhunen (1986). It appears on histology as vascular spaces and endothelial lines. On Contrast Enhanced Ultrasound, the Arterial phase shows peripheral hyper-enhancement and central non-enhancement.

The Venous phase has complete or increased peripheral hyper-enhancement depending on the size of lesion. The Late phase is iso-enhancing. Haemangiomas appear as homogeneous hyper-reflective lesions with well-defined borders on B-mode imaging.

It may occasionally show central heterogeneity. The early Arterial phase imaging shows a progressive peripheral nodular hyper enhancement pattern similar to that seen with contrast CT or MRI imaging. This is however in real time unlike in CT and MRI imaging.

Regenerative nodules occur equally in men and women. Histology shows normal appearing hepatocytes and Kupffer cells within the nodules. The nodules range in size with some too small to be detected with radiological techniques and others with diameters >10 cm. Contrast enhanced ultrasound reveals regenerative nodules as hypo- or isoreflective lesions.

They may have occasional hypo-reflective centres due to haemorrhage. Differential diagnoses for such lesions are hepatocellular carcinoma and metastasis from other sites (Dietrich et al., 2006, p. 1699). The arterial phase is hyper-enhancing whereas the venous phase and late phase are iso-enhancing.

Liver Abscesses are also among the frequent focal lesions on the liver. Individual liver abscesses differ in their appearances on B-mode ultrasound appearance. In contrast enhanced ultrasound, the arterial phase shows a hyper-enhancing rim with a low reflecting area centrally. The venous phase demonstrates hyper- or iso-enhancing rim that is also low reflective centrally.

The late phase shows an iso-reflective rim to surrounding parenchyma with a low reflective central area. Their appearance also changes with time as the contents mature. Solid contents have increased reflectivity and may be confused with a wide range of focal liver lesions.

Contrast enhanced ultrasound demonstrates peripheral rim enhancement and vascularity within septae whenever present. In the vicinity of the abscess, parenchymal hypo-perfusion is demonstrated in the venous phase (Catalano et al., 2004 p. 447).

Hepatocellular adenoma is much less common in men than women (ratio 9: 1). The risk factors to its occurrence include anabolic steroid and oral contraceptive use. Histology shows normal hepatocytes, bile duct elements and connective tissue. It is however devoid of portal vessels. Contrast Enhanced Ultrasound imaging reveals well-defined iso- or hyper-reflective single or multiple lesions with a capsule.

The arterial phase is hyper-enhancing whereas the venous and late phases are iso-enhancing. The main differential diagnosis is focal nodular hyperplasia (FNH). Differentiating between the two has been shown with the use of Contrast enhanced ultrasound (Dietrich et al., 2005, p. 705). Arterial phase imaging shows hyper enhancement of the capsule and central component.

Areas of necrosis or haemorrhage may show hypo-enhancement centrally. The same pattern persists in the venous phase. These differ from focal nodular hyperplasia, which appears hyper-enhanced through to the early venous phase with a central feeding artery, and lack a capsule.

Focal nodular hyperplasia (FNH) has a less aggressive course than hepatocellular adenoma, which may complicate with haemorrhage. Histology shows nodules of hepatocytes and Kupffer cells separated by fibrous tissue with vessels and bile ducts radiating from a central scar. In CEUS, the arterial and venous phases have rapid hyper-enhancement whereas the late phase could be hyper or iso-enhancing.

FNH lacks a capsule, commonly isolated and difficult to distinguish from the normal surrounding liver parenchyma on B-mode imaging. Highly vascular FNH is demonstrable on colour Doppler imaging. Quantitative analysis of contrast-enhanced images has shown a feeding artery that is a useful indicator when differentiating focal nodular hyperplasia from other hypervascular lesions (Huang-Wei et al., 2006, p. 363).

Contrast‐Enhanced Ultrasound of Malignant Lesions

In a prospective study to investigate the ability of contrast-enhanced sonography (CEUS) to differentiate between benign and malignant focal liver lesions, 317 patients (204 males, 113 females, aged 12- 59 years) with focal liver lesions detected by B-mode grey-scale sonography were identified. After intravenous injection of contrast, the liver was examined by CEUS.

The final diagnosis was then established by histopathology, CT, MRI, or HIDA-scintigraphy. Results showed that the CEUS diagnosis had a sensitivity of 90%, a specificity of 99%, and an accuracy of 89% in the diagnosis of malignant liver lesions. It was therefore concluded that CEUS is helpful in the differentiation between benign and malignant focal liver lesions (VonHerbay, et al., 2010, p. 1).

Liver metastases are the most common liver malignancies. According to Wernecke (1991) up to 25-50% of patients with a non-haematological malignancy have liver metastases.

The sensitivity of normal ultrasound for liver metastases is relatively low (53%–77%)) which is inferior to other imaging techniques like computer tomography (CT) and magnetic resonance (MR) imaging ( Dietrich et al., 2006, p. 1699). Early detection of liver metastases is paramount for establishing management plan that determines the prognosis. This is made possible by the use of CUES.

Hypo-vascular metastases are from primary tumours the Gastrointestinal tract, pancreas and lung. The lesions are hypo-reflective on CEUS with internal heterogeneity whenever they have foci of calcification. CEUS has been shown to improve the demonstration of these lesions (Albrecht et al., 2004 p. 25).

As a result, some suggest that CEUS should be a routine assessment in patients with suspected hepatic metastases. CEUS demonstrates arterial phase peripheral rim hyper-enhancement with central hypo-enhancement. The arterial phase shows rim enhancement or iso-enhancement with possible non-enhancing in areas of necrosis. The venous and late phases demonstrate hypo-enhancement.

Hyper-vascular metastases include metastasis from melanoma, neuro-endocrine, tumours, breast carcinoma and renal cell carcinoma. On CEUS, the arterial phase shows hyper-enhancing. The venous phase has hypo-enhancing whereas the late phase may be hypo enhancing or non-enhancing.

Vascularity is best appreciated in the arterial phase where it shows hyper-enhancement of the lesion with focal areas of necrosis that appear as areas of hypo-enhancement (Albrecht et al., 2004, p. 25).

Hepatocellular carcinoma (HCC) is associated with hepatitis C with its incidence rising across the world. Early detection is the key to its management that include resection or liver transplantation. According to Patel (2005) an attempt to use of CEUS as part of HCC screening programmes has been problematic. The arterial phase shows hyper-enhancing with focal areas of non-enhancement in necrotic areas.

The venous phase has iso-enhancing or slight-enhancement whereas the late phase is hypo-enhancing. Small lesions appear as well-defined hypo-reflective lesions while larger lesions may be either hypo- or hyper-reflective. There has been difficulty in differentiating HCC from the surrounding liver parenchyma and regenerative nodules within an attenuating cirrhotic liver (Berry et al., 2004, p.96).

CEUS assists by showing intense arterial enhancement in up to 90% of the cases (Nicolau et al., 2004, p. 63). Subsequent phases of imaging demonstrate iso- or hypo-enhancing with the surrounding parenchyma. According to Nicolau (2004) the degree of cellular differentiation of the tumour is related to the variability in the later phases of imaging with the iso-enhancing lesions being more highly differentiated.

Cholangiocarcinoma may either be intra- or extra-hepatic. Majority arise at the bifurcation of the hepatic ducts. In CEUS, the arterial phase shows rim enhancement or non-enhancement. The venous and late phases are non-enhancing. The tumour secondary effects which include intra-hepatic bile duct dilatation and enlarged regional lymph nodes are appreciated. Identification is often challenging.

