Journal of Ultrasound

https://doi.org/10.1007/s40477-021-00599-3

ORIGINALPAPER

Knowledge and attitudes of ultrasonography physicians

regarding the biological effects of ultrasound in French‑speaking
sub‑Saharan Africa
Kokou Adambounou1,2 · Komlan Amoussou2 · Alexis Agbodjan1 · Amégninou Mawuko Yao Adigo1,3 ·
Lantam Sonhaye2 · Victor Adjenou2

Received: 7 March 2021 / Accepted: 29 May 2021

© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2021

Abstract
Objective To assess the knowledge and practical attitudes of ultrasonography physicians regarding the biological effects of
ultrasound in French-speaking sub-Saharan Africa.
Materials and methods A descriptive cross-sectional study carried out over a period of 03 months (from 1st August to
31st October 2019) which included doctors carrying out ultrasound examinations in French-speaking sub-Saharan African
countries via an electronic survey form.
Results The 137 ultrasonography physicians came from 13 different countries and included 58% radiologists, 15% gynecolo-
gists, 14% cardiologists and 13% general practitioners. The majority of ultrasonography physicians had less than 10 years of
professional experience (87.60%) and performed more than 25 ultrasonographies per week (65.69%). The biological effects
of ultrasound were known by 69.34% of ultrasonography physicians. Only 44% were able to cite the two biological effects
of ultrasounds; 59.13% were unaware of the existence of thermal and mechanical indexes and 66.42% had no idea about
the normal values of these indexes. They were unaware that their devices showed mechanical or thermal index in 48.91%
of cases, consulted these indexes at the beginning of ultrasound explorations in 26.92%, and had no idea about the practi-
cal attitudes to adopt in the face of an increase in these indexes in 54.74% of cases. Half of the gynecologists and general
practitioners and 55% of the radiologists affirmed that they avoid using Doppler as much as possible to explore the embryo.
Conclusion The level of knowledge of ultrasonography physicians about the biological effects of ultrasound was unsatisfac-
tory in French-speaking sub-Saharan Africa and good attitudes to ultrasound safety were not always adopted.

Keywords Ultrasound · Biological effects · Thermal and mechanical index · Sub-Saharan Africa

Introduction elastic waves which can only propagate gradually in an elas-

tic, solid, liquid or gaseous material environment. In their
Ultrasounds are sounds, meaning mechanical vibrations, propagation, they interact with matter through various physi-
but have the particularity of having a higher frequency cal phenomena such as reflection, refraction and diffusion,
between 20 kHz and 200 MHz [1]. They are longitudinal which explains their attenuation. The interactions between

* Kokou Adambounou Victor Adjenou

kadambounou@yahoo.fr kadjenou@yahoo.fr
Komlan Amoussou 1
Biophysic and Medical Imaging Departments, Campus
amoussou_k@yahoo.fr
Teaching Hospital, University of Lomé, Lomé 05BP 633,
Alexis Agbodjan Togo
agbodjanedemalexis@yahoo.com 2
Radiology Department, Campus Teaching Hospital,
Amégninou Mawuko Yao Adigo University of Lomé, Lomé, Togo
landry05@gmail.com 3
Radiology Department, North Ardennes Intercommunal
Lantam Sonhaye Hospital, Charleville‑Mezieres, France
sonhayelantam@gmail.com

