1. science
2. medicine

Journal of
2013
Ultrasound
in Medicine
Official
Proceedings
AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE
Annual Convention
April 6–10 • New York, New York
www.jultrasoundmed.org • www.aium.org
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Official
Proceedings
2013 Annual Convention
April 6–10 • New York, New York
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Leadership and
Program Committee
Executive Committee
Board of Governors
Liaisons
President
Rochelle F. Andreotti, MD
Jude P. Crino, MD
Mark A. Kliewer, MD
Elisa Konofagou, PhD
Mark Lockhart, MD, MPH
Susan A. Lynch, RDMS, RVT, RDCS
Joan Mastrobattista, MD
Christopher L. Moore, MD, RDMS, RDCS
Thomas R. Nelson, PhD
James Pennington, RDMS
Elizabeth Puscheck, MD, MS
Leslie M. Scoutt, MD
Rosy Silverman, RDMS
Jay Smith, MD
Joseph R. Wax, MD
Jade Wong-You-Cheong, MD, RVT, FRCR
American College of Obstetricians and
Gynecologists
American College of Radiology
Medical Imaging and Technology Alliance
Society of Diagnostic Medical Sonography
Society for Maternal-Fetal Medicine
Society of Radiologists in Ultrasound
Society for Vascular Ultrasound
Alfred Z. Abuhamad, MD
First Vice President
Brian D. Coley, MD
Second Vice President
Lisa M. Allen, BS, RDMS, RDCS, RVT
President-Elect
Steven R. Goldstein, MD
Secretary
J. Brian Fowlkes, PhD
Treasurer
Beryl R. Benacerraf, MD
Immediate Past President
Harvey L. Nisenbaum, MD
Chief Executive Officer
Carmine M. Valente, PhD, CAE
2013 Annual Convention
Committee
Rochelle Andreotti, MD, Chair
Joan Mastrobattista, MD, Vice Chair
Reem S. Abu-Rustum, MD
David Bahner, MD, RDMS
Harris L. Cohen, MD
Arthur Fleischer, MD
Phyllis Glanc, MDCM, BSC
Luis Izquierdo, MD
Elisa Konofagou, PhD
Kenneth Lee, MD
Anna Lev-Toaff, MD
Janet O’Brien, RDMS, PA-C
Manuel Porto, MD
Khaled Sakhel, MD
Chandra Sehgal, PhD
Thomas Shipp, MD
James Shwayder, MD, JD
Rosy Silverman, RDMS, RVT, RT(S)
Therese Weber, MD
Beryl Benacerraf, MD
Executive Committee liaison
Rochelle Andreotti, MD, and Joan
Mastrobattista, MD
Board of Governors liaisons
Jenny Clark
Staff liaison
Ex Officio Board Members
Levon N. Nazarian, MD
Journal of Ultrasound in Medicine Editor
Marilyn K. Laughead, MD
Delegate to the American Medical
Association
Michael Blaivas, MD
Alternate Delegate to the American
Medical Association
2013 Annual Convention Program Chairs
Case-of-the-Day Cochairs
Reem S. Abu-Rustum, MD
Kenneth Lee, MD
Therese Weber, MD
E-Posters Cochairs
Harris L. Cohen, MD
Anna Lev-Toaff, MD
Manny Porto, MD
Continuing Medical Education
Committee Representative
Thomas Shipp, MD
Scientific Session Cohairs
Joan Mastrobattista, MD
Deborah Rubens, MD
Chandra Sehgal, PhD
Hands-on Special Interest
Session Cochairs
Janet O’Brien, RDMS, PA-C
James Shwayder, MD, JD
Rosy Silverman
Three- and Four-Dimensional
Volume Data Set Manipulation
Course Chair
Khaled Sakhel, MD
New Investigator Session Cochairs
Arthur Fleischer, MD
Phyllis Glanc, MDCM, BSC
Elisa Konofagou, PhD
Preconvention Program Cochairs
Jacques Abramowicz, MD
David Bahner, MD, RDMS
Beryl Benacerraf, MD
David Fessell, MD
Luis Izquierdo, MD
Beth Kline-Fath, MD
Joan Mastrobattista, MD
Bret Nelson, MD
Mark Sklansky, MD
Ilan Timor, MD
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Table of Contents
2013 AIUM Award Winners
William J. Fry Memorial Lecture Award........................................................................................................................................................................................................iii
Joseph H. Holmes Basic Science Pioneer Award ........................................................................................................................................................................................iv
Joseph H. Holmes Clinical Pioneer Award ....................................................................................................................................................................................................v
Distinguished Sonographer Award ..............................................................................................................................................................................................................vi
Honorary Fellow Award ................................................................................................................................................................................................................................vii
Endowment for Education and Research Donors ....................................................................................................................................................................................viii
2013 Scientific Program
SUNDAY, APRIL 7, 2013
Special Interest Sessions, 7:30 AM–11:30 AM
Recent Innovations in Gynecologic Ultrasound, Including 3-Dimensional Imaging..........................................................................................................S1
Ultrasound-Guided Procedures for the Pediatric Patient: From the Perspective of Both Point-of-Care and Traditional Approaches ..........................S1
Special Interest Session, 8:00 AM–9:30 AM
Hands-on Basic Obstetric Ultrasound and Simulation ..........................................................................................................................................................S1
Special Interest Session, 9:45 AM–11:15 AM
Hands-on Advanced Obstetric Ultrasound and Simulation ..................................................................................................................................................S1
Special Interest Sessions, 3:15 PM–5:00 PM
Advanced Point-of-Care Cardiac Ultrasound in the Emergency and Critical Care Patient ................................................................................................S2
Clinical Applications of Ultrasound Contrast, Part 1 ..............................................................................................................................................................S2
Hands-on Renal and Mesenteric Imaging ..............................................................................................................................................................................S2
How Does Ultrasound Compare in Safety and Radiation Dose to Other Imaging Modalities? ..........................................................................................S2
Interventional Musculoskeletal Ultrasound:
Steroid Injections, Dry Needling, and Platelet-Rich Plasma Injections ................................................................................................................................S3
Point/Counterpoint: Ultrasound Versus Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta,
Congenital Diaphragmatic Hernia, and Central Nervous System Anomalies ......................................................................................................................S3
Ultrasound in Global Health ....................................................................................................................................................................................................S3
MONDAY, APRIL 8, 2013
Special Interest Sessions, 8:15 AM–10:15 AM
Advances in Clinical and Quantitative Pediatric Lung Ultrasound ......................................................................................................................................S5
Doppler Ultrasound: Basic and Advanced (Beyond the Umbilical Artery) ..........................................................................................................................S5
Gynecologic Imaging Using Multiple Imaging Modalities, Including Ultrasound, Computed Tomography, and Magnetic Resonance Imaging ........S5
Hemodialysis Vascular Access ..................................................................................................................................................................................................S6
New Horizons in Contrast Ultrasound ....................................................................................................................................................................................S6
Pediatric Hepatobiliary Disorders ............................................................................................................................................................................................S7
Taboos and Opportunities in Sonothrombolysis for Stroke: From Sonothrombolysis in Animals to Stroke Treatment in Patients ..............................S7
Special Interest Session, 11:00 AM–12:30 PM
How to Be an Effective Manuscript Reviewer for the Journal of Ultrasound in Medicine ..................................................................................................S8
Scientific Sessions, 11:00 AM–12:30 PM
Basic Science: Tissue Characterization, Part 1 ........................................................................................................................................................................S9
Breast Ultrasound and Elastography......................................................................................................................................................................................S12
Contrast-Enhanced Ultrasound..............................................................................................................................................................................................S16
Emergency Ultrasound, Part 1 ................................................................................................................................................................................................S18
Musculoskeletal and Interventional/Intraoperative Ultrasound ........................................................................................................................................S21
Obstetric Ultrasound: Uterus, Placenta, and Cervix ............................................................................................................................................................S24
Pediatrics and Fetal Echocardiography..................................................................................................................................................................................S28
Special Interest Sessions, 1:30 PM–3:30 PM
Cellular Bioeffects and Applications ......................................................................................................................................................................................S31
Elastography 2013 ....................................................................................................................................................................................................................S31
Exploring the Interface of Ethics and Communication in Prenatal Care: A Video-Based Approach ..............................................................................S32
Hands-on Carotid and Transcranial Doppler Ultrasound....................................................................................................................................................S32
New Techniques and Methods in Ultrasound-Guided Interventions ................................................................................................................................S32
Vaginal Bleeding in the First Trimester ..................................................................................................................................................................................S32
Special Interest Sessions, 4:00 PM–5:30 PM
Hands-on Elastography ..........................................................................................................................................................................................................S33
Interventional and Other Ultrasound Techniques: How I Do It ..........................................................................................................................................S33
Quantitative Ultrasound Biomarkers ....................................................................................................................................................................................S33
Ultrasound Incidentalomas ....................................................................................................................................................................................................S33
Scientific Sessions, 4:00 PM–5:30 PM
Carotid/Cerebrovascular Ultrasound and Neurosonology ..................................................................................................................................................S34
TUESDAY, APRIL 9, 2013
Special Interest Sessions, 8:15 AM–10:15 AM
Contrast-Enhanced Ultrasound in Pediatrics: What Have We Learned and How Can We Apply It? ................................................................................S37
Cutting-edge Musculoskeletal Ultrasound: Peripheral Nerves of the Upper Extremity....................................................................................................S37
Doppler Evaluation of the Abdomen......................................................................................................................................................................................S37
Hands-on How to Do Ultrasound-Guided Interventions ....................................................................................................................................................S38
Pearls From the Anatomic Survey (Skeletal Dysplasia and Central Nervous System, Renal, and Chest Abnormalities) ..............................................S38
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Small-Animal Preclinical High-Frequency Imaging..............................................................................................................................................................S38
Scientific Sessions, 11:00 AM–12:30 PM
Applications of Therapeutic Ultrasound................................................................................................................................................................................S38
Basic Science: Instrumentation, Contrast Agents, and Bioeffects ......................................................................................................................................S41
Cardiovascular Ultrasound......................................................................................................................................................................................................S44
Gynecologic Ultrasound ..........................................................................................................................................................................................................S45
New Investigator Award Session ............................................................................................................................................................................................S49
Obstetric Ultrasound: Fetal Anomalies ..................................................................................................................................................................................S53
Special Interest Session, 11:00 AM–12:30 PM
Hands-on How to Do the Biopsy ............................................................................................................................................................................................S57
Special Interest Sessions, 1:30 PM–3:30 PM
Before and After: Case Presentations, Surgical Findings, and Clinical Outcomes ............................................................................................................S57
Hands-on Scanning: Peripheral Nerves of the Upper Extremity ........................................................................................................................................S57
Live Fetal Cardiac Scanning by the Experts ..........................................................................................................................................................................S57
Microbubbles and Drug/Gene Delivery ................................................................................................................................................................................S57
New Horizons in Critical Care Ultrasound ............................................................................................................................................................................S58
Perinatal Malformations of the Head, Face, and Neck ........................................................................................................................................................S58
Transplant Imaging ..................................................................................................................................................................................................................S59
Special Interest Sessions, 4:00 PM–5:30 PM
Abdominal and Lower Extremity Arterial Imaging: Pitfalls and Misdiagnoses ..................................................................................................................S59
Hands-on Ultrasound-Guided Vascular Access ....................................................................................................................................................................S59
Scientific Sessions, 4:00 PM–5:30 PM
Basic Science: Tissue Characterization, Part 2 ......................................................................................................................................................................S60
General and Abdominal Ultrasound ......................................................................................................................................................................................S65
Obstetric Ultrasound: General and Fetal Growth ................................................................................................................................................................S69
WEDNESDAY, APRIL 10, 2013
Special Interest Sessions, 8:15 AM–10:15 AM
Breast Ultrasound ....................................................................................................................................................................................................................S73
Extracranial Ultrasound of the Head and Neck in Children ................................................................................................................................................S73
Gynecologic Ultrasound: The Basics Revisited......................................................................................................................................................................S73
Innovative Directions in Fetal Cardiac Imaging ....................................................................................................................................................................S73
Lumps, Bumps, and Extremity Pain in the Emergency Room: What Is the Role of Ultrasound? ....................................................................................S74
Peripheral Arterial Disease ......................................................................................................................................................................................................S74
Ultrasound-Guided Thrombolysis..........................................................................................................................................................................................S74
Special Interest Sessions, 10:45 AM–12:30 PM
Acoustic Radiation Force Impulse Imaging: Benefits and Challenges With Increasing Acoustic Output Beyond Diagnostic Levels ..........................S75
Advanced Fetal Cardiac Evaluation and Comprehensive Overview....................................................................................................................................S76
Current Vascular Controversies ..............................................................................................................................................................................................S76
Musculoskeletal Ultrasound: Transition From Adults to Pediatrics ....................................................................................................................................S76
Ultrasound of the Head and Neck ..........................................................................................................................................................................................S76
Scientific Sessions, 10:45 AM–12:30 PM
Emergency Ultrasound, Part 2 ................................................................................................................................................................................................S77
Obstetric Ultrasound: Multiple Gestations and New Techniques ......................................................................................................................................S79
Scientific E-Poster Sessions ........................................................................................................................................................................................................................S83
Continuing Medical Education Credit Information ..............................................................................................................................................................................S122
Faculty Disclosures ....................................................................................................................................................................................................................................S123
Disclosures From AIUM Officers, Board Members, Committee Members, and AIUM Staff ..........................................................................................................S129
Policy on Unlabeled/Off-Label Usage ....................................................................................................................................................................................................S130
Disclosure of Commerical Support for the 2013 AIUM Annual Convention ....................................................................................................................................S130
Index ............................................................................................................................................................................................................................................................S131
Manuscripts, Membership, and Business Matters
Correspondence should be addressed to the American Institute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite
100, Laurel, MD 20707-5906 USA; phone: 301-498-4100. Information on membership can be found at
www.aium.org.
General Information
Subscription Rates
Journal of Ultrasound in Medicine (ISSN 0278–4297) is issued monthly in one indexed volume per year by the American
Institute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite 100, Laurel, MD 20707-5906 USA. Subscription prices
per year: institution $450 (online only) or $485 (print + online); individual $340 (print + online). Canada and Mexico
please add $45.00. Outside the United States, Canada, and Mexico please add $60.00. Claims for missing issues, made
within 6 months of the issue date, can be honored through contact with the AIUM Executive Office. The AIUM shall
be responsible for the cost of resending the claimed issue(s) 1 time via USPS Priority Mail. Should the issue(s) be
claimed a second time, the shipping and handling costs shall be the responsibility of the subscriber/member ($7.00
US/Canada/Mexico; $25.00 international). After 6 months, issues will be available at the back issue price. Duplicate
copies will not be sent to replace ones undelivered through failure to notify the American Institute of Ultrasound in
Medicine of a change of address. Single copy and back volume information available from the American Institute of
Ultrasound in Medicine, upon request. Periodicals postage paid at Laurel, MD, and additional mailing offices.
The Journal of Ultrasound in Medicine is indexed/abstracted in Index Medicus, Current Contents/Clinical Medicine,
EMBASE/Excerpta Medica, Science Citation Index, Science Citation Index Expanded, ISI Alerting Service, Engineering
Information, MEDLINE, Medical Documentation Service, and RSNA Index to Imaging Literature.
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Inquiries should be addressed to Advertising Sales, American Institute of Ultrasound in Medicine, 14750 Sweitzer Ln,
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meetings of the Institute) does not constitute a guarantee or endorsement of the quality or value of such product or of
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Printed in the USA. This journal is printed on acid-free paper.
© 2013 by the American Institute of Ultrasound in Medicine
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2013 AIUM Award Winners
William J. Fry Memorial Lecture Award
The William J. Fry Memorial Lecture Award was established by Joseph H. Holmes, MD, in 1969 and presented for the first
time at the AIUM Annual Convention in Winnipeg that year. (William J. Fry was a physicist with a strong interest in ultrasound in medicine, whose innovative research efforts advanced the field of medical ultrasound.) One of Professor Fry’s most
notable contributions was the successful design of an ultrasonic system used to pinpoint lesions in the brain without damaging adjacent tissues. This ultrasonic system was later used to treat various brain pathologies and, in particular,
Parkinson disease. His impassioned interest in ultrasound led him to become president of the AIUM from 1966 until his
death in 1968. The following year, the William J. Fry Memorial Lecture Award was established in his honor. It recognizes a
current or retired AIUM member who has significantly contributed in his or her particular field to the scientific progress of
medical ultrasound.
Paul L. Carson, PhD
This year, the AIUM has bestowed
the honor of the William J. Fry
Memorial Lecture Award on Paul L.
Carson, PhD, but it is actually the
AIUM that is honored to have a person of this caliber who is willing to
share his considerable talents and
extensive expertise with this organization.
In a few paragraphs, it’s impossible to summarize a 108-page curriculum vitae, a full 2 pages of which is a list of the honors
and awards Dr Carson has received during his exceptional
career. Destined to be a leader from a young age (he was
president of both his high school and college student bodies), Dr Carson graduated from Colorado College, followed
by a fellowship at Harvard, and earned his MS and PhD in
physics at the University of Arizona.
His major scientific interest has been in medical
physics with an emphasis in ultrasound, paying particular
attention to the safety of diagnostic ultrasound equipment,
as well as training and teaching. A professor of biomedical
engineering at the University of Michigan, he also serves as
associate director of basic radiological sciences at this same
institution and is concurrent professor at Nanjing University
in China and scientific coordinator at the Quantitative
Imaging Biomarkers Alliance of the Radiological Society of
North America. As if those academic appointments don’t
keep him busy enough, he is currently the coinvestigator
or principal investigator (PI) for 4 major grants from the
National Institutes of Health, the National Science
Foundation, and the Department of Defense Breast Cancer
Research Program and has served as PI for dozens of funded
research projects over the past 4 decades.
Dr Carson’s love of both teaching and research is
evidenced by the numerous dissertations and masters’ theses and projects he has supervised, plus the many postdoctoral fellows he has mentored and the visiting professors he
has hosted. Due to his nurturing, many of these exceptional
individuals have become active in the AIUM and the field of
medical ultrasound.
A prolific writer, with literally hundreds of journal
articles, books and chapters, monographs, abstracts, and
related communications to his credit, as well as the holder of
10 patents, Dr Carson does not limit the sharing of his expertise to academia or publishing. He has long recognized the
value and importance of professional societies in promoting
science and is an active member of a wide variety of associations, serving on committees and often in leadership positions. His commitment to the AIUM is legendary. He has
served on the AIUM’s Board of Governors and the Editorial
Board of the Journal of Ultrasound in Medicine and has been
an active contributing member for dozens of AIUM committees and subcommittees, all with the aim of ensuring quality
and safety in diagnostic ultrasound.
With his intelligence and creativity, his exceptional
leadership skills and drive, and his passion and willingness to
share his time and knowledge with others, Dr Carson has carried on the tradition of Professor Fry and has set the perfect
example for those who will follow in his footsteps.
The title of Dr Carson’s William J. Fry Memorial
Lecture is Ultrasonic Domination: Medical Imaging,
Medicine, Daily Life.
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2013 AIUM Award Winners
Joseph H. Holmes Basic Science Pioneer Award
The Pioneer Award, which honors an individual who has significantly contributed to the growth and development of medical ultrasound, was established in 1977. This special award was renamed in 1982 to honor Joseph H. Holmes, MD, who
died that year. Dr Holmes, the first person named as an AIUM pioneer, was an important figure to both the field of diagnostic ultrasound and the AIUM. His early efforts in ultrasound research, which included tissue characterization and
ultrasound’s diagnostic use in polycystic kidney disease and orthopedics, helped advance the field of ultrasound and
encourage others to conduct new research. Serving the AIUM in many capacities, Dr Holmes was president from 1968 to
1970 and was editor of the AIUM’s official journal, which was then titled the Journal of Clinical Ultrasound, for nearly 10
years. Each year, the Joseph H. Holmes Pioneer Award honors 2 current or retired AIUM members, 1 in clinical science and
1 in basic science.
Christy K. Holland, PhD
You wouldn’t necessarily expect
that a woman who spent her junior
year abroad at the Universität
Freiburg and Hochschule für Musik
Freiburg studying Beethoven and
Schubert would be the recipient of
the prestigious Joseph H. Holmes
Basic Science Pioneer Award, but
then you would be underestimating the talents and breadth of
expertise of Christy K. Holland,
PhD. Dr Holland earned her bachelor’s degree in physics and
music from Wellesley College and her PhD in engineering
and applied science from Yale University. She worked at Yale
until 1994 when she joined the Department of Radiology at
the University of Cincinnati College of Medicine. While
at the University of Cincinnati, she has served in the
Department of Aerospace Engineering and Engineering
Mechanics and in the Department of Biomedical
Engineering and Radiology in the College of Engineering
and Medicine. She is currently a professor in internal medicine in the Division of Cardiovascular Diseases, Biomedical
Engineering Program.
Dr Holland has a long history of reviewing manuscripts for 9 peer-reviewed journals beginning immediately
on graduation, as well as extensive experience reviewing for
multiple national, state, and private funding agencies,
including the National Institutes of Health (NIH) and the
National Science Foundation. This is just one of the factors
that led to her appointment as the editor-in-chief of
Ultrasound in Medicine and Biology (UMB), the preeminent
journal of the World Federation for Ultrasound in Medicine
and Biology.
A fellow of both the Acoustical Society of America
(ASA) and the AIUM, Dr Holland has long been active in
committees and in leadership positions for both organizations. She was elected to the Executive Council of the ASA
and to the AIUM’s Board of Governors and to its Executive
Committee, where she served as secretary. Her particular
interest has focused on bioacoustics and bioeffects; a
dedicated member of the ASA’s Biomedical Acoustics
Committee, she cochaired the AIUM’s Mechanical Bioeffects
Conference and was a guest editor for the resulting publication, Mechanical Bioeffects from Diagnostic Ultrasound:
AIUM Consensus Statements.
Currently engaged in 8 separate research projects
with topics ranging from “Ultrasound-Assisted Thrombolysis
for Stroke Therapy” to “Targeted Liposomes for Acoustic
Cardiovascular Imaging,” Dr Holland has served as principal
investigator or coinvestigator on dozens of research grants
from the NIH and other organizations. With more than 85
publications to her credit, Dr Holland is best known for her
exceptional teaching abilities and the large number of students, postdoctoral fellows, and clinical fellows whom she
has advised. She may be musically gifted, but it is her ongoing scientific contributions to the growth and development
of medical ultrasound for which she will be remembered.
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2013 AIUM Award Winners
Joseph H. Holmes Clinical Pioneer Award
The Pioneer Award, which honors an individual who has significantly contributed to the growth and development of medical ultrasound, was established in 1977. This special award was renamed in 1982 to honor Joseph H. Holmes, MD, who
died that year. Dr Holmes, the first person named as an AIUM pioneer, was an important figure to both the field of diagnostic ultrasound and the AIUM. His early efforts in ultrasound research, which included tissue characterization and
ultrasound’s diagnostic use in polycystic kidney disease and orthopedics, helped advance the field of ultrasound and
encourage others to conduct new research. Serving the AIUM in many capacities, Dr Holmes was president from 1968 to
1970 and was editor of the AIUM’s official journal, which was then titled the Journal of Clinical Ultrasound, for nearly 10
years. Each year, the Joseph H. Holmes Pioneer Award honors 2 current or retired AIUM members, 1 in clinical science and
1 in basic science.
Peter H. Arger, MD
regarding the initiatives occurring under his leadership and
doesn’t begin to address his contributions to the AIUM both
before and after his tenure as president, through his hard work
on almost every AIUM committee in existence. He undertook
all these activities while serving as professor of radiology at the
Hospital of the University of Pennsylvania, where he is now
emeritus professor of radiology and concentrating on ultrasound research and ultrasound training for residents.
A graduate of Washington University in St Louis and
the University of Illinois Medical School, Dr Arger was a captain
in the US Air Force before beginning his long history of awards
for his research and his service to imaging associations, starting
with a certificate of merit for “An Approach to Orbital Lesions”
from the American Roentgen Ray Society more than 30 years
ago to his most recent honor in 2011—the Gold Medallion
Award—from the Pennsylvania Radiological Society.
His many awards are a testament to his ongoing
commitment to imaging. He has served as principal investigator on multiple major grants that addressed an enormously broad range of issues, such as mercury burden in dentists,
staging of ovarian cancer, methods of giving contrast agents,
evaluation of renal failure, and Doppler vascularity in breast
cancer diagnosis. A well-published author with hundreds of
original papers to his credit, as well as abstracts, books,
reviews, and chapters, Dr Arger’s passion for education is further manifested by the countless presentations he has given
and the outstanding courses he has directed.
It’s not surprising that these incredible achievements were completed by an exceptional clinician, what is
remarkable is that they were completed by such a kind, softspoken, self-effacing human being who has earned the highest respect and admiration from his colleagues, his students,
his superiors, his subordinates, and association staff. He is
truly the inveterate clinical pioneer.
If we were to include only the
contributions he made while president of the American Institute of
Ultrasound in Medicine (AIUM),
Peter H. Arger, MD, would still be
the perfectly chosen recipient for
this award. During his tenure as
president of the AIUM (1995–1997),
Dr Arger oversaw changes and
improvements to this organization
and to the field of medical ultrasound that resonate to this day. Recognizing the enormous
potential for ultrasound in medicine but also aware that
funding for research was limited, he spearheaded the establishment of what is now the AIUM’s Endowment for
Education and Research, which has already allocated close to
three-quarters of a million dollars to ultrasound research and
educational endeavors. Dr Arger was also instrumental in the
creation of the AIUM’s ultrasound practice accreditation program. The 2000+ practices that have subsequently received
accreditation have demonstrated their commitment to the
highest quality patient care—a tribute to Dr Arger’s foresight
and vision.
While he was president, the AIUM held an innovative leadership retreat to initiate a 5-year plan; built coalitions
and established liaisons with 27 ultrasound-related associations to ensure the ability to take a proactive stance on legislation and to promote the best practices in diagnostic ultrasound, established the Distinguished Sonographer Award as
well as the New Investigator Award, conducted a conference
in which simultaneous Spanish translation was available,
obtained a seat on the American Medical Association House
of Delegates, and analyzed the entire operation of the Journal
of Ultrasound in Medicine. That is just the tip of the iceberg
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2013 AIUM Award Winners
Distinguished Sonographer Award
Established in 1997, the Distinguished Sonographer Award is a means of recognizing and honoring current or retired
AIUM members who have significantly contributed to the growth and development of medical ultrasound. This annual
presentation honors an individual whose outstanding contributions to the development of medical ultrasound warrant
special merit.
Marsha Neumyer, BS, RVT
The title “distinguished sonographer” does not do justice to the 2013
awardee, Marsha Neumyer, BS, RVT.
Currently chief executive officer and
international director of Vascular
Diagnostic Educational Services,
Ms Neumyer previously was an
assistant professor of surgery at the
Pennsylvania State University College
of Medicine and director of the
vascular laboratory section of the
Pennsylvania State Vascular Institute.
Ms Neumyer earned her bachelor’s degree in zoology from the Pennsylvania State University and spent the next
2 decades involved in research, starting with the Bovine
Lymphosarcoma and Leukemia Research Team and Newcastle
Virus Disease Research. She then founded and served as the
director of the Diagnostic Laboratory and Tissue Culture Cell
Bank, followed by a stint as the director of the Camp Hill
Veterinary Laboratory and as a senior research technician at
the Milton S. Hershey Medical Center.
In 1985, her commitment to vascular imaging
would firmly take hold with her certification as a registered
vascular technologist. It comes as no surprise that this is a
field in which she would excel and for which she has received
multiple awards, including the Award for Excellence in
Scientific Research (twice) from what is now the Society for
Vascular Ultrasound (SVU), the Distinguished Service Award
from the Society of Vascular Technology (SVT), the Burnham
Editor’s Award for outstanding contributions to the field of
vascular technology, the J. Baker Pioneer Award in Medical
Sonography from the Society of Diagnostic Medical
Sonography (SDMS), and the SVU Professional Achievement
Award.
A fellow of the AIUM, the SDMS, and the SVT, Ms
Neumyer has served admirably in leadership roles for these
3 organizations, as a member of the Board of Governors, the
Board of Directors, and president, respectively. In addition,
she has demonstrated her belief in the importance of vascular imaging excellence by her active involvement in numerous committees addressing issues of education, training, bioeffects, risk management, and practice guidelines.
A founding member of what is now the Intersocietal
Accreditation Commission, Ms Neumyer has been the editor
of the Journal of Color Flow Imaging and guest editor of the
Journal for Vascular Technology multiple times. She serves on
the editorial boards of the Journal of Vascular Ultrasound and
the Journal of Diagnostic Medical Sonography and is a reviewer for the Journal of Ultrasound in Medicine, the Journal of
Clinical Ultrasound, and the Journal of Diagnostic Medical
Sonography.
Her editorial responsibilities are a direct reflection
of her prolific output as an author through publications, book
chapters, books, abstracts, posters, and videos, CDs, and
DVDs. But it is in lectures and presentations where her outstanding talents shine through. With her close to 900 presentations, Ms Neumyer has made Herculean efforts to educate
users and promote exceptional and safe vascular imaging.
She is truly a clinician who should be emulated.
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2013 AIUM Award Winners
Honorary Fellow Award
The Honorary Fellow Award bestows an honorary membership to those individuals who have contributed significantly to
the field of ultrasound.
Paul A. Dubbins, MBBS, BSc, FRCR
A graduate of Kings College
Hospital Medical School, Paul A.
Dubbins, MBBS, BSc, FRCR, is
currently consultant radiologist at
Derriford Hospital in Plymouth,
England, where he led the ultrasound department for 30 years, and
civilian consultant adviser in radiology to the Royal Navy. A member of
numerous distinguished societies,
he has been particularly active in
the Royal College of Radiologists, where he has served on
many committees and, most recently, as vice president.
A reviewer for multiple peer-reviewed journals, Dr
Dubbins has served on the editorial board of Clinical
Radiology, the European Journal of Ultrasound, and the
Journal of Ultrasound in Medicine and was the European
editor of Ultrasound International.
Dr Dubbins is a well-published author, with more
than 60 articles and 30 book chapters. In addition, he is the
editor, coeditor, or author of multiple books, some of which
are now in second editions, including Urogenital Ultrasound:
A Text Atlas and Clinical Doppler Ultrasound. A clinician with
exceptional teaching skills, including 2 years as assistant professor in the Division of Diagnostic Ultrasound at Thomas
Jefferson University Hospital and decades of experience as a
course organizer, Dr Dubbins has lectured worldwide on
ultrasound and has developed and led hands-on training
courses in Nepal and India.
Having made contributions to the field of medical
ultrasound on multiple continents, it is not surprising that
he would embrace and become a leader in e-learning. The
Radiology Integrated Training Initiative, a concept proposed
by Dr Dubbins, was initiated in 2005, long before most professionals in any field had begun to consider the advantages
of online learning. This innovative new training program
was based predominantly on an e-learning delivery strategy,
supplemented by skills lab work and traditional apprenticeship-style learning; Dr Dubbins was the author and editor of
the gynecologic imaging module until 2010. Dr Dubbins further developed the education program within health care by
devising an introduction to imaging for the Foundation Year
program (internship), for which he serves as lead editor. Not
content to limit his e-learning ideas to the United Kingdom,
Dr Dubbins has led work commissioned by the World
Federation for Ultrasound in Medicine and Biology to develop an e-learning program for basic ultrasound. The first
module, to be trialed in Uganda this year, consists of 10 interactive learning sessions covering technique, anatomy, and
basic abnormalities. This is a program with worldwide potential to provide state-of-the-art affordable medical education
to countries where it is most needed and where it might otherwise never be available.
It is for his foresight, imagination, expertise, and
pioneering efforts in the field of ultrasound education that
the AIUM is proud to name Paul Dubbins as an honorary
fellow.
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Endowment for Education and
Research Donors
The AIUM’s Endowment for Education and Research (EER) was created to provide much-needed funding for ultrasound research and educational initiatives. What makes this possible is the generous
support of AIUM members, vendors, and individuals who provide gifts in honor or in memory of
ultrasound professionals.
It is with great appreciation that the AIUM thanks the individuals listed below who contributed to
the EER in 2012. These individuals have a ribbon on their name badge acknowledging their
generosity; please thank them for their support.
Contributions of $1000 and
Above
Jacques Abramowicz, MD
Alfred Abuhamad, MD
Peter Arger, MD
Carol Barnewolt, MD
Beryl Benacerraf, MD
Bryann Bromley, MD
Frank Chervenak, MD
Brian Coley, MD
Joshua Copel, MD
Jude Crino, MD
Arthur C. Fleischer, MD
Leonard Glassman, MD
Steven R. Goldstein, MD
Lennard Greenbaum, MD
Luis Izquierdo, MD
Samuel Maslak, DSc
Levon Nazarian, MD
Harvey L. Nisenbaum, MD
William O’Brien Jr, PhD
Kathryn Reed, MD
Rudy Sabbagha, MD
Thomas Shipp, MD, RDMS
James Shwayder, MD, JD
Carmine Valente, PhD, CAE
Joseph Wax, MD
Gary Whitman, MD
Contributions of $250 and Above
Lisa Allen, BS, RDMS, RDCS, RVT
Rochelle Andreotti, MD
David Bahner, MD, RDMS
Carol Benson, MD
John Benson, MD
Michael Blaivas, MD
William Brown III, MD
Charles Church, PhD
Harris L. Cohen, MD
Deborah D’Agostini, RDMS
Peter Doubilet, MD, PhD
Diane Eberle
J. Brian Fowlkes, PhD
Barry Goldberg, MD
H. Harcke Jr, MD
Charlotte Henningsen, MS, RT,
RDMS, RVT
Frederick Kremkau, PhD
Alfred Kurtz, MD
Ernest Madsen, PhD
Thomas Moore, MD
Dolores Pretorius, MD
Victor Reddick, RDMS, RDCS, RT
Leslie Scoutt, MD
Sachita Shah, MD
Ronald Townsend, MD
Isabelle Wilkins, MD
James Zagzebski, PhD
Contributions Up to $249
Samer Abdullah, MD
Monzer Abu-Yousef, MB, BCh, ABR
Susan Ackerman, MD
Debra Acord, MD
Juan Acosta, DO, MS
Charles Adair, MD
El-Zein Adam Jr, MBBS, MSC, PhD
Annette Adams, BSN, RN, RDMS
Germán Adarme, MD
Joseph Adashek, MD
Arun Adhate, MPA, RDMS, BS
Richard Aguilera, MD
Khaled Ahmed, MD
Zaheer Ahmed, BS, RDCS, RVS
Robert Ahrens Jr, MD
Anthony Akamaguna, MB, BS,
DMRD
Brigitte Ala, MD
Sheikh Alam, PhD
Vito Alamia, MD
Joseph Albano, MD
Juan Luis Alcázar, MD
John Alcini Jr, MD
Archie Alexander, MD, JD, LLM
Rustom Al-Khatib, MD
Huda Al-Kouatly, MD
John Allen, PhD
Paul Allen, MD
Mona Alqulali, MD, PhD
Karen Alton, BS, RT, RDMS, RVT
Muna Alzahrani
Anthony Ambrose, MD
David Amponsah, MD, RDCS
Libby Anderson, MD
Panagiotis Andrikopoulos, MD
Anthony Annan
Jackie Appleby, MS
Jose Aquino, MD
Hisham Arab, MD
Irma Aragon, MD
Edward Araujo Júnior, PhD, MD
viii
Beckie Ard, RDMS, RVT
Patricia Ardise, MD
Ellen Arendt, MD
Ignacio Armas, MD
Albert Armstrong Jr, DPM
Erin Arnold, MD
William Arnold, MD
Elsa Arribas, MD
Belinda Artimovich
Hilda Arzola Plascencia
Yasuyuki Asakawa, MD, PhD
Adam Ash, DO
Graham Ashmead, MD
Mohamed Ashour
Fareeda Asif, MBBS
Tamerou Asrat, MD
Fiona Atkins
Stephen Avery, MD
Tin Tin Aye, MBBS
Jean Ayoub, MD, PhD
Daniel Azabache, MD
Nami Azar, MD
Kazunori Baba, MD, PhD
Anthony Bacevice Jr, MD, MSE
Norman Back, MD
Jennifer Bagley, MPH, RDMS, RVT
Emily Baker, MD
Jeffrey Baker, MD
Mary Baker Berzansky, MD
Juanito Baladad, MD
Adrian Balica, MD
Bita Baligh, MD
Natalie Ballweber, PA-C
J. Oscar Barahona, BS, RDMS
Antonio Barbera, MD
Diego Barca
Arlene Bardeguez, MD
Donald Barford, MD
Tudor Barglazan, RVT
Darryl Barnes, MD
Jolyn Barras, RT, RDMS, RVT
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Edgar Barros, RDMS
Juan Barros, RVT, RDMS, RDCS
Patricia Barry, MD
Joan Bartello
James Bartelsmeyer, MD
Peter Barthe, PhD
Edwin Bartlett, MD
Bonnie Bartley, RDMS, RDCS
Norman Barwin, MD, FRCOG,
FSOGC
Ahmet Baschat, MD
Richard Basile, MD
Naz Basit, MBBS, RDMS
Jean-Philippe Bault, MD
Tara Baum, MD
John Baxter, MD
Martine Beaudoin, RN, BSN
Brian Beck, MSEE, MD
Brent Becker, MD
Theodore Bedard, MD
Enrique Bedia, MD
Rob Beekmans
Kimberly Behling, RDMS, RVT,
RRT
Clifford Beinart, MD
Gwendolynn Belle, RDMS
William Benedetto, MD
Richard Benoit, MD, MPH
Eric Bentolila, MD
Paul Bergh, MD
Michele Bergmann, MD
Nancy Berich, RDMS
Daniel Berkowitz, MD
Leslie Berlinsky, AAS, RDMS, RVT,
RT
Richard Bernardi, PhD
James Bernasko, MD
Lisa Bernhard, MD
Vidor Bernstien, MD
Richard Besinger, MD
Pamela Besse, RT, RDMS
Sherri Bethea, RDMS
Maureen Beurskens, MD
Gordon Beute, MD
Connie Bevell, RDMS
Daksha Bhansali, MD
Barbara Biber, MD
Benjamin Bieber, MD
Teresa Bieker, MBA, RT, RDMS,
RVT, RDCS
Kenneth Bielak, MD
Angela Biggs, MD
Christine Bird, BS, RDMS, RVT
Andrea Bishop, RDMS
Mauricio Bitran, MD
Debra Blackford, RDMS, RVT,
RDCS
J. Timothy Blackwelder, MD
Marlene Blair, RT(R), RDMS
Richard Blair, MD
Christine Blake, MD, MPH
Kristi Blanck, RDMS
Ernesto Blanco, MD
Alejandro Blando, MD
Joseph Blankier, MD, FRCS(C)
Alexander Blankstein, MD
Jean Cadet, MD
Alan Cadkin, MD
Kenzie Caine, BA, RDMS
Gail Calamari, MD
Charles Camacho, MD
Helio Sebastiao Camargo Jr, MD
Angelo Campagna, MD, FRCS(C)
Timothy Canavan, MD, MSc
Mario Candal, MD
Patricia Cantu, BS, RT(R), RDMS,
RVT, RDCS
Vito Cardone, MD
Reynaldo Cardoso, MD, FRCSC
Eric Carlson, DO, MPH
Anselmo Carmo
Francis Carmody, MBBS, FRCOG,
FRANZCOG, DDU
Stephen Carolan, MD
Marshall Carpenter, MD
Robert Carpenter Jr, MD, JD
Stephen Carr, MD
Elaine Carroll, MD
Paul Carson, PhD
Anthony Carter, MD
Sarah Carter, MSEd, RDMS
Mark Cartier, BS, RDMS, RT
Carolyn Caruso, BS, RDMS
Elba Cases, BS, RDMS, RDCS
Alejandro Casillas, MD
Meredith Cassidy, MD
Mario Castillo, MD
Augusto Castrillon Sr, MD
Simon Castro, MD
Diane Cervantez, RDMS, BS
David Chaffin, MD
Mark Chag, MD
Laurence Chaise, MD
Albert Chan, MD
Ka Fai Chan, BS
Lisa Charney, BS, RDMS
Ming-Tak Chau, FRCR
Rubila Chaudhry
Meera Chaudhuri, MD, FRCOG
Emiliano Chavira, MD, MPH
Chou-Er Chen, BS
Hee-Joo Cheon, MD
Stephen Cherewaty, MD
Melanie Cherry, MD
Miranda Cheung
Balwant Chhatwal, MD
Suzin Cho Helgaas, MD
Min Choi, PhD
Tae-Sik Choi, MD
Shaila Cholli, BS, RDMS
Hajoon Chun, MD
Marc Clachko, MD
Craig Clark, MD, JD
Linda Clark, RDMS, RT(R)
William Clark, MD
Daniel Clement, MD
Marianne Clements, RDMS
Phillip Clements, MD
Suzanne Clemons, MD
Rosemary Coffey
Leeber Cohen, MD
Veronica Cohen, RDMS
Josef Blankstein, MD
Anna Blask, MD
Joseph Blazina III, BS, RDMS
Andrew Blecher, MD
David Blews, MD
Adam Blickley, MD
Donna Blodgett, RDMS
Amy Blumenthal, MD
Ronnie Bochner, MD
Jean Bolan, MD
J. Scott Bomann, DO
Peter Bonadonna, EMT-P
Gary Boss, RDMS, RDCS
Radine Boss, RDMS
Elton Bowen, MD
Deanna Boyette, MD
William Bracer, MD, RVT, RPVI
Abigail Brackney, MD
Terence Braden, DO
E. Bradley, MD
Kim Brady, MD
Brittany Brasher, RDMS
Amy Breakstone, MD
Ashley Breaux
Fred Brennan, DO
Kim Brennan, MD
Lesley Brennan, RDMS
Steven Brenner, MD
William Brewer, MD
Marla Bridgford, BS, RDCS, RDMS
Justin Briones, MD
Steven Broadstone, PhD
Marsha Brody, RDMS
Fredrik Broekhuizen, MD
Debra Brooks, BS, RTRM, RDMS,
RVT
Pamela Brower, RVT, RVS
Christina Brown, MD
Deborah Brown, BA, RDMS, RDCS
Dina Brown, RDMS
Douglas Brown, MD
Elisa Brown, MD
Carol Brown-Elliott, MD
Hermann Bruhwiler, MD
Stephen Bruny, MD
Neal Buchalter
Carmen Bucher
Richard Budenz, MD, PhD
Susan Bunch, MD
Sherry Bunting, RDMS
Holly Burge, MD
M. Shannon Burke, MD
Deland Burks, MD
Kathleen Burnett, RDMS, RVT
Leigh Burrell, RT, RDMS
Michelle Bursese, RDMS
Frances Buryk, RDMS
Jacqueline Bush, MD
Lawrence Busse, PhD
Raydeen Busse, MD
Jeffrey Butler, DO, RDMS
Helia Buyck
Paul Byrne, MD
Michael Cabbad, MD
James Cabell, MD, PhD
ix
Fred Coleman, MD
Mark Collins, MD
Robert Collins, MD
Terry Collins, MD
Pablo Colon, AAS, RDMS
Lisa Comer, RTR, RDMS, RDCS
Mary Comito, RT, RDMS
Caroline Comparone, RDMS
Frederick Conard III, MD
Lori Conley, RDMS
Mary Connell, MD
Richard Cook, MD
Brian Coolbaugh, MD
Elizabeth Cooper, RDMS
Penny Cooper
Kristin Coppage, MD
Andrea Corda, MD
Raul Cordova, RDMS
Laura Corio, MD
Carla Corry, RDMS
Erich Cosmi, MD, PhD
Seid Cosovic, MD
Carlos Costa
Magda Costa, MD
Tracey Cota
Osterman Cotes, MD
Carole Coughlin, RDMS
Laura Coultrip, MD
Jacqueline Cox, RDMS, RT
Joseph Craig, MD, ChB
William Craig IV, MD
Blane Crandall, MD
Tonie Crandall, MD
Frank Craparo, MD
Luther Creed, MD
Vernon Croft, MD
Kathleen Cross, RDMS,
RT(R)(M)(CT)
Dante Cubangbang, MD
Gail Culbert
Gabriel Culiat, RDMS
Marianne Cullen, BS
Mary Cunnane, MD
Mark Curran, MD
William Curtin, MD
Maria Czerwinski, MD
Diane Dalecki, PhD
Stephen Dalton, MD
Mary D’Alton, MD
Suzanne Dambek, MD
Paxton Daniel, MD
Eugene Danko, MD
Jerome Dansereau
Byron Darby, MD
Joseph Darby Jr, BS, RDMS
Raymon Darling, MD
Barry Davidson, MD, FRCP
Jesse Dawkins Sr, MD
Sue Ann Dayton, RDMS, RRT
Maria De Elejalde, MS, RN
M. Robert De Jong, RDCS, RDMS,
RVT
Marie De Lange, BS, RDMS, RDCS
Jose De Sousa Pereira, MD, RDCS,
RDMS
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Rosa De Vermette, MD, RDCS,
RDMS, ROUB
Anthony Dean, MD
Hollis Dean, RDCS
Philippe Deblieck
Mamta Deenadayal, MD
Tony Deeths, MD
Gary DeGuzman, MD
Patricia Del Bondio, RDCS, RDMS,
RVT
Gerardo Del Valle, MD
Brian Delahoussaye, MD
Kimberly Delaney, RT, RDMS, FE
Michael DeMass
Michael Demishev, MD
Fareed Denath, MB, FRCP(C)
Linda DeOrio, RDMS
Dail DeSouza, BA, BS, RDMS
Stamatia Destounis, MD
Karen DeTommaso
Richard DeVeaux, MD
Lawrence Devoe, MD
Greggory DeVore, MD
Daniel Dexeus, DO
Gunwant Dhaliwal, MD
Diane Di Girolamo, MD
Michael Di Pietro, MD
Lin Diacon, MD, RDMS
Thiendella Diagne, MD
David Dichiara, MD
Jeffrey Dicke, MD
Eitan Dickman, MD, RDMS
William Dittman, MD
Susan Dodd, MD
Steven Domnitz, MD
John Donlon
Alan Donnenfeld, MD
Leslie Donovan, MD
Bernice Doring, RT, RDMS
Jean Dormer, RT, RDMS
N. Carol Dornbluth, MA, MD
Mark Downey, RT, RDMS, RVT
Margaret Drake, AA, RT(R), RDMS
Kathryn Drennan, MD
Dawn Driver, RDCS, RDMS, RVT
Robert Dropkin, MD
Julia Drose, BA, RT, RDMS, RVT,
RDCS
Terry DuBose, MS, RDMS
Jerome Dubowy, MD
Eva Duckett, MD
Kelly Duncan, RDMS
Lisa Dunn-Albanese, MD
James Dunphy, MD
Teresa Durbin, MD
Olga Dynkin
Gerald Dysert, MD
Colette Eastman, DO
Katherine Eastwood, MD
Ian Ebesugawa, MD
Steven Edell, DO
Robert Eden, MD
Rick Edmiston
Peter Edmonds, PhD
Christine Edwards, MD
Robert Edwards III, MD
Jonathan Foster, MD
Lisa Foster, RDMS
Arthur Fougner, MD
Debra Fouts, RDMS, RDCS
Grant Fowler, MD
Lisa Fox, RDMS, RVT
Parham Fox, BA, MD
Pamela Foy, MS, RDMS
Gerard Foye Jr, MD
Terrell Frain, RDMS
Gaetane Francis, MD
Jennifer Franz, RT, RDMS
Mahlon Freeman, MD, MedScD
Atis Freimanis, MD
Maija Freimanis, MD
Dawn Frey, AA, RTR, RDMS
Franklin Friedman, MD
William Fry, MD
Elizabeth Fuentes
Teiichiro Fukushima, MD
Pat Fulgham, MD
Deena Fulton, RRT
Maureen Galang, RDMS, RDCS,
RVT
Paul Gammell, BSEE, PhD
Bryan Ganter, MD
Jing Gao
Rosa Garcia
David Garfinkel, MD
Brian Garra, MD
David Garry, DO
Frank Gaudier Jr, MD
Michael Gebel, MD, PhD
Gino Gennari, RDMS
Herbert Gerstein, MD
Tammy Gerstenfeld, DO
Doreen Getty, RDMS
Nabil Ghali, MD
Goutam Ghoshal, PhD
William Gilbert, MD
Harlan Giles, MFM, MD, RDMS
Cynthia Gill, PT, DScPT, MEd
Jerry Gilles, MD
Michael Ginn, RVT
Anthony Giovine, MD
Thomas Giudice, MD, MS
Vincenzo Giuliano, MD, RPVI,
RVT, RDMS, ARMRIT
Phyllis Glanc, MDCM, BSC
Angela Glaser, RDMS
Mikhail Gleyzer, DO, MD
John Goble
Stephen Gocke, MD
Ricardo Goes
Chris Goeser, DC, MD
Bradley Goldberg, MD
James Goldberg, MD
Nancy Goldenberg, MD
Alan Goldman, MD
Candace Goldstein, BS, RDMS
Edwin Goldstein, MD
Mercedes Gomez de Villasana, MD
Jenice Gonyea, RDMS, RTR
Mario Gonzalez Quiroz
Eduardo Gonzalez-Jove, MD
Antonio Gonzalez-Ruiz, MD
William Edwards, MD
Hugh Ehrenberg, MD
Amy Eichfeld, MD
Doug Eiland, MD
Berit Eklund, RN, MS
B. Rafael Elejalde, MD
Paul Ellenbogen, MD
Byron Elliott, BA, MD
Sandra Emmons, MD
Goodday Eng, RDMS
Heywood Epstein, MD
Christos Erinakes, MD
Ernest Ertmoed, MD
Frederick Eruo Sr, MD, MPH
J. Fernando Escarzaga, RPA, RVT,
RDMS, RT
Sharon Eskam, MD
Kristine Eule, MD
Peter Evan, MUDR
John Evans, MD
Maggie Evans, MD
Wayne Evans, MD
Philippe Extermann, MD
Steven Eyanson, MD
Eric Fackler, MD
Leonard Fagan, MD
Gary Fait, MD
Joseph Fakhry, MD
Iman Fani, MD
Harry Farb, MD
Patricia Farias
Darren Farley, MD
Shahid Farooqi, MD
Juan Fausti, MD
Jean Fava
Mark Favot, MD
Beda Federici-Linehan, MS, RDMS
Ding-Yu Fei, PhD
Deborah Feldman, MD
Damariz Feliz
Terry Feng, MD
Jonathan Fenton, DO
Benedito Fernandes
Hostos Fernandez-Caamano, MD
Lauren Ferrara, MD
Jacqueline Fielding, BS, RDMS
Reinaldo Figueroa, MD
Harris Finberg, MD
Marcus Finch
Janet Fiore, RT, RDMS
Stuart Fischbein, MD
Frank Fischer
Jason Fischer, MD, MSc
Colleen Fitzsimons
Christi Flanagan, RDMS, RVT
Meghan Flannery, MD
Matthew Flannigan, DO
Rodney Florek, MD
Philip Florio, MD
Katherine Foley, MD
Jon Foran, MD
Melissa Foreman, RDMS, RVT
Flemming Forsberg, PhD
Wilbert Fortson Jr, MD
Stephen Fortunato, MD
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Jean Goodman, MD
Barbara Gordon, MD
Alan Gorrell, MD, RDMS
Kiyotoshi Gotoh, MD, PhD
Daniel Gottschall, MD
Gregory Goyert, MD
Neville Graham, MD
Sallye Granberry, MD
Michael Granelli
Vanessa Grano, MD
Andrew Gray, MD, PhD
Caron Gray, MD
Cindy Gray, RDMS, CNMT,
RT(R,M)
Diana Gray, MD
Robyn Gray, DO
Michael Green, MD, FRCS
Richard Green, MD, BS
William Green, MD
Mark Greenberg, MD, CCD
Steven Greenberg, MD
Vinette Greenland, MD
Jill Ann Shu Gregg, RDMS
Natalie Gregory, MD
Kamal Greiss, MD, FRCP, FACE,
ENCU
Tim Grenemyer
Basil Grieco, MD
Kirby Gross, MD
Yvette Groszmann, MD, MPH
Emily Gubert, MD
Alexandr Gudz, MD
Gwen Guglielmi, MD
Lesley Gumbs, MD
Gowthaman Gunabushanam, MD,
FRCR
Shalesh Gupta, MD
Joy Guthrie, PhD, RDCS, RDMS,
RVT
Glenford Guy, BSc, MD
JoAnn Haberman, MD
Shoshana Haberman, MD, PhD
Wendy Hadden, MD
Christine Haines, MD
Lawrence Haines, MD, MPH,
RDMS
John Hale, MD
Anne Hall, PhD
Brian Hall, MD, RDMS, RDCS
Mederic Hall, MD
Michael Hall, MD
Timothy Hall, PhD
Thomas Halloin, MD
Antoinette Ham, MD
Caroline Hamel, MD
Lee Ann Hammond, MD
Lewis Hamner III, MD
Ulrike Hamper, MD, MBA
Magdi Hanafi, MD
Susan Hancaviz, RDMS
Glenn Haninger, MD
Maryellen Hanley, MD, MPH
Lara Hanlon, MD
Kathleen Hanlon-Lundberg, MD
Gina Hanna, MD
Reid Hannon Jr
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Gail Hansen, MD
Regina Hansen, RDMS
James Harding, MD
John Harding, MD
Renee Harding, RDMS
Seemanthini Hariharan, MD
Gamal Haroun, MD, FRCP(C)
Lorie Harper, MD, MSCI
Jeffrey Harris, MD
Herlof Harstad Sr
Musarrat Hasan, MBBS
Rebecca Haskett, RDMS, RVT
Moustafa Hassan, MD
Kathryn Hassinger, MD
Jiro Hata, MD
Toshiyuki Hata, MD
Nawar Hatoum, MD
Karen Havling, RDMS
Clint Hayes, MD, RVT, RPVI
Andrew Healey, MD, RDCS, RDMS,
FRCPC
Amie Healy
Michael Heard, MD
Stephanie Hedstrom, MD
Frederick Hegge, MD
Karen Hehnen, RDMS
Timothy Heiser, RDMS
Andrew Helfgott, MD
Robert Helgans, MD
Douglas Helm, MD
Daryoush Hendessi IV
Harold Henry, MD
Cynthia Herbert, RDMS, RDCS,
RVT
Tomas Hernandez-Mejia, MD
Oscar Herrera, MD
Linda Herrmann, RN, CNP
Barbara Hertzberg, MD
L. Wayne Hess, MD
Peter Heyl, MD
Adam Hiett, MD, RDMS
Kenneth Higby, MD
Joseph Higgins Jr, MD, PhD
Lyndon Hill, MD
Meghan Hill, MBBS
Kim Hillstrom
Roger Hine, MD
Neely Hines, MD
Makiko Hirai, MD
Calvin Hobel, MD
Arthur Hodge, MD
Eric Hodgson, MD
Nicholas Hoff Jr, MD
Douglas Hoffman, MD
Francis Ho-Kang-You, MD
Michael Hold, MD
Lori Holden, RDMS, RVT, BSRT
Christy Holland, PhD
Mark Holland, PhD
James Holman, MD
Jay Holmes, MD
Byron Holt, MD
Todd Holt, MD
Maryruth Hooper, RRT, RDMS
Shari Hopp, RT, RDMS, RDCS
Janet Horenstein, MD
John Kamp, MD
Mark Kandutsch, MD
Leonard Kaplan, DO
Teresa Karcnik-Mahoney, MD
Ardeshir Karimi, MD
Roberta Karlman, MD
Barry Karpel, DO
Namasivayam Karunanithy, MB,
ChB, DRCOG, DMRD, FRCR
Mitsunori Kasamo, MD
Richard Kates, MD
David Kauffman, MD
Yoshio Kawamata
Diane Kawamura, PhD, RT(R),
RDMS
Akihiro Kawauchi, MD, PhD,
RDCS, RDMS, ROUB, RVT
Angela Kay, RN, RDMS
Alena Kazlouskaya, RDMS
Aliaksandr Kazlouski, MS
George Kazzi, MD, MBA
Jeannette Keefe, RDMS, RVT,
RT(R)(M)
Alexandra Keegan, RDMS
Christine Keer, RDMS, RT
Ralph Kehl, MD
Ian Kellman, MD
Kevin Kelly, MD, RVT
Randall Kelly, MD
Anne Kennedy, MBBCh, MRCP,
FRCR
Bernadette Kennedy, BS, RDMS,
RVT
Karen Kennedy, MD
Brian Keroack, MD
Lacy Kessler, MD
Lawrence Kessler, PhD
William Ketcham, MD
Maria Salud Kho, MD
Aldo Khoury, MD
Thomas Khoury, MD, RVT
Butrus Khuri-Yakub, PhD
Ania Kielar, MD, FRCPC
Denise Kieso, RDMS, RVT
Robert Kiltz, MD
Min Kim, MD
Sunny Kim, MD
Young Kim, MD
Andrew Kingzett Taylor
Heidi Kinkade, RDMS, RVT
Karen Kirker, RDMS
Carolyn Kirkland, AS, RT
Mary Kirves
Michael Kirwin, MD
Eugene Kissin, MD
Debra Kitts, RDMS
Harvey Klein, PhD
Nicki Klein, RDMS, RDCS, RVT,
RT
Amy Knoeller, MD
Debra Koenig, RDMS
Alexander Kofinas, MD
William Kohlhoff, BA
Michael Kolios, PhD
Shelley Kolton, MD
Mary Komora, RDMS
Eftichia Kontopoulos, MD, PhD
Naoki Hotta
Michael House, MD
Bobby Howard, MD
Thomas Howard Jr, MD
Candace Howard-Claudio, MD,
PhD
Rodney Hoxsey, MD
Sharlene Hsiao, RDMS
Charles Hsieh, MD
Tsang Tang Hsieh, MD
William Huang, MD
Judy Hudson, RDMS, RVT
John Hughes, MD
Shui Yee Hui, RDMS, RVT
Roderick Hume Jr, MD
Stephen Hunt, MD, PhD
Timothy Hurley, MD
Kristina Huster, RDMS
Thomas Hutchens, MD
Manly Hutchinson Jr, MD
J. Hwang, PhD
James Hwang, MD
Kullervo Hynynen, PhD
Eric Hyson, MD
Debra Ilahi, RDMS
Kenneth Iles, DC
Sania Imtiaz, MBBS, MUSP
Lorraine Iseman, RTR, RDMS
Yoshihiko Iwasa, MD, PhD
Christann Jackson, MD
Jon Jacobson, MD
Robert Jacobson, MD
Daryoush Jadali, MD
Kurt Jaenicke, MD
Wieslaw Jakubowski, MD
Roger Jammal, MD
Warren Janowitz, MD
Philippe Jeanty, MD, PhD
Mussarat Jehan, MBBS
Gary Jensen, MD
Lisa Jervis, MD
Jeng Jiang, MD
Leticia Jimenez, BA, RDMS
Gary Joffe, MD
Lois Johanson-Maxwell, MD
Lori Johansson, RDMS
Christina Johnson, BS, AS, RDMS
Tyronne Johnson, RDCS
Doug Jones, BA, RVT, RDMS,
RDCS, RCT
Frederick Jones, MD
Oliver Jones, MD
Richard Jones, MD
Teresa Jones
William Jones, MD
William M. Jones, MD
Anthony Joseph, MD
Mary Teresa Joseph, MD
Nancy Judge, MD
Svena Julien, MD
Wagdy Kades, MD
Ronny Kafiluddi, MD, PhD, FIPP,
DABIPP
Jeanne Kafoury, RVT, RDMS
Costas Kaiafas, MD
Krishna Kakani, MD
xi
Elizabeth Kopin, MD
Asteris Korantzis, MD, PhD
Jeffrey Korotkin, MD, MBA
Karen Koscica, DO
Helen Kosik-Westly, RDMS
Dana Kottke, RDMS
Bruce Kovacs, MD
Kajoli Krishnan
Mark Kristy, MD
David Kroska, MD
Robert Krugman, MD
Reinhard Kubale, MD
Kathleen Kuhlman, MD
Koteswara Kunda, MD
Gwen Kunken Sterns, MD
Sui Ping Kwong, RDMS
Marilyn LaBatte, RDMS
Lane Laboda, RDMS
Rene Lafreniere, MD, CM, FRCSC
Rachel Lafser, BS, RDMS
Sherelle Laifer-Narin, MD
Faye Laing, MD
Donna Lambers, MD
Edward Lampton Jr, MD
Barton Lane, MD
Roberta Lange-Lifchez, RT, RDMS
Orli Langer Most, MD
Michael Lao, MD
Janet Larson, MD
Larry Larson, MD
Timothy Larson, MD
Elena Last
Wendy Latshaw, MD
Richard Latta, MD
Jennie Lau
Marilyn Laughead, MD
Laura Lawrence, MD
Sanford Lederman, MD
Milton Lee, MD
Yung Jae Lee, DO
Thomas Leigh, MD
Sher Leiman, MD
Marlyn Leisy, MD
Carol Lennon, MD
Jack Lenox, MD
Megan Leo, MD
Tammy Leonard, MD
Michael Leonardi, MD
Armand Leone Jr, MD, Esq
Jodi Lerner, MD
Robert Lerner, MD, PhD
Anna Leung, MD
Wai Hang Leung
David Levene, MD
Roberto Levi-D’Ancona, MD
Aaron Levine, MD
Deborah Levine, MD
Jonathan Levine, MD
Michael Levine, MD
Peter Lewin, MSc, PhD
Dawnette Lewis, MD, MPH
George Lewis, PhD
Resa Lewiss, MD, RDMS
Amy Lex, MS, RT(R), RDMS
Melissa Liebling, MD
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Kee-Hak Lim, MD
G. Sharat Lin, PhD
Tonya Lindgren, RDMS
Norman Lindley, MD
Yael Lipschitz
Michel Lirette, MD
Kelly Liriano
Karen Lissington, DMU
Andrew Liteplo, MD, RDMS
Christian Litton, MD
Ji-Bin Liu, MD
John Loewy, MD
Salvatore Lombardi, MD
Sherri Anne Longo, MD
Luisa Lopez, RDMS
José López-Zeno, MD
Maureen Lorbert, RT(R), RDMS,
CDT
Seth Lotterman, MD
Coreen Lowney, RDMS
Jennifer Luckern
Cristina Lundborg, RDMS, RVT
Carmelina Luongo, MD
David Luthy, MD
Deborah Luthy, RT, RDMS
Juarez Luz
Susan Lynch, RDMS, RVT, RDCS
Sadisu Maaji
Deborah Mabin
Lisa Maccarino, BS
Marion MacInnis
Laurence Mack, MD
Karen Mackey, RVT, RDMS, RDC
Charles Macri, MD
Madhumala Madhavan, MD, ASPLS, MBBS
Kazuo Maeda, MD, PhD
Paul Maertens, MD
David Magarik, MD
Edward Magaziner, MD
Rebecca Mahony, BAS
Denise Main, MD
Inder Makin, MD, PhD
Patricia Ann Malek, RN, FRCN
Srini Malini, MD
Melinda Mann, MD
S. Manohar IV, MD, DMRD
Luis Mansilla, RDMS
Darlene Mansueto, RDMS
Giorgio Marchini, MD
Joshua Markowitz, MD, RDMS
Clifford Marshall, MD
Chester Martin Jr, MD
Clifford Martin, MD
Felix Martin
Jerry Martin, MD
Joseph Martin, MD
Kimberly Martin, MD
Cecilia Martinez, MD
Francis Martinez, DO
Xavier Augusto Martinez Bejarano
Carl Martino, MD
Raymond Marty, MD
Subha Maruvada, PhD
Damon Masaki, MD
Luleta Maslak, RDMS
Subhash Mitra, MD, MPH
Jennifer Mixdorf, RDMS
Debra Mohr, RT, RDMS, BS
Richard Molina, MD
Steven Mollov, MD
Kay Molt
Anna Mongillo, RN, RDMS
Ana Monteagudo, MD, RDMS
Sandye Montes, RDMS
Jules Moodley, MD
Shanmugam Moopanar, MD,
DMRD, DNB
Casey Moore, RCS, RVT, RDMS
Kathleen Moore, RDMS
Nancy Moore, RDMS
Azeema Moosa, MD
Doreen Morales, RT, RDMS
Michael Moretti, MD
Richard Moretuzzo, MD
Gail Morgan, MD
Pablo Morikawa, MD, PhD
Fuminori Moriyasu, MD
Jeanine Morris-Rush, MD
Gerhard Mostbeck, MD
Elias Moukarzel, MD
Mark Muilenburg, MD
Ndaya Muleba, MD
Jill Mulholland, AS
Jean-Paul Muller, MD
Joann Murano, BS, RDCS, RDMS
Colleen Murphy, MD
Deborah Murphy, RDMS
James Murphy, MD
Johanne Murphy, RDMS
Joseph Muscat, MD
Luc Nabet
Michael Nabity, MD
Samuel Nagle, MS
Renuka Naidu, MBBS, RDMS
Dean Nakamoto, MD
Linda Nall, MD
Rakhshanda Nasim, MBBS
Doreen Nassimos, RDMS
Howard Nathanson, MD
Innocent Ndubuisi, BS, RT(R),
RDMS, RDCS, RVT
Gregory Neal, MD
Donna Neale, MD
Laurence Needleman, MD
Kris Neenan, RTR, RDMS, RVT
Joy Neimiller, RT, RDMS
Lewis Nelson III, MD
Thomas Nelson, PhD
Amen Ness, MD
Michael Nethers, MD, FICS
Marsha Neumyer, BS, RVT
Arnold Newman, MD
Chris Nguyen, PhD
Tuyen Nguyen, RDMS
David Nichols, MD
Terry Nicola, MD, MS
Makoto Niizawa, MD
Kurt Nilsson, MD, MS
Takenori Nishi, MD
Midori Nishio, MD
John Nitsche, MD
T. Douglas Mast, PhD
Joan Mastrobattista, MD
Dimitrios Mastrogiannis, MD, PhD
Cherie Mathews, RDMS
Sergey Matiashchuk
Shoichi Matsutani, MD
D. Matthews, MD
Jason Matuszak, MD
Dev Maulik, MD, PhD
Alexander Maximovich, MD
Lisa May, MD
Kathleen Mayor-Lynn, MD
W. Desmond McCallum, MD
Kathleen McCarten, MD
Michael McCoy, MD
Stacy McCrosson, MD
Deirdre McCullough, MD
Darrick McDanald, MD
Elinor McDermott, RDMS
Kelly McGuire, MD
Cindy McKay, RDMS
Elizabeth McKinney, MD
Monique McKnight, MD
Kristen McLaughlin, RDMS
David McLean, MD
Michael McNamara, DO
Thomas McNanley, MD
Jakob McSparron, MD
Joseph McWherter, MD
Mary Meadows, RT(R), RDMS
Jose Medina, MD
Garo Megerian, MD
Sofia Mehmoood
Israel Meizner, MD
Vlatka Mejaski-Bosnjak, MD, PhD
Hugh Melnick, MD
Paula Melone, DO
K. Menon, MD, FRCOG
Alexander Mentakis, MD
John Mercer, MD
Michelle Mercier, RTR
Margret Mergelsberg, MD
Daniel Merton, BS, RDMS
Paul Meyer, MD
Patrick Meyers, BS, RDMS, RDCS,
RVT
Lindsey Micek, RDMS
Matthew Michaels, MD
Joseph Milburn Jr, MD
Ruben Millan
Hugh Miller, MD
James Miller, MS, PhD
Nora Miller, MD
Suzanne Miller, MD
Thomas Miller, BSME
Wayne Miller, MD
Jeanna Miller-Borsini, RT(R),
RDMS
Claire Mills, RDMS, RVT
Gerald Minkowitz, MD
Maria Mintcheva, RDMS
Paoletta Mirk, MD
Carol Mitchell, PhD, RDMS, RDCS,
RVT, RT(R)
John Mitchell, MBBS, FRACR
Maryann Mitchell, RDMS
xii
Jason Nomura, MD, RDMS
Ron Norman, FRACR
Schura Normand, RDMS, RTR
Deborah Nucatola, MD
Francis Nuthalapaty, MD
Dawn Nutt, RT, RDMS
Mitchell Nutt, MD, RDMS
Chima Nwizu, MD
Nkemdilim Nwosa
Jake Ochoa
Avice O’Connell, MD, MA
Lawrence O’Connell, MD
Mary O’Connor, REEGT/EPT,
RNCST, RVT, BCIA
Sean O’Connor, MBBS
Mary O’Day, MD
Svein Odegaard, MD, PhD
Anthony Odibo, MD, MSCE
Charles Odwin, BA, RDMS, PA-C
Cherrie Ogin, RDMS, RVT
Andrea Olanescu, MD
August Olivar, MD
Mark Oliver, RVT, MD
Janine Oliveri, PhD, MSEd, BSRT,
RDMS, RVT
Chiou Li Ong, MBBS, FRCR
Mehmet Onur
Granger Osborne, MD
Newton Osborne, PhD, MD, MS
Kathleen O’Shea
Bryan Oshiro, MD
Steven Ostrow, MD
Laurel Ott, RN, RDMS
William Ott, MD
Elizabeth Ottman, MD
Robert Ozaki, MD
Suha Ozbek
Josephine Ozoemena, MBBS
Kelly Pagidas, MDCM
Lauren Painter, MD
Sue Palmer, MD, PA
Tracy Papa, DO
Emmanuelle Pare, MD
Luis Paredes Sr
Yvon Parent, MD
Barbara Parilla, MD
Hoon Park, MD
Billy Parkhill Jr, MD, PhD
Julie Parrow, RDMS, RDCS, RTR
Cornelia Partain, RNC, RDMS
Richard Paschke, BS, MS
Suean Pascoe
Angela Pascual, PhD, MD
Resad Pasic, MD
Lee Paskar, MD
Raj Mohan Paspulati, MD
Bharatbhushan Patel, RDMS, RDCS
Pravin Patel, MD
Molly Paulson, RDMS
Thea Paulson, RDMS
Charles Paxson, MD
Carlton Pearse, MD
Harold Pedersen, BA, RDMS
Peder Pedersen, PhD
Ahmad Peeroo, MD, FRCP
Linda Pendziwol, RDMS
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Rebecca Pennell, MD
James Pennington, RDMS
Leif Penrose, MHSc, RDMS, RVT,
RDCS, RT(R,CT)
Sima Perelshteyn, RDMS
Phillips Perera, MD
Kalati Perese
Richard Perkins, MD
Anahi Perlas, MD, FRCPC
Kenneth Perry Jr, MD
Judith Peterson, MD
Robert Petite, BS, RDMS, RDCS
Albina Petrosian
William Pfeffer, MD
Pamela Phayre, RVT
Marcia Phelps, RDMS
Edward Phillips, MD
J. Phillips, CCT
Catherine Piccoli, MD
Dana Piedmont, RDMS
Cynthia Pierce
Guy Pierno, RT
Anne Pike, RDMS, RVT
Paulette Pikey, RDMS
James Pilcher, MBBS, MSc, MRCP,
FRCR
Emily Pineda, MD
Jorge Pineda, MD
Steven Pinheiro, MD
Jon Pitman, MD
Barbara Pittenger, RDMS
Julie Platt, MD, MSPH
Christopher Plummer, DO
Ann Podrasky, MD
Robin Poe-Zeigler, MD
Gustavo Poggio, MD
Monica Polacek, RDMS
Betty Polanski, ALA, AAS, RDMS
Donna Politi, RDMS
Scott Pollock, MD
Adrian Pop, MD
Bruce Porter, MD
John Postley, MD
John Powell, MD
Kelli Powell, RDMS
Paul Prachun, MD, FRCP(C)
Uma Prasad, MBBS, MD
Ted Preston, PhD, MD
Brent Price, MD
Richard Price, MD
David Principe, MD
Sandra Pupa, MD
Elizabeth Puscheck, MD, MS
Sharyn Pussell, MBBS, FRACP,
DDU
Scott Puza, MD
Pamela Queen, RDMS
Kathy Quenneville, RDMS, RT(R)
Fred Quenzer Jr, MD
Valerie Quick, RDCS, RDMS
Luis Ortiz Quintana, MD, PhD
Yolanda Rabello
Janet Radford, DMU
Irina Radionova
Monique Rose Rahmani, MBChB,
DABR, FRCP
James Ruiz, MD
Gillian Rush, MBBS, FRANZCR
Gilles Russ
Shahnoz Rustamova, MD
John Ryan, MD
Constantine Saadeh, MD
Alan Sacks, MD
Jason Sagerman, MD
Bal Sahay, MD, FRCP
Christine Sahn, RDCS, RDMS, RVT
David Sahn, MD
Fumikazu Sakai, MD
Sharon Salamat, MD, PhD
Mustafa Salih
Azen Salim, MD
Caryl Salomon, MD
Daniel Saltzman, MD
Hera Sambaziotis, MD, MPH
Timothy Sammon, RDMS, RVT
Nadia Samo
Karen Sanchez, BA, RDCS, AE, PE
Norberto Sanchez, MD
Carlos Sanchez Huerta
Wanda Sanders, RDMS
Anne Sandoval, BS, RDMS, RVT
Aimee Sanfilippo
Peter Sanfilippo, MD
Thomas Sanford, MD
Joaquin Santolaya, MD, PhD
Lorena Santos
Rigoberto Santos-Ramos, MD
Albert Sarno Jr, MD, MPH
Sergio Sartori, MD
Andrew Satin, MD
Michihiro Sato
Satoshi Sato, MD
Takahiro Sato
Jeanette Satriano, RDMS
Fouad Sattar, MD
Lizabeth Sawyer, RDMS, RDCS
Lois Scheffler, RDMS, RDCS, RVT
Mark Schlimgen, MD
Judith Schlissel
James Schmidgall, MD
Anita Schmidt, MD
Mary Schmidt
Ingrid Schneider, MD
James Schneider
Michael Schneider, MD
Neil Schneider, MD
Ronald Schneider, RDMS
Thomas Schramm, MD
Louis Schruff, MD
Patrick Schuette, MD
Harold Schulman, MD
Heinz Schwab, BSc
David Schwartz, MD, FRCOG
Joyce Schwartz, RDMS, RVT, AS
Mark Schwartz, RDMS, RPVI
Ronda Schwartz, RDMS
William Scruggs, MD
Harish Sehdev, MD
Chandra Sehgal, PhD
Shyamashree Sengupta, MD
Nelia Sering, RDMS
Sharon Rais, MD
Shankar Ramamurthy, MD, DMRD
Carlos Ramirez Toledo
Alberto Ramos Cruz, MD
Jagpal Rana, MD
Sheshagiri Rao, MD FRCP(C),
DABR
Cindy Rapp, RDMS
Olga Rasmussen, RDMS
John Reach Jr, MSc, MD
Charles Read, MD
Andrei Rebarber, MD
Linda Rebolo, AS, RDMS, RVT,
RCT
Susan Rech, MD
Raghurami Reddy
Leslee Redfield, BA
Victor Regenbogen, MD
Jonathan Rehberg, MD
Gregory Reid, MD
Wendy Reiling, BS, RDMS
Dale Reisner, MD
Iseko Remilekun, MSc, RDMS
Dana Resop, MD
Janette Reynolds, RDMS
Faranak Rezaie, MD
Jennifer Rhodes
Amy Richardson, MD
Daniel Rightmire, MD, MS, RDMS,
MBA
Christopher Rigsby, MD
Thomas Ripperda, MD
Jennifer Risinger, MD
Kristina Ritter, RRT
Manuel Rivera-Alsina, MD, MBA
Anne Rizzo, MD
Michelle Robbin, MD, MS
Donald Roberts, MD
Dwain Roberts, MD
Robert Robertson, MD, MBBS
Kathryn Robinson, MD
Hope Robinson-Beverly, RT(R),
RDMS
Kathleen Robischon, MD
Thomas Rodenberg
John Rodney, MD
M. Hellen Rodriguez, MD
Veronica Rodriguez, RT(R), RDMS
Dennie Rogers, MD
Ashley Roman, MD, MPH
Nina Romanova, MD
Audrey Romero, MD
Ricardo Rosa
Angel Rosas, MD
Howard Rose, DO
Gary Rosenberg, MD
Emily Rosenbush, MD
Marc Rosenn, MD
Gary Rosensteel
Brenda Ross-Shelton, MD
Siegfried Rotmensch, MD
Susan Rowling, MD
Anna Rozenberg, RDMS
Thomas Rubeo Jr, MD
Tanya Rucker, RTR, RDMS
Perry Rudich, MD
xiii
Edouard Servy, MD
Donna Session, MD
Roy Settergren, MSc, DC
Bharat Shah, MD
Leena Shah, MD
Yogesh Shah, MD
Shane Shapiro, MD
Pradeep Sharma, MD
Ralph Sharman, MD
Candice Shea, MD
Jessica Sheets, MD
Claudette Shephard, MD
Celeste Sheppard, MD
Takashi Shimizu, MD, PhD
Gregg Shimomura, MD
Norio Shinozuka, MD, PhD
Takako Shirakawa, MD, PhD
Arnold Shkolnik, MD
Janie Shunk, RDMS
Jaye Shyken, MD
Jeou-Jong Shyu
Tariq Siddiqi, MD
Salma Siddiqui, BS, RDMS
Denise Sidisky, RDMS, RRT
Neil Sikes Jr, RDMS, RDCS, RVT,
RT(R)
Natia Silagadze, RDMS
Jessica Silliman, RDMS
Rogerio Silva, MD
Elizabeth Silverman, MD
Neil Silverman, MD
Ronald Silverman, PhD
Julian Simmons, MD
Mark Simonelli, MD
Stephen Simons, MD
Douglas Simpson, PhD
Jerry Sims, MD
Jorge Sinclair, MD
Kathleen Singer, RDMS
Shailini Singh, MD, FRCS(C)
Elena Sinkovskaya, PhD, MD
Casey Sinz, RDMS
Daniel Sipple, DO
Adam Sivitz, MD
Daniel Skupski, MD
Dan Skyba, PhD
Povilas Sladkevicius, MD, PhD
Michelle Slater, RDMS
Jan Sloves, RVT, RCS
Diana Smigaj, MD
Jay Smith, MD
Stephen Smith, MD
Lynn Snyder, RDMS, RT
Steven Soberman, MD
Robert Sofferman, MD
Julia Solomon, MD
Kwang-Ho Son, MD
Elie Soussan, MD
Timothy Spaulding, MD
Jean Spitz, MPH, RDMS
Jacqueline Sposito, MD
Melinda Staiger, MD, BS
Camelia Stanciu, MD, RDMS
Ioan Stanciu, MD, RDMS
Jami Star, MD
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David Stark, MD
A. Thomas Stavros, MD
Charles Stedman, MD
Ralph Steiger, MD
Janet Stein, MD
Marjorie Stein, MD
Michel-Patrick Steinmetz
Craig Sternberg, MD
John Stevens Jr, MD
Virginia Stewart, MD
Laurie Stolklane, RDMS, RDCS
Kristine Stolt, RDMS
Richard Strassberg, MD
Mel Stratmeyer, PhD
Heather Straub, MD
Richard Striano
Thomas Stubbs, MD
Robert Stuntz, MD
Hoda Sturman, AA, RT, RDMS
Ian Suchet, MBBCh, FRCPC
Cheryl Suiter, MD, PA
Ronald Sultan, MD
Yasukiyo Sumino, PhD
Donna Summers, RDMS
James Sutherland, MD
M. Linda Sutherland, MD
Robert Sutherland, MD
Stephen Swanson, MD
Manuel Sy, MD
Humera Syeda, MD
Thomas Szabo, PhD
Celso Szmidt, MD
Thomas Tabb, MD
Evan Taber, MD
Claudia Taboada, DO
Filemon Tan, MD, PhD
John Tassone, DPM
Lucille Taverna, MD
Barbara Taylor, MD
Helen Taylor, MIR, DMU
Jeff Taylor, BS, RVT
Nathan Teismann, MD
Shpetim Telegrafi, MD
Deydre Teyhen, PT, PhD, OCS
M. Jay Thomas, RDMS, RRT, RCT
Dan Thomason, MD
Kai Thomenius, PhD
Michael Thompson, MPH, RDMS,
RVT, RDCS, RCS, RVS
Noel Thompson, BA, MS, MD
Robert Thompson, MD
Thomas Thompson, MD
Stephen Thorn, MD
Pietro Ticci, MD
Cheryl Timblin, RDMS
Mark Timken, MD
Ilan Timor, MD
Arkom Tivorsak, MD
Ants Toi, MD, FRCP
Lama Tolaymat, MD, MPH
Tahisha Tolbert, MD
Francis Tomasik, MD
Charles Tomberlin, MD
Jennifer Tomczak, MD
Matthew Tompkins, MD
Jan Weichert, MD
James Weinstein, MD
Judith Weiss, RDMS, BA
Patricia Weiss, AAS, RDMS
Heather Welch, RDMS
Holly Wells, MD, FRCP(C), ABR
Karen Wells, MD
William Wells, MD
Tony Wen, MD
Katharine Wenstrom, MD
Connie Wesley, RDMS
Cathy Wesner, RDMS, RVT
Emily West
Ellen Wetter, MD
Paul Wexler, MD
Thomas Wheeler, MD
Anita Whistler, RDMS, ROUB
Katharine White, MD
Sanford White, MD
Amy Whitley, MD
Gerrie Whitley, RDMS, RN
Craig Whitmore, MD
Rita Whitton, RDMS
Janice Whitty, MD, RN
Willyarto Wibisono, MD
David Wicke, RDMS
Marcin Wiechec
Thomas Wigton, MD
Martin Wilcox, BSEE
Thomas Wilkins, MD
Alisa Williams, MD
John Williams III, MD
Kristi Williams, BS, RT, RDMS, NT
(R)
Margaret Williams, RT, RDMS
Suzanne Williams, RDMS
Terri Williams-Weekes, MD
Cielito Wills, BA, RVT, RDMS
Donna Wilson
Robert Wilson, MD, MSc
Stephanie Wilson, MD
Denise Winder, AS, RDMS
Melissa Winstead, RDMS
Michael Wise, DVM
Kerri Wissmueller, RDMS, RVT,
RDCS, CCT
Dexter Witt, DPT, OCS
Constance Witte, RTR, RDMS
Diane Woelkers, BS, RT(R), RDMS
Mark Wolf, MD
Lynlee Wolfe, MD
Michael Wolfe, MD
Robert Wolfson, MD, PhD
Wayne Wolfson, MD
Cynthia Wong, RDMS, AB, BR, OB,
NE, RVT
Edward Wong, MD, FRCP
Keet-Peng Wong, FRCS
Roberta Wong, BS, RDMS, RDCS
Steven Wong, MD
Jade Wong-You-Cheong, MD, RVT,
FRCR
Aaron Wray, RDMS
Andrew Wright, MD
Jeffrey Wright, MD
Tatyana Wright, RDMS
Felicia Toreno, PhD, RDMS, RDCS,
ROUB, RVT
Eugene Toy, MD
Fatma Trabulsi, ABR
Donald Tradup, RDMS, RT
Lan Tran, MD
Michele Traves, RT(R), CBDT
Dara Treadwell, BS, RT(R)(M),
RDMS
Jillian Trull
Francis Tseng, MD
Jed Turk, MD
Elizabeth Turner, MS, MD
Sandra Turner, RDMS
John Turocy, MD, MS
Carol Uher, RDMS, RT(R)
R. Peter Ulland, MD
Tonda Ulmer, RDMS, RDCS
Richard Ulrich, BS, RDMS
Edet Umana, MD, MBA
Heidi Umphrey, MD, MS
Evan Unger, MD
William Unwin, MD
Yoginder Vaid, MD
Carmen Valderrabano, MD
Antoine Van Straalen, MD
Sue Van Zanten
Elizabeth Vanderburgh, MD
Jean-Louis Vanoverschelde, MD,
PhD
Tomy Varghese, PhD
Ehrlich Varsovia, RDMS
Sanjay Vasudeva, MD
Jean-Claude Veille, MD
Christina Veit, MD
Danilda Veloz, RDMS
Gwen Venegas, RDMS
Priya Venkateswaran, RDMS
Yvan Vial, MD
Alex Vidaeff, MD, MPH
S. Boopathy Vijayaraghavan, MD,
DMRD
Richard Viscarello Jr, MD
Olaf Von Ramm, PhD
Joni Voss, RT(R), RDMS, RVT
Rolf Vrla, MD
Gael Wager, MD, MPH, MBA
Brent Wagner, MD
Jason Wagner, MD
Chu Wai Pong
Lisa Wainright, RT(R), RDMS, RVT
Camil Walker, MD
Janine Wallin, BS, RDMS
Cynthia Walsh, MD
Rodolfo Walss, MD
Barbara Walton, RDMS
Eileen Wang, MD
Shirley Wang, MD
Alice Ward, BS, RDMS
Damon Warhus, MD
Steven Warsof, MD
Antoinina Watkins, MD
Peter Watson, MD
Kevin Weary, MD
Sandra Weber, RDMS
Hassan Wehbeh, MD
xiv
Michael Yamazaki, MD
Diana Yankowitz, BS, RDMS, RDCS
Linxin Yao, PhD
Amaryllis Yazon, MD
Christopher Yenter, MD
Duzgun Yildirim, MD
William Yip, MBBS, MMED, MD,
MRCP, DCH, FRCP
Bruce Young, MD
Donald Young, DO
Warren Young, MD
Mark Yuhasz, MD
Michael Zaladonis Jr, BS, RVT
Ivica Zalud, MD, PhD
Jill Zavitsky, RT, RDMS
Carolyn Zelop, MD
J. Zetterberg, MD, MBBS
Senait Zewde
Xiaoming Zhang, PhD
Ying Zhao, MD
Marvin Ziskin, MD, PhD
Lisa Zorn Smeglin, MD
Patricia Zylman, MD
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2013 Scientific Program
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*Presenter of scientific paper with more than 1 author.
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SPECIAL INTEREST SESSIONS
SUNDAY, APRIL 7, 2013, 7:30 AM–11:30 AM
Recent Innovations in Gynecologic Ultrasound,
Including 3-Dimensional Imaging
Ultrasound-Guided Procedures for the Pediatric
Patient: From the Perspective of Both Point-of-Care
and Traditional Approaches
Moderator: Beryl Benacerraf, MD
Moderators: Alyssa Abo, MD, Beth Kline-Fath, MD
In this session, advances in 3-dimensional sonography will be
discussed, including practical applications for use in many aspects of gynecology practice and many conditions.
The objective of this session is to describe the use of ultrasound
to guide interventions and manage therapy in the pediatric patient by both
point-of-care and traditional approaches.
SPECIAL INTEREST SESSION
SUNDAY, APRIL 7, 2013, 8:00 AM–9:30 AM
Hands-on Basic Obstetric Ultrasound and Simulation
Moderator: Jude Crino, MD
Participants will scan second-trimester pregnant models with
supervision by sonographer and physician experts. Skills taught in this
basic-level session include image optimization, fetal biometry, and the
basic fetal anatomic survey. Simulation stations for endovaginal scanning,
amniocentesis, and fetal blood sampling will be available.
SPECIAL INTEREST SESSION
SUNDAY, APRIL 7, 2013, 9:45 AM–11:15 AM
Hands-on Advanced Obstetric Ultrasound and
Simulation
Moderator: Jude Crino, MD
This session is appropriate for those with experience in basiclevel obstetric ultrasound or who have attended the basic-level hands-on
session. Participants will scan second-trimester pregnant models with
supervision by sonographer and physician experts. Skills taught in this
advanced-level session include detailed fetal anatomy, Doppler velocimetry, and basic 3- and 4-dimensional techniques. Simulation stations for endovaginal scanning, amniocentesis, and fetal blood sampling
will be available.
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SPECIAL INTEREST SESSIONS
SUNDAY, APRIL 7, 2013, 3:15 PM–5:00 PM
Advanced Point-of-Care Cardiac Ultrasound in the
Emergency and Critical Care Patient
Hands-on Renal and Mesenteric Imaging
Moderator: Jennifer McDowell, MM, RDMS, RT, RVT
Moderator: Robert Arntfield, MD, RDMS
Ultrasound Criteria for Renal Disease
Margarita Revzin Diagnostic Radiology, Yale University
Hospital, Wilton, Connecticut USA
Efficient and Effective Point-of-Care Transesophageal Echocardiography: A Proposed Algorithm for Critical Care
Scott Millington University of Ottawa, Ottawa, Ontario,
Canada
During this session, we will focus on the spectrum of renal diseases detected and diagnosed with Doppler ultrasound, with special emphasis on renal artery stenosis. The anatomy and principles of examination
of the native renal vessels will be considered first, followed by a discussion on renal vascular disorders, including renal artery stenosis. In detail,
we will review multiple Doppler-based criteria that are used in diagnosis
of renal artery stenosis, including peak systolic velocity, renal to aortic
ratio, waveform analysis, as well as secondary signs of renal artery stenosis. We will review current literature that validates the proposed criteria for
renal artery stenosis and analyze potential pitfalls that may lead to misinterpretation of the findings affecting the number of false-positive or -negative diagnoses.
Introduction—The use of transesophageal echocardiography
(TEE) in the intensive care unit (ICU) is becoming more prevalent as
point-of-care ultrasound applications expand in general and as specific
providers seek more advanced training.
Problem Identification—Point-of-care TEE differs significantly
from comprehensive TEE in that it is goal directed and time sensitive and
seeks to integrate ultrasound images with real-time physiology. As such,
the traditional sequence of image acquisition applied to comprehensive
TEE exams may not be ideal.
Summary—A goal-directed algorithm for point-of-care TEE is
proposed, comprising 4 core views applied to all patients and 4 additional
views that are useful in specific clinical circumstances. The goals are: (1)
to efficiently identify pathologies that are common in the ICU; and (2) to
identify those pathologies that are less common but that mandate a major
change in clinical management strategy.
How Does Ultrasound Compare in Safety and
Radiation Dose to Other Imaging Modalities?
Moderators: George Lewis Jr, PhD, Thaddeus Wilson, PhD
Clinical Applications of Ultrasound Contrast, Part 1
Food and Drug Administration Perspective on Diagnostic Ultrasound
Safety
Keith Wear, Gerald Harris Center for Devices and Radiological Health, US Food and Drug Administration, Silver
Spring, Maryland USA
Moderator: Richard Barr, MD, PhD
Contrast Imaging of Abdominal Transplants
Paul Sidhu Radiology, King’s College London, London,
England
Diagnostic ultrasound does not produce ionizing radiation, and
it has an excellent safety record over several decades of use. Potential bioeffects from diagnostic ultrasound are categorized into thermal and nonthermal mechanisms. Thermal mechanisms involve heating of tissue. The
concept of the thermal dose, which involves both a temperature rise and
the duration of exposure, is a useful tool in the study of thermal effects.
Nonthermal mechanisms involve mechanical effects, which include
streaming and cavitation. The likelihood of bioeffects is related to acoustic
output. The 1976 Medical Device Amendments require new devices to be
substantially equivalent in terms of safety and effectiveness to legally marketed devices. Consequently, recommended acoustic output levels are
based on levels produced by devices on the market prior to the enactment
of the 1976 Medical Device Amendments. The thermal index and mechanical index, which are indicators of the likelihood of bioeffects, are
often displayed in real time next to the ultrasound image. However, the extent to which these indexes are used to guide examinations is unknown.
Several studies indicate the occurrence of observable bioeffects at diagnostic output levels.
Ultrasound examination of liver and renal transplants has revolutionized patient management with the addition of color Doppler ultrasound, establishing this technique as paramount in interpreting and
investigating vascular abnormalities of any transplant organ. The early
postoperative period is crucial for the establishment of good vascular perfusion to the transplant organ, a cornerstone of further medical management. In liver transplantations, the hepatic artery is crucial to the transplant
and the long-term viability of the biliary system. Contrast-enhanced ultrasound (CEUS) will establish the patency of the hepatic artery, identify
areas of stenosis, and identify any potential hepatic pseudoaneurysm. The
integrity of the portal and hepatic veins may be ascertained. Focal areas of
liver necrosis, abscess formation, and biliary duct dilatation are all clearly
delineated on the CEUS examination. With renal transplantation, the
CEUS examination will readily delineate areas of infarction, will depict
vascular complications, and has the potential to assess regional and global
perfusion. Similarly with pancreatic transplants, the addition of CEUS
may be seen as an aid in the assessment of the vascular pedicle. Longterm follow-up is aided with the depiction of recurrence of disease, the
development of hepatocellular carcinoma, and post-transplant lymphoproliferative disorder. This presentation will detail the use of CEUS in
transplants and will adhere to the guidelines issued by the European Federation of Societies for Ultrasound in Medicine and Biology on liver and
nonliver applications of CEUS.
Radiation: The Two-Edged Sword
Eric Hall Columbia University, New York, New York USA
Modern medicine would be unimaginable without the use of
x-rays for diagnosis, especially computed tomographic (CT) scans, which
have revolutionized radiology. Radiation is often described as a two-edged
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dle tenotomy. This procedure, in which the diseased tendon is repeatedly
punctured by a needle under ultrasound guidance, can induce a healing
response and subsequent clinical improvement in a large proportion of patients. This presentation will review the technique for percutaneous needle tenotomy as well as show evidence from the literature regarding its
effectiveness.
sword because it offers great benefits to mankind but also has the potential to cause harm. Radiation was shown to be a mutagen in Drosophila by
Muller in the 1930s, and for the next 30 years, radiation protection was
based on the risk of genetic effects. That radiation could induce leukemia
and cancer came from the study of the Japanese A-bomb survivors. Cancer risks from CT scans, based on the A-bomb data, were published more
than a decade ago and were greeted with skepticism in many quarters but
accepted by pediatric radiologists, who immediately began to reduce radiation doses. Within the past year, the first epidemiologic studies have
appeared, in which 180,000 children who had received CT scans from
1980 to 2008 showed a small statistically significant excess of leukemia
and brain cancers. The epidemiologic studies confirm the estimates from
the A-bomb survivors and indicate that the risk to an individual is extremely small, so that if a CT examination is clinically justified, there is no
doubt that the benefit will exceed the risk. The remaining concern is from
a public health perspective, since some 70 million CT scans are performed
each year in the United States. To my knowledge, comparable epidemiologic studies have never been performed on magnetic resonance imaging
or ultrasound, and the expectation that these modalities are “safe” is based
on other considerations.
Point/Counterpoint: Ultrasound Versus Magnetic
Resonance Imaging in the Diagnosis of Placenta
Accreta, Congenital Diaphragmatic Hernia, and
Central Nervous System Anomalies
Moderator: Sherelle Laifer-Narin, MD
Placenta Accreta Magnetic Resonance Imaging
Sherelle Laifer-Narin Radiology, Columbia University Medical Center, New York, New York USA
Ultrasound has been the primary imaging modality for routine
evaluation of the pregnant patient. A routine diagnostic scan involves
detailed imaging of the fetus to detect fetal anomalies and evaluation of the
placenta to determine mode of delivery and detect possible placental
abnormalities. Over the past 20 years, the use of magnetic resonance imaging (MRI) has been steadily increasing and has been shown to be of
value in detecting structural fetal abnormalities as well as placental abnormalities. In this session, we will present the role of diagnostic ultrasound and the complementary role of MRI in imaging 3 major categories:
fetal neurologic abnormalities, congenital diaphragmatic hernia, and
abnormal placentation. Advantages and disadvantages for each modality
will be presented, with time for questions and answers from the panel at
the end of the presentations.
Interventional Musculoskeletal Ultrasound:
Steroid Injections, Dry Needling, and Platelet-Rich
Plasma Injections
Moderator: Levon Nazarian, MD
Steroid Injections
Nathalie Bureau Diagnostic Radiology, University of
Montreal Medical Center, Montreal, Quebec, Canada
This presentation will provide an overview of the tendon structure and the mechanisms of tendon failure. We will discuss the potential
adverse effects and the effectiveness of steroid injections in the treatment
of tendon pathology and present different ultrasound-guided techniques of
steroid injections. The tendon is a strong connective tissue band, which
transmits muscular force to the skeleton. Tendons have a hyperechoic fibrillar appearance on ultrasound. The structural and functional properties of
tendons enhance with appropriate exercise, deteriorate with disuse, and
alter with age. Tendon injury may result from direct trauma, impingement,
or friction and from overuse or overload, which may be acute or chronic
and repetitive. Predisposing factors such as aging, chronic metabolic diseases, inflammatory diseases, and the use of steroids may weaken the tendon, thus reducing the threshold of tendon failure. Clinical management
of tendinosis should initially include some form of conservative treatment,
including relative rest, pain control, support, stretching exercises, and correction of provoking factors. There appears to be some evidence for the
effectiveness of steroid injections in stenosing tenosynovitis such as
De Quervain and trigger finger. Most studies agree that steroid injections
are effective only in the short term in the treatment of insertional tendinosis. Although there are still no definite evidence-based guidelines for
the use of steroid injections, suggestions include avoiding intratendinous
injections, using caution with peritendinous injections, advising 2 weeks
of rest after injection, allowing 6 weeks between injections to assess the
effect, and limiting injections to 3 to any one site.
Ultrasound in Global Health
Moderator: Sachita Shah, MD, MPH
Introduction to Ultrasound in Global Health: Strategies for Starting
an Ultrasound Program in a Low-Resource Setting
Sachita Shah Emergency Medicine, University of Washington School of Medicine, Seattle, Washington USA; Partners In
Health, Boston, Massachusetts USA
With improvements in portability, durability, and affordability,
point-of care ultrasound has reached the bedsides of the most vulnerable
populations in the developing world. Due to the lack of specialists in radiology and sonography in much of the developing world, a need for ultrasound training programs focused on clinicians exists. An ever-expanding
body of literature has grown to support the use of bedside point-of-care
ultrasound performed by nonradiologist physicians, nurses, and clinical
officers in developing nations in clinical patient care. Creating a sustainable ultrasound program in a low-resource setting requires much more
than ultrasound equipment and good will but is an important way to make
a long-term impact on a low-resource community. In this session, we will
discuss strategies for implementing a successful ultrasound service program in a low-resource setting, including opportunities for potential equipment donation and organizations of interest, host hospital leadership and
infrastructure, features of ideal equipment, homemade coupling agents,
how to conduct a needs assessment and plan a training course, pitfalls and
barriers to ultrasound programs, and safety and machine maintenance in
low-resource settings.
Dry Needling of Tendons
Levon Nazarian Radiology, Thomas Jefferson University
Hospital, Philadelphia, Pennsylvania USA
Patients with chronic tendon conditions such as tennis elbow
may reach a stage in which they have to either live with their pain or undergo surgery. Real-time ultrasound guidance has allowed development of
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Point of Care Ultrasound in Resource-Limited Settings: Case Review
Krithika Muruganandan Emergency Medicine, Brown
University, Providence, Rhode Island USA
Over the years, the portability and versatility of ultrasound have
resulted in its extension from the hospital setting to disaster relief, military
medicine, and the austere and resource-limited setting. It has moved from
the hands of the specialist to the generalist physician. When developing a
curriculum to train generalist physicians in resource-limited settings, ultrasound education must be tailored to their wide scope of practice while
addressing local disease patterns and available resources. In addition to
the common uses of ultrasound used by emergency physicians locally,
point-of-care ultrasound in the resource-limited setting is valuable for a
broader range of pathologies. Cardiopulmonary ultrasound should include
assessment for rheumatic valvular disease, pericardial and pleural effusions related to tuberculosis and human immunodeficiency virus infection, cardiomyopathy, pulmonary edema, and parenchymal disease.
Abdominal ultrasound education should include evaluation of amebic
liver abscesses, echinococcal cystic disease, cirrhosis, hydronephrosis,
nephropathy, and evaluation of abdominal free fluid (focused assessment
with sonography for trauma exam). Soft tissue ultrasound should include
evaluation for abscesses, pyomyositis, and cellulitis. Obstetric ultrasound
performed by the generalist physician should include evaluation for intrauterine pregnancy, fetal heart rate, placenta positioning, presentation,
and fetal dating. Ultrasound guidance for procedures such as thoracentesis, paracentesis, central and peripheral intravenous line placement, and
suprapubic catheter placement may be useful in decreasing morbidity and
mortality. This presentation will review interesting cases in which bedside
ultrasound was instrumental in correctly identifying pathology unique to
resource-limited settings, thus directing correct patient treatment.
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SPECIAL INTEREST SESSIONS
MONDAY, APRIL 8, 2013, 8:15 AM–10:15 AM
Risk Assessment Associated With Ultrasound Exposure of the Lung
William O’Brien Jr Electrical and Computer Engineering,
University of Illinois, Urbana, Illinois USA
Advances in Clinical and Quantitative Pediatric
Lung Ultrasound
Moderators: Philip Levy, MD, Michael Oelze, PhD
It is well documented that ultrasound-induced lung damage (hemorrhage) can occur in mice, rats, rabbits, pigs, and monkeys. Our own
experimental studies have focused on mice, rats, rabbits, and pigs as animal models. The characteristics of the lung lesions were similar to those
described in studies by our research group and others, suggesting a common pathogenesis for the initiation and propagation of the lesions at the
macroscopic and microscopic levels. Six experimental in vivo studies have
been conducted to evaluate whether cavitation is responsible for ultrasound-induced lung hemorrhage, namely, dependencies of hydrostatic
pressure, frequency, pulse polarity, contrast agents, and lung inflation; the
results of each study appeared inconsistent with the hypothesis that
the mechanism for production of lung hemorrhage was inertial cavitation.
Other dependencies evaluated included beam width, pulse repetition
frequency, pulse duration, exposure duration, and animal species and age.
The results of our studies using mice, rats, rabbits, and pigs have shown 2
important facts relative to the biological mechanisms of damage: (1) there
are no differences in biological mechanisms of injury induced by ultrasound based on species and age; therefore, structural differences among
mammalian species studied are independent of the biological mechanism
that causes ultrasound-induced lung damage; and (2) lesions induced by
ultrasound are similar in morphology in all species and age groups studied, and the character of the lesions is independent of frequency, pulse repetition frequency, and beam width but not necessarily age. The thresholds
for producing ultrasound-induced lung hemorrhage, in general, were less
than the US Food and Drug Administration’s regulatory limit of a mechanical index (MI) of 1.9. Furthermore, the MI does not appear to provide a risk-based index for lung hemorrhage. (Supported by National
Institutes of Health grant R37EB02641.)
Perspectives and History of Clinical Lung Ultrasonography
Daniel Lichtenstein Medical Intensive Care Unit, Hôpital
Ambroise-Paré, Boulogne, France
Lung ultrasonography is one part of critical ultrasound, but its
integration provides a new definition of priorities in diagnosis and management. This application requires a simple machine, the knowledge of
basic techniques, and the mastery of no more than 10 signs. The best machine is the simplest; we use 1992 technology with simple gray scale without Doppler and a microconvex probe to acquire the images. The 10 signs
that are found in children and neonates are the same as those assessed in
adults. They include the bat sign (indicating the pleural line), lung sliding
(yielding the seashore sign), the A-line (horizontal artifact), the quad sign
and the sinusoid sign (indicating pleural effusion regardless of its
echogenicity), the tissue-like sign and the shred sign (indicating lung consolidation), the B-line and the lung rockets (vertical comet tail artifacts indicating interstitial syndrome), abolished lung sliding with the stratosphere
sign (suggesting pneumothorax), and the lung point (indicating pneumothorax). All these disorders were assessed using computed tomography (CT) as a gold standard, with sensitivity and specificity ranging from
90% to 100%, allowing us to consider ultrasound as a reasonable bedside
gold standard in the critically ill. Major applications include the possibility to postpone referral to CT in critically ill patients, immediate diagnosis and cause of an acute respiratory failure (BLUE protocol), and a direct
parameter of clinical volemia, of interest in the management of acute circulatory failure (FALLS protocol). In summary, clinical lung ultrasonography can be performed in trauma, the intensive care unit, as well as
remote areas and has led to a major decrease in irradiation.
Doppler Ultrasound: Basic and Advanced
(Beyond the Umbilical Artery)
Quantitative Acoustic Properties of the Lung: An Open Question
Peder Pedersen Worcester Polytechnic Institute, Worcester,
Massachusetts USA
Moderator: Henry Galan, MD
After attending this session, participants will be able to enumerate the various fetal vessels that can be interrogated.
This presentation will give an overview of pulmonary ultrasound research over the last 50 years. Between 1960 and 1985, several
studies were carried out, which showed that very high attenuation represents the main challenge of obtaining ultrasound diagnostic information
about the adult lungs, even in their fully collapsed state and using frequencies of <1 MHz. An overview of these early investigations will be
presented, covering measurement techniques, acoustic models, and results
in the form of attenuation, phase and group velocities, and lung surface
scattering characteristics. In the 1990s, a number of papers appeared in
the clinical literature, which intriguingly indicated the possibility of imaging pulmonary nodules in the adult collapsed lung, often in connection
with thoracoscopic surgery and using frequencies in the megahertz range.
A summary of these clinical results will be given, along with some possible explanation of which mechanisms made the pulmonary imaging possible. Finally, some speculations as to the future role of pulmonary
ultrasound will be presented.
Gynecologic Imaging Using Multiple Imaging
Modalities, Including Ultrasound, Computed
Tomography, and Magnetic Resonance Imaging
Moderators: Sherelle Laifer-Narin, MD, Anna Lev-Toaff, MD
Gynecologic Multimodality Imaging, Part 1
Sherelle Laifer-Narin Radiology, Columbia University Medical Center, New York, New York USA
In the current medical environment, imaging of the female
pelvis is often performed in the urgent care setting. The imager responsible for interpreting the images may have had little input into the choice of
imaging modality for a given problem. Therefore, familiarity with the appearance of gynecologic abnormalities on multiple imaging modalities is
required. In nonurgent cases, the imaging expert has important input into
the decision regarding the need for and choice of complementary imaging.
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prompting the United States Food and Drug Administration to issue a
“black box” for both of the commercially available perflutren-containing
US contrast agents (Definity and Optison), warning of risks of serious cardiopulmonary reactions, and contraindicating their use in patients with
critical cardiopulmonary conditions. Considerable debate about the safety,
risks, and benefits of US contrast agents ensued and prompted the publication of numerous single- and multi-center retrospective and prospective
analyses, all demonstrating a good safety profile, with a favorable balance
of risks and benefits, comparable to, or better than, contrast agent use in
other imaging modalities. Subsequently, although the black box remains,
several revisions of product labeling have occurred, which have resulted
in softening and/or removal of previous warnings and precautions, simplification of contraindications to the original concerns regarding intracardiac shunting and known hypersensitivity, and expansion of indications
such that stress imaging was no longer an exclusion. In summary, US contrast agents have a favorable risk/benefit profile in patients requiring improved endocardial visualization for rest and stress echocardiographic
imaging, and use for this purpose is currently required by US accreditation organizations.
This session will discuss combining modalities for challenging clinical
dilemmas in both urgent and nonurgent settings. The speakers will review a variety of topics that illustrate when ultrasound alone is sufficient
for diagnosis and when obtaining additional clinically useful information
from computed tomography and/or magnetic resonance imaging is optimal. These topics include the enlarged uterus, uterine anomalies, adnexal
torsion, pelvic inflammation of gynecologic origin, pelvic lesions secondary to bowel disease, pelvic malignancy, evaluation of pelvic pain in
pregnancy, and biopsy/aspiration of pelvic lesions. The lessons of this
session will be reinforced by means of a series of “test” cases using audience participation.
Hemodialysis Vascular Access
Moderator: John Blebea, MD, MBA
Flow Measurement to Predict Access Failure
David Vilkomerson DVX, LLC, Princeton, New Jersey USA
Blood flow is high when a graft is placed and goes to zero when
it clots. Stenoses almost always cause this reduction in flow. It seems reasonable, then, to measure graft flow and, when it falls to a level indicating
an impending clot, to treat the stenoses and prevent the graft failure. Ten
years ago, 2 randomized clinical trials were undertaken to establish the validity of this approach; both showed that monthly flow surveillance led to
more procedures but failed to reduce graft failures. Many suspected that
more frequent flow measurements might be more effective. We developed,
with National Institutes of Health/National Institute of Diabetes and
Digestive and Kidney Diseases Small Business Innovation Research funding, a Doppler ultrasound system especially for weekly graft flow measurement. In an observation-only phase, the instrument was shown to be
quick, inexpensive, and accurate in predicting graft failure. On the basis of
these results, a clinical trial was begun. Dialysis volunteers were randomized to a surveillance group, who had their graft flow measured and
recorded every week, and a control group, who continued to receive conventional treatment, including monthly flow measurements. After 21
months, in the surveillance group measured “per protocol,” only 8% had
grafts that failed and a procedure rate similar to the control group. On an
“intent-to-treat” basis, however, the clinical trial failed: skipped measurements, failure to notice graft flows showing impending clotting, and delays in treatment prevented the trial from meeting its goal of reduced graft
failures. However, having a record of the graft flow after the missed signs
allowed us to determine the important parameter of how fast grafts clot
after reaching the impending failure criteria: about 70% of grafts clotted in
less than a month after meeting the criteria. The most common interval between the signs of impending failure and thrombosis was 1 week. Lesson
1: Monthly flow surveillance can never, no matter the method, significantly
reduce graft failures. Another result of having weekly flow data was being
able to correlate postintervention graft flow with the succeeding graft history. Lesson 2: If postintervention flow is <950 mL/min, 50% of the grafts
will fail in 8 months; if >950 mL/min, >70% will be patent after 21 months.
Review of Molecular Imaging
Joshua Rychak Targeson, Inc, San Diego, California USA
Contrast ultrasound is an emerging technique for imaging tumor
progression, both in clinical and research settings. In particular, targeted
microbubbles are now being used as molecular contrast agents for molecular imaging of angiogenesis, thrombosis, and inflammatory disease.
This presentation will review developments in the field over the past
decade and attempt to trace the path from proof of concept to the introduction of commercial formulations for research and clinical use. Early incarnations of microbubbles for molecular imaging used antibody-targeting
ligands conjugated using a biotin-avidin scheme. This system has proved
to be remarkably robust and, with several modifications, has emerged into
several widely used commercial products for small-animal imaging. Extending ultrasound molecular imaging to larger research species presents
some challenges: antibodies are not always readily available to the desired
molecular target for rabbits, canines, and swine, and the large volume of
microbubble product required per dose makes cost a constraint. The use
of small-molecule ligands that offer activity in a variety of species (and
which can generally be made at low cost) can overcome this limitation. Replacement of biotin-avidin conjugation with covalent-coupling chemistries
can further reduce the cost and improve the consistency of the microbubble product. Selection of conjugation chemistry, in addition to the ligand
and shell components, proves to be an important aspect when translating
to human use. In addition to their incarnation as reagents for biomedical
research, the first generation of ultrasound molecular imaging agents are
now entering clinical trials.
Microvascular Mapping
Paul Dayton,1* Ryan Gessner,1 Stephen Aylward 2
1
Biomedical Engineering, University of North Carolina, Chapel
Hill, North Carolina USA; 2Kitware, Inc, Carrboro, North
Carolina USA
New Horizons in Contrast Ultrasound
Microbubbles are unique as ultrasound contrast agents in that
they are constrained to the microvascular space due to their large size, and
they can be detected with high sensitivity due to their unique echo signatures. Through application of transducers and imaging strategies optimized
to achieve high resolution and high signal to noise coupled with 3D approaches, it is possible to obtain maps of microvascular structures associated with healthy and pathologic tissue. It is well known that angiogenic
processes involved in rapidly growing tumors promote increased vessel
density, tortuosity, and other structural abnormalities. Using vessel segmentation methods, vessel patterns can be identified and characterized
from contrast ultrasound data. We demonstrate that these “microvascular
maps” can be used to characterize tissue volumes as tumor bearing or
Moderator: Paul Dayton, PhD
Safety Aspects of Contrast Ultrasound
Sharon Mulvagh Medicine, Mayo Clinic, Rochester, Minnesota USA
In the mid to late 2000s, several years after approval of ultrasound (US) contrast agents for enhancement of endocardial border
definition and improved feasibility and quality of echocardiographic examinations, postmarketing surveillance suggested a “safety signal,”
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3-hour time window. Systemic tPA administration remains the fastest way
to initiate treatment for acute ischemic stroke. Since tPA works by induction of partial recanalization of large thrombi, early augmentation of fibrinolysis to improve recanalization is desirable. This augmentation is
feasible and can be safely achieved at the bedside with transcranial
Doppler (TCD), or sonothrombolysis. In the CLOTBUST trial, all patients
received systemic tPA as the standard of care, and 73% of patients
achieved any recanalization (46% complete, 27% partial) with tPA + TCD
vs 50% (17% complete, 33% partial) with tPA alone within 2 hours of
treatment (P < .001). Sustained complete recanalization at 2 hours was
38% vs 13%, respectively (P = .03). A recent meta-analysis of 6 randomized and 3 nonrandomized clinical studies of sonothrombolysis showed
that any diagnostic ultrasound monitoring can at least double the chance
of early complete arterial recanalization at no increase in the risk of symptomatic intracerebral hemorrhage. Transcranial ultrasound delivery in an
operator-independent and dose-controlled manner was successfully tested
in phase I and II clinical studies in stroke-free volunteers and stroke patients treated with systemic tPA. A novel operator-independent device for
sonolysis (Cerevast Therapeutics, Inc) is now being tested in a pivotal
phase III clinical trial (CLOTBUSTER, NCT01098981).
healthy, based on microvessel morphologic differences. Thus, contrastenhanced acoustic angiography presents a means to detect the presence
of tumors based on observed microvascular abnormalities, without the
need to evaluate the tumor mass itself.
Pediatric Hepatobiliary Disorders
Moderator: Rob Goodman, MD
Sonographic Differential Diagnoses in Pediatric Focal Liver Lesions
Rob Goodman Yale University, New Haven, Connecticut
USA
Sonographic analysis of the pediatric liver is often the first imaging used that detects a focal liver lesion. Assessment of the sonographic
appearances of these lesions can sometimes be challenging if one is expected to determine a likely cause. The spectrum of conditions that give
rise to focal liver lesions in a child is broad, and many lesions have similar sonographic appearances. In this session, congenital, inflammatory,
traumatic, neoplastic (benign and malignant), vascular, and metabolic
causes of focal liver lesions will be discussed, and specific clinico-sonographic features used to distinguish between these will be emphasized.
With the help of these features, the practicing pediatric sonographer will
be able to more accurately reach an appropriate diagnosis.
Animal Models of Sonothrombolysis and Drug Delivery
Christy Holland,1* Jonathan Sutton,1 Nikolas Ivancevich,2
Stephen Perrin,1 Deborah Vela3 1Internal Medicine, Division
of Cardiovascular Diseases and Biomedical Engineering
Program, University of Cincinnati, Cincinnati, Ohio USA;
2
Siemens Medical Solutions, Issaquah, Washington USA; 3Cardiovascular Pathology, Texas Heart Institute, Houston, Texas
USA
The Spectrum of Ultrasound Findings in the Pediatric Biliary Tree
Valerie Ward Radiology, Boston Children’s Hospital, Boston,
Massachusetts USA
Ultrasound is the imaging modality of choice for the initial and
noninvasive evaluation of biliary diseases in newborns, infants, young
children, and adolescents. Initially in this presentation, patient preparation, sonographic technique, and common clinical indications for sonography of the biliary tract will be reviewed. Then both the common and
infrequent etiologies for biliary disease in children, including cholestasis,
cholelithiasis, choledochalithiasis, cholecystitis, cholangitis, choledochal
cysts, and biliary atresia, will be discussed. Also, the correlation of prenatal
and postnatal sonography will be presented for specific biliary tract diagnoses that can be diagnosed in the fetal period. Where applicable, the benefits of combining sonography with other biliary tract imaging modalities
(such as hepatobiliary scintigraphy, cholangiography, and magnetic resonance cholangiopancreatography) will be also discussed as adjuncts in the
evaluation of pediatric biliary tract abnormalities.