This is a factor in its low survival rate which is 5% at 5 years. Available data suggests that up to 44.4% of peripheral cholangiocarcinomas show rim hyper-enhancement in the arterial phase and demonstrate hypo-enhancement in subsequent phases (Xu et al., 2006, p. 23).

Hepatic lymphoma is of two causes: primary and secondary. Secondary lymphomas are more common occurring in up to 50% of patients with systemic lymphoma. They can also be diffuse infiltrating masses, single or multiple masses. The imaging findings are often non-contributory in the diffuse infiltrating type.

The arterial phase shows both iso-enhancement and hypo-enhancement whereas the venous phase and the late phase demonstrate hypo-enhancement. Multiple and focal lymphoma nodules are hypo-reflective on B-mode imaging. There is a great improvement in the appearance of these lesions in CEUS in the venous and late phases.

Contrast‐Enhanced Ultrasound of Traumatic Lesions

The usefulness of CEUS in trauma management has been proven recently in several studies. CEUS has proved useful in detecting and demonstration of different kinds of solid organ injuries including the liver. Several studies show that it is superior to the normal ultrasound in liver trauma cases because parenchymal lacerations, hematomas and infractions have no enhancement because of lack blood supply.

On CEUS, they appear as dark areas with no echogenicity. Active hemorrhage can be also be visualized by CEUS. This is vital to ensure hemodynamic stability is achieved by identifying and arresting the site in unstable patients. The accuracy of CEUS in trauma has sensitivities ranging from 69%‐100% and specificities ranging from 84%‐100% (Miele, et al., 2004).

According to trauma guidelines, the ideal patients in the trauma are patients with isolated parenchymal trauma, those not able to undergo CT for injury evaluation for several reasons and those in follow‐up after trauma.

Contrast Enhanced Ultrasound Guided Percutaneous Biopsy

In this case, CEUS is being used as an augmentative investigation to achieve more accuracy and precision in percutaneous biopsy of focal liver lesions. Tumour histology may at times be necessary in patients suffering from advanced focal liver lesions. This is also a necessary procedure before initiating proper treatment like chemotherapy.

In such scenario, histological data is the basis of the diagnosis and is obtained through percutaneous needle biopsy. With contrast enhanced ultrasound guidance, the accuracy of diagnosis of these lesions has been increased.

In a study published in 2006 it was shown that when using CEUS the diagnostic accuracy of percutaneous biopsy in the diagnosis of benign and malignant liver tumours, the diagnostic accuracy increased from 87% to 95.3%. The accuracy was even greater in lesions < 2 cm 97.1% compared to 78.8% (Wu et al., 2006, p. 752).

The potential added value of CEUS as an aid in percutaneous liver biopsy may also be related to:

1. Directing the needle in the tumour-affected areas with precision in cases of patchy involvement.
2. The target lesions could be hardly visible for example, small nodules of Hepatocellular carcinoma on cirrhosis.
3. Avoiding iatrogenic injury to surrounding organs and structures e.g. the hepatic artery and inferior vena cava that may lead to massive haemorrhage.

Merits of Contrast Enhanced Ultrasound

The advent of Contrast-enhanced ultrasound (CEUS) has led to a revolution in the detection of malignant lesions against the enhanced normal liver. It has also enabled the visualization of the circulation in larger vessels, capillary and sinusoids as they are imaged in real-time. This has helped overcome the limitations that earlier disadvantaged the ultrasonography thereby improving the ability to demonstrate focal liver lesions.

The sensitivity and specificity of Contrast-enhanced ultrasound (CEUS) now almost equals that of contrast computed tomography (CT) and magnetic resonance imaging (Catala et al., 2007, p. 1066).

According to a report by David Cosgrove of the Imperial College School of Medicine and Hammersmith Hospital, London in 2007, “CEUS has similar sensitivity to contrast-enhanced CT for liver metastases and for HCC, and the same applies in the differential diagnosis of benign focal lesions.”

The total body water makes the body acoustically homogeneous with respect to the conventional ultrasound waves. The body too has similar echogenicity between blood and surrounding tissues making it difficult to clearly demonstrate and determine the rate and degree of blood flow using the normal medical ultrasound.

CEUS imaging allows real-time evaluation of blood flow thus helping to differentiate between blood and the surrounding tissues.

Ultrasonic molecular imaging does not involve the use of radiation exposure making it safer than modalities like radionuclide imaging and X-rays. It is also not nephrotoxic which has been described in other contrast media.

Other molecular imaging modalities like Magnetic resonance imaging (MRI), Positron emission tomography (PET), and Single photon emission computed tomography (SPECT) are costly. This is relatively cheaper in the case in CEUS when compared to MRI, PET and SPECT. The conventional ultrasound, on the other hand, is very cost-efficient and widely available

CEUS uses a lower intravenous contrast dosage. This is because microbubbles generate strong signals. Only micrograms are needed as compared to milligrams that are needed for other molecular imaging modalities e.g. contrast MRI. This minimizes toxicity as the exposure dose is low.

Demerits of Contrast Enhanced Ultrasound And Their Solutions

Contrast-enhanced ultrasound is considered to be costly and time consuming when compared to the conventional ultrasound. It is however more costly and time consuming in the case of contrast-enhanced MRI.

The costs for attached to the contrast used can be reduced by using a continuous infusion or by using one half of a vial. The software and examination costs associated with ultrasound are 30% to 50% lower than those of MRI. More costs are also incurred in the training of personnel required for their use.

Microbubbles have a short half-life. This is because they are taken up by immune system cells and the liver or spleen even when coated with Polyethylglycol.

Contrast enhanced ultrasound generates more heat as the frequency increases and therefore needs careful monitoring. Microbubbles also burst at high mechanical indices and low ultrasound frequencies. Microvasculature rupture and haemolysis could result from microbubble destruction (Klibanov, 2005). In view of this manufacturers are now developing low mechanical index ultrasound imaging techniques.

CEUS has some limitations that are similar to standard ultrasound. Obese and uncooperative patients present a poor acoustic window that affects the clarity with which organs are discerned. The method is also operator dependent which influences the accuracy of diagnosis.

Conclusion

In the management of suspected focal hepatic lesions, Contrast enhanced ultrasound should be employed as part of the necessary investigations to enhance the accuracy in detection and characterization of focal hepatic lesions. It is more sensitive and specific than the conventional ultrasound in the detection of focal liver lesions (Bleuzen et al., 2006, p. 40).

Despite CEUS examination having almost similar accuracy to contrast CT and MRI, it is a non-radiant method, non-nephrotoxic and less costly. The operator however needs to appreciate standard CEUS appearances and utilise them the best advantage to increase its accuracy.

In cases where histology is mandatory, contrast enhanced ultrasound guide percutaneous biopsy can be used to increase the precision and accuracy in sampling the focal lesions in the liver.

List of References

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Berry, D & Sidhu, S 2004, Microbubble contrast-enhanced ultrasound in liver transplantation, European Radiology Supplements, vol. 14, no. 1, pp.96-103.

Bleuzen, A, Huang, C, Olar, M, Tchuenbou, J & Tranquart, F 2006, Diagnostic accuracy of contrast-enhanced ultrasound in focal lesions of the liver using cadence contrast pulse sequencing, Ultraschall Med, vol.27 no. 1, pp. 40-48.

Bleuzen, A & Tranquart, F 2004, Incidental liver lesions: Diagnostic value of cadence contrast pulse sequencing (CPS) and SonoVue, European Radiology Supplements, vol. 14, no.3, pp.53-62.

Catala, V, Nicolau, C & Vilana, R 2007, Characterization of focal liver lesions: Comparative study of contrast-enhanced ultrasound versus spiral computed tomography, European Journal of Radiology, vol.17, pp.1066-1073.