13
Vol.:(0123456789)
 Journal of Ultrasound

ultrasound and matter are at the origin not only of the ultra-
sonic signal but also of these biological effects [2].
In medicine, ultrasound has both diagnostic and thera-
peutic applications, but it is the diagnostic applications rep-
resented by ultrasonography that are the most widespread.
Indeed, ultrasonography is a non-invasive medical imaging
technique, whose physical principle is based on the reflection
of ultrasound waves [1, 3]. It is, therefore, a non-irradiating
imaging modality, relatively accessible and frequently used
as a first-line of treatment in the medical field. Its practice
nowadays extends to almost all medical disciplines to the
point where ultrasound examination is nowadays considered
as an extension of clinical examination [4].
Although to date no harmful pathological effects of
ultrasound have been formally reported under conditions of
diagnostic use in humans, the biological effects of ultra-
sound are undoubtedly real and have been clearly described
experimentally in some animals [5]. These biological effects,
which are mainly thermal and mechanical, are at the origin
of pathologies such as deafness, visual acuity disorders, pul-
monary hemorrhage and chromosomal anomalies described
in some animals but which are also feared in humans for
high acoustic power [6]. This is why numerous scientific
studies have called for greater vigilance in diagnostic ultra-
sound explorations, particularly the use of Doppler in human
medicine [7]. The increase in the acoustic power of ultra-
sound equipment for the sake of diagnostic performance
means that the occurrence of pathological effects linked to
ultrasound imaging in patients can no longer be excluded,
especially when we know that certain epidemiological stud-
ies have already reported the plausible occurrence of certain
pathologies induced by ultrasound imaging in the embryo
and fetus [6, 8]. The need to respect the precautionary meas-
ures published by ultrasound scientific societies is, therefore,
more necessary than ever to guarantee safe ultrasound explo-
ration for patients, especially pregnant women.
Unfortunately, the existence of risks of harmful biologi-
cal effects of ultrasound is little known in the medical field,
particularly in sub-Saharan Africa [9] and there are few stud-
ies in both developed and developing countries devoted to
the effective implementation of precautionary measures by
ultrasonography examiners during ultrasound explorations.
It is with this in mind that we have undertaken this work, the
general objective of which is to evaluate the knowledge and
practical attitudes of ultrasonography physicians with regard
to the biological effects of ultrasound in French-speaking
sub-Saharan Africa.
Materials and methods
This was a descriptive cross-sectional study carried out over
a period of 3 months (from 1st August to 31st October 2019)
and included physicians (general practitioners or special-
ists) carrying out ultrasound examinations of all types in a
French-speaking sub-Saharan African country. Paramedics
(non-physicians) performing ultrasound were not included in
the study. The survey form was elaborated after an in-depth
analysis of the literature data and was articulated around the
following parameters: the country of practice, the qualifica-
tion and the place of practice of the operator, the number
and types of examinations carried out per week, the knowl-
edge of the ultrasound specialists on the biological effects
of ultrasound and their practical attitudes to implement the
precautionary measures recommended by the international
ultrasound scientific societies. These parameters were used
in the development of the survey form which consisted pri-
marily of multiple-choice questions (MCQs).
The data were collected via a form on Google forms on
the following URL address: https://​forms.​gle/​3X8sG​3vjYJ​
9VzWtW ​ A which we sent to our correspondents by email or
by their WhatsApp® numbers.
The data were recorded in Google-Sheet and then trans-
ferred to the Microsoft Excel 2019 spreadsheet program
where we created pivot tables with graphs. Statistical tests
were done with Chi-square and Fisher tests depending on
the variables.
Results
General characteristics of ultrasonographers
A total of 137 predominantly male ultrasonography phy-
sicians (sex ratio of 4.5) dominated by radiologists and
gynecologists had completed the survey forms (Table 1).

Table 1  Distribution of Female Male Total

ultrasonography physicians by
gender and qualification n % n % n %

Cardiologist 5 3.65 14 10.22 19 13.87

Gynecologist 2 1.46 18 13.14 20 14.60
Generalist 1 0.73 17 12.41 18 13.13
Radiologist 17 12.41 63 45.98 80 58.40
Total 25 18.25 112 81.75 137 100

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Journal of Ultrasound

These ultrasonography physicians came from 13 French-
speaking sub-Saharan African countries, mainly Togo,
Cameroon, the Democratic Republic of Congo and Benin
(Fig. 1).
The majority of ultrasonography physicians had less than
5 years of professional experience and 65.69% performed at
least 25 sonograms per week (Table 2).
There were 29 ultrasonography physicians, or 21.17%
working only in a public facility, 33 sonographers, or 24.09%
working only in a private facility and 75, or 54.74% working
in both a public facility and private facility.
The ultrasound examinations carried out by these ultra-
sonography physicians were varied and dominated by
gynecological-obstetrical and abdominal ultrasound (Fig. 2).
Sixty-six ultrasonography physicians (48.18%), of whom
41 (71.93%), of the non-radiologist ultrasonography physi-
cians had never been taught about the biological effects of
ultrasound and 115 (83.94%), had never received patients
who had expressed concern about possible risks of ultra-
sound for their health.
Ultrasonography physicians’ knowledge
of the biological effects of ultrasounds
The existence of the biological effects of ultrasound, as well
as its use for therapeutic purposes, was known by a little
more than 2/3 of ultrasonography physicians, the majority of
whom were radiologists and gynecologists (Table 3).

