trate, to measure endothelium-independent vasodilatation. The methodcorrelates well with studies of coronary artery endothelial function, andits major advantage is that it can be performed serially. Future devel-opments in ultrasound technology are likely to enhance image quality,automate measurements, and provide a means to link abnormalitiesobserved using this method with cardiovascular event rates. With suchdevelopments, non-invasive ultrasound assessment of arterial functionand structure may provide clinically useful means for early detection ofatherosclerosis in high-risk but asymptomatic subjects, where preven-tion strategies may have important health benefits.

Reliable grading of peripheral vascular diseaseJaeger KA, Division of Angiology, Basel, Switzerland

Objective: Duplex sonography (DS) has proven particularly useful forthe detection and grading of peripheral arterial disease (PAD).Methods: DS in PAD is applied for answering specific questionsfollowing a comprehensive clinical assessment including ankle pres-sure measurements. Using appropriate frequencies and techniques, thevascular tree from the infrarenal aorta to the pedal arteries is assessable.Results: B-mode sonography provides the basis for the anatomicallocation of vascular lesions but, due to varying reflectivity of (calcified)plaques, overestimation of the degree of stenosis may result. Color-coded DS allows for a fast and easy visualization of the flow distur-bances but may result in underestimation of disease. Spectral analysisof pulse-wave Doppler sonography provides the basis for quantitativejudgement of the lesions’ degree of severity. Additional techniquessuch as power Doppler, harmonic imaging, or the use of contrast agentsmay be useful as adjuncts to regular DS. Classification of disease into5 categories is based on signal pulsatility, systolic and/or diastolicvelocity increase, the peak systolic velocity ratio, and the poststenoticflow contour. The accuracy depends on the number of categories, themorphology of the stenosis, inflow and outflow resistance, the qualityof the DS device and of the “gold standard,” as well as on the skills orthe examiner.Conclusions: Due to the high diagnostic accuracy, DS is the method ofchoice for a vast majority of PAD patients undergoing medical treat-ment of catheter interventions.

WHAT ARE THE CHALLENGING ISSUES FACING THESONOGRAPHERS IN YOUR COUNTRY?

US Workforce issues that are impacting the diagnostic medicalsonographerEvans KD, Radiology/Cardiology, The Ohio State University,Columbus, OH

The objective of this presentation will be to provide the participantswith a current understanding of the U.S. workforce supply shortage ofdiagnostic medical sonographers and the demand for more complexpatient examinations with ultrasound. This is coupled with the U.S.Department of Labor recently designating the diagnostic medicalsonographer as a new occupational classification separate from radio-logic technology. Survey data will be shared from a 1999 survey of USsonographers that will give a picture of this imbalance in the workforce.A presentation of some of the educational options will be provided thatmight assist in obtaining a better balance in the workforce though thesevaried forms of instruction. Examples of formal and informal work-force learning offerings will be discussed and ways to get sonographersmore involved in keeping abreast of changes in the field. Formalworkforce learning are those efforts that are affiliated with structured

classroom activities, while informal learning are those experiences thattake place outside of a curriculum-based environment. One of the keycomponents of informal learning is action and reflection. A strategy forimplementing these in the workplace will be presented. Finally, adiscussion will be provided about some of the formal distance learningopportunities that are available. These may provide a mechanism thatwill assist in both providing continuing education for practicing sonog-raphers as well as educating a new supply of workers.

Recognizing sonography as a profession—A challenge or a threatChudleigh T, United Kingdom Association of Sonographers, London,United Kingdom

The significant contribution made by non-medical sonographers to theultrasound service in the United Kingdom (UK) has been well recog-nized for over 20 years. Currently, over 85% of sonographers arequalified radiographers with the majority of the remainder being car-diac technologists, midwives, and vascular technologists. Radiographyis an established profession that is legally regulated and recognized bygovernment and by other professions involved in healthcare delivery.Despite the long-standing availability of an education and trainingprogram for sonographers and the pivotal role sonographers play inultrasound service provision, there remains no legal requirement in theUK for a practicing sonographer to hold an ultrasound qualification. Inaddition, sonography remains unrecognized as a profession, and itspractice remains unregulated. Recent data indicate that sonographerswant their profession recognized and their practice regulated. Recog-nizing sonography as a profession requires the cooperation of a numberof professional bodies that are prepared to work together to address theissues of education and training, registration to practice, indemnity forpractice, and continuing professional development. It also has long-term implications that extend into professional career pathways, under-graduate training options, and clinical service delivery. There is a lackof consensus between the various organizations that currently supportsonographers over many of these issues. Finding a way forward that isacceptable to all groups concerned, including the Department ofHealth, is the challenge, or the threat, currently being faced by sonog-raphy in the UK.