Catalano, O, Sandomenico, F, Raso, M & Siani, A 2004, Low Mechanical Index contrast-enhanced sonographic findings of pyogenic hepatic abscesses, American Journal of Roentgenology, Vol. 182, no. 1, pp.447-450.

Cosgrove, D 2007, Contrast-enhanced Ultrasound in Focal Liver Lesions– Guidelines for Clinicians, European Gastroenterology Review, pp. 34-36

Dietrich, F, Kratzer, W & Strobe, D 2006, Assessment of metastatic liver disease in patients with primary extrahepatic tumours by contrast-enhanced sonography versus CT and MRI, World Journal of Gastroenterology, vol.12, no.1, pp.1699-1705.

Dietrich, F, Schuessler, G, Trojan, J, Fellbaum, C & Ignee, A 2005, Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced ultrasound, British Journal of Radiology, vol. 78, no.1, pp.704-707.

Hagspiel, D, Neidl, F & Eichenberger, C 1995, Detection of liver metastases: Comparison of super paramagnetic iron oxide enhanced and unenhanced MR imaging at 1.5 T with dynamic CT, intraoperative US, and percutaneous US, American Journal of Roentgenology, vol. 196, no. 16, pp.47-48.

Huang-Wei, C, Bleuzen, A & Bourlier, P 2006, Differential diagnosis of focal nodular hyperplasia with quantitative parametric analysis in contrast-enhanced sonography, Investigative Radiology Journal vol. 41, no. 1, pp. 363-368.

Karhunen, J 1986, Benign hepatic tumours and tumour like conditions in men, Journal of Clinical Pathology, vol.39, no. 1, pp.183-188.

Klibanov, L. 2005, Ligand-carrying gas-filled microbubbles: Ultrasound contrast agents for targeted molecular imaging, Journal of Bioconjugate Chemistry, vol. 16 no. 1, pp.9-17.

Miele, V, Buffa, V, Stasolla, A, Regine, G, Atzori, M, Lalongo, P & Adami, L 2004, Contrast enhanced ultrasound with second generation contrast agent in traumatic liver lesions, Journal of Radiology, vol. 108 no. 2 pp. 82-91.

Nicolau, C, Vilana, R & Bru, C 2004, The use of contrast-enhanced ultrasound in the management of the cirrhotic patient and for the detection of HCC, European Radiology Supplements, vol. 14, no. 1, pp.63-71.

Nino-Murcia, M, Ralls, W, Jeffrey, B & Johnson M 1992, Colour flow Doppler characterization of focal hepatic lesions, American Journal of Roentgenology, vol. 159, no.1, pp.1195-1197.

Patel, N, Lim, P, Blomley, K, Sidhu, S & Taylor-Robinson, D 2005, Screening for hepatocellular carcinoma: The role of alpha fetoprotein and ultrasound with and without ultrasound contrast agents, Ultrasound Research Medical Journal, vol. 13, no. 4, pp.219-225.

Von Herbay, A, Westendorff, J & Gregor, M, 2010, Contrast-enhanced ultrasound with SonoVue: Differentiation between benign and malignant focal liver lesions in 317 patients, Journal of clinical ultrasound, vol. 38, no.1, pp.1-9.

Wernecke, K, Rummeny, E & Bongartz G 1991, Detection of hepatic masses in patients with carcinoma: Comparative sensitivities of sonography, CT, and MR imaging, American Journal of Roentgenology, vol. 157, no.7, pp. 731-739.

Wu, W, Chen, H & Yin, S 2006, The role of contrast-enhanced sonography of focal liver lesions before percutaneous biopsy, American Journal of Roentgenology, vol. 187 no.1 pp. 752-776.

Xu, H, Lu, D & Li, J 2006, Imaging of peripheral cholangiocarcinoma with low-mechanical index contrast-enhanced sonography and SonoVue: Initial experience, Journal of clinical ultrasound, vol. 25, no.1, pp. 23-33.

Introduction

Medical research indicates that there is an increase in the incidence of Achilles tendon pain (Calder, Freeman, & Pollock, 2014). Traditionally, Achilles tendon pain was believed to be a common problem affecting athletes and especially jumping athletes (Rudavsky & Cook, 2014). However, according to the assertions of Sussmilch-Leitch, Collins, Bialocerkowski, Warden, and Crossley (2012) and Chimenti, Chimenti, Buckley, Houck, and Flemister (2016), the problem is now common in non-active individuals as well. In most of the cases, 55-65% of individuals suffering from Achilles tendon pain cite the middle part of the Achilles tendon while 20-25% feel pain in the insertion (Alfredson & Isaksson, 2014).

According to a study carried out by Alfredson and Isaksson (2014), insertional Achilles tendinopathy (or insertional Achilles tendon problem) is a characteristic of pain in the posterior heel as well as the tendon insertion. Increased activity of the affected individual aggravates the symptoms (Masci, Spang, Schie, & Alfredson, 2016). Even though Achilles tendon insertion problem is a difficult problem to treat, the introduction of ultrasound and color Doppler-guided technology is considered to have significant impact on effective diagnoses and treatment of patients suffering from insertional Achilles tendinopathy (Alfredson & Isaksson, 2014; Ettinger et al., 2015).

Ultrasound technique is useful in this case because it allows the examination of the Achilles tendon insertion, the bone as well as the bursa (Kang, Thordarson, & Charlton, 2012). Also, a Realtime Achilles Ultrasound Thompson (RAUT) Test is rather beneficial in providing the examination of patients (Griffin, Olson, Heckmann, & Charlton, 2016). For example, empirical research on the application of ultrasound alongside color Doppler has revealed that individuals with painful tendons experience a high flow of blood in the affected areas as opposed to pain free-individuals (Plas et al., 2012).

Patients suffering from insertional tendon pain are manageable without operation (Stasinopoulos & Manias, 2013). Primarily, extracorporeal shockwave therapy (Gerdesmeyer et al., 2015; Maffulli, Furia, & Rompe, 2012) or even enough rest and modification of eccentric calf muscle exercises can be used as basic treatment (Mccormack, Underwood, Slaven, & Cappaert, 2016; Notarnicola et al., 2013; Ooi, Schneider, Malliaras, Chadwick, & Connell, 2015; Pearce, Carmichael, & Calder, 2012). However, in a case of failure in conservative treatment, various surgical techniques like upper calcaneus’ resection and retrocalcaneal bursa’s extirpation can be adopted (Sánchez-Ibáñez et al., 2013; Oshri et al., 2012).

In spite of this, most methods take the consideration of tendon invasive processes which necessitate long periods of postoperative rehabilitation (Sànchez-Ibàñez & Fernàndez, 2015; Tallerico, Greenhagen, & Lowery, 2014; Waldecker, Hofmann, & Drewitz, 2012). In addition, several researchers have pointed out that no consensus has been reached as far as effective methods of treating insertional Achilles tendinopathy are concerned (Plas et al., 2012; Santomi & Harold, 2012; Wiegerinck, Kerkhoffs, Sterkenburg, Sierevelt, & Dijk, 2012). Therefore, evaluation of the diagnoses and treatment of patients suffering from insertional Achilles tendinopathy is a subject worth investigating. This qualitative study examines the efficiency of ultrasound and color Doppler-guided technology in diagnosis and treatment of patients suffering from insertional Achilles tendinopathy.