Ultrasound-mediated thrombolysis, or sonothrombolysis, is an
attractive adjuvant to conventional recombinant tissue-type plasminogen
activator (rt-PA) therapy for acute ischemic stroke and other thromboocclusive diseases. Numerous in vitro and ex vivo porcine studies have
demonstrated ultrasound-enhanced clot lysis, yet recent clinical trials have
produced mixed results. Stable cavitation nucleated by an ultrasound contrast agent enhances the penetration of both rt-PA and plasminogen into
clots. This enzymatic fibrinolysis is likely hastened due to an increased
availability of plasminogen binding sites for rt-PA. However, the degree
of clot retraction strongly affects the extent of thrombolytic efficacy. The
lack of dense fibrin matrix formation throughout unretracted clots promotes susceptibility to ultrasound-enhanced thrombolysis. In contrast, the
paucity of plasminogen present within retracted clots prevents ultrasound
acceleration of lysis. Thus, the thrombus etiology and vascular origin may
predispose the degree of sonothrombolytic susceptibility. Recent clinical,
in vitro, and ex vivo data from a variety of clot models will be discussed.
Taboos and Opportunities in Sonothrombolysis for
Stroke: From Sonothrombolysis in Animals to Stroke
Treatment in Patients
Neurovascular Ultrasound in Stroke: What Sonographers Can Do Now
Tatjana Rundek Neurology, University of Miami Miller
School of Medicine, Miami, Florida USA
Moderators: Tatjana Rundek, MD, PhD,
Paul Sierzenski, MD, RDMS
Neurovascular examination is widely used for assessment of
patients in the acute, subacute, or chronic phases of cerebral ischemia. The
availability of aggressive and effective treatments, which can be potentially harmful for acute ischemic stroke patients, requires fast and noninvasive examination of the intracranial and extracranial vasculature.
Effective stroke therapy can be improved through real-time ultrasound
monitoring of the neurologic and cardiovascular responses to treatments.
This requires crucial knowledge on behalf of both the sonographer and
stroke physician to make the best decisions for the patient, which would
minimize the ischemic damage caused by stroke and reduce the risk of
subsequent stroke. Current ultrasound techniques, transcranial Doppler
and extracranial duplex or color Doppler, have the potential to provide
crucial and reliable information about the status of the intracranial and extracranial arteries in a real time. Application of echo-enhancing agents
promises to effectively extend current diagnostic techniques. Application
Ups and Downs in Clinical Trials of Sonothrombolysis
Andrei Alexandrov Comprehensive Stroke Center, University of Alabama, Birmingham, Alabama USA
Intravenous tissue-type plasminogen activator (tPA) remains
the only effective reperfusion therapy to reverse ischemic stroke. Its timely
delivery to all eligible patients should be a priority in development of
stroke treatment centers and ambulance delivery systems. Its augmentation with ultrasound will be discussed. Despite lower revascularization
rates with respect to endovascular thrombectomy, patients treated with
systemic thrombolysis achieve good functional outcomes likely due to
earlier treatment initiation. Currently, no evidence exists that primary intraarterial revascularization could be any better than systemic tPA within the
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of action. Proper disclosure of the acoustic properties involved will aid in
the further development of the field, guiding future research. The first part
of this presentation will review the basics of proper reporting, which
should be included with any presentation of sonothrombolysis results.
Pressure, intensity, frequency, and acoustic field distribution information
are the key elements, and other secondary metrics will also be discussed.
The basic techniques for obtaining these acoustic data will also be presented. The presentation will conclude by discussing an operatorindependent ultrasound therapy device to treat ischemic stroke, which was
specifically designed to incorporate full dosimetric data. The ultrasound
delivery system includes a multiple-transducer transcranial head frame
comprising broadband (1.0–2.5 MHz) transducers placed at the temporal
windows (6 on each side) and the suboccipital window (6 additional transducers). A computer-controlled ultrasound generator receiver system could
energize any transducer with sine bursts of varying frequency, amplitude,
duty factor, and pulse repetition frequency. Prior to clinical deployment,
ultrasonic dosimetry data were recorded for each transducer and saved in
the system. During operation, the system logged all exposures in real time
for later analysis. The system is now in clinical tests with stroke patients.
This system exemplifies the utility of dosimetry/exposimetry in practice.
of sonothrombolysis carries a promise to revolutionize the approach to
treatment of acute stroke and improve stroke outcome. The clinical significance of neurovascular ultrasound, however, needs to be evaluated
prospectively and preferably in an unbiased setting of clinical trials. This
presentation will address the basics of neurovascular ultrasound in the examination of stroke patients, the interpretation of ultrasound studies, and
the application of neurovascular ultrasound in the management and treatment of stroke. The role of sonographers will be emphasized, as neurovascular ultrasound is an important, user-friendly, noninvasive, and
low-cost diagnostic and possibly therapeutic tool for patients with ischemic cerebrovascular disease.
Therapeutic Ultrasound: Lessons Learned and What Should Be
Reported
Mark Schafer Sound Surgical Technologies, LLC, Louisville,
Colorado USA
While sonothrombolysis presents a tremendous clinical opportunity, the field has been hampered by a lack of proper dosimetry reporting. This has led to both confusion and controversy over not only the
specifics of pressure, intensity, etc, but also of the underlying mechanisms
SPECIAL INTEREST SESSION
MONDAY, APRIL 8, 2013, 11:00 AM–12:30 PM
How to Be an Effective Manuscript Reviewer for the
Journal of Ultrasound in Medicine
Moderator: Levon Nazarian, MD
How to Be an Effective Manuscript Reviewer for the Journal of
Ultrasound in Medicine
Levon Nazarian Radiology, Thomas Jefferson University
Hospital, Philadelphia, Pennsylvania USA
Peer review is the method used worldwide to determine
whether manuscripts are suitable for publication, yet few physicians and
sonographers are given formal instruction in how to review journal manuscripts. The purpose of this session is to describe the steps in the peerreview process at the Journal of Ultrasound in Medicine (JUM), to present
the components that constitute a high-quality review, and to discuss ethical issues such as conflicts of interest, duplicate publication, and plagiarism. By demystifying the peer-review process and letting reviewers know
what is expected of them, the ultimate goal is to improve the quality of
manuscripts published in the JUM.
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SCIENTIFIC SESSIONS
MONDAY, APRIL 8, 2013, 11:00 AM–12:30 PM
tography (EVE). It may be easier to distinguish stiffer tumors from healthy
tissue from local shear moduli than inspecting B-mode images. This work
proposes a statistically robust least squares fitting technique capable of
detecting boundaries between materials with different shear wave velocities (SWVs).
Methods—In an EVE tissue-mimicking phantom, an ablation
electrode attached to an inclusion and vibrated by an actuator is used to
generate shear waves. Ultrasound displacement estimators are used to
track the shear wave pulse and record its arrival time at different locations.
Assuming this plot is continuous and piece-wise linear, slopes and break
points are detected using a least squares fit embellished with a Huber
penalty. This penalty function switches from quadratic to linear for very
large errors, thereby mitigating the effect of outliers. An Akaike information criterion is then used to trade off the error in the fit and the number of
break points. The SWV estimates are compared with a commercial shear
wave imaging system and mechanical testing.
Results—SWV estimates are within 20% of those obtained
using the commercial scanning system. Although the stiffness estimates
are lower than those obtained from mechanical testing, the boundary delineation is quite good due to sharp transitions arising from the piece-wise
linear fits.
Conclusions—The use of statistically robust noise filtering
techniques shows promise for improving results in the inverse problem of
shear stiffness reconstruction from noisy ultrasound displacement data.
(Supported by National Institutes of Health grants R01CA112192-05 and
R01CA112192-S103.)
Basic Science: Tissue Characterization, Part 1
Moderators: Keith Wear, PhD, Mark Holland, PhD
1539806 A Feasibility Study of Ultrasound Strain Imaging for Risk
Assessment of Carotid Atherosclerotic Plaques Validated
by Magnetic Resonance Imaging
Xiaochang Pan,1 Shengzhen Tao,1 Lingyun Huang,2 Manwei
Huang,3 Xihai Zhao,1 Le He,1 Chun Yuan,1,4 Jianwen Luo,1*
Jing Bai1 1Biomedical Engineering, School of Medicine,
Beijing, China; 2Philips Research Asia, Shanghai, China;
3
Ultrasonography, Meitan General Hospital, Beijing, China;
4
Radiology, University of Washington, Seattle, Washington USA
Objectives—Conventional B-mode ultrasound images and
Doppler/color flow measurement are mostly used to evaluate the degree
of carotid atherosclerotic plaques, but they have a lack of histologic validation, while the correspondence between multicontrast magnetic resonance imaging (MRI) sequences and histology has been constructed. We
propose a comprehensive MRI and ultrasound feasibility study to quantitatively measure morphologic and mechanic properties of carotid atherosclerotic plaques and develop a risk indicator for plaques.
Methods—Sequences of raw ultrasound (radiofrequency) data
were acquired from a 65-year-old male patient with carotid plaques on a
Philips iU22 ultrasound system. The interframe strain of the plaques was
estimated to indicate relative stiffness of different plaque compositions,
using a coarse-to-fine 2D speckle-tracking algorithm based on cross-correlation and correlation filtering. The same patient underwent doubleblinded MRI scanning on a Philips Achieva 3T TX MR scanner using a
multi–contrast imaging protocol. 3D MR images of this patient were reconstructed, and slices at the same position of the ultrasound incidence
angle were selected and registered. Carotid plaque tissue compositions on
MR images were characterized according to published criteria, while
echogenicity and strain values in the ultrasound images were investigated
and compared with MRI results.
Results—The plaques with intraplaque hemorrhage (IPH) or a
lipid-rich necrotic core (LRNC) on MR images were defined as high risk.
In the ultrasound results, the calcified area of the plaque showed high
echogenicity and low deformation (0.2%); IPH showed mid to high
echogenicity and intermediate deformation (1.2%), and the LRNC showed
the lowest echogenicity and large deformation (2.6%). The locations of
the calcification, IPH, and LRNC were in good agreement with findings
on MR images.
Conclusions—We performed a quantitative measurement of
the morphology and mechanical properties of high-risk plaques and
showed that the combination of echogenicity and strain values obtained
from raw ultrasound data is feasible to quantitatively evaluate the vulnerability of atherosclerotic plaques.
Table 1
SWV, m/s
Young Modulus, kPa
Region
Mechanical
of Interest
EVE
SSI
EVE
SSI
Testing
Inclusion
3.4 ± 1.5 2.8 ± 1.1 42.2 ± 58 24.2 ± 5.8 54.4 ± 0.1
Partially ablated 2.0 ± 0.3 2.3 ± 0.8 12.1 ± 4.2 13.3 ± 3.5 21.6 ± 0.3
Background
1.4 ± 0.4 1.3 ± 0.4 6.5 ± 6.1 4.8 ± 0.5 3.7 ± 0.1
SSI indicates supersonic shear imaging.
1540416 A Comparison of Coherence of Radiofrequency Data
From Ablated and Unablated Liver Tissue Using Multitaper Estimation
Nicholas Rubert,* Tomy Varghese University of Wisconsin,
Madison, Wisconsin USA
Objectives—Thermally ablated liver tissue presents as a zone of
mixed echogenicity on B-mode imaging, making it difficult to delineate
the extent of treatment following thermal ablation. We demonstrate a novel
contrast mechanism for ultrasonic imaging of thermal ablations based on
the spatial distribution of acoustic scatterers. The portal triads and central
vein of the liver are arranged in repeating subunits, which are hypothesized
to correspond to quasi–periodically arranged acoustic scatterers. Estimates
of the mean scatterer spacing (MSS) of these quasi–periodic scatterers
have been hypothesized to be useful indicators of pathologic changes to
the liver. Mathematically, the quasi–periodic scatterers gives rise to an ultrasound radiofrequency (RF) signal-possessing coherence.
Methods—Coherence is a frequency domain quantity computed with tapered fast Fourier transforms of the ultrasound signal. Using
simulation, we show that a coherence estimate using multiple orthogonal
tapers outperforms coherence estimates computed with a single taper. We
1536174 A Huber-Penalized Akaike-Regularized Broken-Stick Least
Squares Regression Algorithm for Shear Wave Velocity Reconstruction
Atul Ingle,1* Tomy Varghese1,2 1Electrical and Computer
Engineering, 2Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
Objectives—Tissue stiffness has been traditionally used as a
qualitative metric for localizing cancerous tumors. The aim of this study
is to obtain quantitative stiffness estimates using electrode vibration elasS9
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also perform receiver operating characteristic (ROC) analysis of 38 regions of interest (ROIs) from ex vivo bovine livers. Ultrasound imaging
was performed using a 9L4 transducer on a Siemens S2000 system prior
to and following RF thermal ablation in 19 independent samples cut from
4 bovine livers. Each ablation was approximately 1 to 2 cm in diameter.
Results—In frequency domain Monte Carlo simulations, the
multiple taper (MT) method was better able to estimate the MSS of
gamma-distributed scatterers than any single taper (ST) calculations. In
analyzing 2 different ROI sizes ex vivo, we found that for a gate length of
5 mm, we achieved an area under the ROC curve of 0.89, while at a gate
length of 7 mm, we achieved an area under the ROC curve of 0.93 using
MT coherence calculations.
Conclusions—ROC analysis indicates that a tissue classifier
using coherence is able to distinguish between ablated and unablated
tissue and that an MT calculation of coherence is a better estimate than an
ST calculation. (Supported by National Institutes of Health grants
R01CA112192-05, R01CA112192-S103, and T32 CA09206-31).
1540510 Acoustic Radiation Force Impulse Delineation of Human
Carotid Atherosclerotic Plaque Composition and Structure
In Vivo
Tomasz Czernuszewicz,1 Melissa Caughey,2 Peter Ford,3
Mark Farber,3 William Marston,3 Raghuveer Vallabhaneni,3
Jonathon Homeister,4 Matthew Mauro,5 Timothy Nichols,2,4
Caterina Gallippi1* 1Joint Department of Biomedical Engineering, 2Medicine, 3Surgery, 4Pathology and Laboratory Medicine, 5Radiology, University of North Carolina, Chapel Hill,
North Carolina USA
Objectives—Conventional atherosclerosis imaging methods
rely on detecting luminal obstruction, which may not occur until late stages
of disease progression and does not reflect plaque rupture potential. Plaque
detection may be expedited and risk assessment improved by imaging
methods that describe the plaque composition and structure. We have previously so demonstrated acoustic radiation force impulse (ARFI) ultrasound preclinically with immunohistochemical validation. The objective
of this work was to similarly validate ARFI in human atherosclerosis. We
hypothesize that ARFI delineates the fibrous cap, lipid/necrotic components, fibrous tissue, and calcium deposits in human atherosclerotic plaque
in vivo.
Methods—ARFI imaging was performed using a Siemens
Acuson Antares imaging system with modifiable beam sequencing and a
VF7-3 transducer in the carotid arteries of 2 patients undergoing clinically
indicated carotid endarterectomy. Imaging was performed presurgically
by focusing on the surgical plaque. After surgery, the extracted specimen
was sectioned according to noted arterial geometry for spatial registration
to the imaging plane. The sections were stained with hematoxylin-eosin,
Verhoff van Gieson, Masson trichrome, and von Kossa. Parametric 2D
ARFI images of peak displacement (PD) were rendered.
Results—In a fibroatheromatic plaque, 3 times higher ARFI
PD was measured in the position of a soft lipid/necrotic region than in the
position of a thick fibrous cap above the region or fibrotic tissue below the
region. ARFI PD was nearly zero in positions of small (<1 mm diameter)
calcium deposits throughout the plaque. In a highly calcified plaque, ARFI
PD was nearly zero throughout a large (15 mm laterally × 5 mm axially)
calcium deposit but was >5 µm in the adjacent arterial tissue.
Conclusions—These spatially matched ARFI and immunohistochemical data suggest that ARFI is relevant to describing the atherosclerotic plaque composition and structure in humans in vivo. The results
also demonstrate the feasibility of collecting data to perform a larger-scale
statistical reader study to evaluate human ARFI atherosclerosis imaging
performance using spatially matched immunohistochemistry as the validating standard.
1539520 Echocardiography-Based Measurements of 3-Dimensional
Myocardial Fiber Structure
Michelle Milne,1 Kirk Wallace,4 Benjamin Johnson,1 Gautam
Singh,2 Ravi Rasalingam,3 James Miller,1 Mark Holland1,2*
1
Physics, 2Pediatrics, 3Internal Medicine, Washington University, St Louis, Missouri USA; 4GE Global Research, Niskayuna,
New York USA
Objectives—Previous studies from our laboratory demonstrated
that quantitative measurements of myocardial fiber structure for individual hearts can be derived from analyses of echocardiographic images.
Echocardiography-based measurements of fiber structure at specific transverse planes agreed well with those obtained using diffusion tensor magnetic resonance imaging methods. The objective of this study was to
extend the echocardiography-based measurements to produce 3D myocardial fiber structure images of the entire heart.
Methods—A series of 2D apical echocardiographic images
were acquired from each of 7 excised intact sheep hearts using a GE Vivid
7 clinical imaging system. Myocardial fiber orientations corresponding to
specific distances from the apex of the heart were generated from analyses of radial line backscatter profiles within the ventricular walls of the
heart in conjunction with a previously determined relationship between
the backscatter level and the angle of insonification relative to myocardial fiber orientation. The fiber orientations at each measured distance
from the apex were assembled to produce a 3D fiber orientation image of
the entire heart. In addition, 3D volumetric apical echocardiographic images were acquired from a subset of the excised hearts for comparison.
Results—3D images depicting myocardial fiber structure obtained from analyses of echocardiographic data appear consistent with the
known fiber structure of the heart. Images demonstrate left ventricular
mid-myocardial fibers oriented within the short-axis plane and gradually
becoming more longitudinally oriented toward the epicardial and endocardial surfaces. Data from 3D volumetric apical echocardiographic images suggest similar results.
Conclusions—These results demonstrate that measurements
of 3D myocardial fiber structure of the entire heart can be successfully
derived from analyses of echocardiographic images. Further development
of this method may provide a method for mapping the myocardial fiber
orientation in individual patients over the heart cycle and provide a means
for assessing potentially altered fiber structure associated with congenital
and acquired heart diseases. (Supported by National Institutes of Health
grant R01 HL040302.)
1541124 Effects of Preprocessing on Reconstructed Shear Wave
Speeds in Human Liver In Vivo
Ned Rouze,1* Seung Yun Lee,1 Michael Wang,1
Mark Palmeri,1 Manal Abdelmalek,2 Kathryn Nightingale1
1
Biomedical Engineering, Duke University, Durham, North
Carolina USA; 2Medicine, Division of Gastroenterology, Duke
University School of Medicine, Durham, North Carolina USA
Objectives—Time-of-flight methods are often employed to provide quantitative measurement of shear wave speed (SWS) from ultrasonically tracked displacements following acoustic radiation force
excitation in liver. These methods estimate overall group velocities of
propagating shear waves and generally require filtering to reduce noise
and motion artifacts. In addition, different systems employ different beam
geometries in their push excitations, which also leads to differences in the
shear wave frequency content. Differences in the shear wave frequency
content can lead to differences in the estimated SWS due to the dispersive
nature of hepatic tissue. In this study, we investigated the impact of these
effects in a nonalcoholic steatohepatitis patient population from data obtained in an Institutional Review Board–approved protocol.
Methods—Data from >170 patients with a range of fibrosis
stages were processed using multiple filtering algorithms. Three types of
motion filters were applied, including a quadratic motion filter, a high-
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pass filter (HPF) with an adjustable cutoff frequency, and differentiation
of the displacement vs time data. The latter determines the axial velocity
of the propagating pulse and allows the wave arrival time to be determined
from the peak slope of the leading edge. This differentiation acts as a ramp
filter in the frequency domain to reduce the effects of low-frequency motion. After filtering, SWSs were estimated using the arrival time as a function of position data and the radon sum algorithm.
Results—Results obtained to date indicate that the application
of motion filters does affect the reconstructed SWS. Both the HPF and
differentiation filter bias the estimated group velocity to the higher phase
velocity components; this effect is less significant for the quadratic filter.
The differentiation filter leads to an ≈16% increase in SWS estimates over
the range of 1.5 to 4.0 m/s compared to the quadratic filter. For the HPF,
increasing the cutoff frequency from 25 to 150 Hz increases the SWS
≈13% over the same SWS range.
Conclusions—Preprocessing algorithms used to remove lowfrequency noise and motion artifacts from in vivo data can skew group
velocity SWS estimates toward the higher phase velocity components.
1540991 Evaluation of Shear Wave Elasticity Imaging for Characterizing the Contribution of Coronary Perfusion to Cardiac
Diastolic Stiffness
Maryam Vejdani-Jahromi,* Annette Kiplagat, Young
Joong-Kim, Douglas Dumont, Gregg Trahey, Patrick Wolf
Biomedical Engineering, Duke University, Durham, North
Carolina USA
Objectives—Heart failure is one of the leading causes of death
in the world in which mechanical properties of the cardiac tissue are damaged. Diastolic heart failure occurs when the left ventricle loses its compliance to receive a sufficient volume of blood. Currently, there is no
universally accepted technique to evaluate changes in mechanical properties of cardiac tissue. Shear wave elasticity imaging (SWEI) is an ultrasound-based technique used to evaluate the stiffness of the tissue by
measuring the shear wave speed of propagation. To evaluate the capability of SWEI in determining the contribution of coronary perfusion to diastolic stiffness, normal and hypoperfused rabbit hearts were studied.
Methods—Six rabbit hearts were isolated on a Langendorff
preparation, perfused with Tyrode solution. Data were acquired using a
VF10-5 linear transducer on a Sonoline Antares ultrasound system (Siemens
Medical Solutions, Mountain View, CA) with a focal point of 1.6 cm, transmit frequency of 5.7 MHz and F-number of 1.5. The probe was fixed approximately 1 cm from the left ventricular free wall along the short axis and
acquired data from the same location. Hypoperfusion was done in 3 isolated
hearts by reducing the perfusion pressure until the flow rate was half of normal, and SWEI data were recorded before and 10 minutes after. Three rabbit hearts with a normal flow rate were studied as control subjects.
Results—Initial results showed that reduction of 50% in perfusion pressure caused an average decrease of 27.7% in the shear wave velocity and 47.7% in the shear modulus, while normal hearts showed
increases of 9.0% and 18.7% for the shear wave velocity and shear modulus, respectively.
Conclusions—From these preliminary data, we conclude that
the shear wave velocity and shear modulus recorded by SWEI can show
the contribution of coronary perfusion pressure to diastolic stiffness. This
new ultrasound-based imaging modality can be used to assess, characterize, and quantify the mechanical properties of the heart.
Table 1
Hearts
Hypoperfused before
Hypoperfused after
Normal before
Normal after
Shear Wave Velocity, m/s
1.69
1.22
1.23
1.34
Shear Modulus, kPa
2.84
1.49
1.50
1.79
1540671 Feasibility and Reproducibility of Right Ventricular Strain
Measurement by Speckle-Tracking Echocardiography in
Preterm Infants
Philip Levy,1* Gautam Singh,1 Tim Sekarski,1 Aaron Hamvas,1
Mark Holland1,2 1Pediatrics, Washington University School
of Medicine, St Louis, Missouri USA; 2Physics, Washington
University, St Louis, Missouri USA
Objectives—The right ventricle (RV) is the dominant ventricle
in premature and term neonates, and its function is an important determinant of the clinical status and prognosis of congenital and acquired cardiopulmonary pathologies. Myocardial strain and the strain rate represent
2 sensitive measures of cardiac function. 2D speckle-tracking echocardiography (2DSE) is an angle-independent method for strain measurement but has not been applied in preterm infants for assessment of RV
function. The aim of this study was to evaluate the feasibility and reproducibility of 2DSE-measured RV global longitudinal strain in preterm infants and establish standardized methods for acquiring and analyzing strain
measurements.
Methods—2DSE (GE EchoPac) was used to measure the peak
global longitudinal strain (pGLS) and strain rate (pGLSR) in the apical 4chamber view of the RV in 50 preterm infants (27 ± 1 weeks at birth) at
32 weeks postmenstrual age. Images were acquired with frame rates between 60 and 100 Hz for 3 cardiac cycles and stored for offline analysis.
Two observers measured the RV pGLS and pGLSR in 25 randomly selected images. Interobserver and Intraobserver reproducibility were assessed using Bland-Altman analysis (relative bias, 95% limits of
agreement [LOA]), and the correlation was tested using linear regression.
Results—Strain imaging was feasible from 85% of the acquisitions. Intraobserver 2DSE RV pGLS and pGLSR reliability demonstrated high reproducibility (bias, 4%; 95% LOA, –2.1 to +1.9; r = 0.98;
P < .01; and bias, 6%; 95% LOA, –0.29 to +0.26; r = 0.94; P < .01, respectively). Interobserver 2DSE RV pGLS and pGLSR reliability also
showed high reproducibility (bias, 7%; 95% LOA, –4.1 to +3.9; r = 0.92;
P < .01; and bias, 7%; 95% LOA, –0.41 to +0.42; r = 0.94; P < .01, respectively).
Conclusions—Our study demonstrates high feasibility and reproducibility of RV strain measurements by 2DSE in preterm infants and
offers specific recommendations for image acquisition and data analysis
that reduce measurement variability. Strain measurement by 2DSE offers
a robust tool for the assessment of global RV function that is not achieved
by conventional methods. (Supported by National Institutes of Health
grants 1U01 HL101465 and R21 HL106417.)
1541514 Statistical Comparison of Backscatter Coefficients for MAT
and 4T1 Tumors Across Multiple Ultrasound-Imaging Systems
Douglas Simpson,1* Nathaniel Hirtz,1,2 William O’Brien Jr2
1
Statistics, 2Bioacoustics Research Laboratory, Electrical and
Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois USA
Objectives—Quantitative ultrasound measurements such as the
backscatter coefficient (BSC) have the potential to greatly enhance tissue
characterization and identification of tumors. A balanced experiment was
conducted to compare consistency across transducers and efficacy for distinguishing 2 well-characterized animal tumor types.
Methods—The study included induced 4T1 and MAT tumors
in mice and rats. Animals were scanned with 5 different transducers with
a target of 5 scan lines per tumor region of interest. BSCs were computed
for each scan. The resulting BSC data were analyzed across tumor types
and transducers using spatially dependent linear mixed model analysis,
where the spatial dependence was between neighboring frequencies within
the same scan line. The model allowed comparison of BSC curves from
transducers with varying frequency ranges.
Results—For 4T1 tumors, transducer differences were not statistically significant. For MAT tumors, significant differences between
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transducers were found. All 5 transducers detected significant differences
between tumor types either through a mean shift model or via changes in
curve shape between tumor groups. Higher-frequency transducers produced
significantly greater separation of mean BSC curves between MAT and
4T1 tumors. Mean differences between tumor types were smaller than the
inherent variability in the BSC curves as measured by the residual standard error values, indicating a low signal to noise ratio for classification.
Conclusions—All 5 ultrasound-imaging transducers were effective in detecting significant differences between MAT and 4T1 tumors,
either through mean shift or through shape changes. Higher frequencies in
the range above 8.5 MHz were more effective than lower frequencies in detecting tumor differences.
1540921 Automatic Detection of Keratoconus From HighFrequency Ultrasound Data
Ronald Silverman,1,2* Raksha Urs,1 Arindam RoyChoudhury,1 Timothy Archer,3 Dan Reinstein3 1Ophthalmology,
Columbia University Medical Center, New York, New York
USA; 2Frederic L. Lizzi Center for Biomedical Engineering,
Riverside Research, New York, New York USA; 3London Vision
Clinic, London, England
Objectives—Keratoconus (KC), a corneal dystrophy characterized by progressive corneal thinning and bulging, is currently detected
by optically determined corneal topography and curvature. The corneal
epithelium, however, tends to remodel to smooth out irregularities in the
underlying stroma, potentially masking early KC topographic changes. In
this report, we describe automated ultrasound detection of KC based on altered epithelial thickness patterns.
Methods—Corneas of 128 normal and 68 KC subjects (1 randomly chosen eye per subject) were scanned using the Artemis-1 (Arcscan, Inc, Morrison, CO) high-frequency ultrasound system. Scans are
performed with an optical fixation target and video monitoring of eye position while the 50-MHz transducer is scanned in an arc such that curvature in the focal plane approximately matches that of the corneal surface.
Radiofrequency data are digitized at 500 MHz. Scans were acquired in 4
planes at 0°, 45°, 90°, and 135°. Postprocessing consisted of automatic
detection of the corneal surfaces and the epithelial/stromal interface. Maps
(100 × 100 at 0.1-mm intervals) of epithelial and stromal thickness were
then automatically analyzed to extract 87 features that might potentially
differentiate normal from KC eyes. Stepwise linear discriminant analysis
(LDA) and neural network (NN) analysis using a radial basis kernel were
then performed. NN analysis was repeated 10 times with different random test sets (30% of cases).
Results—Stepwise LDA produced a model consisting of 11
features with sensitivity of 91.2%, specificity of 99.2%, and an area under
the receiver operating characteristic (ROC) curve of 98.5%. A leave-oneout procedure gave identical sensitivity and specificity. The NN showed
average sensitivity of 93.5% and specificity of 97.4% for the training set
and 88.8% and 97.5%, respectively, for the test set. The area under the
ROC curve was 97.8%.
Conclusions—Our results show ultrasound-detected patterns
in corneal layered topography to be very effective at distinguishing normal from KC corneas. Future studies will combine these methods with
optical data for early detection, which would allow early treatment by collagen cross-linking and avoidance of potentially damaging corneal refractive surgical procedures.
Breast Ultrasound and Elastography
Moderator: Abid Irshad, MD
1538656 Correlation Between Parameters in Ultrasound-Guided
Diffuse Optical Tomography and 18F-Fluorodeoxyglucose
Positron Emission Tomography/Computed Tomography
for Breast Cancer
Woo Jung Choi,* Hak Hee Kim, Joo Hee Cha, Hee Jung
Shin, Hyunji Kim Radiology, Asan Medical Center, Seoul,
Korea
Objectives—The purpose of this study was to correlate parameters in ultrasound (US)-guided diffuse optical tomography and maximum
standardized uptake value in 18F-fluorodeoxyglucose positron emission
tomography/computed tomography (18F-FDG PET/CT).
Methods—We retrospectively evaluated 228 patients (mean
age, 46.9 years; range, 29–71 years) diagnosed with breast cancer between
September 2009 and February 2012. Both US-guided diffuse optical tomography and 18F-FDG PET/CT were performed. For each lesion, the
total hemoglobin concentration (HBT) level and oxygen saturation (SO2)
level were calculated, and the synthesis diagnosis index (SDI) was designed using US-guided diffuse optical tomography. With 18F-FDG
PET/CT, the maximum standardized uptake value (mSUV) was calculated. We compared the parameters in US-guided diffuse optical tomography with the mSUV of known malignant breast lesion on 18F-FDG
PET-CT using the Spearman correlation coefficient.
Results—All 228 malignant lesions were primary breast cancers, and the histologic types included invasive ductal carcinoma (n =
210), invasive lobular carcinoma (n = 4), invasive mammary carcinoma
(n = 12), and metaplastic carcinoma (n = 2). Correlation between the SO2
level and mSUV was statistically significant (Spearman correlation coefficient = –0.280; P < .001). The HBT level and SDI showed a low correlation coefficient with the mSUV (spearman correlation coefficients =
0.049 and 0.072; P = .458 and .280, respectively).
Conclusions—The SO2 level of US-guided diffuse optical tomography correlated well with the mSUV of 18F-FDG PET/CT. A low
SO2 level in optical imaging may predict a high mSUV level on 18F-FDG
PET/CT, and it may serve as a useful tool for predicting the response rate
after neoadjuvant chemotherapy in breast cancer.
1540665 Comparison of Strain and Shear Wave Without or With a
Quality Measure in Evaluation of Breast Masses
Richard Barr Radiology Consultants, Inc, Youngstown, Ohio
USA
Objectives—Shear wave imaging (SVI) in the breast codes
some cancers as soft. Coding a malignancy as soft can be due to poor shear
wave propagation. The addition of a quality measure (QM) that determines if an adequate shear wave formed for accurate measurements. The
aim of this paper was to compare the predictive value of strain (elasticity
imaging [EI]) and SVI without and with a QM.
Methods—Patients scheduled for an ultrasound breast biopsy
had strain (EI) and SVI on a Siemens S2000 system modified to perform
SVI with a QM. Lesions were evaluated for shear wave velocity (Vs ) and
the QM. The highest Vs in the lesion or surrounding ring (if present) was
used. The Vs was classified as benign (<4.5 m/s) or malignant (>4.5 m/s).
For strain, an EI/B-mode ratio of <1 was considered benign, while ≥1 was
considered malignant. Results were correlated with pathology. Receiver
operating characteristic (ROC) curves were obtained.
Results—A total of 144 patients with 166 lesions were enrolled.
Patient age averaged 48.5 (range, 18–81) years. Lesion size averaged 10.6
(range, 5–43) mm. Pathology was benign in 110 (66.3%) and malignant
in 56 (33.7%). Sixteen (14.6%) benign lesions had no SVI signal; 89
(80.9%) were benign on SVI; and 5 (4.5%) were malignant. In the malig-
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nant lesions, SVI had no Vs in 10 (18.1%); 25 (44.6%) were benign; and
21 (37.5%) were malignant. The QM was low in all cases where no SVI
signal was obtained: in 19 of 25 (76.0%) soft malignant lesions, 2 of 5
(40%) hard benign lesions, and 6 of 89 (6.7%) soft benign lesions. The
QM was high in 3 of 25 (12.0%) soft malignant lesions, which were lymphoma. Three false-negatives on EI were lymphomas. In cases were there
is a low QM, if the lesion is solid, it is most likely a cancer.
Conclusions—Strain imaging had the highest sensitivity, while
SVI had the highest specificity (without or with the QM). There was a significant improvement in the sensitivity of SVI with the addition of the
QM; however, an additional 16.9% of cases could not be evaluated.
Table 1. Comparison of Techniques
No. Sensitivity, Specificity,
Evaluable
%
%
AUROC
163
95
88
0.9595
166
41
95
0.6756
138
78
94
0.7988
166
93
87
0.9006
Technique
Strain (EI)
SVI – QM
SVI + QM
SVI + low QM and
solid lesion = malignant
AUROC indicates area under the ROC curve.
1536920 Differentiation of Benign and Malignant Breast Lesions:
A Comparison Between Automatically Generated Breast
Volume Scans and Handheld Ultrasound Examinations
Hongyan Wang,1* Yuxin Jiang,1 Qingli Zhu,1 Jing Zhang,1
Qing Dai,1 He Liu,1 Xingjian Lai,1 Qiang Sun2 1Diagnostic
Ultrasound, 2Breast Surgery, Peking Union Medical College
Hospital, Beijing, China
Objectives—To assess the diagnostic value of automated breast
volume scanning (ABVS) and conventional handheld ultrasonography
(HHUS) for the differentiation of benign and malignant breast lesions.
Methods—The study prospectively evaluated 239 lesions in
213 women who were scheduled
for open biopsy. The patients underwent ABVS and conventional HHUS. The sensitivity, specificity, accuracy, false-positive rate,
false-negative rate, and positive and negative predictive values for HHUS
and ABVS images were calculated using histopathologic examination as
the gold standard. Additionally, diagnostic accuracy was further evaluated
according to the size of the masses.
Results—Among the 239 breast lesions studied, pathology revealed 85 (35.6%) malignant lesions and 154 (64.4%) benign lesions.
ABVS was similar to HHUS in terms of sensitivity (95.3% vs 90.6%),
specificity (80.5% vs 82.5%), accuracy (85.8% vs 85.3%), positive predictive value (73.0% vs 74.0%), and negative predictive value (93.3% vs
94.1%). The area under the receiver operating characteristic curve, which
is used to estimate the accuracy of the methods, demonstrated only minor
differences between HHUS and ABVS (0.928 and 0.948, respectively).
Conclusions—The diagnostic accuracy of HHUS and ABVS in
differentiating benign from malignant breast lesions is almost identical.
However, ABVS can offer new diagnostic information. ABVS may help
distinguish between real lesions and inhomogeneous areas, find small
lesions, and demonstrate the presence of intraductal lesions. This technique is feasible for clinical applications and is a promising new technique
in breast imaging.
1540513 Functional Images of Hemoglobin and Blood Oxygen
Saturation Coregistered With Ultrasound Provide Accurate
Differentiation of Breast Tumors
Pamela Otto,1* Kenneth Kist,1 N. Carol Dornbluth,1 Thomas
Stavros,2 Donald Herzog,2 Thomas Miller,2 Bryan Clingman,2
Jason Zalev,2 Michael Ulissey,3 Philip Lavin,4 Sergey
Ermilov,5 Alexander Oraevsky2,5 1Radiology, University of
Texas Health Science Center, San Antonio, Texas USA; 2Seno
Medical Instruments, San Antonio, Texas USA; 3Radiology,
University of Texas Southwestern Medical Center, Dallas, Texas
USA; 4Aptiv Solutions, Southborough, Massachusetts USA;
5
TomoWave Laboratories, Inc, Houston, Texas USA
Objectives—A novel system called Imagio combines ultrasound (US) and opto-acoustics (OA) to more accurately distinguish malignant from benign tumors. We analyzed the ability of blind readers to
assess the probability of malignancy (POM) using coregistered functional
and anatomic images vs conventional diagnostic ultrasound (DUS) alone.
Methods—Seventy-three patients with breast masses were assessed with OA and DUS. All the masses were biopsied, and histology
was the gold standard. OA employs near-infrared laser pulses at 2 different wavelengths (to provide contrast between oxygenated hemoglobin in
benign lesions and deoxygenated hemoglobin in malignant lesions) to illuminate tissues through a fiber-optic bundle incorporated into a prototype handheld OA US probe. It detects the laser pulse–induced acoustic
pressure waves that are then used for reconstruction of 2D functional and
anatomic images. OA maps of total hemoglobin and blood oxygen saturation provide functional information that is coregistered with the morphological information from B-mode grayscale US images.
Results—Five blinded readers independently assessed POM
for OA and DUS. OA provided a >40% higher mean POM for all malignant lesions, a >30% higher mean POM for malignant Breast Imaging
Reporting and Data System (BI-RADS) 4B lesions, and a >10% higher
mean POM for malignant BI-RADS 5 lesions than did DUS. OA could potentially spare 23.7% more negative biopsies than DUS at the critical 2%
POM level.
Conclusions—The fused functional OA and grayscale
anatomic information significantly improved distinction of benign from
malignant breast masses compared with DUS alone, especially within the
BI-RADS 4B category, where OA better distinguishes benign from malignant lesions and thereby prevents unnecessary biopsies.
1522001 Granulomatous Mastitis: Clinical and Sonographic Features
With Image-Guided Biopsy Correlation
Priyanka Handa,1* Derek Sun,1 Jill Leibman,1,2 Aryeh Goldberg,1 Maria Abadi1,2 1Jacobi Medical Center, Bronx, New
York USA; 2Albert Einstein College of Medicine, Bronx, New
York USA
Objectives—Granulomatous mastitis (GM) is an unusual inflammatory lesion that can mimic breast cancer on clinical exam and
imaging studies. The purpose of this study was to review the clinical presentation and imaging findings (including sonography) associated with GM
and determine the adequacy of image-guided biopsy for diagnosis.
Methods—A retrospective study was performed to identify patients with breast imaging studies and a pathologic diagnosis of GM. The
clinical presentation, imaging findings, biopsy method, and pathology reports were reviewed.
Results—Twenty-seven patients were included; average age
was 35.3 years (range, 21–66 years). Twenty-four patients presented with
pain, a palpable mass, and/or discharge. Three asymptomatic patients presented for screening mammograms. All patients were imaged with ultrasound (US), demonstrating a mass in 19 (70%), tubular lucencies without
a mass in 6 (22%), and no findings in 2 (8%). In the 25 patients with positive sonographic findings, the mass was anechoic in 3 (12%), hypoechoic
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in 12 (48%), hyperechoic in 1 (4%), and mixed echogenicity in 9 (36%).
Four of the 25 masses demonstrated posterior acoustic enhancement
(16%), and 21 of the 25 masses did not demonstrate posterior acoustic enhancement (84%). Doppler vascularity was present in 11 patients (44%).
A mass was demonstrated in 19 patients; 5 masses were well defined
(26%), and 15 masses had irregular margins (74%). Twenty-six of the 27
patients had correlative mammographic findings. Pathologic diagnosis
was made by US-guided biopsy in 11 of 27 (40%), US-guided fine-needle
aspiration in 1 of 27 (4%), and mammotome biopsy in 1 of 27 (4%).
Palpation-guided tissue sampling was performed in 12 of 27 (44%). Surgical excision was performed in 7 of 27 (26%).
Conclusions—The sonographic features of GM are infrequently described. Our study demonstrated that the sonographic findings
are indeterminate and may mimic malignancy. Although previously reported exclusively in young women with palpable findings, our study
demonstrates that it can occur in postmenopausal as well as asymptomatic
patients. The diagnosis of GM is optimally made by US-guided core
biopsy.
1538026 Using a New Ultrasound Image-Processing Technique for
Identification of Microcalcifications in Patients Prior to
Biopsy
Priscilla Machado,* John Eisenbrey, Barbara Cavanaugh,
Flemming Forsberg Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
Objectives—To evaluate a new commercial image-processing
technique (MicroPure; Toshiba America Medical Systems, Tustin, CA)
for the identification of breast microcalcifications in patients undergoing
stereotactic or ultrasound (US)-guided biopsies and to compare results to
x-ray imaging of the tissue retrieved.
Methods—Twelve women, scheduled for stereotactic biopsy
or US-guided biopsy of an area with breast calcifications (identified on a
prior mammogram), were enrolled in the study. The patients underwent a
US examination consisting of real-time dual imaging of grayscale US and
MicroPure using an Aplio XG scanner (Toshiba America Medical Systems) with a broad-bandwidth linear array. MicroPure combines nonlinear imaging and speckle suppression to mark suspected calcifications as
white spots in a blue overlay image. Still images and digital clips of the
target area were acquired. Independent and blinded readers (2 radiologists
and 2 physicists) analyzed 26 digital clips to determine the number of calcifications seen with MicroPure and also to give a subjective view on the
level of suspicion (LOS) of the findings. X-ray imaging of the specimen
was analyzed by a radiologist who counted the exact number of microcalcifications. The number of microcalcifications was compared using the
mean number from the 4 readers with the mean number on the x-ray
image. The LOS was compared with the pathologic findings using receiver operating characteristic (ROC) analysis.
Results—The mean number of microcalcifications seen on
MicroPure was 6.96 (3.33–13.37). These values show excellent agreement with the mean number of microcalcifications seem on the x-ray
image of the tissue retrieved (7.42; P = .39). ROC analysis of the readers’
LOS scores compared to the pathologic findings produced areas under the
curve of 0.74–0.99.
Conclusions—MicroPure imaging was able to identify microcalcifications at the target area as confirmed by x-ray imaging of the tissue specimen. These findings indicate that MicroPure may be used to
guide breast biopsy procedures, but more studies are needed.
1540975 The Natural History of Thyroid Nodules With Peripheral
Calcification
Arash Anvari,* Anthony Samir Radiology, Abdominal
Imaging and Intervention, Massachusetts General Hospital,
Boston, Massachusetts USA
Objectives—Peripheral dystrophic calcification is a known pattern in thyroid nodules seen on ultrasound (US) and can be found in both
benign and malignant nodules. The American Thyroid Association (ATA)
guidelines for recommending biopsy in the setting of nodule follow-up
are predicated on a change in nodule size exceeding 50%. It is unknown
whether rim calcification in a thyroid nodule may prevent nodule enlargement, potentially rendering the ATA biopsy criteria ineffective. The
objective of this study was to determine whether rim calcified nodules undergoing US follow-up are able to enlarge to an extent meeting ATA criteria for fine-needle aspiration biopsy (FNAB).
Methods—We searched our institute’s radiology report database for thyroid nodules with rim calcification between 2002 and 2011. We
then reviewed each subject to determine parameters like demographic
data, nodule size, timing and number of follow-up sonograms, and FNAB
and/or surgical pathologic results. We calculated nodule volumes using
the formula for a rotational ellipsoid (volume = depth × width × length ×
π/6) to evaluate the growth rate between the first and last US reports.
Results—We found 197 thyroid nodules with peripheral rim
calcification in 192 subjects; 164 subjects (85.4%) were female (age range,
30–90 years; 60.35 ± 13.77 years; maximal dimension range, 3–36 mm;
11.95 ± 7.12 mm). We evaluated volume changes in 59 nodules that had
a US follow-up interval of at least 1 year (range, 1–9.5 years; 3.58 ± 2.14
years). Thyroid nodule volumes ranged from 0.02 to 14.19 mL (1.04 ±
2.29 mL) at the initial follow-up and ranged from 0.02 to 10.75 mL (11 ±
2.06 mL) at the last follow-up. Over the period of follow-up, 17 of 59 rim
calcified nodules (28.9%; 95% confidence interval, 17.3%–40.4%)
changed in volume by >50%. The proportion of nodules with volume
changes exceeding 50% increased with longer follow-up and when the
maximal diameter was <10 mm. Of the 197 nodules, we had FNAB findings in 49 nodules (23 benign, 16 malignant/suspicious, and 10 nondiagnostic). We also had surgical pathologic findings in 28 nodules (16
malignant and 12 benign lesions).
Conclusions—Rim calcification does not prevent changes in
thyroid nodule volumes over time.
1541150 Value of Shear Wave Elastography to Differentiate Benign
From Malignant Thyroid Nodules
Lucy Kerr,* Uziel Nunes, Luana Cunha Sonimage dig
Medico por US, São Paulo, Brazil
Objectives—The purpose of this study was to evaluate the value
of the shear wave elastography (E) to differentiate benign from malign
thyroid nodules according 2 criteria: (1) nodule stiffness and (2) differences in size between B-mode sonography (US) and E.
Methods—One hundred fifty thyroid nodules in 84 patients
were prospectively evaluated from September 2010 to August 2012 with
high-resolution US and shear wave E with the AS-2000 (Siemens). The
nodules were grouped according the stiffness in 11 patterns: (1) ≥70%
soft; (2) ≥70% intermediate; (3) ≥70% hard; (4) 51% to 69% soft; (5) 51%
to 69% intermediate; (6) 51% to 69% hard; (7) no hardness dominance;
(8) 50% soft and 50% intermediate; (9) 50% soft and 50% hard; (10) 50%
intermediate and 50% hard; and (11) same stiffness of thyroid parenchyma.
Patterns 1, 4, and 11 were considered benign, 3 and 6 malignant, and the
others inconclusive. We also considered benign if the nodule was bigger
on US than E, malignant if bigger on E than US, and inconclusive if had
the same size in both. All E diagnosis was correlated with cytopathology
and 55 nodules also with histopathology.
Results—Among the 150 thyroid nodules, 21 were malignant.
The sensibility, specificity, positive predictive value, and negative predic-
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tive value using the stiffness criterion were 90% (19/21), 93% (95/102),
73% (19/26), and 98% (95/97); and 88% (15/17), 91% (60/66), 71%
(15/21), and 97% (60/62) using the size criterion. We had 2 false-negatives,
both papillary cancer with cystic content giving the soft appearance, and
7 false-positives (3 lymphocytic thyroiditis and 4 colloid goiter). Of 150,
27 (18%) nodules were classified as inconclusive by the stiffness criterion and 62 (42%) by the size criterion.
Conclusions—Shear wave E of suspicious thyroid nodules
using the stiffness criterion is precise and helpful to differentiate between
benign and malignant thyroid nodules, and we recommend it to be incorporated in clinical practice. The size criterion is less helpful due to many
inconclusive cases, despite having good specificity and a good negative
predictive value.
1506963 Ultrasound- and Ultrasound Elastography-Based Clinical
Score for Screening of Thyroid Nodules
Nami Azar, Edwin Vargas Velandia,* Ronald Novak, Dean
Nakamoto Radiology, University Hospitals Case Medical
Center, Case Western Reserve University, Cleveland, Ohio USA
Objectives—In current clinical practice, most centers perform
biopsies on all thyroid nodules with a size >1 cm independent of the sonographic findings. Our aim was to develop an imaging-based clinical score
for better characterization of thyroid nodules with the aim of reducing
nonindicated thyroid biopsies.
Methods—In a retrospective review, data of patients who presented with suspicious thyroid nodules and underwent conventional
(Doppler) ultrasound (US), US quantification elastography, and USguided fine-needle aspiration (FNA) were analyzed. The nodules were
initially classified as benign or malignant according to the FNA result. The
following imaging parameters (internal flow, irregular margins, hypoechogenicity, calcifications, size [volume and diameter], and quantification
elastography) were analyzed under a direct logistic regression as accurate
predictors of malignancy. Four clinical scores were designed based on
these parameters and compared as diagnostic methods.
Results—A convenience sample of 130 subjects was chosen
for analysis. In this sample, thyroids of 24 subjects (18%) were proven by
pathology to be malignant, and 106 (82%) were benign. Direct logistic regression was used to calculate areas under the curve (AUCs) for 4 clinical scoring indices (S1–S4), and regression parameters were used to
compare the AUCs using the method of DeLong et al. Overall, 1 scoring
index (S1), including irregular margins, hypoechogenicity, size, internal
flow, and quantification elastography, was determined to be the best predictor of malignancy due to its larger AUC of 0.938. Choosing an index
score of 5.0 maximized both sensitivity (95.8%) and specificity (87.7%)
for predicting malignancy and would theoretically curtail the number of
biopsies by 72.3%.
Conclusions—Our clinical score based on imaging parameters
evaluated during a conventional US examination exhibits high sensitivity
and specificity for identifying malignant thyroid nodules. Application of
this tool in daily clinical practice may reduce the number of nonindicated
thyroid biopsies. Our study was limited by a small population size, and further analyses with larger patient samples are warranted.
1540472 Linear and Nonlinear Elastosonographic Data May Aid
Differentiation of Thyroid Nodules
Rafal Slapa,1* Bartosz Migda,1 Wieslaw S Jakubowski,1
Jacek Bierca,2 Jadwiga Slowinska-Srzednicka3 1Diagnostic
Imaging, Medical University of Warsaw, Warsaw, Poland;
2
Surgery, Hospital at Solec, Warsaw, Poland; 3Endocrinology,
Center for Postgraduate Medical Education, Warsaw, Poland
Objectives—Although elastography can assist in the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at
present. Further improvements in the technique and the diagnostic crite-
ria are necessary for this examination to provide a useful contribution to
diagnosis. The aim of the study was to evaluate a new linear/nonlinear approach for strain elastosonography of thyroid nodules, based on the analysis of time-strain curves, and to compare it with classic elasticity score
and thyroid strain ratio methods.
Methods—During 2009 to 2011, 67 patients scheduled for thyroidectomy (62 with myasthenia gravis) were evaluated with B-mode and
power Doppler ultrasound of the whole thyroid. During ultrasound examination, 96 dominant nodules were examined with strain elastosonography with Aplio XG (Toshiba, Japan) with a linear 5–17-MHz transducer.
The stiffness of each thyroid nodule was evaluated with classic features of
strain elastosonography qualitatively (with elasticity scores) and semiquantitatively with thyroid tissue strain/nodule strain ratios with application of Elasto Q (Toshiba). Moreover, a novel original approach to
elasticity data based on evaluation of time-strain curves was applied. Statistical analysis was performed with Statistica 10 (StatSoft, Inc).
Results—There were 7 papillary carcinomas and 89 benign
nodules. Classic elastosonographic analysis with the elasticity score and
elasticity ratio on statistical analysis did not show a significant difference
between cancer and benign nodules (P = .431 and .156). On linear/nonlinear analysis of time-strain curves, excellent differentiation (P = 5.6 × 10–9)
was possible with a new parameter: the relative length of nonlinear relaxation. With a threshold of 0.5, sensitivity was 100% and specificity 85.4%
(area under the receiver operating characteristic curve = 0.975).
Conclusions—The analysis of linear and nonlinear elastosonographic data may greatly improve differential diagnosis of thyroid
nodules. Further multicenter large-scale studies evaluating the usefulness
of linear/nonlinear elastosonographic phenomena (involving evaluation
of vioscoelasticity, eg, shear wave spectroscopy) in differential diagnosis
of thyroid cancer are warranted. (Supported by Ministry of Science of
Poland grant N402 476437.)
1540131 Noninvasive Determination of Corneal Elasticity Using
Acoustic Radiation Force After Corneal Cross-Linking
Raksha Urs,1* Harriet Lloyd,1 Ronald Silverman1,2
1
Ophthalmology, Columbia University Medical Center, New
York, New York USA; 2Frederic L. Lizzi Center for Biomedical
Engineering, Riverside Research Institute, New York, New York
USA
Objectives—There is immense interest in corneal cross-linking
therapy (CXL) to strengthen the cornea for treatment of keratoconus. Currently, biomechanical tests to assess efficacy of CXL in vivo are limited.
The objective of this project is to demonstrate the use of acoustic radiation
force (ARF) to determine the stiffness of the rabbit cornea in vivo before
and after CXL.
Methods—The corneas of 2 live rabbits were exposed to ARF
using a single-element transducer (25-MHz central frequency, 6-mm aperture, 18-mm focal length; Panametrics V324-SU). The beam sequence
consisted of 20 pushing tone bursts of 400 microseconds duration (80%
duty cycle), with imaging impulses interleaved in the dead time to allow
radiofrequency (RF) data acquisition during the push mode. M-mode data
were collected for another 200 milliseconds after the push sequence. The
right eyes of the rabbits were then cross-linked with ultraviolet light and
riboflavin. ARF measurements were performed once a week for 4 weeks
following CXL. A spline-based algorithm was used to determine continuous displacement of the front and back surfaces of the cornea, using RF
data sampled at 400 MHz (12 bits/sample), to determine the change in
corneal thickness and strain. The acoustic output was characterized with
a 40-µm-diameter needle hydrophone calibrated up to 60 MHz and measured to be 2.5 MPa. An absorption coefficient of 0.93 dB/cm-MHz was
used to estimate the force in the cornea. ARF-induced strain was fit to the
Voigt model to determine the elastic modulus.
Results—The mean elastic modulus values during the 4 weeks
of follow-up were 36 ± 8 and 32 ± 1 kPa for the untreated eyes and 49 ±
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5 and 45 ± 12 kPa for the cross-linked eyes. A paired t test revealed a statistically significant difference between untreated and cross-linked eyes
in 1 rabbit (P = .04). While corneal stiffness increased with cross-linking
in the other treated rabbit, the change was not statistically significant.
Conclusions—Results show that changes in corneal stiffness
after CXL can be measured in vivo using ARF. Future studies will be performed to evaluate the use of this method for detection of keratoconus,
where the cornea’s biomechanical properties are believed to be altered.
Contrast-Enhanced Ultrasound
Moderators: Yuko Kono, MD, PhD, Theresa Tuthill, PhD
1541199 Volumetric Contrast-Enhanced Ultrasound Imaging of
Renal Perfusion
Marshall Mahoney, Anna Sorace, Kenneth Hoyt* University of Alabama at Birmingham, Birmingham, Alabama USA
Objectives—The goal of this project was to evaluate wholeorgan ultrasound (US) imaging and microbubble (MB) contrast agents for
characterizing perfusion in a phantom and an animal model and also to assess the impact of US scanning parameters on volumetric image quality.
Methods—Real-time volumetric contrast-enhanced US
(VCEUS) imaging was performed using the BioSONIC VIEW system
(Bioscan Inc) equipped with a broadband 4DL14-5/38 probe. An MBsensitive harmonic imaging mode (transducer transmits at 5 MHz and receives at 10 MHz) was used to acquire VCEUS data. Following
microbubble infusion, custom programs implemented in MATLAB
(MathWorks) processed volumetric data sets and time-intensity curves to
estimate perfusion parameters, namely, peak intensity, time to peak intensity, wash-in rate, and area under the curve. The VCEUS system was tested
in vitro using a tissue-mimicking flow phantom at volume flow rates of 10,
20, 30, and 40 mL/min and MB concentrations of 0.005, 0.01, and 0.02
mL/L. The system was also tested using healthy Sprague Dawley rats to
further analyze renal perfusion imaging results. All experiments used the
Definity (Lantheus Medical Imaging) MB contrast agent.
Results—All 3D reconstructions allowed visualization of in
vitro and in vivo perfusion parameters. Volume summarizing statistics
from in vitro experiments demonstrated that wash-in rate and time-to-peak
measurements were proportional to volume flow rates, while the peak intensity and area under the curve measurements were proportional to the
MB dose concentration. Results acquired in rat kidney demonstrated that
parametric measurements were consistent for each animal. Importantly, rotation of the imaging transducer (up to 90°) did not impact renal perfusion
measurements at high-volume frame rates. Collectively, results indicate
that MB destruction-replenishment and time-intensity curve parametric
analysis with real-time volumetric ultrasound imaging is a promising
modality for characterizing renal perfusion properties.
Conclusions—VCEUS imaging was shown to be a promising
modality for evaluating renal perfusion. Preliminary results are encouraging, and this imaging modality may prove feasible for evaluating acute
and chronic kidney disease.
1540209 Parametric Contrast-Enhanced Ultrasound With Evaluation of Arrival Time Maps May Aid Differentiation Between
Adrenal Nodular Hyperplasia and Adenomas: Initial Results
Rafal Slapa,1* Anna Kasperlik-Zaluska,2 Bartosz Migda,1
Wieslaw S Jakubowski1 1Diagnostic Imaging, Medical University of Warsaw, Warsaw, Poland; 2Endocrinology, Center for
Postgraduate Medical Education, Warsaw, Poland
Objectives—Only some nonmalignant adrenal masses as some
myelolipomas and cysts present pathognomonic features on computed tomography, the examination of choice for evaluation of adrenal gland
pathology. Proper diagnosis in the cohort of nonmalignant adrenal masses
may be important for further management. The aim of the study has been
to evaluate possibilities of differentiation of nonmalignant masses of adrenals with application of a new technique for evaluation of enhancement after
administration of an ultrasound contrast agent: parametric imaging.
Methods—Seventeen nonmalignant adrenal masses in 14 patients were evaluated by dynamic examination after administration of 2.4
mL of the ultrasound contrast agent SonoVue with an Aplio XG convex
1–6-MHz transducer and parametric imaging. Patterns of parametric imaging of the arrival time and time to peak were evaluated. The final diagnosis was based on computed tomography, magnetic resonance imaging,
biochemical studies, follow-up, and/or surgery.
Results—There were 5 myelolipomas, 5 hyperplastic nodules, 4
adenomas, 2 hemangiomas with hemorrhage, and 1 cyst. Arrival time patterns of hyperplastic nodules (5/5) presented characteristic differential features of peripheral laminar inflow of SonoVue. Patterns for adenomas varied:
nonenhancement (1/4), central enhancement (2/4), and peripheral/central
inhomogeneous enhancement (1/4). Patterns for myelolipoma and hemangioma were different from those for adrenal hyperplastic nodules.
Conclusions—Parametric imaging may differentiate adrenal
adenomas from hyperplastic nodules and could be complementary to computed tomography. This could potentially influence the choice of treatment in patients with Conn syndrome and warrants further multicenter
large-scale studies. (Supported by Ministry of Science of Poland grant
N402 481239.)
1541233 Volumetric Molecular Ultrasound Imaging of Tumor
Vascularity in a Preclinical Model of Prostate Cancer
Anna Sorace, Marshall Mahoney, Kurt Zinn, Kenneth Hoyt*
University of Alabama at Birmingham, Birmingham, Alabama
USA
Objectives—The goal of this project was to evaluate volumetric molecular ultrasound (US) imaging of tumor vascularity in a preclinical model or prostate cancer.
Methods—Real-time volumetric molecular US imaging was
performed using the BioSONIC VIEW system (Bioscan Inc) equipped
with a broadband 4DL14-5/38 probe. An MB-sensitive harmonic imaging
mode (transducer transmits at 5 MHz and receives at 10 MHz) was used
to acquire molecular US images. Nude athymic mice (n = 10) were implanted with 2 million prostate cancer cells (PC3), and tumors were allowed to grow to approximately 1 cm in diameter. Microbubbles
(Targestar-SA; Targeson) were conjugated with multiple antibodies targeting tumor vascularity (αvβ3, p-selectin, and vascular endothelial growth
factor receptor 2) or with an immunoglobulin G isotype control antibody.
Following tail vein injection of the MB contrast agent, a 5-minute delay
allowed systemic circulation and target receptor binding. Molecular US
images were captured to determine the amount of MBs bound and flowing. Then a high-intensity pulse via an external US transducer was administered to destroy all MBs, followed by an additional US scan to
determine residual circulating MBs. Custom MATLAB software (MathWorks) was developed to determine overall intratumoral image intensity.
Subtraction of US image data from before and after MB bursting yielded
a measure of MBs bound to the targeted tumor receptors. All animals received both MB types following a 2-hour delay between injections.
Results—Molecular US imaging of targeted MBs yielded a
considerable increase in intratumoral image enhancement over that obtained using control MBs, as evident from volume reconstruction of segmented tumor data. More specifically, molecular US image enhancement
using targeted MBs ranged from 30% to 160% when compared to control
data from the same population of animals. Targeted MB image enhancement was consistent with fraction tumor vascularity measures.
Conclusions—Whole-tumor molecular US imaging is a promising strategy for assessing biomarkers of prostate cancer vascularity, and
further research is warranted.
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1539659 Small Nodules Arising in Cirrhotic Liver During
Surveillance: Possibility of Characterization Among
Dysplastic Nodules, Early Hepatocellular Carcinoma,
and Progressed Hepatocellular Carcinoma Using ContrastEnhanced Ultrasound
Antonio Giorgio, Giorgio Calisti, Umberto Scognamiglio,
Nunzia Farella, Giorgio de Stefano, Filomena Di Martino,
Valentina Giorgio D. Cotugno Hospital, Naples, Italy
Objectives—The evolution from low-grade dysplastic nodules
(DNs) to hepatocellular carcinoma (HCC) is characterized by a gradual
disappearance of intranodular portal tracts and a progressive development
of neoangiogenic unpaired arteries. Contrast-enhanced ultrasound (CEUS)
is able to depict intranodular vascularity. The aim of this study was to evaluate CEUS in the characterization of DNs and HCC in liver cirrhosis.
Methods—Forty-six consecutive patients with liver cirrhosis
and a single hepatic nodule ≤2 cm were enrolled from February to
December 2009. The nodule was continuously observed for 4 to 6 minutes following contrast injected until the disappearing of the enhancement.
We studied and recorded the arterial phase (15–30 seconds after contrast
injection), the portal phase (30–60 seconds), and the sinusoidal phase (60–
240 seconds). Three patients needed a second injection of 2.4 mL of
SonoVue because of inadequate visualization of the enhancement. We
analyzed the pattern of the enhancement of the lesion after contrast injection, and we compared the features of nodule and surrounding liver
parenchyma. All patients underwent CEUS and subsequent US-guided
biopsy of the lesion. Histologic findings and imaging interpretation of
DNs and HCC were compared.
Results—Progressed HCC was identified by a homogeneous
pattern of hypervascularization during the arterial phase with sensitivity of
90.9% and specificity of 100%. Early HCC showed an inhomogeneous
and reticular pattern and was identified with sensitivity of 85.7% and
specificity of 96.1%.
Conclusions—CEUS is able to depict the vascularization pattern of hepatic nodules during the arterial phase and to differentiate DNs,
early HCC, and progressed HCC.
1511998 Thyroscan: A Cost-Effective and Noninvasive Automated
System for Thyroid Lesion Classification in 3-Dimensional
Contrast-Enhanced Ultrasound Images
U. Rajendra Acharya,1 Vinitha Sree,2 M. Mutu Rama Krishnan,1 Filippo Molinari,3 Roberto Garberoglio,4 Jasjit Suri*2,5
1
Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 2Global Biomedical Technologies, Roseville,
California USA; 3Electronics and Telecommunications,
Politecnico Torino, Torino, Italy; 4Scientific Foundation Mauriziana ONLUS, Torino, Italy; 5Biomedical Engineering, Idaho
State University, Pocatello, Idaho USA
Objectives—Ultrasound has great potential to aid in the differential diagnosis of malignant and benign thyroid lesions, but the accuracy
is still poor. We developed and analyzed a range of knowledge representation techniques for characterizing the intranodular vascularization of thyroid lesions by using 3D contrast-enhanced ultrasound images.
Methods—Twenty patients, 10 males (age, 53.5 ± 13.3 years;
range, 22–71 years) and 10 females (age, 50.1 ± 10.8 years; range, 25–68
years) with a previously confirmed diagnosis of a solitary thyroid nodule
were enrolled in this study. All subjects underwent a clinical examination,
hormonal profile, and 3D contrast-enhanced ultrasound volume acquisition after 2.5 mL of SonoVue (Bracco, Italy) injection. The features of the
3D volumes were extracted by using the discrete wavelet transform
(DWT), and the texture of the nodular vascularization was measured by
using statistical and structural measurements. The 10 features were fed to
3 type of classifiers: K-nearest neighbor (K-NN), probabilistic neural networks (PNN), and decision tree (DT).
Results—The performance of the classifiers was compared
using receiver operating characteristic (ROC) curves. The combination of
DWT and texture features coupled with K-NN resulted in good results,
with an area under the ROC curve (AUC) of 0.987, a classification accuracy of 98.9%, sensitivity of 99.8%, and specificity of 98.1%. We proposed a novel integrated index called the thyroid malignancy index (TMI),
made up of DWT and texture features, which was discriminant to diagnose
benign or malignant nodules using just 1 index.
Conclusions—This integrated TMI can be employed for the
diagnosis of benign and malignant nodules effectively. The advantage is
the fact that, to make a diagnosis, the physician needs to only look at the
value of just 1 integrated index instead of checking the range of each individual feature.
Table 1. Performance of the Classifiers
Accuracy, Sensitivity, Specificity,
Classifier TN FN TP FP
%
%
%
AUC
K-NN
40 0 39 1
98.9
99.8
98.1
0.987
PNN
40 0 38 2
97.8
99.8
96.3
0.975
DT
40 0 38 2
97.8
99.8
96.3
0.975
FN indicates false-negative; FP, false-positive; TN, true-negative; and TP,
true-positive.
1466379 Usefulness of Contrast-Enhanced Ultrasound in Clinical
Practice: The Spanish Trial
Carlos Nicolau,1* Teresa Fontanilla,2 Jose del Cura,3 Antonio
Talegon,4 Xavier Serres5 1Radiology, Hospital Clinic,
Barcelona, Spain; 2Radiology, Hospital Universitario Puerta
de Hierro, Majadahonda, Madrid, Spain; 3Radiology, Hospital
de Basurto, Bilbao, Spain; 4Radiology, Hospital Virgen del Rocio,
Seville, Spain; 5Radiology, Hospital Vall Hebro, Barcelona,
Spain
Objectives—The aim of this multicenter study was to evaluate
contrast-enhanced ultrasound (CEUS) diagnostic performance in clinical
practice in Spain.
Methods—A total of 1786 patients (mean age, 59.8 years) from
42 hospitals, with baseline US studies that were considered inconclusive,
were included in this multicenter study. We evaluated 1516 (84.9%) abdominal cases (including 1272 livers [71.2%], 179 kidneys [10%], 35
spleens [2%], 17 pancreases [1%], and 38 in other abdominal locations
[2.1%]), 77 breast studies (4.3%), 111 supra-aortic vessel studies (6.2%),
and 82 in other locations (4.6%). All studies were performed using specific
contrast software and intravenous injection of SonoVue (Bracco, Italy;
mean dose, 3 mL). A low mechanical index (<0.2) was used in most cases.
Results of CEUS studies were compared with the definite diagnosis by
reference procedures.
Results—Only 1 patient (0.001%) was excluded due to contraindications. Most studies (84.8%) were evaluated with a single dose of
the contrast agent, and the mean time employed to perform the CEUS
study was 7.8 minutes. CEUS use determined a significant improvement
in the diagnostic confidence in 91.6% of the cases, allowing a conclusive
diagnosis in 69.2% of the patients. The highest accuracy was obtained in
supra-aortic vessel evaluation, with a conclusive diagnosis in 95.4% of
the cases, followed by 72.6% of the abdominal cases.
Conclusions—The use of CEUS provided a significant improvement in clinical practice with an accurate diagnosis in most of the inconclusive baseline US studies.
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1517021 Four-Dimensional Subharmonic Breast Imaging: Initial
Experiences
John Eisenbrey,1* Anush Sridharan,1,2 Daniel Merton,1
Priscilla Machado,1 Kirk Wallace,3 Carl Chalek,3 Kai Thomenius,3 Flemming Forsberg1 1Radiology, Thomas Jefferson
University, Philadelphia, Pennsylvania USA; 2Electrical and
Computer Engineering, Drexel University, Philadelphia, Pennsylvania USA; 3GE Global Research, Niskayuna, New York
USA
Objectives—To describe initial experiences of using 4D contrast-enhanced subharmonic ultrasound imaging (SHI) and harmonic ultrasound imaging (HI) for the characterization of mammographically
identified breast lesions.
Methods—4D SHI (transmitting 4 cycle pulses at 5.8 MHz, receiving at 2.4 MHz) was performed using a modified LOGIQ 9 ultrasound
scanner with the 4D10L probe (GE Healthcare, Milwaukee, WI). After
providing informed consent, 39 patients scheduled for an ultrasoundguided breast biopsy received 2 injections of the contrast agent Definity
(Lantheus Medical Imaging, North Billerica, MA). Patients first received
a 0.25-mL injection while being continuously scanned with 4D HI (transmitting 2 cycle pulses at 5 MHz, receiving at 10 MHz). After 30 minutes,
patients received a 20-µL/kg injection while undergoing 4D SHI. Both
the screen-captured, rendered images and raw slice data for the entire contrast wash-in/wash-out cycle were digitally stored for analysis and processing.
Results—Volume acquisition rates varied based on the lesion
size and depth of scanning ranged from 1.7 Hz (for a 3.7 × 1.3 × 2.0-cm
lesion) to 6.1 Hz (for a 6 × 4 × 6-mm lesion) with volume angles of 9° to
19°. Contrast enhancement depended heavily on lesion vascularity
(determined during initial physician exam using power Doppler). In 38
of 39 cases, SHI resulted in better tissue suppression relative to HI and
improved contrast visualization in vascular lesions. In vascular cases, vessel connectivity was observed in 3D space with clear visualization of contrast wash-in and wash-out. Raw slice data were successfully processed to
create 3D maximum intensity and perfusion parametric maps. These
processed volumes further improved the ability to delineate blood vessels
from the surrounding tissue and quantify flow parameters.
Conclusions—In almost all cases, 4D SHI resulted in improved
visualization of contrast relative to 4D HI. Access to raw slice data allows
for the generation of 3D parametric maps of the vasculature. Future work
will determine the value of 4D SHI for characterizing breast lesions.
Emergency Ultrasound, Part 1
Moderators: Leslie Scoutt, MD, Gowthaman Gunabushanam, MD
1540915 Accuracy of Lung Ultrasound and Chest Radiography for
Diagnosis of Cardiogenic Dyspnea Among Elderly Emergency Department Patients
Emanuele Pivetta,1,2,3* Livia Ausiello,4 Elke Platz,1 Michael
Stone,1 Maria Tizzani,5 Giulio Porrino,5 Enrico Ferreri,5
Giovanni Volpicelli,6 Paolo Balzaretti,4 Alessandra Banderali,7 Antonello Iacobucci,8 Enrico Lupia,2 Alberto Goffi,9 Giovanna Casoli,10 Gianalfonso Cibinel11 1Emergency Medicine,
Division of Emergency Ultrasound, Brigham and Women’s
Hospital, Boston, Massachusetts USA; 2Emergency Medicine,
3
Oncology and Hematology, Cancer Epidemiology Unit, San
Giovanni Battista Hospital and University of Turin, Turin, Italy;
4
Emergency Medicine, Mauriziano Hospital, Turin, Italy;
5
Emergency Medicine, San Giovanni Battista Hospital, Turin,
Italy; 6Emergency Medicine, San Luigi Gonzaga University
Hospital, Orbassano, Turin, Italy; 7Emergency Medicine, Cardinal Massaia Hospital, Asti, Italy; 8Emergency Medicine,
Santa Croce e Carle Hospital, Cuneo, Italy; 9Critical Care
Medicine, St Michael’s Hospital, Toronto, Ontario, Canada;
10
Emergency Medicine, Martini Hospital, Turin, Italy; 11Emergency Medicine, Pinerolo Civil Hospital, Turin, Italy
Objectives—This study aimed to evaluate the diagnostic accuracy of pleural and lung ultrasound (PLUS) vs chest radiography for the
identification of interstitial syndrome and pleural effusions (indicators of
acute decompensated heart failure) among elderly patients presenting to
the emergency department (ED) with dyspnea.
Methods—This was a prospective multicenter cohort study of
patients presenting to an Italian ED with shortness of breath. After the initial assessment, emergency physicians categorized dyspnea as cardiogenic
or noncardiogenic. Patients then underwent 8-zone PLUS with a curvilinear transducer assessing for sonographic artifacts (B-lines) and pleural
effusions (mean scanning time, 3.47 minutes). Three or more B-lines were
suggestive of interstitial syndrome. The same physician then recorded the
new diagnostic category, incorporating both initial clinical assessment and
PLUS findings. All patients also underwent standard chest radiography.
After discharge, medical records were independently reviewed by 2 emergency physicians blinded to the PLUS results to determine the most likely
cause of dyspnea.
Results—Between October 2010 and August 2012, 674 elderly
patients were enrolled. Median age was 79 years (range, 65–99 years);
54.7% were male; 22.4% had a history of heart failure; and 40.9% had
chronic obstructive pulmonary disease. In 284 subjects (42.1%) the etiology of dyspnea was cardiogenic. PLUS had sensitivity (Se) of 97.7% (confidence interval [CI], 94.6%–99.2%) and specificity (Spe) of 96% (CI,
93.8%–99.3%) for the diagnosis of cardiogenic dyspnea, with a positive
predictive value (PPV) of 98.1% (CI, 95.3%–99.5%) and a negative predictive value (NPV) of 97% (CI, 93%–99%). Chest radiography had Se
of 70.3% (CI, 61.6%–78.1%), Spe of 80% (CI, 70.8%–87.3%), a PPV of
81.8% (CI, 73.3%–88.5%), and an NPV of 67.8% (CI, 58.6%–76.1%).
PLUS improved the clinician’s diagnostic accuracy for cardiogenic dyspnea by 10% (CI, 7.7%–12.3%).
Conclusions—In our study, PLUS had higher diagnostic accuracy than chest radiography for the diagnosis of cardiogenic dyspnea in
elderly ED patients. PLUS may represent a more rapid and accurate tool
in the bedside assessment of patients with suspected acute decompensated
heart failure.
1540969 Bedside Cardiac Ultrasound Examination to Confirm
Central Venous Catheter Placement
Yiju Liu,1 Kathleen Calabrese,1* Kunal Ajmera,2 Mohammad
Salimian,1 Thaison Tran,1 Hamid Shokoohi,1 Keith Boniface,1
Melissa McCarthy1 1Emergency Medicine, George Washington University Medical Center, Washington, DC USA;
2
School of Public Health and Human Services, George Washington University, Washington, DC USA
Objectives—This study evaluated the use of bedside ultrasound
examination (BUE) to confirm proper CVC insertion. More than 5 million
central venous catheters (CVCs) are placed each year in the United States.
Mechanical complications of CVC insertion range between 5% and 19%,
and the malposition rate can be as high as 50%. Current practice of obtaining post-CVC chest radiography (CXR) to confirm placement may
delay care and expose patients to repeated ionizing radiation.
Methods—We prospectively enrolled patients requiring abovethe-diaphragm CVC placement from the emergency department (ED), intensive care unit (ICU), and operating room (OR) at a tertiary academic
center. Within 24 hours of CVC placement, we pushed 10 mL of saline solution through a distal catheter port while simultaneously obtaining a single view of the heart using BUE and documented whether echo signals of
the saline solution appeared in the right heart and the timing of their appearance. We hypothesized that the immediate presence of echogenic sig-
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nals from the saline flush signaled proper catheter tip placement. We compared the agreement between BUE results and those of CXR or computed
tomography (CT) using a κ statistic.
Results—Twenty-seven patients were enrolled, and 26 were
analyzed. One subject was excluded because his surgery was canceled,
and he no longer required CVC. Eight patients were enrolled from the ED,
9 from the ICU, and 9 from the OR. On BUE, 1 patient had a technically
limited study, and 25 demonstrated saline echoes in the right heart. One of
the 25 demonstrated intracardiac catheter malposition, confirmed by CXR.
All 26 patients had CXR, and 2 had additional CT; 25 had confirmed
proper CVC placement, including the 1 patient for whom BUE was inconclusive. Timing for BUE was as follows: 20 cases done concurrently
with CVC placement, 2 done within 1 hour, and 3 done within 24 hours.
Of the 25 BUEs that were interpretable, there was 100% agreement between BUE and CXR in detecting CVC location (P = .000).
Conclusions—Despite the small sample size, this study shows
promise for the use of BUE to accurately confirm CVC placement more
quickly than CXR. A larger study is needed before we can recommend
using BUE routinely to replace post-CVC CXR.
1513191 Bedside Thoracic Ultrasound for Pulmonary Edema:
Which Zones Are the Best?
Zoe Howard,* Feras Khan, Anne-Sophie Beraud, Laleh
Gharahbaghian, Raymond Balise, Ravi Pamnani, Michael
Schaller, Joelle Barral, Sidhartha Sinha, Sarah Williams
Emergency Medicine, Stanford University Medical Center,
Stanford, California USA
Objectives—Thoracic ultrasound (US) has been validated to
predict pulmonary edema with high sensitivity and specificity in the presence of B-lines, a US reverberation artifact caused by interstitial fluid. Our
study investigates whether there are specific anatomic zones with a greater
positive predictive value for pulmonary edema. If so, we could perform
this test more rapidly, an important consideration from both a resource utilization and patient care perspective.
Methods—We performed a prospective observational study,
scanning a convenience sample of adult emergency department (ED) patients with shortness of breath at a large tertiary care academic center. Following previously published protocols, the right anterior chest was divided
into 4 zones with zones 1 and 2 representing an upper and lower midclavicular distribution, respectively, and 3 and 4 upper and lower midaxillary. The division was mirrored on the left with 5 and 6 anterior and 7 and
8 lateral. When there were at least 2 bilateral positive zones, the patient was
enrolled. Compared to a gold standard of chest radiography combined
with brain natriuretic peptide, echocardiography, and discharge diagnosis, patients were confirmed to have acute pulmonary edema. All images
were reviewed by 2 US fellowship-trained ED physicians, and each zone
was scored according to an a priori scale.
Results—During the initial pilot, 24 patients were analyzed.
There was no dominant pattern that emerged among the 8 zones. Thirteen
percent (3/24) were positive in every zone. On the right, zones 2, 3, and 4
were positive in 79% (19/24), while on the left, zone 5 was positive in
71% (17/24) and zone 7 in 67% (16/24). When the right chest was noted
to be positive, the contralateral zone noted to be positive in the greatest
number of patients was zone 5.
Conclusions—While the small number of patients limits this
study, trends were noted in specific zones, particularly the right chest and
zone 5. However, there is no dominant pattern or statistically significant
results to suggest that any zone is more predictive for diagnosing acute
pulmonary edema by B-lines on US. This suggests that it is necessary to
scan all 8 zones and perform a thorough but expeditious thoracic US examination when rapid diagnosis of critically ill patients is crucial.
1538301 Central Venous Catheterization Location Changes and
Complication Rates After the Institution of an Emergency
Ultrasound Division
Tahisha Tolbert,* Lawrence Haines, Lucas McArthur,
Victoria Terentiev, Antonios Likourezos, Eitan Dickman
Emergency Medicine, Maimonides Medical Center, Brooklyn,
New York USA
Objectives—To look at central venous catheter (CVC) placement patterns before and after the establishment of an emergency ultrasound division (EUSD). We hypothesized that the internal jugular vein
(IJ) site would be used more often as familiarity with ultrasound (US)
increased. A secondary objective was to compare the mechanical complication rates associated with CVC placement before and after the establishment of an EUSD.
Methods—This was a retrospective chart review looking at all
CVCs placed in an urban tertiary care medical center’s emergency department (ED) with an emergency medicine residency program and
115,000 ED visits per year. We queried our electronic medical record for
all CVCs placed in the ED between the years 2004 and 2007 and the years
2007 and 2010, representing the 3 years before and after the establishment
of the EUSD. The locations of these CVCs were compared to assess for
any changes. This data set was then queried for patients who had a documented mechanical complication from the CVC placement.
Results—In all, 1876 CVCs were placed between 2004 and
2007, and 1707 were placed between 2007 and 2010. Selection of the
femoral vein CVC location changed from 50.8% to 42.5%, subclavian
from 37.0% to 17.3%, and IJ from 12.2% to 40.2% (P = .0001 for all). The
mechanical complication rate decreased from 9.1% to 5.4% (P = .0001).
Conclusions—The establishment of an EUSD, with formal
training in the use of US for CVC placement, is associated with a significant change in CVC site selection patterns, most notably a sharp increase
in selection of the IJ site and a dramatic reduction in the selection of the
subclavian site. In addition, there was a 41% decrease in the complication
rates such as pneumothorax and arterial puncture.
Table 1. Specific Complications
Complication
Pneumothorax
Chest tube
Arterial puncture
2004–2007
23 (1.2)
18 (1)
47 (2.5)
n (%)
2007–2010
6 (0.4)
4 (0.2)
21 (1.2)
P
.004
.005
.005
1539748 Faster = Better? Pilot Sonographic Evaluation of Internal
Jugular Vein Collapsibility Versus Inferior Vena Cava
Collapsibility Indices in Critically Ill Patients
David Evans,1* Daniel Eiferman,1 Alistair Kent,1 Creagh
Boulger,2 Andrew Springer,3 Eric Adkins,2 Susan Yeager,1
Geoffrey Roelant,1 Stanislaw Stawicki,1 David Bahner2
1
Surgery, 2Emergency Medicine, 3Anesthesiology, Ohio State
University, Columbus, Ohio USA
Objectives—Intensivist-performed bedside sonographic assessment of volume status is a rapidly evolving area. Although the inferior vena cava collapsibility index (IVC-CI) has been shown to correlate
with both clinical assessment and invasive monitoring of intravascular
volume status, it is limited by difficult visualization of the IVC, interference by surgical dressings and tubes, and a relatively steep learning curve.
Many physicians already have experience with internal jugular ultrasound
for vascular access. Due to the ease of the technique and simpler anatomy,
we hypothesized that the internal jugular vein collapsibility index (IJVCI) would be easier to perform than the IVC-CI.
Methods—A prospective observational pilot study comparing
IVC-CI and IJV-CI was performed in surgical intensive care unit patients.
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In addition to patient demographics and basic hemodynamic data, simultaneous M-mode measurements of the IVC-CI and IJV-CI were collected
during each bedside sonographic session. IVC measurements were obtained using curvilinear probes. IJV measurements were obtained using
high-frequency linear array probes. Statistical comparisons for paired data
included linear regression with correlation coefficients and Bland-Altman
analysis with construction of a mean difference plot for bias determination.
Results—A total of 16 patients were enrolled (mean age, 52.8
years). There were 5 women and 11 men. Acquisition of adequate IJV-CI
scans was faster than acquisition of IVC-CI scans (43 vs 105 seconds scanning time, respectively; P < .01). Thirty-five measurement pairs were obtained, with some correlation noted between paired IVC-CI and IJV-CI
measurements (r = 0.54; r2 = 0.289). There was a 6% negative measurement bias between IJV-CI and IVC-CI measurements as determined by the
Bland-Altman method.
Conclusions—IJV-CI measurement can be performed significantly faster than IVC-CI measurement. In our pilot study, there was minimal mean measurement bias (6%) between the 2 techniques, indicating
that the IJV-CI tends to overestimate collapsibility. More data are needed
to better characterize the correlation between the IJV-CI and IVC-CI and
define the role of the IJV-CI in clinical practice.
1540557 Point-of-Care Ultrasound Evaluation of Central Line
Placement
Eric Mervis,1* Elizabeth Turner,3 Alan Chiem,4 Robert Liou,2
Randy Hou,5 Craig Anderson,1 Arthur Youssefian,1 J. Christian Fox1 1Emergency Medicine, 2Pulmonary/Critical Care,
University of California Irvine, Orange, California USA; 3Pulmonary/Critical Care, University of California Los Angeles,
Los Angeles, California USA; 4Emergency Medicine, University
of California Los Angeles, Olive View, Los Angeles, California
USA; 5Pulmonary/Critical Care, Kaiser, Fontana, California
USA
Objectives—In our study we use point-of-care ultrasound
(POC-US) to confirm proper central venous catheter (CVC) placement
and compare the results of POC-US to chest x-ray (CXR), the current standard of evaluating CVC placement.
Methods—This is an ongoing prospective single-center noninferiority study comparing the effectiveness of POC-US and CXR in
confirming placement of CVCs. A convenience sample of critically ill patients that require emergent CVC placement in the intensive care unit
(ICU) or the emergency department at the University of California Irvine
Medical Center have been enrolled. Patients who are >18 years old and
require placement of a subclavian (SC) or internal jugular (IJ) CVC are eligible for enrollment in this study. Qualified emergency medicine and
ICU physicians place CVCs into IJ or SC veins. US is then performed to
obtain multiple views for confirmation of CVC placement. These include
views of the CVC within the central vein, the ipsilateral pleural line to
rule out pneumothorax, and the contralateral IJ vein to rule out malposition. Last, a cardiac view is obtained to show the presence of the tip of the
catheter in the right atrium or turbulence after a 10-mL saline flush, thus
confirming placement of the catheter in the superior vena cava. The times
of US and CXR completion and subsequent review of the CXR by the
physician performing the procedure are recorded.
Results—A total of 55 central lines with complete US imaging
and comparable CXRs have been obtained to date with a goal of enrolling
140 subjects. The US method has identified 2 misplaced lines, and the
CXR has shown 5 misplaced lines. Agreement between the 2 methods for
confirming CVC placement is 91% (50/55). The US method thus far has
a negative predictive value of 92.5% (confidence interval, 82%–98%).
There is an average 17-minute difference between time to US and time to
CXR. There have been no pneumothoraxes identified by either method.
Conclusions—Preliminary data suggest that POC-US and
CXR have similar agreement for identifying misplaced CVCs. There is a
17-minute time difference to POC-US vs CXR, which could translate to
more expeditious use of central lines for intravenous fluids, antibiotics, or
vasopressors in potentially unstable patients.
1541330 Three-Window Bedside Ultrasound Versus Chest Radiography for Confirmation of Endotracheal Tube Placement
Arthur Youssefian,1* Elizabeth Turner,3 Shane Breazeale,2
Angelina Amian,2 Eric Mervis,1 J. Christian Fox,1 Negean
Vandordaklou,4 Craig Anderson1 1Emergency Medicine,
2
Pulmonary and Critical Care, University of California Irvine,
Orange, California USA; 3Pulmonary and Critical Care, University of California Los Angeles, Los Angeles, California USA;
4
Department of Emergency Medicine, Long Beach Memorial
Hospital, Long Beach, California USA
Objectives—In our study, we use 3-window bedside point-ofcare ultrasound (POC-US) to confirm proper endotracheal tube (ETT)
placement and compare the results of POC-US to chest x-ray (CXR), the
current standard of evaluation. The hypothesis is that POC-US will be
noninferior to CXR for ETT placement and will be more expedient.
Methods—This is an ongoing prospective noninferiority study
comparing the effectiveness of 3-window bedside POC-US in confirming
placement of ETTs. A convenience sample of critically ill patients who
required emergent endotracheal intubation in the intensive care unit (ICU)
or the emergency department (ED) at the University of California Irvine
Medical Center have been enrolled. Patients who are >18 years old and require tracheal intubation are eligible for enrollment. Qualified ED and
ICU physicians placed ETTs per the usual protocol. US is then performed
to obtain multiple views for confirmation of ETT placement. These include views of the trachea, bilateral lungs, and diaphragms. The primary
objective was to compare the sonographer’s ability to predict placement
of ETTs based on a 3-window bedside US model compared to the formal
interpretation of the postintubation CXR read by an attending radiologist.
The secondary outcome objective was to measure and compare the time
from the 3-window US exam to the time of the initial availability of postintubation CXR as well as to the time of availability of the radiologist’s formal interpretation of the film.
Results—A total of 136 subjects with complete US imaging
and CXRs have been enrolled to date, with a goal of 140 subjects. The 3window US method correctly identified 124 of 128 ETTs placed in the
trachea (specificity, 94.7%). US correctly identified 1 of 5 ETTs found by
CXR to be in a main stem bronchus (sensitivity, 20%), with a positive
likelihood ratio (LR) of 3.74 and a negative LR of 0.845.
Conclusions—Preliminary data suggest that 3-window POCUS and CXR have similar agreement for identifying correctly placed
ETTs. Additional analysis of subjects with false-positive and false-negative US impressions will aim to determine factors contributing to these
type I and II errors.
1541487 Transcricothyroid Ultrasound for Confirmation of
Endotracheal Tube Placement by United States Military
Emergency Medicine Providers
Michael Rebener,* Chase Donaldson, Eric Chin Emergency
Medicine, San Antonio Military Medical Center, San Antonio,
Texas USA
Objectives—The purpose of this study is to assess the accuracy
of dynamic transcricothyroid ultrasound for confirming endotracheal tube
(ET) placement by military emergency medicine (EM) providers, specifically physicians and physician assistants, and to examine the relationship
between accuracy and prior ultrasound experience in this application.
Methods—A prospective randomized double-blinded validation study to identify ET placement in a cadaver model using ultrasound
was conducted. Twenty-six EM providers with variable ultrasound experience were given a brief presentation on how to identify airway land-
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marks using ultrasound and shown examples of esophageal and tracheal
intubations. The cadavers were randomized to a tracheal or esophageal
intubation, and the EM providers recorded their responses after performing dynamic transcricothyroid ultrasound (DTUS). Responses were timed,
and the experience level of each provider with ultrasound was recorded.
Results—The EM providers correctly identified the ET location
in 266 of 329 scans, for accuracy of 80.1% for all providers. The difference in accuracy between experienced and inexperienced providers was
not statistically significant (P = .433), but more experienced providers had
shorter response times (P = .031). Physicians were not more accurate than
physician assistants (P = .746), but physicians’ response times were shorter
(P < .001).
Conclusions—Our study suggests that EM providers with
more ultrasound experience, defined as >250 scans, are not necessarily
more accurate at identifying correct placement of ETs than those with less
experience. Similarly, no statistically significant difference was seen in
accuracy between provider types. This study suggests that DTUS can be
easily learned by inexperienced sonographers, but given the relatively low
accuracy rate of DTUS in this study, regardless of experience, DTUS
should be used only as an adjunct to current ET confirmation methods.
1541012 Effect of the Prone Maximal Restraint (aka “Hog Tie”)
Position on Cardiac Output and Other Hemodynamic
Measurements
Davut Savaser,* Colleen Campbell, Ted Chan, Virag Shah,
Chris Sloane, Allan Hansen, Eddie Castillo, Gary Vilke
Emergency Medicine, University of California San Diego, San
Diego, California USA
Objectives—To measure the impact of prone maximal restraint
(PMR) with and without weight force on measures of cardiac function,
including vital signs, oxygenation, stroke volume (SV), cardiac output
(CO), and left ventricular outflow tract diameter (LVOTD).
Methods—We conducted a randomized prospective crossover
study of healthy volunteers (18–60 years of age) placed in 5 different body
positions: supine, prone, PMR, PMR with 50 lb added to the subject’s
back (PMR50), and PMR with 100 lb added to the subject’s back
(PMR100) for 3 minutes. Data were collected on subject vital signs and
echocardiographic measurement of SV, CO, and LVOTD, measured by
credentialed emergency department faculty sonographers. Anthropomorphic measurements of height, weight, arm span, chest circumference, and
body mass index were also collected. Data were analyzed using repeated
measures analysis of variance to evaluate changes in each variable with respective positioning.
Results—Twenty-five male subjects were enrolled in the study,
ages ranging from 22 to 43 years. Cardiac output did change from the
supine to prone position, decreasing on average by 0.61 L/min (P = .013;
95% confidence interval [CI], 0.142, 1.086 L/min). However, there was no
significant change in CO when placing the patient in the PMR position
(–0.11 L/min; P = .489; 95% CI, –0.43, 0.21 L/min), PMR50 position
(0.19 L/min; P = .148; 95% CI, –0.07, 0.46 L/min), or the PMR100 position (0.14 L/min; P = .956; 95% CI, –0.29, 0.27 L/min) compared with the
prone position. Systolic blood pressure never dropped below 100 mm Hg
in any position; heart rate never increased above 100 beats per minute,
and there were no incidents of syncope or other subjective complaints.
Conclusions—CO is not significantly affected by the PMR position compared with the prone position, nor is it adversely affected with
application of 50 or 100 lb of weight force to the back while in the PMR
position. The PMR position and a weight force of up to 100 lb does not
cause hemodynamic compromise of the restrained patient.
1541228 Ultrasound-Guided Peripheral Intravenous Insertion:
Right Line at the Right Time
James M. Joseph, Daniel Kagarise, Todd Henkaline, James
White,* David Bahner Vascular Access, Ohio State University Medical Center, Columbus, Ohio USA
Objectives—To increase the success rate of initial intravenous
line (IV) attempts using ultrasound guidance and to use expert assessment
and a triage process to choose the “right line at the right time.”
Methods—We began in September 2005. Physician-initiated
requests were placed in the electronic medical record and sent as consults
to the vascular access team. Ninety-eight insertions occurred between September and December. The program has grown exponentially since its inception and to this date houses 47,153 requests for evaluation and insertion
in a vascular access database. The vascular access team consists of 8 fulltime nurses covering approximately 850 beds. Additionally, we have
trained super users in 3 areas with varying degrees of success and data
collection.
Results—The following data were queried from the vascular
access database. Excluding the insertions completed by super users,
requests for ultrasound-guided peripheral IV line insertion (USGPIV)
totaled 47,153, 76.6% being attempted. Of the patients attempted, 32,366
were successful on the first attempt. Subsequent attempts were successful
92.4% of the time. The total success rate was 98.3%.
Conclusions—USGPIV programs can be successful adjuncts
to vascular access teams in serving patients with difficult access. Key concepts for branding success include using triage, assessment, ultrasound
guidance, and insertion by experienced vascular access nurses.
Musculoskeletal and Interventional/Intraoperative
Ultrasound
Moderator: Humberto Rosas, MD
1540764 Accuracy and Reliability of Direct Versus Indirect Peripheral Nerve Cross-sectional Area
Mark Shoreman,1,2,3* Jeffrey Strakowski,1,2,3 Marcie Bockbrader,1,2 Mark Tornero,1,2 Darin Bradshaw1,2 1Physical
Medicine and Rehabilitation, Ohio State University, Columbus,
Ohio USA; 2Physical Medicine and Rehabilitation, Riverside
Methodist Hospital, Columbus, Ohio USA; 3Musculoskeletal
Department, McConnell Spine, Sport, and Joint Center, Columbus, Ohio USA
Objectives—Standardizing the sonographic examination is essential to achieve diagnostic precision. Aspects of the examination, such
as the cross-sectional area (CSA) measurement technique, can be controlled and ultimately standardized. We sought to determine if direct peripheral nerve CSA measurement increases accuracy and reliability in
comparison to the indirect method.
Methods—Five novice sonographers and 3 healthy models
were recruited. One expert sonographer led the novices through 3 peripheral nerve ultrasound training sessions in addition to a final “test-out” session. The expert then obtained 1 ideal transverse image of each model’s
radial, median, ulnar, and sciatic nerves. Each sonographer (expert and
novice) then obtained 3 direct measurements of each nerve (3 models × 4
nerves × 3 = 36) and 3 indirect measurements of each nerve (36 + 36 = 72
measurements). The image order and method (direct/indirect) were randomized prior to obtainment, and sonographers were blinded to their results as well as their colleagues’. The expert’s measurements represented
the accuracy gold standard. Accuracy was evaluated by calculating percent
deviation from expert (%DE). Inter-rater reliability was evaluated using
the intraclass correlation coefficient (ICC). Variance measurements were
obtained using repeated measures analysis of variance (ANOVA).
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Results—The %DE was decreased with direct measurement in
comparison to indirect in every group of peripheral nerve measures
(radial/median/ulnar/sciatic). The ICC was higher with direct measurement than indirect in every group of peripheral nerves measured. Repeated
measures ANOVA did reveal significant differences between direct vs indirect measurements repeated on the same nerve/model (F(1,4) = 24.262;
P < .008). There was no significant difference between expert and novice
CSA measurements (P = .983), and no significant difference between multiple measurements (direct and indirect) of the same nerve by the same
rater (P = .644).
Conclusions—Direct CSA measurements produce more accurate results and greater inter-rater reliability than indirect measurements.
There is a significant difference between direct and indirect CSA measurements repeated on the same nerve/model.
1540778 Developmental Plasticity of the Hip: Implications for
Infant Hip Ultrasonography
Azriel Benaroya,1,2* Arkady Voloshin,3 Bernard Karmel,2
Ha Phan2 1Orthopedics, Mount Sinai School of Medicine,
New York, New York USA; 2Infant Development, New York State
Institute for Basic Research in Developmental Disabilities,
Staten Island, New York USA; 3Mechanical Engineering and
Mechanics, Lehigh University, Bethlehem, Pennsylvania USA
Objectives—A literature review of the combined method of infant hip ultrasonography (US) reveals persistent problems with overdiagnosis. Clues to these problems can be found in the wide range of
morphologic variations reported in fetal and infant hips. The 2003 American College of Radiology–American Institute of Ultrasound in Medicine
guidelines state that the femoral head is nearly spherical; thus, the position
of the hip during US is unimportant. Authors agree, however, that the
femoral head becomes less spherical during fetal development, that it
reaches its greatest degree of asphericity at the time of birth, and that asphericity is further increased in borderline, immature, and dysplastic hips.
We created a 3D mathematical model of an ellipsoidal infant femoral head
to examine the impact of femoral head asphericity on current US methods.
Methods—The femoral head was modeled as an oblate spheroid with asphericity of 25% (long axis = 20 mm; short axis = 15 mm).
Four positions of the femoral head in space, replicating positions of diagnostic significance used in the combined and Graf methods, were computer simulated. Coronal or transverse sections through the center of the
femoral head model, simulating infant femoral head US images, were produced and analyzed for cross-section diameter and inclination.
Results—Femoral head cross-section diameters in the simulated coronal flexion stress view and transverse flexion stress view were
17.11 and 16.23 mm, respectively, compared to 14.37 mm for the femoral
head cross-section diameter in the Graf coronal view and 13.93 mm for the
coronal view with the hip in the “human” position.
Conclusions—Our model demonstrated changes in the crosssection diameter of an irregularly shaped femoral head with rotation of
the head in different positions. Femoral head asphericity would not affect
the results in the Graf method, but it could affect the results in the combined method. Stress maneuvers of the infant hip in the presence of soft
tissue subclinical morphologic variations, coupled with femoral head
asymmetry, could produce “elastic whipping,” leading to erroneous interpretations of the US image. We recommend that the plasticity of the developing hip be reviewed with respect to its potential impact on the
accuracy of current US methods.
1536958 Efficacy of Sonographically Guided Medial Plantar Nerve
Perineural Space Injection at the Medial Longitudinal Arch
Johnathan Childress,1 Oliver Joseph,2 Oleg Uryasev,2* John
McNamara,1,2 Apostolos Dallas2 1Jefferson College of Health
Sciences, Roanoke, Virginia USA; 2Virginia Tech Carilion
School of Medicine, Roanoke, Virginia USA
Objectives—Medial plantar neuropraxia refers to entrapment
of the medial plantar nerve (MPN) in the medial longitudinal arch by compression from the flexor hallucis longus (FHL) and flexor digitorum
longus tendons. Like other nerve compression syndromes, corticosteroid
injection could likely provide therapeutic relief to those with MPN compression. We hypothesize that sonographic guidance will allow for effective injection of the MPN perineural space distal to the flexor retinaculum
and inferior to the navicular prominence (NP) of the foot.
Methods—This study serves as a pilot study to investigate the
efficacy of MPN perineural injections bilaterally on 4 cadaveric models.
Cadaveric anatomy was unremarkable with the exception of 1 cadaver
who had marked musculoskeletal deformity of the lower limbs, which
precluded successful injection. A 10–5-MHz small linear array transducer
was placed along the malleolar-calcaneal axis, rotated parallel to the tibia,
and guided anteriorly along the medial longitudinal arch to visualize the
NP. The MPN appeared spindle shaped with alternating hypoechoic and
hyperechoic bands superficial to the FHL tendon. The MPN perineural
space was injected inferior to the NP where it divides into its muscular
branches. Using an anterior long-axis approach, 0.35 mL of 0.5% methylene blue was injected with anatomic dissection to provide confirmation.
Injections were classified according to accuracy and precision. Accuracy
referred to nerve staining; precision referred to no damage to adjacent
structures.
Results—Seven of 8 (88%) injections were accurate; 6 of 8
(75%) injections were precise.
Conclusions—Research into sonographically guided MPN
perineural injection is novel. Considering a limited sample size and
marked musculoskeletal deformity of 1 cadaver, accuracy and precision
(88% and 75%, respectively) provide an optimistic outlook for sonographically guided injections. The study supports the approach of sonographically guided perineural injections in the clinical address of medial
plantar neuropathies. Future phases of this study will focus on expanding
the initial data set and correlate the accuracy and precision of injection
with improved patient outcomes.
1538067 Neuromusculoskeletal Ultrasound Courses: How Effective
Are They in the Long Term?
Sathish Rajasekaran,1* Rodney Shan,2 Mohan Radhakrishna3
1
Physical Medicine and Rehabilitation, University of
Saskatchewan, Saskatoon, Saskatchewan, Canada; 2Clinical
Neurosciences, University of Calgary, Calgary, Alberta,
Canada; 3Physical Medicine and Rehabilitation, McGill University Health Center Pain Center and McGill University, Montreal, Quebec, Canada
Objectives—To measure the short- and long-term effectiveness
of a 2-day neuromusculoskeletal ultrasound course offered to Canadian
physical medicine and rehabilitation (PM&R) residents.
Methods—A 2-day course that included lectures, live scanning,
and cadaver-based injection stations was attended by 22 PM&R residents
from across Canada. Participants varied in training level from first- to
final-year residents. Currently, ultrasound training is not a requirement for
PM&R training programs in Canada. Prior to beginning the course, all attendees were asked to fill out a multiple-choice test based on the course
curriculum objectives, which was readministered on completion and 6
months after completion of the course (electronically). Sixteen residents
completed all 3 tests. The Wilcoxon signed rank test was used to compare
scores from the 3 testing periods.
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Results—The mean score (percentage) on the pretest was
50.6% (95% confidence interval [CI], 43.5%–57.6%), on the immediate
posttest was 66.5% (95% CI, 60.6%–72.4%), and on the 6-month posttest
was 53.5% (95% CI, 45.9%–60.6%). The 6-month posttest scores were
not significantly higher than the pretest scores (P = .505). The immediate
posttest scores were significantly higher than the pretest (P = .002) and 6month posttest (P = .003) scores.
Conclusions—This pilot study found that the short-term effectiveness of attending an ultrasound course is supported by higher immediate posttest scores. However, the effectiveness of the course is
diminished in the long term, as the 6-month posttest scores were lower
than the immediate posttest scores. Although 6-month posttest scores still
remained higher than pretest scores, this was not statistically significant.
Our results suggest that the current trend of offering neuromusculoskeletal ultrasound courses as an early exposure may have suboptimal benefits
to the learner on its own and may require reinforcement with continued
structured longitudinal learning opportunities. Future studies done on a
larger scale that also correlate testing performance to postcourse ultrasound use need to be undertaken to further investigate our conclusions.
1467503 Utility of Ultrasound for Detecting Anterior Compartment
Thickness Changes in Chronic Exertional Compartment
Syndrome: A Pilot Study
Sathish Rajasekaran,1* Cole Beavis,2 Abdel-Rahman Aly,1
Dave Leswick3 1Physical Medicine and Rehabilitation,
2
Surgery, 3Diagnostic Imaging, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
Objectives—To test the hypotheses that patients with chronic
exertional compartment syndrome (CECS) of the anterior leg compartment have an increased anterior compartment thickness (ACT) compared
to controls after exertion using ultrasound.
Methods—Four patients with CECS (3 males and 1 female)
and 9 controls participated in the study. Our ultrasound technique was first
validated with a precision phase (10 controls) prior to scanning study subjects. CECS patients ran on a treadmill until symptomatic (≥5 minutes)
using a standardized protocol. ACT and anterior compartment pressures
were measured prior to exercise and at scheduled intervals afterward. Controls underwent the same protocol without compartment pressure testing.
Results—Anterior compartment pressures were diagnostic of
CECS using the modified Pedowitz criteria in all 4 CECS patients. The
mean percent change in ACT from rest in CECS vs controls at 0.5 minutes
was 21.3% (95% confidence interval [CI], 6.92%, 35.6%) vs 6.32% (95%
CI, 0.094%, 12.5%; P = .011); at 2.5 minutes, it was 24.6% (95% CI, 10.7%,
38.5%) vs 4.22% (95% CI, –1.85%, 10.3%; P = .003); and at 4.5 minutes,
it was 24.9% (95% CI, 14.3%, 35.5%) vs 5.08% (95% CI, 0.813%, 11.0%;
P = .003). The mean ACT in CECS patients vs controls was significantly increased after exertion at 0.5, 2.5, and 4.5 minutes (P = .003).
Conclusions—Ultrasound reveals a significant increase in ACT
in patients with CECS of the anterior leg compartment compared to controls. Our study shows a promising role for using ultrasound, a noninvasive, readily available, and cost-effective method, to diagnose CECS.
Further studies are warranted to validate the findings of this study with a
goal of developing anterior leg compartment CECS ultrasound diagnostic criteria and exploring the role of using ultrasound to diagnose CECS
in other compartments.
1541063 Efficacy of Sonographically Guided Injections of the Common Peroneal Nerve Perineural Space at the Fibular Tunnel
Matthew P Kona,1* Oliver Joseph,1 Oleg Uryasev,1 John McNamara,1,2 Apostolos Dallas1 1Virginia Tech Carilion School
of Medicine, Roanoke, Virginia USA; 2Jefferson College of
Health Sciences, Roanoke, Virginia USA
Objectives—The common peroneal nerve (CPN) originates as
a branch of the sciatic nerve within the popliteal fossa. Continuing inferolaterally, the CPN crosses the fibular head and penetrates the posterior intermuscular septum, where it courses through the fibular tunnel (FT),
defined by the fibula and peroneus longus tendon. CPN entrapment within
the FT is associated with motor deficits, such as foot drop, as well as sensory deficits and pain in the distribution of its branches: the anterolateral
third of the lower leg and dorsum of the foot. Treatment may involve
steroid injections into the perineural space of the CPN or its distal
branches. The CPN also serves as a valuable alternative when preoperative sciatic block is unsuccessful or when a faster time to complete block
is desired. The CPN has been effectively imaged using sonography (US).
We hypothesize that using sonography, one can effectively inject the CPN
perineural space at the FT.
Methods—To image the CPN in cross section, 4 cadaveric
models were placed in a prone position, with the transducer over the fibular head, and rotated 20° from a transverse position. A total of 8 injections
with methylene blue were performed using an in-plane technique. FT dissection permitted classification of injections according to accuracy and
precision. Accuracy referred to nerve staining with methylene blue; precision referred to nerve staining without damage to adjacent structures.
Results—One hundred percent of injections were accurate,
while 87.5% were precise.
Conclusions—Limitations of this study stem primarily from
operator dependence and the pronounced musculoskeletal abnormalities
of 1 cadaver. In this case, the superficial branch of the CPN was misidentified as the CPN. All other injection attempts performed in this study were
successful. This study, in conjunction with others designed to investigate
the clinical applications of CPN perineural injections, collectively highlight the utility of sonography in these relevant patient populations. Future
phases of this study will center on expanding the initial data set and correlate the accuracy and precision of sonographically guided CPN injections with improved patient outcomes.
1541082 Efficacy of Sonographically Guided Injections of the Ulnar
Nerve Perineural Space at the Cubital Tunnel
Daniel Plessl,1* Robert Summey,1 Oliver Joseph,1 Oleg
Uryasev,1 John McNamara,1,2 Apostolos Dallas1 1Virginia
Tech Carilion School of Medicine, Roanoke, Virginia USA;
2
Jefferson College of Health Sciences, Roanoke, Virginia USA
Objectives—Ulnar nerve (UN) entrapment is the second most
common nerve entrapment of the upper limb. The most common entrapment site is at the cubital tunnel to produce cubital tunnel syndrome (CTS).
At the elbow, the UN courses subcutaneously between the medial epicondyle and the olecranon in the condylar groove and then enters the cubital tunnel. CTS presents with medial elbow pain and varying symptoms
from sensory complaints to weakness of intrinsic hand muscles. CTS may
be caused by extrinsic compression of the UN, bone deformities, or soft
tissue lesions. The cubital tunnel has been effectively imaged using sonography; however, clinical benefits of such imaging have yet to be confirmed. We hypothesize that, using sonography, one can effectively inject
the UN perineural space at the cubital tunnel.
Methods—In this pilot study, the UN was visualized bilaterally on 4 nonembalmed cadaveric models. The elbow was examined in external rotation, and the transducer was placed transverse to the condylar
groove along the medial epicondyle-olecranon axis. Sonographically
guided lateral-to-medial UN injections with 0.35 mL of methylene blue
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were performed. Incisions were made parallel to the condylar groove deep
to the cubital tunnel retinaculum to expose the underlying UN. Injections
were accurate if the UN perineural space was dyed, and they were precise
if the injection did not damage adjacent anatomy.
Results—Eight of 8 injections were both accurate and precise.
Conclusions—UN perineural injection is significant as it can
provide symptomatic relief for CTS with corticosteroid injections to
reduce inflammation. Sonography is inexpensive, quick, and minimally
invasive. Future phases of this study will investigate efficacy of sonographically guided UN perineural corticosteroid injections in patients with
CTS. This study suggests that injections under sonographic guidance are
accurate and precise, therefore serving as a potential adjunct to treatment
that is worth further investigation. Future phases of this study will center
on expanding the initial data set and correlate the accuracy and precision
of injection with improved patient outcomes.
1539088 Translating Contrast-Enhanced Ultrasound Intraneural
Vascularity From Bench to Bedside
Kevin Evans,* Kevin Volz School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio USA
Objectives—To describe contrast-enhanced ultrasound (CEUS)
imaging of the human median nerve’s intraneural vascularity, with equipment settings and optimizations derived from experiments with a cohort
of Macaca fascicularis.
Methods—The equipment used was a GE LOGIQ 9, complete
with contrast settings, and a GE LOGIQ i, which is considered a handcarried unit. A 9.0-MHz linear broadband transducer was used with the
GE LOGIQ 9, and a 12.0-MHz linear broadband transducer was used with
the GE LOGIQ i hand-carried unit. Definity was used for this study because it possesses the smallest microspheres, 1.1 to 1.3 µm, has stability
of <10 minutes, and resonates at 4 MHz. Equipment settings that had been
used with experiments conducted with 11 M fascicularis were repeated
with 11 patients during a CEUS echocardiogram. PixelFlux Scientific software allowed for semiautomatic assessment of the intensity of the contrast pixels. Descriptive statistics are compared to pixel counts and
intensities between humans and the monkeys, although contrast dosing
amounts varied. The goal was to capture multi-incremental sampling of the
images during CEUS, focused on the median nerve.
Results—The GE LOGIQ equipment settings were applied to
the human study based on previous experiments. A better visual yield was
found with 4% output power and a mechanical index of 0.13; these translated settings provided optimum imaging of the median nerve. The 9.0MHz linear transducer was also downshifted to a transmit frequency of 6.0
MHz for the human studies. Trend graphs are provided for comparison
purposes.
Conclusions—It will be vital to replicate this pilot study to validate these results with a larger set of subjects and correlate the findings
with nerve conduction studies. Higher levels of evidence will promote the
use of CEUS to investigate intraneural vessels and allow for angle correction, thereby yielding increased accuracy.
Table 1. Comparison of Semiautomatic Analysis of CEUS Data Within the Median
Nerve in both Macacas and Humans (n = 11)
Parameter
Mean average intensity
Mean maximum intensity
Mean signal count
Preclinical Dosing
0.39
1.89
3.85
Human Dosing
1.79
4.18
25.6
Obstetric Ultrasound: Uterus, Placenta, and Cervix
Moderators: Harris Finberg, MD, Cyrethia McShane, RDMS, BS
1540994 Cervical Length Assessment by Transabdominal and
Endovaginal Ultrasound
Jennifer Thompson,* Michael Smrtka, Geeta Swamy, Chad
Grotegut, Brita Boyd, Amy Murtha Duke University,
Durham, North Carolina USA
Objectives—Endovaginal (EV) cervical length identifies
women at risk for preterm birth (PTB) and thus eligibility for vaginal progesterone. Our objective was to compare transabdominal (TA) with EV cervical lengths to determine the degree of correlation, the capability of TA
ultrasound (US) to predict an EV-detected short cervix, and the rate of cervical change over time.
Methods—Retrospective review of singleton pregnancies having TA and EV US for cervical length between 16 and 28 weeks’ gestation
at Duke University from January to December 2011. TA measurements are
routinely obtained on midtrimester exams with EV measurement for high
PTB risk, TA <30 mm, assessment of placental location, and/or presence
of cerclage. Serial US with TA and EV are performed when EV <25 mm.
Pearson correlation and receiver operating characteristic -curves were used
to compare TA and EV cervical lengths and determine optimal TA cutoffs
for prediction of an EV cervical length <25 mm. Linear regression was
used to compare the rate of cervical change by TA and EV by term vs
PTBs.
Results—A total of 142 subjects with 245 US observations met
study inclusion criteria. TA and EV measurements were significantly correlated (r = 0.810; P < .0001). A TA cutoff of 30 mm accurately predicted
an EV-detected short cervix (<25 mm): sensitivity, 90.4%; specificity,
80.2%; positive and negative predictive values, 70.1% and 94.2%. Using
linear regression, women delivering preterm had a greater rate of cervical
change by EV compared to women delivering at term (P = .014). TA failed
to demonstrate such a difference (P = .592).
Conclusions—TA and EV cervical lengths correlate well and
TA <30 mm as an accurate predictor of shortened EV cervical length. Serial follow-up of a US-detected short cervix should be via EV measurements, given the better detection of the rate of cervical change than TA in
patients who deliver preterm. Detecting a rapidly changing short cervix
sooner may allow for earlier interventions. Prospective studies are required
to confirm our findings.