Fig. 1  Distribution of ultra-

sonography physicians by Togo(n=37) 27%
country of practice
Cameroon(n=14) 10.21%

DR Congo(n=13) 9.49%

Benin (n=13) 9.49%

Burkina Faso (n=12) 8.76%

Senegal(n=10) 7.30%

Niger(n=9) 6.56%

Ivory Coast(n=6) 4.38%

Chad(n=5) 3.65%

Mali(n=5) 3.65%

Guinea (n=5) 3.65%

Gabon(n=5) 3.65%

Central African Republic (n=3) 2.20%

Table 2  Distribution of the < 5 years 5–10 years 10–15 years > 15 years Total
number of ultrasonographies
performed per week according n % n % n % n % n %
to work experience
< 25 41 29.93 3 2.19 1 0.73 2 1.46 47 34.31
25–50 42 30.65 11 8.03 4 2.92 2 1.46 59 43.0
50–100 8 5.84 8 5.84 4 2.92 4 2.92 24 17.52
> 100 3 2.19 4 2.92 0 0 0 0 7 5.1
Total 94 68.62 26 18.98 9 06.57 8 5.84 137 100

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 Journal of Ultrasound

Fig. 2  Distribution of the types

Obstetrics 13.01%
of examinations performed by
ultrasonography physicians Gynecological 13.01%
10.41%
9.29%
Testicular 9.29%
Mammary 9.29%
Bladder-kidney-prostate 9.29%
Soft tissues 7.81%
Doppler 5.95%
Ocular 4.83%
Musculoskeletal 3.72%
Other** 2.22%
Cardiac 1.86%

Other: trans-frontanelar ultrasonography, ultrasonography of the spine, pleural, salivary glands,

thoracic…….

Table 3  Distribution of ultrasonography physicians with knowledge their equipment did not display them, and 44 (32.12%) stated
of the biological effects of ultrasound and its use for therapeutic pur- the contrary.
poses
More than half (26 or 59.1%) of the ultrasonography physi-
Existence of bio- Use of ultra- cians who stated that their ultrasound equipment displayed TI
logical effects of sound for thera- and MI read the values of these indexes during their ultrasound
ultrasound peutic purposes
explorations. Among them, only 3 ultrasonography physicians
n % n % (11.5%) consulted them from the beginning to the end of the
Cardiologist (n = 19) 8 42.10 5 27.78
ultrasound exploration.
Gynecologist(n = 20) 14 70 10 52.63
Faced with a rise in thermal and mechanical indexes, 75
Generalist (n = 18) 8 44.44 13 65
ultrasonography physicians (54.74%), had no idea about the
Radiologist (n = 80) 65 81.25 65 81.25
practical attitudes to adopt; 6 (4.38%) would stop the ultra-
Total (137) 95 69.34 93 67.88
sound exploration, 56 (40.88%) would optimize the settings of
the equipment and or reduce the examination time.
Table 5 shows that the majority of general practitioners,
gynecologists and radiologists claimed to reduce the explora-
Only about a quarter of the ultrasonography physicians tion time for febrile patients, and that less than half of them
were able to cite the two biological effects of ultrasound as exceptionally performed transvaginal ultrasonography on the
thermal and mechanical (Fig. 3). embryo. It also shows that half of gynecologists and general
The majority of ultrasonography physicians (59.13%) practitioners avoided Doppler ultrasonography as much as
were unaware of the existence of the thermal (TI) and possible in the first trimester of pregnancy. Training on the
mechanical (MI) index; and 72.22% did not know the normal biological effects of ultrasound before any ultrasonography
value of these indexes, including all cardiologists surveyed practice was considered indispensable by 32 ultrasonography
(Table 4). physicians (23.36%), necessary by 81 ultrasonography physi-
cians (59.12%) and compulsory by 24 ultrasonography physi-
Practical attitudes of ultrasonography physicians cians (17.52%).
to the biological effects of ultrasounds

Sixty-seven (67) ultrasonography physicians (48.91%) did

not know whether their ultrasound equipment displayed the
mechanical (MI) and thermal (TI) index, 26 (18.98%) stated

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Journal of Ultrasound

Fig. 3  Distribution of ultra-

sonography physicians by listed
biological effects
Thermal and mechanical
eff ect (n=37)
27%
Thermal effect(n=16)
44%

12% Mechanical effect (n=4)

3%
14% Other (n=20)**

No idea (n=60)

**Other: Deafness, Dissection, Therapeutic effects, Deterministic effects, Endothelial

alteration, Chemical effects, Pulmonary hemorrhage, Teratogenesis.