Methodology and Research Design

Introduction

Creswell (2014) defined study design as the systematic process that involves an effective plan of proposed actions to be used for the purpose of collecting and logically analyzing data in order to understand a given study phenomenon. Thus, research methodology is considered to be any procedures and principles adopted to promote the collection and analysis of data on the given study phenomenon (Abbott & McKinney, 2013; Chesnay, 2015). This section covers the research design, the study of population, and techniques used in sampling as well as methods of collecting and analyzing data on the use of ultrasound and color Doppler-guided technology in diagnoses and treatment of patients suffering from insertional Achilles tendinopathy.

Research design

As it was stated above, insertional Achilles tendinopathy is a difficult problem to diagnose as well as treat. For this reason, the study on ultrasound and color Doppler-guided technology in diagnosis and treatment of patients suffering from insertional Achilles tendinopathy requires effective research design that would ensure collection and analysis of valid and reliable data. This research will use qualitative data on insertional Achilles tendinopathy. Therefore, for comprehensive analysis of the research topic, the study will adopt two study designs which include the cross-sectional case study design and the descriptive study design.

Both descriptive and case study designs are preferable in this study. This is attributed to the fact that there is a need to provide tangible effects and impacts of ultrasound and color Doppler as effective methods of diagnosis and treatment of tendon Achilles pain in patients. On the other hand, the case study design allows effective examination of study variables (LoBiondo-Wood & Haber, 2014). In this research, the case study approach is applicable due to the fact that various patients suffering from tendon Achilles problem will be used as a basis for gauging the effectiveness of the method of ultrasound and color Doppler in diagnosis and treatment of patients suffering from insertional Achilles tendinopathy.

On the other hand, the cross-sectional study design’s use in this study is primarily for complementary purposes given that descriptive research design is affected by the problem of overlying on instrumentation of measurements as well as observation (Chesnay, 2015; Creswell, 2014). As such, the design will not only give the snapshots on the possible success rate of ultrasound and color Doppler method but also will help to examine the conditions of patients under examination for the purpose of ascertaining the efficacy of this method.

Target Population

The population targeted in a study can be defined as the entire people or units for whom a researcher focuses on collecting data for the purpose of drawing meaningful inferences about the given research design (Chesnay, 2015). There are numerous people suffering from insertional Achilles tendinopathy in the US and a high percentage of reported cases related to both athletes and non-athletes. The identification of the targeted individuals will be based on the sampled patients. The research will focus on patients who have a long history of insertional Achilles tendon problem.

Sampling Design and Criteria

A sample is described as a percentage section of the entire population targeted in a study (LoBiondo-Wood & Haber, 2014). As such, a sample of a study ought to be highly representative in the context of the entire population (Creswell, 2014; LoBiondo-Wood & Haber, 2014). For this reason, suitable sampling technique ought to be applied for the purpose of ensuring that the selected sample is representative of the target population.

The sampling frame used for this study will focus on both active and non-active patients with a history of insertional Achilles tendinopathy. Such individuals are the beneficiaries of any technology adopted for effective diagnosis and treatment of insertional Achilles tendinopathy. In spite of this, the sampling criteria in this study will focus on patients who have a long history of insertional Achilles tendinopathy. As such, patients with history of insertional Achilles tendinopathy of less than a year will be excluded. According to Johnson (2015), if a sample frame is taken correctly it will lead to a sample that can be used for the population as a whole. In other words, the results of the study would be sufficient and credible enough to be generalized for the broader understanding of the issue.

Sampling Technique

This study will use the simple random sampling technique for the purpose of identifying the number of patients to be included in the sample. The rationale for the choice of the simple random sampling technique is based on the fact that such an approach is suitable in ensuring inclusivity of the study sample (Chesnay, 2015). Additionally, Johnson (2015) pointed out that the use of the random sampling technique is appropriate due to the fact that it gives study units and people equal chance of being included in the study sample. Furthermore, the author claimed that the simple random sampling technique is effective in that it is free from human bias and has the capability to avoid error classification (Johnson, 2015). For this reason, the adoption of simple random sampling technique in this study will ensure an all-inclusive sample size.

The sample frame chosen comprises numerous individuals suffering from insertional Achilles tendinopathy. However, the use of the simple random sampling technique is expected to provide comprehensive data that can be relied for drawing inferences (LoBiondo-Wood & Haber, 2014).

Sample Size

Various factors affect the process of determining the size of sample used in any study including the replication number which determines the extent of data needed for comprehensive conclusion on the given study phenomenon (Creswell, 2014). As for this study, the sample size depends on the type of data required as well as precision of collected data (Abbott & McKinney, 2013; Yin, 2013). This study upon the use of the simple random sampling technique will use a sample size of 24 patients with long term history of insertional Achilles tendinopathy.

Data Collection and Analysis

Given that the research focuses on examination of the possibility of using the ultrasound and color Doppler technology in the diagnosis and treatment of insertional Achilles tendinopathy, qualitative approach will be used. For this reason, effective methods of collecting qualitative data are applicable in this study. The study cross-sectional case study approach will be used to analyze the level of pain for all patients sampled within the insertional Achilles tendon period.

In addition, structured questionnaire will be used to collect data for the purpose of quantifying the quality of life of the patients suffering from insertional Achilles tendinopathy based on a mental and a physiological perspectives. The data collected from this study will be recorded and stored for analysis (Maxwell, 2013). For example, the data on the quality of life will be expressed through a scale for the purpose of determining the level of quality of life based on the patients’ responses. All collected data will be analyzed using advanced spreadsheets and other statistical methods of analysis such as correlation and regression analysis for the purpose of providing more details on the study phenomenon.

References

Abbott, M., & McKinney, J. (2013). Understanding and applying research design. Hoboken, NJ: Wiley.

Alfredson, H. & Isaksson, M. (2014). Ultrasound and Color Doppler-Guided Surgery for Insertional Achilles Tendinopathy – Results of a Pilot Study. Open Journal of Orthopedics, 4(1), 7-14.

Calder, J., Freeman, R., & Pollock, N. (2014). Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes. British Journal of Sports Medicine, 49(23), 1532-1534.

Chesnay, M. D. (2015). Nursing Research Using Participatory Action Research: Qualitative Designs and Methods in Nursing. New York, NY: Springer.

Chimenti, R., Chimenti, P., Buckley, M., Houck, J., & Flemister, A. (2016). Utility of Ultrasound for Imaging Osteophytes in Patients With Insertional Achilles Tendinopathy. Archives of Physical Medicine and Rehabilitation, 97(7), 1206-1209.

Creswell, J. W. (2014). Research design (4th ed.). Thousand Oaks, CA: Sage Publications.

Ettinger, S., Razzaq, R., Waizy, H., Claassen, L., Daniilidis, K., Stukenborg-Colsman, C., & Plaass, C. (2015). Operative Treatment of the Insertional Achilles Tendinopathy Through a Transtendinous Approach. Foot & Ankle International, 37(3), 288-293.

Gerdesmeyer, L., Mittermayr, R., Fuerst, M., Muderis, M. A., Thiele, R., Saxena, A., & Gollwitzer, H. (2015). Current evidence of extracorporeal shock wave therapy in chronic Achilles tendinopathy. International Journal of Surgery, 24(3), 154-159.

Griffin, M. J., Olson, K., Heckmann, N., & Charlton, T. P. (2016). Realtime Achilles Ultrasound Thompson (RAUT) Test for the Evaluation and Diagnosis of Acute Achilles Tendon Ruptures. Foot & Ankle International, 2(1), 1-5.

Johnson, T. P. (2015). Handbook of health survey methods. Hoboken, NJ: Wiley.

Kang, S., Thordarson, D., & Charlton, T. (2012). Insertional Achilles Tendinitis and Haglund’s Deformity. Foot Ankle International, 33(6), 487-491.