Recent achievements of the Japanese Society of SonographersNishida MI,*1,2,3 Kitamura N,2 Masuda Y,1 1. Japanese Society ofSonographers, Tokyo, Japan, 2. Radiation Oncology, Imaging andDiagnoisis, Sapporo Medical University Graduate School ofMedicine, Sapporo, Hokkaido, Japan, and 3. Ultrasound, OguroGastroenterological Hospital, Sapporo, Hokkaido, Japan

Ultrasound has expanded its frontiers rapidly without standardizingbasic procedures. Such standards are imperative if the diagnostic ac-curacy of ultrasound examinations is to be maximized. Standardizedultrasound procedures for each specialty matching the contemporarystate of sonography in gastroenterology, obstetrics and gynecology,cardiology, and nephro-urology were summarized by the JapaneseSociety of Sonographers (JSS) in 1998. Ultrasound terminology withschema and photographs for each field were published in 2001 as afollowing version of the standard procedures and as a practical com-prehensive guide for those working clinically. This guide was placed onour website for reference purposes. The society also is conducting anationwide questionnaire of sonographers to clarify the current statusof practical sonography in Japan. The questionnaire addresses issuessuch as state of facilities, specialties covered, staff numbers, instrumentmaintenance, involvement in society activities, qualifications and cred-its of sonographers, format of examination reports, measurements made

S46 Ultrasound in Medicine and Biology Volume 29, Number 5S, 2003

of organ and vessel size and of cardiac function. At the same time,sonographers continuously strive to increase their knowledge of newtechniques and improved methodologies. This requires an on-goingcommitment to obtain new knowledge and actively participate ineducational forums. In terms of recent new technological develop-ments, contrast and 3-D ultrasound have become the focus of attentionfor application in sonography. Strong cooperation with other disci-plines such as sonologists, interventional radiologists, and nurses isessential, and sonographers must remain committed to continuousprofessional education. Further issues facing Japanese sonographerswill be described in this presentation.

Defining the advanced practitionerWilson J, Healthcare Studies, University of Leeds, Leeds, UnitedKingdom

In the UK, sonographers have seen a significant change in their pro-fessional career framework during 2002. Most sonographers progressinto ultrasound from a radiography background and undertake master’slevel education in medical ultrasound before they are deemed capableof practicing ultrasound. A combination of factors, including poorrecruitment and retention into ultrasound employment, and a “blurring”of professional boundaries between radiologists and sonographers hasencouraged the formal development of the advanced practitioner rolefor sonographers. To be graded as an advanced practitioner, the sonog-rapher needs to demonstrate that they are “independent and autono-mous in thinking and outlook and have developed judgement anddecision-making skills.” They will also “be recognised as a source ofclinical expertise, and will be reflective and fully accountable profes-sional leaders” (2002, Interim Guidance for the Implementation of theSociety and College of Radiographers Career Progression Framework).The Career Profession Framework also includes the consultant practi-tioner, and this will be introduced within the next year. A briefsummary of this role will be given. The definition of the title and roleof the “advanced practitioner” will be explored, as will the principles,education, and training. The implementation, pay, and grading criteriafor the advanced practitioner will be explained, and examples of howthis new initiative is working in practice will be given.

