Official Proceedings - AIUM

2013Journal ofUltrasoundin MedicineOfficialProceedingsAMERICAN INSTITUTE OF ULTRASOUND IN MEDICINEAnnual ConventionApril 6–10 • New York, New Yorkwww.jultrasoundmed.org • www.aium.org

OfficialProceedings2013 Annual ConventionApril 6–10 • New York, New York

Small-Animal Preclinical High-Frequency Imaging..............................................................................................................................................................S38Scientific Sessions, 11:00 AM–12:30 PMApplications of Therapeutic Ultrasound................................................................................................................................................................................S38Basic Science: Instrumentation, Contrast Agents, and Bioeffects ......................................................................................................................................S41Cardiovascular Ultrasound......................................................................................................................................................................................................S44Gynecologic Ultrasound ..........................................................................................................................................................................................................S45New Investigator Award Session ............................................................................................................................................................................................S49Obstetric Ultrasound: Fetal Anomalies ..................................................................................................................................................................................S53Special Interest Session, 11:00 AM–12:30 PMHands-on How to Do the Biopsy ............................................................................................................................................................................................S57Special Interest Sessions, 1:30 PM–3:30 PMBefore and After: Case Presentations, Surgical Findings, and Clinical Outcomes ............................................................................................................S57Hands-on Scanning: Peripheral Nerves of the Upper Extremity ........................................................................................................................................S57Live Fetal Cardiac Scanning by the Experts ..........................................................................................................................................................................S57Microbubbles and Drug/Gene Delivery ................................................................................................................................................................................S57New Horizons in Critical Care Ultrasound ............................................................................................................................................................................S58Perinatal Malformations of the Head, Face, and Neck ........................................................................................................................................................S58Transplant Imaging ..................................................................................................................................................................................................................S59Special Interest Sessions, 4:00 PM–5:30 PMAbdominal and Lower Extremity Arterial Imaging: Pitfalls and Misdiagnoses ..................................................................................................................S59Hands-on Ultrasound-Guided Vascular Access ....................................................................................................................................................................S59Scientific Sessions, 4:00 PM–5:30 PMBasic Science: Tissue Characterization, Part 2 ......................................................................................................................................................................S60General and Abdominal Ultrasound ......................................................................................................................................................................................S65Obstetric Ultrasound: General and Fetal Growth ................................................................................................................................................................S69WEDNESDAY, APRIL 10, 2013Special Interest Sessions, 8:15 AM–10:15 AMBreast Ultrasound ....................................................................................................................................................................................................................S73Extracranial Ultrasound of the Head and Neck in Children ................................................................................................................................................S73Gynecologic Ultrasound: The Basics Revisited......................................................................................................................................................................S73Innovative Directions in Fetal Cardiac Imaging ....................................................................................................................................................................S73Lumps, Bumps, and Extremity Pain in the Emergency Room: What Is the Role of Ultrasound? ....................................................................................S74Peripheral Arterial Disease ......................................................................................................................................................................................................S74Ultrasound-Guided Thrombolysis..........................................................................................................................................................................................S74Special Interest Sessions, 10:45 AM–12:30 PMAcoustic Radiation Force Impulse Imaging: Benefits and Challenges With Increasing Acoustic Output Beyond Diagnostic Levels ..........................S75Advanced Fetal Cardiac Evaluation and Comprehensive Overview....................................................................................................................................S76Current Vascular Controversies ..............................................................................................................................................................................................S76Musculoskeletal Ultrasound: Transition From Adults to Pediatrics ....................................................................................................................................S76Ultrasound of the Head and Neck ..........................................................................................................................................................................................S76Scientific Sessions, 10:45 AM–12:30 PMEmergency Ultrasound, Part 2 ................................................................................................................................................................................................S77Obstetric Ultrasound: Multiple Gestations and New Techniques ......................................................................................................................................S79Scientific E-Poster Sessions ........................................................................................................................................................................................................................S83Continuing Medical Education Credit Information ..............................................................................................................................................................................S122Faculty Disclosures ....................................................................................................................................................................................................................................S123Disclosures From AIUM Officers, Board Members, Committee Members, and AIUM Staff ..........................................................................................................S129Policy on Unlabeled/Off-Label Usage ....................................................................................................................................................................................................S130Disclosure of Commerical Support for the 2013 AIUM Annual Convention ....................................................................................................................................S130Index ............................................................................................................................................................................................................................................................S131General InformationSubscription RatesJournal of Ultrasound in Medicine (ISSN 0278–4297) is issued monthly in one indexed volume per year by the AmericanInstitute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite 100, Laurel, MD 20707-5906 USA. 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2013 AIUM Award WinnersWilliam J. Fry Memorial Lecture AwardThe William J. Fry Memorial Lecture Award was established by Joseph H. Holmes, MD, in 1969 and presented for the firsttime at the AIUM Annual Convention in Winnipeg that year. (William J. Fry was a physicist with a strong interest in ultrasoundin medicine, whose innovative research efforts advanced the field of medical ultrasound.) One of Professor Fry’s mostnotable contributions was the successful design of an ultrasonic system used to pinpoint lesions in the brain without damagingadjacent 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 hisdeath in 1968. The following year, the William J. Fry Memorial Lecture Award was established in his honor. It recognizes acurrent or retired AIUM member who has significantly contributed in his or her particular field to the scientific progress ofmedical ultrasound.Paul L. Carson, PhDThis year, the AIUM has bestowedthe honor of the William J. FryMemorial Lecture Award on Paul L.Carson, PhD, but it is actually theAIUM that is honored to have a personof this caliber who is willing toshare his considerable talents andextensive expertise with this organization.In a few paragraphs, it’s impossibleto summarize a 108-page curriculumvitae, a full 2 pages of which is a list of the honorsand awards Dr Carson has received during his exceptionalcareer. Destined to be a leader from a young age (he waspresident of both his high school and college student bodies),Dr Carson graduated from Colorado College, followedby a fellowship at Harvard, and earned his MS and PhD inphysics at the University of Arizona.His major scientific interest has been in medicalphysics with an emphasis in ultrasound, paying particularattention to the safety of diagnostic ultrasound equipment,as well as training and teaching. A professor of biomedicalengineering at the University of Michigan, he also serves asassociate director of basic radiological sciences at this sameinstitution and is concurrent professor at Nanjing Universityin China and scientific coordinator at the QuantitativeImaging Biomarkers Alliance of the Radiological Society ofNorth America. As if those academic appointments don’tkeep him busy enough, he is currently the coinvestigatoror principal investigator (PI) for 4 major grants from theNational Institutes of Health, the National ScienceFoundation, and the Department of Defense Breast CancerResearch Program and has served as PI for dozens of fundedresearch projects over the past 4 decades.Dr Carson’s love of both teaching and research isevidenced by the numerous dissertations and masters’ thesesand projects he has supervised, plus the many postdoctoralfellows he has mentored and the visiting professors hehas hosted. Due to his nurturing, many of these exceptionalindividuals have become active in the AIUM and the field ofmedical ultrasound.A prolific writer, with literally hundreds of journalarticles, books and chapters, monographs, abstracts, andrelated communications to his credit, as well as the holder of10 patents, Dr Carson does not limit the sharing of his expertiseto academia or publishing. He has long recognized thevalue and importance of professional societies in promotingscience 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 hasserved on the AIUM’s Board of Governors and the EditorialBoard of the Journal of Ultrasound in Medicine and has beenan active contributing member for dozens of AIUM committeesand subcommittees, all with the aim of ensuring qualityand safety in diagnostic ultrasound.With his intelligence and creativity, his exceptionalleadership skills and drive, and his passion and willingness toshare his time and knowledge with others, Dr Carson has carriedon the tradition of Professor Fry and has set the perfectexample for those who will follow in his footsteps.The title of Dr Carson’s William J. Fry MemorialLecture is Ultrasonic Domination: Medical Imaging,Medicine, Daily Life.iii

2013 AIUM Award WinnersJoseph H. Holmes Basic Science Pioneer AwardThe Pioneer Award, which honors an individual who has significantly contributed to the growth and development of medicalultrasound, was established in 1977. This special award was renamed in 1982 to honor Joseph H. Holmes, MD, whodied that year. Dr Holmes, the first person named as an AIUM pioneer, was an important figure to both the field of diagnosticultrasound and the AIUM. His early efforts in ultrasound research, which included tissue characterization andultrasound’s diagnostic use in polycystic kidney disease and orthopedics, helped advance the field of ultrasound andencourage others to conduct new research. Serving the AIUM in many capacities, Dr Holmes was president from 1968 to1970 and was editor of the AIUM’s official journal, which was then titled the Journal of Clinical Ultrasound, for nearly 10years. Each year, the Joseph H. Holmes Pioneer Award honors 2 current or retired AIUM members, 1 in clinical science and1 in basic science.Christy K. Holland, PhDYou wouldn’t necessarily expectthat a woman who spent her junioryear abroad at the UniversitätFreiburg and Hochschule für MusikFreiburg studying Beethoven andSchubert would be the recipient ofthe prestigious Joseph H. HolmesBasic Science Pioneer Award, butthen you would be underestimatingthe talents and breadth ofexpertise of Christy K. Holland,PhD. Dr Holland earned her bachelor’s degree in physics andmusic from Wellesley College and her PhD in engineeringand applied science from Yale University. She worked at Yaleuntil 1994 when she joined the Department of Radiology atthe University of Cincinnati College of Medicine. Whileat the University of Cincinnati, she has served in theDepartment of Aerospace Engineering and EngineeringMechanics and in the Department of BiomedicalEngineering and Radiology in the College of Engineeringand Medicine. She is currently a professor in internal medicinein the Division of Cardiovascular Diseases, BiomedicalEngineering Program.Dr Holland has a long history of reviewing manuscriptsfor 9 peer-reviewed journals beginning immediatelyon graduation, as well as extensive experience reviewing formultiple national, state, and private funding agencies,including the National Institutes of Health (NIH) and theNational Science Foundation. This is just one of the factorsthat led to her appointment as the editor-in-chief ofUltrasound in Medicine and Biology (UMB), the preeminentjournal of the World Federation for Ultrasound in Medicineand Biology.A fellow of both the Acoustical Society of America(ASA) and the AIUM, Dr Holland has long been active incommittees and in leadership positions for both organizations.She was elected to the Executive Council of the ASAand to the AIUM’s Board of Governors and to its ExecutiveCommittee, where she served as secretary. Her particularinterest has focused on bioacoustics and bioeffects; adedicated member of the ASA’s Biomedical AcousticsCommittee, she cochaired the AIUM’s Mechanical BioeffectsConference and was a guest editor for the resulting publication,Mechanical Bioeffects from Diagnostic Ultrasound:AIUM Consensus Statements.Currently engaged in 8 separate research projectswith topics ranging from “Ultrasound-Assisted Thrombolysisfor Stroke Therapy” to “Targeted Liposomes for AcousticCardiovascular Imaging,” Dr Holland has served as principalinvestigator or coinvestigator on dozens of research grantsfrom the NIH and other organizations. With more than 85publications to her credit, Dr Holland is best known for herexceptional teaching abilities and the large number of students,postdoctoral fellows, and clinical fellows whom shehas advised. She may be musically gifted, but it is her ongoingscientific contributions to the growth and developmentof medical ultrasound for which she will be remembered.iv

2013 AIUM Award WinnersJoseph H. Holmes Clinical Pioneer AwardThe Pioneer Award, which honors an individual who has significantly contributed to the growth and development of medicalultrasound, was established in 1977. This special award was renamed in 1982 to honor Joseph H. Holmes, MD, whodied that year. Dr Holmes, the first person named as an AIUM pioneer, was an important figure to both the field of diagnosticultrasound and the AIUM. His early efforts in ultrasound research, which included tissue characterization andultrasound’s diagnostic use in polycystic kidney disease and orthopedics, helped advance the field of ultrasound andencourage others to conduct new research. Serving the AIUM in many capacities, Dr Holmes was president from 1968 to1970 and was editor of the AIUM’s official journal, which was then titled the Journal of Clinical Ultrasound, for nearly 10years. Each year, the Joseph H. Holmes Pioneer Award honors 2 current or retired AIUM members, 1 in clinical science and1 in basic science.Peter H. Arger, MDIf we were to include only thecontributions he made while presidentof the American Institute ofUltrasound in Medicine (AIUM),Peter H. Arger, MD, would still bethe perfectly chosen recipient forthis award. During his tenure aspresident of the AIUM (1995–1997),Dr Arger oversaw changes andimprovements to this organizationand to the field of medical ultrasoundthat resonate to this day. Recognizing the enormouspotential for ultrasound in medicine but also aware thatfunding for research was limited, he spearheaded the establishmentof what is now the AIUM’s Endowment forEducation and Research, which has already allocated close tothree-quarters of a million dollars to ultrasound research andeducational endeavors. Dr Arger was also instrumental in thecreation of the AIUM’s ultrasound practice accreditation program.The 2000+ practices that have subsequently receivedaccreditation have demonstrated their commitment to thehighest quality patient care—a tribute to Dr Arger’s foresightand vision.While he was president, the AIUM held an innovativeleadership retreat to initiate a 5-year plan; built coalitionsand established liaisons with 27 ultrasound-related associationsto ensure the ability to take a proactive stance on legislationand to promote the best practices in diagnostic ultrasound,established the Distinguished Sonographer Award aswell as the New Investigator Award, conducted a conferencein which simultaneous Spanish translation was available,obtained a seat on the American Medical Association Houseof Delegates, and analyzed the entire operation of the Journalof Ultrasound in Medicine. That is just the tip of the icebergregarding the initiatives occurring under his leadership anddoesn’t begin to address his contributions to the AIUM bothbefore and after his tenure as president, through his hard workon almost every AIUM committee in existence. He undertookall these activities while serving as professor of radiology at theHospital of the University of Pennsylvania, where he is nowemeritus professor of radiology and concentrating on ultrasoundresearch and ultrasound training for residents.A graduate of Washington University in St Louis andthe University of Illinois Medical School, Dr Arger was a captainin the US Air Force before beginning his long history of awardsfor his research and his service to imaging associations, startingwith a certificate of merit for “An Approach to Orbital Lesions”from the American Roentgen Ray Society more than 30 yearsago to his most recent honor in 2011—the Gold MedallionAward—from the Pennsylvania Radiological Society.His many awards are a testament to his ongoingcommitment to imaging. He has served as principal investigatoron multiple major grants that addressed an enormouslybroad 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 breastcancer diagnosis. A well-published author with hundreds oforiginal papers to his credit, as well as abstracts, books,reviews, and chapters, Dr Arger’s passion for education is furthermanifested by the countless presentations he has givenand the outstanding courses he has directed.It’s not surprising that these incredible achievementswere completed by an exceptional clinician, what isremarkable is that they were completed by such a kind, softspoken,self-effacing human being who has earned the highestrespect and admiration from his colleagues, his students,his superiors, his subordinates, and association staff. He istruly the inveterate clinical pioneer.v

2013 AIUM Award WinnersDistinguished Sonographer AwardEstablished in 1997, the Distinguished Sonographer Award is a means of recognizing and honoring current or retiredAIUM members who have significantly contributed to the growth and development of medical ultrasound. This annualpresentation honors an individual whose outstanding contributions to the development of medical ultrasound warrantspecial merit.Marsha Neumyer, BS, RVTThe title “distinguished sonographer”does not do justice to the 2013awardee, Marsha Neumyer, BS, RVT.Currently chief executive officer andinternational director of VascularDiagnostic Educational Services,Ms Neumyer previously was anassistant professor of surgery at thePennsylvania State University Collegeof Medicine and director of thevascular laboratory section of thePennsylvania State Vascular Institute.Ms Neumyer earned her bachelor’s degree in zoologyfrom the Pennsylvania State University and spent the next2 decades involved in research, starting with the BovineLymphosarcoma and Leukemia Research Team and NewcastleVirus Disease Research. She then founded and served as thedirector of the Diagnostic Laboratory and Tissue Culture CellBank, followed by a stint as the director of the Camp HillVeterinary Laboratory and as a senior research technician atthe Milton S. Hershey Medical Center.In 1985, her commitment to vascular imagingwould firmly take hold with her certification as a registeredvascular technologist. It comes as no surprise that this is afield in which she would excel and for which she has receivedmultiple awards, including the Award for Excellence inScientific Research (twice) from what is now the Society forVascular Ultrasound (SVU), the Distinguished Service Awardfrom the Society of Vascular Technology (SVT), the BurnhamEditor’s Award for outstanding contributions to the field ofvascular technology, the J. Baker Pioneer Award in MedicalSonography from the Society of Diagnostic MedicalSonography (SDMS), and the SVU Professional AchievementAward.A fellow of the AIUM, the SDMS, and the SVT, MsNeumyer has served admirably in leadership roles for these3 organizations, as a member of the Board of Governors, theBoard of Directors, and president, respectively. In addition,she has demonstrated her belief in the importance of vascularimaging excellence by her active involvement in numerouscommittees addressing issues of education, training, bioeffects,risk management, and practice guidelines.A founding member of what is now the IntersocietalAccreditation Commission, Ms Neumyer has been the editorof the Journal of Color Flow Imaging and guest editor of theJournal for Vascular Technology multiple times. She serves onthe editorial boards of the Journal of Vascular Ultrasound andthe Journal of Diagnostic Medical Sonography and is a reviewerfor the Journal of Ultrasound in Medicine, the Journal ofClinical Ultrasound, and the Journal of Diagnostic MedicalSonography.Her editorial responsibilities are a direct reflectionof her prolific output as an author through publications, bookchapters, books, abstracts, posters, and videos, CDs, andDVDs. But it is in lectures and presentations where her outstandingtalents shine through. With her close to 900 presentations,Ms Neumyer has made Herculean efforts to educateusers and promote exceptional and safe vascular imaging.She is truly a clinician who should be emulated.vi

2013 AIUM Award WinnersHonorary Fellow AwardThe Honorary Fellow Award bestows an honorary membership to those individuals who have contributed significantly tothe field of ultrasound.Paul A. Dubbins, MBBS, BSc, FRCRA graduate of Kings CollegeHospital Medical School, Paul A.Dubbins, MBBS, BSc, FRCR, iscurrently consultant radiologist atDerriford Hospital in Plymouth,England, where he led the ultrasounddepartment for 30 years, andcivilian consultant adviser in radiologyto the Royal Navy. A member ofnumerous distinguished societies,he has been particularly active inthe Royal College of Radiologists, where he has served onmany committees and, most recently, as vice president.A reviewer for multiple peer-reviewed journals, DrDubbins has served on the editorial board of ClinicalRadiology, the European Journal of Ultrasound, and theJournal of Ultrasound in Medicine and was the Europeaneditor of Ultrasound International.Dr Dubbins is a well-published author, with morethan 60 articles and 30 book chapters. In addition, he is theeditor, coeditor, or author of multiple books, some of whichare now in second editions, including Urogenital Ultrasound:A Text Atlas and Clinical Doppler Ultrasound. A clinician withexceptional teaching skills, including 2 years as assistant professorin the Division of Diagnostic Ultrasound at ThomasJefferson University Hospital and decades of experience as acourse organizer, Dr Dubbins has lectured worldwide onultrasound and has developed and led hands-on trainingcourses in Nepal and India.Having made contributions to the field of medicalultrasound on multiple continents, it is not surprising thathe would embrace and become a leader in e-learning. TheRadiology Integrated Training Initiative, a concept proposedby Dr Dubbins, was initiated in 2005, long before most professionalsin any field had begun to consider the advantagesof online learning. This innovative new training programwas based predominantly on an e-learning delivery strategy,supplemented by skills lab work and traditional apprenticeship-stylelearning; Dr Dubbins was the author and editor ofthe gynecologic imaging module until 2010. Dr Dubbins furtherdeveloped the education program within health care bydevising an introduction to imaging for the Foundation Yearprogram (internship), for which he serves as lead editor. Notcontent to limit his e-learning ideas to the United Kingdom,Dr Dubbins has led work commissioned by the WorldFederation for Ultrasound in Medicine and Biology to developan e-learning program for basic ultrasound. The firstmodule, to be trialed in Uganda this year, consists of 10 interactivelearning sessions covering technique, anatomy, andbasic abnormalities. This is a program with worldwide potentialto provide state-of-the-art affordable medical educationto countries where it is most needed and where it might otherwisenever be available.It is for his foresight, imagination, expertise, andpioneering efforts in the field of ultrasound education thatthe AIUM is proud to name Paul Dubbins as an honoraryfellow.vii

Endowment for Education andResearch DonorsThe AIUM’s Endowment for Education and Research (EER) was created to provide much-needed fundingfor ultrasound research and educational initiatives. What makes this possible is the generoussupport of AIUM members, vendors, and individuals who provide gifts in honor or in memory ofultrasound professionals.It is with great appreciation that the AIUM thanks the individuals listed below who contributed tothe EER in 2012. These individuals have a ribbon on their name badge acknowledging theirgenerosity; please thank them for their support.Contributions of $1000 andAboveJacques Abramowicz, MDAlfred Abuhamad, MDPeter Arger, MDCarol Barnewolt, MDBeryl Benacerraf, MDBryann Bromley, MDFrank Chervenak, MDBrian Coley, MDJoshua Copel, MDJude Crino, MDArthur C. Fleischer, MDLeonard Glassman, MDSteven R. Goldstein, MDLennard Greenbaum, MDLuis Izquierdo, MDSamuel Maslak, DScLevon Nazarian, MDHarvey L. Nisenbaum, MDWilliam O’Brien Jr, PhDKathryn Reed, MDRudy Sabbagha, MDThomas Shipp, MD, RDMSJames Shwayder, MD, JDCarmine Valente, PhD, CAEJoseph Wax, MDGary Whitman, MDContributions of $250 and AboveLisa Allen, BS, RDMS, RDCS, RVTRochelle Andreotti, MDDavid Bahner, MD, RDMSCarol Benson, MDJohn Benson, MDMichael Blaivas, MDWilliam Brown III, MDCharles Church, PhDHarris L. Cohen, MDDeborah D’Agostini, RDMSPeter Doubilet, MD, PhDDiane EberleJ. Brian Fowlkes, PhDBarry Goldberg, MDH. Harcke Jr, MDCharlotte Henningsen, MS, RT,RDMS, RVTFrederick Kremkau, PhDAlfred Kurtz, MDErnest Madsen, PhDThomas Moore, MDDolores Pretorius, MDVictor Reddick, RDMS, RDCS, RTLeslie Scoutt, MDSachita Shah, MDRonald Townsend, MDIsabelle Wilkins, MDJames Zagzebski, PhDContributions Up to $249Samer Abdullah, MDMonzer Abu-Yousef, MB, BCh, ABRSusan Ackerman, MDDebra Acord, MDJuan Acosta, DO, MSCharles Adair, MDEl-Zein Adam Jr, MBBS, MSC, PhDAnnette Adams, BSN, RN, RDMSGermán Adarme, MDJoseph Adashek, MDArun Adhate, MPA, RDMS, BSRichard Aguilera, MDKhaled Ahmed, MDZaheer Ahmed, BS, RDCS, RVSRobert Ahrens Jr, MDAnthony Akamaguna, MB, BS,DMRDBrigitte Ala, MDSheikh Alam, PhDVito Alamia, MDJoseph Albano, MDJuan Luis Alcázar, MDJohn Alcini Jr, MDArchie Alexander, MD, JD, LLMRustom Al-Khatib, MDHuda Al-Kouatly, MDJohn Allen, PhDPaul Allen, MDMona Alqulali, MD, PhDKaren Alton, BS, RT, RDMS, RVTMuna AlzahraniAnthony Ambrose, MDDavid Amponsah, MD, RDCSLibby Anderson, MDPanagiotis Andrikopoulos, MDAnthony AnnanJackie Appleby, MSJose Aquino, MDHisham Arab, MDIrma Aragon, MDEdward Araujo Júnior, PhD, MDBeckie Ard, RDMS, RVTPatricia Ardise, MDEllen Arendt, MDIgnacio Armas, MDAlbert Armstrong Jr, DPMErin Arnold, MDWilliam Arnold, MDElsa Arribas, MDBelinda ArtimovichHilda Arzola PlascenciaYasuyuki Asakawa, MD, PhDAdam Ash, DOGraham Ashmead, MDMohamed AshourFareeda Asif, MBBSTamerou Asrat, MDFiona AtkinsStephen Avery, MDTin Tin Aye, MBBSJean Ayoub, MD, PhDDaniel Azabache, MDNami Azar, MDKazunori Baba, MD, PhDAnthony Bacevice Jr, MD, MSENorman Back, MDJennifer Bagley, MPH, RDMS, RVTEmily Baker, MDJeffrey Baker, MDMary Baker Berzansky, MDJuanito Baladad, MDAdrian Balica, MDBita Baligh, MDNatalie Ballweber, PA-CJ. Oscar Barahona, BS, RDMSAntonio Barbera, MDDiego BarcaArlene Bardeguez, MDDonald Barford, MDTudor Barglazan, RVTDarryl Barnes, MDJolyn Barras, RT, RDMS, RVTviii

Edgar Barros, RDMSJuan Barros, RVT, RDMS, RDCSPatricia Barry, MDJoan BartelloJames Bartelsmeyer, MDPeter Barthe, PhDEdwin Bartlett, MDBonnie Bartley, RDMS, RDCSNorman Barwin, MD, FRCOG,FSOGCAhmet Baschat, MDRichard Basile, MDNaz Basit, MBBS, RDMSJean-Philippe Bault, MDTara Baum, MDJohn Baxter, MDMartine Beaudoin, RN, BSNBrian Beck, MSEE, MDBrent Becker, MDTheodore Bedard, MDEnrique Bedia, MDRob BeekmansKimberly Behling, RDMS, RVT,RRTClifford Beinart, MDGwendolynn Belle, RDMSWilliam Benedetto, MDRichard Benoit, MD, MPHEric Bentolila, MDPaul Bergh, MDMichele Bergmann, MDNancy Berich, RDMSDaniel Berkowitz, MDLeslie Berlinsky, AAS, RDMS, RVT,RTRichard Bernardi, PhDJames Bernasko, MDLisa Bernhard, MDVidor Bernstien, MDRichard Besinger, MDPamela Besse, RT, RDMSSherri Bethea, RDMSMaureen Beurskens, MDGordon Beute, MDConnie Bevell, RDMSDaksha Bhansali, MDBarbara Biber, MDBenjamin Bieber, MDTeresa Bieker, MBA, RT, RDMS,RVT, RDCSKenneth Bielak, MDAngela Biggs, MDChristine Bird, BS, RDMS, RVTAndrea Bishop, RDMSMauricio Bitran, MDDebra Blackford, RDMS, RVT,RDCSJ. Timothy Blackwelder, MDMarlene Blair, RT(R), RDMSRichard Blair, MDChristine Blake, MD, MPHKristi Blanck, RDMSErnesto Blanco, MDAlejandro Blando, MDJoseph Blankier, MD, FRCS(C)Alexander Blankstein, MDJosef Blankstein, MDAnna Blask, MDJoseph Blazina III, BS, RDMSAndrew Blecher, MDDavid Blews, MDAdam Blickley, MDDonna Blodgett, RDMSAmy Blumenthal, MDRonnie Bochner, MDJean Bolan, MDJ. Scott Bomann, DOPeter Bonadonna, EMT-PGary Boss, RDMS, RDCSRadine Boss, RDMSElton Bowen, MDDeanna Boyette, MDWilliam Bracer, MD, RVT, RPVIAbigail Brackney, MDTerence Braden, DOE. Bradley, MDKim Brady, MDBrittany Brasher, RDMSAmy Breakstone, MDAshley BreauxFred Brennan, DOKim Brennan, MDLesley Brennan, RDMSSteven Brenner, MDWilliam Brewer, MDMarla Bridgford, BS, RDCS, RDMSJustin Briones, MDSteven Broadstone, PhDMarsha Brody, RDMSFredrik Broekhuizen, MDDebra Brooks, BS, RTRM, RDMS,RVTPamela Brower, RVT, RVSChristina Brown, MDDeborah Brown, BA, RDMS, RDCSDina Brown, RDMSDouglas Brown, MDElisa Brown, MDCarol Brown-Elliott, MDHermann Bruhwiler, MDStephen Bruny, MDNeal BuchalterCarmen BucherRichard Budenz, MD, PhDSusan Bunch, MDSherry Bunting, RDMSHolly Burge, MDM. Shannon Burke, MDDeland Burks, MDKathleen Burnett, RDMS, RVTLeigh Burrell, RT, RDMSMichelle Bursese, RDMSFrances Buryk, RDMSJacqueline Bush, MDLawrence Busse, PhDRaydeen Busse, MDJeffrey Butler, DO, RDMSHelia BuyckPaul Byrne, MDMichael Cabbad, MDJames Cabell, MD, PhDJean Cadet, MDAlan Cadkin, MDKenzie Caine, BA, RDMSGail Calamari, MDCharles Camacho, MDHelio Sebastiao Camargo Jr, MDAngelo Campagna, MD, FRCS(C)Timothy Canavan, MD, MScMario Candal, MDPatricia Cantu, BS, RT(R), RDMS,RVT, RDCSVito Cardone, MDReynaldo Cardoso, MD, FRCSCEric Carlson, DO, MPHAnselmo CarmoFrancis Carmody, MBBS, FRCOG,FRANZCOG, DDUStephen Carolan, MDMarshall Carpenter, MDRobert Carpenter Jr, MD, JDStephen Carr, MDElaine Carroll, MDPaul Carson, PhDAnthony Carter, MDSarah Carter, MSEd, RDMSMark Cartier, BS, RDMS, RTCarolyn Caruso, BS, RDMSElba Cases, BS, RDMS, RDCSAlejandro Casillas, MDMeredith Cassidy, MDMario Castillo, MDAugusto Castrillon Sr, MDSimon Castro, MDDiane Cervantez, RDMS, BSDavid Chaffin, MDMark Chag, MDLaurence Chaise, MDAlbert Chan, MDKa Fai Chan, BSLisa Charney, BS, RDMSMing-Tak Chau, FRCRRubila ChaudhryMeera Chaudhuri, MD, FRCOGEmiliano Chavira, MD, MPHChou-Er Chen, BSHee-Joo Cheon, MDStephen Cherewaty, MDMelanie Cherry, MDMiranda CheungBalwant Chhatwal, MDSuzin Cho Helgaas, MDMin Choi, PhDTae-Sik Choi, MDShaila Cholli, BS, RDMSHajoon Chun, MDMarc Clachko, MDCraig Clark, MD, JDLinda Clark, RDMS, RT(R)William Clark, MDDaniel Clement, MDMarianne Clements, RDMSPhillip Clements, MDSuzanne Clemons, MDRosemary CoffeyLeeber Cohen, MDVeronica Cohen, RDMSFred Coleman, MDMark Collins, MDRobert Collins, MDTerry Collins, MDPablo Colon, AAS, RDMSLisa Comer, RTR, RDMS, RDCSMary Comito, RT, RDMSCaroline Comparone, RDMSFrederick Conard III, MDLori Conley, RDMSMary Connell, MDRichard Cook, MDBrian Coolbaugh, MDElizabeth Cooper, RDMSPenny CooperKristin Coppage, MDAndrea Corda, MDRaul Cordova, RDMSLaura Corio, MDCarla Corry, RDMSErich Cosmi, MD, PhDSeid Cosovic, MDCarlos CostaMagda Costa, MDTracey CotaOsterman Cotes, MDCarole Coughlin, RDMSLaura Coultrip, MDJacqueline Cox, RDMS, RTJoseph Craig, MD, ChBWilliam Craig IV, MDBlane Crandall, MDTonie Crandall, MDFrank Craparo, MDLuther Creed, MDVernon Croft, MDKathleen Cross, RDMS,RT(R)(M)(CT)Dante Cubangbang, MDGail CulbertGabriel Culiat, RDMSMarianne Cullen, BSMary Cunnane, MDMark Curran, MDWilliam Curtin, MDMaria Czerwinski, MDDiane Dalecki, PhDStephen Dalton, MDMary D’Alton, MDSuzanne Dambek, MDPaxton Daniel, MDEugene Danko, MDJerome DansereauByron Darby, MDJoseph Darby Jr, BS, RDMSRaymon Darling, MDBarry Davidson, MD, FRCPJesse Dawkins Sr, MDSue Ann Dayton, RDMS, RRTMaria De Elejalde, MS, RNM. Robert De Jong, RDCS, RDMS,RVTMarie De Lange, BS, RDMS, RDCSJose De Sousa Pereira, MD, RDCS,RDMSix

Rosa De Vermette, MD, RDCS,RDMS, ROUBAnthony Dean, MDHollis Dean, RDCSPhilippe DeblieckMamta Deenadayal, MDTony Deeths, MDGary DeGuzman, MDPatricia Del Bondio, RDCS, RDMS,RVTGerardo Del Valle, MDBrian Delahoussaye, MDKimberly Delaney, RT, RDMS, FEMichael DeMassMichael Demishev, MDFareed Denath, MB, FRCP(C)Linda DeOrio, RDMSDail DeSouza, BA, BS, RDMSStamatia Destounis, MDKaren DeTommasoRichard DeVeaux, MDLawrence Devoe, MDGreggory DeVore, MDDaniel Dexeus, DOGunwant Dhaliwal, MDDiane Di Girolamo, MDMichael Di Pietro, MDLin Diacon, MD, RDMSThiendella Diagne, MDDavid Dichiara, MDJeffrey Dicke, MDEitan Dickman, MD, RDMSWilliam Dittman, MDSusan Dodd, MDSteven Domnitz, MDJohn DonlonAlan Donnenfeld, MDLeslie Donovan, MDBernice Doring, RT, RDMSJean Dormer, RT, RDMSN. Carol Dornbluth, MA, MDMark Downey, RT, RDMS, RVTMargaret Drake, AA, RT(R), RDMSKathryn Drennan, MDDawn Driver, RDCS, RDMS, RVTRobert Dropkin, MDJulia Drose, BA, RT, RDMS, RVT,RDCSTerry DuBose, MS, RDMSJerome Dubowy, MDEva Duckett, MDKelly Duncan, RDMSLisa Dunn-Albanese, MDJames Dunphy, MDTeresa Durbin, MDOlga DynkinGerald Dysert, MDColette Eastman, DOKatherine Eastwood, MDIan Ebesugawa, MDSteven Edell, DORobert Eden, MDRick EdmistonPeter Edmonds, PhDChristine Edwards, MDRobert Edwards III, MDWilliam Edwards, MDHugh Ehrenberg, MDAmy Eichfeld, MDDoug Eiland, MDBerit Eklund, RN, MSB. Rafael Elejalde, MDPaul Ellenbogen, MDByron Elliott, BA, MDSandra Emmons, MDGoodday Eng, RDMSHeywood Epstein, MDChristos Erinakes, MDErnest Ertmoed, MDFrederick Eruo Sr, MD, MPHJ. Fernando Escarzaga, RPA, RVT,RDMS, RTSharon Eskam, MDKristine Eule, MDPeter Evan, MUDRJohn Evans, MDMaggie Evans, MDWayne Evans, MDPhilippe Extermann, MDSteven Eyanson, MDEric Fackler, MDLeonard Fagan, MDGary Fait, MDJoseph Fakhry, MDIman Fani, MDHarry Farb, MDPatricia FariasDarren Farley, MDShahid Farooqi, MDJuan Fausti, MDJean FavaMark Favot, MDBeda Federici-Linehan, MS, RDMSDing-Yu Fei, PhDDeborah Feldman, MDDamariz FelizTerry Feng, MDJonathan Fenton, DOBenedito FernandesHostos Fernandez-Caamano, MDLauren Ferrara, MDJacqueline Fielding, BS, RDMSReinaldo Figueroa, MDHarris Finberg, MDMarcus FinchJanet Fiore, RT, RDMSStuart Fischbein, MDFrank FischerJason Fischer, MD, MScColleen FitzsimonsChristi Flanagan, RDMS, RVTMeghan Flannery, MDMatthew Flannigan, DORodney Florek, MDPhilip Florio, MDKatherine Foley, MDJon Foran, MDMelissa Foreman, RDMS, RVTFlemming Forsberg, PhDWilbert Fortson Jr, MDStephen Fortunato, MDJonathan Foster, MDLisa Foster, RDMSArthur Fougner, MDDebra Fouts, RDMS, RDCSGrant Fowler, MDLisa Fox, RDMS, RVTParham Fox, BA, MDPamela Foy, MS, RDMSGerard Foye Jr, MDTerrell Frain, RDMSGaetane Francis, MDJennifer Franz, RT, RDMSMahlon Freeman, MD, MedScDAtis Freimanis, MDMaija Freimanis, MDDawn Frey, AA, RTR, RDMSFranklin Friedman, MDWilliam Fry, MDElizabeth FuentesTeiichiro Fukushima, MDPat Fulgham, MDDeena Fulton, RRTMaureen Galang, RDMS, RDCS,RVTPaul Gammell, BSEE, PhDBryan Ganter, MDJing GaoRosa GarciaDavid Garfinkel, MDBrian Garra, MDDavid Garry, DOFrank Gaudier Jr, MDMichael Gebel, MD, PhDGino Gennari, RDMSHerbert Gerstein, MDTammy Gerstenfeld, DODoreen Getty, RDMSNabil Ghali, MDGoutam Ghoshal, PhDWilliam Gilbert, MDHarlan Giles, MFM, MD, RDMSCynthia Gill, PT, DScPT, MEdJerry Gilles, MDMichael Ginn, RVTAnthony Giovine, MDThomas Giudice, MD, MSVincenzo Giuliano, MD, RPVI,RVT, RDMS, ARMRITPhyllis Glanc, MDCM, BSCAngela Glaser, RDMSMikhail Gleyzer, DO, MDJohn GobleStephen Gocke, MDRicardo GoesChris Goeser, DC, MDBradley Goldberg, MDJames Goldberg, MDNancy Goldenberg, MDAlan Goldman, MDCandace Goldstein, BS, RDMSEdwin Goldstein, MDMercedes Gomez de Villasana, MDJenice Gonyea, RDMS, RTRMario Gonzalez QuirozEduardo Gonzalez-Jove, MDAntonio Gonzalez-Ruiz, MDJean Goodman, MDBarbara Gordon, MDAlan Gorrell, MD, RDMSKiyotoshi Gotoh, MD, PhDDaniel Gottschall, MDGregory Goyert, MDNeville Graham, MDSallye Granberry, MDMichael GranelliVanessa Grano, MDAndrew Gray, MD, PhDCaron Gray, MDCindy Gray, RDMS, CNMT,RT(R,M)Diana Gray, MDRobyn Gray, DOMichael Green, MD, FRCSRichard Green, MD, BSWilliam Green, MDMark Greenberg, MD, CCDSteven Greenberg, MDVinette Greenland, MDJill Ann Shu Gregg, RDMSNatalie Gregory, MDKamal Greiss, MD, FRCP, FACE,ENCUTim GrenemyerBasil Grieco, MDKirby Gross, MDYvette Groszmann, MD, MPHEmily Gubert, MDAlexandr Gudz, MDGwen Guglielmi, MDLesley Gumbs, MDGowthaman Gunabushanam, MD,FRCRShalesh Gupta, MDJoy Guthrie, PhD, RDCS, RDMS,RVTGlenford Guy, BSc, MDJoAnn Haberman, MDShoshana Haberman, MD, PhDWendy Hadden, MDChristine Haines, MDLawrence Haines, MD, MPH,RDMSJohn Hale, MDAnne Hall, PhDBrian Hall, MD, RDMS, RDCSMederic Hall, MDMichael Hall, MDTimothy Hall, PhDThomas Halloin, MDAntoinette Ham, MDCaroline Hamel, MDLee Ann Hammond, MDLewis Hamner III, MDUlrike Hamper, MD, MBAMagdi Hanafi, MDSusan Hancaviz, RDMSGlenn Haninger, MDMaryellen Hanley, MD, MPHLara Hanlon, MDKathleen Hanlon-Lundberg, MDGina Hanna, MDReid Hannon Jrx

Gail Hansen, MDRegina Hansen, RDMSJames Harding, MDJohn Harding, MDRenee Harding, RDMSSeemanthini Hariharan, MDGamal Haroun, MD, FRCP(C)Lorie Harper, MD, MSCIJeffrey Harris, MDHerlof Harstad SrMusarrat Hasan, MBBSRebecca Haskett, RDMS, RVTMoustafa Hassan, MDKathryn Hassinger, MDJiro Hata, MDToshiyuki Hata, MDNawar Hatoum, MDKaren Havling, RDMSClint Hayes, MD, RVT, RPVIAndrew Healey, MD, RDCS, RDMS,FRCPCAmie HealyMichael Heard, MDStephanie Hedstrom, MDFrederick Hegge, MDKaren Hehnen, RDMSTimothy Heiser, RDMSAndrew Helfgott, MDRobert Helgans, MDDouglas Helm, MDDaryoush Hendessi IVHarold Henry, MDCynthia Herbert, RDMS, RDCS,RVTTomas Hernandez-Mejia, MDOscar Herrera, MDLinda Herrmann, RN, CNPBarbara Hertzberg, MDL. Wayne Hess, MDPeter Heyl, MDAdam Hiett, MD, RDMSKenneth Higby, MDJoseph Higgins Jr, MD, PhDLyndon Hill, MDMeghan Hill, MBBSKim HillstromRoger Hine, MDNeely Hines, MDMakiko Hirai, MDCalvin Hobel, MDArthur Hodge, MDEric Hodgson, MDNicholas Hoff Jr, MDDouglas Hoffman, MDFrancis Ho-Kang-You, MDMichael Hold, MDLori Holden, RDMS, RVT, BSRTChristy Holland, PhDMark Holland, PhDJames Holman, MDJay Holmes, MDByron Holt, MDTodd Holt, MDMaryruth Hooper, RRT, RDMSShari Hopp, RT, RDMS, RDCSJanet Horenstein, MDNaoki HottaMichael House, MDBobby Howard, MDThomas Howard Jr, MDCandace Howard-Claudio, MD,PhDRodney Hoxsey, MDSharlene Hsiao, RDMSCharles Hsieh, MDTsang Tang Hsieh, MDWilliam Huang, MDJudy Hudson, RDMS, RVTJohn Hughes, MDShui Yee Hui, RDMS, RVTRoderick Hume Jr, MDStephen Hunt, MD, PhDTimothy Hurley, MDKristina Huster, RDMSThomas Hutchens, MDManly Hutchinson Jr, MDJ. Hwang, PhDJames Hwang, MDKullervo Hynynen, PhDEric Hyson, MDDebra Ilahi, RDMSKenneth Iles, DCSania Imtiaz, MBBS, MUSPLorraine Iseman, RTR, RDMSYoshihiko Iwasa, MD, PhDChristann Jackson, MDJon Jacobson, MDRobert Jacobson, MDDaryoush Jadali, MDKurt Jaenicke, MDWieslaw Jakubowski, MDRoger Jammal, MDWarren Janowitz, MDPhilippe Jeanty, MD, PhDMussarat Jehan, MBBSGary Jensen, MDLisa Jervis, MDJeng Jiang, MDLeticia Jimenez, BA, RDMSGary Joffe, MDLois Johanson-Maxwell, MDLori Johansson, RDMSChristina Johnson, BS, AS, RDMSTyronne Johnson, RDCSDoug Jones, BA, RVT, RDMS,RDCS, RCTFrederick Jones, MDOliver Jones, MDRichard Jones, MDTeresa JonesWilliam Jones, MDWilliam M. Jones, MDAnthony Joseph, MDMary Teresa Joseph, MDNancy Judge, MDSvena Julien, MDWagdy Kades, MDRonny Kafiluddi, MD, PhD, FIPP,DABIPPJeanne Kafoury, RVT, RDMSCostas Kaiafas, MDKrishna Kakani, MDJohn Kamp, MDMark Kandutsch, MDLeonard Kaplan, DOTeresa Karcnik-Mahoney, MDArdeshir Karimi, MDRoberta Karlman, MDBarry Karpel, DONamasivayam Karunanithy, MB,ChB, DRCOG, DMRD, FRCRMitsunori Kasamo, MDRichard Kates, MDDavid Kauffman, MDYoshio KawamataDiane Kawamura, PhD, RT(R),RDMSAkihiro Kawauchi, MD, PhD,RDCS, RDMS, ROUB, RVTAngela Kay, RN, RDMSAlena Kazlouskaya, RDMSAliaksandr Kazlouski, MSGeorge Kazzi, MD, MBAJeannette Keefe, RDMS, RVT,RT(R)(M)Alexandra Keegan, RDMSChristine Keer, RDMS, RTRalph Kehl, MDIan Kellman, MDKevin Kelly, MD, RVTRandall Kelly, MDAnne Kennedy, MBBCh, MRCP,FRCRBernadette Kennedy, BS, RDMS,RVTKaren Kennedy, MDBrian Keroack, MDLacy Kessler, MDLawrence Kessler, PhDWilliam Ketcham, MDMaria Salud Kho, MDAldo Khoury, MDThomas Khoury, MD, RVTButrus Khuri-Yakub, PhDAnia Kielar, MD, FRCPCDenise Kieso, RDMS, RVTRobert Kiltz, MDMin Kim, MDSunny Kim, MDYoung Kim, MDAndrew Kingzett TaylorHeidi Kinkade, RDMS, RVTKaren Kirker, RDMSCarolyn Kirkland, AS, RTMary KirvesMichael Kirwin, MDEugene Kissin, MDDebra Kitts, RDMSHarvey Klein, PhDNicki Klein, RDMS, RDCS, RVT,RTAmy Knoeller, MDDebra Koenig, RDMSAlexander Kofinas, MDWilliam Kohlhoff, BAMichael Kolios, PhDShelley Kolton, MDMary Komora, RDMSEftichia Kontopoulos, MD, PhDElizabeth Kopin, MDAsteris Korantzis, MD, PhDJeffrey Korotkin, MD, MBAKaren Koscica, DOHelen Kosik-Westly, RDMSDana Kottke, RDMSBruce Kovacs, MDKajoli KrishnanMark Kristy, MDDavid Kroska, MDRobert Krugman, MDReinhard Kubale, MDKathleen Kuhlman, MDKoteswara Kunda, MDGwen Kunken Sterns, MDSui Ping Kwong, RDMSMarilyn LaBatte, RDMSLane Laboda, RDMSRene Lafreniere, MD, CM, FRCSCRachel Lafser, BS, RDMSSherelle Laifer-Narin, MDFaye Laing, MDDonna Lambers, MDEdward Lampton Jr, MDBarton Lane, MDRoberta Lange-Lifchez, RT, RDMSOrli Langer Most, MDMichael Lao, MDJanet Larson, MDLarry Larson, MDTimothy Larson, MDElena LastWendy Latshaw, MDRichard Latta, MDJennie LauMarilyn Laughead, MDLaura Lawrence, MDSanford Lederman, MDMilton Lee, MDYung Jae Lee, DOThomas Leigh, MDSher Leiman, MDMarlyn Leisy, MDCarol Lennon, MDJack Lenox, MDMegan Leo, MDTammy Leonard, MDMichael Leonardi, MDArmand Leone Jr, MD, EsqJodi Lerner, MDRobert Lerner, MD, PhDAnna Leung, MDWai Hang LeungDavid Levene, MDRoberto Levi-D’Ancona, MDAaron Levine, MDDeborah Levine, MDJonathan Levine, MDMichael Levine, MDPeter Lewin, MSc, PhDDawnette Lewis, MD, MPHGeorge Lewis, PhDResa Lewiss, MD, RDMSAmy Lex, MS, RT(R), RDMSMelissa Liebling, MDxi

Kee-Hak Lim, MDG. Sharat Lin, PhDTonya Lindgren, RDMSNorman Lindley, MDYael LipschitzMichel Lirette, MDKelly LirianoKaren Lissington, DMUAndrew Liteplo, MD, RDMSChristian Litton, MDJi-Bin Liu, MDJohn Loewy, MDSalvatore Lombardi, MDSherri Anne Longo, MDLuisa Lopez, RDMSJosé López-Zeno, MDMaureen Lorbert, RT(R), RDMS,CDTSeth Lotterman, MDCoreen Lowney, RDMSJennifer LuckernCristina Lundborg, RDMS, RVTCarmelina Luongo, MDDavid Luthy, MDDeborah Luthy, RT, RDMSJuarez LuzSusan Lynch, RDMS, RVT, RDCSSadisu MaajiDeborah MabinLisa Maccarino, BSMarion MacInnisLaurence Mack, MDKaren Mackey, RVT, RDMS, RDCCharles Macri, MDMadhumala Madhavan, MD, AS-PLS, MBBSKazuo Maeda, MD, PhDPaul Maertens, MDDavid Magarik, MDEdward Magaziner, MDRebecca Mahony, BASDenise Main, MDInder Makin, MD, PhDPatricia Ann Malek, RN, FRCNSrini Malini, MDMelinda Mann, MDS. Manohar IV, MD, DMRDLuis Mansilla, RDMSDarlene Mansueto, RDMSGiorgio Marchini, MDJoshua Markowitz, MD, RDMSClifford Marshall, MDChester Martin Jr, MDClifford Martin, MDFelix MartinJerry Martin, MDJoseph Martin, MDKimberly Martin, MDCecilia Martinez, MDFrancis Martinez, DOXavier Augusto Martinez BejaranoCarl Martino, MDRaymond Marty, MDSubha Maruvada, PhDDamon Masaki, MDLuleta Maslak, RDMST. Douglas Mast, PhDJoan Mastrobattista, MDDimitrios Mastrogiannis, MD, PhDCherie Mathews, RDMSSergey MatiashchukShoichi Matsutani, MDD. Matthews, MDJason Matuszak, MDDev Maulik, MD, PhDAlexander Maximovich, MDLisa May, MDKathleen Mayor-Lynn, MDW. Desmond McCallum, MDKathleen McCarten, MDMichael McCoy, MDStacy McCrosson, MDDeirdre McCullough, MDDarrick McDanald, MDElinor McDermott, RDMSKelly McGuire, MDCindy McKay, RDMSElizabeth McKinney, MDMonique McKnight, MDKristen McLaughlin, RDMSDavid McLean, MDMichael McNamara, DOThomas McNanley, MDJakob McSparron, MDJoseph McWherter, MDMary Meadows, RT(R), RDMSJose Medina, MDGaro Megerian, MDSofia MehmooodIsrael Meizner, MDVlatka Mejaski-Bosnjak, MD, PhDHugh Melnick, MDPaula Melone, DOK. Menon, MD, FRCOGAlexander Mentakis, MDJohn Mercer, MDMichelle Mercier, RTRMargret Mergelsberg, MDDaniel Merton, BS, RDMSPaul Meyer, MDPatrick Meyers, BS, RDMS, RDCS,RVTLindsey Micek, RDMSMatthew Michaels, MDJoseph Milburn Jr, MDRuben MillanHugh Miller, MDJames Miller, MS, PhDNora Miller, MDSuzanne Miller, MDThomas Miller, BSMEWayne Miller, MDJeanna Miller-Borsini, RT(R),RDMSClaire Mills, RDMS, RVTGerald Minkowitz, MDMaria Mintcheva, RDMSPaoletta Mirk, MDCarol Mitchell, PhD, RDMS, RDCS,RVT, RT(R)John Mitchell, MBBS, FRACRMaryann Mitchell, RDMSSubhash Mitra, MD, MPHJennifer Mixdorf, RDMSDebra Mohr, RT, RDMS, BSRichard Molina, MDSteven Mollov, MDKay MoltAnna Mongillo, RN, RDMSAna Monteagudo, MD, RDMSSandye Montes, RDMSJules Moodley, MDShanmugam Moopanar, MD,DMRD, DNBCasey Moore, RCS, RVT, RDMSKathleen Moore, RDMSNancy Moore, RDMSAzeema Moosa, MDDoreen Morales, RT, RDMSMichael Moretti, MDRichard Moretuzzo, MDGail Morgan, MDPablo Morikawa, MD, PhDFuminori Moriyasu, MDJeanine Morris-Rush, MDGerhard Mostbeck, MDElias Moukarzel, MDMark Muilenburg, MDNdaya Muleba, MDJill Mulholland, ASJean-Paul Muller, MDJoann Murano, BS, RDCS, RDMSColleen Murphy, MDDeborah Murphy, RDMSJames Murphy, MDJohanne Murphy, RDMSJoseph Muscat, MDLuc NabetMichael Nabity, MDSamuel Nagle, MSRenuka Naidu, MBBS, RDMSDean Nakamoto, MDLinda Nall, MDRakhshanda Nasim, MBBSDoreen Nassimos, RDMSHoward Nathanson, MDInnocent Ndubuisi, BS, RT(R),RDMS, RDCS, RVTGregory Neal, MDDonna Neale, MDLaurence Needleman, MDKris Neenan, RTR, RDMS, RVTJoy Neimiller, RT, RDMSLewis Nelson III, MDThomas Nelson, PhDAmen Ness, MDMichael Nethers, MD, FICSMarsha Neumyer, BS, RVTArnold Newman, MDChris Nguyen, PhDTuyen Nguyen, RDMSDavid Nichols, MDTerry Nicola, MD, MSMakoto Niizawa, MDKurt Nilsson, MD, MSTakenori Nishi, MDMidori Nishio, MDJohn Nitsche, MDJason Nomura, MD, RDMSRon Norman, FRACRSchura Normand, RDMS, RTRDeborah Nucatola, MDFrancis Nuthalapaty, MDDawn Nutt, RT, RDMSMitchell Nutt, MD, RDMSChima Nwizu, MDNkemdilim NwosaJake OchoaAvice O’Connell, MD, MALawrence O’Connell, MDMary O’Connor, REEGT/EPT,RNCST, RVT, BCIASean O’Connor, MBBSMary O’Day, MDSvein Odegaard, MD, PhDAnthony Odibo, MD, MSCECharles Odwin, BA, RDMS, PA-CCherrie Ogin, RDMS, RVTAndrea Olanescu, MDAugust Olivar, MDMark Oliver, RVT, MDJanine Oliveri, PhD, MSEd, BSRT,RDMS, RVTChiou Li Ong, MBBS, FRCRMehmet OnurGranger Osborne, MDNewton Osborne, PhD, MD, MSKathleen O’SheaBryan Oshiro, MDSteven Ostrow, MDLaurel Ott, RN, RDMSWilliam Ott, MDElizabeth Ottman, MDRobert Ozaki, MDSuha OzbekJosephine Ozoemena, MBBSKelly Pagidas, MDCMLauren Painter, MDSue Palmer, MD, PATracy Papa, DOEmmanuelle Pare, MDLuis Paredes SrYvon Parent, MDBarbara Parilla, MDHoon Park, MDBilly Parkhill Jr, MD, PhDJulie Parrow, RDMS, RDCS, RTRCornelia Partain, RNC, RDMSRichard Paschke, BS, MSSuean PascoeAngela Pascual, PhD, MDResad Pasic, MDLee Paskar, MDRaj Mohan Paspulati, MDBharatbhushan Patel, RDMS, RDCSPravin Patel, MDMolly Paulson, RDMSThea Paulson, RDMSCharles Paxson, MDCarlton Pearse, MDHarold Pedersen, BA, RDMSPeder Pedersen, PhDAhmad Peeroo, MD, FRCPLinda Pendziwol, RDMSxii

Rebecca Pennell, MDJames Pennington, RDMSLeif Penrose, MHSc, RDMS, RVT,RDCS, RT(R,CT)Sima Perelshteyn, RDMSPhillips Perera, MDKalati PereseRichard Perkins, MDAnahi Perlas, MD, FRCPCKenneth Perry Jr, MDJudith Peterson, MDRobert Petite, BS, RDMS, RDCSAlbina PetrosianWilliam Pfeffer, MDPamela Phayre, RVTMarcia Phelps, RDMSEdward Phillips, MDJ. Phillips, CCTCatherine Piccoli, MDDana Piedmont, RDMSCynthia PierceGuy Pierno, RTAnne Pike, RDMS, RVTPaulette Pikey, RDMSJames Pilcher, MBBS, MSc, MRCP,FRCREmily Pineda, MDJorge Pineda, MDSteven Pinheiro, MDJon Pitman, MDBarbara Pittenger, RDMSJulie Platt, MD, MSPHChristopher Plummer, DOAnn Podrasky, MDRobin Poe-Zeigler, MDGustavo Poggio, MDMonica Polacek, RDMSBetty Polanski, ALA, AAS, RDMSDonna Politi, RDMSScott Pollock, MDAdrian Pop, MDBruce Porter, MDJohn Postley, MDJohn Powell, MDKelli Powell, RDMSPaul Prachun, MD, FRCP(C)Uma Prasad, MBBS, MDTed Preston, PhD, MDBrent Price, MDRichard Price, MDDavid Principe, MDSandra Pupa, MDElizabeth Puscheck, MD, MSSharyn Pussell, MBBS, FRACP,DDUScott Puza, MDPamela Queen, RDMSKathy Quenneville, RDMS, RT(R)Fred Quenzer Jr, MDValerie Quick, RDCS, RDMSLuis Ortiz Quintana, MD, PhDYolanda RabelloJanet Radford, DMUIrina RadionovaMonique Rose Rahmani, MBChB,DABR, FRCPSharon Rais, MDShankar Ramamurthy, MD, DMRDCarlos Ramirez ToledoAlberto Ramos Cruz, MDJagpal Rana, MDSheshagiri Rao, MD FRCP(C),DABRCindy Rapp, RDMSOlga Rasmussen, RDMSJohn Reach Jr, MSc, MDCharles Read, MDAndrei Rebarber, MDLinda Rebolo, AS, RDMS, RVT,RCTSusan Rech, MDRaghurami ReddyLeslee Redfield, BAVictor Regenbogen, MDJonathan Rehberg, MDGregory Reid, MDWendy Reiling, BS, RDMSDale Reisner, MDIseko Remilekun, MSc, RDMSDana Resop, MDJanette Reynolds, RDMSFaranak Rezaie, MDJennifer RhodesAmy Richardson, MDDaniel Rightmire, MD, MS, RDMS,MBAChristopher Rigsby, MDThomas Ripperda, MDJennifer Risinger, MDKristina Ritter, RRTManuel Rivera-Alsina, MD, MBAAnne Rizzo, MDMichelle Robbin, MD, MSDonald Roberts, MDDwain Roberts, MDRobert Robertson, MD, MBBSKathryn Robinson, MDHope Robinson-Beverly, RT(R),RDMSKathleen Robischon, MDThomas RodenbergJohn Rodney, MDM. Hellen Rodriguez, MDVeronica Rodriguez, RT(R), RDMSDennie Rogers, MDAshley Roman, MD, MPHNina Romanova, MDAudrey Romero, MDRicardo RosaAngel Rosas, MDHoward Rose, DOGary Rosenberg, MDEmily Rosenbush, MDMarc Rosenn, MDGary RosensteelBrenda Ross-Shelton, MDSiegfried Rotmensch, MDSusan Rowling, MDAnna Rozenberg, RDMSThomas Rubeo Jr, MDTanya Rucker, RTR, RDMSPerry Rudich, MDJames Ruiz, MDGillian Rush, MBBS, FRANZCRGilles RussShahnoz Rustamova, MDJohn Ryan, MDConstantine Saadeh, MDAlan Sacks, MDJason Sagerman, MDBal Sahay, MD, FRCPChristine Sahn, RDCS, RDMS, RVTDavid Sahn, MDFumikazu Sakai, MDSharon Salamat, MD, PhDMustafa SalihAzen Salim, MDCaryl Salomon, MDDaniel Saltzman, MDHera Sambaziotis, MD, MPHTimothy Sammon, RDMS, RVTNadia SamoKaren Sanchez, BA, RDCS, AE, PENorberto Sanchez, MDCarlos Sanchez HuertaWanda Sanders, RDMSAnne Sandoval, BS, RDMS, RVTAimee SanfilippoPeter Sanfilippo, MDThomas Sanford, MDJoaquin Santolaya, MD, PhDLorena SantosRigoberto Santos-Ramos, MDAlbert Sarno Jr, MD, MPHSergio Sartori, MDAndrew Satin, MDMichihiro SatoSatoshi Sato, MDTakahiro SatoJeanette Satriano, RDMSFouad Sattar, MDLizabeth Sawyer, RDMS, RDCSLois Scheffler, RDMS, RDCS, RVTMark Schlimgen, MDJudith SchlisselJames Schmidgall, MDAnita Schmidt, MDMary SchmidtIngrid Schneider, MDJames SchneiderMichael Schneider, MDNeil Schneider, MDRonald Schneider, RDMSThomas Schramm, MDLouis Schruff, MDPatrick Schuette, MDHarold Schulman, MDHeinz Schwab, BScDavid Schwartz, MD, FRCOGJoyce Schwartz, RDMS, RVT, ASMark Schwartz, RDMS, RPVIRonda Schwartz, RDMSWilliam Scruggs, MDHarish Sehdev, MDChandra Sehgal, PhDShyamashree Sengupta, MDNelia Sering, RDMSEdouard Servy, MDDonna Session, MDRoy Settergren, MSc, DCBharat Shah, MDLeena Shah, MDYogesh Shah, MDShane Shapiro, MDPradeep Sharma, MDRalph Sharman, MDCandice Shea, MDJessica Sheets, MDClaudette Shephard, MDCeleste Sheppard, MDTakashi Shimizu, MD, PhDGregg Shimomura, MDNorio Shinozuka, MD, PhDTakako Shirakawa, MD, PhDArnold Shkolnik, MDJanie Shunk, RDMSJaye Shyken, MDJeou-Jong ShyuTariq Siddiqi, MDSalma Siddiqui, BS, RDMSDenise Sidisky, RDMS, RRTNeil Sikes Jr, RDMS, RDCS, RVT,RT(R)Natia Silagadze, RDMSJessica Silliman, RDMSRogerio Silva, MDElizabeth Silverman, MDNeil Silverman, MDRonald Silverman, PhDJulian Simmons, MDMark Simonelli, MDStephen Simons, MDDouglas Simpson, PhDJerry Sims, MDJorge Sinclair, MDKathleen Singer, RDMSShailini Singh, MD, FRCS(C)Elena Sinkovskaya, PhD, MDCasey Sinz, RDMSDaniel Sipple, DOAdam Sivitz, MDDaniel Skupski, MDDan Skyba, PhDPovilas Sladkevicius, MD, PhDMichelle Slater, RDMSJan Sloves, RVT, RCSDiana Smigaj, MDJay Smith, MDStephen Smith, MDLynn Snyder, RDMS, RTSteven Soberman, MDRobert Sofferman, MDJulia Solomon, MDKwang-Ho Son, MDElie Soussan, MDTimothy Spaulding, MDJean Spitz, MPH, RDMSJacqueline Sposito, MDMelinda Staiger, MD, BSCamelia Stanciu, MD, RDMSIoan Stanciu, MD, RDMSJami Star, MDxiii

