Fall, 2013

Fall, 2013

Greeting NCUS Members and Affiliates;  

Hello everyone! It is hard to believe that the holidays are around the corner.  With so many of us travelling this holiday season, enjoy the time with your families and be safe.  

We had a great fall meeting at the Friday Center, with exciting lectures from ultrasonographic evaluation of aneuplodies to neonatal brain sonography to the echo diagnosis of rheumatic heart disease. The 33th Annual NCUS Spring Symposium is just around the corner, so mark your calendars for April 11-13 2014.  We will be meeting at the Sheraton Imperial in Research Triangle Park just off I-40.  

We are working hard to make this 33th Annual meeting in Raleigh one not to be missed. The Sheraton provides the perfect setting for learning, relaxation and fun, so make plans now to be with us.  

With the buzz being about major changes in health insurance and health care, we are planning keynote speakers to help you understand these changes and how they will impact you and your lab. As usual we are working with all the medical centers in the area to get some great lectures for the meeting.

Remember, the NCUS is YOUR society, so become involved. We want to hear from you! Let us know about great speakers you have heard or topics you want to learn about. Tell us about what is going on in your lab. Connect with your friends and colleagues on our Facebook page. Invite a friend to join the society. We are here for you. 

Thanks again for your continued support. I look forward to seeing you in the spring in Raleigh.

John Cotton, MD, FACC
President, NC Ultrasound Society
With breast awareness month just finishing up and fresh on our minds, I would like to remind everyone of the new breast density law recently passed in North Carolina, specifically General Assembly of North Carolina Session 2013 Session Law 2013-321 House Bill 467. If a patient is diagnosed with dense breast tissue by mammography, by law, they must be notified they may need another means of breast imaging such as breast MRI or breast ultrasound . The difference in the cost of these two modalities will play heavy on the minds of insurance companies, which leads sonographers to be concerned with all the new health care changes and how this will affect us as demands increase.
ACR BI-RADS® The American College of Radiology’s BI-RADS® has long recommended the reporting of breast parenchymal composition as one of the components of the mammogram report, and describes the amount of tissue as one of four categories in the current edition BI-RADS® manual:
  1. The breast is almost entirely fat (<25% glandular).
  2. There are scattered fibroglandular densities (approx 25-50% glandular).
  3. The breast tissue is heterogeneously dense, which could obscure detection of small masses (approx 51-75% glandular).
  4. The breast tissue is extremely dense. This may lower the sensitivity of mammography (>75% glandular).
NC General Statute and January 1, 2014 More recently, however, legislators in many states have mandated that each patient be more fully informed of her individual breast density and its potential impact. North Carolina has joined nearly two dozen states on the list of states where radiologists are now or will soon be required by law to provide this information directly to the patient. Gov. McCrory signed the bill into law on July 23, 2013; after January 1, 2014 the following wording must be given to each patient with heterogeneously or extremely dense breasts:

“Your mammogram indicates that you may have dense breast tissue. Dense breast tissue is relatively common and is found in more than forty percent (40%) of women. The presence of dense tissue may make it more difficult to detect abnormalities in the breast and may be associated with an increased risk of breast cancer. We are providing this information to raise your awareness of this important factor and to encourage you to talk with your physician about this and other breast cancer risk factors. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.”

What Now? North Carolina radiologists are collaborating to ensure a seamless transition and continued high quality care for our patients. The decision to pursue high risk screening breast ultrasound or breast MRI will be made on an individual patient basis. Both hand held and automated whole breast ultrasound exams are those being offered. The North Carolina ACR chapter is currently working with breast imagers from both academic and private practices to develop a NC website with easy access for referring providers and patients alike.

For More Info www.breastdensity.info We will keep you posted on the NC website progress!

Contributed by:
Sheryl G. Jordan MD, RCC 
Associate Professor of Radiology, Breast Imaging
University of North Carolina School of Medicine 
Chapel Hill, North Carolina
This email address is being protected from spambots. You need JavaScript enabled to view it.
Frederick Kremkau, PhD, co-director of the Program for Medical
Ultrasound in the Center for Applied Learning, Wake Forest University, has been inducted as a
fellow of the American College of Radiology (ACR).