INTERVENTIONAL ULTRASOUND—TUMOR ABLATION,INTRAOPERATIVE LIVER, AND CHEST

Intraoperative ultrasound in hepatic resectionBates J, Ultrasound, St. James, Leeds, W Yks, United Kingdom

The trend towards organ-preserving surgical treatment, such as hepaticresection of colo-rectal metastases, has emphasised the need for thehighest quality of pre-operative radiology for staging purposes to planthe most effective course of surgery. Intraoperative ultrasound (IOUS)continues to be a gold standard by which pre-operative imaging ismeasured. The direct impact of IOUS on surgery depends, to a largeextent, upon the quality of the pre-operative imaging. Current literaturesupports the view that IOUS adds significantly to the pre-operativeinformation in around 30% of cases (ranging from 0.7% to 48%) andthat the surgical procedure may be altered in up to 18% of these, butthis figure will continue to reduce as the accuracy of pre-operativediagnosis improves. IOUS, however, continues to maintain its place asa useful tool. Its value has also been demonstrated in the localisation ofpancreatic tumours, renal, and gastrointestinal disease. Surgical tech-niques for the resection of liver metastases continue to develop, with awider range of referrals, and the opportunity for increasingly complexdisease to be considered potentially curative. Combination procedures,involving the addition of ultrasound-guided ablations, are increasing,

and the trend towards laproscopic resection pushes the boudaries oftreatment to provide a range of management options.

Ultrasound-guided chest interventionsBurke BJ, Radiology, North Shore University Hospital, Manhasset,NY

Despite obstacles to sound penetration presented by the aerated lungand the bony thoracic cage, sonography offers advantages as a guidancemodality for percutaneous chest interventions. Advantages of proce-dural speed, patient tolerance, and cost-effectiveness have made ultra-sound our preferred guidance modality for those lesions visible atultrasound. Although lesions surrounded by aerated lung cannot betargeted, almost every other compartment in the thorax can be accessedsonographically: chest wall, axilla, ribs, pleural space, mediastinum,and even pulmonary masses (lesions abutting the pleura or lying withinconsolidated lung). Sonography often provides improved characteriza-tion of the nature of complex masses, facilitating procedural planningand maximizing yield. With portable units, image-guided procedurescan be extended to patients who cannot safely leave the intensive caresetting, and to those confined to isolation wards. Operators utilizingthese techniques should be familiar with the sonographic appearance ofpneumothorax, and the technique of mini-chest tube placement. How-ever, improved accuracy in needle placement resulting from continuousreal-time guidance results in a lower incidence of such complicationscompared with CT or fluoroscopic guidance. Use of sonography as asafe and efficacious means of procedural guidance in the thorax isunderutilized. Skills developed in US-guided procedures in the abdo-men are readily applicable to chest interventions. New technologicaldevelopments, including endobronchial transducers, and the use ofradiofrequency ablation for lung cancers, suggest a potential expandedrole for interventional ultrasound in the thorax. Interventionalists wouldbenefit by incorporating these techniques into their practice.

Ultrasound-guided liver biopsySporea I, Gastroenterology, University of Medicine and Pharmacy,Timisoara, Romania

Liver biopsy for chronic liver diseases is mandatory for the assessmentof grading and staging of the disease and for a proper therapeuticdecision. Several types of biopsy needles are available: suction needles(Menghini type) and cutting needles (Tru-cut or Vim-Silverman nee-dle). The most important question regarding the percutaneous liverbiopsy that should be addressed is: blind or echoguided techniques?The answer depends on the skills of the gastroenterologist. However, itis still debatable whether ultrasound-guided liver biopsy has advantageover the blind one or not. The complications of liver biopsy seem to berelated to the type of the technique, blind or echoguided, respectively.Other two aspects are important to be discussed: 1) the decrease in theincidence of complications in relationship with the experience of thephysician who performs the biopsy, and 2) the correlation between therate of complications and the type of the needles used for biopsy. In ourDepartment of Gastroenterology, we performed 1200 liver biopsiesduring the last 10 years, all echoguided, usually under sedation withMidazolam (3–5 mg i.v.), using Menghini type needles (1.4–1.6 mmdiameter), under hospitalization conditions. We had only one majorcomplication (1/1200 biopsies), haemoperitoneum (0.083%). In con-clusion, echoguided liver biopsy is a safe method for the diagnosis ofchronic diffuse liver diseases (cost-effectiveness in comparison withblind biopsy), and the rate of complications seems to be related to the

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