David Stark, MDA. Thomas Stavros, MDCharles Stedman, MDRalph Steiger, MDJanet Stein, MDMarjorie Stein, MDMichel-Patrick SteinmetzCraig Sternberg, MDJohn Stevens Jr, MDVirginia Stewart, MDLaurie Stolklane, RDMS, RDCSKristine Stolt, RDMSRichard Strassberg, MDMel Stratmeyer, PhDHeather Straub, MDRichard StrianoThomas Stubbs, MDRobert Stuntz, MDHoda Sturman, AA, RT, RDMSIan Suchet, MBBCh, FRCPCCheryl Suiter, MD, PARonald Sultan, MDYasukiyo Sumino, PhDDonna Summers, RDMSJames Sutherland, MDM. Linda Sutherland, MDRobert Sutherland, MDStephen Swanson, MDManuel Sy, MDHumera Syeda, MDThomas Szabo, PhDCelso Szmidt, MDThomas Tabb, MDEvan Taber, MDClaudia Taboada, DOFilemon Tan, MD, PhDJohn Tassone, DPMLucille Taverna, MDBarbara Taylor, MDHelen Taylor, MIR, DMUJeff Taylor, BS, RVTNathan Teismann, MDShpetim Telegrafi, MDDeydre Teyhen, PT, PhD, OCSM. Jay Thomas, RDMS, RRT, RCTDan Thomason, MDKai Thomenius, PhDMichael Thompson, MPH, RDMS,RVT, RDCS, RCS, RVSNoel Thompson, BA, MS, MDRobert Thompson, MDThomas Thompson, MDStephen Thorn, MDPietro Ticci, MDCheryl Timblin, RDMSMark Timken, MDIlan Timor, MDArkom Tivorsak, MDAnts Toi, MD, FRCPLama Tolaymat, MD, MPHTahisha Tolbert, MDFrancis Tomasik, MDCharles Tomberlin, MDJennifer Tomczak, MDMatthew Tompkins, MDFelicia Toreno, PhD, RDMS, RDCS,ROUB, RVTEugene Toy, MDFatma Trabulsi, ABRDonald Tradup, RDMS, RTLan Tran, MDMichele Traves, RT(R), CBDTDara Treadwell, BS, RT(R)(M),RDMSJillian TrullFrancis Tseng, MDJed Turk, MDElizabeth Turner, MS, MDSandra Turner, RDMSJohn Turocy, MD, MSCarol Uher, RDMS, RT(R)R. Peter Ulland, MDTonda Ulmer, RDMS, RDCSRichard Ulrich, BS, RDMSEdet Umana, MD, MBAHeidi Umphrey, MD, MSEvan Unger, MDWilliam Unwin, MDYoginder Vaid, MDCarmen Valderrabano, MDAntoine Van Straalen, MDSue Van ZantenElizabeth Vanderburgh, MDJean-Louis Vanoverschelde, MD,PhDTomy Varghese, PhDEhrlich Varsovia, RDMSSanjay Vasudeva, MDJean-Claude Veille, MDChristina Veit, MDDanilda Veloz, RDMSGwen Venegas, RDMSPriya Venkateswaran, RDMSYvan Vial, MDAlex Vidaeff, MD, MPHS. Boopathy Vijayaraghavan, MD,DMRDRichard Viscarello Jr, MDOlaf Von Ramm, PhDJoni Voss, RT(R), RDMS, RVTRolf Vrla, MDGael Wager, MD, MPH, MBABrent Wagner, MDJason Wagner, MDChu Wai PongLisa Wainright, RT(R), RDMS, RVTCamil Walker, MDJanine Wallin, BS, RDMSCynthia Walsh, MDRodolfo Walss, MDBarbara Walton, RDMSEileen Wang, MDShirley Wang, MDAlice Ward, BS, RDMSDamon Warhus, MDSteven Warsof, MDAntoinina Watkins, MDPeter Watson, MDKevin Weary, MDSandra Weber, RDMSHassan Wehbeh, MDJan Weichert, MDJames Weinstein, MDJudith Weiss, RDMS, BAPatricia Weiss, AAS, RDMSHeather Welch, RDMSHolly Wells, MD, FRCP(C), ABRKaren Wells, MDWilliam Wells, MDTony Wen, MDKatharine Wenstrom, MDConnie Wesley, RDMSCathy Wesner, RDMS, RVTEmily WestEllen Wetter, MDPaul Wexler, MDThomas Wheeler, MDAnita Whistler, RDMS, ROUBKatharine White, MDSanford White, MDAmy Whitley, MDGerrie Whitley, RDMS, RNCraig Whitmore, MDRita Whitton, RDMSJanice Whitty, MD, RNWillyarto Wibisono, MDDavid Wicke, RDMSMarcin WiechecThomas Wigton, MDMartin Wilcox, BSEEThomas Wilkins, MDAlisa Williams, MDJohn Williams III, MDKristi Williams, BS, RT, RDMS, NT(R)Margaret Williams, RT, RDMSSuzanne Williams, RDMSTerri Williams-Weekes, MDCielito Wills, BA, RVT, RDMSDonna WilsonRobert Wilson, MD, MScStephanie Wilson, MDDenise Winder, AS, RDMSMelissa Winstead, RDMSMichael Wise, DVMKerri Wissmueller, RDMS, RVT,RDCS, CCTDexter Witt, DPT, OCSConstance Witte, RTR, RDMSDiane Woelkers, BS, RT(R), RDMSMark Wolf, MDLynlee Wolfe, MDMichael Wolfe, MDRobert Wolfson, MD, PhDWayne Wolfson, MDCynthia Wong, RDMS, AB, BR, OB,NE, RVTEdward Wong, MD, FRCPKeet-Peng Wong, FRCSRoberta Wong, BS, RDMS, RDCSSteven Wong, MDJade Wong-You-Cheong, MD, RVT,FRCRAaron Wray, RDMSAndrew Wright, MDJeffrey Wright, MDTatyana Wright, RDMSMichael Yamazaki, MDDiana Yankowitz, BS, RDMS, RDCSLinxin Yao, PhDAmaryllis Yazon, MDChristopher Yenter, MDDuzgun Yildirim, MDWilliam Yip, MBBS, MMED, MD,MRCP, DCH, FRCPBruce Young, MDDonald Young, DOWarren Young, MDMark Yuhasz, MDMichael Zaladonis Jr, BS, RVTIvica Zalud, MD, PhDJill Zavitsky, RT, RDMSCarolyn Zelop, MDJ. Zetterberg, MD, MBBSSenait ZewdeXiaoming Zhang, PhDYing Zhao, MDMarvin Ziskin, MD, PhDLisa Zorn Smeglin, MDPatricia Zylman, MDxiv

2013 Scientific Program

*Presenter of scientific paper with more than 1 author.

American Institute of Ultrasound in Medicine ProceedingsJ Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSSUNDAY, APRIL 7, 2013, 7:30 AM–11:30 AMRecent Innovations in Gynecologic Ultrasound,Including 3-Dimensional ImagingModerator: Beryl Benacerraf, MDIn this session, advances in 3-dimensional sonography will bediscussed, including practical applications for use in many aspects of gynecologypractice and many conditions.Ultrasound-Guided Procedures for the PediatricPatient: From the Perspective of Both Point-of-Careand Traditional ApproachesModerators: Alyssa Abo, MD, Beth Kline-Fath, MDThe objective of this session is to describe the use of ultrasoundto guide interventions and manage therapy in the pediatric patient by bothpoint-of-care and traditional approaches.SPECIAL INTEREST SESSIONSUNDAY, APRIL 7, 2013, 8:00 AM–9:30 AMHands-on Basic Obstetric Ultrasound and SimulationModerator: Jude Crino, MDParticipants will scan second-trimester pregnant models withsupervision by sonographer and physician experts. Skills taught in thisbasic-level session include image optimization, fetal biometry, and thebasic fetal anatomic survey. Simulation stations for endovaginal scanning,amniocentesis, and fetal blood sampling will be available.SPECIAL INTEREST SESSIONSUNDAY, APRIL 7, 2013, 9:45 AM–11:15 AMHands-on Advanced Obstetric Ultrasound andSimulationModerator: Jude Crino, MDThis session is appropriate for those with experience in basiclevelobstetric ultrasound or who have attended the basic-level hands-onsession. Participants will scan second-trimester pregnant models withsupervision by sonographer and physician experts. Skills taught in thisadvanced-level session include detailed fetal anatomy, Doppler velocimetry,and basic 3- and 4-dimensional techniques. Simulation stationsfor endovaginal scanning, amniocentesis, and fetal blood samplingwill be available.S1

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSSUNDAY, APRIL 7, 2013, 3:15 PM–5:00 PMAdvanced Point-of-Care Cardiac Ultrasound in theEmergency and Critical Care PatientModerator: Robert Arntfield, MD, RDMSEfficient and Effective Point-of-Care Transesophageal Echocardiography:A Proposed Algorithm for Critical CareScott Millington University of Ottawa, Ottawa, Ontario,CanadaIntroduction—The use of transesophageal echocardiography(TEE) in the intensive care unit (ICU) is becoming more prevalent aspoint-of-care ultrasound applications expand in general and as specificproviders seek more advanced training.Problem Identification—Point-of-care TEE differs significantlyfrom comprehensive TEE in that it is goal directed and time sensitive andseeks to integrate ultrasound images with real-time physiology. As such,the traditional sequence of image acquisition applied to comprehensiveTEE exams may not be ideal.Summary—A goal-directed algorithm for point-of-care TEE isproposed, comprising 4 core views applied to all patients and 4 additionalviews that are useful in specific clinical circumstances. The goals are: (1)to efficiently identify pathologies that are common in the ICU; and (2) toidentify those pathologies that are less common but that mandate a majorchange in clinical management strategy.Clinical Applications of Ultrasound Contrast, Part 1Moderator: Richard Barr, MD, PhDContrast Imaging of Abdominal TransplantsPaul Sidhu Radiology, King’s College London, London,EnglandUltrasound examination of liver and renal transplants has revolutionizedpatient management with the addition of color Doppler ultrasound,establishing this technique as paramount in interpreting andinvestigating vascular abnormalities of any transplant organ. The earlypostoperative period is crucial for the establishment of good vascular perfusionto the transplant organ, a cornerstone of further medical management.In liver transplantations, the hepatic artery is crucial to the transplantand the long-term viability of the biliary system. Contrast-enhanced ultrasound(CEUS) will establish the patency of the hepatic artery, identifyareas of stenosis, and identify any potential hepatic pseudoaneurysm. Theintegrity of the portal and hepatic veins may be ascertained. Focal areas ofliver necrosis, abscess formation, and biliary duct dilatation are all clearlydelineated on the CEUS examination. With renal transplantation, theCEUS examination will readily delineate areas of infarction, will depictvascular complications, and has the potential to assess regional and globalperfusion. Similarly with pancreatic transplants, the addition of CEUSmay be seen as an aid in the assessment of the vascular pedicle. Longtermfollow-up is aided with the depiction of recurrence of disease, thedevelopment of hepatocellular carcinoma, and post-transplant lymphoproliferativedisorder. This presentation will detail the use of CEUS intransplants and will adhere to the guidelines issued by the European Federationof Societies for Ultrasound in Medicine and Biology on liver andnonliver applications of CEUS.Hands-on Renal and Mesenteric ImagingModerator: Jennifer McDowell, MM, RDMS, RT, RVTUltrasound Criteria for Renal DiseaseMargarita Revzin Diagnostic Radiology, Yale UniversityHospital, Wilton, Connecticut USADuring this session, we will focus on the spectrum of renal diseasesdetected and diagnosed with Doppler ultrasound, with special emphasison renal artery stenosis. The anatomy and principles of examinationof the native renal vessels will be considered first, followed by a discussionon renal vascular disorders, including renal artery stenosis. In detail,we will review multiple Doppler-based criteria that are used in diagnosisof renal artery stenosis, including peak systolic velocity, renal to aorticratio, waveform analysis, as well as secondary signs of renal artery stenosis.We will review current literature that validates the proposed criteria forrenal artery stenosis and analyze potential pitfalls that may lead to misinterpretationof the findings affecting the number of false-positive or -negativediagnoses.How Does Ultrasound Compare in Safety andRadiation Dose to Other Imaging Modalities?Moderators: George Lewis Jr, PhD, Thaddeus Wilson, PhDFood and Drug Administration Perspective on Diagnostic UltrasoundSafetyKeith Wear, Gerald Harris Center for Devices and RadiologicalHealth, US Food and Drug Administration, SilverSpring, Maryland USADiagnostic ultrasound does not produce ionizing radiation, andit has an excellent safety record over several decades of use. Potential bioeffectsfrom diagnostic ultrasound are categorized into thermal and nonthermalmechanisms. Thermal mechanisms involve heating of tissue. Theconcept of the thermal dose, which involves both a temperature rise andthe duration of exposure, is a useful tool in the study of thermal effects.Nonthermal mechanisms involve mechanical effects, which includestreaming and cavitation. The likelihood of bioeffects is related to acousticoutput. The 1976 Medical Device Amendments require new devices to besubstantially equivalent in terms of safety and effectiveness to legally marketeddevices. Consequently, recommended acoustic output levels arebased on levels produced by devices on the market prior to the enactmentof the 1976 Medical Device Amendments. The thermal index and mechanicalindex, which are indicators of the likelihood of bioeffects, areoften displayed in real time next to the ultrasound image. However, the extentto which these indexes are used to guide examinations is unknown.Several studies indicate the occurrence of observable bioeffects at diagnosticoutput levels.Radiation: The Two-Edged SwordEric Hall Columbia University, New York, New York USAModern medicine would be unimaginable without the use ofx-rays for diagnosis, especially computed tomographic (CT) scans, whichhave revolutionized radiology. Radiation is often described as a two-edgedS2

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013sword because it offers great benefits to mankind but also has the potentialto cause harm. Radiation was shown to be a mutagen in Drosophila byMuller in the 1930s, and for the next 30 years, radiation protection wasbased on the risk of genetic effects. That radiation could induce leukemiaand cancer came from the study of the Japanese A-bomb survivors. Cancerrisks from CT scans, based on the A-bomb data, were published morethan a decade ago and were greeted with skepticism in many quarters butaccepted by pediatric radiologists, who immediately began to reduce radiationdoses. Within the past year, the first epidemiologic studies haveappeared, in which 180,000 children who had received CT scans from1980 to 2008 showed a small statistically significant excess of leukemiaand brain cancers. The epidemiologic studies confirm the estimates fromthe A-bomb survivors and indicate that the risk to an individual is extremelysmall, so that if a CT examination is clinically justified, there is nodoubt that the benefit will exceed the risk. The remaining concern is froma public health perspective, since some 70 million CT scans are performedeach year in the United States. To my knowledge, comparable epidemiologicstudies have never been performed on magnetic resonance imagingor ultrasound, and the expectation that these modalities are “safe” is basedon other considerations.Interventional Musculoskeletal Ultrasound:Steroid Injections, Dry Needling, and Platelet-RichPlasma InjectionsModerator: Levon Nazarian, MDSteroid InjectionsNathalie Bureau Diagnostic Radiology, University ofMontreal Medical Center, Montreal, Quebec, CanadaThis presentation will provide an overview of the tendon structureand the mechanisms of tendon failure. We will discuss the potentialadverse effects and the effectiveness of steroid injections in the treatmentof tendon pathology and present different ultrasound-guided techniques ofsteroid injections. The tendon is a strong connective tissue band, whichtransmits muscular force to the skeleton. Tendons have a hyperechoic fibrillarappearance on ultrasound. The structural and functional properties oftendons enhance with appropriate exercise, deteriorate with disuse, andalter with age. Tendon injury may result from direct trauma, impingement,or friction and from overuse or overload, which may be acute or chronicand 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 managementof tendinosis should initially include some form of conservative treatment,including relative rest, pain control, support, stretching exercises, and correctionof provoking factors. There appears to be some evidence for theeffectiveness of steroid injections in stenosing tenosynovitis such asDe Quervain and trigger finger. Most studies agree that steroid injectionsare effective only in the short term in the treatment of insertional tendinosis.Although there are still no definite evidence-based guidelines forthe use of steroid injections, suggestions include avoiding intratendinousinjections, using caution with peritendinous injections, advising 2 weeksof rest after injection, allowing 6 weeks between injections to assess theeffect, and limiting injections to 3 to any one site.Dry Needling of TendonsLevon Nazarian Radiology, Thomas Jefferson UniversityHospital, Philadelphia, Pennsylvania USAPatients with chronic tendon conditions such as tennis elbowmay reach a stage in which they have to either live with their pain or undergosurgery. Real-time ultrasound guidance has allowed development ofa minimally invasive alternative to surgery, known as percutaneous needletenotomy. This procedure, in which the diseased tendon is repeatedlypunctured by a needle under ultrasound guidance, can induce a healingresponse and subsequent clinical improvement in a large proportion of patients.This presentation will review the technique for percutaneous needletenotomy as well as show evidence from the literature regarding itseffectiveness.Point/Counterpoint: Ultrasound Versus MagneticResonance Imaging in the Diagnosis of PlacentaAccreta, Congenital Diaphragmatic Hernia, andCentral Nervous System AnomaliesModerator: Sherelle Laifer-Narin, MDPlacenta Accreta Magnetic Resonance ImagingSherelle Laifer-Narin Radiology, Columbia University MedicalCenter, New York, New York USAUltrasound has been the primary imaging modality for routineevaluation of the pregnant patient. A routine diagnostic scan involvesdetailed imaging of the fetus to detect fetal anomalies and evaluation of theplacenta to determine mode of delivery and detect possible placentalabnormalities. Over the past 20 years, the use of magnetic resonance imaging(MRI) has been steadily increasing and has been shown to be ofvalue in detecting structural fetal abnormalities as well as placental abnormalities.In this session, we will present the role of diagnostic ultrasoundand the complementary role of MRI in imaging 3 major categories:fetal neurologic abnormalities, congenital diaphragmatic hernia, andabnormal placentation. Advantages and disadvantages for each modalitywill be presented, with time for questions and answers from the panel atthe end of the presentations.Ultrasound in Global HealthModerator: Sachita Shah, MD, MPHIntroduction to Ultrasound in Global Health: Strategies for Startingan Ultrasound Program in a Low-Resource SettingSachita Shah Emergency Medicine, University of WashingtonSchool of Medicine, Seattle, Washington USA; Partners InHealth, Boston, Massachusetts USAWith improvements in portability, durability, and affordability,point-of care ultrasound has reached the bedsides of the most vulnerablepopulations in the developing world. Due to the lack of specialists in radiologyand sonography in much of the developing world, a need for ultrasoundtraining programs focused on clinicians exists. An ever-expandingbody of literature has grown to support the use of bedside point-of-careultrasound performed by nonradiologist physicians, nurses, and clinicalofficers in developing nations in clinical patient care. Creating a sustainableultrasound program in a low-resource setting requires much morethan ultrasound equipment and good will but is an important way to makea long-term impact on a low-resource community. In this session, we willdiscuss strategies for implementing a successful ultrasound service programin a low-resource setting, including opportunities for potential equipmentdonation and organizations of interest, host hospital leadership andinfrastructure, features of ideal equipment, homemade coupling agents,how to conduct a needs assessment and plan a training course, pitfalls andbarriers to ultrasound programs, and safety and machine maintenance inlow-resource settings.S3

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Point of Care Ultrasound in Resource-Limited Settings: Case ReviewKrithika Muruganandan Emergency Medicine, BrownUniversity, Providence, Rhode Island USAOver the years, the portability and versatility of ultrasound haveresulted in its extension from the hospital setting to disaster relief, militarymedicine, and the austere and resource-limited setting. It has moved fromthe hands of the specialist to the generalist physician. When developing acurriculum to train generalist physicians in resource-limited settings, ultrasoundeducation must be tailored to their wide scope of practice whileaddressing local disease patterns and available resources. In addition tothe common uses of ultrasound used by emergency physicians locally,point-of-care ultrasound in the resource-limited setting is valuable for abroader range of pathologies. Cardiopulmonary ultrasound should includeassessment for rheumatic valvular disease, pericardial and pleural effusionsrelated to tuberculosis and human immunodeficiency virus infection,cardiomyopathy, pulmonary edema, and parenchymal disease.Abdominal ultrasound education should include evaluation of amebicliver abscesses, echinococcal cystic disease, cirrhosis, hydronephrosis,nephropathy, and evaluation of abdominal free fluid (focused assessmentwith sonography for trauma exam). Soft tissue ultrasound should includeevaluation for abscesses, pyomyositis, and cellulitis. Obstetric ultrasoundperformed by the generalist physician should include evaluation for intrauterinepregnancy, fetal heart rate, placenta positioning, presentation,and fetal dating. Ultrasound guidance for procedures such as thoracentesis,paracentesis, central and peripheral intravenous line placement, andsuprapubic catheter placement may be useful in decreasing morbidity andmortality. This presentation will review interesting cases in which bedsideultrasound was instrumental in correctly identifying pathology unique toresource-limited settings, thus directing correct patient treatment.S4

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSMONDAY, APRIL 8, 2013, 8:15 AM–10:15 AMAdvances in Clinical and Quantitative PediatricLung UltrasoundModerators: Philip Levy, MD, Michael Oelze, PhDPerspectives and History of Clinical Lung UltrasonographyDaniel Lichtenstein Medical Intensive Care Unit, HôpitalAmbroise-Paré, Boulogne, FranceLung ultrasonography is one part of critical ultrasound, but itsintegration provides a new definition of priorities in diagnosis and management.This application requires a simple machine, the knowledge ofbasic techniques, and the mastery of no more than 10 signs. The best machineis the simplest; we use 1992 technology with simple gray scale withoutDoppler and a microconvex probe to acquire the images. The 10 signsthat are found in children and neonates are the same as those assessed inadults. They include the bat sign (indicating the pleural line), lung sliding(yielding the seashore sign), the A-line (horizontal artifact), the quad signand the sinusoid sign (indicating pleural effusion regardless of itsechogenicity), the tissue-like sign and the shred sign (indicating lung consolidation),the B-line and the lung rockets (vertical comet tail artifacts indicatinginterstitial syndrome), abolished lung sliding with the stratospheresign (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 from90% to 100%, allowing us to consider ultrasound as a reasonable bedsidegold standard in the critically ill. Major applications include the possibilityto postpone referral to CT in critically ill patients, immediate diagnosisand cause of an acute respiratory failure (BLUE protocol), and a directparameter of clinical volemia, of interest in the management of acute circulatoryfailure (FALLS protocol). In summary, clinical lung ultrasonographycan be performed in trauma, the intensive care unit, as well asremote areas and has led to a major decrease in irradiation.Quantitative Acoustic Properties of the Lung: An Open QuestionPeder Pedersen Worcester Polytechnic Institute, Worcester,Massachusetts USAThis presentation will give an overview of pulmonary ultrasoundresearch over the last 50 years. Between 1960 and 1985, severalstudies were carried out, which showed that very high attenuation representsthe main challenge of obtaining ultrasound diagnostic informationabout the adult lungs, even in their fully collapsed state and using frequenciesof

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013This session will discuss combining modalities for challenging clinicaldilemmas in both urgent and nonurgent settings. The speakers will reviewa variety of topics that illustrate when ultrasound alone is sufficientfor diagnosis and when obtaining additional clinically useful informationfrom computed tomography and/or magnetic resonance imaging is optimal.These topics include the enlarged uterus, uterine anomalies, adnexaltorsion, pelvic inflammation of gynecologic origin, pelvic lesions secondaryto bowel disease, pelvic malignancy, evaluation of pelvic pain inpregnancy, and biopsy/aspiration of pelvic lesions. The lessons of thissession will be reinforced by means of a series of “test” cases using audienceparticipation.Hemodialysis Vascular AccessModerator: John Blebea, MD, MBAFlow Measurement to Predict Access FailureDavid Vilkomerson DVX, LLC, Princeton, New Jersey USAprompting the United States Food and Drug Administration to issue a“black box” for both of the commercially available perflutren-containingUS contrast agents (Definity and Optison), warning of risks of serious cardiopulmonaryreactions, and contraindicating their use in patients withcritical cardiopulmonary conditions. Considerable debate about the safety,risks, and benefits of US contrast agents ensued and prompted the publicationof numerous single- and multi-center retrospective and prospectiveanalyses, all demonstrating a good safety profile, with a favorable balanceof risks and benefits, comparable to, or better than, contrast agent use inother imaging modalities. Subsequently, although the black box remains,several revisions of product labeling have occurred, which have resultedin softening and/or removal of previous warnings and precautions, simplificationof contraindications to the original concerns regarding intracardiacshunting and known hypersensitivity, and expansion of indicationssuch that stress imaging was no longer an exclusion. In summary, US contrastagents have a favorable risk/benefit profile in patients requiring improvedendocardial visualization for rest and stress echocardiographicimaging, and use for this purpose is currently required by US accreditationorganizations.Blood flow is high when a graft is placed and goes to zero whenit clots. Stenoses almost always cause this reduction in flow. It seems reasonable,then, to measure graft flow and, when it falls to a level indicatingan impending clot, to treat the stenoses and prevent the graft failure. Tenyears ago, 2 randomized clinical trials were undertaken to establish the validityof this approach; both showed that monthly flow surveillance led tomore procedures but failed to reduce graft failures. Many suspected thatmore frequent flow measurements might be more effective. We developed,with National Institutes of Health/National Institute of Diabetes andDigestive 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 bequick, inexpensive, and accurate in predicting graft failure. On the basis ofthese results, a clinical trial was begun. Dialysis volunteers were randomizedto a surveillance group, who had their graft flow measured andrecorded every week, and a control group, who continued to receive conventionaltreatment, including monthly flow measurements. After 21months, in the surveillance group measured “per protocol,” only 8% hadgrafts 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 delaysin treatment prevented the trial from meeting its goal of reduced graftfailures. However, having a record of the graft flow after the missed signsallowed us to determine the important parameter of how fast grafts clotafter reaching the impending failure criteria: about 70% of grafts clotted inless than a month after meeting the criteria. The most common interval betweenthe signs of impending failure and thrombosis was 1 week. Lesson1: Monthly flow surveillance can never, no matter the method, significantlyreduce graft failures. Another result of having weekly flow data was beingable to correlate postintervention graft flow with the succeeding graft history.Lesson 2: If postintervention flow is 950 mL/min, >70% will be patent after 21 months.New Horizons in Contrast UltrasoundModerator: Paul Dayton, PhDSafety Aspects of Contrast UltrasoundSharon Mulvagh Medicine, Mayo Clinic, Rochester, MinnesotaUSAIn the mid to late 2000s, several years after approval of ultrasound(US) contrast agents for enhancement of endocardial borderdefinition and improved feasibility and quality of echocardiographic examinations,postmarketing surveillance suggested a “safety signal,”S6Review of Molecular ImagingJoshua Rychak Targeson, Inc, San Diego, California USAContrast ultrasound is an emerging technique for imaging tumorprogression, both in clinical and research settings. In particular, targetedmicrobubbles are now being used as molecular contrast agents for molecularimaging of angiogenesis, thrombosis, and inflammatory disease.This presentation will review developments in the field over the pastdecade and attempt to trace the path from proof of concept to the introductionof commercial formulations for research and clinical use. Early incarnationsof microbubbles for molecular imaging used antibody-targetingligands conjugated using a biotin-avidin scheme. This system has provedto be remarkably robust and, with several modifications, has emerged intoseveral widely used commercial products for small-animal imaging. Extendingultrasound molecular imaging to larger research species presentssome challenges: antibodies are not always readily available to the desiredmolecular target for rabbits, canines, and swine, and the large volume ofmicrobubble product required per dose makes cost a constraint. The useof small-molecule ligands that offer activity in a variety of species (andwhich can generally be made at low cost) can overcome this limitation. Replacementof biotin-avidin conjugation with covalent-coupling chemistriescan further reduce the cost and improve the consistency of the microbubbleproduct. Selection of conjugation chemistry, in addition to the ligandand shell components, proves to be an important aspect when translatingto human use. In addition to their incarnation as reagents for biomedicalresearch, the first generation of ultrasound molecular imaging agents arenow entering clinical trials.Microvascular MappingPaul Dayton, 1 * Ryan Gessner, 1 Stephen Aylward 21Biomedical Engineering, University of North Carolina, ChapelHill, North Carolina USA; 2 Kitware, Inc, Carrboro, NorthCarolina USAMicrobubbles are unique as ultrasound contrast agents in thatthey are constrained to the microvascular space due to their large size, andthey can be detected with high sensitivity due to their unique echo signatures.Through application of transducers and imaging strategies optimizedto achieve high resolution and high signal to noise coupled with 3D approaches,it is possible to obtain maps of microvascular structures associatedwith healthy and pathologic tissue. It is well known that angiogenicprocesses involved in rapidly growing tumors promote increased vesseldensity, tortuosity, and other structural abnormalities. Using vessel segmentationmethods, vessel patterns can be identified and characterizedfrom contrast ultrasound data. We demonstrate that these “microvascularmaps” can be used to characterize tissue volumes as tumor bearing or

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013healthy, based on microvessel morphologic differences. Thus, contrastenhancedacoustic angiography presents a means to detect the presenceof tumors based on observed microvascular abnormalities, without theneed to evaluate the tumor mass itself.Pediatric Hepatobiliary DisordersModerator: Rob Goodman, MDSonographic Differential Diagnoses in Pediatric Focal Liver LesionsRob Goodman Yale University, New Haven, ConnecticutUSASonographic analysis of the pediatric liver is often the first imagingused that detects a focal liver lesion. Assessment of the sonographicappearances of these lesions can sometimes be challenging if one is expectedto determine a likely cause. The spectrum of conditions that giverise to focal liver lesions in a child is broad, and many lesions have similarsonographic appearances. In this session, congenital, inflammatory,traumatic, neoplastic (benign and malignant), vascular, and metaboliccauses of focal liver lesions will be discussed, and specific clinico-sonographicfeatures used to distinguish between these will be emphasized.With the help of these features, the practicing pediatric sonographer willbe able to more accurately reach an appropriate diagnosis.The Spectrum of Ultrasound Findings in the Pediatric Biliary TreeValerie Ward Radiology, Boston Children’s Hospital, Boston,Massachusetts USA3-hour time window. Systemic tPA administration remains the fastest wayto initiate treatment for acute ischemic stroke. Since tPA works by inductionof partial recanalization of large thrombi, early augmentation of fibrinolysisto improve recanalization is desirable. This augmentation isfeasible and can be safely achieved at the bedside with transcranialDoppler (TCD), or sonothrombolysis. In the CLOTBUST trial, all patientsreceived systemic tPA as the standard of care, and 73% of patientsachieved any recanalization (46% complete, 27% partial) with tPA + TCDvs 50% (17% complete, 33% partial) with tPA alone within 2 hours oftreatment (P < .001). Sustained complete recanalization at 2 hours was38% vs 13%, respectively (P = .03). A recent meta-analysis of 6 randomizedand 3 nonrandomized clinical studies of sonothrombolysis showedthat any diagnostic ultrasound monitoring can at least double the chanceof early complete arterial recanalization at no increase in the risk of symptomaticintracerebral hemorrhage. Transcranial ultrasound delivery in anoperator-independent and dose-controlled manner was successfully testedin phase I and II clinical studies in stroke-free volunteers and stroke patientstreated with systemic tPA. A novel operator-independent device forsonolysis (Cerevast Therapeutics, Inc) is now being tested in a pivotalphase III clinical trial (CLOTBUSTER, NCT01098981).Animal Models of Sonothrombolysis and Drug DeliveryChristy Holland, 1 * Jonathan Sutton, 1 Nikolas Ivancevich, 2Stephen Perrin, 1 Deborah Vela 3 1 Internal Medicine, Divisionof Cardiovascular Diseases and Biomedical EngineeringProgram, University of Cincinnati, Cincinnati, Ohio USA;2Siemens Medical Solutions, Issaquah, Washington USA; 3 CardiovascularPathology, Texas Heart Institute, Houston, TexasUSAUltrasound is the imaging modality of choice for the initial andnoninvasive evaluation of biliary diseases in newborns, infants, youngchildren, and adolescents. Initially in this presentation, patient preparation,sonographic technique, and common clinical indications for sonographyof the biliary tract will be reviewed. Then both the common andinfrequent etiologies for biliary disease in children, including cholestasis,cholelithiasis, choledochalithiasis, cholecystitis, cholangitis, choledochalcysts, and biliary atresia, will be discussed. Also, the correlation of prenataland postnatal sonography will be presented for specific biliary tract diagnosesthat can be diagnosed in the fetal period. Where applicable, the benefitsof combining sonography with other biliary tract imaging modalities(such as hepatobiliary scintigraphy, cholangiography, and magnetic resonancecholangiopancreatography) will be also discussed as adjuncts in theevaluation of pediatric biliary tract abnormalities.Taboos and Opportunities in Sonothrombolysis forStroke: From Sonothrombolysis in Animals to StrokeTreatment in PatientsModerators: Tatjana Rundek, MD, PhD,Paul Sierzenski, MD, RDMSUps and Downs in Clinical Trials of SonothrombolysisAndrei Alexandrov Comprehensive Stroke Center, Universityof Alabama, Birmingham, Alabama USAIntravenous tissue-type plasminogen activator (tPA) remainsthe only effective reperfusion therapy to reverse ischemic stroke. Its timelydelivery to all eligible patients should be a priority in development ofstroke treatment centers and ambulance delivery systems. Its augmentationwith ultrasound will be discussed. Despite lower revascularizationrates with respect to endovascular thrombectomy, patients treated withsystemic thrombolysis achieve good functional outcomes likely due toearlier treatment initiation. Currently, no evidence exists that primary intraarterialrevascularization could be any better than systemic tPA within theS7Ultrasound-mediated thrombolysis, or sonothrombolysis, is anattractive adjuvant to conventional recombinant tissue-type plasminogenactivator (rt-PA) therapy for acute ischemic stroke and other thromboocclusivediseases. Numerous in vitro and ex vivo porcine studies havedemonstrated ultrasound-enhanced clot lysis, yet recent clinical trials haveproduced mixed results. Stable cavitation nucleated by an ultrasound contrastagent enhances the penetration of both rt-PA and plasminogen intoclots. This enzymatic fibrinolysis is likely hastened due to an increasedavailability of plasminogen binding sites for rt-PA. However, the degreeof clot retraction strongly affects the extent of thrombolytic efficacy. Thelack of dense fibrin matrix formation throughout unretracted clots promotessusceptibility to ultrasound-enhanced thrombolysis. In contrast, thepaucity of plasminogen present within retracted clots prevents ultrasoundacceleration of lysis. Thus, the thrombus etiology and vascular origin maypredispose the degree of sonothrombolytic susceptibility. Recent clinical,in vitro, and ex vivo data from a variety of clot models will be discussed.Neurovascular Ultrasound in Stroke: What Sonographers Can Do NowTatjana Rundek Neurology, University of Miami MillerSchool of Medicine, Miami, Florida USANeurovascular examination is widely used for assessment ofpatients in the acute, subacute, or chronic phases of cerebral ischemia. Theavailability of aggressive and effective treatments, which can be potentiallyharmful for acute ischemic stroke patients, requires fast and noninvasiveexamination of the intracranial and extracranial vasculature.Effective stroke therapy can be improved through real-time ultrasoundmonitoring of the neurologic and cardiovascular responses to treatments.This requires crucial knowledge on behalf of both the sonographer andstroke physician to make the best decisions for the patient, which wouldminimize the ischemic damage caused by stroke and reduce the risk ofsubsequent stroke. Current ultrasound techniques, transcranial Dopplerand extracranial duplex or color Doppler, have the potential to providecrucial and reliable information about the status of the intracranial and extracranialarteries in a real time. Application of echo-enhancing agentspromises to effectively extend current diagnostic techniques. Application

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013of sonothrombolysis carries a promise to revolutionize the approach totreatment of acute stroke and improve stroke outcome. The clinical significanceof neurovascular ultrasound, however, needs to be evaluatedprospectively and preferably in an unbiased setting of clinical trials. Thispresentation will address the basics of neurovascular ultrasound in the examinationof stroke patients, the interpretation of ultrasound studies, andthe application of neurovascular ultrasound in the management and treatmentof stroke. The role of sonographers will be emphasized, as neurovascularultrasound is an important, user-friendly, noninvasive, andlow-cost diagnostic and possibly therapeutic tool for patients with ischemiccerebrovascular disease.Therapeutic Ultrasound: Lessons Learned and What Should BeReportedMark Schafer Sound Surgical Technologies, LLC, Louisville,Colorado USAWhile 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 thespecifics of pressure, intensity, etc, but also of the underlying mechanismsof action. Proper disclosure of the acoustic properties involved will aid inthe further development of the field, guiding future research. The first partof this presentation will review the basics of proper reporting, whichshould be included with any presentation of sonothrombolysis results.Pressure, intensity, frequency, and acoustic field distribution informationare 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 operatorindependentultrasound therapy device to treat ischemic stroke, which wasspecifically designed to incorporate full dosimetric data. The ultrasounddelivery system includes a multiple-transducer transcranial head framecomprising broadband (1.0–2.5 MHz) transducers placed at the temporalwindows (6 on each side) and the suboccipital window (6 additional transducers).A computer-controlled ultrasound generator receiver system couldenergize 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 inthe system. During operation, the system logged all exposures in real timefor later analysis. The system is now in clinical tests with stroke patients.This system exemplifies the utility of dosimetry/exposimetry in practice.SPECIAL INTEREST SESSIONMONDAY, APRIL 8, 2013, 11:00 AM–12:30 PMHow to Be an Effective Manuscript Reviewer for theJournal of Ultrasound in MedicineModerator: Levon Nazarian, MDHow to Be an Effective Manuscript Reviewer for the Journal ofUltrasound in MedicineLevon Nazarian Radiology, Thomas Jefferson UniversityHospital, Philadelphia, Pennsylvania USAPeer review is the method used worldwide to determinewhether manuscripts are suitable for publication, yet few physicians andsonographers are given formal instruction in how to review journal manuscripts.The purpose of this session is to describe the steps in the peerreviewprocess at the Journal of Ultrasound in Medicine (JUM), to presentthe components that constitute a high-quality review, and to discuss ethicalissues such as conflicts of interest, duplicate publication, and plagiarism.By demystifying the peer-review process and letting reviewers knowwhat is expected of them, the ultimate goal is to improve the quality ofmanuscripts published in the JUM.S8

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SCIENTIFIC SESSIONSMONDAY, APRIL 8, 2013, 11:00 AM–12:30 PMBasic Science: Tissue Characterization, Part 1Moderators: Keith Wear, PhD, Mark Holland, PhD1539806 A Feasibility Study of Ultrasound Strain Imaging for RiskAssessment of Carotid Atherosclerotic Plaques Validatedby Magnetic Resonance ImagingXiaochang Pan, 1 Shengzhen Tao, 1 Lingyun Huang, 2 ManweiHuang, 3 Xihai Zhao, 1 Le He, 1 Chun Yuan, 1,4 Jianwen Luo, 1 *Jing Bai 1 1 Biomedical Engineering, School of Medicine,Beijing, China; 2 Philips Research Asia, Shanghai, China;3Ultrasonography, Meitan General Hospital, Beijing, China;4Radiology, University of Washington, Seattle, Washington USAObjectives—Conventional B-mode ultrasound images andDoppler/color flow measurement are mostly used to evaluate the degreeof carotid atherosclerotic plaques, but they have a lack of histologic validation,while the correspondence between multicontrast magnetic resonanceimaging (MRI) sequences and histology has been constructed. Wepropose a comprehensive MRI and ultrasound feasibility study to quantitativelymeasure morphologic and mechanic properties of carotid atheroscleroticplaques and develop a risk indicator for plaques.Methods—Sequences of raw ultrasound (radiofrequency) datawere acquired from a 65-year-old male patient with carotid plaques on aPhilips iU22 ultrasound system. The interframe strain of the plaques wasestimated to indicate relative stiffness of different plaque compositions,using a coarse-to-fine 2D speckle-tracking algorithm based on cross-correlationand correlation filtering. The same patient underwent doubleblindedMRI scanning on a Philips Achieva 3T TX MR scanner using amulti–contrast imaging protocol. 3D MR images of this patient were reconstructed,and slices at the same position of the ultrasound incidenceangle were selected and registered. Carotid plaque tissue compositions onMR images were characterized according to published criteria, whileechogenicity and strain values in the ultrasound images were investigatedand compared with MRI results.Results—The plaques with intraplaque hemorrhage (IPH) or alipid-rich necrotic core (LRNC) on MR images were defined as high risk.In the ultrasound results, the calcified area of the plaque showed highechogenicity and low deformation (0.2%); IPH showed mid to highechogenicity and intermediate deformation (1.2%), and the LRNC showedthe lowest echogenicity and large deformation (2.6%). The locations ofthe calcification, IPH, and LRNC were in good agreement with findingson MR images.Conclusions—We performed a quantitative measurement ofthe morphology and mechanical properties of high-risk plaques andshowed that the combination of echogenicity and strain values obtainedfrom raw ultrasound data is feasible to quantitatively evaluate the vulnerabilityof atherosclerotic plaques.1536174 A Huber-Penalized Akaike-Regularized Broken-Stick LeastSquares Regression Algorithm for Shear Wave Velocity ReconstructionAtul Ingle, 1 * Tomy Varghese 1,2 1 Electrical and ComputerEngineering, 2 Medical Physics, University of Wisconsin, Madison,Wisconsin, USAS9Objectives—Tissue stiffness has been traditionally used as aqualitative metric for localizing cancerous tumors. The aim of this studyis to obtain quantitative stiffness estimates using electrode vibration elastography(EVE). It may be easier to distinguish stiffer tumors from healthytissue from local shear moduli than inspecting B-mode images. This workproposes a statistically robust least squares fitting technique capable ofdetecting boundaries between materials with different shear wave velocities(SWVs).Methods—In an EVE tissue-mimicking phantom, an ablationelectrode attached to an inclusion and vibrated by an actuator is used togenerate shear waves. Ultrasound displacement estimators are used totrack the shear wave pulse and record its arrival time at different locations.Assuming this plot is continuous and piece-wise linear, slopes and breakpoints are detected using a least squares fit embellished with a Huberpenalty. This penalty function switches from quadratic to linear for verylarge errors, thereby mitigating the effect of outliers. An Akaike informationcriterion is then used to trade off the error in the fit and the number ofbreak points. The SWV estimates are compared with a commercial shearwave imaging system and mechanical testing.Results—SWV estimates are within 20% of those obtainedusing the commercial scanning system. Although the stiffness estimatesare lower than those obtained from mechanical testing, the boundary delineationis quite good due to sharp transitions arising from the piece-wiselinear fits.Conclusions—The use of statistically robust noise filteringtechniques shows promise for improving results in the inverse problem ofshear stiffness reconstruction from noisy ultrasound displacement data.(Supported by National Institutes of Health grants R01CA112192-05 andR01CA112192-S103.)Table 1SWV, m/sYoung Modulus, kPaRegionMechanicalof Interest EVE SSI EVE SSI TestingInclusion 3.4 ± 1.5 2.8 ± 1.1 42.2 ± 58 24.2 ± 5.8 54.4 ± 0.1Partially ablated 2.0 ± 0.3 2.3 ± 0.8 12.1 ± 4.2 13.3 ± 3.5 21.6 ± 0.3Background 1.4 ± 0.4 1.3 ± 0.4 6.5 ± 6.1 4.8 ± 0.5 3.7 ± 0.1SSI indicates supersonic shear imaging.1540416 A Comparison of Coherence of Radiofrequency DataFrom Ablated and Unablated Liver Tissue Using MultitaperEstimationNicholas Rubert,* Tomy Varghese University of Wisconsin,Madison, Wisconsin USAObjectives—Thermally ablated liver tissue presents as a zone ofmixed echogenicity on B-mode imaging, making it difficult to delineatethe extent of treatment following thermal ablation. We demonstrate a novelcontrast mechanism for ultrasonic imaging of thermal ablations based onthe spatial distribution of acoustic scatterers. The portal triads and centralvein of the liver are arranged in repeating subunits, which are hypothesizedto correspond to quasi–periodically arranged acoustic scatterers. Estimatesof the mean scatterer spacing (MSS) of these quasi–periodic scatterershave been hypothesized to be useful indicators of pathologic changes tothe liver. Mathematically, the quasi–periodic scatterers gives rise to an ultrasoundradiofrequency (RF) signal-possessing coherence.Methods—Coherence is a frequency domain quantity computedwith tapered fast Fourier transforms of the ultrasound signal. Usingsimulation, we show that a coherence estimate using multiple orthogonaltapers outperforms coherence estimates computed with a single taper. We

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013also perform receiver operating characteristic (ROC) analysis of 38 regionsof interest (ROIs) from ex vivo bovine livers. Ultrasound imagingwas performed using a 9L4 transducer on a Siemens S2000 system priorto and following RF thermal ablation in 19 independent samples cut from4 bovine livers. Each ablation was approximately 1 to 2 cm in diameter.Results—In frequency domain Monte Carlo simulations, themultiple taper (MT) method was better able to estimate the MSS ofgamma-distributed scatterers than any single taper (ST) calculations. Inanalyzing 2 different ROI sizes ex vivo, we found that for a gate length of5 mm, we achieved an area under the ROC curve of 0.89, while at a gatelength of 7 mm, we achieved an area under the ROC curve of 0.93 usingMT coherence calculations.Conclusions—ROC analysis indicates that a tissue classifierusing coherence is able to distinguish between ablated and unablatedtissue and that an MT calculation of coherence is a better estimate than anST calculation. (Supported by National Institutes of Health grantsR01CA112192-05, R01CA112192-S103, and T32 CA09206-31).1540510 Acoustic Radiation Force Impulse Delineation of HumanCarotid Atherosclerotic Plaque Composition and StructureIn VivoTomasz Czernuszewicz, 1 Melissa Caughey, 2 Peter Ford, 3Mark Farber, 3 William Marston, 3 Raghuveer Vallabhaneni, 3Jonathon Homeister, 4 Matthew Mauro, 5 Timothy Nichols, 2,4Caterina Gallippi 1 *1 Joint Department of Biomedical Engineering,2 Medicine, 3 Surgery, 4 Pathology and Laboratory Medicine,5 Radiology, University of North Carolina, Chapel Hill,North Carolina USAObjectives—Conventional atherosclerosis imaging methodsrely on detecting luminal obstruction, which may not occur until late stagesof disease progression and does not reflect plaque rupture potential. Plaquedetection may be expedited and risk assessment improved by imagingmethods that describe the plaque composition and structure. We have previouslyso demonstrated acoustic radiation force impulse (ARFI) ultrasoundpreclinically with immunohistochemical validation. The objectiveof this work was to similarly validate ARFI in human atherosclerosis. Wehypothesize that ARFI delineates the fibrous cap, lipid/necrotic components,fibrous tissue, and calcium deposits in human atherosclerotic plaquein vivo.Methods—ARFI imaging was performed using a SiemensAcuson Antares imaging system with modifiable beam sequencing and aVF7-3 transducer in the carotid arteries of 2 patients undergoing clinicallyindicated carotid endarterectomy. Imaging was performed presurgicallyby focusing on the surgical plaque. After surgery, the extracted specimenwas sectioned according to noted arterial geometry for spatial registrationto the imaging plane. The sections were stained with hematoxylin-eosin,Verhoff van Gieson, Masson trichrome, and von Kossa. Parametric 2DARFI images of peak displacement (PD) were rendered.Results—In a fibroatheromatic plaque, 3 times higher ARFIPD was measured in the position of a soft lipid/necrotic region than in theposition of a thick fibrous cap above the region or fibrotic tissue below theregion. ARFI PD was nearly zero in positions of small (5 µm in the adjacent arterial tissue.Conclusions—These spatially matched ARFI and immunohistochemicaldata suggest that ARFI is relevant to describing the atheroscleroticplaque composition and structure in humans in vivo. The resultsalso demonstrate the feasibility of collecting data to perform a larger-scalestatistical reader study to evaluate human ARFI atherosclerosis imagingperformance using spatially matched immunohistochemistry as the validatingstandard.S101539520 Echocardiography-Based Measurements of 3-DimensionalMyocardial Fiber StructureMichelle Milne, 1 Kirk Wallace, 4 Benjamin Johnson, 1 GautamSingh, 2 Ravi Rasalingam, 3 James Miller, 1 Mark Holland 1,2 *1Physics, 2 Pediatrics, 3 Internal Medicine, Washington University,St Louis, Missouri USA; 4 GE Global Research, Niskayuna,New York USAObjectives—Previous studies from our laboratory demonstratedthat quantitative measurements of myocardial fiber structure for individualhearts can be derived from analyses of echocardiographic images.Echocardiography-based measurements of fiber structure at specific transverseplanes agreed well with those obtained using diffusion tensor magneticresonance imaging methods. The objective of this study was toextend the echocardiography-based measurements to produce 3D myocardialfiber structure images of the entire heart.Methods—A series of 2D apical echocardiographic imageswere acquired from each of 7 excised intact sheep hearts using a GE Vivid7 clinical imaging system. Myocardial fiber orientations corresponding tospecific distances from the apex of the heart were generated from analysesof radial line backscatter profiles within the ventricular walls of theheart in conjunction with a previously determined relationship betweenthe backscatter level and the angle of insonification relative to myocardialfiber orientation. The fiber orientations at each measured distancefrom the apex were assembled to produce a 3D fiber orientation image ofthe entire heart. In addition, 3D volumetric apical echocardiographic imageswere acquired from a subset of the excised hearts for comparison.Results—3D images depicting myocardial fiber structure obtainedfrom analyses of echocardiographic data appear consistent with theknown fiber structure of the heart. Images demonstrate left ventricularmid-myocardial fibers oriented within the short-axis plane and graduallybecoming more longitudinally oriented toward the epicardial and endocardialsurfaces. Data from 3D volumetric apical echocardiographic imagessuggest similar results.Conclusions—These results demonstrate that measurementsof 3D myocardial fiber structure of the entire heart can be successfullyderived from analyses of echocardiographic images. Further developmentof this method may provide a method for mapping the myocardial fiberorientation in individual patients over the heart cycle and provide a meansfor assessing potentially altered fiber structure associated with congenitaland acquired heart diseases. (Supported by National Institutes of Healthgrant R01 HL040302.)1541124 Effects of Preprocessing on Reconstructed Shear WaveSpeeds in Human Liver In VivoNed Rouze, 1 * Seung Yun Lee, 1 Michael Wang, 1Mark Palmeri, 1 Manal Abdelmalek, 2 Kathryn Nightingale 11Biomedical Engineering, Duke University, Durham, NorthCarolina USA; 2 Medicine, Division of Gastroenterology, DukeUniversity School of Medicine, Durham, North Carolina USAObjectives—Time-of-flight methods are often employed to providequantitative measurement of shear wave speed (SWS) from ultrasonicallytracked displacements following acoustic radiation forceexcitation in liver. These methods estimate overall group velocities ofpropagating shear waves and generally require filtering to reduce noiseand motion artifacts. In addition, different systems employ different beamgeometries in their push excitations, which also leads to differences in theshear wave frequency content. Differences in the shear wave frequencycontent can lead to differences in the estimated SWS due to the dispersivenature of hepatic tissue. In this study, we investigated the impact of theseeffects in a nonalcoholic steatohepatitis patient population from data obtainedin an Institutional Review Board–approved protocol.Methods—Data from >170 patients with a range of fibrosisstages were processed using multiple filtering algorithms. Three types ofmotion filters were applied, including a quadratic motion filter, a high-

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013pass filter (HPF) with an adjustable cutoff frequency, and differentiationof the displacement vs time data. The latter determines the axial velocityof the propagating pulse and allows the wave arrival time to be determinedfrom the peak slope of the leading edge. This differentiation acts as a rampfilter in the frequency domain to reduce the effects of low-frequency motion.After filtering, SWSs were estimated using the arrival time as a functionof position data and the radon sum algorithm.Results—Results obtained to date indicate that the applicationof motion filters does affect the reconstructed SWS. Both the HPF anddifferentiation filter bias the estimated group velocity to the higher phasevelocity components; this effect is less significant for the quadratic filter.The differentiation filter leads to an ≈16% increase in SWS estimates overthe 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 lowfrequencynoise and motion artifacts from in vivo data can skew groupvelocity SWS estimates toward the higher phase velocity components.1540991 Evaluation of Shear Wave Elasticity Imaging for Characterizingthe Contribution of Coronary Perfusion to CardiacDiastolic StiffnessMaryam Vejdani-Jahromi,* Annette Kiplagat, YoungJoong-Kim, Douglas Dumont, Gregg Trahey, Patrick WolfBiomedical Engineering, Duke University, Durham, NorthCarolina USAObjectives—Heart failure is one of the leading causes of deathin the world in which mechanical properties of the cardiac tissue are damaged.Diastolic heart failure occurs when the left ventricle loses its complianceto receive a sufficient volume of blood. Currently, there is nouniversally accepted technique to evaluate changes in mechanical propertiesof cardiac tissue. Shear wave elasticity imaging (SWEI) is an ultrasound-basedtechnique used to evaluate the stiffness of the tissue bymeasuring the shear wave speed of propagation. To evaluate the capabilityof SWEI in determining the contribution of coronary perfusion to diastolicstiffness, normal and hypoperfused rabbit hearts were studied.Methods—Six rabbit hearts were isolated on a Langendorffpreparation, perfused with Tyrode solution. Data were acquired using aVF10-5 linear transducer on a Sonoline Antares ultrasound system (SiemensMedical Solutions, Mountain View, CA) with a focal point of 1.6 cm, transmitfrequency of 5.7 MHz and F-number of 1.5. The probe was fixed approximately1 cm from the left ventricular free wall along the short axis andacquired data from the same location. Hypoperfusion was done in 3 isolatedhearts by reducing the perfusion pressure until the flow rate was half of normal,and SWEI data were recorded before and 10 minutes after. Three rabbithearts with a normal flow rate were studied as control subjects.Results—Initial results showed that reduction of 50% in perfusionpressure caused an average decrease of 27.7% in the shear wave velocityand 47.7% in the shear modulus, while normal hearts showedincreases of 9.0% and 18.7% for the shear wave velocity and shear modulus,respectively.Conclusions—From these preliminary data, we conclude thatthe shear wave velocity and shear modulus recorded by SWEI can showthe contribution of coronary perfusion pressure to diastolic stiffness. Thisnew ultrasound-based imaging modality can be used to assess, characterize,and quantify the mechanical properties of the heart.Table 1Hearts Shear Wave Velocity, m/s Shear Modulus, kPaHypoperfused before 1.69 2.84Hypoperfused after 1.22 1.49Normal before 1.23 1.50Normal after 1.34 1.79S111540671 Feasibility and Reproducibility of Right Ventricular StrainMeasurement by Speckle-Tracking Echocardiography inPreterm InfantsPhilip Levy, 1 * Gautam Singh, 1 Tim Sekarski, 1 Aaron Hamvas, 1Mark Holland 1,2 1 Pediatrics, Washington University Schoolof Medicine, St Louis, Missouri USA; 2 Physics, WashingtonUniversity, St Louis, Missouri USAObjectives—The right ventricle (RV) is the dominant ventriclein premature and term neonates, and its function is an important determinantof the clinical status and prognosis of congenital and acquired cardiopulmonarypathologies. Myocardial strain and the strain rate represent2 sensitive measures of cardiac function. 2D speckle-tracking echocardiography(2DSE) is an angle-independent method for strain measurementbut has not been applied in preterm infants for assessment of RVfunction. The aim of this study was to evaluate the feasibility and reproducibilityof 2DSE-measured RV global longitudinal strain in preterm infantsand establish standardized methods for acquiring and analyzing strainmeasurements.Methods—2DSE (GE EchoPac) was used to measure the peakglobal longitudinal strain (pGLS) and strain rate (pGLSR) in the apical 4-chamber view of the RV in 50 preterm infants (27 ± 1 weeks at birth) at32 weeks postmenstrual age. Images were acquired with frame rates between60 and 100 Hz for 3 cardiac cycles and stored for offline analysis.Two observers measured the RV pGLS and pGLSR in 25 randomly selectedimages. Interobserver and Intraobserver reproducibility were assessedusing Bland-Altman analysis (relative bias, 95% limits ofagreement [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 demonstratedhigh 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 alsoshowed 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 reproducibilityof RV strain measurements by 2DSE in preterm infants andoffers specific recommendations for image acquisition and data analysisthat reduce measurement variability. Strain measurement by 2DSE offersa robust tool for the assessment of global RV function that is not achievedby conventional methods. (Supported by National Institutes of Healthgrants 1U01 HL101465 and R21 HL106417.)1541514 Statistical Comparison of Backscatter Coefficients for MATand 4T1 Tumors Across Multiple Ultrasound-Imaging SystemsDouglas Simpson, 1 * Nathaniel Hirtz, 1,2 William O’Brien Jr 21Statistics, 2 Bioacoustics Research Laboratory, Electrical andComputer Engineering, University of Illinois at Urbana-Champaign,Urbana, Illinois USAObjectives—Quantitative ultrasound measurements such as thebackscatter coefficient (BSC) have the potential to greatly enhance tissuecharacterization and identification of tumors. A balanced experiment wasconducted to compare consistency across transducers and efficacy for distinguishing2 well-characterized animal tumor types.Methods—The study included induced 4T1 and MAT tumorsin mice and rats. Animals were scanned with 5 different transducers witha target of 5 scan lines per tumor region of interest. BSCs were computedfor each scan. The resulting BSC data were analyzed across tumor typesand transducers using spatially dependent linear mixed model analysis,where the spatial dependence was between neighboring frequencies withinthe same scan line. The model allowed comparison of BSC curves fromtransducers with varying frequency ranges.Results—For 4T1 tumors, transducer differences were not statisticallysignificant. For MAT tumors, significant differences between