1472715 Cervical Length in the Second and Early Third Trimesters
as a Predictor of Cesarean Delivery in Singleton Gestations
Ashley Roman,1,2,3* Terri-Ann Bennett,1 Nathan Fox,1,2,3
Daniel Saltzman,1,2,3 Chad Klauser,1,2,3 Andrei Rebarber1,2,3
1
Obstetrics and Gynecology, New York University School of
Medicine, New York, New York USA; 2Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York
USA; 3Maternal-Fetal Medicine, Carnegie Imaging for
Women, New York, New York USA
Objectives—A long cervical length (CL) at 22 to 24 weeks’ gestation has been shown to be associated with an increased risk of cesarean
delivery. The objective of this study was to determine the association between CL at 28 to 32 weeks and the risk of cesarean delivery in singleton
pregnancies and to evaluate whether it is more predictive of cesarean delivery than CL at 22 to 24 weeks.
Methods—This was a retrospective cohort study of singleton
gestations with a history of prior spontaneous singleton preterm birth managed in a single practice between 2005 and 2011. All patients were followed with serial CL measurements via transvaginal ultrasound. Patients
met criteria for inclusion if they had a CL measurement between 28 and
32 weeks’ gestation. Patients were excluded if they underwent a planned
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cesarean delivery. The primary outcome was risk of cesarean delivery in
labor. Groups were compared using Fisher exact and χ2 tests with significance defined as P < .05.
Results—A total of 216 patients met inclusion criteria. At 22 to
24 weeks, the mean CL was 35 mm (range, 4–60 mm); at 28 to 32 weeks,
the mean CL was 29 mm (range, 3–54 mm). CL at 22 to 24 weeks was not
significantly associated with the risk of cesarean delivery. However, CL at
28 to 32 weeks was significantly associated with the risk of cesarean delivery (Table 1). A CL ≥50 mm (95th percentile) had sensitivity of 20%,
specificity of 99%, a positive predictive value of 71.4%, and a negative
predictive value of 90.4% for cesarean delivery in labor (P < .001).
Conclusions—CL at 28 to 32 weeks is significantly associated
with the likelihood of cesarean delivery in labor; however, CL at 22 to 24
weeks did not correlate with the risk of cesarean delivery. A longer CL in
the early third trimester may represent underdevelopment of the uterus,
leading to a higher risk of cesarean delivery in labor. The lack of an association at 22 to 24 weeks suggests that the normal cervical ripening process
is one that occurs after the second trimester.
Table 1. Risk of Cesarean Delivery in Labor by CL Quartile at 28 to 32 Weeks’
Gestation
Quartile
1st (3–23 mm)
2nd (24–29 mm)
3rd (30–36 mm)
4th (37–54 mm)
P
Cesarean Delivery, % (n)
5.6 (3/54)
10.9 (6/55)
9.1 (5/55)
21.2 (11/52)
<.001
Vaginal Delivery, % (n)
94.4 (51/54)
89.1 (49/55)
90.9 (50.55)
78.8 (41/52)
<.001
1524943 Intramuscular Progesterone Slows the Rate of Cervical
Shortening
Cara Pessel, Saila Moni,* Noelia Zork, Sara Brubaker,
Samantha Do, Joy Vink, Karin Fuchs, Chia-Ling NhanChang, Cande Ananth, Cynthia Gyamfi Obstetrics and
Gynecology, Columbia University Medical Center, New York,
New York USA
Objectives—To evaluate whether 17-alpha-hydroxyprogesterone caproate (17-OHPC) exposure is associated with the rate of cervical shortening.
Methods—Women with a history of spontaneous preterm birth
(PTB; <37 0/7 weeks) who had serial cervical length (CL) measurements
in 2011 and 2012 were identified. 17-OHPC administration and outcome
data were collected. We excluded multiple gestations, patients lacking outcome data, medically indicated PTBs, and pregnancies with major fetal
anomalies, vaginal progesterone use, and abdominal or vaginal cerclage.
CL values from the second and third trimesters were recorded, and the
rate of cervical change was modeled based on 17-OHPC status using
methods for longitudinal analysis.
Results—A total of 103 patients were included, with a total of
555 CL values. Eighty-five (82.5%) patients were exposed to 17-OHPC,
and 18 (17.5%) were not. Gestational age (GA) and the number of previous PTBs, along with the timing of CL exams, were similar between these
2 groups, although women that did not receive 17-OHPC were more likely
to have delivered multiples in their previous PTB (27.8% vs 4.8%). CL
was plotted against GA for every patient starting at 16 weeks. Women
were analyzed separately according to whether they delivered at term or
preterm. The rate of CL change in women that delivered preterm was modeled using linear terms for GA at CL assessment, while the rate in women
that delivered at term was modeled using second-degree polynomials. There
was no difference in the risk of spontaneous PTB according to 17-OHPC exposure; however, among women who delivered preterm, the rate of CL
shortening was slower in those exposed to 17-OHPC (1 vs 4 mm/wk).
Conclusions—In women with previous PTB, cervical shortening occurs more gradually when exposed to 17-OHPC. Further studies
may evaluate how 17-OHPC influences the cervical remodeling that leads
to PTB.
1539329 Impaired Sonographic Cervical Assessment After Voiding:
A Randomized Controlled Trial
William Schnettler,1,2,3* Melissa March,1,2,3 Michele Hacker,2,3
Anna Merport Modest,2 Diana Rodriguez1,2,3 1MaternalFetal Medicine, 2Obstetrics and Gynecology, Beth Israel
Deaconess Medical Center, Boston, Massachusetts USA;
3
Harvard Medical School, Boston, Massachusetts USA
Objectives—Sonographic cervical assessment is the leading
tool for preterm birth prediction, and optimizing image quality is paramount. Focal myometrial contractions (FMCs) can impair imaging.
We sought to determine if the timing of bladder emptying impacts FMC
development and image adequacy.
Methods—Women at 14.0 to 32.0 weeks’ gestation undergoing
clinically indicated transvaginal ultrasound from January 1, 2012, to September 1, 2012, were eligible for this blinded randomized controlled trial.
Participants were randomly assigned to undergo transvaginal imaging immediately after urination (within 5 minutes) or to defer the imaging by at
least 15 minutes. The primary outcome was FMC development as determined by 2 independent blinded reviews of the images. Secondary outcomes
included image adequacy and the diagnosis of placenta previa. Analysis was
by intent to treat. Data are presented as proportions and medians (interquartile range). Relative risks (RRs) and 95% confidence intervals (CIs)
were calculated using repeated measures log binomial regression.
Results—A total of 222 women provided 336 randomized encounters; 1 was excluded due to poor image quality. In the immediate scan
group, women voided a median of 3.0 (3.0–5.0) minutes before the scan
and in the deferred scan group, and women voided a median of 28.0 (21.0–
38.0) minutes before. Women in the deferred group were 30% less likely
to experience an FMC (RR, 0.70; 95% CI, 0.52–0.93) and 40% less likely
to have inadequate images due to an FMC (RR, 0.60; 95% CI, 0.40–0.89).
In the absence of an FMC, the 2 groups were equally likely to be diagnosed with placenta previa (P = .60). In the presence of an FMC, the deferred group was 76% less likely to be diagnosed with previa (RR, 0.24;
95% CI, 0.09–0.62) than women in the immediate scan group.
Conclusions—A brief interval between voiding and transvaginal cervical evaluation is associated with a decrease in FMC incidence
and improved imaging.
Table 1
Immediate Scan
(n = 168), n (%)
FMC
68 (40.5)
Inadequate imaging with FMC
49 (29.2)
Previa without FMC
12 (7.1)
Previa with FMC
21 (12.5)
S25
Deferred Scan
(n = 167), n (%)
47 (28.1)
29 (17.4)
17 (10.2)
5 (3.0)
P
.02
.01
.60
.003
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1537208 Midtrimester Transabdominal Ultrasound for Detection of
Placenta Previa
Hayley Quant,* Alexander Friedman, Eileen Wang, Samuel
Parry, Nadav Schwartz Maternal and Child Health Research
Program, Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania USA
Objectives—Transvaginal ultrasound (TVUS) is the gold standard for diagnosing placenta previa. Transabdominal ultrasound (TAUS)
is often used as a screening test given the cost and invasiveness of TVUS.
We sought to determine the ability of TAUS to diagnose previa.
Methods—TAUS was performed prior to TVUS for all
anatomic surveys at 18 to 23 6/7 weeks. Sonographers prospectively
recorded the distance from the leading placental edge (if visible) to the internal os on both TA and TV scans. The primary outcome was a TV placental distance of 0 cm (complete previa). Secondary outcomes included
TV distances of ≤1, ≤2, and ≤2.5 cm. ROC curves were generated using
all cases with TA placental distance of ≤5cm. The TA placental distance
cutoffs at 100% and 90% sensitivity were identified for each outcome and
then applied to the entire cohort to determine the sensitivity, specificity,
positive predictive value (PPV), and negative predictive value (NPV) of
TAUS for detecting previa.
Results—A total of 1214 patients underwent both TAUS and
TVUS; 415 (34.2%) had a TA distance ≤5cm from placenta to os. The
prevalence, optimal TA cutoffs by outcome and, test characteristics are
presented Table 1. A TA measurement of ≤4.2 cm detected 93.3% of complete previas by TVUS with an NPV of 99.8% and a screen-positive rate
(SPR) of 25%. A TA cutoff of 2.8 cm lowered the SPR to 11.4%, though
the sensitivity decreased to 86.7% and the NPV to 88.6%.
Conclusions—Despite a high NPV, the lack of a cutoff to exclude placenta previa makes TAUS an inadequate screen. Universal TVUS
would improve midtrimester detection and allow for appropriate followup. Since most suspected previas resolve, further investigation is needed
to assess whether TVUS can decrease morbidity later in gestation.
Table 1
TV
TA Placental
Placental
Distance
Distance
Cutoff, cm
0 (complete previa) 4.2
n = 30 (2.5%)
2.8
≤1 cm
4.2
n = 45 (3.7%)
3.1
≤2 cm
4.9
n = 100 (8.2%)
3.9
≤2.5 cm
5.0
n = 146 (12.0%)
4.2
SPR, Sensitivity, Specificity, PPV,
%
%
%
%
25.0
93.3
76.7
9.2
11.4
86.7
90.5
18.7
25.0
93.3
77.6
13.8
13.5
84.4
89.2
23.2
32.9
89.0
72.2
22.3
21.0
81.0
84.4
31.8
34.2
82.9
72.5
29.2
25.0
76.7
82.0
36.8
NPV,
%
99.8
88.6
99.7
99.3
98.7
98.0
96.9
96.3
1539742 Outcome of Pregnancies With a Low-Lying Placenta Diagnosed Between 16 and 24 Weeks’ Gestation
Howard Heller,1 Katherine Mullen,1* Robert Gordon,1
Rosemary Reiss,2 Carol Benson1 1Radiology, 2Obstetrics and
Gynecology, Brigham and Women’s Hospital, Boston,
Massachusetts USA
Objectives—To determine how often a low-lying placenta diagnosed between 16 and 24 weeks resolves prior to delivery.
Methods—We assessed all cases of a low-lying placenta, defined as a placenta ending within 2 cm of the internal cervical os, diagnosed by sonography between 16 and 24 weeks’ gestation from July 1,
2007, to September 4, 2011. We reviewed medical records to determine the
gestational age when a low-lying placenta was diagnosed, the gestational
age at which the placenta was no longer low lying or previa, and, for those
whose placentas never cleared sonographically, how many went on to cesarean section for placenta previa.
Results—A total of 1416 pregnancies were diagnosed with a
low-lying placenta between 16 and 24 weeks’ gestation. Of these, 174
were lost to follow-up. Of the remaining 1242 pregnancies, 1220 (98.2%)
resolved to no previa prior to delivery. The mean age at resolution was
26.0 weeks. The age at resolution was similar in those diagnosed prior to
20 weeks’ gestation to those diagnosed after 20 weeks. Approximately
77% of placentas that eventually cleared did so before 29 weeks. Twentytwo patients had persistent placenta previa by sonography at or near term,
all of which were confirmed at cesarean section.
Conclusions—A low-lying placenta diagnosed between 16 and
24 weeks rarely (1.8% of the time) persists as placenta previa to term, necessitating cesarean section. Most cases resolve during the early third
trimester. Thus, we suggest that reevaluation of the placental location in
such cases be performed at approximately 28 to 30 weeks, not earlier.
In addition, patients diagnosed with a low-lying placenta in the second
trimester can be reassured that the likelihood of persistent placenta previa
at the time of delivery is small.
1533371 Association Between Transvaginal Ultrasonographic
Cervical Characteristics and Preterm Delivery After a
History-Indicated Cerclage
Emily Miller,* Susan Gerber Maternal-Fetal Medicine,
Northwestern University, Chicago, Illinois USA
Objectives—To assess the relationship between the transvaginal ultrasonographic characteristics of the cervix in the mid trimester and
the risk of delivery prior to 34 weeks in women with a history-indicated
cerclage.
Methods—A retrospective case-control study of subjects with
a singleton gestation and a history-indicated cerclage placed in the first
trimester. Transvaginal ultrasound images of the cervix at the time of the
anatomic survey in the second trimester were reviewed, and measurements
of cervical length (CL) proximal and distal to the cervical suture as well
as the presence or absence of funneling were recorded. χ2 tests and logistic regression analysis were performed to evaluate the association between
these cervical variables and preterm birth prior to 34 weeks.
Results—One hundred three subjects met inclusion criteria.
Sixteen (15.5%) delivered prior to 34 weeks’ gestation. CL proximal to the
suture was lower in women who delivered prior to 34 weeks (1.6 vs 2.5
cm; P = .005), whereas distal CL was similar (1.5 vs 1.7 cm; P = .18). The
frequency of cervical funneling was higher in women who delivered prior
to 34 weeks (57% vs 9%; P < .001). In multivariable regression, only the
presence of a cervical funnel remained significantly associated with an increased risk of preterm delivery before 34 weeks (Table 1).
Conclusions—Cervical funneling is strongly associated with
an increased risk of delivery before 34 weeks in women with a history-indicated cerclage. Midtrimester transvaginal cervical imaging can be used
to augment risk assessment this patient population.
Table 1. Odds Ratios for Birth Prior to 34 Weeks According to Ultrasonographic
Cervical Appearance
OR
95% CI
aOR
95% CI
Proximal CL
0.48
0.27–0.82
0.88
0.41–1.85
Distal CL
0.46
0.14–1.45
0.64
0.19–2.21
Cervical funnel present
13.5 3.74–48.74 9.96 1.62–61.03
aOR indicates adjusted odds ratio; CI, confidence interval; and OR, odds ratio.
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1541264 The Natural History of Vasa Previa Across Gestation
Andrei Rebarber,1,2,3* Cara Dolin,2 Nathan Fox,1,2,3 Chad
Klauser,1,2,3 Daniel Saltzman,1,2,3 Ashley Roman1,2 1Carnegie
Imaging for Women, New York, New York USA; 2Obstetrics and
Gynecology, New York University School of Medicine, New
York, New York USA; 3Obstetrics and Gynecology, Mount Sinai
School of Medicine, New York, New York USA
Objectives—To estimate the prevalence and persistence of vasa
previa in at-risk pregnancies using a standardized screening protocol.
Methods—A descriptive study of patients from 1 ultrasound
practice from June 2005 to May 2012. Cases were identified by ICD-9
code and content search analysis of the 2 ultrasound reporting systems,
Sonultra and AS Ob/Gyn using the key words “vasa previa.” Vasa previa
was defined as any velamentous fetal vessel (arterial or venous) noted to
be within 2 cm of the internal cervical os. Screening for vasa previa using
transvaginal ultrasound with color flow mapping was performed routinely
in the following situations: resolved placenta previa, history of vasa previa in a prior pregnancy, velamentous insertion of the cord in the lower
uterine segment, placenta succenturiata with implantation in the lower
uterine segment, and twin gestations.
Results—A total of 27,573 patients were referred to our unit
for fetal anatomic surveys over the study period. Thirty-two cases of vasa
previa were identified. Twenty-nine cases were available for analysis: 6 patients had migration and resolution of the vasa previa. When the initial diagnosis of vasa previa was made during the second trimester (<26 weeks),
there was 28.6% resolution rate; if the diagnosis was made in the third
trimester, none resolved (0/7 cases). Of the 23 cases (5 twin gestations and
18 singleton gestations) with persistent vasa previa, there was 100% survival with a median length of gestation of 35 weeks (range, 27 5/7–36 5/7
weeks). The median gestational age at diagnosis was 22 6/7 weeks (range,
16 1/7–36 5/7 weeks). The median gestational age at hospital admission
was 33 weeks (range, 28–36 5/7 weeks).
Conclusions—The incidence of vasa previa was 1.1 per 1000
pregnancies in our population. When vasa previa was diagnosed during the
second trimester, there was a 28.6% resolution rate, but if diagnosed in
the third trimester, none resolved. More than 90% of cases of vasa previa
that were identified had either a history of a resolved placenta previa or a
twin gestation. Effective prenatal diagnosis of vasa previa screening using
transvaginal imaging with color flow mapping is attainable using focused
criteria for evaluation.
1536702 Uterine Volume Between 11 and 14 Weeks’ Gestation in
Singleton and Dichorionic Diamniotic Twins as Seen by
Ultrasound
Lindsay Kugler,* Joaquin Santolaya Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey–
Robert Wood Johnson Medical School, New Brunswick, New
Jersey USA
Objectives—We analyzed the changes in uterine volume in singleton and dichorionic diamniotic (DCDA) pregnancies between 11 and
14 weeks’ gestation.
Methods—This was a nested case-control study performed in
patients that were followed and delivered at our center. All patients had a
<1 in 300 risk for Down syndrome after the first-trimester screening test
and delivered vigorous newborns with a birth weight appropriate for gestational age. Pregnancies ending in stillbirth or with newborns with malformations or abnormal birth weight were excluded. The Student t test and
regression analysis were used for group comparisons. P < .05 was considered significant.
Results—At 11 weeks’ gestation, the mean uterine volume for
singletons was 357 cm3 and for DCDA twins was 652 cm3 (P < .05). At
14 weeks’ gestation, the mean uterine volume in singleton pregnancies
was 698 cm3 and in DCDA twins was 1026 cm3 (P < .05).
Conclusions—Gaining insights into the normal and abnormal
uterine changes early in gestation might have potential for predicting maternal maladaptations to pregnancy. This study provides a novel sonographic approach to the early physiologic uterine capacities. These
preliminary data demonstrate the plasticity of the uterus early in pregnancy, becoming almost 50% larger in DCDA twins than singleton pregnancies by 11 weeks’ gestation. Interestingly, the difference in uterine
volume decreases to 30% by 14 weeks’ gestation. This study paves the
way to investigations aimed at determining if decreased uterine plasticity
can be used for the early prediction of adverse perinatal outcomes in singleton and twin pregnancies.
Table 1. Clinical Variables in Nested Case-Control Study With Singleton and Dichorionic
Twins: Summary Statistics
Mean
Mean Mean
Mean Fetal Nulli- GA at Newborn Median Median Newborn
Maternal CRL, para, Delivery, Weight, 1-min 5-min
Male, Cesarean
Age, y mm %
wk
kg
Apgar Apgar
% Delivery, %
Singleton
32
60
46
39.4
3.4
8
9
49
27
(n = 78)
(5.4) (7.1)
(1.0)
(0.4)
Twins
35
62.4 57
34.6
2.1
AB
AB
36
95
(n = 23)
(4.4) (10)
(3.3)
(0.6)
89
99
P
.008
NS
— < .001 < .001
NS
NS
—
—
CRL indicates crown-rump length; GA, gestational age; and NS, not significant. Patients’ ethnic background (%): singleton: Caucasian, 42; Asian, 20; African American, 7.5; unknown, 30;
twins: Caucasian, 33; Asian, 20; African American, 10; other/unknown, 37.
1540615 Can 3-Dimensional Power Doppler Ultrasound of the
Cervix Predict Preterm Labor in Women at Increased
Risk?
Ahmed Ahmed,* Shoshana Haberman, Howard Minkoff
Maimonides Medical Center, Brooklyn, New York USA
Objectives—To evaluate the diagnostic potential of 3D Doppler
ultrasound measured by Virtual Organ Computer-Aided Analysis
(VOCAL) for prediction of preterm labor (PTL) in asymptomatic women
(singleton) at risk.
Methods—A prospective ongoing cohort study (Institutional
Review Board approved). Included: 300 -pregnant women at 18 to 24
weeks, singleton at high risk for PTL (prior spontaneous preterm delivery,
history of cone biopsy, or >2 dilations and evacuations). Excluded: multiple gestation, preterm contractions, or fetal anomalies. Transvaginal
sonographic (TVS) evaluation of the cervix using a GE Voluson E8 system (7.5 MHz) was performed. The stored volumes were processed using
4D View software for calculation of cervical volume in cubic centimeters
and 3D Doppler indices (vascularization index [VI], flow index [FI], and
vascularization flow index [VFI]) using VOCAL. The cervical length (CL)
was measured using the tomographic ultrasound imaging (TUI) mode. All
participants were observed until delivery. Using SPSS 11.5 software, the
sensitivity, specificity, positive and negative predictive values (PPV and
NPV), and receiver operating characteristic curve were calculated. Regression analysis was done.
Results—Only 105 women have delivered thus far. Eleven patients (group I) had PTL ≤34 weeks; 24 patients (group II) had PTL >34
to <37 weeks; and 70 patients (group III) delivered ≥37 weeks. Using
analysis of variance, significant differences existed between the 3 groups
with regard to CL by TUI, cervical volume, and FI (P = .019, .037, and
.002, respectively). Unlike VI and VFI, a significant negative correlation
was found between FI and gestational age at the time of delivery (R 2 =
0.176; P < .001). The highest sensitivity, specificity, and area under the
curve (AUC) were for FI (Table 1).
Conclusions—Women who delivered before 37 weeks had
higher FI values when screened between 18 and 24 weeks, reflecting a
more vascularized cervix during early ripening. 3D Doppler ultrasound
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of the cervix might be helpful for detection of the ripening process and
possibly predicting PTL.
Table 1. AUC, Sensitivity, Specificity, PPV, and NPV for 3D Ultrasound Parameters of the
Cervix
AUC
CL by 2D TVS, mm
0.643
CL by TUI, mm
0.649
Cervical volume, cm3 0.501
FI
0.822
CI indicates confidence interval.
Cutoff
Point
29
32
44.6
46.2
Sensi- SpeciSignificant
tivity, ficity, PPV, NPV, Level
95%
%
%
%
% AUC P
CI
72
68
20
95
.055 0.54–0.73
73
63
19
95
.049 0.54–0.74
64
55
14
93
.987 0.40–0.60
82
82
36
98
.0002 0.73–0.89
Pediatrics and Fetal Echocardiography
Moderator: Gary Satou, MD
1522495 Is Fetal Echocardiography Necessary in In Vitro Fertilization/Intracytoplasmic Sperm Injection Pregnancies After
an Anatomic Survey?
Oluyemi Aderibigbe,1* Angela Ranzini,1 Sumekala Nadaraj2
1
Obstetrics and Gynecology, Saint Peters University Hospital,
New Brunswick, New Jersey USA; 2Pediatric Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
USA
Objectives—In vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is one of the indications for fetal echocardiography
(ECHO) due to a reported increased risk for cardiac anomalies. In this
study, we evaluated the utility of ECHO after an anatomic survey (AS) in
an experienced center. At the time of the AS, cardiac evaluation included
views of the 4-chamber heart and attempts at outflow tracts and arch
views.
Methods—Records of patients seen in our hospital’s Antenatal
Testing Unit with the indication of IVF/ICSI for an AS and ECHO between January 1996 and October 2010 and who delivered at our institution were evaluated.
Results—Eighty-five patients carrying 110 fetuses were identified. Six cardiac anomalies (4 ventricular septal defects [VSDs], 1 pulmonary artery [PA]-aortic disproportion, and 1 postvalvular PA dilatation)
were suspected on the AS. At ECHO, 2 VSDs were confirmed, 2 were
not, and 2 additional VSDs were seen; 1 aberrant right subclavian artery
(ARSA) and 1 right aortic arch (RAA) were found, and PA dilatation was
confirmed. On neonatal ECHO, only 2 of the 7 VSDs seen at either the AS
or ECHO were present; the postvalvular PA dilatation and RAA were confirmed. Second-trimester ECHO, however, identified only 2 additional
anomalies confirmed at birth: an RAA in a fetus with a known VSD and
an additional fetus with a VSD. Neonatally, 3 patients with a normal AS
and ECHO were found to have VSDs. The most common cardiac abnormality in IVF/ICSI fetuses is a VSD, which is identified in 4.5% of all
cases in the neonatal period. VSDs identified in the antenatal period resolved in 82% of cases. A RAA and an ARSA should be identified on the
transtracheal view (3-vessel view [3VV]) of the heart.
Conclusions—In IVF/ICSI pregnancies, VSDs are common
but likely to resolve or be seen only at birth. In expert centers, fetal ECHO
may not be necessary if the 3VV of the heart is evaluated and the heart is
evaluated for VSDs.
1538566 Application of Acoustic Radiation Force Impulse Imaging
in Quantitative Evaluation of Neonatal Brain Development
Su Yijin,* Du Lianfang, Xia Jin, Wu Ying, Jia Xiao, Cai
Yingyu, Li Yunhua, Zhao Jing, Liu Qian, Zhang Juan
School of Medicine, Shanghai Jiaotong University, Shanghai,
China
Objectives—To quantitatively evaluate the effect of acoustic
radiation force impulse imaging (ARFI) in neonatal brain development.
Methods—we used ARFI on a Siemens S2000 system to quantitative evaluate white and gray matter of neonatal different tissues in brain
with different gestational ages. We used a new technical index, Virtual Touch
Tissue Quantification (VTQ) to evaluate elastic changes of brain tissues.
Results—Different tissues in the brain had different elastic numerical values. Neonates with different gestational ages had different elastic numerical values. Elastic numerical values of full-term infants were
higher than preterm infants.
Conclusions—ARFI provides a new quantitative index to evaluate neonatal brain development. It increases objectivity and reliability of
clinical analysis. Ultrasound is an examination method that is noninvasive, safe, simple, and convenient, so it has more usefulness with ARFI in
quantitative evaluation of neonatal brain development.
Table 1. Comparison of VTQ Values for Preterm and Full-Term Neonates
Neonates
Cases, n
Mean, m/s
SD, m/s
Preterm
23
1.89
1.07
Full-term
35
2.35
1.24
Compared with full-term neonates, the VTQ value for preterm neonates was lower
(P < .001).
1538283 Is Follow-up Sonography Necessary in Babies With Morphologically Normal but Unstable Hips?
Christine Iseman, Bokyung Han, Henrietta Kotlus Rosenberg* Radiology, Mount Sinai Medical Center, New York,
New York USA
Objectives—To determine if follow-up (FU) hip ultrasound
(US) is necessary in babies with an unstable hip when the hip morphology
is normal (nl).
Methods—This retrospective study included patients (pts) with
at least 2 hip US examinations performed between January 1, 2008, and
January 31, 2012. Pt population: 342 pts, 42 excluded as FU US performed
in a Pavlik harness, 15 excluded as both hips nl aligned on first and FU US,
and 10 excluded due to poor technique. A total of 515 hips were analyzed
in 285 pts. Of those, 68 hips were excluded as they were normal on the first
study. In total, 480 hips were analyzed. All sonograms and associated reports were reviewed by 1 attending and 1 resident radiologist. Degree of
subluxation/dislocation assessed and graded: normal = 0; mild = 1; moderate = 2; severe = 3; and dislocation = 4.
Results—A total of 447 hips were initially subluxed or dislocated and resolved on FU (93%; group 1). Thirty-three hips were initially
subluxed or dislocated and did not resolve (7%). Of hips that did not resolve on FU, 4% were morphologically nl (group 2), and 2% were initially morphologically abnormal (abnl) but became morphologically nl on
FU (group 3). Four hundred six of 447 hips (91%) demonstrated normal
α angles ≥ 60° at first US and nl alignment during all maneuvers on FU.
Forty-one of 447 hips had abnl α angles ≤60° initially and nl alignment
during all maneuvers on FU. Age range at time of initial US: 1 to 136
days. Age range at time of FU US, which demonstrated resolution of subluxation/dislocation: 23 to 362 days for group 1, 35 to 174 days for group
2, and 23 to 174 days for group 3. One hundred fifty-one babies whose
subluxation/dislocation resolved had US performed within the first 30
days of life; 21% resolved within 28 days; 52% in 29 to 56 days, 16% in
56 to 84 days, and 21% in >84 days.
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Conclusions—The vast majority (94%) of unstable hips became stable on FU examination; 91% of these hips were morphologically
nl at initial US, while 9% were morphologically abnl at the initial study but
became morphologically nl on FU. Approximately 6% of total hips analyzed remained unstable on FU, 4% of these being morphologically nl
hips. While these findings can be comforting to parents whose babies have
hip instability, they also support the current practice of obtaining FU sonograms until stability is achieved.
1538513 Neonatal Ovarian Cysts: Can Sonography Predict Torsion?
Dinesh Chinchure,1* Chiou Li Ong2 1Diagnostic Radiology,
Khoo Teck Puat Hospital, Singapore; 2Diagnostic Imaging, K.
K. Women’s and Children’s Hospital, Singapore
Objectives—The purpose of this study was to evaluate whether
sonography can predict torsion in neonatal ovarian cysts.
Methods—Seven surgically proven cases of neonatal ovarian
cysts were included in this retrospective study. The patients were divided
into 2 groups: torsion and nontorsion. These 7 patients were evaluated for
clinical presentation, sonographic features, and surgical and pathologic findings. The findings on follow-up sonography after surgery were also noted.
Results—The sonographic appearance was variable. Of the 4
cases with torsion, 2 lesions had internal echoes with a “fishnet appearance.” The other 2 lesions were predominantly cystic on sonography with
internal echoes and echogenic nodules. A calcific focus was present in 1
of these echogenic nodules. One of the cysts had a fluid-fluid level. In the
nontorsion group, only 1 of the lesions had a mixed echogenic appearance. The other 2 lesions were cystic with low-level internal echoes in 1
of the cysts. The surgical procedure performed in the torsion group was
salpingo-oophorectomy in 2 patients and oophorectomy in 1 patient. In 1
patient, cystectomy was attempted without success. In the nontorsion
group, only cystectomy was performed with preservation of normal
ovaries, which was confirmed on follow-up sonography.
Conclusions—The sonographic features of cysts with a fishnet
appearance, a fluid-debris level, and echogenic nodules favor torsion. The
former sign has so far not been described as a sonographic predictor for
neonatal ovarian torsion.
1539741 Sonographic Evaluation of Pediatric Skeletal Lesions: Is It
Worthwhile?
Henrietta Kotlus Rosenberg,* Neil Lester Radiology, Mount
Sinai Medical Center, New York, New York USA
Objectives—To demonstrate how ultrasound (US) may serve
as a readily available, cost-effective, noninvasive, nonionizing, practical
tool for the evaluation of a variety of skeletal abnormalities in the pediatric
age range.
Methods—We reviewed the clinical and imaging findings in
31 patients in whom US demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or developmental
dysplasia of the hip.
Results—US proved useful in the following situations: evaluation of a hard superficial immobile mass (osteoma shin; 1), absent medial
end clavicle on x-ray in the region of a neck mass (US showed an aneurysmal bone cyst in the medial end clavicle; 1), to determine if a soft tissue
mass involves adjacent bone (nodular fasciitis surrounding the clavicular
head; 1), diagnosis and follow-up of fracture (displaced/nondisplaced) in an
infant (4), diagnosis of osteomyelitis in patients with cellulitis (4), question of fracture underlying cephalohematoma or subgaleal hematoma (4),
rib mass (osteochondroma; 1; or a mass in costochondral junctions: contour
deformities in the costochondral cartilage; 6), firm posterior knee mass
(Baker’s cyst; 1), firm anterior knee mass (septated cystic mass in the suprapatella region due to rheumatoid disease; 1), immobile hard scalp mass due
to an epidermoid cranial vault (1), painful mass in the occipital bone with
soft tissue components extending through the skull externally and inter-
nally due to Langerhan’s histiocytosis (1), indeterminate mass in the clavicle clinically thought to be posttraumatic sequelae, resolved on follow-up
(1), assessment of craniosynostosis (3), ad differentiation of a pathologic entity from a normal anatomic structure (lump on the back of a slender baby
proven to be a normal posterior spinous process; 1).
Conclusions—US is worthwhile for evaluation of a wide range
of pediatric skeletal abnormalities and helps determine if the a lesion is one
that is “touch” or “don’t touch.” To maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, and laboratory and other imaging findings. In equivocal cases or in
those patients in whom the field of view is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, US serves to
triage those patients in whom further imaging is necessary.
1539575 Evaluation of Automated Multiplanar 3-/4-Dimensional
Sonography in Prenatal Diagnosis of Conotruncal Cardiac
Defects: Analysis of 150 Cases
Elena Sinkovskaya,* Sharon Horton, Anna Klassen, Alfred
Abuhamad Division of Maternal-Fetal Medicine, Eastern
Virginia Medical School, Norfolk, Virginia USA
Objectives—The aim of this study was to assess potential clinical applicability of automated multiplanar imaging (AMI) in prenatal detection of conotruncal heart defects.
Methods—Detailed 2D echocardiography was performed in
75 fetuses with normal cardiac anatomy and 75 fetuses with conotruncal
heart anomalies between 18 and 23 weeks’ gestation by a trained sonographer. In addition, 3D/spatiotemporal image correlation volumes of the
fetal chest were acquired at the level of the 4-chamber view. Two volume
data sets per case (with and without color Doppler) were included in the
study. The initial scan was interpreted and reported based on the 2D images. The volume data sets were independently reviewed offline using
AMI software by a pediatric cardiologist with experience in fetal heart assessment. The diagnostic value, image quality, as well as time for acquisition and reading of AMI were evaluated and compared with the original
2D report. The prenatal diagnosis was confirmed in all cases by postnatal
echocardiography, angiography, operative findings, or autopsy.
Results—A summary of the results is provided in Table 1.
Conclusions—The developed software demonstrates an excellent display of the diagnostic landmarks of conotruncal defects with
appropriate image quality in most cases. This should help improve the detection of these heart anomalies in the future. Automated sonography also
has the potential for improving the efficiency of ultrasound imaging by
reducing the time needed to complete an ultrasound examination, thereby
resulting in increased throughput of ultrasound laboratories.
Table 1
Parameter
Acquisition time, min
Reading time, min
Image quality, %
Excellent
Good
Poor
Sensitivity, %
Specificity, %
NS indicates not significant.
S29
2D
16 ± 4
12 ± 2
AMI
0.3 ± 0.1
7±2
P
<.001
<.01
37
53
10
88
96
41
43
16
92
96
NS
NS
NS
NS
NS
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1540606 Fetal Diagnosis of Hypoplastic Left Heart: Associations and
Outcomes in the Current Era
Roland Axt-Fliedner,1* Christian Enzensberger,1 Melanie
Vogel,2 Jan Weichert,4 Ulrich Gembruch,5 Ute Germer,6
Thomas Kohl,3 Martin Krapp,7 Jan Degenhardt1 1Division
of Prenatal Medicine, 2Division of Pediatric Cardiology,
3
German Center for Fetal Surgery and Minimally Invasive
Therapy, University of Giessen & Marburg, Giessen, Germany;
4
Division of Prenatal Medicine, University of SchleswigHolstein, Campus Luebeck, Luebeck, Germany; 5Division of
Prenatal Medicine, University of Bonn, Bonn, Germany;
6
Center for Prenatal Medicine, Caritas Krankenhaus St Josef,
Regensburg, Germany; 7Center for Endocrinology and
Reproductive and Prenatal Medicine, Amedes Hamburg, Hamburg, Germany
Objectives—Hypoplastic left heart (HLH) is one of the most
common forms of cardiac abnormality detectable during gestation by fetal
echocardiography. Antenatal diagnosis allows for appropriate counseling
and time to consider treatment options. We report the actual outcome data
after fetal diagnosis of HLH.
Methods—We conducted a retrospective analysis of the outcome in all cases with HLH from 1994 to 2011 presenting in fetal life at
2 tertiary referral centers for prenatal diagnosis and pediatric cardiology.
Results—One hundred five cases were included, and the overall survival was 40.9% (43/105) after prenatal diagnosis. There was an
81.1% survival rate in infants undergoing surgery and a 64.1% survival
rate from an intention-to-treat position. Two neonates died due to tamponade and cardiac arrest following balloon septostomy and 1 neonate
from sepsis before surgery. Extracardiac anomalies occurred in 3 fetuses
and karyotype anomalies in 7 fetuses (18.9%). In 4 of 5 babies born with
additional extracradiac or karyotype anomalies, parents opted for compassionate care. The first had trisomy 13; the second had trisomy 18; the
third neonate presented with spina bifida; and the fourth presented with hydronephrosis and pulmonary atresia. Termination of pregnancy took place
in 17 cases (16.1%).
Conclusions—Thorough antenatal evaluation should include
karyotyping and detailed extracardiac and intracardiac assessment to accurately predict the risks of surgery. Prenatal counseling might be modified after the exclusion of additional anomalies. These data provide
up-to-date information for parental counseling.
1539318 Fetal Pulmonary Venous Flow and a Restrictive Foramen
Ovale in Hypoplastic Left Heart
Roland Axt-Fliedner,1* Jan Degenhardt,1 Melanie Vogel,2
Jan Weichert,4 Ulrich Gembruch,5 Thomas Kohl,3 Christian
Enzensberger1 1Division of Prenatal Medicine, 2Division of
Pediatric Cardiology, 3German Center for Fetal Surgery and
Minimally Invasive Therapy, University of Giessen & Marburg,
Giessen, Germany; 4Division of Prenatal Medicine, University
of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany;
5
Division of Prenatal Medicine, University of Bonn, Bonn,
Germany
Objectives—Hypoplastic left heart (HLH) with intact or restrictive interatrial communication (HLH- IAS/RAS) is associated with
high mortality rates. The objective was to correlate pulmonary venous
(PV) Doppler spectra and direct foramen ovale (FO) assessment with the
neonatal need for early atrial septostomy (EAS) and neonatal outcome.
Methods—We reviewed all prenatal echocardiograms and
outcomes of 51 fetuses with HLH and information about the interatrial
communication between 1994 and 2011. IAS/RAS was defined as a
small/absent interatrial shunt on 2D imaging. Three PV Doppler spectra
were observed: type A, continuous forward flow with a small a-wave reversal; type B, continuous forward flow with increased a-wave reversal;
and type C, brief to-and-fro flow.
Results—Three of 51 neonates with the type C PV flow pattern
and suspicion of IAS/ RAS on 2D evaluation required EAS. In 1 fetus, PV
flow changed from type B to type C spectra throughout gestation. Fetuses
with type C spectra showed 71.4% survival after 30 days compared to
92.3% in fetuses with type A spectra. Short-term survival after EAS was
33%.
Conclusions—The prenatal PV flow pattern and 2D evaluation of the FO size help in identifying the fetus at risk for neonatal EAS
and patient selection for fetal cardiac intervention. Most late secondtrimester values will not change over time.
1538894 The Fetal-Maternal Vascular Impedance Index: A Potential New Tool for Characterization of Fetal Circulatory
Health
Debbra Soffer,* Margaret McCann, Xi Liu, Zhiyun Tian,
Jack Rychik Fetal Heart Program, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania USA
Objectives—Fetal circulatory health is often determined by
characterization of (1) umbilical arterial blood flow, (2) cerebrovascular
blood flow, or (3) the ratio between the two. However, these measures ignore the maternal contribution to placental perfusion. We sought to investigate the utility of the fetal-maternal vascular impedance index
(FMVI), a new measure of vascular characterization that incorporates fetal
cerebrovascular, umbilical, and maternal uterine circulations in assessing
overall fetal well-being.
Methods—Doppler interrogation of the fetal middle cerebral
artery (MCA), umbilical artery (UA), and right maternal uterine artery
(UTA) was performed and vascular impedance calculated for each through
the pulsatility index (PI). Three groups of gestationally age-matched subjects were studied: (1) normal controls, (2) fetuses with maternal diabetes
(MD), and (3) fetuses with a severe form of congenital heart disease
(CHD), hypoplastic left heart syndrome (HLHS). The FMVI was calculated as the (MCA PI – UA PI)/UTA PI.
Results—Mean and SD data are listed in Table 1. There was
no difference in gestational age between the 3 groups. The MCA PI for the
MD group was no different than for normal; however, HLHS was significantly lower (P < .05). There was no difference in the UA PI or UTA PI
between the 3 groups. The FMVI for the MD group was significantly
lower (P < .05) and for the HLHS group was markedly lower (P < .001),
than normal.
Conclusions—The FMVI is an index of relative vascular impedance between the fetal cerebrovasculature, UA, and maternal contribution to placental flow, which varies from normal in MD and complex
CHD. Vascular impedance is naturally highest in the MCA, followed by
the UA, and lowest in the UTA. The FMVI evaluates this natural trend,
which may aid in detecting subtle circulatory alterations that are not evident by analysis of individual PI values alone.
Table 1
n
Normal 47
MD
54
HLHS 29
S30
Gestational
Age, wk
MCA PI
UA PI
23.2 (3.7) 1.99 (0.38) 1.25 (0.19)
23.5 (4.8) 1.92 (0.39) 1.30 (0.29)
24 (3.4) 1.85 (0.31) 1.34 (0.26)
UTA PI
0.92 (0.38)
0.91 (0.36)
0.89 (0.21)
FMVI
0.97 (0.63)
0.73 (0.73)
0.62 (0.49)
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SPECIAL INTEREST SESSIONS
MONDAY, APRIL 8, 2013, 1:30 PM–3:30 PM
Directing Extracellular Matrix Protein Microstructure With Ultrasound
Denise Hocking Pharmacology and Physiology, University
of Rochester, Rochester, New York USA
Cellular Bioeffects and Applications
Moderator: Diane Dalecki, PhD
Applications of Ultrasound Standing Wave Fields in Tissue Engineering
Diane Dalecki University of Rochester, Rochester, New York
USA
The field of tissue engineering aims to develop technologies
that enable the repair or replacement of diseased or injured tissues and organs. The spatial organization of cells within native and engineered tissues
is essential for proper tissue assembly and organ function. Thus, successful engineering of complex tissues and organs requires methods to control
cell organization in 3 dimensions. Acoustic radiation forces associated
with ultrasound standing wave fields provide a rapid, noninvasive approach to spatially pattern cells in 3 dimensions without affecting cell viability. Results of several investigations will be presented that demonstrate
the use of ultrasound standing wave fields to pattern cells or protein-bound
microparticles in 3D hydrogels. Furthermore, patterning of endothelial
cells with ultrasound standing wave fields leads to rapid and extensive
vessel network formation in 3D collagen-based constructs. Thus, ultrasound standing wave fields provide new strategies to pattern cells and direct vascular network formation and morphology within engineered tissue
constructs.
Interactions of Microbubbles With Cells and Their Applications for
Drug and Gene Delivery
Cheri Deng University of Michigan, Ann Arbor, Michigan
USA
Sonoporation uses ultrasound application to generate microbubble activities to transiently disrupt the cell membrane for enhancing intracellular transport of exogenous agents for drug and gene delivery
applications. However, success of sonoporation is hindered by low delivery efficiencies and variable outcomes. These difficulties are due to the
lack of understanding of the detailed processes supporting ultrasound-induced transport into and within the cytoplasm of living cells. The dynamic
microbubble activities driven by ultrasound application induce cellular
bioeffects that can determine the delivery outcome, including delivery efficiency and cell viability. In this presentation, we provide an examination of these biophysical and biochemical effects resulting from interaction
of ultrasound-driven microbubbles with cells and whether they play important roles in the sonoporation outcome. We developed novel techniques
to control and investigate ultrasound-driven microbubble cavitation in reference to single cells and the resulting membrane disruptions. We used simultaneous whole-cell patch clamp recording and fluorescence microscopy
to characterize the formation and resealing of ultrasound-induced membrane pores. We demonstrated spatiotemporally controlled subcellular delivery and calcium signaling in targeted cells. In addition, based on the
ultrasound-driven microbubble activities, we implemented an ultrasound
exposure strategy to improve gene transfection. These results may provide relevant information for further development of sonoporation.
The extracellular matrix is a complex network of interconnected
proteins and polysaccharides that provides structure to tissues and instructs
cell behaviors. The microstructure and molecular conformation of extracellular matrix proteins provide signals that direct cell functions critical to
tissue formation and regeneration, including proliferation, migration, and
matrix remodeling. Thus, controlling extracellular matrix protein structure provides a means to regulate the mechanical properties of biomaterials and control cellular responses. Moreover, biomaterials with regionally
defined extracellular matrix structure could provide local cues to instruct
cell behavior and drive proper tissue function in 3 dimensions. Collagen
is the primary fibrous component of the extracellular matrix. The tremendous diversity of the functional properties of type I collagen arises from
variations in the micromolecular and macromolecular structure of polymerized collagen fibers. Results of our studies demonstrate the capability
of ultrasound to spatially pattern various collagen microstructures within
an engineered tissue noninvasively, thus enhancing the level of complexity of extracellular matrix microenvironments and cellular functions
achievable within 3D engineered tissues.
Elastography 2013
Moderator: Richard Barr, MD, PhD
Elastography of Diffuse Liver Disease
Giovanna Ferraioli,* Carlo Filice Infectious Diseases, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico,
Policlinico San Matteo, Medical School, University of Pavia,
Pavia, Italy
The prognosis and management of patients with chronic liver
diseases largely depend on the extent and progression of liver fibrosis.
Liver biopsy is still considered the reference standard for assessing liver
fibrosis. It is an invasive procedure that carries a risk of complications.
Moreover, it is not an ideal method for repeated evaluation of disease progression. For these reasons, techniques that noninvasively assess liver fibrosis have been developed. Elastography is a technique that analyzes the
mechanical and elastic properties of soft tissue that could be modified by
pathologic conditions. Real-time elastography, which allows measurement
of tissue’s stiffness while guided by the B-mode image, is either strain
based or shear wave based. With strain-based elastography, the displacement of tissues due to an applied stress is detected. With all the shear wavebased techniques, there is a generation of shear waves determined by
tissue’s displacement induced by the force of a focused ultrasound beam.
Real-time elastographic methods are included in standard ultrasound systems. Based on our experience and that of other groups, we believe that
shear wave–based methods are ready to be used in patients with chronic
hepatitis C to assess liver fibrosis before therapy at a safe level of predictability.
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Exploring the Interface of Ethics and Communication
in Prenatal Care: A Video-Based Approach
Moderator: Stephen Brown, MD
Exploring the Interface of Ethics and Communication in Prenatal
Counseling: A Video-Based Approach
Stephen Brown,1* Bryann Bromley,3,4,5 Elaine Meyer2,6
1
Radiology, 2Institute for Professionalism and Ethical Practice,
Boston Children’s Hospital, Boston, Massachusetts USA;
3
Diagnostic Ultrasound Associates, Boston, Massachusetts
USA; 4Obstetrics and Gynecology, Massachusetts General
Hospital and Brigham and Women’s Hospital, Boston, Massachusetts USA; 5Radiology, Brigham and Women’s Hospital,
Boston, Massachusetts USA; 6Psychiatry, Harvard Medical
School, Boston, Massachusetts USA
Course objectives: (1) Evaluate strategies to communicate effectively when conveying difficult information to patients. (2) Explore
how micro-ethical issues are embedded in patient-clinician communication. (3) Examine the clinical and ethical dimensions of prenatal counseling from the perspectives of upstream and downstream clinical providers.
Course description: In this interactive workshop, faculty and audience will
view and discuss videotaped counseling sessions between experienced
clinicians and trained actors portraying expectant parents after diagnoses
of miscarriage in the first trimester and spina bifida in the second trimester.
When such conditions are diagnosed, practitioners who counsel patients
must convey cognitively and ethically complex information under emotionally charged circumstances. Few educational opportunities exist to
help practitioners acquire the skills necessary to approach these conversations effectively. Such skills are essential for obstetric and pediatric specialists who engage in prenatal diagnosis and counseling. In this workshop,
participants will collectively explore and share their perspectives regarding: (1) the “art” of difficult communication; (2) how values may influence
decision making; (3) how language usage, framing of choices, provision
of information, and offers of resources may confound neutrality; (4) potential differences in attitudes and counseling practices between practitioners from different disciplines; and (5) strategies to teach this difficult
communication process. Workshop faculty includes a pediatric and obstetric imaging specialist and bioethicist, a maternal-fetal medicine and
obstetric imaging specialist, and a psychologist and pediatric critical care
nursing specialist who is an expert in health care communication.
Hands-on Carotid and Transcranial Doppler
Ultrasound
Moderator: Tatjana Rundek, MD
In this session, participants will be provided with live demonstrations of carotid and transcranial Doppler scanning protocols and handson practice sessions at ultrasound stations.
New Techniques and Methods in Ultrasound-Guided
Interventions
Moderator: Corinne Deurdulian, MD
Utilization of Contrast-Enhanced Ultrasound in Interventional
Radiology
Dean Huang Clinical Radiology, King’s College Hospital,
London, England
The aim of this talk is to consider the applications of contrast-enhanced ultrasound (CEUS) in interventional radiology. One of the most es-
tablished techniques in imaging-guided, minimally invasive procedures is
with ultrasound, a tool that is safe, mobile, and cost-effective. CEUS provides better images than conventional B-mode images, improves the ability
to differentiate between normal and abnormal tissue, and simplifies the precise navigation of needles during an intervention. CEUS therefore could play
an important role in procedure planning, needle navigation, and postprocedure follow-up imaging, particularly when iodinated contrast or ionizing radiation is undesirable or in unstable patients where “bedside” procedures are
advantageous. A number of interventional procedures in which CEUS has
been integrated into the management, both in nonvascular and vascular intervention, are illustrated. Examples of nonvascular applications include urologic intervention with CEUS-guided nephrostomy and CEUS-guided
nephrostography, CEUS-guided percutaneous biopsy and abscess drainage,
CEUS-guided transhepatic T-tube cholangiography, and CEUS-guided oncologic intervention in thermal ablation of hepatic and renal tumors. Examples of vascular intervention with CEUS include management of endoleaks
following endovascular aortic stent graft repair, pseudoaneurysms following
arterial injury with CEUS-guided percutaneous thrombin injection, and
CEUS-guided dialysis arteriovenous fistula angioplasty. Through a casebased approach, this talk aims to demonstrate that CEUS not only can be utilized safely and effectively in radiologic intervention but may also provide
novel, tailor-made solutions to complex clinical problems.
Vaginal Bleeding in the First Trimester
Moderator: Leslie Scoutt, MD
Ultrasound Evaluation for Retained Products of Conception
Douglas Brown Radiology, Mayo Clinic, Rochester,
Minnesota USA
In this session, we will review sonographic features for identifying retained products of conception in patients with spontaneous miscarriage and after surgical intervention. Limitations of ultrasound for this
purpose will be reviewed. Miscellaneous abnormalities occurring in
women after spontaneous miscarriage will also be reviewed, including subinvolution of the placental bed, which can present a diagnostic dilemma.
Diagnostic Criteria for Miscarriage and Nonviable Pregnancy in the
Early First Trimester
Peter Doubilet Radiology, Brigham and Women’s Hospital,
Boston, Massachusetts USA; Radiology, Harvard Medical
School, Boston, Massachusetts USA
When a woman presents with symptoms of pain or bleeding in
early pregnancy, the main diagnostic possibilities are currently viable intrauterine pregnancy, failed (or failing) intrauterine pregnancy, and ectopic
pregnancy. Serum human chorionic gonadotropin (hCG) measurement
and pelvic ultrasound are commonly performed to aid in the differential
diagnosis. At that point, unless an emergently life-threatening situation
dictates management, a key question is: “Is there a chance of a viable pregnancy?”. This question is central to management decision making in 2
main clinical settings: intrauterine pregnancy of uncertain viability and
pregnancy of unknown location. Research over the past 2 to 3 years has
called into question previously accepted dogma regarding criteria for ruling out the possibility of a viable pregnancy, which had been based on
small study populations. We will consider 3 scenarios: (1) Ultrasound
demonstrates an intrauterine gestational sac, with or without a visible embryo, with no cardiac activity: What are the criteria for definitive diagnosis of failed pregnancy (“miscarriage”)? (2) Ultrasound demonstrates a
small saclike structure in the uterus, without a visible yolk sac or embryo:
Is it a gestational sac or pseudogestational sac? (3) Ultrasound demonstrates no intrauterine fluid collection and no adnexal mass suspicious for
ectopic pregnancy: What is the significance if the hCG value is above the
“discriminatory level” or if it is below the “discriminatory level”?
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Ectopic Pregnancy
James Shwayder Obstetrics and Gynecology, University of
Mississippi Medical Center, Jackson, Mississippi USA
This portion of the session will address new nomenclature related to ectopic pregnancies and pregnancies of unknown location. It will
discuss the relative merit of various laboratory and ultrasound findings in
diagnosing ectopic pregnancies, presented with clinical correlation.
SPECIAL INTEREST SESSIONS
MONDAY, APRIL 8, 2013, 4:00 PM–5:30 PM
Hands-on Elastography
Moderator: Richard Barr, MD, PhD
This session is designed to provide a workshop with various
vendors demonstrating how to perform and interpret elastography with
their equipment and demonstrating the differences in techniques between
vendors to obtain optimal images.
Interventional and Other Ultrasound Techniques:
How I Do It
histopathologic methods. The QUS methods of particular interest in
these applications are spectrum analysis and envelope statistics. QUS
applied to detection of prostate cancer produces an area under the receiver operating characteristic curve of 0.84, while QUS applied to detection of lymph node colorectal and gastric cancer metastases produces
an area exceeding 0.95; both results are markedly superior to the performance of current methods. The implications for prostate cancer management are improved biopsies, noninvasive disease monitoring, and
accurate focal treatment targeting; the implications for lymph node
histopathology are improved detection of metastases and more accurate
cancer staging.
Moderator: David Fessell, MD
Ultrasound Incidentalomas
After attending this session, participants will know when and
how to use interventional musculoskeletal ultrasound techniques.
Moderator: Franklin Tessler, MD, CM
Incidental Findings in the Soft Tissue and Extremities
Deborah Rubens Imaging Science, University of Rochester,
Rochester, New York USA
Quantitative Ultrasound Biomarkers
Moderators: Paul Carson, PhD, Timothy Hall, PhD, ABR
Quantitative Ultrasound Applied to Detection and Imaging of
Prostate Cancer and Lymph Node Metastases
Ernest Feleppa Frederic L. Lizzi Center for Biomedical
Engineering, Riverside Research, New York, New York USA
This session will cover incidental findings discovered during
examination of the soft tissues and extremities. Topics will include solid
masses, fluid collections, and vascular findings that are unexpected and not
part of the original diagnostic question. Management and reporting issues
will be addressed: which findings require immediate phone calls, which
can be mentioned in the report but are not urgent, and which can be ignored altogether.
Ultrasound is a popular clinical-imaging modality for displaying the macroscopic anatomy of soft tissue structures in medical and
research applications. While conventional ultrasound methods (eg, Bmode, harmonic, and Doppler methods) are well established and continue to advance technically, quantitative ultrasound (QUS) technologies
also are emerging that appear to offer exciting promise for significantly
improving clinical imaging of disease. These emerging methods include
spectrum analysis, envelope statistics analysis, strain and Young’s modulus estimation, contrast-based perfusion kinetics, and advanced flow
detection and measurement techniques. Each QUS method provides independent information, and each offers powerful quantitative tissue-typing and imaging capabilities. However, a multifeature approach that
combines estimates derived from different QUS methods may provide
even more powerful capabilities, eg, by combining spectrum analysis
and envelope statistic parameters. This presentation will review progress
specifically in QUS applied to tissue-type imaging of prostate cancer
and detection of lymph node metastases. Prostate cancer cannot be reliably imaged by conventional ultrasound, and small, but clinically significant, lymph node metastases easily can be overlooked by current
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SCIENTIFIC SESSIONS
MONDAY, APRIL 8, 2013, 4:00 PM–5:30 PM
Carotid/Cerebrovascular Ultrasound and
Neurosonology
Moderator: David Vilkomerson, PhD
1538396 Monitoring the Formation of Aneurysms in Murine Aortas
Using Pulse Wave Imaging
Sacha Nandlall,* Monica Goldklang, Jeanine d’Armiento,
Elisa Konofagou Columbia University, New York, New York
USA
Objectives—Abdominal Aortic Aneurysms (AAAs) are a common vascular disease. The leading cause of AAA-induced death is rapid internal bleeding following a sudden rupture of the vessel wall, typically
within the sac of the aneurysm. This study aimed at showing that pulse
wave imaging (PWI) can be used to differentiate normal murine aortas
from AAAs, even for aneurysms that are not visible or easily detectable on
a standard B-mode. PWI is a noninvasive technique for tracking the propagation of pulse waves along the wall of the aorta at high spatial and temporal resolutions. The velocity of these waves is a well-established marker
of wall stiffness, which is closely related to the likelihood of rupture.
Methods—An AAA model was generated by infusing 13
ApoE/TIMP-1 knockout mice with angiotensin II, delivered at a constant
flow rate via subcutaneously implanted osmotic pumps. The suprarenal
sections of the abdominal aortas were scanned every 2 to 3 days after implantation using a Vevo 770 imager (VisualSonics Inc) with axial and lateral resolutions of 55 and 115 µm, respectively. Pulse wave propagation
was tracked at an effective frame rate of 8 kHz by using retrospective electrocardiographic gating. The displacements induced by the pulse waves
were estimated by performing 1D cross-correlation on the pre–beamformed radiofrequency signals.
Results—In normal aortas, the pulse waves propagated at constant velocities (r2 ≥ 0.9) between 2 and 4 m/s, indicating that the composition of these vessels was relatively homogeneous. However, in AAAs
where the vessel diameter had increased by at least 50%, the wave speeds
exhibited higher variances along the wall (r2 < 0.9). Moreover, the wall displacements induced by the pulse waves were at least 80% lower within the
aneurysmal sacs, indicating that the AAAs had a higher relative stiffness.
Conclusions—This study demonstrates that PWI can be used
to distinguish normal murine aortas from AAAs based on the higher variance and lower wall displacements induced by the pulse wave in the latter case. Hence, PWI could potentially be used to monitor the growth and
propensity for rupture of human aneurysms by providing complementary
information to that provided by a standard B-mode.
1510020 Results of Evaluation of the Spectral Curve in Aortoiliac
Disease
Mireia Cussó Sorribas,* Xavier Martí Mestre, Nicolo Rizza
Siniscalchi, Sara Garcia Pelegrí, Antonio Romera Villegas,
Ramon Vila Coll Vascular Surgery, Hospital de Bellvitge,
Hospitalet de Llobregat, Barcelona, Spain
Objectives—To evaluate the morphology of the spectral curve
of the supraceliac aorta as a complement of the diagnosis of aortoiliac occlusive disease.
Methods—We studied 86 patients (70 men) with a mean age of
62 years (range, 16–90 years) recruited from August to February 2012.
Arterial Doppler ultrasound of the aortoiliac and femoro-popliteal sector
was used as a method of diagnosis of the stenotic-occlusive disease in
these sectors. Stenosis was considered significant when it exceeded 70%,
characterized by a ratio of peak systolic velocities in the stenosis compared to the previous stenosis ≥3. Occlusion was considered in the absence of flow. We determined the spectral wave morphology of the aortic
flow at the visceral arteries level looking for the presence of a deceleration
in the late systolic phase or a biphasic wave in the systolic waveform
(notch). We studied the relationship of these signs of the spectral visceral
aortic wave with the presence of disease of the aortoiliac sector in terms
of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), overall efficiency, and κ correlation index. Data were
treated using SPSS 15.0 for Windows.
Results—Fifty-seven percent had aortoiliac disease, and 51.2%
had femoro-popliteal disease. We detected the presence of alteration in the
spectral visceral aorta wave in 46 patients (53.5%), of which 41 had aortoiliac disease. The sensitivity, specificity, PPV, and NPV for the morphologic alteration of the aortic spectral curve in the aortoiliac segment
were 83.6%, 86.5%, 89.1%, and 80%, respectively, with overall efficiency
of 84.9% and a κ correlation index of 0.695 (good agreement).
Conclusions—The existence of spectral wave disturbances in
the visceral aortic territory might suggest the presence of stenotic-occlusive disease in the aortoiliac segment.
1530492 Comparison of Automatic and Manual Transcranial Sonographic Morphometric Measurement of the Substantia Nigra
Monika Jelinkova,1 David Školoudík,2,3* Jiri Blahuta,4 Tomas
Soukup,4 Petr Cermak,4 Petra Bartova,2 Katerina Langova,5
Roman Herzig3 1Neurology, Hospital Karvina-Raj, Karvina,
Czech Republic; 2Neurology, University Hospital Ostrava,
Ostrava, Czech Republic; 3Neurology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech
Republic; Institute of Computer Science, Faculty of Philosophy and Science, Silesian University Opava, Opava, Czech
Republic; Biophysics, Faculty of Medicine and Dentistry,
Institute of Molecular and Translational Medicine, Palacký
University Olomouc, Olomouc, Czech Republic
Objectives—Increased echogenicity of the substantia nigra
(SN) is a typical transcranial sonographic (TCS) finding in Parkinson’s
disease (PD). Experimental software for quantitative evaluation of the
echogenic SN area was developed to overcome the main limitation of
TCS, the dependency on the sonographer’s experience. The aim of the
study was to compare the morphometric measurement of the SN using
developed software with manual measurement and results achieved by 2
different ultrasound machines in PD patients and healthy volunteers.
Methods—Totally, 113 healthy volunteers were enrolled in the
derivation cohort and 50 healthy volunteers and 30 PD patients in the validation cohort. The SN was imaged from the right and left temporal bone
windows in the mesencephalic plane using TCS. All subjects were examined twice using different sonographic machines (MyLab Twice, Esaote;
and Vivid 7 Pro, GE). DICOM images of the SN were saved, encoded, and
processed. Manual and automatic morphologic measurements of the SN
were performed by an experienced sonographer. The 90th percentile of
derivation cohort values was used as a cut point for the evaluation of a
hyperechoic SN in the validation cohort. Spearman’s coefficient was used
for the assessment of correlation between manual and automatic measurements. Cohen’s κ coefficient was used for the assessment of correlation
between automatic or manual measurement and PD diagnosis.
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Results—Spearman’s coefficient between measurements using
different machines was 0.686 for automatic and 0.721 for manual measurement (P < .0001 for both measurements). A hyperechoic SN was detected in the same 26 (86.7%) PD patients using both automatic and
manual measurements. Cohen’s κ coefficients for automatic and manual
measurements were 0.787 and 0.762, respectively (P < .0001 for both
measurements).
Conclusions—The results of the presented study showed
comparable findings for SN feature measurement using the designed application with manual measurement. (Supported by a grant from the
Moravian-Silesian Region.)
1540954 Investigation of Asymmetries in Cerebral Collateral Flow
for Patients With Carotid Stenosis
Khalid Al Muhanna,1* Limin Zhao,2 Kirk Beach,3 Brajesh
Lal,4,5 Gregory Kowalewski,5 Siddhartha Sikdar1 1Electrical
and Computer Engineering and Bioengineering, George
Mason University, Fairfax, Virginia USA; 2University of
Maryland Medical Center, Baltimore, Maryland USA; 3Surgery
and Bioengineering, University of Washington, Seattle, Washington USA; 4Vascular Surgery, University of Maryland
Medical Center, Baltimore, Maryland USA; 5Baltimore Veterans Affairs Medical Center, Baltimore, Maryland USA
Objectives— Stroke affects millions of people in the world
each year. About 25% of ischemic strokes are caused by rupture of
carotid artery plaque. Currently, stenosis severity is used as a surrogate
for the risk of plaque rupture; however, other factors may play a larger
role, such as the hemodynamics around the plaque, which may be affected both by extracranial hemodynamics and intracranial collateralization. In the present study, we investigated how an incomplete
(noncollateralized) intracranial circle of Willis (COW) might affect intraluminal velocity around the carotid plaque and whether there are
asymmetries of flow in the middle cerebral artery (MCA) in patients
with extracranial carotid stenosis.
Methods—We created a simple linear simulation model of the
intracranial and extracranial circulation to investigate the relationship between MCA flow waveforms on the contralateral (normal) and ipsilateral
(diseased) sides and carotid stenosis for a complete and incomplete COW.
Then we compared the predictions of this model with bilateral MCA
velocity measurements performed in patients with asymptomatic carotid
stenosis using transcranial Doppler.
Results—Simulation results showed no asymmetries in MCA
flow waveforms for a complete (collateralized) COW, but for an incomplete COW, the systolic peak had a lower magnitude and was delayed by
about 100 milliseconds on the ipsilateral side. In our clinical measurements on 32 patients, we found that 25 had waveforms consistent with
those predicted for a collateralized COW, with minimal differences in
delay, velocity magnitude, and resistivity index between the ipsilateral and
contralateral sides. In 6 cases, some unexpected findings were noted, such
as large delays for 2 patients who had ≤50% stenosis and a larger velocity difference with low delays for 5 patients with >50% stenosis.
Conclusions—Our results indicate that intracranial flow is an
important variable when interpreting intrastenotic velocities. The present
study does not allow us to definitely interpret the reason for MCA flow
asymmetries, since the COW was not directly imaged. We intend to enroll
additional patients in our cohort with concomitant imaging of the COW to
further strengthen our results.
1512012 Left-to-Right Image Registration of Longitudinal Carotid
Images Improves Intima-Media Thickness and Atheroscerlsosis Disease Monitoring
Filippo Molinari,1 Nobutaka Ikeda,2 U Rajendra Acharya,3
Luca Saba,4 Andrew Nicolaides,5 Jasjit Suri6,7* 1Electronics
and Telecommunications, Politecnico Torino, Torino, Italy;
2
Division of Cardiovascular Medicine, Toho University Medical
Center, Tokyo, Japan; 3Electronics and Computer Engineering,
Ngee Ann Polytechnic, Singapore; 4Radiology, Azienda
Ospedaliero, Universitaria di Cagliari, Cagliari, Italy;
5
Imperial College, London, England; 6Global Biomedical Technologies, Roseville, California USA; 7Biomedical Engineering,
Idaho State University, Pocatello, Idaho USA
Objectives—Automated systems for the measurement of the
carotid intima-media thickness (CIMT) are useful in clinical practice if
they ensure high measurement accuracy and high reproducibility. We developed a registration-based method to improve the carotid distal wall segmentation and CIMT measurement in noisy images.
Methods—We tested 50 patients and acquired left and right
common carotid arteries in 3 projections: anteroposterior, anterolateral,
and lateroposterior. The total number of images was 300 (50 subjects, 2 arteries, 3 insonation angles), and we had all images manually segmented by
3 independent expert readers. We processed each image by a 3-stage system. Stage 1 is relative to automated carotid localization and far adventitia tracing. Stage 2 is relative to the definition of a guidance zone and
registration of the left to the right distal wall. Registration was performed
by relying on the profile of the far adventitia. The segmentation is carried
out in stage 3 by using a edge snapper. We compared the CIMT measurement accuracy of the registered and unregistered image sets.
Results—Stage 1 was successful in all 300 images. Left-toright registration was successful in 140 of 150 cases (93.3% success),
whereas right-to-left registration was successful in 138 cases (92.0% success). The average CIMT measurement bias in the unregistered case was
0.012 ± 0.079 mm, which decreased to 0.006 ± 0.081 mm for the registered images. The figure of merit (FoM) increased from 98.19% for the unregistered to 99.09% for the registered image set.
Conclusions—Registering the left to the right carotid artery
images can increase CIMT measurement accuracy. We plan to extend this
work by also including arteries with plaques in the registration framework.
Table 1. Auto Edge Performance for the 3 Operators
GT1
GT2
Original
0.020 ± 0.079 0.051 ± 0.083
CIMT bias,
mm
FoM, %
96.99
92.00
Registered 0.014 ± 0.085 0.045 ± 0.086
CIMT bias,
mm
FoM, %
97.90
92.96
GT3
–0.034 ± 0.090
Average GT
0.012 ± 0.079
95.24
–0.040 ± 0.090
98.19
0.006 ± 0.081
94.39
99.09
1540884 More Easily Deployable Long-term Transcranial Doppler
Monitoring of the Middle Cerebral Artery
Bill Beck PhysioSonics, Inc, Bellevue, Washington USA
Objectives—Develop a system to facilitate long-term transcranial Doppler monitoring of the M1 segment of the middle cerebral artery
(M1 MCA), allowing continuous data collection over a period of days
without operator intervention after initial setup.
Methods—Deployment of M1 MCA monitoring is facilitated
by a structured procedure to guide the operator in: (1) positioning a 2D
phased array transducer, mounted in a headset, over the temporal window,
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by measuring echo strength from the far side of the skull, then (2) articulating the transducer to point at the M1 MCA, through the use of flash
color Doppler insonation of the 3D conical region of interest (ROI). The
phased array is then electronically steered to gather data from the peak
Doppler signal in the ROI; the Doppler spectrum is analyzed, and standard
flow metrics are logged for future review. The peak Doppler signal is automatically relocated as required to maintain continuous monitoring without operator intervention. An alert is generated if the signal is lost or if
flow metrics exceed user-specified limits.
Results—The objective was achieved through development of
appropriate acoustics, supported by refinements in signal processing and
an enhanced user interface.
Conclusions—A system has been developed to make transcranial Doppler monitoring of the M1 MCA more easily deployable and to
support long-term monitoring over a period of days, without operator intervention.
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SPECIAL INTEREST SESSIONS
TUESDAY, APRIL 9, 2013, 8:15 AM–10:15 AM
Contrast-Enhanced Ultrasound in Pediatrics:
What Have We Learned and How Can We Apply It?
Cutting-edge Musculoskeletal Ultrasound: Peripheral
Nerves of the Upper Extremity
Moderator: Beth McCarville, MD
Moderator: Corrie Yablon, MD
Voiding Urosonography
Kassa Darge Perelman School of Medicine, University of
Pennsylvania, Radiology, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania USA
After attending this session, participants should know how and
when to perform ultrasound examinations of the peripheral nerves of the
upper extremity, including interventional techniques.
Currently, the most widespread application of ultrasound contrast agents (UCAs) in children is for the diagnosis of vesicoureteral reflux
(VUR). This entails the intravesical administration of a UCA and is known
as contrast-enhanced voiding urosonography (ceVUS). The procedure of
ceVUS encompasses 5 steps: precontrast scan of the bladder and kidneys,
intravesical UCA injection or infusion, postcontrast scan of the bladder
and kidneys, during and postvoiding scans of the bladder and kidneys, and
suprapubic and transperineal scans of the urethra during voiding. The use
of harmonic imaging or contrast-specific ultrasound (US) modalities with
low or high mechanical indices enables the conspicuous depiction of the
echogenic microbubbles. The most widely used UCAs are the first- and
second-generation ones, namely Levovist (Bayer-Schering, Berlin, Germany) and SonoVue (Bracco, Milan, Italy), respectively. The former one
has been withdrawn from the market, and thus currently only the secondgeneration UCA is being used. There are many comparative studies of
ceVUS with the conventional reflux diagnostic methods, voiding cystourethrography, and direct radionuclide cystography. Not only is ceVUS
a radiation-free method, but these studies have also demonstrated that it is
more sensitive in detection of VUR. The evaluations of the safety of intravesical UCA administration have found that no adverse events directly
related to the UCA have been reported to date in children. This US method
is widespread in Europe. There is currently a concerted effort by the Society of Pediatric Radiology Contrast-Enhanced Ultrasound Task Force
to promote research and application of this method.
Doppler Evaluation of the Abdomen
Contrast-Enhanced Ultrasound in Pediatric Abdominal Trauma
Annamaria Deganello Radiology, King’s College Hospital,
London, England
The objectives are to review the role of contrast-enhanced ultrasound (CEUS) in the setting of blunt abdominal trauma in the pediatric
population and illustrate its applications in a major trauma center, describing the typical sonographic features of solid-organ injuries. CEUS
has been proven to be a reliable and useful tool in the assessment of abdominal trauma in the adult population, as it provides detailed evaluation
of parenchymal, capsular, and also vascular injuries. In addition to its established use in the liver, CEUS is applied, as an “off-label” use to the
study of renal, splenic, intestinal, and testicular traumas. Equally, in the pediatric and young adult populations, CEUS has an increasingly important
role, even though this area represents another off-label application of the
technique. CEUS can depict active bleeding and posttraumatic pseudoaneurysm formation during the arterial phase, whereas in the late phase, it
shows with accurate detail the extent of a parenchymal laceration, as the
noninjured tissue enhances. Trauma patients often need to be reassessed
to monitor progression or ensure resolution of the injuries, and CEUS becomes a valid, safe, and readily available alternative to repeated computed
tomographic (CT) imaging; this is crucial in the pediatric population,
where limitation of radiation exposure is of paramount importance. The
typical CEUS features of hepatic, splenic, and renal injuries will be described, including examples with CEUS/CT correlation.
Moderator: M. Robert De Jong, RDMS, RDCS, RVT
Sonographic Evaluation of Portal Hypertension
Monzer Abu-Yousef Radiology, University of Iowa, Iowa
City, Iowa USA
In this presentation, normal portal vein (PV) Doppler findings
and variations will be discussed. Typically, this has biphasic pattern with
mild undulations. All waves are above baseline: Vmax = 19 ± 3; Vmin = 13
± 3, with Vmin /Vmax ≥0.5. With Valsalva, flow becomes nonphasic. Postprandially, flow velocity and volume and PV diameter increase. The
Doppler ultrasound (US) findings in portal hypertension include increased
PV diameter, splenomegaly, ascites, loss of PV flow phasicity, decreased
PV flow velocity, reversed PV flow, and dilated portosystemic collaterals.
The latter include a recanalized umbilical vein, flow reversal in the coronary vein, dilated gastric varices, splenorenal collaterals, a recanalized
ductus venosus, gallbladder varices, and perihepatic collaterals. The portosystemic shunts will also be discussed, with emphasis on the transjugular intrahepatic portosystemic shunt (TIPS), including Doppler US signs
of TIPS malfunction, direct and indirect. Direct signs include velocity in
any stent segment of <60 or >200 cm/s, interval velocity change in the
same area of >50 cm/s, velocity transition zone of >2 times, TIPS nonfilling or trickle flow, narrowing of the stent or the hepatic vein that drains
it, and aliasing seen in any segment of the stent on color Doppler. Indirect
signs include a decrease in PV velocity to <30 cm/s, a decrease in PV velocity of >33% of baseline, antegrade flow in PV branches, flow seen in
the umbilical vein, loss of the triphasic flow pattern in the PV, worsening
ascites, and splenomegaly.
Pathologic Findings in Abdominal Vasculature
Hanh Nghiem William Beaumont Hospital, Royal Oak,
Michigan USA
Color Doppler and spectral Doppler imaging have substantially
enhanced the diagnostic capabilities of abdominal ultrasonography. When
properly performed, Doppler ultrasonography provides rapid, comprehensive, and accurate evaluation of the hepatic vasculature and major abdominal vessels. In this session, we will discuss the Doppler imaging
appearances of Budd-Chiari syndrome, a manifestation of hepatic venous
outflow obstruction. Doppler imaging findings of hepatic artery abnormalities in native liver and abnormalities of the splenic vessels will also
be reviewed, including vascular thrombosis and pseudoaneurysms. Participants should gain a greater understanding of the pathophysiology of
hepatic vein and splenic vein thrombosis, causes of elevated and decreased
hepatic arterial resistive indexes, and vascular thrombosis and pseudoaneurysms of the hepatic and splenic artery in non–liver transplant patients
and recognize the sonographic images showing these conditions.
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Hands-on How to Do Ultrasound-Guided
Interventions
Small-Animal Preclinical High-Frequency Imaging
Moderator: Michael Kolios, PhD
Moderator: Dean Nakamoto, MD
After attending this session, participants will be able to describe
prebiopsy preparations, use and have hands-on experience with the techniques of doing biopsies of soft tissue masses, thyroid nodules, breast
masses, the liver, and kidneys, and recognize and manage complications.
Pearls From the Anatomic Survey (Skeletal Dysplasia
and Central Nervous System, Renal, and Chest
Abnormalities)
Moderator: Ana Monteagudo, MD, RDMS
Fetal Central Nervous System
Ana Monteagudo Obstetrics and Gynecology, New York
University School of Medicine, New York, New York USA
Advances in High-Frequency Transducers and Arrays
K. Kirk Shung Biomedical Engineering, University of Southern California, Los Angeles, California USA
High-frequency ultrasound (HFU) allows improved spatial resolution. Biomedical applications have been found for HFU in preclinical
small-animal, intravascular, and eye imaging. Pediatric imaging is another
area that holds great promise. As a result, high-frequency linear arrays,
phased arrays, and curved linear arrays have been developed to satisfy
these needs. More recently, miniature high-frequency arrays have been
studied for intravascular and other clinical applications. In addition, ultra
high-frequency high-performance single-element transducers have been
investigated for cellular applications. Technical advances that have been
made in these areas and potential biomedical applications will be reviewed
in this talk.
A significant number of sonographers and sonologists count the
fetal central nervous system (CNS) as the most challenging organ to scan.
This has resulted in an explosion in the number of fetal magnetic resonance imaging examinations of the CNS being ordered over the last few
years. In this lecture, a systematic approach to the fetal CNS will be provided, as well as multiple imaging tips or pearls to improve the individual
practitioner ability to diagnose common as well as relatively rare anomalies of the fetal CNS.
SCIENTIFIC SESSIONS
TUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PM
Applications of Therapeutic Ultrasound
Moderators: George Lewis Jr, PhD, Maggie Zhang, PhD
1541279 Antitumor Effects of Combining Docetaxel and Paclitaxel
With the Antivascular Effects of Ultrasound-Stimulated
Microbubbles
Margarita Todorova,1,2 Vlad Agache,1 Raffi Karshafian,3
Kullervo Hynynen,1,2 David Goertz1,2* 1Sunnybrook Research
Institute, Toronto, Ontario, Canada; 2Medical Biophysics,
University of Toronto, Toronto, Ontario, Canada; 3Ryerson
University, Toronto, Ontario, Canada
Objectives—Docetaxel (DTX) and paclitaxel (PTX) are used to
treat a broad spectrum of cancers. We previously reported that the combination of DTX with ultrasound (US)-stimulated microbubble (MB) therapy resulted in enhanced antitumor effects in PC3 tumors. While the focus
of US + MB therapy has been to promote drug uptake, these experiments
were conducted with exposures that produced a vascular shutdown. As
DTX and PTX can themselves induce antivascular effects, it was hypothesized that there may be an interaction between drug and MB antivascular effects. In this study, experiments were conducted on a cell line that is
largely resistant to DTX and exhibits only mild sensitivity to PTX.
Methods—EMT6 tumors were initiated in Balb/C mice and
were exposed to pulsed 1-MHz US (1.6 MPa; n = 5–6/group) following
the bolus injection of Definity MBs. The treatment scheme consisted of a
sequence of 50 0.1-millisecond bursts sent at 1 KHz, repeated every 20
seconds for 3 minutes following MB injection. Growth delay experiments
were performed when tumors reached a size of 100 to 120 mm3. The
groups were control, drug + MBs, US + MBs, and combined drug + US
+ MBs. One set of experiments was performed with DTX at 5 mg/kg and
a second set of experiments with PTX at 6 mg/kg, where drugs were injected 10 minutes prior to US treatment. The effects of treatment on blood
flow were monitored with 7-MHz contrast imaging.
Results—The exposure conditions were found to produce a
pronounced acute vascular shutdown within the tumors and resulted in
MB inertial cavitation. Neither the DTX-only or PTX-only groups produced significant growth inhibition relative to controls. The US + MB
group induced significant growth delays relative to control tumors. Both
the combined DTX + US + MB and the PTX + US + MB groups produced significant growth inhibition relative to the US + MB group.
Conclusions—Given the low sensitivity of the tumor cell line
to these drugs, and that they have the capacity at these low dose levels to
act in an antivascular manner, the results suggest that there may be a synergistic antivascular action between these therapies in addition to a drug
uptake mechanism.
1540384 Dynamic Positron Emission Tomographic Imaging of Drug
Delivery and Hypoxia Using Acoustic Droplet Vaporization
Mario Fabiilli, Morand Piert, Philip Sherman, Carole Quesada, Oliver D Kripfgans* Radiology, University of Michigan, Ann Arbor, Michigan USA
Objectives—Perfluorocarbon (PFC) emulsions and acoustic
droplet vaporization (ADV) have been used in therapeutic applications
such as drug delivery and embolotherapy. The objective of this work was
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to use positron emission tomography (PET) to study (1) the biodistribution of an emulsion used in ADV and (2) the extent to which localized hypoxia can be induced by ADV.
Methods—For the biodistribution study, a metabolic tracer,
18
F-fluorodeoxyglucose (FDG) was injected into Fisher 344 rats (n = 3)
bearing vascular endothelial growth factor–positive glioma tumors (9L).
The rats were imaged for 60 minutes after injection using dynamic PET
imaging. After 24 hours, the same rats were injected with a PFC-FDG
emulsion (2 µm mean size) and imaged again. In both cases, standardized
uptake values (SUVs) were calculated using the tissue activity concentration, body weight, and injected dose. To confirm the imaging findings, a
traditional ex vivo biodistribution was performed (n = 5 rats). For the hypoxia study, similar animal and tumor models were used. A PFC single
emulsion was administered, followed by ADV in the feeder artery of the
tumor using focused pulsed ultrasound (3.5 MHz). Dynamic PET imaging was performed before and after ADV using 18F-fluoroazomycin arabinoside (FAZA) as a tracer for hypoxia.
Results—The area under the curve (AUC) for the SUVs was
calculated for brain, tumor, and lungs as a measure of drug/FDG exposure for future drug encapsulation. A 39.1% ± 5.3% and 35.7% ± 15.6%
AUC decrease was observed when compared to solution for brain and
tumor, respectively. No significant difference in AUC was observed for
lung. The biodistribution study showed a 67% and 70% decrease in the
percent injected dose per gram for brain and tumor tissue, respectively,
when comparing FDG emulsion versus solution. FAZA was retained in the
tumor after ADV.
Conclusions—The lower AUC values for the emulsion in
highly metabolic tissues (brain and tumor) demonstrate that FDG is retained within the emulsion and is confirmed by alternative biodistribution.
FAZA imaging confirms generation of localized hypoxia using ADV.
Overall, PET imaging can provide critical feedback in developing stable
drug-loaded PFC emulsions as well as tracking the effects of ADV-induced
hypoxia.
1540880 Evaluation and Optimization of Nonfocused Sonothrombolysis Parameters in an In Vitro Chamber Model
Shane Fleshman,* Adelaide de Guillebon, George Lewis Jr
Zetroz, LLC, Ithaca, New York USA
Objectives—Sonothrombolysis is emerging as a potential clinical tool to rapidly emulsify acute and chronic thrombi. The goal of this
work was to study the effects of different therapeutics, frequency, thrombus diameter, and type of surrounding medium on the percent mass reduction of a thrombus after 1, 2, and 3 hours of sonothrombolysis treatment.
Methods—Silicone tubing of 10 or 15 mm diameter was coated
with or without 500 U of thrombin, filled with fresh porcine blood, allowed to clot for 1 hour, and stored at 4°C for 8 to 10 days (Institutional
Animal Care and Use Committee–approved protocol). Sonothrombolysis was evaluated in multiple-element custom ultrasonic chambers (75 ×
55 × 55 cm) designed at both 85- and 191-kHz resonant frequencies.
Blood clots of 2.0 ± 0.1 g were perforated with a guide wire, placed inside
a chamber filled with either Dulbecco’s phosphate-buffered saline (DPBS)
or freshly thawed human plasma, and injected with 0.5 mL of either 0.5mg/mL human tissue plasminogen activator (tPA), 1-mg/mL active plasmin, or 1× DPBS with a Uni-Fuse catheter 30 minutes after treatment
commencement. Blood clot mass was recorded 1, 2, and 3 hours after
treatment.
Results—Thrombus treatment at 85 kHz with a peak pressure
of 1.7 MPa was the only treatment that yielded significant results for
thrombin and nonthrombin blood clots when compared to the control
(P < .01) and was further used in the remaining experiments. Both thrombin and nonthrombin clots treated with ultrasound were statistically different from the control at all time points (P < .01). Comparisons of 15- or
10-mm-diameter clots and clots in DPBS or human plasma media treated
with ultrasound yielded no significant results (P > .05). Comparisons of
ultrasound-treated, tPA- or plasmin-injected clots with their respective
controls yielded significant results at all time points (P < .0001) and at 1
hour (P < .01), respectively.
Conclusions—We discovered that diameter, thrombin treatment, and medium do not play significant roles in thrombus dissolution.
Using twelve 85-kHz transducers with mean peak pressures of 1.7 MPa
and injecting the thrombus with tPA yielded the most significant results,
with mean percent mass losses of >90% after 3 hours.
1540858 Hydrogel Materials as Ultrasound Coupling Media
Matthew Langer,* Shane Fleshman, George Lewis Jr
Zetroz, LLC, Ithaca, New York USA
Objectives—The use of ultrasound in therapeutic medicine to
promote healing and relieve pain has been thoroughly tested. Recent research has demonstrated that low-intensity therapeutic ultrasound applied
on a daily basis is highly effective, and miniaturization technology has
been developed, which will enable user-operated ultrasound systems. One
significant challenge in developing a user-operated device is finding a coupling medium that is effective, easily used, and desirable for the patient.
To facilitate the spread of user-operated ultrasound devices, novel coupling materials must be developed. Water is a perfect coupling medium for
ultrasound, but its low viscosity makes it impractical to contain. Hydrogels are swollen polymer networks, which can be as much as 99% water
by weight, but due to the size of the polymer, or its structure, they have
properties of viscoelastic materials. High–water content hydrogels were
evaluated for their ability to mediate transmission of ultrasound.
Methods—Polyethylene oxide (PEO) hydrogels were tested
and evaluated, along with polyethylene glycol (PEG) hydrogels and PEGbased copolymer hydrogels. The gels were tested as coupling media between a 3-MHz therapeutic 25-mm-diameter transducer and freshly
harvested porcine skin. On the underside of the skin, ultrasound gel was
used to couple the skin to a transducer hydrophone in a custom measurement apparatus. The electrical signal reported by the detector was read off
a digital oscilloscope in millivolts. The signal measured with the hydrogel as a coupling medium was compared to that of the ultrasound gel as a
coupling medium. The ultrasound transmission hydrogels was normalized to traditional ultrasound gel–based coupling.
Results—The ultrasonic transmission of several hydrogels was
measured. The PEG copolymer–based gel had a relative transmission of
0.70 ± 0.06. A PEO hydrogel with water content >90% had a relative transmission of 1.0 ± 0.07.
Conclusions—PEO hydrogels with high water content possess
similar sonic transmission properties to commercial ultrasound gel. These
findings open the door to replacing commercial ultrasound gel with high–
water content hydrogels.
1541006 Low-Intensity Pulsed Ultrasound Enhances Reactive Oxygen Species Production Following a Blunt Impact Injury in
Articular Cartilage
Kee Jang,1,2* Prem Ramakrishnan,1 Tae-Hong Lim,2 Joseph
Buckwalter,3 James Martin1 1Orthopedics and Rehabilitation, 2Biomedical Engineering, University of Iowa, Iowa City,
Iowa USA; 3Veterans Affairs Medical Center, Iowa City, Iowa
USA
Objectives—Elevated levels of reactive oxygen species (ROS)
are associated with development of osteoarthritis. Previously we reported
that mechanotransduction of mitochondrial ROS modulates cell survival
and metabolism in a dose-dependent manner. Here, we hypothesized that
low-intensity pulsed ultrasound (LIPUS) elicits its mechanotransductive effects by inducing ROS in cartilage, and we investigated the effect of LIPUS
on ROS release in articular cartilage that underwent a blunt impact injury.
Methods—Osteochondral explants (2.5 × 2.5 cm2) were prepared from mature bovine stifle joints and cultured in conditioned media at
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37°C and 5% O2. After 48 hours, explants were subjected to a 7-J/cm2
impact with a customized drop tower device, and LIPUS (1 MHz, 54
mW/cm2, and durations of 30, 60, and 90 minutes) was immediately applied. A sham group was subjected to identical procedures except LIPUS
stimulation. After LIPUS stimulation, cell viability (calcein AM/ethidium
homodimer) and oxidative stress (dihydroethidine) were imaged with confocal microscopy and quantified.
Results—Sixty-minute LIPUS after the 7-J/cm2 impact resulted
in a significant increase in ROS production (≈2-fold) compared to the
sham group. In contrast, no difference in ROS production was apparent in
uninjured explants with or without LIPUS stimulation. After injury, the
ROS response to the LIPUS duration showed a strong linear relationship
(R2 = 0.75) with an increasing duration of stimulation inside the impacted
area, whereas such a relationship was not observed in areas adjacent to
the impact. No difference in post–24-hour chondrocyte viability was observed between LIPUS and sham groups.
Conclusions—Our findings demonstrate that LIPUS stimulates
ROS production in injured articular cartilage in a duration-dependent manner, and enhanced ROS production did not affect cell viability in cartilage. Although the exact role of enhanced ROS in response to LIPUS in
injured cartilage remains unclear, we hypothesize that the increased oxidative stress may have implications in cartilage repair processes by modulating chondrocyte energy production, metabolism, and matrix synthesis.
1543362 Microbubble and Ultrasound Enhancement of RadiationInduced Tumor Cell Death In Vivo: ASMase Dependence
Gregory Czarnota,1* Amr Hashim,1 Ahmed El Kaffas,1 Raffi
Karshafian,2 Anoja Giles,1 Sara Iradji,1 Azza Al Mahrouki1
1
Radiation Oncology/Physical Sciences, Sunnybrook Health
Sciences Center, Toronto, Ontario, Canada; 2Physics, Ryerson
University, Toronto, Ontario, Canada
Objectives—It is now appreciated that radiation not only damages the DNA inside tumor cells in vivo but also may act by damaging the
endothelial cells of the vasculature. In this study, we tested the hypothesis
that microbubble agents in vivo may be used a priori to cause endothelial
cell perturbations, thus causing “radiosensitization” of tumors.
Methods—Fibrosarcoma xenograft-bearing mice (n = 200+)
were exposed to combinations of ultrasound, activated microbubbles, and
radiation (8 animals per group). For ultrasound treatments, animals were
exposed to a 500-kHz center frequency and 570-kPa peak negative pressure for treatment. For treatments involving bubbles, Definity bubbles
(Bristol Myers-Squibb) were administered, and for radiation treatments
160-kVp x-rays were used at doses of 2 and 8 Gy. Representative tumor
sections were examined using immunohistochemistry. Clonogenic assays
and growth delay studies were also carried out. Experiments were carried
out in ASMase +/+ and –/– mice to investigate endothelial cell apoptosis
effects.
Results—Analyses indicated a synergistic increase in tumor
cell kill due to vascular disruption that was ASMase dependent, caused
by the combined therapies that increased when microbubbles were used
in conjunction with radiation, with increases of cell kill from 5% to >50%
with combined single treatments. Immunohistochemistry indicated endothelial cell apoptosis and activation of the ceramide cell death pathway
to be caused by microbubbles. Multiple treatments indicated a better therapeutic outcome with multiple treatments combining both modalities compared to single-modality treatments.
Conclusions—Radiation effects were synergistically enhanced
by using microbubbles to perturb tumor vasculature prior to the administration of radiotherapy. Analyses indicated activation of ceramide-mediated apoptotic cell death in endothelial cells leading to vascular
disruption in tumors. This led to profoundly enhanced tumor cell death
even after 1 combined treatment using a 2-Gy radiation dose. This work
forms the basis for ultrasound-induced spatial targeting of radiotherapy
enhancement.
1540684 On the Acceleration of Ultrasound Thermal Therapy by
Patterned Acoustic Droplet Vaporization
Oliver Kripfgans,1* Mario Fabiilli,1 Scott Swanson,1 Charles
Mougenot,2 Paul Carson,1 Man Zhang,1 J. Brian Fowlkes1
1
Radiology, University of Michigan, Ann Arbor, Michigan USA;
2
Philips Healthcare, Toronto, Ontario, Canada
Objectives—High-intensity focused ultrasound (HIFU), an established method for treating cancer and hyperplasia, often suffers from
uneven heating and requires in general long treatment times for large target volumes. In situ gas bubbles have become more accepted as energy
conversion agents for HIFU. If carefully controlled, these agents increase
lesion sizes dramatically.
Methods—Emulsions of perfluorocarbon droplets (lipid coated,
C5F12, Ø 2.0 ± 0.1 µm, ≈99% < 8 µm Ø) were used to create thermal agents
in polyacrylamide phantoms. The emulsion concentration in the gel was
3 × 105 droplets/mL. This corresponds to a volume fraction of 1 ppm
(vol/vol). The samples were placed in thermal contact with a heating system to maintain 35°C. Egg white was incorporated to allow for visual inspection of the phantoms after acoustic exposure from a Philips Sonalleve
magnetic resonance–guided focused ultrasound system (1.5 T) using a
256-element phased array with a 120-mm focal length. At a transmit center frequency of 1.45 MHz, maximum electronic steering of 10 mm was
achieved at a depth of 10 cm. In situ temperature monitoring limited focal
heating to 75°C. Lesion sizes were measured as a function of applied
acoustic power. Acoustic trenches were created to accelerate thermal therapy, in which individual lesions were spaced 5.5 mm apart to create 25mm-diameter spiral patterns.
Results—Single HIFU exposures in droplet-laden phantoms
resulted in lesions of 2 to 5 mm in diameter. Rapid repetition of electronically steered therapy pulses (40 pulses/s) allowed for the generation of homogeneous and contiguous composite lesions at a rate >1 mL/s. For
acoustic power levels ranging from 40 to 300 W (acoustic), lesion volumes increased by a factor of at least 15 when comparing lesion volumes
in phantoms with droplets to without droplets. With the use of acoustic
droplet vaporization (ADV) and the resulting trench, a uniform ablation
volume of 15 mL was achieved in 15 seconds; without ADV, <15% of
this volume was filled.
Conclusions—Perfluorocarbon droplet emulsions have the potential to enhance clinically relevant HIFU performance by decreasing
treatment time and increasing lesion homogeneity.
1540272 Potential Strong High-Intensity Focused Ultrasound Ablation-Induced Tissue Damage as Measured by Viscoelastic
Characterization of Canine Liver Tissue After Ablation
Danial Shahmirzadi,1* Gary Hou,1 Elisa Konofagou1,2
1
Biomedical Engineering, 2Radiology, Columbia University,
New York, New York USA
Objectives—High-intensity focused ultrasound (HIFU) has
been shown capable of ablating soft tissues in vitro and in vivo. However,
mainly due to the lack of knowledge of the exerted radiation force in tissue, mechanical characterization of ablated tissues, particularly at very
high HIFU powers, remains largely understudied. This study aims at quantifying the canine liver tissue viscoelastic properties following a wide
range of HIFU ablation powers.
Methods—Fresh canine liver specimens (n = 6) were used.
HIFU targeting and ablation were performed using a 7.5-MHz pulse-echo
and 4.8-MHz therapeutic transducers, respectively. Mechanical testing
using shear rheometry was performed on a set of unablated control samples (n = 13), as well as 4 sets of samples under increasing HIFU energies
of 360 (n = 4), 750 (n = 8), 900 (n = 8), and 1080 (n = 8) J. The complex
shear modulus and viscosity were measured.
Results—The shear complex modulus and dynamic viscosity
of all ablated samples were found to increase by approximately an order
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of magnitude higher compared to unablated samples. However, reduction
in stiffening was obtained in samples ablated at higher energy levels relative to samples at lower energy levels (Table 1), which can be explained
by the strong tissue thermo-mechanical effects occurring at very high temperatures that essentially alter the structure of the tissue.
Conclusions—The monotonic increase in tissue stiffness and
viscosity under increasing HIFU ablation power has been shown to hold
up only up to a certain point, beyond which the tissue stiffening starts to
decay due to structural changes mainly due to rapid boiling. Such quantitative understanding of tissue phenomenologic alterations during ablation
is significant in the effective design and application of any HIFU-based
therapeutic technique where a combination of tissue mechanical, thermal,
and structural effects is expected.
Table 1. Viscoelastic Properties of Canine Liver After Ablation
Shear modulus,
kPa
Phase shift, °
Normalized shear
modulus
HIFU Energy, J
0
360
750
900
1080
4.4 ± 2.0 73.6 ± 19.0 85.7 ± 54.5 50.1 ± 38.7 53.9 ± 27.6
8.4 ± 1.9
1
12.3 ± 0.8 12.3 ± 0.4 12.2 ± 0.4 12.1 ± 0.6
15.8 ± 6.9 18.5 ± 13.9 10.4 ± 9.5 11.3 ± 7.4
1540029 Therapeutic Ultrasound as Treatment for Chronic Bacterial
Prostatitis
Mingde Li South China University of Technology, Richmond,
British Columbia, Canada
Objectives—Antibiotic therapy for chronic bacterial prostatitis
often fails to eradicate pathogens due to poor antibiotic penetration into
prostatic secretions where the infection occurs, caused by the bloodprostate barrier of the prostatic epithelium. It is our purpose to report antibiotic therapy enhanced by therapeutic ultrasound for a patient with
chronic bacterial prostatitis with mixed pathogenic microorganisms of
Staphylococcus aureus, coagulase-negative Staphylococcus and Ureaplasma urealyticum and with hardness of the prostate who was difficult
to treat with methods in literature.
Methods—After antibiotic medication, ultrasonic irradiation
from the lower abdomen, perineum, and anus (not transrectally) on his
prostate followed immediately. The working ultrasonic intensity was 3
W/cm2.
Results—Without ultrasound, intravenous azithromycin and
levofloxacin hydrochloride therapies could not eradicate the pathogens,
and his symptoms recurred and became more severe. Under continuous
ultrasonic irradiation at the intensity of 3 W/cm2, intravenous antibiotic
therapies with azithromycin and imipenem eradicated S aureus and U urealyticum, but intravenous antibiotic therapies could not treat coagulasenegative Staphylococcus; interventional antibiotic therapies with imipenem
and urethral perfusion treated coagulase-negative Staphylococcus successfully. The National Institutes of Health Chronic Prostatitis Symptom
Index of the patient was reduced from 26 (pain, 16; urinary symptoms, 5;
quality of life impact, 5) to 3 (pain, 0; urinary symptoms, 2; quality of life
impact, 1).
Conclusions—The eradication of S aureus and U urealyticum
indicates the continuous therapeutic ultrasound can open the bloodprostate barrier. The blood-prostate barrier opening is explained by the
hypothesis of ultrasonic emulsification of a secreted steroidogenic lipid
in the basal layers of the prostatic epithelium caused by cavitations. Intravenous antibiotic therapies cannot treat coagulase-negative Staphylococcus due to the formation of biofilms adherent to the epithelium of the
ductal system. The treatment for the patient was successful.
1540196 Ultrasound-Assisted Chronic Wound Management:
Clinical Outcome
Joshua Samuels,1* Michael Weingarten,2 Leonid Zubkov,1
Youhan Sunny,1 Christopher Bawiec,1 David Margolis,3 Peter
Lewin1 1Biomedical Engineering, Drexel University,
Philadelphia, Pennsylvania USA; 2Surgery, Drexel University
College of Medicine, Philadelphia, Pennsylvania USA; 3Epidemiology, University of Pennsylvania Perelman School of
Medicine, Philadelphia, Pennsylvania USA
Objectives—The purpose of this research was to examine
whether low-frequency (<100 kHz), low-intensity (<100 mW/cm2, spatialpeak temporal-peak [SPTP]) ultrasound applied to human patients can be
used as an effective treatment of venous stasis ulcers; no similar study was
reported to date. Venous ulcers affect >500,000 patients annually, costing
$1 billion dollars, so in addition to helping patients, there is a strong financial motivation for reduction of the healing time. The frequency and ultrasound parameters were chosen based on the widely accepted safety of
prolonged exposure at 100 mW/cm2 and previously published findings indicating that frequencies <100 kHz might be more effective than 1- to 3MHz frequencies.
Methods—In a 20-human pilot study, patients were randomly
assigned to 1 of 4 experimental groups: 15 minutes of 20-kHz ultrasound,
45 minutes of 20-kHz ultrasound, 15 minutes of 100-kHz ultrasound, or
15 minutes of sham (no treatment). All active treatments were at 100
mW/cm2 SPTP. All 4 groups received the standard of care, including moist
wound dressings and compression therapy. Eligible patients were between
the ages of 18 and 65 years, had wounds of at least 1 cm2, which were
clinically documented for 8 weeks, and had no concomitant arterial disease. Progress was monitored through reduction in the wound area combined with an optical assessment using diffuse near-infrared spectroscopy.
Results—Of the 20 patients who completed the study, 10 healed
and 10 did not heal during the 4 treatments of the study. One particular
treatment group, namely those receiving 20 kHz for 15 minutes, experienced complete healing in 100% (n = 5) of patients by the fourth treatment.
Furthermore, this group showed a statistically (P < .03) faster rate of
wound closure compared to the sham group. Overall, 8 of the 15 treated
patients healed, versus 2 of the 5 control patients.
Conclusions—Although statistically limited, this work is of
importance as it represents the first systematic human study indicating that
the use of low-intensity, low-frequency ultrasound holds promise as an
effective tool for successful treatment of chronic venous ulcers. (Supported
by National Institutes of Health grant 5 R01 EB009670.)
Basic Science: Instrumentation, Contrast Agents, and
Bioeffects
Moderators: Chandra Sehgal, PhD, David Vilkomerson, PhD
1536946 Improved Accuracy in the Measurement of Acoustic Output Parameters via Complex Deconvolution of Hydrophone
Sensitivity
Keith Wear,1* Paul Gammell,2 Subha Maruvada,1 Yunbo Liu,1
Gerald Harris1 1Center for Devices and Radiological Health,
US Food and Drug Administration, Silver Spring, Maryland
USA; 2Gammell Applied Technologies, Exmore, Virginia USA
Objectives—Hydrophones are often used to measure acoustic
pressure waveforms from diagnostic ultrasound transducers. The standard
approach for estimation of acoustic pressure is to take the ratio of the hydrophone output voltage to the value of the hydrophone sensitivity at the
acoustic working frequency. This approach assumes that hydrophone sensitivity is independent of frequency over the usable bandwidth of the
source transducer. A more accurate approach entails performing a complex
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deconvolution between the hydrophone output voltage and the hydrophone frequency-dependent complex sensitivity. We have previously
reported a method for measuring the magnitude and phase of hydrophone
sensitivity using time delay spectrometry (TDS). The goal of this work is
to assess the improvement in the accuracy of estimates of acoustic output
parameters (pulse intensity integral and peak rarefactional pressure) using
complex deconvolution.
Methods—In the first set of experiments, a swept-frequency
TDS system was used to measure magnitude and phase responses of several types of hydrophones used in medical ultrasound exposimetry. These
included polyvinylidene difluoride spot-poled membrane, needle, and capsule designs. Measurements were performed using 4 broadband source
transducers to measure hydrophone sensitivity over the band from 1 to 30
MHz. In the second set of experiments, 6 hydrophones were used to measure the acoustic pressure waveform generated by a 3-MHz single-element
source transducer. The voltage waveforms acquired in the second set of experiments were deconvolved with sensitivities measured in the first set of
experiments. The effect of deconvolution on measurements of the pulse intensity integral and peak rarefactional pressure was measured.
Results—The effect of deconvolution on measurements of
pulse the intensity integral and peak rarefactional pressure sometimes exceeded 10%.
Conclusions—The frequency dependence of hydrophone sensitivity can have a substantial impact on measurements of the pulse intensity integral and peak rarefactional pressure. In these cases, complex
deconvolution can be used to compensate for frequency-dependent hydrophone sensitivity.
1538679 Pulmonary Hemorrhage Induced by Diagnostic Ultrasound
Revealed by Growth of Comet Tail Artifacts in the Image
Douglas Miller Radiology, University of Michigan, Ann
Arbor, Michigan USA
Objectives—Ultrasound examination of the lung has become
an important part of chest medicine, particularly for point-of-care diagnosis in emergency rooms and intensive care units. The objective of this
study was to explore the potential for lung injury, which may arise from
the interaction of ultrasound pulses with alveolar gas, using a rat model of
pulmonary diagnostic ultrasound.
Methods—Anesthetized rats were prepared by shaving the
right thorax and then mounted in a 37°C water bath. A linear array (CL157, HDI 5000; Philips Healthcare, Andover MA) was used for B-mode imaging of the right lung at ≈7.6 MHz. A low mechanical index (MI) of 0.21
was used to align the scan plane through an intercostal space. The MI then
was raised for 5 minutes to higher settings in different groups of 5 rats. For
a sham group, the rats were prepared but not scanned. The real-time image
was recorded and evaluated for occurrence of comet tail artifacts (CTAs),
which are indicative of alveolar fluid. The lungs were evaluated for the size
of any pulmonary hemorrhages (PHs).
Results—For the highest available MI (0.9), the image immediately displayed growing CTAs, which rapidly spread across the entire
bright-line image of the lung surface. The CTAs appeared within seconds
at MI = 0.7 or 0.9 but more slowly at lower MIs. Contusion-like PHs were
found on the lungs, which appeared to have a one-to-one correspondence
with the CTAs in the image. The proportion of positive results was statistically significant for MI = 0.52 (4 of 5 rats; P < .01) but not for MI = 0.37
(2 of 5, P > .1), relative to no PH in shams.
Conclusions—PH was induced in a rat model of pulmonary diagnostic ultrasound at moderate MIs, and this bioeffect was indicated by the
growth of CTAs in the image. The induction of PHs by pulsed ultrasound
was discovered over 20 years ago but appeared to pose little risk to patients, because only incidental scanning of the lung was expected. However,
direct scanning, which occurs for pulmonary applications, may carry a risk
of pulmonary injury for some patients. More information will be needed to
provide safety guidance consistent with optimal diagnostic imaging.
1528109 Evaluation of Definity Stability Over Time Using Double
Passive Cavitation Detection
Marianne Gauthier,1,2* Daniel King,1,3 William O’Brien Jr1,2
1
Bioacoustics Research Laboratory, 2Electrical and Computer
Engineering, 3Mechanical Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois USA
Objectives—Definity is the first ultrasound contrast agent
(UCA) approved by the US Food and Drug Administration that offers
flexible dosing and administration through intravenous bolus injection or
continuous intravenous infusion. In a clinical context (for diagnosis, therapy, and bioeffect studies), temporal stability of the UCA can be critical
using either infusion or bolus: infusion implies stability of the microbubbles during the time of the injection, while bolus may be repeated to acquire several images for the same patient, implying the microbubbles to
exhibit the same properties over time.
Methods—This study’s aim was to assess the stability of Definity over time. Experiments were performed using the double passive cavitation detection (DPCD) method, allowing the evaluation of the collapse
thresholds of an isolated microbubble based on the detection of postexcitation signals occurring 1 to 5 microseconds after the principle excitation
of the bubble. Five sets of DPCD experiments (3-cycle tone bursts at the
central frequency of 2.8 MHz) were performed over 3 weeks. For each
set of experiments, 5% and 50% collapse thresholds were determined with
their 95% confidence interval (CI) based on the generalized linear model
regression performed using MatLab. We also compared the size distribution of each tested microbubble set.
Results—Statistical analysis exhibited no significant differences in the bubble size distributions and the 5% and 50% collapse thresholds measured using the DPCD method (Table 1).
Conclusions—Definity microbubbles have been found to be
stable over the 3 weeks of experiments from the size distribution and the
5% and 50% collapse thresholds points of view. Definity can be used without extra precaution concerning its temporal stability. (Supported by National Institutes of Health grant R37EB002641.)
Table 1. Bubble Diameter, 5% and 50% Postexcitation Thresholds ± 95% CIs
Evaluated Over 3 Weeks
Group
1
2
3
4
5
Bubble Diameter
± 95% CI, μm
1.40 (1.28–1.52)
1.23 (1.12–1.34)
1.39 (1.26–1.52)
1.26 (1.13–1.39)
1.42 (1.31–1.53)
5% Postexcitation
Threshold ± 95% CI,
MPa
0.022 (0.001–0.191)
0.05 (0.001–0.277)
0.077 (0.003–0.226)
0.116 (0.015–0.269)
0.058 (0.001–0.235)
50% Postexcitation
Threshold ± 95% CI,
MPa
0.173 (0.001–0.559)
0.455 (0.005–0.944)
0.38 (0.075–0.671)
0.464 (0.162–0.72)
0.315 (0.01–0.663)
1541018 Arrival Time Estimation in a Sparsely Sampled Hemispheric Transducer Array
Jason Tillett,1* Jeffrey Astheimer,1 Robert Waag1,2 1Electrical
and Computer Engineering, 2Imaging Sciences, University of
Rochester, Rochester, New York USA
Objectives—Estimate waveform arrival time fluctuations
caused by propagation through a breast model in a sparsely sampled
faceted approximation of a hemispheric transducer array.
Methods—A 3D pseudospectral k-space method was used to
calculate acoustic propagation from a point source located near the center
of an array of widely separated transducers. The point source, with a center frequency of 5 MHz and –6-dB bandwidth of 2.5 MHz, was situated
near the chest wall of a numeric anthropomorphic breast model, and the
transducer array surrounded the pendant boundary of the breast. The hemisphere was approximated using 40 triangular facets. The separation of elements averaged about 1.5 times the wavelength at 5 MHz, ie, about 3
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times larger than the usual half-wavelength element separation. The sparse
distribution of transducer elements and severe aberration caused by propagation through the breast model reduced correlation of waveforms in
neighboring transducers that are typically used to estimate arrival time differences. Instead of cross-correlations, waveform 0 crossings in the neighborhood of the waveform arrival events were used to estimate arrival time
differences at neighboring transducers. A least mean square estimate of
arrival times was derived from the set of arrival time differences. Waveform similarity factors that equal 1 for identical waveforms were calculated and used to optimize parameters of the estimation method and
evaluate the performance of the method.
Results—A waveform similarity of 0.10 before compensation
was increased to 0.94 after compensation using estimated arrival times.
The 170-nanosecond SD of the arrival time distribution over the whole
40-facet array before compensation was decreased to 20 nanoseconds after
compensation. For a single facet, the 154-nanosecond average SD of the
arrival time distribution before compensation decreased to 15 nanoseconds after compensation.
Conclusions—The developed method for arrival time estimation in a sparsely sampled hemispheric array for the described combination of source and transducer produces accurate estimates of arrival times
for use in aberration correction methods.
1539831 The USAGES Study (Ultrasonographic Study of Alternative Gel Experimental Substances): A Trial of Alternative
Substances for Use in Clinical Sonographic Imaging
Davut Savaser,* Siobhan Gray, Anthony Medak, Virag Shah,
Derrick Allen, Eddie Castillo, Mary Beth Johnson
Emergency Medicine, University of California, San Diego,
California USA
Objectives—We sought to investigate image quality and the diagnostic utility of sonographic images obtained using household products
as alternative conducting media. Tested alternatives included hand sanitizer (HS), hand lotion (HL), liquid detergent (LD), baby shampoo (BS),
hairstyling gel (HG), and olive oil (OOi) and were compared to standard
ultrasound gel (USG).
Methods—We conducted a prospective reviewer-blinded
crossover study of healthy volunteers (>18 years) obtaining 7 different
sonographic images on each patient, including the right upper quadrant,
subxiphoid, left upper quadrant, bladder, aorta, right lung, and right internal jugular vein views. Six alternative gel substances were tested in addition to standard USG. Images were obtained by a credentialed emergency
sonographer and were reviewed and rated by 2 additional credentialed
emergency sonographers and a credentialed radiologist. Image quality was
rated on a visual analog scale (VAS) ranging from 0 to 10, and the diagnostic utility of each was assessed and compared to reviewer VAS thresholds. Data were analyzed by calculating image quality VAS means and
using repeated measures analysis of variance to evaluate VAS mean differences for each substance.
Results—A total of 189 images were obtained. Final VAS mean
scores were: HS, 9.2; HL, 8.8; LD, 8.8; BS, 8.3; HG, 8.9; OOi, 8.9; and
USG, 9.6. Compared to control (USG), HS was the only substance to not
exhibit a statistically significant mean VAS difference: HS, 0.118 (P =
.114); HL, 0.711 (P = .000); LD, 0.696 (P = .000); BS, 0.951 (P = .000);
HG, 0.565 (P = .000); and OOi, 0.600 (P = .000). All VAS means for each
substance scored above reviewer thresholds for diagnostic utility.
Conclusions—Sonographic image quality and the diagnostic
utility of HS are similar to those of standard USG. HL, LD, BS, HG, and
OOi may still be used as alternatives for clinically useful diagnostic imaging but are comparatively inferior to images obtained using HS and
standard USG as conducting media.
1540013 User-friendly System for Assessing Imaging Performance
in the Clinic
Ernest Madsen,* Chihwa Song, Gary Frank Medical
Physics, University of Wisconsin, Madison, Wisconsin USA
Objectives—One indicator of the effectiveness of a scanner/
transducer configuration to delineate the boundary of an abnormal mass
is the level of detectability it affords for small low-echo cyst-like targets.
(A scanner/transducer configuration includes the make and model of the
scanner and transducer, foci, depth of field, time-gain compensation, sector angle, etc). Phantoms with spatially random distributions of 2-, 3.2-, or
4-mm-diameter low-echo spheres and scanning windows allowing use
with any shape-emitting surface were reported at the 2012 AIUM meeting. Software allows quantification of sphere detectability as a function
of depth. One objective is to complete refinements in data acquisition
and reduction so that the phantoms and software are easily employed by
clinical personnel for comparing scanner/transducer configurations. Another objective is to provide for minimal cost of production for commercial versions.
Methods—Current MatLab software is being converted to a
form executable on any personal computer with a user-friendly generalized user interface (GUI). The large laboratory data acquisition apparatus
will be replaced with a small semiautomatic one to be part of the phantom.
Also, minimal data acquisition will be determined for acceptable reproducibility.
Results—The methods of data acquisition and reduction will
be described. A transducer holder and stepper motor system provide for
translation of the transducer in steps of one-fourth of the sphere diameter
needed for determining the centers of the spheres. The procedure for using
the GUI will be demonstrated. Also, reproducibility of detectability-versus-depth curves will be demonstrated. Imaging performance comparisons
between scanner/transducer configurations will be shown; one interesting
result using a pediatric transducer is that a 4-cm focus resulted in lesser detectability overall than a 3-cm focus.
Conclusions—Comparisons will aid in choosing equipment
for a given set of clinical applications, provide a new means of acceptance testing, and allow optimization of configurations of installed scanners
for specific applications. The phantoms may also be useful for manufacturers to refine their systems. The cost of production may result in the need
for multiple users to share one commercial form of the system.
1541363 Pulse-Echo–Based Sound Speed Estimations Using Speckle
Statistics
Ivan Rosado-Mendez, Kibo Nam, Timothy Hall, James
Zagzebski* Medical Physics, University of Wisconsin,
Madison, Wisconsin USA
Objectives—Speed of sound estimates are required for optimal
focusing and beam forming in medical ultrasound. Moreover, measurements of tissue sound speeds (ct ) have potential diagnostic value. We
investigate a method for sound speed estimation using second-order
speckle statistics to analyze ultrasound image clarity as a function of the
assumed sound speed during beam forming (cbf ). The size of a region of
interest (ROI) analyzed can be limited by tissue heterogeneities. This work
focuses on defining a minimum ROI size required to obtain reliable ct
estimates and on comparing estimates performed near the transmit focus
with values obtained at other depths.