Table 4  Distribution of ultrasonography physicians with a notion of imaging technique and every radiologist is systematically
TI/MI and those with knowledge of TI/MI values trained in its practice. The high representation of radiolo-
Notions about TI/MI Knowledge of gists among ultrasonography examiners was also reported
IT/IM standards in a study on the practice of routine ultrasonography in
n % n % pregnancy monitoring by Essiben et al. in Cameroon [12].
On the other hand, Matar et al. in France in their study of
Cardiologist (n = 19) 3 15.79 0 0 second trimester obstetrical ultrasonography reported a
Gynecologist (n = 20) 7 35 5 25 high proportion of gynecologists (55%) compared to 18%
Generalist (n = 18) 6 33.33 5 27.78 of radiologists [13].
Radiologist (n = 80) 40 50 28 35 The majority (71.93%) of the non-radiologist ultra-
Total (137) 56 40.87 38 27.78 sonography physicians in the study had never been taught
about biological effects of ultrasounds. This result can
be explained by the fact that in our French-speaking sub-
Discussion Saharan African countries, most of the non-radiologist
ultrasonography examiners who practice ultrasonography
We did not include non-physician ultrasonography exam- learned it on the job and did not receive any diploma train-
iners such as radiology manipulators and midwives in ing in ultrasonography. Moreover, they often do not benefit
our study because sonography is primarily a medical act, from further training in ultrasound. Thus, Essiben et al. in
and therefore, assumed to be the exclusive competence Cameroon, in their study, had noticed that nearly 66% of
of the physicians. In our African countries, these non- ultrasonography examiners had never received retraining or
physician sonographers are most often practitioners who continuing education in ultrasound [12] unlike Boyer et al.
have not received any theoretical training in ultrasonog- in France who noted that 64.28% of ultrasonography exam-
raphy practice. iners had a certificate of specialized study qualifying them
The ultrasonography physicians in our study came from to practice ultrasonography [14]. As the biological effects
13 of the 25 countries in French-speaking sub-Saharan of ultrasound are not always taught to doctors during their
Africa, a proportion of 52% when considering all of sub- initial training in African medical schools, it is, therefore,
Saharan Africa and 100% when considering West Africa not surprising to note that about 30% of the mainly non-
[10, 11]. radiologist ultrasonography physicians in our sample were
These ultrasonography physicians were composed of unaware of the biological effects of ultrasounds. An earlier
radiologists, gynecologists, cardiologists and general prac- study we conducted only among Togolese ultrasonography
titioners with a predominance of radiologists. This result is prescribing physicians revealed that about 95% of them
not surprising since ultrasonography is above all a medical were unaware that ultrasound has deleterious biological
effects [9]. Ultrasound, through its interaction with living

13
 Journal of Ultrasound

Table 5  Distribution of attitudes Reduction of exploration Performing transvaginal Performing Dop-

of gynecologists, general time for febrile patients and ultrasonography on the pler in the first
practitioners and radiologists embryos embryo only in exceptional trimester only
towards precautionary measures circumstances in exceptional
for embryo explorations circumstance
n % n % n %

Gynecologist 14 70 7 35 10 50
< 5 years (n = 12) 8 66.67 4 33.33 4 33.33
5–10 years (n = 4) 3 75 2 50 2 50
10–15 years (n = 1) 0 0 0 0 1 100
> 15 years (n = 3) 3 100 1 33.33 3 100
Generalist 12 66.67 6 33.33 9 50
< 5 years (n = 16) 10 62.50 5 31.25 8 50
5–10 years (n = 1) 1 100 0 0 1 100
> 15 years (n = 1) 1 100 1 100 0 0
Radiologist 59 73.75 35 43.75 44 55
< 5 years (n = 50) 38 76 20 40 27 54
5–10 years (n = 18) 13 72.22 8 44.44 9 50
10–15 years (n = 8) 7 87.50 6 75 7 87.50
> 15 years (n = 4) 1 25 1 25 1 25