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013transducers were found. All 5 transducers detected significant differencesbetween tumor types either through a mean shift model or via changes incurve shape between tumor groups. Higher-frequency transducers producedsignificantly greater separation of mean BSC curves between MAT and4T1 tumors. Mean differences between tumor types were smaller than theinherent variability in the BSC curves as measured by the residual standarderror values, indicating a low signal to noise ratio for classification.Conclusions—All 5 ultrasound-imaging transducers were effectivein detecting significant differences between MAT and 4T1 tumors,either through mean shift or through shape changes. Higher frequencies inthe range above 8.5 MHz were more effective than lower frequencies in detectingtumor differences.1540921 Automatic Detection of Keratoconus From High-Frequency Ultrasound DataRonald Silverman, 1,2 * Raksha Urs, 1 Arindam RoyChoudhury,1 Timothy Archer, 3 Dan Reinstein 3 1 Ophthalmology,Columbia University Medical Center, New York, New YorkUSA; 2 Frederic L. Lizzi Center for Biomedical Engineering,Riverside Research, New York, New York USA; 3 London VisionClinic, London, EnglandObjectives—Keratoconus (KC), a corneal dystrophy characterizedby progressive corneal thinning and bulging, is currently detectedby optically determined corneal topography and curvature. The cornealepithelium, however, tends to remodel to smooth out irregularities in theunderlying stroma, potentially masking early KC topographic changes. Inthis report, we describe automated ultrasound detection of KC based on alteredepithelial thickness patterns.Methods—Corneas of 128 normal and 68 KC subjects (1 randomlychosen eye per subject) were scanned using the Artemis-1 (Arcscan,Inc, Morrison, CO) high-frequency ultrasound system. Scans areperformed with an optical fixation target and video monitoring of eye positionwhile the 50-MHz transducer is scanned in an arc such that curvaturein the focal plane approximately matches that of the corneal surface.Radiofrequency data are digitized at 500 MHz. Scans were acquired in 4planes at 0°, 45°, 90°, and 135°. Postprocessing consisted of automaticdetection of the corneal surfaces and the epithelial/stromal interface. Maps(100 × 100 at 0.1-mm intervals) of epithelial and stromal thickness werethen automatically analyzed to extract 87 features that might potentiallydifferentiate normal from KC eyes. Stepwise linear discriminant analysis(LDA) and neural network (NN) analysis using a radial basis kernel werethen performed. NN analysis was repeated 10 times with different randomtest sets (30% of cases).Results—Stepwise LDA produced a model consisting of 11features with sensitivity of 91.2%, specificity of 99.2%, and an area underthe receiver operating characteristic (ROC) curve of 98.5%. A leave-oneoutprocedure gave identical sensitivity and specificity. The NN showedaverage sensitivity of 93.5% and specificity of 97.4% for the training setand 88.8% and 97.5%, respectively, for the test set. The area under theROC curve was 97.8%.Conclusions—Our results show ultrasound-detected patternsin corneal layered topography to be very effective at distinguishing normalfrom KC corneas. Future studies will combine these methods withoptical data for early detection, which would allow early treatment by collagencross-linking and avoidance of potentially damaging corneal refractivesurgical procedures.Breast Ultrasound and ElastographyModerator: Abid Irshad, MD1538656 Correlation Between Parameters in Ultrasound-GuidedDiffuse Optical Tomography and 18 F-FluorodeoxyglucosePositron Emission Tomography/Computed Tomographyfor Breast CancerWoo Jung Choi,* Hak Hee Kim, Joo Hee Cha, Hee JungShin, Hyunji Kim Radiology, Asan Medical Center, Seoul,KoreaObjectives—The purpose of this study was to correlate parametersin ultrasound (US)-guided diffuse optical tomography and maximumstandardized uptake value in 18 F-fluorodeoxyglucose positron emissiontomography/computed tomography ( 18 F-FDG PET/CT).Methods—We retrospectively evaluated 228 patients (meanage, 46.9 years; range, 29–71 years) diagnosed with breast cancer betweenSeptember 2009 and February 2012. Both US-guided diffuse optical tomographyand 18 F-FDG PET/CT were performed. For each lesion, thetotal hemoglobin concentration (HBT) level and oxygen saturation (SO2)level were calculated, and the synthesis diagnosis index (SDI) was designedusing US-guided diffuse optical tomography. With 18 F-FDGPET/CT, the maximum standardized uptake value (mSUV) was calculated.We compared the parameters in US-guided diffuse optical tomographywith the mSUV of known malignant breast lesion on 18 F-FDGPET-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 SO 2level and mSUV was statistically significant (Spearman correlation coefficient= –0.280; P < .001). The HBT level and SDI showed a low correlationcoefficient with the mSUV (spearman correlation coefficients =0.049 and 0.072; P = .458 and .280, respectively).Conclusions—The SO 2level of US-guided diffuse optical tomographycorrelated well with the mSUV of 18 F-FDG PET/CT. A lowSO 2level in optical imaging may predict a high mSUV level on 18 F-FDGPET/CT, and it may serve as a useful tool for predicting the response rateafter neoadjuvant chemotherapy in breast cancer.1540665 Comparison of Strain and Shear Wave Without or With aQuality Measure in Evaluation of Breast MassesRichard Barr Radiology Consultants, Inc, Youngstown, OhioUSAObjectives—Shear wave imaging (SVI) in the breast codessome cancers as soft. Coding a malignancy as soft can be due to poor shearwave propagation. The addition of a quality measure (QM) that determinesif an adequate shear wave formed for accurate measurements. Theaim of this paper was to compare the predictive value of strain (elasticityimaging [EI]) and SVI without and with a QM.Methods—Patients scheduled for an ultrasound breast biopsyhad strain (EI) and SVI on a Siemens S2000 system modified to performSVI with a QM. Lesions were evaluated for shear wave velocity (V s ) andthe QM. The highest V s in the lesion or surrounding ring (if present) wasused. The V s was classified as benign (4.5 m/s).For strain, an EI/B-mode ratio of

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013nant lesions, SVI had no V s in 10 (18.1%); 25 (44.6%) were benign; and21 (37.5%) were malignant. The QM was low in all cases where no SVIsignal 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. TheQM was high in 3 of 25 (12.0%) soft malignant lesions, which were lymphoma.Three false-negatives on EI were lymphomas. In cases were thereis a low QM, if the lesion is solid, it is most likely a cancer.Conclusions—Strain imaging had the highest sensitivity, whileSVI had the highest specificity (without or with the QM). There was a significantimprovement in the sensitivity of SVI with the addition of theQM; however, an additional 16.9% of cases could not be evaluated.Table 1. Comparison of TechniquesNo. Sensitivity, Specificity,Technique Evaluable % % AUROCStrain (EI) 163 95 88 0.9595SVI – QM 166 41 95 0.6756SVI + QM 138 78 94 0.7988SVI + low QM and 166 93 87 0.9006solid lesion = malignantAUROC indicates area under the ROC curve.1536920 Differentiation of Benign and Malignant Breast Lesions:A Comparison Between Automatically Generated BreastVolume Scans and Handheld Ultrasound ExaminationsHongyan Wang, 1 * Yuxin Jiang, 1 Qingli Zhu, 1 Jing Zhang, 1Qing Dai, 1 He Liu, 1 Xingjian Lai, 1 Qiang Sun 2 1 DiagnosticUltrasound, 2 Breast Surgery, Peking Union Medical CollegeHospital, Beijing, ChinaObjectives—To assess the diagnostic value of automated breastvolume scanning (ABVS) and conventional handheld ultrasonography(HHUS) for the differentiation of benign and malignant breast lesions.Methods—The study prospectively evaluated 239 lesions in213 women who were scheduledfor open biopsy. The patients underwent ABVS and conventionalHHUS. The sensitivity, specificity, accuracy, false-positive rate,false-negative rate, and positive and negative predictive values for HHUSand ABVS images were calculated using histopathologic examination asthe gold standard. Additionally, diagnostic accuracy was further evaluatedaccording to the size of the masses.Results—Among the 239 breast lesions studied, pathology revealed85 (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 predictivevalue (73.0% vs 74.0%), and negative predictive value (93.3% vs94.1%). The area under the receiver operating characteristic curve, whichis used to estimate the accuracy of the methods, demonstrated only minordifferences between HHUS and ABVS (0.928 and 0.948, respectively).Conclusions—The diagnostic accuracy of HHUS and ABVS indifferentiating benign from malignant breast lesions is almost identical.However, ABVS can offer new diagnostic information. ABVS may helpdistinguish between real lesions and inhomogeneous areas, find smalllesions, and demonstrate the presence of intraductal lesions. This techniqueis feasible for clinical applications and is a promising new techniquein breast imaging.1540513 Functional Images of Hemoglobin and Blood OxygenSaturation Coregistered With Ultrasound Provide AccurateDifferentiation of Breast TumorsPamela Otto, 1 * Kenneth Kist, 1 N. Carol Dornbluth, 1 ThomasStavros, 2 Donald Herzog, 2 Thomas Miller, 2 Bryan Clingman, 2Jason Zalev, 2 Michael Ulissey, 3 Philip Lavin, 4 SergeyErmilov, 5 Alexander Oraevsky 2,5 1 Radiology, University ofTexas Health Science Center, San Antonio, Texas USA; 2 SenoMedical Instruments, San Antonio, Texas USA; 3 Radiology,University of Texas Southwestern Medical Center, Dallas, TexasUSA; 4 Aptiv Solutions, Southborough, Massachusetts USA;5TomoWave Laboratories, Inc, Houston, Texas USAObjectives—A novel system called Imagio combines ultrasound(US) and opto-acoustics (OA) to more accurately distinguish malignantfrom benign tumors. We analyzed the ability of blind readers toassess the probability of malignancy (POM) using coregistered functionaland anatomic images vs conventional diagnostic ultrasound (DUS) alone.Methods—Seventy-three patients with breast masses were assessedwith OA and DUS. All the masses were biopsied, and histologywas the gold standard. OA employs near-infrared laser pulses at 2 differentwavelengths (to provide contrast between oxygenated hemoglobin inbenign lesions and deoxygenated hemoglobin in malignant lesions) to illuminatetissues through a fiber-optic bundle incorporated into a prototypehandheld OA US probe. It detects the laser pulse–induced acousticpressure waves that are then used for reconstruction of 2D functional andanatomic images. OA maps of total hemoglobin and blood oxygen saturationprovide functional information that is coregistered with the morphologicalinformation from B-mode grayscale US images.Results—Five blinded readers independently assessed POMfor OA and DUS. OA provided a >40% higher mean POM for all malignantlesions, a >30% higher mean POM for malignant Breast ImagingReporting and Data System (BI-RADS) 4B lesions, and a >10% highermean POM for malignant BI-RADS 5 lesions than did DUS. OA could potentiallyspare 23.7% more negative biopsies than DUS at the critical 2%POM level.Conclusions—The fused functional OA and grayscaleanatomic information significantly improved distinction of benign frommalignant breast masses compared with DUS alone, especially within theBI-RADS 4B category, where OA better distinguishes benign from malignantlesions and thereby prevents unnecessary biopsies.1522001 Granulomatous Mastitis: Clinical and Sonographic FeaturesWith Image-Guided Biopsy CorrelationPriyanka Handa, 1 * Derek Sun, 1 Jill Leibman, 1,2 Aryeh Goldberg,1 Maria Abadi 1,2 1 Jacobi Medical Center, Bronx, NewYork USA; 2 Albert Einstein College of Medicine, Bronx, NewYork USAObjectives—Granulomatous mastitis (GM) is an unusual inflammatorylesion that can mimic breast cancer on clinical exam andimaging studies. The purpose of this study was to review the clinical presentationand imaging findings (including sonography) associated with GMand determine the adequacy of image-guided biopsy for diagnosis.Methods—A retrospective study was performed to identify patientswith breast imaging studies and a pathologic diagnosis of GM. Theclinical presentation, imaging findings, biopsy method, and pathology reportswere reviewed.Results—Twenty-seven patients were included; average agewas 35.3 years (range, 21–66 years). Twenty-four patients presented withpain, a palpable mass, and/or discharge. Three asymptomatic patients presentedfor screening mammograms. All patients were imaged with ultrasound(US), demonstrating a mass in 19 (70%), tubular lucencies withouta mass in 6 (22%), and no findings in 2 (8%). In the 25 patients with positivesonographic findings, the mass was anechoic in 3 (12%), hypoechoicS13

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013in 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 27patients had correlative mammographic findings. Pathologic diagnosiswas made by US-guided biopsy in 11 of 27 (40%), US-guided fine- needleaspiration in 1 of 27 (4%), and mammotome biopsy in 1 of 27 (4%).Palpation-guided tissue sampling was performed in 12 of 27 (44%). Surgicalexcision was performed in 7 of 27 (26%).Conclusions—The sonographic features of GM are infrequentlydescribed. Our study demonstrated that the sonographic findingsare indeterminate and may mimic malignancy. Although previously reportedexclusively in young women with palpable findings, our studydemonstrates that it can occur in postmenopausal as well as asymptomaticpatients. The diagnosis of GM is optimally made by US-guided corebiopsy.1538026 Using a New Ultrasound Image-Processing Technique forIdentification of Microcalcifications in Patients Prior toBiopsyPriscilla Machado,* John Eisenbrey, Barbara Cavanaugh,Flemming Forsberg Radiology, Thomas Jefferson University,Philadelphia, Pennsylvania USAObjectives—To evaluate a new commercial image-processingtechnique (MicroPure; Toshiba America Medical Systems, Tustin, CA)for the identification of breast microcalcifications in patients undergoingstereotactic or ultrasound (US)-guided biopsies and to compare results tox-ray imaging of the tissue retrieved.Methods—Twelve women, scheduled for stereotactic biopsyor US-guided biopsy of an area with breast calcifications (identified on aprior mammogram), were enrolled in the study. The patients underwent aUS examination consisting of real-time dual imaging of grayscale US andMicroPure using an Aplio XG scanner (Toshiba America Medical Systems)with a broad-bandwidth linear array. MicroPure combines nonlinearimaging and speckle suppression to mark suspected calcifications aswhite spots in a blue overlay image. Still images and digital clips of thetarget area were acquired. Independent and blinded readers (2 radiologistsand 2 physicists) analyzed 26 digital clips to determine the number of calcificationsseen with MicroPure and also to give a subjective view on thelevel of suspicion (LOS) of the findings. X-ray imaging of the specimenwas analyzed by a radiologist who counted the exact number of microcalcifications.The number of microcalcifications was compared using themean number from the 4 readers with the mean number on the x-rayimage. The LOS was compared with the pathologic findings using receiveroperating characteristic (ROC) analysis.Results—The mean number of microcalcifications seen onMicroPure was 6.96 (3.33–13.37). These values show excellent agreementwith the mean number of microcalcifications seem on the x-rayimage of the tissue retrieved (7.42; P = .39). ROC analysis of the readers’LOS scores compared to the pathologic findings produced areas under thecurve of 0.74–0.99.Conclusions—MicroPure imaging was able to identify microcalcificationsat the target area as confirmed by x-ray imaging of the tissuespecimen. These findings indicate that MicroPure may be used toguide breast biopsy procedures, but more studies are needed.1540975 The Natural History of Thyroid Nodules With PeripheralCalcificationArash Anvari,* Anthony Samir Radiology, AbdominalImaging and Intervention, Massachusetts General Hospital,Boston, Massachusetts USAObjectives—Peripheral dystrophic calcification is a known patternin thyroid nodules seen on ultrasound (US) and can be found in bothbenign and malignant nodules. The American Thyroid Association (ATA)guidelines for recommending biopsy in the setting of nodule follow-upare predicated on a change in nodule size exceeding 50%. It is unknownwhether rim calcification in a thyroid nodule may prevent nodule enlargement,potentially rendering the ATA biopsy criteria ineffective. Theobjective of this study was to determine whether rim calcified nodules undergoingUS follow-up are able to enlarge to an extent meeting ATA criteriafor fine-needle aspiration biopsy (FNAB).Methods—We searched our institute’s radiology report databasefor thyroid nodules with rim calcification between 2002 and 2011. Wethen reviewed each subject to determine parameters like demographicdata, nodule size, timing and number of follow-up sonograms, and FNABand/or surgical pathologic results. We calculated nodule volumes usingthe 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 rimcalcification 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 hada US follow-up interval of at least 1 year (range, 1–9.5 years; 3.58 ± 2.14years). 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 rimcalcified nodules (28.9%; 95% confidence interval, 17.3%–40.4%)changed in volume by >50%. The proportion of nodules with volumechanges exceeding 50% increased with longer follow-up and when themaximal diameter was

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013tive 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, and7 false-positives (3 lymphocytic thyroiditis and 4 colloid goiter). Of 150,27 (18%) nodules were classified as inconclusive by the stiffness criterionand 62 (42%) by the size criterion.Conclusions—Shear wave E of suspicious thyroid nodulesusing the stiffness criterion is precise and helpful to differentiate betweenbenign and malignant thyroid nodules, and we recommend it to be incorporatedin clinical practice. The size criterion is less helpful due to manyinconclusive cases, despite having good specificity and a good negativepredictive value.1506963 Ultrasound- and Ultrasound Elastography-Based ClinicalScore for Screening of Thyroid NodulesNami Azar, Edwin Vargas Velandia,* Ronald Novak, DeanNakamoto Radiology, University Hospitals Case MedicalCenter, Case Western Reserve University, Cleveland, Ohio USAObjectives—In current clinical practice, most centers performbiopsies on all thyroid nodules with a size >1 cm independent of the sonographicfindings. Our aim was to develop an imaging-based clinical scorefor better characterization of thyroid nodules with the aim of reducingnonindicated thyroid biopsies.Methods—In a retrospective review, data of patients who presentedwith suspicious thyroid nodules and underwent conventional(Doppler) ultrasound (US), US quantification elastography, and USguidedfine-needle aspiration (FNA) were analyzed. The nodules wereinitially classified as benign or malignant according to the FNA result. Thefollowing imaging parameters (internal flow, irregular margins, hypoechogenicity,calcifications, size [volume and diameter], and quantificationelastography) were analyzed under a direct logistic regression as accuratepredictors of malignancy. Four clinical scores were designed based onthese parameters and compared as diagnostic methods.Results—A convenience sample of 130 subjects was chosenfor analysis. In this sample, thyroids of 24 subjects (18%) were proven bypathology to be malignant, and 106 (82%) were benign. Direct logistic regressionwas used to calculate areas under the curve (AUCs) for 4 clinicalscoring indices (S1–S4), and regression parameters were used tocompare the AUCs using the method of DeLong et al. Overall, 1 scoringindex (S1), including irregular margins, hypoechogenicity, size, internalflow, and quantification elastography, was determined to be the best predictorof malignancy due to its larger AUC of 0.938. Choosing an indexscore of 5.0 maximized both sensitivity (95.8%) and specificity (87.7%)for predicting malignancy and would theoretically curtail the number ofbiopsies by 72.3%.Conclusions—Our clinical score based on imaging parametersevaluated during a conventional US examination exhibits high sensitivityand specificity for identifying malignant thyroid nodules. Application ofthis tool in daily clinical practice may reduce the number of nonindicatedthyroid biopsies. Our study was limited by a small population size, and furtheranalyses with larger patient samples are warranted.1540472 Linear and Nonlinear Elastosonographic Data May AidDifferentiation of Thyroid NodulesRafal Slapa, 1 * Bartosz Migda, 1 Wieslaw S Jakubowski, 1Jacek Bierca, 2 Jadwiga Slowinska-Srzednicka 3 1 DiagnosticImaging, Medical University of Warsaw, Warsaw, Poland;2Surgery, Hospital at Solec, Warsaw, Poland; 3 Endocrinology,Center for Postgraduate Medical Education, Warsaw, PolandObjectives—Although elastography can assist in the differentialdiagnosis of thyroid nodules, its diagnostic performance is not ideal atpresent. Further improvements in the technique and the diagnostic criteriaare necessary for this examination to provide a useful contribution todiagnosis. The aim of the study was to evaluate a new linear/nonlinear approachfor strain elastosonography of thyroid nodules, based on the analysisof time-strain curves, and to compare it with classic elasticity scoreand thyroid strain ratio methods.Methods—During 2009 to 2011, 67 patients scheduled for thyroidectomy(62 with myasthenia gravis) were evaluated with B-mode andpower Doppler ultrasound of the whole thyroid. During ultrasound examination,96 dominant nodules were examined with strain elastosonographywith Aplio XG (Toshiba, Japan) with a linear 5–17-MHz transducer.The stiffness of each thyroid nodule was evaluated with classic features ofstrain elastosonography qualitatively (with elasticity scores) and semiquantitativelywith thyroid tissue strain/nodule strain ratios with applicationof Elasto Q (Toshiba). Moreover, a novel original approach toelasticity data based on evaluation of time-strain curves was applied. Statisticalanalysis was performed with Statistica 10 (StatSoft, Inc).Results—There were 7 papillary carcinomas and 89 benignnodules. Classic elastosonographic analysis with the elasticity score andelasticity ratio on statistical analysis did not show a significant differencebetween cancer and benign nodules (P = .431 and .156). On linear/nonlinearanalysis 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 elastosonographicdata may greatly improve differential diagnosis of thyroidnodules. Further multicenter large-scale studies evaluating the usefulnessof linear/nonlinear elastosonographic phenomena (involving evaluationof vioscoelasticity, eg, shear wave spectroscopy) in differential diagnosisof thyroid cancer are warranted. (Supported by Ministry of Science ofPoland grant N402 476437.)1540131 Noninvasive Determination of Corneal Elasticity UsingAcoustic Radiation Force After Corneal Cross-LinkingRaksha Urs, 1 * Harriet Lloyd, 1 Ronald Silverman 1,21Ophthalmology, Columbia University Medical Center, NewYork, New York USA; 2 Frederic L. Lizzi Center for BiomedicalEngineering, Riverside Research Institute, New York, New YorkUSAObjectives—There is immense interest in corneal cross-linkingtherapy (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 radiationforce (ARF) to determine the stiffness of the rabbit cornea in vivo beforeand after CXL.Methods—The corneas of 2 live rabbits were exposed to ARFusing a single-element transducer (25-MHz central frequency, 6-mm aperture,18-mm focal length; Panametrics V324-SU). The beam sequenceconsisted of 20 pushing tone bursts of 400 microseconds duration (80%duty cycle), with imaging impulses interleaved in the dead time to allowradiofrequency (RF) data acquisition during the push mode. M-mode datawere collected for another 200 milliseconds after the push sequence. Theright eyes of the rabbits were then cross-linked with ultraviolet light andriboflavin. ARF measurements were performed once a week for 4 weeksfollowing CXL. A spline-based algorithm was used to determine continuousdisplacement of the front and back surfaces of the cornea, using RFdata sampled at 400 MHz (12 bits/sample), to determine the change incorneal thickness and strain. The acoustic output was characterized witha 40-µm-diameter needle hydrophone calibrated up to 60 MHz and measuredto be 2.5 MPa. An absorption coefficient of 0.93 dB/cm-MHz wasused to estimate the force in the cornea. ARF-induced strain was fit to theVoigt model to determine the elastic modulus.Results—The mean elastic modulus values during the 4 weeksof follow-up were 36 ± 8 and 32 ± 1 kPa for the untreated eyes and 49 ±S15

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20135 and 45 ± 12 kPa for the cross-linked eyes. A paired t test revealed a statisticallysignificant difference between untreated and cross-linked eyesin 1 rabbit (P = .04). While corneal stiffness increased with cross-linkingin the other treated rabbit, the change was not statistically significant.Conclusions—Results show that changes in corneal stiffnessafter CXL can be measured in vivo using ARF. Future studies will be performedto evaluate the use of this method for detection of keratoconus,where the cornea’s biomechanical properties are believed to be altered.Contrast-Enhanced UltrasoundModerators: Yuko Kono, MD, PhD, Theresa Tuthill, PhD1541199 Volumetric Contrast-Enhanced Ultrasound Imaging ofRenal PerfusionMarshall Mahoney, Anna Sorace, Kenneth Hoyt* Universityof Alabama at Birmingham, Birmingham, Alabama USAObjectives—The goal of this project was to evaluate wholeorganultrasound (US) imaging and microbubble (MB) contrast agents forcharacterizing perfusion in a phantom and an animal model and also to assessthe 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 MBsensitiveharmonic imaging mode (transducer transmits at 5 MHz and receivesat 10 MHz) was used to acquire VCEUS data. Followingmicrobubble infusion, custom programs implemented in MATLAB(MathWorks) processed volumetric data sets and time-intensity curves toestimate perfusion parameters, namely, peak intensity, time to peak intensity,wash-in rate, and area under the curve. The VCEUS system was testedin 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 0.02mL/L. The system was also tested using healthy Sprague Dawley rats tofurther analyze renal perfusion imaging results. All experiments used theDefinity (Lantheus Medical Imaging) MB contrast agent.Results—All 3D reconstructions allowed visualization of invitro and in vivo perfusion parameters. Volume summarizing statisticsfrom in vitro experiments demonstrated that wash-in rate and time-to-peakmeasurements were proportional to volume flow rates, while the peak intensityand area under the curve measurements were proportional to theMB dose concentration. Results acquired in rat kidney demonstrated thatparametric measurements were consistent for each animal. Importantly, rotationof the imaging transducer (up to 90°) did not impact renal perfusionmeasurements at high-volume frame rates. Collectively, results indicatethat MB destruction-replenishment and time-intensity curve parametricanalysis with real-time volumetric ultrasound imaging is a promisingmodality for characterizing renal perfusion properties.Conclusions—VCEUS imaging was shown to be a promisingmodality for evaluating renal perfusion. Preliminary results are encouraging,and this imaging modality may prove feasible for evaluating acuteand chronic kidney disease.1540209 Parametric Contrast-Enhanced Ultrasound With Evaluationof Arrival Time Maps May Aid Differentiation BetweenAdrenal Nodular Hyperplasia and Adenomas: Initial ResultsRafal Slapa, 1 * Anna Kasperlik-Zaluska, 2 Bartosz Migda, 1Wieslaw S Jakubowski 1 1 Diagnostic Imaging, Medical Universityof Warsaw, Warsaw, Poland; 2 Endocrinology, Center forPostgraduate Medical Education, Warsaw, PolandObjectives—Only some nonmalignant adrenal masses as somemyelolipomas and cysts present pathognomonic features on computed tomography,the examination of choice for evaluation of adrenal glandpathology. Proper diagnosis in the cohort of nonmalignant adrenal massesmay be important for further management. The aim of the study has beento evaluate possibilities of differentiation of nonmalignant masses of adrenalswith application of a new technique for evaluation of enhancement afteradministration of an ultrasound contrast agent: parametric imaging.Methods—Seventeen nonmalignant adrenal masses in 14 patientswere evaluated by dynamic examination after administration of 2.4mL of the ultrasound contrast agent SonoVue with an Aplio XG convex1–6-MHz transducer and parametric imaging. Patterns of parametric imagingof the arrival time and time to peak were evaluated. The final diagnosiswas based on computed tomography, magnetic resonance imaging,biochemical studies, follow-up, and/or surgery.Results—There were 5 myelolipomas, 5 hyperplastic nodules, 4adenomas, 2 hemangiomas with hemorrhage, and 1 cyst. Arrival time patternsof hyperplastic nodules (5/5) presented characteristic differential featuresof peripheral laminar inflow of SonoVue. Patterns for adenomas varied:nonenhancement (1/4), central enhancement (2/4), and peripheral/centralinhomogeneous enhancement (1/4). Patterns for myelolipoma and hemangiomawere different from those for adrenal hyperplastic nodules.Conclusions—Parametric imaging may differentiate adrenaladenomas from hyperplastic nodules and could be complementary to computedtomography. This could potentially influence the choice of treatmentin patients with Conn syndrome and warrants further multicenterlarge-scale studies. (Supported by Ministry of Science of Poland grantN402 481239.)1541233 Volumetric Molecular Ultrasound Imaging of TumorVascularity in a Preclinical Model of Prostate CancerAnna Sorace, Marshall Mahoney, Kurt Zinn, Kenneth Hoyt*University of Alabama at Birmingham, Birmingham, AlabamaUSAObjectives—The goal of this project was to evaluate volumetricmolecular ultrasound (US) imaging of tumor vascularity in a preclinicalmodel or prostate cancer.Methods—Real-time volumetric molecular US imaging wasperformed using the BioSONIC VIEW system (Bioscan Inc) equippedwith a broadband 4DL14-5/38 probe. An MB-sensitive harmonic imagingmode (transducer transmits at 5 MHz and receives at 10 MHz) was usedto acquire molecular US images. Nude athymic mice (n = 10) were implantedwith 2 million prostate cancer cells (PC3), and tumors were allowedto grow to approximately 1 cm in diameter. Microbubbles(Targestar-SA; Targeson) were conjugated with multiple antibodies targetingtumor vascularity (α vβ 3, p-selectin, and vascular endothelial growthfactor receptor 2) or with an immunoglobulin G isotype control antibody.Following tail vein injection of the MB contrast agent, a 5-minute delayallowed systemic circulation and target receptor binding. Molecular USimages were captured to determine the amount of MBs bound and flowing.Then a high-intensity pulse via an external US transducer was administeredto destroy all MBs, followed by an additional US scan todetermine residual circulating MBs. Custom MATLAB software (Math-Works) was developed to determine overall intratumoral image intensity.Subtraction of US image data from before and after MB bursting yieldeda measure of MBs bound to the targeted tumor receptors. All animals receivedboth MB types following a 2-hour delay between injections.Results—Molecular US imaging of targeted MBs yielded aconsiderable increase in intratumoral image enhancement over that obtainedusing control MBs, as evident from volume reconstruction of segmentedtumor data. More specifically, molecular US image enhancementusing targeted MBs ranged from 30% to 160% when compared to controldata from the same population of animals. Targeted MB image enhancementwas consistent with fraction tumor vascularity measures.Conclusions—Whole-tumor molecular US imaging is a promisingstrategy for assessing biomarkers of prostate cancer vascularity, andfurther research is warranted.S16

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131539659 Small Nodules Arising in Cirrhotic Liver DuringSurveillance: Possibility of Characterization AmongDysplastic Nodules, Early Hepatocellular Carcinoma,and Progressed Hepatocellular Carcinoma Using Contrast-Enhanced UltrasoundAntonio Giorgio, Giorgio Calisti, Umberto Scognamiglio,Nunzia Farella, Giorgio de Stefano, Filomena Di Martino,Valentina Giorgio D. Cotugno Hospital, Naples, ItalyObjectives—The evolution from low-grade dysplastic nodules(DNs) to hepatocellular carcinoma (HCC) is characterized by a gradualdisappearance of intranodular portal tracts and a progressive developmentof neoangiogenic unpaired arteries. Contrast-enhanced ultrasound (CEUS)is able to depict intranodular vascularity. The aim of this study was to evaluateCEUS in the characterization of DNs and HCC in liver cirrhosis.Methods—Forty-six consecutive patients with liver cirrhosisand a single hepatic nodule ≤2 cm were enrolled from February toDecember 2009. The nodule was continuously observed for 4 to 6 minutesfollowing contrast injected until the disappearing of the enhancement.We studied and recorded the arterial phase (15–30 seconds after contrastinjection), the portal phase (30–60 seconds), and the sinusoidal phase (60–240 seconds). Three patients needed a second injection of 2.4 mL ofSonoVue because of inadequate visualization of the enhancement. Weanalyzed the pattern of the enhancement of the lesion after contrast injection,and we compared the features of nodule and surrounding liverparenchyma. All patients underwent CEUS and subsequent US-guidedbiopsy of the lesion. Histologic findings and imaging interpretation ofDNs and HCC were compared.Results—Progressed HCC was identified by a homogeneouspattern of hypervascularization during the arterial phase with sensitivity of90.9% and specificity of 100%. Early HCC showed an inhomogeneousand reticular pattern and was identified with sensitivity of 85.7% andspecificity of 96.1%.Conclusions—CEUS is able to depict the vascularization patternof hepatic nodules during the arterial phase and to differentiate DNs,early HCC, and progressed HCC.1511998 Thyroscan: A Cost-Effective and Noninvasive AutomatedSystem for Thyroid Lesion Classification in 3-DimensionalContrast-Enhanced Ultrasound ImagesU. Rajendra Acharya, 1 Vinitha Sree, 2 M. Mutu Rama Krishnan,1 Filippo Molinari, 3 Roberto Garberoglio, 4 Jasjit Suri* 2,51Electronics and Computer Engineering, Ngee Ann Polytechnic,Singapore; 2 Global Biomedical Technologies, Roseville,California USA; 3Electronics and Telecommunications,Politecnico Torino, Torino, Italy; 4 Scientific Foundation MaurizianaONLUS, Torino, Italy; 5 Biomedical Engineering, IdahoState University, Pocatello, Idaho USAObjectives—Ultrasound has great potential to aid in the differentialdiagnosis of malignant and benign thyroid lesions, but the accuracyis still poor. We developed and analyzed a range of knowledge representationtechniques for characterizing the intranodular vascularization of thyroidlesions 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, 25–68years) with a previously confirmed diagnosis of a solitary thyroid nodulewere enrolled in this study. All subjects underwent a clinical examination,hormonal profile, and 3D contrast-enhanced ultrasound volume acquisitionafter 2.5 mL of SonoVue (Bracco, Italy) injection. The features of the3D volumes were extracted by using the discrete wavelet transform(DWT), and the texture of the nodular vascularization was measured byusing statistical and structural measurements. The 10 features were fed to3 type of classifiers: K-nearest neighbor (K-NN), probabilistic neural networks(PNN), and decision tree (DT).Results—The performance of the classifiers was comparedusing receiver operating characteristic (ROC) curves. The combination ofDWT and texture features coupled with K-NN resulted in good results,with an area under the ROC curve (AUC) of 0.987, a classification accuracyof 98.9%, sensitivity of 99.8%, and specificity of 98.1%. We proposeda novel integrated index called the thyroid malignancy index (TMI),made up of DWT and texture features, which was discriminant to diagnosebenign or malignant nodules using just 1 index.Conclusions—This integrated TMI can be employed for thediagnosis of benign and malignant nodules effectively. The advantage isthe fact that, to make a diagnosis, the physician needs to only look at thevalue of just 1 integrated index instead of checking the range of each individualfeature.Table 1. Performance of the ClassifiersAccuracy, Sensitivity, Specificity,Classifier TN FN TP FP % % % AUCK-NN 40 0 39 1 98.9 99.8 98.1 0.987PNN 40 0 38 2 97.8 99.8 96.3 0.975DT 40 0 38 2 97.8 99.8 96.3 0.975FN indicates false-negative; FP, false-positive; TN, true-negative; and TP,true-positive.1466379 Usefulness of Contrast-Enhanced Ultrasound in ClinicalPractice: The Spanish TrialCarlos Nicolau, 1 * Teresa Fontanilla, 2 Jose del Cura, 3 AntonioTalegon, 4 Xavier Serres 5 1 Radiology, Hospital Clinic,Barcelona, Spain; 2 Radiology, Hospital Universitario Puertade Hierro, Majadahonda, Madrid, Spain; 3 Radiology, Hospitalde Basurto, Bilbao, Spain; 4 Radiology, Hospital Virgen del Rocio,Seville, Spain; 5Radiology, Hospital Vall Hebro, Barcelona,SpainObjectives—The aim of this multicenter study was to evaluatecontrast-enhanced ultrasound (CEUS) diagnostic performance in clinicalpractice in Spain.Methods—A total of 1786 patients (mean age, 59.8 years) from42 hospitals, with baseline US studies that were considered inconclusive,were included in this multicenter study. We evaluated 1516 (84.9%) abdominalcases (including 1272 livers [71.2%], 179 kidneys [10%], 35spleens [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 specificcontrast software and intravenous injection of SonoVue (Bracco, Italy;mean dose, 3 mL). A low mechanical index (

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131517021 Four-Dimensional Subharmonic Breast Imaging: InitialExperiencesJohn Eisenbrey, 1 * Anush Sridharan, 1,2 Daniel Merton, 1Priscilla Machado, 1 Kirk Wallace, 3 Carl Chalek, 3 Kai Thomenius,3 Flemming Forsberg 1 1 Radiology, Thomas JeffersonUniversity, Philadelphia, Pennsylvania USA; 2 Electrical andComputer Engineering, Drexel University, Philadelphia, PennsylvaniaUSA; 3 GE Global Research, Niskayuna, New YorkUSAObjectives—To describe initial experiences of using 4D contrast-enhancedsubharmonic ultrasound imaging (SHI) and harmonic ultrasoundimaging (HI) for the characterization of mammographicallyidentified breast lesions.Methods—4D SHI (transmitting 4 cycle pulses at 5.8 MHz, receivingat 2.4 MHz) was performed using a modified LOGIQ 9 ultrasoundscanner with the 4D10L probe (GE Healthcare, Milwaukee, WI). Afterproviding informed consent, 39 patients scheduled for an ultrasoundguidedbreast biopsy received 2 injections of the contrast agent Definity(Lantheus Medical Imaging, North Billerica, MA). Patients first receiveda 0.25-mL injection while being continuously scanned with 4D HI (transmitting2 cycle pulses at 5 MHz, receiving at 10 MHz). After 30 minutes,patients received a 20-µL/kg injection while undergoing 4D SHI. Boththe screen-captured, rendered images and raw slice data for the entire contrastwash-in/wash-out cycle were digitally stored for analysis and processing.Results—Volume acquisition rates varied based on the lesionsize and depth of scanning ranged from 1.7 Hz (for a 3.7 × 1.3 × 2.0-cmlesion) to 6.1 Hz (for a 6 × 4 × 6-mm lesion) with volume angles of 9° to19°. Contrast enhancement depended heavily on lesion vascularity(determined during initial physician exam using power Doppler). In 38of 39 cases, SHI resulted in better tissue suppression relative to HI andimproved contrast visualization in vascular lesions. In vascular cases, vesselconnectivity was observed in 3D space with clear visualization of contrastwash-in and wash-out. Raw slice data were successfully processed tocreate 3D maximum intensity and perfusion parametric maps. Theseprocessed volumes further improved the ability to delineate blood vesselsfrom the surrounding tissue and quantify flow parameters.Conclusions—In almost all cases, 4D SHI resulted in improvedvisualization of contrast relative to 4D HI. Access to raw slice data allowsfor the generation of 3D parametric maps of the vasculature. Future workwill determine the value of 4D SHI for characterizing breast lesions.Emergency Ultrasound, Part 1Moderators: Leslie Scoutt, MD, Gowthaman Gunabushanam, MD1540915 Accuracy of Lung Ultrasound and Chest Radiography forDiagnosis of Cardiogenic Dyspnea Among Elderly EmergencyDepartment PatientsEmanuele Pivetta, 1,2,3 * Livia Ausiello, 4 Elke Platz, 1 MichaelStone, 1 Maria Tizzani, 5 Giulio Porrino, 5 Enrico Ferreri, 5Giovanni Volpicelli, 6 Paolo Balzaretti, 4 Alessandra Banderali,7 Antonello Iacobucci, 8 Enrico Lupia, 2 Alberto Goffi, 9 GiovannaCasoli, 10 Gianalfonso Cibinel 11 1 Emergency Medicine,Division of Emergency Ultrasound, Brigham and Women’sHospital, Boston, Massachusetts USA; 2 Emergency Medicine,3Oncology and Hematology, Cancer Epidemiology Unit, SanGiovanni Battista Hospital and University of Turin, Turin, Italy;4Emergency Medicine, Mauriziano Hospital, Turin, Italy;5Emergency Medicine, San Giovanni Battista Hospital, Turin,Italy; 6 Emergency Medicine, San Luigi Gonzaga UniversityHospital, Orbassano, Turin, Italy; 7 Emergency Medicine, CardinalMassaia Hospital, Asti, Italy; 8 Emergency Medicine,Santa Croce e Carle Hospital, Cuneo, Italy; 9 Critical CareMedicine, St Michael’s Hospital, Toronto, Ontario, Canada;10Emergency Medicine, Martini Hospital, Turin, Italy; 11 EmergencyMedicine, Pinerolo Civil Hospital, Turin, ItalyObjectives—This study aimed to evaluate the diagnostic accuracyof pleural and lung ultrasound (PLUS) vs chest radiography for theidentification of interstitial syndrome and pleural effusions (indicators ofacute decompensated heart failure) among elderly patients presenting tothe emergency department (ED) with dyspnea.Methods—This was a prospective multicenter cohort study ofpatients presenting to an Italian ED with shortness of breath. After the initialassessment, emergency physicians categorized dyspnea as cardiogenicor noncardiogenic. Patients then underwent 8-zone PLUS with a curvilineartransducer assessing for sonographic artifacts (B-lines) and pleuraleffusions (mean scanning time, 3.47 minutes). Three or more B-lines weresuggestive of interstitial syndrome. The same physician then recorded thenew diagnostic category, incorporating both initial clinical assessment andPLUS findings. All patients also underwent standard chest radiography.After discharge, medical records were independently reviewed by 2 emergencyphysicians blinded to the PLUS results to determine the most likelycause of dyspnea.Results—Between October 2010 and August 2012, 674 elderlypatients 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% hadchronic obstructive pulmonary disease. In 284 subjects (42.1%) the etiologyof dyspnea was cardiogenic. PLUS had sensitivity (Se) of 97.7% (confidenceinterval [CI], 94.6%–99.2%) and specificity (Spe) of 96% (CI,93.8%–99.3%) for the diagnosis of cardiogenic dyspnea, with a positivepredictive value (PPV) of 98.1% (CI, 95.3%–99.5%) and a negative predictivevalue (NPV) of 97% (CI, 93%–99%). Chest radiography had Seof 70.3% (CI, 61.6%–78.1%), Spe of 80% (CI, 70.8%–87.3%), a PPV of81.8% (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 dyspneaby 10% (CI, 7.7%–12.3%).Conclusions—In our study, PLUS had higher diagnostic accuracythan chest radiography for the diagnosis of cardiogenic dyspnea inelderly ED patients. PLUS may represent a more rapid and accurate toolin the bedside assessment of patients with suspected acute decompensatedheart failure.1540969 Bedside Cardiac Ultrasound Examination to ConfirmCentral Venous Catheter PlacementYiju Liu, 1 Kathleen Calabrese, 1 * Kunal Ajmera, 2 MohammadSalimian, 1 Thaison Tran, 1 Hamid Shokoohi, 1 Keith Boniface, 1Melissa McCarthy 1 1 Emergency Medicine, George WashingtonUniversity Medical Center, Washington, DC USA;2School of Public Health and Human Services, George WashingtonUniversity, Washington, DC USAObjectives—This study evaluated the use of bedside ultrasoundexamination (BUE) to confirm proper CVC insertion. More than 5 millioncentral 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 obtainingpost-CVC chest radiography (CXR) to confirm placement maydelay care and expose patients to repeated ionizing radiation.Methods—We prospectively enrolled patients requiring abovethe-diaphragmCVC placement from the emergency department (ED), intensivecare unit (ICU), and operating room (OR) at a tertiary academiccenter. Within 24 hours of CVC placement, we pushed 10 mL of saline solutionthrough a distal catheter port while simultaneously obtaining a singleview of the heart using BUE and documented whether echo signals ofthe saline solution appeared in the right heart and the timing of their appearance.We hypothesized that the immediate presence of echogenic sig-S18

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013nals from the saline flush signaled proper catheter tip placement. We comparedthe agreement between BUE results and those of CXR or computedtomography (CT) using a κ statistic.Results—Twenty-seven patients were enrolled, and 26 wereanalyzed. 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 technicallylimited study, and 25 demonstrated saline echoes in the right heart. One ofthe 25 demonstrated intracardiac catheter malposition, confirmed by CXR.All 26 patients had CXR, and 2 had additional CT; 25 had confirmedproper CVC placement, including the 1 patient for whom BUE was inconclusive.Timing for BUE was as follows: 20 cases done concurrentlywith CVC placement, 2 done within 1 hour, and 3 done within 24 hours.Of the 25 BUEs that were interpretable, there was 100% agreement betweenBUE and CXR in detecting CVC location (P = .000).Conclusions—Despite the small sample size, this study showspromise for the use of BUE to accurately confirm CVC placement morequickly than CXR. A larger study is needed before we can recommendusing 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, LalehGharahbaghian, Raymond Balise, Ravi Pamnani, MichaelSchaller, Joelle Barral, Sidhartha Sinha, Sarah WilliamsEmergency Medicine, Stanford University Medical Center,Stanford, California USAObjectives—Thoracic ultrasound (US) has been validated topredict pulmonary edema with high sensitivity and specificity in the presenceof B-lines, a US reverberation artifact caused by interstitial fluid. Ourstudy investigates whether there are specific anatomic zones with a greaterpositive predictive value for pulmonary edema. If so, we could performthis test more rapidly, an important consideration from both a resource utilizationand patient care perspective.Methods—We performed a prospective observational study,scanning a convenience sample of adult emergency department (ED) patientswith shortness of breath at a large tertiary care academic center. Followingpreviously published protocols, the right anterior chest was dividedinto 4 zones with zones 1 and 2 representing an upper and lower midclaviculardistribution, respectively, and 3 and 4 upper and lower midaxillary.The division was mirrored on the left with 5 and 6 anterior and 7 and8 lateral. When there were at least 2 bilateral positive zones, the patient wasenrolled. Compared to a gold standard of chest radiography combinedwith brain natriuretic peptide, echocardiography, and discharge diagnosis,patients were confirmed to have acute pulmonary edema. All imageswere reviewed by 2 US fellowship-trained ED physicians, and each zonewas 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. Thirteenpercent (3/24) were positive in every zone. On the right, zones 2, 3, and 4were positive in 79% (19/24), while on the left, zone 5 was positive in71% (17/24) and zone 7 in 67% (16/24). When the right chest was notedto be positive, the contralateral zone noted to be positive in the greatestnumber of patients was zone 5.Conclusions—While the small number of patients limits thisstudy, trends were noted in specific zones, particularly the right chest andzone 5. However, there is no dominant pattern or statistically significantresults to suggest that any zone is more predictive for diagnosing acutepulmonary edema by B-lines on US. This suggests that it is necessary toscan all 8 zones and perform a thorough but expeditious thoracic US examinationwhen rapid diagnosis of critically ill patients is crucial.1538301 Central Venous Catheterization Location Changes andComplication Rates After the Institution of an EmergencyUltrasound DivisionTahisha Tolbert,* Lawrence Haines, Lucas McArthur,Victoria Terentiev, Antonios Likourezos, Eitan DickmanEmergency Medicine, Maimonides Medical Center, Brooklyn,New York USAObjectives—To look at central venous catheter (CVC) placementpatterns before and after the establishment of an emergency ultrasounddivision (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 complicationrates associated with CVC placement before and after the establishmentof an EUSD.Methods—This was a retrospective chart review looking at allCVCs placed in an urban tertiary care medical center’s emergency department(ED) with an emergency medicine residency program and115,000 ED visits per year. We queried our electronic medical record forall CVCs placed in the ED between the years 2004 and 2007 and the years2007 and 2010, representing the 3 years before and after the establishmentof the EUSD. The locations of these CVCs were compared to assess forany changes. This data set was then queried for patients who had a documentedmechanical complication from the CVC placement.Results—In all, 1876 CVCs were placed between 2004 and2007, and 1707 were placed between 2007 and 2010. Selection of thefemoral vein CVC location changed from 50.8% to 42.5%, subclavianfrom 37.0% to 17.3%, and IJ from 12.2% to 40.2% (P = .0001 for all). Themechanical complication rate decreased from 9.1% to 5.4% (P = .0001).Conclusions—The establishment of an EUSD, with formaltraining in the use of US for CVC placement, is associated with a significantchange in CVC site selection patterns, most notably a sharp increasein selection of the IJ site and a dramatic reduction in the selection of thesubclavian site. In addition, there was a 41% decrease in the complicationrates such as pneumothorax and arterial puncture.Table 1. Specific Complicationsn (%)Complication 2004–2007 2007–2010 PPneumothorax 23 (1.2) 6 (0.4) .004Chest tube 18 (1) 4 (0.2) .005Arterial puncture 47 (2.5) 21 (1.2) .0051539748 Faster = Better? Pilot Sonographic Evaluation of InternalJugular Vein Collapsibility Versus Inferior Vena CavaCollapsibility Indices in Critically Ill PatientsDavid Evans, 1 * Daniel Eiferman, 1 Alistair Kent, 1 CreaghBoulger, 2 Andrew Springer, 3 Eric Adkins, 2 Susan Yeager, 1Geoffrey Roelant, 1 Stanislaw Stawicki, 1 David Bahner 21Surgery, 2 Emergency Medicine, 3 Anesthesiology, Ohio StateUniversity, Columbus, Ohio USAObjectives—Intensivist-performed bedside sonographic assessmentof volume status is a rapidly evolving area. Although the inferiorvena cava collapsibility index (IVC-CI) has been shown to correlatewith both clinical assessment and invasive monitoring of intravascularvolume status, it is limited by difficult visualization of the IVC, interferenceby surgical dressings and tubes, and a relatively steep learning curve.Many physicians already have experience with internal jugular ultrasoundfor vascular access. Due to the ease of the technique and simpler anatomy,we hypothesized that the internal jugular vein collapsibility index (IJV-CI) would be easier to perform than the IVC-CI.Methods—A prospective observational pilot study comparingIVC-CI and IJV-CI was performed in surgical intensive care unit patients.S19

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013In addition to patient demographics and basic hemodynamic data, simultaneousM-mode measurements of the IVC-CI and IJV-CI were collectedduring each bedside sonographic session. IVC measurements were obtainedusing curvilinear probes. IJV measurements were obtained usinghigh-frequency linear array probes. Statistical comparisons for paired dataincluded linear regression with correlation coefficients and Bland-Altmananalysis with construction of a mean difference plot for bias determination.Results—A total of 16 patients were enrolled (mean age, 52.8years). There were 5 women and 11 men. Acquisition of adequate IJV-CIscans was faster than acquisition of IVC-CI scans (43 vs 105 seconds scanningtime, respectively; P < .01). Thirty-five measurement pairs were obtained,with some correlation noted between paired IVC-CI and IJV-CImeasurements (r = 0.54; r 2 = 0.289). There was a 6% negative measurementbias between IJV-CI and IVC-CI measurements as determined by theBland-Altman method.Conclusions—IJV-CI measurement can be performed significantlyfaster than IVC-CI measurement. In our pilot study, there was minimalmean measurement bias (6%) between the 2 techniques, indicatingthat the IJV-CI tends to overestimate collapsibility. More data are neededto better characterize the correlation between the IJV-CI and IVC-CI anddefine the role of the IJV-CI in clinical practice.1540557 Point-of-Care Ultrasound Evaluation of Central LinePlacementEric Mervis, 1 * Elizabeth Turner, 3 Alan Chiem, 4 Robert Liou, 2Randy Hou, 5 Craig Anderson, 1 Arthur Youssefian, 1 J. ChristianFox 1 1 Emergency Medicine, 2 Pulmonary/Critical Care,University of California Irvine, Orange, California USA; 3 Pulmonary/CriticalCare, University of California Los Angeles,Los Angeles, California USA; 4 Emergency Medicine, Universityof California Los Angeles, Olive View, Los Angeles, CaliforniaUSA; 5 Pulmonary/Critical Care, Kaiser, Fontana, CaliforniaUSAObjectives—In our study we use point-of-care ultrasound(POC-US) to confirm proper central venous catheter (CVC) placementand compare the results of POC-US to chest x-ray (CXR), the current standardof evaluating CVC placement.Methods—This is an ongoing prospective single-center noninferioritystudy comparing the effectiveness of POC-US and CXR inconfirming placement of CVCs. A convenience sample of critically ill patientsthat require emergent CVC placement in the intensive care unit(ICU) or the emergency department at the University of California IrvineMedical Center have been enrolled. Patients who are >18 years old andrequire placement of a subclavian (SC) or internal jugular (IJ) CVC are eligiblefor enrollment in this study. Qualified emergency medicine andICU physicians place CVCs into IJ or SC veins. US is then performed toobtain multiple views for confirmation of CVC placement. These includeviews of the CVC within the central vein, the ipsilateral pleural line torule 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 thecatheter in the right atrium or turbulence after a 10-mL saline flush, thusconfirming placement of the catheter in the superior vena cava. The timesof US and CXR completion and subsequent review of the CXR by thephysician performing the procedure are recorded.Results—A total of 55 central lines with complete US imagingand comparable CXRs have been obtained to date with a goal of enrolling140 subjects. The US method has identified 2 misplaced lines, and theCXR has shown 5 misplaced lines. Agreement between the 2 methods forconfirming CVC placement is 91% (50/55). The US method thus far hasa negative predictive value of 92.5% (confidence interval, 82%–98%).There is an average 17-minute difference between time to US and time toCXR. There have been no pneumothoraxes identified by either method.Conclusions—Preliminary data suggest that POC-US andCXR have similar agreement for identifying misplaced CVCs. There is a17-minute time difference to POC-US vs CXR, which could translate tomore expeditious use of central lines for intravenous fluids, antibiotics, orvasopressors in potentially unstable patients.1541330 Three-Window Bedside Ultrasound Versus Chest Radiographyfor Confirmation of Endotracheal Tube PlacementArthur Youssefian, 1 * Elizabeth Turner, 3 Shane Breazeale, 2Angelina Amian, 2 Eric Mervis, 1 J. Christian Fox, 1 NegeanVandordaklou, 4 Craig Anderson 1 1 Emergency Medicine,2Pulmonary and Critical Care, University of California Irvine,Orange, California USA; 3 Pulmonary and Critical Care, Universityof California Los Angeles, Los Angeles, California USA;4Department of Emergency Medicine, Long Beach MemorialHospital, Long Beach, California USAObjectives—In our study, we use 3-window bedside point-ofcareultrasound (POC-US) to confirm proper endotracheal tube (ETT)placement and compare the results of POC-US to chest x-ray (CXR), thecurrent standard of evaluation. The hypothesis is that POC-US will benoninferior to CXR for ETT placement and will be more expedient.Methods—This is an ongoing prospective noninferiority studycomparing the effectiveness of 3-window bedside POC-US in confirmingplacement of ETTs. A convenience sample of critically ill patients whorequired emergent endotracheal intubation in the intensive care unit (ICU)or the emergency department (ED) at the University of California IrvineMedical Center have been enrolled. Patients who are >18 years old and requiretracheal intubation are eligible for enrollment. Qualified ED andICU physicians placed ETTs per the usual protocol. US is then performedto obtain multiple views for confirmation of ETT placement. These includeviews of the trachea, bilateral lungs, and diaphragms. The primaryobjective was to compare the sonographer’s ability to predict placementof ETTs based on a 3-window bedside US model compared to the formalinterpretation of the postintubation CXR read by an attending radiologist.The secondary outcome objective was to measure and compare the timefrom the 3-window US exam to the time of the initial availability of postintubationCXR as well as to the time of availability of the radiologist’s formalinterpretation of the film.Results—A total of 136 subjects with complete US imagingand CXRs have been enrolled to date, with a goal of 140 subjects. The 3-window US method correctly identified 124 of 128 ETTs placed in thetrachea (specificity, 94.7%). US correctly identified 1 of 5 ETTs found byCXR to be in a main stem bronchus (sensitivity, 20%), with a positivelikelihood ratio (LR) of 3.74 and a negative LR of 0.845.Conclusions—Preliminary data suggest that 3-window POC-US and CXR have similar agreement for identifying correctly placedETTs. Additional analysis of subjects with false-positive and false-negativeUS impressions will aim to determine factors contributing to thesetype I and II errors.1541487 Transcricothyroid Ultrasound for Confirmation ofEndotracheal Tube Placement by United States MilitaryEmergency Medicine ProvidersMichael Rebener,* Chase Donaldson, Eric Chin EmergencyMedicine, San Antonio Military Medical Center, San Antonio,Texas USAObjectives—The purpose of this study is to assess the accuracyof dynamic transcricothyroid ultrasound for confirming endotracheal tube(ET) placement by military emergency medicine (EM) providers, specificallyphysicians and physician assistants, and to examine the relationshipbetween accuracy and prior ultrasound experience in this application.Methods—A prospective randomized double-blinded validationstudy to identify ET placement in a cadaver model using ultrasoundwas conducted. Twenty-six EM providers with variable ultrasound experiencewere given a brief presentation on how to identify airway land-S20