Methods—Radiofrequency (RF) echo signals from a “nonfatty
tissue” (N-F)- and a “fatty tissue” (F)-mimicking phantom were acquired
with a Siemens S2000 system allowing control over cbf . Excitation frequencies were 6 and 9 MHz, and the nominal transmit focus was 5 cm.
This process was repeated at 5 uncorrelated planes. RF echo signals were
envelope detected and squared to obtain intensity data. 2D “correlation
cell areas” (Sc ), based on the 2D autocovariance of the intensity data within
the ROI, was tracked as the ROI size was reduced. Then, Sc was tracked
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as cbf varied from 1350 to 1550 m/s and from 1440 to 1640 m/s when
scanning phantoms F and N-F, respectively, in steps of 10 m/s. The cbf at
which Sc was minimized was chosen as the ct estimate. The ct estimate
bias was computed as the interplane average of the percentage difference
from substitution measurements (F phantom, 1452 m/s; N-F phantom,
1544 m/s).
Results—The minimum required ROI size was 20 pulse
lengths and 14 uncorrelated scan lines (7 × 9 mm2 in this experiment). In
general, ct was underestimated by –1.0% ± 0.1% and by –1.3% ± 0.3% for
the F and N-F phantoms, respectively. No significant differences were
found among estimates from different excitation frequencies or among
those at the physical location or the nominal location of the transmit focus.
Conclusions—Results indicate that estimates can be performed within 1 cm2 at the location of the nominal transmit focus, which
can be a fixed parameter during the in vivo application of this method.
The method is being applied in the characterization of liver diseases and
lesions.
Cardiovascular Ultrasound
Moderator: John Blebea, MD, MBA
1521708 Lagrangian Deformation Tracking of the Left Ventricle for
Cardiac Ultrasound Strain Imaging
Chi Ma,* Tomy Varghese Medical Physics, University of
Wisconsin, Madison, Wisconsin USA
Objectives—Lagrangian description of myocardial tissue structure deformation is key to accurate regional strain estimation of the left
ventricular wall over time. Failure to couple the estimated displacement
and strain information with the correct myocardial tissue structures will
lead to erroneous result in the displacement and strain distribution over
time.
Methods—This study presents a method to obtain Lagrangianbased displacement tracking. Myocardial issue structures are divided into
a fixed number of pixels whose deformation is tracked over the cardiac
cycle. An algorithm that uses a polar grid generated between the estimated
endocardial and epicardial contours for the left ventricle in cardiac shortaxis images is proposed to ensure Lagrangian description of the pixels.
Displacement estimations from consecutive radiofrequency frames were
then mapped onto the polar grid to obtain a distribution of the actual displacement that is mapped to the polar grid over time.
Results—The method was validated against a finite-element–
based canine heart model coupled with an ultrasound simulation program.
Segmental analysis of the accumulated displacement and strain over a cardiac cycle demonstrated excellent agreement between the ideal result obtained directly from the finite-element model and our Lagrangian approach
to strain estimation. Traditional Eulerian-based estimation results, on the
other hand, showed a significant deviation from the ideal result. An in vivo
comparison of the displacement and strain estimated using parasternal
short-axis views is also presented.
Conclusions—Lagrangian strain estimation using a polar grid
demonstrates accurate results when validated in a finite-element cardiac
model. In addition to the cardiac application, this approach can also be
applied to transverse scans of arteries, where a polar grid can be generated
between the contours delineating the outer and inner walls of the vessels
from the blood flowing though the vessels. (Supported by National Institutes of Health grants 5R21EB010098 and R01CA112192-S103.)
1509371 Effects of Respiration on Estimation of Systolic Pulmonary
Artery Pressure in Patients With Right Ventricle Systolic
Dysfunction
Xiao-Yong Zhang,* Tie-Sheng Cao, Li-Jun Yuan Ultrasound Diagnostics, Tangdu Hospital, Fourth Military Medical
University, Xi’an, China
Objectives—We investigated the effects of respiration on the
peak velocity of tricuspid regurgitation (TR) and estimation of systolic
pulmonary artery pressure (SPAP) in patients with right ventricle (RV)
systolic dysfunction by Doppler echocardiography.
Methods—Continuous wave Doppler spectra of TR were
recorded in 32 patients with and 28 controls without RV systolic dysfunction. Electrocardiography and respiratory tracing were recorded simultaneously. The expiratory and inspiratory peak velocities of TR were
acquired and averaged for 5 consecutive respiratory cycles. The SPAP
during expiration and inspiration was calculated.
Results—The velocity of TR and SPAP did not vary significantly
between expiration and inspiration in controls (2.77 ± 0.23 and 2.82 ± 0.26
m/s; P = .776; 35.94 ± 4.96 and 36.18 ± 5.12 mm Hg; P = .747), whereas
the velocity of TR and SPAP decreased significantly from expiration to inspiration in patients with RV systolic dysfunction (3.27 ± 0.35 and 2.59 ±
0.22 m/s; P < .001; 53.72 ± 7.39 and 38.45 ± 5.63 mm Hg; P < .001).
Conclusions—Respiration has significant effects on the velocity of TR and SPAP in patients with RV systolic dysfunction, and the measurement should be carried out when patients are at the end of expiration.
1541517 High–Frame Rate Lateral Strain Estimation Using Virtual
Beam Focusing in Canine and Human Hearts In Vivo
Ethan Bunting,1* Jean Provost,1 Elisa Konofagou1,2
1
Biomedical Engineering, 2Radiology, Columbia University,
New York, New York USA
Objectives—Ultrasonic strain imaging is capable of providing clinicians with useful information regarding cardiac function in a fast, noninvasive manner. Lateral strain estimation is required to obtain the full 2D strain
tensor of the heart and accurately represent the cardiac deformation within the
image plane. Previous work has shown that 2 major parameters influencing
the quality of lateral strain estimation are the motion estimation rate and beam
density (Provost et al. Phys Med Biol 2011). Using element channel data,
virtual beam focusing can be used to reconstruct a large number of beams
from only a few acoustic interrogations. Furthermore, the rate of motion estimation can be increased by using temporally unequispaced acquisition sequences (TUAS), a technique developed previously by our group, which
increases the motion estimation rate while reducing the motion sampling rate.
Methods—Using a Verasonics scanner with a custom TUAS
and virtual beam focusing, we have acquired short-axis views of human
(n = 1) and open-chest canine (n = 3) hearts. Virtual beam focusing was
used to reconstruct 156 radiofrequency (RF) lines from 12 focused
acoustic transmits. Lateral displacement estimation was performed using
RF cross-correlation, and strain was computed using a least squares strain
estimator. The quality of strain estimation was evaluated by using the elastographic signal-to-noise ratio (SNRe).
Results—We first show that lateral strain estimation can be
achieved in vivo using virtual beam focusing and that the results are similar to conventional beam focusing. Also, we show that it is possible to
use TUAS to estimate strain using a wide range of frame rates (57, 130,
447, 894, 1788, and 2682 Hz) while maintaining this high beam density.
The SNRe for lateral strain was found to range from 2 to 10 and be optimal at a motion estimation rate of 894 Hz.
Conclusions—In conventional scanners, there is a trade-off between the beam density and motion estimation rate, leading to a theoretical limit on the quality of strain estimation. The use of virtual beam
focusing and TUAS techniques for lateral strain imaging was shown to
eliminate this tradeoff and lead to good-quality lateral strain estimation at
high frame rates.
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1540358 Nurse-Based Use of Handheld Ultrasound Examination for
Heart Failure
Mikael Gustafsson,* Ulf Dahlström, Urban Alehagen,
Peter Johansson Cardiology, Medicine and Care, Linköping,
Sweden
Objectives—Heart failure (HF) is a syndrome of high prevalence and poor prognosis. Structured nurse-based visits, where basic clinical data such as body weight, edemas, New York Heart Association
(NYHA) functional class, respiratory symptoms, and biomarkers are assessed, is a strategy implemented in recent years to improve the quality of
care. Ultrasound lung imaging can reveal lung water by the appearance of
the so-called “comet tail artifact” (CTA), which is reported to be easily recognized after a short period of training. Pleural effusion (PE) and dilatation
of liver veins and the inferior vena cava (IVC) are also common findings
in decompensated HF that can be evaluated with ultrasound. Knowledge of
these data may improve understanding of the current hemodynamic status
of HF patients. We hypothesized that HF clinic nurses with 1 day of training would be able to record and correctly identify the CTA and PE using a
handheld ultrasound scanner (HHUS). We also tested whether they would
be able to correctly record the IVC diameter and liver veins.
Methods—Using an HHUS (Vscan; GE Healthcare), 4 nurses
recorded cine loops from all lung lobes, pleura IVCs, and liver veins in 58
consecutive HF outpatients. An experienced echocardiographer, blinded to
the results, reviewed all recorded image sequences in parallel.
Results—In this outpatient population of HF patients with median N-terminal pro-brain natriuretic peptide (NTproBNP) of 1670,
nurses’ findings were CTA in 18, PE in 5, dilated IVC in 12, and dilated
liver veins in 18 cases. These conditions, all associated with HF, were significantly (P < .05) found to covariate. CTA and a dilated IVC also correlated (both r = 0.4; P < .05) with the biomarker NTproBNP. CTAs were
less abundant in NYHA I and II than in NYHA III (r = 0.10; P < .05).
Agreement between nurse and echocardiographer findings was good for
CTA (70%) and PE (90%), while IVC and liver vein assessments were
less accurate. The HHUS examination time was on average 8 minutes.
Conclusions—Nurse-performed HHUS examination directed
to assess signs of increased lung water content and elevated central venous pressure can provide additional information with a potential impact
on management of HF patients.
1520493 Performance Assessment of Cardiac Strain Imaging Using
Radiofrequency and Envelope Signals
Chi Ma,* Tomy Varghese Medical Physics, University of
Wisconsin, Wisconsin USA
Objectives—Clinical cardiac strain images are currently generated using B-mode signals. Accurate regional myocardial function analysis requires high spatial and temporal resolution in addition to fidelity to
the underlying deformation. Performance analysis of radiofrequency (RF),
envelope, and B-mode signals in the context of cardiac strain imaging will
yield a better understanding of their respective properties.
Methods—In this study, strain estimation performance is compared using a tissue-mimicking phantom, finite-element–based cardiac
simulation, and clinical in vivo data to demonstrate the differences between the use of RF, envelope, and B-mode signals. Two performance
metrics, ie, the regional mean value and the SD of the regional mean value,
are studied.
Results—In phantom studies, the signal-to-noise ratio improvements of the RF signal for linear array and phased array geometry are
5.80 and 9.48 dB, respectively, when compared with the envelope signal
at the peak strain value. The cardiac simulation study shows that at the
peak strain value, the SDs of the estimated strain of the envelope signal
from anterior and anterolateral segments are 1.55 and 1.12 times larger
than RF signal estimations, respectively. In vivo study results also show
that the standard deviation of estimated strain is lower with RF signals.
Conclusions—Results in phantom studies show that RF signals provide superior performance under cyclic compression for both linear array and phased array transducers when compared to the use of
envelope signals. Cardiac simulation study and in vivo results also indicate performance advantages of strain estimation using RF signals over
envelope signals. (Supported by National Institutes of Health grants
5R21EB010098 and R01CA112192-S103.)
Gynecologic Ultrasound
Moderator: Jodi Lerner, MD
1541483 Three-Dimensional Ultrasound Assessment of Uterine Cavity Remodeling After Surgical Correction of Subseptations
Laura Detti Obstetrics and Gynecology University of Tennessee, Memphis, Tennessee USA
Objectives—Arcuate and subseptate uteri taken together account for 53% of all müllerian anomalies. Their incidence is even higher
in patients with infertility and recurrent pregnancy loss, and restoration of
normal fertility/pregnancy outcomes is achieved with surgical correction.
We sought to evaluate uterine cavity measurements in patients with arcuate or subseptate uteri in the pre- and post-resection periods.
Methods—This was a prospective cohort study. Patients diagnosed with arcuate or subseptate uteri were evaluated with 3D ultrasound
before and after undergoing surgical resection of the anomalies by hysteroscopic separation of the anterior from the posterior wall. Measurements of the subseptum’s length (measured from the base to the tip of the
septum: <10 mm defined arcuate, and ≥10 mm defined subseptate uterus,
respectively) and width (measured at the septum’s base as it comes off the
fundus) and cavity width (measured between the tubal ostia, at the fundus)
were obtained on a frozen coronal view of the uterus. A paired t test and
simple t test were used for comparisons. P < .05 defined significance.
Results—Ten patients were diagnosed with either an arcuate
(n = 3) or subseptate (n = 7) uterus and underwent surgical correction.
The overall uterine dimensions (length, width, and height) before and after
resection were similar, as were the subseptum widths, despite the different lengths. However, cavity width was significantly decreased after resection (3.3 ± 0.4 cm preop vs 2.6 ± 0.4 cm postop, respectively; P < .001).
The difference remained significant in the septate and arcuate uteri groups,
when analyzed separately.
Conclusions—It appears that the uterine fundus is only
stretched by the septum, and the cavity is able to regain a normal shape and
size after surgical correction. Postoperative measurements of the uterine
cavity revealed a remarkable remodeling capacity of the uterus. 3D ultrasound was instrumental in characterizing this unique uterine elasticity outside the pregnant state.
1541423 Assessment of Levator Ani Muscle Deformation During the
First and Third Trimesters of Pregnancy Using Tissue
Doppler Imaging at Maximal Kegel: A Pilot Study
Timothy Canavan Obstetrics, Gynecology & Reproductive
Sciences, University of Pittsburgh, Magee Women’s Hospital,
Pittsburgh, Pennsylvania USA
Objectives—To assess the feasibility of using tissue Doppler
imaging (TDI) to evaluate levator ani muscle function by measuring the
velocity, displacement, and strain of a levator ani contraction during a
kegel in the first and third trimesters of primigravida pregnancies.
Methods—This was a prospective pilot study of serial TDI of
the levator ani muscle in 27 primigravid subjects in the first trimester and
7 who were also imaged in the third trimester. Measurements were obtained using TDI of the midsagittal plane of the pelvic floor at the level of
the levator hiatus, recorded during maximal kegel. The mean velocities,
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displacements, strains, and strain rates were determined by postprocessing using QLab version 8.0 (Philips, Andover, MA).
Results—The findings in the first and third trimesters are summarized in Table 1. There was no statistically significant effect of age,
race, or body mass index (BMI) on any of the measurements; except for
BMI (P = .03) on mean velocity in the third trimester. Gestational age at
the time of the exam had a negative effect on mean velocity in the first
(P <.001) and third (P = .04) trimesters. Wilcoxon signed rank testing was
used to compare the first- and third-trimester means. There was no statistical difference in the mean velocities or strain testing between the
trimesters; however, there was a statistical difference between the mean
displacements, with a larger displacement in the third compared to the first
trimester (P = .04).
Conclusions—Tissue Doppler imaging has potential to be used
to assess levator ani function. There may be a difference in the functional
capacity of the levator ani between early and late pregnancy.
Table 1. Mean velocity, Displacement, Strain, and Strain Rate by Gestational Age
Mean
Mean
Gestational
Velocity
Age, wk
± 1 SD, cm/s
13.0
0.82 ± 0.65
31.0
1.13 ± 0.69
Mean
Displacement
± 1 SD, mm
2.6 ± 2.0
4.0 ± 2.2
Mean Strain
± 1 SD, 1/s
6.89 ± 6.45
13.04 ± 9.37
Mean
Strain Rate
± 1 SD, %
0.17 ± 0.14
0.27 ± 0.17
1523456 Biometric Ultrasound Findings of Trophoblastic Implantation on Cesarean Scars
Elysia Moschos,1* C. Edward Wells,1 Diane Twickler1,2
1
Obstetrics and Gynecology, 2Radiology, University of Texas
Southwestern Medical Center, Dallas, Texas USA
Objectives—To review first-trimester transvaginal ultrasound
(TVUS) of patients with cervicoisthmic implantations and a history of cesarean deliveries to determine whether biometry can distinguish between
placenta accreta, cesarean scar pregnancy, and other outcomes.
Methods—Our database was reviewed from October 2006 to
December 2011 for patients with first-trimester US diagnoses of cervicoisthmic implantations and previous history of cesarean deliveries. Biometry was performed based on the location of the trophoblast on sagittal
TVUS images of the uterus: (1) smallest distance from the anterior trophoblastic border to the uterine serosa; (2) anterior trophoblastic border
distance from the endometrial center; and (3) posterior trophoblastic border distance from the endometrial center. Outcomes were classified into 5
categories: (1) cesarean scar pregnancy (n = 11); (2) placental invasion (accreta/increta/percreta) (n = 7); (3) previa without invasion (n = 1); (4) cervical ectopic pregnancy (n = 2); and (5) noninvaded pregnancy (spontaneous
abortion, n = 31; or delivered intrauterine pregnancy, n = 4). Statistical methods included analysis of variance with the Tukey range test and Student t test.
Results—Of 77 studies, outcome data were available for 56 patients. The average gestational age was 8.8 weeks (minimum, 2.0; maximum, 14.9). The anterior trophoblastic border distance from the uterine
serosa was significantly smaller in cesarean scar and placental invasion
pregnancies. Both trophoblastic borders of cesarean scar pregnancies were
significantly different compared to placenta accretas.
Conclusions—Smaller trophoblastic border distances from the
uterine serosa are seen in cesarean scar pregnancies and placenta accretas;
this distance distinguishes them from other pregnancy outcomes. Trophoblastic borders and their relative distances from the endometrial center at the hysterotomy implantation site are significantly different between
cesarean scar pregnancies and placenta accretas.
Table 1
Outcome (n)
Mean distance
Cesarean
Placental
Noninvaded
(SD), mm
Pregnancy (11) Invasion (7)
Pregnancy (35)
Anterior trophoblastic
1.6a (0.6)
2.2a (1.0)
7.9 (3.3)
border to uterine serosa
Anterior trophoblastic
32.0b (14.4)
16.3b (8.7)
10.7 (9.2)
border
Posterior trophoblastic
2.1c (4.7)
9.6c (3.8)
8.7 (6.7)
border
a
Significantly different from the other pregnancy groups (P < .0001).
b
P = .02.
c
P = .003.
1537573 Diagnosis of Polycystic Ovaries (PCO) by Ovarian
Appearance Only: A Prospective Study of Infertility
Patients Comparing Those With Unilateral, Bilateral, and
No PCO With Regard to Body Mass Index and Cycle
Regularity
Alex Hartman,* Rose Lee, Brian Hartman Imaging, True
North Imaging, Thornhill, Ontario, Canada
Objectives—Polycystic ovaries (PCO) is commonly diagnosed
using the ovarian appearance and volume criteria. We hypothesized that
using PCO appearance criteria alone, there would be a difference in cycle
regularity and body mass index (BMI) between patients who do or do not
have PCO and between patients with unilateral versus bilateral PCO.
Methods—We studied 3871 consecutive infertility patients.
Using the PCO syndrome Rotterdam Consensus Criteria for the appearance of ovaries (12 follicles in either/both ovaries), we determined whether
the patient had unilateral, bilateral, or no PCO. BMI (height/weight) and
cycle regularity were self-reported. χ2 tests of independence and 1-way
analysis of variance were performed.
Results—Of 3871 consecutive patients, 363 (9.4%) had unilateral, 1045 (27%) had bilateral, and 2463 (63.6%) did not have PCO.
There was a significant difference in cycle irregularity (present vs absent)
based on PCO status (χ2 = 1208.7; df = 2; P < .01). Woman with bilateral
PCO had the highest frequency of menstrual cycle irregularity (71.9%) vs
34.8% in unilateral and 12.7% with no PCO. There was also a significant
difference in mean BMI based on PCO status (F = 19.1; df = 2; P < .01).
The mean BMI of woman with bilateral PCO was 26.0 (SD 6.2), while
woman with unilateral or no PCO had a mean BMI of 25.2 (SD 5.7) and
24.5 (SD 6.5), respectively.
Conclusions—This is the first study showing the PCO appearance alone to be significant when comparing unilateral vs bilateral PCO
in infertility patients. While BMI was significantly different between patients with or without PCO, there was no significant difference in BMI
between those with unilateral vs bilateral PCO. There was a significant
difference in cycle regularity between those with and without PCO and between those with unilateral versus bilateral PCO using appearance criteria alone.
Table 1
No. of patients
BMI
Irregular cycles, %
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No PCO
2463
24.5
12.7
Unilateral
363
25.2
34.8
Bilateral
1045
26.0
71.9
P
<.01
<.01
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1538495 Evaluation of Cervical Cancer Detection With Acoustic
Radiation Force Impulse Ultrasound Imaging: Preliminary
Results
Yijin Su,* Lianfang Du, Ying Wu, Juan Zhang, Xuemei
Zhang, Xiao Jia, Yingyu Cai, Yunhua Li, Jing Zhao, Qian
Liu School of Medicine, Shanghai Jiaotong University,
Shanghai, China
Objectives—To evaluate the application of acoustic radiation
force impulse (ARFI) ultrasound imaging and its potential value for characterizing cervical cancer.
Methods—ARFI of the uterine cervix was performed in 58 patients with cervical cancer before operation. Elastographic imaging (EI),
Virtual Touch tissue imaging (VTI), and Virtual Touch tissue quantification (VTQ; Siemens Medical Solutions, Mountain View, CA) were
used to qualitatively and quantitatively analyze the elasticity and hardness
of lesions.
Results—Compared to the surrounding cervix tissue, the EI,
VTI, and VTQ images between malignant lesions and surrounding normal
tissues showed a significant difference (P < .001).
Conclusions—ARFI of the uterine cervix may be an objective
method for assessment of softening of tissue. It has high sensitivity and
specificity in evaluating cervical cancer and therefore has good diagnostic value in clinical applications.
Table 1. Comparison of VTQ Between Cervical Cancer and Normal Tissue
Tissue
Cases, n
Mean, m/s
SD, m/s
Cervical cancer
58
3.41
1.59
Normal tissue
58
2.12
1.27
Compared with normal tissue, VTQ of cervical cancer was higher (P < .001).
1512000 Texture-Based Ovarian Tumor Characterization Using
3-Dimensional Ultrasound
U. Rajendra Acharya,1 Stefano Guerriero,2 Filippo Molinari,3
Luca Saba,4 Jasjit Suri5,6* 1Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 2Obstetrics and
Gynecology, University of Cagliari, Cagliari, Italy; 3Electronics and Telecommunications, Politecnico Torino, Torino, Italy;
4
Radiology, Azienda Ospedaliero Universitaria di Cagliari,
Cagliari, Italy; 5Global Biomedical Technologies, Roseville,
California USA; 6Biomedical Engineering, Idaho State University, Pocatello, Idaho USA
Objectives—Among gynecologic malignancies, ovarian cancer is the most frequent cause of death. Differential diagnosis is difficult,
thus exposing patients to unneeded surgical treatment. We developed a
computer-aided diagnostic technique that uses ultrasound images of the
ovary to accurately classify benign and malignant ovarian tumors.
Methods—Twenty women (age range, 29–74 years; mean ±
SD, 49.5 ± 13.48 years), 11 premenopausal and 9 postmenopausal, were
recruited for this study. The histologic specimens revealed 10 malignant
and 10 benign lesions. Prior to surgery, each patient was associated with
a 3D volume of 100 images. Feature extraction was made by using local
binary pattern and laws texture energy. The data were used to train a classifier based on a support vector machine (SVM) with 5 different kernels.
The data set was randomly split into 10 equal folds, each fold containing
the same ratio of nonrepetitive samples from both classes (malignant and
benign). At each iteration, 9 folds were used to train the SVM, and 1 fold
was classified. We iterated the procedure 10 times to explore all the possible combinations. The averages of the performance metrics obtained in
all the iterations are reported as the overall performance metrics.
Results—The performance metrics obtained on training the
SVM classifier of various kernel configurations using the 14 significant
features are reported in Table 1. All the kernels demonstrated excellent
ability in classifying the samples from both classes. The highest accuracy
of 99.9% was registered by the radial basis function (RBF) kernel.
Conclusions—The novelty of this study is the use of low-cost
ultrasound images and a highly discriminating combination of simple texture features fed to an SVM classifier to obtain the highest accuracy of
nearly 100% in ovarian tumor classification.
Table 1. Classifier Performance
SVM
Accuracy, Sensitivity, Specificity, PPV,
Kernel TP TN FP FN
%
%
%
%
Linear 100 99 0 1
99.8
99.6
100
100
Poly 1 100 100 0 0
99.8
99.6
100
100
Poly 2 100 100 0 0
99.9
100
99.9
99.9
Poly 3 100 100 0 0
99.8
99.9
99.8
99.8
RBF
100 100 0 0
99.9
100
99.8
99.8
FN indicates false-negative; FP, false-positive; PPV, positive predictive value;
TN, true-negative; and TP, true-positive.
1512001 Tumor Characterization From 3-Dimensional Gynecologic
Ultrasound: A New Online Feature-Based Paradigm
U. Rajendra Acharya,1 Luca Saba,2 Filippo Molinari,3
Stefano Guerriero,4 Jasjit Suri5,6* 1Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 2Radiology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari,
Italy; 3Electronics and Telecommunications, Politecnico Torino,
Torino, Italy; 4Obstetrics and Gynecology, University of
Cagliari, Cagliari, Italy; 5Global Biomedical Technologies,
Roseville, California USA; 6Biomedical Engineering, Idaho
State University, Pocatello, Idaho USA
Objectives—Among gynecologic malignancies, ovarian cancer
is the most frequent cause of death. Differential diagnosis is difficult, exposing patients to unneeded surgical treatment. The objective of this work
was to develop a computer-aided diagnostic (CAD) technique that uses 3D
acquired ultrasound images of the ovary and image-mining algorithms to
characterize and classify benign and malignant ovarian tumors.
Methods—Twenty women (age range, 29–74 years; mean ±
SD, 49.5 ± 13.5 years), 11 premenopausal and 9 postmenopausal, were recruited for this study. The histologic specimens revealed 10 had malignant and 10 had benign lesions. Prior to surgery, each patient was
associated with a 3D volume of 100 images. We extracted features based
on the textural changes in the image and also features based on the higherorder spectra (HOS) information. The significant features were then selected and used to train and evaluate the decision tree (DT) classifier.
The data set was randomly split into 10 equal folds, each fold containing
the same ratio of nonrepetitive samples from both the classes (malignant
and benign). At each iteration, 9 folds were used to train the DT, and 1
fold was classified. We iterated the procedure 10 times to explore all the
possible combinations. The averages of the performance obtained in all the
iterations are reported as the overall performance.
Results—The simple DT classifier presented high accuracy of
95.1%, sensitivity of 92.5%, and specificity of 97.7%. Full performance
is given in Table 1.
Conclusions—A novel combination of 4 texture and HOS
based features that adequately quantify the nonlinear changes in both benign and malignant ovarian ultrasound images was used to develop classifiers. The CAD tool would be a more objective alternative to manual
analysis of ultrasound images, which might result in interobserver variations. The system can be installed as a stand-alone software application in
the physician’s office at no extra cost.
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Table 1. Classifier Performance
Accuracy, Sensitivity, Specificity, PPV,
TN FN TP FP
%
%
%
%
DT 98
8 93
2
95.1
97.8
92.5
97.7
FN indicates false-negative; FP, false-positive; PPV, positive predictive value; TN,
true-negative; and TP, true-positive.
1537972 Value of Transvaginal Ultrasonography in Diagnosing
Adenomyosis
Birsen Ogutcu,1,2* Kathryn Gunnison,2 Bakytbubu Arynova,1
Jack Garon,1,2 Josef Blankstein1,2 1Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, Illinois USA; 2Obstetrics
and Gynecology, Rosalind Franklin University of Medicine and
Science, North Chicago, Illinois USA
Objectives—The purpose of this study was to look at ultrasonographic findings of uteri with adenomyosis confirmed by histopathology after hysterectomy.
Methods—The ultrasound reports and images from 76 patients
who underwent hysterectomy with a diagnosis of adenomyosis on pathologic reports were evaluated. Data collection included the myometrial
echogenicity (focal or diffuse heterogeneous echo texture vs homogeneous
echo texture), the presence or absence of myometrial cysts, the presence
or absence of subendometrial linear striations, and the quality of the endometrial/myometrial border (ill defined vs well defined).
Results—Of the 73 ultrasound images reviewed, 70 (96%)
were shown to have a heterogeneous myometrial echo texture. Of these 70,
11 (26%) were described as focal heterogeneity. Myometrial cysts were
found in 53 (72%) of the images. Forty-six (63%) images were shown to
have an ill-defined endometrial/myometrial border. Thirty-two (44%) images were shown to have subendometrial linear striations. Of the images
shown to have myometrial cysts, all 53 (100%) were shown to have a heterogeneous myometrial echo texture.
Conclusions—In conclusion, based on our retrospective studies and others, transvaginal ultrasonography is a cost-effective, noninvasive, and widely available method to look for ultrasonographic findings
that are common in uteri with pathologically confirmed adenomyosis. In
this study, we identified a heterogeneous myometrial echo texture as the
most common ultrasonographic finding in uteri with confirmed adenomyosis. Additional prospective studies to further determine the accuracy
and reliability of transvaginal ultrasonography as a tool to diagnose adenomyosis are needed.
1509704 To Chaperone or Not to Chaperone
Jenny Parkes,1,2* Michal Schneider-Kolsky,2 Paul Lombardo2
1
Australian School of Medical Imaging, Sydney, New South
Wales, Australia; 2Medical Imaging and Radiation Science,
Monash University, Melbourne, Victoria, Australia
Objectives—Chaperone use during transvaginal (TV) ultrasound is variable. This paper discusses such use in regard to both the sonographer/sonologist and patient’s perspectives.
Methods—A survey of sonographer members of the Australian
Sonographers Association was performed online to audit current practice;
in addition, a literature review of current international practices, protocols,
and opinions was undertaken.
Results—Three-hundred fifty of 2219 (15.8%) sonographers
participated in this survey. Most sonographers surveyed used a chaperone
occasionally (42.9%), with 70% preferring to never use a chaperone.
Patient embarrassment and lack of privacy were key issues, findings that
were supported by the literature. Female sonographers used chaperones
occasionally or never (89%), while 60% of male sonographers used a
chaperone always or most of the time to comply with departmental protocols and for medicolegal protection. Sonographers in private specialist
obstetric and gynecologic centers where TV pelvic ultrasound is commonly a routine part of the examination never, or only occasionally, used
a chaperone. Review of the current literature and protocols highlighted
that the use of a chaperone should consider the patient’s privacy, embarrassment, and preference. In regard to the sonographer/sonologist, selection of an appropriate chaperone, availability, and the informed consent of
the patient are important considerations.
Conclusions—Chaperones for TV scanning are predominantly
used by male sonographers in Australia. It is unclear if the patient preference for a chaperone to be present is taken into account. The appropriate
protection for both sonographers/sonologists and patients needs to be considered, in particular, privacy issues. Protocols should be developed to
take all of these factors into account.
1538726 What Causes Postmenopausal Bleeding (PMB)? A Prospective Study of 670 Consecutive Patients With PMB Examined With Regard to Body Mass Index and the Prevalence
of Abnormalities on Sonohysterography
Alex Hartman,* Rose Lee, Brian Hartman Imaging, True
North Imaging, Thornhill, Ontario, Canada
Objectives—The causes of postmenopausal bleeding (PMB)
are myriad. This prospective study examines the causes of PMB and correlates these findings to patient body mass index (BMI).
Methods—Sonohysterography was performed on 1108 consecutive postmenopausal women at an academically oriented private practice from October 2010 to August 2011. Six hundred seventy of the
patients had PMB. The prevalence of uterine abnormalities and the patient’s BMI were obtained for each group. χ2 tests of independence and
1-way analysis of variance were performed to determine significant differences.
Results—Of the 670 with PMB, 262 (39.1%) had endometrial
polyps; 273 (40.1%) had fibroids; 39 (6.8%) had submucosal fibroids; and
369 (55%) had a normal cavity, with no polyps, or submucosal fibroids.
There was a statistically significant difference between the mean BMI of
patients with endometrial polyps (28.34) and those with normal cavities
(27.33) and only fibroids (27.64) (F = 2.95; df = 3; P = .03).
Conclusions—More than half of patients with PMB have a
normal uterine cavity, and almost 40% have endometrial polyps. Patients
with endometrial polyps have a higher BMI than those without polyps.
Table 1
No uterine abnormality
Intramural fibroid
Polyp
Submucosal fibroid
Polyp + intramural fibroid
Polyp + submucosal fibroid
Total
Patients, n
233
136
164
39
91
7
670
Patients, %
34.8
20.3
24.5
5.8
13.6
1.0
100
BMI
27.33
27.64
28.34
27.60
28.80
28.76
27.93
1541040 Spatial Variability of Shear Wave Speed Estimation in the
Normal Nonpregnant Cervix
Lindsey Carlson,1* Mark Palmeri,2 Lisa Reusch,1 Helen
Feltovich,1,3 Timothy Hall1 1Medical Physics, University of
Wisconsin, Madison , Wisconsin USA; 2Biomedical Engineering, Duke University Pratt School of Engineering, Durham,
North Carolina USA; 3Maternal-Fetal Medicine, Intermountain Healthcare, Park City, Utah USA
Objectives—Throughout pregnancy, beginning soon after conception, the cervix remodels, resulting in softening, shortening, and dilation to allow for eventual delivery of a fetus. Premature remodeling may
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lead to premature birth, yet there is no clinically established method to objectively and quantitatively measure softening. Our objective is to develop
a safe, reliable, noninvasive quantitative method to assess cervical softness.
We have shown that shear wave speed estimation (SWS) is an effective
method to measure cervical softness in hysterectomy specimens. A critical step toward transitioning to in vivo studies is to determine the spatial
variability in cervical softness, and that is the aim of the current work.
Methods—Five multiparous hysterectomy specimens from
nonpregnant women were bivalved, placed in a saline bath, and scanned
with a 9L4 linear array transducer aligned parallel with the endocervical
canal using a Siemens Acuson S2000 system. SWS measurements were
obtained in 5 positions along the canal (10–30 mm from the external os)
and at 3 depths from the surface of the canal (0.25–8.25 mm deep) with
10 replicate measurements at each location. The shear wave speeds were
estimated using an iterative random sample consensus (RANSAC)
method.
Results—In all specimens, the shear wave speed systematically
increased along the canal from distal to proximal (closer to the uterus) on
the anterior side (1.47 ± 0.08 vs 4.54 ± 0.22 m/s for distal and proximal,
respectively). This represents an increase in SWS of 1.5 m/s/cm along the
length of the cervix. The posterior side showed much greater, and less systematic, spatial variation (3.61 ± 0.98 vs 4.14 ± 0.58 m/s for distal and
proximal, respectively). All estimates had a RANSAC inlier percentage of
99%, representing strong confidence in the SWS estimates.
Conclusions—Normal cervical tissue has a significant stiffness
gradient that can be characterized with acoustic radiation force-based shear
elasticity imaging methods. With careful development and testing, SWS
measurement will provide a means to noninvasively assess softening of the
pregnant cervix and could be a useful research tool for exploring premature cervical remodeling.
New Investigator Award Session
Moderators: Arthur Fleischer, MD, Elisa Konofagou, PhD
1434714 Longitudinal Analysis of Grayscale Imaging and Electromyography in an Animal Model of Carpal Tunnel Syndrome
Shawn Roll,1* Kevin Evans,2 Kevin Volz,2 Carolyn Sommerich2
1
Division of Occupational Science and Occupational Therapy,
University of Southern California, Los Angeles, California
USA; 2School of Health and Rehabilitation Sciences, Ohio State
University, Columbus, Ohio USA
Objectives—The objective of this research was to determine
the ability of sonography to identify changes over time in median nerve
morphology due to controlled exposure to a physical task related to the development of carpal tunnel syndrome.
Methods—Fifteen Macaca fascicularis monkeys pinched a
lever while in various amounts of wrist flexion to receive a treat. Subjects
worked at a self-regulated pace up to 8 hours a day, 5 days a week, for 14
weeks. Nerve conduction velocity (NCV) and sonographic evaluation of
the median nerve were completed every other week during 4 weeks of
training (baseline), 16 weeks of working, and 6 weeks of recovery. A GE
LOGIQ i with a 12-MHz linear transducer was used for sonographic evaluation. Cross-sectional area (CSA) was measured via a direct trace around
the inner hyperechoic border of the nerve in the forearm and at the level
of the pisiform. NCV and CSA measures were analyzed across the 3
phases using analysis of variance and trend graphs.
Results—NCV slowed slightly from baseline to the working
phase across all subjects (P = .03). CSA of the nerve at the level of the
pisiform was noted to increase significantly from baseline and working
phases as compared to the recovery phase (P = .03). At the same time,
CSA of the median nerve in the distal forearm did not change across the
phases (P = .20).
Conclusions—Based on this controlled study, changes in CSA
of the median nerve can be observed over time and may be directly associated with work exposure. Sonography may be a highly useful tool for
periodic preventative screening for work-related musculoskeletal disorders. Early detection of these changes through longitudinal evaluations in
workers at risk for carpal tunnel syndrome could trigger interventions
meant to reverse the progression of tissue pathology.
Table 1. Average (SD) Nerve Measurements Across the Study Phases
Nerve conduction velocity,
m/sec
CSA in forearm, mm2
CSA at pisiform, mm2
CSA change (pisiform –
forearm), mm2
Baseline
Working
Recovery P
35.96 (3.46) 34.33 (3.76) 34.81 (3.19) .03
0.61 (0.15)
0.82 (0.28)
0.20 (0.28)
0.59 (0.16)
0.81 (0.29)
0.22 (0.31)
0.64 (0.17) .20
0.96 (0.36) .03
0.30 (0.38) .27
1526604 Risk Reduction of Brain Infarction During Carotid
Endarterectomy or Stenting Using Sonolysis: Prospective
Randomized Study Pilot Data
Martin Kuliha,1* David Školoudík,1,4 Eva Hurtíková,1
Martin Roubec,1 Andrea Goldírová,1 Roman Herzig,4 Václav
Procházka,2 Tomáš Jonszta,2 Dan Czerný,2 Jan Krajča,2 David
Otáhal,3 Tomáš Hrbáč3 1Neurology, 2Radiology, 3Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic; 4Neurology, University Hospital Olomouc, Olomouc, Czech
Republic
Objectives—Sonolysis is a new therapeutic option for acceleration of arterial recanalization. The aim of this study was to confirm risk
reduction of brain infarction during carotid endarterectomy (CEA) and
carotid stenting (CS) of the internal carotid artery (ICA) using sonolysis
with continuous transcranial Doppler monitoring by a diagnostic 2-MHz
probe.
Methods—All patients with ICA stenosis >70%, an indication
for CEA or CS, and signed informed consent were enrolled to the study
during 18 months. Patients were randomized into 2 groups: group 1 with
sonolysis during intervention and group 2 without sonolysis. Neurologic
examination, cognitive tests, and brain magnetic resonance imaging were
performed before and 24 hours after intervention in all patients. New brain
infarctions, infarctions >0.5 cm3, a mini–mental state examination, a clock
test, and a speech fluency test were statistically evaluated using a t test.
Results—Totally, 127 patients were included in the study.
Sixty-two (48 males; mean age, 65.6 ± 7.6 years) were randomized into
group 1; 33 underwent CEA and 29 CS. Sixty-five patients (39 males;
mean age, 65.6 ± 7.8 years) were randomized into group 2; 30 underwent
CEA and 35 CS. New brain infarctions/infarctions >0.5 cm3 were found
in 19 (30.6%)/4 (6.5%) patients in group 1 and in 26 (40.0%)/12 (18.5%)
patients in group 2, respectively (P = .14/P = .02, respectively). No significant differences were found in cognitive tests (P > .05 in all tests).
Conclusions—Sonolysis seems to be effective in prevention of
large brain infarction during CEA and CS. (Supported by grants IGA MH
CR NT/11386-5/2010, NT/11046-6/2010, and NT/13498-4/2012.)
1536178 Measured Single-Bubble Postexcitation Collapse Thresholds
for Standard and Size-Altered Ultrasound Contrast Agents
Daniel King,1,2* William O’Brien Jr2,3 1Mechanical Science
and Engineering, 2Bioacoustics Research Laboratory, 3Electrical
and Computer Engineering, University of Illinois at UrbanaChampaign, Urbana, Illinois USA
Objectives—Experimentally measured responses of ultrasound
contrast agents (UCAs) at high acoustic pressures are valuable for imaging and therapeutic ultrasound applications as well as for interpreting bio-
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effect mechanisms. Therefore, the goals for this research were to compare
the size distribution and shell composition dependence for a characteristic type of collapse using 2 commercially available UCAs, lipid-shelled
Definity and albumin-shelled Optison.
Methods—Two Definity and 2 Optison populations of varying
size distributions were tested. Experiments were conducted using a double passive cavitation detection setup at several frequencies (2.8–7.1 MHz)
across a range of peak rarefactional pressures (0.1–6.0 MPa). Data were
analyzed using a peak detection algorithm for the presence or absence of
the postexcitation signal (PES), a rebound characteristic indicative of shell
rupture, inertial cavitation, and symmetric collapse for single UCAs.
Results—With standard preparations, Definity had lower postexcitation collapse thresholds than Optison at most frequencies (Table 1).
Using alternate preparations to change the mean size of the bubble populations had little effect on these thresholds, except around 4.6 MHz.
Furthermore, the predicted shift in PES thresholds using the Marmottant
model followed similar trends to the experiments for Definity UCAs,
showing greater variation around 4.6 MHz than at 2.8 or 7.1 MHz.
Conclusions—Significant differences were found between the
collapse thresholds of Definity and Optison. Moreover, the comparisons
between varied size distributions showed that the different shell compositions had a significant impact on the measured PES thresholds at all
frequencies, independent of mean size. (Supported by National Institutes
of Health grant R37 EB002641.)
Table 1. Mean Diameter ± SD and 50% Postexcitation Thresholds (95% Confidence
Intervals) for Peak Rarefactional Pressure Amplitude
50%
UCA
Mean
Threshold at
Population
Diameter, µm 2.8 MHz, MPa
Definity
1.99 ± 0.54 0.81 (0.71–0.90)
Altered Definity 2.50 ± 2.32 0.80 (0.75–0.85)
Optison
4.24 ± 2.44 1.20 (0.99–1.39)
Altered Optison 2.61 ± 2.04 1.17 (0.92–1.39)
50%
Threshold at
4.6 MHz, MPa
2.26 (2.06–2.43)
1.65 (1.56–1.72)
1.76 (1.34–2.06)
2.62 (2.20–2.95)
50%
Threshold at
7.1 MHz, MPa
3.90 (3.50–4.40)
3.61 (3.30–4.19)
4.24 (2.81–4.94)
4.04 (3.85–4.20)
1538841 Computer-Assisted Detection of Proximal Arterial Stenosis
on Doppler Ultrasound
John Millet,1* Gowthaman Gunabushanam,1 Erik Stilp,2
Forrest Crawford,3 Robert McNamara,2 Leslie Scoutt1
1
Diagnostic Radiology, 2Internal Medicine, Yale University
School of Medicine, New Haven, Connecticut USA; 3Biostatistics, Yale University School of Public Health, New Haven,
Connecticut USA
Objectives—To determine if use of a novel computer-generated quantitative measure, effective acceleration time (effAT), can improve accuracy for detecting proximal arterial stenosis on Doppler
ultrasound.
Methods—This was a retrospective case-control study whereby
aortic stenosis (AS) was used as a model to detect distal tardus parvus
physiology. Patients with echocardiography-confirmed AS (n = 132; 60
mild, 44 moderate, 28 severe) and controls (n = 48) who underwent carotid
ultrasound within 90 days were identified through a diagnostic imaging
database at a single medical center. A custom-built computerized spectral
analysis program generated effAT values for all carotid artery spectral
Doppler waveforms, and a receiver operating characteristic (ROC) analysis was performed to determine the optimal median effAT cutoff value to
detect AS. Two radiologists, blinded to subject disease status, reviewed
all carotid sonograms for the presence of tardus parvus waveforms. Interobserver variability was measured, and the accuracy of the radiologists to
detect AS with and without use of the effAT cutoff was calculated. Accuracy of the effAT cutoff to detect AS independent of radiologist waveform
interpretation was also determined.
Results—There were no significant differences between cases
and controls with regard to age, sex, body mass index, or ejection fraction.
Accuracy of radiologist detection of AS via waveform interpretation
ranged from 43% to 61%. Observer agreement in the detection of tardus
parvus waveforms was 76% (136/180 cases; Κ = 0.44; P < .001). ROC
analysis revealed an optimal effAT cutoff of ≥48 milliseconds to detect
AS with a corresponding area under the curve of 0.77 (95% confidence interval, 0.74–0.84). Use of the effAT cutoff independent of radiologist
waveform interpretation demonstrated accuracy of 72%. The combination of a tardus parvus pattern and a median effAT of ≥48 milliseconds
demonstrated an accuracy range of 73% to 74%.
Conclusions—Radiologist detection of proximal arterial stenosis though visual interpretation of spectral Doppler waveform morphology
is limited by low accuracy and moderate interobserver variability. Use of
a computer-generated median effAT cutoff markedly improves diagnostic accuracy and eliminates observer variability.
1536020 Contrast Ultrasound Imaging of the Aorta Does Not Affect
Progression of Atherosclerosis in ApoE–/– Mice
Brendon Smith,1,2* Douglas Simpson,3 Sandhya Sarwate,1,4
Rita Miller,1 Rami Abuhabsah,1 John Erdman,2,5 William
O’Brien Jr1,2 1Bioacoustics Research Laboratory, Electrical
and Computer Engineering, 2Division of Nutritional Sciences,
3
Statistics, 4Pathology, 5Food Science and Human Nutrition,
University of Illinois at Urbana-Champaign, Urbana, Illinois
USA
Objectives—Ultrasound contrast agents (UCAs) are used clinically to enhance ultrasound imaging of the cardiovascular system. Adverse biological effects have been noted after administration of UCAs in
human patients and animal models, and more research is needed for a
comprehensive understanding of the biological effects of UCAs. We used
the ApoE–/– mouse model of atherosclerosis to characterize these effects.
Methods—Male ApoE–/– mice (8 weeks old; n = 38) were intravenously infused with the Definity UCA (2 × 1010 UCA/h) and either
exposed to 2.8-MHz, 10-Hz pulse repetition frequency, 1.4-microsecond
pulse duration, 2-minute exposure duration, 1.4-MPa peak rarefactional
pressure amplitude ultrasound or sham exposed, and then consumed either
a chow or Western diet for either 4 or 8 weeks after ultrasound exposure
(n = 4–5 per group). The ultrasound exposure conditions, by design and
independent measures, matched Definity’s 80% collapse threshold. Blood
plasma samples were collected before ultrasound exposure and at 2, 4, 6,
and 8 weeks after exposure. Animals were then euthanized, and tissues
were collected for analysis. A pathologist measured atheroma thickness
in formalin-fixed, hematoxylin-eosin–stained transverse sections of the
aorta and scored them for severity of atherosclerosis.
Results—Plasma total cholesterol initially averaged 302 mg/dL
in the Western diet group, increased significantly to 742 mg/dL after 2
weeks on the diet (P < .0001), and remained significantly elevated after
that. Total cholesterol increased significantly from 309 mg/dL at baseline
to 420 mg/dL in the chow diet group after 4 weeks (P < .05) but was not
significantly different from baseline at 6 or 8 weeks. Total cholesterol was
significantly greater in the Western diet group than the chow group for all
time points after baseline (P < .0001). Atheroma thickness was significantly greater in animals consuming the Western diet than in chow-fed
animals (P < .001) and in animals euthanized after 8 weeks than after 4
weeks (P < .005). Ultrasound did not affect plasma total cholesterol levels or atheroma thickness.
Conclusions—Contrast ultrasound did not increase the severity of atherosclerosis in the ApoE–/– mouse model. (Supported by National
Institutes of Health grant R37EB002641.)
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1540161 Heterogeneity Assessment of Tumor Perfusion Using Highresolution Dynamic Contrast-Enhanced Ultrasound and
Dynamic Contrast-Enhanced Magnetic Resonance Imaging
Song-Ee Baek,* Patrick Pan, Ergys Subashi, Cäcilia Reiner,
Daniele Marin, Allan Johnson, Rendon Nelson Radiology,
Duke University Hospital, Durham, North Carolina USA
Objectives—To determine the reproducibility of measurements
of tumor perfusion heterogeneity using high-resolution contrast-enhanced
ultrasound compared to high-resolution dynamic contrast-enhanced (DCE)
magnetic resonance imaging (MRI) in murine colorectal cancer. We anticipate using this technique to predict and monitor treatment response to an
antiangiogenesis agent.
Methods—Experiments were approved by the local Animal
Care Committee. Five CD-1 nu/nu athymic female mice with subcutaneous murine colorectal carcinomas (mean tumor height/width, 0.66/1.21
cm) were injected with SonoVue (Bracco Diagnostic, Inc) via a tail vein.
At first, we determined reproducibility of tumor perfusion measurement
with DCE-US using a GE LOGIQ E9 with an ML6-15-D transducer (4–
13 MHz). Three separate injections by 2 radiologists were performed, and
maximum peak intensity (in video intensity) of all pixels within the regions of interest (ROIs) and coefficients of the enhancement for wash-in
and wash-out (25%–75% of the peak enhancement) slopes were calculated. Quantitative measurements were performed by positioning of ROIs
in the frame displaying maximum contrast enhancement of the tumor. A
coefficient of variation was used to compare the variability for each parameter. Second, perfusion heterogeneity according to tumor region was
performed with DCE-US and DCE-MRI, and the 2 results were compared
(perfusion graph: wash-in and wash-out slopes) in 1 mouse.
Results—The average coefficients of variation for repeated injections in the 5 mice were 3% (range, 1%–4%) for peak enhancement,
12% (range, 3%–25%) for slope of the wash-in phase, and 12% (range,
3%–19%) for slope of the wash-out phase. Perfusion measurement with
DCE US showed reproducible results. Perfusion graphs showed a different pattern by regions presenting tumor heterogeneity. DCE-US and DCEMRI wash-in and wash-out slopes are well correlated.
Conclusions—We obtained reproducible measurements of heterogeneity of tumor perfusion with DCE-US. These results also showed
compatible perfusion patterns with DCE-MRI. As a result of this information, we will pursue a further experiment design to determine the ability of this technique to predict treatment response.
1541104 Subharmonic Imaging of Angiogenesis in a Murine Breast
Cancer Model
Andrew Marshall,1,3* Valgerdur Halldorsdottir,1,3 Jaydev
Dave,1 Anya Forsberg,1,4 Manasi Dahibawkar,1,3 Traci Fox,2
Ji-Bin Liu,1 Xiangdong Hu,1,5 Yu He,1,6 Flemming Forsberg1
1
Radiology, 2Radiological Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania USA; 3School of Biomedical
Engineering, Sciences, and Health Systems, Drexel University,
Philadelphia, Pennsylvania USA; 4Plymouth Whitemarsh High
School, Plymouth Meeting, Pennsylvania USA; 5Ultrasonography, Beijing Friendship Hospital, Beijing, China; 6Ultrasound, First Hospital of Jilin University, Jilin, China
Objectives—To compare contrast-enhanced subharmonic ultrasound imaging (SHI) of breast tumor neovascularity to 3 immunohistochemical markers of angiogenesis in nude rats.
Methods—Twenty-five athymic nude female rats were implanted with 5 × 106 breast cancer cells (MDA MB 231) in the mammary
fat pad. The contrast agent Definity (Lantheus Medical Imaging, North
Billerica, MA) was injected in a tail vein (dose, 200 µL/kg), and fundamental ultrasound imaging as well as pulse-inversion SHI were performed
with a modified Sonix RP scanner (Ultrasonix Imaging, Richmond, British
Columbia, Canada) using a L9-4 linear array (transmitting at 8 MHz and
receiving at 4 MHz in SHI mode). After the experiments, specimens were
stained for endothelial cells (CD31), vascular endothelial growth factor,
and cyclooxygenase-2. Fractional tumor vascularity was calculated from
digital images as contrast-enhanced pixels over tumor area (for SHI) and
staining over tumor area (for specimens). Results were compared using a
linear regression analysis.
Results—Of the 25 rats implanted 16 (64 %) exhibited tumor
growth, and 13 were successfully imaged. SHI depicted the tortuous morphology of tumor neovessels and delineated areas of necrosis better than
fundamental ultrasound imaging, due to the marked suppression of tissue
signals. The strongest correlation determined by linear regression in this
breast cancer model was between SHI and percent area stained with CD31
(r = 0.42).
Conclusions—Quantitative contrast-enhanced SHI measures
of tumor neovascularity in a breast cancer xenograft model appear to provide a noninvasive marker for angiogenesis corresponding to the expression of CD31, albeit based on a limited sample size. (Supported by US
Army Medical Research Material Command grant W81XWH-08-1-0503
and Lantheus Medical Imaging.)
1539281 A Sequential Stepwise Algorithm Helps Improve Detection
of Fetal Venous Anomalies
Elena Sinkovskaya,* Anna Klassen, Sharon Horton, Alfred
Abuhamad Division of Maternal-Fetal Medicine, Eastern
Virginia Medical School, Norfolk, Virginia USA
Objectives—The assessment of the fetal venous system is an
essential component to fetal echocardiography as it adds significantly to
the complete diagnosis of heart defects. The purpose of this study was to
develop a method to standardize and simplify comprehensive examination
of the fetal venous system.
Methods—Eight hundred thirty-four fetal congenital cardiovascular anomalies (CVAs) were detected between January 2005 and
December 2010 in the Division of Maternal-Fetal Medicine at Eastern
Virginia Medical School. Fetal echocardiograms, which incorporated the
assessment of anatomic components of the fetal venous system, were performed between 16 and 39 weeks’ gestation. Since 2008, the stepwise
approach, which included evaluation of 5 transverse planes, was used: (1)
view of the upper abdomen; (2) coronary sinus view; (3) 4-chamber view;
(4) Three-vessel trachea view; and (5) view of the left brachiocephalic
vein. Color and pulsed Doppler was used to detect blood flow patterns.
Prenatal diagnosis was confirmed in most cases by postnatal echocardiography, angiography, operative findings, or autopsy.
Results—Of 834 cases of CVAs, 333 (39.9%) were detected
between years 2005 and 2007 and 501 (59.1%) between years 2008 and
2010. Since 2008, the detection of fetal isolated systemic and pulmonary
vein anomalies significantly increased (Table 1), while the distribution of
congenital heart defects (CHDs) with and without venous malformations
stayed the same. This increased identification of fetal venous system abnormalities may be related to the adoption of the new stepwise approach.
Conclusions—Our results demonstrated that the sequential
analysis of 5 transverse views helps significantly improve the detection
of isolated fetal anomalies of systemic and pulmonary veins.
Table 1. Detection of Fetal Cardiovascular Anomalies
Isolated Venous
CHDs With
Observation
Anomalies,
Venous System
Period
N
n (%)
Anomalies, n (%)
2005–2007
333
32/333 (9.6)
33/333 (10)
2008–2010
501
137/501 (27.3)a
40/501 (8)
a
Significant difference, P < .05.
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CHDs With
Normal Venous
System, n (%)
268/333 (80.4)
324/501 (64.7)
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1539534 Assessment of Longitudinal Myocardial Function of the
Right Ventricle in Fetuses With Agenesis of the Ductus
Venosus Using Tissue Doppler Imaging
Anna Klassen,* Elena Sinkovskaya, Sharon Horton, Alfred
Abuhamad Division of Maternal-Fetal Medicine, Eastern
Virginia Medical School, Norfolk, Virginia USA
Objectives—Agenesis of the ductus venosus (DV) may lead to
fetal congestive heart failure (CHF). Tissue Doppler imaging (TDI) is a
relatively new method used for direct analysis of the myocardial function.
The aim of this study was to analyze the systolic and diastolic myocardial
function of the right ventricle (RV) in fetuses with an absent DV using TDI.
Methods—Myocardial function of the RV was assessed in 42
normal fetuses and 27 fetuses with DV agenesis between 27 and 39 weeks’
gestation. Detailed echocardiography combined with pulsed and tissue
Doppler was performed in all cases. To determine the degree of CHF, the
cardiovascular score (CVS) was evaluated on each subject. TDI data were
obtained at the level of the 4-chamber view by placing the sample volume
at the lateral part of the tricuspid annulus. Pre-ejection (S1), systolic (S2),
early diastolic (E′), and late diastolic (A′) myocardial velocities were assessed. The ratio of peak velocities in early and late diastole (E′/A′), ratio
of peak velocities in early diastole measured by pulsed and tissue Doppler
(E/E′), and index of global contractility (Tei index) were also calculated.
Results—The CVS in fetuses with an absent DV ranged from
8 to 2 (mean, 6 ± 1.5), but none of these fetuses developed hydrops. The
TDI Tei index was significantly higher in the group with an absent DV
compared to normal (1.06 ± 0.11 vs 0.53 ± 0.8; P < .001). The ratio E/E′
was also greater in fetuses with agenesis of the DV (10.5 ± 2.3 vs 5.8 ± 1.1;
P < .01). In fetuses with an absent DV, the following changes of myocardial velocities were noted: E′ was significantly decreased or absent (average Z score = –3.2); A′ was significantly increased (average Z score = 6.2);
and S1 and S2 were elevated (average Z scores = 4.7 and 4.3, respectively).
Conclusions—This represents the first study evaluating cardiac function in fetuses with agenesis of the DV. Agenesis of the DV results in systolic and diastolic myocardial dysfunction of the RV in the fetus.
Our results validate the potential clinical applicability of the TDI technique in assessment of cardiac function in fetuses with an absent DV.
1541422 Does Early Second-Trimester Ultrasound Predict Obstetric
and Neonatal Outcomes in Monochorionic Diamniotic Twin
Pregnancies?
M. Baraa Allaf,1* Sina Haeri,2 Ali Ozhand,3 Amir Shamshirsaz,4
Martin Chavez,1 Samadeh Ravangard,5 Adam Borgida,6
Glenn Markenson,7 Joseph Wax,8 Sarah Davis,9 Rebecca
Habenicht,10 Manisha Gandhi,2 Jeff Johnson,10 Marjorie
Meyer,9 Rodrigo Ruano,2 Paul Ogburn,1 Melissa Spiel,5
Winston Campbell,5 Anthony Vintzileos,1 Alireza Shamshirsaz2,5
1
Obstetrics and Gynecology, Stony Brook–Winthrop University
Hospitals, Long Island, New York USA; 2Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas USA; 3Preventive Medicine, University of Southern California, Los Angeles,
California USA; 4Obstetrics and Gynecology, George Washington
University, Washington, DC USA; 5Obstetrics and Gynecology,
University of Connecticut, Farmington, Connecticut USA; 6Obstetrics and Gynecology, Hartford Hospital, Hartford, Connecticut USA; 7Obstetrics and Gynecology, Baystate Medical Center,
Springfield, Massachusetts USA; 8Obstetrics and Gynecology,
Maine Medical Center, Portland, Maine USA; 9Obstetrics and
Gynecology, University of Vermont College of Medicine, Burlington, Vermont USA; 10Obstetrics and Gynecology, DartmouthHitchcock Medical Center, Concord, New Hampshire USA
Objectives—To determine the association of discordant abdominal circumference (AC), femoral length (FL), head circumference
(HC), or estimated fetal weight (EFW) at time of early second-trimester
ultrasound with adverse obstetric and neonatal outcomes.
Methods—This was a multicenter retrospective cohort study
in 9 perinatal centers in the United States from January 2006 to June 2011.
All monochorionic diamniotic twin pregnancies with 2 live fetuses at early
second-trimester (16–20 weeks) ultrasound and serial follow-up ultrasound until delivery were included. Pregnancies with known chromosomal abnormalities or major malformations were excluded. The composite
obstetric outcome included intrauterine fetal demise (IUFD), twin-to-twin
transfusion syndrome (TTTS), intrauterine fetal growth restriction
(IUGR), and preterm birth ≤28 weeks. The composite neonatal outcome
included Apgar score <7 at 5 minutes, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, early-onset sepsis,
and neonatal demise. Receiver operating characteristic (ROC) curves of
AC, FL, HC, and EFW discordance cutoffs were developed for the prediction of composite obstetric and neonatal outcomes.
Results—A total of 180 twin pregnancies met inclusion criteria. Mean gestational age at delivery was 33 ± 3.4 weeks; 26.1% and 32%
of pregnancies were found to have adverse composite obstetric and neonatal outcomes, respectively. Adverse obstetric outcomes included TTTS in
14 (7.7%), IUGR in 19 (10.5%), IUFD in 13 (7.2%), and preterm birth
(≤28 weeks) in 14 (7.7%).
Conclusions—In our population, AC and EFW discordances
in monochorionic diamniotic twin pregnancies were fairly accurate in predicting an adverse composite obstetric outcome.
Table 1. Early Second-Trimester Ultrasound Biometric Discordances for the Prediction of Adverse Composite Obstetric and Neonatal Outcomes
AUC (95% CI)
Composite Obstetric Composite Neonatal
Outcome
Outcome
AC discordance
0.743 (0.66–0.81)
0.463 (0.34–0.58)
HC discordance
0.651 (0.55–0.74)
0.556 (0.44–0.67)
FL discordance
0.677 (0.58–0.76)
0.545 (0.42–0.66)
EFW discordance
0.734 (0.65–0.81)
0.517 (0.40–0.63)
AUC indicates area under the ROC curve; and CI, confidence interval.
1525459 Prenatal Visualization of the Pituitary Gland Using 2- and
3-Dimensional Ultrasound Imaging
Eldad Katorza,1* Jean-Philippe Bault,2 Yinon Gilboa,1
Yoav Yinon,1 Reuven Achiron1 1Obstetrics and Gynecology,
Sheba Medical Center, Tel Hashomer, Israel; 2Obstetrics and
Gynecology, Maternité Necker-Brune, Paris, France
Objectives—The pituitary gland is critically important in the
function of the endocrine axis. So far, antenatal demonstration of the pituitary gland was possible only by using magnetic resonance imaging. The
objective of our study was to describe antenatal visualization of the pituitary gland using 2D and 3D ultrasound.
Methods—Using a Voluson E8 ultrasound machine (GE Medical Systems, Zipf, Austria) equipped with a transabdominal multifrequency 4–8-MHz probe, during the third trimester of pregnancy, 2D
images and 3D volume acquisitions were taken.
Results—We identified the unique shape of the pituitary gland
using 2D and 3D ultrasound imaging, on an axial plane of the skull, parallel to and slightly below the biparietal diameter plane, showing the circle of Willis. Four manipulated steps from the native volume were needed
for 3D reconstruction of the gland using transabdominal ultrasound. The
insertion of the stalk to the posterior part of the gland could be seen. The
circle of Willis was found to be an excellent marker for the gland location.
Conclusions—This is the first report to date indicating that prenatal visualization of the pituitary gland using ultrasound imaging is feasible. In cases with midline anomalies of the brain, face, or cranium, the
demonstration of the pituitary gland, which is an essential endocrine gland,
is recommended.
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MRI may not be indicated for diagnoses where it is unlikely to improve
on the diagnostic accuracy of US alone. Notably, this study does consider
potential cost, prognostic, and surgical-planning benefits of fetal MRI.
Obstetric Ultrasound: Fetal Anomalies
Moderators: Israel Meizner, MD, Heather Welch, MD
1525585 Late Diagnosis of Fetal Central Nervous System Anomalies
Following a Normal Second-Trimester Anatomy Scan:
Should a Third-Trimester Anatomy Scan Be Routinely
Recommended?
Eldad Katorza,1* Yoav Yinon,1 Chen Hoffmann,2 Shlomo
Lipitz,1 Reuven Achiron,1 Boaz Weisz1 1Obstetrics and Gynecology, 2Radiology, Sheba Medical Center, Tel Hashomer, Israel
Objectives—To determine the prevalence and nature of central
nervous system (CNS) anomalies diagnosed during the third trimester following a normal anatomy scan at 21 to 24 weeks of gestation.
Methods—This was a retrospective cohort study of all pregnant women referred to the fetal medicine unit at Sheba Medical Center
due to fetal CNS anomalies detected at the late second and third trimesters
following a normal anatomy scan at 21 to 24 weeks of gestation. All patients underwent a thorough workup, which consisted of a detailed
anatomy scan, dedicated neurosonography, and amniocentesis as indicated. Fetal magnetic resonance imaging was performed in most patients
to confirm the sonographic diagnosis. Maternal records and sonographic
data of all patients with fetal CNS anomalies were reviewed.
Results—During the study period, 47 patients were diagnosed
with fetal CNS anomalies at a median gestational age of 31.1 weeks
(range, 24–38 weeks) following a normal second-trimester anatomy scan.
The 4 most common anomalies found included brain cysts (19%), mild
ventriculomegaly (15%), absence or dysgenesis of the corpus callosum
(10%), and intracerebral hemorrhage (10%). Other CNS anomalies detected in this group of patients included hydrocephalus, Dandy-Walker
malformation, large cisterna magna, microcephalus with lissencephaly,
craniosynestosis, periventricular pseudocysts, global brain ischemia, cerebellar hypoplasia, and a subependymal nodule.
Conclusions—The fetal brain continues to evolve throughout
gestation; therefore, some of the CNS anomalies can be diagnosed only
during the late second and third trimesters of pregnancy. Consequently, a
late anatomy scan at 30 to 32 weeks of gestation should be considered.
1531347 Fetal Magnetic Resonance Imaging as an Adjunct to Antenatal Ultrasound for Assessment of Fetal Anomalies
Amber Samuel,* Sherelle Laifer-Narin, Christina Herrera,
Lynn Simpson, Russell Miller Obstetrics and Gynecology,
Columbia University Medical Center, New York, New York USA
Objectives—Fetal magnetic resonance imaging (MRI) is used
to enhance diagnosis of fetal anomalies without robust data to support
benefit over ultrasound (US) alone. Our objective was to assess fetal MRI
as an adjunct to conventional diagnostic US when compared to US alone
in a cohort with known postnatal outcomes.
Methods—In a retrospective review from 2003 to 2011 at a tertiary care center, potential cases were identified if MRI was performed
following sonographic concern for a fetal anomaly. Inclusion required
documented neonatal outcomes or postmortem assessments. Diagnostic
accuracy of adjunct MRI was assessed with qualitative statistics.
Results—Of 799 MRIs performed, 406 subjects possessed documented neonatal or pathologic outcomes. MRI agreed with US in 68%
of cases. Overall, MRI confirmed the neonatal diagnosis in 56.4% of cases,
improved the diagnosis in 12.8% of cases, detracted from the diagnosis in
5.9% of cases, and had no benefit in 24.9% of cases. Among individual
anomalies, there were no cases of diaphragmatic hernia, omphalocele,
vein of Galen malformation, or Dandy-Walker complex where MRI correctly changed the ultrasound diagnosis. Findings varied for all other diagnoses (Table 1).
Conclusions—Fetal MRI generally agrees with US performed
at a tertiary care center, which may limit its adjunct diagnostic benefit.
Table 1
MRI
MRI
MRI
Detracts
MRI
Confirms Improves
From
Has No
Diagnosis, Diagnosis, Diagnosis, Benefit,
n (%)
n (%)
n (%)
n (%)
n (%)
60 (15) 20 (33)
10 (17)
8 (13)
22 (37)
14 (4)
11 (79)
1 (7)
1 (7)
1 (7)
10 (3)
2 (20)
4 (40)
0
4 (40)
9 (2)
6 (67)
1 (11)
0
2 (22)
Diagnosis
Multiple anomalies
Ventriculomegaly
Meningomyelocele
Bronchopulmonary
sequestration
Congenital cystic
24 (6)
adenomatoid malformation
Congenital diaphragmatic
69 (17)
hernia
Omphalocele
7 (2)
Vein of Galen malformation 5 (1)
Dandy-Walker complex
5 (1)
16 (67)
2 (8)
3 (13)
3 (13)
66 (96)
0
3 (4)
0
0
0
0
0
0
0
0
1 (20)
0
7 (100)
4 (80)
5(100)
1541099 Fetal Lymphatic Malformations: More Variable Than We
Think?
Beverly Coleman,1,2 Suzanne Iyoob,2 Edward Oliver,1,2*
Teresa Victoria,2 Devon Looney,2 Steven Horii,1,2 Julie Moldenhauer,2 Lori Howell,2 N. Scott Adzick2 1Radiology, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania USA; 2Center for Fetal Diagnosis
and Treatment, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA
Objectives—To evaluate the ultrasound (US) characteristics of
fetal lymphatic abnormalities referred to the Center for Fetal Diagnosis
and Treatment at the Children’s Hospital of Philadelphia. The literature
states that lymphangiomas can be reasonably differentiated from other
masses by the predominance of cystic spaces with multiple septations and
the lack of solid components.
Methods—We performed a database search from September
1997 to August 2012 of all fetal imaging and medical records for cases
where lymphatic malformations other than cystic hygroma were diagnosed or included in the differential. A detailed fetal anatomic survey was
performed to determine mass location, volume, and US texture. Imaging
findings were correlated with the final outcome.
Results—The study population consisted of 73 patients, and 68
cases were correlated with fetal neurologic and/or body magnetic resonance imaging. The mean maternal age was 29 years, and the mean gestational age was 27 weeks 2 days. The location was classified as 46
head/neck/face, 9 axilla/upper extremity, 8 internal abdomen/pelvis, 5
chest/mediastinum, 3 superficial pelvis/back, and 2 lower extremity. The
mean mass volume was 70 mL. The US texture was 40 (55%) multiseptate/cystic, 10 (14%) predominantly cystic with 1 or few septations, 11
(15%) purely cystic, and 12 (16%) mixed with cystic and solid components. Calcifications were reported in 4 cases of mixed masses. These
anomalies are largely isolated and not associated with other structural defects. There were no findings of nonimmune hydrops.
Conclusions—Fetal lymphatic malformations have a variable
range of locations, sizes, and textures. In our series, 31% of masses were
atypical, 4 with calcifications and confused as teratomas. A better understanding of the US features will result in improved diagnostic accuracy.
This may allow for better parental counseling and overall pregnancy management.
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1541459 Fetal Growth Restriction in Pregnancies Complicated by
Isolated Cleft Lip or Palate
Emily DeFranco,1,2* Jessica Smith,1 Paul DeFranco3
1
Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio USA; 2Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio USA; 3Neonatology, Springview Hospital,
Lebanon, Kentucky USA
Objectives—Children with isolated cleft lip and/or cleft palate
havedelayedgrowthduringinfancyandchildhood.Theassociationbetween
fetal growth delay and isolated orofacial clefts has not been definitively ascertained. Few prior studies have aimed to assess the association between
cleftsandintrauterinegrowthrestriction(IUGR)butmayhavebeenlimited
by unaccounted confounding factors and other methodologic constraints.
Methods—In a population-based retrospective cohort study of
5 years (2001–2005) of US birth cohort–infant death data, we identified
913,707 birth records in which cleft lip and/or cleft palate was recorded on
the birth certificate. A variable was created including any case of cleft lip,
palate, or combination of both. There were minimal missing data on cleft
lip/palate (n = 854 [0.6%]). Multivariate logistic regression assessed the
association between IUGR and isolated cleft lip/palate after accounting
for important coexisting risk factors.
Results—There were 1086 cases of cleft lip/palate of 913,707
births reporting this anomaly. The frequency of cleft lip/palate was 0.12%,
which is likely accurately reported given the previously reported frequency
in the population of 1 in 700 (0.14%). Of the 1086 cases of cleft, 252
(23%) were associated with other congenital malformations, leaving 834
(77%) isolated cases of cleft lip/palate for analysis. The frequency of
IUGR <10th percentile (Alexander) with isolated cleft was 24.8% vs 14%
with no anomalies (P < .001; crude odds ratio [OR], 2.0 [1.7–2.3]), and the
frequency of IUGR <5th percentile with isolated cleft was 14% vs 6.6%
in pregnancies with no anomalies (P < .001; crude OR, 2.2 [1.8–2.7]).
However, after adjustment for maternal age, race, marital status, tobacco,
chronic hypertension, diabetes mellitus, and route of delivery, the relative
risk (RR) of IUGR <10th percentile was not substantially increased (adjusted RR, 1.02; 95% confidence interval [CI], 1.01, 1.03), nor was it at
<5th percentile (adjusted RR, 1.04; 95% CI, 1.03, 1.05).
Conclusions—Pregnancies complicated by isolated cleft
lip/palate have a 2-fold increase in the frequency of IUGR at <10th and
<5th percentiles compared to pregnancies without anomalies; however,
the risk does not remain significantly increased once adequate adjustment
for confounding factors is considered.
1539040 Detection of Structural Anomalies in a Basic FirstTrimester Screening Program for Aneuploidy
Bryann Bromley,1,2,3 Thomas Shipp,1,3 Jennifer Lyons,4
Reshama Navathe,5 Yvette Groszmann,1 Beryl Benacerraf1,2,3*
1
Obstetrics and Gynecology, Diagnostic Ultrasound Associates,
Brookline, Massachusetts USA; 2Obstetrics and Gynecology,
Massachusetts General Hospital, Boston, Massachusetts USA;
3
Obstetrics and Gynecology/Radiology, Brigham and Women’s
Hospital, Boston, Massachusetts USA; 4Epidemiology, Boston
University School of Public Health, Boston, Massachusetts
USA; 5Harvard Medical School, Boston, Massachusetts USA
Objectives—To determine if a basic first-trimester screening
program for aneuploidy is useful for the detection of anomalies between
11 and 14 weeks’ gestation.
Methods—This is a retrospective medical record review of all
patients referred to a private ultrasound facility for a nuchal translucency
(NT) measurement between January 1, 2008, and June 30 2012. Transabdominal scans were performed to measure NT and crown-rump length
(CRL). Nasal bone (NB) evaluation was performed if requested. Providers
credentialed in NT/NB by the Nuchal Translucency Quality Review performed all scans. Patients were allotted 30 minutes for the scan, and trans-
vaginal sonography (TV) was performed at the discretion of the sonologist. Patients were included in the study if the fetus was alive and had a
CRL between 38 and 84 mm. Additional anatomic components evaluated
if technically facile included the cranium, stomach, cord insertion, and extremities. Outcome was evaluated by review of the medical record and
the results of a detailed anatomic survey done between 16 and 22 weeks.
Fetal anomalies were categorized as lethal, major, and minor. The category
of anomaly and gestational age at diagnosis (≤14 vs >14 weeks) were
compared.
Results—A total of 9698 NT scans were performed. The mean
maternal age was 32.9 (SD, 4.4) years. Singletons made up 92.5% of the
study group. The mean CRL was 59.6 (SD, 1.2) mm, and the mean NT
was 1.6 (SD, 0.6) mm. An NT ≥3.0 mm was identified in 149 (1.5%), and
TV evaluation was performed in 924 (9.5%). Anatomic surveys were performed on 9099 (93.8%) fetuses at 18 (SD, 1.2) weeks. Anomalies were
detected in 49 (0.5%) fetuses at ≤14 weeks and in 131 fetuses (1.4%) at
>14 weeks. Overall, 45 of 110 (41%) lethal or major anomalies were detected at the time of the NT scan. Two suspected minor abnormalities at
the NT scan were not evident at the anatomic scan.
Conclusions—A basic first-trimester risk assessment scan can
pick up a significant portion of lethal and major anomalies.
Table 1
Anomaly
Lethal
Major
Minor
Total
≤14 wk
12
33
4
49
>14 wk
6
59
66
131
Total
18
92
70
180
1508165 Maternal Serum α-Fetoprotein Does Not Improve the
Detection Rate for Neural Tube Defects in Patients Who
Receive First- and Early Second-Trimester Ultrasound for
a Fetal Anatomic Survey
Ashley Roman,1,2,3* Simi Gupta,1 Nathan Fox,1,2,3 Daniel
Saltzman,1,2,3 Chad Klauser,1,2,3 Andrei Rebarber1,2,3 1Obstetrics
and Gynecology, New York University, New York, New York
USA; 2Maternal-Fetal Medicine, Carnegie Imaging for Women,
New York, New York USA; 3Obstetrics and Gynecology, Mount
Sinai School of Medicine, New York, New York USA
Objectives—Maternal serum α-fetoprotein (MSAFP) is used
to identify patients at high risk for open neural tube defects (ONTDs).
Many centers have started performing anatomic surveys during the first
and early second trimesters in addition to the routine 18- to 20-week scan.
This study evaluates whether MSAFP improves the detection rate for
ONTDs in patients undergoing first- and early second-trimester anatomic
surveys.
Methods—A historical cohort of patients undergoing fetal ultrasound in a single ultrasound practice between May 2005 and August
2011 met criteria for inclusion. All patients were offered nuchal translucency ultrasound with evaluation of the fetal anatomy at 11 to 14 weeks
and an early second-trimester fetal anatomic survey between 15 and 17
weeks. All cases of ONTDs diagnosed in our unit during this interval of
time were identified using ICD-9 codes, and all MSAFP results over the
same time frame were queried. Groups were compared using the Fisher
exact test with P < .05 as significance.
Results—Our unit performed 17,656 nuchal translucency ultrasound examinations and 21,436 early anatomic surveys and sent 11,809
specimens for MSAFP during the study period. Eleven ONTDs were diagnosed by our unit during this time frame (incidence of 0.56–0.67 per
1000). Eleven of 11 ONTDs (100%) were diagnosed by ultrasound; 0 of
11 (0%) were detected after MSAFP screening (P < .0001). The median
gestational age at diagnosis was 12 weeks (range, 11–17 weeks). Seven of
11 cases (64%) were diagnosed during the first trimester; 4 of 11 (36%)
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were diagnosed at the early second-trimester anatomy scan. No cases of
ONTD were diagnosed after 18 weeks’ gestation, and no cases of ONTD
were missed by our unit (sensitivity, 100%).
Conclusions—Ultrasound for a fetal anatomic survey during
the first and early second trimesters detected 100% of ONTDs in our population, with the majority identified in the first trimester. MSAFP was not
useful as a screening tool for ONTDs in the setting of this ultrasound
screening protocol. Given the sensitivity of first- and early secondtrimester ultrasound in detecting ONTDs, physicians may choose not to
offer MSAFP for this indication.
1541097 Novel Insights Into Early Embryonic Demise via 3Dimensional Surface-Rendered Imaging in 107 Cases
David Hartge, Andreas Schroer, Jan Weichert* Division of
Prenatal Medicine, University of Schleswig-Holstein, Luebeck,
Schleswig-Holstein, Germany
Objectives—Modern sonographic imaging techniques such as
3D volumetry will be evaluated for 107 cases of pregnant women with
missed abortions in the first trimester. Special emphasis is put on the impact of additional information and improved visualization of embryonic
and fetal anomalies due to application of newest imaging tools, eg, HD
Live. Additionally, parental acceptance of a more realistic display of the
embryo/fetus in missed abortion is analyzed.
Methods—Between September 2009 and September 2012, 109
pregnancies with a missed abortion during the first trimester were included
in this survey. Using a transvaginal approach, all studies were carried out
with high-resolution 5–9- and 6–12-MHz probes. Postrendering processing of actual and stored volume sets included application of HD Live technology. 2D evaluation was also conducted during the same examination.
Results—Two of 109 cases with a missed abortion were excluded from our study. In 1 case, the parents refused to participate in the
survey. In another case, the 3D volume acquisition was not completed successfully. One hundred seven cases were included in the final evaluation.
The mean gestational age was 70.4 days (range, 44–110 days). Mean
crown-rump length (CRL) was 17.3 mm (2.9–49.9 mm). The difference
between estimated gestational age and sonographic age at evaluation for
missed abortion was 14.4 days (0–40 days). Sufficient sonographic evaluation was possible in 91 of 107 cases (85.0%). Additional information via
3D volume acquisition such as craniofacial deformities, clefts, neural tube
defects, abdominal wall defects, and sirenomelia could be documented in
11 of 107 cases (10.3%), which were not detected by conventional 2D imaging. In 1 of 107 cases, the parents disapproved of the 3D visualization
due to the more realistic presentation.
Conclusions—3D ultrasound in cases of missed abortions can
provide additional information regarding the presence of structural anomalies and may further give hints regarding the timing of embryonic/fetal
demise in early pregnancy. Based on our data, sufficient informational
value is regularly obtained in cases having a CRL >5 mm. In counseling
parents, 3D ultrasound is a useful tool and is generally well accepted.
1536871 Prenatal Sonographic Predictors of Surgery-Treated
Ureteropelvic Junction Obstruction: Which Is the Best
Predictor?
Hadar Mudrik-Zohar,1* Israel Meizner,1,2 Zvi Bar-Sever,1,3
David Ben-Meir,1,4 Miriam Davidovits1,5 1Sackler Faculty of
Medicine, Tel Aviv University, Tel-Aviv, Israel; 2Gynecologic
Ultrasound Unit, Rabin Medical Center, Beilinson Campus,
Petah Tikva, Israel; 3Nuclear Medicine Institute, 4Pediatric
Urology Unit, 5Institute of Pediatric Nephrology, Schneider
Children’s Medical Center, Petah Tikva, Israel
Objectives—Prenatally detected hydronephrosis (HN) with no
evidence of ureter dilatation or bladder anomalies might suggest ureteropelvic junction obstruction (UPJO), which requires postnatal pyeloplasty.
Yet, in the majority of fetuses, the HN is transient and conservatively
treated. Our study aimed to identify prenatal sonographic predictors of
surgery-treated UPJO and their cutoff values.
Methods—This case-control study compared the sonographic prenatal findings of HN-diagnosed fetuses that underwent
pyeloplasty after birth and HN-diagnosed fetuses that needed conservative management only, all treated in Schneider Children’s Medical
Center. We retrospectively evaluated 39 cases of patients who underwent pyeloplasty due to UPJO between 2001 and 2012 and 30 cases of
patients that were diagnosed prenatally with HN and treated conservatively between 2005 and 2012. Prenatal sonographic data for both patient groups were taken from the Gynecologic Ultrasound unit at Rabin
Medical Center. The main sonographic measures we tested were (1)
anterior-posterior diameter (APD) of the affected kidney, (2) parenchymal thickness (PT), (3) calyces dilatation, and (4) renal length. A few
patients had records of only some of the measures.
Results—The prenatal APD dilatation of the surgery-treated
UPJO group (mean, 22.9 mm; SD, 8.7 mm) was higher than the control
group (mean, 14.3 mm; SD, 5.9 mm; P < .001). Furthermore, the PT in the
surgery-treated UPJO group (mean, 5.9 mm; SD, 2.8 mm) was lower than
the control group (mean, 8.1 mm; SD, 2.6 mm; P = .009). Logistic regression reveled that APD was the main parameter significantly associated
with surgery-treated UPJO cases (receiver operating characteristic plot
was 0.79). A possible threshold of 14 mm APD may be used as a cutoff
value of the surgery-treated UPJO group with sensitivity of 77% and specificity of 69%.
Conclusions—APD dilatation was the strongest predictor of
surgery-treated UPJO. PT and renal length also significantly discriminate
the two groups and correlate with APD, only with lower predictive power.
Our findings expand the clinical knowledge in the field of prenatal consultation by highlighting a threshold of APD, which predicts the need for
surgery in prenatally detected HN cases.
1540842 Prenatal Diagnosis and Neonatal Outcomes in Nonimmune
Hydrops: A Comparison of 2 Decades at an Academic Center
Padmalatha Gurram,1* Peter Benn,2 Naveed Hussain,3 Christine Crawford,1 Kisti Fuller,1 Ann Marie Prabulos,1 Winston
Campbell1 1Obstetrics and Gynecology, 2Genetics and Developmental Biology, 3Pediatrics, University of Connecticut,
Farmington, Connecticut USA
Objectives—To evaluate the differences in the maternal characteristics, prenatal ultrasound (US) diagnosis and outcomes of nonimmune hydrops (NIH) delivered between 1990 and 2010.
Methods—We performed a retrospective review of NIH cases
diagnosed antenatally and delivered at our institution. The cases were divided into 2 groups: 1990 to 1999 and 2000 to 2010. Stillbirths and multiple gestations were excluded. Gestational age (GA) at diagnosis, prenatal
US findings, GA at delivery, mode of delivery, birth weight (BW), postnatal diagnosis, length of neonatal intensive care unit (NICU) stay, survival
>28 days, and mortality were compared.
Results—In the 20-year period, there were 19 live-born cases
of NIH (11 cases in the 1990 group vs 8 in the 2000 group). The mean
GA at diagnosis was 2 weeks earlier in the 2000 group (Table 1). Ascites
was the most common US feature in both groups, followed by pleural effusion. Amniocentesis was done in 50% of cases in the 2000 group vs
37.5% in 1990. The GA at delivery was similar in both groups, and BW
was lower in the 1990 group (Table 1). In the 1990 group, 10 of 11 cases
were delivered by cesarean delivery vs 8 of 8 in 2000. The etiologies
were cardiac (27%), idiopathic (27%), genetic (18%), and infectious
(9%) in 1990 vs idiopathic (50%), genetic (25%), and cardiac (12.5%)
in 2000. The average length of the NICU stay for cases that were discharged home alive in the 1990 group (4 of 11) was 28.5 days and in the
2000 group (3 of 8) was 70 days. In the 2000 group, 3 of 8 cases were
transferred to other facilities compared to 1 of 11 cases in the 1990 group
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for further care. There were 6 of 11 deaths in the 1990 group vs 2 of 8
deaths in 2000.
Conclusions—The outcome of NIH cases improved in the later
decade. The commonest etiology continues to be idiopathic.
Table 1. Prenatal and Neonatal Characteristics
Mean GA at diagnosis, wk
Ascites on US, %
GA at delivery, wk
BW, g
Idiopathic etiology, %
Survival >28 d, %
Mortality, %
1990–1999 (n = 11)
31
63
31
2018
27
46
54
2000–2010 (n = 8)
29
75
31
2560
50
75
25
1528272 Qualitative Performance of Fetal Magnetic Resonance
Imaging Compared to Ultrasound in Cases of Multiple
Fetal Anomalies
Christina Herrera,* Amber Samuel, Sherelle Laifer-Narin,
Lynn Simpson, Russell Miller Obstetrics and Gynecology,
Columbia University Medical Center, New York, New York USA
Objectives—Pregnancies complicated by multiple fetal anomalies are a common indication for fetal magnetic resonance imaging (MRI)
as an adjunct to diagnostic ultrasound (US). This study investigated the diagnostic performance of fetal MRI when compared to US alone for the accurate characterization of fetuses with multiple anomalies.
Methods—In a retrospective review from 2003 to 2011 at a single tertiary care center, potential cases were identified if MRI was performed following sonographic concern for multiple fetal anomalies.
Inclusion required documented neonatal outcomes or postmortem assessments. Interstudy reliability between MRI and US was assessed by calculating κ. Diagnostic accuracy of adjunct MRI compared to US alone
was assessed using qualitative statistics.
Results—A total of 121 MRIs were performed due to antenatal sonographic concern for multiple fetal anomalies, of which 60 cases
possessed documented neonatal or pathologic outcomes. The κ for MRI
compared with US was 0.28. The correct diagnosis was secured in 47%
of cases by US and 50% of cases by MRI (Table 1). Nearly all inaccurate
sonographic diagnoses were due to additional postnatal findings (48%).
While MRI was most commonly inaccurate due to additional postnatal
findings (27%), discrepant postnatal findings (3%), discrepant and additional postnatal findings (13%), and false-positive imaging findings (5%)
also contributed significantly to study inaccuracies.
Conclusions—Agreement is poor between MRI and US for the
characterization of fetuses with multiple anomalies. For either imaging
modality, complete and accurate diagnosis of fetal anomalies occurs in
approximately half of cases, with the majority of inaccuracies due to incomplete antenatal characterizations.
Table 1
Accurate diagnosis
Additional anomalies discovered postnatally
Discrepant findings between imaging and
postnatal assessment
Discrepant and additional anomalies
False-positive imaging findings
Study inconclusive
US, n (%)
28 (47)
29 (48)
2 (3)
MRI, n (%)
30 (50)
16 (27)
2 (3)
0
1 (2)
0
8 (13)
3 (5)
1 (2)
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SPECIAL INTEREST SESSION
TUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PM
Hands-on How to Do the Biopsy
Moderator: Dean Nakamoto, MD
After attending this session, participants will be able to describe
prebiopsy preparations, use and have hands-on experience with the techniques of doing biopsies of soft tissue masses, thyroid nodules, breast
masses, the liver, and kidneys, and recognize and manage complications.
SPECIAL INTEREST SESSIONS
TUESDAY, APRIL 9, 2013, 1:30 PM–3:30 PM
Before and After: Case Presentations, Surgical
Findings, and Clinical Outcomes
Moderator: James Shwayder, MD, JD
Adnexal Masses
James Shwayder Obstetrics and Gynecology, University of
Mississippi Medical Center, Jackson, Mississippi USA
This portion of the session will present clinical cases addressing the options for diagnosing adnexal masses. Ultrasound findings
comprising morphology, vascular studies, and 3D will be reviewed.
The presentations will focus on clinical history and ultrasound findings
correlated with surgical outcomes.
recognition of normal outflow tracts in different orientations will increase
the likelihood of identifying fetuses in which these connections are abnormal. Imaging the 3-vessel view can further help distinguish that the
outflow tracts are normal. Vessel size, alignment, arrangement, number, direction of flow, and turbulent flow at the level of the 3-vessel view provide
additional information about the normalcy of the outflow tracts. Given its
high prevalence and significant infant morbidity and mortality, universal
screening for congenital heart disease is warranted. Early detection allows
for an assessment for associated chromosomal, syndromic, or extracardiac abnormalities as well as consideration of pregnancy options and planning for ongoing obstetric and neonatal care. A thorough evaluation of the
outflow tracts can improve the overall prenatal diagnosis of major fetal
heart malformations.
Microbubbles and Drug/Gene Delivery
Hands-on Scanning: Peripheral Nerves of the
Upper Extremity
Moderators: Christy Holland, PhD, and Kai Thomenius, PhD
Moderator: Kenneth Lee, MD
After attending this session, participants will have gained handson experience in scanning the peripheral nerves of the upper extremity.
Live Fetal Cardiac Scanning by the Experts
Moderator: Lami Yeo, MD
Basics of Fetal Cardiac Screening: How to Confirm Normal Outflow
Tracts
Lynn Simpson Obstetrics and Gynecology, Columbia
University Medical Center, New York, New York USA
Although the majority of pregnant women undergo obstetric
ultrasound, only a third to one-half of all major congenital heart defects are
detected prior to birth. The 4-chamber view of the fetal heart can identify
40% to 50% of major cardiac anomalies. The prenatal detection of heart
malformations can be increased to 60% to 80% when views of the right
and left ventricular outflow tracts are also assessed. It is now recommended that in addition to the 4-chamber view, views of the outflow tracts
be evaluated as part of the cardiac screening examination. This has the
potential to increase the identification of conotruncal anomalies that frequently are associated with a normal-appearing 4-chamber view. The
Improving Sonoporation Delivery and Gene Transfection by
Controlling Ultrasound Excitation of Microbubbles
Cheri Deng Biomedical Engineering, University of Michigan,
Ann Arbor, Michigan USA
Microbubble-facilitated disruption of the cell membrane, or
sonoporation, has been exploited for nonviral intracellular delivery of therapeutic agents. However, ultrasound-mediated microbubble activities and
their impact on cells are difficult to control and optimize due to the complex characteristics of ultrasound interaction with microbubbles. These
often result in low delivery efficiency and variable delivery outcome. To
develop sonoporation technique to achieve reproducible, robust delivery
outcomes, we examined the detail characteristics of ultrasound interaction with microbubbles. The goal of our study is to improve ultrasoundmediated intracellular delivery and gene transfection by designing
ultrasound exposure conditions based on the detailed dynamic processes
of ultrasound interaction with microbubbles in the context of their impact
to cells. We performed experiments using both free microbubbles and targeted microbubbles that were attached to a cell membrane via receptor-ligand binding. We identified 3 distinct regimes of ultrasound excitation of
targeted microbubbles characterized by the rate of microbubble collapse
and translational movement (displacement): stable cavitation with minimal displacement, coalescence and translation, and rapid collapse (inertial
cavitation) with minimal displacement. We quantified and correlated the
microbubble dynamics with the resulting membrane disruption, intracel-
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lular delivery, and cell viability. We found that rapid collapse of microbubbles with limited translational movement, typically generated by ultrasound excitations with high acoustic pressure and short duration,
generated the highest delivery efficiency while maintaining high cell viability. Based on characterization of microbubble activities and membrane
disruption, we implemented a 2-pulse ultrasound exposure scheme with
ramped amplitude to improve gene transfection efficiency in mice (aortic)
vascular smooth muscle cells for green fluorescence protein gene transfection. Our results show that rational design of ultrasound exposure parameters can be obtained from microbubble dynamics to improve delivery
outcomes.
Microbubbles and Gene/Drug Delivery: Future Therapeutic Applications of Contrast-Enhanced Ultrasound Imaging
Steven Feinstein Cardiology/Medicine, Rush University
Medical Center, Chicago, Illinois USA
Today, the clinical applications of contrast-enhanced ultrasound
imaging (CEUS) are solely based on diagnostic imaging. It is anticipated
that the future applications of CEUS will provide a paradigm shift in the
field of therapeutics. In fact, CUES as a therapy uses gas-filled microspheres as intravascular indicators and provides unprecedented microvascular access to tissues and organs. Hence, acoustic microspheres are ideal
carrier vehicles for ultrasound-based, site-specific drug/gene delivery. The
basis for devising newer therapeutic options is created by local in vivo
microsphere disruption using externally applied acoustic energy. Based
on data dating to at least to 1995, it appears that the application of therapeutic ultrasound delivery systems has a bright future. The advantages of
using an acoustically medicated system derive from the value of using a
nonviral, mediated system accompanied by low risk/benefit ratios. Leading scientists throughout the world have successfully demonstrated nonviral transduction in a variety of preclinical scenarios. The combined
applications for diagnosis and therapy provide unique opportunities for
clinicians and researchers to image, direct therapy, and monitor individuals during treatment.
Targeted Thrombolysis With Ultrasound and Microbubbles
Thomas Porter Section of Cardiology, University of
Nebraska Medical Center, Omaha, Nebraska USA
Ultrasound-induced cavitation has been explored as a method
of dissolving intravascular and microvascular thrombi in acute myocardial
infarction (STEMI). Ongoing studies are being performed to determine
the type of cavitation required for success and whether longer–pulse duration therapeutic impulses (which sustain the duration of cavitation) could
restore both microvascular and epicardial flow with this technique. In 36
hyperlipidemic atherosclerotic pigs, thrombotic occlusions were induced
in the mid left anterior descending artery. Pigs were then randomized to either (1) ½ dose of tissue plasminogen activator (TPA; 0.5 mg/kg) alone or
the same dose of TPA and an intravenous microbubble infusion with
either (2) guided high–mechanical index (MI) short-pulse (2.0 MI; 5microsecond) therapeutic ultrasound (TUS) impulses or (3) guided 1.0 MI
long-pulse (20 microsecond) impulses. Passive cavitation detectors indicated that the high-MI impulses (both long and short pulse durations)
induced inertial cavitation within the microvasculature. Epicardial recanalization rates at all time points following randomized treatments were
highest in pigs treated with the long–pulse duration TUS impulses (83%
vs 59% for short pulse and 49% for TPA alone; P < .05). Even without epicardial recanalization, however, early microvascular recovery (ST recovery) occurred with both short- and long-pulse TUS impulses (P < .005
compared to TPA alone), and wall thickening improved within the risk
area only in pigs treated with ultrasound and microbubbles. These findings
indicate that although short-pulse TUS impulses transiently improve microvascular flow, long-pulse TUS impulses are required to produce sustained epicardial and microvascular reflow in acute STEMI.
New Horizons in Critical Care Ultrasound
Moderator: Paul Mayo, MD
New Horizons in Critical Care Ultrasound
Michael Blaivas Northside Hospital Forsyth, Cumming,
Georgia USA
Point-of-care ultrasound has undergone tremendous growth in
the last 5 years, and this has heralded multiple advancements in applications and techniques used on critically ill patients. In addition, new equipment available on the market has targeted ultrasound use in the emergency
and critical care settings. Availability of multiple transducer types, highend imaging, and even transesophageal echocardiography has opened the
door for previously unexplored levels of patient evaluation during the most
critical presentations. One of the most exciting is the effect ultrasound has
had on the evaluation, diagnosis, and management of the cardiac arrest
and periarrest states. This presentation will focus on new applications in
point-of-care ultrasound for the care and treatment of the cardiac arrest
and periarrest patient. Current literature and applications including transesophageal echocardiography in point-of-care and intravascular volume
determination for immediate clinical decision making in this critically ill
patient population will be discussed.
Perinatal Malformations of the Head, Face, and Neck
Moderator: Eva Rubio, MD
Perinatal Malformations of the Head, Face, and Neck: Head
Beth Kline-Fath Radiology, Cincinnati Children’s Hospital
Medical Center, Cincinnati, Ohio USA
Ultrasound is an integral part of prenatal care. With regard to the
brain, sonographic imaging offers a rapid noninvasive window. Additional
benefits of this technique are lack of radiation, portability, and low cost.
The ability to use color and Doppler of intracranial vessels is also extremely valuable. Prenatal cranial ultrasound provides information regarding congenital anomalies, masses, and hydrocephalous. Destructive,
vascular, hemorrhagic, infectious, and hypoxic ischemic pathologies are
also demonstrated by this technique. In this lecture, the common prenatal
abnormalities of the brain will be illustrated with ultrasound imaging. Correlation with fetal magnetic resonance imaging will also be provided to
allow the sonographer to improve imaging technique and anatomy. The
ability of prenatal sonography to promptly diagnose these central nervous
system conditions is invaluable in directing fetal treatment and prenatal
counseling.
Perinatal Malformations of the Head, Face, and Neck
Eva Rubio Children’s National Medical Center, Washington,
DC USA
This session will review common, rare, and urgent abnormalities of the head, face, and neck seen in the prenatal and early infant period.
The timing of prenatal as well as postnatal imaging of these lesions, imaging parameters, and current recommendations will be discussed. What
do the surgeons need to know, and what kind of team needs to be assembled for the most challenging cases? How should parents be counseled?
This session will be both didactic and interactive.
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Transplant Imaging
Moderator: Susan Ackerman, MD
Sonographic Evaluation of Liver Transplants
Susan Ackerman Medical University of South Carolina,
Charleston, South Carolina USA
The purpose of this lecture is to discuss the use of ultrasound to
evaluate liver transplants. In addition to normal or expected findings in
the post-transplant patient, complications will also will be discussed.
SPECIAL INTEREST SESSIONS
TUESDAY, APRIL 9, 2013, 4:00 PM–5:30 PM
Abdominal and Lower Extremity Arterial Imaging:
Pitfalls and Misdiagnoses
Hands-on Ultrasound-Guided Vascular Access
Moderator: Jason Nomura, MD, RDMS
Moderator: Jennifer McDowell, MM, RDMS, RT, RVT
This session will review case studies in abdominal and lower
extremity vascular imaging and demonstrate examples of technical pitfalls, artifacts, and misdiagnoses to learn how to prevent them.
In this session, participants will be given a short didactic lecture
on patient preparation, sterile technique, and basics of ultrasound-guided
vascular access and fluid aspiration. This will be immediately followed
by hands-on practice and interactions at various stations with expert faculty to learn and improve on techniques.
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SCIENTIFIC SESSIONS
TUESDAY, APRIL 9, 2013, 4:00 PM–5:30 PM
Basic Science: Tissue Characterization, Part 2
Moderators: Michael Oleze, PhD, James Miller, PhD
1540933 Three-Dimensional In Vivo Prostate Shear Wave Elasticity
Image Reconstruction
Stephen Rosenzweig,1* Mark Palmeri,1 Samantha Lipman,1
Ned Rouze,2 Evan Kulbacki,2 John Madden,2 Thomas Polascik,2 Kathryn Nightingale1 1Biomedical Engineering, Duke
University, Durham, North Carolina USA; 2Duke University
Medical Center, Durham, North Carolina USA
Objectives—Shear wave elasticity imaging (SWEI) and
acoustic radiation force impulse (ARFI) imaging techniques have been
reported to portray cancer and other pathologies as stiffer than the surrounding tissue.1,2 Previous work has shown artifacts in reconstructing
SWEI images due to reflected waves.3,4 In this work, methods for reconstructing SWEI images designed to reduce these artifacts were validated
in phantoms, applied to in vivo data, and compared to concurrently acquired ARFI data.
Methods—Data were collected using a Siemens Acuson
SC2000 and an ER7B transducer (Mountain View, CA) and a transducer
rotation stage. The pulse sequence consisted of rapidly pushing at multiple foci (SSI-type push4) and tracking the resulting displacement using 16
parallel receive beams. The beam sequence was then translated laterally
0.7 mm and repeated across the field of view. The resulting SWEI data
were spatially and temporally aligned to generate an image using high
spatial sampling of the data. Separate left and right wave propagation images were generated along with combining the data via mean and maximum value approaches; these were compared to matched ARFI images in
both calibrated CIRS (Norfolk, VA) phantoms and radical prostatectomy
patients from an ongoing Institutional Review Board–approved study.
Results—The contrast to noise ratios (CNRs) in the phantom
data for the different combined SWEI methods were higher than those for
the individual propagating waves. For example, a 10-mm cylindrical target with a 4:1 stiffness ratio had SWEI image CNR values of 1.65 (left),
1.47 (right), 2.59 (mean), and 3.74 (maximum). We will present data from
all methods in various phantoms in addition to results from prostatectomy
patients, after the whole-mount pathology is registered in 3D to the SWEI
and ARFI volumes.
Conclusions—The high spatial sampling of SWEI data obtained from concurrent acquisition with ARFI data affords opportunities
for reducing SWEI image artifacts and improving the CNR. We are now
applying the algorithms to data from an ongoing in vivo study to detect
pathologies in the prostate.
References
1. Zhai L, et al. Ultrasound Med Biol 2012; 38:50–61.
2. Barr RG, et al. Ultrasound Q 2012; 28:13–20.
3. Rouze N, et al. IEEE Trans Ultrason Ferroelectr Freq Control 2012;
59:1729–1740.
4. Deffieux T, et al. IEEE Trans Ultrason Ferroelectr Freq Control 2011;
58:2032–2035.
1511996 Hashimoto’s Thyroiditis Tissue Characterization and Pixel
Classification Using Ultrasound
Agnieszka Witkowska,1 U. Rajendra Acharya,2,3 Ratna
Yantri,2 Filippo Molinari,4 Witold Zieleznik,5 Justyna Tumidajewicz,5 Beata Stepien,5 Ricardo Bardales,6 Jasjit Suri7, 8*
1
Internal Medicine, Diabetology, and Nephrology, Medical
University of Silesia, Katowice, Poland; 2Electronics and
Computer Engineering, Ngee Ann Polytechnic, Singapore;
3
Biomedical Engineering, University of Malaya, Kuala Lumpur,
Malaysia; 4Electronics and Telecommunications, Politecnico
Torino, Torino, Italy; 5Internal Medicine Practice, Silesia,
Poland; 6Outpatient Pathology Associates, Sacramento,
California USA; 7Global Biomedical Technologies, Roseville,
California USA; 8Biomedical Engineering, Idaho State University, Pocatello, Idaho USA
Objectives—Hashimoto’s thyroiditis (HT) is the most common
type of inflammation of the thyroid gland, and accurate diagnosis of HT
would be helpful to better manage the disease process and predict thyroid
failure. This paper presents a computer-aided diagnostic (CAD) technique
that uses grayscale features and classifiers to provide a more objective and
reproducible classification of normal and HT-affected cases.
Methods—Thyroid images were obtained from 68 normal and
82 patients affected by HT (a total of 150 patients). In this paradigm, we
extracted grayscale features based on entropy, Gabor wavelet, moments,
image texture, and higher-order spectra from the 100 normal and 100 HTaffected thyroid ultrasound images. Significant features were selected
using the t test. The resulting feature vectors were used to build the following 3 classifiers using a 10-fold stratified cross-validation technique:
support vector machine (SVM), K-nearest neighbor (KNN), and radial
basis probabilistic neural network (RBPNN).
Results—Our results show that a combination of 12 features
coupled with the SVM classifier with the polynomial kernel of order 1
and linear kernel gives the highest accuracy of 80%, sensitivity of 76%,
specificity of 84%, and positive predictive value (PPV) of 83.3% for the
detection of HT.
Conclusions—The proposed CAD system uses novel features
that have not yet been explored for HT diagnosis. The technique is noninvasive, cost-effective, fast, and automatic and provides a more objective
and reproducible classification of the thyroid in normal and HT-affected
patients. Even though the accuracy is only 80%, the presented preliminary results are encouraging to warrant analysis of more such powerful
features on larger databases.
Table 1. Classifier Performance Measures
Accuracy, PPV, Sensitivity, Specificity,
TN FN TP FP
%
%
%
%
8
2
8
2
80
83.3
76
84
SVMlinear
SVMpoly 1
8
2
8
2
80
83.3
76
84
8
3
7
2
78.5 82.3
74
83
SVMRBF
KNN
7
2
8
3
75.5 75.6
77
74
RBPNN
8
4
6
2
74
80.3
64
84
FN indicates false-negative; FP, false-positive; RBF, radial basis function; TN,
true-negative; and TP, true-positive.
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1543325 Novel Quantitative Conventional-Frequency Detection of
Cell Death In Vivo With Neoadjuvant Chemotherapy for
Locally Advanced Breast Cancer
Gregory Czarnota,1* Ali Sadeghi-Naini,1 Omar Falou,1 Sara
Iradji,1 William Tran,1 Michael Kolios2 1Radiation Oncology/
Physical Sciences, Sunnybrook Health Sciences Center,
Toronto, Ontario, Canada; 2Physics, Ryerson University,
Toronto, Ontario, Canada
Objectives—We have previously demonstrated that highfrequency ultrasound and spectral analysis can detect cell death. Here we
investigated whether quantitative conventional-frequency (7-MHz) ultrasound incorporating spectral analysis and textural parameters may be used
for the same purpose in vivo in human patients receiving chemotherapy.
Methods—A clinical study was undertaken investigating the
efficacy of ultrasound to quantify cell death in tumor responses with cancer treatment. Patients (n = 60) with locally advanced breast cancer received anthracyline- and taxane-based chemotherapy treatments. Data
collection consisted of acquiring tumor images and radiofrequency data
prior to treatment onset and at 4 times during treatment (weeks 0, 1, 4, 8,
and preoperatively). Digital low-frequency ultrasound data were collected
and sampled with a 15-bit dynamic range using an Ultrasonix-RP device
with a 7-MHz central frequency (3–10 MHz, –6-dB range). Whole-mount
histology was obtained for all samples.
Results—Data indicated that spectral ultrasound changes were
significant at 4 weeks after the start of treatment. Increases of approximately 9 dBr (±1.67) in ultrasound backscatter were observed in patients
who responded to treatment. Patients assessed as responding poorly
demonstrated significantly lower increases (2.3 ± 1.7 dBr). Increases in 0MHz intercept followed similar trends, while increases in spectral slope
were observed from tumor regions demonstrating increases in tissue
echogenicity. Textural analysis of parametric images indicated that features such as homogeneity and contrast could detect responses as early as
1 week after the start of treatment.
Conclusions—This study demonstrates the potential of ultrasound to quantify changes in tumors in response to cancer treatment administration in a clinical setting. This approach may assist in the
customization of cancer treatments facilitating switching from ineffective
treatments to efficacious therapies.
1540914 Nonlinear Modeling of the Canine Liver With Increasing
Hepatic Pressure
Veronica Rotemberg,1* Brett Byram,1 Mark Palmeri,1,2
Michael Wang,1 Kathryn Nightingale1 1Biomedical Engineering, Duke University, Durham, North Carolina USA;
2
Anesthesiology, Duke Medical Center, Durham, North Carolina USA
Objectives—Elevated hepatic venous pressure is associated
with leading causes of death from advancing liver disease and is currently
monitored using an invasive and expensive method. The mechanical behavior of the liver during pressurization is not well understood. In this
work, liver strain during hepatic pressurization was characterized using
successively acquired 3D B-mode volumes and was compared with concurrent shear wave speed (SWS) estimates. An experiment was designed
to elucidate liver nonlinear material properties by using volumetric imaging in unconstrained ex vivo canine livers to estimate the change in liver
strain with pressurization and compare this change in strain with simultaneous SWS estimates. The concurrent strain and SWS estimate information is actively being used to develop a nonlinear material model for
hepatic behavior with increasing portal venous pressure.
Methods—Hepatic pressure was increased stepwise from 0 to
20 mm Hg with 3D B-mode acquisition during each step at 3.2 volumes/s
using a Siemens Acuson SC-2000 scanner and 4z1c matrix array transducer (Mountain View, CA). Displacements were calculated using 3D
cross-correlation and a 2.88 × 0.60 × 0.68-mm tracking kernel.1 Strains
were estimated in a 20 × 12 × 12-mm region of interest (ROI). Six acoustic
radiation force impulse–based SWS estimates in the same ROI were generated at the end of each step.
Results—Increases in SWS and axial strain as a function of hepatic pressure as well as the relationship between axial strain and SWS
estimates were developed. During portal venous pressurization, 10% increases in axial strain corresponded to a 1.25-m/s increase in hepatic SWS
estimates above baseline estimates at 0 to 5 mm Hg.
Conclusions—Increases in axial strain and SWS estimates observed with increasing hepatic pressure support the development of a nonlinear mechanical material model for the pressurized liver. This material
model may lead to noninvasive hepatic pressure characterization using
stiffness metrics.
References
1. Byram BC, et al. 3-D phantom and in vivo cardiac speckle tracking
using a matrix array and raw echo data. IEEE Trans Ultrason Ferroelectr Freq Control 2010; 57:839–854.
1514461 UroImage: A Prostate Tissue Characterization/Classification
System Using Grayscale Features
Gyan Pareek,1 Rajendra Acharya,2,3 Swapna Goutham,4
Vinitha Sree,5 Ratna Yantri,2 Roshan Martis,2 Luca Saba,6
Ganapathy Krishnamurthi,7 Giorgio Mallarini,6 Ayman
El-Baz,8 Shadi Al Ekish,1 Michael Beland,9 Jasjit Suri5,10*
1
Section of Minimally Invasive Urologic Surgery, Warren Alpert
Medical School, Brown University, Providence, Rhode Island
USA; 2Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 3Biomedical Engineering, University of
Malaya, Kuala Lumpur, Malaysia; 4Applied Electronics and Instrumentation, Government Engineering College, Kozhikode,
Kerala, India; 5Global Biomedical Technologies, Roseville,
California USA; 6Radiology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy; 7Mayo Clinic, Rochester, Minnesota USA; 8Bioengineering, Speed School of Engineering,
University of Louisville, Louisville, Kentucky USA; 9Ultrasound, Rhode Island Hospital, Providence, Rhode Island USA;
10
Biomedical Engineering, Idaho State University, Pocatello,
Idaho USA
Objectives—Prostate transrectal ultrasound (TRUS) images can
be easily acquired in real time at lower cost and hence are widely used for
prostate cancer (CaP) diagnosis. However, the prostate regions in TRUS
images are characterized by a weak texture, speckle, short grayscale
ranges, and shadow regions. There is a need for image analysis frameworks that effectively quantify the subtle textural changes in cancerous
and noncancerous TRUS prostate images to accurately detect CaP. In this
work, we have proposed an online computer-aided diagnostic system
called “UroImage” that classifies a TRUS image into cancerous or noncancerous with the help of nonlinear higher-order spectra (HOS) features
and discrete wavelet transform (DWT) coefficients.
Methods—The UroImage system consists of an online system
where 5 significant features (1 DWT-based feature and 4 HOS-based features) are extracted from the test image. These online features are transformed by the classifier parameters obtained using the training data set to
determine the class label of the test image. We trained and tested 6 classifiers. The data set used for evaluation had 144 TRUS images, which were
split into training and testing sets, and cross-validation was adapted for
training and estimating the accuracy of the classifiers. The ground truth
used for training was obtained using the biopsy results.
Results—Among the 6 classifiers, using 3- and 10-fold crossvalidation techniques, support vector machine and fuzzy Sugeno classifiers
presented the best classification accuracy of 97.95% with equally high
values for sensitivity, specificity, and positive predictive value.
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Conclusions—Our proposed automated system uses a novel
combination of DWT and HOS features to adequately characterize
prostate TRUS images. On evaluation, the system presented high accuracy
of 97.95% in detecting CaP. Thus, the preliminary results indicate that the
UroImage system can be an adjunct tool to provide an initial diagnosis for
the identification of patients with prostate cancer.
1540270 Quantitative Ultrasound as an Aid to Differentiate Benign
From Malignant Breast Masses
Haidy Nasief, Ivan Rosado-Mendez, James Zagzebski,
Timothy Hall* Medical Physics, University of Wisconsin,
Madison, Wisconsin USA
Objectives—Ultrasound attenuation (Att), backscatter coefficients (BSC), effective scatterer diameter (ESD), and a scatterer size “heterogeneity index”(HI) give useful insight into the nature of a breast mass.
The purpose of this study was to evaluate the potential of these quantitative features, both individually and in combination, to differentiate benign
from malignant breast masses.
Methods—Radiofrequency echo data from 26 patients scheduled for ultrasound-guided biopsy of suspicious breast masses were obtained, along with conventional grayscale and color flow images. Scans
were done using a Siemens Acuson S2000 equipped with an 18L6 linear
array transducer. Beam-steered acquisitions ranging between –20° to 20°
were obtained in both radial and antiradial planes projecting through the
mass. Att and BSC within masses were measured using the reference
phantom method. ESDs were estimated using the BSC vs frequency data
and a Gaussian form factor. HI was characterized using the SD among the
ESD estimates (ignoring correlations among them). Isotropic features of
the masses were studied by computing power law fits of Att vs frequency
at each beam-steering angle. Combinations of quantitative ultrasound parameters were examined with a Bayesian classifier to estimate those with
the strongest influence on characterization.
Results—The mean Att in dB/cm-MHz was slightly higher for
carcinomas (1.3 ± 0.7) than fibroadenomas (1.1 ± 0.5), the average value
of the ESD was smaller for carcinomas (83.1 ± 9.8 µm) than for fibroadenomas (97.8 ± 13.1 µm), and carcinomas exhibited lower HI than
fibroadenomas. Surprisingly, both tumor types exhibited a certain degree
of anisotropic behavior. However, considerable overlap exists in backscatter and attenuation properties of benign and malignant masses. Using only
pairs of parameters to classify the disease type performed relatively poorly,
but the performance of a Bayesian classifier combining 3 parameters (Att,
ESD, and HI) was cautiously encouraging (all classified correctly but on
a very limited data set).
Conclusions—Att, ESD, and HI show promise for characterizing breast masses. Very promising results are possible using combinations of these 3 parameters.
