Re: 'Terrifying Sonogram' Dilemma: patient with single (new) 'soft marker' -- all other screens normal
From: Terry J DuBose (tjdubose@juno.com)
Fri May 23 09:05:16 2003
Found the reference: Filly R; Editorial: Radiology 1988; 166:274-275...
"Just as Roy Filly decried promulgation of ever-increasing levels of
sonographic examinations because of lack of experience and claims that a
level I examination is less diagnostic than a level II, III, IV, or V, a
limited examination that misses diagnosis still harms the patient."
DuBose, FETAL SONOGRAPHY, Saunders 1996, p. 479.
--
Terry J DuBose
On Fri, 23 May 2003 08:06:23 -0500 Terry J DuBose <tjdubose@juno.com>
writes:
> Dr. Worrall, I agree. I think Filly's article was "I'll see your
> level
> II and raise you III.", meaning the exam is only as good as the
> operator... "levels" don't mean anything without proper experience
> and
> education. It was the JUM, but at this time I don't have the
> reference
> in front of me. Terry J DuBose
>
> On Thu, 22 May 2003 22:42:34 -0500 "Allen Worrall"
> <jworrall@alaska.net>
> writes:
> > Is the radiologist specially trained or experienced in nasal bone
>
> > imaging?
> > Why is there uncertainty about the presence of absence of the
> nasal
> > bone? Is
> > this the same as saying the nuchal translucency MAY be increased,
> or
> > the
> > nuchal fold MAY be increased? If I got that kind of report from
> > someone, I
> > would assume they know almost nothing about nuchal translucency or
>
> > nuchal
> > fold, and I would not pay much attention to that part of their
> > report.
> >
> > I am totally unfamiliar with imaging the nasal bone, but I suspect
>
> > in some
> > ways it presents the same problems as the nuchal translucency: you
>
> > have to
> > have a midsagittal view, and that is not always available. If I
> > cannot do
> > the nuchal translucency, I say so in my report and suggest the
> > patient come
> > back in a few days for another try, in the hopes the baby's
> position
> > is more
> > favorable. If I get widely differing nuchal translucency
> > measurements during
> > the same scan, I just keep scanning until I make up my mind what I
>
> > am going
> > to report. I do not say "the nuchal translucency MAY be
> increased."
> >
> > Can you obtain a targeted ultrasound examination from someone else
>
> > with
> > experience in imaging the fetal nasal bone? If so, that might be a
>
> > good
> > thing to do. It would also be good to make sure the patient
> > understands the
> > dilemma. Can the radiologist tell you what he or she means when
> they
> > say the
> > nasal bone MAY be absent?
> >
> > Incidentally, Dr. Filly also wrote a famous paper about levels of
>
> > ultrasound
> > exams. I do not know the title exactly, but something about your
> > level I, my
> > level II, I'll raise you one.
> >
> > Allen Worrall
> >
> > Joseph A Worrall MD RDMS
> > OB/GYN Ultrasound at the Fairbanks Clinic
> > Fairbanks, Alaska, USA
> > jworrall@alaska.net
> > http://www.obgynsono.com
> >
>> > ----- Original Message -----
> > From: "RBurns" <bito02@aol.com>
> > To: "Multiple recipients of list ULTRASOUND"
> > <ultrasound@mail.medispecialty.com>
> > Sent: Thursday, May 22, 2003 5:53 PM
> > Subject: 'Terrifying Sonogram' Dilemma: patient with single (new)
>
> > 'soft
> > marker' -- all other screens normal
> >
> > > I rarely post to this board, but I followed with some interest
> > your
> > > discussion regarding Filly's article about sonography and soft
> > markers.
> > >
> > > I will share with you my dilemma -- which also raises concerns
> > regarding
> > > the "new" soft marker -- the nasal bone.
> > >
> > > My patient is 36 years old and 25wks pregnant with partial
> previa.
> > She
> > > had the NT screen which yielded 1:809 risk for ds; her AFP
> results
> > were
> > > 1:420. On the basis of this, we did not strongly advise her to
>
> > have an
> > > amnio and instead, scheduled her for a Level II.
> > >
> > > At my patient's level II, no abnormalities were found (though we
>
> > did
> > > discover the previa) -- no soft markers, etc.
> > >
> > > Thereafter, at her 25wk previa follow-up u/s, the radiologist
> > identified
> > > what MAY be an absent or short nasal bone -- the famous and
> > uncertain
> > > "marker" in an otherwise low-risk patient. It is not clear
> > whether or
> > > not the nasal bone was seen in the Level II or indeed, if it
> was
> > > screened.
> > >
> > > As Filly so aptly described, we are in a dilemma. We are
> inclined
> > to
> > > believe that our patient continues to be at extremely low risk
> of
> > ds and
> > > we are very cognizant of her already anxious state, given the
> > previa. At
> > > the same time, we are also concerned that we give our patient
> > > appropriate follow up recommendations. On the basis of this
> > screening
> > > picture, would you recommend amnio? A follow up Level II?
> > >
> > > Regards and debate away!
> > >
> >
>