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013marks using ultrasound and shown examples of esophageal and trachealintubations. The cadavers were randomized to a tracheal or esophagealintubation, and the EM providers recorded their responses after performingdynamic 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 locationin 266 of 329 scans, for accuracy of 80.1% for all providers. The differencein accuracy between experienced and inexperienced providers wasnot statistically significant (P = .433), but more experienced providers hadshorter response times (P = .031). Physicians were not more accurate thanphysician assistants (P = .746), but physicians’ response times were shorter(P < .001).Conclusions—Our study suggests that EM providers withmore ultrasound experience, defined as >250 scans, are not necessarilymore accurate at identifying correct placement of ETs than those with lessexperience. Similarly, no statistically significant difference was seen inaccuracy between provider types. This study suggests that DTUS can beeasily learned by inexperienced sonographers, but given the relatively lowaccuracy rate of DTUS in this study, regardless of experience, DTUSshould 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 HemodynamicMeasurementsDavut Savaser,* Colleen Campbell, Ted Chan, Virag Shah,Chris Sloane, Allan Hansen, Eddie Castillo, Gary VilkeEmergency Medicine, University of California San Diego, SanDiego, California USAObjectives—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 crossoverstudy of healthy volunteers (18–60 years of age) placed in 5 different bodypositions: supine, prone, PMR, PMR with 50 lb added to the subject’sback (PMR50), and PMR with 100 lb added to the subject’s back(PMR100) for 3 minutes. Data were collected on subject vital signs andechocardiographic measurement of SV, CO, and LVOTD, measured bycredentialed emergency department faculty sonographers. Anthropomorphicmeasurements of height, weight, arm span, chest circumference, andbody mass index were also collected. Data were analyzed using repeatedmeasures analysis of variance to evaluate changes in each variable with respectivepositioning.Results—Twenty-five male subjects were enrolled in the study,ages ranging from 22 to 43 years. Cardiac output did change from thesupine 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 nosignificant 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 theprone position. Systolic blood pressure never dropped below 100 mm Hgin 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 positioncompared with the prone position, nor is it adversely affected withapplication of 50 or 100 lb of weight force to the back while in the PMRposition. The PMR position and a weight force of up to 100 lb does notcause hemodynamic compromise of the restrained patient.1541228 Ultrasound-Guided Peripheral Intravenous Insertion:Right Line at the Right TimeJames M. Joseph, Daniel Kagarise, Todd Henkaline, JamesWhite,* David Bahner Vascular Access, Ohio State UniversityMedical Center, Columbus, Ohio USAObjectives—To increase the success rate of initial intravenousline (IV) attempts using ultrasound guidance and to use expert assessmentand a triage process to choose the “right line at the right time.”Methods—We began in September 2005. Physician-initiatedrequests were placed in the electronic medical record and sent as consultsto the vascular access team. Ninety-eight insertions occurred between Septemberand December. The program has grown exponentially since its inceptionand to this date houses 47,153 requests for evaluation and insertionin a vascular access database. The vascular access team consists of 8 fulltimenurses covering approximately 850 beds. Additionally, we havetrained super users in 3 areas with varying degrees of success and datacollection.Results—The following data were queried from the vascularaccess 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, 32,366were successful on the first attempt. Subsequent attempts were successful92.4% of the time. The total success rate was 98.3%.Conclusions—USGPIV programs can be successful adjunctsto vascular access teams in serving patients with difficult access. Key conceptsfor branding success include using triage, assessment, ultrasoundguidance, and insertion by experienced vascular access nurses.Musculoskeletal and Interventional/IntraoperativeUltrasoundModerator: Humberto Rosas, MD1540764 Accuracy and Reliability of Direct Versus Indirect PeripheralNerve Cross-sectional AreaMark Shoreman, 1,2,3 * Jeffrey Strakowski, 1,2,3 Marcie Bockbrader,1,2 Mark Tornero, 1,2 Darin Bradshaw 1,2 1 PhysicalMedicine and Rehabilitation, Ohio State University, Columbus,Ohio USA; 2 Physical Medicine and Rehabilitation, RiversideMethodist Hospital, Columbus, Ohio USA; 3 MusculoskeletalDepartment, McConnell Spine, Sport, and Joint Center, Columbus,Ohio USAObjectives—Standardizing the sonographic examination is essentialto achieve diagnostic precision. Aspects of the examination, suchas the cross-sectional area (CSA) measurement technique, can be controlledand ultimately standardized. We sought to determine if direct peripheralnerve CSA measurement increases accuracy and reliability incomparison to the indirect method.Methods—Five novice sonographers and 3 healthy modelswere recruited. One expert sonographer led the novices through 3 peripheralnerve ultrasound training sessions in addition to a final “test-out” session.The expert then obtained 1 ideal transverse image of each model’sradial, median, ulnar, and sciatic nerves. Each sonographer (expert andnovice) then obtained 3 direct measurements of each nerve (3 models × 4nerves × 3 = 36) and 3 indirect measurements of each nerve (36 + 36 = 72measurements). The image order and method (direct/indirect) were randomizedprior to obtainment, and sonographers were blinded to their resultsas well as their colleagues’. The expert’s measurements representedthe accuracy gold standard. Accuracy was evaluated by calculating percentdeviation from expert (%DE). Inter-rater reliability was evaluated usingthe intraclass correlation coefficient (ICC). Variance measurements wereobtained using repeated measures analysis of variance (ANOVA).S21

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Results—The %DE was decreased with direct measurement incomparison to indirect in every group of peripheral nerve measures(radial/median/ulnar/sciatic). The ICC was higher with direct measurementthan indirect in every group of peripheral nerves measured. Repeatedmeasures ANOVA did reveal significant differences between direct vs indirectmeasurements repeated on the same nerve/model (F(1,4) = 24.262;P < .008). There was no significant difference between expert and noviceCSA measurements (P = .983), and no significant difference between multiplemeasurements (direct and indirect) of the same nerve by the samerater (P = .644).Conclusions—Direct CSA measurements produce more accurateresults and greater inter-rater reliability than indirect measurements.There is a significant difference between direct and indirect CSA measurementsrepeated on the same nerve/model.1540778 Developmental Plasticity of the Hip: Implications forInfant Hip UltrasonographyAzriel Benaroya, 1,2 * Arkady Voloshin, 3 Bernard Karmel, 2Ha Phan 2 1 Orthopedics, Mount Sinai School of Medicine,New York, New York USA; 2 Infant Development, New York StateInstitute for Basic Research in Developmental Disabilities,Staten Island, New York USA; 3 Mechanical Engineering andMechanics, Lehigh University, Bethlehem, Pennsylvania USAObjectives—A literature review of the combined method of infanthip ultrasonography (US) reveals persistent problems with overdiagnosis.Clues to these problems can be found in the wide range ofmorphologic variations reported in fetal and infant hips. The 2003 AmericanCollege of Radiology–American Institute of Ultrasound in Medicineguidelines state that the femoral head is nearly spherical; thus, the positionof the hip during US is unimportant. Authors agree, however, that thefemoral head becomes less spherical during fetal development, that itreaches its greatest degree of asphericity at the time of birth, and that asphericityis further increased in borderline, immature, and dysplastic hips.We created a 3D mathematical model of an ellipsoidal infant femoral headto examine the impact of femoral head asphericity on current US methods.Methods—The femoral head was modeled as an oblate spheroidwith asphericity of 25% (long axis = 20 mm; short axis = 15 mm).Four positions of the femoral head in space, replicating positions of diagnosticsignificance used in the combined and Graf methods, were computersimulated. Coronal or transverse sections through the center of thefemoral head model, simulating infant femoral head US images, were producedand analyzed for cross-section diameter and inclination.Results—Femoral head cross-section diameters in the simulatedcoronal flexion stress view and transverse flexion stress view were17.11 and 16.23 mm, respectively, compared to 14.37 mm for the femoralhead cross-section diameter in the Graf coronal view and 13.93 mm for thecoronal view with the hip in the “human” position.Conclusions—Our model demonstrated changes in the crosssectiondiameter of an irregularly shaped femoral head with rotation ofthe head in different positions. Femoral head asphericity would not affectthe results in the Graf method, but it could affect the results in the combinedmethod. Stress maneuvers of the infant hip in the presence of softtissue subclinical morphologic variations, coupled with femoral headasymmetry, could produce “elastic whipping,” leading to erroneous interpretationsof the US image. We recommend that the plasticity of the developinghip be reviewed with respect to its potential impact on theaccuracy of current US methods.1536958 Efficacy of Sonographically Guided Medial Plantar NervePerineural Space Injection at the Medial Longitudinal ArchJohnathan Childress, 1 Oliver Joseph, 2 Oleg Uryasev, 2 * JohnMcNamara, 1,2 Apostolos Dallas 2 1 Jefferson College of HealthSciences, Roanoke, Virginia USA; 2 Virginia Tech CarilionSchool of Medicine, Roanoke, Virginia USAObjectives—Medial plantar neuropraxia refers to entrapmentof the medial plantar nerve (MPN) in the medial longitudinal arch by compressionfrom the flexor hallucis longus (FHL) and flexor digitorumlongus tendons. Like other nerve compression syndromes, corticosteroidinjection could likely provide therapeutic relief to those with MPN compression.We hypothesize that sonographic guidance will allow for effectiveinjection of the MPN perineural space distal to the flexor retinaculumand inferior to the navicular prominence (NP) of the foot.Methods—This study serves as a pilot study to investigate theefficacy of MPN perineural injections bilaterally on 4 cadaveric models.Cadaveric anatomy was unremarkable with the exception of 1 cadaverwho had marked musculoskeletal deformity of the lower limbs, whichprecluded successful injection. A 10–5-MHz small linear array transducerwas placed along the malleolar-calcaneal axis, rotated parallel to the tibia,and guided anteriorly along the medial longitudinal arch to visualize theNP. The MPN appeared spindle shaped with alternating hypoechoic andhyperechoic bands superficial to the FHL tendon. The MPN perineuralspace was injected inferior to the NP where it divides into its muscularbranches. Using an anterior long-axis approach, 0.35 mL of 0.5% methyleneblue was injected with anatomic dissection to provide confirmation.Injections were classified according to accuracy and precision. Accuracyreferred to nerve staining; precision referred to no damage to adjacentstructures.Results—Seven of 8 (88%) injections were accurate; 6 of 8(75%) injections were precise.Conclusions—Research into sonographically guided MPNperineural injection is novel. Considering a limited sample size andmarked musculoskeletal deformity of 1 cadaver, accuracy and precision(88% and 75%, respectively) provide an optimistic outlook for sonographicallyguided injections. The study supports the approach of sonographicallyguided perineural injections in the clinical address of medialplantar neuropathies. Future phases of this study will focus on expandingthe initial data set and correlate the accuracy and precision of injectionwith improved patient outcomes.1538067 Neuromusculoskeletal Ultrasound Courses: How EffectiveAre They in the Long Term?Sathish Rajasekaran, 1 * Rodney Shan, 2 Mohan Radhakrishna 31Physical Medicine and Rehabilitation, University ofSaskatchewan, Saskatoon, Saskatchewan, Canada; 2 ClinicalNeurosciences, University of Calgary, Calgary, Alberta,Canada; 3 Physical Medicine and Rehabilitation, McGill UniversityHealth Center Pain Center and McGill University, Montreal,Quebec, CanadaObjectives—To measure the short- and long-term effectivenessof a 2-day neuromusculoskeletal ultrasound course offered to Canadianphysical 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 residentsfrom across Canada. Participants varied in training level from first- tofinal-year residents. Currently, ultrasound training is not a requirement forPM&R training programs in Canada. Prior to beginning the course, all attendeeswere asked to fill out a multiple-choice test based on the coursecurriculum objectives, which was readministered on completion and 6months after completion of the course (electronically). Sixteen residentscompleted all 3 tests. The Wilcoxon signed rank test was used to comparescores from the 3 testing periods.S22

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Results—The mean score (percentage) on the pretest was50.6% (95% confidence interval [CI], 43.5%–57.6%), on the immediateposttest was 66.5% (95% CI, 60.6%–72.4%), and on the 6-month posttestwas 53.5% (95% CI, 45.9%–60.6%). The 6-month posttest scores werenot significantly higher than the pretest scores (P = .505). The immediateposttest scores were significantly higher than the pretest (P = .002) and 6-month posttest (P = .003) scores.Conclusions—This pilot study found that the short-term effectivenessof attending an ultrasound course is supported by higher immediateposttest scores. However, the effectiveness of the course isdiminished in the long term, as the 6-month posttest scores were lowerthan the immediate posttest scores. Although 6-month posttest scores stillremained higher than pretest scores, this was not statistically significant.Our results suggest that the current trend of offering neuromusculoskeletalultrasound courses as an early exposure may have suboptimal benefitsto the learner on its own and may require reinforcement with continuedstructured longitudinal learning opportunities. Future studies done on alarger scale that also correlate testing performance to postcourse ultrasounduse need to be undertaken to further investigate our conclusions.1467503 Utility of Ultrasound for Detecting Anterior CompartmentThickness Changes in Chronic Exertional CompartmentSyndrome: A Pilot StudySathish Rajasekaran, 1 * Cole Beavis, 2 Abdel-Rahman Aly, 1Dave Leswick 3 1 Physical Medicine and Rehabilitation,2Surgery, 3 Diagnostic Imaging, University of Saskatchewan,Saskatoon, Saskatchewan, CanadaObjectives—To test the hypotheses that patients with chronicexertional compartment syndrome (CECS) of the anterior leg compartmenthave an increased anterior compartment thickness (ACT) comparedto 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 firstvalidated 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 pressureswere measured prior to exercise and at scheduled intervals afterward. Controlsunderwent the same protocol without compartment pressure testing.Results—Anterior compartment pressures were diagnostic ofCECS using the modified Pedowitz criteria in all 4 CECS patients. Themean percent change in ACT from rest in CECS vs controls at 0.5 minuteswas 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 increasedafter exertion at 0.5, 2.5, and 4.5 minutes (P = .003).Conclusions—Ultrasound reveals a significant increase in ACTin 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 agoal of developing anterior leg compartment CECS ultrasound diagnosticcriteria and exploring the role of using ultrasound to diagnose CECSin other compartments.1541063 Efficacy of Sonographically Guided Injections of the CommonPeroneal Nerve Perineural Space at the Fibular TunnelMatthew P Kona, 1 * Oliver Joseph, 1 Oleg Uryasev, 1 John Mc-Namara, 1,2 Apostolos Dallas 1 1 Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USA; 2 Jefferson College ofHealth Sciences, Roanoke, Virginia USAObjectives—The common peroneal nerve (CPN) originates asa branch of the sciatic nerve within the popliteal fossa. Continuing inferolaterally,the CPN crosses the fibular head and penetrates the posterior intermuscularseptum, where it courses through the fibular tunnel (FT),defined by the fibula and peroneus longus tendon. CPN entrapment withinthe FT is associated with motor deficits, such as foot drop, as well as sensorydeficits and pain in the distribution of its branches: the anterolateralthird of the lower leg and dorsum of the foot. Treatment may involvesteroid injections into the perineural space of the CPN or its distalbranches. The CPN also serves as a valuable alternative when preoperativesciatic block is unsuccessful or when a faster time to complete blockis desired. The CPN has been effectively imaged using sonography (US).We hypothesize that using sonography, one can effectively inject the CPNperineural space at the FT.Methods—To image the CPN in cross section, 4 cadavericmodels were placed in a prone position, with the transducer over the fibularhead, and rotated 20° from a transverse position. A total of 8 injectionswith methylene blue were performed using an in-plane technique. FT dissectionpermitted classification of injections according to accuracy andprecision. Accuracy referred to nerve staining with methylene blue; precisionreferred 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 fromoperator dependence and the pronounced musculoskeletal abnormalitiesof 1 cadaver. In this case, the superficial branch of the CPN was misidentifiedas the CPN. All other injection attempts performed in this study weresuccessful. This study, in conjunction with others designed to investigatethe clinical applications of CPN perineural injections, collectively highlightthe utility of sonography in these relevant patient populations. Futurephases of this study will center on expanding the initial data set and correlatethe accuracy and precision of sonographically guided CPN injectionswith improved patient outcomes.1541082 Efficacy of Sonographically Guided Injections of the UlnarNerve Perineural Space at the Cubital TunnelDaniel Plessl, 1 * Robert Summey, 1 Oliver Joseph, 1 OlegUryasev, 1 John McNamara, 1,2 Apostolos Dallas 1 1 VirginiaTech Carilion School of Medicine, Roanoke, Virginia USA;2Jefferson College of Health Sciences, Roanoke, Virginia USAObjectives—Ulnar nerve (UN) entrapment is the second mostcommon nerve entrapment of the upper limb. The most common entrapmentsite is at the cubital tunnel to produce cubital tunnel syndrome (CTS).At the elbow, the UN courses subcutaneously between the medial epicondyleand the olecranon in the condylar groove and then enters the cubitaltunnel. CTS presents with medial elbow pain and varying symptomsfrom sensory complaints to weakness of intrinsic hand muscles. CTS maybe caused by extrinsic compression of the UN, bone deformities, or softtissue 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 injectthe UN perineural space at the cubital tunnel.Methods—In this pilot study, the UN was visualized bilaterallyon 4 nonembalmed cadaveric models. The elbow was examined in externalrotation, and the transducer was placed transverse to the condylargroove along the medial epicondyle-olecranon axis. Sonographicallyguided lateral-to-medial UN injections with 0.35 mL of methylene blueS23

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013were performed. Incisions were made parallel to the condylar groove deepto the cubital tunnel retinaculum to expose the underlying UN. Injectionswere accurate if the UN perineural space was dyed, and they were preciseif 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 canprovide symptomatic relief for CTS with corticosteroid injections toreduce inflammation. Sonography is inexpensive, quick, and minimallyinvasive. Future phases of this study will investigate efficacy of sonographicallyguided UN perineural corticosteroid injections in patients withCTS. This study suggests that injections under sonographic guidance areaccurate and precise, therefore serving as a potential adjunct to treatmentthat is worth further investigation. Future phases of this study will centeron expanding the initial data set and correlate the accuracy and precisionof injection with improved patient outcomes.1539088 Translating Contrast-Enhanced Ultrasound IntraneuralVascularity From Bench to BedsideKevin Evans,* Kevin Volz School of Health and RehabilitationSciences, Ohio State University, Columbus, Ohio USAObjectives—To describe contrast-enhanced ultrasound (CEUS)imaging of the human median nerve’s intraneural vascularity, with equipmentsettings and optimizations derived from experiments with a cohortof Macaca fascicularis.Methods—The equipment used was a GE LOGIQ 9, completewith contrast settings, and a GE LOGIQ i, which is considered a handcarriedunit. A 9.0-MHz linear broadband transducer was used with theGE LOGIQ 9, and a 12.0-MHz linear broadband transducer was used withthe GE LOGIQ i hand-carried unit. Definity was used for this study becauseit possesses the smallest microspheres, 1.1 to 1.3 µm, has stabilityof

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013cesarean delivery. The primary outcome was risk of cesarean delivery inlabor. Groups were compared using Fisher exact and χ 2 tests with significancedefined as P < .05.Results—A total of 216 patients met inclusion criteria. At 22 to24 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 notsignificantly associated with the risk of cesarean delivery. However, CL at28 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 negativepredictive value of 90.4% for cesarean delivery in labor (P < .001).Conclusions—CL at 28 to 32 weeks is significantly associatedwith the likelihood of cesarean delivery in labor; however, CL at 22 to 24weeks did not correlate with the risk of cesarean delivery. A longer CL inthe early third trimester may represent underdevelopment of the uterus,leading to a higher risk of cesarean delivery in labor. The lack of an associationat 22 to 24 weeks suggests that the normal cervical ripening processis one that occurs after the second trimester.Table 1. Risk of Cesarean Delivery in Labor by CL Quartile at 28 to 32 Weeks’GestationQuartile Cesarean Delivery, % (n) Vaginal Delivery, % (n)1st (3–23 mm) 5.6 (3/54) 94.4 (51/54)2nd (24–29 mm) 10.9 (6/55) 89.1 (49/55)3rd (30–36 mm) 9.1 (5/55) 90.9 (50.55)4th (37–54 mm) 21.2 (11/52) 78.8 (41/52)P

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131537208 Midtrimester Transabdominal Ultrasound for Detection ofPlacenta PreviaHayley Quant,* Alexander Friedman, Eileen Wang, SamuelParry, Nadav Schwartz Maternal and Child Health ResearchProgram, Obstetrics and Gynecology, University of PennsylvaniaPerelman School of Medicine, Philadelphia, PennsylvaniaUSAObjectives—Transvaginal ultrasound (TVUS) is the gold standardfor 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 allanatomic surveys at 18 to 23 6/7 weeks. Sonographers prospectivelyrecorded the distance from the leading placental edge (if visible) to the internalos on both TA and TV scans. The primary outcome was a TV placentaldistance of 0 cm (complete previa). Secondary outcomes includedTV distances of ≤1, ≤2, and ≤2.5 cm. ROC curves were generated usingall cases with TA placental distance of ≤5cm. The TA placental distancecutoffs at 100% and 90% sensitivity were identified for each outcome andthen applied to the entire cohort to determine the sensitivity, specificity,positive predictive value (PPV), and negative predictive value (NPV) ofTAUS for detecting previa.Results—A total of 1214 patients underwent both TAUS andTVUS; 415 (34.2%) had a TA distance ≤5cm from placenta to os. Theprevalence, optimal TA cutoffs by outcome and, test characteristics arepresented Table 1. A TA measurement of ≤4.2 cm detected 93.3% of completeprevias 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%, thoughthe sensitivity decreased to 86.7% and the NPV to 88.6%.Conclusions—Despite a high NPV, the lack of a cutoff to excludeplacenta previa makes TAUS an inadequate screen. Universal TVUSwould improve midtrimester detection and allow for appropriate followup.Since most suspected previas resolve, further investigation is neededto assess whether TVUS can decrease morbidity later in gestation.Table 1TVTA PlacentalPlacental Distance SPR, Sensitivity, Specificity, PPV, NPV,Distance Cutoff, cm % % % % %0 (complete previa) 4.2 25.0 93.3 76.7 9.2 99.8n = 30 (2.5%) 2.8 11.4 86.7 90.5 18.7 88.6≤1 cm 4.2 25.0 93.3 77.6 13.8 99.7n = 45 (3.7%) 3.1 13.5 84.4 89.2 23.2 99.3≤2 cm 4.9 32.9 89.0 72.2 22.3 98.7n = 100 (8.2%) 3.9 21.0 81.0 84.4 31.8 98.0≤2.5 cm 5.0 34.2 82.9 72.5 29.2 96.9n = 146 (12.0%) 4.2 25.0 76.7 82.0 36.8 96.31539742 Outcome of Pregnancies With a Low-Lying Placenta DiagnosedBetween 16 and 24 Weeks’ GestationHoward Heller, 1 Katherine Mullen, 1 * Robert Gordon, 1Rosemary Reiss, 2 Carol Benson 1 1 Radiology, 2 Obstetrics andGynecology, Brigham and Women’s Hospital, Boston,Massachusetts USAObjectives—To determine how often a low-lying placenta diagnosedbetween 16 and 24 weeks resolves prior to delivery.Methods—We assessed all cases of a low-lying placenta, definedas a placenta ending within 2 cm of the internal cervical os, diagnosedby sonography between 16 and 24 weeks’ gestation from July 1,2007, to September 4, 2011. We reviewed medical records to determine thegestational age when a low-lying placenta was diagnosed, the gestationalage at which the placenta was no longer low lying or previa, and, for thosewhose placentas never cleared sonographically, how many went on to cesareansection for placenta previa.Results—A total of 1416 pregnancies were diagnosed with alow-lying placenta between 16 and 24 weeks’ gestation. Of these, 174were lost to follow-up. Of the remaining 1242 pregnancies, 1220 (98.2%)resolved to no previa prior to delivery. The mean age at resolution was26.0 weeks. The age at resolution was similar in those diagnosed prior to20 weeks’ gestation to those diagnosed after 20 weeks. Approximately77% of placentas that eventually cleared did so before 29 weeks. Twentytwopatients 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 and24 weeks rarely (1.8% of the time) persists as placenta previa to term, necessitatingcesarean section. Most cases resolve during the early thirdtrimester. Thus, we suggest that reevaluation of the placental location insuch cases be performed at approximately 28 to 30 weeks, not earlier.In addition, patients diagnosed with a low-lying placenta in the secondtrimester can be reassured that the likelihood of persistent placenta previaat the time of delivery is small.1533371 Association Between Transvaginal UltrasonographicCervical Characteristics and Preterm Delivery After aHistory-Indicated CerclageEmily Miller,* Susan Gerber Maternal-Fetal Medicine,Northwestern University, Chicago, Illinois USAObjectives—To assess the relationship between the transvaginalultrasonographic characteristics of the cervix in the mid trimester andthe risk of delivery prior to 34 weeks in women with a history-indicatedcerclage.Methods—A retrospective case-control study of subjects witha singleton gestation and a history-indicated cerclage placed in the firsttrimester. Transvaginal ultrasound images of the cervix at the time of theanatomic survey in the second trimester were reviewed, and measurementsof cervical length (CL) proximal and distal to the cervical suture as wellas the presence or absence of funneling were recorded. χ 2 tests and logisticregression analysis were performed to evaluate the association betweenthese 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 thesuture was lower in women who delivered prior to 34 weeks (1.6 vs 2.5cm; P = .005), whereas distal CL was similar (1.5 vs 1.7 cm; P = .18). Thefrequency of cervical funneling was higher in women who delivered priorto 34 weeks (57% vs 9%; P < .001). In multivariable regression, only thepresence of a cervical funnel remained significantly associated with an increasedrisk of preterm delivery before 34 weeks (Table 1).Conclusions—Cervical funneling is strongly associated withan increased risk of delivery before 34 weeks in women with a history-indicatedcerclage. Midtrimester transvaginal cervical imaging can be usedto augment risk assessment this patient population.Table 1. Odds Ratios for Birth Prior to 34 Weeks According to UltrasonographicCervical AppearanceOR 95% CI aOR 95% CIProximal CL 0.48 0.27–0.82 0.88 0.41–1.85Distal CL 0.46 0.14–1.45 0.64 0.19–2.21Cervical funnel present 13.5 3.74–48.74 9.96 1.62–61.03aOR indicates adjusted odds ratio; CI, confidence interval; and OR, odds ratio.S26

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131541264 The Natural History of Vasa Previa Across GestationAndrei Rebarber, 1,2,3 * Cara Dolin, 2 Nathan Fox, 1,2,3 ChadKlauser, 1,2,3 Daniel Saltzman, 1,2,3 Ashley Roman 1,2 1 CarnegieImaging for Women, New York, New York USA; 2 Obstetrics andGynecology, New York University School of Medicine, NewYork, New York USA; 3 Obstetrics and Gynecology, Mount SinaiSchool of Medicine, New York, New York USAObjectives—To estimate the prevalence and persistence of vasaprevia in at-risk pregnancies using a standardized screening protocol.Methods—A descriptive study of patients from 1 ultrasoundpractice from June 2005 to May 2012. Cases were identified by ICD-9code and content search analysis of the 2 ultrasound reporting systems,Sonultra and AS Ob/Gyn using the key words “vasa previa.” Vasa previawas defined as any velamentous fetal vessel (arterial or venous) noted tobe within 2 cm of the internal cervical os. Screening for vasa previa usingtransvaginal ultrasound with color flow mapping was performed routinelyin the following situations: resolved placenta previa, history of vasa previain a prior pregnancy, velamentous insertion of the cord in the loweruterine segment, placenta succenturiata with implantation in the loweruterine segment, and twin gestations.Results—A total of 27,573 patients were referred to our unitfor fetal anatomic surveys over the study period. Thirty-two cases of vasaprevia were identified. Twenty-nine cases were available for analysis: 6 patientshad migration and resolution of the vasa previa. When the initial diagnosisof vasa previa was made during the second trimester (34to

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013of the cervix might be helpful for detection of the ripening process andpossibly predicting PTL.Table 1. AUC, Sensitivity, Specificity, PPV, and NPV for 3D Ultrasound Parameters of theCervixSensi- Speci-SignificantCutoff tivity, ficity, PPV, NPV, Level 95%AUC Point % % % % AUC P CICL by 2D TVS, mm 0.643 29 72 68 20 95 .055 0.54–0.73CL by TUI, mm 0.649 32 73 63 19 95 .049 0.54–0.74Cervical volume, cm 3 0.501 44.6 64 55 14 93 .987 0.40–0.60FI 0.822 46.2 82 82 36 98 .0002 0.73–0.89CI indicates confidence interval.Pediatrics and Fetal EchocardiographyModerator: Gary Satou, MD1522495 Is Fetal Echocardiography Necessary in In Vitro Fertilization/IntracytoplasmicSperm Injection Pregnancies Afteran Anatomic Survey?Oluyemi Aderibigbe, 1 * Angela Ranzini, 1 Sumekala Nadaraj 21Obstetrics and Gynecology, Saint Peters University Hospital,New Brunswick, New Jersey USA; 2 Pediatric Cardiology, Children’sHospital of Philadelphia, Philadelphia, PennsylvaniaUSAObjectives—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 thisstudy, we evaluated the utility of ECHO after an anatomic survey (AS) inan experienced center. At the time of the AS, cardiac evaluation includedviews of the 4-chamber heart and attempts at outflow tracts and archviews.Methods—Records of patients seen in our hospital’s AntenatalTesting Unit with the indication of IVF/ICSI for an AS and ECHO betweenJanuary 1996 and October 2010 and who delivered at our institutionwere evaluated.Results—Eighty-five patients carrying 110 fetuses were identified.Six cardiac anomalies (4 ventricular septal defects [VSDs], 1 pulmonaryartery [PA]-aortic disproportion, and 1 postvalvular PA dilatation)were suspected on the AS. At ECHO, 2 VSDs were confirmed, 2 werenot, and 2 additional VSDs were seen; 1 aberrant right subclavian artery(ARSA) and 1 right aortic arch (RAA) were found, and PA dilatation wasconfirmed. On neonatal ECHO, only 2 of the 7 VSDs seen at either the ASor ECHO were present; the postvalvular PA dilatation and RAA were confirmed.Second-trimester ECHO, however, identified only 2 additionalanomalies confirmed at birth: an RAA in a fetus with a known VSD andan additional fetus with a VSD. Neonatally, 3 patients with a normal ASand ECHO were found to have VSDs. The most common cardiac abnormalityin IVF/ICSI fetuses is a VSD, which is identified in 4.5% of allcases in the neonatal period. VSDs identified in the antenatal period resolvedin 82% of cases. A RAA and an ARSA should be identified on thetranstracheal view (3-vessel view [3VV]) of the heart.Conclusions—In IVF/ICSI pregnancies, VSDs are commonbut likely to resolve or be seen only at birth. In expert centers, fetal ECHOmay not be necessary if the 3VV of the heart is evaluated and the heart isevaluated for VSDs.1538566 Application of Acoustic Radiation Force Impulse Imagingin Quantitative Evaluation of Neonatal Brain DevelopmentSu Yijin,* Du Lianfang, Xia Jin, Wu Ying, Jia Xiao, CaiYingyu, Li Yunhua, Zhao Jing, Liu Qian, Zhang JuanSchool of Medicine, Shanghai Jiaotong University, Shanghai,ChinaObjectives—To quantitatively evaluate the effect of acousticradiation force impulse imaging (ARFI) in neonatal brain development.Methods—we used ARFI on a Siemens S2000 system to quantitativeevaluate white and gray matter of neonatal different tissues in brainwith different gestational ages. We used a new technical index, Virtual TouchTissue Quantification (VTQ) to evaluate elastic changes of brain tissues.Results—Different tissues in the brain had different elastic numericalvalues. Neonates with different gestational ages had different elasticnumerical values. Elastic numerical values of full-term infants werehigher than preterm infants.Conclusions—ARFI provides a new quantitative index to evaluateneonatal brain development. It increases objectivity and reliability ofclinical analysis. Ultrasound is an examination method that is noninvasive,safe, simple, and convenient, so it has more usefulness with ARFI inquantitative evaluation of neonatal brain development.Table 1. Comparison of VTQ Values for Preterm and Full-Term NeonatesNeonates Cases, n Mean, m/s SD, m/sPreterm 23 1.89 1.07Full-term 35 2.35 1.24Compared with full-term neonates, the VTQ value for preterm neonates was lower(P < .001).1538283 Is Follow-up Sonography Necessary in Babies With MorphologicallyNormal but Unstable Hips?Christine Iseman, Bokyung Han, Henrietta Kotlus Rosenberg*Radiology, Mount Sinai Medical Center, New York,New York USAObjectives—To determine if follow-up (FU) hip ultrasound(US) is necessary in babies with an unstable hip when the hip morphologyis normal (nl).Methods—This retrospective study included patients (pts) withat least 2 hip US examinations performed between January 1, 2008, andJanuary 31, 2012. Pt population: 342 pts, 42 excluded as FU US performedin 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 analyzedin 285 pts. Of those, 68 hips were excluded as they were normal on the firststudy. In total, 480 hips were analyzed. All sonograms and associated reportswere reviewed by 1 attending and 1 resident radiologist. Degree ofsubluxation/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 dislocatedand resolved on FU (93%; group 1). Thirty-three hips were initiallysubluxed or dislocated and did not resolve (7%). Of hips that did not resolveon FU, 4% were morphologically nl (group 2), and 2% were initiallymorphologically abnormal (abnl) but became morphologically nl onFU (group 3). Four hundred six of 447 hips (91%) demonstrated normalα 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 alignmentduring all maneuvers on FU. Age range at time of initial US: 1 to 136days. 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 group2, and 23 to 174 days for group 3. One hundred fifty-one babies whosesubluxation/dislocation resolved had US performed within the first 30days of life; 21% resolved within 28 days; 52% in 29 to 56 days, 16% in56 to 84 days, and 21% in >84 days.S28

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Conclusions—The vast majority (94%) of unstable hips becamestable on FU examination; 91% of these hips were morphologicallynl at initial US, while 9% were morphologically abnl at the initial study butbecame morphologically nl on FU. Approximately 6% of total hips analyzedremained unstable on FU, 4% of these being morphologically nlhips. While these findings can be comforting to parents whose babies havehip instability, they also support the current practice of obtaining FU sonogramsuntil stability is achieved.1538513 Neonatal Ovarian Cysts: Can Sonography Predict Torsion?Dinesh Chinchure, 1 * Chiou Li Ong 2 1 Diagnostic Radiology,Khoo Teck Puat Hospital, Singapore; 2 Diagnostic Imaging, K.K. Women’s and Children’s Hospital, SingaporeObjectives—The purpose of this study was to evaluate whethersonography can predict torsion in neonatal ovarian cysts.Methods—Seven surgically proven cases of neonatal ovariancysts were included in this retrospective study. The patients were dividedinto 2 groups: torsion and nontorsion. These 7 patients were evaluated forclinical 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 4cases with torsion, 2 lesions had internal echoes with a “fishnet appearance.”The other 2 lesions were predominantly cystic on sonography withinternal echoes and echogenic nodules. A calcific focus was present in 1of these echogenic nodules. One of the cysts had a fluid-fluid level. In thenontorsion group, only 1 of the lesions had a mixed echogenic appearance.The other 2 lesions were cystic with low-level internal echoes in 1of the cysts. The surgical procedure performed in the torsion group wassalpingo-oophorectomy in 2 patients and oophorectomy in 1 patient. In 1patient, cystectomy was attempted without success. In the nontorsiongroup, only cystectomy was performed with preservation of normalovaries, which was confirmed on follow-up sonography.Conclusions—The sonographic features of cysts with a fishnetappearance, a fluid-debris level, and echogenic nodules favor torsion. Theformer sign has so far not been described as a sonographic predictor forneonatal ovarian torsion.1539741 Sonographic Evaluation of Pediatric Skeletal Lesions: Is ItWorthwhile?Henrietta Kotlus Rosenberg,* Neil Lester Radiology, MountSinai Medical Center, New York, New York USAObjectives—To demonstrate how ultrasound (US) may serveas a readily available, cost-effective, noninvasive, nonionizing, practicaltool for the evaluation of a variety of skeletal abnormalities in the pediatricage range.Methods—We reviewed the clinical and imaging findings in31 patients in whom US demonstrated abnormalities related to the skeletalsystem, excluding patients with hip joint effusions or developmentaldysplasia of the hip.Results—US proved useful in the following situations: evaluationof a hard superficial immobile mass (osteoma shin; 1), absent medialend clavicle on x-ray in the region of a neck mass (US showed an aneurysmalbone cyst in the medial end clavicle; 1), to determine if a soft tissuemass involves adjacent bone (nodular fasciitis surrounding the clavicularhead; 1), diagnosis and follow-up of fracture (displaced/nondisplaced) in aninfant (4), diagnosis of osteomyelitis in patients with cellulitis (4), questionof fracture underlying cephalohematoma or subgaleal hematoma (4),rib mass (osteochondroma; 1; or a mass in costochondral junctions: contourdeformities in the costochondral cartilage; 6), firm posterior knee mass(Baker’s cyst; 1), firm anterior knee mass (septated cystic mass in the suprapatellaregion due to rheumatoid disease; 1), immobile hard scalp mass dueto an epidermoid cranial vault (1), painful mass in the occipital bone withsoft tissue components extending through the skull externally and internallydue to Langerhan’s histiocytosis (1), indeterminate mass in the clavicleclinically thought to be posttraumatic sequelae, resolved on follow-up(1), assessment of craniosynostosis (3), ad differentiation of a pathologic entityfrom a normal anatomic structure (lump on the back of a slender babyproven to be a normal posterior spinous process; 1).Conclusions—US is worthwhile for evaluation of a wide rangeof pediatric skeletal abnormalities and helps determine if the a lesion is onethat is “touch” or “don’t touch.” To maximize diagnostic accuracy, the imagershould have thorough knowledge of the clinical history, physical findings,and laboratory and other imaging findings. In equivocal cases or inthose patients in whom the field of view is insufficient for complete visualizationof an obvious lesion or if malignancy is suspected, US serves totriage those patients in whom further imaging is necessary.1539575 Evaluation of Automated Multiplanar 3-/4-DimensionalSonography in Prenatal Diagnosis of Conotruncal CardiacDefects: Analysis of 150 CasesElena Sinkovskaya,* Sharon Horton, Anna Klassen, AlfredAbuhamad Division of Maternal-Fetal Medicine, EasternVirginia Medical School, Norfolk, Virginia USAObjectives—The aim of this study was to assess potential clinicalapplicability of automated multiplanar imaging (AMI) in prenatal detectionof conotruncal heart defects.Methods—Detailed 2D echocardiography was performed in75 fetuses with normal cardiac anatomy and 75 fetuses with conotruncalheart anomalies between 18 and 23 weeks’ gestation by a trained sonographer.In addition, 3D/spatiotemporal image correlation volumes of thefetal chest were acquired at the level of the 4-chamber view. Two volumedata sets per case (with and without color Doppler) were included in thestudy. The initial scan was interpreted and reported based on the 2D images.The volume data sets were independently reviewed offline usingAMI software by a pediatric cardiologist with experience in fetal heart assessment.The diagnostic value, image quality, as well as time for acquisitionand reading of AMI were evaluated and compared with the original2D report. The prenatal diagnosis was confirmed in all cases by postnatalechocardiography, angiography, operative findings, or autopsy.Results—A summary of the results is provided in Table 1.Conclusions—The developed software demonstrates an excellentdisplay of the diagnostic landmarks of conotruncal defects withappropriate image quality in most cases. This should help improve the detectionof these heart anomalies in the future. Automated sonography alsohas the potential for improving the efficiency of ultrasound imaging byreducing the time needed to complete an ultrasound examination, therebyresulting in increased throughput of ultrasound laboratories.Table 1Parameter 2D AMI PAcquisition time, min 16 ± 4 0.3 ± 0.1

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131540606 Fetal Diagnosis of Hypoplastic Left Heart: Associations andOutcomes in the Current EraRoland Axt-Fliedner, 1 * Christian Enzensberger, 1 MelanieVogel, 2 Jan Weichert, 4 Ulrich Gembruch, 5 Ute Germer, 6Thomas Kohl, 3 Martin Krapp, 7 Jan Degenhardt 1 1 Divisionof Prenatal Medicine, 2 Division of Pediatric Cardiology,3German Center for Fetal Surgery and Minimally InvasiveTherapy, University of Giessen & Marburg, Giessen, Germany;4Division of Prenatal Medicine, University of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany; 5 Division ofPrenatal Medicine, University of Bonn, Bonn, Germany;6Center for Prenatal Medicine, Caritas Krankenhaus St Josef,Regensburg, Germany; 7 Center for Endocrinology andReproductive and Prenatal Medicine, Amedes Hamburg, Hamburg,GermanyObjectives—Hypoplastic left heart (HLH) is one of the mostcommon forms of cardiac abnormality detectable during gestation by fetalechocardiography. Antenatal diagnosis allows for appropriate counselingand time to consider treatment options. We report the actual outcome dataafter fetal diagnosis of HLH.Methods—We conducted a retrospective analysis of the outcomein all cases with HLH from 1994 to 2011 presenting in fetal life at2 tertiary referral centers for prenatal diagnosis and pediatric cardiology.Results—One hundred five cases were included, and the overallsurvival was 40.9% (43/105) after prenatal diagnosis. There was an81.1% survival rate in infants undergoing surgery and a 64.1% survivalrate from an intention-to-treat position. Two neonates died due to tamponadeand cardiac arrest following balloon septostomy and 1 neonatefrom sepsis before surgery. Extracardiac anomalies occurred in 3 fetusesand karyotype anomalies in 7 fetuses (18.9%). In 4 of 5 babies born withadditional extracradiac or karyotype anomalies, parents opted for compassionatecare. The first had trisomy 13; the second had trisomy 18; thethird neonate presented with spina bifida; and the fourth presented with hydronephrosisand pulmonary atresia. Termination of pregnancy took placein 17 cases (16.1%).Conclusions—Thorough antenatal evaluation should includekaryotyping and detailed extracardiac and intracardiac assessment to accuratelypredict the risks of surgery. Prenatal counseling might be modifiedafter the exclusion of additional anomalies. These data provideup-to-date information for parental counseling.1539318 Fetal Pulmonary Venous Flow and a Restrictive ForamenOvale in Hypoplastic Left HeartRoland Axt-Fliedner, 1 * Jan Degenhardt, 1 Melanie Vogel, 2Jan Weichert, 4 Ulrich Gembruch, 5 Thomas Kohl, 3 ChristianEnzensberger 1 1 Division of Prenatal Medicine, 2 Division ofPediatric Cardiology, 3 German Center for Fetal Surgery andMinimally Invasive Therapy, University of Giessen & Marburg,Giessen, Germany; 4 Division of Prenatal Medicine, Universityof Schleswig-Holstein, Campus Luebeck, Luebeck, Germany;5Division of Prenatal Medicine, University of Bonn, Bonn,GermanyObjectives—Hypoplastic left heart (HLH) with intact or restrictiveinteratrial communication (HLH- IAS/RAS) is associated withhigh mortality rates. The objective was to correlate pulmonary venous(PV) Doppler spectra and direct foramen ovale (FO) assessment with theneonatal need for early atrial septostomy (EAS) and neonatal outcome.Methods—We reviewed all prenatal echocardiograms andoutcomes of 51 fetuses with HLH and information about the interatrialcommunication between 1994 and 2011. IAS/RAS was defined as asmall/absent interatrial shunt on 2D imaging. Three PV Doppler spectrawere 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.S30Results—Three of 51 neonates with the type C PV flow patternand suspicion of IAS/ RAS on 2D evaluation required EAS. In 1 fetus, PVflow changed from type B to type C spectra throughout gestation. Fetuseswith type C spectra showed 71.4% survival after 30 days compared to92.3% in fetuses with type A spectra. Short-term survival after EAS was33%.Conclusions—The prenatal PV flow pattern and 2D evaluationof the FO size help in identifying the fetus at risk for neonatal EASand patient selection for fetal cardiac intervention. Most late secondtrimestervalues will not change over time.1538894 The Fetal-Maternal Vascular Impedance Index: A PotentialNew Tool for Characterization of Fetal CirculatoryHealthDebbra Soffer,* Margaret McCann, Xi Liu, Zhiyun Tian,Jack Rychik Fetal Heart Program, Children’s Hospital ofPhiladelphia, Philadelphia, Pennsylvania USAObjectives—Fetal circulatory health is often determined bycharacterization of (1) umbilical arterial blood flow, (2) cerebrovascularblood flow, or (3) the ratio between the two. However, these measures ignorethe maternal contribution to placental perfusion. We sought to investigatethe utility of the fetal-maternal vascular impedance index(FMVI), a new measure of vascular characterization that incorporates fetalcerebrovascular, umbilical, and maternal uterine circulations in assessingoverall fetal well-being.Methods—Doppler interrogation of the fetal middle cerebralartery (MCA), umbilical artery (UA), and right maternal uterine artery(UTA) was performed and vascular impedance calculated for each throughthe pulsatility index (PI). Three groups of gestationally age-matched subjectswere 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 calculatedas the (MCA PI – UA PI)/UTA PI.Results—Mean and SD data are listed in Table 1. There wasno difference in gestational age between the 3 groups. The MCA PI for theMD group was no different than for normal; however, HLHS was significantlylower (P < .05). There was no difference in the UA PI or UTA PIbetween the 3 groups. The FMVI for the MD group was significantlylower (P < .05) and for the HLHS group was markedly lower (P < .001),than normal.Conclusions—The FMVI is an index of relative vascular impedancebetween the fetal cerebrovasculature, UA, and maternal contributionto placental flow, which varies from normal in MD and complexCHD. Vascular impedance is naturally highest in the MCA, followed bythe UA, and lowest in the UTA. The FMVI evaluates this natural trend,which may aid in detecting subtle circulatory alterations that are not evidentby analysis of individual PI values alone.Table 1Gestationaln Age, wk MCA PI UA PI UTA PI FMVINormal 47 23.2 (3.7) 1.99 (0.38) 1.25 (0.19) 0.92 (0.38) 0.97 (0.63)MD 54 23.5 (4.8) 1.92 (0.39) 1.30 (0.29) 0.91 (0.36) 0.73 (0.73)HLHS 29 24 (3.4) 1.85 (0.31) 1.34 (0.26) 0.89 (0.21) 0.62 (0.49)

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSMONDAY, APRIL 8, 2013, 1:30 PM–3:30 PMCellular Bioeffects and ApplicationsModerator: Diane Dalecki, PhDApplications of Ultrasound Standing Wave Fields in Tissue EngineeringDiane Dalecki University of Rochester, Rochester, New YorkUSAThe field of tissue engineering aims to develop technologiesthat enable the repair or replacement of diseased or injured tissues and organs.The spatial organization of cells within native and engineered tissuesis essential for proper tissue assembly and organ function. Thus, successfulengineering of complex tissues and organs requires methods to controlcell organization in 3 dimensions. Acoustic radiation forces associatedwith ultrasound standing wave fields provide a rapid, noninvasive approachto spatially pattern cells in 3 dimensions without affecting cell viability.Results of several investigations will be presented that demonstratethe use of ultrasound standing wave fields to pattern cells or protein-boundmicroparticles in 3D hydrogels. Furthermore, patterning of endothelialcells with ultrasound standing wave fields leads to rapid and extensivevessel network formation in 3D collagen-based constructs. Thus, ultrasoundstanding wave fields provide new strategies to pattern cells and directvascular network formation and morphology within engineered tissueconstructs.Interactions of Microbubbles With Cells and Their Applications forDrug and Gene DeliveryCheri Deng University of Michigan, Ann Arbor, MichiganUSASonoporation uses ultrasound application to generate microbubbleactivities to transiently disrupt the cell membrane for enhancingintracellular transport of exogenous agents for drug and gene deliveryapplications. However, success of sonoporation is hindered by low deliveryefficiencies and variable outcomes. These difficulties are due to thelack of understanding of the detailed processes supporting ultrasound-inducedtransport into and within the cytoplasm of living cells. The dynamicmicrobubble activities driven by ultrasound application induce cellularbioeffects that can determine the delivery outcome, including delivery efficiencyand cell viability. In this presentation, we provide an examinationof these biophysical and biochemical effects resulting from interactionof ultrasound-driven microbubbles with cells and whether they play importantroles in the sonoporation outcome. We developed novel techniquesto control and investigate ultrasound-driven microbubble cavitation in referenceto single cells and the resulting membrane disruptions. We used simultaneouswhole-cell patch clamp recording and fluorescence microscopyto characterize the formation and resealing of ultrasound-induced membranepores. We demonstrated spatiotemporally controlled subcellular deliveryand calcium signaling in targeted cells. In addition, based on theultrasound-driven microbubble activities, we implemented an ultrasoundexposure strategy to improve gene transfection. These results may providerelevant information for further development of sonoporation.Directing Extracellular Matrix Protein Microstructure With UltrasoundDenise Hocking Pharmacology and Physiology, Universityof Rochester, Rochester, New York USAThe extracellular matrix is a complex network of interconnectedproteins and polysaccharides that provides structure to tissues and instructscell behaviors. The microstructure and molecular conformation of extracellularmatrix proteins provide signals that direct cell functions critical totissue formation and regeneration, including proliferation, migration, andmatrix remodeling. Thus, controlling extracellular matrix protein structureprovides a means to regulate the mechanical properties of biomaterialsand control cellular responses. Moreover, biomaterials with regionallydefined extracellular matrix structure could provide local cues to instructcell behavior and drive proper tissue function in 3 dimensions. Collagenis the primary fibrous component of the extracellular matrix. The tremendousdiversity of the functional properties of type I collagen arises fromvariations in the micromolecular and macromolecular structure of polymerizedcollagen fibers. Results of our studies demonstrate the capabilityof ultrasound to spatially pattern various collagen microstructures withinan engineered tissue noninvasively, thus enhancing the level of complexityof extracellular matrix microenvironments and cellular functionsachievable within 3D engineered tissues.Elastography 2013Moderator: Richard Barr, MD, PhDElastography of Diffuse Liver DiseaseGiovanna Ferraioli,* Carlo Filice Infectious Diseases, FondazioneIstituto di Ricovero e Cura a Carattere Scientifico,Policlinico San Matteo, Medical School, University of Pavia,Pavia, ItalyThe prognosis and management of patients with chronic liverdiseases largely depend on the extent and progression of liver fibrosis.Liver biopsy is still considered the reference standard for assessing liverfibrosis. 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 fibrosishave been developed. Elastography is a technique that analyzes themechanical and elastic properties of soft tissue that could be modified bypathologic conditions. Real-time elastography, which allows measurementof tissue’s stiffness while guided by the B-mode image, is either strainbased or shear wave based. With strain-based elastography, the displacementof tissues due to an applied stress is detected. With all the shear wavebasedtechniques, there is a generation of shear waves determined bytissue’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 thatshear wave–based methods are ready to be used in patients with chronichepatitis C to assess liver fibrosis before therapy at a safe level of predictability.S31

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Exploring the Interface of Ethics and Communicationin Prenatal Care: A Video-Based ApproachModerator: Stephen Brown, MDExploring the Interface of Ethics and Communication in PrenatalCounseling: A Video-Based ApproachStephen Brown, 1 * Bryann Bromley, 3,4,5 Elaine Meyer 2,61Radiology, 2 Institute for Professionalism and Ethical Practice,Boston Children’s Hospital, Boston, Massachusetts USA;3Diagnostic Ultrasound Associates, Boston, MassachusettsUSA; 4 Obstetrics and Gynecology, Massachusetts GeneralHospital and Brigham and Women’s Hospital, Boston, MassachusettsUSA; 5 Radiology, Brigham and Women’s Hospital,Boston, Massachusetts USA; 6 Psychiatry, Harvard MedicalSchool, Boston, Massachusetts USACourse objectives: (1) Evaluate strategies to communicate effectivelywhen conveying difficult information to patients. (2) Explorehow micro-ethical issues are embedded in patient-clinician communication.(3) Examine the clinical and ethical dimensions of prenatal counselingfrom the perspectives of upstream and downstream clinical providers.Course description: In this interactive workshop, faculty and audience willview and discuss videotaped counseling sessions between experiencedclinicians and trained actors portraying expectant parents after diagnosesof miscarriage in the first trimester and spina bifida in the second trimester.When such conditions are diagnosed, practitioners who counsel patientsmust convey cognitively and ethically complex information under emotionallycharged circumstances. Few educational opportunities exist tohelp practitioners acquire the skills necessary to approach these conversationseffectively. Such skills are essential for obstetric and pediatric specialistswho 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 influencedecision making; (3) how language usage, framing of choices, provisionof information, and offers of resources may confound neutrality; (4) potentialdifferences in attitudes and counseling practices between practitionersfrom different disciplines; and (5) strategies to teach this difficultcommunication process. Workshop faculty includes a pediatric and obstetricimaging specialist and bioethicist, a maternal-fetal medicine andobstetric imaging specialist, and a psychologist and pediatric critical carenursing specialist who is an expert in health care communication.Hands-on Carotid and Transcranial DopplerUltrasoundModerator: Tatjana Rundek, MDIn this session, participants will be provided with live demonstrationsof carotid and transcranial Doppler scanning protocols and handsonpractice sessions at ultrasound stations.New Techniques and Methods in Ultrasound-GuidedInterventionsModerator: Corinne Deurdulian, MDUtilization of Contrast-Enhanced Ultrasound in InterventionalRadiologyDean Huang Clinical Radiology, King’s College Hospital,London, EnglandS32The aim of this talk is to consider the applications of contrast-enhancedultrasound (CEUS) in interventional radiology. One of the most establishedtechniques in imaging-guided, minimally invasive procedures iswith ultrasound, a tool that is safe, mobile, and cost-effective. CEUS providesbetter images than conventional B-mode images, improves the abilityto differentiate between normal and abnormal tissue, and simplifies the precisenavigation of needles during an intervention. CEUS therefore could playan important role in procedure planning, needle navigation, and postprocedurefollow-up imaging, particularly when iodinated contrast or ionizing radiationis undesirable or in unstable patients where “bedside” procedures areadvantageous. A number of interventional procedures in which CEUS hasbeen integrated into the management, both in nonvascular and vascular intervention,are illustrated. Examples of nonvascular applications include urologicintervention with CEUS-guided nephrostomy and CEUS-guidednephrostography, CEUS-guided percutaneous biopsy and abscess drainage,CEUS-guided transhepatic T-tube cholangiography, and CEUS-guided oncologicintervention in thermal ablation of hepatic and renal tumors. Examplesof vascular intervention with CEUS include management of endoleaksfollowing endovascular aortic stent graft repair, pseudoaneurysms followingarterial injury with CEUS-guided percutaneous thrombin injection, andCEUS-guided dialysis arteriovenous fistula angioplasty. Through a casebasedapproach, this talk aims to demonstrate that CEUS not only can be utilizedsafely and effectively in radiologic intervention but may also providenovel, tailor-made solutions to complex clinical problems.Vaginal Bleeding in the First TrimesterModerator: Leslie Scoutt, MDUltrasound Evaluation for Retained Products of ConceptionDouglas Brown Radiology, Mayo Clinic, Rochester,Minnesota USAIn this session, we will review sonographic features for identifyingretained products of conception in patients with spontaneous miscarriageand after surgical intervention. Limitations of ultrasound for thispurpose will be reviewed. Miscellaneous abnormalities occurring inwomen after spontaneous miscarriage will also be reviewed, including subinvolutionof the placental bed, which can present a diagnostic dilemma.Diagnostic Criteria for Miscarriage and Nonviable Pregnancy in theEarly First TrimesterPeter Doubilet Radiology, Brigham and Women’s Hospital,Boston, Massachusetts USA; Radiology, Harvard MedicalSchool, Boston, Massachusetts USAWhen a woman presents with symptoms of pain or bleeding inearly pregnancy, the main diagnostic possibilities are currently viable intrauterinepregnancy, failed (or failing) intrauterine pregnancy, and ectopicpregnancy. Serum human chorionic gonadotropin (hCG) measurementand pelvic ultrasound are commonly performed to aid in the differentialdiagnosis. At that point, unless an emergently life-threatening situationdictates management, a key question is: “Is there a chance of a viable pregnancy?”.This question is central to management decision making in 2main clinical settings: intrauterine pregnancy of uncertain viability andpregnancy of unknown location. Research over the past 2 to 3 years hascalled into question previously accepted dogma regarding criteria for rulingout the possibility of a viable pregnancy, which had been based onsmall study populations. We will consider 3 scenarios: (1) Ultrasounddemonstrates an intrauterine gestational sac, with or without a visible embryo,with no cardiac activity: What are the criteria for definitive diagnosisof failed pregnancy (“miscarriage”)? (2) Ultrasound demonstrates asmall saclike structure in the uterus, without a visible yolk sac or embryo:Is it a gestational sac or pseudogestational sac? (3) Ultrasound demonstratesno intrauterine fluid collection and no adnexal mass suspicious forectopic pregnancy: What is the significance if the hCG value is above the“discriminatory level” or if it is below the “discriminatory level”?