LoBiondo-Wood, G., & Haber, J. (2014). Nursing research: Methods and critical appraisal for evidence-based practice: Study guide (8th ed.). St. Louis, Mo.: Mosby.

Maffulli, N., Furia, J., & Rompe, J. (2012). Paper 20: Insertional Achilles Tendinopathy – Eccentric Loading vs. Radial Shock Wave Treatment. Arthroscopy: The Journal Of Arthroscopic & Related Surgery, 28(9), e346.

Masci, L., Spang, C., Schie, H. T., & Alfredson, H. (2016). How to diagnose plantaris tendon involvement in midportion Achilles tendinopathy – clinical and imaging findings. Musculoskeletal Disorders, 17(1), 1-6.

Maxwell, J. A. (2013). Qualitative research design: An interactive approach (3rd ed.). Thousand Oaks, CA: Sage.

Mccormack, J. R., Underwood, F. B., Slaven, E. J., & Cappaert, T. A. (2016). Eccentric Exercise versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy: A Randomized Controlled Trial. Sports Health: A Multidisciplinary Approach, 8(3), 230-237.

Notarnicola, A., Maccagnano, G., Tafuri, S., Forcignanò, M., Panella, A., & Moretti, B. (2013). CHELT therapy in the treatment of chronic insertional Achilles tendinopathy. Lasers in Medical Science, 29(3), 1217-1225.

Ooi, C., Schneider, M., Malliaras, P., Chadwick, M., & Connell, D. (2015). Diagnostic Performance of Axial-Strain Sonoelastography in Confirming Clinically Diagnosed Achilles Tendinopathy: Comparison with B-Mode Ultrasound and Color Doppler Imaging. Ultrasound in Medicine & Biology, 41(1), 15-25.

Oshri, Y., Palmanovich, E., Brin, Y. S., Karpf, R., Massarwe, S., Kish, S., & Nyska, M. (2012). Chronic insertional Achilles tendinopathy: Surgical outcomes. Muscles Ligaments Tendons Journal, 2(2), 91-95.

Pearce, C., Carmichael, J., & Calder, J. (2012). Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot and Ankle Surgery, 18(2), 124-127.

Plas, A. V., Jonge, S. D., Vos, R. J., Van Der Heide, H. J., Verhaar, J. A., Weir, A., & Tol, J. L. (2012). A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. British Journal of Sports Medicine, 46(3), 214-218.

Rudavsky, A., & Cook, J. (2014). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy, 60(3), 122-129.

Sànchez-Ibàñez, J. & Fernàndez, M. (2015). Ultrasound-Guided EPI® Technique and Eccentric Exercise, New Treatment for Achilles and Patellar Tendinopathy Focused on the Region-Specific of the Tendon. Orthopedic & Muscular System, 4(4), 1-6.

Sánchez-Ibáñez, J., Alves, R., Polidori, F., Valera, F., Minaya, F., Valles-Martí, S., & Baños, L. (2013). Effectiveness of Ultrasound-guided Percutaneous Electrolysis Intratendon (epi) in the Treatment of Insertional Patellar Tendinopathy in Soccer Players. British Journal of Sports Medicine, 47(9), e2.

Stasinopoulos, D., & Manias, P. (2013). Comparing two eccentric exercise programmes for the management of Achilles tendinopathy. A pilot trial. Journal of Bodywork and Movement Therapies, 17(3), 309-315.

Sussmilch-Leitch, S. P., Collins, N. J., Bialocerkowski, A. E., Warden, S. J., & Crossley, K. M. (2012). Physical therapies for Achilles tendinopathy: Systematic review and meta-analysis. Journal of Foot and Ankle Research, 5(1), 1-16.

Tallerico, V., Greenhagen, R., & Lowery, C. (2014). Isolated Gastrocnemius Recession for Treatment of Insertional Achilles Tendinopathy: A Pilot Study. Foot & Ankle Specialist, 8(4), 260-265.

Waldecker, U., Hofmann, G., & Drewitz, S. (2012). Epidemiologic investigation of 1394 feet: Coincidence of hindfoot malalignment and Achilles tendon disorders. Foot and Ankle Surgery, 18(2), 119-123.

Wiegerinck, J. I., Kerkhoffs, G. M., Sterkenburg, M. N., Sierevelt, I. N., & Dijk, C. N. (2012). Treatment for insertional Achilles tendinopathy: A systematic review. Knee Surgery, Sports Traumatology, 21(6), 1345-1355.

Yin, R. K. (2013). Case study research: Design and methods (5th ed.). Los Angeles, CA: Sage Publications.

Literature Review

In their research, Miller et al. (2012) dwelled on the application of ultrasound in therapeutic treatments and discussed the best ways to minimize side-effect risks and help patients as much as possible. They mentioned that ultrasound had several definite benefits supported by evidence and could be used to increase patient safety when the clinician dealt with chronic pains (Miller et al., 2012). Throughout the research process, the investigators found that the amount of safety information is either insufficient or confusing. Research on the subject of ultrasound therapy revealed that even commercial conflicts might arise throughout the implementation of this kind of treatment. Miller et al. (2012) also highlighted the significance of communicating the safety principles to the patients that were subject to being treated using ultrasound. Their qualitative meta-analysis of the effects of ultrasound on the quality of therapeutic approaches to chronic pains helped find numerous ultrasound methods that can be utilized in different situations. Overall, Miller et al. (2012) proved that the clinical use of ultrasound bears a positive connotation to patient outcomes, and the safety of this method is one of the biggest advantages.

Another research project intended to support the use of ultrasound therapy was conducted by Ulus et al. (2012). In that study, they addressed the short-term impact of ultrasound therapy in the cases where it was necessary to ease the pain or restore physical functions of the patients. Ulus et al.’s (2012) study involved several patients (42) with knee osteoarthritis. A researcher that was not involved in the evaluation of the outcomes randomized the sample, and two groups were formed – continuous ultrasound therapy and sham ultrasound therapy.

All of the participants of the study (patients) were subject to receiving 20 minutes of hot packs and at least 15 minutes of specific knee-focused isometric exercises in addition to ten minutes of interferential current (Ulus et al., 2012). The treatment was received throughout three weeks straight (five times per week). The researchers evaluated the data based on the baseline information and the end date. To measure the outcomes, Ulus et al. (2012) used a visual analog scale, a specific osteoarthritis index, Lequesne index, and depression scale. Nonetheless, the study outcomes showed that the application of ultrasound in association with conventional physiotherapy does not have any significant effects on patients with knee osteoarthritis. Instead, it was recommended to apply ultrasound therapy exclusively.

The Gap in Scientific Knowledge

The gap in scientific knowledge is accurately addressed by the authors of the reviewed research study. Their research points at several factors that had not been discussed in the previous literature on the subject of continuous ultrasound. This study is different because Ebadi et al. (2012) dwell on the evidence regarding the effectiveness of physiotherapy practices aimed at treating chronic LBP. Owing to this research project, it turned out that the presence of an effect mitigated the lack of evidence. Therefore, it is safe to say that such findings impact the field of the use of ultrasound for the treatment of chronic pains and prove its efficiency. Ebadi et al. (2012) stated that their research results might bear several practical implications for the healthcare facilities that are keen on finding new treatment methods for patients with chronic back pains.

Research Problem

Within the framework of the research project conducted by Ebadi et al. (2012), the research problem consisted in the fact that the effects of continuous ultrasound were underresearched. The investigators especially became interested in addressing the issue of continuous/ placebo ultrasound therapy and its effect on the patients with NSCLBP. Additionally, Ebadi et al. (2012) saw the problem in investigating the secondary outcomes such as the endurance of lower back muscles and lumbar variety of locomotion.