1536102 Stochastic Hidden Markov Model–Based Filtering
Algorithm for Tracking Shear Waves Through Disparate
Media in Electrode Vibration Elastography
Atul Ingle,1* Tomy Varghese1,2 1Electrical and Computer
Engineering, 2Medical Physics, University of Wisconsin, Madison, Wisconsin USA
Objectives—Much research effort in quantitative ultrasound
elastography has been directed toward methods for setting up shear waves
in tissue and modeling wave propagation characteristics. However, data
processing has been mostly limited to using off-the-shelf function-fitting
algorithms. The present work proposes a specialized noise-filtering algorithm to improve boundary delineation while reducing the risk of excessive smoothing.
Methods—A shear wave pulse traveling through dissimilar
media is assumed to have constant velocity while in the same medium,
whereas its velocity changes abruptly when it crosses an interface. Ultra-
sound displacement estimates are used to get the time of arrival (TOA) of
the wave pulse at different locations. The noiseless TOA plot is assumed
to be piece-wise linear with unknown transition points. The noisy data are
described using a hidden Markov model whose hidden states are the noiseless TOA values and observed states corrupted by Gaussian noise. A particle filter is then used to unravel the hidden states. An electrode vibration
elastography phantom is used, which consists of 3 different media. A needle bound to an inclusion in the phantom and attached to an actuator is
used to set up shear waves.
Results—Visual boundary delineation is improved because this
algorithm uses probabilistic prior information of wave pulse propagation.
Mean shear wave velocity estimates are within 1 m/s of those obtained
using a commercial shear wave imaging system.
Conclusions—Model-based algorithms have a potential to significantly improve results in shear wave elastography quantitatively in
terms of estimates of mechanical properties and qualitatively in terms of
the visualization of stiffness images. (Supported by National Institutes of
Health grants R01CA112192-05 and R01CA112192-S103.)
Table 1
Shear Wave Velocity, m/s
Young’s Modulus, kPa
Mechanical
ROI
EVE
SSI
EVE
SSI
Testing
Inclusion
3.8 ± 2.2 2.8 ± 1.1 57.2 ± 70 24.2 ± 5.8 54.4 ± 0.1
Partially ablated 2.0 ± 0.2 2.3 ± 0.8
11.9 ± 2.6 13.3 ± 3.5 21.5 ± 0.3
Background
1.3 ± 0.2 1.3 ± 0.4
5.0 ± 1.9 4.8 ± 0.5 3.7 ± 0.1
EVE indicates electrode vibration elastography; ROI, region of interest; and SSI,
supersonic shear imaging.
1540426 Viscoelastic Strain Response Ultrasound Assessment of Serial Changes in the Viscoelastic Property and Composition
of Human Dystrophic Muscle In Vivo
Mallory Scola,1 Melissa Caughey,2 Diane Meyer,3 Regina
Emmitt,3 James Howard,2,4 Manisha Chopra,4 Caterina
Gallippi1* 1Joint Department of Biomedical Engineering,
2
Medicine, 3Physical and Occupational Therapy, 4Neurology,
University of North Carolina, Chapel Hill, North Carolina USA
Objectives—In Duchenne muscular dystrophy (DMD), where
muscle tissue undergoes necrosis and is replaced by fat and collagen, delineating the complex and poorly understood disease process and monitoring responses to novel therapies may be facilitated by imaging muscle
viscoelasticity. Viscoelastic strain response (ViSR) ultrasound is a method
for quantitatively evaluating the relaxation time constant, τ, in the Voigt
model. The objective of this work is to demonstrate ViSR’s clinical relevance to monitoring dystrophic muscle degeneration over time. We hypothesize that ViSR ultrasound detects changes in percent fat/necrosis
composition in DMD muscles that correspond to altered physical performance.
Methods—ViSR ultrasound was performed on a 5-year-old boy
with DMD at baseline and at 4-month follow-up using a Siemens Acuson
Antares imaging system equipped for modifiable beam sequencing and a
VF7-3 transducer. The acquired ViSR data were processed to calculate τ,
and parametric 2D ViSR τ images were rendered. Fat/necrosis composition was calculated as the percent muscle area with ViSR τ values above
an empirically determined threshold. Within 1 hour following each imaging episode, the boy underwent standardized timed function tests. ViSR
outcome was compared to physical performance.
Results—See Table 1.
Conclusions—ViSR ultrasound detected a 39% increase from
baseline to 4-month follow-up in fat/necrosis composition in the rectus
femoris (RF), a 5% decrease in the sartorius (SART), and a 7% increase
in the gastrocnemius (GAST), which is consistent with expected phenotypic variation in these muscles for a 5-year-old boy. The ViSR change
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was associated with a 39% increase in time to standing, a 13% decrease
in distance walked in 6 minutes, and a 23% increase in time to walk 30 ft.
These data suggest the relevance of ViSR ultrasound as a noninvasive biomarker for monitoring dystrophic muscle degeneration.
Table 1. Serial ViSR and Physical Testing Outcomes
ViSR % Fat/Necrosis
Time Point
Baseline
RF SART GAST
29.2 7.1 19.8
4-mo follow-up
40.6 6.7
21.1
Physical Testing
Time to
Standing
6-min
(5×)
Walk
7.91 s 1488 ft,
0 falls, 0 rests
10.96 s 1300 ft,
1 fall, 0 rests
30-ft
Walk
4.19 s
5.17 s
1506729 Prostate Cancer Ultrasound–Magnetic Resonance Imaging
Fusion Cybernetic Biopsies
Robert Bard Biofoundation, New York, New York USA
Objectives—To show that 3D ultrasound computer fusion with
magnetic resonance imaging (MRI) improves image cybernetic-guided
biopsies of the prostate.
Methods—Eleven patients with elevated prostate-specific antigen and abnormal sonographic and MRI findings were scanned with a cybernetic ultrasound system that fused the image of the MRI onto the
sonogram, creating a template for biopsy. Targeted biopsies were performed
based on image guidance. Twelve cores were obtained on each patient.
Results—Gleason grade 3 (low grade): 72 of 87 cores were
positive for cancer. Gleason grade 4 (medium): 41 of 45 cores were positive for cancer
Conclusions—Ultrasound-MRI computer image-guided fusion
biopsies improved cancer detection to 92% for Gleason 4 tumors and 81%
for Gleason 3 cancers.
Education and Training
Moderator: James Pennington, RDMS
1540985 Enhancing Ultrasound Education Through Volunteer
Participation in Cardiac Screening
Mason Shieh,* Suzanne Klaus, Carter English, Stacy Hata,
Bassil Aish, Uthara Mohan, J. Christian Fox University of
California, Irvine, Yorba Linda, California USA
Objectives—To develop medical student sonography skills
through volunteer involvement in cardiac screening on local athletes for
hypertrophic cardiomyopathy (HCM).
Methods—University of California, Irvine, medical students
were recruited and trained to obtain cardiac ultrasound images to detect
HCM in local high school athletes. HCM ultrasound training involved
watching an instructional video and up to 2 hours of supervised hands-on
ultrasound use. Students had unlimited access to an ultrasound machine for
nonsupervised practice.
Ten Orange County, California, high schools and junior colleges hosted the ultrasound cardiac screening team of 5 to 12 medical students and 1 to 3 supervising physicians as part of student athlete physical
events. An average of 150 student athletes were scanned during each 4hour screening. For each athlete, a medical student obtained 2-second
video clips of parasternal long and parasternal short cardiac views. From
the parasternal short view, apical to the mitral valve, the muscular ventricular septum and the left ventricular wall were monitored in motion
mode (M-mode) and were measured in systole and diastole on a still Mmode image. The recorded ultrasound videos and images were reviewed
by a pediatric cardiologist after the screening. Medical students were asked
to complete a brief survey about their participation.
Results—Twenty-five medical student volunteers and 5 physicians obtained cardiac ultrasound data for more than 1500 young athletes
in Orange County over a 4-month period. The incidence of findings is
pending final review by the research team pediatric cardiologist, who determined 67% to 74% of student-performed cardiac scans adequate for
HCM assessment. Students reported increased confidence in obtaining
specific cardiac views quickly, using extensive features of the ultrasound
machine, and teaching the screening process to other students.
Conclusions—Student participation in public ultrasound screening provides a public service and enhances student skills and confidence.
1536499 State of Ultrasound Education: A National Survey of
Medical Schools
David Bahner,1* Nelson Royall,2,3 David Way,1 Claudia Ranninger,4 Ellen Goldman,5 Yiju Liu4 1Emergency Medicine,
Ohio State University College of Medicine, Columbus, Ohio
USA; 2Surgery, Orlando Health, Orlando, Florida USA; 3College of Medicine, University of Central Florida, Orlando,
Florida USA; 4Emergency Medicine, George Washington
University Medical Center, Washington, DC USA; 5Human and
Organizational Learning, George Washington University,
Washington, DC USA
Objectives—Ultrasound education is rapidly becoming a component of the curricula at medical schools across the United States. The
teaching of focused ultrasound at earlier levels of training seems to be a
byproduct of increased use of ultrasound in patient care. Early efforts to
introduce ultrasound training in the undergraduate medical education
(UGME) curricula have ranged from short workshops to full vertical integration. The purpose of this study was to profile the current landscape
of ultrasound education in US medical schools.
Methods—We developed a 9-item survey provided to the 135
Liaison Committee on Medical Education–accredited US medical schools.
Curriculum deans were asked to report how, when, and for what purpose
ultrasonography was taught to students. Additional items asked for opinions about how and when ultrasonography should be taught and about
barriers to its inclusion in the UGME curriculum.
Results—We received 82 surveys for a response rate of 61%.
While a majority (62%) of respondents reported that ultrasound is taught
at their medical school, only 16% reported it as a priority. More schools
teach ultrasound at the clinical (56.1%) rather than preclinical (47.6%)
level of training. More than half (52.4%) teach ultrasound at more than 1
level. The primary purpose for ultrasound at the preclinical level was as a
tool for teaching science (57.3%). The primary purpose for ultrasound at
the clinical level was to teach scan interpretation (45.1%). Seventy-nine
percent of the respondents believe that ultrasound training should be integrated into existing UGME curricula.
Conclusions—Focused ultrasound education is becoming more
prevalent in US medical schools. We found that most schools have integrated ultrasound education into their UGME curricula. Despite general
acceptance of the benefits of focused ultrasonography, further efforts to define the scope and sequence of teaching ultrasound at the UGME level are
necessary.
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1443469 Role of Spatial Ability as a Possible Ability Determinant in
Skill Acquisition for Sonographic Scanning
Douglas Clem,1* Brad Curs,2 Joe Donaldson,2 Sharlette
Anderson,1 Moses Hdeib1 1Cardiopulmomnary and Diagnostic Sciences, 2Educational Leadership and Policy Analysis,
University of Missouri, Columbia, Missouri USA
Objectives—Spatial ability refers to an individual’s capacity to
visualize and mentally manipulate 3D objects. Since sonographers manually manipulate 2D and 3D sonographic images to generate renderings
of anatomic structures, it can be assumed that spatial ability is an ability
determinant for understanding and producing these medical images. Using
Ackerman’s theory of ability determinants of skilled performance as a
conceptual framework, this study explored the relationship of spatial ability and learning sonographic scanning.
Methods—Beginning sonography students from 3 different
types of educational institutions were administered a spatial abilities test
prior to their initial scanning lab coursework. The students’ spatial test
scores were compared with their scanning competency performance scores
after the first scanning competency test and then to the overall average of
the competency scores for the 2 semesters. The spatial ability test was
again administered after the 2-semester learning period to see if the students’ spatial ability had increased. Additionally, the role of spatial ability
and student retention was explored.
Results—A significant relationship between the students’ spatial ability test scores and their scanning performance scores was found
after the first scanning competency (r = 9.46; P <.05) and slightly increased when averaging all competency scores throughout the learning
period (r = 0.49; P < .05). A moderate increase in the spatial ability of the
students was also found. Incoming grade point average was found to be
more predictive of the students’ scanning scores than spatial or ACT test
scores. No relationship was found for spatial ability as being predictive of
student retention.
Conclusions—Spatial ability is an important ability determinant for student achievement in sonographic scanning and may be an appropriate additional component of admissions data to be used in selecting
candidates for admission to sonographic programs across the country. It is
also appropriate for identifying low–spatial ability students who may require extra time for practice and/or additional instruction and remediation
for success.
1539296 Daily Ultrasound Image Review Provides No Benefit Over
Weekly Review for Physicians Learning Point-of-Care
Ultrasound
Romolo Gaspari Emergency Medicine, University of Massachusetts, Worcester, Massachusetts USA
Objectives—Point-of-care ultrasound programs perform routine image review for educational purposes. At some academic centers,
this review is used to improve both image quality and accuracy of image
interpretation through feedback to the physician sonographers. Due to staff
limitations, most programs review their images weekly. We hypothesize
that more frequent quality assurance would produce more accurate interpretation and image quality.
Methods—We conducted a prospective study comparing 1 year
of weekly image review and 1 year of daily image review. During both
time periods, ultrasound images were reviewed in a standardized fashion
with data entered into an electronic database at the point of image review.
Image quality was assessed using an 8-point scale from 1 (poor image
quality) to 8 (excellent image quality). Interpretation was assessed as
agreement with an expert reviewer for the presence of a primary finding.
Physicians performing image review had a minimum of 3 years of experience following emergency ultrasound fellowship. All information from
the review was e-mailed to the physician sonographer within a few hours
of the review. Comparison between groups was performed using the Student t test or χ2 where appropriate.
Results—Ninety-six physicians participated in the first phase of
the study (weekly review) and 104 in the second phase (daily review).
A total of 21,078 ultrasound examinations were performed during both
study periods with 9830 performed during the first phase and 11,248 performed during the second phase of the study. When comparing weekly vs
daily, there was a statistical improvement in imaging quality for cardiac
(5.3 vs 5.5; P = .02), gallbladder (5.9 vs 6.2; P = .0002), lower extremity
duplex (5.6 vs 6.0; P = .0001), and renal (6.2 vs 6.5; P = .0002). There was
no difference in imaging quality for aorta, focused assessment with sonography for trauma, soft tissue, or endovaginal uterus. There was an improvement in interpretation when comparing soft tissue (8% vs 4%; P =
.009) but no improvement in other ultrasound types.
Conclusions—Implementation of a daily quality assurance review improved image quality and interpretation when compared to weekly
review, but the differences were not clinically significant.
1538080 Implementation and Assessment of a Formal Curriculum
for Bedside Ultrasound Training
Elizabeth Turner,1* Angela Allen,2 J. Christian Fox,3 Mark
Rosen,4 Craig Anderson3 1Pulmonary and Critical Care,
University of California, Los Angeles, California USA;
2
University of California, Irvine, Irvine, California USA;
3
Pulmonary and Critical Care, 4Emergency Medicine, University of California, Irvine, Orange, California USA
Objectives—Training programs for bedside ultrasound (US)
are widespread, but few have been evaluated for efficacy. This study
assessed a curriculum for teaching bedside US to physicians (MDs). We
hypothesized that a formal training program would lead to greater confidence, knowledge, and skills as compared to apprentice-based learning
and similar to expert training paths.
Methods—A program that incorporated e-learning paired with
hands-on training by experts was administered to “simulation-based learners” (SBLs), MDs with no formal training in bedside US. The SBLs also
completed a survey of attitudes and confidence before and after training.
Confidence, knowledge, and skills in bedside US were measured. The survey and test results of the SBLs were compared to the scores of “expert”
(EX) subjects, trained emergency MDs, and “traditional learners” (TL),
critical care MDs trained via an apprentice model. Both comparison
groups took the e-learning test and the survey but did not participate in
the study curriculum.
Results—There was a significant difference in the self-reported
level of prior training between groups (SBL, 2.8; TL, 3.7; EX, 4.1; scale
of 1–5; P = .02*), but there was no difference in interest level or perceived
importance of bedside US. The study curriculum was successful in training subjects as demonstrated by scores that exceeded the comparison
groups in the cardiac and pulmonary courses (cardiac SBL, 79%; TL,
73%; EX, 62%; P = .001*; pulmonary 84%, 75%, 72%; P = .02*). The
SBLs gained confidence in overall skills, while both comparison groups
lost confidence after taking the test (P < .00005*); however, the SBLs
gained confidence in areas of US not presented during the curriculum (abdomen, P = .0002*; miscellaneous, P = .005*).
Conclusions—The SBL curriculum produces comparable or
higher knowledge scores and confidence in each area of US vs comparison groups. However, there is a risk of overgeneralization of confidence
that highlights the importance of quality assurance and supervision in bedside US training programs. This method requires only 14 weeks to achieve
scores equal to or superior to other paths that span 2 to 3 years, and this
has implications for widespread dissemination of such a program.
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1428470 Ultrasound Knowledge and Image Interpretation Gains by
Students on Emergency Medicine Rotation
Uche Blackstock,* Jaclyn Munson, Nina Yeboah, Demian
Szyld Emergency Medicine, Bellevue Hospital/New York University Medical Center, New York, New York USA
Objectives—Bedside ultrasound (BUS) competency is considered integral to emergency medicine (EM) practice, and EM residencies
require BUS training. However, medical students are rarely formally
taught BUS. We sought to develop and evaluate a BUS curriculum for
medical students on their EM rotation.
Methods—We prospectively enrolled a convenience sample of
26 medical students (second year, 8 [30.8%]; third year, 11 [42.3%]; and
fourth year, 7 [26.9%]) on their EM rotation. Students completed a 33–
multiple-choice question Web-based pretest assessing knowledge of
physics (Ph; 17 items [51.5%]) and image interpretation (Im; 16 items
[49.5%]). On pretest completion, participants viewed video tutorials covering (1) Ph, 2) focused assessment with sonography for trauma, and (3)
ultrasound-guided vascular access. Next, participants attended a 3-hour
hands-on BUS session covering the tutorial topics. Subsequently, participants completed a Web-based posttest, containing identical questions as
the pretest. To validate results, a sample of 15 EM residents took the same
Web-based posttest (5 postgraduate year 1 [PGY-1, 33.3%]; 3 PGY-2
[20%], 5 PGY-3 [33.3%], and 2 PGY-4 [13.3%]) We performed a withingroup analysis of participants’ pretest and posttest performance and between-group analysis as compared to the EM residents.
Results—The students’ pretest mean score was 21.6/33 (65.6%;
SD, 11.1%) made up of a Ph mean score of 11.5/17 (67.9%; SD, 14.1%)
and an Im mean score of 10.1/16 (63.2%; SD, 15.6%). The students’
posttest mean score was 28.4/33 (86.3%; SD, 9.35%), with a Ph mean
score of 15.0/17 (88.0%; SD, 10.8%) and an Im mean score of 13.4/16
(84.1%; SD, 12.8%), corresponding to an overall effect size of d = 1.7
(95% confidence interval [CI], 1.1, 2.3), Ph effect size of d = 1.5 (95% CI,
0.9, 2.0), and Im effect size of d = 1.2 (95% CI, 0.7, 1.7). There were no
statistically significant differences between students’ and residents’ posttest
scores (P = .47) or in any subcategory (Ph, P = .13; Im, P = .93).
Conclusions—A standardized formal curriculum in BUS significantly improved medical students’ Ph knowledge and ability to interpret ultrasound images. Medical students performed as well as a sample
of EM residents.
1540627 Enhancing Third-Year Medical Student Primary Care
Clerkships With Handheld Ultrasound
Mary Elizabeth Poston,1 Duncan Howe,2* Victor Rao,2
Richard Hoppmann,2 Chung Yoon1 1Internal Medicine,
2
Ultrasound Institute, University of South Carolina School of
Medicine, Columbia, South Carolina USA
Objectives—Future physicians may be better prepared to provide safer, higher-quality patient care if point-of-care ultrasound (US) is
included in the medical school curricula. We piloted a handheld US curriculum for third-year medical students. The primary objective was to determine students’ ability to learn to perform and interpret point-of-care US
images of the heart and assess global heart function. Secondary objectives
included determining patterns of use (number/types of scans performed,
indications for scans, and impact on patient management) and assessing
impact on student learning.
Methods—Fifty-four third-year medical students each received
handheld US for 22 weeks during the M3 year (8 weeks each for internal
medicine and pediatrics, 6 weeks for family medicine). During the M1
and M2 years, these students had previously been taught cardiac and abdominal scanning techniques with laptop US on live patient models. During each clerkship, students received didactic lectures on the use of the
device and were instructed to view Web-based modules on global heart
function assessment. Additional Web-based modules on other US-appro-
priate scans were also available. Students received hands-on instruction at
least once per clerkship using standardized patients. Students were instructed to save at least 1 cardiac and 2 other images and to record the
type, indication, and impact of scans.
Results—Students submitted information on patterns of use and
pathology evaluated for 305 cardiovascular (heart/inferior vena cava [IVC]),
131 abdominal, 97 nonobstetric genitourinary, 9 lung, and 6 obstetric scans.
In an end-of-the-year objective structured clinical examination, M3 students
demonstrated the ability to obtain images of the heart (parasternal long-axis
view) as well as IVC and comment on global heart function and volume
status. In end-of-year surveys, students stated that their ability to recognize,
understand, and manage patient problems improved with US, but lack of
US-trained faculty to supervise was a major limitation.
Conclusions—M3 students with some prior experience can
learn to assess global heart function with handheld US. Students felt that
understanding of patient pathology and management was improved. Lack
of trained faculty is a barrier to this curriculum.
1541489 Cloud Documentation and iPad Telesonography From a
Teaching Hospital in the Andes: A Culturally Competent
Model for Obstetric Ultrasound Education, Quality Assurance, and Practice Improvement in Remote Ecuador
John Rodney,1* Erin Dooley,2 John Simmons,1 Matthew
Horning,3 Kelly Arnold,4 William Rodney2 1Family Medicine, Texas A&M Health Science Center, Bryan, Texas USA;
2
Surgical Family Medicine, Obstetrics, Medicos Para la Familia, Memphis, Tennessee USA; 3Family Medicine, St Luke’s
Hospital, Ashland, Wisconsin USA; 4Family Medicine, University of Tennessee, Chattanooga, Tennessee USA
Objectives—To create and implement a Spanish language–
based obstetric ultrasound curriculum and record-keeping system by creating a cloud-enhanced iPad application as well as a textbook and lecture
series translated into Spanish.
Methods—Using AIUM guidelines for obstetric and gynecologic ultrasound, we developed a cloud-based iPad application to address
the educational and data storage needs of a geographically isolated teaching hospital in the mountains of remote Ecuador. After a brief ultrasound
seminar that included Spanish language–based lectures, texts, and demonstrations, the investigators used the iPad application to remotely monitor
the performance and documentation of obstetric ultrasound examinations
by family medicine trainees and physicians over a 6-week period.
Results—We successfully addressed the educational and information management needs of family medicine trainees and physicians
in an isolated Spanish-speaking teaching hospital in remote Ecuador.
Conclusions—Cloud-enhanced tablet technology is a feasible
means of overcoming geographic and cultural barriers for the purposes of
ultrasound education, quality assurance, and practice improvement for
family medicine trainees and physicians practicing in remote, resourcelimited locations.
General and Abdominal Ultrasound
Moderator: Abid Irshad, MD
1536712 European Federation of Societies for Ultrasound in Medicine
and Biology Guidelines on the Clinical Use of Elastography
David Cosgrove,1* Christoph Dietrich,2 Fabio Piscaglia3
1
Imaging Sciences, Imperial College, London, England; 2Gastroenterology, S. Orsola-Malpighi, Bologna, Italy; 3Medicine,
Caritas Krankenhaus, Bad Mergentheim, Germany
Objectives—Elastography has emerged as a clinically useful
addition to conventional ultrasound in many diagnostic applications. How-
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ever, there is a need to improve standards of practice and interpretation as
well as to standardize terminology.
Methods—A steering committee commissioned experienced
European users to submit sections of guidelines along the lines of those
previously published for contrast-enhanced ultrasound.1,2 An introductory section on the basic principles was followed by sections covering
parts of the body in which elastography is widely used, including the liver,
the breast, endoscopic uses, the bowel, the prostate, the thyroid, and the
musculoskeletal system.
Results—The basic principles section aims to improve understanding of clinical elastography by synthesizing the underlying principles of the 2 most commonly used forms: strain and shear wave
elastography. Each clinical section contains a survey of the literature,
especially where there are meta-analyses, and practical advice on the
performance and interpretation of elasticity examinations. The edited
document is to be submitted to the European Journal of Ultrasound (Ultraschall in der Medizin) with a target date of January 2013.
Conclusions—It is hoped that the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines on
elastography will be as useful as the contrast-enhanced ultrasound guidelines in improving understanding and clinical practice. The contributions of
the EFSUMB Elastography Guidelines Team are gratefully acknowledged.
References
1. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinical practice recommendations for contrast-enhanced ultrasound
(CEUS): update 2008. Ultraschall Med 2008; 29:28–44.
2. Piscaglia F, Nolsoe C, Dietrich CF, et al. The EFSUMB guidelines and
recommendations on the clinical practice of contrast-enhanced ultrasound (CEUS): update 2011 on nonhepatic applications. Ultraschall
Med 2012; 33:33–59.
1540689 Implementation of Bedside Ultrasonography Within an
Internal Medicine Faculty and Residency: The IMBUS
Program
David Tierney,* Terry Rosborough Medical Education,
Abbott Northwestern Hospital, Minneapolis, Minnesota USA
Objectives—Describe in detail and provide a rationale for a
curriculum, structure, and successful implementation of an internal medicine bedside ultrasound (IMBUS) program in a residency program and
its faculty.
Methods—Design: Prospective cohort study in an internal
medicine (IM) residency program at a private academic 700-bed tertiary
care center. Participants: 33 residents and 13 full-time faculty members
without significant prior ultrasound experience. Intervention: (1) Development of an IM ultrasound curriculum to maximize sensitivity/specificity of our routine physical exam as well as critical time sensitive
diagnoses; (2) overlap training method using top-down and bottom-up
methodologies; (3) 35-hour “boot camp” including didactic, hands-on
model-based, and simulator-based training; (4) bedside hands-on training
with faculty mentors until the trainee meets a prespecified exam count in
each component and is deemed competent in that exam area; (5) ongoing
mentored and remotely submitted/reviewed images until adequate technical and interpretive sensitivity/specificity are obtained; (6) final test-out
using bedside and simulator-based summative evaluation prior to certification; and (7) a robust ongoing quality assurance system. Measurements:
Comparative effectiveness of multiple implementation strategies; time to,
variation in, and predictive factors of competence in each exam component; clinical impact of chosen components on patient outcomes; and effect of implementation on resident/faculty work flow, efficiency, and job
satisfaction.
Results—We describe in detail and rigorously critique a full ultrasound curriculum and implementation strategy for an IM residency.
Thirty IM residents and 12 faculty members were trained using the
IMBUS program. Learning curves for each ultrasound exam component
have been established. We are analyzing multiple outcomes, including
competency learning curves, skill decay, patient outcomes and experience,
and physician impact of bedside ultrasound.
Conclusions—We hope that by describing in detail our curriculum, methods, and learning, we can help other residency programs
implement bedside ultrasound in an efficient, focused, evidence-based,
politically aware, and impactful manner.
1506540 Prostate Cancer Responses to Testosterone and Growth
Hormone
Robert Bard Biofoundation, New York, New York USA
Objectives—Hypogonadal patients with low-grade prostate
cancer are now treated with testosterone +/– growth hormone. It has been
established that high vascular density indicates a high-grade tumor. Our
study was to observe Doppler sonographic vessel density imaging in
known cancer sites to predict aggressive changes and arrest testosterone
and or growth hormone supplementation.
Methods—Sixty-three patients treated with testosterone having low-grade (Gleason 6) disease were followed over a 3-year period.
The vessel index was assessed on sonography by 3D histogram analysis
and by dynamic contrast-enhanced magnetic resonance imaging (DCEMRI). Follow-up biopsies were obtained shortly after imaging studies,
which occurred at 6-month intervals for 3 years on patients with prostatespecific antigen (PSA) rises. Nineteen of 63 patients were concomitantly
taking growth hormone formulations.
Results—Forty-one of 63 testosterone patients had no increase
in PSA or neovascularity at 6, 12, 24, and 36 months. Three of 63 patients
had increased PSA and vessel density at 6 months. Biopsy confirmed
Gleason 4+3 disease in 1 patient and Gleason 3+4 in 2 others. Testosterone
was discontinued. One of 19 patients taking testosterone and growth hormone showed increased PSA at 6 months. Biopsy showed Gleason 3+4.
Testosterone and growth hormone were discontinued. None of the studied
group developed increased vessel densities after the initial 6-month period.
Conclusions—Vessel density sonographic indexing and DCEMRI analysis correlated well with the biochemical response to testosterone/growth hormone therapies. There was high correlation with
histologic findings. Vascular density increases may signal the need to discontinue hormone replacement therapies. Vascular density stability in the
face of rising PSA most likely indicates progression of benign hyperplasia with increased prostate glandular volume.
1540891 Liver Sonography Is Predictive of Liver Steatosis; However,
the Severity of Fatty Liver on Sonography Does Not Correlate With the Presence of Steatohepatitis
Roberta diFlorio,* Robert Harris, David Kim, Eric Goodman,
Alex Spinosa, Megan Murphy Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA
Objectives—The spectrum of nonalcoholic fatty live disease
(NAFLD) ranges from bland steatosis to cell injury and inflammation
(steatohepatitis or nonalcoholic steatohepatitis [NASH]) to fibrosis/cirrhosis. End-stage disease is associated with increased risk of hepatocellular carcinoma (HCC). Patients with NASH are far more likely to progress
to fibrosis than patients with simple steatosis. Currently, liver biopsy is
considered the gold standard for diagnosis of NAFLD and for differentiating steatosis from NASH. However, there is significant variability in
liver biopsy due to the error of a small sample size of a heterogeneous
process. A noninvasive marker of NAFLD would allow detection of global
disease status and allow stratification of risk for the development of fibrosis. This would permit early drug therapy and allow for surveillance of
cirrhosis complications and HCC. Ultrasound findings that would differentiate simple steatosis from NASH would be helpful in diagnosing and
monitoring the disease status of NAFLD.
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Methods—We retrospectively reviewed the results of all abdominal ultrasound examinations in patients who also had liver biopsies
from 2006 to 2010 to determine the positive predictive value of ultrasound for the detection of NAFLD in our department. We scored the
severity of fatty liver on ultrasound from 0 to 3: 0, normal liver echo texture; 1, increased liver echogenicity relative to kidney; 2, increased liver
echogenicity that obscures echogenic periportal fat; and 3, increased liver
echogenicity that obscures visualization of deep liver parenchyma. We
compared the ultrasound score to histology.
Results—A total of 170 patients were included in the study.
The sensitivity of ultrasound for detection of NAFLD in this patient population was 91% (86%–95%), specificity 75% (35%–97%), and positive
predictive value 99% (95%–100%). There was, however, no correlation
between the sonographic severity of NAFLD and the presence of NASH
or fibrosis.
Conclusions—Ultrasound has a high predictive value for the
diagnosis of NAFLD in patients who undergo liver biopsy. However,
the severity of fatty liver based on the sonographic appearance does not
correlate with the histologic severity of fatty liver disease and does not differentiate between bland steatosis and NASH.
1537502 Shear Wave Velocity Discrimination of Inflamed Fibrotic
Bowel Segments in a Crohn’s Disease Animal Model
Jonathan Dillman, Ryan Stidham, Peter Higgins, David
Moons, Laura Johnson, Jonathan Rubin* University of
Michigan, Ann Arbor, Michigan USA
Objectives—To determine if acoustic radiation force impulse
(ARFI) elastography-derived bowel wall shear wave velocity (SWV) can
distinguish inflamed from fibrotic intestine in a Crohn’s disease animal
model.
Methods—An acute inflammation Crohn’s disease model was
produced by treating Lewis rats with a single trinitrobenzenesulfonic acid
(TNBS) enema, with imaging performed 2 days later (n = 8). Colonic fibrosis in Lewis rats was achieved by administering repeated TNBS enemas over 4 weeks, with imaging performed 7 days later to allow resolution
of acute inflammation (n = 8). Nine transcutaneous bowel wall SWV
measurements (Virtual Touch IQ/Acuson S3000 ultrasound system;
Siemens Medical Solutions USA) were obtained from the rectosigmoid
colon region in all rats without and with applied strain. Mean bowel wall
SWVs without and with applied strain were compared between animal
cohorts. Receiver operating characteristic curves were created to assess
diagnostic performance. Three rats were excluded from analysis due to
demise.
Results—Mean bowel wall SWVs were significantly higher
for fibrotic vs acute inflammation cohort rats at 0% (3.42 ± 1.12 vs 2.30
± 0.51 m/s; P = .047) and 30% (6.27 ± 2.20 vs 3.61 ± 0.87 m/s; P = .021)
applied strain. Both acute inflammation and fibrotic cohort rats demonstrated linear increases in mean SWVs with increasing applied strain, with
no overlap in the 95% confidence intervals. The mean slopes (0.054 ±
0.029 vs 0.114 ± 0.044; P = .016) and y-intercepts (2.07 ± 0.32 vs 3.33 ±
1.14; P = .023) were significantly different. The c-statistic of SWV for
differentiating fibrotic from inflamed bowel was 0.764.
Conclusions—Bowel wall SWV distinguishes fibrotic from inflamed intestine in a Crohn’s disease animal model. This finding could
have a major impact in the diagnosis and treatment of strictures in Crohn’s
disease where fibrotic strictures can only be treated surgically, while inflammatory strictures are treated medically. In addition, the linearity of
the slopes in the shear wave vs applied strain model would remove preloading effects up to at least 30% applied strains, which could remove
variations due to different operator preloads.
1540986 Volumetric Blood Flow Assessment in Transjugular Intrahepatic Portosystemic Shunt Revision Using 3-Dimensional
Ultrasound
Stephen Pinter,1* Jonathan Rubin,1 Oliver Kripfgans,1 Paula
Novelli,1 Mario Vargas-Vila,2 Anne Hall,3 J. Brian Fowlkes1
1
Radiology, 2Medical School, University of Michigan, Ann Arbor,
Michigan USA; 3GE Healthcare, Wauwatosa, Wisconsin USA
Objectives—Transjugular intrahepatic portosystemic shunts
(TIPS) are prone to thrombosis and stenosis over time and must be monitored to identify cases requiring flow restoration. The purpose of this
study was to evaluate shunt patency using 3D ultrasound volumetric
blood flow in patients undergoing shunt revision. Shunt volume flow is
intended to provide a more sensitive and robust alternative to standard
pulsed wave Doppler shunt velocity or invasive portosystemic pressure
gradient measurements.
Methods—Ten patients were recruited. A GE LOGIQ 9 ultrasound system (4D3CL, 2.0–5.0 MHz) was used to acquire multivolume
respiratory-gated 3D color Doppler data sets for each patient to assess
shunt volume flow before and after the revision procedure. Volume flow
was computed offline by surface integration of Doppler-measured velocity vectors in a c-surface (lateral-elevational plane) positioned at the color
flow focal depth, which ranged from 8.0 to 11.5 cm. Doppler power
yielded pixel-by-pixel correction factors for partial volume integration.
Volume flow was compared to routine measurements of pre and post pressure gradient across the shunt measured by catheterization.
Results—Seven of the 10 patients recruited had their TIPS revised. Of these 7, the data from 2 were discarded because 1 had a deep
shunt (14–15 cm due to ascites) and therefore insufficient signal power,
while the other had a completely thrombosed shunt. Results from the remaining 5 patients show prerevision flows of 500 to 1200 mL/min and
postrevision flows of 1300 to 2550 mL/min. A corresponding decrease in
the prerevision and postrevision portosystemic pressure gradient was observed in each case. An important result was observed for patient 9, whose
prerevision flow was 1910 mL/min, which suggests a revision may be unnecessary. Following shunt revision, the pressure gradient for patient 9
was unchanged, and postrevision flow was 1938 mL/min, effectively unchanged compared to prerevision flow.
Conclusions—Results demonstrate that shunt volume flow has
a negative correlation with the prerevision and postrevision portosystemic
pressure gradient, illustrating that volume flow may be an effective indicator of shunt performance.
1541365 Implementation of a Competency-Based Online Curriculum to Train Medical Students and Primary Care Residents
and Physicians in Point-of-Care Ultrasound
Nicholas Cohen,1* Justin Lappen,1,2 Honor Wolfe,1 Kimberly
Gecsi,2 Ashish Bhimani3 1Family Medicine and Community
Health, 2Obstetrics and Gynecology, 3Cardiology, University
Hospitals Case Medical Center, Cleveland, Ohio USA
Objectives—The objective of our study was to design and integrate into the medical school curriculum at Case Western Reserve University School of Medicine and the family medicine residency curriculum at
University Hospitals Case Medical Center a competency-based online curriculum to train medical students and residents in point-of-care ultrasound.
Methods—We assembled a multidisciplinary team of physicians
in obstetrics and gynecology, cardiology, and the Department of Family
Medicine at our institution to design the curriculum. The modules consist
of an introduction to ultrasound and modules focused on specific application of point-of-care ultrasound for obstetrics, cardiology, abdominal, vascular, and procedure guidance. Each module includes a didactic component
featuring a Web-delivered screen capture PowerPoint video by an expert in
the field, a demonstration of technique using a model and actual ultrasound,
an online pretest and posttest to ensure competency, and a downloadable
checklist for a hands-on evaluation by a credentialed sonographer.
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Results—This curriculum has been adopted by the medical
school as well as the residency program and is in its second year of implementation. One hundred fifty learners have participated in the curriculum. Eighty-five percent of learners rate the curriculum good or excellent.
We demonstrate a 35% increase in knowledge from pretest to posttest.
Ninety-eight percent of learners who achieve a score of ≥90% on the
posttest are able to pass the hands-on skills test.
Conclusions—We have demonstrated that our curriculum can
be implemented in a medical school and primary care residency program,
provides competency-based assessment, and results in knowledge and
practical skills proficiency for learners with no prior training in ultrasound.
This curriculum is available online and has the potential for adoption at
medical schools and residency programs across the country.
1541515 Quantification of Renal Perfusion With Dynamic Power
Doppler Ultrasonography in Allograft Kidneys
Shuo-Meng Wang,1* Jeou-Jong Shyu,3 Nai-Kung Chou,2
Hao-Chih Tai,2 Sun-Hua Pao,4 Yio-Wha Shau4 1Urology,
2
Surgery, National Taiwan University Hospital, Taipei, Taiwan;
3
Veterinary Medicine, National Taiwan University, Taipei, Taiwan;
4
Industrial Technology Research Institute, Hsinchu, Taiwan
Objectives—Kidney transplantation is the most effective
method to save a patient’s life after renal failure. How to keep an allograft
kidney in good condition is very important in clinics. The serum creatinine
(Cre) assay is the most popular method used to diagnose renal function because of a single functioning kidney in the body. Dynamic power Doppler
(PD) ultrasonography can examine the hemodynamic change of renal perfusion directly. To understand the application of the power Doppler vascular index (PDVI) for the diagnosis of renal function and the correlation
with the serum Cre assay, allograft patients were used for study.
Methods—Three groups of patients according to the result of
Cre concentration (<1.0 vs <1.5 vs >1.5 mg/dL) were selected for PD ultrasonography. An HDI-5000 ultrasound system was applied, and serial
renal vascular images were collected in the DICOM format. Lab-designed
image-processing software was used for analysis. The PDVI was defined
as the percentage of color pixels within a region of interest (ROI) among
interlobular vessels of the cortex. Several PDVI indices, including (1)
PDVImax/PDVImin during cardiac cycles, (2) mean of weighted PDVI
(WPDVImean), (3) total vascular area (T) in the ROI, (4) small terminal
pulsation area (S), and (5) S/T ratio, were applied for analysis.
Results—The data for the PD indices in first group were:
PDVImax/PDVImin, 1.19; WPDVImean, 21.81; T, 0.71 cm2; S/T ratio, 16.90%;
resistive index (RI), 0.60 (0.55–0.65); and Cre, 1.07 (0.8–1.4) (n = 10). The
data in the second group were: PDVImax/PDVImin, 1.75; WPDVImean, 14.23;
T, 0.518 cm2; S/T ratio, 33.73%; RI, 0.66 (0.62–0.70); and Cre, 1.39 (1.2–
1.5) (n = 10). The data in the third group were: PDVImax/PDVImin, 3.81;
WPDVImean, 10.81; T, 0.37 cm2; S/T ratio, 47.38%; RI, 0.78 (0.72–0.88);
and Cre, 2.92 (1.9–5.3) (n = 20).
Conclusions—The difference between each group and correlation with the Cre assay were significant. These novel PD indices used to
evaluate the hemodynamic changes of renal perfusion in allograft kidneys
have the potential to be applied in renal clinics in the near future.
1538512 Renal Perfusion Change of Dehydation Examined With
Dynamic Power Doppler Ultrasonography in a Canine
Model
Jeou-Jong Shyu,1* Shuo-Meng Wang,2 Jiann-Gwu Lee,1 NaiKung Chou,3 Hao-Chih Tai,3 Sun-Hua Pao,4 Yio-Wha Shau4
1
Veterinary Medicine, National Taiwan University, Taipei, Taiwan; 2Urology, 3Surgery, National Taiwan University Hospital,
Taipei, Taiwan; 4Industrial Technology Research Institute,
Hsinchu, Taiwan
How to make a precise diagnosis for effective treatment is very important
to protect the allograft kidney. The renal perfusion is directly related to
renal function. To identify the correlation between dehydration and renal
perfusion, dynamic power Doppler (PD) ultrasonography was used to examine the hemodynamic change of renal perfusion in a canine model with
a dehydration condition.
Methods—Two groups of dogs aged 4 to 5 years (n = 4) and 10
to 12 years (n = 4) were used for study. The supplement of water was inhibited for 2 days to examine the renal perfusion change after dehydration.
An HDI-5000 ultrasound system was applied, and serial renal vascular
images were collected in the DICOM format. Lab-designed image-processing software was used for analysis. The power Doppler vascular index
(PDVI) was defined as the percentage of color pixels within a region of
interest (ROI) among interlobular vessels of the cortex. Several PDVI indices, including (1) PDVImax/PDVImin during cardiac cycles, (2) mean of
weighted PDVI (WPDVImean), (3) total vascular area (T) in the ROI, (4)
small terminal pulsation area (S), and (5) S/T ratio, were applied for analysis. The resistive index (RI) was also collected for comparison.
Results—The data for the PD indices before water inhibition
were: PDVImax/PDVImin, 1.215; WPDVImean, 17.25; T, 0.459 cm2; S/T ratio,
17.86%; and RI, 0.524 in the young group, and the data were 1.41, 16.03,
0.533 cm2, 25.98%, and 0.539, respectively, in the old group. After 1 day
of water inhibition, renal perfusion changes were observed in 2 young
dogs (1.533, 15.51, 0.438 cm2, 30.96%, and 0.547) and 3 old dogs (2.08,
12.49, 0.46 cm2, 43.91%, and 0.612). Renal perfusion changes occurred
in 2 other young dogs after 2 days of water inhibition (1.515, 15.42, 0.403
cm2, 30.15%, and 0.626).
Conclusions—The detailed change of renal perfusion during
dehydration can be evaluated with dynamic PD ultrasonography, and these
novel PD indices have the potential to be applied in renal clinics in the
near future.
1516829 Upper Body Quadrant Pain in Sonographers
Frank Claes,* Jan Berger, Gaetane Stassijns Physiotherapy,
University Hospital Antwerp, Edegem, Belgium
Objectives—The aims of this study were to evaluate the prevalence of upper body quadrant pain among sonographers and to evaluate the
association between individual ergonomics, musculoskeletal disorders,
and occurrence of neck pain.
Methods—One hundred ten Belgian and Dutch male and female hospital sonographers were consecutively enrolled in the study.
Data pertaining to work-related ergonomic and musculoskeletal disorders were collected with an electronic inquiry, including questions about
ergonomics (position of the screen, high-low table, and ergonomic chair),
symptoms (neck pain and upper limb pain) and work-related factors (consecutive working hours per day and average working hours per week).
Results—Subjects with the screen on their left had significantly
more neck pain (odds ratio [OR], 3.619; P = .0286). Depending on the
work space, high-low tables increase the chance of developing neck-pain
(OR, 12.90; P = .0246). A screen at eye level causes less neck pain (OR,
0.229; P = .0610). Employees with a fixed working space are less susceptible to arm pain (OR, 0.137; P 0.0058). The incidence of arm pain is
significantly higher in the vascular department compared to the radiology,
urology, and gynecology departments (OR, 9.273; P = 0.0278).
Conclusions—In the prevention of upper limb pain in sonographers, attention should be paid to the work environment in general and
to the more specific aspects of the ultrasound workstation layout. Primary
ergonomic prevention can help sonographers work painlessly during their
medical tasks.
Objectives—Many allograft patients have dehydration problems due to diarrhea in clinics, which cause deterioration of renal function.
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Obstetric Ultrasound: General and Fetal Growth
Moderators: Wesley Lee, MD, Mani Montazemi, RDMS
1539437 Fetal Loss Rate and Associated Risk Factors After
Amniocentesis, Chorionic Villus Sampling, and Fetal
Blood Sampling
Christian Enzensberger,1* Christina Pulvermacher,1
Jan Degenhardt,1 Andreaa Kawecki,1 Ute Germer,2 Ulrich
Gembruch,3 Martin Krapp,4 Jan Weichert,5 Roland
Axt-Fliedner1 1Division of Prenatal Medicine, University of
Giessen & Marburg, Giessen, Germany; 2Center for Prenatal
Medicine, Caritas Krankenhaus St Josef, Regensburg, Germany; 3Division of Prenatal Medicine, University of Bonn,
Bonn, Germany; 4Center for Endocrinology and Reproductive
and Prenatal Medicine, Amedes Hamburg, Hamburg, Germany; 5Division of Prenatal Medicine, University of SchleswigHolstein, Campus Luebeck, Luebeck, Germany
relation coefficients and percent agreement (“excellent”: score difference,
0–1 points; “acceptable”: 2 points; “poor”: ≥3 points) were used to estimate inter-reviewer reproducibility. Bland-Altman plots were used to assess bias and compare the 95% limits of agreement between reviewers.
Results—There was a significant correlation between the 2 reviewers’ overall scores (ρ = 0.73; P < .001). One hundred percent excellent agreement was observed in the individual categories of femur, outflow
tracts, stomach/diaphragm, and spine. Poor agreement was rare (kidney,
2.5%; and face, 2.5%) Bland-Altman statistics demonstrated no evidence
of systematic bias in the overall score (mean difference = 1.5; P = .761).
The 95% limits of agreement were clinically acceptable for the overall
score (–2.4 to 5.4) and all individual categories except fetal face views
(Table 1).
Conclusions—This image quality scoring tool demonstrated
overall acceptable reproducibility without evidence of systematic bias.
Careful evaluation of specific criteria comprising each individual scoring
category is, however, warranted prior to implementation into practice.
Table 1
Objectives—To assess the total and procedure-related fetal loss
rates and associated risk factors following amniocentesis (AC), chorionic
villus sampling (CVS), and fetal blood sampling (FBS).
Methods—We performed a retrospective analysis of patients
with invasive diagnostics from 1993 to 2011 in 2 tertiary referral centers.
We aimed to classify pregnancy loss after an invasive procedure and included the time after the invasive procedure and the result of targeted ultrasound/karyotype analysis in the analysis. Fetal losses occurring within
2 weeks after an invasive procedure were classified as procedure related.
Results—After excluding 1553 pregnancies with abnormal
karyotypes, fetal malformations, and multiple insertions, 6256 cases were
retrieved for final analysis. The total fetal loss rate was 1.5%. The procedure-related fetal loss rates were 0.4% for AC, 1.1% for CVS, and 0.4 %
for FBS. Maternal vaginal bleeding in the first trimester was significantly
associated with an increased procedure-related fetal loss rate (P = .008).
The number of invasive procedures declined during the study period with
increasing numbers of CVS in the first trimester.
Conclusions—In our population, the procedure-related fetal
loss rates were 0.4% after AC and 1.1% and 0.4% after CVS and FBS, respectively. Different gestational ages at the time of invasive procedures
might account in part for those differences. Vaginal bleeding during the
first trimester is associated with increased procedure-related fetal loss.
Overall, declining numbers of invasive procedures are the result of changing attitudes toward invasive procedures and more sophisticated noninvasive prenatal screening programs over the last 20 years.
1537806 Quality Control in Obstetric Ultrasound: Evaluating the
Reproducibility of an Image Scoring Tool for the SecondTrimester Anatomic Survey
Katherine Goetzinger,* Methodius Tuuli, Alison Cahill,
George Macones, Anthony Odibo Obstetrics and Gynecology, Washington University, St Louis, Missouri USA
Objectives—To evaluate the reproducibility of an image scoring tool for quality control of second-trimester fetal anatomic surveys in
a US academic center.
Methods—This was a retrospective study of 40 randomly selected nonanomalous singleton gestations between 18 and 22 weeks who
presented for an anatomic survey. Images from each ultrasound exam were
evaluated by 2 independent reviewers and assigned a score based on a
quality control tool, previously derived in a European ultrasound unit. This
tool assigns an overall score (46 points possible), which is the sum of individual scores for each of the following anatomic views: head (6), abdomen (6), femur (4), 4-chamber heart (6), outflow tracts (5), kidneys (4),
spine (5), stomach/diaphragm (6), and face (4). Individual scores are based
on the number of specific criteria fulfilled for each view. Spearman cor-
Category
Head
Abdomen
Femur
4-Chamber heart
Outflow tract
Kidneys
Stomach and diaphragm
Spine
Face
Bias
0.2
0.2
–0.1
0.5
–0.1
0.4
–0.2
0.1
0.7
95% Limits of Agreement
–1.0 to 1.5
–1.4 to 1.8
–1.2 to 1.1
–1.0 to 2.1
–1.4 to 2.2
–1.4 to 2.2
–1.7 to 1.2
–0.6 to 0.4
–1.3 to 2.7
1540992 Time Required for the Fetal Anatomic Survey in Obese and
Morbidly Obese Women
Robert Ehsanipoor,* Gofran Tarabulsi, Shannon Trebes,
Erika Werner, Janice Henderson, Jude Crino Johns Hopkins University School of Medicine, Baltimore, Maryland USA
Objectives—To determine if there is a difference in time required to perform the fetal anatomy survey in obese and morbidly obese
women compared to women with a body mass index (BMI) of <30 m2/kg.
Methods—Ultrasound examinations and reports were reviewed
for women undergoing a fetal anatomic survey between 18 and 28 weeks’
gestation. The time required for the exam was determined by subtracting
the time of the first image from the time of the last image. Examinations
involving trainees and those that detected fetal anomalies were excluded.
Maternal height and prepregnancy weight were self-reported and used to
calculate BMI. Obese was defined as a BMI between 30.0 and 39.9, and
morbid obesity was defined as a BMI of ≥40.0. χ2, the Student t test, analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs)
were used to compare the groups.
Results—A total of 306 women were included. Seventeen
women (5.5%) were morbidly obese; 67 (21.8%) were obese; and 222
(72.5%) were not obese. The mean ± SD ultrasound times required for the
fetal anatomy survey were as follows: morbidly obese, 61.2 ± 34.5 minutes; obese, 47.3 ± 23.1 minutes; and nonobese, 39.2 ± 19.3 minutes (P =
.01). Women with a BMI of ≥30 m2/kg were less likely have a complete
anatomic survey on 1 attempt (OR, 0.3; 95% CI, 0.16–0.47) and more
likely to never obtain a complete evaluation of the fetal anatomy (OR, 8.2;
95% CI, 2.5–26.6). The groups were not significantly different in regard
to maternal age, previous cesarean delivery, or gestational age at the initial examination.
Conclusions—More time is required to evaluate the fetal
anatomy in obese and morbidly obese women. Additionally, they are more
likely to require more than 1 examination to evaluate the fetal anatomy and
never have anatomy satisfactorily evaluated.
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1539702 Association of Third-Trimester Abdominal Circumference
With Provider-Initiated Preterm Delivery
Leah Hawkins,1* William Schnettler,1,2 Anna Modest,2
Michele Hacker,1,2 Diana Rodriguez1,2 1Harvard Medical
School, Boston, Massachusetts USA; 2Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts USA
Objectives—To evaluate the association of a small abdominal
circumference (AC, <10th percentile) at third-trimester ultrasound with gestational age (GA) at delivery, indication for delivery, and neonatal outcomes.
Methods—All women seen at our institution from 2009
through 2011 for measurements from 28 to 34 weeks’ gestation with a singleton nonanomalous pregnancy were included in this retrospective cohort. We compared GA at delivery, indication for delivery, and neonatal
outcomes between 2 groups: Normal AC (AC and estimate fetal weight
[EFW] ≥10th percentile) and small AC (AC <10th percentile and EFW
≥10th percentile). Indications for delivery were categorized as spontaneous or provider initiated. Data are presented as medians, interquartile
ranges (IQRs), and risk ratios (RRs) with 95% confidence intervals (CIs).
Results—A total of 597 women met eligibility criteria. The
median GA at ultrasound was 32.0 weeks (IQR, 30.6–33.0 weeks), and
median maternal age at delivery was 32.9 years (IQR, 28.8–36.7 years).
A small AC was found in 10.6% of the fetuses. The incidence of preterm
delivery (PTD) in the cohort was 12.2%. Compared to fetuses in the normal-AC group, those with a small AC experienced a higher incidence of
overall PTD, provider-initiated PTD, and provider-initiated PTD for a fetal
indication (Table 1). No significant differences in immediate neonatal outcomes between the normal- and small-AC groups were witnessed aside
from an expected difference in mean birth weight.
Conclusions—A small AC, even in the setting of an EFW
≥10th percentile, is associated with a higher incidence of PTD, specifically, provider-initiated PTD. Fetal growth concerns appeared to drive the
decision for delivery. Immediate neonatal outcomes were comparable between groups, challenging the need for provider-initiated PTD of fetuses
with an isolated small AC. Further investigation into the rationale for PTD
and long-term neonatal outcomes of such fetuses is warranted.
Table 1. Pregnancy Outcomes
Normal AC
Small AC
(n = 537 [90.7%]) (n = 55 [9.3%]) P
Overall PTD
59 (11.0%)
13 (23.6%)
.006
Iatrogenic PTD
24 (4.5%)
9 (16.4%)
.003
Fetal indication for PTD 10 (1.86%)
7 (12.7%) < .001
RR (95% CI)
2.2 (1.3–3.7)
3.7 (1.8–7.5)
6.8 (2.7–17.2)
1508162 Incidence and Timing of Onset of Intrauterine Growth
Restriction in Singleton Pregnancies With Low PregnancyAssociated Plasma Protein A, Elevated Maternal Serum
α-Fetoprotein, or Both Biochemical Abnormalities
Simi Gupta,1* Nathan Fox,1,2,3 Andrei Rebarber,1,2,3 Daniel
Saltzman,1,2,3 Chad Klauser,1,2,3 Ashley Roman1,2,3 1Obstetrics
and Gynecology, New York University, New York, New York
USA; 2Maternal-Fetal Medicine, Carnegie Imaging for Women,
New York, New York USA; 3Obstetrics and Gynecology, Mount
Sinai School of Medicine, New York, New York USA
Objectives—Low pregnancy-associated plasma protein A
(PAPP-A) and elevated maternal serum α-fetoprotein (MSAFP) are each
individually associated with an increased risk of intrauterine growth restriction (IUGR). However, little is known about the incidence or timing
of onset of IUGR in these pregnancies or in those affected by both biochemical abnormalities. The objective of this study was to compare the
incidence and timing of IUGR in pregnancies affected by these abnormalities individually and in combination.
Methods—This was a retrospective cohort study of singleton
gestations with PAPP-A <5th percentile and/or MSAFP ≥2.0 multiples of
the median at a single center from May 2005 through August 2011.
Patients with low PAPP-A and/or elevated MSAFP were typically followed with ultrasound for fetal growth at least every 4 weeks from 20
weeks until delivery. Patients were excluded if the fetus was known to
have an abnormal karyotype, an adverse obstetric event unrelated to
IUGR, or no documented ultrasound examinations for growth. IUGR was
defined as an estimated fetal weight on ultrasound <10th percentile for
gestational age. The incidence of IUGR was compared using the Fisher
exact test with P < .05 as significance.
Results—The incidence of IUGR by biochemical abnormality
is reported in Table 1. Patients with both low PAPP-A and elevated
MSAFP were significantly more likely to be diagnosed with IUGR than
patients with either biochemical abnormality alone. More than 70% of patients with IUGR in the setting of isolated elevated MSAFP or low PAPPA were diagnosed with IUGR after 28 weeks, whereas 100% of patients
with IUGR in the setting of both biochemical abnormalities were diagnosed prior to 28 weeks (P = .03).
Conclusions—The incidence and timing of onset of IUGR are
similar in patients with isolated low PAPP-A and elevated MSAFP. When
these biochemical abnormalities are seen in combination, the risk of IUGR
is >3-fold greater than either abnormality alone, and the onset of IUGR is
earlier. Patients with both low PAPP-A and elevated MSAFP represent a
group at highest risk of IUGR in whom close fetal surveillance is merited.
Table 1
IUGR
No IUGR
Low PAPP-A
Only
24/421 (5.7%)
397/421 (94.3%)
Elevated
Low PAPP-A and
MSAFP Only
Elevated MSAFP
7/134 (5.2%)
2/11 (18%)
127/134 (94.8%)
9/11 (82%)
P
.02
1540608 Prenatal Ultrasound and Ethanol Biomarkers for Early
Identification of Prenatal Alcohol Exposure
Brennan Mathew,* Steffen Brown, Mahek Garg, Daniel
Savage, William Rayburn, Ludmila Bakhireva Obstetrics
and Gynecology, University of New Mexico, Albuquerque, New
Mexico USA
Objectives—A barrier in limiting effective treatment of fetal alcohol spectrum disorder is the lack of early and reliable diagnostic indices.
Limited human studies suggest that selected fetal brain measures might be
particularly affected by prenatal alcohol exposure (PAE). The objective
of this study is to identify prenatal ultrasound indices associated with history and biomarker-proven PAE.
Methods—This prospective study included 11 alcohol-exposed
pregnant women (≥3 drinks/wk or binge drinking episodes during pregnancy and positivity for at least 1 ethanol biomarker) and 36 patients on
opioid maintenance therapy (OMT) who abstained from alcohol during
pregnancy (confirmed by 5 ethanol biomarkers) who were recruited at an
early prenatal care visit and followed to term. The panel of ethanol biomarkers included serum γ-glutamyltranspeptidase, urine ethyl glucuronide,
urine ethyl sulfate, and whole-blood phosphatidylethanol (PEth). PEth
was also measured in a dry blood spot card obtained from the newborn.
Third-trimester sonograms were performed, and standard fetal biometry
was obtained. The standard biparietal diameter (BPD) image was then reviewed to obtain the caval-calvarial distance (CCD) and fronto-thalamic
distance (FTD). Fetal brain measures were compared among alcohol-exposed and OMT patients by analysis of covariance adjusting for gestational age at the exam.
Results—The majority of patients were Hispanic (79%) and
had a high school education or less (85%). The mean maternal age at recruitment was 26.1 ± 4.8 years. Fetuses of alcohol-exposed patients had a
significantly shorter mean CCD and transcerebellar diameter (TCD) (P <
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.05) and demonstrated a trend toward a lower BPD and FTD (P < .1) compared to OMT patients.
Conclusions—Prenatal ultrasound evaluation of the CCD and
TCD correlate with biomarker-proven PAE. These results indicate that ultrasound parameters may be helpful in conjunction with other diagnostic indices in detecting PAE. Future studies need to examine the predictive utility
of ultrasound indices on neurodevelopmental outcomes in children with PAE.
1521317 Effect of Maternal Body Mass Index on Fetal Growth: Use
of Individualized Growth Assessment and 2-Level Modeling
Timothy Canavan,1* Russell Deter2 1Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh–
Magee Women’s Hospital, Pittsburgh, Pennsylvania USA;
2
Obstetrics and Gynecology, Baylor College of Medicine,
Houston, Texas USA
Objectives—To determine the effect of the maternal body mass
index (BMI) on fetal biometry estimates of growth using individual
growth assessment (IGA) and 2-level linear modeling.
Methods—A retrospective review of serial biometry in the second and third trimesters from 246 normal term singleton fetuses was performed. Four to 8 biparietal diameter (BPD), head circumference (HC),
abdominal circumference (AC), and femur diaphysis length (FDL) measurements per fetus were available and used to determine second-trimester
growth rates. Expected third-trimester size trajectories were generated
from these data and percent deviations (%Dev = [{observed – expected}/
expected] × 100) were calculated. Two-level linear modeling was used to
determine individual %Dev slopes and the effect of BMI on these slopes.
Relationships between individual second- and third-trimester slopes and
BMI values were also evaluated using regression analysis.
Results—Linear regression analysis of second-trimester growth
indicated no significant relationships between the fetal growth rate and
the BMI (adjusted R2 = 0.0%–1.0% except for AC in 1 subgroup [5.6%]).
With third-trimester %Dev slopes, there was a definite BMI effect for HC,
but only a marginal effect was seen for AC (critical value = 1.98; t = 2.00).
There was no BMI effect on BPD or FDL slopes. Regression analysis indicated no significant relationships (adjusted R 2 = 0%–0.2%) between
BMI values and third-trimester %Dev slopes for any anatomic parameter.
Conclusions—Our findings support the premise that the maternal BMI does not alter fetal growth in either the second or third
trimester. It also demonstrates that IGA and 2-level linear modeling, used
together, can assess the effect of an extrinsic factor on fetal growth.
1541336 Cerebral Autoregulation in Normal Pregnancy
Teelkien van Veen,1* Sina Haeri,2 Rodrigo Ruano,2 Ronny
Panerai,3 Gerda Zeeman,1,4 Michael Belfort2 1Obstetrics and
Gynecology, University Medical Center Groningen, Groningen, the Netherlands; 2Obstetrics and Gynecology, Baylor
College of Medicine, Houston, Texas USA; 3Cardiovascular
Sciences, University of Leicester, Leicester Royal Infirmary,
Leicester, England; 4Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands
Objectives—Recent advances in transcranial Doppler (TCD)
methodology now allow direct real-time estimation of the functional state of
cerebral autoregulation. Since no normative data exist for pregnant patients,
our aim was to establish baseline data for cerebral autoregulation in healthy
pregnancy against which women with disease states can be compared.
Methods—In this prospective cohort analysis, cerebral blood
flow velocity (CBFV) in the middle cerebral artery (using TCD), blood
pressure (using noninvasive continuous plethysmography), and end–tidal
carbon dioxide (etCO2) were simultaneously evaluated at baseline and
during voluntary breath holding (increased etCO2). The transfer function
parameters (gain, phase, and coherence in the low-frequency range [<0.1
Hz]) were used to estimate the degree of autoregulation.
Results—Nineteen normotensive pregnant women were enrolled, of whom 15 had good signal quality and were analyzed (maternal
age, 28 ± 5 years; gestational age, 27 weeks [13−34 weeks]). Breath holding led to increases in etCO2 (34 ± 2 vs 38 ± 2 mm Hg; P < .001), mean
arterial pressure (76 ± 8 vs 86 ± 11 mm Hg; P = .01), and CBFV (59 ± 15
vs 71 ± 15 cm/s; P = .04), along with increases in coherence and gain and
a decrease in phase.
Conclusions—The baseline data and the changes seen with
breath holding in normal pregnancy are consistent with those seen in normal cerebral autoregulation as reported in nonpregnant individuals. These
data now allow for further studies in pregnant women with disease states
and drug exposures that may be expected to affect cerebral autoregulation.
1539866 Do Clinical Practitioners Seeking Credentialing for Nuchal
Translucency Measurement Have an Understanding of
Biosafety? The Experience of The Nuchal Translucency
Quality Review Program
Bryann Bromley,1,2* Karin Fuchs,3 Loralei Thornburg,4 Jean
Spitz,5 Gregory Toland5 1Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA;
2
Obstetrics and Gynecology and Radiology, Brigham and
Women’s Hospital, Boston, Massachusetts USA; 3MaternalFetal Medicine, Columbia University Medical Center, New
York, New York USA; 4Maternal-Fetal Medicine, University of
Rochester, Rochester, New York USA; 5Nuchal Translucency
Quality Review, Perinatal Quality Foundation, Oklahoma City,
Oklahoma USA
Objectives—To evaluate compliance with the ALARA (as low
as reasonably achievable) principle by practitioners seeking credentialing
for nuchal translucency (NT) measurement between 11 and 14 weeks’
gestation.
Methods—This was a retrospective evaluation of images submitted by 100 consecutive practitioners seeking NT credentialing prior to
September 18, 2012. For each practitioner, the 5 required submitted images were r-evaluated for the presence or absence of the output display
standard (ODS). In images with the ODS visible, the type of thermal index
used (soft tissue [TIs] or bone [TIb]) was recorded as well as the numeric
value of the index. Additional data collected included outcome of image
submission (pass/fail), provider type (physician or sonographer), and, for
sonographers, American Registry for Diagnostic Medical Sonography
(ARDMS) status. A TIb <0.5 was considered the optimal setting for this
gestational age window. The length of examination and dwell times were
not available for review with a single static image.
Results—Seventy-seven practitioners submitted at least 1
image demonstrating the ODS. Fifteen (19.5%) providers used TIb exclusively, while 37 (48.1%) used TIs exclusively; 25 providers (32.4%)
submitted a batch using both TIb and TIs. The range for both TIb and TIs
was 0.0 to 1.6. The mean, median, and mode were 0.7, 0.6, and 0.1 for TIb
and 0.4, 0.2, and 0.1 for TIs. Of the 40 providers who used TIb for any
image, 18 (45%) had a TIb between ≥0.5 and 1.0, and 11 (27.5%) had a
TIb of >1.0. Although 44 of 77 (57%) providers maintained a TI (TIb or
TIs) <0.5, only 4 of 77 (5.2%) used TIb exclusively at <0.5. Providers
passing the image review process were twice as likely to be using TIb than
those who failed (21.9% vs 9.1%), although this did not reach statistical
significance (P = .33). No difference in TIb or TIs use was seen between
sonographers (n = 59) and sonologists (n = 18; P = .78). Among sonographers, 41 held ARDMS credentials, but this did not influence the use of
TI <.5 (66% vs 56%; P = .45).
Conclusions—Clinicians seeking credentialing in NT measurement do not demonstrate compliance with the recommended use of
TIb in monitoring acoustic output.
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1537546 Early Second-Trimester Fetal Anatomy Scans Improve
the Rate of Complete Anatomy Scans in Obese Patients
Simi Gupta,* Judith Chervenak, Ilan Timor, Ana
Monteagudo Obstetrics and Gynecology, New York University, New York, New York USA
Objectives—Fetal anatomy scans are more difficult to perform
on obese patients. However, there are little data available on methods to
improve the rate of complete anatomy scans in these patients. The objective of this study was to determine if the addition of an early secondtrimester fetal anatomy scan improves the rate of complete anatomy
ultrasound examinations in obese patients.
Methods—This was a prospective cohort study at an inner-city
public hospital of 100 obese patients who were scheduled for a fetal
anatomy scan via transvaginal and transabdominal modalities at 14 to 16
weeks’ gestation (early fetal anatomy) and an anatomy scan at 18 to 22
weeks’ gestation (routine fetal anatomy). Inclusion criteria were body mass
index (BMI) >30 kg/m2, singleton pregnancy, and presentation for prenatal care prior to 16 weeks’ gestation. Data for the routine anatomy scan
alone versus the combination of early anatomy and routine anatomy scans
was calculated using the McNemar χ2 test for categorical outcomes and
Wilcoxon signed ranks test for continuous variables.
Results—The range of BMI in the study was 30–49.6 kg/m2
with an average BMI of 34.3 kg/m2. Table 1 shows the results for the routine anatomy scan alone and the combination of early anatomy and routine anatomy scans.
Conclusions—The addition of an early second-trimester fetal
anatomy ultrasound scan significantly improves the rate of complete
anatomic scans and mean number of items seen in obese patients. The addition of this ultrasound scan may improve the detection of congenital
anomalies in obese patients.
Table 1
Routine
Early and Routine
Anatomy Anatomy Combination
P
% complete anatomy
42
51
< .01
Mean no. of items seen (1–21)
18.6
19.4
< .01
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SPECIAL INTEREST SESSIONS
WEDNESDAY, APRIL 10, 2013, 8:15 AM–10:15 AM
Breast Ultrasound
Extracranial Ultrasound of the Head and Neck in
Children
Moderator: Abid Irshad, MD
Moderator: Beth McCarville, MD
Clinical Breast Ultrasound in an Outpatient Community Breast Center
Stamatia Destounis Elizabeth Wende Breast Care, LLC,
Rochester, New York USA
This lecture will cover the clinical use of breast ultrasound in an
outpatient community breast center. Topics to be covered will include evaluation of breast pain, palpable abnormalities, breast lesions in young patients, breast-feeding/lactating patients, and patients with dense breasts
presenting for additional screening ultrasound. Particular discussion will
be focused on screening breast ultrasound, in response to recent state legislation mandating that the patient be informed of her breast density. In
addition, screening of the high-risk patient will be covered. Last, this lecture will discuss the role of diagnostic breast ultrasound. The role of new
technologies, including elastography and automated breast ultrasound,
will be briefly discussed.
Significance and Implications of Various Sonographic Features in
Breast Lesions
Abid Irshad Radiology, Medical University of South Carolina, Charleston, South Carolina USA
This lecture will encompass the diagnostic significance of various sonographic features seen in breast lesions from a clinical and pathologic perspective. The management issues regarding concordance after
biopsy of these lesions will also be discussed. Additionally, various sonographic features seen in breast cancers will be individually discussed in
light of literature to see how confidently the biological behavior such as
the tumor grade and estrogen receptor/progesterone receptor/human epidermal growth factor receptor 2 status of these cancers can be predicted
based on these individual sonographic features.
Ultrasound as a Problem-Solving Tool in Breast Imaging
Julie Mack Radiology, Penn State Hershey, Hershey, Pennsylvania USA
Breast ultrasound is integral to the imaging evaluation of breast
disease, and core biopsy under ultrasound guidance provides a mechanism for rapid diagnosis of breast pathology. This session will focus on the
use of breast ultrasound as a problem-solving tool in patients presenting
with mammographic or clinical evidence of breast disease. The sonographic findings in a variety of breast abnormalities of the female and male
breast will be illustrated and correlated with the mammographic and
magnetic resonance imaging (MRI) findings. The utility of breast ultrasound as a “second-look” exam after MRI will be discussed. Biopsy
planning and radiologic-pathologic correlation will also be emphasized.
Finally, a brief review of the data on breast ultrasound as a screening tool
will be examined.
This session is designed to educate the radiologist and sonographer about the value of ultrasound in assessing non-brain pathology in
the head and neck of children, including the thyroid, superficial masses,
and ocular disease.
Gynecologic Ultrasound: The Basics Revisited
Moderator: Ana Monteagudo, MD
Getting to Know Your Ultrasound Machine: Essentials of Knobology
Ana Monteagudo Obstetrics and Gynecology, New York
University School of Medicine, New York, New York USA
“Knobology” is defined as the functionality of controls on an instrument as relevant to their application. In the case of ultrasound (US), it
is the function of the controls (knobs) on the US machine. All machines
have essentially the same set of controls; however, in each brand, the controls (“knobs”) are arranged slightly differently. Therefore, it is imperative
to become familiar with the location of the controls on the machine that
you are using on a regular basis. Adjusting the controls is a way to improve the image quality, since a good image is an essential component of
making a correct and reliable diagnosis. Controls that change the following parameters are indispensable: depth, gain, time-gain-compensation
(TGC), focal zone, field of view, frame rate, “optimize” (this control
changes several parameters as needed for a particular set of pictures), and
zoom. Of course, there are many more of them; however, as you gain confidence with the scanning and working with the US machine, the utility of
changing other parameters will become evident. Improving images not
only requires knowing which control to use, but it also requires choosing
the right transducer for the scanning approach; transducers commonly
used in obstetrics and gynecology range from 3.5 to 7.5 MHZ (or higher).
Low-frequency transducers achieve better penetration at the expense of a
lower resolution; these are the ones employed when scanning transabdominally. Higher-frequency transducers have less penetration, but their
real value is the increased resolution, and these are usually used transvaginally. Last, besides knowing what each control does and which transducer to use, we must know the indication for the scan and the age and last
menstrual period of the patient. They all assist in making the diagnosis.
Innovative Directions in Fetal Cardiac Imaging
Moderator: Lami Yeo, MD
The objective of this session is to review several new directions
in the field of fetal cardiac imaging: imaging for fetal interventions, fetal
magnetic resonance imaging, and automated screening for congenital heart
disease.
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Lumps, Bumps, and Extremity Pain in the Emergency Room: What Is the Role of Ultrasound?
Ultrasound-Guided Thrombolysis
Moderator: George Lewis Jr, PhD
Moderator: Leslie Scoutt, MD
Sonography of Abdominal Wall Hernias
Levon Nazarian Radiology, Thomas Jefferson University
Hospital, Philadelphia, Pennsylvania USA
Small abdominal wall hernias may be difficult to palpate on
physical examination; therefore, hernias are an often-overlooked cause of
pain or other complications. Because of its real-time nature, ultrasound
has taken a central role in the evaluation of abdominal wall hernias, since
many hernias are not present in the resting state. Since dynamic maneuvers may be necessary for diagnosis, many hernias go undetected by computed tomography or magnetic resonance imaging. This presentation will
discuss the anatomy and technique pertinent to the diagnosis of abdominal wall hernias. Pathologic examples of the different hernia types will be
presented using both static images and video clips.
Lumps and Bumps
Jason Wagner Radiological Sciences, University of Oklahoma, Edmond, Oklahoma USA
This presentation will describe an algorithm-based approach to
the ultrasound evaluation of a superficial mass, based on patient history,
physical examination, lesion location, and sonographic findings. Specific
topics will include identification of fluid collections, distinguishing nonneoplastic causes of a lump from neoplasms, and the differential diagnosis of superficial neoplasms.
Peripheral Arterial Disease
Medical Technology and Instrumentation for Sonothrombolysis:
Current, Pipeline, and Future Platforms
George Lewis Jr Zetroz, Ithaca, New York USA
Ultrasound technologies to provide and monitor sonothrombolysis can currently be grouped into two broad categories: (1) catheterdirected and/or delivered ultrasound and (2) extracorporeal focused and/or
applied ultrasound. The first class of technology is generally minimally invasive and carried out with a sterile field in an interventional radiology
suite. The second class of device covers a much larger use case scenario
relative to where it can be applied and used. In both categories of technology, sonothrombolysis effectiveness in thrombus dissolution is most
regularly measured with precontrast and postcontrast fluoroscopy. More
recently, however, ultrasound imaging including B-mode, Doppler flow,
and intravascular ultrasound is making its way into fully integrated closedloop sonothrombolysis treatment and monitoring systems. This talk will
review current sonothrombolysis ultrasound technologies, their performance characteristics, methods of use, and basic mechanisms of action in
which they rely on. Catheter-directed ultrasound technologies include
commercial systems such as Ekos and Omnisonics, as well as pipeline
technologies still undergoing research in academia and the private sector.
Extracorporeal noninvasive technologies, including power Doppler, lowintensity therapeutic ultrasound, plane-wave pulsed ultrasound, high-intensity focused ultrasound, and histotripsy, will be described along with
their current use case scenarios, characteristics, and regulatory pathways.
The catheter-directed sonothrombolysis approaches will be compared and
contrasted to noninvasive sonothrombolysis. Additionally, recent innovations in closed-loop sonothrombolysis treatment monitoring and crossover
sonothrombolysis platforms will be discussed as a gateway into clinical research presentations.
Moderator: John Blebea, MD, MBA
Ultrasound in the Preintervention Stage of Patient Evaluation
Gowthaman Gunabushanam Diagnostic Radiology, Yale
University School of Medicine, New Haven, Connecticut USA;
Radiology, VA Medical Center, West Haven, Connecticut USA
This presentation will review the noninvasive evaluation of
lower extremity peripheral arterial disease (PAD) in the vascular laboratory, including ankle-brachial index (ABI), toe-brachial index (TBI), pulse
volume recording (PVR), segmental blood pressure measurement, and ultrasound of native arteries and bypass grafts. ABI is used to confirm vascular etiology and provide prognostic information in symptomatic patients.
ABI is also used to screen high-risk asymptomatic patients for PAD and
to monitor the efficacy of therapeutic interventions. ABI <0.9 is abnormal. Exercise ABI improves sensitivity for PAD detection in patients with
normal rest ABI. TBI is especially useful when ABI is >1.3 as digital arteries are usually spared the medial calcinosis that affects the more proximal arteries. Segmental pressure measurements and PVR help determine
the level of stenosis. A gradient >20 mm Hg between adjacent segments
or between the two sides at the same level is significant. PVR provides an
arterial pressure waveform profile by measuring limb volume changes
with each cardiac cycle. A normal waveform has a rapid upstroke, a sharp
peak, a dicrotic notch, and a downslope bowed toward the baseline. A
slower rise time, flattened or rounded peaks, absence of a dicrotic notch,
and a downslope bowed away from baseline suggest a proximal stenosis.
Velocity criteria are used for grading stenosis on ultrasound. Peak systolic
velocity (PSV) of 200 to 350 cm/s and PSV ratio of 2 to 3.5 are suggestive
of moderate stenosis. PSV >350 cm/s and PSV ratio >3.5 are consistent
with severe stenosis.
Sonothrombolysis: Techniques, Mechanisms, and Safety
Zhen Xu Biomedical Engineering, University of Michigan,
Ann Arbor, Michigan, USA
Ultrasound has been shown to promote clot breakdown, as both
a stand-alone procedure and in conjunction with thrombolytic drugs or
contrast agents. In this talk, 3 sonothrombolysis approaches and their underlying mechanisms reported in the literature will be reviewed. First, lowintensity ultrasound is combined with fibrinolytic enzymes (such as
plasminogen activator) to accelerate the clot dissolution. The mechanism
underlying this approach includes the accelerated transport of drug molecules into the clot and alteration in fibrin structure to enhance enzyme
binding. Both of these effects are caused by stable cavitation (ie, microstreaming and bubble translation) and inertial cavitation (ie, intense localized stresses and microjets). Microbubble contrast agents can be used
in conjunction with fibrinolytic enzymes to enhance cavitation and further augment thrombolysis. Second, higher-intensity ultrasound and microbubble contrast agents are used together to cause clot fragmentation.
The microbubbles that accumulate at the surface or within the clot serve
as cavitation nuclei. For this approach, the primary mechanism is inertial
cavitation, where energetic bubble growth and collapse induce high local
stress and microjets, resulting in clot microfragmentation. Third, very
high-intensity focused ultrasound pulses are used alone to produce rapid
clot fragmentation. Similar to the second approach, the mechanism for
this method is also inertial cavitation, where pre-exiting gas nuclei in clots
are used to generate cavitation. No contrast agents or drugs are required.
To conclude, safety studies of sonothrombolysis techniques will be discussed, including damage to vessel walls and surrounding tissue, changes
in blood chemistry, and embolization.
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Clinical Role and Potential of Ultrasound-Enhanced Thrombolysis
in Peripheral Arterial Disease
Richard Shlansky-Goldberg Radiology, University of Pennsylvania, Philadelphia, Pennsylvania USA
Thrombosis from peripheral arterial disease (PAD) due to underlying atherosclerotic disease or thrombosis of a surgical bypass graft
used to treat PAD can lead to limb loss. In addition, thrombosis of the
deep venous system (DVT) can lead to chronic leg swelling due to postphlebitic syndrome. DVT can also lead to life-threatening pulmonary embolic disease (PE). Catheter-directed pharmacologic thrombolysis is a
well-established technique to treat these arterial, venous, and graft occlusions. The utility of this approach continues to be limited by several factors, including the cost of the lytic dose, the duration of treatment required
for effective clot lysis, costly intensive care monitoring, and the exposure
of patients to the risk of intracranial hemorrhage and other life-threatening bleeding. Attempts to improve the efficacy of thrombolysis with different catheter configurations and mechanical devices have met with
varied success. The addition of ultrasound by itself or with pharmacologic
agents has been demonstrated to primarily induce or enhance thrombolysis. To date, the clinical applicability of these approaches has been limited.
We will explore the current clinical data to determine the success of these
approaches to improve lysis in DVT, PAD, and PE. Although the use of
ultrasound appears promising, the question still remains whether the current iteration of techniques and devices will add enough efficiency to have
a clinically significant impact on outcomes. We will evaluate what thresholds need to be crossed for ultrasound to dramatically improve on how
these diseases will be treated in the future.
SPECIAL INTEREST SESSIONS
WEDNESDAY, APRIL 10, 2013, 10:45 AM–12:30 PM
Acoustic Radiation Force Impulse Imaging:
Benefits and Challenges With Increasing Acoustic
Output Beyond Diagnostic Levels
Moderators: Kathy Nightingale, PhD, Thomas Szabo, PhD
The Historical Basis for the Food and Drug Administration’s Maximum Exposure Level Guidance for Diagnostic Ultrasound
Gerald Harris US Food and Drug Administration, Silver
Spring, Maryland USA
US Food and Drug Administration (FDA) regulations designate most diagnostic imaging and Doppler ultrasound devices as class 2,
which means that before a new device can be marketed in the United
States, a “510(k)” (named for a section of the 1976 FDA Medical Device
Amendments) premarket notification must be cleared by the FDA. In this
notification, a device sponsor must demonstrate that the device is substantially equivalent (SE) in terms of safety and effectiveness to either a
device legally marketed before May 28, 1976, the date of enactment of the
FDA Medical Device Amendments, or to a device that has been legally
marketed as a class 2 device since that date. To evaluate equivalent safety,
the FDA has used several acoustic output quantities to compare maximum
output levels, including the derated spatial-peak temporal-average intensity and the thermal index for thermal safety comparisons and the derated
spatial-peak pulse-average intensity and the mechanical index for nonthermal considerations. In this presentation, the origin and use of these
quantities in making SE determinations will be described. Also, their possible shortcomings for evaluating the safety of applications that employ
long-duration, high-intensity pulse bursts, such as acoustic radiation force
impulse imaging, will be discussed.
An Analysis of the Mechanical Index as a Means for Ensuring Patient Safety During Acoustic Radiation Force Impulse Imaging
Charles Church,* Cecille Labuda National Center for Physical Acoustics, University of Mississippi, University, Mississippi
USA
The mechanical index (MI) quantifies the likelihood that diagnostic ultrasound will produce an adverse biological effect by a nonthermal mechanism. The current formulation of the MI is based on inertial
cavitation thresholds in water and blood as calculated for pulse durations
of 1 period. However, tissue is not a liquid but a viscoelastic solid, and
further, acoustic radiation force impulse imaging employs high-intensity
pulses up to several hundred acoustic periods long. To quantify the importance of these differences, thresholds for inertial cavitation were determined in water, blood, and several representative tissues by performing
numerical computations similar to the analytical work underlying the MI
for pulse lengths of 1 to 1000 acoustic periods, equilibrium bubble radii
(Ro) of 0.01 to 10.0 µm, a frequency range of 0.5 to 10 MHz, and 4 threshold criteria, including the criterion used for the MI (5000 K). Water and
blood were modeled using the Gilmore equation, while tissues (smooth
and skeletal muscle, kidney, liver, and skin) were modeled using a KellerMiksis–like equation assuming a linear Voigt solid. It is shown that the
likelihood of an adverse biological effect due to cavitation is less in soft
tissues, and much less in muscle, than in blood. More importantly, the literature suggests that the experimental threshold for cavitation in tissue is
much higher than predicted here, casting doubt on the value of this simple theoretical approach in assessments of patient safety. By combining
theoretical and experimental data, several options for transiently increasing output levels while ensuring patient safety become available.
Investigation of the Use of Increased Acoustic Output Levels for
Acoustic Radiation Force Impulse Imaging in the Research Setting
Mark Palmeri Biomedical Engineering, Duke University,
Durham, North Carolina USA
Acoustic radiation force impulse (ARFI) imaging has experienced rapid development over the past decade, growing from a novel elasticity imaging method used in tissue-mimicking phantoms to clinical
testing in a variety of target organs, including the liver, breast, prostate, vessels, and heart, to commercial implementation. While current commercial
ARFI imaging implementation operates within current US Food and Drug
Administration diagnostic ultrasound acoustic output guidelines, studies in
the research environment have not been similarly restricted. For example,
pilot clinical ARFI imaging research studies at Duke University involve a
custom method for characterizing acoustic intensity, tissue heating, transducer heating, and the mechanical index to support in vivo safety of using
increased output during acoustic radiation force excitations. Given the
strong acoustic waveform nonlinearity that can occur when characterizing
high pressures in water, acoustic radiation force pressure waveforms and
intensity values are characterized using hydrophone measurements
through attenuating fluids similar to that of the target organ. Thermocou-
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ple measurements are made at the transducer face to characterize lens heating. We are exploring the hypothesis that increases in tissue displacement
amplitude associated with elevated acoustic output will lead to improvements in ARFI images and shear wave speed estimates. To that end, parametric clinical studies are in progress with ARFI shear wave liver imaging
to quantify the correlations between displacement amplitude, jitter, shear
wave speed reconstruction performance metrics, and increased acoustic
output. A summary of the acoustic output characterization methods used
in the research setting and preliminary results from the parametric clinical studies will be presented.
The Role of Ultrasound in Screening for Vascular Disease
Edward Bluth Radiology, Ochsner Medical Institutions, New
Orleans, Louisiana USA
Moderator: James Huhta, MD
It has been suggested that it would be more useful to reallocate
health care dollars to screening asymptomatic healthy patients compared
to the large allocation of resources for end-of-life care. Ultrasound has an
important role to play in screening for medical problems. As a noninvasive study that does not use ionizing radiation, ultrasound has an advantage over other imaging modalities. Included in the areas where screening
studies can be useful with ultrasound are assessment of the carotid arteries for stenosis as well as evaluation of the aorta for the presence of
aneurysms. Intima-media thickness is another study that has been described as valuable in assessing cardiovascular risk. A reemphasis on the
value of screening the healthy would be advantageous to the ultrasound
community as we enter into health care reform in the United States.
Twin-Twin Transfusion Syndrome
Jack Rychik Fetal Heart Program, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania USA
Musculoskeletal Ultrasound: Transition From Adults
to Pediatrics
Advanced Fetal Cardiac Evaluation and
Comprehensive Overview
Twin-twin transfusion syndrome (TTTS) affects approximately
15% of monochorionic twin pregnancies. The condition is triggered by a
placental vasculopathy, which then leads to a cascade of physiologic
events. TTTS results in a donor twin who manifests hypovolemia and
oligohydramnios and a recipient twin with polyhydramnios. The cardiovascular systems of both twins are affected in a unique and fascinating
manner, which is observable through fetal echocardiography. The donor
exhibits hyperdynamic ventricular function with increased placental resistance. The recipient develops a cardiomyopathy consisting of ventricular dilation, hypertrophy, decreased compliance, and systolic dysfunction
with tricuspid and mitral regurgitation. Approximately 15% to 20% of recipients develop changes within the right ventricular outflow and pulmonary valve complex such as pulmonic stenosis or pulmonary atresia of
a functional or anatomic nature. A scoring system for characterization of
these changes, the Children’s Hospital of Philadelphia (CHOP) TTTS cardiovascular score, has been developed and is useful in assessing disease
severity and response to therapy. Studies using fetal echocardiographyderived modalities such as ventricular strain and strain rate analysis have
provided insight into the pathophysiology of this disease. Placental laser
photocoagulation is an effective treatment therapy for TTTS. Laser results
in regression of cardiovascular findings. Cardiovascular characterization
through the CHOP score and other parameters can be performed after laser.
Long-term outcomes and, in particular, cardiovascular outcomes after laser
therapy are of great interest. TTTS may impact cardiovascular health and
provide imprints for disease long into adulthood.
Current Vascular Controversies
Moderator: John Blebea, MD, MBA
This session will examine the indications and follow-up duplex
criteria for carotid stenting, review the indications, results, and imaging criteria for angioplasty and stenting of the renal arteries, and discuss the recommended protocols for deep vein thrombosis imaging in different clinical
scenarios.
Moderator: Michael Di Pietro, MD
The objective of this session is to cover some of the anatomy
and entities familiar to experienced adult musculoskeletal radiologists but
not to pediatric radiologists, which pediatric radiologists are now being
asked by their clinicians (pediatric orthopedics, pediatric sports medicine,
and pediatric physical medicine and rehabilitation) to address.
Ultrasound of the Head and Neck
Moderator: Sharlene Teefey, MD
Ultrasound of the Thyroid and Parathyroid
Sharlene Teefey Mallinckrodt Institute of Radiology, Saint
Louis, Missouri USA
This lecture will focus on the thyroid and parathyroid glands.
The different types of thyroid carcinoma will be discussed, including demographics, histopathology, presenting features, and recurrence and mortality. The sonographic features of papillary carcinoma, medullary
carcinoma, primary thyroid lymphoma, and nodular hyperplasia will also
be discussed, and examples will be shown. The American Thyroid Association guidelines for fine-needle aspiration and follow-up of benign nodules and the Bethesda system for reporting cytology will be presented. In
the next part of the lecture, Graves’ disease and Hashimoto’s thyroiditis
will be discussed, including clinical and pathologic features. Sonographic
findings will be discussed and examples shown. There will also be a brief
discussion of subacute thyroiditis. In the last part of the lecture, primary
hyperparathyroidism will be presented, including etiology, symptoms,
anatomy, sonographic technique, and appearance, and examples will be
shown.
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SCIENTIFIC SESSIONS
WEDNESDAY, APRIL 10, 2013, 10:45 AM–12:30 PM
Emergency Ultrasound, Part 2
Moderator: Leslie Scoutt, MD
1540052 A Systematic Review of the Diagnostic Accuracy of Bedside
Ocular Ultrasound in the Diagnosis of Retinal Detachment
Jonathan Kirschner,* Hal Minnigan, Michael Vrablik,
Gregory Snead, Rawle Seupaul Emergency Medicine, Indiana
University School of Medicine, Indianapolis, Indiana USA
Objectives—Systematically review the literature to determine
the diagnostic accuracy of bedside ocular ultrasound (OUS) in the diagnosis of retinal detachment.
Methods—The design of this review conformed to the recommendations from the Meta-analysis of Observational Studies in Epidemiology statement. An experienced medical librarian searched the following
databases from their inception without language restrictions: Ovid MEDLINE, PubMed, EMBASE, the full Cochrane Library, Emergency Medical Abstracts, and Google Scholar. Content experts were contacted, and
bibliographies of relevant studies were reviewed to identify additional references. Studies were included if they prospectively recruited adult patients with acute signs and symptoms suggestive of retinal detachment
and provided enough detail on diagnostic test and criterion standard results
to construct contingency tables. Evidence quality was independently assessed by 2 investigators using the revised Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Discrepancies were resolved
by consensus or adjudication by a third reviewer. Diagnostic test characteristics were summarized for trials with a low risk of bias.
Results—Of 7771 unique citations identified, 78 were selected
for full text review, resulting in 4 trials assessed for quality. Agreement
between authors’ QUADAS-2 scoring was good (κ = 0.63). Overall trial
quality was deemed to be excellent with a low risk of bias in 3 studies. All
3 trials enrolled emergency department–based patients (N = 199) and evaluated clinician-performed bedside OUS using either a 7.5- or 10-MHz linear array probe. The prevalence of retinal detachment ranged from 13%
to 38%. Sensitivity and specificity ranged from 97% to 100% and 83% to
100%, respectively.
Conclusions—Bedside OUS has a high degree of accuracy in
identifying retinal detachment based on 3 small prospective investigations.
A larger prospective validation of these findings would be valuable.
1540708 Accuracy and Interobserver Agreement of Point-of-Care
Ultrasound for Diagnosis of Skull Fractures in Children
Joni Rabiner,1* Jeffrey Avner,1 Hnin Khine,1 Lana Friedman,2
James Tsung2 1Pediatrics, Division of Emergency Medicine,
Children’s Hospital at Montefiore/Albert Einstein College of
Medicine, Bronx, New York USA; 2Emergency Medicine, Division of Pediatric Emergency Medicine, Mount Sinai School of
Medicine/Mount Sinai Medical Center, New York, New York
USA
Objectives—To determine the test performance characteristics
and interobserver agreement for point-of-care ultrasound (US) performed
by clinicians compared to computed tomography (CT) or x-ray diagnosis
of skull fractures.
Methods—This was a prospective study of a convenience sample of patients <21 years of age who presented to the emergency department with head injuries or suspected skull fractures requiring a CT scan
or x-ray evaluation. After a 1-hour focused US training session, clinicians
performed US examinations to evaluate patients for skull fractures. CT
scan and x-ray interpretations by attending radiologists were the reference
standards for this study. Point-of-care US scans were reviewed by an experienced sonologist to evaluate interobserver agreement.
Results—Point-of-care US was performed on 72 subjects with
suspected skull fractures by 17 clinicians. The mean age was 6.5 years
(SD, 6.2 years), and 67% of patients were male. The prevalence of fracture was 11% (n = 8). Point-of-care US for skull fracture had sensitivity
of 88% (95% confidence interval [CI], 53%–98%), specificity of 97%
(95% CI, 89%–99%), a positive likelihood ratio of 28 (95% CI, 7–112),
and a negative likelihood ratio of 0.13 (95% CI, 0.02–0.81). The only
false-negative scan was due to a skull fracture not directly under a scalp
hematoma, but rather adjacent to it. The κ for interobserver agreement was
0.86 (95% CI, 0.67–1.0).
Conclusions—Clinicians with focused US training were able to
diagnose skull fractures in children with high specificity and interobserver
agreement.
1540563 Bedside Ultrasonography as an Adjunct to Routine
Workup in Evaluation of Suspected Acute Appendicitis in
the Emergency Department
Samuel Lam,1* Anthony Grippo,1 Christopher Kerwin,1 P.
John Konicki,1 Diana Strasburger1,2 1Emergency Medicine,
Advocate Christ Medical Center, Oak Lawn, Illinois USA;
2
Emergency Medicine, MacNeal Hospital, Berwyn, Illinois USA
Objectives—To evaluate the test characteristics of emergency
physician–performed bedside ultrasound (BUS) for the diagnosis of appendicitis. To identify components of routine emergency department (ED)
workup and BUS that are associated with the presence of appendicitis.
Methods—Patients 4 years of age and older presenting to the
ED with suspected appendicitis were eligible for enrollment. After informed
consent was obtained, BUS was performed on the subjects by trained emergency physicians who had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose appendicitis. Elements of the clinical
history and physical examination, white blood cell count (WBC) with polymorphonuclear percentage (PMN), and BUS findings were recorded on
data forms. Recorded BUS images were reviewed weekly during quality
assurance sessions. Subject outcomes were ascertained by a combination
of medical record review and telephone follow-up.
Results—A total of 125 subjects consented for the study, and
116 of them had adequate data for final analysis. The prevalence of
appendicitis was 37%. The mean age of the subjects was 20.2 years, and
51% were male. BUS was 100% sensitive (95% confidence interval [CI],
87%–100%) for detection of appendicitis, with a positive predictive value
of 72% (95% CI, 56%–84%). Specificity was not calculated because of
the large number of nondiagnostic BUS studies. Subjects with appendicitis had a significantly higher occurrence of anorexia, nausea, and vomiting
and higher WBC and PMN counts on presentation when compared to those
without appendicitis. Their BUS studies were also significantly more likely
to lead to visualization of the appendix, as well as findings of appendix diameter >6 mm, appendix wall thickness >2 mm, periappendiceal fluid, and
sonographic McBurney’s sign (univariate analysis, P < .05). BUS success
and accuracy were independent of operator, parenteral narcotic or
antiemetic administration, subject body mass index, or scanning time.
Conclusions—BUS was highly sensitive for appendicitis diagnosis in the ED in our study. The presence of several findings in the history, physical exam, and laboratory testing and on BUS increased the
likelihood of the diagnosis.
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1536633 Retrospective Review of Emergency Bedside Ultrasound
for Diagnosis of Pediatric Intussusception
Adam Wise,* P. John Konicki, Christopher Yenter, Samuel
Lam Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois USA
Objectives—To report the test characteristics of emergency
physician–performed bedside ultrasound (BUS) for the diagnosis of pediatric intussusception at a single institution.
Methods—The pediatric emergency department (ED) electronic medical record and BUS archive were first screened to retrospectively identify visits between January 1, 2909, and August 31, 2012, during
which BUS was performed. These records were then reviewed to identify
patients meeting the following inclusion criteria: (1) age 0 to 18 years seen
in the ED with a clinical presentation concerning for intussusception, (2)
BUS performed to identify intussusception and bedside impression documented in the medical record, and (3) a “formal” diagnostic study (computed tomography, ultrasound, or barium enema) was performed by the
radiology department after BUS was completed. All emergency physicians who performed BUS had undergone a minimum of 1-hour didactic
training on the use of BUS to diagnose pediatric intussusception.
Results—A total of 1607 charts were reviewed, with 46 meeting inclusion criteria. Four of those were later excluded for incomplete
documentation or lack of saved BUS images. Of the 42 patients ultimately
included, 28 were male (67%). The prevalence of intussusception was
21%. The mean age of the subjects was 32 months. There were a total of
11 positive and 31 negative BUS studies. BUS was 100% sensitive (95%
confidence interval [CI], 62%–100%) and 94% specific (95% CI, 78%–
99%) for detection of intussusception compared to radiology study results.
There were 2 false-positives (1 of which was determined to be transient intussusception after review of the bedside images with the radiologist) and
no false-negative BUS studies. Specificity of BUS increased to 97% if
only 1 false-positive was taken into account.
Conclusions—BUS is an accurate means of diagnosing pediatric
intussusception. Further study may be indicated to confirm such benefits.
Table 1. Test Characteristics of BUS Against Radiology Study Results
Radiology Results
Intussusception
Intussusception
BUS Results
Positive
Negative
2 (1a)
Intussusception positive
9 (10a)
Intussusception negative
0
31
a
Case of transient intussusception counted as true-positive.
1539106 Extension of the Thoracic Spine Sign as an Indicator of
Pleural Effusion
Eitan Dickman,* Suzanne Bialeck, Lawrence Haines,
Catherine Baxtrom, Victoria Terentiev, Antonios Likourezos,
Sergey Ayvazyan Emergency Department, Maimonides Medical Center, Brooklyn, New York USA
Objectives—Shortness of breath is a frequent complaint for
emergency department (ED) patients. Pleural effusion (PEf) is a common
cause of dyspnea. While computed tomography (CT) is considered the
criterion standard for the diagnosis of PEf, chest x-ray (CXR) is often employed. Ultrasonography can be rapidly performed at the bedside to identify many causes of dyspnea. PEf may appear as an anechoic collection
superior to the diaphragm, but this finding is not always present. In a normal ultrasound, the thoracic spine is not detected superior to the diaphragm
due to the high acoustic impedance of the lungs. If the thoracic spine is visualized extending superior to the diaphragm, this is likely due to the presence of fluid in the thorax. This study attempted to determine the utility of
the extension of the thoracic spine as a sonographic sign for detecting PEf
and to compare its diagnostic sensitivity to that of CXR.
Methods—Emergency physicians enrolled ED patients who
were undergoing a CXR and CT of the trunk. All participating physicians
attended a lecture covering lung ultrasonography and performed supervised chest ultrasound examinations until deemed proficient. The sonographers were blinded to any other imaging results. Patients were placed
supine with the head of the bed at approximately 45°. A 6–2-MHz curved
array transducer was placed in a coronal orientation in the midaxillary line
in the right and left upper quadrants so that the diaphragm and the abdominal spine could be identified. Both hemithoraces were imaged, and
the investigator documented whether the thoracic spine extended superior
to the diaphragm, thus providing evidence of fluid in the hemithorax.
These results were compared to radiologists’ interpretation of the CXR
and CT.
Results—A total of 149 patients were enrolled. Sensitivity of
the extension of the thoracic spine sign for PEf was 72%; specificity was
89%. For CXR, sensitivity was 61%; specificity was 98%.
Conclusions—The extension of the thoracic spine sign is helpful in determining the presence or absence of PEf.
1537918 Bedside Ultrasound Skills Acquisition by Medical Students
on Emergency Medicine Rotation
Uche Blackstock,* Jacqueline Munson, Christian Koziatek,
Demian Szyld Emergency Medicine, Bellevue Hospital/New
York University Medical Center, New York, New York USA
Objectives—Few opportunities exist for medical students to receive formal instruction in bedside ultrasound (BUS). Therefore, we developed a BUS simulation-based curriculum for rotating emergency
medicine (EM) students consisting of Web-based didactics and a handson skills session. We hypothesized that the curriculum would adequately
prepare students to perform 2 common EM procedures: a focused assessment with sonography for trauma (FAST) exam and placement of ultrasound-guided internal jugular central venous access (IJ CVA).
Methods—Forty-five medical students (16 second year, 21 third
year, 8 fourth year) on an EM rotation were enrolled. Participants viewed
3 instructional Web-based videos about BUS physics, the FAST exam, and
BUS-guided IJ CVA. Subsequently, participants attended a 3-hour handson BUS simulation-based training session led by a BUS expert, an EM attending physician with >7 years of BUS experience and >3000 completed
BUS scans. After the initial training session, the BUS expert observed participants’ FAST exams on a live volunteer, while a trained research assistant evaluated participants’ IJ CVA skills on an instructional mannequin.
Standardized checklists were used for both assessments. A passing score of
70% on each checklist was chosen prior to study initiation.
Results—Eighty-nine percent (40/45) of participants passed the
FAST and 96% (43/45) passed the IJ CVA skills assessments. Participants
were successful in obtaining most required FAST views, yielding a right
upper quadrant mean score of 90.6%, left upper quadrant score of 88.3%,
bladder view score of 97.2%, and lung sliding score of 90.6%, but had the
most difficulty with the cardiac view (72.2%). Eighty-four percent (38/45)
of participants placed successful IJ CVA within 3 attempts, 64.4% (29/45)
achieving success on the first attempt. Ninety-one percent (41/45) avoided
inadvertent puncture of the carotid artery.
Conclusions—A standardized curriculum consisting of Webbased didactics followed by a simulation-based hands-on session yields
high passing rates by rotating EM medical students on BUS skills assessments. Further studies are required to investigate the impact of undergraduate BUS education on skills acquisition and retention once students
reach residency.
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1434950 Number of Proctored Pediatric Focused Assessment With
Sonography for Trauma Exams Required for Proficiency
Sharon Yellin,1,2* Jennifer Chao,2 Richard Sinert,2 John
Gullett,2 Gerardo Chiricolo1 1Pediatric Emergency Medicine/Emergency Ultrasound, New York Methodist Hospital,
Brooklyn, New York USA; 2Pediatric Emergency Medicine/
Emergency Medicine, Kings County Hospital/State University
of New York Downstate Medical Center, Brooklyn, New York
USA
Objectives—To assess the number of proctored focused assessment with sonography for trauma (FAST) exams necessary for the
novice sonographer to accurately acquire the 4 views of the exam.
Methods—This was a prospective educational intervention
study of FAST exam mastery by novice third- and fourth-year medical
students (MS). Students were excluded if they had formal ultrasound training or prior experience. All students received a 2-hour online didactic
course on basic ultrasound and FAST. Students were then randomized into
1 of 3 groups: group 1, students performed 5 proctored exams; group 2,
10 exams; and group 3, 15 exams. Proctored exams were designed to give
the students hands-on practice under the guidance of trained sonographers.
The proctored exams were administered monthly and limited to 10 minutes to standardize the training sessions. At the end of each month, students
were tested on the FAST exam with the same 2 standardized patients, either a male 8 years old (body mass index [BMI] = 16.5 [66th percentile])
or a female 12 years old (BMI = 18.8 [60th percentile]). Students had 2
minutes to perform the test exam starting from the time they picked up
the probe. The test exams were recorded using video and later reviewed
and graded by examiners blinded (to groups) using a standardized data
scoring sheet. To pass, the students were required to obtain the standard
views of the organs and/or structures necessary to identify free fluid.
Results—Forty-five students consisting of 23 MS3s and 22
MS4s, ages 24 to 43 years, were enrolled. Groups were evenly matched
for MS year, age, and gender. Pass rates were lowest for group 1 (n = 15;
6.7%; 95% confidence interval [CI], 0.0%–31.8%) and significantly (P <
.05) higher for group 2 (n = 15; 60%; 95% CI, 35.7%–80.2%) and group
3 (n = 15; 86.7%; 95% CI, 60.9%–97.5%). The majority of failures in
group 1 were secondary to inability to complete the exam in the allotted
time, followed by difficulty in identifying the splenorenal interface.
Conclusions—An online course and proctored exams provides
students with the skills to perform FAST accurately on children. Five proctored exams is insufficient training for novice sonographers to master
FAST. Differentiating the added effect of increasing the number of proctored exams from 10 to 15 will depend on future enrollment.
1540999 Didactic and Hands-on Ultrasound Courses: Improving the
Point-of-Care Ultrasound Knowledge Base and Confidence
Levels in Emergency Medicine Providers
Athena Mihailos,* Kevin O’Rourke, Timothy Mooney,
Andrew Balk, Larissa Dudley, Lawrence Melniker, Sharon
Yellin, Gerardo Chiricolo Ultrasound, New York Methodist
Hospital, Brooklyn, New York USA
Objectives—Point-of-care ultrasonography (POCUS) has
proven to be a valuable, safe, and life-saving tool in the emergency department for ascertaining quick and often critical diagnoses. The goal of
our study was to evaluate the effect of an ultrasound course on the knowledge base (KB) and overall confidence level (CL) of emergency medicine (EM) physicians in performing and interpreting ultrasounds. This
course included didactics and hands-on training.
Methods—On July 25, 2012, the Emergency Ultrasound Division at New York Methodist Hospital led a 9-hour didactic and hands-on
ultrasound course. First, there were introductory lectures on the basics of
POCUS: exam setup, knobology, reporting, and data management as well
as the 5 life-saving competencies: procedural, echocardiography, focused
assessment with sonography for trauma, first trimester, and aorta. A handson tutorial then followed. Two tests were administered to 30 providers assessing KB and CL in performing and interpreting the ultrasounds both
prior to and at the conclusion of the course. The providers consisted of
EM residents and attendings that were separated into 2 groups. Novice
providers had not met the American College of Emergency Physicians ultrasound training guidelines, and more experienced providers had either
met or exceeded the guidelines. The data were interpreted using the change
in CL and KB of both groups prior to and on completion of the course.
Results—There was a 75% increase in overall CL in the novice
group on completion of the course vs a 35% increase in the more experienced providers. There was a 54% increase in the grades of the novice
participants vs a 33% increase in the more experienced participants. There
was no drop in CL or grades in either group.
Conclusions—An Emergency Ultrasound Division course followed by hands-on training led to increased CL and KB in both performing and interpreting POCUS by all participating providers. The greatest
percentage increase was appreciated in the novice providers.
Obstetric Ultrasound: Multiple Gestations and
New Techniques
Moderators: Anthony Johnson, MD, Martha Kelly-Martinez,
RDMS
1540640 Accuracy of Ultrasonographic Chorionicity Classification
Yair Blumenfeld Eunice Kennedy Shriver National Institute
of Child Health and Human Development, Maternal-Fetal
Medicine Units Network, Bethesda, Maryland USA
Objectives—Ultrasonographic (US) classification of chorionicity
is important in managing multiple gestations, as some antepartum surveillance and delivery timing recommendations differ by chorionicity. Our objective was to estimate the accuracy of US chorionicity classification in a
multicenter cohort of twins and investigate factors associated with accuracy.
Methods—This was a secondary analysis of a randomized trial
of preterm birth prevention of twins. Patients lacking data regarding US
chorionicity classification or pathologic chorionicity determination were
excluded. Maternal, obstetric, and US factors were assessed for possible
effects on US accuracy.
Results—A total of 545 twin sets whose chorionicity was classified by US prior to 20 weeks were included in this analysis (116 excluded). Of those, 455 were dichorionic and 90 were monochorionic by
pathologic evaluation. US misclassified 35 of 545 twins (6.4% overall
misclassification); 18 of 455 dichorionic twins were misclassified as
monochorionic by US (4%), while 17 of 90 monochorionic twins were
misclassified as dichorionic by US (19%). The sensitivity, specificity, and
positive and negative predictive values of US chorionicity determination
were 96%, 81%, 96%, and 80%. First-trimester US (<14 weeks’ gestation) was less likely to misclassify chorionicity than that performed from
15 to 20 weeks (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.23,
0.96). For each 1-day increase in gestational age, the odds of misclassification rose by 1% (OR. 1.01; 95% CI, 1.002, 1.03). None of the other factors, including maternal age, body mass index, parity, and prior cesarean,
affected US accuracy.
Conclusions—US performed prior to 20 weeks incorrectly
identified chorionicity in 6.4% of twin gestations. Importantly, 1 in 5
monochorionic gestations were incorrectly classified as dichorionic and
may not have been optimally managed. These data highlight the importance of evaluating chorionicity early in gestation and reconsidering the
classification of dichorionicity in certain circumstances (eg, with features
suggestive of twin-to-twin transfusion).
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1539223 Outcome After Second-Trimester Amniocentesis and
First-Trimester Chorionic Villus Sampling for Prenatal
Diagnosis in Multiple Gestations
Christian Enzensberger,1* Christina Pulvermacher,1 Jan
Degenhardt,1 Andreaa Kawecki,1 Ute Germer,2 Jan Weichert,3
Martin Krapp,4 Ulrich Gembruch,5 Roland Axt-Fliedner1
1
Division of Prenatal Medicine, University of Giessen &
Marburg, Giessen, Germany; 2Center for Prenatal Medicine,
Caritas Krankenhaus St Josef, Regensburg, Germany; 3Division of Prenatal Medicine, University of Schleswig-Holstein,
Campus Luebeck, Luebeck, Germany; 4Center for Endocrinology, Reproductive and Prenatal Medicine, Amedes Hamburg,
Hamburg, Germany; 5Division of Prenatal Medicine, University of Bonn, Bonn, Germany
Objectives—The purpose of this study was to classify pregnancy loss and fetal loss as well as the influence of maternal risk factors
in multiple pregnancies.
Methods—Details of the procedure and pregnancy outcome of
all patients were extracted from the clinical audit databases of 2 tertiary
centers. The files were collected in the time from January 1993 to December 2010. The procedure-related pregnancy and fetal loss rates were
classified as all unplanned abortions without important fetal abnormalities
or obstetric complications within 14 days after amniocentesis (AC) and
chorionic villus sampling (CVS).
Results—We had a total of 288 multiple pregnancies with a
total of 637 fetuses. After exclusion of 112 pregnancies with an abnormal
karyotype or fetal abnormalities detected by ultrasound as well as cases of
selective feticide, repeated invasive procedures, and monochorionic
monoamniotic pregnancies, 176 pregnancies and 380 fetuses, respectively,
were left for final analysis. Overall, 132 ACs and 44 CVSs were performed. The total pregnancy loss rate was 8.0% (14/176): 6.1% (n = 8) for
AC and 13.6% (n = 6) for CVS. The procedure-related pregnancy loss
rate was 3.4%: 2.3% after AC (3 cases) and 6.8% after CVS (3 cases).
There was no statistical significance between the 2 procedures (P = .15).
Conclusions—The procedure-related loss rate of 3.4% can be
compared with those in literature. The higher loss rates in multiple pregnancies than in singleton pregnancies have to be discussed when counseling parents.
1540424 Breaking Bad News During Perinatal Sonography:
Practical Aspects of a Novel Educational Pilot Using Highfidelity Hybrid Simulation
David Jackson,1* Petar Planinic,1 James Pennington,1 Gigi
Guizado de Nathan,2 Gwen Shonkwiler,3 Thomas Abdella1
1
Maternal-Fetal Medicine, 2Clinical Simulation Center of Las
Vegas, University of Nevada School of Medicine, Las Vegas,
Nevada USA; 3Medical Education and Evaluations, University
of Nevada School of Medicine, Reno, Nevada USA
Objectives—Few issues are as predictably inevitable as bad
news occurring during fetal sonography. There are currently no standards
on how to teach this essential communication skill. A pilot program using
high-fidelity hybrid standardized patient (SP) encounters for the delivery
of bad news in perinatal imaging is presented.
Methods—The budget for the project was $7200. Four residents (25% of our program) experienced 2 simulations each. A live video
feed allowed additional medical and sonography students to observe in a
classroom setting. Transvaginal simulation of an anembryonic gestation
and transabdominal simulation of severe fetal hydrocephalus were presented. Resident sonographers were unaware of the impending scenario
outcome. The transvaginal exam used a MedaPhor virtual reality “realfeel” haptic simulator placed between the actor’s legs (covered by a sheet).
The transabdominal exam used a linear video played on the screen of an
ultrasound machine. Following the simulation, faculty gave immediate
feedback on verbal and nonverbal mannerisms by sharing observations
from the recorded video. SPs then provided additional insight on perceived
communication skills. The exercise was completed with a classroom didactic on evidence-based techniques for breaking bad news followed by
faculty and participant group discussion.
Results—Residents and medical students enthusiastically reported that the simulation should be part of any future curricula. Postgraduate year 1 was designated as the year to begin. Despite varying levels
of training, both residents and medical students rated the experience as
level appropriate. The simulation was rated 5 overall (with 5 as excellent).
Individual segments were rated as: didactic (5), faculty feedback (5), video
review (4.9), SP feedback (4.75), and viewing in the classroom (4.7).
Conclusions—High-fidelity hybrid simulation allows needed
skill training in communicating bad news during perinatal sonography. Actor
simulation, faculty video feedback, and a classroom didactic with group discussion are valued components. The use of simulation-based training for all
sonographers in communicating bad news is an area for future study.
1525554 Coronal Measurement of Fetal Lateral Ventricles: A Crosssectional Ultrasonographic Study
Eldad Katorza,1* Nir Duvdevani,1 Jeffrey-Michael Jacobson,2
Yinon Gilboa,1 Chen Hoffmann,2 Reuven Achiron1
1
Obstetrics and Gynecology, 2Radiology, Sheba Medical Center, Tel Hashomer, Israel
Objectives—The aim of this study was to compare the diameter of the lateral cerebral ventricles measured on a traditional axial view
with measurements obtained in an unconventional coronal plane.
Methods—We conducted a prospective study of 144 fetuses in
which 2D sonographic measurements of the lateral ventricles in both axial
and coronal planes were performed at 19 to 38 weeks of gestation. Seventy-seven fetuses were evaluated as part of a routine fetal scan (routine
group), and 67 were referred for a dedicated scan (referral group). For
each fetus, only the distal lateral ventricle’s diameter was able to be measured by the “classic” transventricular axial plane, whereas both ventricles
were visible in the posterior coronal plane at the level of the atria using a
transcerebellar approach.
Results—The mean gestational age was 27.7 ± 4.6 weeks.
Good visualization of both ventricles was achieved in 91% of the cases
using the coronal plane. For the entire study group, the mean width of the
distal lateral ventricle on the axial plane was 7.9 ± 1.9 mm vs 8.2 ± 1.9 mm
on the coronal plane (P < .001). The mean axial width was 6.6 ± 1.1 mm
in the routine group vs 9.3 ± 1.6 mm in the referral group (P < .001). Coronal measurements yielded similar results. In addition, slight asymmetry
of the ventricles was detected in the routine group (0.2 mm), and the asymmetry was even more significant in the referral group (1.6 mm; P < .001).
Conclusions—Measurement of both proximal and distal ventricles is very important in the diagnosis of ventriculomegaly and essential in measuring ventricular asymmetry, both of which can be associated
with a bad prognosis. Our study showed that coronal measurement of both
proximal and distal ventricles is feasible, an advantage over the axial view
in which only the distal ventricle is clearly visible and measurable.