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Ectopic PregnancyJames Shwayder Obstetrics and Gynecology, University ofMississippi Medical Center, Jackson, Mississippi USAThis portion of the session will address new nomenclature relatedto ectopic pregnancies and pregnancies of unknown location. It willdiscuss the relative merit of various laboratory and ultrasound findings indiagnosing ectopic pregnancies, presented with clinical correlation.SPECIAL INTEREST SESSIONSMONDAY, APRIL 8, 2013, 4:00 PM–5:30 PMHands-on ElastographyModerator: Richard Barr, MD, PhDThis session is designed to provide a workshop with variousvendors demonstrating how to perform and interpret elastography withtheir equipment and demonstrating the differences in techniques betweenvendors to obtain optimal images.Interventional and Other Ultrasound Techniques:How I Do ItModerator: David Fessell, MDAfter attending this session, participants will know when andhow to use interventional musculoskeletal ultrasound techniques.Quantitative Ultrasound BiomarkersModerators: Paul Carson, PhD, Timothy Hall, PhD, ABRQuantitative Ultrasound Applied to Detection and Imaging ofProstate Cancer and Lymph Node MetastasesErnest Feleppa Frederic L. Lizzi Center for BiomedicalEngineering, Riverside Research, New York, New York USAUltrasound is a popular clinical-imaging modality for displayingthe macroscopic anatomy of soft tissue structures in medical andresearch applications. While conventional ultrasound methods (eg, B-mode, harmonic, and Doppler methods) are well established and continueto advance technically, quantitative ultrasound (QUS) technologiesalso are emerging that appear to offer exciting promise for significantlyimproving clinical imaging of disease. These emerging methods includespectrum analysis, envelope statistics analysis, strain and Young’s modulusestimation, contrast-based perfusion kinetics, and advanced flowdetection and measurement techniques. Each QUS method provides independentinformation, and each offers powerful quantitative tissue-typingand imaging capabilities. However, a multifeature approach thatcombines estimates derived from different QUS methods may provideeven more powerful capabilities, eg, by combining spectrum analysisand envelope statistic parameters. This presentation will review progressspecifically in QUS applied to tissue-type imaging of prostate cancerand detection of lymph node metastases. Prostate cancer cannot be reliablyimaged by conventional ultrasound, and small, but clinically significant,lymph node metastases easily can be overlooked by currenthistopathologic methods. The QUS methods of particular interest inthese applications are spectrum analysis and envelope statistics. QUSapplied to detection of prostate cancer produces an area under the receiveroperating characteristic curve of 0.84, while QUS applied to detectionof lymph node colorectal and gastric cancer metastases producesan area exceeding 0.95; both results are markedly superior to the performanceof current methods. The implications for prostate cancer managementare improved biopsies, noninvasive disease monitoring, andaccurate focal treatment targeting; the implications for lymph nodehistopathology are improved detection of metastases and more accuratecancer staging.Ultrasound IncidentalomasModerator: Franklin Tessler, MD, CMIncidental Findings in the Soft Tissue and ExtremitiesDeborah Rubens Imaging Science, University of Rochester,Rochester, New York USAThis session will cover incidental findings discovered duringexamination of the soft tissues and extremities. Topics will include solidmasses, fluid collections, and vascular findings that are unexpected and notpart of the original diagnostic question. Management and reporting issueswill be addressed: which findings require immediate phone calls, whichcan be mentioned in the report but are not urgent, and which can be ignoredaltogether.S33

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SCIENTIFIC SESSIONSMONDAY, APRIL 8, 2013, 4:00 PM–5:30 PMCarotid/Cerebrovascular Ultrasound andNeurosonologyModerator: David Vilkomerson, PhD1538396 Monitoring the Formation of Aneurysms in Murine AortasUsing Pulse Wave ImagingSacha Nandlall,* Monica Goldklang, Jeanine d’Armiento,Elisa Konofagou Columbia University, New York, New YorkUSAObjectives—Abdominal Aortic Aneurysms (AAAs) are a commonvascular disease. The leading cause of AAA-induced death is rapid internalbleeding following a sudden rupture of the vessel wall, typicallywithin the sac of the aneurysm. This study aimed at showing that pulsewave imaging (PWI) can be used to differentiate normal murine aortasfrom AAAs, even for aneurysms that are not visible or easily detectable ona standard B-mode. PWI is a noninvasive technique for tracking the propagationof pulse waves along the wall of the aorta at high spatial and temporalresolutions. The velocity of these waves is a well-established markerof wall stiffness, which is closely related to the likelihood of rupture.Methods—An AAA model was generated by infusing 13ApoE/TIMP-1 knockout mice with angiotensin II, delivered at a constantflow rate via subcutaneously implanted osmotic pumps. The suprarenalsections of the abdominal aortas were scanned every 2 to 3 days after implantationusing a Vevo 770 imager (VisualSonics Inc) with axial and lateralresolutions of 55 and 115 µm, respectively. Pulse wave propagationwas tracked at an effective frame rate of 8 kHz by using retrospective electrocardiographicgating. The displacements induced by the pulse waveswere estimated by performing 1D cross-correlation on the pre–beamformedradiofrequency signals.Results—In normal aortas, the pulse waves propagated at constantvelocities (r 2 ≥ 0.9) between 2 and 4 m/s, indicating that the compositionof these vessels was relatively homogeneous. However, in AAAswhere the vessel diameter had increased by at least 50%, the wave speedsexhibited higher variances along the wall (r 2 < 0.9). Moreover, the wall displacementsinduced by the pulse waves were at least 80% lower within theaneurysmal sacs, indicating that the AAAs had a higher relative stiffness.Conclusions—This study demonstrates that PWI can be usedto distinguish normal murine aortas from AAAs based on the higher varianceand lower wall displacements induced by the pulse wave in the lattercase. Hence, PWI could potentially be used to monitor the growth andpropensity for rupture of human aneurysms by providing complementaryinformation to that provided by a standard B-mode.1510020 Results of Evaluation of the Spectral Curve in AortoiliacDiseaseMireia Cussó Sorribas,* Xavier Martí Mestre, Nicolo RizzaSiniscalchi, Sara Garcia Pelegrí, Antonio Romera Villegas,Ramon Vila Coll Vascular Surgery, Hospital de Bellvitge,Hospitalet de Llobregat, Barcelona, SpainObjectives—To evaluate the morphology of the spectral curveof the supraceliac aorta as a complement of the diagnosis of aortoiliac occlusivedisease.Methods—We studied 86 patients (70 men) with a mean age of62 years (range, 16–90 years) recruited from August to February 2012.Arterial Doppler ultrasound of the aortoiliac and femoro-popliteal sectorwas used as a method of diagnosis of the stenotic-occlusive disease inthese sectors. Stenosis was considered significant when it exceeded 70%,characterized by a ratio of peak systolic velocities in the stenosis comparedto the previous stenosis ≥3. Occlusion was considered in the absenceof flow. We determined the spectral wave morphology of the aorticflow at the visceral arteries level looking for the presence of a decelerationin the late systolic phase or a biphasic wave in the systolic waveform(notch). We studied the relationship of these signs of the spectral visceralaortic wave with the presence of disease of the aortoiliac sector in termsof sensitivity, specificity, positive predictive value (PPV), negative predictivevalue (NPV), overall efficiency, and κ correlation index. Data weretreated 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 thespectral visceral aorta wave in 46 patients (53.5%), of which 41 had aortoiliacdisease. The sensitivity, specificity, PPV, and NPV for the morphologicalteration of the aortic spectral curve in the aortoiliac segmentwere 83.6%, 86.5%, 89.1%, and 80%, respectively, with overall efficiencyof 84.9% and a κ correlation index of 0.695 (good agreement).Conclusions—The existence of spectral wave disturbances inthe visceral aortic territory might suggest the presence of stenotic-occlusivedisease in the aortoiliac segment.1530492 Comparison of Automatic and Manual Transcranial SonographicMorphometric Measurement of the Substantia NigraMonika Jelinkova, 1 David Školoudík, 2,3 * Jiri Blahuta, 4 TomasSoukup, 4 Petr Cermak, 4 Petra Bartova, 2 Katerina Langova, 5Roman Herzig 3 1 Neurology, Hospital Karvina-Raj, Karvina,Czech Republic; 2 Neurology, University Hospital Ostrava,Ostrava, Czech Republic; 3 Neurology, Palacký University MedicalSchool and University Hospital Olomouc, Olomouc, CzechRepublic; Institute of Computer Science, Faculty of Philosophyand Science, Silesian University Opava, Opava, CzechRepublic; Biophysics, Faculty of Medicine and Dentistry,Institute of Molecular and Translational Medicine, PalackýUniversity Olomouc, Olomouc, Czech RepublicObjectives—Increased echogenicity of the substantia nigra(SN) is a typical transcranial sonographic (TCS) finding in Parkinson’sdisease (PD). Experimental software for quantitative evaluation of theechogenic SN area was developed to overcome the main limitation ofTCS, the dependency on the sonographer’s experience. The aim of thestudy was to compare the morphometric measurement of the SN usingdeveloped software with manual measurement and results achieved by 2different ultrasound machines in PD patients and healthy volunteers.Methods—Totally, 113 healthy volunteers were enrolled in thederivation cohort and 50 healthy volunteers and 30 PD patients in the validationcohort. The SN was imaged from the right and left temporal bonewindows in the mesencephalic plane using TCS. All subjects were examinedtwice using different sonographic machines (MyLab Twice, Esaote;and Vivid 7 Pro, GE). DICOM images of the SN were saved, encoded, andprocessed. Manual and automatic morphologic measurements of the SNwere performed by an experienced sonographer. The 90th percentile ofderivation cohort values was used as a cut point for the evaluation of ahyperechoic SN in the validation cohort. Spearman’s coefficient was usedfor the assessment of correlation between manual and automatic measurements.Cohen’s κ coefficient was used for the assessment of correlationbetween automatic or manual measurement and PD diagnosis.S34

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Results—Spearman’s coefficient between measurements usingdifferent machines was 0.686 for automatic and 0.721 for manual measurement(P < .0001 for both measurements). A hyperechoic SN was detectedin the same 26 (86.7%) PD patients using both automatic andmanual measurements. Cohen’s κ coefficients for automatic and manualmeasurements were 0.787 and 0.762, respectively (P < .0001 for bothmeasurements).Conclusions—The results of the presented study showedcomparable findings for SN feature measurement using the designed applicationwith manual measurement. (Supported by a grant from theMoravian-Silesian Region.)1540954 Investigation of Asymmetries in Cerebral Collateral Flowfor Patients With Carotid StenosisKhalid Al Muhanna, 1 * Limin Zhao, 2 Kirk Beach, 3 BrajeshLal, 4,5 Gregory Kowalewski, 5 Siddhartha Sikdar 1 1 Electricaland Computer Engineering and Bioengineering, GeorgeMason University, Fairfax, Virginia USA; 2 University ofMaryland Medical Center, Baltimore, Maryland USA; 3 Surgeryand Bioengineering, University of Washington, Seattle, WashingtonUSA; 4 Vascular Surgery, University of MarylandMedical Center, Baltimore, Maryland USA; 5 Baltimore VeteransAffairs Medical Center, Baltimore, Maryland USAObjectives— Stroke affects millions of people in the worldeach year. About 25% of ischemic strokes are caused by rupture ofcarotid artery plaque. Currently, stenosis severity is used as a surrogatefor the risk of plaque rupture; however, other factors may play a largerrole, such as the hemodynamics around the plaque, which may be affectedboth by extracranial hemodynamics and intracranial collateralization.In the present study, we investigated how an incomplete(noncollateralized) intracranial circle of Willis (COW) might affect intraluminalvelocity around the carotid plaque and whether there areasymmetries of flow in the middle cerebral artery (MCA) in patientswith extracranial carotid stenosis.Methods—We created a simple linear simulation model of theintracranial and extracranial circulation to investigate the relationship betweenMCA 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 MCAvelocity measurements performed in patients with asymptomatic carotidstenosis using transcranial Doppler.Results—Simulation results showed no asymmetries in MCAflow waveforms for a complete (collateralized) COW, but for an incompleteCOW, the systolic peak had a lower magnitude and was delayed byabout 100 milliseconds on the ipsilateral side. In our clinical measurementson 32 patients, we found that 25 had waveforms consistent withthose predicted for a collateralized COW, with minimal differences indelay, velocity magnitude, and resistivity index between the ipsilateral andcontralateral sides. In 6 cases, some unexpected findings were noted, suchas large delays for 2 patients who had ≤50% stenosis and a larger velocitydifference with low delays for 5 patients with >50% stenosis.Conclusions—Our results indicate that intracranial flow is animportant variable when interpreting intrastenotic velocities. The presentstudy does not allow us to definitely interpret the reason for MCA flowasymmetries, since the COW was not directly imaged. We intend to enrolladditional patients in our cohort with concomitant imaging of the COW tofurther strengthen our results.1512012 Left-to-Right Image Registration of Longitudinal CarotidImages Improves Intima-Media Thickness and AtheroscerlsosisDisease MonitoringFilippo Molinari, 1 Nobutaka Ikeda, 2 U Rajendra Acharya, 3Luca Saba, 4 Andrew Nicolaides, 5 Jasjit Suri 6,7 * 1Electronicsand Telecommunications, Politecnico Torino, Torino, Italy;2Division of Cardiovascular Medicine, Toho University MedicalCenter, Tokyo, Japan; 3 Electronics and Computer Engineering,Ngee Ann Polytechnic, Singapore; 4 Radiology, AziendaOspedaliero, Universitaria di Cagliari, Cagliari, Italy;5Imperial College, London, England; 6 Global Biomedical Technologies,Roseville, California USA; 7 Biomedical Engineering,Idaho State University, Pocatello, Idaho USAObjectives—Automated systems for the measurement of thecarotid intima-media thickness (CIMT) are useful in clinical practice ifthey ensure high measurement accuracy and high reproducibility. We developeda registration-based method to improve the carotid distal wall segmentationand CIMT measurement in noisy images.Methods—We tested 50 patients and acquired left and rightcommon 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 by3 independent expert readers. We processed each image by a 3-stage system.Stage 1 is relative to automated carotid localization and far adventitiatracing. Stage 2 is relative to the definition of a guidance zone andregistration of the left to the right distal wall. Registration was performedby relying on the profile of the far adventitia. The segmentation is carriedout in stage 3 by using a edge snapper. We compared the CIMT measurementaccuracy of the registered and unregistered image sets.Results—Stage 1 was successful in all 300 images. Left-torightregistration 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 was0.012 ± 0.079 mm, which decreased to 0.006 ± 0.081 mm for the registeredimages. The figure of merit (FoM) increased from 98.19% for the unregisteredto 99.09% for the registered image set.Conclusions—Registering the left to the right carotid arteryimages can increase CIMT measurement accuracy. We plan to extend thiswork by also including arteries with plaques in the registration framework.Table 1. Auto Edge Performance for the 3 OperatorsGT1 GT2 GT3 Average GTOriginal 0.020 ± 0.079 0.051 ± 0.083 –0.034 ± 0.090 0.012 ± 0.079CIMT bias,mmFoM, % 96.99 92.00 95.24 98.19Registered 0.014 ± 0.085 0.045 ± 0.086 –0.040 ± 0.090 0.006 ± 0.081CIMT bias,mmFoM, % 97.90 92.96 94.39 99.091540884 More Easily Deployable Long-term Transcranial DopplerMonitoring of the Middle Cerebral ArteryBill Beck PhysioSonics, Inc, Bellevue, Washington USAS35Objectives—Develop a system to facilitate long-term transcranialDoppler monitoring of the M1 segment of the middle cerebral artery(M1 MCA), allowing continuous data collection over a period of dayswithout operator intervention after initial setup.Methods—Deployment of M1 MCA monitoring is facilitatedby a structured procedure to guide the operator in: (1) positioning a 2Dphased array transducer, mounted in a headset, over the temporal window,

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013by measuring echo strength from the far side of the skull, then (2) articulatingthe transducer to point at the M1 MCA, through the use of flashcolor Doppler insonation of the 3D conical region of interest (ROI). Thephased array is then electronically steered to gather data from the peakDoppler signal in the ROI; the Doppler spectrum is analyzed, and standardflow metrics are logged for future review. The peak Doppler signal is automaticallyrelocated as required to maintain continuous monitoring withoutoperator intervention. An alert is generated if the signal is lost or ifflow metrics exceed user-specified limits.Results—The objective was achieved through development ofappropriate acoustics, supported by refinements in signal processing andan enhanced user interface.Conclusions—A system has been developed to make transcranialDoppler monitoring of the M1 MCA more easily deployable and tosupport long-term monitoring over a period of days, without operator intervention.S36

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSTUESDAY, APRIL 9, 2013, 8:15 AM–10:15 AMContrast-Enhanced Ultrasound in Pediatrics:What Have We Learned and How Can We Apply It?Moderator: Beth McCarville, MDCutting-edge Musculoskeletal Ultrasound: PeripheralNerves of the Upper ExtremityModerator: Corrie Yablon, MDVoiding UrosonographyKassa Darge Perelman School of Medicine, University ofPennsylvania, Radiology, Children’s Hospital of Philadelphia,Philadelphia, Pennsylvania USACurrently, the most widespread application of ultrasound contrastagents (UCAs) in children is for the diagnosis of vesicoureteral reflux(VUR). This entails the intravesical administration of a UCA and is knownas contrast-enhanced voiding urosonography (ceVUS). The procedure ofceVUS encompasses 5 steps: precontrast scan of the bladder and kidneys,intravesical UCA injection or infusion, postcontrast scan of the bladderand kidneys, during and postvoiding scans of the bladder and kidneys, andsuprapubic and transperineal scans of the urethra during voiding. The useof harmonic imaging or contrast-specific ultrasound (US) modalities withlow or high mechanical indices enables the conspicuous depiction of theechogenic microbubbles. The most widely used UCAs are the first- andsecond-generation ones, namely Levovist (Bayer-Schering, Berlin, Germany)and SonoVue (Bracco, Milan, Italy), respectively. The former onehas been withdrawn from the market, and thus currently only the secondgenerationUCA is being used. There are many comparative studies ofceVUS with the conventional reflux diagnostic methods, voiding cystourethrography,and direct radionuclide cystography. Not only is ceVUSa radiation-free method, but these studies have also demonstrated that it ismore sensitive in detection of VUR. The evaluations of the safety of intravesicalUCA administration have found that no adverse events directlyrelated to the UCA have been reported to date in children. This US methodis widespread in Europe. There is currently a concerted effort by the Societyof Pediatric Radiology Contrast-Enhanced Ultrasound Task Forceto promote research and application of this method.Contrast-Enhanced Ultrasound in Pediatric Abdominal TraumaAnnamaria Deganello Radiology, King’s College Hospital,London, EnglandThe objectives are to review the role of contrast-enhanced ultrasound(CEUS) in the setting of blunt abdominal trauma in the pediatricpopulation and illustrate its applications in a major trauma center, describingthe typical sonographic features of solid-organ injuries. CEUShas been proven to be a reliable and useful tool in the assessment of abdominaltrauma in the adult population, as it provides detailed evaluationof parenchymal, capsular, and also vascular injuries. In addition to its establisheduse in the liver, CEUS is applied, as an “off-label” use to thestudy of renal, splenic, intestinal, and testicular traumas. Equally, in the pediatricand young adult populations, CEUS has an increasingly importantrole, even though this area represents another off-label application of thetechnique. CEUS can depict active bleeding and posttraumatic pseudoaneurysmformation during the arterial phase, whereas in the late phase, itshows with accurate detail the extent of a parenchymal laceration, as thenoninjured tissue enhances. Trauma patients often need to be reassessedto monitor progression or ensure resolution of the injuries, and CEUS becomesa valid, safe, and readily available alternative to repeated computedtomographic (CT) imaging; this is crucial in the pediatric population,where limitation of radiation exposure is of paramount importance. Thetypical CEUS features of hepatic, splenic, and renal injuries will be described,including examples with CEUS/CT correlation.S37After attending this session, participants should know how andwhen to perform ultrasound examinations of the peripheral nerves of theupper extremity, including interventional techniques.Doppler Evaluation of the AbdomenModerator: M. Robert De Jong, RDMS, RDCS, RVTSonographic Evaluation of Portal HypertensionMonzer Abu-Yousef Radiology, University of Iowa, IowaCity, Iowa USAIn this presentation, normal portal vein (PV) Doppler findingsand variations will be discussed. Typically, this has biphasic pattern withmild undulations. All waves are above baseline: V max = 19 ± 3; V min = 13± 3, with V min /V max ≥0.5. With Valsalva, flow becomes nonphasic. Postprandially,flow velocity and volume and PV diameter increase. TheDoppler ultrasound (US) findings in portal hypertension include increasedPV diameter, splenomegaly, ascites, loss of PV flow phasicity, decreasedPV flow velocity, reversed PV flow, and dilated portosystemic collaterals.The latter include a recanalized umbilical vein, flow reversal in the coronaryvein, dilated gastric varices, splenorenal collaterals, a recanalizedductus venosus, gallbladder varices, and perihepatic collaterals. The portosystemicshunts will also be discussed, with emphasis on the transjugularintrahepatic portosystemic shunt (TIPS), including Doppler US signsof TIPS malfunction, direct and indirect. Direct signs include velocity inany stent segment of 200 cm/s, interval velocity change in thesame area of >50 cm/s, velocity transition zone of >2 times, TIPS nonfillingor trickle flow, narrowing of the stent or the hepatic vein that drainsit, and aliasing seen in any segment of the stent on color Doppler. Indirectsigns include a decrease in PV velocity to 33% of baseline, antegrade flow in PV branches, flow seen inthe umbilical vein, loss of the triphasic flow pattern in the PV, worseningascites, and splenomegaly.Pathologic Findings in Abdominal VasculatureHanh Nghiem William Beaumont Hospital, Royal Oak,Michigan USAColor Doppler and spectral Doppler imaging have substantiallyenhanced the diagnostic capabilities of abdominal ultrasonography. Whenproperly performed, Doppler ultrasonography provides rapid, comprehensive,and accurate evaluation of the hepatic vasculature and major abdominalvessels. In this session, we will discuss the Doppler imagingappearances of Budd-Chiari syndrome, a manifestation of hepatic venousoutflow obstruction. Doppler imaging findings of hepatic artery abnormalitiesin native liver and abnormalities of the splenic vessels will alsobe reviewed, including vascular thrombosis and pseudoaneurysms. Participantsshould gain a greater understanding of the pathophysiology ofhepatic vein and splenic vein thrombosis, causes of elevated and decreasedhepatic arterial resistive indexes, and vascular thrombosis and pseudoaneurysmsof the hepatic and splenic artery in non–liver transplant patientsand recognize the sonographic images showing these conditions.

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Hands-on How to Do Ultrasound-GuidedInterventionsModerator: Dean Nakamoto, MDAfter attending this session, participants will be able to describeprebiopsy preparations, use and have hands-on experience with the techniquesof doing biopsies of soft tissue masses, thyroid nodules, breastmasses, the liver, and kidneys, and recognize and manage complications.Pearls From the Anatomic Survey (Skeletal Dysplasiaand Central Nervous System, Renal, and ChestAbnormalities)Moderator: Ana Monteagudo, MD, RDMSFetal Central Nervous SystemAna Monteagudo Obstetrics and Gynecology, New YorkUniversity School of Medicine, New York, New York USASmall-Animal Preclinical High-Frequency ImagingModerator: Michael Kolios, PhDAdvances in High-Frequency Transducers and ArraysK. Kirk Shung Biomedical Engineering, University of SouthernCalifornia, Los Angeles, California USAHigh-frequency ultrasound (HFU) allows improved spatial resolution.Biomedical applications have been found for HFU in preclinicalsmall-animal, intravascular, and eye imaging. Pediatric imaging is anotherarea that holds great promise. As a result, high-frequency linear arrays,phased arrays, and curved linear arrays have been developed to satisfythese needs. More recently, miniature high-frequency arrays have beenstudied for intravascular and other clinical applications. In addition, ultrahigh-frequency high-performance single-element transducers have beeninvestigated for cellular applications. Technical advances that have beenmade in these areas and potential biomedical applications will be reviewedin this talk.A significant number of sonographers and sonologists count thefetal central nervous system (CNS) as the most challenging organ to scan.This has resulted in an explosion in the number of fetal magnetic resonanceimaging examinations of the CNS being ordered over the last fewyears. In this lecture, a systematic approach to the fetal CNS will be provided,as well as multiple imaging tips or pearls to improve the individualpractitioner ability to diagnose common as well as relatively rare anomaliesof the fetal CNS.SCIENTIFIC SESSIONSTUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PMApplications of Therapeutic UltrasoundModerators: George Lewis Jr, PhD, Maggie Zhang, PhD1541279 Antitumor Effects of Combining Docetaxel and PaclitaxelWith the Antivascular Effects of Ultrasound-StimulatedMicrobubblesMargarita Todorova, 1,2 Vlad Agache, 1 Raffi Karshafian, 3Kullervo Hynynen, 1,2 David Goertz 1,2 *1 Sunnybrook ResearchInstitute, Toronto, Ontario, Canada; 2 Medical Biophysics,University of Toronto, Toronto, Ontario, Canada; 3 RyersonUniversity, Toronto, Ontario, CanadaObjectives—Docetaxel (DTX) and paclitaxel (PTX) are used totreat a broad spectrum of cancers. We previously reported that the combinationof DTX with ultrasound (US)-stimulated microbubble (MB) therapyresulted in enhanced antitumor effects in PC3 tumors. While the focusof US + MB therapy has been to promote drug uptake, these experimentswere conducted with exposures that produced a vascular shutdown. AsDTX and PTX can themselves induce antivascular effects, it was hypothesizedthat there may be an interaction between drug and MB antivasculareffects. In this study, experiments were conducted on a cell line that islargely resistant to DTX and exhibits only mild sensitivity to PTX.Methods—EMT6 tumors were initiated in Balb/C mice andwere exposed to pulsed 1-MHz US (1.6 MPa; n = 5–6/group) followingthe bolus injection of Definity MBs. The treatment scheme consisted of asequence of 50 0.1-millisecond bursts sent at 1 KHz, repeated every 20seconds for 3 minutes following MB injection. Growth delay experimentswere performed when tumors reached a size of 100 to 120 mm 3 . Thegroups were control, drug + MBs, US + MBs, and combined drug + US+ MBs. One set of experiments was performed with DTX at 5 mg/kg anda second set of experiments with PTX at 6 mg/kg, where drugs were injected10 minutes prior to US treatment. The effects of treatment on bloodflow were monitored with 7-MHz contrast imaging.Results—The exposure conditions were found to produce apronounced acute vascular shutdown within the tumors and resulted inMB inertial cavitation. Neither the DTX-only or PTX-only groups producedsignificant growth inhibition relative to controls. The US + MBgroup induced significant growth delays relative to control tumors. Boththe combined DTX + US + MB and the PTX + US + MB groups producedsignificant growth inhibition relative to the US + MB group.Conclusions—Given the low sensitivity of the tumor cell lineto these drugs, and that they have the capacity at these low dose levels toact in an antivascular manner, the results suggest that there may be a synergisticantivascular action between these therapies in addition to a druguptake mechanism.1540384 Dynamic Positron Emission Tomographic Imaging of DrugDelivery and Hypoxia Using Acoustic Droplet VaporizationMario Fabiilli, Morand Piert, Philip Sherman, Carole Quesada,Oliver D Kripfgans* Radiology, University of Michigan,Ann Arbor, Michigan USAObjectives—Perfluorocarbon (PFC) emulsions and acousticdroplet vaporization (ADV) have been used in therapeutic applicationssuch as drug delivery and embolotherapy. The objective of this work wasS38

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013to use positron emission tomography (PET) to study (1) the biodistributionof an emulsion used in ADV and (2) the extent to which localized hypoxiacan be induced by ADV.Methods—For the biodistribution study, a metabolic tracer,18F-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 PETimaging. After 24 hours, the same rats were injected with a PFC-FDGemulsion (2 µm mean size) and imaged again. In both cases, standardizeduptake values (SUVs) were calculated using the tissue activity concentration,body weight, and injected dose. To confirm the imaging findings, atraditional ex vivo biodistribution was performed (n = 5 rats). For the hypoxiastudy, similar animal and tumor models were used. A PFC singleemulsion was administered, followed by ADV in the feeder artery of thetumor using focused pulsed ultrasound (3.5 MHz). Dynamic PET imagingwas performed before and after ADV using 18 F-fluoroazomycin arabinoside(FAZA) as a tracer for hypoxia.Results—The area under the curve (AUC) for the SUVs wascalculated for brain, tumor, and lungs as a measure of drug/FDG exposurefor future drug encapsulation. A 39.1% ± 5.3% and 35.7% ± 15.6%AUC decrease was observed when compared to solution for brain andtumor, respectively. No significant difference in AUC was observed forlung. The biodistribution study showed a 67% and 70% decrease in thepercent injected dose per gram for brain and tumor tissue, respectively,when comparing FDG emulsion versus solution. FAZA was retained in thetumor after ADV.Conclusions—The lower AUC values for the emulsion inhighly metabolic tissues (brain and tumor) demonstrate that FDG is retainedwithin 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 stabledrug-loaded PFC emulsions as well as tracking the effects of ADV- inducedhypoxia.1540880 Evaluation and Optimization of Nonfocused SonothrombolysisParameters in an In Vitro Chamber ModelShane Fleshman,* Adelaide de Guillebon, George Lewis JrZetroz, LLC, Ithaca, New York USAObjectives—Sonothrombolysis is emerging as a potential clinicaltool to rapidly emulsify acute and chronic thrombi. The goal of thiswork was to study the effects of different therapeutics, frequency, thrombusdiameter, and type of surrounding medium on the percent mass reductionof a thrombus after 1, 2, and 3 hours of sonothrombolysis treatment.Methods—Silicone tubing of 10 or 15 mm diameter was coatedwith or without 500 U of thrombin, filled with fresh porcine blood, allowedto clot for 1 hour, and stored at 4°C for 8 to 10 days (InstitutionalAnimal Care and Use Committee–approved protocol). Sonothrombolysiswas 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 insidea chamber filled with either Dulbecco’s phosphate-buffered saline (DPBS)or freshly thawed human plasma, and injected with 0.5 mL of either 0.5-mg/mL human tissue plasminogen activator (tPA), 1-mg/mL active plasmin,or 1× DPBS with a Uni-Fuse catheter 30 minutes after treatmentcommencement. Blood clot mass was recorded 1, 2, and 3 hours aftertreatment.Results—Thrombus treatment at 85 kHz with a peak pressureof 1.7 MPa was the only treatment that yielded significant results forthrombin and nonthrombin blood clots when compared to the control(P < .01) and was further used in the remaining experiments. Both thrombinand nonthrombin clots treated with ultrasound were statistically differentfrom the control at all time points (P < .01). Comparisons of 15- or10-mm-diameter clots and clots in DPBS or human plasma media treatedwith ultrasound yielded no significant results (P > .05). Comparisons ofultrasound-treated, tPA- or plasmin-injected clots with their respectivecontrols yielded significant results at all time points (P < .0001) and at 1hour (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 MPaand 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 MediaMatthew Langer,* Shane Fleshman, George Lewis JrZetroz, LLC, Ithaca, New York USAObjectives—The use of ultrasound in therapeutic medicine topromote healing and relieve pain has been thoroughly tested. Recent researchhas demonstrated that low-intensity therapeutic ultrasound appliedon a daily basis is highly effective, and miniaturization technology hasbeen developed, which will enable user-operated ultrasound systems. Onesignificant challenge in developing a user-operated device is finding a couplingmedium that is effective, easily used, and desirable for the patient.To facilitate the spread of user-operated ultrasound devices, novel couplingmaterials must be developed. Water is a perfect coupling medium forultrasound, but its low viscosity makes it impractical to contain. Hydrogelsare swollen polymer networks, which can be as much as 99% waterby weight, but due to the size of the polymer, or its structure, they haveproperties of viscoelastic materials. High–water content hydrogels wereevaluated for their ability to mediate transmission of ultrasound.Methods—Polyethylene oxide (PEO) hydrogels were testedand evaluated, along with polyethylene glycol (PEG) hydrogels and PEGbasedcopolymer hydrogels. The gels were tested as coupling media betweena 3-MHz therapeutic 25-mm-diameter transducer and freshlyharvested porcine skin. On the underside of the skin, ultrasound gel wasused to couple the skin to a transducer hydrophone in a custom measurementapparatus. The electrical signal reported by the detector was read offa digital oscilloscope in millivolts. The signal measured with the hydrogelas a coupling medium was compared to that of the ultrasound gel as acoupling medium. The ultrasound transmission hydrogels was normalizedto traditional ultrasound gel–based coupling.Results—The ultrasonic transmission of several hydrogels wasmeasured. The PEG copolymer–based gel had a relative transmission of0.70 ± 0.06. A PEO hydrogel with water content >90% had a relative transmissionof 1.0 ± 0.07.Conclusions—PEO hydrogels with high water content possesssimilar sonic transmission properties to commercial ultrasound gel. Thesefindings open the door to replacing commercial ultrasound gel with high–water content hydrogels.1541006 Low-Intensity Pulsed Ultrasound Enhances Reactive OxygenSpecies Production Following a Blunt Impact Injury inArticular CartilageKee Jang, 1,2 * Prem Ramakrishnan, 1 Tae-Hong Lim, 2 JosephBuckwalter, 3 James Martin 1 1 Orthopedics and Rehabilitation,2 Biomedical Engineering, University of Iowa, Iowa City,Iowa USA; 3 Veterans Affairs Medical Center, Iowa City, IowaUSAObjectives—Elevated levels of reactive oxygen species (ROS)are associated with development of osteoarthritis. Previously we reportedthat mechanotransduction of mitochondrial ROS modulates cell survivaland metabolism in a dose-dependent manner. Here, we hypothesized thatlow-intensity pulsed ultrasound (LIPUS) elicits its mechanotransductive effectsby inducing ROS in cartilage, and we investigated the effect of LIPUSon ROS release in articular cartilage that underwent a blunt impact injury.Methods—Osteochondral explants (2.5 × 2.5 cm 2 ) were preparedfrom mature bovine stifle joints and cultured in conditioned media atS39

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 201337°C and 5% O 2. After 48 hours, explants were subjected to a 7-J/cm 2impact with a customized drop tower device, and LIPUS (1 MHz, 54mW/cm 2 , and durations of 30, 60, and 90 minutes) was immediately applied.A sham group was subjected to identical procedures except LIPUSstimulation. After LIPUS stimulation, cell viability (calcein AM/ethidiumhomodimer) and oxidative stress (dihydroethidine) were imaged with confocalmicroscopy and quantified.Results—Sixty-minute LIPUS after the 7-J/cm 2 impact resultedin a significant increase in ROS production (≈2-fold) compared to thesham group. In contrast, no difference in ROS production was apparent inuninjured explants with or without LIPUS stimulation. After injury, theROS response to the LIPUS duration showed a strong linear relationship(R 2 = 0.75) with an increasing duration of stimulation inside the impactedarea, whereas such a relationship was not observed in areas adjacent tothe impact. No difference in post–24-hour chondrocyte viability was observedbetween LIPUS and sham groups.Conclusions—Our findings demonstrate that LIPUS stimulatesROS 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 ininjured cartilage remains unclear, we hypothesize that the increased oxidativestress may have implications in cartilage repair processes by modulatingchondrocyte energy production, metabolism, and matrix synthesis.1543362 Microbubble and Ultrasound Enhancement of Radiation-Induced Tumor Cell Death In Vivo: ASMase DependenceGregory Czarnota, 1 * Amr Hashim, 1 Ahmed El Kaffas, 1 RaffiKarshafian, 2 Anoja Giles, 1 Sara Iradji, 1 Azza Al Mahrouki 11Radiation Oncology/Physical Sciences, Sunnybrook HealthSciences Center, Toronto, Ontario, Canada; 2 Physics, RyersonUniversity, Toronto, Ontario, CanadaObjectives—It is now appreciated that radiation not only damagesthe DNA inside tumor cells in vivo but also may act by damaging theendothelial cells of the vasculature. In this study, we tested the hypothesisthat microbubble agents in vivo may be used a priori to cause endothelialcell perturbations, thus causing “radiosensitization” of tumors.Methods—Fibrosarcoma xenograft-bearing mice (n = 200+)were exposed to combinations of ultrasound, activated microbubbles, andradiation (8 animals per group). For ultrasound treatments, animals wereexposed to a 500-kHz center frequency and 570-kPa peak negative pressurefor treatment. For treatments involving bubbles, Definity bubbles(Bristol Myers-Squibb) were administered, and for radiation treatments160-kVp x-rays were used at doses of 2 and 8 Gy. Representative tumorsections were examined using immunohistochemistry. Clonogenic assaysand growth delay studies were also carried out. Experiments were carriedout in ASMase +/+ and –/– mice to investigate endothelial cell apoptosiseffects.Results—Analyses indicated a synergistic increase in tumorcell kill due to vascular disruption that was ASMase dependent, causedby the combined therapies that increased when microbubbles were usedin conjunction with radiation, with increases of cell kill from 5% to >50%with combined single treatments. Immunohistochemistry indicated endothelialcell apoptosis and activation of the ceramide cell death pathwayto be caused by microbubbles. Multiple treatments indicated a better therapeuticoutcome with multiple treatments combining both modalities comparedto single-modality treatments.Conclusions—Radiation effects were synergistically enhancedby using microbubbles to perturb tumor vasculature prior to the administrationof radiotherapy. Analyses indicated activation of ceramide-mediatedapoptotic cell death in endothelial cells leading to vasculardisruption in tumors. This led to profoundly enhanced tumor cell deatheven after 1 combined treatment using a 2-Gy radiation dose. This workforms the basis for ultrasound-induced spatial targeting of radiotherapyenhancement.1540684 On the Acceleration of Ultrasound Thermal Therapy byPatterned Acoustic Droplet VaporizationOliver Kripfgans, 1 * Mario Fabiilli, 1 Scott Swanson, 1 CharlesMougenot, 2 Paul Carson, 1 Man Zhang, 1 J. Brian Fowlkes 11Radiology, University of Michigan, Ann Arbor, Michigan USA;2Philips Healthcare, Toronto, Ontario, CanadaObjectives—High-intensity focused ultrasound (HIFU), an establishedmethod for treating cancer and hyperplasia, often suffers fromuneven heating and requires in general long treatment times for large targetvolumes. In situ gas bubbles have become more accepted as energyconversion agents for HIFU. If carefully controlled, these agents increaselesion sizes dramatically.Methods—Emulsions of perfluorocarbon droplets (lipid coated,C 5F 12, Ø 2.0 ± 0.1 µm, ≈99% < 8 µm Ø) were used to create thermal agentsin polyacrylamide phantoms. The emulsion concentration in the gel was3 × 10 5 droplets/mL. This corresponds to a volume fraction of 1 ppm(vol/vol). The samples were placed in thermal contact with a heating systemto maintain 35°C. Egg white was incorporated to allow for visual inspectionof the phantoms after acoustic exposure from a Philips Sonallevemagnetic resonance–guided focused ultrasound system (1.5 T) using a256-element phased array with a 120-mm focal length. At a transmit centerfrequency of 1.45 MHz, maximum electronic steering of 10 mm wasachieved at a depth of 10 cm. In situ temperature monitoring limited focalheating to 75°C. Lesion sizes were measured as a function of appliedacoustic power. Acoustic trenches were created to accelerate thermal therapy,in which individual lesions were spaced 5.5 mm apart to create 25-mm-diameter spiral patterns.Results—Single HIFU exposures in droplet-laden phantomsresulted in lesions of 2 to 5 mm in diameter. Rapid repetition of electronicallysteered therapy pulses (40 pulses/s) allowed for the generation of homogeneousand contiguous composite lesions at a rate >1 mL/s. Foracoustic power levels ranging from 40 to 300 W (acoustic), lesion volumesincreased by a factor of at least 15 when comparing lesion volumesin phantoms with droplets to without droplets. With the use of acousticdroplet vaporization (ADV) and the resulting trench, a uniform ablationvolume of 15 mL was achieved in 15 seconds; without ADV,

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013of magnitude higher compared to unablated samples. However, reductionin stiffening was obtained in samples ablated at higher energy levels relativeto samples at lower energy levels (Table 1), which can be explainedby the strong tissue thermo-mechanical effects occurring at very high temperaturesthat essentially alter the structure of the tissue.Conclusions—The monotonic increase in tissue stiffness andviscosity under increasing HIFU ablation power has been shown to holdup only up to a certain point, beyond which the tissue stiffening starts todecay due to structural changes mainly due to rapid boiling. Such quantitativeunderstanding of tissue phenomenologic alterations during ablationis significant in the effective design and application of any HIFU-basedtherapeutic technique where a combination of tissue mechanical, thermal,and structural effects is expected.Table 1. Viscoelastic Properties of Canine Liver After AblationHIFU Energy, J0 360 750 900 1080Shear modulus, 4.4 ± 2.0 73.6 ± 19.0 85.7 ± 54.5 50.1 ± 38.7 53.9 ± 27.6kPaPhase shift, ° 8.4 ± 1.9 12.3 ± 0.8 12.3 ± 0.4 12.2 ± 0.4 12.1 ± 0.6Normalized shear 1 15.8 ± 6.9 18.5 ± 13.9 10.4 ± 9.5 11.3 ± 7.4modulus1540029 Therapeutic Ultrasound as Treatment for Chronic BacterialProstatitisMingde Li South China University of Technology, Richmond,British Columbia, CanadaObjectives—Antibiotic therapy for chronic bacterial prostatitisoften fails to eradicate pathogens due to poor antibiotic penetration intoprostatic secretions where the infection occurs, caused by the bloodprostatebarrier of the prostatic epithelium. It is our purpose to report antibiotictherapy enhanced by therapeutic ultrasound for a patient withchronic bacterial prostatitis with mixed pathogenic microorganisms ofStaphylococcus aureus, coagulase-negative Staphylococcus and Ureaplasmaurealyticum and with hardness of the prostate who was difficultto treat with methods in literature.Methods—After antibiotic medication, ultrasonic irradiationfrom the lower abdomen, perineum, and anus (not transrectally) on hisprostate followed immediately. The working ultrasonic intensity was 3W/cm 2 .Results—Without ultrasound, intravenous azithromycin andlevofloxacin hydrochloride therapies could not eradicate the pathogens,and his symptoms recurred and became more severe. Under continuousultrasonic irradiation at the intensity of 3 W/cm 2 , intravenous antibiotictherapies with azithromycin and imipenem eradicated S aureus and U urealyticum,but intravenous antibiotic therapies could not treat coagulasenegativeStaphylococcus; interventional antibiotic therapies with imipenemand urethral perfusion treated coagulase-negative Staphylococcus successfully.The National Institutes of Health Chronic Prostatitis SymptomIndex 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 lifeimpact, 1).Conclusions—The eradication of S aureus and U urealyticumindicates the continuous therapeutic ultrasound can open the bloodprostatebarrier. The blood-prostate barrier opening is explained by thehypothesis of ultrasonic emulsification of a secreted steroidogenic lipidin the basal layers of the prostatic epithelium caused by cavitations. Intravenousantibiotic therapies cannot treat coagulase-negative Staphylococcusdue to the formation of biofilms adherent to the epithelium of theductal system. The treatment for the patient was successful.1540196 Ultrasound-Assisted Chronic Wound Management:Clinical OutcomeJoshua Samuels, 1 * Michael Weingarten, 2 Leonid Zubkov, 1Youhan Sunny, 1 Christopher Bawiec, 1 David Margolis, 3 PeterLewin 1 1 Biomedical Engineering, Drexel University,Philadelphia, Pennsylvania USA; 2 Surgery, Drexel UniversityCollege of Medicine, Philadelphia, Pennsylvania USA; 3 Epidemiology,University of Pennsylvania Perelman School ofMedicine, Philadelphia, Pennsylvania USAObjectives—The purpose of this research was to examinewhether low-frequency (

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013deconvolution between the hydrophone output voltage and the hydrophonefrequency-dependent complex sensitivity. We have previouslyreported a method for measuring the magnitude and phase of hydrophonesensitivity using time delay spectrometry (TDS). The goal of this work isto assess the improvement in the accuracy of estimates of acoustic outputparameters (pulse intensity integral and peak rarefactional pressure) usingcomplex deconvolution.Methods—In the first set of experiments, a swept-frequencyTDS system was used to measure magnitude and phase responses of severaltypes of hydrophones used in medical ultrasound exposimetry. Theseincluded polyvinylidene difluoride spot-poled membrane, needle, and capsuledesigns. Measurements were performed using 4 broadband sourcetransducers to measure hydrophone sensitivity over the band from 1 to 30MHz. In the second set of experiments, 6 hydrophones were used to measurethe acoustic pressure waveform generated by a 3-MHz single-elementsource transducer. The voltage waveforms acquired in the second set of experimentswere deconvolved with sensitivities measured in the first set ofexperiments. The effect of deconvolution on measurements of the pulse intensityintegral and peak rarefactional pressure was measured.Results—The effect of deconvolution on measurements ofpulse the intensity integral and peak rarefactional pressure sometimes exceeded10%.Conclusions—The frequency dependence of hydrophone sensitivitycan have a substantial impact on measurements of the pulse intensityintegral and peak rarefactional pressure. In these cases, complexdeconvolution can be used to compensate for frequency-dependent hydrophonesensitivity.1538679 Pulmonary Hemorrhage Induced by Diagnostic UltrasoundRevealed by Growth of Comet Tail Artifacts in the ImageDouglas Miller Radiology, University of Michigan, AnnArbor, Michigan USAObjectives—Ultrasound examination of the lung has becomean important part of chest medicine, particularly for point-of-care diagnosisin emergency rooms and intensive care units. The objective of thisstudy was to explore the potential for lung injury, which may arise fromthe interaction of ultrasound pulses with alveolar gas, using a rat model ofpulmonary diagnostic ultrasound.Methods—Anesthetized rats were prepared by shaving theright thorax and then mounted in a 37°C water bath. A linear array (CL15-7, HDI 5000; Philips Healthcare, Andover MA) was used for B-mode imagingof the right lung at ≈7.6 MHz. A low mechanical index (MI) of 0.21was used to align the scan plane through an intercostal space. The MI thenwas raised for 5 minutes to higher settings in different groups of 5 rats. Fora sham group, the rats were prepared but not scanned. The real-time imagewas recorded and evaluated for occurrence of comet tail artifacts (CTAs),which are indicative of alveolar fluid. The lungs were evaluated for the sizeof any pulmonary hemorrhages (PHs).Results—For the highest available MI (0.9), the image immediatelydisplayed growing CTAs, which rapidly spread across the entirebright-line image of the lung surface. The CTAs appeared within secondsat MI = 0.7 or 0.9 but more slowly at lower MIs. Contusion-like PHs werefound on the lungs, which appeared to have a one-to-one correspondencewith the CTAs in the image. The proportion of positive results was statisticallysignificant 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 diagnosticultrasound at moderate MIs, and this bioeffect was indicated by thegrowth of CTAs in the image. The induction of PHs by pulsed ultrasoundwas 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 riskof pulmonary injury for some patients. More information will be needed toprovide safety guidance consistent with optimal diagnostic imaging.1528109 Evaluation of Definity Stability Over Time Using DoublePassive Cavitation DetectionMarianne Gauthier, 1,2 * Daniel King, 1,3 William O’Brien Jr 1,21Bioacoustics Research Laboratory, 2 Electrical and ComputerEngineering, 3 Mechanical Science and Engineering, Universityof Illinois at Urbana-Champaign, Urbana, Illinois USAObjectives—Definity is the first ultrasound contrast agent(UCA) approved by the US Food and Drug Administration that offersflexible dosing and administration through intravenous bolus injection orcontinuous intravenous infusion. In a clinical context (for diagnosis, therapy,and bioeffect studies), temporal stability of the UCA can be criticalusing either infusion or bolus: infusion implies stability of the microbubblesduring the time of the injection, while bolus may be repeated to acquireseveral images for the same patient, implying the microbubbles toexhibit the same properties over time.Methods—This study’s aim was to assess the stability of Definityover time. Experiments were performed using the double passive cavitationdetection (DPCD) method, allowing the evaluation of the collapsethresholds of an isolated microbubble based on the detection of postexcitationsignals occurring 1 to 5 microseconds after the principle excitationof the bubble. Five sets of DPCD experiments (3-cycle tone bursts at thecentral frequency of 2.8 MHz) were performed over 3 weeks. For eachset of experiments, 5% and 50% collapse thresholds were determined withtheir 95% confidence interval (CI) based on the generalized linear modelregression performed using MatLab. We also compared the size distributionof each tested microbubble set.Results—Statistical analysis exhibited no significant differencesin the bubble size distributions and the 5% and 50% collapse thresholdsmeasured using the DPCD method (Table 1).Conclusions—Definity microbubbles have been found to bestable over the 3 weeks of experiments from the size distribution and the5% and 50% collapse thresholds points of view. Definity can be used withoutextra precaution concerning its temporal stability. (Supported by NationalInstitutes of Health grant R37EB002641.)Table 1. Bubble Diameter, 5% and 50% Postexcitation Thresholds ± 95% CIsEvaluated Over 3 Weeks5% Postexcitation 50% PostexcitationBubble Diameter Threshold ± 95% CI, Threshold ± 95% CI,Group ± 95% CI, μm MPa MPa1 1.40 (1.28–1.52) 0.022 (0.001–0.191) 0.173 (0.001–0.559)2 1.23 (1.12–1.34) 0.05 (0.001–0.277) 0.455 (0.005–0.944)3 1.39 (1.26–1.52) 0.077 (0.003–0.226) 0.38 (0.075–0.671)4 1.26 (1.13–1.39) 0.116 (0.015–0.269) 0.464 (0.162–0.72)5 1.42 (1.31–1.53) 0.058 (0.001–0.235) 0.315 (0.01–0.663)1541018 Arrival Time Estimation in a Sparsely Sampled HemisphericTransducer ArrayJason Tillett, 1 * Jeffrey Astheimer, 1 Robert Waag 1,2 1 Electricaland Computer Engineering, 2 Imaging Sciences, University ofRochester, Rochester, New York USAObjectives—Estimate waveform arrival time fluctuationscaused by propagation through a breast model in a sparsely sampledfaceted approximation of a hemispheric transducer array.Methods—A 3D pseudospectral k-space method was used tocalculate acoustic propagation from a point source located near the centerof an array of widely separated transducers. The point source, with a centerfrequency of 5 MHz and –6-dB bandwidth of 2.5 MHz, was situatednear the chest wall of a numeric anthropomorphic breast model, and thetransducer array surrounded the pendant boundary of the breast. The hemispherewas approximated using 40 triangular facets. The separation of elementsaveraged about 1.5 times the wavelength at 5 MHz, ie, about 3S42

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013times larger than the usual half-wavelength element separation. The sparsedistribution of transducer elements and severe aberration caused by propagationthrough the breast model reduced correlation of waveforms inneighboring transducers that are typically used to estimate arrival time differences.Instead of cross-correlations, waveform 0 crossings in the neighborhoodof the waveform arrival events were used to estimate arrival timedifferences at neighboring transducers. A least mean square estimate ofarrival times was derived from the set of arrival time differences. Waveformsimilarity factors that equal 1 for identical waveforms were calculatedand used to optimize parameters of the estimation method andevaluate the performance of the method.Results—A waveform similarity of 0.10 before compensationwas increased to 0.94 after compensation using estimated arrival times.The 170-nanosecond SD of the arrival time distribution over the whole40-facet array before compensation was decreased to 20 nanoseconds aftercompensation. For a single facet, the 154-nanosecond average SD of thearrival time distribution before compensation decreased to 15 nanosecondsafter compensation.Conclusions—The developed method for arrival time estimationin a sparsely sampled hemispheric array for the described combinationof source and transducer produces accurate estimates of arrival timesfor use in aberration correction methods.1539831 The USAGES Study (Ultrasonographic Study of AlternativeGel Experimental Substances): A Trial of AlternativeSubstances for Use in Clinical Sonographic ImagingDavut Savaser,* Siobhan Gray, Anthony Medak, Virag Shah,Derrick Allen, Eddie Castillo, Mary Beth JohnsonEmergency Medicine, University of California, San Diego,California USAObjectives—We sought to investigate image quality and the diagnosticutility of sonographic images obtained using household productsas 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 standardultrasound gel (USG).Methods—We conducted a prospective reviewer-blindedcrossover study of healthy volunteers (>18 years) obtaining 7 differentsonographic images on each patient, including the right upper quadrant,subxiphoid, left upper quadrant, bladder, aorta, right lung, and right internaljugular vein views. Six alternative gel substances were tested in additionto standard USG. Images were obtained by a credentialed emergencysonographer and were reviewed and rated by 2 additional credentialedemergency sonographers and a credentialed radiologist. Image quality wasrated on a visual analog scale (VAS) ranging from 0 to 10, and the diagnosticutility of each was assessed and compared to reviewer VAS thresholds.Data were analyzed by calculating image quality VAS means andusing repeated measures analysis of variance to evaluate VAS mean differencesfor each substance.Results—A total of 189 images were obtained. Final VAS meanscores were: HS, 9.2; HL, 8.8; LD, 8.8; BS, 8.3; HG, 8.9; OOi, 8.9; andUSG, 9.6. Compared to control (USG), HS was the only substance to notexhibit 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 eachsubstance scored above reviewer thresholds for diagnostic utility.Conclusions—Sonographic image quality and the diagnosticutility of HS are similar to those of standard USG. HL, LD, BS, HG, andOOi may still be used as alternatives for clinically useful diagnostic imagingbut are comparatively inferior to images obtained using HS andstandard USG as conducting media.1540013 User-friendly System for Assessing Imaging Performancein the ClinicErnest Madsen,* Chihwa Song, Gary Frank MedicalPhysics, University of Wisconsin, Madison, Wisconsin USAObjectives—One indicator of the effectiveness of a scanner/transducer configuration to delineate the boundary of an abnormal massis the level of detectability it affords for small low-echo cyst-like targets.(A scanner/transducer configuration includes the make and model of thescanner and transducer, foci, depth of field, time-gain compensation, sectorangle, etc). Phantoms with spatially random distributions of 2-, 3.2-, or4-mm-diameter low-echo spheres and scanning windows allowing usewith any shape-emitting surface were reported at the 2012 AIUM meeting.Software allows quantification of sphere detectability as a functionof depth. One objective is to complete refinements in data acquisitionand reduction so that the phantoms and software are easily employed byclinical personnel for comparing scanner/transducer configurations. Anotherobjective is to provide for minimal cost of production for commercialversions.Methods—Current MatLab software is being converted to aform executable on any personal computer with a user-friendly generalizeduser interface (GUI). The large laboratory data acquisition apparatuswill 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 willbe described. A transducer holder and stepper motor system provide fortranslation of the transducer in steps of one-fourth of the sphere diameterneeded for determining the centers of the spheres. The procedure for usingthe GUI will be demonstrated. Also, reproducibility of detectability-versus-depthcurves will be demonstrated. Imaging performance comparisonsbetween scanner/transducer configurations will be shown; one interestingresult using a pediatric transducer is that a 4-cm focus resulted in lesser detectabilityoverall than a 3-cm focus.Conclusions—Comparisons will aid in choosing equipmentfor a given set of clinical applications, provide a new means of acceptancetesting, and allow optimization of configurations of installed scannersfor specific applications. The phantoms may also be useful for manufacturersto refine their systems. The cost of production may result in the needfor multiple users to share one commercial form of the system.1541363 Pulse-Echo–Based Sound Speed Estimations Using SpeckleStatisticsIvan Rosado-Mendez, Kibo Nam, Timothy Hall, JamesZagzebski* Medical Physics, University of Wisconsin,Madison, Wisconsin USAObjectives—Speed of sound estimates are required for optimalfocusing and beam forming in medical ultrasound. Moreover, measurementsof tissue sound speeds (c t) have potential diagnostic value. Weinvestigate a method for sound speed estimation using second-orderspeckle statistics to analyze ultrasound image clarity as a function of theassumed sound speed during beam forming (c bf). The size of a region ofinterest (ROI) analyzed can be limited by tissue heterogeneities. This workfocuses on defining a minimum ROI size required to obtain reliable c testimates and on comparing estimates performed near the transmit focuswith values obtained at other depths.Methods—Radiofrequency (RF) echo signals from a “nonfattytissue” (N-F)- and a “fatty tissue” (F)-mimicking phantom were acquiredwith a Siemens S2000 system allowing control over c bf. Excitation frequencieswere 6 and 9 MHz, and the nominal transmit focus was 5 cm.This process was repeated at 5 uncorrelated planes. RF echo signals wereenvelope detected and squared to obtain intensity data. 2D “correlationcell areas” (S c), based on the 2D autocovariance of the intensity data withinthe ROI, was tracked as the ROI size was reduced. Then, S cwas trackedS43

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013as c bfvaried from 1350 to 1550 m/s and from 1440 to 1640 m/s whenscanning phantoms F and N-F, respectively, in steps of 10 m/s. The c bfatwhich S cwas minimized was chosen as the c testimate. The c testimatebias was computed as the interplane average of the percentage differencefrom substitution measurements (F phantom, 1452 m/s; N-F phantom,1544 m/s).Results—The minimum required ROI size was 20 pulselengths and 14 uncorrelated scan lines (7 × 9 mm 2 in this experiment). Ingeneral, ct was underestimated by –1.0% ± 0.1% and by –1.3% ± 0.3% forthe F and N-F phantoms, respectively. No significant differences werefound among estimates from different excitation frequencies or amongthose at the physical location or the nominal location of the transmit focus.Conclusions—Results indicate that estimates can be performedwithin 1 cm 2 at the location of the nominal transmit focus, whichcan be a fixed parameter during the in vivo application of this method.The method is being applied in the characterization of liver diseases andlesions.Cardiovascular UltrasoundModerator: John Blebea, MD, MBA1521708 Lagrangian Deformation Tracking of the Left Ventricle forCardiac Ultrasound Strain ImagingChi Ma,* Tomy Varghese Medical Physics, University ofWisconsin, Madison, Wisconsin USAObjectives—Lagrangian description of myocardial tissue structuredeformation is key to accurate regional strain estimation of the leftventricular wall over time. Failure to couple the estimated displacementand strain information with the correct myocardial tissue structures willlead to erroneous result in the displacement and strain distribution overtime.Methods—This study presents a method to obtain Lagrangianbaseddisplacement tracking. Myocardial issue structures are divided intoa fixed number of pixels whose deformation is tracked over the cardiaccycle. An algorithm that uses a polar grid generated between the estimatedendocardial and epicardial contours for the left ventricle in cardiac shortaxisimages is proposed to ensure Lagrangian description of the pixels.Displacement estimations from consecutive radiofrequency frames werethen mapped onto the polar grid to obtain a distribution of the actual displacementthat 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 cardiaccycle demonstrated excellent agreement between the ideal result obtaineddirectly from the finite-element model and our Lagrangian approachto strain estimation. Traditional Eulerian-based estimation results, on theother hand, showed a significant deviation from the ideal result. An in vivocomparison of the displacement and strain estimated using parasternalshort-axis views is also presented.Conclusions—Lagrangian strain estimation using a polar griddemonstrates accurate results when validated in a finite-element cardiacmodel. In addition to the cardiac application, this approach can also beapplied to transverse scans of arteries, where a polar grid can be generatedbetween the contours delineating the outer and inner walls of the vesselsfrom the blood flowing though the vessels. (Supported by National Institutesof Health grants 5R21EB010098 and R01CA112192-S103.)S441509371 Effects of Respiration on Estimation of Systolic PulmonaryArtery Pressure in Patients With Right Ventricle SystolicDysfunctionXiao-Yong Zhang,* Tie-Sheng Cao, Li-Jun Yuan UltrasoundDiagnostics, Tangdu Hospital, Fourth Military MedicalUniversity, Xi’an, ChinaObjectives—We investigated the effects of respiration on thepeak velocity of tricuspid regurgitation (TR) and estimation of systolicpulmonary artery pressure (SPAP) in patients with right ventricle (RV)systolic dysfunction by Doppler echocardiography.Methods—Continuous wave Doppler spectra of TR wererecorded 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 wereacquired and averaged for 5 consecutive respiratory cycles. The SPAPduring expiration and inspiration was calculated.Results—The velocity of TR and SPAP did not vary significantlybetween expiration and inspiration in controls (2.77 ± 0.23 and 2.82 ± 0.26m/s; P = .776; 35.94 ± 4.96 and 36.18 ± 5.12 mm Hg; P = .747), whereasthe velocity of TR and SPAP decreased significantly from expiration to inspirationin 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 velocityof TR and SPAP in patients with RV systolic dysfunction, and the measurementshould be carried out when patients are at the end of expiration.1541517 High–Frame Rate Lateral Strain Estimation Using VirtualBeam Focusing in Canine and Human Hearts In VivoEthan Bunting, 1 * Jean Provost, 1 Elisa Konofagou 1,21Biomedical Engineering, 2 Radiology, Columbia University,New York, New York USAObjectives—Ultrasonic strain imaging is capable of providing clinicianswith useful information regarding cardiac function in a fast, noninvasivemanner. Lateral strain estimation is required to obtain the full 2D straintensor of the heart and accurately represent the cardiac deformation within theimage plane. Previous work has shown that 2 major parameters influencingthe quality of lateral strain estimation are the motion estimation rate and beamdensity (Provost et al. Phys Med Biol 2011). Using element channel data,virtual beam focusing can be used to reconstruct a large number of beamsfrom only a few acoustic interrogations. Furthermore, the rate of motion estimationcan be increased by using temporally unequispaced acquisition sequences(TUAS), a technique developed previously by our group, whichincreases the motion estimation rate while reducing the motion sampling rate.Methods—Using a Verasonics scanner with a custom TUASand virtual beam focusing, we have acquired short-axis views of human(n = 1) and open-chest canine (n = 3) hearts. Virtual beam focusing wasused to reconstruct 156 radiofrequency (RF) lines from 12 focusedacoustic transmits. Lateral displacement estimation was performed usingRF cross-correlation, and strain was computed using a least squares strainestimator. The quality of strain estimation was evaluated by using the elastographicsignal-to-noise ratio (SNRe).Results—We first show that lateral strain estimation can beachieved in vivo using virtual beam focusing and that the results are similarto conventional beam focusing. Also, we show that it is possible touse 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 optimalat a motion estimation rate of 894 Hz.Conclusions—In conventional scanners, there is a trade-off betweenthe beam density and motion estimation rate, leading to a theoreticallimit on the quality of strain estimation. The use of virtual beamfocusing and TUAS techniques for lateral strain imaging was shown toeliminate this tradeoff and lead to good-quality lateral strain estimation athigh frame rates.