This status recognizes individuals who have made outstanding
contributions to the field of radiology and is limited to 10 percent
of the ACR’s membership.

Kremkau was inducted May 5 in Washington, D.C., during the annual
meeting of the ACR, a 36,000-member organization devoted to making
medical imaging safe, effective and accessible to those who need it.

Congratulations Dr. Kremkau! Thank you for being a friend of the North Carolina Ultrasound Society from its beginning!
Sonographic artistry.
As sonographers we create beautiful images all day long. Now the NCUS is asking you to put down your transducer and pick up a pencil. We are looking for an ultrasound icon for our Website.    


The winner of the contest will receive registration to an NCUS meeting. That’s a fantastic prize, right? E-mail all entries to This email address is being protected from spambots. You need JavaScript enabled to view it..  Deadline is December 31, 2013.        Get busy artists!
In January 2011, the NCUS Board of Directors implemented the Student Mentoring Program, a leadership program designed to establish professional relationships between Ultrasound Practitioners and Ultrasound Students across North Carolina. The purpose of the Mentoring Program is to foster an active, participatory, professional relationship between the NCUS and students by promoting professional leadership skills. A student from each accredited Sonography program in NC is chosen by program faculty to apply to the NCUS mentoring program. The student will commit to assisting the society at the NCUS Symposiums and attend all pertinent meetings. The student will be assigned to a NCUS mentor to work with for a one year period beginning in August of each year. Mentees are required to attend a minimum of 75% of NCUS meetings (This will involve three of four scheduled meetings). The NCUS Board of Directors meeting schedule may be accessed at www.NCUS.org. Mentees are required to attend the Fall and Spring meetings and will be assigned specific duties by their NCUS Mentor.

Eligibility criteria require that a first year student be recommended by their Program Faculty and must express interest in being a part of this Mentoring program, demonstrating professional behavior and actions. The student must be in good academic standing with a minimum of a 3.0 GPA overall and demonstrate leadership through community and/or college involvement. The student must submit a Mentoring Program Application to their Program Director by March 1. The Program Director will forward the completed application to the NCUS Board of Directors for approval. Mentees are also required to present a case study for the NCUS newsletter and prepare a Case of the Day for the Annual Spring Symposium. Expenses (other than registration fees) to attend the meetings will be the responsibility of the student. Registration fees for the Fall and Spring meetings will be waived for mentees accepted into the NCUS Mentoring Program. Additional information about the NCUS Mentoring Program may be obtained by visiting http://ncus.org/mentoringinfo.pdf

The first mentees selected for the NCUS Mentoring Program were Laurie Reinhardt and Nefer Patton, both serving beyond expectations at the Spring and Fall symposiums. Laurie graduated from the medical sonography program at Johnston Community College and Nefer graduated from the medical sonography program at South Piedmont Community College. Their professionalism and leadership have been instrumental in the continued development of the NCUS Mentoring Program and both will continue to serve in the Mentoring Network through the NCUS. Thank you Laurie and Nefer for such a great first year!

2013 – 2014 NCUS Mentees are: Randy Gay from Johnston Community College, Hudson O’Keefe from Cape Fear Community College and Irina Makovskaya from South Piedmont Community College.
Cervical pregnancies represent less than 1% of all ectopic pregnancies. Risk factors include multiparity, prior abortion, or instrumentation of the cervix or endometrial cavity. Because the cervix is composed predominantly of fibrous tissue, patients may bleed profusely. Once an extremely rare entity, cesarean section scar pregnancy is being increasingly reported. The hypothesis is that the conceptus enters the myometrium through a microscopic dehiscent tract or defect in the cesarean section scar. There is a complete gestational sac embedding into the myometrium.