1537200 Feasibility of an Automated Modified Myocardial Performance Index System: A Novel Technique for Automated Measurement of a Modified Fetal Myocardial Performance Index
Mi-Young Lee,1* Hye-Sung Won,1 Eun-Jin Jeon,1 Jae-Yoon
Shim,1 Hee-Chul Yoon,2 Jin-Young Choi,3 Soon-Jae Hong3
1
Maternal-Fetal Medicine, Asan Medical Center, Seoul, Korea;
2
Digital Media City Research and Development Center,
3
Reserch and Development Team, Health and Medical Equipment Business Team, Samsung Electronics Co, Ltd, Suwon, Korea
Objectives—To evaluate the reliability and reproducibility of
the fetal left modified myocardial performance index (Mod-MPI) meas-
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urements using an Auto Mod-MPI system as a novel technique for measuring the Mod-MPI.
Methods—This was a prospective study of 117 cases from 110
normal singleton fetuses at 16.4 to 35.0 weeks of gestation. Two experienced operators each measured the left Mod-MPI twice manually and twice
automatically using the Auto Mod-MPI system (Samsung Electronics Co,
Ltd). This system operates as follows. At first, the clear image of the opening and closing clicks of mitral and aortic valves should be obtained. When
the operator places the cursor on the aortic outflow in a single Doppler
waveform and presses the Set key, the system automatically places the
calipers at the beginning of each click and calculates the Mod-MPI within
0.1 second. We evaluated whether the automated system can successfully
measure the left Mod-MPI. Intraoperator and interoperator reproducibility
were also assessed using intraclass correlation coefficients (ICCs), and the
manual and automated measurements obtained by a more experienced operator were compared using the Bland-Altman plot and ICCs.
Results—Among 117 cases, both operators successfully measured the left Mod-MPI in 114 cases using the Auto Mod-MPI system (success rate, 97.4%). All values of automated measurements by both operators
were perfectly matched (ICC = 1 for both intraoperator and interoperator
reproducibility). Among the manual measurements, the intraoperator ICCs
of both operators were 0.910 (95% confidence interval [CI], 0.872–0.937)
and 0.826 (95% CI, 0.758–0.877), respectively. The interoperator ICC
was 0.731 (95% CI, 0.678–0.785), and the mean difference between the
operators was 0.017 (95% CI, 0.010–0.024). There was good agreement
between the manual and automated values measured by the more experienced operator (ICC = 0.841).
Conclusions—The Auto Mod-MPI system is a fast and reliable
technique for measuring the Mod-MPI with excellent reproducibility.
1541081 First-Trimester Pregnancy Dating by Fetal Heart Rate:
A Simple Formula
Sarah Obican,1,2* Slava Khodak Gelman,2 John Larsen2
1
Maternal-Fetal Medicine, Obstetrics and Gynecology,
Columbia University, New York, New York USA; 2Obstetrics
and Gynecology, Maternal-Fetal Medicine, George Washington
University, Washington, DC USA
Objectives—Accurate dating is an essential tool in the management of pregnancies. Thus, we sought:
(1) to develop a new formula that establishes an association between fetal heart rate (FHR) and gestational age in pregnancies <9 weeks;
and (2) to compare the 2 methods of early pregnancy dating by crownrump length (CRL) measurement (established method) and FHR measurement (proposed method).
Methods—We conducted a retrospective analysis of early ultrasound exams of 176 singleton pregnancies with care at George Washington University between January 2001 and May 2011. The FHR was
obtained by standard Doppler techniques with low indices on pregnancies
seen for dating ultrasound between 4.5 and 8.5 weeks. Three variables
were subsequently retrieved for analysis from the selected cases: fetal heart
motion (FHMO), CRL, and gestational age based on CRL measurement).
A fourth variable, gestational age calculated from FHR measurement
(GAFHRM), was created using a proposed formula: GAFHRM =
FHR/20. The 2 methods of gestational age calculation were compared statistically using the Pearson correlation and the Student t test.
Results—There was a very strong correlation between the established method and our proposed method (r = 0.95). The average difference between methods was 0.13 days with an SD of 2.5 days. There was
no significant difference in gestational age (P = .48), suggesting that the
methods did not differ significantly in pregnancy dating. It was found that
87.5% of the pairings of measurements were within the 2.5 days.
Conclusions—We developed a novel formula to calculate gestational age early in pregnancy based on FHR: GAFHRM = FHR/20 ±
2.5 days, where 2.5 days is the SD derived from comparison to the estab-
lished CRL method. Data analysis of this pilot study demonstrates that
this method of pregnancy dating is highly consistent with the traditional
approach of dating pregnancy by the CRL method during early pregnancy.
Further study in an independent patient cohort is warranted to validate this
approach.
1537085 Umbilical Cord Blood Volume Flow Evaluation Using
3-Dimensional Ultrasound
Stephen Pinter,1* Jonathan Rubin,1 Oliver Kripfgans,1
Marjorie Treadwell,2 Vivian Romero,2 Michael Richards,1
Man Zhang,1 Anne Hall,3 J. Brian Fowlkes1 1Radiology,
2
Obstetrics and Gynecology, University of Michigan, Ann
Arbor, Michigan, USA; 3GE Healthcare, Wauwatosa, Wisconsin USA
Objectives—Umbilical cord blood volume flow measurement
with the intention of providing a straightforward and accurate method that
overcomes the limitations associated with traditional pulsed wave Doppler
flow methods and provides a means to recognize and manage at-risk pregnancies.
Methods—A GE LOGIQ 9 ultrasound system (4D16L [4.5–
16.0 MHz]; 4D3CL [2.0–5.0 MHz]) was used to acquire multivolume 3D
color Doppler data sets to assess umbilical flow. Volume flow was computed offline by surface integration of Doppler-measured velocity vectors
in a c-surface (lateral-elevational plane) positioned near the color flow
focal depth. Partial volume effects were corrected using Doppler power.
The proposed flow measurement technique overcomes the limitations of
traditional pulsed wave Doppler flow methods. The first study involved
volume flow measurements in 7 healthy ewes whose pregnancies ranged
from 18 to 19 weeks’ gestation (7 singletons). Sonographic umbilical arterial and venous flow measurements (4D16L) from each fetus were compared to the corresponding average measured arterial/venous flow to
assess measurement feasibility in a static vessel. A second complementary study involved flow measurements (4D3CL) in 7 healthy women
whose pregnancies ranged from 17.9 to 36.3 weeks’ gestation (6 singletons, 1 twin). Umbilical venous flow measurements were compared to
values reported in the literature to assess measurement feasibility in a dynamic vessel.
Results—In the fetal sheep model, arterial/venous flow comparisons yielded errors of ≤10% for 8 of the 9 measurements. In the clinical study, venous flow measurements showed agreement with the
literature over a gestational range of 24.6 to 36.3 weeks. Two of the 7 patients in the clinical study demonstrated lower flow than anticipated for
gestational age; 1 was subsequently diagnosed with intrauterine growth restriction and the other with preeclampsia.
Conclusions—Accurate measurements of umbilical cord blood
volume flow can be performed with relative ease in both the sheep model
and humans using the proposed 3D ultrasound flow measurement technique. Results encourage further development of the method as a clinical
means for diagnosis and identification of at-risk pregnancies.
1536973 Defining the Spatial Relationships Between 8 Anatomic
Planes in the 11 + 6- to 13 + 6-Week Fetus: A Pilot Study
Reem Abu-Rustum,1* Sameer Abu-Rustum,2 M. Fouad
Ziade3 1Center for Advanced Fetal Care, Tripoli, Lebanon;
2
Obstetrics and Gynecology, Nini Hospital, Tripoli, Lebanon;
3
Faculty of Public Health, Lebanese University, Tripoli,
Lebanon
Objectives—Our study aimed at investigating the spatial relationships between 8 anatomic planes in the 11 + 6- to 13 + 6-week fetus.
Methods—This was a retrospective pilot study where 3D/4D
stored data sets were manipulated to retrieve 8 anatomic planes starting
from the midsagittal plane of the fetus. The initial volumes were manipulated in reference plane A using rotation along the x-, y-, and z-axes to de-
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pict the fetus in the same midsagittal plane required for nuchal translucency measurement. Subsequently, to ensure uniformity in the approach,
standardization, a prerequisite for automation, had to be completed in 2 of
the 3 orthogonal planes prior to navigating through the volume to commence the navigation from the plane of the transverse abdominal circumference. This was accomplished by placing the reference dot in the fetal
spine at the level of the diaphragm in plane A, generating a transverse
plane of the fetal abdomen with the fetal stomach visible in plane B. Plane
B was then chosen as the designated reference plane 0 from which to navigate within the volume. We coined this standardized approach the midsagittal volume technique, and it was carried out on all the volume data sets
prior to navigating through each volume. Parallel shift was used starting
from plane 0, and the spatial relationships to 7 planes (5 cephalad and 2
caudad) were established. The median and range were calculated for each
of the planes, and they were evaluated as a function of the fetal crown
rump length. P < .05 was considered statistically significant.
Results—A total of 63 volume data sets were analyzed. The 8
anatomic planes were found to adhere to normal distribution curves, and
most of the planes were in a definable relationship to each other with statistically significant correlations.
Conclusions—To our knowledge, this is the first study to describe the possible spatial relationships between eight 2D anatomic planes
in the 11 + 6- to 13 + 6-week fetus, using a standardized approach. Defining these spatial relationships may serve as the first step for the potential
future development of automation software for fetal anatomic assessment
at 11 + 6 to 13 + 6 weeks.
1537670 Does Cervical Cerclage Placement Prolong Gestation in
Twin Pregnancies With a Sonographically Short Cervix?
Sara Brubaker,* Samantha Do, Noelia Zork, Cara Pessel,
Joy Vink, Annette Perez-Delboy, Sreedhar Gaddipati
Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA
Objectives—There are limited data to support the use of cervical cerclage in twin pregnancies. The practice has become less common
since the 2005 publication of a meta-analysis that revealed an increased
risk of adverse pregnancy outcomes among twin pregnancies in which a
cerclage was placed. The practice continues, however, likely driven in part
by patient request. Our objective was to compare gestational age at delivery among patients with twins and a short cervix who underwent cerclage
placement with those who did not.
Methods—We created a retrospective database of twin gestations that were diagnosed with a short cervix (cervical length ≤2.5 cm)
between 2004 and 2012 at our institution. Mean gestational age (GA) at
delivery was compared in women who did and did not undergo cerclage
placement using a 2-sample t test. The relative risk (RR) of delivery prior
to 32 and 34 weeks’ gestation was compared using a 2-sided χ2 test.
Results—Of the 158 women that met the inclusion criteria, 25
underwent cerclage placement. The mean GA at delivery in the cerclage
group was 32.6 weeks vs 33.8 weeks for the no-cerclage group (P = 0.77).
The RRs of delivery at <32 and <34 weeks’ gestation in the cerclage vs nocerclage groups were 1.12 (confidence interval [CI], 0.81–1.58) and 0.99
(CI, 0.8–1.45), respectively.
Conclusions—Studies evaluating the efficacy of cerclage in
twin gestations are mixed and are limited by small sample sizes. This is
among the largest single-center case series of cerclage in twin pregnancies
with a short cervix. We found that cerclage placement in these patients is
not associated with prolonged gestation. Larger prospective randomized
trials are required to more definitively answer this question.
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SCIENTIFIC E-POSTERS
1426579 Process for Selection and Implementation of a New Ultrasound Imaging System
Donald Tradup,1* Scott Stekel,1 Deirdre King,1,2 Nicholas
Hangiandreou1 1Radiology, Mayo Clinic, Rochester,
Minnesota USA; 2Trust Addenbrooke’s Hospital, Cambridge,
England
Objectives—Many factors come into play when selecting a new
ultrasound (US) imaging system, including image quality, work flow efficiency, ergonomics and system usability, and system serviceability. This
presentation will describe a comprehensive process for US equipment selection and implementation in the practice.
Methods—(A) Assessment of practice requirements. (B) Key
scanner features to consider: (1) available transducers; (2) imaging features; (3) work flow efficiency and ergonomic enhancements; (4) technical characteristics and features. (C) In-house prepurchase scanner
evaluation: (1) performance testing; (2) volunteer imaging and image quality assessment; (3) patient imaging.
Results—Clinical implementation after purchase: (1) acceptance testing; (2) configuration of image presets and exam protocols; (3)
user training.
Conclusions—This presentation will describe a comprehensive process for selection and implementation of new US imaging systems. Key elements of the selection process include a practice needs
assessment, review of available scanner features and capabilities, and an
in-house evaluation of all candidate systems prior to purchase. After purchase, acceptance testing, system configuration, and user training must all
be addressed.
1427024 Usefulness of 4-Dimensional Ultrasonogaraphy to Evaluate
Effects of Therapeutic Radiofrequency Ablation for Hepatocellular Carcinoma
Naoki Hotta Gastroenterology, Masuko Memorial Hospital,
Nagoya, Japan
Objectives—Studies to evaluate the tumor vascularity in hepatocellular carcinoma (HCC) have been done extensively with various imaging modalities because the finding of the vascularity is helpful to
evaluate the biological features of the tumor. In the present study, we investigated whether 4D real-time flow imaging is useful to display the accurate position of the radiofrequency ablation (RFA) needle in the tumor
and evaluated the efficacy of RFA therapy in patients with HCC.
Methods—Fifty-eight patients with 58 HCC lesions admitted to
our Masuko Memorial Hospital between November 2007 and February
2011 were enrolled in the present study. Their diagnosis was confirmed by
dynamic computed tomography and celiac angiography. All patients gave
written informed consent, and this protocol had been approved by the
Human Studies Committee at Masuko Memorial Hospital. For ultrasound
(US) imaging, we used Voluson 730 (GE Medical Systems, Milwaukee,
WI), Aplio XG (Toshiba Medical Systems, Tokyo, Japan), and iU22 (Philips
Healthcare, Bothell, WA) systems for RFA therapy with a convex probe as
US systems. The Aplio and Voluson machine probe is mechanical probe, and
the iU22 probe is matrix array probe. 4D real-time refers here to the display
of 3D moving images composed of 3 orthogonally intersecting scans in the
transverse, longitudinal, and horizontal planes. RFA was carried out under
real-time US guidance. We used an RF generator with 200 W of power connected to a 17-gauge perfusion needle (Radionics Inc, Burlington, MA); the
circuit was closed through a dispersive electrode.
Results—It was possible to obtain an accurate position of the
cool-tip needle and to perform the RFA procedure in all 58 HCC patients
with 58 nodules using 4D real-time US machines. We confirmed by various angles that the needle was inserted into the center of the tumor nodule. The simultaneous study before RFA therapy showed the inflow of
arterial blood and tumor stain, and importantly, it appeared that 4D realtime US provided much perceptible information on the spatial relationship
between the RFA needle and the target lesion.
Conclusions—We experienced the treatment of 58 patient with
HCC by RFA using 4D real-time US systems. Application of this method
allowed more accurate cauterization of the tumor.
1463047 Using Lung Ultrasound in the Diagnosis of Transient
Tachypnea of the Newborn and Hyaline Membrane Disease in Neonates at 28 Weeks’ Gestation and Later
Claudia Cadet,* James Tsung, Ian Holzman Neonatology,
Mount Sinai School of Medicine, New York, New York USA
Objectives—Hyaline membrane disease (HMD) and transient
tachypnea of the newborn (TTN) are common neonatal respiratory disorders with overlapping clinical presentations, gestational ages, and radiographic pictures. Ultrasonographic findings may distinguish these
disorders; however, data comparing diagnoses and disease severity by
lung ultrasound with those by chest radiography and clinical impression
are lacking. This study aimed to determine if ultrasound (1) can predict the
severity of the clinical course and (2) is diagnostically consistent with
chest radiography and the clinical impression.
Methods—We conducted a prospective study of infants ≥28
weeks’ gestation admitted from October 15, 2011, to June 15, 2012, with
respiratory distress. A group of similar but well patients were enrolled as
controls. Lung ultrasound was performed on each subject in the first 24
hours of life using a GE LOGIQ P5 ultrasound machine with a 10 linear
probe in both sagittal and transverse planes on anterior, axillary, and posterior views of each lung. Demographic data, duration of respiratory support (DRS), surfactant administration, radiographic diagnosis, and clinical
diagnosis were collected. An expert blinded to clinical data determined
ultrasonic diagnoses and percentage of B-line confluence (PBC). The primary outcome was to correlate ultrasound PBC with DRS. Secondary outcomes were comparisons of ultrasound diagnoses with those by
radiography and clinical impression.
Results—Twenty-six neonates (1040–4430 g, 30–40 weeks)
were enrolled. Sixteen had clinical diagnosis of TTN; 5, HMD; and 5, normal. DRS ranged from 0 to 797 hours. Linear regression gave a significant
correlation of DRS with PBC (R = 0.693; P = .001), improved by gestational age in a multivariable model (R = 0.765, P = .024) but not by birth
weight, age at ultrasound, maternal steroids, and mode of delivery. Ultrasound was 62.5% sensitive and 100% specific in diagnosing HMD.
Conclusions—PBC on lung ultrasound in the first 24 hours of
life in neonates with respiratory distress correlates well with the duration
of respiratory support and thus may be a useful predictor of disease severity. Ultrasound was a moderately sensitive and extremely specific test to
diagnose HMD.
1464510 Central Line Confirmation With Saline and Echocardiography
Ershad Elahi,* Ninfa Mehta, Shahriar Zehtabchi Emergency Medicine, State University of New York Downstate,
Brooklyn, New York USA
Objectives—The purpose of this study is to determine the confirmation of central venous catheter (CVC) placement by using echocardiography and agitated saline flushed through the catheter port.
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Methods—This study will be a prospective convenience sample of adults who received either subclavian of internal jugular CVCs as
deemed necessary by the attending physician independent of the study.
Enrolled patients will undergo CVC placement by a resident or attending
physician with a study investigator present to perform echocardiography
and interpret the study of the agitated saline flush in real time A chest xray will be performed to confirm CVC placement as the gold standard in
confirmation. Outcome Measures: The primary outcome of the study is the
correlation of positive interpretation of confirmation of CVC placement on
echo with correct placement as seen on chest x-ray. The other outcome
measure is time to confirmation with echo vs time to confirmation with
chest x-ray. Methods of Data Analysis: Data will be presented as median
and interquartiles (25%–75% quartiles) for continuous variables and percentages with 95% confidence intervals (CIs) for categorical variables.
Operating characteristics of bedside ultrasound in confirmation of CVC
will be reported by calculating sensitivity, specificity, and positive and
negative likelihood ratios, with respective 95% CIs. The time from procedure completion to confirmation by bedside ultrasound and time from
procedure completion to confirmation by chest x-ray will be presented as
median minutes with interquartiles. The comparison of these 2 measurements will be performed by Mann-Whitney U test. Occurrence of adverse
events will be reported as percentages with 95% CI. Sample size was calculated with projected sensitivity of 0.95 with a lower CI limit of 0.90; 91
patients will be enrolled in the study. Bedside ultrasounds for each enrolled subject will be saved and reviewed by a trained sonographer blinded
to the chest x-ray results. The inter-rater agreement of the blinded sonographer with the real-time sonogram interpretations will be measured by
Cohen’s weighted κ.
Results—This study is still undergoing Institutional Review
Board approval.
Conclusions—None yet.
Results—3D-PDS and DCE-MRI showed the vascularity absent posttreatment in 8 of 9 rheumatoid patients with 80% symptomatic
improvement and 4 of 6 psoriatic patients with 80% symptomatic improvement. Inflammatory neovascularity decreases occurred 1 to 2 months
before 80% improvement attained in all responders.
Conclusions—Vascular imaging combining DCE-MRI and
Doppler ultrasound appears useful in follow-up of medical anti-inflammatory treatments.
1489583 Multimodality Imaging of Laser-Ablated Prostate Tumors
Robert Bard,* Daniel Sperling Biofoundation, New York,
New York USA
Objectives—To follow thermal treatment progress of prostate
cancers with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).
Methods—Fifty-nine patients with Gleason grade 3 or 4 focal
prostate cancer were prospectively scanned with a GE Voluson E9 unit
employing a linear 18-MHz probe with conventional 3D/4D imaging
using 3D angio and glass body power Doppler image reconstruction. All
patient images were imaged by DCE-MRI with a 3.0-T Siemens unit
within 1 week of the sonogram. Patients were treated with a 980-wavelength diode laser with end-fire heat distribution. Safety thermal zones
were outlined to protect the rectum and neurovascular bundles.
Results—3D-PDS and DCE-MRI showed the tumor vascularity absent posttreatment in 59 of 59 patients. No posttreatment complications were noted.
Conclusions—Vascular imaging combining DCE-MRI and
Doppler ultrasound appears useful in preoperative planning and follow-up
of laser ablative treatments.
1489649 Multimodality Vascular Imaging of Bladder Tumors
Robert Bard,* Daniel Sperling Biofoundation, New York,
New York USA
1489380 Vascular Imaging of Lymph Node Metastases
Robert Bard Biofoundation, New York, New York USA
Objectives—To demonstrate the appearance of benign and malignant lymphadenopathy with 3D power Doppler sonography (3D-PDS)
and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).
Methods—One hundred twenty-five patients with invasive
breast cancer and 221 patients with postoperative lumpectomy/mastectomy follow-up were prospectively scanned with a GE Voluson E9 unit
employing a linear 12–18-MHz probe with conventional 3D/4D imaging
using 3D angio and glass body power Doppler image reconstruction. All
patient images were imaged by DCE-MRI with a 3T Siemens unit within
1 week of the sonogram. All lesions were later confirmed by surgery.
Results—3D PDS and DCE-MRI showed the nodal neovascularity in both axillae in 56 of 346 and 80 of 346 in a unilateral axilla. The
lesions were imaged well by both modalities and showed high correlation
with surgical findings. Imaging showed 136 of 346 positive axillae as
compared to 69 of 346 clinically detectable by palpation.
Conclusions—3D power Doppler imaging appears to as sensitive as DCE-MRI in detecting axillary lymphadenopathy. Vascular mapping may be useful in preoperative lymphadenectomy planning. 3D
mapping may permit image-guided treatment.
1489474 Ultrasonic Imaging of Treated Rheumatoid and Psoriatic
Arthritis
Robert Bard Biofoundation, New York, New York USA
Objectives—To follow treatment progress of arthritis with 3D
power Doppler sonography (3D-PDS) and dynamic contrast-enhanced
magnetic resonance imaging (DCE-MRI).
Methods—Nine patients with active rheumatoid arthritis of the
wrist and digits and 6 patients with psoriatic arthritis of the phalanges were
studied over a 1-year period.
Objectives—To demonstrate the appearance of benign and malignant bladder masses with 3D power Doppler sonography (3D-PDS)
and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).
Methods—Ninety-five patients with a Gleason grade 4 and/or
5 base of prostate cancer and 21 patients with bladder polyps and stones
were prospectively scanned with a GE Voluson E9 unit employing a linear 12–18-MHz probe with conventional 3D/4D imaging using 3D angio
and glass body power Doppler image reconstruction. Contrast-enhanced
ultrasound was performed on 3 patients. All patient images were imaged
by DCE-MRI with a 1.5-T Siemens unit within 1 week of the sonogram.
All lesions were later confirmed by cystoscopy or surgery.
Results—3D-PDS and DCE-MRI showed the tumor vascular
connection from the prostate extending into the bladder base. The vascular framework of transitional cell carcinomas was generally separable from
the previously noted base of prostate tumors. The lesions of a benign nature were imaged well by both modalities and included intravesical diseases such as polyps, stones, blood clots, and intraluminal prostate debris
following postoperative procedures.
Conclusions—3D power Doppler imaging appears to as sensitive as DCE-MRI in detecting bladder tumors. The role of a possible
screening test for evaluating hematuria deserves further study. Imaging in
patients with bladder base lesions may disclose unsuspected primary prostatic tumors. Vascular mapping may be useful in preoperative planning.
1505305 Multimodality Imaging of Microwave-Treated Prostate Tumors
Robert Bard Biofoundation, New York, New York USA
Objectives—To follow the thermal treatment progress of microwaved prostate cancers with 3D power Doppler sonography (3D-PDS)
and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).
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Methods—Twelve patients with Gleason grade 4 prostate cancer were prospectively scanned with a GE Voluson E9 unit employing a
linear 18-MHz probe with conventional 3D/4D imaging using 3D angio
and glass body power Doppler image reconstruction. All patients were
imaged by DCE-MRI with a 1.5-T Siemens unit within 1 week of the
sonogram. All lesions were followed by serial vascular imaging for 5
years. Six recurrences were found and biopsy proven. Three were retreated
by microwave, remaining stable, and 3 were retreated with MRI-guided
laser ablation in 2012.
Results—3D-PDS and DCE-MRI showed the tumor vascular
recurrence in 6 of 12 patients who were retreated and followed without recurrence measured either by a vascularity increase or prostate-specific
antigen rise.
Conclusions—Vascular imaging appears useful in preoperative planning and follow-up of microwave thermal treatments.
1505306 Multiplanar Mapping of Cellulite
Robert Bard Biofoundation, New York, New York USA
Objectives—To compare the accuracy of 3D sonographic mapping of cellulite with high-resolution small-field 3-T magnetic resonance
imaging (MRI).
Methods—Over a 2-year period, 99 consecutive patients with
palpable lower extremity subcutaneous nodules were preoperatively
scanned with a GE Voluson E9 unit employing a linear 18-MHz probe
with 3D angio and glass body power Doppler image reconstruction and a
3.0-T MRI small field of view within 1 week. All images were compared
with histologic sections. During the last year of the study, access to 22–70MHz linear probes permitted the concomitant study of 53 patients with
cellulite. Cellulite was studied with A- and B-mode ultrasound, color,
power, and angio Doppler, and 3D histogram analysis of the regional blood
supply and small-field 3-T MRI. Treatment used laser and antioxidant
therapies.
Results—With the use of 22–70-MHz probes, areas of cellulite
were imaged as part of a study using antioxidant therapies to reduce disfiguring areas. MRI had no diagnostic value in cellulite evaluation, although it accurately depicted fat compartments. Additionally, Doppler
ultrasound blood flow analysis showed abnormal flows in the regions of
greatest cellulite architectural distortion. The depth of the subcutaneous
fat may be measured and the penetration of the cellulite may be assessed
with 3D volumetric dermal/subdermal imaging.
Conclusions—3D multiplanar ultrasound imaging appears to
be significantly more accurate than MRI in diagnosing cellulite and may
facilitate laser ultrasound-guided treatments. Previsual treatment improvement may be noted by a decrease in inflammatory neovascularity.
1506560 Prostate Cancer Neovascular Responses to Antioxidants
Robert Bard Biofoundation, New York, New York USA
Objectives—To show Doppler sonographic vessel density imaging responses to antioxidant therapies.
Methods—One hundred eleven patients with prostate cancer
treated with antioxidant supplement therapies composed of beta-sitosterol,
resveratrol, and herbal antioxidants and followed over a 4-year period
were prospectively scanned with a GE Voluson E9 unit employing an endorectal 18-MHz probe with conventional 3D/4D imaging using 3D angio
and glass body power Doppler image reconstruction. Eighty-seven patients had Gleason 3, and 23 had Gleason 4. Follow-up at 6, 12, 18, 24, 30,
and 36 months was obtained. The vessel index was assessed on sonography by 3D histogram analysis and by dynamic contrast enhanced magnetic
resonance imaging (DCE-MRI). Follow-up biopsies were obtained shortly
after imaging studies, which occurred on a 6-month basis.
Results—Gleason grade 3 (low grade): 72 of 87 patients had
decreased vascular indices, indicating a positive response to the protocol.
Prostate-specific antigen (PSA) lowering was noted. Gleason grade 4 (high
grade): 10 of 23 patients had decreased vascular indices, indicating a positive response to the protocol. PSA lowering was noted. Five patients were
stable. Eight patients showed disease progression and a PSA rise, indicating a negative response to the protocol. DCE-MRI confirmed all sonographic tumor vascular findings. Biopsy correlation was good.
Conclusions—Vessel density sonographic indexing and DCEMRI analysis correlated well with a positive biochemical response to antioxidant therapies. Twenty-one percent of patients with aggressive tumors
who were nonresponders to this protocol were referred for alternative treatments in a timely manner.
1506561 Prostate Cancer 3-Dimensional Capsular Erosion Alert for
Bone Metastases and Lymphadenopathy Evaluations
Robert Bard Biofoundation, New York, New York USA
Objectives—To show capsular erosion as an alert to bone
metastases.
Methods—Eighty-one patients with capsular erosion evident
on 3D imaging were prospectively scanned with a GE Voluson E9 unit
employing an endorectal 18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction
and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).
Results—Sixty-seven of 81 patients had boney metastases
identified on MRI and bone scans. Two hundred forty patients without
capsular erosion on 3D imaging showed bone metastases in 3 of 240
cases. Capsular erosion was associated with perirectal adenopathy in 40
of 81 patients.
Conclusions—Patients with capsular erosion demonstrated a
3× incidence of bone metastases and a 2× incidence of perirectal lymphadenopathy. Since bone metastases are difficult to image on some standard MRI protocols, DCE-MRI may be requested to highlight abnormal
neovascularity.
1507806 Evaluation of a Small Abdominal Circumference by Ultrasound as a Predictor of Increased Doppler Resistance
Pedro Roca,1* Allen Kunselman,2 Gabor Mezei,1 Kari Whitley,1 Serdar Ural,1 John Repke1 1Obstetrics and Gynecology,
2
Public Health Sciences, Penn State Hershey Medical Center,
Hershey, Pennsylvania USA
Objectives—Ultrasonographic fetal evaluation has been used
to diagnose intrauterine growth restriction (IUGR). A measurement that
has shown to be predictor of IUGR is the fetal abdominal circumference
(AC). The use of Doppler of the umbilical arteries is helpful in following
fetuses previously diagnosed with IUGR. However, Doppler evaluation of
umbilical arteries has failed to be diagnostic for IUGR. To date, no study
has specifically examined the relationship if any between AC measurements by ultrasound and umbilical artery Doppler values. The objective of
this study was to determine if findings of decreased AC during ultrasound
can be used as an independent predictor of increased umbilical artery
Doppler resistance in fetuses.
Methods—After Institutional Review Board approval, we conducted a retrospective cohort study of all ultrasound studies performed at
the maternal-fetal medicine Unit in our center from July to November
2009. We obtained the fetal AC expressed as a percentile of gestational age
and measured the umbilical artery Doppler. The association between AC
and elevated umbilical artery Doppler was evaluated.
Results—A total of 299 patients were evaluated. We used the
SAS 9.2 system to evaluate the 2 main variables, AC percentile and umbilical artery Doppler. We found a linear association between AC percentiles and umbilical artery Doppler percentiles. The Pearson
correlation coefficient was –0.03 (95% confidence interval, –0.40, –
0.19). The R2 value was only 0.09, which means that only 9% of the
umbilical artery Doppler percentile variability is explained by the AC
percentile.
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Conclusions—The AC percentile is a weak predictor of abnormal umbilical artery Dopplers. Further research may help in determining if ultrasound evaluations other than the AC percentile may strongly
correlate with IUGR.
1508173 Persistence of Placenta Previa in Twin Pregnancies Diagnosed in the Second Trimester by the Degree of Cervical
Overlap
Simi Gupta,1* Nathan Fox,1,2,3 Andrei Rebarber,1,2,3 Daniel
Saltzman,1,2,3 Chad Klauser,1,2,3 Ashley Roman1,2,3 1Obstetrics and Gynecology, New York University School of Medicine,
New York, New York USA; 2Maternal-Fetal Medicine, Carnegie
Imaging for Women, New York, New York USA; 3Obstetrics and
Gynecology, Mount Sinai School of Medicine, New York, New
York USA
Objectives—Several studies in singleton gestations with complete previa have determined that the degree of placental overlap correlates
with the likelihood of persistence of previa at the time of delivery. However, no studies have correlated these findings in twin gestations. The objective of this study was to determine if the measurement of placental
overlap in twin pregnancies diagnosed with complete previa during the
second trimester will predict persistence of placenta previa at the time of
delivery.
Methods—This was a retrospective cohort study of twin pregnancies with complete placenta previa diagnosed at 15 to 19 and 20 to 23
weeks’ gestation from 2005 to 2011. All patients underwent transvaginal
ultrasound using GE Voluson or Medison equipment. The degree of
placental overlap was measured from the internal os to the edge of the
placenta and was correlated with the risk of persistence at the time of delivery. Groups were compared using the Mann-Whitney U test and Fisher
exact test as appropriate with P < .05 as significance.
Results—Of 532 twin gestations, 41 patients (7.7%) were
identified as having complete previa at 15 to 19 weeks’ gestation, and 9
of 41 patients (22%) had persistence of placenta previa at the time of
delivery. At 15 to 19 weeks, there was no significant difference in median overlap between patients who had persistence of previa or resolution of previa at delivery (17 vs 12 mm; P = .26) . A subset of 14 patients
(2.6%) were identified as having complete previa at 20 to 23 weeks’ gestation, and 8 of 14 patients (57%) had persistence at the time of delivery. At 20 to 23 weeks, there was no significant difference in median
overlap between patients who had persistence of previa or resolution of
previa at delivery (12.5 vs 14 mm; P = .85). Using thresholds of 5, 10,
15, 20, and 25 mm overlap at either 15 to 19 or 20 to 23 weeks, there was
no significant difference in the risk of persistence at the time of delivery.
Conclusions—In our population of twin gestations, the degree
of overlap of complete previa during the second trimester did not correlate with the likelihood of resolution by the time of delivery.
1509891 Sonographic Morphologic Score as a Predictor of the Outcome in Fetal Sacrococcygeal Teratoma
Marjan Bolouri,1* Eveline Shue,2 Douglas Miniati,2 Vicky
Feldstein1 1Radiology and Biomedical Imaging, 2Surgery,
University of California San Francisco Medical Center, San
Francisco, California USA
Objectives—Sacrococcygeal teratoma (SCT) is the most common tumor of the neonate. Ultrasound (US) is critical in the prenatal evaluation of fetuses with SCT, for whom outcomes vary widely. The purpose
of this study was to develop a morphologic scoring scheme to use as a
predictor of the outcome in fetuses with SCT.
Methods—The records of all patients carrying fetuses diagnosed with SCT between 1986 and 2011 at our fetal treatment center were
reviewed; those with available outcome data and US examinations were
included in the study (n = 40). Two radiologists, blinded to the outcome,
retrospectively reviewed the obstetric sonograms performed at presenta-
tion. Tumor sonographic morphology was classified as predominantly
cystic (>60%), predominantly solid (>60%), or mixed (40%–60% solid
and cystic). Tumor volume measurements and volume/estimated fetal
weight ratios were calculated. Good outcomes were defined as survival to
hospital discharge, whereas poor outcomes were defined as intrauterine
fetal demise, termination for hydrops or maternal mirror syndrome, perinatal death, or need for fetal intervention. Sensitivity, specificity, and the
positive predictive value (PPV) of morphology as a predictor of outcome
was calculated.
Results—A predominantly solid (>60%) sonographic appearance was associated with a poor outcome. Of 40 cases in this series, 10
SCTs were predominantly cystic, and 29 were predominantly solid on initial US. One mass appeared 50% cystic and 50% solid. The mean gestational age at presentation was 23 weeks. No significant difference in mean
tumor volume was seen between those with a poor outcome and those with
a good outcome (347 versus 183 cm3; P = .124). Mixed to predominantly
solid US morphology was associated with poor outcomes (sensitivity,
100%; specificity, 67%; PPV, 83%). None of the SCT cases presenting with
predominantly cystic sonographic morphology had a poor outcome.
Conclusions—A predominantly solid SCT appearance by US
is a highly sensitive predictor of a poor outcome. Therefore, sonographic
morphologic assessment is a useful predictor of the postnatal outcome in
the prenatal evaluation of fetal SCT. This may be useful for prognosis and
guiding obstetric management.
1511819 Retrospective Review of Fetal Body Lymphangioma
Including Postnatal Outcome
Kari Thomas, Karen Oh, Roya Sohaey* Diagnostic Radiology,
Oregon Health and Science University, Portland, Oregon USA
Objectives—The purpose of this retrospective review is to study
a series of 8 fetal body lymphangiomas (a type of lymphatic malformation)
detected on prenatal ultrasound and to assess how findings on fetal magnetic resonance imaging (MRI) and/or postnatal MRI or computed tomography (CT) differed from the prenatal ultrasound, primarily with
regard to the overall anatomic extent of the malformation. Accurate
determination of the overall extent of these malformations is critical in
delivery and postnatal treatment planning.
Methods—We reviewed each patient’s prenatal ultrasound and
then compared these findings with subsequent fetal MRI and/or postnatal
imaging. Postnatal imaging included MRI and/or CT. Maternal and neonatal electronic records were reviewed.
Results—In each of the 8t cases in our series, fetal MRI (4/8)
and postnatal imaging provided clinically relevant information for delivery planning (with fetal MRI) and treatment options (with both fetal MRI
and postnatal imaging). This information, regarding the size of the malformation and involvement of adjacent organs, was not fully disclosed by
prenatal ultrasound findings alone.
Conclusions—The extent of fetal body lymphangiomas is routinely underestimated by prenatal ultrasound. Fetal MRI and/or postnatal
cross-sectional imaging provided additive diagnostic benefit in every case.
These imaging modalities should be offered to patients when fetal lymphangioma is diagnosed on prenatal ultrasound.
1513506 Effect of Targeted Ultrasound Contrast Agent Attachment
on Nonlinear Frequency Emissions
John Eisenbrey,1* Valgerdur Halldorsdottir,1,2 Anush Sridharan,1,3 Joshua Rychak,4 Flemming Forsberg1 1Radiology,
Thomas Jefferson University, Philadelphia, Pennsylvania USA;
2
School of Biomedical Engineering and Health Systems, 3Electrical and Computer Engineering, Drexel University, Philadelphia,
Pennsylvania USA; 4Targeson Inc, San Diego, California USA
Objectives—Current strategies for differentiating attached from
unattached targeted ultrasound contrast agents (UCAs) rely on using motion tracking or signal changes after destructive pulses, both of which in-
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herently introduce temporal artifacts. In this study, the effect of UCA attachment on nonlinear frequency emissions was investigated as a potential real-time discriminatory attachment marker.
Methods—Nonlinear UCA behavior was studied using singleelement transducers and acoustically transparent Opticells (Nalge Nunc
International, Rochester, NY). Attachment Opticells were coated with
streptavidin (to provide a site for attachment) followed by incubation with
5% bovine serum albumin (BSA) solution to reduce nonspecific binding.
The coated Opticell was then incubated with Targestar-B microbubbles
(Targeson Inc) followed by phosphate-buffered saline washing in triplicate
and attachment counting/confirmation via light microscopy. An Opticell
coated with BSA alone was used as a negative specificity control with an
equivalent concentration of microbubbles (≈19 microbubbles/mL) added.
Nonlinear bubble behavior was investigated by transmitting 4- and 5-MHz
64-cycle pulses with a spherically focused single-element transducer
(Panametrics, Waltham, MA) and receiving signals with a 3.5-MHz spherically focused single-element transducer. Frequency spectra were then
compared after normalization to the fundamental peak.
Results—Secondary harmonics (2f0) were evident in all cases
with no differences in relative amplitudes observed between attached
and unattached UCAs. Generating subharmonic signals (f0/2; 2.0/2.5
MHz) proved difficult for both UCA groups. However, at 4 MHz, unattached bubbles began to show subharmonic behavior at 470 kPa with a
clear peak at 694 kPa. No definitive subharmonic peak was observed
using attached UCAs. Excitation at 5 MHz did generate some nonlinear
behavior in the subharmonic range, but differentiation of the subharmonic peak was difficult, presumably due to reflections generated by
the Opticell surface.
Conclusions—Targeted UCA attachment does not appear to
affect the second harmonic but may potentially inhibit the subharmonic.
This criterion may be useful for real-time identification of microbubble
attachment.
1513519 Correlation of Ultrasound Contrast Agent–Derived Blood
Flow Parameters With Immunohistochemical Markers in
Murine Xenografts: Influence of the Imaging Mode, Tumor
Model, and Subcutaneous Location
John Eisenbrey,1* Christian Wilson,1,3 Raymond Ro,1,4 Traci
Fox,2 Ji-Bin Liu,1 See-Ying Chiou,1 Flemming Forsberg1
1
Radiology, 2Radiological Sciences, Jefferson College of Health
Professions, Thomas Jefferson University, Philadelphia, Pennsylvania USA; 3College of Physicians and Surgeons, Columbia
University, New York, New York USA; 4School of Biomedical
Engineering, Sciences, and Health Systems, Drexel University,
Philadelphia, Pennsylvania USA
Objectives—To compare ultrasound contrast agent (UCA)derived blood flow parameters to immunohistochemical markers in glioma
and breast cancer murine xenograft models.
Methods—Breast cancer (NMU) or glioma (C6) cells were implanted in either the abdomen or thigh of 144 Sprague Dawley rats and
randomly separated into groups of 6, 8, or 10 days post implantation (12
rats per time point × 2 cell lines × 2 implant locations). Imaging was performed using power Doppler imaging (PDI), harmonic imaging (HI), and
microflow imaging (MFI) on with an Aplio scanner with a 7.5-MHz linear array (Toshiba America Medical Systems, Tustin, CA) during bolus tail
vein injection of the UCA Optison (GE Healthcare, Princeton, NJ; 0.4
mL/kg). Contrast kinetic blood flow parameters consisting of maximum
intensity, time to peak, perfusion, and time-integrated intensity (TII) were
calculated from time-intensity curves using parametric analysis on a pixelby-pixel basis and averaged over the tumor area. These values were compared to 4 immunohistochemical markers (basic fibroblast growth factor,
CD31, cyclooxygenase 2, and vascular endothelial growth factor [VEGF])
determined after tumor excision.
Results—When analyzing the entire data set, a significant inverse correlation was only observed between TII and VEGF for all 3 im-
aging modes (R = –0.35, –0.54, and –0.32 for PDI, HI, and MFI, respectively). When grouping data by tumor type, the NMU group correlations
became nonsignificant, while the correlation within the C6 group increased
(R = –0.43, –0.54, and –0.52 for PDI, HI, and MFI, respectively). When
grouping by tumor location, a significant correlation was not observed for
the thigh-implanted group, while the correlation within the abdominal
tumor group again strengthened relative to the entire data set (R = –0.41,
–0.58, and –0.38 for PDI, HI, and MFI, respectively). Consistent with the
above trends, the strongest correlation of TII to VEGF for all subgroups
was found to be abdominally implanted C6 cells (R = –0.51, –0.55, and –
0.57 for PDI, HI, and MFI, respectively).
Conclusions—TII appears to correlate best with the angiogenic
marker VEGF. However, these correlations were found to depend on both
tumor type and location.
1514789 Time From Nursing Request to Probe Placement Delays
Ultrasound-Guided Peripheral Intravenous Catheter Placement in Emergency Department Difficult-Access Patients
Glenn Heimburger,* Leigh Patterson, Kori Brewer Emergency Medicine, East Carolina University, Greenville, North
Carolina USA
Objectives—To assess the total time needed for ultrasound
(US)-guided peripheral intravenous (IV) catheter placement by emergency
medicine (EM) physicians in difficult-access patients.
Methods—Prospective convenience sample of patients presenting to an academic tertiary care center emergency department. Inclusion criteria were the need for IV access and inability of any available
nurse to establish a peripheral IV catheter. Exclusion criteria were the need
for central venous access or unstable patients as defined by the treating
physician. All physicians received introductory training prior to enrolling
patients. Outcomes measured were times from nursing request to probe
placement, probe placement to first skin puncture, first skin puncture to
successful cannulation or procedure abandonment, and total time from
nursing request to procedure completion. Number of failed nursing attempts, skin punctures, physician experience with US-guided peripheral
IV catheter placements (0–4, 5–9, or ≥10 previously placed), and physician training level were recorded.
Results—Sixty-four patients were enrolled. The mean (±SD;
range) times were: total time, 35.5 minutes (±21; 5–110 minutes); nursing
request to probe placement, 20.9 minutes (±18; 1–100 minutes); probe
placement to first skin puncture, 5.8 minutes (±5; 1–34 minutes), and first
skin puncture to successful cannulation or procedure abandonment, 8.7
minutes (±8; 1–36 minutes). Average number of failed nursing attempts
was 3.2 (range, 0–7). Average number of skin punctures was 1.5 (range,
1–5). Physician training level had no effect on time. Having performed
≥10 previous US-guided peripheral IV catheter placements vs 0 to 4 decreased total procedure time (P = .04) and time from probe placement to
first skin puncture (P = .04).
Conclusions—The largest delay in placing a US-guided peripheral IV catheter by an EM physician after nursing failure occurs from
nursing request to probe placement. Future studies should examine if variables exist during this period that could decrease total procedure time. Previous experience with placing US-guided peripheral IV catheters decreases
overall procedure time.
1514851 A New Sonographic Sign for Perinatal Torsion: the “Kiwi
Sign”
Ashraf Goubran,1,3* Fern Karlicki,1 Karen Letourneau,1
Ganesh Srinivasan2 1Ultrasound, 2Neonatology, St Boniface
General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; 3Diagnostic Imaging, Ain Shams University,
Cairo, Egypt
Objectives—Perinatal torsion must be recognized in an urgent
fashion if the testicle is to be salvaged. The purpose of this limited case se-
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ries is to describe a new sonographic sign for perinatal torsion that has, to
our knowledge, not been described previously.
Methods—Five cases underwent grayscale, color, and pulsed
Doppler evaluation for suspected torsion in the perinatal period during a
26-month interval. The age of presentation ranged from birth to 30 days.
The studies were performed using a Philips iU22 ultrasound machine. A
linear high-frequency transducer (17 MHz) was used for scanning. These
cases were retrospectively analyzed with regard to clinical and sonographic findings.
Results—The grayscale appearance of the affected testicle was
quite abnormal in our cases (n = 5). We subdivided our cases into 2 groups
based on the sonographic findings. The first group (n = 2) represented the
early phase of perinatal torsion, which we believe could have been potentially salvageable. The affected testicle in this group was markedly enlarged with a heterogeneous echo texture. Linear hypoechoic striations
were seen, radially oriented from the mediastinum testicle, giving a characteristic appearance of a section in a kiwi fruit. The second group (n = 3)
represented the nonsalvageable late phase of perinatal torsion, in which the
affected testicle was small and heterogeneous. Color Doppler assessment
in the affected testicle in both groups showed no flow.
Conclusions—On the basis of the limited number of cases included in our study and a review of the literature, we suggest that the “kiwi
sign” may become a useful finding representing the early phase of perinatal torsion. Future studies on a larger scale may prove that this sign can
be established as a reliable indicator to aid in surgical decision making.
1515353 The Swollen Pediatric Scrotum: Ultrasound Technique and
Differential Diagnosis
Kelli Schmitz,1 Kathryn Snyder,1 David Geldermann,2 Roya
Sohaey1* 1Diagnostic Radiology, Oregon Health and Science
University, Portland, Oregon USA; 2Colgate University, Hamilton, New York USA
Objectives—Review the ultrasound protocol for performance
of scrotal ultrasound in pediatric patients and illustrate the ultrasound appearance of conditions resulting in scrotal swelling. Provide a brief summary of scrotal embryology.
Methods—Retrospective review of an imaging database of pediatric patients presenting with scrotal swelling who underwent diagnostic ultrasound at a tertiary pediatric referral center. When available,
surgical/pathologic correlation was obtained. Some cases were diagnosed
in utero.
Results—Causes for pediatric scrotal swelling include intravaginal and extravaginal torsion, epididymitis/orchitis, hydrocele (simple,
inguinoscrotal, abdominoscrotal, iatrogenic, and spermatic cord), varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular
neoplasms.
Conclusions—A variety of typical and atypical pathologic
processes resulting in pediatric scrotal swelling will be presented in this
pictorial review. Best-practice ultrasound technique will be reviewed.
1515361 Suprarenal Masses in the Fetus
Sarah Rogers, Karen Oh, Roya Sohaey* Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon
USA
Objectives—Our objective is to review the imaging and differential diagnosis of fetal suprarenal masses.
Methods—Prenatal ultrasound and magnetic resonance imaging of fetal suprarenal masses is presented, along with clinical information
and follow-up. Imaging pearls and differential considerations for each diagnosis will be discussed.
Results—Fetal suprarenal masses, diagnoses include congenital adrenal hyperplasia (symmetric and asymmetric), extralobar pulmonary
sequestration, neuroblastoma, partial multicystic dysplastic kidney, renal
duplication, urinoma, gastric duplication cyst, and splenic cyst. Fetal adrenal masses are often malignant, and every attempt should be made to
differentiate between them and other diagnoses. Recognizing the range of
malignant and benign suprarenal fetal masses that can present on prenatal imaging can help guide patient counseling and management.
Conclusions—The differential diagnosis of a suprarenal mass
is broad but can be narrowed by imaging characteristics. A pictorial review
of suprarenal masses is presented along with technique and imaging pearls
toward accurate diagnosis.
1518185 Extraovarian Adnexal Sonographic Findings in Ectopic
Pregnancy: A Reappraisal
Mary Frates,* Peter Doubilet, Hope Peters, Carol Benson
Radiology , Brigham and Women’s Hospital, Boston, Massachusetts USA
Objectives—To assess the frequency of extraovarian adnexal
sonographic findings in patients with ectopic pregnancy using state-ofthe-art sonographic equipment.
Methods—All patients with pathologic or sonographic confirmation of ectopic pregnancy between July 1, 2008, and August 31, 2011,
who underwent transvaginal sonography (TVS) prior to treatment were included. The sonogram performed closest to the point of treatment was retrospectively reviewed for the presence of an extraovarian adnexal mass
and for a moderate-to-large amount of free fluid. In cases with an adnexal
mass, the presence of a tubal ring, yolk sac, or embryonic cardiac activity
was recorded.
Results—Our study population comprised 231 patients. A positive finding—adnexal mass and/or free fluid—was present in 220 of 231
patients (95.2%): adnexal mass in 218 of 231 (94.4%) and a moderate-tolarge amount of free fluid in 56 of 231(24.2%). Among our 231 study
cases, sonography demonstrated a tubal ring in 75 (32.5%), a yolk sac in
19 (8.3%), and embryonic cardiac activity in 17 (7.4%). In 140 cases
(60.6%), TVS demonstrated a nonspecific adnexal mass (without tubal
ring, yolk sac, or cardiac activity).
Conclusions—TVS demonstrates an adnexal abnormality in
>95% of patients with ectopic pregnancy. The most common finding is a
nonspecific adnexal mass. A tubal ring is found in fewer than half of cases
and a yolk sac and cardiac activity in <10%.
1518748 Axillary Lymph Nodes: Beyond Size and Shape
Abdelmohsen Hussien,* Avice O’Connell Women’s Imaging, University of Rochester, Rochester, New York USA
Objectives—Although ultrasound is helpful in detecting suspicious lymph nodes from breast cancer, many affected lymph nodes may
be missed. It is known that size is a poor criterion for evaluation of metastasis. Also, lymph node shape has low sensitivity. In this presentation, we
emphasize the role of ultrasound in detecting abnormal-appearing metastatic lymph nodes. Also, we will focus on the subtle sonographic signs of
metastatic lymph nodes.
Methods—We will demonstrate the value of the evaluation of
subdermal lymphatics, the use of harmonics, Doppler, and sonoelastography in assessment of the metastatic axillary lymph nodes.
Results—Some of the ultrasound techniques demonstrate better detection of the abnormal axillary lymph nodes.
Conclusions—The use of advanced ultrasound techniques is
helpful in evaluation of metastatic axillary lymph nodes and increases sensitivity.
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1518801 Ultrasound-Guided Fine-Needle Aspiration Biopsy of
Thyroid Nodules Performed by Family Practitioners in a
Health Clinic Setting
María Mata Castrillo,1* Jose Ignacio Jaen Diaz,1 Blanca
Cordero Garcia,1 Eugenio Cerezo Lopez,2 Francisco Lopez
de Castro,1 Paolo Ciardo1 1Buenavista Health Care Center,
Toledo, Spain; 2Ultrasound Explorations, Madrid, Spain
Objectives—Evaluate the impact of family practitioner interventions on the development of nodular thyroid pathology: techniques diagnosis, fine-needle aspiration biopsy (FNAB), and surgical follow-up.
Methods—Two family practitioners at a health clinic in Toledo,
Spain, which is charged with overseeing the health of 16,800 individuals,
performed all thyroid ultrasonography requested by the health center
physicians for their patients. These evaluations were previously performed
in a reference hospital. All explorations were analyzed in writing, and the
reports included a recommendation regarding patient follow-up and treatment. According to recommendations from the international literature, and
following informed consent, FNAB was performed on those nodules that
were suitable for the procedure. Previously, the decision to perform the
FNAB, its execution, and the treatment course were all left in the hands
of the reference hospital.
Results—A total of 392 ultrasonographic explorations were
performed between July 2011 and July 2012. Of these, 336 (85.7%) of
the subjects were female (mean age, 46.4 years), and 56 (14,3%) were
male (mean age, 45.2 years). The reasons for performing the explorations
included the following: clinical suspicion of thyroid pathology (goiter,
nodules), 37.5%; suspicion of thyroid pathology based on clinical analyses, 15.9%; follow-up of known nodular pathology, 34.4%; and follow-up
of other known thyroid problems (thyroiditis, postsurgical thyroids),
12.2%. Seventy-five FNAB procedures were performed, 9 (12%) of which
yielded insufficient material for diagnosis. Four cases of cancer were detected, all of them of a papillary nature. There were no complications during the conduct of these procedures.
Conclusions—Ultrasound-guided thyroid FNAB is a simple
and uncomplicated procedure that can be performed with a high degree of
success by family practitioners in community health centers as part of the
comprehensive management of nodular thyroid pathology. In our study,
this approach was time efficient for patients and provided a mechanism for
rapid intervention in a rather frequent pathology. Future studies will be required to evaluate the overall cost-effectiveness of this approach.
1522432 Small Retained Foreign Bodies: What Is the Limit of Detection Using Current Emergency Ultrasound Equipment?
Daniel Jafari,1 Kenneth Cody,2 Nova Panebianco,1 Frances
Shofer,1 Bon Ku,3 Arthur Au,3 Anthony Dean1* 1Emergency
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA; 2Emergency Medicine, Kaiser Oakland Medical
Center, Oakland, California USA; 3Emergency Medicine,
Thomas Jefferson University, Philadelphia, Pennsylvania USA
Objectives—Previous studies of small foreign bodies (FBs)
have shown a wide range of accuracies of FB detection using animal models, with high accuracy rates for FBs >10 mm and variable accuracy rates
for 4- to 5-mm FBs. This study aimed to determine the lower limit of sonographic detection of FB using current emergency ultrasound equipment in
a soft tissue model.
Methods—FBs made of metal, glass, wood, and plastic (3 of
each), 1 × 1 × 3 mm in size, were placed at a depth of 0.5 to 2.0 cm in 12
pork feet. Eight feet were punctured without FB placement. Pork feet were
submerged during this process to minimize air in tissue. Seven emergency
department (ED) sonologists with >2 years of experience were blinded to
the overall number, type, and depth of FBs but not to size. FB sites were
scanned by each sonologist using either a hockey stick or traditional lin-
ear array transducer in a randomized preassigned order. Sonologist confidence in the diagnosis was reported using a visual analog scale for each
site. Sensitivity, specificity, and positive and negative predictive values
(PPV and NPV) with 95% confidence intervals (CIs) were calculated. To
determine if sonologist confidence differed by the perceived presence or
absence of a foreign body, a paired t test was used.
Results—A total of 140 ultrasound scans were performed,
which reported sensitivity, specificity, PPV, and NPV as 50% (95% CI,
39%–61%), 50% (37%–61%), 60% (48%–72%), and 40% (28%–52%),
respectively. There was little agreement among the sonologists (only 2
sites with 100% agreement). Sensitivity ranged from 25% to 75%, specificity 37% to 62%, PPV 42% to 75%, and NPV 25% to 57% for each sonologist. Sonologists were more confident reporting a positive result (81%
vs 51%; P < .0001), irrespective of the actual presence of FBs. The difference between detection rates of 4 types of FB did not reach statistical
significance.
Conclusions—Current emergency ultrasound equipment used
by ED sonologists is unreliable in detection of 3-mm FBs in a human extremity soft tissue model. Future studies may further delineate accuracy
rates among different sizes and materials of FBs.
1522516 Four Consecutive Recurrent Cesarean Scar Pregnancies in
a Single Patient
Simi Gupta,1* Christina Cordeiro,2 Grace Pineda,1 Sherman
Rubin,3 Ilan Timor1 1Obstetrics and Gynecology, New York
University, New York, New York USA; 2Weill Cornell Medical
College, New York, New York USA; 3Sherman Rubin, Jackson
Heights, New York USA
Objectives—With the increase in conservative management of
cesarean scar pregnancies (CSP), there has been a growing interest in fertility outcomes for these patients. This is the first known report of 4 recurrent CSPs.
Methods—This is a case report on a patient who was referred
to a single institution with 4 recurrent CSPs. Data on evaluation, treatment, and follow-up of each of the pregnancies were collected.
Results—The patient had a pertinent obstetric history of 2 cesarean sections, the first for breech presentation and the second an elective
repeat cesarean section. The patient’s first CSP was diagnosed 7 years later
with an ultrasound finding of a pregnancy in the prior cesarean section
scar at 7 6/7 weeks of gestation with positive fetal cardiac activity. This
pregnancy was initially treated with transcervical intra-amniotic injection
of methotrexate with complete resolution. Nine months later, the patient
presented with her second CSP at 6 0/7 weeks of gestation with positive
fetal cardiac activity and was treated similarly with transcervical injection
of methotrexate with complete resolution. The patient’s third recurrence
was 9 months later when she presented at 5 4/7 weeks of gestation with
positive fetal cardiac activity and again was treated with transcervical injection of methotrexate with complete resolution. Finally, the patient’s
fourth recurrence occurred 8 months later. She was diagnosed at 6 1/7
weeks of gestation with positive fetal cardiac activity and again was treated
with transcervical injection of methotrexate. The patient is currently receiving follow-up for this CSP.
Conclusions—This is the first case report of 4 recurrent CSPs
in single patient. Each of this patient’s CSPs was treated conservatively
with local methotrexate. In reviewing the literature, there have been 6
cases of recurrent CSPs, with 1 report of 3 CSPs in the same patient. Those
cases were reportedly treated with methotrexate or surgery with or without resection of the scar. This information is important to help counsel patients who desire future fertility after a CSP.
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1522877 Many Faces of Uterine Adenomyosis: Ultrasound and
Magnetic Resonance Imaging
Vijayanadh Ojili Radiology, University of Texas Health
Science Center, San Antonio, Texas USA
Objectives—To describe the sonographic findings in different
types of uterine adenomyosis and correlate these with magnetic resonance
imaging (MRI) findings where available.
Methods—A brief review of different types of uterine adenomyosis (diffuse adenomyosis, focal adenomyosis/adenomyoma, and cystic adenomyosis) will be presented. The sonographic findings will be
described and correlated with MRI findings. The potential role of newer
ultrasound techniques (3D sonography and elastosonography) and pertinent management issues will be briefly discussed.
Results—Not applicable as this is a pictorial review.
Conclusions—Uterine adenomyosis is often misdiagnosed or
is not easily recognized, although it is responsible for disabling symptoms
such as menorrhagia, dysmenorrhea, and infertility. Therefore, it is important for the radiologist to accurately diagnose this condition in a timely
fashion. Although MRI is the imaging modality of choice for comprehensive evaluation, ultrasound is often the initial imaging test performed
in the diagnostic workup of these patients and will provide a diagnosis in
most cases.
1527190 Determining the Accuracy of Ultrasound in Identifying
Axillary Lymph Node Metastasis in Breast Cancer Patients
Madelene Lewis,* Abid Irshad, Susan Ackerman Radiology, Medical University of South Carolina, Charleston, South
Carolina USA
Objectives—Axillary lymph node staging is the most important prognostic indicator of outcome in breast cancer patients. A positive
percutaneous biopsy eliminates the need for sentinel lymph node (SLN)
biopsy, saving patients discomfort, time, and money. The purpose of this
study was to evaluate our ability to predict axillary nodal involvement
using ultrasound (US) in patients with invasive breast cancer.
Methods—After Institutional Review Board approval, a retrospective review was performed of 116 patients diagnosed with invasive
breast cancer between January 2010 and June 2011. Sonographic evaluation of the axilla was performed as part of our standard protocol for patients undergoing biopsy of a breast mass at our institution. Lymph nodes
were considered positive by US if any of the following criteria were present: cortical thickness ≥3 mm, eccentric cortical thickening, cortical lobulation, loss of fatty hilum, or nonhilar blood flow. US findings were
correlated with pathology results from fine-needle aspiration (FNA), core
needle biopsy (CNB), SLN, and/or axillary lymph node dissection
(ALND).
Results—A total of 116 patients (all females) were diagnosed
with invasive breast cancer. Mean age was 58.6 ± 11.9 (SD) years (range,
33–84 years) and included 69 white, 42 black, and 4 females from other
races. Axillary US was performed in all 116 patients. Sonographically, 41
patients had positive axillary lymph nodes, and 39 (95.1%) of these 41
were sampled by FNA, CNB, SLN, or ALND. Metastatic disease was
positive in 28 (72%) of 39 patients. Of the 75 patients with negative axillary US, 68 patients had final pathology. Of these, 51 (75%) remained
negative on SLN or ALND, while 17 (25%) of 68 had metastatic nodes.
The sensitivity, specificity, positive predictive value, and negative predictive value of US for predicting axillary metastasis were 72% (95% confidence interval [CI], 55%–84%), 75% (95% CI, 63%–84%), 62% (95%
CI, 47%–76%), and 82% (95% CI, 70%–90%). The overall accuracy of
US was 74%.
Conclusions—Preoperative US evaluation of the axilla in
breast cancer patients is effective for determining metastatic nodes. However, an SLN biopsy is still required in patients with negative preoperative
US.
1527866 Equivalence of 2- and 3-Dimensional Ultrasound in
the Evaluation of First-Trimester Nuchal Translucency by
Maternal-Fetal Medicine Fellows
Steffen Brown,* Michael Wolfe, Lesley de la Torre, Matthew
Brennan, Rebecca Hall Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico USA
Objectives—Conflicting data exist that 3D ultrasound produces
equivalent images to 2D for nuchal translucency (NT) assessment. We
aimed to prospectively evaluate the equivalence of 2D and 3D techniques
for obtaining the NT measurement as performed by maternal-fetal medicine fellows.
Methods—Prospectively enrolled subjects had first-trimester
screening performed per protocol at our institution by a fellow in maternal-fetal medicine under the supervision of an NT-certified sonologist.
This included transabdominal imaging first, followed by endovaginal imaging if necessary to obtain the proper image. A 3D image using the same
approach was then obtained and manipulated for measurement of the NT.
The 2D and 3D measurements were then compared using a Fisher exact
test and Bland-Altman plot, including root mean squared (RMS) to quantify paired differences.
Results—A total of 43 women were enrolled in the study.
Acceptable transabdominal NT measurements were obtained in 34 of the
43 subjects (79%), and the remaining 9 (21%) required endovaginal assessment to complete the exam. The differences in the NT measurements
using 2D vs 3D nuchal translucency values were normally distributed by
the Shapiro-Wilk test (P = .97). The 2D and 3D values averaged 1.40 ±
0.43 and 1.46 ± 0.49 mm, respectively. The 3D image did not significantly
overmeasure or undermeasure the NT (P = .69). 2D and 3D modalities
correlated within 3.7 mm (RMS) of one another. 3D imaging required an
average of 105 seconds more than 2D to complete (P < .001), though total
time for 3D averaged around 3 minutes (197 ± 179 seconds).
Conclusions—2D and 3D NT measurements correlate closely.
Performance and manipulation of a 3D volume sweep during NT assessment may provide an adjunct or confirmatory image.
1528363 Comparative Effectiveness of Fetal Magnetic Resonance
Imaging for Improvement of Diagnostic Accuracy
Christina Herrera,* Amber Samuel, Sherelle Laifer-Narin,
Lynn Simpson, Russell Miller Obstetrics and Gynecology,
Columbia University Medical Center, New York, New York USA
Objectives—Fetal magnetic resonance imaging (MRI) is performed as an adjunct to routine ultrasound with the intent of improving diagnostic accuracy, yet data are limited to substantiate benefit to this costly
imaging modality. This study analyzed the billed cost of fetal MRI relative to diagnostic information gained for patients with antenatal diagnoses
of a fetal anomaly and known postnatal outcomes.
Methods—This was a retrospective review of all fetal MRIs
performed between 2003 and 2011 at a tertiary care center. Potential cases
were identified if MRI was performed following sonographic concern for
a fetal anomaly. Inclusion required documented neonatal outcomes or
postmortem assessments. Test performance characteristics were calculated, from which the number needed to secure an additional accurate diagnosis by MRI was determined. Applying the cost per MRI at the study
center to this estimate, the cost per additional accurate diagnosis was calculated.
Results—A total of 799 MRIs were performed, of which 406
had documented neonatal or pathologic outcomes. One hundred thirtyone postnatal diagnoses were secured, of which MRI identified 51 (12.6%)
that ultrasound failed to correctly characterize. When the most common diagnosis groups were considered, meningomyelocele had the lowest cost
per additional correct diagnosis by MRI and ventriculomegaly the highest (Table 1). The cost per additional accurate diagnosis for cases of congenital diaphragmatic hernia, omphalocele, vein of Galen malformation,
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and Dandy-Walker complex could not be calculated, as there were no
pregnancies where MRI was accurate but ultrasound alone was not.
Conclusions—There is a variable cost per additional diagnosis
correctly secured that should be weighed when considering a pregnancy
for adjunct fetal MRI. Further study should be directed at assessing the
global cost-benefit of fetal MRI, as well as considering the value of MRI
for prognostication and surgical planning purposes.
1530478 Transcranial Sonography and 123I-FP-CIT Single-Photon
Emssion Computed Tomography in Movement Disorders
David Školoudík,1,3* Petra Bartova,1 Tana Fadrna,1 Otakar
Kraft,2 Martin Havel2 1Neurology, 2Nuclear Medicine,
University Hospital Ostrava, Ostrava, Czech Republic;
3
Neurology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic
Table 1
Objectives—Diagnosis of Parkinson’s disease (PD) and other
Parkinsonian syndromes (PS) could be difficult in early stages of the disease. Transcranial sonography (TCS) is able to detect structural changes in
the substantia nigra and basal ganglia in PD and PS patients, and fluoropropyl-carbomethoxy-iodophenyl-tropane (FP-CIT) single-photon emission computed tomography (SPECT) could detect presynaptic dysfunction
in several neurodegenerative diseases, including PD and PS. The aim of
our study was to assess correlation between TCS and SPECT findings and
diagnosis of PD, other PS, essential tremor (ET), and psychogenic movement disorder (PMD).
Methods—A total of 49 (32 male; age range, 26–73 years;
mean age, 56.1 ± 9.1 years) out of 53 screened patients were enrolled in
the study: 29 PD patients, 7 PS patients, 11 patients with ET, and 2 PMD
patients. Substantial nigra (SN) echogenicity and SN area were measured
using TCS. SPECT evaluation of basal ganglia was performed using a
dopamine active transporter ligand (123I-ioflupane). Both examinations
were performed within 2 months after clinical examination. The sensitivity, specificity, positive predictive value (PPV), and negative predictive
value (NPV) for TCS and SPECT were evaluated.
Results—TCS and SPECT findings correlated in 84% patients
(κ = 0.62; 95% confidence interval [CI], 0.38–0.86; ACE1 = 0.61; P =
.00002). TCS/SPECT sensitivity, specificity, PPV, and NPV for diagnosis
of PD were 89.7%/96.6%, 60.0%/70.0%, 76.5%/82.4% and 80.0%/93.3%,
respectively. Both positive TCS and SPECT findings correlated significantly with diagnosis of PD (κ = 0.52; 95% CI, 0.27–0.76; ACE1 = 0.59;
P = .0002; and κ = 0.69; 95% CI, 0.49–0.90; ACE1 = 0.74; P = .000001,
respectively).
Conclusions—TCS and SPECT are helpful in early diagnosis
of PD with high correlation. The sensitivity, specificity, PPV, and NPV
were similar for both methods. (Supported by a grant from the MoravianSilesian Region).
MRI Studies
Needed for 1
Cost per
Additional Accurate
Additional
Diagnosis
Diagnosis
Accurate Diagnosis
Meningomyelocele
3
$6,466.20
Multiple anomalies
6
$12,932.40
Brochopulmonary sequestration
9
$19,398.60
Congenital cystic adenomatoid malformation 12
$25,864.80
Ventriculomegaly
14
$31,175.60
1530454 Comparison of Brain Vessel Imaging From Transtemporal
and Subcondylar Approaches Using Contrast-Enhanced
Transcranial Color-Coded Duplex Sonography and a Virtual Navigator
David Školoudík,1,3* Martin Roubec,1 Martin Kuliha,1
Jaroslav Havelka,2 Katerina Langova,4 Roman Herzig3
1
Neurology, 2Radiology, University Hospital Ostrava, Ostrava,
Czech Republic; 3Neurology, Palacký University Medical
School and University Hospital Olomouc, Olomouc, Czech Republic; 4Biophysics, Faculty of Medicine and Dentistry, Institute
of Molecular and Translational Medicine, Palacký University
Olomouc, Olomouc, Czech Republic
Objectives—The transcondylar approach is a new approach
used for detection of chronic cerebrospinal venous insufficiency and intracranial venous reflux in patients with multiple sclerosis. The aim of the
study was to assess the capability of native and contrast-enhanced (CE-)
transcranial color-coded duplex sonography (TCCS) to detect flow and
reflux in deep cerebral veins and intracranial venous sinuses from
transcondylar and transtemporal approaches.
Methods—Brain magnetic resonance imaging and TCCS from
transtemporal and transcondylar approaches using the new technology,
fusion imaging, were performed in 8 volunteers and 5 patients with multiple sclerosis.
Results—Root mean square error <0.5 cm and accuracy of the
system <1 mm, measured using a registration pen, were detected in all
subjects. Using TCCS and CE-TCCS, arteries of the circle of Willis were
detected from the transtemporal approach in 13 of 13 and 13 of 13 subjects
and venous system in 8 of 13 and 10 of 13 subjects, respectively. However,
arteries of the circle of Willis and venous system were detected from the
transcondylar approach in only 5 of 13 (P < .01) and 1 of 13 (P = .03) subjects using TCCS and in 10 of 13 (P > .05) and 8 of 13 (P > .05) subjects
using CE-TCCS, respectively. Intracranial venous reflux was not detected
in any subject. A bidirectional Doppler signal from the region of the cavernous sinus detected in 3 subjects was evaluated as a breathing artifact.
Conclusions—The study results showed that the TCCS
transcondylar approach has serious limitations for standard detection of intracranial venous reflux.
1535936 Cell-Free Fetal DNA Testing for Aneuploidy: Initial Experience
Kisti Fuller,1,2* Adam Borgida2 1Maternal-Fetal Medicine,
University of Connecticut, West Hartford, Connecticut USA;
2
Maternal-Fetal Medicine, Hartford Hospital, Hartford, Connecticut USA
Objectives—Cell-free fetal DNA (cffDNA) tesing is now
widely available from commercial labs. We evaluated our initial experience of patients choosing cffDNA testing for fetal aneuploidy.
Methods—Since January 2012, we have been routinely offering cffDNA testing as an alternative to invasive testing for fetal aneuploidy. We reviewed our database of patients undergoing cffDNA testing.
Data collected included maternal age, indication for testing, gestational
age at time of testing, type of cffDNA test, length of time for results, and
out-of-pocket costs when known.
Results—There were 106 patients who met with a genetic
counselor for possible cffDNA testing. Of these 14 of 106 (13%) declined
testing, and 1 of 106 (1%) chose to undergo invasive testing. Of the 91 remaining patients, 24 (26.4%) chose directed DNA (dDNA) testing, and 67
(73.6%) chose massive parallel shotgun sequencing (MPSS). After the
initial draw, 3 of 24 (12.5%) samples for dDNA failed to produce a result,
and a repeat sample was required. The average patient age was 36 years.
The average gestational age at the time of testing was 16.5 weeks. The
average time from serum sample until initial results were received was 10
days. Testing indications were: advanced maternal age, 67%; abnormal
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serum screen, 46.2%; ultrasound anomaly, 28.6%; and/or family history,
4.4%. Patients that chose dDNA were not billed up front, and no information on their out-of-pocket costs was available. Patients that chose
MPSS testing required some prepayment. Of the 53 patients with a known
up-front charge, it was $235 for 26 and $475 for 27 patients.
Conclusions—The most common indication for cffDNA testing was advanced maternal age. The testing was most commonly done in
the early second trimester, and it took an average of 10 days for results.
There was a higher rate of test failure in the dDNA group (12%). The outof-pocket cost prior to testing may affect the patient’s desire for testing.
1536107 Hospital-Wide Survey of Bacterial Contamination of Pointof-Care Ultrasound Probes
Matthew Lawrence,1* James Blanks,2 Ruben Ayala,2 Joel
Schofer,1 Diana Macian,1 Douglas Talk,3 Jessie Glasser4
1
Emergency Department, Naval Medical Center Portsmouth,
Chesapeake, Virginia USA; 2Laboratory Services, Microbiology Division, 3Obstetrics and Gynecology, 4Internal Medicine,
Infectious Disease Division, Naval Medical Center Portsmouth,
Portsmouth, Virginia USA
Objectives—With the increasing use of point-of-care ultrasound
in many areas of medicine, there is a concern that ultrasound equipment
can facilitate transmission of infection to patients, especially methicillinresistant Staphylococcus aureus (MRSA). The primary objective of this
study is to determine the prevalence of bacterial colonization on hospitalwide point-of-care ultrasound probes by performing cultures of the probes.
Our hypothesis is that bacterial contamination is not a significant problem, and that our current ultrasound probe cleaning protocols are sufficient to protect patients against such nosocomial spread of infection.
Methods—The study was conducted at a single military hospital on 43 point-of-care ultrasound machines (87 probes) located within 9 departments over an 8-week period. Every probe was cultured 4 times during
the study period, at 2-week intervals. Intracavitary probes were excluded
from the study due to high-level disinfection protocols at our institution.
Positive cultures underwent species identification in the microbiology lab.
Results—At the time of this submission, the first half of data
collection was complete (2 culture sets performed on each machine, 2 culture sets remaining). Of the 174 probe cultures, 13 resulted in positive
growth (7.5%). Three cultures (1.7%) identified Micrococcus species, and
8 cultures (4.6%) identified coagulase-negative Staphylococcus, both of
which are common human skin flora. Three cultures (1.7%) identified
Bacillus species, not B anthracis or B cereus. Finally, 3 cultures (1.7%)
identified Pseudomonas species, which was not P aeruginosa. No cultures identified MRSA.
Conclusions—As hypothesized, bacterial contamination of
point-of-care ultrasound probes is low and primarily involves organisms
common to normal skin flora and the environment. MRSA contamination
was not identified at our institution. Antibacterial wipes after each use
seem to prevent significant bacterial growth on ultrasound probe surfaces.
(The views expressed in this article are those of the authors and do not
necessarily reflect the official policy or position of the Department of the
Navy, Department of Defense, or the United States Government.)
1536431 A Novel Approach to Visualizing the Vasculature Architecture of the Placenta Using 3-Dimensional Slicer Software:
A Pilot Study
Rie Oyama,1* Chizuko Isurugi,1 Tomonobu Kanasugi,1 Akihiko Kikuchi,1 Toru Sugiyama,1 Sonia Pujol,2 Ron Kikinis2
1
Obstetrics and Gynecology, Iwate Medical University,
Morioka, Japan; 2Radiology, Brigham and Women’s Hospital,
Boston, Massachusetts USA
Objectives—The aim of this pilot study presents a novel approach to visualize the vasculature architecture of the placenta using
grayscale to acquire volume data of the villous tree from the 3D ultrasound machine, and then these data restructure the placental vasculature
using 3D Slicer software, which is an open-source medical visualization
and analysis software package for medical image computing.
Methods—We used a Voluson E6 (GE Healthcare) system with
a RAB4-8-D/OB 3D/4D 8-MHz transabdominal wideband convex volume transducer. The 3D volume image was adjusted to include the entire
placenta. The volume data set was stored in the DICOM format for restructuring on the 3D Slicer software. This study included 2 women with
singleton pregnancies seen at 16 and 20 weeks at Iwate Medical University Hospital. Informed consent was obtained from each patient. The Institutional Review Board approved this study. The raw volume data were
imported into the Slicer software, which was loaded to display on the 2D
viewer (axial, sagittal, and coronal), and then the 3D image was displayed
on the 3D viewer. The 3D volume image restructured the placental vasculature using volume rendering, and the manual segmentation module
and label statistical analysis were used. (1) Volume-rendering module: We
determined region of interest of the placenta. Parameter set: The preset
chosen was CT-AAA, and the rendering used VTK CPU casting. (2) Manual segmentation module: Threshold Paint was used to create a region of
interest of the placenta and an umbilical cord image, which was based on
the grayscale volume of original raw data. (3) Label statistical analysis:
This module counted the number of voxels, which was the 3D volume
image of the placenta displayed using the manual segmentation.
Results—This study showed the placental vasculature of the
ultrasound image using 2 module methods. The number of voxels (10 ×
3) at 16 weeks was 60.519 and at 20 weeks was 193.934.
Conclusions—The 3D Slicer visualized the vasculature architecture of the placenta, which came from raw ultrasound data. Also, it will
be able to impact the filed of obstetric ultrasound and elucidation of the
placenta.
1536710 Efficacy of Ultrasound-Guided Tibial Nerve Perineural
Injections at the Posterior Tarsal Tunnel
Oliver Joseph,* Oleg Uryasev, John McNamara, Apostolos
Dallas Virginia Tech Carilion School of Medicine, Roanoke,
Virginia USA
Objectives—Compression of the tibial nerve (TN) within the
tarsal tunnel results in posterior tarsal tunnel syndrome. Like other nerve
compression syndromes, corticosteroid injections are a potential therapeutic modality. We hypothesize that one can effectively inject the TN
perineural space immediately proximal to the tarsal tunnel.
Methods—This research is a pilot study to investigate the efficacy of TN perineural injections bilaterally on 4 cadaveric models.
A 10–5-MHz small linear array transducer was placed along the medial
malleolus and Achilles tendon to visualize the neurovascular bundle. The
TN appeared spindle shaped with alternating hypoechoic and hyperechoic
bands superficial and anterior to the flexor hallucis longus tendon. Anterior long-axis injections of 0.35 mL of 0.5% methylene blue with subsequent anatomic dissection were confirmatory. Injections were designated
accurate (nerve stained) and precise (no damage to adjacent anatomy).
Results—Five of 8 (63%) injections were accurate and 6 of 8
(75%) precise. Initial attempts were unsuccessful, while later injections were
accurate and precise. The most apparent source of error was from 1 cadaver’s
pronounced musculoskeletal deformity, which precluded successful injections bilaterally. Of the 3 cadavers unaffected by musculoskeletal deformity,
accuracy was 5 of 6 (83%), and precision was 6 of 6 (100%).
Conclusions—While surgery is the definitive treatment for refractory posterior tarsal tunnel syndrome, corticosteroid injections could
likely provide symptomatic relief and postpone surgical intervention. This
study suggests that ultrasound guidance can increase accuracy and precision and is a potential adjunct to treatment. Future study will expand the
initial data set and allow for a consistent protocol, while later studies of patient outcomes will demonstrate clinical relevance.
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1536801 Cloacal Exstrophy: When an Omphalocele Is Not Just an
Omphalocele
Reza Pakdaman,1* Anne Kennedy,1,2 Mark Molitor,3 Janice
Byrne,2 Paula Woodward1,2 1Radiology, 2Obstetrics and Gynecology, 3Surgery, University of Utah, Salt Lake City, Utah USA
Objectives—(1) Illustrate additional congenital abnormalities
that, when seen in a fetus with an omphalocele, should lead to the diagnosis of cloacal exstrophy. (2) Illustrate the role of fetal magnetic resonance imaging (MRI) in making the diagnosis. (3) Correlate prenatal
findings with postnatal imaging and surgical findings in survivors. (4) Illustrate autopsy findings.
Methods—Retrospective review of 7 cases seen at 1 institution. Prenatal findings were correlated with postnatal multimodality imaging, surgical, or autopsy results.
Results—7 cases were seen for prenatal ultrasound (US). Fetal
MRI was performed in 4. See Table 1 for US findings. Pregnancy outcomes were live birth in 4, perinatal death in 1, intrauterine demise in 1,
and termination of pregnancy in 1.
Conclusions—The presence of an omphalocele should alert the
sonologist to perform additional views and seek other anomalies in an effort to refine the diagnosis. In particular, inability to demonstrate a normal
bladder and rectum and the presence of spine abnormalities should
heighten suspicion for cloacal exstrophy. Cloacal exstrophy is a rare anomaly not associated with aneuploidy; however, the condition requires multiple surgeries, and survivors require lifelong specialist care. Faced with the
long-term consequences of this condition, families may choose termination of pregnancy. Therefore, correct prenatal diagnosis is of paramount
importance. In ongoing pregnancies, delivery should be planned at an appropriate facility with the resources to manage children with complex
metabolic, surgical, and psychosocial needs.
Table 1. US Findings
Case
AWD
Bladder
Anus
Spine
Genitalia
1
Y
N
NA
Ab
NA
2
Y
N
N
Ab
Amb
3
Y
N
N
Ab
Amb
4
Y
N
NA
NA
Bifid
5
Y
N
NA
Ab
Amb
6
Y
N
NA
Ab
NA
7
Y
N
NA
Ab
NA
Ab indicates abnormal; Amb, ambiguous; and AWD, abdominal wall defect.
1536808 Imaging Spectrum of Fetal Autosomal Recessive Polycystic
Kidney Disease
Tony Trinh,1* Anne Kennedy,2,3 Joe Sherbotie,4 Janice Byrne3
1
School of Medicine, 2Radiology, 3Obstetrics and Gynecology,
4
Nephrology, University of Utah, Salt Lake City, Utah USA
Objectives—(1) Illustrate the spectrum of findings of fetal autosomal recessive polycystic kidney disease (ARPKD). (2) Correlate fetal
studies with postnatal imaging or autopsy results.
Methods—Retrospective review of cases seen at a single referral center.
Results—Renal enlargement was our most consistent finding.
Most kidneys looked normal up to 20 weeks but abnormally echogenic
kidneys were seen as early as 16 weeks. Echogenicity varied from the
classic highly echogenic pattern with loss of normal architecture to increased echogenicity with identifiable medullary pyramids to a pattern of
very echogenic pyramids similar to that seen in medullary sponge kidney
in adults. Amniotic fluid volume was variable from severe oligohydramnios to normal. Not all cases had evidence of pulmonary hypoplasia.
Conclusions—Not all cases of ARPKD present with the classic findings of large, brightly echogenic kidneys and severe oligohy-
dramnios. This reflects the variable phenotype with perinatal, neonatal,
and infantile types described. It is very important that sonologists recognize the full spectrum of findings to suggest ARPKD and differentiate it
from other causes of renal enlargement or abnormal renal echogenicity.
Fetuses with echogenic kidneys require postnatal follow-up. The prognosis is variable. Awareness of the possibility of ARPKD will result in appropriate testing of the parents for recessive gene carrier status. Affected
couples will have a 1:4 recurrence risk for future pregnancies.
1536912 Abnormal Ultrasound Findings in Patients With Clinical
Suspicion of Chronic Liver Disease in Sokoto and Its
Environs
Sadisu Maaji,* Abdulmuminu Yakubu, Danielle Odunko
Radiology, Usmanu Danfodiyo University Teaching Hospital,
Sokoto, Nigeria; Radiology, Federal Medical Center Birnin
Kebbi, Birnin Kebbi, Nigeria
Objectives—To describe the pattern of abnormal ultrasonographic findings in patients with clinical suspicion of chronic liver disease
in Nigeria, especially from the northwestern region.
Methods—A total of 61 consecutive patients with clinical signs
and symptoms of chronic liver disease attending medical outpatient clinics at the Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, and Federal Medical Center Birnin Kebbi were scanned at
radiology departments for any abnormal intra- abdominal findings from
May 2011 to April 2012. The exclusion criteria were patients with confirmed liver biopsy or diagnosis of chronic liver disease. Patients with cardiac cirrhosis and tropical splenomegaly syndrome were also excluded in
this study.
Results—A total of 61 abdominal ultrasound examinations
were performed during this study period. All the cases met the inclusion
criteria. The mean age was 46 ± 12.6 years (range, 50 years). The mean
liver sizes were 13.25 ± 1.48 cm (range, 11 cm) and 14.00 ± 0.77 cm
(range, 0.77 cm) for right and left lobes, respectively. The mean spleen
size was 15.9 ± 1.22 cm (range, 6 cm). The sex distribution was 43 males
(70.49%) and 18 females (29.5%). Of the 61 cases included, the indications for abdominal ultrasound were hepatitis in 1 (1.61%), liver cirrhosis
in 20 (50.82%), obstructive jaundice in 2 (3.28%), chronic liver disease in
25 (40.98%), and chronic abdominal swelling in 2 (3.2%). Gallbladder
wall thickening was demonstrated in 49 (80.33%) of the patients, while 12
(19.67) showed a normal gallbladder wall. Ascites was demonstrated in 45
(73.77%) of the patients, and the remaining 16 (26.23%) of the patients
had no ascites. Destroyed intrahepatic vascular architecture was demonstrated in 58 (95%), while 3 (4.9%) showed normal vascular architecture.
Conclusions—Ultrasound is useful in the diagnosis of chronic
liver disease in daily clinical practice. However, the sensitivity can be improved if a high-frequency probe is used and done by experienced and
dedicated operators. Liver biopsy remains the gold standard, especially
when patients are clinically asymptomatic.
1536944 Carotid Ultrasound May Not Be Sufficient to Perform
Carotid Endarterectomy
Robert Colvin,1* Alvaro Magalhaes2 1Kansas City University
of Medicine and Biosciences, Kansas City, Missouri USA;
2
Radiology, University of Missouri, Kansas City, Missouri USA
Objectives—Evaluate the accuracy of ultrasound to determine
treatment of carotid artery stenosis when compared to advanced imaging
modalities.
Methods—This study consisted of 47 patients who underwent
imaging for carotid artery stenosis by magnetic resonance imaging with
angiography or computed tomography with angiography at a Midwest regional medical center over a 27-month period. The results of the previously obtained duplex ultrasound studies were compared to results from
advanced imaging studies.
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Results—Of the 47 patients, 12 (25.53%) had a carotid artery
stenosis percentage diagnosed by ultrasound that agreed with the advanced
imaging modality. Fifteen (31.91%) patients likely would have had alternate treatment based on their advanced imaging studies. Based on the accepted current treatment, carotid endarterectomy for a symptomatic patient
with >70% stenosis by ultrasound, 3 patients would have undergone an unnecessary carotid endarterectomy. Additionally, 12 patients would have
met criteria for carotid endarterectomy and not received one.
Conclusions—Clinicians must consider that many patients may
receive inappropriate treatment of carotid artery stenosis if ultrasound is
the sole modality used for diagnosis. Eighty percent of endarterectomies
are performed based on ultrasound alone in the United States, meaning a
large impact on American health care overall. While more research is
needed, alternate imaging and close monitoring may be required with atypical or symptomatic patients before medical management or carotid endarterectomy is chosen as treatment.
1536948 Efficacy of Ultrasound-Guided Injection of the Sternoclavicular Joint Space
Yisrael Katz,* Oliver Joseph, Oleg Uryasev, John McNamara,
Apostolos Dallas Virginia Tech Carilion School of Medicine,
Roanoke, Virginia USA
Objectives—The sternoclavicular joint (SCJ) space can be affected by various osteoarthropathies, including degenerative, crystal deposition, and inflammatory. Like other osteoarthropathies, corticosteroid
injections could likely provide therapeutic relief to individuals with SCJ
osteoarthropathy. While the literature discusses the success of computed
tomography (CT)-guided injection, we hypothesize that ultrasound (US)
can be used to guide SCJ intra-articular injection without exposing patients to unnecessary radiation.
Methods—This study serves as a pilot study. The SCJ was injected bilaterally on 4 nonembalmed cadaveric models. The anatomy for
all cadavers was within normal limits, with the exception of 1, which had
marked musculoskeletal deformity of the lower limbs; an identical procedure was followed, and pathologic anatomy did not affect data collection. A 10–5-MHz small linear array transducer (L38n) was used. The SCJ
was palpated, and the transducer was aligned parallel to the angle of the
SCJ. Using a short-axis approach, US-guided injection was performed. A
1.5-in 22-gauge needle with 0.25 mL of 0.5% methylene blue was used.
Incisions were made parallel and perpendicular to the SCJ. The joint capsule was dissected to visualize the dye as confirmation. Attempts were
classified according to accuracy and precision. Accuracy measured if the
joint space was stained with dye; precision measured if the injection was
localized without damage to adjacent anatomy.
Results—Bilateral injections on all 4 cadavers were accurate
and precise.
Conclusions—US is inexpensive, quick, and minimally invasive
compared to CT. Given that CT-guided intra-articular SCJ injection with a
corticosteroid and anesthetic has provided symptomatic relief to patients
with SCJ pain, the analogous procedure can be performed under US guidance. Future phases of this study will expand the current data set and investigate the efficacy of US-guided SCJ injection in patients with SCJ arthralgia.
1536971 Efficacy of Ultrasonographically Guided Anterior
Interosseus Nerve Perineural Injection at Its Bifurcation
From the Median Nerve
Elizabeth Glazier,* Oleg Uryasev, Oliver Joseph, John
McNamara, Apostolos Dallas Virginia Tech Carilion School
of Medicine, Roanoke, Virginia USA
Objectives—Compression of the anterior interosseus nerve
(AIN) immediately distal to its bifurcation from the median nerve (MN)
results in Kiloh-Nevin syndrome. Like other nerve compression syndromes, corticosteroid injections are a potential therapeutic modality. We
hypothesize that one can effectively inject the AIN perineural space at its
bifurcation from the MN.
Methods—This study serves as a pilot study. The AIN perineural space was injected bilaterally on 4 cadaveric models. Cadaveric
anatomy was unremarkable with the exception of 1, which had marked
musculoskeletal deformity that did not affect the upper extremities. An
identical procedure was followed, and pathologic anatomy did not affect
data collection. A 10–5-MHz linear array transducer was used. The transducer was placed transversely through the antecubital fossa. The MN was
identified proximally as it coursed over the supracondylar eminence. It
appeared spindle shaped with alternating hyperechoic and hypoechoic
bands. The MN was traced inferolateral to the origin of the pronator teres
muscle, where the AIN bifurcation was visualized. Ultrasonographically
(US) guided injections were achieved with a long-axis, medial-to-lateral
approach with a 22-gauge syringe and 0.35 mL of 0.5% methylene blue.
Anatomic dissection and dye visualization allowed for confirmation.
Attempts were classified according to accuracy and precision. Accuracy
measured nerve staining; precision measured localized injection without
damage to adjacent structures.
Results—Six of 8 (75%) injections were accurate, while 4 of 8
(50%) were precise.
Conclusions—AIN perineural injection at its bifurcation from
the MN is significant. Such ability can likely provide symptomatic relief
with corticosteroid administration to patients with Kiloh-Nevin syndrome.
US is inexpensive, quick, and minimally invasive. Future phases of this
study will expand on our current data set and, pending such results, investigate efficacy of US-guided AIN perineural corticosteroid injections
in patients with Kiloh-Nevin syndrome.
1536975 Efficacy of Ultrasonographically Guided Injection of the
Ulnar Nerve Perineural Space at the Guyon Canal
Jeffrey Heimiller,* Oliver Joseph, Oleg Uryasev, John
McNamara, Apostolos Dallas Virginia Tech Carilion School
of Medicine, Roanoke, Virginia USA
Objectives—The ulnar nerve (UN) can become compressed as
it passes through the Guyon canal (GC). Like other nerve compression
syndromes, corticosteroid injection is a therapeutic modality. We therefore hypothesize that ultrasonographic (US) guidance can aid in effective
UN perineural injections in the GC at the level of the pisiform.
Methods—This is a pilot study to explore the feasibility of USguided injections of the UN perineural space in the GC at the level of the
pisiform. Injections were performed on 4 unembalmed cadavers, 1 of
which had marked musculoskeletal deformity that did not affect the upper
extremities. The GC was imaged in the transverse plane at the level of the
pisiform, and 0.25 mL of 0.5% methylene blue dye was injected into the
UN perineural space using a long-axis approach from the medial end of
the probe, just superficial to the pisiform. Anatomic dissection was performed subsequently to evaluate injection accuracy and precision: accuracy refers to nerve staining, while precision denotes that adjacent
structures were not damaged.
Results—Six of 8 (75%) were accurate. All injections were precise.
Conclusions—This study was able to demonstrate an effective
means of visualizing and injecting the UN perineural space at the GC
under US guidance. Inaccuracies were primarily operator dependent. The
operator for most injections was a second-year medical student with no
prior experience performing perineural injections. Initial attempts established an effective protocol. In the method described here, the operator
discovered and consistently visualized a narrow window immediately superficial to the pisiform that allowed for repeatedly accurate and precise
injections. Despite the initial learning curve, the operator was overall successful with accuracy of 75% and precision of 100%. US is a viable means
of increasing the accuracy and precision, and therefore effectiveness, of
UN perineural injections into the GC, but it must be combined with a
working knowledge of superficial landmarks and target anatomy.
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1537060 Comparative Analysis of Sonographic and Doppler Signs
and Perinatal Outcomes in Patients With Twin-Twin Transfusion Variants and Selective Intrauterine Growth Restriction
of One of the Monozygote Twins
Inessa Safonova,1* Irina Lukjanova,2 Rizvan Abdullaev1
1
HMAPO, Kharkiv, Ukraine; 2Pediatrics, Obstetrics, and
Gynecology Institute, Kiev, Ukraine
1537241 Unusual Anechoic Portal Vein Thrombosis and its Significance for Predicting the Response to Anticoagulant Therapy
Shoichi Matsutani,1,2* Hideaki Muzumoto,2 Akitoshi
Kobayshi,2 Atsuyoshi Seki,2 Takeshi Ando2 1Chiba Prefectural University of Health Science, Chiba, Japan; 2Gastroenterology, Funabashi Municipal Medical Center, Funabashi,
Japan
Objectives—Some complications of monochorionic (MH) multiple pregnancy, twin-twin transfusion syndrome (TTTS), twin anemiapolycythemia sequence (TAPS), acute intertwin transfusion, and selective
intrauterine growth restriction (sIGR) of one of the twins, have different
perinatal prognoses and require differential tactics. Our objective was to
compare their sonographic and Doppler signs, sequences, and the perinatal results.
Methods—Nine cases of complicated diamniotic MH pregnancy were studied: with chronic progressive unimproved TTTS (4),
TAPS (1), acute intertwin transfusion (2), and sIGR (2). Fetometry and
fetal weight calculation were carried out. The amniotic fluid amount and
Doppler of the umbilical artery, ductus venosus, and middle cerebral artery were estimated.
Results—The sequence of ultrasound signs and the perinatal
results in all cases have been described and compared. In 7 of 9 described
cases, the common sonographic feature turned out to be a discorded twin’s
growth. In 8 of 9 cases, a volume asymmetry of the twin’s amniotic fluid
was observed. The worst perinatal outcomes and the most substantial
weight differences were in women with natural flow of the TTTS, and all
4 cases were accompanied by fetal bladder asymmetry and donor cardiomegaly. At birth, hematologic distinctions of the twins were the most
considerable with TAPS.
Conclusions—Dynamic sonographic monitoring of an MH
pregnancy should take into account several aspects, such as fetometric,
amniometric, and Doppler as well as twin bladder symmetry and fetal cardiothoracic ratio control.
Objectives—Acute portal vein thrombosis is still a challenging
problem in daily clinical practice. Ultrasonography usually contributes to
an early diagnosis of portal vein thrombosis, which thus leads to appropriate treatment. However, the response to anticoagulant therapy is somewhat unpredictable, and these situations trouble clinicians in the
management of the disease. This report describes the unusual ultrasonographic appearance of acute portal vein thrombosis, which can predict a
poor response to anticoagulant therapy.
Methods—Sonographic changes in acute portal vein thrombi
were examined in 4 patients treated with anticoagulant therapy (heparin
and vitamin K antagonist). The background diseases were acute colitis in
2 patients, acute cholecystitis in 1 patient, and acute cholangitis in 1 patient. The thrombus was located in the right portal vein in 2 patients and
in both the right and left portal veins in 2 patients. A Toshiba SSA 770A
system with a 3.75-MHz convex probe was used for ultrasonography.
Results—Two of the thrombi in the right portal vein (group A)
completely recanalized with the disappearance of the thrombus in response
to anticoagulant therapy. However, 4 thrombi (group B) remained unrecanalized without a response to the treatment. The group A thrombi
showed echogenic material in the portal vein, which is a common sonographic appearance of thrombosis at the initiation of anticoagulant treatment. However, the group B thrombi were anechoic without any blood
flow signals at the initiation of the treatment, which was quite different
than the sonographic appearance of group A. The thrombus in 2 patients
in group B, which had a 1-week interval before anticoagulation, showed
echogenic material, which was similar to that seen in group A at the initial diagnosis. However, these 2 thrombi became anechoic 1 week later
after the initiation of the treatment. All portal veins with an anechoic
thrombus became occluded and changed to a hyperechoic band.
Conclusions—An unusual anechoic appearance of portal vein
thrombosis may therefore indicate a poor response to anticoagulant therapy, although the mechanism of this kind of ultrasonographic appearance
of blood clots is undetermined.
1537067 Transvaginal Sonographic Differential Diagnosis of the
Causes of Postpartum Uterus Involution Slowdown:
Clinical Experience of a Specialized Hospital Department
Inessa Safonova,1,2* Yuri Paraschuk,2,3 Roman Safonov2,3
1
HMAPO, Kharkiv, Ukraine; 2Kharkiv Regional Perinatal
Center, Kharkiv, Ukraine; 3Kharkov National Medical University,
Kharkiv, Ukraine
Objectives—to compare the sonographic, clinical, and histopathologic research results in patients with slowing down of involution of
the postpartum uterus.
Methods—Transvaginal sonographic (TVS) examinations
were undertaken in 140 postpartum women receiving care in a specialized hospital department for treatment of postpartum complications. In 38
of them, the uterine histopathology was studied.
Results—The opportunities of TVS in the differential diagnosis of retained lochia, endometrial inflammation, and retained placental
fragments in the postpartum uterine cavity were defined. Some specific
sonographic criteria of metritis after vaginal and operational births, as well
as retained unseparated placental fragments in the postpartum uterine cavity were exposed.
Conclusions—The diagnostic accuracy of most ultrasound criteria for postpartum complications was not great. At the same time, TVS
helped identify and differentiate the causes of uterine involution slowdown in some forms of endometritis and in women with unseparated placental fragments in the uterine cavity.
1537456 Sonographic Appearance of Cutaneous Basal Cell Carcinomas of the Head and Neck
Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile
Objectives—To assess the sonographic morphology of cutaneous basal cell carcinomas of the head and neck.
Methods—A retrospective review of cutaneous basal cell carcinomas of the head and neck sonographically diagnosed and confirmed
by histology was performed (September 2009–July 2012). Postoperative
cases and medically treated lesions were excluded from the analysis. Information about extension, location, blood flow, and deeper-layer involvement was analyzed.
Results—Forty-one lesions in 36 patients (55.6% female [n =
20], 44.4% male [n = 16]; mean age, 65 years [range, 38–92 years]).
Number of lesions per patient: 1, 86.1% (n = 31); 2, 8.3% (n = 3); 3, 2.8%
(n = 1); ≥4, 2.8% (n = 1). One hundred percent of cases were hypoechoic.
Location: 52% nose, 15% lower eyelid, 8% inner canthus, 5% scalp, 5%
supraciliary, 2.5% nasal fold line, 2.5% infraorbitary, 2.5% frontal region,
2.5% ear pinna, 2.5% other facial locations, 2.5% neck. Mean sizes: 7.79
mm transverse (range, 0.3–21.9 mm), 2.73 mm depth (range, 0.1–13 mm),
7.91 mm longitudinal (range, 0.5–31.1 mm). Mean area: 184.92 mm2
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(range, 0.01–2149 mm2). Location of blood flow: 86.9% intralesional,
7.9% peripheral, 2.6% sublesional, 2.6% mixed,. Type of vessels: 74.3%
arterial, 5.2% venous, 20.5% mixed arterial and venous. Mean thickness
of vessels: 0.94 mm (range, 0.5–1.8 mm). Mean peak systolic velocity of
the arterial vessels: 10 cm/s (range, 3.7–31 cm/s). One hundred percent of
arteries showed peak systolic velocity <15 cm/s. Deeper involvement:
14% of lesions affected the nasal cartilage and 15.6% the orbicularis muscles in the face.
Conclusions—Sonography can provide detailed anatomic data
on cutaneous basal cell carcinomas of the face and neck. This information
may support diagnosis and treatment.
1537466 Sonographic Staging in Hidradenitis Suppurativa With
Clinical Correlation
Ximena Wortsman,1* Claudia Moreno,2 Rosamary Soto,2
Javier Arellano,2 Carlo Pezo2 1Radiology, Dermatology,
Clinica Servet, Faculty of Medicine, 2Dermatology, Faculty of
Medicine, University of Chile, Santiago, Chile
Objectives—To correlate the clinical (cutaneous) and ultrasound findings in hidradenitis suppurativa (HS) and assess the role of
sonography in disease staging.
Methods—A retrospective study of the ultrasound examinations of the HS cases was performed (January 2010–May 2012). The patients were clinically classified (Hurley) by 3 dermatologists through
teledermatology. A radiologist performed the sonographic examinations
and designed 2 sonographically based scorings, 1 based on Hurley parameters (HLS) and other based on sonographic parameters (SOS). A double-blind analysis of the clinical and sonographic stages was performed.
The dermatologists and radiologist were blinded to each other’s report.
The statistical analysis included the mode of the clinical classification
using bivariate analysis of categorical variables. A κ test was used to evaluate concordance (95% confidence interval). The study was approved by
the Institutional Review Board.
Results—Thirty-four HS patients (80% female; mean age, 26.7
± 10 years) were evaluated. Combined locations were detected, and the
most frequent sites were: axillae, 82.4%; groin, 26.5%; simultaneous axillae and groin 17.7%. Other locations included the inframammary,
retroauricular, and thoracic regions: 3% for each, respectively. A significant correlation (bivariate analysis, P < .05) was observed between the
clinicians. When comparing the clinical with the sonographic scoring
(HLS and SOS), an underestimation of the severity (staging phase) by the
clinical examinations was found. Concordance values were κ = 0.343;
P = .009 for clinical/HLS and κ = 0.272; P = .023 for clinical/SOS scoring.
Conclusions—Clinical examination can underestimate the
severity (stage) of HS. Sonography may be a diagnostic tool to assess extension, types of lesions, and disease stage. It can provide noninvasive
scoring of this dermatologic disease, which may support early and better
management of these cases.
1537472 Sonographic Characterization of Glomus Tumors of the
Nail Unit
Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile
Objectives—To assess the sonographic morphology of glomus
tumors of the nail unit.
Methods—A retrospective review of glomus tumor cases in the
ungual region that were sonographically diagnosed and histologically confirmed was performed (January 2010–August 2012).
Results—Thirty-two glomus tumor cases (81% female/19%
male; mean age, 47 years; range, 21–80 years) were studied. Ninety-seven
percent of the cases involved the fingernails, 3% toenails; 71.9% affected
the thumb, 9.3% index finger, 6.2% ring finger, 6.2% middle finger, 3.1%
little finger, 3.3% big toe. Left side, 59%; right side, 41%. Morphology:
100% of tumors showed as a single oval hypoechoic nodule. Location in
the nail bed: proximal, 69%; distal, 25%; middle third, 6%. Mean transverse axis, 4 mm (range, 1.4–7.4 mm); depth axis, 2.7 mm (range, 0.8–5.7
mm); longitudinal axis, 5.4 mm (range, 1.7–10 mm). Fifty-nine percent of
the cases (n = 19) presented a depth axis <3 mm. Mean area of tumors:
41.2 mm2 (range, 1–220.8 mm2). Mean thickness of the tumor blood vessels: 1 mm (range, 0.6–2 mm); peak systolic arterial velocity: 10.5 cm/s
(range, 3.3–18.2 cm/s). In 3% of cases, blood flow was not detected within
the tumor. Eighty-one percent of tumors showed scalloping of the bony
margin of the distal phalanx.
Conclusions—Sonography provides detailed anatomic data on
glomus tumors of the nail unit that can be used for surgical planning, including tumors that measure <3 mm.
1537544 Correlation of Central Obesity and Body Mass Index With
the Number of Items Seen on Routine Anatomy Ultrasound
in Obese Patients
Simi Gupta,* Judith Chervenak, Ilan Timor, Ana Monteagudo
Obstetrics and Gynecology, New York University, New York,
New York USA
Objectives—Fetal anatomy scans are more difficult to perform
on obese patients. It has been suggested that central obesity may be a more
accurate predictor of the difficulty of an anatomy scan than body mass
index (BMI). The objective of this study was to determine if central obesity or BMI is correlated with the number of items seen on routine anatomy
ultrasound in obese patients.
Methods—This was a prospective cohort study at an inner city
public hospital of 67 obese patients (BMI ≥30) who underwent routine
anatomy ultrasound at 18 to 22 weeks’ gestation. Central obesity was
measured by placing an ultrasound probe horizontally below the umbilicus and measuring the amount of subcutaneous fat between the skin and
fascia. The number of items seen on ultrasound was based on the AIUM
guidelines for second-trimester anatomy ultrasound. Data were calculated
using Spearman’s ρ.
Results—The range of subcutaneous fat was 1.69 to 8.00 cm.
The range of BMI was 30 to 49.6 kg/m2. The correlation between central
obesity and the number of items seen on ultrasound was –0.216 (P = .08).
The correlation between BMI and the number of items seen on ultrasound
was –0.198 (P < .05). The correlation between central obesity and BMI
was 0.568 (P < .01).
Conclusions—BMI but not central obesity is significantly correlated with the number of items seen on a routine anatomy scan in obese
patients. This supports prior data that BMI is associated with the level of
difficulty in fetal ultrasound.
1537561 Sonographic Assessment of the Efficacy of Propanolol in
Cutaneous Hemangiomas of Infancy
Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile
Objectives—To assess the efficacy of propanolol in the treatment of cutaneous hemangiomas of infancy using sonography.
Methods—A retrospective cohort study was performed that included ultrasound cases that were medically referred by dermatologists
(September 2009–August 2012) with the diagnosis of hemangioma of infancy. Inclusion criteria were children ≤1 year old, 2 sonographic examinations with a minimum separation of 6 months, and a maximum
separation of 12 months between baseline and follow-up. Exclusion criteria were patients presenting ≥3 lesions or exposed to other treatment
(systemic or topical). The cases were separated in 2 groups: exposed to
propanolol (2 mg/kg twice a day orally administered) and nonexposed to
propanolol. Informed consent was obtained from the parents or guardians
in all cases. The Institutional Review Board approved this study. Analysis of the location, size in all axes, and blood flow was performed. The
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Fisher test was used to assess the significance of the morphologic changes
between the exposed and nonexposed groups.
Results—Twenty hemangiomas in 18 patients (66% female/
34% male; age range, 1 month–1 year) were studied. Nine patients were in the
exposed group and 9 in the nonexposed group. Single lesions: 89%; 2 lesions:
11%. Location: 75% head and neck (20% cheek, 20% lips, 13.6% nose, 13.3%
scalp, 13.3% temple, 6.6% eyelid, 6.6% neck, 6.6% submandibular), 15%
trunk, 5% upper extremity, 5%lower extremity. The exposed group showed a
significant decrease (P < .05) of the volume (P = .033) and transverse axis (P
= .033) of hemangiomas in comparison with the nonexposed group. The rest
of the P values were thickness, P = .057; longitudinal axis, P = .37; thickness of vessels, P = 1; and peak systolic velocity, P = 1.
Conclusions—Sonography can register the changes in the morphology of cutaneous hemangiomas of infancy that are medically treated.
Propanolol can significantly reduce the volume and transverse axis of hemangiomas of infancy in comparison with the nontreated group of patients.
1537671 Natural History of Fetal Pyelectasis and Risk of Infant
Uropathy
Emily Neri,1* Jean Goodman,1,3 Jennifer Peck2 1Obstetrics
and Gynecology, 2School of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA;
3
Obstetrics and Gynecology, Loyola University Medical Center,
Maywood, Illinois USA
Objectives—The objectives of this study were to (1) determine
the rate of resolution of fetal pyelectasis identified in the second trimester
prior to delivery and (2) determine the predictive value of varied degrees
of pyelectasis identified in the antenatal period and infant uropathy.
Methods—A retrospective study was designed, with review of
all prenatal ultrasounds with a diagnosis of second-trimester pyelectasis in
our established database between May 2010 and January 2011. Per our
routine for this diagnosis, repeat ultrasounds in the third trimester were
performed and also reviewed. Maternal and newborn records from our
electronic medical record and infant renal ultrasound records were examined. Exclusion criteria were chromosome abnormalities, fetal anomalies,
multiple pregnancies, and delivery not at our facility. The incidences of pyelectasis in the second trimester, persistence in the third trimester, and persistence after delivery were defined. Varied pyelectasis measure cut points
were determined to assess the utility of pyelectasis as a screening test for
postnatal uropathy.
Results—During the 9-month period, there were 119 secondtrimester ultrasounds with isolated pyelectasis identified with subsequent
third-trimester ultrasound and delivery at our facility. The incidence of pyelectasis was 1%, with a mean anteroposterior renal pelvis diameter of 5.2
mm in the second trimester and 6.0 mm in the third trimester (range, 4–10
mm). Twelve percent of second-trimester pyelectasis resolved by the third
trimester, and 45% resolved by delivery. Of third-trimester follow-up scans,
all those who resolved by delivery had measured diameters <9 mm. Thirtysix infants had postnatal ultrasound with 28 (78%) abnormal. Of those, 21 infants had voiding cystourethrograms with 4 abnormal (19%), and 4 required
surgical intervention (1.9%). With a third-trimester cut point of 7 mm, all
those requiring surgery were identified (sensitivity, 100%; specificity, 67%;
positive predictive value, 11%; negative predictive value, 100%).
Conclusions—Second-trimester pyelectasis of ≥4 mm warrants
follow-up in the third trimester given the high likelihood of persistence.
Follow-up at delivery is advised if pyelectasis is ≥7 mm on third-trimester
assessment.
1537779 The Stripe Unraveled: From Dysfunctional Uterine Bleeding to Postmenopausal Bleeding
Chitra Chandrasekhar,* Verghese George Diagnostic and
Interventional Imaging, University of Texas Health Science
Center, Houston, Texas USA
Objectives—Transvaginal sonography (TVS) has become an
acceptable and standard means of evaluation of the female patient with
dysfunctional uterine bleeding or postmenopausal bleeding. TVS is a standard initial investigative tool easily performed in the office. The demonstration of a normal stripe by TVS is a reliable and easily performed
noninvasive investigative procedure that obviates the necessity for endometrial biopsy. At least 70% of perimenopausal and postmenopausal
visits and 20% of gynecologic office visits are for abnormal uterine bleeding, which call for sonographic evaluation of the endometrial stripe.
Methods—(1) To comprehend the physiologic variations of the
endometrial stripe (EMS) in the premenopausal, perimenopausal, and
postmenopausal female. (2) To demonstrate normal and abnormal appearances of the EMS, including focal and diffuse processes within the
endometrium and the effects of tamoxifen therapy. (3) To illustrate technical approaches for TVS and hysterosonography as methods to study the
EMS and to prevent technical and interpretative pitfalls.
Results—Review of this poster will enable the viewer to understand the following: (1) The standard of care in evaluation of the EMS
is transvaginal sonography and should not be limited to the transabdominal approach only. A transabdominal scan alone is not considered sufficient
to exclude endometrial pathology. (2) Technical pitfalls in imaging of the
EMS will be illustrated. (3) Saline-infused hysterosonography is useful in
delineating endometrial pathology to lead the clinician toward the next
step such as a directed endometrial biopsy in the investigation of abnormal vaginal bleeding.
Conclusions—Understanding the appearance of the EMS in
premenopausal and postmenopausal females is critical to exclude or include underlying pathology. TVS is a standard, safe, and widely accepted
first line of investigation in patients presenting with abnormal vaginal
bleeding regardless of their reproductive status. Recognition of a normal
stripe excludes or directs the clinician toward the next step in the investigation of vaginal bleeding. Demonstration of focal nodularity or thickening may direct the clinician to hysteroscopy and biopsy rather than a blind
endometrial biopsy in the office.
1537941 Prevalence of Fluid Associated With the Iliotibial Band in
Asymptomatic Recreational Runners: An Ultrasonographic
Study
Elena Jelsing,1,2* Jonathan Finnoff,3 Bruce Levy,1 Jay
Smith1,2 1Sports Medicine, 2Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota USA; 3Sports Medicine, Tahoe Orthopedics and Sports Medicine, South Lake
Tahoe, California USA
Objectives—To evaluate the prevalence and distribution of fluid
associated with the iliotibial band (ITB) in asymptomatic recreational runners.
Methods—Five male and 15 female asymptomatic recreational
runners (10–30 miles/wk), ages 18 to 40 years, were examined using ultrasonography to assess for the presence of fluid at the level of the lateral
femoral epicondyle and determine its relationship to the ITB at 0° and 30°
of knee flexion in both supine (non–weight-bearing) and standing (weightbearing) positions.
Results—All subjects exhibited fluid associated with the ITB in
at least 1 knee, and this finding was bilateral in 90% of subjects. When examined in full extension, fluid was seen in 67.5% of knees (n= 40) when
supine, compared to 95% of the knees when standing. When examined in
30° of flexion, the presence of fluid decreased to 30% when supine and
22.5% when standing. With the knee in full extension in a supine/standing position, fluid was located anterior and deep 70%/74% of the time and
anterior only 11%/0% of the time. With the knee flexed to 30° in a
supine/standing position, fluid was located anterior and deep 50%/33%
of the time and anterior only 33%/67% of the time.
Conclusions—Fluid was associated with the ITB in at least 1
limb in 100% of asymptomatic recreational runners and was bilateral in
90%. Clinicians should use caution when interpreting the clinical significance of ITB-associated fluid in runners presenting with lateral knee pain
syndromes.