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131540358 Nurse-Based Use of Handheld Ultrasound Examination forHeart FailureMikael Gustafsson,* Ulf Dahlström, Urban Alehagen,Peter Johansson Cardiology, Medicine and Care, Linköping,SwedenObjectives—Heart failure (HF) is a syndrome of high prevalenceand poor prognosis. Structured nurse-based visits, where basic clinicaldata 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 ofcare. Ultrasound lung imaging can reveal lung water by the appearance ofthe so-called “comet tail artifact” (CTA), which is reported to be easily recognizedafter a short period of training. Pleural effusion (PE) and dilatationof liver veins and the inferior vena cava (IVC) are also common findingsin decompensated HF that can be evaluated with ultrasound. Knowledge ofthese data may improve understanding of the current hemodynamic statusof HF patients. We hypothesized that HF clinic nurses with 1 day of trainingwould be able to record and correctly identify the CTA and PE using ahandheld ultrasound scanner (HHUS). We also tested whether they wouldbe able to correctly record the IVC diameter and liver veins.Methods—Using an HHUS (Vscan; GE Healthcare), 4 nursesrecorded cine loops from all lung lobes, pleura IVCs, and liver veins in 58consecutive HF outpatients. An experienced echocardiographer, blinded tothe results, reviewed all recorded image sequences in parallel.Results—In this outpatient population of HF patients with medianN-terminal pro-brain natriuretic peptide (NTproBNP) of 1670,nurses’ findings were CTA in 18, PE in 5, dilated IVC in 12, and dilatedliver 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 wereless abundant in NYHA I and II than in NYHA III (r = 0.10; P < .05).Agreement between nurse and echocardiographer findings was good forCTA (70%) and PE (90%), while IVC and liver vein assessments wereless accurate. The HHUS examination time was on average 8 minutes.Conclusions—Nurse-performed HHUS examination directedto assess signs of increased lung water content and elevated central venouspressure can provide additional information with a potential impacton management of HF patients.1520493 Performance Assessment of Cardiac Strain Imaging UsingRadiofrequency and Envelope SignalsChi Ma,* Tomy Varghese Medical Physics, University ofWisconsin, Wisconsin USAObjectives—Clinical cardiac strain images are currently generatedusing B-mode signals. Accurate regional myocardial function analysisrequires high spatial and temporal resolution in addition to fidelity tothe underlying deformation. Performance analysis of radiofrequency (RF),envelope, and B-mode signals in the context of cardiac strain imaging willyield a better understanding of their respective properties.Methods—In this study, strain estimation performance is comparedusing a tissue-mimicking phantom, finite-element–based cardiacsimulation, and clinical in vivo data to demonstrate the differences betweenthe use of RF, envelope, and B-mode signals. Two performancemetrics, ie, the regional mean value and the SD of the regional mean value,are studied.Results—In phantom studies, the signal-to-noise ratio improvementsof the RF signal for linear array and phased array geometry are5.80 and 9.48 dB, respectively, when compared with the envelope signalat the peak strain value. The cardiac simulation study shows that at thepeak strain value, the SDs of the estimated strain of the envelope signalfrom anterior and anterolateral segments are 1.55 and 1.12 times largerthan RF signal estimations, respectively. In vivo study results also showthat the standard deviation of estimated strain is lower with RF signals.Conclusions—Results in phantom studies show that RF signalsprovide superior performance under cyclic compression for both lineararray and phased array transducers when compared to the use ofenvelope signals. Cardiac simulation study and in vivo results also indicateperformance advantages of strain estimation using RF signals overenvelope signals. (Supported by National Institutes of Health grants5R21EB010098 and R01CA112192-S103.)Gynecologic UltrasoundModerator: Jodi Lerner, MD1541483 Three-Dimensional Ultrasound Assessment of Uterine CavityRemodeling After Surgical Correction of SubseptationsLaura Detti Obstetrics and Gynecology University of Tennessee,Memphis, Tennessee USAObjectives—Arcuate and subseptate uteri taken together accountfor 53% of all müllerian anomalies. Their incidence is even higherin patients with infertility and recurrent pregnancy loss, and restoration ofnormal fertility/pregnancy outcomes is achieved with surgical correction.We sought to evaluate uterine cavity measurements in patients with arcuateor subseptate uteri in the pre- and post-resection periods.Methods—This was a prospective cohort study. Patients diagnosedwith arcuate or subseptate uteri were evaluated with 3D ultrasoundbefore and after undergoing surgical resection of the anomalies by hysteroscopicseparation of the anterior from the posterior wall. Measurementsof the subseptum’s length (measured from the base to the tip of theseptum:

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013displacements, strains, and strain rates were determined by postprocessingusing QLab version 8.0 (Philips, Andover, MA).Results—The findings in the first and third trimesters are summarizedin Table 1. There was no statistically significant effect of age,race, or body mass index (BMI) on any of the measurements; except forBMI (P = .03) on mean velocity in the third trimester. Gestational age atthe time of the exam had a negative effect on mean velocity in the first(P

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131538495 Evaluation of Cervical Cancer Detection With AcousticRadiation Force Impulse Ultrasound Imaging: PreliminaryResultsYijin Su,* Lianfang Du, Ying Wu, Juan Zhang, XuemeiZhang, Xiao Jia, Yingyu Cai, Yunhua Li, Jing Zhao, QianLiu School of Medicine, Shanghai Jiaotong University,Shanghai, ChinaObjectives—To evaluate the application of acoustic radiationforce impulse (ARFI) ultrasound imaging and its potential value for characterizingcervical cancer.Methods—ARFI of the uterine cervix was performed in 58 patientswith cervical cancer before operation. Elastographic imaging (EI),Virtual Touch tissue imaging (VTI), and Virtual Touch tissue quantification(VTQ; Siemens Medical Solutions, Mountain View, CA) wereused to qualitatively and quantitatively analyze the elasticity and hardnessof lesions.Results—Compared to the surrounding cervix tissue, the EI,VTI, and VTQ images between malignant lesions and surrounding normaltissues showed a significant difference (P < .001).Conclusions—ARFI of the uterine cervix may be an objectivemethod for assessment of softening of tissue. It has high sensitivity andspecificity in evaluating cervical cancer and therefore has good diagnosticvalue in clinical applications.Table 1. Comparison of VTQ Between Cervical Cancer and Normal TissueTissue Cases, n Mean, m/s SD, m/sCervical cancer 58 3.41 1.59Normal tissue 58 2.12 1.27Compared with normal tissue, VTQ of cervical cancer was higher (P < .001).1512000 Texture-Based Ovarian Tumor Characterization Using3-Dimensional UltrasoundU. Rajendra Acharya, 1 Stefano Guerriero, 2 Filippo Molinari, 3Luca Saba, 4 Jasjit Suri 5,6 *1 Electronics and Computer Engineering,Ngee Ann Polytechnic, Singapore; 2 Obstetrics andGynecology, University of Cagliari, Cagliari, Italy; 3 Electronicsand Telecommunications, Politecnico Torino, Torino, Italy;4Radiology, Azienda Ospedaliero Universitaria di Cagliari,Cagliari, Italy; 5 Global Biomedical Technologies, Roseville,California USA; 6 Biomedical Engineering, Idaho State University,Pocatello, Idaho USAObjectives—Among gynecologic malignancies, ovarian canceris the most frequent cause of death. Differential diagnosis is difficult,thus exposing patients to unneeded surgical treatment. We developed acomputer-aided diagnostic technique that uses ultrasound images of theovary 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, wererecruited for this study. The histologic specimens revealed 10 malignantand 10 benign lesions. Prior to surgery, each patient was associated witha 3D volume of 100 images. Feature extraction was made by using localbinary pattern and laws texture energy. The data were used to train a classifierbased on a support vector machine (SVM) with 5 different kernels.The data set was randomly split into 10 equal folds, each fold containingthe same ratio of nonrepetitive samples from both classes (malignant andbenign). At each iteration, 9 folds were used to train the SVM, and 1 foldwas classified. We iterated the procedure 10 times to explore all the possiblecombinations. The averages of the performance metrics obtained inall the iterations are reported as the overall performance metrics.Results—The performance metrics obtained on training theSVM classifier of various kernel configurations using the 14 significantfeatures are reported in Table 1. All the kernels demonstrated excellentability in classifying the samples from both classes. The highest accuracyof 99.9% was registered by the radial basis function (RBF) kernel.Conclusions—The novelty of this study is the use of low-costultrasound images and a highly discriminating combination of simple texturefeatures fed to an SVM classifier to obtain the highest accuracy ofnearly 100% in ovarian tumor classification.Table 1. Classifier PerformanceSVM Accuracy, Sensitivity, Specificity, PPV,Kernel TP TN FP FN % % % %Linear 100 99 0 1 99.8 99.6 100 100Poly 1 100 100 0 0 99.8 99.6 100 100Poly 2 100 100 0 0 99.9 100 99.9 99.9Poly 3 100 100 0 0 99.8 99.9 99.8 99.8RBF 100 100 0 0 99.9 100 99.8 99.8FN indicates false-negative; FP, false-positive; PPV, positive predictive value;TN, true-negative; and TP, true-positive.1512001 Tumor Characterization From 3-Dimensional GynecologicUltrasound: A New Online Feature-Based ParadigmU. Rajendra Acharya, 1 Luca Saba, 2 Filippo Molinari, 3Stefano Guerriero, 4 Jasjit Suri 5,6 * 1Electronics and ComputerEngineering, Ngee Ann Polytechnic, Singapore; 2 Radiology,Azienda Ospedaliero Universitaria di Cagliari, Cagliari,Italy; 3 Electronics and Telecommunications, Politecnico Torino,Torino, Italy; 4 Obstetrics and Gynecology, University ofCagliari, Cagliari, Italy; 5 Global Biomedical Technologies,Roseville, California USA; 6 Biomedical Engineering, IdahoState University, Pocatello, Idaho USAObjectives—Among gynecologic malignancies, ovarian canceris the most frequent cause of death. Differential diagnosis is difficult, exposingpatients to unneeded surgical treatment. The objective of this workwas to develop a computer-aided diagnostic (CAD) technique that uses 3Dacquired ultrasound images of the ovary and image-mining algorithms tocharacterize 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 recruitedfor this study. The histologic specimens revealed 10 had malignantand 10 had benign lesions. Prior to surgery, each patient wasassociated with a 3D volume of 100 images. We extracted features basedon the textural changes in the image and also features based on the higherorderspectra (HOS) information. The significant features were then selectedand used to train and evaluate the decision tree (DT) classifier.The data set was randomly split into 10 equal folds, each fold containingthe same ratio of nonrepetitive samples from both the classes (malignantand benign). At each iteration, 9 folds were used to train the DT, and 1fold was classified. We iterated the procedure 10 times to explore all thepossible combinations. The averages of the performance obtained in all theiterations are reported as the overall performance.Results—The simple DT classifier presented high accuracy of95.1%, sensitivity of 92.5%, and specificity of 97.7%. Full performanceis given in Table 1.Conclusions—A novel combination of 4 texture and HOSbased features that adequately quantify the nonlinear changes in both benignand malignant ovarian ultrasound images was used to develop classifiers.The CAD tool would be a more objective alternative to manualanalysis of ultrasound images, which might result in interobserver variations.The system can be installed as a stand-alone software application inthe physician’s office at no extra cost.S47

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Table 1. Classifier PerformanceAccuracy, Sensitivity, Specificity, PPV,TN FN TP FP % % % %DT 98 8 93 2 95.1 97.8 92.5 97.7FN indicates false-negative; FP, false-positive; PPV, positive predictive value; TN,true-negative; and TP, true-positive.1537972 Value of Transvaginal Ultrasonography in DiagnosingAdenomyosisBirsen Ogutcu, 1,2 * Kathryn Gunnison, 2 Bakytbubu Arynova, 1Jack Garon, 1,2 Josef Blankstein 1,2 1 Obstetrics and Gynecology,Mount Sinai Hospital, Chicago, Illinois USA; 2 Obstetricsand Gynecology, Rosalind Franklin University of Medicine andScience, North Chicago, Illinois USAObjectives—The purpose of this study was to look at ultrasonographicfindings of uteri with adenomyosis confirmed by histopathologyafter hysterectomy.Methods—The ultrasound reports and images from 76 patientswho underwent hysterectomy with a diagnosis of adenomyosis on pathologicreports were evaluated. Data collection included the myometrialechogenicity (focal or diffuse heterogeneous echo texture vs homogeneousecho texture), the presence or absence of myometrial cysts, the presenceor absence of subendometrial linear striations, and the quality of the endometrial/myometrialborder (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 werefound in 53 (72%) of the images. Forty-six (63%) images were shown tohave an ill-defined endometrial/myometrial border. Thirty-two (44%) imageswere shown to have subendometrial linear striations. Of the imagesshown to have myometrial cysts, all 53 (100%) were shown to have a heterogeneousmyometrial echo texture.Conclusions—In conclusion, based on our retrospective studiesand others, transvaginal ultrasonography is a cost-effective, noninvasive,and widely available method to look for ultrasonographic findingsthat are common in uteri with pathologically confirmed adenomyosis. Inthis study, we identified a heterogeneous myometrial echo texture as themost common ultrasonographic finding in uteri with confirmed adenomyosis.Additional prospective studies to further determine the accuracyand reliability of transvaginal ultrasonography as a tool to diagnose adenomyosisare needed.1509704 To Chaperone or Not to ChaperoneJenny Parkes, 1,2 * Michal Schneider-Kolsky, 2 Paul Lombardo 21Australian School of Medical Imaging, Sydney, New SouthWales, Australia; 2 Medical Imaging and Radiation Science,Monash University, Melbourne, Victoria, AustraliaObjectives—Chaperone use during transvaginal (TV) ultrasoundis variable. This paper discusses such use in regard to both the sonographer/sonologistand patient’s perspectives.Methods—A survey of sonographer members of the AustralianSonographers 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%) sonographersparticipated in this survey. Most sonographers surveyed used a chaperoneoccasionally (42.9%), with 70% preferring to never use a chaperone.Patient embarrassment and lack of privacy were key issues, findings thatwere supported by the literature. Female sonographers used chaperonesoccasionally or never (89%), while 60% of male sonographers used achaperone always or most of the time to comply with departmental protocolsand for medicolegal protection. Sonographers in private specialistobstetric and gynecologic centers where TV pelvic ultrasound is commonlya routine part of the examination never, or only occasionally, useda chaperone. Review of the current literature and protocols highlightedthat the use of a chaperone should consider the patient’s privacy, embarrassment,and preference. In regard to the sonographer/sonologist, selectionof an appropriate chaperone, availability, and the informed consent ofthe patient are important considerations.Conclusions—Chaperones for TV scanning are predominantlyused by male sonographers in Australia. It is unclear if the patient preferencefor a chaperone to be present is taken into account. The appropriateprotection for both sonographers/sonologists and patients needs to be considered,in particular, privacy issues. Protocols should be developed totake all of these factors into account.1538726 What Causes Postmenopausal Bleeding (PMB)? A ProspectiveStudy of 670 Consecutive Patients With PMB ExaminedWith Regard to Body Mass Index and the Prevalenceof Abnormalities on SonohysterographyAlex Hartman,* Rose Lee, Brian Hartman Imaging, TrueNorth Imaging, Thornhill, Ontario, CanadaObjectives—The causes of postmenopausal bleeding (PMB)are myriad. This prospective study examines the causes of PMB and correlatesthese findings to patient body mass index (BMI).Methods—Sonohysterography was performed on 1108 consecutivepostmenopausal women at an academically oriented private practicefrom October 2010 to August 2011. Six hundred seventy of thepatients had PMB. The prevalence of uterine abnormalities and the patient’sBMI were obtained for each group. χ 2 tests of independence and1-way analysis of variance were performed to determine significant differences.Results—Of the 670 with PMB, 262 (39.1%) had endometrialpolyps; 273 (40.1%) had fibroids; 39 (6.8%) had submucosal fibroids; and369 (55%) had a normal cavity, with no polyps, or submucosal fibroids.There was a statistically significant difference between the mean BMI ofpatients 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 anormal uterine cavity, and almost 40% have endometrial polyps. Patientswith endometrial polyps have a higher BMI than those without polyps.Table 1Patients, n Patients, % BMINo uterine abnormality 233 34.8 27.33Intramural fibroid 136 20.3 27.64Polyp 164 24.5 28.34Submucosal fibroid 39 5.8 27.60Polyp + intramural fibroid 91 13.6 28.80Polyp + submucosal fibroid 7 1.0 28.76Total 670 100 27.931541040 Spatial Variability of Shear Wave Speed Estimation in theNormal Nonpregnant CervixLindsey Carlson, 1 * Mark Palmeri, 2 Lisa Reusch, 1 HelenFeltovich, 1,3 Timothy Hall 1 1 Medical Physics, University ofWisconsin, Madison , Wisconsin USA; 2 Biomedical Engineering,Duke University Pratt School of Engineering, Durham,North Carolina USA; 3 Maternal-Fetal Medicine, IntermountainHealthcare, Park City, Utah USAObjectives—Throughout pregnancy, beginning soon after conception,the cervix remodels, resulting in softening, shortening, and dilationto allow for eventual delivery of a fetus. Premature remodeling mayS48

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013lead to premature birth, yet there is no clinically established method to objectivelyand quantitatively measure softening. Our objective is to developa safe, reliable, noninvasive quantitative method to assess cervical softness.We have shown that shear wave speed estimation (SWS) is an effectivemethod to measure cervical softness in hysterectomy specimens. A criticalstep toward transitioning to in vivo studies is to determine the spatialvariability in cervical softness, and that is the aim of the current work.Methods—Five multiparous hysterectomy specimens fromnonpregnant women were bivalved, placed in a saline bath, and scannedwith a 9L4 linear array transducer aligned parallel with the endocervicalcanal using a Siemens Acuson S2000 system. SWS measurements wereobtained 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) with10 replicate measurements at each location. The shear wave speeds wereestimated using an iterative random sample consensus (RANSAC)method.Results—In all specimens, the shear wave speed systematicallyincreased along the canal from distal to proximal (closer to the uterus) onthe 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 thelength 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 andproximal, respectively). All estimates had a RANSAC inlier percentage of99%, representing strong confidence in the SWS estimates.Conclusions—Normal cervical tissue has a significant stiffnessgradient that can be characterized with acoustic radiation force-based shearelasticity imaging methods. With careful development and testing, SWSmeasurement will provide a means to noninvasively assess softening of thepregnant cervix and could be a useful research tool for exploring prematurecervical remodeling.New Investigator Award SessionModerators: Arthur Fleischer, MD, Elisa Konofagou, PhD1434714 Longitudinal Analysis of Grayscale Imaging and Electro -myography in an Animal Model of Carpal Tunnel SyndromeShawn Roll, 1 * Kevin Evans, 2 Kevin Volz, 2 Carolyn Sommerich 21Division of Occupational Science and Occupational Therapy,University of Southern California, Los Angeles, CaliforniaUSA; 2 School of Health and Rehabilitation Sciences, Ohio StateUniversity, Columbus, Ohio USAObjectives—The objective of this research was to determinethe ability of sonography to identify changes over time in median nervemorphology due to controlled exposure to a physical task related to the developmentof carpal tunnel syndrome.Methods—Fifteen Macaca fascicularis monkeys pinched alever while in various amounts of wrist flexion to receive a treat. Subjectsworked at a self-regulated pace up to 8 hours a day, 5 days a week, for 14weeks. Nerve conduction velocity (NCV) and sonographic evaluation ofthe median nerve were completed every other week during 4 weeks oftraining (baseline), 16 weeks of working, and 6 weeks of recovery. A GELOGIQ i with a 12-MHz linear transducer was used for sonographic evaluation.Cross-sectional area (CSA) was measured via a direct trace aroundthe inner hyperechoic border of the nerve in the forearm and at the levelof the pisiform. NCV and CSA measures were analyzed across the 3phases using analysis of variance and trend graphs.Results—NCV slowed slightly from baseline to the workingphase across all subjects (P = .03). CSA of the nerve at the level of thepisiform was noted to increase significantly from baseline and workingphases 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 thephases (P = .20).Conclusions—Based on this controlled study, changes in CSAof the median nerve can be observed over time and may be directly associatedwith work exposure. Sonography may be a highly useful tool forperiodic preventative screening for work-related musculoskeletal disorders.Early detection of these changes through longitudinal evaluations inworkers at risk for carpal tunnel syndrome could trigger interventionsmeant to reverse the progression of tissue pathology.Table 1. Average (SD) Nerve Measurements Across the Study PhasesBaseline Working Recovery PNerve conduction velocity, 35.96 (3.46) 34.33 (3.76) 34.81 (3.19) .03m/secCSA in forearm, mm 2 0.61 (0.15) 0.59 (0.16) 0.64 (0.17) .20CSA at pisiform, mm 2 0.82 (0.28) 0.81 (0.29) 0.96 (0.36) .03CSA change (pisiform – 0.20 (0.28) 0.22 (0.31) 0.30 (0.38) .27forearm), mm 21526604 Risk Reduction of Brain Infarction During CarotidEndarterectomy or Stenting Using Sonolysis: ProspectiveRandomized Study Pilot DataMartin Kuliha, 1 * David Školoudík, 1,4 Eva Hurtíková, 1Martin Roubec, 1 Andrea Goldírová, 1 Roman Herzig, 4 VáclavProcházka, 2 Tomáš Jonszta, 2 Dan Czerný, 2 Jan Krajča, 2 DavidOtáhal, 3 Tomáš Hrbáč 3 1 Neurology, 2 Radiology, 3 Neurosurgery,University Hospital Ostrava, Ostrava, Czech Republic;4 Neurology, University Hospital Olomouc, Olomouc, CzechRepublicObjectives—Sonolysis is a new therapeutic option for accelerationof arterial recanalization. The aim of this study was to confirm riskreduction of brain infarction during carotid endarterectomy (CEA) andcarotid stenting (CS) of the internal carotid artery (ICA) using sonolysiswith continuous transcranial Doppler monitoring by a diagnostic 2-MHzprobe.Methods—All patients with ICA stenosis >70%, an indicationfor CEA or CS, and signed informed consent were enrolled to the studyduring 18 months. Patients were randomized into 2 groups: group 1 withsonolysis during intervention and group 2 without sonolysis. Neurologicexamination, cognitive tests, and brain magnetic resonance imaging wereperformed before and 24 hours after intervention in all patients. New braininfarctions, infarctions >0.5 cm 3 , a mini–mental state examination, a clocktest, 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 intogroup 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 underwentCEA and 35 CS. New brain infarctions/infarctions >0.5 cm 3 were foundin 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 significantdifferences were found in cognitive tests (P > .05 in all tests).Conclusions—Sonolysis seems to be effective in prevention oflarge brain infarction during CEA and CS. (Supported by grants IGA MHCR NT/11386-5/2010, NT/11046-6/2010, and NT/13498-4/2012.)1536178 Measured Single-Bubble Postexcitation Collapse Thresholdsfor Standard and Size-Altered Ultrasound Contrast AgentsDaniel King, 1,2 * William O’Brien Jr 2,3 1 Mechanical Scienceand Engineering, 2 Bioacoustics Research Laboratory, 3 Electricaland Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois USAObjectives—Experimentally measured responses of ultrasoundcontrast agents (UCAs) at high acoustic pressures are valuable for imagingand therapeutic ultrasound applications as well as for interpreting bio-S49

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013effect mechanisms. Therefore, the goals for this research were to comparethe size distribution and shell composition dependence for a characteristictype of collapse using 2 commercially available UCAs, lipid-shelledDefinity and albumin-shelled Optison.Methods—Two Definity and 2 Optison populations of varyingsize distributions were tested. Experiments were conducted using a doublepassive cavitation detection setup at several frequencies (2.8–7.1 MHz)across a range of peak rarefactional pressures (0.1–6.0 MPa). Data wereanalyzed using a peak detection algorithm for the presence or absence ofthe postexcitation signal (PES), a rebound characteristic indicative of shellrupture, inertial cavitation, and symmetric collapse for single UCAs.Results—With standard preparations, Definity had lower postexcitationcollapse thresholds than Optison at most frequencies (Table 1).Using alternate preparations to change the mean size of the bubble populationshad little effect on these thresholds, except around 4.6 MHz.Furthermore, the predicted shift in PES thresholds using the Marmottantmodel 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 thecollapse thresholds of Definity and Optison. Moreover, the comparisonsbetween varied size distributions showed that the different shell compositionshad a significant impact on the measured PES thresholds at allfrequencies, independent of mean size. (Supported by National Institutesof Health grant R37 EB002641.)Table 1. Mean Diameter ± SD and 50% Postexcitation Thresholds (95% ConfidenceIntervals) for Peak Rarefactional Pressure Amplitude50% 50% 50%UCA Mean Threshold at Threshold at Threshold atPopulation Diameter, µm 2.8 MHz, MPa 4.6 MHz, MPa 7.1 MHz, MPaDefinity 1.99 ± 0.54 0.81 (0.71–0.90) 2.26 (2.06–2.43) 3.90 (3.50–4.40)Altered Definity 2.50 ± 2.32 0.80 (0.75–0.85) 1.65 (1.56–1.72) 3.61 (3.30–4.19)Optison 4.24 ± 2.44 1.20 (0.99–1.39) 1.76 (1.34–2.06) 4.24 (2.81–4.94)Altered Optison 2.61 ± 2.04 1.17 (0.92–1.39) 2.62 (2.20–2.95) 4.04 (3.85–4.20)1538841 Computer-Assisted Detection of Proximal Arterial Stenosison Doppler UltrasoundJohn Millet, 1 * Gowthaman Gunabushanam, 1 Erik Stilp, 2Forrest Crawford, 3 Robert McNamara, 2 Leslie Scoutt 11Diagnostic Radiology, 2 Internal Medicine, Yale UniversitySchool of Medicine, New Haven, Connecticut USA; 3 Biostatistics,Yale University School of Public Health, New Haven,Connecticut USAObjectives—To determine if use of a novel computer-generatedquantitative measure, effective acceleration time (effAT), can improveaccuracy for detecting proximal arterial stenosis on Dopplerultrasound.Methods—This was a retrospective case-control study wherebyaortic stenosis (AS) was used as a model to detect distal tardus parvusphysiology. Patients with echocardiography-confirmed AS (n = 132; 60mild, 44 moderate, 28 severe) and controls (n = 48) who underwent carotidultrasound within 90 days were identified through a diagnostic imagingdatabase at a single medical center. A custom-built computerized spectralanalysis program generated effAT values for all carotid artery spectralDoppler waveforms, and a receiver operating characteristic (ROC) analysiswas performed to determine the optimal median effAT cutoff value todetect AS. Two radiologists, blinded to subject disease status, reviewedall carotid sonograms for the presence of tardus parvus waveforms. Interobservervariability was measured, and the accuracy of the radiologists todetect AS with and without use of the effAT cutoff was calculated. Accuracyof the effAT cutoff to detect AS independent of radiologist waveforminterpretation was also determined.Results—There were no significant differences between casesand controls with regard to age, sex, body mass index, or ejection fraction.Accuracy of radiologist detection of AS via waveform interpretationranged from 43% to 61%. Observer agreement in the detection of tardusparvus waveforms was 76% (136/180 cases; Κ = 0.44; P < .001). ROCanalysis revealed an optimal effAT cutoff of ≥48 milliseconds to detectAS with a corresponding area under the curve of 0.77 (95% confidence interval,0.74–0.84). Use of the effAT cutoff independent of radiologistwaveform interpretation demonstrated accuracy of 72%. The combinationof a tardus parvus pattern and a median effAT of ≥48 millisecondsdemonstrated an accuracy range of 73% to 74%.Conclusions—Radiologist detection of proximal arterial stenosisthough visual interpretation of spectral Doppler waveform morphologyis limited by low accuracy and moderate interobserver variability. Use ofa computer-generated median effAT cutoff markedly improves diagnosticaccuracy and eliminates observer variability.1536020 Contrast Ultrasound Imaging of the Aorta Does Not AffectProgression of Atherosclerosis in ApoE–/– MiceBrendon Smith, 1,2 * Douglas Simpson, 3 Sandhya Sarwate, 1,4Rita Miller, 1 Rami Abuhabsah, 1 John Erdman, 2,5 WilliamO’Brien Jr 1,2 1 Bioacoustics Research Laboratory, Electricaland Computer Engineering, 2 Division of Nutritional Sciences,3Statistics, 4 Pathology, 5 Food Science and Human Nutrition,University of Illinois at Urbana-Champaign, Urbana, IllinoisUSAObjectives—Ultrasound contrast agents (UCAs) are used clinicallyto enhance ultrasound imaging of the cardiovascular system. Adversebiological effects have been noted after administration of UCAs inhuman patients and animal models, and more research is needed for acomprehensive understanding of the biological effects of UCAs. We usedthe ApoE –/– mouse model of atherosclerosis to characterize these effects.Methods—Male ApoE –/– mice (8 weeks old; n = 38) were intravenouslyinfused with the Definity UCA (2 × 10 10 UCA/h) and eitherexposed to 2.8-MHz, 10-Hz pulse repetition frequency, 1.4-microsecondpulse duration, 2-minute exposure duration, 1.4-MPa peak rarefactionalpressure amplitude ultrasound or sham exposed, and then consumed eithera chow or Western diet for either 4 or 8 weeks after ultrasound exposure(n = 4–5 per group). The ultrasound exposure conditions, by design andindependent measures, matched Definity’s 80% collapse threshold. Bloodplasma samples were collected before ultrasound exposure and at 2, 4, 6,and 8 weeks after exposure. Animals were then euthanized, and tissueswere collected for analysis. A pathologist measured atheroma thicknessin formalin-fixed, hematoxylin-eosin–stained transverse sections of theaorta and scored them for severity of atherosclerosis.Results—Plasma total cholesterol initially averaged 302 mg/dLin the Western diet group, increased significantly to 742 mg/dL after 2weeks on the diet (P < .0001), and remained significantly elevated afterthat. Total cholesterol increased significantly from 309 mg/dL at baselineto 420 mg/dL in the chow diet group after 4 weeks (P < .05) but was notsignificantly different from baseline at 6 or 8 weeks. Total cholesterol wassignificantly greater in the Western diet group than the chow group for alltime points after baseline (P < .0001). Atheroma thickness was significantlygreater in animals consuming the Western diet than in chow-fedanimals (P < .001) and in animals euthanized after 8 weeks than after 4weeks (P < .005). Ultrasound did not affect plasma total cholesterol levelsor atheroma thickness.Conclusions—Contrast ultrasound did not increase the severityof atherosclerosis in the ApoE –/– mouse model. (Supported by NationalInstitutes of Health grant R37EB002641.)S50

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131540161 Heterogeneity Assessment of Tumor Perfusion Using HighresolutionDynamic Contrast-Enhanced Ultrasound andDynamic Contrast-Enhanced Magnetic Resonance ImagingSong-Ee Baek,* Patrick Pan, Ergys Subashi, Cäcilia Reiner,Daniele Marin, Allan Johnson, Rendon Nelson Radiology,Duke University Hospital, Durham, North Carolina USAObjectives—To determine the reproducibility of measurementsof tumor perfusion heterogeneity using high-resolution contrast-enhancedultrasound compared to high-resolution dynamic contrast-enhanced (DCE)magnetic resonance imaging (MRI) in murine colorectal cancer. We anticipateusing this technique to predict and monitor treatment response to anantiangiogenesis agent.Methods—Experiments were approved by the local AnimalCare Committee. Five CD-1 nu/nu athymic female mice with subcutaneousmurine colorectal carcinomas (mean tumor height/width, 0.66/1.21cm) were injected with SonoVue (Bracco Diagnostic, Inc) via a tail vein.At first, we determined reproducibility of tumor perfusion measurementwith DCE-US using a GE LOGIQ E9 with an ML6-15-D transducer (4–13 MHz). Three separate injections by 2 radiologists were performed, andmaximum peak intensity (in video intensity) of all pixels within the regionsof interest (ROIs) and coefficients of the enhancement for wash-inand wash-out (25%–75% of the peak enhancement) slopes were calculated.Quantitative measurements were performed by positioning of ROIsin the frame displaying maximum contrast enhancement of the tumor. Acoefficient of variation was used to compare the variability for each parameter.Second, perfusion heterogeneity according to tumor region wasperformed 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 injectionsin 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 withDCE US showed reproducible results. Perfusion graphs showed a differentpattern by regions presenting tumor heterogeneity. DCE-US and DCE-MRI wash-in and wash-out slopes are well correlated.Conclusions—We obtained reproducible measurements of heterogeneityof tumor perfusion with DCE-US. These results also showedcompatible perfusion patterns with DCE-MRI. As a result of this information,we will pursue a further experiment design to determine the abilityof this technique to predict treatment response.1541104 Subharmonic Imaging of Angiogenesis in a Murine BreastCancer ModelAndrew Marshall, 1,3 * Valgerdur Halldorsdottir, 1,3 JaydevDave, 1 Anya Forsberg, 1,4 Manasi Dahibawkar, 1,3 Traci Fox, 2Ji-Bin Liu, 1 Xiangdong Hu, 1,5 Yu He, 1,6 Flemming Forsberg 11Radiology, 2 Radiological Sciences, Thomas Jefferson University,Philadelphia, Pennsylvania USA; 3 School of BiomedicalEngineering, Sciences, and Health Systems, Drexel University,Philadelphia, Pennsylvania USA; 4 Plymouth Whitemarsh HighSchool, Plymouth Meeting, Pennsylvania USA; 5 Ultrasonography,Beijing Friendship Hospital, Beijing, China; 6 Ultrasound,First Hospital of Jilin University, Jilin, ChinaObjectives—To compare contrast-enhanced subharmonic ultrasoundimaging (SHI) of breast tumor neovascularity to 3 immunohistochemicalmarkers of angiogenesis in nude rats.Methods—Twenty-five athymic nude female rats were implantedwith 5 × 10 6 breast cancer cells (MDA MB 231) in the mammaryfat pad. The contrast agent Definity (Lantheus Medical Imaging, NorthBillerica, MA) was injected in a tail vein (dose, 200 µL/kg), and fundamentalultrasound imaging as well as pulse-inversion SHI were performedwith a modified Sonix RP scanner (Ultrasonix Imaging, Richmond, BritishColumbia, Canada) using a L9-4 linear array (transmitting at 8 MHz andreceiving at 4 MHz in SHI mode). After the experiments, specimens werestained for endothelial cells (CD31), vascular endothelial growth factor,and cyclooxygenase-2. Fractional tumor vascularity was calculated fromdigital images as contrast-enhanced pixels over tumor area (for SHI) andstaining over tumor area (for specimens). Results were compared using alinear regression analysis.Results—Of the 25 rats implanted 16 (64 %) exhibited tumorgrowth, and 13 were successfully imaged. SHI depicted the tortuous morphologyof tumor neovessels and delineated areas of necrosis better thanfundamental ultrasound imaging, due to the marked suppression of tissuesignals. The strongest correlation determined by linear regression in thisbreast cancer model was between SHI and percent area stained with CD31(r = 0.42).Conclusions—Quantitative contrast-enhanced SHI measuresof tumor neovascularity in a breast cancer xenograft model appear to providea noninvasive marker for angiogenesis corresponding to the expressionof CD31, albeit based on a limited sample size. (Supported by USArmy Medical Research Material Command grant W81XWH-08-1-0503and Lantheus Medical Imaging.)1539281 A Sequential Stepwise Algorithm Helps Improve Detectionof Fetal Venous AnomaliesElena Sinkovskaya,* Anna Klassen, Sharon Horton, AlfredAbuhamad Division of Maternal-Fetal Medicine, EasternVirginia Medical School, Norfolk, Virginia USAObjectives—The assessment of the fetal venous system is anessential component to fetal echocardiography as it adds significantly tothe complete diagnosis of heart defects. The purpose of this study was todevelop a method to standardize and simplify comprehensive examinationof the fetal venous system.Methods—Eight hundred thirty-four fetal congenital cardiovascularanomalies (CVAs) were detected between January 2005 andDecember 2010 in the Division of Maternal-Fetal Medicine at EasternVirginia Medical School. Fetal echocardiograms, which incorporated theassessment of anatomic components of the fetal venous system, were performedbetween 16 and 39 weeks’ gestation. Since 2008, the stepwiseapproach, 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 brachiocephalicvein. 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 detectedbetween years 2005 and 2007 and 501 (59.1%) between years 2008 and2010. Since 2008, the detection of fetal isolated systemic and pulmonaryvein anomalies significantly increased (Table 1), while the distribution ofcongenital heart defects (CHDs) with and without venous malformationsstayed the same. This increased identification of fetal venous system abnormalitiesmay be related to the adoption of the new stepwise approach.Conclusions—Our results demonstrated that the sequentialanalysis of 5 transverse views helps significantly improve the detectionof isolated fetal anomalies of systemic and pulmonary veins.Table 1. Detection of Fetal Cardiovascular AnomaliesIsolated Venous CHDs With CHDs WithObservation Anomalies, Venous System Normal VenousPeriod N n (%) Anomalies, n (%) System, n (%)2005–2007 333 32/333 (9.6) 33/333 (10) 268/333 (80.4)2008–2010 501 137/501 (27.3) a 40/501 (8) 324/501 (64.7)aSignificant difference, P < .05.S51

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131539534 Assessment of Longitudinal Myocardial Function of theRight Ventricle in Fetuses With Agenesis of the DuctusVenosus Using Tissue Doppler ImagingAnna Klassen,* Elena Sinkovskaya, Sharon Horton, AlfredAbuhamad Division of Maternal-Fetal Medicine, EasternVirginia Medical School, Norfolk, Virginia USAObjectives—Agenesis of the ductus venosus (DV) may lead tofetal congestive heart failure (CHF). Tissue Doppler imaging (TDI) is arelatively new method used for direct analysis of the myocardial function.The aim of this study was to analyze the systolic and diastolic myocardialfunction of the right ventricle (RV) in fetuses with an absent DV using TDI.Methods—Myocardial function of the RV was assessed in 42normal fetuses and 27 fetuses with DV agenesis between 27 and 39 weeks’gestation. Detailed echocardiography combined with pulsed and tissueDoppler was performed in all cases. To determine the degree of CHF, thecardiovascular score (CVS) was evaluated on each subject. TDI data wereobtained at the level of the 4-chamber view by placing the sample volumeat 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′), ratioof 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 from8 to 2 (mean, 6 ± 1.5), but none of these fetuses developed hydrops. TheTDI Tei index was significantly higher in the group with an absent DVcompared 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 myocardialvelocities were noted: E′ was significantly decreased or absent (averageZ 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 cardiacfunction in fetuses with agenesis of the DV. Agenesis of the DV resultsin systolic and diastolic myocardial dysfunction of the RV in the fetus.Our results validate the potential clinical applicability of the TDI techniquein assessment of cardiac function in fetuses with an absent DV.1541422 Does Early Second-Trimester Ultrasound Predict Obstetricand Neonatal Outcomes in Monochorionic Diamniotic TwinPregnancies?M. Baraa Allaf, 1 * Sina Haeri, 2 Ali Ozhand, 3 Amir Shamshirsaz, 4Martin Chavez, 1 Samadeh Ravangard, 5 Adam Borgida, 6Glenn Markenson, 7 Joseph Wax, 8 Sarah Davis, 9 RebeccaHabenicht, 10 Manisha Gandhi, 2 Jeff Johnson, 10 MarjorieMeyer, 9 Rodrigo Ruano, 2 Paul Ogburn, 1 Melissa Spiel, 5Winston Campbell, 5 Anthony Vintzileos, 1 Alireza Shamshirsaz 2,51Obstetrics and Gynecology, Stony Brook–Winthrop UniversityHospitals, Long Island, New York USA; 2 Obstetrics and Gynecology,Baylor College of Medicine, Houston, Texas USA; 3 PreventiveMedicine, University of Southern California, Los Angeles,California USA; 4 Obstetrics and Gynecology, George WashingtonUniversity, Washington, DC USA; 5 Obstetrics and Gynecology,University of Connecticut, Farmington, Connecticut USA; 6 Obstetricsand Gynecology, Hartford Hospital, Hartford, ConnecticutUSA; 7 Obstetrics and Gynecology, Baystate Medical Center,Springfield, Massachusetts USA; 8 Obstetrics and Gynecology,Maine Medical Center, Portland, Maine USA; 9 Obstetrics andGynecology, University of Vermont College of Medicine, Burlington,Vermont USA; 10 Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Concord, New Hampshire USAObjectives—To determine the association of discordant abdominalcircumference (AC), femoral length (FL), head circumference(HC), or estimated fetal weight (EFW) at time of early second-trimesterultrasound with adverse obstetric and neonatal outcomes.S52Methods—This was a multicenter retrospective cohort studyin 9 perinatal centers in the United States from January 2006 to June 2011.All monochorionic diamniotic twin pregnancies with 2 live fetuses at earlysecond-trimester (16–20 weeks) ultrasound and serial follow-up ultrasounduntil delivery were included. Pregnancies with known chromosomalabnormalities or major malformations were excluded. The compositeobstetric outcome included intrauterine fetal demise (IUFD), twin-to-twintransfusion syndrome (TTTS), intrauterine fetal growth restriction(IUGR), and preterm birth ≤28 weeks. The composite neonatal outcomeincluded Apgar score

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Obstetric Ultrasound: Fetal AnomaliesModerators: Israel Meizner, MD, Heather Welch, MDMRI may not be indicated for diagnoses where it is unlikely to improveon the diagnostic accuracy of US alone. Notably, this study does considerpotential cost, prognostic, and surgical-planning benefits of fetal MRI.1525585 Late Diagnosis of Fetal Central Nervous System AnomaliesFollowing a Normal Second-Trimester Anatomy Scan:Should a Third-Trimester Anatomy Scan Be RoutinelyRecommended?Eldad Katorza, 1 * Yoav Yinon, 1 Chen Hoffmann, 2 ShlomoLipitz, 1 Reuven Achiron, 1 Boaz Weisz 1 1 Obstetrics and Gynecology,2 Radiology, Sheba Medical Center, Tel Hashomer, IsraelObjectives—To determine the prevalence and nature of centralnervous system (CNS) anomalies diagnosed during the third trimester followinga normal anatomy scan at 21 to 24 weeks of gestation.Methods—This was a retrospective cohort study of all pregnantwomen referred to the fetal medicine unit at Sheba Medical Centerdue to fetal CNS anomalies detected at the late second and third trimestersfollowing a normal anatomy scan at 21 to 24 weeks of gestation. All patientsunderwent a thorough workup, which consisted of a detailedanatomy scan, dedicated neurosonography, and amniocentesis as indicated.Fetal magnetic resonance imaging was performed in most patientsto confirm the sonographic diagnosis. Maternal records and sonographicdata of all patients with fetal CNS anomalies were reviewed.Results—During the study period, 47 patients were diagnosedwith 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%), mildventriculomegaly (15%), absence or dysgenesis of the corpus callosum(10%), and intracerebral hemorrhage (10%). Other CNS anomalies detectedin this group of patients included hydrocephalus, Dandy-Walkermalformation, large cisterna magna, microcephalus with lissencephaly,craniosynestosis, periventricular pseudocysts, global brain ischemia, cerebellarhypoplasia, and a subependymal nodule.Conclusions—The fetal brain continues to evolve throughoutgestation; therefore, some of the CNS anomalies can be diagnosed onlyduring the late second and third trimesters of pregnancy. Consequently, alate anatomy scan at 30 to 32 weeks of gestation should be considered.1531347 Fetal Magnetic Resonance Imaging as an Adjunct to AntenatalUltrasound for Assessment of Fetal AnomaliesAmber Samuel,* Sherelle Laifer-Narin, Christina Herrera,Lynn Simpson, Russell Miller Obstetrics and Gynecology,Columbia University Medical Center, New York, New York USAObjectives—Fetal magnetic resonance imaging (MRI) is usedto enhance diagnosis of fetal anomalies without robust data to supportbenefit over ultrasound (US) alone. Our objective was to assess fetal MRIas an adjunct to conventional diagnostic US when compared to US alonein a cohort with known postnatal outcomes.Methods—In a retrospective review from 2003 to 2011 at a tertiarycare center, potential cases were identified if MRI was performedfollowing sonographic concern for a fetal anomaly. Inclusion requireddocumented neonatal outcomes or postmortem assessments. Diagnosticaccuracy of adjunct MRI was assessed with qualitative statistics.Results—Of 799 MRIs performed, 406 subjects possessed documentedneonatal 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 in5.9% of cases, and had no benefit in 24.9% of cases. Among individualanomalies, there were no cases of diaphragmatic hernia, omphalocele,vein of Galen malformation, or Dandy-Walker complex where MRI correctlychanged the ultrasound diagnosis. Findings varied for all other diagnoses(Table 1).Conclusions—Fetal MRI generally agrees with US performedat a tertiary care center, which may limit its adjunct diagnostic benefit.S53Table 1MRIMRI MRI Detracts MRIConfirms Improves From Has NoDiagnosis, Diagnosis, Diagnosis, Benefit,Diagnosis n (%) n (%) n (%) n (%) n (%)Multiple anomalies 60 (15) 20 (33) 10 (17) 8 (13) 22 (37)Ventriculomegaly 14 (4) 11 (79) 1 (7) 1 (7) 1 (7)Meningomyelocele 10 (3) 2 (20) 4 (40) 0 4 (40)Bronchopulmonary 9 (2) 6 (67) 1 (11) 0 2 (22)sequestrationCongenital cystic 24 (6) 16 (67) 2 (8) 3 (13) 3 (13)adenomatoid malformationCongenital diaphragmatic 69 (17) 66 (96) 0 3 (4) 0herniaOmphalocele 7 (2) 7 (100) 0 0 0Vein of Galen malformation 5 (1) 4 (80) 0 0 1 (20)Dandy-Walker complex 5 (1) 5(100) 0 0 01541099 Fetal Lymphatic Malformations: More Variable Than WeThink?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 Adzick 2 1 Radiology, PerelmanSchool of Medicine, University of Pennsylvania,Philadelphia, Pennsylvania USA; 2 Center for Fetal Diagnosisand Treatment, Children’s Hospital of Philadelphia, Philadelphia,Pennsylvania USAObjectives—To evaluate the ultrasound (US) characteristics offetal lymphatic abnormalities referred to the Center for Fetal Diagnosisand Treatment at the Children’s Hospital of Philadelphia. The literaturestates that lymphangiomas can be reasonably differentiated from othermasses by the predominance of cystic spaces with multiple septations andthe lack of solid components.Methods—We performed a database search from September1997 to August 2012 of all fetal imaging and medical records for caseswhere lymphatic malformations other than cystic hygroma were diagnosedor included in the differential. A detailed fetal anatomic survey wasperformed to determine mass location, volume, and US texture. Imagingfindings were correlated with the final outcome.Results—The study population consisted of 73 patients, and 68cases were correlated with fetal neurologic and/or body magnetic resonanceimaging. The mean maternal age was 29 years, and the mean gestationalage was 27 weeks 2 days. The location was classified as 46head/neck/face, 9 axilla/upper extremity, 8 internal abdomen/pelvis, 5chest/mediastinum, 3 superficial pelvis/back, and 2 lower extremity. Themean 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. Theseanomalies are largely isolated and not associated with other structural defects.There were no findings of nonimmune hydrops.Conclusions—Fetal lymphatic malformations have a variablerange of locations, sizes, and textures. In our series, 31% of masses wereatypical, 4 with calcifications and confused as teratomas. A better understandingof the US features will result in improved diagnostic accuracy.This may allow for better parental counseling and overall pregnancy management.

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131541459 Fetal Growth Restriction in Pregnancies Complicated byIsolated Cleft Lip or PalateEmily DeFranco, 1,2 * Jessica Smith, 1 Paul DeFranco 31Obstetrics and Gynecology, University of Cincinnati, Cincinnati,Ohio USA; 2 Center for Prevention of Preterm Birth, PerinatalInstitute, Cincinnati Children’s Hospital Medical Center,Cincinnati, Ohio USA; 3 Neonatology, Springview Hospital,Lebanon, Kentucky USAObjectives—Children with isolated cleft lip and/or cleft palatehavedelayedgrowthduringinfancyandchildhood.Theassociationbetweenfetal growth delay and isolated orofacial clefts has not been definitively ascertained.Few prior studies have aimed to assess the association betweencleftsandintrauterinegrowthrestriction(IUGR)butmayhavebeenlimitedbyunaccountedconfoundingfactorsandothermethodologicconstraints.Methods—In a population-based retrospective cohort study of5 years (2001–2005) of US birth cohort–infant death data, we identified913,707 birth records in which cleft lip and/or cleft palate was recorded onthe birth certificate. A variable was created including any case of cleft lip,palate, or combination of both. There were minimal missing data on cleftlip/palate (n = 854 [0.6%]). Multivariate logistic regression assessed theassociation between IUGR and isolated cleft lip/palate after accountingfor important coexisting risk factors.Results—There were 1086 cases of cleft lip/palate of 913,707births reporting this anomaly. The frequency of cleft lip/palate was 0.12%,which is likely accurately reported given the previously reported frequencyin 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 ofIUGR

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013were diagnosed at the early second-trimester anatomy scan. No cases ofONTD were diagnosed after 18 weeks’ gestation, and no cases of ONTDwere missed by our unit (sensitivity, 100%).Conclusions—Ultrasound for a fetal anatomic survey duringthe first and early second trimesters detected 100% of ONTDs in our population,with the majority identified in the first trimester. MSAFP was notuseful as a screening tool for ONTDs in the setting of this ultrasoundscreening protocol. Given the sensitivity of first- and early secondtrimesterultrasound in detecting ONTDs, physicians may choose not tooffer MSAFP for this indication.1541097 Novel Insights Into Early Embryonic Demise via 3-Dimensional Surface-Rendered Imaging in 107 CasesDavid Hartge, Andreas Schroer, Jan Weichert* Division ofPrenatal Medicine, University of Schleswig-Holstein, Luebeck,Schleswig-Holstein, GermanyObjectives—Modern sonographic imaging techniques such as3D volumetry will be evaluated for 107 cases of pregnant women withmissed abortions in the first trimester. Special emphasis is put on the impactof additional information and improved visualization of embryonicand fetal anomalies due to application of newest imaging tools, eg, HDLive. Additionally, parental acceptance of a more realistic display of theembryo/fetus in missed abortion is analyzed.Methods—Between September 2009 and September 2012, 109pregnancies with a missed abortion during the first trimester were includedin this survey. Using a transvaginal approach, all studies were carried outwith high-resolution 5–9- and 6–12-MHz probes. Postrendering processingof 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 excludedfrom our study. In 1 case, the parents refused to participate in thesurvey. 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). Meancrown-rump length (CRL) was 17.3 mm (2.9–49.9 mm). The differencebetween estimated gestational age and sonographic age at evaluation formissed abortion was 14.4 days (0–40 days). Sufficient sonographic evaluationwas possible in 91 of 107 cases (85.0%). Additional information via3D volume acquisition such as craniofacial deformities, clefts, neural tubedefects, abdominal wall defects, and sirenomelia could be documented in11 of 107 cases (10.3%), which were not detected by conventional 2D imaging.In 1 of 107 cases, the parents disapproved of the 3D visualizationdue to the more realistic presentation.Conclusions—3D ultrasound in cases of missed abortions canprovide additional information regarding the presence of structural anomaliesand may further give hints regarding the timing of embryonic/fetaldemise in early pregnancy. Based on our data, sufficient informationalvalue is regularly obtained in cases having a CRL >5 mm. In counselingparents, 3D ultrasound is a useful tool and is generally well accepted.1536871 Prenatal Sonographic Predictors of Surgery-TreatedUreteropelvic Junction Obstruction: Which Is the BestPredictor?Hadar Mudrik-Zohar, 1 * Israel Meizner, 1,2 Zvi Bar-Sever, 1,3David Ben-Meir, 1,4 Miriam Davidovits 1,5 1 Sackler Faculty ofMedicine, Tel Aviv University, Tel-Aviv, Israel; 2 GynecologicUltrasound Unit, Rabin Medical Center, Beilinson Campus,Petah Tikva, Israel; 3 Nuclear Medicine Institute, 4 PediatricUrology Unit, 5 Institute of Pediatric Nephrology, SchneiderChildren’s Medical Center, Petah Tikva, IsraelObjectives—Prenatally detected hydronephrosis (HN) with noevidence of ureter dilatation or bladder anomalies might suggest ureteropelvicjunction obstruction (UPJO), which requires postnatal pyeloplasty.Yet, in the majority of fetuses, the HN is transient and conservativelytreated. Our study aimed to identify prenatal sonographic predictors ofsurgery-treated UPJO and their cutoff values.Methods—This case-control study compared the sonographicprenatal findings of HN-diagnosed fetuses that underwentpyeloplasty after birth and HN-diagnosed fetuses that needed conservativemanagement only, all treated in Schneider Children’s MedicalCenter. We retrospectively evaluated 39 cases of patients who underwentpyeloplasty due to UPJO between 2001 and 2012 and 30 cases ofpatients that were diagnosed prenatally with HN and treated conservativelybetween 2005 and 2012. Prenatal sonographic data for both patientgroups were taken from the Gynecologic Ultrasound unit at RabinMedical Center. The main sonographic measures we tested were (1)anterior-posterior diameter (APD) of the affected kidney, (2) parenchymalthickness (PT), (3) calyces dilatation, and (4) renal length. A fewpatients had records of only some of the measures.Results—The prenatal APD dilatation of the surgery-treatedUPJO group (mean, 22.9 mm; SD, 8.7 mm) was higher than the controlgroup (mean, 14.3 mm; SD, 5.9 mm; P < .001). Furthermore, the PT in thesurgery-treated UPJO group (mean, 5.9 mm; SD, 2.8 mm) was lower thanthe control group (mean, 8.1 mm; SD, 2.6 mm; P = .009). Logistic regressionreveled that APD was the main parameter significantly associatedwith surgery-treated UPJO cases (receiver operating characteristic plotwas 0.79). A possible threshold of 14 mm APD may be used as a cutoffvalue of the surgery-treated UPJO group with sensitivity of 77% and specificityof 69%.Conclusions—APD dilatation was the strongest predictor ofsurgery-treated UPJO. PT and renal length also significantly discriminatethe two groups and correlate with APD, only with lower predictive power.Our findings expand the clinical knowledge in the field of prenatal consultationby highlighting a threshold of APD, which predicts the need forsurgery in prenatally detected HN cases.1540842 Prenatal Diagnosis and Neonatal Outcomes in NonimmuneHydrops: A Comparison of 2 Decades at an Academic CenterPadmalatha Gurram, 1 * Peter Benn, 2 Naveed Hussain, 3 ChristineCrawford, 1 Kisti Fuller, 1 Ann Marie Prabulos, 1 WinstonCampbell 1 1 Obstetrics and Gynecology, 2 Genetics and DevelopmentalBiology, 3 Pediatrics, University of Connecticut,Farmington, Connecticut USAObjectives—To evaluate the differences in the maternal characteristics,prenatal ultrasound (US) diagnosis and outcomes of nonimmunehydrops (NIH) delivered between 1990 and 2010.Methods—We performed a retrospective review of NIH casesdiagnosed antenatally and delivered at our institution. The cases were dividedinto 2 groups: 1990 to 1999 and 2000 to 2010. Stillbirths and multiplegestations were excluded. Gestational age (GA) at diagnosis, prenatalUS findings, GA at delivery, mode of delivery, birth weight (BW), postnataldiagnosis, 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 casesof NIH (11 cases in the 1990 group vs 8 in the 2000 group). The meanGA at diagnosis was 2 weeks earlier in the 2000 group (Table 1). Asciteswas the most common US feature in both groups, followed by pleural effusion.Amniocentesis was done in 50% of cases in the 2000 group vs37.5% in 1990. The GA at delivery was similar in both groups, and BWwas lower in the 1990 group (Table 1). In the 1990 group, 10 of 11 caseswere delivered by cesarean delivery vs 8 of 8 in 2000. The etiologieswere 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 dischargedhome alive in the 1990 group (4 of 11) was 28.5 days and in the2000 group (3 of 8) was 70 days. In the 2000 group, 3 of 8 cases weretransferred to other facilities compared to 1 of 11 cases in the 1990 groupS55

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013for further care. There were 6 of 11 deaths in the 1990 group vs 2 of 8deaths in 2000.Conclusions—The outcome of NIH cases improved in the laterdecade. The commonest etiology continues to be idiopathic.Table 1. Prenatal and Neonatal Characteristics1990–1999 (n = 11) 2000–2010 (n = 8)Mean GA at diagnosis, wk 31 29Ascites on US, % 63 75GA at delivery, wk 31 31BW, g 2018 2560Idiopathic etiology, % 27 50Survival >28 d, % 46 75Mortality, % 54 251528272 Qualitative Performance of Fetal Magnetic ResonanceImaging Compared to Ultrasound in Cases of MultipleFetal AnomaliesChristina Herrera,* Amber Samuel, Sherelle Laifer-Narin,Lynn Simpson, Russell Miller Obstetrics and Gynecology,Columbia University Medical Center, New York, New York USAObjectives—Pregnancies complicated by multiple fetal anomaliesare a common indication for fetal magnetic resonance imaging (MRI)as an adjunct to diagnostic ultrasound (US). This study investigated the diagnosticperformance of fetal MRI when compared to US alone for the accuratecharacterization of fetuses with multiple anomalies.Methods—In a retrospective review from 2003 to 2011 at a singletertiary care center, potential cases were identified if MRI was performedfollowing sonographic concern for multiple fetal anomalies.Inclusion required documented neonatal outcomes or postmortem assessments.Interstudy reliability between MRI and US was assessed by calculatingκ. Diagnostic accuracy of adjunct MRI compared to US alonewas assessed using qualitative statistics.Results—A total of 121 MRIs were performed due to antenatalsonographic concern for multiple fetal anomalies, of which 60 casespossessed documented neonatal or pathologic outcomes. The κ for MRIcompared 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 inaccuratesonographic diagnoses were due to additional postnatal findings (48%).While MRI was most commonly inaccurate due to additional postnatalfindings (27%), discrepant postnatal findings (3%), discrepant and additionalpostnatal findings (13%), and false-positive imaging findings (5%)also contributed significantly to study inaccuracies.Conclusions—Agreement is poor between MRI and US for thecharacterization of fetuses with multiple anomalies. For either imagingmodality, complete and accurate diagnosis of fetal anomalies occurs inapproximately half of cases, with the majority of inaccuracies due to incompleteantenatal characterizations.Table 1US, n (%) MRI, n (%)Accurate diagnosis 28 (47) 30 (50)Additional anomalies discovered postnatally 29 (48) 16 (27)Discrepant findings between imaging and 2 (3) 2 (3)postnatal assessmentDiscrepant and additional anomalies 0 8 (13)False-positive imaging findings 1 (2) 3 (5)Study inconclusive 0 1 (2)S56