p = 1.57 × ­10–12

matter, does indeed have deleterious biological effects on
biological tissues. These biological effects, as only 27%
of the ultrasonography physicians in our study knew, are
mainly of two types, namely the thermal effect and the
mechanical effect. The thermal effect results from the rise
in local temperature and the mechanical effect results from
the modification of the structural pressure of the material.
Heat produces a wide variety of tissue damage including
necrosis, apoptosis, genomic alterations and cell membrane
dysfunction. Changes in local pressure, on the other hand,
create shear forces that may be responsible for the release
of certain molecules and cavitation in the material being
passed through [15]. These biological effects are the basis
of the therapeutic use of ultrasound in certain pathologies
such as renal lithiasis (lithotripsy) and prostate cancer [16].
Unfortunately, 32% of ultrasonography physicians were not
aware that ultrasound also has medical therapeutic applica-
tions. If ultrasound can destroy malignant cells, it is, there-
fore, well understood that it can also destroy healthy cells.
These biological effects, which occur at high sound power
levels, are the cause of ultrasound-induced diseases such
as deafness, visual acuity disorders, pulmonary hemorrhage
and chromosomal abnormalities, which have been described
in some animals but are feared in patients due to the ever-
increasing sound power levels of ultrasound equipment
today [5, 6, 17]. It is true that to date the formal scientific
proof of the pathological effects of ultrasound has not yet
been definitively established in humans under the conditions
of medical diagnostic use of ultrasound [18]. However, pre-
cautionary measures are strongly recommended by several
medical ultrasonography scientific societies, to prevent the
possible occurrence of these deleterious biological effects of
ultrasound, particularly in ultrasound imaging [5, 18]. This
is how the thermal and mechanical indexes were thus defined
to evaluate the risk of occurrence of the 2 main biological
effects of ultrasounds. The thermal index (TI) evaluates the
risk of occurrence of the thermal effect and the mechani-
cal index (MI) that of the mechanical effect notably cavita-
tion. The existence of these 2 indexes was unfortunately not
known by the majority (59.13%) of ultrasonography physi-
cians, including half of the radiologists in our study. This
lack of knowledge of the existence of TI and MI is not a
specificity of African ultrasonography physicians because
the other authors such as Sheiner et al. in Germany [19] had
reported a rate of ignorance of these indices of 68% and Jen-
nifer et al. in the USA [20] a rate of ignorance of 53%. Ther-
mal indexes have standards which every ultrasonography
examiner must respect during his ultrasound exploration.
For example, according to the British Medical Ultrasonog-
raphy Society (BMUS), the tolerable normal value for TI is
0.7 and the tolerable normal value for MI is 0.3 [18]. These
are values below which obstetric and neonatal ultrasonog-
raphy examinations can be carried out with complete peace
of mind. These normal safety values for ultrasonographic
exploration were very little known (27.78%) by the ultra-
sonography physicians in our study.
Thermal and mechanical indexes are monitored and
displayed in the upper left or right corner of the screen
of any new generation ultrasound scanner [21] and the
values displayed on the screen must be monitored by the