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Table 1. Fluid Location in Relation to the Lateral Femoral Epicondyle at 0° and 30°
of Knee Flexion (N = 40 Knees)
Presence of Fluid
No fluid
Anterior only
Anterior and deep
Deep only
Posterior
Supine
Supine 30°
Standing Standing 30°
Extended (%) Flexed (%) Extended (%) Flexed (%)
13 (32.5)
28 (70)
2 (5)
31 (77.5)
3 (7.5)
4 (10)
0 (0)
6 (15)
19 (47.5)
6 (15)
28 (70)
3 (7.5)
5 (12.5)
2 (5)
10 (25)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
1538060 Three-Dimensional Ultrasound of the Cumulus Oophorus
Kyle Beiter,1* Thomas Hilgers,2 Jeanine Johnson,2 Rachel
Stites2 1Saint Peter’s Healthcare System, New Brunswick,
New Jersey USA; 2Reproductive Ultrasound Center, Pope Paul
VI Institute for the Study of Human Reproduction, Omaha, Nebraska USA
Objectives—The ability to observe the cumulus oophorus by
ultrasound has been controversial over the years. The Pope Paul VI Institute for the Study of Human Reproduction’s Reproductive Ultrasound
Center has been very interested in this topic for a number of years and has
published on it. This e-poster introduces the first published photos of the
cumulus oophorus taken by 3D ultrasound.
Methods—Examination was performed using a Medison Accuvix V20 Prestige ultrasound system. A 3D endovaginal 5–9-MHz transducer was used. After 2D scanning of the cumulus oophorus was
completed, a 3D acquisition with the region of interest set to encompass
the area of the dominant follicle and cumulus oophorus was acquired.
SonoView Pro software was used to manipulate the 3D volumetric data by
rotating the x-, y-, and z-axes to obtain a 3D rendering of the cumulus
oophorus.
Results—A 3D image of the mature follicle with the eccentrically located cumulus oophorus was obtained and is shown. This image is
then rotated on its axis, and it can be seen from different directions.
Conclusions—This presentation shows that 3D ultrasound can
provide extraordinary pictures of the cumulus oophorus in a way that
leaves the determination of its presence inescapable. Further refinement of
this technique should help in the ultrasound evaluation of normal ovulation patterns and the various disorders of human ovulation.
1538125 Design and Evaluation of a Point-of-Care Ultrasound
Curriculum for Pediatricians Involved in Global Health
Sachita Shah,1,2* Meera Muruganandan,3 Sachin Shah,4
Randheer Shailam,5 Sara Stulac,2,6 Kim Wilson6 1Emergency Medicine, Harborview Medical Center, University of
Washington School of Medicine, Seattle, Washington USA;
2
Partners in Health, Boston, Massachusetts USA; 3Emergency
Medicine, Rhode Island Hospital, Brown University, Providence, Rhode Island USA; 4Cardiology, Lahey Clinic, Burlington, Massachusetts USA; 5Radiology, Massachusetts General
Hospital, Harvard Medical School, Boston, Massachusetts
USA; 6Pediatric Global Health, Boston Children’s Hospital,
Boston, Massachusetts USA
Objectives—As ultrasound becomes more portable, durable,
and affordable, point-of-care ultrasound use by nonradiologists has been
rapidly increasing both in the United States and in resource-poor developing world settings. However, training programs for ultrasound skills
specific to global health work and pediatrics are lacking, leading to a dangerous knowledge gap for this operator-dependent technology. We describe
our response to this knowledge and training gap with a novel curriculum
in bedside ultrasound focused on pediatric clinical conditions common in
resource-limited settings. Our primary objective is to describe this curriculum and response to the pilot training program.
Methods—The 15-hour course was taught by a multidisciplinary faculty and focused on bedside clinician-performed ultrasound techniques for assessment of the pediatric global burden of disease. Lecture
didactics were complemented by practical skills sessions using live models and hand-carried ultrasound machines. An anonymous postcourse selfassessment survey was conducted to assess confidence and attitudes.
Results—The curriculum included training on ultrasound safety
and physics, uses in trauma, including the focused assessment with sonography for trauma exam, hemothorax and pneumothorax, procedural guidance, echocardiography (pericardial effusion, systolic dysfunction, and
rheumatic valvular disease), liver lesions, splenomegaly, appendicitis, pyloric stenosis, and skin/soft tissue infections, including pyomyositis. Postcourse self-assessments of the participants were overwhelmingly positive
with high levels of confidence in the various ultrasound techniques explored during the course despite no prior experience. After the training, students felt the most confident with trauma, pericardial effusion, skin/soft
tissue ultrasound, and procedural guidance and the least confident with
identification of specific liver lesions and use of the inferior vena cava as
a proxy for dehydration. One hundred percent of the participants believed
ultrasound would be useful in low-resource settings.
Conclusions—This clinical course of ultrasound skills for pediatricians embarking on global health careers may serve as one model
for more effectively preparing trainees to work in developing countries.
1538182 Emergency Medicine Intern Ultrasound Proficiency:
A Longitudinal Study
Elizabeth Pontius,1* Kerri Layman,1,2 Michael Antonis1,2
1
Emergency Department, MedStar Washington Hospital
Center, Washington, DC USA; 2Emergency Department, MedStar Georgetown University Hospital, Washington, DC USA
Objectives—Our goal was to determine the level of proficiency
that interns had with emergency bedside ultrasound (US) over the course
of a year.
Methods—Nineteen Georgetown School of Medicine 2010
graduates entered emergency medicine residencies. An e-mail was sent to
each of the 19 graduates 3 times over the course of the 2010–2011 academic year, in July 2010, February 2011, and July 2011. The e-mail contained a link to a 6-question Web-based survey. Graduates were asked
whether they had participated in an emergency bedside US elective and if
they had other exposure to US during medical school. They were also
asked to rate their proficiency with bedside US at the start of residency and
at the time of the survey. Last, they were asked to rate themselves against
their peers in bedside US proficiency.
Results—Of the 19 graduates, 15 responded to the survey in
July 2010, 12 in February 2011, and 8 in July 2011. Half of respondents
had participated in an emergency bedside US elective, and approximately
75% had exposure to US in another setting during medical school. In the
first survey, respondents reported their level of comfort as 5.67 at the start
of the year and 6.47 currently on a 10-point scale. By midyear, respondents
rated their level of comfort as 4 at the start of the year and 6.83 currently.
In July 2011, respondents rated their comfort level as 4.13 at the start of
the year and 7.5 currently. The resident’s self-assessed level of proficiency
when graded against their peers did not change appreciably, from 7.13 on
a 10-point scale at the start of the year, 6.83 at the midyear mark, and 7.13
at the end of the year.
Conclusions—Emergency medicine interns became more proficient with bedside US over the course of their intern year. As the year progressed, however, they rated their level of comfort at the start of the year
lower than they had initially. Further study is needed to determine if the
emergency bedside US elective in medical school provides any benefit.
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1538313 Case Presentations of “Cloudy Ascites” Associated With
Female Pelvic Malignancies
Raydeen Busse,1,2 Gail Hoshiko-Reed,2 Chrystie Fujimoto1,2*
1
Obstetrics, Gynecology, and Women’s Health, University of
Hawaii, Honolulu, Hawaii USA; 2Hawaii Pacific Health, Honolulu, Hawaii USA
Objectives—There is no effective early detection available for
ovarian cancer screening; therefore, vague symptoms of early satiety, abdominal discomfort, and abdominal bloating commonly result in pelvic ultrasound imaging. Ascites in the gynecologic patient is easily identified
using high-resolution transvaginal pelvic ultrasound imaging even when
present in trace amounts. Although the presence of cul-de-sac free fluid in
patients of childbearing age is a routine finding due to ovulation and the
menstrual cycle, the presence in postmenopausal women regardless of
amount warrants further investigation. We present 3 cases of echogenic
pelvic fluid or “cloudy ascites” found in perimenopausal and postmenopausal women in whom pelvic malignancies were diagnosed.
Methods—Transvaginal ultrasound that is performed in our
unit classifies and subjectively quantifies free pelvic fluid in all patients.
We noted 3 cases in which the presence of free pelvic fluid in perimenopausal and postmenopausal women changed in character and quantity over a short period of time. There were no ovarian masses. The
presence and change of the pelvic fluid was solely what led to the subsequent operative diagnoses of 3 different pelvic malignancies in our 3 cases.
Results—The presence of clear or anechoic cul-de-sac free
fluid was present in each of the 3 cases, and short-term follow-up was recommended. In each case, the ascites changed from anechoic to complex
on ultrasound imaging or increased in subjective amount. No ovarian abnormalities were seen in any of the 3 cases. Further evaluation was initiated,
and subsequent operative pathology revealed a mucinous adenocarcinoma
of the appendix, metastatic breast cancer after 15 years of remission, and
a fallopian tube carcinoma.
Conclusions—In perimenopausal, specifically, postmenopausal
women, our premise is that ascites or pelvic free fluid should always be
classified as to its echogenicity and amount. If the fluid appears to represent an exudate or contain echoes, some type of inflammatory process
could be present, or the fluid could represent malignant ascites. Although
complex or cloudy ascites is not pathognomonic for malignancy, it certainly is a cause for further evaluation.
1538648 Predicting Prognostic Factors of Breast Cancer Using Shear
Wave Elastography
Woo Jung Choi,* Hak Hee Kim, Joo Hee Cha, Hee Jung
Shin, Hyunji Kim, Min Ji Hong, Eun Suk Cha, Hyeon Sook
Kim, Sung Hun Kim Radiology, Asan Medical Center, Seoul,
Korea
Objectives—To investigate the correlation between histologic
factors, including immunohistochemical factors, of breast cancer related
to the prognosis of tumors using shear wave elastography (SWE).
Methods—One hundred twenty-two pathologically proven
breast cancers from 116 women (age range, 27–77 years; mean age, 48.1
years) were included in this study. For each lesion, B-mode ultrasound
and SWE images were obtained. Of the SWE features, the mean elasticity value, maximum elasticity value, and SWE ratio were extracted. The
SWE ratio was calculated as the ratio of the stiffest portion of the lesion
to the similar region of interest in fat tissue. Histologic findings from
pathologic reports were used for comparison, namely, nuclear and histologic grade, nodal status, vascular invasion, invasive size, and immunohistochemical factors such as estrogen receptor (ER), progesterone
receptor (PR), Her-2 (c-erb B2), Her-1 (epidermal growth factor receptor), CK5/6, p53, and Ki-67. The Mann-Whitney U test and Kruskal-Wallis test were used to compare the SWE values in the groups of histologic
parameters. Subtypes based on the immunohistochemical profile were
compared with SWE values using the Kruskal-Wallis test.
Results—The negative group of ER (P = .004), negative group
of PR (P = .016), positive group of p53 (P = .024), and positive group of
Ki-67 (P = .008) showed statistically significant positive associations with
a high SWE ratio. A high nuclear grade (P = .014), high histologic grade
(P = .015), and large invasive size (P = .010) was associated with a significant high SWE ratio. The mean elasticity value and maximum elasticity value showed less statistical significance with the histologic factors.
The Kruskal-Wallis analysis showed that the SWE ratio was significantly
different across the subtypes based on the immunohistochemical profile
(P = .013).
Conclusions—The SWE ratio may provide useful information
for predicting prognostic factors of breast cancer.
1538793 Understanding How Ultrasound Technology Promotes Student Attention During Instruction of the Physical Exam
Caridad Hernandez,1* Christine Bellew,1 Alfredo Tirado,1,2
Andrew Payer,1 Manette Monroe,1 Juan Cendan1 1Medical
Education, University of Central Florida College of Medicine,
Orlando, Florida USA; 2Emergency Medicine, Florida Hospital, Orlando, Florida USA
Objectives—The use of point-of-care ultrasonography (US) is
increasing in medical practice. Accompanying this is an interest in incorporating US education in undergraduate medical education. Here we explore the role of US technology as part of an instructional strategy to
enhance students’ motivation to learn to perform the neck/thyroid exam.
Methods—We used a qualitative research design using
prompted text responses. Second-year students in the physical diagnosis course participated. All students received traditional instruction on
the physical exam of the neck/thyroid with the addition of a student-run
US exam of the neck. Students worked in small groups with a faculty
instructor and a standardized patient. Following the sessions, they submitted responses to 5 items aimed at assessing 4 categories of motivational variables: attention, relevance, confidence, and satisfaction. Data
were analyzed using a grounded theory approach. Two authors reviewed the responses, devised a coding framework, and generated
themes. NVivo, a qualitative data analysis platform, was used to evaluate the data.
Results—Sixty-five students completed the prompted-response
items. We report analysis of students’ responses to the item, “Using US
worked to maintain my attention by.” Four major themes emerged: (1)
engagement—the session was “fun,” “engaging,” “extremely interesting,”
and “interactive”; (2) active learning—being actively involved in identifying structures and getting to handle the probes was key to maintaining
their attention; (3) clinical application of anatomy—application of their
knowledge of anatomy and anticipated applicability maintained their attention; (4) hands-on learning—actually doing the US themselves helped
them learn the procedure/anatomic structures and relationships as opposed
to looking at still images obtained by others.
Conclusions—Incorporating the use of US with the physical
exam of the neck/thyroid helps maintain students’ attention because it promotes learner engagement and provides clinical contextualization of
anatomy. Another theme that emerged was that hands-on real-time capturing of images by the students themselves improved their understanding
of relevant anatomy.
1538852 Value of Qualitative Sonoelastographic Evaluations in the
Diagnosis of Solid Breast Masses
Hasan Yerli,1* Tugbahan Yilmaz,2 Banu Ural2 1Radiology,
2
General Surgery, Baskent University Zubeyde Hanim, Practice and Research Center, Izmir, Turkey
Objectives—To determine whether the use of a qualitative elasticity scoring method by sonoelastography (SE) is useful to differentiate
between benign and malignant breast masses.
Methods—One hundred seventy lesions in 145 consecutive pa-
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tients with solid breast masses (139 benign, 31 malignant) were prospectively included in this study. For each lesion, B-mode ultrasound (US) and
SE images were obtained. For each lesion, elasticity scores were determined with a 5-point scoring method by SE. The findings were compared
with histopathology. The diagnostic performances for the elasticity scoring and B-mode US methods were determined.
Results—The mean scores on SE were 2.58 ± 0.57 for benign
lesions and 3.85 ± 0.69 for malignant lesions. Sensitivity, specificity, and
accuracy for the 5-point scoring method were 78%, 92%, and 88%, respectively; 88%, 74%, and 84% for B-mode US when a cutoff point between scores 3 and 4 was used.
Conclusions—After B-mode US analysis, qualitative evaluation with the 5-point scoring method by SE is a complementary method
that increases specificity when differentiating between benign and malignant breast masses.
1538946 Masses in Pregnancy: Blood Flow Provides Vascular Clues
to Diagnosis
Constance Bitters,* Beth Kline-Fath Ultrasound, Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio USA
Objectives—Determining the etiology of an intrauterine mass
can be difficult. The goal of this study was to determine if the origin of
these masses can be established via color Doppler flow.
Methods—An Institutional Review Board–approved retrospective review was performed by searching our fetal database from 2004
to 2012. Twelve cases of intrauterine soft tissue masses without identifiable fetal parts were discovered. The lesions were evaluated with ultrasound for location and echo texture. Doppler was used to determine the
vascular supply, site of supply, number of vessels (hypervascular ≥3 vessels), and waveforms.
Results—The lesions were 8 proven chorioangiomas (CA), 2
twin reversed arterial perfusion (TRAP), 1 fibroid, and 1 chronic intrauterine demise (IUD). In the CA, the soft tissue mass was hypervascular and embedded in the placenta with the fetal placental cord insertion
along the margin. Six were heterogeneous and 2 homogeneous. Vascularity extended primarily from the placental cord insertion and superficial
placenta with less extending to the deep placenta. Five contained low-resistance arteries, and all had pulsatile veins. The 2 TRAP were heterogeneous and abutted the placenta contained in an encircling membrane. Both
had 2 vessel feeders with a single artery and vein centralized in the mass.
In 1 pregnancy, the arterial waveform was documented as reversed when
compared to the normal fetus. The fibroid was homogeneous and in the
myometrium along the placental edge with a supplying artery and vein
extending deep myometrium. The chronic IUD showed heterogeneous
tissue with no color flow. A membrane was noted, supporting diamniotic
twin gestation.
Conclusions—The vascular supply can be helpful in evaluation of amorphous intrauterine masses. In CA, the lesion is hypervascular
and embedded in the placenta, with vessels originating from the placental
surface and fetal placental cord. In TRAP, the lesion demonstrates a centralized vascular supply, with diagnosis supported by the presence of reversed arterial flow. Fibroids demonstrate vessels extending into the deep
myometrium. Chronic IUD should be considered in the absence of vascular flow, especially in the presence of a separating membrane.
1539098 Ultrasound-Guided Vascular Access on a Phantom: A
Training Model for Medical Student Education—Trends in
Data, 2010–2012
Lydia Sahlani,1* Eric Adkins,1,2 David Bahner1 1Emergency
Medicine, 2Internal Medicine, Ohio State University Wexner
Medical Center, Columbus, Ohio USA
Objectives—Patient safety and prevention of medical errors
have been emphasized as an integral part of medical education. Focusing
on ultrasound-guided vascular access (USGVA) in the medical school curriculum can improve patient safety and prevent errors. We reviewed a cohort of second-year medical students (MS2) to assess their proficiency
with USGVA access in 2010, 2011, and 2012.
Methods—This study was an observational cohort study of
MS2s during their Introduction to Clinical Medicine program during 2010,
2011, and 2012. Students reviewed an online training module from EMSONO.com about USGVA, completed a quiz, and participated in a didactic session using a Blue Phantom block gel model. Students were divided
into groups and allowed to practice the skills. After the practice session,
they were graded by a proctor using a standardized scoring sheet. The students were evaluated on their ability to visualize the simulated vessel in
different planes, perform vascular cannulation in both the short and long
axes, the number of needle sticks attempted, and successful cannulation.
Results—A total of 600 MS2s with complete data from 2010
through 2012 were included. Students were able to cannulate the vessel in
the long axis with a mean of 1.25 sticks (SD, 0.60; 95% confidence interval [CI], 1.20–1.30). They were able to cannulate the vessel in the short
axis with a mean of 1.33 sticks (SD, 0.67; 95% CI, 1.27–1.38). A nonparametric test, the Wilcoxon signed rank test, for paired data was used for
further analysis. We tested the hypothesis that the median of difference
between the number of sticks in long and short axes would equal 0. Combined data show there was a significant difference (P = .0007) between the
number of long- and short-axis sticks.
Conclusions—A structured ultrasound curriculum can help
MS2s learn the psychomotor skills necessary to cannulate a vessel on a
phantom using ultrasound guidance. Results indicate that there is a significant difference between long- and short-axis sticks, with the short axis
requiring more sticks to cannulation. Future studies could focus on improvement of short-axis sticks to cannulation and retention of the skill as
tested at various intervals of training.
1539608 Bayesian Methods for Streamlining and Enhancing the
Analysis and Presentation of Myocardial Strain and Strain
Rate Data
Olga Neyman,1* Michelle Milne,2 Gautam Singh,3 Ravi
Rasalingam,4 James Miller,2 Mark Holland2,3 1Biomedical
Engineering, 2Physics, 3Pediatrics, 4Internal Medicine, Washington University, St Louis, Missouri USA
Objectives—Quantitative evaluation of global and regional myocardial strain has been shown to be feasible in the echocardiographic laboratory. In spite of the potential for such strain-based evaluation, clinicians
frequently find the time required to analyze the data to be prohibitive and
the amount of data to be far too large and unwieldy to permit routine clinical use. The goal of this work is to present to the physician a concise summary of physiologically meaningful results (eg, values of the maximum
strain, strain rate, and time to maximum strain) as well as significantly improved strain rate vs time curves to facilitate meaningful interpretations.
Methods—We introduce Bayesian methods for model selection and parameter estimation that result in improved quality of automated
data reduction and reporting. Bayesian probability-based methods that
permit modeling strain and strain rate curves such that analysis, interpretation, and identification of specific features in these data are simplified,
less time intensive, less affected by anomalous noise, and less operator
dependent than current manual interpretation approaches will be described
and illustrated.
Results—Bayesian-based analysis methods were applied to
myocardial strain data collected from the left ventricle of 49 adolescents.
Echocardiographic data were acquired using a GE Vivid 7 imaging system, and the strain data were generated using the GE EchoPac system.
Initial results show strain curves derived from model functions constructed
using the Bayesian parameter estimation approach to be in good agreement with the acquired strain data. The strain rate data derived from the
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models for the strain data provided smoothly varying curves that are easily interpreted and compare favorably to results anticipated based on physiologic considerations.
Conclusions—Bayesian probability-based methods appear to
provide an approach that shows promise for providing objective, operatorindependent analysis of clinical myocardial strain and strain rate data along
with significant reductions in the amount of time required of the cardiologist analyzing the data. (Supported by National Institutes of Health grant
R21 HL106417.)
1539642 Sonographic Characterization of Keloids
Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile
Objectives—To assess the sonographic morphology of keloids.
Methods—A retrospective review of keloids that were sonographically diagnosed and confirmed by histology was performed (September 2009–August 2012). Data on extension (millimeters), location,
blood flow (activity), deeper layer involvement, and accompanying fistulas were analyzed.
Results—Twenty-five keloids in 20 patients (50% female [n =
10], 50% male [n = 10]; total mean age, 26 years [22 years females and
30 years old for males]; age range, 4–66 years) were found. Number of lesions per patient: 1 lesion, 85% (n = 17); 2 lesions, 10% (n = 2); multiple
lesions (≥3 lesions), 5% (n = 1). Body segment location of lesions: anterior thorax, 24% (n = 6); upper extremity, 24% (n = 6); face, 20% (n = 5);
lower extremity, 12% (n = 3); submandibular region, 12% (n = 3); dorsal
region, 4% (n = 1); epigastric region, 4% (n = 1). Layer location of lesions: dermis, 84% (n = 21); epidermis and dermis, 8% (n = 2); dermis and
hypodermis, 4% (n = 1); epidermis, 4% (n = 1). Echo structure: hypoechoic, 84% (n = 21); heterogeneous, 16% (n = 4). A linear pattern was
present in 20% (n = 5) of keloids. Fistulas within the lesions were observed in 8% (n = 2) of cases. Mean size: transverse axis, 22.58 mm
(range, 7.1–69.1 mm); thickness, 5.79 mm (range, 2–17.5 mm); longitudinal, 24.77 mm (range, 6.2–66 mm). Mean area: 2596.65 mm2 (range,
59.92–12922.07 mm2). Vascularity was detected in 60% (n = 15) of lesions, and 100% of these lesions demonstrated a peak systolic velocity
of arterial vessels <15 cm/s. Mean thickness of vessels was 0.8 mm
(range, 0.5–1.1 mm). Mean maximum arterial peak systolic velocity:
5.45 cm/s (range, 4–9.5 cm/s). Location of vascularity: peripheral,
59.9%; intralesional, 33.5%; mixed type (peripheral and intralesional),
6.6%. Type of blood flow: arterial, 93.3%; arterial and venous, 6.7%.
None the lesions showed deeper-layer involvement (tendon, muscle, or
bone) or calcifications.
Conclusions—Sonography can provide morphologic data on
keloids, which can support diagnosis and/or treatment.
1539652 Contribution of Contrast-Enhanced Sonography to Transjugular Intrahepatic Portosystemic Shunt Follow-up
Jean Ayoub,* Jean Marc Perarnau, Frédéric Patat University hospital, Chambray Les Tours, France
Objectives—The objective of this study was to demonstrate the
efficacy of a color Doppler velocity (CDV) profile combined with contrast-enhanced ultrasound (CEUS) in assessment of transjugular intrahepatic portosystemic shunt (TIPS) obstruction.
Methods—Procedural data, including stent size and portal vein
pressure (PVP) before and after TIPS placement, were obtained prospectively in 22 patients (14 males, 8 females; median age, 59 years; range, 44–
72 years). Patients were examined in a fasting condition. Patients had
baseline CDV examinations 1 day before (D–1), and 1 day after (D+1)
TIPS placement, with scheduled follow-up at 1, 3, 6, 9, and 12 months
after the procedure. The following parameters (mean velocity [Vm], flow
volume [Qv], hepatic resistance index, and PVP) of the portal vein, TIPS,
and hepatic artery parameters were analyzed.
Results—A total of 208 CDV examinations were performed on
22 patients with TIPS, for an average 9.5 studies per patient. At D+1, portal vein and hepatic artery Vm increased significantly by 407% and 199%.
Qv increased by 501% in the portal vein and by 287% in the hepatic artery. The PVP decreased by 35%. There was a correlation between PVP
and portal Vm (r = 0.54; P < .05) after the procedure. Most of these hemodynamic parameters decreased with time. One year after the TIPS procedure, portal vein Vm and hepatic artery Qv decreased respectively by
47% and 70%; within the TIPS, Vm decreased by 10% (P < .05). TIPS dilatation is decided in conjunction with modifications of these quantitative
hemodynamic parameters. The TIPS is dilated in cases of reversed flow in
portal branches or pronounced spectral curve dispersal on pulsed Doppler.
CEUS was also used to confirm TIPS obstruction. CDV diagnosis was
confirmed by angiography and portal vein pressure during dilatation.
Thirty-six percent of these patients have TIPS dilatation 1 year after the
procedure.
Conclusions—Color Doppler ultrasonography combined with
CEUS allowed quantitative and qualitative confirmation of the diagnosis
of TIPS obstruction.
1539664 The Ultrasound Challenge: A Novel Approach to Ultrasound Education
Eric Cortez,1* Creagh Boulger,1 Matthew Blickendorf,1 Emily
Hoover,2 Adam Jasne,2 Stacy Boore,2 Anthony Mueller,2 Eric
Adkins,1 David Bahner1 1Emergency Medicine, 2College of
Medicine, Ohio State University, Columbus, Ohio USA
Objectives—Our institution has a well-established extracurricular ultrasound program, which involves a sizable portion of the 4 medical school classes. The Ultrasound Challenge began in 2010 as a method
of encouraging medical students to refine their skills in performing various focused ultrasound scans and demonstrate their abilities in a controlled
setting. Now approaching its fourth year, the Ultrasound Challenge also
encourages collegiality and interaction between the medical school classes.
Methods—The Ultrasound Challenge comprises 6 events: focused assessment with sonography for trauma (FAST), aorta, cardiac,
pelvic, musculoskeletal, and vascular access. Participants may choose to
compete in 1 or all of these events. FAST, aorta, and cardiac scans were
completed using medical student–trained simulated ultrasound patients.
The musculoskeletal scan requires the participant to visualize his or her
own anatomy. Pelvic and vascular access scans are completed using a
phantom model. Time is limited for all scans. Images are reviewed and
scored using a B-QUIET model with the exception of the procedural scan,
which is scored in real time based on specific procedural technique.
Awards were given to the top 3 students acquiring and labeling the best images in the allotted time.
Results—Thirty-three medical students competed in the Ultrasound Challenge in 2012. This included 6 med 1, 15 med 2, 5 med 3, and
8 med 4 students. Event winners included individuals from each of the 4
classes (Table 1).
Conclusions—The Ultrasound Challenge is a unique method
of encouraging medical students to refine their learned skills in various
focused ultrasound scans. Students participated in open scanning sessions
to gain additional practice prior to the event. Medical students of all levels proficiently performed 6 focused ultrasound scans. Future competitions may involve residents or students from other institutions. Model
criteria may also be instituted to further standardize the process.
Table 1. Event Winners by Medical Student Year
1st place
2nd place
3rd place
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2nd
4th
4th
4th
4th
2nd
4th
1st
4th
3rd
3rd
4th
1st
4th
4th
3rd
2nd
2nd
3rd
4th
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1539668 A Committee Structure for Improved Efficacy of a Student
Ultrasound Interest Group
Katherine Pollard,* Emily Hoover, David Bahner Emergency
Medicine, Ohio State University College of Medicine, Columbus,
Ohio USA
Objectives—To assess the impact of a new committee structure
on the efficacy of a student ultrasound interest group.
Methods—Our institution has a well-established student-run
ultrasound interest group. Since its founding, the interest group has served
as a central organizing body for all ultrasound educational activities. The
ultrasound interest group has traditionally been led by a group of 4 secondand fourth-year medical student officers and a faculty advisor. During this
academic year, a new committee structure was developed to provide more
opportunities for medical student involvement within ultrasound leadership and to improve the ability of the interest group to support ultrasound
education initiatives. Six committees were formed focusing on medical
student education, resident/fellow/faculty education, outreach, research,
grants/funding, and technology.
Results—The initial development of the committee structure
allowed the ultrasound interest group to better define its core goals and
values. The committee structure has also provided opportunities for approximately 30 medical students (currently 15 first-year, 5 second-year, 1
third-year, and 7 fourth-year students) to take new leadership roles within
our ultrasound education program while decreasing the burden on the officers and advisor. The committee structure has improved ultrasound education in numerous ways. Examples of this improvement include forming
new connections with ultrasound advocates within our institution, expanding the ultrasound interest group’s online presence, and identifying
new student research funding opportunities.
Conclusions—The implementation of a new committee structure for our student ultrasound interest group has greatly improved the
ability of our interest group to educate medical students, residents, and
faculty on the applications of and techniques involved in performing bedside ultrasonography.
1539712 Sonographic Characterization of Pilomatrixomas
Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile
Objectives—To assess the sonographic morphology of pilomatrixomas.
Methods—A retrospective review of pilomatrixomas that were
sonographically diagnosed and confirmed by histology (September 2009–
July 2012) was performed. Extension in all axes, location, blood flow,
deeper-layer involvement, and calcium deposits were analyzed.
Results—A total of 118 pilomatrixomas in 107 patients were
analyzed. Mean age: 17 years (age range, 5 months–82 years). Number of
lesions per patient: 1 lesion, 93.4% (n = 100); 2 lesions, 4.6% (n = 5); 3
lesions, 0.9% (n = 1); 4 lesions, 0.9% (n = 1). Location of lesions: face,
55.1% (n = 65); upper extremity, 17.8% (n = 21); neck, 10.2% (n = 12);
lower extremity, 9.3% (n = 11); trunk, 7.6% (n = 9). Layer location of lesions: dermis and hypodermis, 66% (n = 78); only hypodermis, 31% (n =
36); only dermis, 3% (n = 4). Echo structure: hypoechoic rim and hyperechoic center, 68,8% (n = 81); hyperechoic, 18.6% (n = 22); heterogeneous, 7.6% (n = 9); hypoechoic, 5% (n = 6). Mean size: transverse axis,
6.32 mm (range, 0.5–19 mm); depth, 3.81 mm (range, 0.3–12 mm); longitudinal axis, 6.22 mm (range, 0.5–19 mm). Mean volume: 187.32 cm3
(range, 0.07–2148.44 cm3). Calcium deposits were present in 90% (n =
106), and anechoic areas (cystic variant) were detected in 4% (n = 5) of
lesions. A posterior acoustic shadowing artifact was present in 24.6%
(n = 29) of lesions. Inner septa were observed in 1% (n = 1) of tumors.
Blood flow was detected in 66% (n = 78), and 96% of these cases showed
maximum arterial peak systolic velocity <15 cm/s. Blood flow location:
peripheral, 79.4% (n = 62); mixed (peripheral and intralesional), 18%
(n = 14); intralesional, 2.5% (n = 2). Type of vessels within lesions: arterial, 48.7% (n = 38); arterial and venous, 48.7% (n = 38); venous, 2.6%
(n = 2). Mean thickness of the vessels: 0.95 mm (range, 0.5–1.7 mm).
Mean maximum peak systolic velocity of arterial vessels: 10.14 cm/s
(range, 5.3–23.1 cm/s). Extrinsic compression of muscles (orbicularis eyelid and epicranius frontal muscles): 5% (n = 6); extrinsic compression of
cartilage (ear pinna): 1.6% (n = 2).
Conclusions—Sonography can characterize pilomatrixomas,
which may support diagnosis and surgical planning.
1539749 Accuracy of Sonographically Guided Deep Plantar Fascia
(Intrafascial) Injections: Where Does the Injectate Go?
Eugene Maida,* James Presley, Wojciech Pawlina, Jay Smith
Physical Medicine and Rehabilitation, Mayo Clinic Sports
Medicine Center, Mayo Clinic, Rochester, Minnesota USA
Objectives—To determine the accuracy and distribution of
sonographically guided deep plantar fascia (intrafascial) injections using
a cadaveric model.
Methods—A single experienced operator completed sonographically guided intrafascial injections in 10 unembalmed cadaveric
specimens (5 right and 5 left) obtained from 2 male and 4 female donors
ages 49 to 95 years (mean, 77.5 years) with an average body mass index
of 23.2 kg/m2. A 12–3-MHz linear array transducer was used to direct a
25-gauge, 38-mm stainless steel needle deep to the plantar fascia at the
anterior aspect of the calcaneus using an in-plane, medial-to-lateral approach. In each case, 1.5 mL of 50% diluted colored latex was injected just
deep to the plantar fascia. After a minimum of 72 hours, study coinvestigators dissected each specimen to assess injectate placement.
Results—All 10 injections accurately placed latex adjacent to
the deep side of the plantar fascia at the anterior calcaneus. No intrafascial
latex was found in any specimen. In 9 of 10 (90%) specimens, small
amounts of latex were found interdigitating within the flexor digitorum
brevis at its origin from the deep plantar fascia. In all 10 specimens, latex
also covered the traversing first branch of the lateral plantar nerve (ie, Baxter’s nerve).
Conclusions—Within the methodological limitations of this
cadaveric investigation, sonographically guided deep plantar fascia injections accurately deliver latex adjacent to the deep side of the plantar fascia while simultaneously covering the traversing first branch of the lateral
plantar nerve (Baxter’s nerve). When clinically indicated, sonographically
guided intrafascial injections may be used to deliver injectate to the deep
portion of the plantar fascia and would probably anesthetize that traversing portion of Baxter’s nerve adjacent to the anterior calcaneus. Thus, intrafascial injections may have a role in the diagnosis and management of
plantar fasciopathy, including chronic or atypical cases potentially involving Baxter’s nerve at the level of the anterior calcaneus.
1539819 Biopsy Diagnosis of Lung Tumors Situated Peripherally
Marek Chorazy,1* Marta Majcher,1 Jedrzej Glasek,2
Katarzyna Urbanowicz,1 Robert Kwiatkowski3 1Clinical
Oncology and Internal Medicine, 2Radiodiagnostics, 3Radiotherapy, St Leszczynski Hospital, Katowice, Poland
Objectives—The most widely used test that could provide information as to the pattern of malignant tumors of the lung is fiber-optic
bronchoscopy and its modifications. Another method that is also used is
aspiration biopsy performed under the control of computed tomography
(CT). In this study, the authors decided to present their own experiences
in using traditional ultrasonography to diagnose peripherally situated lung
tumors.
Methods—Fiber-optic bronchoscopy was performed in the
cases of 2429 patients out of 2572 CT examinations performed between
January 2002 and September 2009. In 143 (5.55%) cases, out of 2572 patients, which could not be diagnosed by fiber-optic bronchoscopy because
the tumor was located at the chest wall, an ultrasound examination was
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done. In 130 cases, ultrasound showed nodular lesions, and these patients
had a percutaneous biopsy performed under the control of ultrasound.
Results—The authors have demonstrated that, in rare cases, ultrasound examination may be useful to illustrate nodular lesions located at
the chest wall. It is true that it is not possible to prepare an initial diagnosis of a lung tumor on this basis; to obtain such a diagnosis, a CT examination was used, but a precise collection of samples from a lesion located
peripherally makes its display on real-time ultrasonography very easy.
Conclusions—(1) It is possible to display 90.9% of lesions located peripherally in a traditional ultrasound examination. (2) In most
cases, as part of that procedure, it is necessary to establish the location of
the tumor and the depth of the CT-guided biopsy. (3) Displaying lesions
on ultrasonography makes it possible to collect material for histopathologic examination accurately in 88.7%.
Table 1. Number of Studies Carried out Under the Control of Ultrasound (out of
2572 Cases)
Inability of fiber-optic bronchoscopy
Tumors located peripherally
Ultrasound-controlled biopsy
Histopathologic diagnosis
143
130 (90.9%)
130 (90.9%)
127 (88.8%)
1539837 Sonoelastographic Qualitative Analysis in the Management
of Salivary Gland Masses
Hasan Yerli,1* Erkan Eski,2 Ekrem Korucuk,3 A. Muhtesem
Agildere4 1Radiology, 2Otolaryngology, Baskent University
Zubeyde Hanim, Practice and Research Center, Izmir, Turkey;
3
Otolaryngology, Karsiyaka State Hospital, Izmir, Turkey;
4
Radiology, Baskent University Faculty of Medicine, Izmir, Turkey
Objectives—Our aim was to investigate whether the use of a
qualitative elasticity scoring method by sonoelastography is useful for the
management of salivary gland masses.
Methods—Forty-six patients with salivary gland masses (38
parotid and 8 submandibular) were prospectively included in this study.
For each lesion, B-mode sonographic and sonoelastographic images were
obtained. Elasticity scores were determined with a 4-point scoring method.
Differences among scores for benign and malignant salivary gland masses
were assessed using the Mann-Whitney U test. Qualitative variables were
compared using the Pearson χ2 test. The findings were compared with
histopathology.
Results—The score values of 37 benign masses ranged from 1
to 4, while the score values of 9 malignant masses ranged from 2 to 4. The
mean scores were 2.28 ± 0.94 for benign lesions and 3.1 ± 0.72 for malignant lesions (P < .05). When we considered scores 1 and 2 benign and
scores 3 and 4 malignant, 12 false-positives were determined by the 4point scoring method, and 62% of benign masses were diagnosed.
Conclusions—Sonoelastography might be regarded as another
ultrasound parameter in the management of salivary gland masses in terms
of detecting benign masses.
1539862 Peripubertal Ovarian and Uterine Volumes: Are Historical
Values Still Valid Today?
Steven Kraus,1,2 Sara O’Hara,1,2* Janet Adams,1 Rachel Mistur2
1
Radiology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio USA; 2Radiology, University of Cincinnati
College of Medicine, Cincinnati, Ohio USA
Objectives—With increasing reports of precocious puberty and
concerns of environmental exposures to young girls, we wondered if published reference values for normal peripubertal ovarian and uterine volumes dating back to the 1990s were still applicable today. Previous sample
sizes were small, and accurate values are needed for diagnosis of peripubertal disorders.
Methods—We retrospectively reviewed pelvic ultrasound
exams performed on girls aged 7 to 12 years over a 29-month period, regardless of indication for the scan. Ovarian and uterine dimensions were
recorded along with age at the time of the scan, menstrual status, and clinical history. We excluded patients with precocious puberty and clear pelvic
abnormalities including: masses, cysts >2.5 cm in diameter, ovarian torsion, incomplete exams, postsurgical pelvis, polycystic ovarian syndrome,
and nonvisualized organs. In patients with multiple exams, we used only
the most recent exam. The volume of the ovary was calculated using the
ellipsoid formula: volume = (longitudinal × transverse × anteroposterior)
× 0.5233.
Results—Searching radiology records revealed 600 patients.
After exclusions, 476 patients formed our data set. Three hundred thirtyeight patients had not started their menses, while 138 had experienced at
least 1 menstrual cycle. Ovarian and uterine volumes with SD by age are
tabulated below.
Conclusions—The normative values obtained represent the
current peripubertal population and reflect changes in pubertal development that have evolved over the past 20 years. Our study results highlight
the importance of age and menstrual status classification when assessing
ovarian volume; therefore, reference values for ovarian and uterine volumes should be revised to include age and menstrual status categorization. These data provide reassurance when evaluating patients with
premature puberty.
Table 1. Ovarian Volume by Age
Age, y
7
8
9
10
11
12
Premenarchal
Mean Volume,
mL (SD)
1.47 (1.14)
1.65 (0.84)
2.17 (1.66)
2.67 (1.78)
3.32 (1.90)
4.68 (2.54)
n
34
44
54
72
74
60
Postmenarchal
Mean Volume,
mL (SD)
3.80 (0.00)
2.01 (0.83)
6.33 (3.23)
6.02 (3.59)
4.65 (2.99)
5.89 (2.71)
n
1
2
4
13
21
97
1539863 @EDUltrasoundQA: An Updated Twitter Curriculum
David Bahner,1 Saad Raginwala,1,2 Nilesh Patel,1* Creagh
Boulger,1 Eric Adkins,1 Eric Cortez1 1Emergency Medicine,
Ohio State University, Columbus, Ohio USA; 2Grand Rapids
Medical Education Partners, Grand Rapids, Michigan USA
Objectives—To demonstrate an updated Twitter-based ultrasound curriculum designed to provide educational pearls in a questionanswer–based format.
Methods—A curriculum consisting of high-yield ultrasound
concepts in a question-answer format was developed and posted to a Twitter page every morning at 9 AM and evening at 5 PM beginning on July
1, 2012. As with the previous curriculum, each post or “tweet” was limited to 140 characters. Each month covers a separate ultrasound topic, including focused assessment with sonography for trauma, ultrasound
physics, and cardiac scanning. The curriculum is supplemented by normal
and pathologic images.
Results—As of September 26, 2012, there were 106 followers;
153 tweets have been published with an average length of 46 characters
per question and 94 characters per answer. Followers of @EDUltrasoundQA come from a variety of backgrounds and levels of training, including emergency medicine attendings and residents, sonographers,
midlevel providers, medical students, and educators. Several followers are
contributors in various areas of social media, including podcasts, blogs,
and medicine-related Twitter feeds. The feed has been mentioned 11 times
by other accounts and has been ranked in the FOAMed (Free Open Access
Meducation) top 25 Twitter feeds.
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Conclusions—Twitter provides an excellent means to deliver
educational content to learners at all levels of training. This project has
demonstrated another novel type of curriculum that has the potential to be
used in many educational endeavors. Future goals include increasing interactivity between the curriculum designers and participants, further categorizing followers, and better characterizing its impact on education.
Finally, given its broad applicability, additional efforts are being made to
enable other educators to easily implement this technology.
Conclusions—These cases illustrate the critical importance of
postnatal correlation of ultrasound findings in rare conditions, especially
when multiple types of a disorder are known. Types 1 (original proposed
diagnosis) and 3 atelosteogenesis are autosomal dominant and would confer a negligible recurrence risk given the unaffected parents. Type 2, on the
other hand, is autosomal recessive with a 25% recurrence risk. Identification of a mutation in the DTDST sulfate transporter gene will allow preimplantation genetic diagnosis in a future pregnancy.
1539867 Ultrasound of Arteriovenous Malformations of the Genitourinary System
Vijayanadh Ojili,1* Gowthaman Gunabushanam,2 Ravi
Vassa,1 Nagar Arpit,3 Kedar Chintapalli,1 Leslie Scoutt2
1
Radiology, University of Texas Health Science Center, San
Antonio, Texas USA; 2Diagnostic Radiology, Yale University
School of Medicine, New Haven, Connecticut USA; 3Radiology,
Ohio State University Medical Center, Columbus, Ohio USA
1539948 Association Between First-Trimester Ultrasonographic Twin
Crown-Rump Length Discrepancies and Neonatal Outcomes
Pedro Roca,1* Allen Kunselman,2 Gabor Mezei,1 Kari Whitley,1
Dennis Mujsce,3 Ian Paul,3 Serdar Ural1 1Obstetrics and
Gynecology, 2Public Health Sciences, 3Pediatrics, Penn State
Hershey, Hershey, Pennsylvania USA
Objectives—To describe the sonographic findings of arteriovenous malformations (AVMs) of the genitourinary system and correlate
these with computed tomographic (CT) and angiographic findings where
available.
Methods—A brief review of the AVMs of the genitourinary
system (including renal and uterine AVMs) will be presented. The sonographic findings will be described and correlated with CT and angiographic findings. Pertinent management issues, including angiography
and embolization procedures, will be briefly discussed.
Results—Not applicable as this is a pictorial review.
Conclusions—AVMs of the genitourinary tract are potentially
life-threatening conditions that require aggressive image-guided or surgical management. Therefore, it is important for the radiologist to accurately
diagnose these conditions in a timely fashion. Although multidetector CT
and digital subtraction angiography are the imaging modalities of choice
for comprehensive evaluation, ultrasound is often the initial imaging test
performed in the diagnostic workup of these patients and will provide a diagnosis in most cases.
1539898 Prenatal Diagnosis of Recurrent Atelosteogenesis
Janice Byrne,1,2* Anne Kennedy,3 Paula Woodward,3 Deborah
Krakow,4 John Carey2 1Obstetrics and Gynecology, 2Pediatrics, 3Radiology, University of Utah, Salt Lake City, Utah
USA; 4Human Genetics, University of California, Los Angeles,
California USA
Objectives—Document the prenatal ultrasound and postnatal
clinical findings in a rare condition.
Methods—Prospective identification of recurrence of a very
rare lethal skeletal dysplasia by prenatal imaging and comparison with
postnatal findings from the previous affected pregnancy.
Results—A 28-year-old G2P1001 married Caucasian woman
was referred at 35 weeks’ gestation for findings concerning for a skeletal
dysplasia, possibly type 1 atelosteogenesis. Micromelia with severely affected fibulae and humeri, mild long bone curvature, clubfeet, a small
chest, and polyhydramnios were noted. At 38 weeks, the patient delivered
vaginally a live-born infant with obvious skeletal dysplasia. In addition to
the findings noted by ultrasound, severely abducted (“hitchhiker”) thumbs
and great toes were seen. Characteristic radiographic findings including tapered hypoplastic humeri confirmed the suspicion of type 2 atelosteogenesis. DTDST mutation analysis was sent, but prior to the results being
available, the patient again became pregnant. Ultrasound at 11 weeks
showed a cystic hygroma, and 2 weeks later, short curved long bones and
“hitchhiker” thumbs and great toes could be seen. The patient terminated
the pregnancy. Gross examination confirmed the ultrasound findings.
Objectives—Determine the association between increased fetal
size discrepancies in crown-rump length (CRL) during first-trimester ultrasound and poor perinatal outcomes.
Methods—Retrospective study, all twin pregnancies delivered
at our institution before December 2009. We excluded pregnancies that
commenced with higher-order multiples as well as those with major fetal
congenital anomalies.
Results—Forty-six pregnancies were included. The firsttrimester ultrasound was performed on average at 10 3/7 weeks (SD, 2
weeks). The median percent discrepancy in CRL relative to the smaller twin
in each pregnancy was 7.2% (25th percentile, 2.8%; 75th percentile, 10.8%).
Generalized estimating equations with a logit link were used to assess the association of 4 predictors (ie, CRL during the first trimester [11–14 weeks’
gestation] ultrasound of each twin, the deviation [ie, difference] from the
mean CRL for each twin set per delivery, the week of the first-trimester ultrasound, and the twin birth order) with each early neonatal outcome. This
is an extension of logistic regression that accounts for the clustering of twins
per delivery. Similarly for continuous outcomes, mixed-effects models that
account for twin clustering were fit using the same 4 predictors. Table 1 reports the adjusted odds ratios (AORs), 95% confidence intervals (CIs), and
P values for 4 early neonatal outcomes. There was no evidence of an association of CRL or the deviation from the mean CRL for twins with respiratory distress syndrome (RDS), need for mechanical ventilation (MV), need
for total parenteral nutrition (TPN), or need for a nasogastric tube (NGT).
Conclusions—The difference of CRL during first-trimester ultrasound is a poor predictor for early neonatal complications. This study
suggests little relationship between the difference in size of twins as assessed by CRL during routine first-trimester ultrasound and early neonatal outcomes targeted above.
Table 1. Predictor of Outcomes
CRL
Deviation from
mean CRL of twins
S104
RDS
0.94
(0.85–1.03)
[.17]
1.12
(0.93–1.35)
[.23]
AOR (95% CI) [P]
MV
TPN
NGT
1.18
0.97
0.95
(0.95–1.48) (0.90–1.05) (0.87–1.04)
[.14]
[.45]
[.28]
1.00
1.18
1.05
(0.73–1.38) (0.95–1.47) (0.90–1.23)
[.99]
[.14]
[.53]
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1539989 The Work Flow Impact of Universal Transvaginal Cervical
Length Screening With Anatomic Surveys in an Ultrasound
Unit
Eileen Wang,* Alexander Friedman, Samuel Parry, Nadav
Schwartz Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania USA
Objectives—Low-risk women with a short cervix transvaginally at time of the second-trimester anatomic survey may have an increased risk of preterm birth. Vaginal progesterone may be offered to
reduce this risk. Cost-effective analyses of universal transvaginal cervical
screening (TVCL) have not included the impact of the extra time to perform TVCLs on the work flow of an ultrasound (US) lab. We compare
the times for anatomic surveys and growth scans in periods before and
after universal TVCLs were instituted.
Methods—This is a prospective observational study done in an
urban tertiary care center. In our 4-room US unit, after sonographers (SGs)
scan, the images are reviewed by the physician (MD), who then sees the
patient to either scan or discuss results. After implementation of TVCL, patients void prior to TVCL after the anatomic survey. Durations of studies
were recorded for quality improvement. Studies by maternal-fetal medicine fellows or with missing times were excluded. The times for anatomic
surveys, for growth scans, and for patients to void were collected and categorized per SG (n = 8) and per supervising MD (n = 9). Data from 5
weeks before and from a convenience sample of 6 weeks after implementation were compared. The data are presented as mean ± SD. The Student t test and 1-way analysis of variance were used to evaluate pre-CL and
post-CL study times.
Results—The time difference in anatomic surveys before (n =
275) vs after (n = 340) universal TVCL screening was statistically significant, 46.9 ± 11.6 vs 58.3 ± 11.9 minutes (P < .0001), regardless of MD.
Seventy-three percent of postimplementation anatomic surveys included
TVCLs with a mean duration of 61.0 ± 10.5 minutes. Mean voiding time
was 9.1 ± 6.2 minutes, ranging from 2 to 35 minutes. The mean time increase per SG per scan with TVCL was 9.1 ± 3.8 minutes. As expected,
there was no difference in the duration of growth scans in the 2 time periods (pre, 27.8 ± 11.2 vs post, 28.4 ± 9.6 minutes; P = .5).
Conclusions—Universal TVCL lengthens each anatomic survey by almost 15 minutes, primarily due to the time to void. This must be
accounted for when exploring ways to optimize work flow. The potential
to impact the number of scans that can be accommodated should be considered in future cost-benefit studies.
1540030 Association of Ultrasonographic Twin Estimated Fetal
Weight Discrepancies With Early Neonatal Outcomes
Pedro Roca,1* Allen Kunselman,2 Anthony Ambrose,1
Ian Paul,3 Dennis Mujsce,3 Serdar Ural,1 Kari Whitley1
1
Obstetrics and Gynecology, 2Public Health Science, 3Pediatrics, Penn State Hershey, Hershey, Pennsylvania USA
Objectives—Determine the association between increased fetal
size discrepancy during routine second-trimester ultrasound and poor perinatal outcomes.
Methods—We designed a retrospective study including all twin
pregnancies from our institution before December 2009. We excluded
pregnancies with major fetal anomalies. A total of 98 pregnancies met the
inclusion criteria. The second-trimester ultrasound was performed on average at 20.0 weeks (SD, 2.5). The average estimated fetal weight (EFW)
of twin A was 356 g (SD, 271) and for twin B was 351 g (SD, 247). The
median percent discrepancy in EFW relative to the lighter twin in each
pregnancy was 6.8% (25th percentile, 3.8%; 75th percentile, 25.0%). Thirteen (13.3%) of the pregnancies were at least 20% discordant.
Results—Generalized estimating equations with a logit link
were used to assess the association of 4 predictors. There was no association of the deviation from the mean EFW for twins with gestational
age at delivery (P = .84) or for twins with admission to the neonatal intensive care unit (adjusted odds ratio [AOR], 1.00; 95% confidence interval [CI], 0.99–1.01; P = .53) after adjusting for EFW, week of
second-trimester ultrasound, and birth order. The only significant effect
was the association of the deviation from the mean EFW of twins with
necrotizing enterocolitis.
Conclusions—For every 1-g increase in the deviation from the
mean EFW of twins, the odds of NEC increase by 1.03 (or 3%), adjusting
for EFW, week of second-trimester ultrasound, and birth order (AOR,
1.03; 95% CI, 1.01–1.07; P = .02). This unique study shows that deviation
from the mean EFW of twins during second-trimester ultrasound is a poor
predictor for early neonatal complications.
Table 1. Predictor of Outcomes
AOR (95% CI) [P]
IV Catheter
RDS
MV
Days (≥1 vs 0) NEC
TPN
NGT
EFW (g)
0.998
1.00
0.996
0.98
0.995
0.997
(0.994–1.002) (0.99–1.01) (0.991–1.001)(0.96–0.99) (0.991–1.000)(0.992–1.001)
[.36]
[.92]
[.15]
[.004]
[.04]
[.12]
Deviation
1.00
1.01
1.00
1.03
1.01
1.00
from
(0.99–1.01) (1.00–1.02) (0.99–1.01) (1.01–1.07) (1.00–1.02) (0.99–1.01)
mean
[.48]
[.13]
[.46]
[.02]
[.06]
[.41]
EFW of
twins (g)
Week of
1.36
1.14
1.81
5.32
1.76
1.55
2nd(0.86–2.16) (0.56–2.35) (0.98–3.35) (2.12–13.28) (1.07–2.88) (0.92–2.62)
trimester
[.18]
[.71]
[.06]
[<.001]
[.02]
[.10]
ultrasound
Birth order
0.77
0.84
0.78
0.89
0.90
0.85
(twin A vs (0.55–1.09) (0.49–1.43) (0.56–1.09) (0.24–3.36) (0.63–1.29) (0.66–1.10)
twin B)
[.14]
[.53]
[.14]
[.87]
[.56]
[.21]
IV indicates intravenous; MV, mechanical ventilation, NEC, necrotizing enterocolitis; NGT,
nasogastric tube; RDS, respiratory distress syndrome; and TPN, total parenteral nutrition.
1540075 Ultrasonographic Findings of Malignancy-Like Ovarian
Deciduosis of Endometrioma During Pregnancy
Marta Oliva,* M. Angela Pascual, Lourdes Hereter, Betlem
Graupera, Cristina Pedrero, Maria Fernandez-Cid Obstetrics, Gynecology, and Reproduction, Institut Universitari
Dexeus, Barcelona, Spain
Objectives—The aim of this study is to provide the description
of ultrasound findings of a rare entity that occurs during pregnancy in patients with endometrioma, whose echo pattern changes by hormonal influences and mimics a malignant ovarian tumor.
Methods—Six cases are described, in which an ovarian mass
was discovered during pregnancy. We reported the patient’s age, weeks of
gestation, tumor size, echo pattern, and blood flow observed by ultrasonography and the tumor marker cancer antigen 125 (CA-125).
Results—The results are summarized in Table 1. The average
age was 34.5 years. The tumor was bilateral in 1 case. In all cases, ultrasonographic findings showed the presence of papillae, and a color
Doppler study showed intense vascularization with an intensity score of
4 according to the International Ovarian Tumor Analysis consensus.
Patients 1 to 4 underwent a minimally invasive approach, with a histologic result of endometriosis with extensive decidualization. When this
paper was written, patients 5 and 6 were pregnant, 1 of them pending
surgery and the other 1 with doubts about the benefit of intervention
during pregnancy. The tumor marker CA-125 showed a minimal elevation in some cases, as shown in Table 1, and 2 patients did not have
information.
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Conclusions—There are few published cases, and almost all
show ultrasonographic findings similar to our cases. Until more evidence
becomes available regarding the echo pattern and blood flow mimicking
a malignant ovarian tumor, surgical treatment cannot be avoided. In our experience, conservative surgery has had satisfactory results; all patients
gave birth without complications.
1540166 Usefulness of Uterine Tranverse Diameter Measurement in
Suspicion of Congenital Uterine Anomalies
Meritxell Vila,* M. Angela Pascual, Betlem Graupera, Lourdes Hereter, Cristina Pedrero, Maria Fernandez-Cid
Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
Table 1
Objectives—The purpose of this study was to evaluate the potential role of the transverse diameter, measured by conventional ultrasonography (2DUS), of the uterus in the diagnosis of suspected congenital
uterine anomalies.
Methods—Between February 2011 and June 2012, women
aged 15 to 45 years with suspected uterine anomalies such as arcuate, septate, and bicornuate with 2DUS were evaluated by 3D ultrasonography
(3DUS) using multiplanar reformatted sections. The uterine anomalies
were suspected when measured by 2DUS when the transverse diameter of
the uterus was >45 mm. Women were categorized according to the size
range of the transverse diameter: 45 to 54, 55 to 64, and ≥65 mm. To compare the size range rate, Pearson’s χ2 was used, and data were expressed
as percentages according to its distribution.
Results—Of all the patients that had a transverse diameter >45
mm, 138 of them were diagnosed by 3DUS as having uterine anomalies.
Among the women diagnosed with uterine anomalies, the minimum transverse diameter measured was 45 mm, and the maximum was 88 mm.
Table 1 shows the distribution of the uterine anomalies diagnosed and the
size range for each type. The results show that most arcuate septate and
partial septate anomalies have a transverse diameter of 45 to 54 mm, with
statistical significance (P < .001).
Conclusions—Diameter measurements of the uterus through
transverse diameter 2DUS provide indirect information on possible uterine
anomalies. It seems a transverse diameter from 45 mm is a good indicator
to suspect possible uterine anomalies and thus complete the study by 3DUS
for the diagnosis and classification of congenital uterine anomaly types.
1
Age, y
34
Gestation, wk
21
Laterality
Right
Size, mm
87
Papillae
Present
Blood flow
Present
CA-125, IU/mL 43.71
Surgery
During
pregnancy
2
36
8
Bilateral
60/75
Present
Present
22
During
pregnancy
Patient
3
32
23
Left
55
Present
Present
40.20
During
pregnancy
4
31
16
Left
49
Present
Present
26
During
pregnancy
5
36
8
Right
59
Present
Present
—
No
6
38
12
Left
39
Present
Present
—
No
1540162 Correcting for Acoustic Cavitation and Acoustic Streaming
in Ultrasound Calibration
Victor Frenke,l* Thanh Nguyen,2 Loan Bui,1 Nghia Huu
Tran2 1Biomedical Engineering, 2Electrical Engineering,
Catholic University of America, Washington, DC USA
Objectives—Commercial power meters for calibrating ultrasound transducers are used ubiquitously in clinical and laboratory settings.
These devices are inherently inaccurate in that they do not compensate for
the effects of acoustic cavitation (AC) and acoustic streaming (AS). Both
phenomena can alter displacements generated on the meter’s target, introducing errors in power measurement. The objectives of this study were
to investigate these phenomena and to propose a standardized procedure
to marginalize their effects on power measurement.
Methods—The experimental setup included a nonreflecting target suspended from an analytical balance, reproducing the procedure employed in commercial devices. Measurements were performed at 1 and 3.3
MHz, where intensities employed precluded the onset of AC at the higher
frequency. The attenuating effect of AC bubbles in the ultrasound beam
was quantified by using a transmitting and receiving ultrasound transducer
to determine the power loss within the beam. Evidence of the contribution
of AS to erroneous measurements was demonstrated using an acoustically
transparent membrane positioned immediately above the target.
Results—AS was found to significantly increase the power
being sensed, indicating its dependence on the attenuating effects of AC.
The acoustically transparent membrane above the target effectively eliminated these effects. AC was found to significantly decrease the power
being measured where discrepancies with noncavitation measurements
correlated positively with intensity. AC activity, itself, also correlated with
intensity, as demonstrated using passive detection of harmonic emissions.
Conclusions—This study demonstrated that AC and AS can
significantly introduce errors in standard calibration measurements. These
effects were consistent with acoustic theory, including the dependence of
AS on the attenuation effects of AC bubbles. An acoustically transparent
membrane eliminated the effects of AS. The numerical relationship between the attenuation of AC bubbles, and the manner by which they affected the measurements, was found to accurately correct for these
discrepancies. The setup employed for the study can easily be assembled
using standard laboratory equipment.
Table 1
Anomaly Type
45–54
Arcuate, n (%)
74 (76)
Partial septate, n (%) 12 (70.6)
Septate, n (%)
13 (59.1)
Bicornuate, n (%)
1 (33.3)
Total
100
Transverse Diameter, mm
55–64
≥65
19 (19.8)
3 (3.1)
4 (23.5)
1 (5.9)
8 (36.4)
1 (4.5)
0 (0)
2 (66.7)
31
7
Total
96
17
22
3
138
1540206 Ultrasonographic Diagnosis of Ovarian Ectopic Pregnancy
After In Vitro Fertilization With Salpingectomy and Literature Review
M. Angela Pascual,1* Lourdes Hereter,1 Betlem Graupera,1
Francisco Tresserra,2 Alicia Perez,1 Buenaventura Coroleu,1
Pedro Barri1 1Obstetrics, Gynecology, and Reproduction,
2
Pathology, Institut Universitari Dexeus, Barcelona, Spain
Objectives—Among ectopic pregnancies, ovarian ones are extremely rare and much less frequent with previous history of salpingectomy. Diagnosis and treatment of this condition continue to be challenging
given that no typical risk factors exist compared with other types of ectopic
pregnancy, and signs and symptoms are similar to those observed in ruptured corpus luteal cysts. Ultrasonographic diagnosis is feasible, although
differential diagnosis from the corpus luteum is difficult. In this context,
the goal is to diagnose as accurately as possible to apply the surgical treatment to remove the ectopic pregnancy, preserving ovarian tissue.
Methods—This is a case of a 31-year-old woman with right
salpingectomy, which presented a right ovarian ectopic pregnancy (OEP)
after intracytoplasmic sperm injection–embryo transfer (ICSI-ET);
laparoscopy was done to remove the OEP, preserving the ovary, and a re-
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view of the literature was performed to assess the frequency of this condition and its association with in vitro fertilization procedures.
Results—We identified >250 reported cases, most of them case
reports and some series. Among the articles, 5 cases of OEP were found
in patients with a history of salpingectomy, and 4 papers reported OEP
after ICSI-ET.
Conclusions—OEP may be an unexpected finding in patients
with salpingectomy; unfortunately, this condition cannot prevent OEP.
Monitoring of β-human chorionic gonadotropin levels and the accuracy of
ultrasonographic diagnosis allowed a conservative therapeutic strategy
and proper postoperative course.
1540300 Ultrasound Screening of the Dense Breast: An Analysis of
the Costs and Benefits to Both the Patient and the Practitioner
Ren Tianbo, Sirisha Jasti,* Katherine Kaproth-Joslin, Avice
O’Connell Radiology, University of Rochester, Rochester,
New York USA
follicular neoplasms were reviewed to determine how often these lesions
had calcifications and/or were cystic. Thirty-three of the patients diagnosed with follicular neoplasms subsequently underwent thyroidectomy.
The surgical pathology reports were reviewed to determine how frequent
the follicular neoplasms were malignant.
Results—The database included 62 patients with follicular neoplasms after ultrasound-guided thyroid biopsy. On ultrasound imaging, 21
of 62 follicular neoplasms had cystic components, and 13 of 62 follicular
neoplasms had calcifications. Four of the 33 FNB follicular neoplasm
lesions were found to be malignant on surgical pathology. One was diagnosed as follicular carcinoma, 1 as papillary carcinoma, and 2 as the follicular variant of papillary thyroid carcinoma.
Conclusions—Follicular neoplasms did not often have calcifications and were often solid. Follicular neoplasms were more often benign
lesions than malignant.
1540408 Advanced Ultrasound Evaluation of Carotid Plaque: Can
a Combined 2-Dimensional and 3-Dimensonal Ultrasound
Analysis Provide Additional Information and Identify Significant Plaque Characteristics Responsible for Strokes?
Lysa Legault Kingstone,1,2* Carlos Torres,1 Geoffrey Currie2
1
Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario,
Canada; 2School of Dentistry and Health Sciences, Charles
Sturt University, Wagga Wagga, New South Wales, Australia
Objectives—Approximately 40% of all women undergoing
screening mammography are found to have dense breasts. Unfortunately,
the sensitivity and specificity of mammography are reduced in patients with
dense breasts, and some research indicates that dense breasts have an increased risk of breast cancer development. Recent studies have suggested
that mammography combined with screening breast ultrasound can help detect breast cancers in patients with dense breasts. California and Connecticut are currently the only 2 states where screening ultrasound has been
approved, and New York has recently passed a bill requiring the inclusion
of breast density information sent to women after their mammogram. The
purpose of this presentation is to review the advantages and disadvantages
of screening breast ultrasound and to analyze the feasibility of screening ultrasound as a standard screening protocol in current radiology practice, including both the cost and time expenses to the patient and practitioner.
Methods—In this presentation, we will review the sensitivity
and specificity of screening ultrasound plus mammography. We will analyze both the monetary and time costs to the patient and to the practitioner
associated with screening ultrasound plus mammography vs standard
mammography alone, with a close examination of what is occurring in
Connecticut and California, including who is or will be paying for these
exams. Finally, we will discuss the general impact of additional ultrasound
screening of dense breast tissue in light of the US Preventive Services
Task Force 2009 recommendations, where even routine mammographic
screening for breast cancer is being questioned.
Results—The results of our analysis as described above will be
discussed in the presentation.
Conclusions—With the recent US Food and Drug Administration approval of an automated breast ultrasound system and the push for
screening ultrasound as a standard screening procedure in Connecticut
and California, as well as the new legislation passed in New York State to
notify women of their breast density, it is necessary to understand the costs
and benefits of screening ultrasound to both the patient and the practitioner, including efficacy of the procedure.
Objectives—Using ultrasound (US) to image plaque morphology may improve stroke prevention by identifying atherosclerotic plaques
at higher risk for cerebrovascular events and associating morphologic characteristics with additional risk factors. This study evaluated how integrating an advanced US plaque imaging analysis adjunct to stenotic grading
identifies vulnerable characteristics in carotid atheromatous structure.
Methods—Patients with known high-grade carotid artery disease, confirmed on computed tomography (CT), and who were scheduled
for a future endarterectomy, were recruited for this study. Prior to surgery,
these participants received advanced US plaque imaging to identify
combined high-risk morphologic features such as specific homogeneity, internal echo texture, ulceration, surface irregularities, intraplaque
hemorrhage/lipid core, and calcification. These identified morphologic
features were further enhanced with the use of high-frequency and 3D reformatted imaging. We strengthened the study’s results by analyzing the
carotid US imaging findings and then correlating them with their postendartertectomy histologic studies.
Results—At the time of abstract submission, final data collection was not yet available; however, preliminary results indicate a high
correlation rate, sensitivity, and specificity between the US findings and
the detailed surgical specimens.
Conclusions—Applying advanced US plaque imaging to further identify significant plaque characteristics responsible for strokes can
provide insight into early causative conditions of carotid atherosclerosis.
This advanced imaging protocol could potentially shift the paradigm in
early carotid plaque imaging and possibly predict the onset in asymptomatic or mild to moderate plaques.
1540301 Ultrasound Features of Follicular Neoplasms and Ultrasound Features of Follicular Neoplasms Proven to Be Follicular Carcinoma at Surgery
Annette Ho,* Michael Davis, Annemarie Buadu Medical
Imaging, University of Arizona, Tucson, Arizona USA
1540482 Utility of 3-Dimensional Plaque Imaging in Carotid Stenosis
Lysa Legault Kingstone,1,2* Carlos Torres,1 Geoffrey Currie2
1
Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario,
Canada; 2School of Dentistry and Health Sciences, Charles
Sturt University, Wagga Wagga, New South Wales, Australia
Objectives—To determine how often follicular neoplasms diagnosed by ultrasound-guided fine-needle biopsy (FNB) had cystic components or calcifications. Also, to determine how often follicular neoplasms
diagnosed with FNB are proven to be malignant after thyroidectomy.
Methods—Two hundred thirty-one lesions in 202 patients who
underwent thyroid biopsy were reviewed. Of these, 62 were diagnosed as
follicular neoplasms by ultrasound-guided FNB. Ultrasound features of
Objectives—Emerging data suggest that carotid plaque morphology and severity can significantly affect the cerebrovascular prognosis. Recent studies have reported that 3D ultrasound (3DUS) used as an
adjuvant imaging technique may provide additional information in the
evaluation and risk stratification of vulnerable carotid plaque. The aim of
this study was to evaluate the utility of 3DUS in characterizing plaque
from various degrees of stenosis.
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Methods—In a cohort of symptomatic patients referred from
neurosurgery, 3DUS of the carotid arteries was conducted using a vascular ultrasound system (iU22; Philips Medical Systems) equipped with a
volumetric mechanical high-resolution linear array transducer for 3D imaging. We employed a 3DUS imaging method to allow high-detail studies in mild, moderate, and severe stenotic plaques. Constructed 3D plaque
images were quantified using the internal plaque echo texture, volume,
and surface morphology and evaluated by 2 independent observers using
our own classification protocol.
Results—At the time of abstract submission, final data were not
yet available; however, preliminary results indicate that 3DUS for plaque
characterization was significantly better in mild to moderate imaging, possibly due to the fluid-filled lumen acting as a substantial acoustic transmission for optimal plaque visualization. Higher-grade stenoses (>70%)
were difficult to assess; however, proximal and edge surface imaging was
diagnostic. These preliminary results indicate that our 3D approach may be
a sensitive tool in the identification of early vulnerable markers in lowergraded stenoses, possibly identifying early prediction of stroke.
Conclusions—Preliminary results show a high sensitivity and
negative predictive value of carotid plaque 3DUS in mild to moderate
stenosis and can reliably characterize the surface, volume, and ulcerations.
The sensitivity decreased with the severity of stenoses. 3DUS carotid
plaque quantification may serve as an important clinical screening tool in
early onset of significant carotid disease, for high-risk patients, and for
those without known significant carotid disease.
1540523 Practical Uniformity Evaluation of Ultrasound Systems:
Tips and Pitfalls
Donald Tradup,* Nicholas Hangiandreou, Scott Stekel
Radiology, Mayo Clinic, Rochester, Minnesota USA
Objectives—We have found uniformity evaluation (UE) to be
the single most effective imaging test to ensure proper function of medical ultrasound (US) imaging systems. In this presentation, we will describe our process for efficient and effective UE.
Methods—Display quality assessment and mechanical inspection of the imaging system should occur prior to UE. Begin the UE by annotating the image with the device identification and visually inspecting
in-air images. Some scan controls should be set to standard values (output, dynamic range, depth, compounding, transmit frequency, and focus)
as will be described in the presentation. Gain and time-gain compensation are visually optimized. Next, acquire clips of a phantom. These clips
should show a dynamic speckle pattern across the entire transducer face.
We use a previously described custom, flexible, liquid phantom. Tips for
optimal use of this phantom will be described. Commercial phantoms may
be used, but multiple clips may be needed to test the complete face of
curved arrays. Store 3 phantom clips (to guard against false-positive findings due to poor coupling) and 1 in-air clip. If possible, compute median
images from each clip, and inspect these for artifacts. Review of median
images acquired at acceptance (or use of subtracted median images) will
reduce the incidence of false-positives. Any artifacts observed at any point
during testing should be debugged to rule out poor coupling with the phantom, dirt/debris on the transducer face or connector, or scanner port, to
identify mechanical damage, cable-flex issues, and differentiate port vs
transducer problems. The severity of reproducible artifacts should be determined by assessing visibility of the artifact when scanning anatomy and
the size and location of the artifact.
Results—This UE approach has allowed us to detect artifacts
in our US practice with good sensitivity and specificity, and staff efficiency. For ≈10% to 15% of transducers, a potential artifact is noted during initial testing that is discounted during debugging.
Conclusions—Artifacts and equipment problems can be effectively identified using a standard UE protocol. The debugging step is
essential for minimizing the incidence of false-positives.
1540556 Utility of the Prefrontal Space Ratio to Screen for Trisomy
21 in a Racially Diverse Population: A Pilot Study
Barrie Suskin Kaplan,1,2 Anne Marie Roe,2,3 Komal Bajaj2,3*
1
Obstetrics and Gynecology, Montefiore Medical Center, Bronx,
New York USA; 2Albert Einstein College of Medicine, Bronx,
New York USA; 3Obstetrics and Gynecology, North Bronx
Healthcare Network, Bronx, New York USA
Objectives—The characteristic facial features of trisomy 21, including the dorsal displacement of the edge of the maxilla and thickening
of the prenasal skin, have been well described. The prefrontal space (PFS)
ratio capitalizes on these changes and has been shown to be an effective
screening marker for trisomy 21 when calculated from midsagittal 2D
sonographic images of the fetal profile in the second and third trimesters.
These studies, which have been performed exclusively in Caucasian populations, reported a mean PFS ratio in euploid fetuses of 0.97. As facial
morphology varies among different racial groups, it is plausible that the
PFS ratio may differ in non-Caucasian fetuses. The objective of this study
was to evaluate the PFS ratio of euploid fetuses of African American decent
to determine whether this difference may exist.
Methods—The PFS ratio was calculated retrospectively from
stored 2D images of euploid African American fetuses in the second and
third trimesters. These prenatal sonograms were performed at an urban
academic maternal-fetal testing unit under strict supervision by reproductive genetics and maternal-fetal medicine specialists. The cases were
drawn from chronologic birth records from our institution. Images were
excluded if the fetal profile was not truly midsagittal or if the anterior
edges of the maxilla and skin were not clearly identifiable. Other data including the presence of the nasal bone, maternal age, gestational age, and
ethnicity were also collected.
Results—Mean maternal age was 29.3 years. Median gestational age at the time of ultrasound examination was 20 weeks 4 days (18
weeks 3 days–25 weeks 4 days). The mean PFS ratio was 0.61 (SD, 0.21).
In a subset of fetuses with a hypoplastic or absent nasal bone, the mean
PFS ratio was 0.51 (SD, 0.17).
Conclusions—Though not statistically significant, the prefrontal space ratio in African American euploid fetuses trended lower than
that reported in euploid Caucasian fetuses in the literature. This pilot study
suggests that different racial groups may have different normal prefrontal
space ratios. We plan to expand this study as well as assess the prefrontal
space ratio of other groups to establish accurate normal values for a racially
diverse population.
1540570 An Objective Tool to Evaluate Ultrasound Image Quality:
The Ultrasound Standardized Assessment Tool
Creagh Boulger,* Katherine Pollard, David Bahner Emergency Medicine, Ohio State University College of Medicine,
Columbus, Ohio USA
Objectives—Evaluation of the skill of a sonographer requires
objective assessments of his or her ultrasound scans. However, little literature exists to define a high-quality ultrasound image. The purpose of this
study is to develop a standardized tool (Ultrasound Standardized Assessment Tool [USAT]) to assess ultrasound image quality and perform a pilot
reliability study of the tool.
Methods—A specific USAT was developed for each core emergency ultrasound application: trauma, intrauterine pregnancy, abdominal
aortic aneurysm, cardiac, biliary, urinary tract, deep venous thrombosis,
soft tissue/musculoskeletal, thoracic, ocular, and procedural guidance. The
USAT uses a series of objective yes-or-no questions in conjunction with
a difficulty rating of each view to produce a score. Ten beginning sonographers (first-year medical students in our institution’s introductory ultrasound training program), 10 experienced sonographers (fourth-year
medical students in our institution’s honors ultrasound course), and 5 expert
sonographers (ultrasound-credentialed faculty members at our institution)
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will perform ultrasound scans on a group of standardized ultrasound patients. The ultrasound scans will be evaluated using the USAT by 3 ultrasound-credentialed faculty evaluators from emergency medicine, critical
care, and radiology, who will be blinded to the identity of the scanners. The
USAT will then be evaluated for reliability.
Results—A specific USAT has been developed for each core
emergency ultrasound application. Ultrasound scans for evaluation are
being performed.
Conclusions—The need for a standardized method to both objectively evaluate the quality of an ultrasound image and provide distinct
differentiation between skill levels of ultrasound users is well documented.
The USAT represents one of the first attempts to provide objective assessment of ultrasound images. We anticipate that the USAT will be a
valuable resource to assess the current skills of sonographers and follow
the development of these skills over time.
1540597 Mid or Late Second-Trimester Doppler Ultrasound of the
Uterine Artery: Is There a Difference?
Koen Deurloo,1* John van Vugt,2 Annemieke Bolte,3 Martijn
Heymans4 1Obstetrics and Gynecology, Diakonessenhuis,
Utrecht, the Netherlands; 2Obstetrics and Gynecology,
Radboud University Medical Center, Nijmegen, the Netherlands; 3Obstetrics and Gynecology, 4Clinical Epidemiology and
Biostatics, VU University Medical Center, Amsterdam, the
Netherlands
Objectives—Uterine artery (UA) Doppler measurements for
screening for hypertensive complications in pregnancy is usually performed at 22 to 24 weeks of gestation. However, most routine targeted
ultrasound examinations are performed at 19 to 21 weeks of gestation.
It would be convenient to include the UA Doppler measurement in the
routine targeted ultrasound; therefore, we studied the correlation of UA
Doppler measurements at 19 to 21 and 22 to 24 weeks of gestation.
Methods—Ninety-seven primigravidas with uncomplicated
singleton pregnancies were analyzed. Combined UA velocity waveforms
were assessed using transabdominal color Doppler ultrasound between 19
and 24 weeks of gestation. The resistance index (RI) was calculated for
left and right UAs, and the results were averaged as a combined US RI.
After log transformation of the US RI variable, the results were analyzed
with linear regression models and corrected for known confounders (ethnicity, assisted reproductive technology, age, body mass index, and smoking). Unpaired t testing was used to assess the correlation between UA RIs
between 19 and 21 and 22 and 24 weeks of gestation.
Results—Adequate UA velocity waveforms were assessed in
all cases. There was no confounding demonstrated for the known confounders. Linear regression analysis showed a significant correlation (r =
0.79) between mid and late second-trimester UA Doppler measurements
(P < .05).
Conclusions—RIs of blood velocity waveforms of the UA at
19 to 21 and 22 to 24 weeks of gestation are strongly correlated, and UA
Doppler measurements might be included in the routine targeted ultrasound at 19 to 21 weeks of gestation. Further research is needed to assess
its screening performance.
1540605 Simulation Model as an Adjunct Method for Emergency
Medicine Transvaginal Ultrasound Education
Omar Corujo Vazquez,* Marie Romney, Penelope Chun
Lema, Cara Brown, Michael Radeos, Eric Tran, Anita Datta
Emergency Medicine, New York Hospital Queens, Flushing,
New York USA
Objectives—This study assessed the importance of a mannequin simulator model as an addition to a didactic lecture in point-ofcare pelvic ultrasound. We hypothesized an improvement in ultrasound
knowledge, technique, satisfaction, and confidence for residents exposed
to the simulation model.
Methods—First-year residents in emergency medicine were
enrolled in a prospective cohort study to assess an educational intervention. Subjects were randomly divided into a didactic-only group (group A)
or didactic combined with simulation group (group B). Both groups received didactic education. Group B received additional hands-on ultrasound simulation training with the Combination IUP Ectopic Pregnancy
Transvaginal Ultrasound Training Model (Blue Phantom, Redmond, WA).
Both groups were evaluated by a written test and an objective structured
clinical exam (OSCE) on pelvic ultrasound before and after the intervention. A survey was given to assess resident satisfaction and confidence.
Results—Group B increased their pretest to posttest written
score by 50% compared to group A (32% vs 21% median increase) but did
not reach statistical significance (P = .074). Group B increased their pretest
to posttest OSCE score when compared to group A (31% vs 29.9% median), but this difference was not statistically significant (P = .92). Prior to
the course, 90% of the subjects reported feeling “not at all comfortable”
with performing and interpreting normal pelvic ultrasound examinations.
After the course, this number decreased to 30% and reached statistical significance (P = .002). When analysis was performed from group B independently, 80% of subjects were either “very comfortable” or “extremely
comfortable” performing transvaginal ultrasound after the intervention.
Conclusions—Simulation combined with didactic training may
be superior for resident satisfaction and confidence in point-of-care pelvic
ultrasound teaching. Although there was improvement in knowledge and
technique, a larger study is needed on the use of simulation training in resident education to show significance.
1540609 Analysis of Uniformity Artifacts Detected During Clinical
Ultrasound Quality Control
Scott Stekel,* Nicholas Hangiandreou, Donald Tradup
Radiology, Mayo Clinic, Rochester, Minnesota USA
Objectives—Characterize trends in severity ratings of observed
transducer uniformity artifacts.
Methods—We reviewed the results of quarterly quality control
(QC) uniformity testing for the previous ≈2 years and characterized the
evaluation history of all transducers exhibiting artifacts of any severity.
Our evaluation protocol is able to reveal subtle transducer artifacts. All artifacts were scored by a single author (D.T.) using a subjective severity
scale. Uniformity artifacts attributed to scanner defects were excluded
from this analysis.
Results—A total of 58 probes with artifacts of varying severity, observed at QC between March 2010 and August 2012, were analyzed. These included probes that exhibited critical artifacts (failed, with
score F), as well as those that did not fail but exhibited at least 2 successive subcritical artifact scores (P1, P2, or P3).
Thirty-one of these 58 probes failed (score F). Twenty-two of
the 31 failing scores (71%) directly followed a prior QC assessment with
a passing score (score P, no artifact seen). Only 9 failures (29%) were directly preceded by ≥1 subcritical scores. The time between the first subcritical score and the failure ranged from 3 to 14 months, with a mean of
9.1 months. No reliable trend of progressively worsening subcritical scores
ending in failure was seen (the numbers of probe failures with prior improving, stable, and worsening subcritical scores were 2, 7, and 0, respectively). Twenty-seven of the 58 probes with subcritical scores have not
failed. Two of these artifacts spontaneously resolved, returning to scores
of P. The remaining 25 artifacts were observed up to the last recorded QC
session. The time duration of these subcritical artifacts ranged from 0.5 to
16.5 months, with a mean of 10.5 months. No reliable trend of progressively worsening subcritical scores was seen (the numbers of these probes
with improving, stable, and worsening subcritical scores were 5, 18, and
3, respectively).
Conclusions—These subjective artifact data are not consistent
with a model of initial minor defects progressively increasing in severity
until failure occurs. We are working on methods to objectively score artifact
severity, which should allow a more sensitive analysis of artifact behavior.
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1540628 Carotid Plaque Classification System: A New Standard
Diagnostic Criterion
Lysa Legault Kingstone,1,2* Carlos Torres,1 Geoffrey Currie2
1
Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario,
Canada; 2School of Dentistry and Health Sciences, Charles
Sturt University, Wagga Wagga, New South Wales, Australia
Objectives—2D and 3D ultrasound (US) for carotid plaque imaging can provide valuable information on the morphology. Particular
sonographic features of the plaque have been recognized as the foundation
for stroke. Carotid plaque imaging is increasingly recognized as being as
important as stenotic grading; however, various methods of echographic
image standardization have been described. Standard plaque analysis and
characterization are lacking, and, to our knowledge, no global classification system or form of image standardization exists. Our objective was to
develop a standard US characterization method and reporting system for
carotid atherosclerotic lesions.
Methods—We created and implemented a quality assurance
tool for plaque classification criteria in an effort to globalize image and reporting standardization without the use of complex or expensive software.
US images were subjectively graded using a standardized classification report form that combines echographic image features. Three categorical
groups were defined according to risk of vulnerability: type A (low risk),
type B (moderate risk), and type C (high risk). Accuracy of the method was
determined by measuring the agreement of plaque characterization using
standardized US images and comparing inter-observer agreement and
inter-reader reliabilities. In addition, highly vulnerable plaques incorporated Radpath correlation.
Results—At the time of submission, final data analysis was
being completed. Preliminary results indicate that our plaque classification
system provided excellent sensitivity, specificity, positive predictive value,
negative predictive value, and accuracy.
Conclusions—Our standardized classification system has allowed us to improve the consistency and accuracy of plaque characterization imaging and assessment without of the use of computed or
automated methodologies. This plaque analysis criterion may help promote the use of a standard global US classification analysis and uniform
reporting for carotid atherosclerotic lesions. Large-scale studies are required to fully assess the potential of this grading system.
1540646 A Decade of Ultrasound Practice Accreditation at California Prenatal Diagnosis Centers and Experience With Fetal
Echocardiography Accreditation
Sara Goldman Genetic Disease Screening Program, California Department of Public Health, Richmond, California USA
Objectives—Monitor the ultrasound practice accreditation and
reaccreditation at prenatal diagnosis centers (PDCs) from 2001 to 2011
and fetal echocardiography accreditation since April 2011.
Methods—All PDCs were required to achieve obstetric (OB)
ultrasound practice accreditation by 2000. By March 2012, Fetal echo–approved PDCs were required to apply for fetal echocardiography accreditation with the AIUM or Intersocietal Commission for the Accreditation
of Echocardiography Laboratories (ICAEL).
Results—In 2001, 50 ultrasound practices (65 %) had achieved
AIUM accreditation; 17 practices (22%) were in the process of achieving
AIUM accreditation; and 10 practices (13%) had chosen American College of Radiology (ACR) accreditation. In 2011, there were a total of 80
ultrasound practices at 141 PDC sites. Seventy-five practices (94%) had
achieved AIUM accreditation, and 5 ultrasound practices had chosen ACR
accreditation. On average, 18 ultrasound practices achieve reaccreditation
each year. In March 2012, 34 ultrasound or pediatric cardiology practices
submitted a fetal echocardiography accreditation application representing
56 PDC sites, and 18 (53%) practices are currently accredited by either the
AIUM or ICAEL representing 30 PDC sites.
Conclusions—A requirement for OB ultrasound practice accreditation at PDCs and fetal echocardiography accreditation at fetal echo–
approved PDCs is achievable through monitoring of the reaccreditation
progress.
1540658 Medical Student Ultrasound Education as Part of the
Clinical Skills Immersion Experience
Zachary Robinson,1 Colin Turney,1 Creagh Boulger,2 David
Bahner2* 1Ohio State University College of Medicine,
Columbus, Ohio USA; 2Emergency Medicine, Wexner Medical
Center, Ohio State University, Columbus, Ohio USA
Objectives—Focused ultrasound (US) allows physicians to
quickly obtain high-quality, cost-effective images. While the technology
has advanced, education in ultrasound has lagged at the graduate medical
education and medical student levels. Over the last several years, Ohio
State has emerged as a leader in ultrasound education by teaching focused
US to medical students. US has been integrated into the Clinical Skills
Immersion Experience (CSIE), a unique 7-day course providing third-year
medical students with experience in a variety of procedural and imaging
techniques.
Methods—The CSIE curriculum consists of a series of lectures
and workshops over a variety of clinical skills. As part of this curriculum,
we conducted a 3-hour session on focused ultrasound, which included
pelvic, aorta, and cardiac imaging, as well as evaluation of lung sliding and
the focused assessment with sonography for trauma scan. The session included a brief lecture on basic US principles followed by extensive handson experience. After the session, students completed a survey evaluating
their skills with US using a 5-point Likert scale, where 1 = low skill level
and 5 = highly skilled. They were also asked how well the session improved their understanding of ultrasound, where 1 = not at all and 5 =
greatly improved.
Results—Ten of 38 students responded to the survey for the
August session (response rate, 26%). Nine of 10 respondents had performed <10 ultrasound exams previously. On a scale of 1 to 5, students
graded their ultrasound skills as 2.1 (±0.62) before the session and 3.3
(±0.42) after the session. When asked if the session improved their understanding of ultrasound, the mean score was 3.7 (±0.3).
Conclusions—Students felt the CSIE US session improved
their understanding of and skill with US. These results are for the first of
6 sessions this academic year, each with a different group of students. We
have asked the CSIE director to mandate participation in the educational
survey to improve the response rate. Further evaluation of this curriculum
will include elective standardized assessment tests to determine students’
acquisition of and long-term retention of the US material presented.
1540661 Increased Incidence of Renal Colic in the Pediatric Emergency Department
Anita Datta, Omar Corujo Vazquez, William Apterbach,*
Gregg Rusczyk, Sanjey Gupta, Marie Romney, Michael
Radeos, Kruti Joshi, Penny Chun Lema Emergency Medicine, New York Hospital Queens, Flushing, New York USA
Objectives—Multiple studies demonstrate an increasing incidence of urolithiasis. This increased incidence, combined with the trend
toward reducing ionizing radiation use among children, makes ultrasonography (US) more desirable. The purpose of this study was to assess
the incidence of renal colic among pediatric patients in an urban emergency department (ED) over a 5-year span. We reviewed the time to treatment, ED provider, patient demographics, and diagnostic modality used in
patient workup.
Methods—This was a retrospective analysis of medical records
of patients seen in the Pediatric Emergency Department at New York Hospital Queens from January 2007 to September 2011. A search of key words
such as renal colic, ureterolithiasis, flank pain, kidney stone, nephrolithi-
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asis, abdominal pain, and hematuria was performed. Descriptive statistics
were used for all subjects. Normalcy for data was calculated, and all continuous data were evaluated utilizing the Student t test or analysis of variance, when appropriate. All categorical data were calculated using the
Fisher exact test or χ2 analysis.
Results—We found 153 cases of kidney stones among the pediatric population from January 2007 to 2011. The mean age was 19 years.
Patients were evaluated by 24% ED physicians, 66% pediatric emergency
physicians, and 10% midlevel providers (MLPs). Though there was an
overall increase in the incidence of renal colic in 2011 compared to 2007,
it was not found to be statistically significant by the Fisher exact test
(P = .11). The use of ultrasound increased with each progressive year
(from 10% in 2007 to 27% in 2011). The type of provider (ED attending
vs pediatric attending vs MLP) had no significant effect on the use of computed tomography (CT) or US (P = .15; P = .15, respectively). The type
of provider or diagnostic modality did not affect the ED length of stay of
patients (P = .08).
Conclusions—There has been an overall increase in renal colic
among the pediatric emergency patient population over the past 5 years.
CT was more frequently used in the diagnostic workup compared to US.
We plan to use these data to educate health care providers on the use of US
in patients suspected of having nephrolithiasis to further minimize the use
of CT scans.
1540672 Prenatal Stomach Size: Association With Cleft Lip and/or
Cleft Palate
Kristin Burhans,1* Lauren Mack,1 Peter Koltz,2 Stephanie
Henderson,1 John Girotto,2 Loralei Thornburg1 1Obstetrics
and Gynecology, 2Plastic Surgery, University of Rochester,
Rochester, New York USA
Objectives—Cleft lip/palate is listed as associated with an absent stomach due to poor fetal swallowing; however, it is unclear if a
“small” stomach is also associated, especially without concurrent brain
abnormalities.
Methods—Records were reviewed for all nonanomalous infants at Strong Memorial Hospital from 2003 to 2011 with cleft lip/cleft
palate with available second- or third-trimester images. In each abdominal circumference, stomach width (W) and anterior-posterior (AP) measurements were measured by a single author (L.M.), and polyhydramnios
or “absent” stomach was recorded. Nondiabetic controls matched 2:1 for
all but 9 patients (1:1) for the gestational age (GA) of measurement within
1 week. As per prior nomograms, mean W and AP were compared in 3to 5-week GA groups between infants with clefts and those without.
Results—Of 32 infants with clefts, 108 measurements matched
207 control measurements. The majority of infants received 2 or 3 prenatal ultrasound examinations. There were only 3 infants with cleft with an
absent stomach at any point in gestation, 1 with polyhydramnios. The
mean W and AP were both significant at 19 to 21 and 22 to 24 weeks’ gestation, W only at 25 to 27 and 37 to 40 weeks, and AP only at 28 to 30 and
31 to 36 weeks.
Conclusions—Few nonanomalous infants with clefts had an
absent stomach on ultrasound, suggesting this is an insensitive marker;
however, mean W and AP stomach measurements were significantly
smaller in the mid trimester between 19 and 24 weeks when many
anatomic ultrasound examinations are performed. Abnormalities in prenatal stomach measurements, especially during this period, should prompt
evaluation for cleft lip/palate. Stomach size at 16 to 18 weeks did not differ in either dimension, suggesting this is a poor marker prior to 19 weeks.
Table 1. Stomach (mm), Mean ± SD
Infants With Cleft
GA, wk
W
AP
16–18
5.0 ± 3.1 6.5 ± 5.3
19–21
5.9 ± 2.8 6.4 ± 3.3
22–24
4.9 ± 3.0 8.0 ± 4.9
25–27
8.7 ± 2.2 10.5 ± 3.1
28–30
9.8 ± 3.9 13.1 ± 1.7
31–36
12.4 ± 3.3 15.3 ± 4.8
37–40
12.5 ± 6.0 18.8 ± 11
Infants Without Cleft
W
AP
6.8 ± 2.4 9.1 ± 4.5
8.3 ± 2.4 9.3 ± 2.7
9.4 ± 2.3 12.4 ± 4.3
10.9 ± 4.2 12.5 ± 4.4
11.2 ± 3
17.2 ± 6.7
13.4 ± 3.6 19.3 ± 7.7
16.5 ± 6
25 ± 9.1
P, W
.09
.01
<.001
.03
.4
.2
.04
P, AP
.15
.01
.01
.09
.02
.005
.06
1540674 Emergency Ultrasound of Hemodialysis Arteriovenous
Fistulas and Grafts
Gowthaman Gunabushanam,1* John Millet,1 Vijayanadh
Ojili,2 Leslie Scoutt1 1Diagnostic Radiology, Yale University
School of Medicine, New Haven, Connecticut USA; 2Radiology, University of Texas Health Science Center, San Antonio,
Texas USA
Objectives—Patients with hemodialysis arteriovenous fistulas
and grafts (AVF/AVG) may emergently present with pain, swelling, and
decreased or absent thrill. The purpose of this exhibit is to describe the
spectrum of sonographic findings of acute complications of hemodialysis AVF/AVG and to correlate these with angiographic findings when
available.
Methods—A classification system for the acute complications
of hemodialysis AVF/AVG will be provided by anatomic location and etiology. The sonographic appearances of these complications, including arterial inflow dissection, pseudoaneurysm, thrombosis, critical stenosis,
graft disruption, hematoma, infection, and postoperative seroma, will be
demonstrated. Grayscale, color, and pulsed Doppler imaging findings will
be described. When available, sonographic findings will be correlated to
other imaging modalities. Pertinent management issues, including endovascular and surgical therapy, will be briefly discussed.
Results—Not applicable as this is a pictorial review.
Conclusions—Ultrasound is the initial and often only diagnostic imaging modality used in the evaluation of hemodialysis AVF/AVG.
Knowledge of the sonographic appearance of acute complications is essential for early detection and may enable a reduction in patient morbidity.
1540676 Radiation Dose Reduction Through the Use of Ultrasound
Smart Fusion for Liver
Nami Azar,* Edwin Vargas Velandia, Dean Nakamoto
Radiology, Case Medical Center, Case Western Reserve
University, Cleveland, Ohio USA
Objectives—Radiation dose reduction without decreasing quality care delivery is one of the main priorities in the current interventional
radiology practice. We seek to evaluate the value of using fused multimodality imaging (Smart Fusion software, ultrasound [US]-computed tomography [CT] fusion) in the reduction of the radiation dose in CT-guided
liver biopsies. We present our current experience.
Methods—In a retrospective review, data of patients who presented to the Interventional Radiology Department for liver biopsies during the months of January and February 2012 were analyzed. A statistical
comparison of average radiation dose measured as milliamperes (mA) and
dose length product (DLP) was performed between 2 groups. The first
group underwent CT-guided guided biopsies only, and in the second group,
Smart Fusion software (US-CT fusion) was used.
Results—A convenience sample 12 subjects was chosen for
analysis. In this sample, 5 cases had liver biopsies in which Smart Fusion
software (US-CT fusion) was used vs 7 cases performed under CT guidance only. The mean age for this sample was 62.8 years, and the mean intervention time was 50.6 minutes. Patients in the group where Smart
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Fusion software was used had mean mA of 8574 and DLP of 1676 vs mA
of 16,219 and DLP of 3342 in the group where solely CT-guided biopsies
were performed. Total reductions of 52% in mA and 50.1% in DLP were
achieved using Smart Fusion software.
Conclusions—After examining the data gathered, we conclude
that Smart Fusion software improves patients’ safety through radiation
dose reduction as well as having a positive impact in interventional radiology resource utilization. Multimodality imaging is a promising tool that
might also decrease the cost of patient care. A larger sample will document the value of Smart Fusion software.
1540683 Ultrasound of Musculoskeletal Conditions That Clinically
Mimic Lower Extremity Deep Venous Thrombosis
Gowthaman Gunabushanam,1* Vijayanadh Ojili,2 Leslie
Scoutt1 1Diagnostic Radiology, Yale University School of
Medicine, New Haven, Connecticut USA; 2Radiology, University of Texas Health Science Center, San Antonio, Texas USA
Objectives—Venous Doppler examination is the first imaging
study done to evaluate patients presenting with clinical symptoms (pain,
swelling, tenderness, or erythema) of lower extremity deep venous thrombosis (DVT). This review presents a systematic approach to the ultrasound
diagnosis of musculoskeletal conditions that can clinically present as DVT.
Methods—The exact anatomic location (groin, thigh, knee,
calf, or ankle) of the patient’s symptoms provides useful clues to the diagnosis. The sonographic findings of common musculoskeletal conditions
that mimic DVT are described, including: Baker’s cyst (ruptured, hemorrhagic, or infected); muscle tear, hematoma, or other injury; tendon inflammation and/or rupture; bursitis and infectious and inflammatory
arthritis; and primary and metastatic muscle and bone tumors.
Results—Not applicable as this is a pictorial review.
Conclusions—In patients with focal symptoms in the lower extremities, meticulous examination of all anatomic structures in the vicinity of the symptomatic region enables an accurate alternate diagnosis of
musculoskeletal pathologies.
1540701 Implementation of Bedside Ultrasonography Within an
Internal Medicine Faculty and Residency: The IMBUS
Program
David Tierney,* Terry Rosborough Medical Education,
Abbott Northwestern Hospital, Minneapolis, Minnesota USA
Objectives—Describe in detail and provide a rationale for a curriculum, structure, and successful implementation of an internal medicine bedside ultrasound program (IMBUS) in a residency program and its faculty.
Methods—Design: Prospective cohort study in an internal
medicine (IM) residency program at a private academic 700-bed tertiary
care center. Participants: Thirty-three residents and 13 full-time faculty
members without significant prior ultrasound experience. Intervention:
(1) Development of an IM ultrasound curriculum to maximize sensitivity/
specificity of our routine physical exam as well as critical time-sensitive
diagnoses; (2) overlap training method using top-down and bottom-up
methodologies; (3) 35-hour “boot camp” including didactic, hands-on
model-based, and simulator-based training; (4) bedside hands-on training
with faculty mentors until trainee meets a prespecified exam count in each
component and is deemed competent in that exam area; (5) ongoing mentored and remotely submitted/reviewed images until adequate technical
and interpretive sensitivity/specificity obtained; (6) final test-out using
bedside and simulator-based summative evaluation prior to certification;
and (7) a robust ongoing quality assurance system. Measurements: (1)
Comparative effectiveness of multiple implementation strategies; (2) time
to, variation in, and predictive factors of competence in each exam component; (3) clinical impact of chosen components on patient outcomes;
(4) effect of implementation on resident/faculty work flow, efficiency, and
job satisfaction.
Results—We describe in detail and rigorously critique a full ultrasound curriculum and implementation strategy for an IM residency.
Thirty IM residents and 12 faculty were trained using the IMBUS program. Learning curves for each ultrasound exam component have been
established. We are analyzing multiple outcomes, including competency
learning curves, skill decay, patient outcomes and experience, and physician impact of bedside ultrasound.
Conclusions—We hope that by describing in detail our curriculum, methods, and learning, we can help other residency programs
implement bedside ultrasound in an efficient, focused, evidence-based,
politically aware, and impactful manner.
1540730 Utility of Point-of-care Ultrasound in the Management of
Snake Bite
Srikar Adhikari,* Mazda Shirazi, Austin Gross Emergency
Medicine, University of Arizona Medical Center, Tucson,
Arizona USA
Objectives—To describe the use of point-of-care Ultrasound in
the management of a snake bite case in the emergency department (ED).
Methods—We present a 67-year-old male who presented to the
ED with a rattlesnake bite to the right index finger approximately 4 hours
prior to arrival to the ED. The patient denied any history of diabetes, hypertension, or any other medical diseases. Physical examination revealed
normal vital signs. Puncture wounds were noted on the second digit at the
metacarpophalangeal joint with surrounding ecchymosis. There was significant edema of the right hand and forearm, with limitation of range of
motion. He received 4 units of CroFab (antivenom) initially. A toxicology
consult was obtained. Per toxicologist recommendations, the leading edge
of the swelling at the envenomation site was marked. Proximal progression of swelling and induration were monitored to determine the need for
additional doses of CroFab. Two hours later, the treating emergency physician was asked to mark the leading edge of the swelling and induration in
the forearm to assess for any proximal progression. Based on clinical examination findings, it was determined that there was no significant proximal progression of swelling and induration. Soft tissue ultrasound of the
forearm was performed by another emergency physician who was not involved in this patient’s care.
Results—Bedside ultrasound revealed edema and subcutaneous fluid extending proximally into the elbow, beyond the leading edge
marked by the treating physician. The subcutaneous tissues were also hyperechoic in appearance. These ultrasound findings were highly suggestive of proximal progression of local findings. Based on the sonographic
findings, additional doses of CroFab were given to the patient, who was
admitted to the hospital.
Conclusions—In this case, point-of-care ultrasound helped
clinicians make an accurate assessment of proximal progression of local
findings due to a snake bite. This case highlights the utility of bedside ultrasound in the management of snake bite in ED patients. Point-of-care
ultrasound can expedite the consultation and appropriate treatment in patients with snake bite.
1540763 Scaled Signal Intensity of Uterine Fibroids on T2-weighted
Magnetic Resonance Images: Objective Parameter to
Determine the Suitability for Magnetic Resonance–Guided
Focused Ultrasound Surgery of Uterine Fibroids
Sanghee Lee,1* Sang-Wook Yoon,2 Mi Hee Lee,3 Su Min
Kang1 1Radiology, Healthcare System, Gangnam Center,
Seoul National University Hospital, Seoul, Korea; 2Radiology,
CHA Bundang Medical Center, CHA University, Seongnam,
Korea; 3Radiology, Seoul Metropolitan Government–Seoul
National University Boramae Medical Center, Seoul, Korea
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surgery (MRgFUS) is a noninvasive treatment for symptomatic uterine
fibroids. Patient selection is the most important step to achieve good results. The purpose of this study was to assess the initial efficacy of scaled
signal intensity (SSI) of uterine fibroids on T2-weighted MR images as a
new objective parameter to determine the suitability for MRgFUS.
Methods—Twenty-four uterine fibroids in 20 premenopausal
women were treated using MRgFUS. Treatments were performed from
October 2008 to January 2010, and the mean age of the patients was 37.9
± 5.9 years. SSI was measured on T2-weighted MR images by standardizing its mean pixel intensity to a 0 to 100 scale, using reference intensities
of muscle (0) and fat (100), respectively. SSI in each fibroid was retrospectively analyzed according to the nonperfusion volume (NPV) ratio.
Results—The mean NPV ratio in uterine fibroids with SSI <10
(n = 28) was 65% ± 17.5%. In the case of uterine fibroids with SSI >10 (n
= 18), the mean NPV ratio was 51.8% ± 21.0%. Uterine fibroids with SSI
<10 on T2-weighted MR images showed a higher NPV ratio than uterine
fibroids with SSI >10.
Conclusions—SSI of uterine fibroids on T2-weighted MR images can be suggested as an objective parameter for patient selection in
MRgFUS. Uterine fibroids with <10 are more eligible for MRgFUS.
1540772 Patient and Practitioner Perceptions of Ultrasound Screening in Pregnancy
Susan Bradford,* Loralei Thornburg, J. Christopher Glantz
Obstetrics and Gynecology, University of Rochester Medical
Center, Rochester, New York USA
Objectives—To evaluate how patients and obstetric providers
perceive ultrasound examinations in pregnancy, including safety and accuracy of screening.
Methods—Anonymous surveys of pregnant patients undergoing first- or second-trimester ultrasound and obstetric providers who refer
patients to ultrasound units were conducted.
Results—Surveys were completed by 337 patients (42% firsttrimester screening [FTS], 47% anatomic screening [AS], and 12%
unknown) as well as 142 practitioners (63% obstetrics and gynecology,
25% family practice, and 14% midlevel providers).
The FTS patients were significantly more likely than AS to correctly identify the reason for ultrasound (67% vs 48%; P = .006), as were
patients receiving care from a private office vs a hospital-based clinic regardless of the type of ultrasound (82% vs 46%; P < .0001). Among AS
patients, 59% indicated that their doctor had sent them to determine the
fetal sex; however, patients felt that determination of fetal growth (43%)
and fetal sex (41%) were their personal primary reasons for the ultrasound.
The majority of both patients and providers felt ultrasound to be safe
(68%). Patients’ and providers’ understanding of the baseline anomaly risk
was poor (29% providers and 5% patients; P < .0001). Providers’ understanding of the residual anomaly risk after normal anatomic ultrasound
was better, but patients continued to have poor understanding (57%
providers and 10% patients; P < .0001), and only 51% of patients knew
that ultrasound cannot detect all problems. Despite these deficiencies, 86%
of patients believed they had adequate information before their ultrasound.
Only 25% of patients planned nonmedical ultrasound; this was significantly higher among FTS patients (30% FTS vs 20% AS; P = .03).
Conclusions—Obstetric providers have significant gaps in their
knowledge regarding ultrasound screening tests, and current counseling
practices do not adequately provide patients with an understanding of these
tests. Despite this, most patients feel adequately counseled.
1540777 Which Parameters Could Be Useful for Predicting Malignancy in Solid Adnexal Masses?
Jesus Utrilla-Layna,* Begoña Olartecoechea, María Aubá,
Daisy Diaz, Laura Pineda, Leyre Juez, Juan Luis Alcazar
Obstetrics and Gynecology, Clinica Universidad de Navarra,
Pamplona, Spain
Objectives—To determine which clinical, biochemical, and
other sonographic parameters could be useful to predict malignancy in
sonographically purely solid adnexal masses.
Methods—Clinical (age and menopausal status), biochemical
(serum cancer antigen 125 [CA-125] level) and other sonographic features (tumor volume, ascites, bilaterality, signs of carcinomatosis, tumor
contour [irregular or regular], presence of acoustic shadowing, and blood
flow score) from women diagnosed as having a purely solid adnexal mass
on B-mode grayscale sonography were reviewed for this retrospective
study. In those women with bilateral masses, only the solid mass was included; if there were bilateral solid masses, the largest one was selected for
the analysis. All patients had undergone surgery and mass removal. Definitive histologic diagnosis was available in all cases. All parameters were
compared to final histologic diagnosis (benign or malignant) in univariate
statistical analysis. Then a stepwise forward logistic regression analysis
was performed to identify those features that independently predict malignancy and develop a model for prediction.
Results—A total of 227 women were included. Patients’ mean
age was 52.9 years (range, 15–84 years). One hundred fifty masses were
malignant, and 77 were benign. All women with carcinomatosis (n = 52)
on sonography had a malignant tumor; most of them had advanced stage
primary ovarian cancer (84%). No case of a benign tumor had signs of
carcinomatosis on sonography (specificity, 100%). In the remaining 175
cases, logistic regression analysis showed that log CA-125 (odds ratio
[OR], 5.8; 95% confidence interval [CI], 2.3–14.7), an irregular tumor
contour (OR, 3.1; 95% CI, 1.1–10.46), absence of acoustic shadowing
(OR, 6.0; 95% CI, 1.5–25.7), and moderate or abundant blood flow (OR,
27.3; 95% CI, 8.4–88.6) were independent predictors of malignancy.
Using the proposed model, 94.4% of malignant tumors and 85.7% of benign tumors were correctly identified.
Conclusions—In purely solid masses with the presence of carcinomatosis on sonography, malignancy is the rule. In cases without carcinomatosis, the CA-125 level, an irregular tumor contour, absence of
acoustic shadowing, and moderate or abundant blood flow are predictors
of malignancy.
1540783 Efficacy of Ultrasound-Guided Radiofrequency Ablation
for Selective Feticide in Complicated Monochorionic
Pregnancy
Jae-Won Yoon,* Hye-Sung Won, Jae-Yoon Shim, Pil-Ryang
Lee, Ahm Kim Asan Medical Center, Seoul, Korea
Objectives—The purpose of this study was to evaluate the
efficacy and safety of radiofrequency ablation (RFA) for selective feticide
in complicated monochorionic multiple gestations.
Methods—This was a retrospective review of patients who underwent selective feticide by RFA between December 2003 and June 2012
at Asan Medical Center.
Results—Seventeen cases were included in the study (14 twins
and 3 triplets). There were 3 intrauterine cotwin fetal deaths (17.6%), 1
within 24 hours and 2 by cord stricture regardless of procedure. There
were 2 terminations of pregnancy because of preterm labor at 23.4 weeks
and severe hydrops fetalis in a case of twin-twin transfusion syndrome at
23.5 weeks. The median gestational age at intervention was 21.4 weeks
(range, 16.6–25.0 weeks) and at delivery was 37.1 weeks (range, 29.1–
39.0 weeks). The median operation time was 4 minutes (range, 2–13 minutes). Preterm prelabor rupture of membranes before 37 weeks occurred
in 23.5% (4/17). The overall neonatal survival rate was 70.5% (12/17).
All of the surviving infants are doing well without any complications.
Conclusions—RFA is an effective method for selective feticide in monochorionic multiple pregnancies.
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1540840 Spectrum of Ultrasound Findings in Patients With Anorectal Malformation
Steven Kraus,1,2* Sara O’Hara,1,2 Janet Adams1 1Radiology,
Cincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio USA; 2Radiology, University of Cincinnati College of
Medicine, Cincinnati, Ohio USA
Objectives—There are many secondary and associated malformations of multiple organ systems that can be discovered by ultrasound
(US) and are important to detect in the clinical management of patients
with anorectal malformation (ARM). The objective of this poster is to review the most common and important findings that can change the clinical management of these patients.
Methods—Our radiology database was searched for patients
with ARM and US exams performed on these patients. The exams were
reviewed, and both still images and US clips were collected and presented
pictorially, some with selective, radiographic, fluoroscopic, magnetic resonance (MR), and/or clinical images for correlation.
Results—The most common associated malformations in patients with ARM detected by US are genitourinary (GU) and spinal in etiology. Vesicoureteral reflux, absent kidney, multicystic dysplastic kidney,
crossed fused ectopia, and horseshoe kidney are common renal anomalies
detected. Ectopic ureter insertion in the urethra with resultant hydroureter
and hydronephrosis is also seen and must be detected early to avoid a
significant effect on long-term renal function. In females with cloaca, hydrocolpos is seen in about 50% of patients at birth due to vaginal obstruction and is extremely important to detect since these patients
invariably have urinary obstruction, which can cause permanent renal sequelae, vaginitis, and even vaginal perforation if not treated in the postnatal
period. Other various anomalies of the female genital tract were seen, and
examples are shown. Males can present with multiple episodes of epidydymitis if they have high-pressure voiding due to a neurogenic bladder
(bladder-sphincter incoordination), resulting in reflux of urine into the vas
deferens. Neonatal spine US is an excellent screening exam to detect spinal
cord tethering, filar thickening or a mass, evidence of caudal regression,
and a presacral mass (important to detect prior to definitive repair).
Conclusions—Examples of the most important US findings of
the GU tract and spine in patients with ARM are reviewed and presented
pictorially, some with radiographic, fluoroscopic, MR, and/or clinical correlation.
1540916 Doppler Echocardiographic Estimates of Right Ventricular Pressure Are Inaccurate in Children With Elevated
Right Heart Pressure
Georgeann Groh,1* Mark Holland,2 Joshua Murphy,1 Timothy Sekarski,1 Philip Levy,1 Craig Myers,1 Diana Hartman,1
Gautam Singh1 1Pediatrics, 2Physics, Washington University
School of Medicine, St Louis, Missouri USA
Objectives—Doppler echocardiography (DE)-estimated right
ventricular systolic pressure (RVp) is widely used as a surrogate for RVp
measured by right heart catheterization (RHC), the gold standard. However, its accuracy has not been prospectively validated in children. Our
objective was to prospectively validate the accuracy of DE-estimated RVp
in children.
Methods—Simultaneous pressure gradients between the right
ventricle and right atrium were prospectively assessed by RHC and DE
using tricuspid valve regurgitation in 94 consecutive children (age 0–18
years; median, 5.7 years) with 2-ventricle physiology. Subjects were classified into 2 groups based on RHC-measured RVp: group 1 (n = 53) with
normal RVp (RVp <1/2 systemic systolic blood pressure [SBP]) and group
2 (n = 41) with elevated RVp (RVp >1/2 SBP). Correlation and agreement
between the 2 methods were assessed using linear regression and BlandAltman analysis, respectively. Accuracy was predefined as 95% limits of
agreement (LOA) ± 10 mm Hg for DE RVp estimates.
Results—The correlation between DE- and RHC-measured
RVp was strong in both groups (group 1, r = 0.8; P < .001; group 2,
r = 0.77; P < .001). The agreement between the 2 methods was good in
group 1 (bias, 2.5 mm Hg; 95% LOA, +9.7 to –4.8 mm Hg) but poor in
group 2 (bias, 0.89 mm Hg; 95% LOA, +25.1 to –25.1 mm Hg). DEestimated RVp was inaccurate, with both overestimation and underestimation, in 2% of subjects in group 1 vs 34% in group 2.
Conclusions—DE estimates of RVp are frequently inaccurate
in children with elevated RVp. They should not be solely relied on in the
management of children with elevated RVp.
1540920 Cranial Ultrasound Findings in Preterm Infants With
Germinal Matrix and Periventricular Leukomalacia
Arash Anvari,1* Anthony Samir,1 Michael Gee2 Radiology,
1
Abdominal Imaging and Intervention, 2Pediatrics Division,
Massachusetts General Hospital, Boston, Massachusetts USA
Objectives—This educational poster will review germinal matrix and periventricular leukomalacia (PVL) in preterm infants and the
role of cranial ultrasound in the diagnosis and characterization.
Methods—Content Organization: (1) Introduction of germinal
matrix hemorrhage: epidemiology, pathophysiology, its complications like
hydrocephalus and periventricular leukomalacia, and clinical outcomes.
(2) Cranial ultrasound technique: transducer, standard views, supplemental acoustic windows, timing, advantages, and limitations. (3) Ultrasound
findings in different classes (I–IV) of germinal matrix hemorrhage and
PVL.
Results—Not applicable because it is an educational e-poster.
Conclusions—This e-poster emphasizes the clinical application of cranial ultrasound in early diagnosis of germinal matrix hemorrhage and PVL and its important role in clinical management.
1540927 Focal Lesions in the Transplanted Liver: Differential Diagnosis
Ronald Wachsberg New Jersey Medical School , Newark,
New Jersey USA
Objectives—To illustrate the spectrum of focal lesions and
pseudolesions that can be seen in liver transplant recipients.
Methods—Cases are presented of various focal lesions and
pseudolesions detected in liver transplant recipients at a busy transplant
center.
Results—A focal lesion in a liver graft can be an infarct, abscess, biloma, hematoma, steatosis, recurrent or de novo malignancy, preexisting incidental lesion in the donor liver, and arteriovenous fistula.
Several pseudolesions, eg, loculated intrafissural fluid, thrombus within
the donor inferior vena cava, and others, can mimic a liver lesion.
Conclusions—Awareness of the spectrum and features of focal
lesions and pseudolesions that can be detected in a liver graft is essential
to arrive at the correct diagnosis.
1540949 First-Trimester 3-Dimensional Placental Volume and Its
Association With Gestational Diabetes
Nwamaka Obi,* Karenrose Contreras, Andre Bieniarz, Jean
Goodman, Paula Melone, Roberta Karlman Maternal-Fetal
Medicine, Loyola University Medical Center, Maywood, Illinois USA
Objectives—Gestational diabetes mellitus (GDM) a common
metabolic disorder in pregnancy and complicates about 3% to 10% of
pregnancies worldwide. The goal of predicting GDM has not been
reached, and its impact extends beyond just perinatal outcomes. The objective of the study was to determine if first-trimester 3D placental volume
is predictive of GDM.