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Hands-on How to Do the BiopsyModerator: Dean Nakamoto, MDAfter attending this session, participants will be able to describeprebiopsy preparations, use and have hands-on experience with the techniquesof doing biopsies of soft tissue masses, thyroid nodules, breastmasses, the liver, and kidneys, and recognize and manage complications.SPECIAL INTEREST SESSIONTUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PMSPECIAL INTEREST SESSIONSTUESDAY, APRIL 9, 2013, 1:30 PM–3:30 PMBefore and After: Case Presentations, SurgicalFindings, and Clinical OutcomesModerator: James Shwayder, MD, JDAdnexal MassesJames Shwayder Obstetrics and Gynecology, University ofMississippi Medical Center, Jackson, Mississippi USAThis portion of the session will present clinical cases addressingthe options for diagnosing adnexal masses. Ultrasound findingscomprising morphology, vascular studies, and 3D will be reviewed.The presentations will focus on clinical history and ultrasound findingscorrelated with surgical outcomes.Hands-on Scanning: Peripheral Nerves of theUpper ExtremityModerator: Kenneth Lee, MDAfter attending this session, participants will have gained handsonexperience in scanning the peripheral nerves of the upper extremity.recognition of normal outflow tracts in different orientations will increasethe likelihood of identifying fetuses in which these connections are abnormal.Imaging the 3-vessel view can further help distinguish that theoutflow tracts are normal. Vessel size, alignment, arrangement, number, directionof flow, and turbulent flow at the level of the 3-vessel view provideadditional information about the normalcy of the outflow tracts. Given itshigh prevalence and significant infant morbidity and mortality, universalscreening for congenital heart disease is warranted. Early detection allowsfor an assessment for associated chromosomal, syndromic, or extracardiacabnormalities as well as consideration of pregnancy options and planningfor ongoing obstetric and neonatal care. A thorough evaluation of theoutflow tracts can improve the overall prenatal diagnosis of major fetalheart malformations.Microbubbles and Drug/Gene DeliveryModerators: Christy Holland, PhD, and Kai Thomenius, PhDImproving Sonoporation Delivery and Gene Transfection byControlling Ultrasound Excitation of MicrobubblesCheri Deng Biomedical Engineering, University of Michigan,Ann Arbor, Michigan USALive Fetal Cardiac Scanning by the ExpertsModerator: Lami Yeo, MDBasics of Fetal Cardiac Screening: How to Confirm Normal OutflowTractsLynn Simpson Obstetrics and Gynecology, ColumbiaUniversity Medical Center, New York, New York USAAlthough the majority of pregnant women undergo obstetricultrasound, only a third to one-half of all major congenital heart defects aredetected prior to birth. The 4-chamber view of the fetal heart can identify40% to 50% of major cardiac anomalies. The prenatal detection of heartmalformations can be increased to 60% to 80% when views of the rightand left ventricular outflow tracts are also assessed. It is now recommendedthat in addition to the 4-chamber view, views of the outflow tractsbe evaluated as part of the cardiac screening examination. This has thepotential to increase the identification of conotruncal anomalies that frequentlyare associated with a normal-appearing 4-chamber view. TheS57Microbubble-facilitated disruption of the cell membrane, orsonoporation, has been exploited for nonviral intracellular delivery of therapeuticagents. However, ultrasound-mediated microbubble activities andtheir impact on cells are difficult to control and optimize due to the complexcharacteristics of ultrasound interaction with microbubbles. Theseoften result in low delivery efficiency and variable delivery outcome. Todevelop sonoporation technique to achieve reproducible, robust deliveryoutcomes, we examined the detail characteristics of ultrasound interactionwith microbubbles. The goal of our study is to improve ultrasoundmediatedintracellular delivery and gene transfection by designingultrasound exposure conditions based on the detailed dynamic processesof ultrasound interaction with microbubbles in the context of their impactto cells. We performed experiments using both free microbubbles and targetedmicrobubbles that were attached to a cell membrane via receptor-ligandbinding. We identified 3 distinct regimes of ultrasound excitation oftargeted microbubbles characterized by the rate of microbubble collapseand translational movement (displacement): stable cavitation with minimaldisplacement, coalescence and translation, and rapid collapse (inertialcavitation) with minimal displacement. We quantified and correlated themicrobubble dynamics with the resulting membrane disruption, intracel-

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013lular delivery, and cell viability. We found that rapid collapse of microbubbleswith limited translational movement, typically generated by ultrasoundexcitations with high acoustic pressure and short duration,generated the highest delivery efficiency while maintaining high cell viability.Based on characterization of microbubble activities and membranedisruption, we implemented a 2-pulse ultrasound exposure scheme withramped 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 parameterscan be obtained from microbubble dynamics to improve deliveryoutcomes.Microbubbles and Gene/Drug Delivery: Future Therapeutic Applicationsof Contrast-Enhanced Ultrasound ImagingSteven Feinstein Cardiology/Medicine, Rush UniversityMedical Center, Chicago, Illinois USAToday, the clinical applications of contrast-enhanced ultrasoundimaging (CEUS) are solely based on diagnostic imaging. It is anticipatedthat the future applications of CEUS will provide a paradigm shift in thefield of therapeutics. In fact, CUES as a therapy uses gas-filled microspheresas intravascular indicators and provides unprecedented microvascularaccess to tissues and organs. Hence, acoustic microspheres are idealcarrier vehicles for ultrasound-based, site-specific drug/gene delivery. Thebasis for devising newer therapeutic options is created by local in vivomicrosphere disruption using externally applied acoustic energy. Basedon data dating to at least to 1995, it appears that the application of therapeuticultrasound delivery systems has a bright future. The advantages ofusing an acoustically medicated system derive from the value of using anonviral, mediated system accompanied by low risk/benefit ratios. Leadingscientists throughout the world have successfully demonstrated nonviraltransduction in a variety of preclinical scenarios. The combinedapplications for diagnosis and therapy provide unique opportunities forclinicians and researchers to image, direct therapy, and monitor individualsduring treatment.Targeted Thrombolysis With Ultrasound and MicrobubblesThomas Porter Section of Cardiology, University ofNebraska Medical Center, Omaha, Nebraska USAUltrasound-induced cavitation has been explored as a methodof dissolving intravascular and microvascular thrombi in acute myocardialinfarction (STEMI). Ongoing studies are being performed to determinethe type of cavitation required for success and whether longer–pulse durationtherapeutic impulses (which sustain the duration of cavitation) couldrestore both microvascular and epicardial flow with this technique. In 36hyperlipidemic atherosclerotic pigs, thrombotic occlusions were inducedin 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 orthe same dose of TPA and an intravenous microbubble infusion witheither (2) guided high–mechanical index (MI) short-pulse (2.0 MI; 5-microsecond) therapeutic ultrasound (TUS) impulses or (3) guided 1.0 MIlong-pulse (20 microsecond) impulses. Passive cavitation detectors indicatedthat the high-MI impulses (both long and short pulse durations)induced inertial cavitation within the microvasculature. Epicardial recanalizationrates at all time points following randomized treatments werehighest 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 epicardialrecanalization, however, early microvascular recovery (ST recovery)occurred with both short- and long-pulse TUS impulses (P < .005compared to TPA alone), and wall thickening improved within the riskarea only in pigs treated with ultrasound and microbubbles. These findingsindicate that although short-pulse TUS impulses transiently improve microvascularflow, long-pulse TUS impulses are required to produce sustainedepicardial and microvascular reflow in acute STEMI.New Horizons in Critical Care UltrasoundModerator: Paul Mayo, MDNew Horizons in Critical Care UltrasoundMichael Blaivas Northside Hospital Forsyth, Cumming,Georgia USAPoint-of-care ultrasound has undergone tremendous growth inthe last 5 years, and this has heralded multiple advancements in applicationsand techniques used on critically ill patients. In addition, new equipmentavailable on the market has targeted ultrasound use in the emergencyand critical care settings. Availability of multiple transducer types, highendimaging, and even transesophageal echocardiography has opened thedoor for previously unexplored levels of patient evaluation during the mostcritical presentations. One of the most exciting is the effect ultrasound hashad on the evaluation, diagnosis, and management of the cardiac arrestand periarrest states. This presentation will focus on new applications inpoint-of-care ultrasound for the care and treatment of the cardiac arrestand periarrest patient. Current literature and applications including transesophagealechocardiography in point-of-care and intravascular volumedetermination for immediate clinical decision making in this critically illpatient population will be discussed.Perinatal Malformations of the Head, Face, and NeckModerator: Eva Rubio, MDPerinatal Malformations of the Head, Face, and Neck: HeadBeth Kline-Fath Radiology, Cincinnati Children’s HospitalMedical Center, Cincinnati, Ohio USAUltrasound is an integral part of prenatal care. With regard to thebrain, sonographic imaging offers a rapid noninvasive window. Additionalbenefits of this technique are lack of radiation, portability, and low cost.The ability to use color and Doppler of intracranial vessels is also extremelyvaluable. Prenatal cranial ultrasound provides information regardingcongenital anomalies, masses, and hydrocephalous. Destructive,vascular, hemorrhagic, infectious, and hypoxic ischemic pathologies arealso demonstrated by this technique. In this lecture, the common prenatalabnormalities of the brain will be illustrated with ultrasound imaging. Correlationwith fetal magnetic resonance imaging will also be provided toallow the sonographer to improve imaging technique and anatomy. Theability of prenatal sonography to promptly diagnose these central nervoussystem conditions is invaluable in directing fetal treatment and prenatalcounseling.Perinatal Malformations of the Head, Face, and NeckEva Rubio Children’s National Medical Center, Washington,DC USAThis session will review common, rare, and urgent abnormalitiesof 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, imagingparameters, and current recommendations will be discussed. Whatdo the surgeons need to know, and what kind of team needs to be assembledfor the most challenging cases? How should parents be counseled?This session will be both didactic and interactive.S58

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Transplant ImagingModerator: Susan Ackerman, MDSonographic Evaluation of Liver TransplantsSusan Ackerman Medical University of South Carolina,Charleston, South Carolina USAThe purpose of this lecture is to discuss the use of ultrasound toevaluate liver transplants. In addition to normal or expected findings inthe post-transplant patient, complications will also will be discussed.SPECIAL INTEREST SESSIONSTUESDAY, APRIL 9, 2013, 4:00 PM–5:30 PMAbdominal and Lower Extremity Arterial Imaging:Pitfalls and MisdiagnosesModerator: Jennifer McDowell, MM, RDMS, RT, RVTThis session will review case studies in abdominal and lowerextremity vascular imaging and demonstrate examples of technical pitfalls,artifacts, and misdiagnoses to learn how to prevent them.Hands-on Ultrasound-Guided Vascular AccessModerator: Jason Nomura, MD, RDMSIn this session, participants will be given a short didactic lectureon patient preparation, sterile technique, and basics of ultrasound-guidedvascular access and fluid aspiration. This will be immediately followedby hands-on practice and interactions at various stations with expert facultyto learn and improve on techniques.S59

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SCIENTIFIC SESSIONSTUESDAY, APRIL 9, 2013, 4:00 PM–5:30 PMBasic Science: Tissue Characterization, Part 2Moderators: Michael Oleze, PhD, James Miller, PhD1540933 Three-Dimensional In Vivo Prostate Shear Wave ElasticityImage ReconstructionStephen Rosenzweig, 1 * Mark Palmeri, 1 Samantha Lipman, 1Ned Rouze, 2 Evan Kulbacki, 2 John Madden, 2 Thomas Polascik,2 Kathryn Nightingale 1 1 Biomedical Engineering, DukeUniversity, Durham, North Carolina USA; 2 Duke UniversityMedical Center, Durham, North Carolina USAObjectives—Shear wave elasticity imaging (SWEI) andacoustic radiation force impulse (ARFI) imaging techniques have beenreported to portray cancer and other pathologies as stiffer than the surroundingtissue. 1,2 Previous work has shown artifacts in reconstructingSWEI images due to reflected waves. 3,4 In this work, methods for reconstructingSWEI images designed to reduce these artifacts were validatedin phantoms, applied to in vivo data, and compared to concurrently acquiredARFI data.Methods—Data were collected using a Siemens AcusonSC2000 and an ER7B transducer (Mountain View, CA) and a transducerrotation stage. The pulse sequence consisted of rapidly pushing at multiplefoci (SSI-type push 4 ) and tracking the resulting displacement using 16parallel receive beams. The beam sequence was then translated laterally0.7 mm and repeated across the field of view. The resulting SWEI datawere spatially and temporally aligned to generate an image using highspatial sampling of the data. Separate left and right wave propagation imageswere generated along with combining the data via mean and maximumvalue approaches; these were compared to matched ARFI images inboth calibrated CIRS (Norfolk, VA) phantoms and radical prostatectomypatients from an ongoing Institutional Review Board–approved study.Results—The contrast to noise ratios (CNRs) in the phantomdata for the different combined SWEI methods were higher than those forthe individual propagating waves. For example, a 10-mm cylindrical targetwith 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 fromall methods in various phantoms in addition to results from prostatectomypatients, after the whole-mount pathology is registered in 3D to the SWEIand ARFI volumes.Conclusions—The high spatial sampling of SWEI data obtainedfrom concurrent acquisition with ARFI data affords opportunitiesfor reducing SWEI image artifacts and improving the CNR. We are nowapplying the algorithms to data from an ongoing in vivo study to detectpathologies in the prostate.References1. 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 PixelClassification Using UltrasoundAgnieszka Witkowska, 1 U. Rajendra Acharya, 2,3 RatnaYantri, 2 Filippo Molinari, 4 Witold Zieleznik, 5 Justyna Tumidajewicz,5 Beata Stepien, 5 Ricardo Bardales, 6 Jasjit Suri 7, 8 *1Internal Medicine, Diabetology, and Nephrology, MedicalUniversity of Silesia, Katowice, Poland; 2 Electronics andComputer Engineering, Ngee Ann Polytechnic, Singapore;3Biomedical Engineering, University of Malaya, Kuala Lumpur,Malaysia; 4 Electronics and Telecommunications, PolitecnicoTorino, Torino, Italy; 5 Internal Medicine Practice, Silesia,Poland; 6 Outpatient Pathology Associates, Sacramento,California USA; 7 Global Biomedical Technologies, Roseville,California USA; 8 Biomedical Engineering, Idaho State University,Pocatello, Idaho USAObjectives—Hashimoto’s thyroiditis (HT) is the most commontype of inflammation of the thyroid gland, and accurate diagnosis of HTwould be helpful to better manage the disease process and predict thyroidfailure. This paper presents a computer-aided diagnostic (CAD) techniquethat uses grayscale features and classifiers to provide a more objective andreproducible classification of normal and HT-affected cases.Methods—Thyroid images were obtained from 68 normal and82 patients affected by HT (a total of 150 patients). In this paradigm, weextracted grayscale features based on entropy, Gabor wavelet, moments,image texture, and higher-order spectra from the 100 normal and 100 HTaffectedthyroid ultrasound images. Significant features were selectedusing the t test. The resulting feature vectors were used to build the following3 classifiers using a 10-fold stratified cross-validation technique:support vector machine (SVM), K-nearest neighbor (KNN), and radialbasis probabilistic neural network (RBPNN).Results—Our results show that a combination of 12 featurescoupled with the SVM classifier with the polynomial kernel of order 1and linear kernel gives the highest accuracy of 80%, sensitivity of 76%,specificity of 84%, and positive predictive value (PPV) of 83.3% for thedetection of HT.Conclusions—The proposed CAD system uses novel featuresthat have not yet been explored for HT diagnosis. The technique is noninvasive,cost-effective, fast, and automatic and provides a more objectiveand reproducible classification of the thyroid in normal and HT-affectedpatients. Even though the accuracy is only 80%, the presented preliminaryresults are encouraging to warrant analysis of more such powerfulfeatures on larger databases.Table 1. Classifier Performance MeasuresAccuracy, PPV, Sensitivity, Specificity,TN FN TP FP % % % %SVM linear8 2 8 2 80 83.3 76 84SVM poly 18 2 8 2 80 83.3 76 84SVM RBF8 3 7 2 78.5 82.3 74 83KNN 7 2 8 3 75.5 75.6 77 74RBPNN 8 4 6 2 74 80.3 64 84FN indicates false-negative; FP, false-positive; RBF, radial basis function; TN,true-negative; and TP, true-positive.S60

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131543325 Novel Quantitative Conventional-Frequency Detection ofCell Death In Vivo With Neoadjuvant Chemotherapy forLocally Advanced Breast CancerGregory Czarnota, 1 * Ali Sadeghi-Naini, 1 Omar Falou, 1 SaraIradji, 1 William Tran, 1 Michael Kolios 2 1 Radiation Oncology/Physical Sciences, Sunnybrook Health Sciences Center,Toronto, Ontario, Canada; 2 Physics, Ryerson University,Toronto, Ontario, CanadaObjectives—We have previously demonstrated that highfrequencyultrasound and spectral analysis can detect cell death. Here weinvestigated whether quantitative conventional-frequency (7-MHz) ultrasoundincorporating spectral analysis and textural parameters may be usedfor the same purpose in vivo in human patients receiving chemotherapy.Methods—A clinical study was undertaken investigating theefficacy of ultrasound to quantify cell death in tumor responses with cancertreatment. Patients (n = 60) with locally advanced breast cancer receivedanthracyline- and taxane-based chemotherapy treatments. Datacollection consisted of acquiring tumor images and radiofrequency dataprior to treatment onset and at 4 times during treatment (weeks 0, 1, 4, 8,and preoperatively). Digital low-frequency ultrasound data were collectedand sampled with a 15-bit dynamic range using an Ultrasonix-RP devicewith a 7-MHz central frequency (3–10 MHz, –6-dB range). Whole-mounthistology was obtained for all samples.Results—Data indicated that spectral ultrasound changes weresignificant at 4 weeks after the start of treatment. Increases of approximately9 dBr (±1.67) in ultrasound backscatter were observed in patientswho responded to treatment. Patients assessed as responding poorlydemonstrated significantly lower increases (2.3 ± 1.7 dBr). Increases in 0-MHz intercept followed similar trends, while increases in spectral slopewere observed from tumor regions demonstrating increases in tissueechogenicity. Textural analysis of parametric images indicated that featuressuch as homogeneity and contrast could detect responses as early as1 week after the start of treatment.Conclusions—This study demonstrates the potential of ultrasoundto quantify changes in tumors in response to cancer treatment administrationin a clinical setting. This approach may assist in thecustomization of cancer treatments facilitating switching from ineffectivetreatments to efficacious therapies.1540914 Nonlinear Modeling of the Canine Liver With IncreasingHepatic PressureVeronica Rotemberg, 1 * Brett Byram, 1 Mark Palmeri, 1,2Michael Wang, 1 Kathryn Nightingale 1 1 Biomedical Engineering,Duke University, Durham, North Carolina USA;2Anesthesiology, Duke Medical Center, Durham, North CarolinaUSAObjectives—Elevated hepatic venous pressure is associatedwith leading causes of death from advancing liver disease and is currentlymonitored using an invasive and expensive method. The mechanical behaviorof the liver during pressurization is not well understood. In thiswork, liver strain during hepatic pressurization was characterized usingsuccessively acquired 3D B-mode volumes and was compared with concurrentshear wave speed (SWS) estimates. An experiment was designedto elucidate liver nonlinear material properties by using volumetric imagingin unconstrained ex vivo canine livers to estimate the change in liverstrain with pressurization and compare this change in strain with simultaneousSWS estimates. The concurrent strain and SWS estimate informationis actively being used to develop a nonlinear material model forhepatic behavior with increasing portal venous pressure.Methods—Hepatic pressure was increased stepwise from 0 to20 mm Hg with 3D B-mode acquisition during each step at 3.2 volumes/susing a Siemens Acuson SC-2000 scanner and 4z1c matrix array transducer(Mountain View, CA). Displacements were calculated using 3Dcross-correlation and a 2.88 × 0.60 × 0.68-mm tracking kernel. 1 Strainswere estimated in a 20 × 12 × 12-mm region of interest (ROI). Six acousticradiation force impulse–based SWS estimates in the same ROI were generatedat the end of each step.Results—Increases in SWS and axial strain as a function of hepaticpressure as well as the relationship between axial strain and SWSestimates were developed. During portal venous pressurization, 10% increasesin axial strain corresponded to a 1.25-m/s increase in hepatic SWSestimates above baseline estimates at 0 to 5 mm Hg.Conclusions—Increases in axial strain and SWS estimates observedwith increasing hepatic pressure support the development of a nonlinearmechanical material model for the pressurized liver. This materialmodel may lead to noninvasive hepatic pressure characterization usingstiffness metrics.References1. Byram BC, et al. 3-D phantom and in vivo cardiac speckle trackingusing a matrix array and raw echo data. IEEE Trans Ultrason FerroelectrFreq Control 2010; 57:839–854.1514461 UroImage: A Prostate Tissue Characterization/ClassificationSystem Using Grayscale FeaturesGyan Pareek, 1 Rajendra Acharya, 2,3 Swapna Goutham, 4Vinitha Sree, 5 Ratna Yantri, 2 Roshan Martis, 2 Luca Saba, 6Ganapathy Krishnamurthi, 7 Giorgio Mallarini, 6 AymanEl-Baz, 8 Shadi Al Ekish, 1 Michael Beland, 9 Jasjit Suri 5,10 *1Section of Minimally Invasive Urologic Surgery, Warren AlpertMedical School, Brown University, Providence, Rhode IslandUSA; 2 Electronics and Computer Engineering, Ngee Ann Polytechnic,Singapore; 3 Biomedical Engineering, University ofMalaya, Kuala Lumpur, Malaysia; 4 Applied Electronics and Instrumentation,Government Engineering College, Kozhikode,Kerala, India; 5 Global Biomedical Technologies, Roseville,California USA; 6 Radiology, Azienda Ospedaliero Universitariadi Cagliari, Cagliari, Italy; 7 Mayo Clinic, Rochester, MinnesotaUSA; 8 Bioengineering, Speed School of Engineering,University of Louisville, Louisville, Kentucky USA; 9 Ultrasound,Rhode Island Hospital, Providence, Rhode Island USA;10Biomedical Engineering, Idaho State University, Pocatello,Idaho USAObjectives—Prostate transrectal ultrasound (TRUS) images canbe easily acquired in real time at lower cost and hence are widely used forprostate cancer (CaP) diagnosis. However, the prostate regions in TRUSimages are characterized by a weak texture, speckle, short grayscaleranges, and shadow regions. There is a need for image analysis frameworksthat effectively quantify the subtle textural changes in cancerousand noncancerous TRUS prostate images to accurately detect CaP. In thiswork, we have proposed an online computer-aided diagnostic systemcalled “UroImage” that classifies a TRUS image into cancerous or noncancerouswith the help of nonlinear higher-order spectra (HOS) featuresand discrete wavelet transform (DWT) coefficients.Methods—The UroImage system consists of an online systemwhere 5 significant features (1 DWT-based feature and 4 HOS-based features)are extracted from the test image. These online features are transformedby the classifier parameters obtained using the training data set todetermine the class label of the test image. We trained and tested 6 classifiers.The data set used for evaluation had 144 TRUS images, which weresplit into training and testing sets, and cross-validation was adapted fortraining and estimating the accuracy of the classifiers. The ground truthused for training was obtained using the biopsy results.Results—Among the 6 classifiers, using 3- and 10-fold crossvalidationtechniques, support vector machine and fuzzy Sugeno classifierspresented the best classification accuracy of 97.95% with equally highvalues for sensitivity, specificity, and positive predictive value.S61

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Conclusions—Our proposed automated system uses a novelcombination of DWT and HOS features to adequately characterizeprostate TRUS images. On evaluation, the system presented high accuracyof 97.95% in detecting CaP. Thus, the preliminary results indicate that theUroImage system can be an adjunct tool to provide an initial diagnosis forthe identification of patients with prostate cancer.1540270 Quantitative Ultrasound as an Aid to Differentiate BenignFrom Malignant Breast MassesHaidy Nasief, Ivan Rosado-Mendez, James Zagzebski,Timothy Hall* Medical Physics, University of Wisconsin,Madison, Wisconsin USAObjectives—Ultrasound attenuation (Att), backscatter coefficients(BSC), effective scatterer diameter (ESD), and a scatterer size “heterogeneityindex”(HI) give useful insight into the nature of a breast mass.The purpose of this study was to evaluate the potential of these quantitativefeatures, both individually and in combination, to differentiate benignfrom malignant breast masses.Methods—Radiofrequency echo data from 26 patients scheduledfor ultrasound-guided biopsy of suspicious breast masses were obtained,along with conventional grayscale and color flow images. Scanswere done using a Siemens Acuson S2000 equipped with an 18L6 lineararray transducer. Beam-steered acquisitions ranging between –20° to 20°were obtained in both radial and antiradial planes projecting through themass. Att and BSC within masses were measured using the referencephantom method. ESDs were estimated using the BSC vs frequency dataand a Gaussian form factor. HI was characterized using the SD among theESD estimates (ignoring correlations among them). Isotropic features ofthe masses were studied by computing power law fits of Att vs frequencyat each beam-steering angle. Combinations of quantitative ultrasound parameterswere examined with a Bayesian classifier to estimate those withthe strongest influence on characterization.Results—The mean Att in dB/cm-MHz was slightly higher forcarcinomas (1.3 ± 0.7) than fibroadenomas (1.1 ± 0.5), the average valueof the ESD was smaller for carcinomas (83.1 ± 9.8 µm) than for fibroadenomas(97.8 ± 13.1 µm), and carcinomas exhibited lower HI thanfibroadenomas. Surprisingly, both tumor types exhibited a certain degreeof anisotropic behavior. However, considerable overlap exists in backscatterand attenuation properties of benign and malignant masses. Using onlypairs 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 ona very limited data set).Conclusions—Att, ESD, and HI show promise for characterizingbreast masses. Very promising results are possible using combinationsof these 3 parameters.1536102 Stochastic Hidden Markov Model–Based FilteringAlgorithm for Tracking Shear Waves Through DisparateMedia in Electrode Vibration ElastographyAtul Ingle, 1 * Tomy Varghese 1,2 1 Electrical and ComputerEngineering, 2 Medical Physics, University of Wisconsin, Madison,Wisconsin USAObjectives—Much research effort in quantitative ultrasoundelastography has been directed toward methods for setting up shear wavesin tissue and modeling wave propagation characteristics. However, dataprocessing has been mostly limited to using off-the-shelf function-fittingalgorithms. The present work proposes a specialized noise-filtering algorithmto improve boundary delineation while reducing the risk of excessivesmoothing.Methods—A shear wave pulse traveling through dissimilarmedia is assumed to have constant velocity while in the same medium,whereas its velocity changes abruptly when it crosses an interface. Ultrasounddisplacement estimates are used to get the time of arrival (TOA) ofthe wave pulse at different locations. The noiseless TOA plot is assumedto be piece-wise linear with unknown transition points. The noisy data aredescribed using a hidden Markov model whose hidden states are the noiselessTOA values and observed states corrupted by Gaussian noise. A particlefilter is then used to unravel the hidden states. An electrode vibrationelastography phantom is used, which consists of 3 different media. A needlebound to an inclusion in the phantom and attached to an actuator isused to set up shear waves.Results—Visual boundary delineation is improved because thisalgorithm uses probabilistic prior information of wave pulse propagation.Mean shear wave velocity estimates are within 1 m/s of those obtainedusing a commercial shear wave imaging system.Conclusions—Model-based algorithms have a potential to significantlyimprove results in shear wave elastography quantitatively interms of estimates of mechanical properties and qualitatively in terms ofthe visualization of stiffness images. (Supported by National Institutes ofHealth grants R01CA112192-05 and R01CA112192-S103.)Table 1Shear Wave Velocity, m/s Young’s Modulus, kPaMechanicalROI EVE SSI EVE SSI TestingInclusion 3.8 ± 2.2 2.8 ± 1.1 57.2 ± 70 24.2 ± 5.8 54.4 ± 0.1Partially ablated 2.0 ± 0.2 2.3 ± 0.8 11.9 ± 2.6 13.3 ± 3.5 21.5 ± 0.3Background 1.3 ± 0.2 1.3 ± 0.4 5.0 ± 1.9 4.8 ± 0.5 3.7 ± 0.1EVE indicates electrode vibration elastography; ROI, region of interest; and SSI,supersonic shear imaging.1540426 Viscoelastic Strain Response Ultrasound Assessment of SerialChanges in the Viscoelastic Property and Compositionof Human Dystrophic Muscle In VivoMallory Scola, 1 Melissa Caughey, 2 Diane Meyer, 3 ReginaEmmitt, 3 James Howard, 2,4 Manisha Chopra, 4 CaterinaGallippi 1 *1 Joint Department of Biomedical Engineering,2Medicine, 3 Physical and Occupational Therapy, 4 Neurology,University of North Carolina, Chapel Hill, North Carolina USAObjectives—In Duchenne muscular dystrophy (DMD), wheremuscle tissue undergoes necrosis and is replaced by fat and collagen, delineatingthe complex and poorly understood disease process and monitoringresponses to novel therapies may be facilitated by imaging muscleviscoelasticity. Viscoelastic strain response (ViSR) ultrasound is a methodfor quantitatively evaluating the relaxation time constant, τ, in the Voigtmodel. The objective of this work is to demonstrate ViSR’s clinical relevanceto monitoring dystrophic muscle degeneration over time. We hypothesizethat ViSR ultrasound detects changes in percent fat/necrosiscomposition in DMD muscles that correspond to altered physical performance.Methods—ViSR ultrasound was performed on a 5-year-old boywith DMD at baseline and at 4-month follow-up using a Siemens AcusonAntares imaging system equipped for modifiable beam sequencing and aVF7-3 transducer. The acquired ViSR data were processed to calculate τ,and parametric 2D ViSR τ images were rendered. Fat/necrosis compositionwas calculated as the percent muscle area with ViSR τ values abovean empirically determined threshold. Within 1 hour following each imagingepisode, the boy underwent standardized timed function tests. ViSRoutcome was compared to physical performance.Results—See Table 1.Conclusions—ViSR ultrasound detected a 39% increase frombaseline to 4-month follow-up in fat/necrosis composition in the rectusfemoris (RF), a 5% decrease in the sartorius (SART), and a 7% increasein the gastrocnemius (GAST), which is consistent with expected phenotypicvariation in these muscles for a 5-year-old boy. The ViSR changeS62

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013was associated with a 39% increase in time to standing, a 13% decreasein 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 biomarkerfor monitoring dystrophic muscle degeneration.Table 1. Serial ViSR and Physical Testing OutcomesViSR % Fat/NecrosisPhysical TestingTime toStanding 6-min 30-ftTime Point RF SART GAST (5×) Walk WalkBaseline 29.2 7.1 19.8 7.91 s 1488 ft, 4.19 s0 falls, 0 rests4-mo follow-up 40.6 6.7 21.1 10.96 s 1300 ft, 5.17 s1 fall, 0 rests1506729 Prostate Cancer Ultrasound–Magnetic Resonance ImagingFusion Cybernetic BiopsiesRobert Bard Biofoundation, New York, New York USAObjectives—To show that 3D ultrasound computer fusion withmagnetic resonance imaging (MRI) improves image cybernetic-guidedbiopsies of the prostate.Methods—Eleven patients with elevated prostate-specific antigenand abnormal sonographic and MRI findings were scanned with a cyberneticultrasound system that fused the image of the MRI onto thesonogram, creating a template for biopsy. Targeted biopsies were performedbased on image guidance. Twelve cores were obtained on each patient.Results—Gleason grade 3 (low grade): 72 of 87 cores werepositive for cancer. Gleason grade 4 (medium): 41 of 45 cores were positivefor cancerConclusions—Ultrasound-MRI computer image-guided fusionbiopsies improved cancer detection to 92% for Gleason 4 tumors and 81%for Gleason 3 cancers.Education and TrainingModerator: James Pennington, RDMS1540985 Enhancing Ultrasound Education Through VolunteerParticipation in Cardiac ScreeningMason Shieh,* Suzanne Klaus, Carter English, Stacy Hata,Bassil Aish, Uthara Mohan, J. Christian Fox University ofCalifornia, Irvine, Yorba Linda, California USAObjectives—To develop medical student sonography skillsthrough volunteer involvement in cardiac screening on local athletes forhypertrophic cardiomyopathy (HCM).Methods—University of California, Irvine, medical studentswere recruited and trained to obtain cardiac ultrasound images to detectHCM in local high school athletes. HCM ultrasound training involvedwatching an instructional video and up to 2 hours of supervised hands-onultrasound use. Students had unlimited access to an ultrasound machine fornonsupervised practice.Ten Orange County, California, high schools and junior collegeshosted the ultrasound cardiac screening team of 5 to 12 medical studentsand 1 to 3 supervising physicians as part of student athlete physicalevents. An average of 150 student athletes were scanned during each 4-hour screening. For each athlete, a medical student obtained 2-secondvideo clips of parasternal long and parasternal short cardiac views. Fromthe parasternal short view, apical to the mitral valve, the muscular ventricularseptum and the left ventricular wall were monitored in motionmode (M-mode) and were measured in systole and diastole on a still M-mode image. The recorded ultrasound videos and images were reviewedby a pediatric cardiologist after the screening. Medical students were askedto complete a brief survey about their participation.Results—Twenty-five medical student volunteers and 5 physiciansobtained cardiac ultrasound data for more than 1500 young athletesin Orange County over a 4-month period. The incidence of findings ispending final review by the research team pediatric cardiologist, who determined67% to 74% of student-performed cardiac scans adequate forHCM assessment. Students reported increased confidence in obtainingspecific cardiac views quickly, using extensive features of the ultrasoundmachine, and teaching the screening process to other students.Conclusions—Student participation in public ultrasound screeningprovides a public service and enhances student skills and confidence.1536499 State of Ultrasound Education: A National Survey ofMedical SchoolsDavid Bahner, 1 * Nelson Royall, 2,3 David Way, 1 Claudia Ranninger,4 Ellen Goldman, 5 Yiju Liu 4 1 Emergency Medicine,Ohio State University College of Medicine, Columbus, OhioUSA; 2 Surgery, Orlando Health, Orlando, Florida USA; 3 Collegeof Medicine, University of Central Florida, Orlando,Florida USA; 4 Emergency Medicine, George WashingtonUniversity Medical Center, Washington, DC USA; 5 Human andOrganizational Learning, George Washington University,Washington, DC USAObjectives—Ultrasound education is rapidly becoming a componentof the curricula at medical schools across the United States. Theteaching of focused ultrasound at earlier levels of training seems to be abyproduct of increased use of ultrasound in patient care. Early efforts tointroduce 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 landscapeof ultrasound education in US medical schools.Methods—We developed a 9-item survey provided to the 135Liaison Committee on Medical Education–accredited US medical schools.Curriculum deans were asked to report how, when, and for what purposeultrasonography was taught to students. Additional items asked for opinionsabout how and when ultrasonography should be taught and aboutbarriers 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 taughtat their medical school, only 16% reported it as a priority. More schoolsteach ultrasound at the clinical (56.1%) rather than preclinical (47.6%)level of training. More than half (52.4%) teach ultrasound at more than 1level. The primary purpose for ultrasound at the preclinical level was as atool for teaching science (57.3%). The primary purpose for ultrasound atthe clinical level was to teach scan interpretation (45.1%). Seventy-ninepercent of the respondents believe that ultrasound training should be integratedinto existing UGME curricula.Conclusions—Focused ultrasound education is becoming moreprevalent in US medical schools. We found that most schools have integratedultrasound education into their UGME curricula. Despite generalacceptance of the benefits of focused ultrasonography, further efforts to definethe scope and sequence of teaching ultrasound at the UGME level arenecessary.S63

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131443469 Role of Spatial Ability as a Possible Ability Determinant inSkill Acquisition for Sonographic ScanningDouglas Clem, 1 * Brad Curs, 2 Joe Donaldson, 2 SharletteAnderson, 1 Moses Hdeib 1 1 Cardiopulmomnary and DiagnosticSciences, 2 Educational Leadership and Policy Analysis,University of Missouri, Columbia, Missouri USAObjectives—Spatial ability refers to an individual’s capacity tovisualize and mentally manipulate 3D objects. Since sonographers manuallymanipulate 2D and 3D sonographic images to generate renderingsof anatomic structures, it can be assumed that spatial ability is an abilitydeterminant for understanding and producing these medical images. UsingAckerman’s theory of ability determinants of skilled performance as aconceptual framework, this study explored the relationship of spatial abilityand learning sonographic scanning.Methods—Beginning sonography students from 3 differenttypes of educational institutions were administered a spatial abilities testprior to their initial scanning lab coursework. The students’ spatial testscores were compared with their scanning competency performance scoresafter the first scanning competency test and then to the overall average ofthe competency scores for the 2 semesters. The spatial ability test wasagain administered after the 2-semester learning period to see if the students’spatial ability had increased. Additionally, the role of spatial abilityand student retention was explored.Results—A significant relationship between the students’ spatialability test scores and their scanning performance scores was foundafter the first scanning competency (r = 9.46; P

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131428470 Ultrasound Knowledge and Image Interpretation Gains byStudents on Emergency Medicine RotationUche Blackstock,* Jaclyn Munson, Nina Yeboah, DemianSzyld Emergency Medicine, Bellevue Hospital/New York UniversityMedical Center, New York, New York USAObjectives—Bedside ultrasound (BUS) competency is consideredintegral to emergency medicine (EM) practice, and EM residenciesrequire BUS training. However, medical students are rarely formallytaught BUS. We sought to develop and evaluate a BUS curriculum formedical students on their EM rotation.Methods—We prospectively enrolled a convenience sample of26 medical students (second year, 8 [30.8%]; third year, 11 [42.3%]; andfourth year, 7 [26.9%]) on their EM rotation. Students completed a 33–multiple-choice question Web-based pretest assessing knowledge ofphysics (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-hourhands-on BUS session covering the tutorial topics. Subsequently, participantscompleted a Web-based posttest, containing identical questions asthe pretest. To validate results, a sample of 15 EM residents took the sameWeb-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 withingroupanalysis of participants’ pretest and posttest performance and between-groupanalysis 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 meanscore 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 nostatistically significant differences between students’ and residents’ posttestscores (P = .47) or in any subcategory (Ph, P = .13; Im, P = .93).Conclusions—A standardized formal curriculum in BUS significantlyimproved medical students’ Ph knowledge and ability to interpretultrasound images. Medical students performed as well as a sampleof EM residents.1540627 Enhancing Third-Year Medical Student Primary CareClerkships With Handheld UltrasoundMary Elizabeth Poston, 1 Duncan Howe, 2 * Victor Rao, 2Richard Hoppmann, 2 Chung Yoon 1 1 Internal Medicine,2Ultrasound Institute, University of South Carolina School ofMedicine, Columbia, South Carolina USAObjectives—Future physicians may be better prepared to providesafer, higher-quality patient care if point-of-care ultrasound (US) isincluded in the medical school curricula. We piloted a handheld US curriculumfor third-year medical students. The primary objective was to determinestudents’ ability to learn to perform and interpret point-of-care USimages of the heart and assess global heart function. Secondary objectivesincluded determining patterns of use (number/types of scans performed,indications for scans, and impact on patient management) and assessingimpact on student learning.Methods—Fifty-four third-year medical students each receivedhandheld US for 22 weeks during the M3 year (8 weeks each for internalmedicine and pediatrics, 6 weeks for family medicine). During the M1and M2 years, these students had previously been taught cardiac and abdominalscanning techniques with laptop US on live patient models. Duringeach clerkship, students received didactic lectures on the use of thedevice and were instructed to view Web-based modules on global heartfunction assessment. Additional Web-based modules on other US-appropriatescans were also available. Students received hands-on instruction atleast once per clerkship using standardized patients. Students were instructedto save at least 1 cardiac and 2 other images and to record thetype, indication, and impact of scans.Results—Students submitted information on patterns of use andpathology 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 studentsdemonstrated the ability to obtain images of the heart (parasternal long-axisview) as well as IVC and comment on global heart function and volumestatus. In end-of-year surveys, students stated that their ability to recognize,understand, and manage patient problems improved with US, but lack ofUS-trained faculty to supervise was a major limitation.Conclusions—M3 students with some prior experience canlearn to assess global heart function with handheld US. Students felt thatunderstanding of patient pathology and management was improved. Lackof trained faculty is a barrier to this curriculum.1541489 Cloud Documentation and iPad Telesonography From aTeaching Hospital in the Andes: A Culturally CompetentModel for Obstetric Ultrasound Education, Quality Assurance,and Practice Improvement in Remote EcuadorJohn Rodney, 1 * Erin Dooley, 2 John Simmons, 1 MatthewHorning, 3 Kelly Arnold, 4 William Rodney 2 1 Family Medicine,Texas A&M Health Science Center, Bryan, Texas USA;2Surgical Family Medicine, Obstetrics, Medicos Para la Familia,Memphis, Tennessee USA; 3 Family Medicine, St Luke’sHospital, Ashland, Wisconsin USA; 4 Family Medicine, Universityof Tennessee, Chattanooga, Tennessee USAObjectives—To create and implement a Spanish language–based obstetric ultrasound curriculum and record-keeping system by creatinga cloud-enhanced iPad application as well as a textbook and lectureseries translated into Spanish.Methods—Using AIUM guidelines for obstetric and gynecologicultrasound, we developed a cloud-based iPad application to addressthe educational and data storage needs of a geographically isolated teachinghospital in the mountains of remote Ecuador. After a brief ultrasoundseminar that included Spanish language–based lectures, texts, and demonstrations,the investigators used the iPad application to remotely monitorthe performance and documentation of obstetric ultrasound examinationsby family medicine trainees and physicians over a 6-week period.Results—We successfully addressed the educational and informationmanagement needs of family medicine trainees and physiciansin an isolated Spanish-speaking teaching hospital in remote Ecuador.Conclusions—Cloud-enhanced tablet technology is a feasiblemeans of overcoming geographic and cultural barriers for the purposes ofultrasound education, quality assurance, and practice improvement forfamily medicine trainees and physicians practicing in remote, resourcelimitedlocations.General and Abdominal UltrasoundModerator: Abid Irshad, MD1536712 European Federation of Societies for Ultrasound in Medicineand Biology Guidelines on the Clinical Use of ElastographyDavid Cosgrove, 1 * Christoph Dietrich, 2 Fabio Piscaglia 31Imaging Sciences, Imperial College, London, England; 2 Gastroenterology,S. Orsola-Malpighi, Bologna, Italy; 3 Medicine,Caritas Krankenhaus, Bad Mergentheim, GermanyObjectives—Elastography has emerged as a clinically usefuladdition to conventional ultrasound in many diagnostic applications. How-S65

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013ever, there is a need to improve standards of practice and interpretation aswell as to standardize terminology.Methods—A steering committee commissioned experiencedEuropean users to submit sections of guidelines along the lines of thosepreviously published for contrast-enhanced ultrasound.1,2 An introductorysection on the basic principles was followed by sections coveringparts of the body in which elastography is widely used, including the liver,the breast, endoscopic uses, the bowel, the prostate, the thyroid, and themusculoskeletal system.Results—The basic principles section aims to improve understandingof clinical elastography by synthesizing the underlying principlesof the 2 most commonly used forms: strain and shear waveelastography. Each clinical section contains a survey of the literature,especially where there are meta-analyses, and practical advice on theperformance and interpretation of elasticity examinations. The editeddocument is to be submitted to the European Journal of Ultrasound (Ultraschallin der Medizin) with a target date of January 2013.Conclusions—It is hoped that the European Federation of Societiesfor Ultrasound in Medicine and Biology (EFSUMB) guidelines onelastography will be as useful as the contrast-enhanced ultrasound guidelinesin improving understanding and clinical practice. The contributions ofthe EFSUMB Elastography Guidelines Team are gratefully acknowledged.References1. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinicalpractice 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 andrecommendations on the clinical practice of contrast-enhanced ultrasound(CEUS): update 2011 on nonhepatic applications. UltraschallMed 2012; 33:33–59.1540689 Implementation of Bedside Ultrasonography Within anInternal Medicine Faculty and Residency: The IMBUSProgramDavid Tierney,* Terry Rosborough Medical Education,Abbott Northwestern Hospital, Minneapolis, Minnesota USAObjectives—Describe in detail and provide a rationale for acurriculum, structure, and successful implementation of an internal medicinebedside ultrasound (IMBUS) program in a residency program andits faculty.Methods—Design: Prospective cohort study in an internalmedicine (IM) residency program at a private academic 700-bed tertiarycare center. Participants: 33 residents and 13 full-time faculty memberswithout significant prior ultrasound experience. Intervention: (1) Developmentof an IM ultrasound curriculum to maximize sensitivity/specificityof our routine physical exam as well as critical time sensitivediagnoses; (2) overlap training method using top-down and bottom-upmethodologies; (3) 35-hour “boot camp” including didactic, hands-onmodel-based, and simulator-based training; (4) bedside hands-on trainingwith faculty mentors until the trainee meets a prespecified exam count ineach component and is deemed competent in that exam area; (5) ongoingmentored and remotely submitted/reviewed images until adequate technicaland interpretive sensitivity/specificity are obtained; (6) final test-outusing 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 effectof implementation on resident/faculty work flow, efficiency, and jobsatisfaction.Results—We describe in detail and rigorously critique a full ultrasoundcurriculum and implementation strategy for an IM residency.Thirty IM residents and 12 faculty members were trained using theIMBUS program. Learning curves for each ultrasound exam componenthave been established. We are analyzing multiple outcomes, includingcompetency 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 programsimplement bedside ultrasound in an efficient, focused, evidence-based,politically aware, and impactful manner.1506540 Prostate Cancer Responses to Testosterone and GrowthHormoneRobert Bard Biofoundation, New York, New York USAObjectives—Hypogonadal patients with low-grade prostatecancer are now treated with testosterone +/– growth hormone. It has beenestablished that high vascular density indicates a high-grade tumor. Ourstudy was to observe Doppler sonographic vessel density imaging inknown cancer sites to predict aggressive changes and arrest testosteroneand or growth hormone supplementation.Methods—Sixty-three patients treated with testosterone havinglow-grade (Gleason 6) disease were followed over a 3-year period.The vessel index was assessed on sonography by 3D histogram analysisand by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Follow-up biopsies were obtained shortly after imaging studies,which occurred at 6-month intervals for 3 years on patients with prostatespecificantigen (PSA) rises. Nineteen of 63 patients were concomitantlytaking growth hormone formulations.Results—Forty-one of 63 testosterone patients had no increasein PSA or neovascularity at 6, 12, 24, and 36 months. Three of 63 patientshad increased PSA and vessel density at 6 months. Biopsy confirmedGleason 4+3 disease in 1 patient and Gleason 3+4 in 2 others. Testosteronewas discontinued. One of 19 patients taking testosterone and growth hormoneshowed increased PSA at 6 months. Biopsy showed Gleason 3+4.Testosterone and growth hormone were discontinued. None of the studiedgroup developed increased vessel densities after the initial 6-month period.Conclusions—Vessel density sonographic indexing and DCE-MRI analysis correlated well with the biochemical response to testosterone/growthhormone therapies. There was high correlation withhistologic findings. Vascular density increases may signal the need to discontinuehormone replacement therapies. Vascular density stability in theface of rising PSA most likely indicates progression of benign hyperplasiawith increased prostate glandular volume.1540891 Liver Sonography Is Predictive of Liver Steatosis; However,the Severity of Fatty Liver on Sonography Does Not CorrelateWith the Presence of SteatohepatitisRoberta diFlorio,* Robert Harris, David Kim, Eric Goodman,Alex Spinosa, Megan Murphy Radiology, Dartmouth-HitchcockMedical Center, Lebanon, New Hampshire USAObjectives—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 hepatocellularcarcinoma (HCC). Patients with NASH are far more likely to progressto fibrosis than patients with simple steatosis. Currently, liver biopsy isconsidered the gold standard for diagnosis of NAFLD and for differentiatingsteatosis from NASH. However, there is significant variability inliver biopsy due to the error of a small sample size of a heterogeneousprocess. A noninvasive marker of NAFLD would allow detection of globaldisease status and allow stratification of risk for the development of fibrosis.This would permit early drug therapy and allow for surveillance ofcirrhosis complications and HCC. Ultrasound findings that would differentiatesimple steatosis from NASH would be helpful in diagnosing andmonitoring the disease status of NAFLD.S66

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Methods—We retrospectively reviewed the results of all abdominalultrasound examinations in patients who also had liver biopsiesfrom 2006 to 2010 to determine the positive predictive value of ultrasoundfor the detection of NAFLD in our department. We scored theseverity of fatty liver on ultrasound from 0 to 3: 0, normal liver echo texture;1, increased liver echogenicity relative to kidney; 2, increased liverechogenicity that obscures echogenic periportal fat; and 3, increased liverechogenicity that obscures visualization of deep liver parenchyma. Wecompared 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 populationwas 91% (86%–95%), specificity 75% (35%–97%), and positivepredictive value 99% (95%–100%). There was, however, no correlationbetween the sonographic severity of NAFLD and the presence of NASHor fibrosis.Conclusions—Ultrasound has a high predictive value for thediagnosis of NAFLD in patients who undergo liver biopsy. However,the severity of fatty liver based on the sonographic appearance does notcorrelate with the histologic severity of fatty liver disease and does not differentiatebetween bland steatosis and NASH.1537502 Shear Wave Velocity Discrimination of Inflamed FibroticBowel Segments in a Crohn’s Disease Animal ModelJonathan Dillman, Ryan Stidham, Peter Higgins, DavidMoons, Laura Johnson, Jonathan Rubin* University ofMichigan, Ann Arbor, Michigan USAObjectives—To determine if acoustic radiation force impulse(ARFI) elastography-derived bowel wall shear wave velocity (SWV) candistinguish inflamed from fibrotic intestine in a Crohn’s disease animalmodel.Methods—An acute inflammation Crohn’s disease model wasproduced by treating Lewis rats with a single trinitrobenzenesulfonic acid(TNBS) enema, with imaging performed 2 days later (n = 8). Colonic fibrosisin Lewis rats was achieved by administering repeated TNBS enemasover 4 weeks, with imaging performed 7 days later to allow resolutionof acute inflammation (n = 8). Nine transcutaneous bowel wall SWVmeasurements (Virtual Touch IQ/Acuson S3000 ultrasound system;Siemens Medical Solutions USA) were obtained from the rectosigmoidcolon region in all rats without and with applied strain. Mean bowel wallSWVs without and with applied strain were compared between animalcohorts. Receiver operating characteristic curves were created to assessdiagnostic performance. Three rats were excluded from analysis due todemise.Results—Mean bowel wall SWVs were significantly higherfor 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 demonstratedlinear increases in mean SWVs with increasing applied strain, withno 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 fordifferentiating fibrotic from inflamed bowel was 0.764.Conclusions—Bowel wall SWV distinguishes fibrotic from inflamedintestine in a Crohn’s disease animal model. This finding couldhave a major impact in the diagnosis and treatment of strictures in Crohn’sdisease where fibrotic strictures can only be treated surgically, while inflammatorystrictures are treated medically. In addition, the linearity ofthe slopes in the shear wave vs applied strain model would remove preloadingeffects up to at least 30% applied strains, which could removevariations due to different operator preloads.S671540986 Volumetric Blood Flow Assessment in Transjugular IntrahepaticPortosystemic Shunt Revision Using 3-DimensionalUltrasoundStephen Pinter, 1 * Jonathan Rubin, 1 Oliver Kripfgans, 1 PaulaNovelli, 1 Mario Vargas-Vila, 2 Anne Hall, 3 J. Brian Fowlkes 11Radiology, 2 Medical School, University of Michigan, Ann Arbor,Michigan USA; 3 GE Healthcare, Wauwatosa, Wisconsin USAObjectives—Transjugular intrahepatic portosystemic shunts(TIPS) are prone to thrombosis and stenosis over time and must be monitoredto identify cases requiring flow restoration. The purpose of thisstudy was to evaluate shunt patency using 3D ultrasound volumetricblood flow in patients undergoing shunt revision. Shunt volume flow isintended to provide a more sensitive and robust alternative to standardpulsed wave Doppler shunt velocity or invasive portosystemic pressuregradient measurements.Methods—Ten patients were recruited. A GE LOGIQ 9 ultrasoundsystem (4D3CL, 2.0–5.0 MHz) was used to acquire multivolumerespiratory-gated 3D color Doppler data sets for each patient to assessshunt volume flow before and after the revision procedure. Volume flowwas computed offline by surface integration of Doppler-measured velocityvectors in a c-surface (lateral-elevational plane) positioned at the colorflow focal depth, which ranged from 8.0 to 11.5 cm. Doppler poweryielded pixel-by-pixel correction factors for partial volume integration.Volume flow was compared to routine measurements of pre and post pressuregradient 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 deepshunt (14–15 cm due to ascites) and therefore insufficient signal power,while the other had a completely thrombosed shunt. Results from the remaining5 patients show prerevision flows of 500 to 1200 mL/min andpostrevision flows of 1300 to 2550 mL/min. A corresponding decrease inthe prerevision and postrevision portosystemic pressure gradient was observedin each case. An important result was observed for patient 9, whoseprerevision flow was 1910 mL/min, which suggests a revision may be unnecessary.Following shunt revision, the pressure gradient for patient 9was unchanged, and postrevision flow was 1938 mL/min, effectively unchangedcompared to prerevision flow.Conclusions—Results demonstrate that shunt volume flow hasa negative correlation with the prerevision and postrevision portosystemicpressure gradient, illustrating that volume flow may be an effective indicatorof shunt performance.1541365 Implementation of a Competency-Based Online Curriculumto Train Medical Students and Primary Care Residentsand Physicians in Point-of-Care UltrasoundNicholas Cohen, 1 * Justin Lappen, 1,2 Honor Wolfe, 1 KimberlyGecsi, 2 Ashish Bhimani 3 1 Family Medicine and CommunityHealth, 2 Obstetrics and Gynecology, 3 Cardiology, UniversityHospitals Case Medical Center, Cleveland, Ohio USAObjectives—The objective of our study was to design and integrateinto the medical school curriculum at Case Western Reserve UniversitySchool of Medicine and the family medicine residency curriculum atUniversity Hospitals Case Medical Center a competency-based online curriculumto train medical students and residents in point-of-care ultrasound.Methods—We assembled a multidisciplinary team of physiciansin obstetrics and gynecology, cardiology, and the Department of FamilyMedicine at our institution to design the curriculum. The modules consistof an introduction to ultrasound and modules focused on specific applicationof point-of-care ultrasound for obstetrics, cardiology, abdominal, vascular,and procedure guidance. Each module includes a didactic componentfeaturing a Web-delivered screen capture PowerPoint video by an expert inthe field, a demonstration of technique using a model and actual ultrasound,an online pretest and posttest to ensure competency, and a downloadablechecklist for a hands-on evaluation by a credentialed sonographer.