Research Questions

There was no hypothesis in the study conducted by Ebadi et al. (2012). Still, the research question revolved around the idea that ultrasound might be a useful instrument when dealing with patients suffering from the NSCLBP. The researchers were able to answer this question and provide relevant evidence to support their point of view.

General Methodology

This is mixed research that features both qualitative and quantitative characteristics. The researchers outlined the methodology as follows: 50 patients with NSCLBP took part in the blind placebo-controlled study. To follow the study design, the patients were randomized into two groups – placebo ultrasound (and extra exercises) and continuous ultrasound (with extra exercises as well) (Ebadi et al., 2012). The process of treatment took four full weeks. There were ten treatment sessions with a frequency of three times a week. To randomize correctly, the researchers used opaque taped up envelopes. The latter was arranged by a statistician that created a randomization schedule using a computer. All the envelopes were distributed equally between the subjects of both groups. This study design allowed the researchers to minimize the level of bias and answer the research question because they backed the theoretical findings with statistical data.

Measures/Instruments

To measure the outcomes of the study, Ebadi et al. (2012) used the functional rating index (to address the primary outcome of functional disability) and a visual analog scale (to assess the global pain. There was also feedback data collected using a questionnaire. Throughout their observations, the investigators recorded all the information using electronic data collection forms.

Population and Sampling Plan

There were several inclusion criteria that Ebadi et al. (2012) enumerated in their research article. Those included the presence of NSCLBP and age limit (18-60). On the other hand, there were numerous exclusion criteria: the presence of systemic diseases, previous lower back surgery, specific psychological problems, pregnancy, and fractures (Ebadi et al., 2012). The sample (2 groups, 23 participants each) consisted of the patients coming from three Tehran hospitals. All the study participants were required to sign a consent form and acquire the information regarding the experiment. The information that was presented by Ebadi et al. (2012) may be helpful, but it is not enough to recreate their study. There was no clear rationale for the researchers’ sampling decisions, but they aligned their project with the expected sample size. There were identified no supporting sources that would justify the sample size decision. Ebadi et al. (2012) were able to conduct the study “as is” and did not have to review their sampling plans.

Data Collection

To obtain all the necessary electromyographic data, Ebadi et al. (2012) used an 8-channel EMG recorder. After the data acquisition, it was analyzed using the built-in software titled DATA LOG. According to the information presented by Ebadi et al. (2012), the signal was gathered at 1000 Hz and 1000 decibels. All the outcome measures were documented at the starting point, after the end of the study, and one month after the end of the study. According to the information in the article, the author of this submission may claim that there is not enough data available to replicate the study despite a detailed description of the instruments used. One of the missing things is the direct outline of collecting the data, which may be rather important because incorrect study design may cause adverse outcomes in the study participants.

Findings

The majority of the findings outlined by Ebadi et al. (2012) revolved around the idea that the patients receiving continuous ultrasound treatment had a higher endurance time rate than their placebo counterparts. Within this research framework, the investigators defined endurance as the ability to sustain mobile activity (which is directly associated with fatigue). The researchers concluded that one of the main predictors of muscle fatigue is the presence of metabolite wastes in the lower back region. Continuous ultrasound was found to increase blood circulation and trigger muscle contraction, which ultimately led to improved low back muscle strength. It may be concluded that Ebadi et al. (2012) successfully answered their original research questions within the framework of the reviewed research study.

Limitations

The most important limitation of the study consisted in the fact that the treating physiotherapist knew everything about the group allocation (Ebadi et al., 2012). This means that the collected data may be biased, and consequently, this may be considered the biggest weakness of this particular study. Another limitation was the number of patients that decided to drop out of the study (approximately 22%) (Ebadi et al., 2012). One of the areas of the study that cannot be improved is the self-reported compliance rate. On the other hand, throughout their future research on the topic, Ebadi et al. (2012) may slightly revise the study’s design to be able to observe individual interventions discretely. Bearing in mind the limitations mentioned above, there is a need to redesign the study to obtain valid results.

Future Research

Further research in the area will have to concentrate on the differential effects of various interventions (including those described in Ebadi et al.’s (2012) study on NSCLBP patients. Also, the author of this submission believes that future investigation on the topic of NSCLBP should include the measurement of electromyography parameters not included in this research article (for instance, normalized median and mean frequency). This may help the researchers to inspect the impact of these parameters on the patients with NSCLBP. In addition to this, the future research in the area should critically focus on the methodological shortcomings of Ebadi et al.’s (2012) study and verify the outcomes in patients with chronic low back pain related to the dose-response.

Site Permission

All of the permissions were granted by the Tehran University of Medical Sciences (including the Ethical Committee and the Research Council). The Netherlands Trial Registry validated the experiment. At the time of the experiment, the site did not have a separate IRB. To obtain all the necessary permissions, Ebadi et al. (2012) asked for informed consent and went through the previous literature.

Participant Contact

The researchers contacted the future participants of the study at the territory of the healthcare facility. After the study was over, all the participants were contacted again to share the outcomes and provide the necessary recommendations. It may be concluded that Ebadi et al. (2012) approached the participants in a correct manner and made them feel safe.

Ethical Considerations

From the study’s design, we may learn that the study is in line with all the necessary ethical considerations. The authors did not discriminate against anyone and kept the personal data safe. After the research study was over, Ebadi et al. (2012) carefully analyzed the data and made everything possible not to disclose the study results before validating the obtained information. Overall, the researchers did a great job of protecting the participants from any internal or external adverse influence.

Risk Assessment

The author of this submission did not identify any serious risks that could impact any study participants or examiners. Therefore, the study is within the limits of minimal risk and can be considered reliable. The population that was reviewed in the article could be considered vulnerable. Nonetheless, the level of risk would not differ significantly when the participants were a part of the vulnerable population. The authors of the reviewed study protected their participants by limiting their medication intake and getting used to the specific exercises.

References

Ebadi, S., Ansari, N. N., Naghdi, S., Jalaei, S., Sadat, M., Bagheri, H.,… Fallah, E. (2012). The effect of continuous ultrasound on chronic non-specific low back pain: A single blind placebo-controlled randomized trial. BMC Musculoskeletal Disorders, 13(1), 192.

Miller, D. L., Smith, N. B., Bailey, M. R., Czarnota, G. J., Hynynen, K., & Makin, I. R. S. (2012). Overview of therapeutic ultrasound applications and safety considerations. Journal of Ultrasound in Medicine, 31(4), 623-634.

Ulus, Y., Tander, B., Akyol, Y., Durmus, D., Buyukakıncak, O., Gul, U.,… Kuru, O. (2012). Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: A randomized double‐blind controlled clinical study. International Journal of Rheumatic Diseases, 15(2), 197-206.

Mammography screening is one of the most recognized options for analyzing breast tissue in adult women. Recommendations note that clinicians need to explain all the benefits and drawbacks of this process due to mammogram’s potential in increasing cancer risk (Løberg, Lousdal, Bretthauer, & Kalager, 2015). Nonetheless, mammogram also has different limitations in cancer screening, and they can significantly reduce the effectiveness of this test. For instance, some breast tissue may be considered suspicious on the mammogram but not be breast cancer (Welch, Prorok, O’Malley, & Kramer, 2016). As a result, a patient can undergo unnecessary treatment that causes side effects and lowers one’s quality of life. Women with dense breast tissue are in a group with a higher rate of false mammography results (Hugo et al., 2018). They should be offered to undergo other tests to determine whether they are or at risk of having breast cancer.