13
Journal of Ultrasound
ultrasonography examiner throughout the scan to ensure that
they do not exceed accepted standards. These good practice
rules for the safety of ultrasound exploration were far from
being respected in French-speaking sub-Saharan Africa
since only 32.12% of ultrasonography physicians had stated
that their devices actually displayed TI and MI and among
them only 11.5% monitored TI and MI values throughout
the ultrasound exploration. This situation is regrettable and
goes against the precautionary measures published by inter-
national ultrasound societies.
Faced with a rise in thermal and mechanical indexes,
54.74% of ultrasonography physicians had no idea what
practical attitudes to adopt and 40.88% would optimize the
settings of the device and or reduce the examination time.
Indeed, ultrasonography examiners must regularly check the
TI and MI and adjust the device settings to keep them as
low as reasonably possible (according to the ALARA prin-
ciple “As Low As Reasonable Achievable” according to the
Anglo-Saxons) without compromising the diagnostic value
of the examination. When low values cannot be achieved,
the examination times should be kept as short as possible to
limit possible tissue damage. Thus, according to the BMUS,
for obstetrical and neonatal explorations, when the TI is
between 0.7 and 1, the exposure time should be limited to a
maximum of 60 min. For non-obstetrical and non-neonatal
investigations, when the TI is between 1 and 2, the exposure
time can be limited to a maximum of 60 min; no examina-
tion is recommended for TI values ≥ 6. It is also important
to remember that some ultrasound modes are more likely
than others to produce significant acoustic output. Color
and power Doppler modes in particular, produce more heat
in the tissue and therefore higher TI values, as do B-mode
techniques involving coded transmissions. Tissue harmonic
imaging mode can sometimes involve higher MI values. The
4D (real-time 3D) mode involves continuous exposure and
therefore higher thermal and mechanical indexes [18, 22].
The risk of biological effects is also high with the use of
ultrasound contrast agents [22].
The majority of general practitioners, gynecologists
and radiologists claimed to reduce the exploration time for
febrile patients and less than half of them exceptionally per-
formed transvaginal ultrasonography on the embryo. Half
of gynecologists and general practitioners avoided Doppler
ultrasonography as much as possible in the first trimester
of pregnancy. These good attitudes towards the safety of
first trimester ultrasound exploration of pregnancy adopted
by the ultrasonography physicians in our study are to be
encouraged.
In addition to the exposure time, the risk of tempera-
ture rise during the ultrasound examination also depends
on other factors such as ultrasound frequency, focus and
absorption coefficient [23]. Since the endocavity probe
is a high-frequency probe, the risk of tissue heating is
even higher. If the patient already has a fever before the
start of the examination, the fever may worsen during
the examination. With the Doppler mode, temperature
increases are usually greater than 1 °C during an ultra-
sound examination.
Finally, it is important to emphasize that ultrasounds are
not ionizing, and therefore, does not cause the determinis-
tic and stochastic effects described for ionizing radiation.
Ultrasonography is, therefore, to be preferred to irradiating
imaging techniques such as radiological imaging and scin-
tigraphic imaging. However, it is necessary, as the majority
of the ultrasonography physicians in this study felt, that all
medical personnel wishing to practice ultrasonography be
trained on the biological and pathological effects of ultra-
sound as well as on the precautionary measures that should
govern the use of ultrasound for diagnostic purposes. Ultra-
sonography performed in accordance with the precaution-
ary principle therefore remains, until proven otherwise, a
technique presumed to be harmless for patients.
Conclusion
This first study to assess the knowledge and attitudes of
ultrasonography physicians in French-speaking sub-Saharan
Africa regarding the biological effects of ultrasound showed
that their level of knowledge was unsatisfactory with a sig-
nificant number of ultrasonography physicians unaware of
the existence of the harmful biological effects of ultrasound.
The precautionary measures recommended by international
medical ultrasonography societies to prevent the possible
risks of these effects occurring in patients, particularly preg-
nant women, were little respected. The reinforcement of the
initial training of physicians in ultrasound biophysics and the
regular organization of continuing education on the biologi-
cal effects of ultrasound are highly desirable to guarantee
a safe ultrasonographic exploration of patients, especially
pregnant women in our French-speaking sub-Saharan Afri-
can countries.
Author contributions KA put the idea and the design of the study.
AMYA, KA and AK data collection and have contributed to the con-
ception and design of the manuscript. AA, LS and VA had contributed
to the conception and design of the manuscript. All the authors have
been involved in drafting and revising the manuscript. All the authors
read and approved the final manuscript.
Funding This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Data availability The data used and/or analyzed during the current
study are available from the corresponding author on reasonable
request.
13