Methods—This was a prospective cohort study that included
140 women aged ≥18 years with singleton pregnancies. At the time of
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nuchal translucency ultrasound, 3D images of the placenta were obtained
and volumes measured using the multiplanar volume method with Philips
QLAB. The development of GDM and other pregnancy outcomes were
recorded. Continuous and categorical variables were compared using the
Student t test and χ2 test. Logistic regression analysis was performed to determine the association of first-trimester placental volume with gestational
diabetes while controlling for confounders.
Results—A total of 140 women were included in the study.
There were complete pregnancy outcomes recorded for 98 (70%), 8 (8%)
of which had GDM. Mean first-trimester 3D placental volumes (57.6 ± 2.2
vs 51.6 ± 2.65 mL) and infant birth weights (3312.2 ± 61.2 vs 3629.6 ±
186.3g) were similar between the non GDM and GDM groups. In logistic regression analysis, first-trimester placental volume was not statistically significant while controlling for age, race, and body mass index
(BMI) between the groups. Women with a higher BMI were at significantly increased risk of GDM. 3D placental volume was predictive of birth
weight regardless of the presence of gestational diabetes.
Conclusions—First-trimester 3D placental volume was similar
in women with and without gestational diabetes. A high BMI is a wellknown risk factor for the development of GDM, which was also seen in
this study. Larger studies are needed to confirm our findings.
Table 1. Logistic Regression Analysis
Age
Race
BMI
Placental volume
OR indicates odds ratio.
Adjusted OR
1.127
0.859
1.133
0.968
P
.160
.85
.021
.228
1540968 Role of Bedside 3/4-Dimensional Ultrasonography in the
Diagnosis of Acute Appendicitis
Timothy Mooney,* Kevin O’Rourke, Gerardo Chiricolo
Emergency, New York Methodist Hospital, Brooklyn, New York
USA
Objectives—Abdominal ultrasonography (US) is commonly
used in diagnosing acute appendicitis (AA).Traditional 2D US is both safe
and quickly performed. Diagnostic accuracy can be limited, and equivocal studies are common. 3D/4D US technology could improve diagnostic
accuracy by enhancing visualization of anatomy and spatial relationships.
Our objective was to evaluate the performance and accuracy of bedside
3D/4D US in patients with suspected AA.
Methods—All adult and pediatric patients with suspected AA
were eligible for enrollment. We excluded patients who underwent computed tomographic scanning prior to enrollment and those with a prearrival
diagnosis of AA. Patients were enrolled when there was an emergency
sonographer available. These emergency department physician sonographers had a 4-hour tutorial by an experienced application specialist on
3D/4D image acquisition. The same sonographer scanned each patient’s
right lower quadrant first using both 2D and 3D/4D multiplanar and surface-rendering US. All clips and images were deindentified and interpreted
by another sonographer who recorded an impression separately. The US interpretations were then compared to surgical pathology or phone follow-up.
Results—A total of 30 patients met inclusion criteria and were
enrolled. Twenty-one patients (70%) were ultimately diagnosed with
AA. Of the 30 total patients, 13 (43%) were diagnosed with AA using
conventional 2D US, with the other 17 diagnosed with a nonvisualized
appendix, inconclusive US of the right lower quadrant. Two patients
(6%) were diagnosed with AA from 3D/4D US images and clips (both
had a diagnosis of AA from 2D US examination also). Sensitivity for
2D US was 62% (95% confidence interval [CI], 48%–62%); specificity
was 100% (95% CI, 65%–100%); positive predictive value was 100%
(95% CI, 78%–100%); and negative predictive value was 53% (95%
CI, 36%–53%), with overall accuracy of 72%. 3D/4D US had sensitivity of 10% (95% CI, 2%–10%); specificity was 100% (95% CI, 82%–
100%); positive predictive value was 100% (95% CI, 21%–100%); and
negative predictive value was 32% (95% CI, 27%–32%), with overall
accuracy of 36%.
Conclusions—3D/4D US fails to increase the diagnostic accuracy of US in AA and has little utility in AA’s staged diagnostic workup.
1540972 Reliability of Linear Measurements of the Thoracic Paraspinal Muscles Using Ultrasound Imaging
Nancy Talbott,* Dexter Witt Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio USA
Objectives—Ultrasound imaging (USI) has become more common in the rehabilitation area. Muscles critical to the stabilization of the
spine have been assessed to assist in guiding interventions. In the shoulder, function relies on scapular muscles, which work most effectively
when the thoracic spine is stabilized. To assist in understanding the role of
the thoracic paraspinal muscles (TPSM) during arm elevation and in using
that information in determining effective rehabilitation treatment, realtime monitoring of the changes in the TPSM would be of benefit. The objective of this study was to determine if USI can reliably measure the
TPSM during arm movements.
Methods—USI of 18 healthy subjects was performed with subjects prone and the arm elevated fully in the scapular plane. The spinous
process and lamina of T7 were imaged as the subject rested the arm on a
stable surface, actively contracted, and held a weight. After resting, testing was repeated twice on one arm and 3 times on the opposite arm. Nine
subjects returned to have the testing performed again by the original examiner. TPSM linear measurements were recorded in 2 locations: (1) between the superior hyperechoic line of the laminae and the inferior
hyperechoic line of the lower trapezius muscle; and (2) between the superior hyperechoic line of the transverse process and the inferior hyperechoic line of the lower trapezius.
Results—Intrasession correlation values were strong. Within a
session, intra-tester reliability ranged from 0.882 to 0.960. Inter-tester reliability within a session was also good, with intraclass correlation coefficients (ICCs) ranging from 0.706 to 0.906. Agreement between sessions
was also acceptable, with ICCs ranging from 0.733 to 0.885.
Conclusions—The USI methodology used in this study
achieved TPSM measurements with high intra-rater reliability and good
inter-rater reliability at rest and during active contractions. Changes in the
TPSM thickness occurring during active contraction of the shoulder and
scapula can be reliably monitored by USI. As small but significant changes
occur during arm activities, USI of these muscles may be useful for guiding interventions.
1540981 Reliability of Ultrasound Measurements of the Lower
Trapezius Muscle During Active and Resisted Movements
Dexter Witt,* Nancy Talbott Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio USA
Objectives—Ultrasound imaging (USI) to assess patients with
shoulder pain often emphasizes structural changes of the tendons. Pain,
however, may be related to alterations in the scapular muscles, including
abnormal activation of the lower trapezius (LT). The ability to make reliable measurements of the LT during active contraction using USI would
be of benefit in determining firing patterns, identifying muscle atrophy,
and designing interventions. While previous USI studies have established
the reliability of USI measurements of the LT at rest, the objective of this
study was to determine if USI could be used to reliably measure the thickness of the LT muscle during LT contraction.
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Methods—USI images of the LT were captured bilaterally in 20
normal subjects at the T7 level. With the arm in 120° of abduction, images
were taken in the prone position with the subject’s arm at rest, actively
holding the position and while holding a weight. This process was repeated
3 times on both shoulders by a single examiner. Within 7 days, 10 of the
subjects returned. The same testing sequence was repeated on the dominant arm by the original examiner and by a second examiner. Images were
stored electronically and analyzed offline. Reliability was assessed via intraclass correlation coefficients (ICCs).
Results—Intersession intra-rater reliability agreement was
good, with ICC values of 0.835, 0.871, and 0.909 at rest, during an active
hold, and holding the weight, respectively. Same-session inter-rater reliability was also good, with ICC values of 0.864, 0.881, and 0.891 in the respective states of rest, active hold, and holding the weight.
Conclusions—The USI methodology used in this study
achieved LT measurements with high inter-rater and intra-rater reliability
at rest and with the addition of active contraction and resistance. Benefits
for having this reliability method include: (1) identification of percent
changes of thickness between rest and contraction; (2) an adjunct to electromyography in the determination of muscle changes during activities; (3)
a viable tool for clinical facilitation of LT activation; and (4) documenting
atrophy of the LT.
1540998 Evaluation of Acquisition and Interpretation of Focused
Assessment With Sonography for Trauma Scans in an
Urban Level 1 Trauma Center
Zachary Robinson,1* Lem Smith,1 Eliza Beal,1 Brian Abbott,2
Creagh Boulger,2 Daniel Eiferman,3 David Bahner2
1
College of Medicine, 2Emergency Medicine, 3Critical Care,
Trauma, and Burn Surgery, Wexner Medical Center, Ohio State
University, Columbus, Ohio USA
Objectives—Focused assessment with sonography for trauma
(FAST) has become the standard of care in the evaluation of trauma
patients. A review of recent literature showed sensitivity of 84% to 94%,
specificity of 96% to 98%, a positive predictive value of 61% to 87%, and
a negative predictive value of 98% to 100%. A formalized ultrasound training program has been introduced at our institution for surgical residents to
ensure proper acquisition and interpretation of ultrasound images. A quality review process was initiated to evaluate accuracy in using FAST in
trauma patients.
Methods—Trauma FAST exams are wirelessly saved to a picture archiving and communication system, and generated reports are saved
to an electronic medical record. Patients who presented as a level 1 or level
2 trauma between January and March 2012 and received a FAST scan as
part of their assessment were included in the quality review. The results of
the FAST scan and any other imaging performed during the same encounter were recorded and reviewed. The results of FAST were compared
to confirmatory testing of abdominal computed tomography (CT), chest
CT, or operative reports. The results of FAST were then determined to be
true-positive, true-negative, false-positive, or false-negative.
Results—There were 200 trauma alerts during the study period. One hundred twenty-one patients were eligible for review with both
saved images and a generated report in the chart. Fifteen patients were excluded because the FAST scan results were not available; the FAST scan
was indeterminate; or the patient died prior to confirmatory imaging. There
were 94 true-negatives, 2 false-negatives, 7 true-positives, and 3 falsepositives in the remaining 106 patients reviewed, yielding sensitivity of
78% and specificity of 97%. The positive predictive value was 70%; the
negative predictive value was 98%; and the accuracy was 95%.
Conclusions—Our results confirm that FAST has a high negative predictive value for abdominal injury in patients experiencing
trauma. These quality results, collected after a focused training program,
show the training to be effective in educating surgical residents on the
proper acquisition and interpretation of FAST in trauma patients.
1541009 An Educational Model for Teaching Focused Assessment
With Sonography for Trauma to Surgical Residents
Eliza Beal,1* Ashley Zielinski,1 Creagh Boulger,2 Sereana
Dresbach,3 David Bahner,2 Daniel Eiferman4 1College of
Medicine, 2Emergency Medicine, 3Pulmonary, Allergy, Critical
Care, and Sleep, 4Critical Care, Burn, and Trauma Surgery, Wexner
Medical Center, Ohio State University, Columbus, Ohio USA
Objectives—Focused assessment with sonography for trauma
has become indispensable in the evaluation of trauma patients. Few surgical training programs have specific courses to teach the FAST exam.
The Wexner Medical Center at Ohio State University has established a
pilot program with hands-on teaching sessions and self-directed learning
to teach surgery residents the skills needed to accurately obtain and interpret FAST scan images.
Methods—Thirteen postgraduate year 1 (PGY-1)-level residents participated in an initial evaluation session, which included 10 confidence questions, 12 ultrasound knowledge questions, and a practical
exam where they were asked to perform both the FAST exam and the
long-axis rescue cardiac view. Participants answered confidence questions
on a spectrum from 1 to 8 with 1 being strongly disagree, 7 being strongly
agree, and 8 indicating that the individual had no experience with the skill.
The practical exam was evaluated by 2 attending physicians with significant experience with the FAST exam and ultrasound education. The images were graded on a 1 to 5 scale (1 = no image obtained and 5 = image
perfectly obtained with proper settings and labeling). The 13 PGY-1 residents will undergo 2-hour hands-on training and will be reevaluated for
knowledge and skill acquisition.
Results—With little formalized training in focused ultrasound,
PGY-1 residents responded with fairly low overall confidence in skills
(mean = 2.08). When asked about confidence in acquiring specific views,
participants generally rated their views in the “disagree” portion of the
continuum, but the means on the 9 confidence questions ranged from
slightly to strongly disagree (3.94–1.92). No resident answered “no experience” for any question. Skills assessed by the proctors showed a general
tendency of not being able to attain the image or missing relevant anatomy,
with the means ranging from 1.38 to 2.46 for the 5 images obtained.
Conclusions—Preliminary data show that confidence and
knowledge are low, and practical scores show an inability to perform
FAST scans among PGY-1 level surgical residents. The initial results suggest that training in the FAST exam is necessary for PGY-1 surgical residents to adequately obtain images used for clinical decision making.
1541032 Cervical Length Assessment by Transabdominal and Endovaginal Ultrasound
Jennifer Thompson,* Michael Smrtka, Geeta Swamy, Chad
Grotegut, Brita Boyd, Amy Murtha Duke University,
Durham, North Carolina USA
Objectives—Endovaginal (EV) cervical length identifies women
at risk for preterm birth (PTB) and thus eligibility for vaginal progesterone.
Our objective was to compare transabdominal (TA) with EV cervical
lengths to determine the degree of correlation, the capability of TA to predict an EV-detected short cervix, and the rate of cervical change over time.
Methods—Retrospective review of singleton pregnancies having
TA and EV ultrasound (US) for cervical length between 16 and 28 weeks’
gestation at Duke University from January to December 2011. TA measurements are routinely obtained on midtrimester exams with EV measurement for high PTB risk, TA <30 mm, and assessment of placental location
and/or presence of cerclage. Serial US with TA and EV are performed when
EV <25 mm. Pearson correlation and receiver operating curves were used
to compare TA and EV cervical lengths and determine optimal TA cutoffs
for prediction of an EV cervical length <25 mm. Linear regression was used
to compare the rate of cervical change by TA and EV by term vs PTB.
Results—A total of 142 subjects with 245 US observations met
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study inclusion criteria. TA and EV measurements were significantly correlated (r = 0.810; P < .0001). A TA cutoff of 30 mm accurately predicted
an EV-detected short cervix (<25 mm): sensitivity, 90.4%; specificity,
80.2%; positive and negative predictive values, 70.1% and 94.2%. Using
linear regression, women delivering preterm had a greater rate of cervical
change by EV compared to women delivering term (P = .014). TA failed
to demonstrate such a difference (P = .592).
Conclusions—TA and EV cervical lengths correlate well, and
TA <30 mm is an accurate predictor of shortened EV cervical length. Serial follow-up of a US-detected short cervix should be via EV measurements, given the better detection of rate of cervical change than TA in
patients who deliver preterm. Detecting a rapidly changing short cervix
sooner may allow for earlier interventions. Prospective studies are required
to confirm our findings.
1541037 Teaching Basic Obstetric Ultrasound Skills at Mulago
Hospital, Kampala, Uganda
Homa Ahmadzia,1* Urania Magriples,2 France Galerneau,2
Imelda Namagembe3 1Obstetrics and Gynecology, Duke
University, Durham, North Carolina USA; 2Obstetrics and
Gynecology, Yale University, New Haven, Connecticut USA;
3
Obstetrics and Gynecology, Makerere University, Kampala,
Uganda
Objectives—Basic ultrasound skills are useful in the assessment and management of obstetric patients. The purpose of the study is to
assess the effectiveness of a teaching intervention (via pretest and posttest
survey) implemented to teach basic obstetric ultrasound skills to residents,
interns, and medical students at Mulago Hospital, Kampala, Uganda.
Methods—Prior to the teaching intervention, participants completed a survey designed to assess their comfort level, knowledge, and
skills via multiple-choice questions. The teaching intervention included a
1-hour didactic PowerPoint presentation coupled with a 1-hour hands-on
skills training session. Topics reviewed include general principles of ultrasound, biometry, placental location, fetal position, amniotic fluid index,
and biophysical profile. Following completion of the teaching intervention,
participants completed the survey. Of the 40 total participants, there were
12 medical students, 23 interns. and 5 residents. Data were analyzed in
Microsoft Excel and SAS software.
Results—When pretest responses were compared to posttest
responses, participants were more comfortable with any skill taught after
the intervention (23% vs 73%; P < .0001). Further, when individual groups
were compared separately, the mean survey score of medical students
went from 34% to 76% correct (P < .0001); for interns, 33% to 71% correct (P < .0001); and for residents, 60% to 69% (P= .30).
Conclusions—This original teaching intervention was an effective method to improve knowledge and skills for medical students and
interns at Mulago Hospital in the area of basic obstetric ultrasound.
1541039 Improving Musculoskeletal Ultrasonography Through a
Local Community Practice Inititative
Brandon Price,1 David Bahner,2* Kendra McCamey,3 Nicole
Bundy,4 Kimberly Fisher,5 Andrew Aten,1 Michael Roesch1
1
Ohio State University College of Medicine, Columbus, Ohio
USA; 2Emergency Medicine, 3Family Medicine, 4Rheumatology and Immunology, 5Internal Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio USA
Objectives—Communities of practice (COPs) involving groups
of people from different backgrounds with similar interests commonly are
encountered within medicine. Barriers often exist within the group because of variances like nomenclature, standards of care, and differences in
charges for services. This project describes the creation of a COP for musculoskeletal (MSK) ultrasonography (US). The goals are to establish a
multidisciplinary approach to MSK US education and standards of prac-
tice at all levels of training to standardize MSK US within our institution.
Methods—This group comprises attending physicians from
emergency medicine, rheumatology, physical medicine, and rehabilitation
and sports medicine, along with resident and medical student representatives. Regular meetings are held to establish credentialing guidelines,
clinical protocols, and educational opportunities. Coordinated scanning
sessions focused around MSK imaging have been implemented, allowing all levels of training to scan various joints while teaching MSK topics. This COP also is establishing an integrated MSK curriculum for
medical students.
Results—This group has convened administratively and during MSK scanning sessions to coordinate activities and standardize the
MSK US educational framework. Commonalities such as proper probe
orientation and standard labeling have been established and extend across
all specialties involved. A multidisciplinary credentialing document with
tiered privileging has been authorized, and 2 attendings have been granted
these privileges. Standard billing practice for focused ultrasound has been
discussed. The new MSK curriculum involving ultrasound is also being
implemented thanks to aid from this COP.
Conclusions—Local COPs are one way for focused US within
specific specialties to coordinate goals and improve the training throughout all levels of expertise. Incorporating shared governance toward operationalizing an academic vision, this COP has helped focus these MSK
US efforts at this medical center. The trajectory of this COP will continue
to address the academic needs of the various departments and work toward improving the quality of US education and delivery of care.
1541050 Cervical Length Ultrasound Does Not Predict Preterm
Birth in Patients With Cerclage
Jennifer Thompson,* Michael Smrtka, Geeta Swamy, Chad
Grotegut, Sarah Ellestad, Amy Murtha Obstetrics and Gynecology, Duke University, Durham, North Carolina USA
Objectives—Cervical incompetence is an important contributor
to preterm birth (PTB). Cerclage placement for cervical incompetence
may reduce the risk of preterm birth in at-risk individuals. Once a cerclage
is placed, endovaginal (EV) cervical lengths are used to monitor for cervical shortening. Our objective was to determine if cervical length and the
rate of change of cervical length predict PTB (<34 weeks) in women with
cerclage.
Methods—We conducted a retrospective review of subjects
with cerclage having both transabdominal and EV ultrasound for cervical
length assessment between 16 and 28 weeks’ gestation at Duke University
from January to December 2011. Serial EV measurements are routinely
obtained on all patients with cerclage. EV ultrasound measurements were
obtained following bladder emptying with application of fundal pressure.
Measurements were divided into ≤25 mm (n = 73) and >25 mm (n = 98).
Preterm birth rates were compared between groups by χ2 analysis. Linear
regression was used to compare the rate of cervical change in subjects
who delivered preterm and term.
Results—Twenty-nine subjects with 171 EV measurements
met inclusion criteria. PTB rates were not significantly different when EV
≤25 mm compared to EV >25 mm (37% vs 26%; P = .1) Using linear regression, there was significant cervical shortening over time in subjects delivering term and preterm (preterm, P = .02; term, P < .0001). Importantly,
the rate of cervical change in cerclage subjects delivering preterm was not
significantly different from the rate of cervical change in cerclage subjects
delivering at term (P = .868 for differences in slopes).
Conclusions—In women with cerclage, a shortened cervical
length does not appear to be related to PTB risk. Cervical length does significantly shorten over time in women with a cerclage; however, serial ultrasound for cervical length may not provide additional clinical guidance
in women who deliver preterm.
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1541066 Maximum Effort of the Multifidi Muscles in the Prone
Position Using Musculoskeletal Ultrasound Imaging and
Electromyography
Rose Smith,* Dervarshi Patel, Susan Kotowski, Dexter Witt,
Lauren Farwick, Erin Rathje, Ryan Steiner Rehabilitation
Sciences, University of Cincinnati, Cincinnati, Ohio USA
Objectives—The lumbar paraspinal muscles play a critical role
in supporting the trunk during functional activities. Rehabilitative ultrasound imaging (RUSI) has been found to be a valid and noninvasive
method to measure the activation of these muscles. RUSI of the multifidi
has shown 19% to 43% of maximum effort on electromyography (EMG)
while measuring muscle thickness. No study has compared EMG with
RUSI using the trace method. The purpose of this study was to look at the
relationship of EMG activity of the multifidi using RUSI by measuring the
cross-sectional area (CSA) using the trace method.
Methods—A sample of convenience consisted of 22 volunteers
(11 female and 11 male) with a mean age of 25 years. Exclusion criteria
included current or recent history (within 6 months) of shoulder, lumbar,
or lower extremity pathology/surgery or pregnancy. Musculoskeletal ultrasound images of the multifidi were obtained using the Biosound Esaote
model MyLab 25 Gold. The area was found using the trace method of the
right and left multifidus during an arm raise, arm raise with weight, and
leg raise activity while the subject lay prone. A simultaneous DataLINK
(Biometrics, Ltd) EMG system was used to measure muscle activity. EMG
sensors were placed over the belly of the muscle in the line of action. Maximum voluntary contractions (MVCs) were taken at the start of data collection by having the subject lie prone and raise the opposite arm and leg
against manual resistance. The measured trace area of each image was
normalized against the measured area of the MVC trial.
Results—Analysis showed that overall, RUSI trace-measured
CSA muscle activity ranged from ≈22% MVC (trial maximum) to ≈28%
MVC (trial average), which corresponded to a measured area of the multifidus of 100% MVCs. Minimal nonsignificant differences were noted
between the 3 activities with RUSI and EMG activity.
Conclusions—The change in trace-measured CSA as compared to EMG activity is consistent with measuring muscle thickness via
RUSI. This information can be helpful in guiding clinical practice but cannot be applied without considering its limitations.
1541115 Ocular Ultrasound Simulation Lab: Does It Translate to
the Bedside?
Kevin O’Rourke,* Sharon Yellin, Adam Vytykac, Timothy
Mooney, Larry Melniker, Athena Mihailos, Andrew Balk,
Gerardo Chiricolo Emergency Department, New York
Methodist Hospital, Brooklyn, New York USA
Objectives—Two percent of emergency department visits are
eye-related complaints. Ocular ultrasound (US) gives the emergency
physician the ability to noninvasively assess the eye for a variety of disease processes. The Council of Residency Directors Emergency Ultrasound Consensus Committee does not identify ocular US as a core US
competency for emergency medicine resident graduation but recommends
that it is incorporated into the resident curriculum. The accuracy of bedside ocular US has been studied, and published reports of models used for
simulation exist. The breadth of knowledge about the effectiveness of
using simulation for ocular US is limited. The goal of this study was to
evaluate if an ocular US lecture and simulation lab led to increased use at
the bedside and what diagnoses were found.
Methods—In this retrospective review, we compiled data from
our US database for all ocular US examinations performed the 6 months
before and after an ocular US lecture and simulation lab. We included all
patients who had US between September 21, 2011, and September 22,
2012. Data collection included when the US was performed and what the
diagnosis was based on US.
Results—In the 6 months before the lecture and lab, 18 ocular
US examinations were performed. The findings included 9 normal US
findings, 2 vitreous hemorrhages (1 with posterior vitreous detachment),
3 with an increased optic nerve sheath diameter, 2 retinal detachments, 1
with postoperative changes, and 1 with a foreign body. In the 6 months
after the lab, 28 ocular US examinations were performed. The findings
included 11 normal US findings, 7 with an increased optic nerve sheath diameter, 5 with vitreous hemorrhage, 1 globe rupture, 1 with choroidal detachment, 1 with vitreous detachment, and 2 incomplete studies. There
were 10 more US examinations performed in the emergency department
after the intervention, which equates to a 55% increase in US use.
Conclusions—An ocular US lecture and simulation lab led to
increased use of bedside US for patients. In the future, we anticipate this
skill to decrease inappropriate transfers and increase appropriate and
timely evaluations by an ophthalmologist.
1541203 Factors Influencing Intraoperator Variability When Assessing Fibroid Growth
Malana Moshesh,* Shyamal Peddada, Donna Baird
National Institute of Environmental Health, Research Triangle
Park, North Carolina USA
Objectives—To assess factors associated with intraoperator
variability (measured by the coefficient of variation [CV]) of fibroid measurements and apply this to current practice.
Methods—Study participants, recruited through community
outreach and health care facilities were young African American women,
aged 23 to 34 years, who had never been diagnosed with fibroids. All participants underwent transvaginal ultrasound to screen for the presence of
uterine fibroids (≥0.5 cm in diameter). The fibroid diameter was measured in 3 perpendicular planes (longitudinal, sagittal, and transverse) at 3
separate times during the examination. Volume was calculated using the
ellipsoid formula. Intraobserver variability as measured by the CV for fibroid diameter and volume was calculated for each fibroid, and factors
associated with the CV were assessed using regression models adjusting
for fibroid characteristics and individual participant characteristics.
Results—Ninety-six women out of 300 women initially
screened were found to have at least 1 fibroid, yielding a total of 174
fibroids for this analysis. The median CV for the 3 measurements of the
fibroid maximum diameter was 4.9%, and the mean CV was 5.9%. The
median CV for fibroid volume was 10.5%, and the mean CV was 12.7 %.
Fibroid size contributed significantly to the prediction of the CV for both
fibroid diameter (P = .04) and volume (P = .005). The CV was greater for
smaller fibroids. Individual participant factors and the fibroid type were not
significantly associated with intraobserver measurement variability.
Conclusions—When assessing fibroid growth, baseline fibroid
size should be considered. Small fibroids have greater measurement variability than large fibroids. Thus, a small fibroid must have a proportionately greater increase in size compared to a large fibroid to conclude that
it is growing.
1541265 Role of Transvaginal Ultrasound in the Diagnosis of Cesarean
Section and Its Complications
Lourdes Hereter,* M. Angela Pascual, Betlem Graupera,
Pere Barri-Soldevila, Cristina Pedrero, Maria Fernandez-Cid
Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
Objectives—To describe the findings of transvaginal ultrasound
(TUS) in cesarean scar defects and their complications in nonpregnant
women.
Methods—Nonpregnant premenopausal women with a history
of a previous cesarean section, referred to TUS for an annual checkup,
were included in this study. A cesarean scar defect was defined as a hypoechoic indentation at the anterior wall of the lower uterine segment,
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measured in 3 dimensions. The number of previous cesarean sections and
complications were reviewed. These included dehiscence (separation of
the scar that does not disrupt the uterine serosa), uterine rupture (a complete disruption of the myometrium and serosa), and ectopic pregnancy in
the cesarean section scar.
Results—Thirty-eight women were diagnosed with a cesarean
scar defect at TUS. The number of previous cesarean sections in patients
with uterine dehiscence and ectopic pregnancy in the cesarean scar is
shown in Table 1. Eleven patients (29%) showed uterine dehiscence.
Seven cases were repaired by laparoscopy, and 4 cases required hysterectomy. Five ectopic pregnancies (13%) were diagnosed at TUS. Two patients required hysterectomy; 2 were treated with local methotrexate
guided by TUS; and 1 was surgically sutured. Two patients (5%) had a
complete uterine rupture. One of them was diagnosed 6 months after the
cesarean section and required hysterectomy. The other was diagnosed during the puerperium period and was treated by surgical repair.
Conclusions—TUS is useful for detecting cesarean scar defects, providing information for treatment in case of complications.
Table 1
Dehiscense
Ectopic pregnancy
1
5
3
Previous Cesarean
2
3
4
1
0
1
4
1
1
1541304 Ultrasound-Guided Dorsal Approach for Chemodenervation of the Psoas Muscle
David Spinner Rehabilitation Medicine, Mount Sinai School
of Medicine, New York, New York USA
Objectives—To directly treat the primary motor end plates of
the psoas muscle for spasticity.
Methods—Case report with description of procedure. Bilateral
ultrasound-guided psoas muscle injections were performed. An axial or
short-axis view was used for both the right- and left-sided injections. The
right psoas muscle was injected with an out-of-plane approach where only
the needle tip was visualized. We then turned the probe 90° to visualize the
length of the needle in addition to using electromyography (EMG) for
confirmation. The left psoas muscle was injected using an in-plane technique with EMG confirmation.
Results—The left and right psoas muscle injections were confirmed with EMG. The patient gained 30° of extension from baseline to
bilateral hip joints. The patient had overlying hip contractures that did not
allow for further range of motion.
Conclusions—The ultrasound-guided dorsal approach for performing psoas muscle chemodenervation is a novel approach for treating
hip flexor spasticity while targeting the primary motor end plates.
1541312 The BUILD Project: Bringing Ultrasound Internationally
for Long-Term Development
Keith Rosenberg, Fadi Kasyouhanan, David Bahner*
Emergency Medicine, Ohio State University College of Medicine, Columbus, Ohio USA
Objectives—With technological advances in imaging, ultrasound (US) equipment is increasingly affordable and portable. Studies
have shown that portable US can be an effective modality in low-resource
environments. Bringing Ultrasound Internationally for Long-term Development (BUILD), a global outreach project, is an attempt to collaborate
with Ohio State University’s (OSU’s) Office of Global Health to provide
third- and fourth-year medical students from OSU’s College of Medicine
the opportunity to enroll in a longitudinal US program.
Methods—BUILD creates a collaboration between the College
of Medicine and the Office of Global Health. The group combines exist-
ing medical mission programs and promotes an effort to coordinate both
groups. Current US resources were centralized, streamlined, and made
available to the program.
Results—The Office of Global Health has funded 51 trips over
the past 5 years, while the medical school has sent 244 trips, to >25 developing countries. BUILD’s team of 2 senior medical students and 1
physician US expert acts to bridge these separate but similar programs.
Approximately 6 of these trips have incorporated US. The program developed a needs assessment survey of current US resources for medical
missions. BUILD has fostered interest among students traveling abroad to
integrate US into their trips.
Conclusions—As trends in medicine shift toward more prudent use of resources, US will become an integral part of medical training.
It is increasingly common for students and residents to gain exposure to
US early in their schooling. Studies have shown that physicians and medical students have successfully used portable US to determine medical
management. BUILD intends to establish a protocol for students and faculty to bring US to underserved areas. The group will design didactics to
teach travelers US skills and enable them to become teachers at their sites.
BUILD will create partnerships leading to opportunities for travelers to
bring donated equipment. The findings of this study will be used to show
that US can be successfully incorporated into global health programs.
BUILD hopes to integrate this into the medical student curriculum as an
optional course.
1541434 Trained Simulated Ultrasound Patients: Medical Students
as Models, Learners, and Teachers
Matt Blickendorf,1* Lindsay Mooney,2 Krista Rath,2 Eric
Adkins,1,2 David Bahner1,2 1Emergency Medicine, Wexner
Medical Center, Ohio State University, Columbus, Ohio USA;
2
Ohio State University College of Medicine, Columbus, Ohio
USA
Objectives—Despite the increased use of bedside ultrasound
(US) by clinicians, US is not fully established in undergraduate and graduate medical education. Medical schools and residency programs must
develop US education programs to ensure future physicians become competent with this operator-dependent technology. Medical educators are
often challenged to find human models for hands-on scanning sessions.
The goal is to outline the educational model of a university medical center that uses medical students to fulfill the need for human models while
also offering these individuals a basic introduction to US education.
Methods—Second-year medical students from the Ohio State
University College of Medicine serve as trained simulated US patients
(TSUPs) for hands-on scanning sessions held by the college and residency
programs at the medical center. Students are offered a didactic and handson US education program as an added incentive for serving as a TSUP.
Students were given a postcourse 5-point Likert survey to assess their perceived benefit from the TSUP program.
Results—During the 2011–2012 academic year, 47 secondyear and 7 first-year students served as normal models for 71 hands-on
scanning sessions, while only 28 sessions were left without TSUP participation. Counting each time a TSUP was used, a total of 173 models were
used for 160 hours of scanning. The college and 7 residency programs
used the TSUP program. Student volunteers were split equally male and
female with a diverse range of specialty interests. Approximately 75% of
TSUP participants served as US models for an average of 6 to 15 hours for
the year. Most attended a majority of the US educational events, and almost all TSUP participants endorsed increased US interest, knowledge,
and skill as a result of the program.
Conclusions—The TSUP program is a feasible and sustainable
method of fulfilling the need for normal anatomy models in US education
while serving as a valuable extracurricular US educational program for
TSUP participants. The program offers a model for the establishment of
US education programs by educators at undergraduate and graduate levels.
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1541460 Developing and Evaluating an Ultrasound Curriculum for
a Urology Residency Training Program
Joseph Lopez,1* Daniel Box,1 Geoffrey Box,1 David Bahner2
1
Urology, 2Emergency Medicine, Wexner Medical Center, Ohio
State University, Columbus, Ohio USA
Objectives—In medicine, much has been written on ultrasound
(US) use in focused settings looking for specific findings consistent with
pathology and using this to make specific medical decisions. With the advent of other fields of discipline using US, some hospital infrastructure
exists with US in critical care, emergency medicine, anesthesiology, and
surgery. In urology, program directors expressed a significant need for formalized US training. This project sought to provide an educational framework from which a urology program could incorporate US training and
increase proficiency and confidence in performing urologic US. The curriculum was developed using the AIUM Practice Guideline for Ultrasound
Examinations in the Practice of Urology developed in collaboration with
the American Urological Association.
Methods—In our study, 13 urology residents were participants
in this pilot curriculum. Didactic and hands-on US training sessions on
basic US physics and techniques, kidney, bladder, scrotal, and prostate US
were undertaken, and a posttest was administered in addition to surveys
evaluating their experience in the program. The implementation occurred
over 1 year.
Results—The results notably yielded a mean duration of approximately 30 hours of hands-on, didactic, and clinic US experiences at
the bedside reported by each of the residents in the study. Approximately
66% of the residents were confident in their ability to interpret their own
images.
Conclusions—We can conclude from the survey and posttest
data that the developed US curriculum for residents is beneficial for developing clinical acumen as well as confidence in making use of this imaging modality. In the future, we hope to increase the participation in this
curriculum and develop a more concrete timeline at which these trainees
progress through the curriculum as well as improve evaluation of the educational efficacy of the course.
1541471 Sonographic 2- and 3-Dimensional Aspects of Intrauterine
Device Evaluation: What Additional Information Can 3Dimensional Images Provide?
Claudia Maksoud Ultrasound, Colégio Estadual Padre Eduardo Michelis, Rio de Janeiro, Brazil
Objectives—Our goal is to show the role of identification of intrauterine device (IUD) positioning and integrity using 2D images and to
demonstrate the possibilities 3D images can provide, by giving a better
view of the uterine cavity in the coronal plane, and also more details of
IUD location, especially with a levonorgestrel-releasing IUD.
Methods—All ultrasound procedures were performed by radiologists, and the images were acquired using multifrequency transvaginal transducers. 3D images were obtained from freehand scans. The 2D
images included both longitudinal and transverse views and 3D images the
coronal view.
Results—3D images can better localize the IUD position and
give a better identification of the arms of the IUD. In the case of a levonorgestrel-releasing IUD, we can see more details of the shaft with 3D
images than with 2D images. Problems like an IUD embedded in the myometrium are better identified in the 3D coronal view.
Conclusions—2D ultrasound evaluation can be the classic
technique for IUD evaluation, but 3D images can improve the analysis,
giving more spatial details of the uterine cavity, IUD integrity, and position. As freehand 3D acquisition is easy and quick to perform, once it is
available, it can be used as a helpful tool in the evaluation of IUDs.
1541516 Point-of-Care Ultrasound in the Diagnosis of Complex
Subcutaneous Abscesses Requiring Surgical Intervention
Srikar Adhikari, Austin Gross* Emergency Medicine, University of Arizona Medical Center, Tucson, Arizona USA
Objectives—We present the utility of point-of-care ultrasound
(US) in the management of 2 cases of complex subcutaneous abscesses.
Methods—A 45-year-old male presented to the emergency department (ED) with left thigh swelling and pain. He developed pain 10
days prior to the arrival to the ED while jogging. He subsequently noted
redness and swelling in the thigh. Physical examination revealed lowgrade fever and a warm, tender, and swollen thigh with induration. It was
determined that the patient had an abscess, and an incision and drainage
(I&D) was planned by the treating emergency physician. Bedside US was
performed by the emergency physician to assist with the procedure. The
US examination revealed a large complex fluid collection extending >10
cm deep into the subcutaneous tissues and facial planes and beneath the
muscles. Based on the sonographic findings, a surgical consult was obtained. The patient was taken to the operating room (OR) where the abscess was drained under general anesthesia. The initial surgical incision
had to be extended to drain >200 mL of pus. We report another case, a 36year-old male presenting to the ED with left arm swelling, pain, and redness of 3 days’ duration. He gave a history of low-grade fever. He
presented with similar symptoms to the ED twice within 2 months prior
to this ED visit. An I&D was performed during both ED visits. Clinical examination revealed fluctuant, tender, erythematous swelling with an open
area spontaneously draining some purulent material. Because of repeat
ED visits, bedside US was performed by the emergency physician, which
revealed a 6-cm hyperechoic foreign body embedded deep in the tissues
of the upper arm along with a complex fluid collection. A surgical consult
was obtained. The patient was taken to the OR for foreign body removal
with drainage of the abscess.
Results—Point-of-care US allowed visualization of the extent
of the abscess and occult foreign body in these cases. It helped prevent an
underestimation of the extent of the infection and determined the need for
operative intervention.
Conclusions—Point-of-care ultrasound can help determine the
need for operative intervention in ED patients with complex subcutaneous
abscesses.
1541519 Impact of the Maternal Body Mass Index on the Duration
and Completion of Fetal Anatomic Ultrasound
Dana Smith,* Carmen Beamon, Kacey Eichelberger, Lisa
Carroll, Neeta Vora Maternal Fetal Medicine, University of
North Carolina, Chapel Hill, North Carolina USA
Objectives—Our objective was to examine the impact of the
prepregnancy body mass index (BMI) on both the duration and completion of the fetal anatomic survey.
Methods—A retrospective cohort study of singleton nonanomalous gestations presenting for fetal anatomic ultrasound between 16 and
25 weeks’ gestation at our institution was performed over a 3-month period. Standard BMI categories were computed using self-reported prepregnancy weight and height. Outcomes of interest were the duration of
ultrasound (defined as the difference in minutes between the first and last
abdominal image) and completion of ultrasound (“incomplete” defined as
a provider recommending the subject return for reevaluation). Univariate
and bivariate analyses as well as logistic regression modeling were used
to determine odds ratios for having an incomplete scan among subjects
with BMI ≥25.
Results—Of the 551 women analyzed, 52.7% of the cohort was
overweight or obese, with a mean BMI of 26.8 (range, 16.6–65.2). The average duration of basic ultrasound was 28.8 minutes vs 35.2 minutes for
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J Ultrasound Med 32(suppl):S1–S134, 2013
targeted ultrasound (P < .001). After controlling for gestational age, individual sonographer, race, and maternal age, we identified no statistically
significant effect of BMI on the duration of either basic (P = .81) or targeted (P = .80) scans. An incomplete evaluation occurred in 13.4% of patients. Overweight and obese women had a higher likelihood of having
an incomplete ultrasound evaluation compared to normal-weight women
(adjusted odds ratio, 2.31; 95% confidence interval, 1.36–3.96).
Conclusions—Overweight and obese women are more likely
to have an incomplete fetal anatomic survey when compared to normal
weight referents, although we identified no impact of obesity on the duration of the scan.
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Continuing Medical Education (CME) Credit Information
2013 AIUM Annual Convention
Activity Description
The 2013 AIUM Annual Convention is the most comprehensive, cutting-edge
meeting for the entire medical ultrasound community. Our unique multidisciplinary program provides a collaborative environment for all specialties and disciplines, from beginner to advanced.
Accreditation Statement
The American Institute of Ultrasound in Medicine (AIUM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME
activities for physicians.
Designation Statement
The AIUM designates the 2013 Annual Convention for a maximum of up to 30.5
AMA PRA Category 1 CME Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Credit for Sonographers
Sonographers participating in AIUM educational activities may earn credits toward
maintaining their professional certification from the following organizations:
American Registry for Diagnostic Medical Sonography (ARDMS)
The ARDMS accepts AMA PRA Category 1 CME Credits™.
American Registry of Radiologic Technologists (ARRT)
The AIUM is a Recognized Continuing Education Evaluation Mechanism
(RCEEM) for the American Registry of Radiologic Technologists (ARRT). These
educational activities are approved by the AIUM for ARRT Category A Credits.
Target Audience
This activity is designed to meet the needs of ultrasound professionals from various medical disciplines and specialty areas who perform and interpret ultrasound
examinations.
Course Objectives
Upon completion of this learning activity, participants should be able to:
•
Demonstrate updated knowledge in: Basic Science and Instrumentation;
Cardiovascular Ultrasound; Contrast-Enhanced Ultrasound; Emergency and
Critical Care Ultrasound; Fetal Echocardiography; General and Abdominal
Ultrasound; Gynecologic Ultrasound; High-Frequency Clinical and Preclinical Imaging; Interventional-Intraoperative Ultrasound; Musculoskeletal
Ultrasound; Neurosonology; Obstetric Ultrasound; Pediatric Ultrasound;
Sonography; and Therapeutic Ultrasound.
•
Discuss state-of-the art ultrasound research.
•
Practice updated ultrasound skills for more effective diagnosis.
•
Apply updated knowledge and clinical skills in improving patient care.
Activity Designed to Change
•
Competence
•
Performance
Disclosure Policy
As a provider accredited by the ACCME, the AIUM must ensure balance, independence, objectivity, and scientific rigor in all its activities. Anyone involved in
planning this CME activity is required to disclose to learners any relevant financial
relationship(s) that have occurred within the last 12 months with any commercial
interest(s) whose products or services are discussed in the CME content. Such relationships are defined by remuneration in any amount from the commercial interest(s) in the form of grants; research support; consulting fees; salary; ownership
interest (eg, stocks, stock options, or ownership interest excluding diversified mutual funds); honoraria or other payments for participation in speakers bureaus, advisory boards, or boards of directors; and other financial benefits. Individuals
involved in planning will be asked to recuse themselves from any portion of the
planning where a bias might exist.
All faculty participating in an educational activity provided by the AIUM are required to disclose to the provider and to the learner any relevant financial relationships with any commercial interest. The AIUM must determine if the faculty’s
relationships may influence the educational content with regard to exposition or
conclusion and resolve any conflicts of interest prior to the commencement of the
educational activity. The intent of this disclosure is not to prevent faculty with relevant financial relationships from serving as faculty but rather to provide members
of the audience with information on which they can make their own judgments.
The AIUM has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.
Policy on Unlabeled/Off-Label Usage
The AIUM has determined that disclosure of unlabeled/off-label or investigational
use of commercial products is informative for audiences and therefore requires this
information to be disclosed to the learners at the beginning of the presentation. Uses
of specific therapeutic agents, devices, and other products discussed in this educational activity may not be the same as those indicated in product labeling approved
by the US Food and Drug Administration. The AIUM requires that any discussions
of such “off-label” use be based on scientific research that conforms to generally
accepted standards of experimental design, data collection, and data analysis.
Before recommending or prescribing any therapeutic agent or device, learners
should review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse events.
Disclaimer
The information presented in this activity represents the opinion of the faculty and
is not necessarily the official position of the AIUM.
Documenting CME Credits
The AIUM provides CME certificates to those who have participated in an AIUM
educational activity. The AIUM does not submit credits to regulating bodies or certifying organizations on behalf of the participant. It is the participant’s responsibility to submit proof of credits on his or her own behalf.
Accreditation Council of Graduate Medical Education (ACGME)
Competencies
These courses are designed to meet one or more of the following ACGME competencies:
•
Interpersonal and Communication Skills
•
Medical Knowledge
•
Patient Care and Procedural Skills
•
Practice-Based Learning and Improvement
•
Professionalism
•
Systems-Based Learning
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Faculty Disclosures
As of March 5, 2013, listed below are faculty members who disclosed that they have relevant relationship(s) with commercial interest(s) that
may create a conflict of interest. Faculty members are instructed to advise the AIUM if new financial relationships with commercial interests
arise since completing their disclosure forms. Described below each name are the commercial interest(s) and the nature of the financial relationship(s). Disclosures, if any, are listed under the speaker’s name. Otherwise, the speaker has indicated that he or she does not have any relevant financial relationships. All completed disclosure forms are on file and available for review at the AIUM office.
Abadi, Maria
Abbott, Brian
Abdella, Thomas
Abdelmalek, Manal
Abdullaev, Rizvan
Abo, Alyssa
Abramowicz, Jacques
Institute for Advanced Medical
Education: honorarium;
speaker
Philips Healthcare: consultant;
research machines
Abuhabsah, Rami
Abuhamad, Alfred
Abu-Rustum, Reem
Abu-Rustum, Sameer
Abu-Yousef, Monzer
Acharya, U. Rajendra
Achiron, Reuven
Ackerman, Susan
Adams, Janet
Aderibigbe, Oluyemi
Adhikari, Srikar
Adkins, Eric
Adler, Ronald
Adzick, N. Scott
Agache, Vlad
Agildere, A. Muhtesem
Ahmadzia, Homa
Ahmed, Ahmed
Aish, Bassil
Ajmera, Kunal
Alcázar, Juan Luis
Alehagen, Urban
Al Ekish, Shadi
Alexandrov, Andrei
Allaf, M. Baraa
Allen, Angela
Allen, Derrick
Al Mahrouki, Azza
Al Muhanna, Khalid
Aly, Abdel-Rahman
Amian, Angelina
Amponsah, David
Ananth, Cande
Anderson, Craig
Anderson, Sharlette
Ando, Takeshi
Andreotti, Rochelle
Antonios, Likourezos
Antonis, Michael
Anvari, Arash
Apterbach, William
Archer, Timothy
Arellano, Javier
Arnold, Kelly
Arntfield, Robert
Arpit, Nagar
Arroyo, Alex
Arynova, Bakyytbubu
Astheimer, Jeffrey
Aten, Andrew
Au, Arthur
Aubá, Maria
Ausiello, Livia
Avner, Jeffrey
Axt-Fliedner, Roland
Ayala, Ruben
Aylward, Stephen
Ayoub, Jean
Ayvazyan, Sergey
Azar, Nami
Aziz, Seerat
Baek, Song-Ee
Bahner, David
Bai, Jing
Baird, Donna
Bajaj, Komal
Bakhireva, Ludmila
Balise, Raymond
Balk, Andrew
Balzaretti, Paolo
Banderali, Alessandra
Bantignies, Claire
Barahona, J. Oscar
Bard, Robert
Bardales, Ricardo
Barnewolt, Carol
Barr, Richard
Philips Healthcare: equipment
and research grant; advisor,
researcher, speaker
Siemens Medical Solutions:
equipment and research grant;
advisor, researcher, speaker
SuperSonic Imagine: equipment grant; researcher, speaker
Toshiba America Medical
Systems: honoraria; advisor
Barral, Joelle
Barri, Pedro
Barri-Soldevila, Pere
Bar-Sever, Zvi
Bartels, Eva
Bartova, Petra
Baschat, Ahmet
Bault, Jean-Philippe
Bawiec, Christoper
Baxtrom, Catherine
Beach, Kirk
Beal, Eliza
Beamon, Carmen
Beavis, Cole
Beck, Bill
PhysioSonics, Inc: independent
contractor; consultant
Beiter, Kyle
Beland, Michael
Belfort, Michael
Bellew, Christine
Benacerraf, Beryl
Benaroya, Azriel
Bendick, Philip
Ben-Meir, David
Benn, Peter
Bennett, Terri-Ann
Benson, Carol
Beraud, Anne-Sophie
Berdejo, George
Berger, Jan
Bhatt, Shweta
Bhimani, Ashish
Bialeck, Suzanne
Bieniarz, Andre
Bierca, Jacek
Bird, Christine
Bitters, Constance
Blackstock, Uche
Blahuta, Jiri
Blaivas, Michael
Blanchette Porter, Misty
Blanks, James
Blankstein, Josef
Blebea, John
Blews, David
Blickendorf, Matthew
Blumenfeld, Yair
Bluth, Edward
Bockbrader, Marcie
Bolouri, Marjan
Bolte, Annemieke
Boniface, Keith
Boore, Stacy
Borgida, Adam
Bouffard, J. Anthony
Boulger, Creagh
Box, Daniel
Box, Geoffrey
Boyd, Brita
Bradford, Susan
Bradley, Kathleen
Bradshaw, Darin
Breazeale, Shane
Brennan, Matthew
Brewer, Kori
Bromley, Bryann
Brown, Cara
Brown, Douglas
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Brown, James
Brown, Steffen
Brown, Stephen
Brown III, William
Brubaker, Sara
Buadu, Annemarie
Buckwalter, Joseph
Bui, Loan
Bulas, Dorothy
Bundy, Nicole
Bunting, Ethan
Bureau, Nathalie
Burhans, Kristin
Burns, Peter
Busse, Raydeen
Byram, Brett
Byrne, Janice
Cabral, Digna
Cadet, Claudia
Cahill, Alison
Calabrese, Kathleen
Calisti, Giorgio
Calvo-Garcia, Maria
Campbell, Colleen
Campbell, Winston
Canavan, Timothy
Cao, Tie-Sheng
Carey, John
Carlson, Lindsey
Carroll, Lisa
Carroll, Mary
Carson, Paul
GE Global Research: federal
grants, research collaboration;
principal investigator
Light Age, Inc: modification of
their commercial laser; help in
specification and testing
Sonetics Ultrasound, Inc:
salary on their Small Business
Innovation Research project;
advised on transducer arrays
and applications
Casoli, Giovanna
Cassady, Christopher
Castillo, Eddie
Caughey, Melissa
Cavanaugh, Barbara
Cendan, Juan
Cermak, Petr
Cha, Joo Hee
Chalek, Carl
Chan, Ted
Chandrasekhar, Chitra
Chao, Jennifer
Chavez, Martin
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Chervenak, Judith
Childress, Johnathan
Chin, Eric
Chinchure, Dinesh
Chintapalli, Kedar
Chiou, See-Ying
Chiricolo, Gerardo
Choi, Woo Jung
Chong, Wui
Chopra, Manisha
Chorazy, Marek
Chou, Nai-Kung
Chow, Kira
Church, Charles
Ciardo, Paolo
Cibinel, GianAlfonso
Claes, Frank
Clem, Douglas
Clingman, Bryan
Cody, Kenneth
Cohen, Harris L.
Cohen, Leeber
GE Healthcare: honoraria;
speaker
Philips Healthcare: honoraria;
speaker
Samsung Ultrasound: honoria;
speaker
Cohen, Nicholas
Coleman, Beverly
Coley, Brian
Colvin, Robert
Comerota, Anthony
Contreras, Karenrose
Cordeiro, Christina
Coroleu, Buenaventura
Correas, Jean-Michel
Philips Healthcare: speaker’s
fee; advisory board, speaker
SuperSonic Imagine: speaker’s
fee; speaker
Toshiba Medical Systems:
speaker’s fee; speaker
Cortez, Eric
Corujo, Omar
Cosgrove, David
Craig, Joseph
Crawford, Christine
Crawford, Forrest
Crino, Jude
Crites, Lori
Cruz, Joshua
Cunha, Luana Torres
Currie, Geoffrey
Curs, Brad
Cussó Sorribas, Mireia
Czarnota, Gregory
Czernuszewicz, Tomasz
Czerný, Dan
Dahibawkar, Manasi
Dahiya, Nirvka
Dahlström, Ulf
Dai, Qing
Dalecki, Diane
Dallas, Apostolos
J Ultrasound Med 32(suppl):S1–S134, 2013
Darge, Kassa
D’Armiento, Jeanine
Datta, Anita
Dave, Jaydev
Davidovits, Miriam
Davis, Michael
Davis, Sarah
Dayton, Paul
Targeson, Inc: stock options;
consultant, Scientific Advisory
Board
Dean, Anthony
De Castro, Francisco
De Franco, Emily
De Franco, Paul
Deganello, Annmaria
Bracco SpA: lecture fees;
speaker
Degenhardt, Jan
De Guillebon, Adelaide
De Jong, M. Robert
De la Torre, Lesley
Del Cura, Jose
Deng, Cheri
Destounis, Stamatia
Deter, Russell
Detti, Laura
Deurdulian, Corinne
Deurloo, Koen
Deutch, Todd
GE Healthcare: consulting fee;
speaker
DeVore, Greggory
GE Healthcare: honorarium;
speaker
Diaz, Daisy
Dickman, Eitan
Dietrich, Christoph
Diffenderfer, Kristen
DiFlorio, Roberta
Dillman, Jonathan
Di Matino, Filomena
Di Pietro, Michael
Do, Samantha
Dogra, Vikram
Dolin, Cara
Donaldson, Chase
Donaldson, Joe
Doniger, Stephanie
Donofrio, Mary
Dooley, Erin
Dornbluth, Carol
Doubilet, Peter
Dresbach, Sereana
Dudley, Larissa
Dumont, Douglas
Duvdevani, Nir
Ehsanipoor, Robert
Eichelberger, Kacey
Eiferman, Daniel
Eisenbrey, John
Elahi, Ershad
El-Baz, Ayman
El Kaffas, Ahmed
Ellestad, Sarah
Emmitt, Regina
English, Carter
Enzensberger, Christian
Erdman, John
Ermilov, Sergey
Seno Medical Instruments:
consultant; consulting fee
Eski, Erkan
Estroff, Judy
Evans, David
Evans, Kevin
Fabiilli, Mario
GE: other activities; other
financial benefit
Fadrna, Tana
Falou, Omar
Farber, Mark
Farella, Nunzia
Farwick, Lauren
Feinstein, Steven
GE Healthcare: consulting
fees; consultant; research
funds, research
Feldstein, Vicky
Feleppa, Ernest
Feltovich, Helen
Fenster, Aaron
Eigen: royalties; research collaborator
Fernandez-Cid, Maria
Ferraioli, Giovanna
Ferreri, Enrico
Fessell, David
Filice, Carlo
Finnoff, Jonathan
Fischer, Jason
Fisher, Kimberley
Fleischer, Arthur
Fleshman, Shane
ZetrOZ, LLC: employment;
salary
Fontanilla, Teresa
Ford, Peter
Fordham, Lynn
Forsberg, Anya
Forsberg, Flemming
Foster, F. Stuart
Fowlkes, J. Brian
GE Healthcare: equipment
support; other financial benefits; other activities; research
Fox, J. Christian
SonoSim, Inc: shares; consultant
SonoSite, Inc: equipment loan;
consultant
Fox, Nathan
Fox, Traci
Francis, Charles
Frank, Gary
Frates, Mary
Frenkel, Victor
Friedman, Alexander
Friedman, Lana
Fuchs, Karin
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Fujimoto, Chrystie
Fujitani, Roy
Fuller, Kisti
Gadddipati, Sreedhar
Galan, Henry
Galerneau, France
Gallippi, Caterina
Gammell, Paul
Gandhi, Manisha
Gandikota, Girish
Garami, Zsolt
Edwards Lifesciences:
honoraria; consultant
Gore Medical: honoraria;
consultant
Garberoglio, Roberto
Garcia, Blanca
Garcia, Sara
Garg, Mahek
Garon, Jack
Garra, Brian
Gaspari, Romolo
Gauthier, Marianne
Gecsi, Kimberly
Gee, Michael
Geiger, Miwa
Geldermann, David
Gelman, Slava
Gembruch, Ulrich
George, Verghese
Gerardo, Chiricolo
Gerber, Susan
Germer, Ute
Geria, Rajesh
Gessner, Ryan
Gharahbaghian, Laleh
Gilboa, Yinon
Giles, Anoja
Gindes, Liat
Giorgio, Antonio
Giorgio, Valentina
Girish, Gandikota
Girotto, John
Glanc, Phyllis
Glantz, J. Christopher
Glasek, Jedrzej
Glaser, Angela
Glasser, Jessie
Glazier, Elizabeth
Goertz, David
Goetzinger, Katherine
Goffi, Alberto
Goldberg, Aryeh
Goldírová, Andrea
Goldklang, Monica
Goldman, Ellen
Goldman, Sara
Goldstein, Ruth
Goldstein, Steven
Amgen: speakers bureau;
honorarium
Bayer: Gynecology Advisory
Board; honorarium
Cook Ob/Gyn: consultant,
consulting fees
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American Institute of Ultrasound in Medicine Proceedings
Philips Healthcare: consultant,
equipment loan
Warner Chilcott: speakers bureau; honorarium
Gonçalves, Luis
GE Healthcare: honorarium,
speaker
Philips Healthcare: honorarium, speaker
Goodman, Eric
Goodman, Jean Ricci
Goodman, Rob
Goodman, Thomas
Gordon, Robert
Goubran, Ashraf
Goutham, Swapna
Graupera, Betlem
Gray, Siobhan
Grippo, Anthony
Groh, Georgeann
Gross, Austin
Groszmann, Yvette
Grotegut, Chad
Guerriero, Stefano
Guizado de Nathan, Gigi
Gullett, John
Gunabushanam, Gowthaman
Gunnison, Kathryn
Gupta, Sanjey
Gupta, Simi
Gurewitsch, Edith
Gurram, Padmalatha
Gustafsson, Mikael
Gyamfi, Cynthia
Haberman, Shoshana
Habnenicht, Rebecca
Hacker, Michele
Haeir, Sina
Haggerty, Patricia
Haines, Lawrence
Hall, Anne
Hall, Eric
Hall, Rebecca
Hall, Timothy
Halldorsdottir, Valgerdur
Hamper, Ulrike
Hamrick, M. Ann
Hamvas, Aaron
Han, Bokyung
Handa, Priyanka
Hangiandreou, Nicholas
Hansen, Allan
Harris, Gerald
Harris, Robert
Hartge, David
Hartman, Alex
Hartman, Brian
Hartman, Diana
Hashim, Amr
Hata, Stacy
Havel, Martin
Havelka, Jaroslav
Hawkins, Leah
Hbeib, Moses
He, Le
He, Yu
Heimburger, Glenn
Heimiller, Jeffrey
Heller, Howard
Henderson, Janice
Henderson, Stephanie
Henkaline, Todd
Hereter, Lourdes
Hernandez, Caridad
Herrera, Christina
Herzig, Roman
Herzog, Donald
Heymans, Martijn
Higgins, Peter
Hilgers, Thomas
Hingorani, Anil
Hirtz, Nathaniel
Ho, Annette
Hobbs, Susan
Hocking, Denise
Hoffman, Chen
Holland, Christy
Holland, Mark
Holzman, Ian
Homeister, Jonathon
Hong, Min Ji
Hong, Soon Jae
Hooley, Regina
Hoover, Emily
Hoppmann, Richard
Horii, Steven
Hornberger, Lisa
Horning, Matthew
Horrow, Mindy
Horton, Sharon
Hoshiko-Reed, Gail
Hotta, Naoki
Hou, Gary
Hou, Randy
Housman, Elise
Howard James
Howard, Zoe
Howe, Duncan
Howell Lori
Hoyt, Kenneth
Hrbáč, Tomáš
Hu, Xiangdong
Huang, Dean
Huang, Lingyun
Huang, Manwei
Huhta, James
Hurtíková, Eva
Hussain, Naveed
Hussien, Abdelmohsen
Hynynen, Kullervo
Iacobucci, Antonello
Ibrahim, Deena
Ikeda, Nobutaka
Ingle, Atul
Iradji, Sara
Irshad, Abid
Iseman, Christine
Ivancevich, Nikolas
Izquierdo, Luis
Jackson, David
J Ultrasound Med 32(suppl):S1–S134, 2013
Jackson, Matt
Jacobowitz, Glenn
Jacobson, Jeffrey-Michael
Jacobson, Jon
Jaen Diaz, Jose
Jafari, Daniel
Jakubowski, Wieslaw
Jang, Kee
Jasne, Adam
Jasti, Sirisha
Jelinkova, Monika
Jelsing, Elena
Jeon, Eun-Jin
Jiang, Yuxin
Jing, Zhao
Johansson, Peter
Johnson, Allan
Johnson, Benjamin
Johnson, Jeanine
Johnson, Jeff
Johnson, Laura
Johnson, Mary Beth
Johnson, Neil
Jon, Xia
Jonszta, Tomáš
Joong-Kim, Young
James, Joseph
Joseph, Oliver
Joshi, Kruti
Ju, Hyeyoung
Juan, Zhang
Juez, Leyre
Kagarise, Daniel
Kang, Su Min
Kaproth-Joslin, Katherine
Karlicki, Fern
Karlman, Roberta
Karmel, Bernard
Karshafian, Rarri
Kasperlik-Zaluska, Anna
Kasyouhanan, Fadi
Katorza, Eldad
Katz, Yisrael
Kawecki, Andreaa
Kelley-Martinez, Martha
Kennedy, Anne
Kent, Alistair
Kerr, Lucy
Kerwin, Christopher
Ketterling, Jeff
Khan, Feras
Khine, Hnin
Khorana, Alok
Khoury, Viviane
Khuri-Yakub, Butrus
Kim, Ahm
Kim, David
Kim, Hak Hee
Kim, Hyunji
Kim, Laura
King, Daniel
King, Deirdre
Kiplagat, Annette
Kirschner, Jonathan
Kist, Kenneth
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Klassen, Anna
Klaus, Suzanne
Klauser, Chad
Kliewer, Mark
Kline-Fath, Beth
Kobayshi, Akitoshi
Kohl, Thomas
Kolios, Michael
Koltz, Peter
Kona, Matthew
Konicki, P. John
Konofagou, Elisa
Korucuk, Ekrem
Kotowski, Susan
Kowalewski, Gregory
Koziatek, Christian
Kraft, Otakar
Krajča, Jan
Krakow, Deborah
Krapp, Martin
Kraus, Steven
Kremkau, Fredrick
Kripfgans, Oliver
GE Healthcare: equipment
support; other activities; other
financial benefit
Krishnamurthi, Ganapathy
Krishnan, M. Muta Rama
Kugler, Lindsay
Kuhlmann, Randall
Kulbacki, Evan
Kuliha, Martin
Kunselman, Allen
Kunselman, Bon
Kwiatkowski, Robert
Labuda, Cecille
LaFerriere, Janet
Lai, Xingjian
Laifer-Narin, Sherelle
Lal, Brajesh
Lam, Samuel
Langer, Jill
Langer, Matthew
ZetrOZ, LLC: employment;
salary
Langova, Katerina
Lappen, Justin
Larsen, John
LaRusso, Salvatore
Lavin, Philip
Lawrence, Matthew
Layman, Kerri
Lee, Jiann-Gwu
Lee, Kenneth
GE Healthcare: honorarium;
course faculty
Philips Healthcare: limited
research support; principal
investigator
Siemens Medical Solutions:
limited research support;
principal investigator
Lee, Mi Hee
Lee, Mi-Young
Lee, Pil-Ryang
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Lee, Rose
Lee, Sanghee
Lee, Seung Yun
Legault Kingstone, Lysa
Leibman, Jill
Lema, Penelope
Lerner, Jodi
Lester, Neil
Leswick, Dave
Lethiecq, Marc
Letourneau, Karen
Levine, Adam
Levitov, Alexander
Lev-Toaff, Anna
Levy, Bruce
Levy, Philip
Lewin, Peter
Lewis, George
ZetrOZ, LLC: management
position; salary
Lewis, Madelene
Lewiss, Resa
Li, Mingde
Lianfang, Du
Lichtenstein, Daniel
Likourezos, Antonios
Lim, Tae-Hong
Linam, Leann
Liou, Robert
Li Pi Shan, Rodney
Lipitz, Shlomo
Lipman, Samantha
Liu, He
Liu, Ji-Bin
Liu, Teresa
Liu, Yunbo
Liu, Xi
Lloyd, Harriet
Lobos, Nelson
Lockhart, Mark
Lombardo, Paul
Long, Suzanne
Looney, Devon
Lopez, Eugenio
Lopez, Joseph
Lopez, Robert
Lowe, Lisa
Ludomirsky, Achi
Lukjanova, Irina
Luo, Jianwen
Lupia, Enrico
Lyons, Jennifer
Lyshchik, Andrej
Philips Healthcare: research support; consultant
Ma, Chi
Maaji, Sadisu
Machado, Priscilla
Macian, Diana
Mack, Julie
Macones, George
Madden, John
Madsen, Ernest
Madoff, David
Magalhaes, Alvaro
J Ultrasound Med 32(suppl):S1–S134, 2013
Magriples, Urania
Mahoney, Marshall
Maida, Eugene
Majcher, Marta
Maksoud, Claudia
Mallarini, Giorgio
Mamou, Jonathan
March, Melissa Irene
Margolis, David
Marin, Daniele
Markenson, Glenn
Marks, William
Marshall, Andrew
Marshall, Randolph
Marston, William
Martí Mestre, Xavier
Martin, James
Martis, Roshan
Maruvada, Subha
Mastrobattista, Joan
Mata Castrillo, Maria
Mathew, Brennan
Matsutani, Shoichi
Matthew Mauro
Mayo, Paul
Mazza, Rachel
McArthur, Lucas
McCamey, Kendra
McCann, Margaret
McCarthy, Melissa
McCarville, Beth
McDowell, Jennifer
McNamara, John
McNamara, Robert
McShane, Cyrethia
Medak, Anthony
Medford, William
SonoSite, Inc: salary; hands-on
instructor
Mehta, Ninfa
Meizner, Israel
Melniker, Lawrence
Melone, Paula
Merport Modest, Anna
Merritt, Christopher
Merton, Daniel
Mervis, Eric
Meyer, Diane
Meyer, Elaine
Meyer, Marjorie
Mezei, Gabor
Middleton, William
Migda, Bartosz
Mihailos, Athena
Millard, Sarah
Miller, Douglas
Miller, Emily
Miller, James
Miller, Rita
Miller, Russell
Miller, Theodore
Miller, Thomas
Millet, John
Millington, Scott
Milne, Michelle
Miniati, Douglas
Minkoff, Howard
Minnigan, Hal
Mistur, Rachel
Mohan, Uthara
Mojibian, Hamid
Moldenhauer, Julie
Molinari, Filippo
Molitor, Mark
Moni, Saila
Monroe, Manette
Monteagudo, Ana
Moon-Grady, Anita
Mooney, Lindsay
Mooney, Timothy
Moons, David
Moore, Christopher
Philips Healthcare: consultant,
consulting fee
Sonosite, Inc: consultant,
consulting fee
Moreno, Claudia
Moschos, Elysia
Moshesh, Malana
Mougenot, Charles
Philips Healthcare: employment; salary
Mueller, Anthony
Mudrik-Zohar, Hadar
Mujsce, Dennis
Mullen, Katherine
Mulvagh, Sharon
GE Healthcare: consulting fee;
consultant
Lantheus Medical Imaging:
research grant; research support
Munden, Martha
Munson, Jacqueline
Murphy, Joshua
Murphy, Megan
Murtha, Amy
Muruganandan, Krithika
Muruganandan, Meera
Muzumoto, Hideaki
Myers, Craig
Nadaraj, Sumekala
Nakamoto, Dean
Galil Medical: research support;
research
Toshiba America Medical
Systems: honorarium; speaker
Nakashima, Kazutaka
GE Healthcare: salary; speaker
Hitachi Aloka Medical, Ltd:
salary; speaker
Philips Healthcare: salary;
speaker
Nam, Kibo
Namagembe, Imelda
Nandlall, Sacha
Nasief, Haidy
Navathe, Reshama
Nazarian, Levon
Needleman, Laurence
Nelson, Bret
S126
Nelson, Rendon
Neri, Emily
Neyman, Olga
Nghiem, Hahn
Nguyen, Thanh
Nhan-Chang, Chai-Ling
Nichols, Timothy
Nicolaides, Andrew
Nicolau, Carlos
Nightingale, Kathy
Noble, Vicki
Nomura, Jason
Emergency Ultrasound Consultants, LLC: consulting fee;
director of medical education
Nomura Consulting, LLC:
ownership; principle/owner
Novak, Ronald
Novelli, Paula
Nunes, Uziel
Obi, Nwamaka
Obican, Sarah
O’Brien, William Jr
National Institutes of Health:
funding for the work; other activities; other financial benefit
O’Connell, Avice
O’Connor, Rory
O’Day, Mary
Odibo, Anthony
Odunko, Danielle
Oelze, Michael
Ogburn, Paul
Ogutcu, Birsen
Oh, Karen
O’Hara, Sara
Toshiba Medial Systems:
equipment software; consulting
Ojili, Vijayanadh
Olartecoechea, Begoña
Olivia, Marta
Oliver, Edward
Ong, Chiou Li
Oraevsky, Alexander
Seno Medical Instruments:
consulting; consulting fee
O’Rourke, Kevin
Otáhal, David
Otto, Pamela
Seno Medical Instruments:
consulting; consulting fee
Ozhand, Ali
Pakdaman, Reza
Palma, James
Palmeri, Mark
Paltiel, Harriet
Pamnani, Ravi
Pan, Patrick
Pan, Xiaochang
Panebianco, Nova
Panerai, Ronny
Pao, Sun-Hua
Pareek, Gyan
Parkes, Jenny
Parry, Samuel
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Pascual, M. Angela
Paspulati, Raj Mohan
Patat, Frédéric
Patel, Dervarshi
Patel, Nilesh
Patterson, Leigh
Paul, Ian
Pawlina, Wojciech
Payer, Andrew
Peck, Jennifer
Peddada, Shyamal
Pedersen, Peder
Pedrero, Cristina
Pellerito, John
Pennington, James
Perarnau, Jean Marc
Perez, Alicia
Perez-Delboy, Annette
Perrin, Stephen
Pessel, Cara
Peters, Hope
Pezo, Carlo
Phan, Ha
Piert, Morand
GE: other activities; other
financial benefits
Pineda, Grace
Pineda, Laura
Pinter, Stephen
GE Healthcare: equipment
support; other activities; other
financial benefits
Piscaglia, Fabio
Pivetta, Emanuele
Planinic, Petar
Platt, Lawrence
GE Healthcare: honorarium;
consultant, speaker
Platz, Elke
Plessl, Daniel
Polascik, Thomas
Pollard, Katherine
Pontius, Elizabeth
Porrino, Giulio
Porter, Thomas
GE Healthcare: research support; principal investigator
Lantheus Medical Imaging:
research support; principal
investigator
Philips Healthcare North
America: research support;
principal investigator
Posh, John
Metrasens: consulting fee;
employee trianing
Poston, Mary Elizabeth
Prabulos, Ann Marie
Presley, James
Pretorius, Dolores
Price, Brandon
Procházka, Václav
Provost, Jean
Pruetz, Jay
Pulvermacher, Christina
J Ultrasound Med 32(suppl):S1–S134, 2013
Qian, Liu
Quant, Hayley
Quesada, Carole
Rabener, Michael
Rabiner, Joni
Racadio, John
Radeos, Michael
Radhakrishna, Mohan
Raginwala, Saad
Raio, Christopher
ZONARE Medical Systems:
consulting fee; medical advisor
Rajasekaran, Sathish
Ramakrishnan, Prem
Ranninger, Claudia
Ranzini, Angela
Rao, Victor
Rasalingam, Ravi
Rath, Krista
Rathje, Erin
Ravangard, Samadeh
Rayburn, William
Rebarber, Andrei
Reeves, Shane
Reiner, Cäcilia
Reinstein, Dan
Arcsan, Inc: other activities;
ownership interest
Reiss, Rosemary
Repke, John
Reusch, Lisa
Revzin, Margarita
Richards, Michael
GE Healthcare: equipment
support; other activities; other
financial benefit
Rizza Siniscalchi, Nicolo
Ro, Raymond
Roberts, Jessica
Robinson, Kathryn
Robinson, Zachary
Roca, Pedro
Rodney Rocco, John
Rodney, William
Rochon, Paul
Rodriguez, Diana
Roe, Anne Marie
Roelant, Geoffrey
Resch, Michael
Rogers, Sarah
Roll, Shawn
Roman, Ashley
Romera Villegas, Antonio
Romero, Vivian
Romney, Marie
Rosado-Mendez, Ivan
Rosas, Humberto
Rosborough, Terry
Rosen, Mark
Rosenberg, Henrietta Kotlus
Rosenberg, Keith
Rosenzweig, Stephen
Rotemberg, Veronica
Roubec, Martin
Rouze, Ned
Royall, Nelson Andrew
RoyChoudhury, Arindam
Ruanno, Rodrigo
Rubens, Deborah
Rubert, Nicholas
Rubin, Jonathan
Rubin, Sherman
Rubio, Eva
Rundek, Tatjana
Rutledge, Amy
Rusczyk, Gregg
Rychak, Joshua
Siemens Medical Solutions:
equipment support; collaborator/researcher
Targeson, Inc: employment,
stock ownership; employee,
founder
VisualSonics, Inc: consulting
fee; technical consultant
Saad, Nael
Saba, Luca
Sadeghi-Naini, Ali
Safonova, Inessa
Sahlani, Lydia
Sahn, David
Sakhel, Khaled
Conceptus: speaker fee,
speaker
Hologic: consulting fee;
consultant, speaker
Salimian, Mohammad
Saltzman, Daniel
Samir, Anthony
SuperSonic Imagine: speaker
fee, speaker
Samuel, Amber
Samuels, Joshua
Santolaya, Joaquin
Sarwate, Sandhya
Satou, Gary
Savage, Daniel
Savaser, Davut
Schafer, Mark
Schaller, Michael
Scher, Lawrence
Schmitz, Kelli
Schneider, Darren
Schneider-Kolsky, Michal
Schnettler, William
Schofer, Joel
Schroer, Andreas
Schwartz, Nadav
Scissons, Robert
Unetixs Vascular, Inc: independent contractor; royalty
Scognamiglio, Umberto
Scola, Mallory
Scoutt, Leslie
Philips Healthcare: honoraria;
speaker
Seed, Michael
Sehgal, Chandra
Sekarski, Timothy
Seki, Atsuyoshi
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Serres, Xavier
Seupaul, Rawle
Shah, Sachita
Shah, Virag
Shahmirzadi, Danial
Shailam, Randheer
Shamshirsaz, Amir
Shau, Yio-Wha
Sheets, Linda
Philips Healthcare: employee;
salary
Sheppard, Celeste
Sherbotie, Joe
Sherman, Philip
Shieh, Mason
Shiels, William
Sierzenski, Paul
Emergency Ultrasound Consultants, LLC: partner; president
and CEO
Emergency Ultrasound Consultants, LLC: spouse/partner,
COO, partner
Sonosite, Inc: consulting fee,
speaker
Shim, Jae-Yoon
Shin, Hee Jung
Shipp, Thomas
Shirazi, Mazda
Shlansky-Goldberg, Richard
Shofer, Frances
Shokoohi, Hamid
Shonkwiler, Gwen
Shoreman, Mark
Shue, Eveline
Shung, K. Kirk
Shwayder, James
Cook Ob/Gyn: royaties;
coinventor
Philips Healthcare: consulting
fees; consultant
Shyu, Jeou-Jong
Sidhu, Paul
Hitachi, Inc: consulting fee;
speaker
Siemens AG: consulting fee;
speaker
Sierzenski, Paul
Sikdar, Siddhartha
Silas, Anne
Silverman, Norman
Silverman, Ronald
Arcscan, Inc: interest other
activities; ownership
Simmons, John
Simpson, Douglas
Simpson, Lynn
Sinert, Richard
Singh, Gautam
Sinha, Sidhartha
Sinkovskaya, Elena
Sivitz, Adam
Sklansky, Mark
Školoudik, David
Slapa, Rafal
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Sloane, Chris
Slowinska-Srzednicka, Jadwiga
Smith, Brendon
Smith Dana
Smith, Jay
Tenex Health: other financial
benefit; other activities
Smith, Jessica
Smith, Lem
Smith, Matthew
Smith, Rose
Smith, Susan
Smrtka, Michael
Snead, Gregory
Snyder, Kathryn
Soffer, Debbra
Sohaey, Roya
Solomon, Julia
GE Healthcare: honorarium;
preparation of educational materials
Sommerich, Carolyn
Song, Chihwa
Sprace, Anna
Soto, Rosamary
Soukup, Tomas
Sperling, Daniel
Spiel, Melissa
Spinner, David
Spinosa, Al
Spitz, Jean
Springer, Andrew
Sree, Vinitha
Sridharan, Anush
Srinivasan, Ganesh
Stassijns, Gaetane
Stavros, Thomas
Seno Medical Instruments:
consultant; consulting fee
Stawicki, Stabuskaw
Steiner, Ryan
Stekel, Scott
Stepien, Beata
Stidham, Ryan
Stilp, Erik
Stites, Rachel
Stone, Michael
Philips Healthcare: consulting
fee; consultant
Strakowski, Jeffry
Strasburger, Diana
Strickland, Colin
Amirsys: royalty for content;
content author
Elsevier: honorarium; book
section editor
iiCME: honorarium; speaker
Stulac, Sara
Subashi, Ergys
Summey, Robert
Sun, Derek
Sun, Qiang
Sunny, Youhan
Suri, Jasjit
Swamy, Geeta
Swanson, Scott
Szabo, Thomas
Szyld, Demian
Tai, Hao-Chih
Talbott, Nancy
Talegon, Antonio
Talk, Douglas
Tao, Shengzhen
Tarabulsi, Gofran
Tchelepi, Hisham
Teefey, Sharlene
Tegeler, Charles
Terentiev, Victoria
Tessler, Franklin
Philips Healthcare: conulting
fee; consultant
Thomas, Kari
Thomenius, Kai
GE Healthcare: empoyment;
salary
Thompson, Jennifer
Thornburg, Loralei
Tian, Zhiyun
Tierney, David
Tillett, Jason
Timor, Ilan
Tirado, Alfredo
Tizzani, Maria
Todorova, Margarita
Toland, Gregory
Tolbert, Tahisha
Tornero, Mark
Torres, Carlos
Tradup, Donald
Trahey, Gregg
Tran, Eric
Tran, Nghia
Tran, Thaison
Tran, William
Treadwell, Marjorie
Trebes, Shannon
Tresserra, Francisco
Trinh, Tony
Tsung, James
Tumidajewicz, Justyna
Tur-Kaspa, Ilan
Turner, Elizabeth
Turney, Colin
Tuuli, Methodius
Twickler, Diane
Tworetsky, Wayne
Ulissey, Michael
Seno Medical Instruments:
consultant; consulting fee
Ural, Banu
Ural, Serdar
Urbanowicz, Katarzyna
Urs, Raksha
Uryasev, Oleg
Utrilla-Layna, Jesus
Vallabhaneni, Raghuveer
Vance, Cheryl
GE Healthcare: salary; WHS
education
Vandordaklou, Negean
van Holsbeeck, Marnix
van Veen, Teelkien
J Ultrasound Med 32(suppl):S1–S134, 2013
Van Vugt, John
Vargas Velandia, Edwin
Vargas-Vila, Mario
Varghese, Tomy
Vassa, Ravi
Vejdani-Jahromi, Maryam
Vela, Deborah
Victoria, Teresa
Vila, Meritxell
Vila Coll, Ramon
Vilke, Gary
Vilkomerson, David
DVX, LLC: salary; management; ownership
Vink, Joy
Vintzileos, Anthony
Vogel, Melanie
Voloshin, Arkady
Volpicelli, Giovanni
Volz, Kevin
Vora, Neeta
Vrablik, Michael
Vytkac, Adam
Waag, Robert
Wachsberg, Ronald
Wagner, Jason
Walker, Cynthia
Wallace, Kirk
GE Healthcare: employment;
salary
Wang, Eileen
Wang, Hongyan
Wang, Michael
Wang, Shuo-Meng
Ward, Valerie
Wax, Joseph
Way, David
Wear, Keith
Weichert, Jan
Weingarten, Michael
Weisz, Boaz
Wells, C. Edward
Werner, Erika
White James
White, Katherine
Whitley, Kari
Wildes, Douglas
GE: dividends; salary;
employee; stockholder
Wilkens, Isabelle
Williams, Sarah
Wilson, Kim
Wilson, Thaddeus
Wise, Adam
Wislon, Christian
Witkowska, Agnieszka
Witt, Dexter
Wolf, Patrick
Wolfe, Honor
Wolfe, Michael
Won, Hye-Sung
Woodward, Paula
Wortsman, Ximena
Xiao, Jia
Xu, Jonathan
Xu, Zhen
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Xuemei, Zhang
Yablon, Corrie
Yakubu, Abdulmuminu
Yantri, Ratna
Yeager, Susan
Yeboah, Nina
Yellin, Sharon
Yenter, Christopher
Yerli, Hasan
Yeo, Lami
Yijin, Su Master
Yilma, Tugbahan
Ying, Wu
Yingyu, Cai
Yinon, Yoav
Yoob, Suzanne
Yoon, Chung
Yoon, Hee-Chul
Yoon, Jae-Won
Yoon, Sang-Wook
Youssefian, Arthur
Yuan, Chun
Yuan, Li-Jun
Yunhua, Li
Zagzebski, James
Zaharieva, Maria
Zalel, Yaron
Zalev, Jason
Seno Medical Instruments:
consultant; consulting fee
Zeeman, Gerda
Zehtabchi, Shahriar
Zhang, Jing
Zhang, Man
Zhang, Xiao-Yong
Zhao, Limin
Zhao, Xihai
Zhum, Qingli
Ziade, M. Fouad
Zieleznik, Witold
Zielinski, Ashley
Zinn, Kurt
Zork, Noelia
Zubkov, Leonid
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Disclosures From AIUM Officers, Board Members,
Committee Members, and AIUM Staff
The faculty, committee members, and AIUM staff involved in planning this CME activity have completed a Disclosure of Financial Relationship.
Disclosures are listed under the speaker’s name. All disclosures are printed in the 2013 Annual Convention Official Proceedings. All completed disclosure forms are on file and available for review at the AIUM office.
Abo, Alyssa, MD
Abuhamad, Alfred, MD
Verinata Health: $10,000
(stock option/year)
Abu-Rustum, Reem, MD
Allen, Lisa, BS, RDMS, RDCS,
RVT
Andreotti, Rochelle, MD
Bahner, David, MD, RDMS
Benacerraf, Beryl, MD
Bromley, Bryan, MD
Clark, Jenny
Cohen, Harris L., MD
Coley, Brian, MD
Cooper, Therese, BS, RDMS
Costello, Jennifer
Crino, Jude, MD
Delanko, Danielle
DiGiovanni, Laura, MD
Eberle, Diane
Fleischer, Arthur, MD
Fowlkes, J. Brian, PhD
Histosonics, Inc: ownership
interest; researcher
Glanc, Phyllis, MDCM, BSC
Goldstein, Steven, MD
Amgen: gynecology advisory
board; honorarium
Bayer: gynecology advisory
board; honorarium
Cook Ob/Gyn: consultant; consulting fees
Philips Healthcare: consultant;
equipment loan
Shionogi: Gynecology Advisory Board; honorarium
Warner Chilcott: honorarium
Harvey, Glynis
Hertzberg, Barbara, MD
Izquierdo, Luis, MD
Kinney, Brenda
Kliewer, Mark, MD
Konofagou, Elisa, PhD
Kripfgans, Oliver, MD
GE Healthcare: only equipment loaner
Langer, Jill, MD
LaRusso, Salvatore, MeD,
RDMS, ARRT
Lee, Kenneth, MD
Lev-Toaff, Anna, MD
Lewis, Michele
Lockhart, Mark, MD, MPH
Lynch, Susan, RDMS, RVT,
RDCS
Mastrobattista, Joan, MD
Moore, Christopher, MD, RDMS,
RDCS
Philips Healthcare: consultant;
consulting fee
SonoSite, Inc: consultant; consulting fee
Minton, Katherine, MA, RDMS,
RDCS
Muncey, Susan
Nazarian, Levon, MD
Nelson, Thomas, PhD
Nisenbaum, Harvey L., MD
O’Brien, Janet, RDMS, PA-C
Pennington, James, RDMS
Porto, Manuel, MD
Robbin, Michele, MD
Philips Healthcare: evaluate
the utility of new transducer;
new transducer/software
upgrade
Puscheck, Elizabeth, MD, MS
Sakhel, Khaled, MD
Hologic: consulting fee; speaker
Scoutt, Leslie, MD
Philips Healthcare: honoraria;
teaching/speaking
Sehgal, Chandra, PhD
Shipp, Thomas, MD
Shwayder, James, MD, JD
Cook Ob/Gyn: coinventor
royalties
Silverman, Rosy, RDMS, RVT,
RT(S)
Smith, Jay, MD
Andrews Institute: honoraria;
teaching/speaking
Gulf Coast Ultrasound Institute: honoraria; teaching/
speaking
Tenex Health: consultant;
consulting fee; royalties; stock;
stock owner
Toreno, Felicia, PhD, RDMS,
RDCS, ROUB, RVT
Valente, Carmine, PhD, CAE
Wax, Joseph, MD
Weber, Therese, MD
Whitman, Gary, MD
Woletz, Paula, MPH, RDMS,
RDCS
Wong-You-Cheong, Jade, MD
Zanin, Linda, EdD, RDMS
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Policy on Unlabeled/Off-Label Usage
The AIUM has determined that disclosure of unlabeled/off-label or investigational use of commercial product(s) is informative for audiences
and therefore requires this information to be disclosed to the learners at the beginning of the presentation. Uses of specific therapeutic agents,
devices, and other products discussed in this educational activity may not be the same as those indicated in product labeling approved by the
US Food and Drug Administration. The AIUM requires that any discussions of such “off-label” use be based on scientific research that conforms to generally accepted standards of experimental design, data collection, and data analysis. Before recommending or prescribing any therapeutic agent or device, learners should review the complete prescribing information, including indications, contraindications, warnings,
precautions, and adverse events.
Alexandrov, Andrei
Aylward, Stephen
Barr, Richard
Bulas, Dorothy
Darge, Kassa
Dayton, Paul
Deganello, Annmaria
Deng, Cheri
Feinstein, Steven
Feltovich, Helen
Ferraioli, Giovanna
Forsberg, Flemming
Hata, Stacy
Huang, Dean
Hiang, Yuxin
Jing, Zhao
Johnson, Neil
Kasperlik-Zaluska, Anna
Klaus, Suzanne
Lai, Xingjian
Langer, Matthew
Lewis, George
Li, Mingde
Liu, He
Lyshchik, Andrej
McCarville, Beth
Sidhu, Paul
Strickland, Colin
Sun, Qiang
Volz, Kevin
Wang, Hongyan
Xiao, Jia
Xuemei, Zhang
Ying, Wu
Zhang, Jing
Zhu, Qingli
Migda, Bartosz
Mohan, Uthara
Mooney, Timothy
Mulvagh, Sharon
Nakamoto, Dean
Nakashima, Kazutaka
Novak, Ronald
Palmeri, Mark
Paltiel, Harriet
Porter, Thomas
Qian, Liu
Reusch, Lisa
Scissons, Robert
Disclosure of Commercial Support for the
2013 AIUM Annual Convention
Advertising
In-kind Donations
Support
ADVANCE for Imaging and Radiation
Oncology
ALPINION Medical Systems
Applied Radiology
Diagnóstico Journal
Digisonics, Inc
Health Imaging & IT
Parker Laboratories, Inc
Radiology Today
Samsung Electronics America, Inc
SuperSonic Imagine
Texas Children’s Pavilion for Women
Ultrasonix Medical Corporation
Sidra Medical and Research Center
ALPINION Medical Systems
ATS Laboratories, Inc
CIRS, Inc
CIVCO Medical Solutions
Esaote North America, Inc
FUJIFILM SonoSite, Inc
GE Healthcare
Hitachi Aloka Medical, Ltd
Nanosonics, Inc
Parker Laboratories, Inc
PCI Medical, Inc
Philips Healthcare
Samsung Electronics America, Inc
Siemens Medical Solutions USA, Inc
SIMULab Corporation
Sound Ergonomics, LLC
SuperSonic Imagine
Terason Ultrasound
Toshiba America Medical Solutions, Inc
Ultrasonix Medical Corporation
ZONARE Medical Systems, Inc
Sidra Medical and Research Center
Parker Laboratories, Inc
Samsung Electronics America, Inc
S130
Unrestricted Educational Grant
AS Software, Inc
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American Institute of Ultrasound in Medicine Proceedings
J Ultrasound Med 32(suppl):S1–S134, 2013
Index
A
Abadi M S13
Abbott B S116
Abdella T S80
Abdelmalek M S10
Abdullaev R S95
Abo A S1
Abu-Rustum R S81
Abu-Rustum S S81
Abu-Yousef M S37
Abuhabsah R S50
Abuhamad A S29, S51, S52
Acharya R S61
Acharya UR S17, S35, S47, S60
Achiron R S52, S53, S80
Ackerman S S59, S90
Adams J S103, S114
Aderibigbe O S28
Adhikari S S112, S120
Adkins E S19, S100, S101, S103, S119
Adzick NS S53
Agache V S38
Agildere AM S103
Ahmadzia H S117
Ahmed A S27
Aish B S63
Ajmera K S18
Al Ekish S S61
Al Mahrouki A S40
Al Muhanna K S35
Alcazar JL S113
Alehagen U S45
Alexandrov A S7
Allaf MB S52
Allen A S64
Allen D S43
Aly A-R S23
Ambrose A S105
Amian A S20
Ananth C S25
Anderson C S20, S64
Anderson S S64
Ando T S95
Antonis M S98
Anvari A S14, S114
Apterbach W S110
Archer T S12
Arellano J S96
Arnold K S65
Arntfield R S2
Arpit N S104
Arynova B S48
Astheimer J S42
Aten A S117
Au A S89
Aubá M S113
Ausiello L S18
Avner J S77
Axt-Fliedner R S30, S69, S80
Ayala R S92
Aylward S S6
Ayoub J S101
Ayvazyan S S78
Azar N S15, S111
B
Baek S-E S51
Bahner D S19, S21, S63, S100, S101,
S102, S103, S108, S110, S116, S117,
S119, S120
Bai J S9
Baird D S118
Bajaj K S108
BakhirevavL S70
Balise R S19
Balk A S79, S118
Balzaretti P S18
Banderali A S18
Bar-Sever Z S55
Bard R S63, S66, S84, S85
Bardales R S60
Barr R S2, S12, S31, S33
Barral J S19
Barri-Soldevila P S118
Bartova P S34, S91
Bault J-P S52
Bawiec C S41
Baxtrom C S78
Beach K S35
Beal E S116
Beamon C S120
Beavis C S23
Beck B S35
Beiter K S98
Beland M S61
Belfort M S71
Bellew C S99
Ben-Meir D S55
Benacerraf B S1, S54
Benaroya A S22
Benn P S55
Bennett TA S24
Benson C S26, S88
Beraud A-S S19
Berger J S68
Bhimani A S67
Bialeck S S78
Bieniarz A S114
Bierca J S15
Bitters C S100
Blackstock U S65, S78
Blahuta J S34
Blaivas M S58
Blanks J S92
Blankstein J S48
Blebea J S6, S44, S74, S76
Blickendorf M S101, S119
Blumenfeld Y S79
Bluth E S76
Bockbrader M S21
Bolouri M S86
Bolte A S109
Boniface K S18
Boore S S101
Borgida A S52, S91
Boulger C S19, S101, S103, S108, S110,
S116
Box D S120
Box G S120
Boyd B S24, S116
Bradford S S113
Bradshaw D S21
Breazeale S S20
Brennan M S90
Brewer K S87
Bromley B S32, S54, S71
Brown C S109
Brown D S32
Brown S S32, S70, S90
Brubaker S S25, S82
Buadu A S107
Buckwalter J S39
Bui L S106
Bundy N S117
Bunting E S44
Bureau N S3
Burhans K S111
Busse R S99
Byram B S61
Byrne J S93, S104
C
Cadet C S83
Cahill A S69
Cai Y S47
Calabrese K S18
Calisti G S17
Campbell C S21
Campbell W S52, S55
Canavan T S45, S71
Cao T-S S44
Carey J S104
Carlson L S48
Carroll L S120
Carson P S33, S40
Casoli G S18
Castillo E S21, S43
Caughey M S10, S62
Cavanaugh B S14
Cendan J S99
Cerezo Lopez E S89
Cermak P S34
Cha ES S99
Cha JH S12, S99
Chalek C S18
Chan T S21
Chandrasekhar C S97
Chao J S79
Chavez M S52
Chervenak J S72, S96
Chiem A S20
Childress J S22
Chin E S20
Chinchure D S29
Chintapalli K S104
Chiou S-Y S87
Chiricolo G S79, S115, S118
Choi J-Y S80
Choi WJ S12, S99
Chopra M S62
Chorazy M S102
Chou N-K S68
Chun Lema P S109, S110
Church C S75
Ciardo P S89
Cibinel G S18
Claes F S68
Clem D S64
Clingman B S13
Cody K S89
Cohen N S67
Coleman B S53
Coll RV S34
Colvin R S93
Contreras K S114
Cordeiro C S89
Cordero Garcia B S89
Coroleu B S106
Cortez E S101, S103
Corujo Vazquez O S109, S110
Cosgrove D S65
Crawford C S55
Crawford F S50
Crino J S1, S69
Cunha L S14
Currie G S107, S110
Curs B S64
Czarnota G S40, S61
Czernuszewicz T S10
Czerný D S49
D
d’Armiento J S34
Dahibawkar M S51
Dahlström U S45
Dai Q S13
S131
Dalecki D S31
Dallas A S22, S23, S92, S94
Darge K S37
Datta A S109, S110
Dave J S51
Davidovits M S55
Davis M S107
Davis S S52
Dayton P S6
de Guillebon A S39
De Jong MR S37
de la Torre L S90
de Stefano G S17
Dean A S89
DeFranco E S54
DeFranco P S54
Deganello A S37
Degenhardt J S30, S69, S80
del Cura J S17
Deng C S31, S57
Destounis S S73
Deter R S71
Detti L S45
Deurdulian C S32
Deurloo K S109
Di Martino F S17
Di Pietro M S76
Diaz D S113
Dickman E S19, S78
Dietrich C S65
diFlorio R S66
Dillman J S67
Do S S25, S82
Dolin C S27
Donaldson C S20
Donaldson J S64
Dooley E S65
Dornbluth NC S13
Doubilet P S32, S88
Dresbach S S116
Du L S47
Dudley L S79
Dumont D S11
Duvdevani N S80
E
Ehsanipoor R S69
Eichelberger K S120
Eiferman D S19, S116
Eisenbrey J S14, S18, S86, S87
El Kaffas A S40
El-Baz A S61
Elahi E S83
Ellestad S S117
Emmitt R S62
English C S63
Enzensberger C S30, S69, S80
Erdman J S50
Ermilov S S13
Eski E S103
Evans D S19
Evans K S24, S49
F
Fabiilli M S38, S40
Fadrna T S91
Falou O S61
Farber M S10
Farella N S17
Farwick L S118
Feinstein S S58
Feldstein V S86
Feleppa E S33
Feltovich H S48
Fernandez-Cid M S105, S106, S118
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Ferraioli G S31
Ferreri E S18
Fessell D S33
Filice C S31
Finberg H S24
Finnoff J S97
Fisher K S117
Fleischer A S49
Fleshman S S39
Fontanilla T S17
Ford P S10
Forsberg A S51
Forsberg F S14, S18, S51, S86, S87
Fowlkes JB S40, S67, S81
Fox JC S20, S63, S64
Fox N S24, S27, S54, S70, S86
Fox T S51, S87
Frank G S43
Frates M S88
Frenke V S106
Friedman A S26, S105
Friedman L S77
Fuchs K S25, S71
Fujimoto C S99
Fuller K S55, S91
G
Gaddipati S S82
Galan H S5
Galerneau F S117
Gallippi C S10, S62
Gammell P S41
Gandhi M S52
Garberoglio R S17
Garg M S70
Garon J S48
Gaspari R S64
Gauthier M S42
Gecsi K S67
Gee M S114
Geldermann D S88
Gelman SK S81
Gembruch U S30, S69, S80
George V S97
Gerber S S26
Germer U S30, S69, S80
Gessner R S6
Gharahbaghian L S19
Gilboa Y S52, S80
Giles A S40
Giorgio A S17
Giorgio V S17
Girotto J S111
Glantz JC S113
Glasek J S102
Glasser J S92
Glazier E S94
Goertz D S38
Goetzinger K S69
Goffi A S18
Goldberg A S13
Goldírová A S49
Goldklang M S34
Goldman E S63
Goldman S S110
Goodman E S66
Goodman J S97, S114
Goodman R S7
Gordon R S26
Goubran A S87
Goutham S S61
Graupera B S105, S106, S118
Gray S S43
Grippo A S77
Groh G S114
Gross A S112, S120
Groszmann Y S54
Grotegut C S24, S116, S117
Guerriero S S47
Guizado de Nathan G S80
Gullett J S79
Gunabushanam G S18, S50, S74, S104,
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S111, S112
Gunnison K S48
Gupta S S54, S70, S72, S86, S89, S96,
S110
Gurram P S55
Gustafsson M S45
Gyamfi C S25
Huang M S9
Huhta J S76
Hurtíková E S49
Hussain N S55
Hussien A S88
Huu Tran N S106
Hynynen K S38
H
Habenicht R S52
Haberman S S27
Hacker M S25, S70
Haeri S S52, S71
Haines L S19, S78
Hall A S67, S81
Hall E S2
Hall R S90
Hall T S33, S43, S48, S62
Halldorsdottir V S51, S86
Hamvas A S11
Han B S28
Handa P S13
Hangiandreou N S83, S108, S109
Hansen A S21
Harris G S2, S41, S75
Harris R S66
Hartge D S55
Hartman A S46, S48
Hartman B S46, S48
Hartman D S114
Hashim A S40
Hata S S63
Havel M S91
Havelka J S91
Hawkins L S70
Hdeib M S64
He L S9
He Y S51
Hee Lee M S112
Heimburger G S87
Heimiller J S94
Heller H S26
Henderson J S69
Henderson S S111
Henkaline T S21
Hereter L S105, S106, S118
Hernandez C S99
Herrera C S53, S56, S90
Herzig S91
Herzig R S34, S49
Herzog D S13
Heymans M S109
Higgins P S67
Hilgers T S98
Hirtz N S11
Ho A S107
Hocking D S31
Hoffmann C S53, S80
Holland C S7, S57
Holland M S9, S10, S11, S100, S114
Holzman I S83
Homeister J S10
Hong MJ S99
Hong S-J S80
Hoover E S101, S102
Hoppmann R S65
Horii S S53
Horning M S65
Horton S S29, S51, S52
Hoshiko-Reed G S99
Hotta N S83
Hou G S40
Hou R S20
Howard J S62
Howard Z S19
Howe D S65
Howell L S53
Hoyt K S16
Hrbáč T S49
Hu X S51
Huang D S32
Huang L S9
I
Iacobucci A S18
Ikeda N S35
Ingle A S9, S62
Iradji S S40, S61
Irshad A S12, S65, S73, S90
Iseman C S28
Isurugi C S92
Ivancevich N S7
Iyoob S S53
J
Jackson D S80
Jacobson J-M S80
Jaen Diaz JI S89
Jafari D S89
Jakubowski WS S15, S16
Jang K S39
Jasne A S101
Jasti S S107
Jelinkova M S34
Jelsing E S97
Jeon E-J S80
Jia X S47
Jiang Y S13
Jin X S28
Jing Z S28
Johansson P S45
Johnson A S51, S79
Johnson B S10
Johnson J S52, S98
Johnson L S67
Johnson MB S43
Jonszta T S49
Joong-Kim Y S11
Joseph JM S21
Joseph O S22, S23, S92, S94
Joshi K S110
Juan Z S28
Juez L S113
K
Kagarise D S21
Kanasugi T S92
Kaplan BS S108
Kaproth-Joslin S107
Karlicki F S87
Karlman R S114
Karmel B S22
Karshafian R S38, S40
Kasperlik-Zaluska A S16
Kasyouhanan F S119
Katorza E S52, S53, S80
Katz Y S94
Kawecki A S69, S80
Kelly-Martinez M S79
Kennedy A S93, S104
Kent A S19
Kerr L S14
Kerwin C S77
Khan F S19
Khine H S77
Kikinis R S92
Kikuchi A S92
Kim A S113
Kim D S66
Kim H S12, S99
Kim HH S12, S99
Kim HS S99
Kim SH S99
King D S42, S49, S83
Kiplagat A S11
Kirschner J S77
Kist K S13
S132
Klassen A S29, S51, S52
Klaus S S63
Klauser C S24, S27, S54, S70, S86
Kline-Fath B S1, S58, S100
Kobayshi A S95
Kohl T S30
Kolios M S38, S61
Koltz P S111
Kona MP S23
Konicki PJ S77, S78
Kono Y S16
Konofagou E S34, S40, S44, S49
Korucuk E S103
Kotowski S S118
Kowalewski G S35
Koziatek C S78
Kraft O S91
Krajča J S49
Krakow D S104
Krapp M S30, S69, S80
Kraus S S103, S114
Kripfgans O S40, S67, S81
Kripfgans OD S38
Krishnamurthi G S61
Krishnan MMR S17
Ku B S89
Kugler L S27
Kulbacki E S60
Kuliha M S49, S91
Kunselman A S85, S104, S105
Kwiatkowski R S102
L
Labuda C S75
Lai X S13
Laifer-Narin S S3, S5, S53, S56, S90
Lal B S35
Lam S S77, S78
Langer M S39
Langova K S34, S91
Lappen J S67
Larsen J S81
Lavin P S13
Lawrence M S92
Layman K S98
Lee J-G S68
Lee K S57
Lee M-Y S80
Lee P-R S113
Lee R S46, S48
Lee S S112
Lee SY S10
Lee W S69
Legault Kingstone L S107, S110
Leibman J S13
Lerner J S45
Lester N S29
Leswick D S23
Letourneau K S87
Lev-Toaff A S5
Levy S114
Levy B S97
Levy L S11
Levy P S5
Lewin P S41
Lewis Jr G S2, S38, S39, S74
Lewis M S90
Li M S41
Li Y S47
Lianfang D S28
Lichtenstein S S5
Likourezos A S19, S78
Lim T-H S39
Liou R S20
Lipitz S S53
Lipman S S60
Liu H S13
Liu J-B S51, S87
Liu Q S47
Liu X S30
Liu Y S18, S41, S63
Lloyd H S15
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Lobos N S95, S96, S101, S102
Lombardo P S48
Looney D S53
Lopez de Castro L S89
Lopez J S120
Lukjanova I S95
Luo J S9
Lupia E S18
Lyons J S54
M
Ma C S44, S45
Maaji S S93
Machado P S14, S18
Macian D S92
Mack J S73
Mack L S111
Macones G S69
Madden J S60
Madsen E S43
Magalhaes A S93
Magriples U S117
Mahoney M S16
Maida E S102
Majcher M S102
Maksoud C S120
Mallarini G S61
Marc Perarnau J S101
March M S25
Margolis D S41
Marin D S51
Markenson G S52
Marshall A S51
Marston W S10
Martin J S39
Martis R S61
Maruvada S S41
Mata Castrillo M S89
Mathew B S70
Matsutani S S95
Mauro M S10
Mayo P S58
McArthur L S19
McCamey K S117
McCann M S30
McCarthy M S18
McCarville B S37, S73
McDowell J S2, S59
McNamara J S22, S23, S92, S94
McNamara R S50
McShane C S24
Medak A S43
Mehta N S83
Meizner I S53, S55
Melniker L S79, S118
Melone P S114
Merton D S18
Mervis E S20
Mestre XM S34
Meyer D S62
Meyer E S32
Meyer M S52
Mezei G S85, S104
Migda B S15, S16
Mihailos A S79, S118
Miller D S42
Miller E S26
Miller J S10, S60, S100
Miller R S50, S53, S56, S90
Miller T S13
Millet J S50, S111
Millington S S2
Milne M S10, S100
Min Kang S S112
Miniati D S86
Minkoff H S27
Minnigan H S77
Mistur R S103
Modest A S70
Modest AM S25
Mohan U S63
Moldenhauer J S53
Molinari S35
Molinari F S17, S47, S60
Molitor M S93
Moni S S25
Monroe M S99
Montazemi M S69
Monteagudo A S38, S72, S73, S96
Mooney L S119
Mooney T S79, S115, S118
Moons D S67
Moreno C S96
Moschos E S46
Moshesh M S118
Mougenot C S40
Mudrik-Zohar H S55
Mueller A S101
Mujsce D S104, S105
Mullen K S26
Mulvagh S S6
Munson J S65, S78
Murphy J S114
Murphy M S66
Murtha A S24, S116, S117
Muruganandan K S4
Muruganandan M S98
Muzumoto H S95
Myers C S114
N
Nadaraj S S28
Nakamoto D S15, S38, S57, S111
Nam K S43
Namagembe I S117
Nandlall S S34
Nasief H S62
Navathe R S54
Nazarian L S3, S8, S74
Nelson R S51
Neri E S97
Neyman O S100
Nghiem H S37
Nguyen T S106
Nhan-Chang CL S25
Nichols T S10
Nicolaides A S35
Nicolau C S17
Nightingale K S10, S60, S61, S75
Nomura J S59
Novak R S15
Novelli P S67
Nunes U S14
O
O’Brien Jr W S5, S11, S42, S49, S50
O’Connell A S88, S107
O’Hara S S103, S114
O’Rourke K S79, S115, S118
Obi N S114
Obican S S81
Odibo A S69
Odunko D S93
Oelze M S5
Ogburn P S52
Ogutcu B S48
Oh K S86, S88
Ojili V S90, S104, S111, S112
Olartecoechea B S113
Oleze M S60
Oliva M S105
Oliver E S53
Ong CL S29
Oraevsky A S13
Otáhal D S49
Otto P S13
Oyama R S92
Ozhand A S52
P
Pakdaman R S93
Palmeri M S10, S48, S60, S61, S75
Pamnani R S19
Pan P S51
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Pan X S9
Panebianco N S89
Panerai R S71
Pao S-H S68
Paraschuk Y S95
Pareek G S61
Parkes J S48
Parry S S26, S105
Pascual MA S105, S106, S118
Patat F S101
Patel D S118
Patel N S103
Patterson L S87
Paul I S104, S105
Pawlina W S102
Payer A S99
Peck J S97
Peddada S S118
Pedersen P S5
Pedrero C S105, S106, S118
Pelegrí SG S34
Pennington J S63, S80
Perez A S106
Perez-Delboy A S82
Perrin S S7
Pessel C S25, S82
Peters H S88
Pezo C S96
Phan H S22
Piert M S38
Pineda G S89
Pineda L S113
Pinter S S67, S81
Piscaglia F S65
Pivetta E S18
Planinic P S80
Platz E S18
Plessl D S23
Polascik T S60
Pollard K S102, S108
Pontius E S98
Porrino S18
Porter T S58
Poston ME S65
Prabulos AM S55
Presley J S102
Price B S117
Procházka V S49
Provost J S44
Pujol S S92
Pulvermacher C S69, S80
Q
Qian L S28
Quant H S26
Quesada C S38
R
Rabiner J S77
Radeos M S109, S110
Radhakrishna M S22
Raginwala S S103
Rajasekaran S S22, S23
Ramakrishnan P S39
Ranninger C S63
Ranzini A S28
Rao V S65
Rasalingam R S10, S100
Rath K S119
Rathje E S118
Ravangard S S52
Rayburn W S70
Rebarber A S24, S27, S54, S70, S86
Rebener M S20
Reiner C S51
Reinstein D S12
Reiss R S26
Repke J S85
Reusch L S48
Revzin M S2
Richards M S81
Ro R S87
S133
Robinson Z S110, S116
Roca P S85, S104, S105
Rodney J S65
Rodney W S65
Rodriguez D S25, S70
Roe AM S108
Roelant G S19
Roesch M S117
Rogers S S88
Roll S S49
Roman A S24, S27, S54, S70, S86
Romero V S81
Romney M S109, S110
Rosado-Mendez I S43, S62
Rosas H S21
Rosborough T S66, S112
Rosen M S64
Rosenberg HK S28, S29
Rosenberg K S119
Rosenzweig S S60
Rotemberg V S61
Roubec M S49, S91
Rouze N S10, S60
Royall N S63
RoyChoudhury A S12
Ruano R S52, S71
Rubens D S33
Rubert N S9
Rubin J S67, S81
Rubin S S89
Rubio E S58
Rundek R S7
Rundek T S7, S32
Rusczyk G S110
Rychak J S6, S86
Rychik J S30, S76
S
Saba L S35, S47, S61
Sadeghi-Naini A S61
Safonov R S95
Safonova I S95
Sahlani L S100
Salimian M S18
Saltzman D S24, S27, S54, S70, S86
Samir A S14, S114
Samuel A S53, S56, S90
Samuels J S41
Santolaya J S27
Sarwate S S50
Satou G S28
Savage D S70
Savaser D S21, S43
Schafer M S8
Schaller M S19
Schmitz K S88
Schneider-Kolsky M S48
Schnettler W S25, S70
Schofer J S92
Schroer A S55
Schwartz N S26, S105
Scognamiglio U S17
Scola M S62
Scoutt L S18, S32, S50, S74, S77, S104,
S111, S112
Sehgal S41
Sekarski T S11, S114
Seki A S95
Serres X S17
Seupaul R S77
Shah S S3, S98
Shah V S21, S43
Shahmirzadi D S40
Shailam R S98
Shamshirsaz A S52
Shan R S22
Shau Y-W S68
Sherbotie J S93
Sherman P S38
Shieh M S63
Shim J-Y S80, S113
Shin HJ S12, S99
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Shipp T S54
Shirazi M S112
Shlansky-Goldberg R S75
Shofer F S89
Shokoohi H S18
Shonkwiler G S80
Shoreman M S21
Shue E S86
Shung KK S38
Shwayder J S33, S57
Shyu J-J S68
Sidhu P S2
Sierzenski P S7
Sikdar S S35
Silverman R S12, S15
Simmons J S65
Simpson D S11, S50
Simpson L S53, S56, S57, S90
Sinert R S79
Singh G S10, S11, S100, S114
Sinha S S19
Siniscalchi NR S34
Sinkovskaya E S29, S51, S52
Školoudík D S34, S49, S91
Slapa R S15, S16
Sloane C S21
Slowinska-Srzednicka S15
Smith B S50
Smith D S120
Smith J S54, S97, S102
Smith L S116
Smith R S118
Smrtka M S24, S116, S117
Snead G S77
Snyder K S88
Soffer D S30
Sohaey R S86, S88
Sommerich C S49
Song C S43
Sorace A S16
Sorribas MC S34
Soto R S96
Soukup T S34
Sperling D S84
Spiel M S52
Spinner D S119
Spinosa A S66
Spitz J S71
Springer A S19
Sree V S17, S61
Sridharan A S18, S86
Srinivasan G S87
Stassijns G S68
Stavros T S13
Stawicki S S19
Steiner R S118
Stekel S S83, S108, S109
Stepien B S60
Stidham R S67
Stilp E S50
Stites R S98
Stone M S18
Strakowski J S21
Strasburger D S77
Stulac S S98
Su Y S47
Subashi E S51
Sugiyama T S92
Summey R S23
Sun D S13
Sun Q S13
Sunny Y S41
Suri J S17, S35, S47, S60, S61
Sutton J S7
Swamy G S24, S116, S117
Swanson S S40
Szabo T S75
Szyld D S65, S78
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Tai H-C S68
Talbott N S115
Talegon A S17
Talk D S92
Tao S S9
Tarabulsi G S69
Teefey S S76
Terentiev V S19, S78
Tessler F S33
Thomas K S86
Thomenius K S18, S57
Thompson J S24, S116, S117
Thornburg L S71, S111, S113
Tian Z S30
Tianbo R S107
Tierney D S66, S112
Tillett J S42
Timor I S72, S89, S96
Tirado A S99
Tizzani M S18
Todorova M S38
Toland G S71
Tolbert T S19
Tornero M S21
Torres C S107, S110
Tradup D S83, S108, S109
Trahey G S11
Tran E S109
Tran T S18
Tran W S61
Treadwell M S81
Trebes S S69
Tresserra F S106
Trinh T S93
Tsung J S77, S83
Tumidajewicz J S60
Turner E S20, S64
Turney C S110
Tuthill T S16
Tuuli M S69
Twickler D S46
U
Ulissey M S13
Ural B S99
Ural S S85, S104, S105
Urbanowicz K S102
Urs R S12, S15
Uryasev O S22, S23, S92, S94
Utrilla-Layna J S113
V
Vallabhaneni R S10
van Veen T S71
van Vugt J S109
Vandordaklou N S20
Vargas Velandia E S15, S111
Vargas-Vila M S67
Varghese S45
Varghese T S9, S44, S62
Varghese Y S9
Vassa R S104
Vejdani-Jahromi M S11
Vela D S7
Victoria T S53
Vila M S106
Vilke G S21
Vilkomerson D S6, S34, S41
Villegas AM S34
Vink J S25, S82
Vintzileos A S52
Vogel M S30
Voloshin A S22
Volpicelli G S18
Volz K S24, S49
Vora N S120
Vrablik M S77
Vytykac A S118
W
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Wachsberg R S114
Wagner J S74
Wallace K S10, S18
J Ultrasound Med 32(suppl):S1–S134, 2013
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Wang H S13
Wang M S10, S61
Wang S-M S68
Ward V S7
Wax J S52
Way D S63
Wear K S2, S9, S41
Weichert J S30, S55, S69, S80
Weingarten M S41
Weisz B S53
Welch H S53
Wells CE S46
Werner E S69
White J S21
Whitley K S85, S104, S105
Williams S S19
Wilson C S87
Wilson K S98
Wilson T S2
Wise A S78
Witkowska A S60
Witt D S115, S118
Wolf P S11
Wolfe H S67
Wolfe M S90
Won H-S S80, S113
Woodward P S104
WoodwardcP S93
Wortsman X S95, S96, S101, S102
Wu Y S47
X
Xiao J S28
Xu Z S74
Y
Yablon C S37
Yakubu A S93
Yantri R S60, S61
Yeager S S19
Yeboah N S65
Yellin S S79, S118
Yenter C S78
Yeo L S57, S73
Yerli H S99, S103
Yijin S S28
Yilmaz T S99
Ying W S28
Yingyu C S28
Yinon Y S52, S53
Yoon C S65
Yoon H-C S80
Yoon J-W S113
Yoon S-W S112
Youssefian A S20
Yuan C S9
Yuan L-J S44
Yunhua L S28
Z
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Zalev J S13
Zeeman G S71
Zehtabchi S S83
Zhang J S13, S47
Zhang M S38, S40, S81
Zhang X S47
Zhang X-Y S44
Zhao L S35
Zhao X S9
ZhaocJ S47
Zhu Q S13
Ziade MF S81
Zieleznik W S60
Zielinski A S116
Zinn K S16
Zork N S25, S82
Zubkov L S41
S134
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