One of the options for patients with dense tissue is ultrasound. This procedure does not use radiation but high-frequency sound waves, which do not have the same adverse effects on patients’ health (Hugo et al., 2018). In contrast, the accuracy of this procedure allows it to be an alternative for women who cannot undergo mammography due to the increased potential of false mammogram results (Hugo et al., 2018). Moreover, if the residence area of a patient does not have mammography equipment available, ultrasound can be used instead. Another option for women with dense breast tissue is magnetic resonance imaging (MRI). Similar to ultrasound, MRI does not rely on radiation, but its accuracy remains under question for this particular screening (Hugo et al., 2018). Overall, the decision of the advanced practice nurse concerning choosing an appropriate method should be based on a woman’s personal choice, patient history, financial concerns, and equipment availability.

References

Hugo, H. J., Tourell, M. C., O’Gorman, P. M., Paige, A. E., Wellard, R. M., Lloyd, T.,… Thompson, E. W. (2018). Looking beyond the mammogram to assess mammographic density: A narrative review. Biomedical Spectroscopy and Imaging, 7(1-2), 63-80.

Løberg, M., Lousdal, M. L., Bretthauer, M., & Kalager, M. (2015). Benefits and harms of mammography screening. Breast Cancer Research, 17(1), 63.

Welch, H. G., Prorok, P. C., O’Malley, A. J., & Kramer, B. S. (2016). Breast-cancer tumor size, overdiagnosis, and mammography screening effectiveness. New England Journal of Medicine, 375(15), 1438-1447.

Technology is an important factor in the medical fraternity. Moreover, the high rate of technological change has brought many measures in the field of medicine. One sector that has been affected by technology is obstetrics and gynecology in which ultrasound imaging plays an important role. Ultrasound employs the use of sounds to create an image depicting the development inside the body. The ultrasound scanner sends the sound waves into the body and when the sound bounces back, the sound produces an image on the computer screen.

This is amplified by the use of the 3D/4D ultrasound that can amass volume of echoes, store it digitally and shade producing images of fetus and adds an element of movement. Thus, this enables the activity and state of the fetus to be easily analyzed. Therefore, the aim of this paper is to analyze the benefits of 3D/4D ultrasound imaging in the field of obstetrics and gynecology.

The technology of ultrasound has played an important diagnostic role in the field of obstetrics because it employs sound waves to form images replacing ionizing methods e.g. x-ray to receive the same information. It has replaced the 2D that has been in place for a long time that showed white and black, grainy and flat images that require an expert to interpret the given results. However, the introduction of the 3D ultrasound added depth dimensions that made the photographic image clearer, and the image is easily interpreted by the untrained eye. The inclusion of the 4D ultrasound ensures capturing of movement of the given fetus (DeVore & Platt, 2004). Thus, the use of 3D and 4D ultrasound has made it cheaper for the information to be achieved and at the same time reduces the time that the results will be obtained (return time).

The 3D and 4D volume sonography usually provides useful diagnostic information for evaluation by gynecologists especially in the uterine duplication anomalies and evaluation of the uterine cavity. Utilization of the 3D and 4D ultrasound in the assessment of the fetal anomalies predicts prenatal characterization of the fetus congenital defects e.g. skeletal and facial anomalies. The information that is obtained from this exam assists the health care providers in counseling parents on the development of the fetus especially in the nature of anomalies, prognosis, and the postnatal consideration of the congenital abnormalities.

2D sonography plays an important role in imaging, but the inclusion of surface rendering (multi-planar reconstruction) in the 3D image has played an important role in the fetal face. This is because the acquisition of fetal face volume can be easily used to reconstruct the midline sagittal plane; a phenomenon that lacked in other techniques e.g. 2D. Such information is crucial in evaluating the fetal nasal bone or evaluation of suspected micrognathia cases. Moreover, the information that is available from the surface-rendered and multi-planar views from the collected data of fetal face helps in explaining a suspected palate or cleft lip and/or any possible mental and orbital abnormalities.

Some expert physicians have utilized the 3D ultrasound fetal imaging in fetal echocardiography. The utilization of volume data in reconstructing the image of the heart has enabled the analysis of normal cardiac structures. Standardized planes of the given fetal heart can be constructed from the sonographic data reducing operator dependence. The fetal heart volumes can be easily acquired in real-time with the help of gated technology and can be stored as a cine loop of the given cardiac cycle.

Thus, surface rendering image capabilities have ensured that the dependence towards the operator has been drastically reduced. 3D color capability also plays an important role in extra-cardiac vasculature assessment. This technique ensures that the fetal placental cord insertion site images can be produced. Moreover, other information such as the vascular anastomoses, abnormal vessels from the pulmonary sequestration, and the aberrations of the central nervous system can be easily known.

The capability of the 3D and 4D ultrasound in storing volume data plays an important role after the patient has left the examination site. The data that was obtained during the examination procedure can be manipulated and reconstructed in any orientation for interpretation. Nevertheless, it is quick to store a single volume of data, and the same data permits interpretation of the scanned region in a variety of planes.

This capability ensures improved patient throughput and promotes a more efficient ultrasound practice. The stored information can be easily electronically transmitted for better interpretation and evaluation promoting the use of teleradiology in improving image interpretation and at the same time decreasing the dependency of the operator. Thus, it enables the utilization of ultrasound technology in remote areas where an ultrasound expert is absent.

The three and four-dimensional images play an important role in the psychological perspective of the parent towards the fetus. A patient who utilizes volume sonography and views the 3D/4D images enhances the bond between them and the fetus. Moreover, the parents have a positive feeling towards the developing fetus. Even though 2D offers the same functionality, but the 3D/4D image offers more satisfaction.

In certain circumstances, the 3D and 4D images can be used in providing keepsake images of the maturing fetus to its parents. When the parents, friends, and other family members view the features, movements, and facial expressions of the fetus they try to recreate resemblance of the fetus (baby) with the people around the family creating a bond at a time that the pregnancy is some few months old (Jurgens & Chaoui, 2003). Thus, the visualization of the fetus enables an unparalleled bonding experience involving parties involved. Moreover, the fetal visualization may at times alleviate maternal depression and anxiety, and at the same time enables the father to feel that he is connected to the pregnancy hence, strengthening the bond between the father and the child.

Bio-effects should be placed into consideration when utilizing ultrasounds since it is a form of energy. Ultrasound has two common effects in tissues, which include mechanical and heating. However, 2D ultrasound has no harmful effects through studies that have been carried out in epidemiology. Since the 3D and 4D ultrasound involves reconstructions of the 2D images, the energy that is released is to some extent equal to 2D (Espinoza & Lee, 2004). Moreover, the level of exposure is reduced because the manipulations and reconstructions are performed after the patient leaves the ultrasound machine or offline.

Capabilities of 3D and 4D imaging ensures that fetal anatomy is seen clearly. Some of the features that can be seen easily are the arms, fingers, toes and face. This also allows detected of other features such as the cleft palate when compared to the capability of the 2D imaging (Mangione & Horovitz, 2003). Moreover, it allows fetus movement such as smiling, yawning, swallowing and moving of the fingers to be seen easily with the capability of the 4D sonography. It also allows the doctors to analyze small movements and health just like how pediatrician exams a newborn baby, but the doctors assess the fetus from head to the toe through the computer screen. Thus, 3D and 4D ultrasound technology plays an important role in ensuring that the status of the fetus is known in advance.

Three and four-dimensional (3D/4D) ultrasound plays an important part in the world of sonographic imaging in the gynecology and obstetrics. It is an important problem-solving tool when it is called upon. Its potential is huge and able to improve efficiency and patient throughput when properly utilized. The maturing technology in the field of sonography is important in advancing the health requirements of the parent and fetus.