Declarations
Conflict of interest The authors declare that they have no competing
interests.
Ethical approval An approval from the radiation protection commis-
sion of the Togolese Ministry of Health had been obtained. The study
did not involve the use of animals. The manuscript has not been submit-
ted to any other journal/site in part or in whole for consideration. It is
solely submitted to this journal.
Consent to participate The physicians included in this study gave writ-
ten informed consent to participate in this research.
Consent for publication The physicians included in this study gave
written informed consent to publish this research.
References
1. Aurengo A, Petitclerc T, Kas A (2013) Biophysique, 4th edn.
Lavoisier, Paris
2. Millner R (2012) Ultrasound Interactions in Biology and Medi-
cine. Springer Science & Business Media, p 216
3. Gennisson J-L, Deffieux T, Fink M, Tanter M (2013) Ultra-
sound Elastography: principles and processes. Elsevier Mason
94(5):504–513
4. Newman PG, Rozycki GS (2011) The history of ultrasound. Else-
vier Mason 78(2):179–195
5. Fowlkes JB (2013) Bioeffects Committee of the American Insti-
tute of ultrasound in medicine. American Institute of Ultrasound
in Medicine Consensus Report on Potential Bioeffects of Diag-
nostic Ultrasound: Executive Summary
6. Stratmeyer M, Greenleaf J, Dalecki D, Salvesen K (2008) Fetal
ultrasound: mechanical effects. J Ultrasound Med 27:597–605
7. Salvesen KA (2002) EFSUMB: safety tutorial Epidemiology of
diagnostic ultrasound exposure during pregnancy /European com-
mittee for medical ultrasoundsafety (ECMUS). Eur J Ultrasound
15:165–171
8. Maulik D (2006) Doppler ultrasound in obstetrics and gynecology.
Springer Science & Business Media, p 625
9. Adambounou K, Bathily EHAL, Adigo AMY, Gbandé P, Bak-
patina-Batako KD, Sonhaye L et al (2017) Knowledge of Togo-
lese doctors on biological effects of ultrasound and their attitudes
towards the ultrasonographic explorations performed in Lome
(Togo). Open J Biophys 8(1):1–8
13
Journal of Ultrasound
10. UNESCO, UIS (2011) Financing education in sub-Saharan Africa:
meeting the challenges of expansion, equity and quality. UNE-
SCO, p 129
11. Big F (2012) Science and developing countries : French-speaking
sub-Saharan Africa. EDP Sciences, p 423
12. Essiben F, Foumane P, Moifo B, Dohbit J, Mboudou E, Doh A
(2016) Practice of routine ultrasound in pregnancy monitoring in
Yaoundé (Cameroon): analysis of prescribers’ knowledge. Health
Sci Dis 17(1):548
13. Matar M, Picone O, Dalmon C, Ayoubi J-M (2013) Evaluation
of sonographers’ knowledge of second trimester screening ultra-
sound images recommended by the National Technical Committee
on Ultrasound. J Gynecol Obst Bio R 42(5):473–478
14. Boyer J-P, Porret P (1989) Echos and what sonographers have to
say about ultrasound during pregnancy. JEMU 10(3):135–144
15. Piscaglia F, Tewelde AG, Righini R, Gianstefani A, Calliada F,
Bolondi L (2009) Knowledge of the bio-effects of ultrasound
among physicians performing clinical ultrasonography: results
of a survey conducted by the Italian Society for Ultrasound in
Medicine and Biology (SIUMB). J Ultrasound 12(1):6–11
16. Izadifar Z, Babyn P, Chapman D (2017) Mechanical and biologi-
cal effects of ultrasound: a review of present knowledge. Ultra-
sound Med Biol 43(6):1085–1104
17. Campbell JD, Elford RW, Brant RF (1993) Case-control study
of prenatal ultrasonography exposure in children with delayed
speech. Can Med Assoc J 149:1435–1440
18 The safety Group of the British Medical Ultrasound Society
(2010) Guidelines for the safe use of diagnostic ultrasound equip-
ment. Ultrasound 18(2):52–59
19 Sheiner E, Abramowick J, Shoham-Vardi I (2007) What do clini-
cal users know regarding safety of ultrasound during pregnancy?
Ultrasound Med 26:319–325
20. Jennifer B, Kimberly T (2011) Safety practice of sonographers and
their knowledge of the biologic effects of sonography. J Diagnos-
tic Medical Sonography 26:252–261
21 Duck FA (1997) The meaning of thermal index (TI) and mechani-
cal index (MI) values. BMUS Bull 5(4):36–40
22. Joy J, Cooke I, Love M (2006) Is ultrasound safe? Obst and
Gynaecol 8(4):222–227
23. Shankar H, Pagel PS (2011) Potential adverse ultrasound-related
biological effects a critical review. Anesthesiol J Am Soc Anes-
thesiol. 115(5):1109–1124
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