In the past, as a result of life-threatening hemorrhage, the diagnosis of a cervical or cesarean scar pregnancy frequently led to hysterectomy. At present, conservative treatments are possible with the hope of preserving future reproductive potential, including sonographically guided local potassium chloride injection, systematic or local methotrexate, or preoperative uterine artery embolization before dilation and evacuation. (1, p.1037-1038)

Patient Presentation
  • 53 yo African American female
  • Normal body habitus
  • ER visit for persistent back pain
  • Patient has no other complaints or significant personal/familial medical history.
  • Upon examination a skin ulceration is found on right breast adjacent to areola/nipple region

Acute appendicitis is a common cause of abdominal pain that often results in immediate surgical removal of the appendix. Due to the complications that may occur from appendicitis, such as rupture and subsequent infection, a careful evaluation of the appendix is warranted to confirm its diagnosis. The use of sonographic imaging has been recognized as an effective approach for determining acute appendicitis. This particular case involves a patient that presented to the emergency room with clinical features associated with acute appendicitis, and with the use of sonography, was able to confirm the suspected diagnosis.

Acute appendicitis is one of the most common causes of emergency abdominal surgeries in the United States.1 Its occurrence is more prevalent between the ages of 10-20 years old1, but no specific age group is exempt.1 Acute appendicitis is often the result of some type of blockage within the lumen of the appendix such as an appendicolith (calcified concretion) or more specifically, a fecalith (calcified fecal matter).2 Additionally, appendicitis can also be caused by a parasitic infection.2 In all cases, inflammation of the wall of the appendix occurs as a result of bacterial invasion. As the infection proliferates within the appendix, the risk of perforation increases. Should perforation occur, the bacterial infection can no longer be contained and could therefore spread into the abdominal peritoneum (a membranous lining of the abdominal organs); a condition known as peritonitis.3

Clinical findings associated with cases of acute appendicitis include abdominal pain (epigastric and right lower quadrant), rebound tenderness, nausea and vomiting, fever, and possibly an elevated white blood cell count (leukocytosis).2 Unfortunately, because these findings are somewhat non-specific and imprecise, acute appendicitis can often disguise itself as something else and can be difficult to diagnose clinically without the assistance of accurate diagnostic imaging.4 The use of sonography can provide physicians with a quick and non-invasive method to detect appendicitis.

Jennifer Epperly, RDMS, RDCS

Staff Sonographer

Dept of OB-GYN

Brody School of Medicine
East Carolina University

Greenville, NC

Jennifer, tell us why and how you became a sonographer?

As a radiologic technologist, I was working in special procedures and the cath lab.  Ultrasound was a very new imaging modality at that time and the hospital needed another sonographer.  I was offered the opportunity to attend a short 3 month training program if I agreed to work at that hospital for 2 years as a sonographer.  I have always wanted to learn 'new things' in my job, so I took that opportunity.

Jennifer continued her education while working as a sonographer and earned a BS in Radiology Administration at the Medical College of Virginia.  She has her registry in Abdomen, Adult Echocardiography, Breast and Obstetrics/Gynecology.

What do you like most about the profession?

I  like knowing my input on cases is important to the physician and that I am an integral part of the patient's care.

The least about the profession?

The entertainment factor.  Patients underestimate the importance of their sonography exam.  I am also disappointed in the profession's lack of advancement of the ultrasound practitioner as a mid-level provider.

Does anything encourage you about the direction sonography is heading as a profession?

I am encouraged by advances in technology with regards to instrumentation and how it may one day allow shortened scan time for complete studies.

What would you want to say to new sonographers and sono students to encourage them?
Whenever you are offered an opportunity to learn something new or do something different, DO IT!
Several months ago I had a young man approximately in his mid twenties for a testicular ultrasound. During the course of the time that I was explaining to him the procedure and how to prepare for it, I could sense this exam was causing him a great deal of stress.  I tried to get his history and talk a little with him to ease the stress during the exam but then there was that awkward moment of silence. He then, nervously, asked the most famous question a sonographer hears..."Is it a boy or a girl?"  I thought for a second and said "Congratulations!  It's twins!" He burst into laughter and seemed much more relaxed during the remainder of the exam.