This is exemplified by its ability in depicting the development of the fetus and predicting any anomalies that may occur. If used well it brings important bonding between the parents and other family related members. It plays an important role in pathogenesis allowing appropriate measures to be taken in advance. The equipment does not have ionizing effect or bio-effect that is associative with other equipments that are relevant in the given situation. However, the main requirement to achieve the benefits that are associated with 3D/4D in obstetrics and gynecology is if it is properly utilized.

References

Chaoui, R. & Heling, K. (2004). Three-dimensional (3D) and 4D color Doppler fetal echocardiography using spatio-temporal image correlation (STIC). Ultrasound Obstetrics Gynecology, 23, p. 535–545.

DeVore, G. & Platt, L. (2004). The “spin” technique: a new method for examination of the fetal outflow tracts using three-dimensional ultrasound. Ultrasound Obstetrics Gynecology, 24, p. 72–82.

Espinoza J. & Lee W. (2004). The use of the minimum projection mode in 4-dimensional examination of the fetal heart with spatiotemporal image correlation. Journal Ultrasound Medicine, 23, p. 1337–1348.

Gonçalves L. & Lee W. (2003). Four-dimensional ultrasonography of the fetal heart with spatiotemporal image correlation. American Journal Obstetrics Gynecology, 189, p. 1792–1802.

Jurgens J. & Chaoui R. (2003). Three-dimensional multiplanar time-motion ultrasound or anatomical M-mode of the fetal heart: a new technique in fetal echocardiography. Ultrasound Obstetrics Gynecology, 21, p. 119–123

Mangione R, & Horovitz J. (2003). Craniofacial dysmorphology and three-dimensional ultrasound: a prospective study on practicability for prenatal diagnosis. Prenatal Diagnosis, 23, p. 810–818.

Introduction

Ultrasound is sound energy in the form of wave which has increased above 20 KHZ (Srbely 2009, 3). Generally, the human beings can only detect a maximum of sound frequency not more than 20,000 Hz. So far there are only two vital types of Ultrasound diagnostic and therapeutic that is well known. In point of fact, Medical imaging provides the most perfect task of diagnostic to Ultrasound, whereas, the main usage of therapeutic Ultrasound is to treat the numerous types of diseases and disorders in human beings (Srbely 2009, 3).

Towards the turn of a new decade, there has been various technological advancement in machinery of ultrasound; in fact, the new improvements have provided more reliable and accurate ways of treating all diseases and disorders treatable under these category and the outcome of these developments are seemingly more advantageous since they save time and the patient incur less pain compared to the past (Nicholas 2010). Therefore, in this paper we shall assess the two major technological developments in real time imaging: extended file of view and 3-D Ultrasound. Moreover, this paper will discuss the numerous benefits that have been brought about by both advances in real time imaging for the conventional imaging.

Extended field -of -view in Ultrasound

The first chief developments is the Extended field of view (EFOV) which urbanized shortly after the production of static image by transmitting the 1-D probe through the assessing the region utilizing “mechanical positing arm” (Poon and Rohling 2005). However, the process of producing the static image (D-2) was slow due to complication and it has not been included in the real time. For this reason, new developments in Ultrasound have led to using real time imaging. The extended view approach is based on “sweeping” the probe in sideways direction on the targeted section (Poon and Rohling 2005).

The advanced approach -Extended field- of- view in Ultrasound can provide high quality panoramic image even without the need to change the resolution when being used manually. Additionally, the mechanism of Extended field-of-View technology is more advanced based on the fact that it can be used to evaluating of the probe by comparing the sequential images produced through the different types of motion of the probe. Such images are transmuted geometrically accordingly in a careful manner to ensure quality result is established, the images are then inserted in (the Extended filed-of-View) image buffer and later integrated with the other images to provide a quality EFOV (Extended field-of-View) image (Kim, et al. 2003). An EFOV image is more advanced and can also enable recording of images measuring up-to to 60cm long raised above the ground. Furthermore, EFOV has multi-options such as watching the “topographic anatomic structure” (Kim, et al. 2003).

Example of clinical study of EFOV

In this case we shall give a factual case involving a 54 year old male patient who was experiencing shoulder pain. Because of the nature of his problem, the right recommendation is to use EFOV images in order to show the muscles of “supraspinatus and infraspinatus” (Srbely 2009, 3).

(S: supraspinatus muscles, T: trapezius muscles, I: infraspinatus, *: acoustic shadowing fromscabular spine)

The above shown figures are image result of EFOV; with a clear focus, the image shows clearly especially focusing on figure 1. We can be able to wrap up from the observation of these images that, the use EFOV technology is essential especially for musculosketal examination and it is evidently reliable. In fact, from the well elaborated figure using EFOV the images of supraspinatus and infraspinatus gives an opportunity to have a vivid picture of the structure and we can also be able have a comparison of the adjacent muscles.

3-D Ultrasound

The second technological advancement is that of the 3-D Ultrasound. The 3-D represents the three basic parts of the Ultrasound which are; data acquisition area, data analysis area and the 3-dimensional volume display (3D Ultrasound Imaging Group 2009). The 2-dimension images are acquired through by taking the images diagonally along the body surface in order to have a clear image; when the 2-Dimensional scan have been acquired they are then put in a computer software which is used to figure 3D images. There are a number of 3D imaging which offers a wide variety of focus which may facilitate to detect cancerous and benign tumors, examining of sensitive cases such as detecting prostates gland for early discovery of tumors, assessing the colon and rectum, imaging a fetus to evaluate its growth especially to observe cases of abnormal growth and so on (Freudenrich 2008).

Example of clinical study of 3-D Ultrasound

One of the basic applications of 3-D imaging is focusing development of foetuses. With the use of 3-D imaging, high and quality images of foetus can be acquired. In figure 5 provided in this paper, it is clearly observable that 3-D Ultrasound imaging has produced vivid images that can be used to draw a good contrast between the imaged tissues and the surroundings structures, such as, fluid and tissue.

Conclusion

Generally, there are numerous advancements in the real time imaging with two chief developments having taken place in the last decade. Extended field-of-View and 3-D Ultrasound technologies represents the two most significant developments and application these technologies in the society has seen a great revolution in the department of nursing. The two techniques can offer image with high resolution and display vivid images. EFOV can provide a huge display in one single image while the 3-D Ultrasound is widely helpful in focusing foetus. With the changing trends of technology, the future looks more promising and we might see more advancement of real time imaging for social change.

List of references

3D Ultrasound Imaging Group. 3D/4D Ultra. Web.

Antony, J. Ultrasound image gallery, A free gallery of high-resolution, ultrasound, color doppler and 3D images. 2007. Web.

Freudenrich, C. How Ultrasound Works. 2008. Web.

Kavanagh, E, and G koulourous. “Does extende field-of-view sonography improve interrater relaiability for the detection of rotator cuff muscle atrophy?” American Roentgen RAY Society 190 (2008): 27-31.

Kim, S, B Choi, K Kim, K Lee, and J Han. “Extended field-of-view sonography,advantages in abdominal applications.” Ultrasound Med 22 (2003): 385-394.

Nicholas, B. The Development of Ultrasound Machines. 2010. Web.

Poon, T, and R Rohling. “Three-dimensional extended filed of view Ultrasound.” World Federation For Ultrasound in Medicine and Biology (Elesevier) 32, no. 3 (2005): 357-369.

Srbely, J. “The Biophysical Effects of Ultrasound,a review of the current literature.” 2009, 3.