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Results—This curriculum has been adopted by the medicalschool 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 theposttest are able to pass the hands-on skills test.Conclusions—We have demonstrated that our curriculum canbe implemented in a medical school and primary care residency program,provides competency-based assessment, and results in knowledge andpractical skills proficiency for learners with no prior training in ultrasound.This curriculum is available online and has the potential for adoption atmedical schools and residency programs across the country.1541515 Quantification of Renal Perfusion With Dynamic PowerDoppler Ultrasonography in Allograft KidneysShuo-Meng Wang, 1 * Jeou-Jong Shyu, 3 Nai-Kung Chou, 2Hao-Chih Tai, 2 Sun-Hua Pao, 4 Yio-Wha Shau 4 1 Urology,2Surgery, National Taiwan University Hospital, Taipei, Taiwan;3Veterinary Medicine, National Taiwan University, Taipei, Taiwan;4Industrial Technology Research Institute, Hsinchu, TaiwanObjectives—Kidney transplantation is the most effectivemethod to save a patient’s life after renal failure. How to keep an allograftkidney in good condition is very important in clinics. The serum creatinine(Cre) assay is the most popular method used to diagnose renal function becauseof a single functioning kidney in the body. Dynamic power Doppler(PD) ultrasonography can examine the hemodynamic change of renal perfusiondirectly. To understand the application of the power Doppler vascularindex (PDVI) for the diagnosis of renal function and the correlationwith the serum Cre assay, allograft patients were used for study.Methods—Three groups of patients according to the result ofCre concentration (

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Obstetric Ultrasound: General and Fetal GrowthModerators: Wesley Lee, MD, Mani Montazemi, RDMS1539437 Fetal Loss Rate and Associated Risk Factors AfterAmniocentesis, Chorionic Villus Sampling, and FetalBlood SamplingChristian Enzensberger, 1 * Christina Pulvermacher, 1Jan Degenhardt, 1 Andreaa Kawecki, 1 Ute Germer, 2 UlrichGembruch, 3 Martin Krapp, 4 Jan Weichert, 5 RolandAxt-Fliedner 1 1 Division of Prenatal Medicine, University ofGiessen & Marburg, Giessen, Germany; 2 Center for PrenatalMedicine, Caritas Krankenhaus St Josef, Regensburg, Germany;3 Division of Prenatal Medicine, University of Bonn,Bonn, Germany; 4 Center for Endocrinology and Reproductiveand Prenatal Medicine, Amedes Hamburg, Hamburg, Germany;5 Division of Prenatal Medicine, University of Schleswig-Holstein, Campus Luebeck, Luebeck, GermanyObjectives—To assess the total and procedure-related fetal lossrates and associated risk factors following amniocentesis (AC), chorionicvillus sampling (CVS), and fetal blood sampling (FBS).Methods—We performed a retrospective analysis of patientswith invasive diagnostics from 1993 to 2011 in 2 tertiary referral centers.We aimed to classify pregnancy loss after an invasive procedure and includedthe time after the invasive procedure and the result of targeted ultrasound/karyotypeanalysis in the analysis. Fetal losses occurring within2 weeks after an invasive procedure were classified as procedure related.Results—After excluding 1553 pregnancies with abnormalkaryotypes, fetal malformations, and multiple insertions, 6256 cases wereretrieved for final analysis. The total fetal loss rate was 1.5%. The procedure-relatedfetal loss rates were 0.4% for AC, 1.1% for CVS, and 0.4 %for FBS. Maternal vaginal bleeding in the first trimester was significantlyassociated with an increased procedure-related fetal loss rate (P = .008).The number of invasive procedures declined during the study period withincreasing numbers of CVS in the first trimester.Conclusions—In our population, the procedure-related fetalloss 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 proceduresmight account in part for those differences. Vaginal bleeding during thefirst trimester is associated with increased procedure-related fetal loss.Overall, declining numbers of invasive procedures are the result of changingattitudes toward invasive procedures and more sophisticated noninvasiveprenatal screening programs over the last 20 years.1537806 Quality Control in Obstetric Ultrasound: Evaluating theReproducibility of an Image Scoring Tool for the Second-Trimester Anatomic SurveyKatherine Goetzinger,* Methodius Tuuli, Alison Cahill,George Macones, Anthony Odibo Obstetrics and Gynecology,Washington University, St Louis, Missouri USAObjectives—To evaluate the reproducibility of an image scoringtool for quality control of second-trimester fetal anatomic surveys ina US academic center.Methods—This was a retrospective study of 40 randomly selectednonanomalous singleton gestations between 18 and 22 weeks whopresented for an anatomic survey. Images from each ultrasound exam wereevaluated by 2 independent reviewers and assigned a score based on aquality control tool, previously derived in a European ultrasound unit. Thistool assigns an overall score (46 points possible), which is the sum of individualscores 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 basedon the number of specific criteria fulfilled for each view. Spearman correlationcoefficients and percent agreement (“excellent”: score difference,0–1 points; “acceptable”: 2 points; “poor”: ≥3 points) were used to estimateinter-reviewer reproducibility. Bland-Altman plots were used to assessbias 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 excellentagreement was observed in the individual categories of femur, outflowtracts, stomach/diaphragm, and spine. Poor agreement was rare (kidney,2.5%; and face, 2.5%) Bland-Altman statistics demonstrated no evidenceof systematic bias in the overall score (mean difference = 1.5; P = .761).The 95% limits of agreement were clinically acceptable for the overallscore (–2.4 to 5.4) and all individual categories except fetal face views(Table 1).Conclusions—This image quality scoring tool demonstratedoverall acceptable reproducibility without evidence of systematic bias.Careful evaluation of specific criteria comprising each individual scoringcategory is, however, warranted prior to implementation into practice.Table 1Category Bias 95% Limits of AgreementHead 0.2 –1.0 to 1.5Abdomen 0.2 –1.4 to 1.8Femur –0.1 –1.2 to 1.14-Chamber heart 0.5 –1.0 to 2.1Outflow tract –0.1 –1.4 to 2.2Kidneys 0.4 –1.4 to 2.2Stomach and diaphragm –0.2 –1.7 to 1.2Spine 0.1 –0.6 to 0.4Face 0.7 –1.3 to 2.71540992 Time Required for the Fetal Anatomic Survey in Obese andMorbidly Obese WomenRobert Ehsanipoor,* Gofran Tarabulsi, Shannon Trebes,Erika Werner, Janice Henderson, Jude Crino Johns HopkinsUniversity School of Medicine, Baltimore, Maryland USAObjectives—To determine if there is a difference in time requiredto perform the fetal anatomy survey in obese and morbidly obesewomen compared to women with a body mass index (BMI) of

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131539702 Association of Third-Trimester Abdominal CircumferenceWith Provider-Initiated Preterm DeliveryLeah Hawkins, 1 * William Schnettler, 1,2 Anna Modest, 2Michele Hacker, 1,2 Diana Rodriguez 1,2 1 Harvard MedicalSchool, Boston, Massachusetts USA; 2 Obstetrics and Gynecology,Division of Maternal-Fetal Medicine, Beth Israel DeaconessMedical Center, Boston, Massachusetts USAObjectives—To evaluate the association of a small abdominalcircumference (AC,

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013.05) and demonstrated a trend toward a lower BPD and FTD (P < .1) comparedto OMT patients.Conclusions—Prenatal ultrasound evaluation of the CCD andTCD correlate with biomarker-proven PAE. These results indicate that ultrasoundparameters may be helpful in conjunction with other diagnostic indicesin detecting PAE. Future studies need to examine the predictive utilityof ultrasound indices on neurodevelopmental outcomes in children with PAE.1521317 Effect of Maternal Body Mass Index on Fetal Growth: Useof Individualized Growth Assessment and 2-Level ModelingTimothy Canavan, 1 * Russell Deter 2 1 Obstetrics, Gynecology,and Reproductive Sciences, University of Pittsburgh–Magee Women’s Hospital, Pittsburgh, Pennsylvania USA;2Obstetrics and Gynecology, Baylor College of Medicine,Houston, Texas USAObjectives—To determine the effect of the maternal body massindex (BMI) on fetal biometry estimates of growth using individualgrowth assessment (IGA) and 2-level linear modeling.Methods—A retrospective review of serial biometry in the secondand 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) measurementsper fetus were available and used to determine second-trimestergrowth rates. Expected third-trimester size trajectories were generatedfrom these data and percent deviations (%Dev = [{observed – expected}/expected] × 100) were calculated. Two-level linear modeling was used todetermine individual %Dev slopes and the effect of BMI on these slopes.Relationships between individual second- and third-trimester slopes andBMI values were also evaluated using regression analysis.Results—Linear regression analysis of second-trimester growthindicated no significant relationships between the fetal growth rate andthe BMI (adjusted R 2 = 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 indicatedno significant relationships (adjusted R 2 = 0%–0.2%) betweenBMI values and third-trimester %Dev slopes for any anatomic parameter.Conclusions—Our findings support the premise that the maternalBMI does not alter fetal growth in either the second or thirdtrimester. It also demonstrates that IGA and 2-level linear modeling, usedtogether, can assess the effect of an extrinsic factor on fetal growth.1541336 Cerebral Autoregulation in Normal PregnancyTeelkien van Veen, 1 * Sina Haeri, 2 Rodrigo Ruano, 2 RonnyPanerai, 3 Gerda Zeeman, 1,4 Michael Belfort 2 1 Obstetrics andGynecology, University Medical Center Groningen, Groningen,the Netherlands; 2 Obstetrics and Gynecology, BaylorCollege of Medicine, Houston, Texas USA; 3 CardiovascularSciences, University of Leicester, Leicester Royal Infirmary,Leicester, England; 4 Obstetrics and Gynecology, Erasmus MedicalCenter, Rotterdam, the NetherlandsObjectives—Recent advances in transcranial Doppler (TCD)methodology now allow direct real-time estimation of the functional state ofcerebral autoregulation. Since no normative data exist for pregnant patients,our aim was to establish baseline data for cerebral autoregulation in healthypregnancy against which women with disease states can be compared.Methods—In this prospective cohort analysis, cerebral bloodflow velocity (CBFV) in the middle cerebral artery (using TCD), bloodpressure (using noninvasive continuous plethysmography), and end–tidalcarbon dioxide (etCO 2) were simultaneously evaluated at baseline andduring voluntary breath holding (increased etCO 2). The transfer functionparameters (gain, phase, and coherence in the low-frequency range [

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131537546 Early Second-Trimester Fetal Anatomy Scans Improvethe Rate of Complete Anatomy Scans in Obese PatientsSimi Gupta,* Judith Chervenak, Ilan Timor, AnaMonteagudo Obstetrics and Gynecology, New York University,New York, New York USAObjectives—Fetal anatomy scans are more difficult to performon obese patients. However, there are little data available on methods toimprove the rate of complete anatomy scans in these patients. The objectiveof this study was to determine if the addition of an early secondtrimesterfetal anatomy scan improves the rate of complete anatomyultrasound examinations in obese patients.Methods—This was a prospective cohort study at an inner-citypublic hospital of 100 obese patients who were scheduled for a fetalanatomy scan via transvaginal and transabdominal modalities at 14 to 16weeks’ gestation (early fetal anatomy) and an anatomy scan at 18 to 22weeks’ gestation (routine fetal anatomy). Inclusion criteria were body massindex (BMI) >30 kg/m 2 , singleton pregnancy, and presentation for prenatalcare prior to 16 weeks’ gestation. Data for the routine anatomy scanalone versus the combination of early anatomy and routine anatomy scanswas calculated using the McNemar χ 2 test for categorical outcomes andWilcoxon signed ranks test for continuous variables.Results—The range of BMI in the study was 30–49.6 kg/m 2with an average BMI of 34.3 kg/m 2 . Table 1 shows the results for the routineanatomy scan alone and the combination of early anatomy and routineanatomy scans.Conclusions—The addition of an early second-trimester fetalanatomy ultrasound scan significantly improves the rate of completeanatomic scans and mean number of items seen in obese patients. The additionof this ultrasound scan may improve the detection of congenitalanomalies in obese patients.Table 1Routine Early and RoutineAnatomy Anatomy Combination P% complete anatomy 42 51 < .01Mean no. of items seen (1–21) 18.6 19.4 < .01S72

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSWEDNESDAY, APRIL 10, 2013, 8:15 AM–10:15 AMBreast UltrasoundModerator: Abid Irshad, MDClinical Breast Ultrasound in an Outpatient Community Breast CenterStamatia Destounis Elizabeth Wende Breast Care, LLC,Rochester, New York USAThis lecture will cover the clinical use of breast ultrasound in anoutpatient community breast center. Topics to be covered will include evaluationof breast pain, palpable abnormalities, breast lesions in young patients,breast-feeding/lactating patients, and patients with dense breastspresenting for additional screening ultrasound. Particular discussion willbe focused on screening breast ultrasound, in response to recent state legislationmandating that the patient be informed of her breast density. Inaddition, screening of the high-risk patient will be covered. Last, this lecturewill discuss the role of diagnostic breast ultrasound. The role of newtechnologies, including elastography and automated breast ultrasound,will be briefly discussed.Significance and Implications of Various Sonographic Features inBreast LesionsAbid Irshad Radiology, Medical University of South Carolina,Charleston, South Carolina USAThis lecture will encompass the diagnostic significance of varioussonographic features seen in breast lesions from a clinical and pathologicperspective. The management issues regarding concordance afterbiopsy of these lesions will also be discussed. Additionally, various sonographicfeatures seen in breast cancers will be individually discussed inlight of literature to see how confidently the biological behavior such asthe tumor grade and estrogen receptor/progesterone receptor/human epidermalgrowth factor receptor 2 status of these cancers can be predictedbased on these individual sonographic features.Ultrasound as a Problem-Solving Tool in Breast ImagingJulie Mack Radiology, Penn State Hershey, Hershey, PennsylvaniaUSABreast ultrasound is integral to the imaging evaluation of breastdisease, and core biopsy under ultrasound guidance provides a mechanismfor rapid diagnosis of breast pathology. This session will focus on theuse of breast ultrasound as a problem-solving tool in patients presentingwith mammographic or clinical evidence of breast disease. The sonographicfindings in a variety of breast abnormalities of the female and malebreast will be illustrated and correlated with the mammographic andmagnetic resonance imaging (MRI) findings. The utility of breast ultrasoundas a “second-look” exam after MRI will be discussed. Biopsyplanning and radiologic-pathologic correlation will also be emphasized.Finally, a brief review of the data on breast ultrasound as a screening toolwill be examined.Extracranial Ultrasound of the Head and Neck inChildrenModerator: Beth McCarville, MDThis session is designed to educate the radiologist and sonographerabout the value of ultrasound in assessing non-brain pathology inthe head and neck of children, including the thyroid, superficial masses,and ocular disease.Gynecologic Ultrasound: The Basics RevisitedModerator: Ana Monteagudo, MDGetting to Know Your Ultrasound Machine: Essentials of KnobologyAna Monteagudo Obstetrics and Gynecology, New YorkUniversity School of Medicine, New York, New York USA“Knobology” is defined as the functionality of controls on an instrumentas relevant to their application. In the case of ultrasound (US), itis the function of the controls (knobs) on the US machine. All machineshave essentially the same set of controls; however, in each brand, the controls(“knobs”) are arranged slightly differently. Therefore, it is imperativeto become familiar with the location of the controls on the machine thatyou are using on a regular basis. Adjusting the controls is a way to improvethe image quality, since a good image is an essential component ofmaking a correct and reliable diagnosis. Controls that change the followingparameters are indispensable: depth, gain, time-gain-compensation(TGC), focal zone, field of view, frame rate, “optimize” (this controlchanges several parameters as needed for a particular set of pictures), andzoom. Of course, there are many more of them; however, as you gain confidencewith the scanning and working with the US machine, the utility ofchanging other parameters will become evident. Improving images notonly requires knowing which control to use, but it also requires choosingthe right transducer for the scanning approach; transducers commonlyused in obstetrics and gynecology range from 3.5 to 7.5 MHZ (or higher).Low-frequency transducers achieve better penetration at the expense of alower resolution; these are the ones employed when scanning transabdominally.Higher-frequency transducers have less penetration, but theirreal value is the increased resolution, and these are usually used transvaginally.Last, besides knowing what each control does and which transducerto use, we must know the indication for the scan and the age and lastmenstrual period of the patient. They all assist in making the diagnosis.Innovative Directions in Fetal Cardiac ImagingModerator: Lami Yeo, MDThe objective of this session is to review several new directionsin the field of fetal cardiac imaging: imaging for fetal interventions, fetalmagnetic resonance imaging, and automated screening for congenital heartdisease.S73

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Lumps, Bumps, and Extremity Pain in the EmergencyRoom: What Is the Role of Ultrasound?Moderator: Leslie Scoutt, MDSonography of Abdominal Wall HerniasLevon Nazarian Radiology, Thomas Jefferson UniversityHospital, Philadelphia, Pennsylvania USASmall abdominal wall hernias may be difficult to palpate onphysical examination; therefore, hernias are an often-overlooked cause ofpain or other complications. Because of its real-time nature, ultrasoundhas taken a central role in the evaluation of abdominal wall hernias, sincemany hernias are not present in the resting state. Since dynamic maneuversmay be necessary for diagnosis, many hernias go undetected by computedtomography or magnetic resonance imaging. This presentation willdiscuss the anatomy and technique pertinent to the diagnosis of abdominalwall hernias. Pathologic examples of the different hernia types will bepresented using both static images and video clips.Lumps and BumpsJason Wagner Radiological Sciences, University of Oklahoma,Edmond, Oklahoma USAThis presentation will describe an algorithm-based approach tothe ultrasound evaluation of a superficial mass, based on patient history,physical examination, lesion location, and sonographic findings. Specifictopics will include identification of fluid collections, distinguishing nonneoplasticcauses of a lump from neoplasms, and the differential diagnosisof superficial neoplasms.Peripheral Arterial DiseaseModerator: John Blebea, MD, MBAUltrasound in the Preintervention Stage of Patient EvaluationGowthaman Gunabushanam Diagnostic Radiology, YaleUniversity School of Medicine, New Haven, Connecticut USA;Radiology, VA Medical Center, West Haven, Connecticut USAThis presentation will review the noninvasive evaluation oflower extremity peripheral arterial disease (PAD) in the vascular laboratory,including ankle-brachial index (ABI), toe-brachial index (TBI), pulsevolume recording (PVR), segmental blood pressure measurement, and ultrasoundof native arteries and bypass grafts. ABI is used to confirm vascularetiology and provide prognostic information in symptomatic patients.ABI is also used to screen high-risk asymptomatic patients for PAD andto monitor the efficacy of therapeutic interventions. ABI 1.3 as digital arteriesare usually spared the medial calcinosis that affects the more proximalarteries. Segmental pressure measurements and PVR help determinethe level of stenosis. A gradient >20 mm Hg between adjacent segmentsor between the two sides at the same level is significant. PVR provides anarterial pressure waveform profile by measuring limb volume changeswith each cardiac cycle. A normal waveform has a rapid upstroke, a sharppeak, a dicrotic notch, and a downslope bowed toward the baseline. Aslower 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 systolicvelocity (PSV) of 200 to 350 cm/s and PSV ratio of 2 to 3.5 are suggestiveof moderate stenosis. PSV >350 cm/s and PSV ratio >3.5 are consistentwith severe stenosis.Ultrasound-Guided ThrombolysisModerator: George Lewis Jr, PhDMedical Technology and Instrumentation for Sonothrombolysis:Current, Pipeline, and Future PlatformsGeorge Lewis Jr Zetroz, Ithaca, New York USAUltrasound technologies to provide and monitor sonothrombolysiscan currently be grouped into two broad categories: (1) catheterdirectedand/or delivered ultrasound and (2) extracorporeal focused and/orapplied ultrasound. The first class of technology is generally minimally invasiveand carried out with a sterile field in an interventional radiologysuite. The second class of device covers a much larger use case scenariorelative to where it can be applied and used. In both categories of technology,sonothrombolysis effectiveness in thrombus dissolution is mostregularly measured with precontrast and postcontrast fluoroscopy. Morerecently, however, ultrasound imaging including B-mode, Doppler flow,and intravascular ultrasound is making its way into fully integrated closedloopsonothrombolysis treatment and monitoring systems. This talk willreview current sonothrombolysis ultrasound technologies, their performancecharacteristics, methods of use, and basic mechanisms of action inwhich they rely on. Catheter-directed ultrasound technologies includecommercial systems such as Ekos and Omnisonics, as well as pipelinetechnologies still undergoing research in academia and the private sector.Extracorporeal noninvasive technologies, including power Doppler, lowintensitytherapeutic ultrasound, plane-wave pulsed ultrasound, high-intensityfocused ultrasound, and histotripsy, will be described along withtheir current use case scenarios, characteristics, and regulatory pathways.The catheter-directed sonothrombolysis approaches will be compared andcontrasted to noninvasive sonothrombolysis. Additionally, recent innovationsin closed-loop sonothrombolysis treatment monitoring and crossoversonothrombolysis platforms will be discussed as a gateway into clinical researchpresentations.Sonothrombolysis: Techniques, Mechanisms, and SafetyZhen Xu Biomedical Engineering, University of Michigan,Ann Arbor, Michigan, USAUltrasound has been shown to promote clot breakdown, as botha stand-alone procedure and in conjunction with thrombolytic drugs orcontrast agents. In this talk, 3 sonothrombolysis approaches and their underlyingmechanisms reported in the literature will be reviewed. First, lowintensityultrasound is combined with fibrinolytic enzymes (such asplasminogen activator) to accelerate the clot dissolution. The mechanismunderlying this approach includes the accelerated transport of drug moleculesinto the clot and alteration in fibrin structure to enhance enzymebinding. Both of these effects are caused by stable cavitation (ie, microstreamingand bubble translation) and inertial cavitation (ie, intense localizedstresses and microjets). Microbubble contrast agents can be usedin conjunction with fibrinolytic enzymes to enhance cavitation and furtheraugment thrombolysis. Second, higher-intensity ultrasound and microbubblecontrast agents are used together to cause clot fragmentation.The microbubbles that accumulate at the surface or within the clot serveas cavitation nuclei. For this approach, the primary mechanism is inertialcavitation, where energetic bubble growth and collapse induce high localstress and microjets, resulting in clot microfragmentation. Third, veryhigh-intensity focused ultrasound pulses are used alone to produce rapidclot fragmentation. Similar to the second approach, the mechanism forthis method is also inertial cavitation, where pre-exiting gas nuclei in clotsare 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, changesin blood chemistry, and embolization.S74

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Clinical Role and Potential of Ultrasound-Enhanced Thrombolysisin Peripheral Arterial DiseaseRichard Shlansky-Goldberg Radiology, University of Pennsylvania,Philadelphia, Pennsylvania USAThrombosis from peripheral arterial disease (PAD) due to underlyingatherosclerotic disease or thrombosis of a surgical bypass graftused to treat PAD can lead to limb loss. In addition, thrombosis of thedeep venous system (DVT) can lead to chronic leg swelling due to postphlebiticsyndrome. DVT can also lead to life-threatening pulmonary embolicdisease (PE). Catheter-directed pharmacologic thrombolysis is awell-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 requiredfor effective clot lysis, costly intensive care monitoring, and the exposureof patients to the risk of intracranial hemorrhage and other life-threateningbleeding. Attempts to improve the efficacy of thrombolysis with differentcatheter configurations and mechanical devices have met withvaried success. The addition of ultrasound by itself or with pharmacologicagents 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 theseapproaches to improve lysis in DVT, PAD, and PE. Although the use ofultrasound appears promising, the question still remains whether the currentiteration of techniques and devices will add enough efficiency to havea clinically significant impact on outcomes. We will evaluate what thresholdsneed to be crossed for ultrasound to dramatically improve on howthese diseases will be treated in the future.SPECIAL INTEREST SESSIONSWEDNESDAY, APRIL 10, 2013, 10:45 AM–12:30 PMAcoustic Radiation Force Impulse Imaging:Benefits and Challenges With Increasing AcousticOutput Beyond Diagnostic LevelsModerators: Kathy Nightingale, PhD, Thomas Szabo, PhDThe Historical Basis for the Food and Drug Administration’s MaximumExposure Level Guidance for Diagnostic UltrasoundGerald Harris US Food and Drug Administration, SilverSpring, Maryland USAUS Food and Drug Administration (FDA) regulations designatemost diagnostic imaging and Doppler ultrasound devices as class 2,which means that before a new device can be marketed in the UnitedStates, a “510(k)” (named for a section of the 1976 FDA Medical DeviceAmendments) premarket notification must be cleared by the FDA. In thisnotification, a device sponsor must demonstrate that the device is substantiallyequivalent (SE) in terms of safety and effectiveness to either adevice legally marketed before May 28, 1976, the date of enactment of theFDA Medical Device Amendments, or to a device that has been legallymarketed as a class 2 device since that date. To evaluate equivalent safety,the FDA has used several acoustic output quantities to compare maximumoutput levels, including the derated spatial-peak temporal-average intensityand the thermal index for thermal safety comparisons and the deratedspatial-peak pulse-average intensity and the mechanical index for nonthermalconsiderations. In this presentation, the origin and use of thesequantities in making SE determinations will be described. Also, their possibleshortcomings for evaluating the safety of applications that employlong-duration, high-intensity pulse bursts, such as acoustic radiation forceimpulse imaging, will be discussed.An Analysis of the Mechanical Index as a Means for Ensuring PatientSafety During Acoustic Radiation Force Impulse ImagingCharles Church,* Cecille Labuda National Center for PhysicalAcoustics, University of Mississippi, University, MississippiUSAThe mechanical index (MI) quantifies the likelihood that diagnosticultrasound will produce an adverse biological effect by a nonthermalmechanism. The current formulation of the MI is based on inertialcavitation thresholds in water and blood as calculated for pulse durationsS75of 1 period. However, tissue is not a liquid but a viscoelastic solid, andfurther, acoustic radiation force impulse imaging employs high-intensitypulses up to several hundred acoustic periods long. To quantify the importanceof these differences, thresholds for inertial cavitation were determinedin water, blood, and several representative tissues by performingnumerical computations similar to the analytical work underlying the MIfor 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 thresholdcriteria, including the criterion used for the MI (5000 K). Water andblood were modeled using the Gilmore equation, while tissues (smoothand skeletal muscle, kidney, liver, and skin) were modeled using a Keller-Miksis–like equation assuming a linear Voigt solid. It is shown that thelikelihood of an adverse biological effect due to cavitation is less in softtissues, and much less in muscle, than in blood. More importantly, the literaturesuggests that the experimental threshold for cavitation in tissue ismuch higher than predicted here, casting doubt on the value of this simpletheoretical approach in assessments of patient safety. By combiningtheoretical and experimental data, several options for transiently increasingoutput levels while ensuring patient safety become available.Investigation of the Use of Increased Acoustic Output Levels forAcoustic Radiation Force Impulse Imaging in the Research SettingMark Palmeri Biomedical Engineering, Duke University,Durham, North Carolina USAAcoustic radiation force impulse (ARFI) imaging has experiencedrapid development over the past decade, growing from a novel elasticityimaging method used in tissue-mimicking phantoms to clinicaltesting in a variety of target organs, including the liver, breast, prostate, vessels,and heart, to commercial implementation. While current commercialARFI imaging implementation operates within current US Food and DrugAdministration diagnostic ultrasound acoustic output guidelines, studies inthe research environment have not been similarly restricted. For example,pilot clinical ARFI imaging research studies at Duke University involve acustom method for characterizing acoustic intensity, tissue heating, transducerheating, and the mechanical index to support in vivo safety of usingincreased output during acoustic radiation force excitations. Given thestrong acoustic waveform nonlinearity that can occur when characterizinghigh pressures in water, acoustic radiation force pressure waveforms andintensity values are characterized using hydrophone measurementsthrough attenuating fluids similar to that of the target organ. Thermocou-

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013ple measurements are made at the transducer face to characterize lens heating.We are exploring the hypothesis that increases in tissue displacementamplitude associated with elevated acoustic output will lead to improvementsin ARFI images and shear wave speed estimates. To that end, parametricclinical studies are in progress with ARFI shear wave liver imagingto quantify the correlations between displacement amplitude, jitter, shearwave speed reconstruction performance metrics, and increased acousticoutput. A summary of the acoustic output characterization methods usedin the research setting and preliminary results from the parametric clinicalstudies will be presented.Advanced Fetal Cardiac Evaluation andComprehensive OverviewModerator: James Huhta, MDTwin-Twin Transfusion SyndromeJack Rychik Fetal Heart Program, Children’s Hospital ofPhiladelphia, Philadelphia, Pennsylvania USATwin-twin transfusion syndrome (TTTS) affects approximately15% of monochorionic twin pregnancies. The condition is triggered by aplacental vasculopathy, which then leads to a cascade of physiologicevents. TTTS results in a donor twin who manifests hypovolemia andoligohydramnios and a recipient twin with polyhydramnios. The cardiovascularsystems of both twins are affected in a unique and fascinatingmanner, which is observable through fetal echocardiography. The donorexhibits hyperdynamic ventricular function with increased placental resistance.The recipient develops a cardiomyopathy consisting of ventriculardilation, hypertrophy, decreased compliance, and systolic dysfunctionwith tricuspid and mitral regurgitation. Approximately 15% to 20% of recipientsdevelop changes within the right ventricular outflow and pulmonaryvalve complex such as pulmonic stenosis or pulmonary atresia ofa functional or anatomic nature. A scoring system for characterization ofthese changes, the Children’s Hospital of Philadelphia (CHOP) TTTS cardiovascularscore, has been developed and is useful in assessing diseaseseverity and response to therapy. Studies using fetal echocardiographyderivedmodalities such as ventricular strain and strain rate analysis haveprovided insight into the pathophysiology of this disease. Placental laserphotocoagulation is an effective treatment therapy for TTTS. Laser resultsin regression of cardiovascular findings. Cardiovascular characterizationthrough the CHOP score and other parameters can be performed after laser.Long-term outcomes and, in particular, cardiovascular outcomes after lasertherapy are of great interest. TTTS may impact cardiovascular health andprovide imprints for disease long into adulthood.Current Vascular ControversiesModerator: John Blebea, MD, MBAThis session will examine the indications and follow-up duplexcriteria for carotid stenting, review the indications, results, and imaging criteriafor angioplasty and stenting of the renal arteries, and discuss the recommendedprotocols for deep vein thrombosis imaging in different clinicalscenarios.The Role of Ultrasound in Screening for Vascular DiseaseEdward Bluth Radiology, Ochsner Medical Institutions, NewOrleans, Louisiana USAIt has been suggested that it would be more useful to reallocatehealth care dollars to screening asymptomatic healthy patients comparedto the large allocation of resources for end-of-life care. Ultrasound has animportant role to play in screening for medical problems. As a noninvasivestudy that does not use ionizing radiation, ultrasound has an advantageover other imaging modalities. Included in the areas where screeningstudies can be useful with ultrasound are assessment of the carotid arteriesfor stenosis as well as evaluation of the aorta for the presence ofaneurysms. Intima-media thickness is another study that has been describedas valuable in assessing cardiovascular risk. A reemphasis on thevalue of screening the healthy would be advantageous to the ultrasoundcommunity as we enter into health care reform in the United States.Musculoskeletal Ultrasound: Transition From Adultsto PediatricsModerator: Michael Di Pietro, MDThe objective of this session is to cover some of the anatomyand entities familiar to experienced adult musculoskeletal radiologists butnot to pediatric radiologists, which pediatric radiologists are now beingasked by their clinicians (pediatric orthopedics, pediatric sports medicine,and pediatric physical medicine and rehabilitation) to address.Ultrasound of the Head and NeckModerator: Sharlene Teefey, MDUltrasound of the Thyroid and ParathyroidSharlene Teefey Mallinckrodt Institute of Radiology, SaintLouis, Missouri USAThis 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, medullarycarcinoma, primary thyroid lymphoma, and nodular hyperplasia will alsobe discussed, and examples will be shown. The American Thyroid Associationguidelines for fine-needle aspiration and follow-up of benign nodulesand the Bethesda system for reporting cytology will be presented. Inthe next part of the lecture, Graves’ disease and Hashimoto’s thyroiditiswill be discussed, including clinical and pathologic features. Sonographicfindings will be discussed and examples shown. There will also be a briefdiscussion of subacute thyroiditis. In the last part of the lecture, primaryhyperparathyroidism will be presented, including etiology, symptoms,anatomy, sonographic technique, and appearance, and examples will beshown.S76

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SCIENTIFIC SESSIONSWEDNESDAY, APRIL 10, 2013, 10:45 AM–12:30 PMEmergency Ultrasound, Part 2Moderator: Leslie Scoutt, MD1540052 A Systematic Review of the Diagnostic Accuracy of BedsideOcular Ultrasound in the Diagnosis of Retinal DetachmentJonathan Kirschner,* Hal Minnigan, Michael Vrablik,Gregory Snead, Rawle Seupaul Emergency Medicine, IndianaUniversity School of Medicine, Indianapolis, Indiana USAObjectives—Systematically review the literature to determinethe diagnostic accuracy of bedside ocular ultrasound (OUS) in the diagnosisof retinal detachment.Methods—The design of this review conformed to the recommendationsfrom the Meta-analysis of Observational Studies in Epidemiologystatement. An experienced medical librarian searched the followingdatabases from their inception without language restrictions: Ovid MED-LINE, PubMed, EMBASE, the full Cochrane Library, Emergency MedicalAbstracts, and Google Scholar. Content experts were contacted, andbibliographies of relevant studies were reviewed to identify additional references.Studies were included if they prospectively recruited adult patientswith acute signs and symptoms suggestive of retinal detachmentand provided enough detail on diagnostic test and criterion standard resultsto construct contingency tables. Evidence quality was independently assessedby 2 investigators using the revised Quality Assessment Tool for DiagnosticAccuracy Studies (QUADAS-2). Discrepancies were resolvedby consensus or adjudication by a third reviewer. Diagnostic test characteristicswere summarized for trials with a low risk of bias.Results—Of 7771 unique citations identified, 78 were selectedfor full text review, resulting in 4 trials assessed for quality. Agreementbetween authors’ QUADAS-2 scoring was good (κ = 0.63). Overall trialquality was deemed to be excellent with a low risk of bias in 3 studies. All3 trials enrolled emergency department–based patients (N = 199) and evaluatedclinician-performed bedside OUS using either a 7.5- or 10-MHz lineararray probe. The prevalence of retinal detachment ranged from 13%to 38%. Sensitivity and specificity ranged from 97% to 100% and 83% to100%, respectively.Conclusions—Bedside OUS has a high degree of accuracy inidentifying 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-CareUltrasound for Diagnosis of Skull Fractures in ChildrenJoni Rabiner, 1 * Jeffrey Avner, 1 Hnin Khine, 1 Lana Friedman, 2James Tsung 2 1 Pediatrics, Division of Emergency Medicine,Children’s Hospital at Montefiore/Albert Einstein College ofMedicine, Bronx, New York USA; 2 Emergency Medicine, Divisionof Pediatric Emergency Medicine, Mount Sinai School ofMedicine/Mount Sinai Medical Center, New York, New YorkUSAObjectives—To determine the test performance characteristicsand interobserver agreement for point-of-care ultrasound (US) performedby clinicians compared to computed tomography (CT) or x-ray diagnosisof skull fractures.Methods—This was a prospective study of a convenience sampleof patients 6 mm, appendix wall thickness >2 mm, periappendiceal fluid, andsonographic McBurney’s sign (univariate analysis, P < .05). BUS successand accuracy were independent of operator, parenteral narcotic orantiemetic administration, subject body mass index, or scanning time.Conclusions—BUS was highly sensitive for appendicitis diagnosisin the ED in our study. The presence of several findings in the history,physical exam, and laboratory testing and on BUS increased thelikelihood of the diagnosis.S77

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131434950 Number of Proctored Pediatric Focused Assessment WithSonography for Trauma Exams Required for ProficiencySharon Yellin, 1,2 * Jennifer Chao, 2 Richard Sinert, 2 JohnGullett, 2 Gerardo Chiricolo 1 1 Pediatric Emergency Medicine/EmergencyUltrasound, New York Methodist Hospital,Brooklyn, New York USA; 2 Pediatric Emergency Medicine/Emergency Medicine, Kings County Hospital/State Universityof New York Downstate Medical Center, Brooklyn, New YorkUSAObjectives—To assess the number of proctored focused assessmentwith sonography for trauma (FAST) exams necessary for thenovice sonographer to accurately acquire the 4 views of the exam.Methods—This was a prospective educational interventionstudy of FAST exam mastery by novice third- and fourth-year medicalstudents (MS). Students were excluded if they had formal ultrasound trainingor prior experience. All students received a 2-hour online didacticcourse on basic ultrasound and FAST. Students were then randomized into1 of 3 groups: group 1, students performed 5 proctored exams; group 2,10 exams; and group 3, 15 exams. Proctored exams were designed to givethe students hands-on practice under the guidance of trained sonographers.The proctored exams were administered monthly and limited to 10 minutesto standardize the training sessions. At the end of each month, studentswere tested on the FAST exam with the same 2 standardized patients, eithera 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 2minutes to perform the test exam starting from the time they picked upthe probe. The test exams were recorded using video and later reviewedand graded by examiners blinded (to groups) using a standardized datascoring sheet. To pass, the students were required to obtain the standardviews of the organs and/or structures necessary to identify free fluid.Results—Forty-five students consisting of 23 MS3s and 22MS4s, ages 24 to 43 years, were enrolled. Groups were evenly matchedfor 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

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131539223 Outcome After Second-Trimester Amniocentesis andFirst-Trimester Chorionic Villus Sampling for PrenatalDiagnosis in Multiple GestationsChristian Enzensberger, 1 * Christina Pulvermacher, 1 JanDegenhardt, 1 Andreaa Kawecki, 1 Ute Germer, 2 Jan Weichert, 3Martin Krapp, 4 Ulrich Gembruch, 5 Roland Axt-Fliedner 11Division of Prenatal Medicine, University of Giessen &Marburg, Giessen, Germany; 2 Center for Prenatal Medicine,Caritas Krankenhaus St Josef, Regensburg, Germany; 3 Divisionof Prenatal Medicine, University of Schleswig-Holstein,Campus Luebeck, Luebeck, Germany; 4 Center for Endocrinology,Reproductive and Prenatal Medicine, Amedes Hamburg,Hamburg, Germany; 5 Division of Prenatal Medicine, Universityof Bonn, Bonn, GermanyObjectives—The purpose of this study was to classify pregnancyloss and fetal loss as well as the influence of maternal risk factorsin multiple pregnancies.Methods—Details of the procedure and pregnancy outcome ofall patients were extracted from the clinical audit databases of 2 tertiarycenters. The files were collected in the time from January 1993 to December2010. The procedure-related pregnancy and fetal loss rates wereclassified as all unplanned abortions without important fetal abnormalitiesor obstetric complications within 14 days after amniocentesis (AC) andchorionic villus sampling (CVS).Results—We had a total of 288 multiple pregnancies with atotal of 637 fetuses. After exclusion of 112 pregnancies with an abnormalkaryotype or fetal abnormalities detected by ultrasound as well as cases ofselective feticide, repeated invasive procedures, and monochorionicmonoamniotic 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) forAC and 13.6% (n = 6) for CVS. The procedure-related pregnancy lossrate 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 becompared with those in literature. The higher loss rates in multiple pregnanciesthan in singleton pregnancies have to be discussed when counselingparents.1540424 Breaking Bad News During Perinatal Sonography:Practical Aspects of a Novel Educational Pilot Using HighfidelityHybrid SimulationDavid Jackson, 1 * Petar Planinic, 1 James Pennington, 1 GigiGuizado de Nathan, 2 Gwen Shonkwiler, 3 Thomas Abdella 11Maternal-Fetal Medicine, 2 Clinical Simulation Center of LasVegas, University of Nevada School of Medicine, Las Vegas,Nevada USA; 3 Medical Education and Evaluations, Universityof Nevada School of Medicine, Reno, Nevada USAObjectives—Few issues are as predictably inevitable as badnews occurring during fetal sonography. There are currently no standardson how to teach this essential communication skill. A pilot program usinghigh-fidelity hybrid standardized patient (SP) encounters for the deliveryof 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 videofeed allowed additional medical and sonography students to observe in aclassroom setting. Transvaginal simulation of an anembryonic gestationand transabdominal simulation of severe fetal hydrocephalus were presented.Resident sonographers were unaware of the impending scenariooutcome. 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 anultrasound machine. Following the simulation, faculty gave immediatefeedback on verbal and nonverbal mannerisms by sharing observationsfrom the recorded video. SPs then provided additional insight on perceivedcommunication skills. The exercise was completed with a classroom didacticon evidence-based techniques for breaking bad news followed byfaculty and participant group discussion.Results—Residents and medical students enthusiastically reportedthat the simulation should be part of any future curricula. Postgraduateyear 1 was designated as the year to begin. Despite varying levelsof training, both residents and medical students rated the experience aslevel appropriate. The simulation was rated 5 overall (with 5 as excellent).Individual segments were rated as: didactic (5), faculty feedback (5), videoreview (4.9), SP feedback (4.75), and viewing in the classroom (4.7).Conclusions—High-fidelity hybrid simulation allows neededskill training in communicating bad news during perinatal sonography. Actorsimulation, faculty video feedback, and a classroom didactic with group discussionare valued components. The use of simulation-based training for allsonographers in communicating bad news is an area for future study.1525554 Coronal Measurement of Fetal Lateral Ventricles: A CrosssectionalUltrasonographic StudyEldad Katorza, 1 * Nir Duvdevani, 1 Jeffrey-Michael Jacobson, 2Yinon Gilboa, 1 Chen Hoffmann, 2 Reuven Achiron 11Obstetrics and Gynecology, 2 Radiology, Sheba Medical Center,Tel Hashomer, IsraelObjectives—The aim of this study was to compare the diameterof the lateral cerebral ventricles measured on a traditional axial viewwith measurements obtained in an unconventional coronal plane.Methods—We conducted a prospective study of 144 fetuses inwhich 2D sonographic measurements of the lateral ventricles in both axialand coronal planes were performed at 19 to 38 weeks of gestation. Seventy-sevenfetuses were evaluated as part of a routine fetal scan (routinegroup), and 67 were referred for a dedicated scan (referral group). Foreach fetus, only the distal lateral ventricle’s diameter was able to be measuredby the “classic” transventricular axial plane, whereas both ventricleswere visible in the posterior coronal plane at the level of the atria using atranscerebellar approach.Results—The mean gestational age was 27.7 ± 4.6 weeks.Good visualization of both ventricles was achieved in 91% of the casesusing the coronal plane. For the entire study group, the mean width of thedistal lateral ventricle on the axial plane was 7.9 ± 1.9 mm vs 8.2 ± 1.9 mmon the coronal plane (P < .001). The mean axial width was 6.6 ± 1.1 mmin the routine group vs 9.3 ± 1.6 mm in the referral group (P < .001). Coronalmeasurements yielded similar results. In addition, slight asymmetryof the ventricles was detected in the routine group (0.2 mm), and the asymmetrywas even more significant in the referral group (1.6 mm; P < .001).Conclusions—Measurement of both proximal and distal ventriclesis very important in the diagnosis of ventriculomegaly and essentialin measuring ventricular asymmetry, both of which can be associatedwith a bad prognosis. Our study showed that coronal measurement of bothproximal and distal ventricles is feasible, an advantage over the axial viewin which only the distal ventricle is clearly visible and measurable.1537200 Feasibility of an Automated Modified Myocardial PerformanceIndex System: A Novel Technique for Automated Measurementof a Modified Fetal Myocardial Performance IndexMi-Young Lee, 1 * Hye-Sung Won, 1 Eun-Jin Jeon, 1 Jae-YoonShim, 1 Hee-Chul Yoon, 2 Jin-Young Choi, 3 Soon-Jae Hong 31Maternal-Fetal Medicine, Asan Medical Center, Seoul, Korea;2Digital Media City Research and Development Center,3Reserch and Development Team, Health and Medical EquipmentBusiness Team, Samsung Electronics Co, Ltd, Suwon, KoreaObjectives—To evaluate the reliability and reproducibility ofthe fetal left modified myocardial performance index (Mod-MPI) meas-S80

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013urements using an Auto Mod-MPI system as a novel technique for measuringthe Mod-MPI.Methods—This was a prospective study of 117 cases from 110normal singleton fetuses at 16.4 to 35.0 weeks of gestation. Two experiencedoperators each measured the left Mod-MPI twice manually and twiceautomatically using the Auto Mod-MPI system (Samsung Electronics Co,Ltd). This system operates as follows. At first, the clear image of the openingand closing clicks of mitral and aortic valves should be obtained. Whenthe operator places the cursor on the aortic outflow in a single Dopplerwaveform and presses the Set key, the system automatically places thecalipers at the beginning of each click and calculates the Mod-MPI within0.1 second. We evaluated whether the automated system can successfullymeasure the left Mod-MPI. Intraoperator and interoperator reproducibilitywere also assessed using intraclass correlation coefficients (ICCs), and themanual and automated measurements obtained by a more experienced operatorwere compared using the Bland-Altman plot and ICCs.Results—Among 117 cases, both operators successfully measuredthe left Mod-MPI in 114 cases using the Auto Mod-MPI system (successrate, 97.4%). All values of automated measurements by both operatorswere perfectly matched (ICC = 1 for both intraoperator and interoperatorreproducibility). Among the manual measurements, the intraoperator ICCsof 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 ICCwas 0.731 (95% CI, 0.678–0.785), and the mean difference between theoperators was 0.017 (95% CI, 0.010–0.024). There was good agreementbetween the manual and automated values measured by the more experiencedoperator (ICC = 0.841).Conclusions—The Auto Mod-MPI system is a fast and reliabletechnique for measuring the Mod-MPI with excellent reproducibility.1541081 First-Trimester Pregnancy Dating by Fetal Heart Rate:A Simple FormulaSarah Obican, 1,2 * Slava Khodak Gelman, 2 John Larsen 21Maternal-Fetal Medicine, Obstetrics and Gynecology,Columbia University, New York, New York USA; 2 Obstetricsand Gynecology, Maternal-Fetal Medicine, George WashingtonUniversity, Washington, DC USAObjectives—Accurate dating is an essential tool in the managementof pregnancies. Thus, we sought:(1) to develop a new formula that establishes an association betweenfetal heart rate (FHR) and gestational age in pregnancies

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013pict the fetus in the same midsagittal plane required for nuchal translucencymeasurement. Subsequently, to ensure uniformity in the approach,standardization, a prerequisite for automation, had to be completed in 2 ofthe 3 orthogonal planes prior to navigating through the volume to commencethe navigation from the plane of the transverse abdominal circumference.This was accomplished by placing the reference dot in the fetalspine at the level of the diaphragm in plane A, generating a transverseplane of the fetal abdomen with the fetal stomach visible in plane B. PlaneB was then chosen as the designated reference plane 0 from which to navigatewithin the volume. We coined this standardized approach the midsagittalvolume technique, and it was carried out on all the volume data setsprior to navigating through each volume. Parallel shift was used startingfrom plane 0, and the spatial relationships to 7 planes (5 cephalad and 2caudad) were established. The median and range were calculated for eachof the planes, and they were evaluated as a function of the fetal crownrump length. P < .05 was considered statistically significant.Results—A total of 63 volume data sets were analyzed. The 8anatomic planes were found to adhere to normal distribution curves, andmost of the planes were in a definable relationship to each other with statisticallysignificant correlations.Conclusions—To our knowledge, this is the first study to describethe possible spatial relationships between eight 2D anatomic planesin the 11 + 6- to 13 + 6-week fetus, using a standardized approach. Definingthese spatial relationships may serve as the first step for the potentialfuture development of automation software for fetal anatomic assessmentat 11 + 6 to 13 + 6 weeks.1537670 Does Cervical Cerclage Placement Prolong Gestation inTwin Pregnancies With a Sonographically Short Cervix?Sara Brubaker,* Samantha Do, Noelia Zork, Cara Pessel,Joy Vink, Annette Perez-Delboy, Sreedhar GaddipatiObstetrics and Gynecology, Columbia University Medical Center,New York, New York USAObjectives—There are limited data to support the use of cervicalcerclage in twin pregnancies. The practice has become less commonsince the 2005 publication of a meta-analysis that revealed an increasedrisk of adverse pregnancy outcomes among twin pregnancies in which acerclage was placed. The practice continues, however, likely driven in partby patient request. Our objective was to compare gestational age at deliveryamong patients with twins and a short cervix who underwent cerclageplacement with those who did not.Methods—We created a retrospective database of twin gestationsthat were diagnosed with a short cervix (cervical length ≤2.5 cm)between 2004 and 2012 at our institution. Mean gestational age (GA) atdelivery was compared in women who did and did not undergo cerclageplacement using a 2-sample t test. The relative risk (RR) of delivery priorto 32 and 34 weeks’ gestation was compared using a 2-sided χ 2 test.Results—Of the 158 women that met the inclusion criteria, 25underwent cerclage placement. The mean GA at delivery in the cerclagegroup was 32.6 weeks vs 33.8 weeks for the no-cerclage group (P = 0.77).The RRs of delivery at

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013SCIENTIFIC E-POSTERS1426579 Process for Selection and Implementation of a New UltrasoundImaging SystemDonald Tradup, 1 * Scott Stekel, 1 Deirdre King, 1,2 NicholasHangiandreou 1 1 Radiology, Mayo Clinic, Rochester,Minnesota USA; 2 Trust Addenbrooke’s Hospital, Cambridge,EnglandObjectives—Many factors come into play when selecting a newultrasound (US) imaging system, including image quality, work flow efficiency,ergonomics and system usability, and system serviceability. Thispresentation will describe a comprehensive process for US equipment selectionand implementation in the practice.Methods—(A) Assessment of practice requirements. (B) Keyscanner features to consider: (1) available transducers; (2) imaging features;(3) work flow efficiency and ergonomic enhancements; (4) technicalcharacteristics and features. (C) In-house prepurchase scannerevaluation: (1) performance testing; (2) volunteer imaging and image qualityassessment; (3) patient imaging.Results—Clinical implementation after purchase: (1) acceptancetesting; (2) configuration of image presets and exam protocols; (3)user training.Conclusions—This presentation will describe a comprehensiveprocess for selection and implementation of new US imaging systems.Key elements of the selection process include a practice needsassessment, review of available scanner features and capabilities, and anin-house evaluation of all candidate systems prior to purchase. After purchase,acceptance testing, system configuration, and user training must allbe addressed.1427024 Usefulness of 4-Dimensional Ultrasonogaraphy to EvaluateEffects of Therapeutic Radiofrequency Ablation for HepatocellularCarcinomaNaoki Hotta Gastroenterology, Masuko Memorial Hospital,Nagoya, JapanObjectives—Studies to evaluate the tumor vascularity in hepatocellularcarcinoma (HCC) have been done extensively with various imagingmodalities because the finding of the vascularity is helpful toevaluate the biological features of the tumor. In the present study, we investigatedwhether 4D real-time flow imaging is useful to display the accurateposition of the radiofrequency ablation (RFA) needle in the tumorand evaluated the efficacy of RFA therapy in patients with HCC.Methods—Fifty-eight patients with 58 HCC lesions admitted toour Masuko Memorial Hospital between November 2007 and February2011 were enrolled in the present study. Their diagnosis was confirmed bydynamic computed tomography and celiac angiography. All patients gavewritten informed consent, and this protocol had been approved by theHuman 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 (PhilipsHealthcare, Bothell, WA) systems for RFA therapy with a convex probe asUS systems. The Aplio and Voluson machine probe is mechanical probe, andthe iU22 probe is matrix array probe. 4D real-time refers here to the displayof 3D moving images composed of 3 orthogonally intersecting scans in thetransverse, longitudinal, and horizontal planes. RFA was carried out underreal-time US guidance. We used an RF generator with 200 W of power connectedto a 17-gauge perfusion needle (Radionics Inc, Burlington, MA); thecircuit was closed through a dispersive electrode.Results—It was possible to obtain an accurate position of thecool-tip needle and to perform the RFA procedure in all 58 HCC patientswith 58 nodules using 4D real-time US machines. We confirmed by variousangles that the needle was inserted into the center of the tumor nodule.The simultaneous study before RFA therapy showed the inflow ofarterial blood and tumor stain, and importantly, it appeared that 4D realtimeUS provided much perceptible information on the spatial relationshipbetween the RFA needle and the target lesion.Conclusions—We experienced the treatment of 58 patient withHCC by RFA using 4D real-time US systems. Application of this methodallowed more accurate cauterization of the tumor.1463047 Using Lung Ultrasound in the Diagnosis of TransientTachypnea of the Newborn and Hyaline Membrane Diseasein Neonates at 28 Weeks’ Gestation and LaterClaudia Cadet,* James Tsung, Ian Holzman Neonatology,Mount Sinai School of Medicine, New York, New York USAObjectives—Hyaline membrane disease (HMD) and transienttachypnea of the newborn (TTN) are common neonatal respiratory disorderswith overlapping clinical presentations, gestational ages, and radiographicpictures. Ultrasonographic findings may distinguish thesedisorders; however, data comparing diagnoses and disease severity bylung ultrasound with those by chest radiography and clinical impressionare lacking. This study aimed to determine if ultrasound (1) can predict theseverity of the clinical course and (2) is diagnostically consistent withchest radiography and the clinical impression.Methods—We conducted a prospective study of infants ≥28weeks’ gestation admitted from October 15, 2011, to June 15, 2012, withrespiratory distress. A group of similar but well patients were enrolled ascontrols. Lung ultrasound was performed on each subject in the first 24hours of life using a GE LOGIQ P5 ultrasound machine with a 10 linearprobe in both sagittal and transverse planes on anterior, axillary, and posteriorviews of each lung. Demographic data, duration of respiratory support(DRS), surfactant administration, radiographic diagnosis, and clinicaldiagnosis were collected. An expert blinded to clinical data determinedultrasonic diagnoses and percentage of B-line confluence (PBC). The primaryoutcome was to correlate ultrasound PBC with DRS. Secondary outcomeswere comparisons of ultrasound diagnoses with those byradiography 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 significantcorrelation of DRS with PBC (R = 0.693; P = .001), improved by gestationalage in a multivariable model (R = 0.765, P = .024) but not by birthweight, age at ultrasound, maternal steroids, and mode of delivery. Ultrasoundwas 62.5% sensitive and 100% specific in diagnosing HMD.Conclusions—PBC on lung ultrasound in the first 24 hours oflife in neonates with respiratory distress correlates well with the durationof respiratory support and thus may be a useful predictor of disease severity.Ultrasound was a moderately sensitive and extremely specific test todiagnose HMD.1464510 Central Line Confirmation With Saline and EchocardiographyErshad Elahi,* Ninfa Mehta, Shahriar Zehtabchi EmergencyMedicine, State University of New York Downstate,Brooklyn, New York USAObjectives—The purpose of this study is to determine the confirmationof central venous catheter (CVC) placement by using echocardiographyand agitated saline flushed through the catheter port.S83

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Methods—This study will be a prospective convenience sampleof adults who received either subclavian of internal jugular CVCs asdeemed necessary by the attending physician independent of the study.Enrolled patients will undergo CVC placement by a resident or attendingphysician with a study investigator present to perform echocardiographyand interpret the study of the agitated saline flush in real time A chest x-ray will be performed to confirm CVC placement as the gold standard inconfirmation. Outcome Measures: The primary outcome of the study is thecorrelation of positive interpretation of confirmation of CVC placement onecho with correct placement as seen on chest x-ray. The other outcomemeasure is time to confirmation with echo vs time to confirmation withchest x-ray. Methods of Data Analysis: Data will be presented as medianand interquartiles (25%–75% quartiles) for continuous variables and percentageswith 95% confidence intervals (CIs) for categorical variables.Operating characteristics of bedside ultrasound in confirmation of CVCwill be reported by calculating sensitivity, specificity, and positive andnegative likelihood ratios, with respective 95% CIs. The time from procedurecompletion to confirmation by bedside ultrasound and time fromprocedure completion to confirmation by chest x-ray will be presented asmedian minutes with interquartiles. The comparison of these 2 measurementswill be performed by Mann-Whitney U test. Occurrence of adverseevents will be reported as percentages with 95% CI. Sample size was calculatedwith projected sensitivity of 0.95 with a lower CI limit of 0.90; 91patients will be enrolled in the study. Bedside ultrasounds for each enrolledsubject will be saved and reviewed by a trained sonographer blindedto the chest x-ray results. The inter-rater agreement of the blinded sonographerwith the real-time sonogram interpretations will be measured byCohen’s weighted κ.Results—This study is still undergoing Institutional ReviewBoard approval.Conclusions—None yet.1489380 Vascular Imaging of Lymph Node MetastasesRobert Bard Biofoundation, New York, New York USAObjectives—To demonstrate the appearance of benign and malignantlymphadenopathy with 3D power Doppler sonography (3D-PDS)and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).Methods—One hundred twenty-five patients with invasivebreast cancer and 221 patients with postoperative lumpectomy/mastectomyfollow-up were prospectively scanned with a GE Voluson E9 unitemploying a linear 12–18-MHz probe with conventional 3D/4D imagingusing 3D angio and glass body power Doppler image reconstruction. Allpatient images were imaged by DCE-MRI with a 3T Siemens unit within1 week of the sonogram. All lesions were later confirmed by surgery.Results—3D PDS and DCE-MRI showed the nodal neovascularityin both axillae in 56 of 346 and 80 of 346 in a unilateral axilla. Thelesions were imaged well by both modalities and showed high correlationwith surgical findings. Imaging showed 136 of 346 positive axillae ascompared to 69 of 346 clinically detectable by palpation.Conclusions—3D power Doppler imaging appears to as sensitiveas DCE-MRI in detecting axillary lymphadenopathy. Vascular mappingmay be useful in preoperative lymphadenectomy planning. 3Dmapping may permit image-guided treatment.1489474 Ultrasonic Imaging of Treated Rheumatoid and PsoriaticArthritisRobert Bard Biofoundation, New York, New York USAObjectives—To follow treatment progress of arthritis with 3Dpower Doppler sonography (3D-PDS) and dynamic contrast-enhancedmagnetic resonance imaging (DCE-MRI).Methods—Nine patients with active rheumatoid arthritis of thewrist and digits and 6 patients with psoriatic arthritis of the phalanges werestudied over a 1-year period.Results—3D-PDS and DCE-MRI showed the vascularity absentposttreatment in 8 of 9 rheumatoid patients with 80% symptomaticimprovement and 4 of 6 psoriatic patients with 80% symptomatic improvement.Inflammatory neovascularity decreases occurred 1 to 2 monthsbefore 80% improvement attained in all responders.Conclusions—Vascular imaging combining DCE-MRI andDoppler ultrasound appears useful in follow-up of medical anti-inflammatorytreatments.1489583 Multimodality Imaging of Laser-Ablated Prostate TumorsRobert Bard,* Daniel Sperling Biofoundation, New York,New York USAObjectives—To follow thermal treatment progress of prostatecancers with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhancedmagnetic resonance imaging (DCE-MRI).Methods—Fifty-nine patients with Gleason grade 3 or 4 focalprostate cancer were prospectively scanned with a GE Voluson E9 unitemploying a linear 18-MHz probe with conventional 3D/4D imagingusing 3D angio and glass body power Doppler image reconstruction. Allpatient images were imaged by DCE-MRI with a 3.0-T Siemens unitwithin 1 week of the sonogram. Patients were treated with a 980-wavelengthdiode laser with end-fire heat distribution. Safety thermal zoneswere outlined to protect the rectum and neurovascular bundles.Results—3D-PDS and DCE-MRI showed the tumor vascularityabsent posttreatment in 59 of 59 patients. No posttreatment complicationswere noted.Conclusions—Vascular imaging combining DCE-MRI andDoppler ultrasound appears useful in preoperative planning and follow-upof laser ablative treatments.1489649 Multimodality Vascular Imaging of Bladder TumorsRobert Bard,* Daniel Sperling Biofoundation, New York,New York USAObjectives—To demonstrate the appearance of benign and malignantbladder 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/or5 base of prostate cancer and 21 patients with bladder polyps and stoneswere prospectively scanned with a GE Voluson E9 unit employing a linear12–18-MHz probe with conventional 3D/4D imaging using 3D angioand glass body power Doppler image reconstruction. Contrast-enhancedultrasound was performed on 3 patients. All patient images were imagedby 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 vascularconnection from the prostate extending into the bladder base. The vascularframework of transitional cell carcinomas was generally separable fromthe previously noted base of prostate tumors. The lesions of a benign naturewere imaged well by both modalities and included intravesical diseasessuch as polyps, stones, blood clots, and intraluminal prostate debrisfollowing postoperative procedures.Conclusions—3D power Doppler imaging appears to as sensitiveas DCE-MRI in detecting bladder tumors. The role of a possiblescreening test for evaluating hematuria deserves further study. Imaging inpatients with bladder base lesions may disclose unsuspected primary prostatictumors. Vascular mapping may be useful in preoperative planning.1505305 Multimodality Imaging of Microwave-Treated Prostate TumorsRobert Bard Biofoundation, New York, New York USAObjectives—To follow the thermal treatment progress of microwavedprostate cancers with 3D power Doppler sonography (3D-PDS)and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).S84

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Methods—Twelve patients with Gleason grade 4 prostate cancerwere prospectively scanned with a GE Voluson E9 unit employing alinear 18-MHz probe with conventional 3D/4D imaging using 3D angioand glass body power Doppler image reconstruction. All patients wereimaged by DCE-MRI with a 1.5-T Siemens unit within 1 week of thesonogram. All lesions were followed by serial vascular imaging for 5years. Six recurrences were found and biopsy proven. Three were retreatedby microwave, remaining stable, and 3 were retreated with MRI-guidedlaser ablation in 2012.Results—3D-PDS and DCE-MRI showed the tumor vascularrecurrence in 6 of 12 patients who were retreated and followed without recurrencemeasured either by a vascularity increase or prostate-specificantigen rise.Conclusions—Vascular imaging appears useful in preoperativeplanning and follow-up of microwave thermal treatments.1505306 Multiplanar Mapping of CelluliteRobert Bard Biofoundation, New York, New York USAObjectives—To compare the accuracy of 3D sonographic mappingof cellulite with high-resolution small-field 3-T magnetic resonanceimaging (MRI).Methods—Over a 2-year period, 99 consecutive patients withpalpable lower extremity subcutaneous nodules were preoperativelyscanned with a GE Voluson E9 unit employing a linear 18-MHz probewith 3D angio and glass body power Doppler image reconstruction and a3.0-T MRI small field of view within 1 week. All images were comparedwith histologic sections. During the last year of the study, access to 22–70-MHz linear probes permitted the concomitant study of 53 patients withcellulite. Cellulite was studied with A- and B-mode ultrasound, color,power, and angio Doppler, and 3D histogram analysis of the regional bloodsupply and small-field 3-T MRI. Treatment used laser and antioxidanttherapies.Results—With the use of 22–70-MHz probes, areas of cellulitewere imaged as part of a study using antioxidant therapies to reduce disfiguringareas. MRI had no diagnostic value in cellulite evaluation, althoughit accurately depicted fat compartments. Additionally, Dopplerultrasound blood flow analysis showed abnormal flows in the regions ofgreatest cellulite architectural distortion. The depth of the subcutaneousfat may be measured and the penetration of the cellulite may be assessedwith 3D volumetric dermal/subdermal imaging.Conclusions—3D multiplanar ultrasound imaging appears tobe significantly more accurate than MRI in diagnosing cellulite and mayfacilitate laser ultrasound-guided treatments. Previsual treatment improvementmay be noted by a decrease in inflammatory neovascularity.1506560 Prostate Cancer Neovascular Responses to AntioxidantsRobert Bard Biofoundation, New York, New York USAObjectives—To show Doppler sonographic vessel density imagingresponses to antioxidant therapies.Methods—One hundred eleven patients with prostate cancertreated with antioxidant supplement therapies composed of beta-sitosterol,resveratrol, and herbal antioxidants and followed over a 4-year periodwere prospectively scanned with a GE Voluson E9 unit employing an endorectal18-MHz probe with conventional 3D/4D imaging using 3D angioand glass body power Doppler image reconstruction. Eighty-seven patientshad 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 sonographyby 3D histogram analysis and by dynamic contrast enhanced magneticresonance imaging (DCE-MRI). Follow-up biopsies were obtained shortlyafter imaging studies, which occurred on a 6-month basis.Results—Gleason grade 3 (low grade): 72 of 87 patients haddecreased vascular indices, indicating a positive response to the protocol.Prostate-specific antigen (PSA) lowering was noted. Gleason grade 4 (highgrade): 10 of 23 patients had decreased vascular indices, indicating a positiveresponse to the protocol. PSA lowering was noted. Five patients werestable. Eight patients showed disease progression and a PSA rise, indicatinga negative response to the protocol. DCE-MRI confirmed all sonographictumor vascular findings. Biopsy correlation was good.Conclusions—Vessel density sonographic indexing and DCE-MRI analysis correlated well with a positive biochemical response to antioxidanttherapies. Twenty-one percent of patients with aggressive tumorswho were nonresponders to this protocol were referred for alternative treatmentsin a timely manner.1506561 Prostate Cancer 3-Dimensional Capsular Erosion Alert forBone Metastases and Lymphadenopathy EvaluationsRobert Bard Biofoundation, New York, New York USAObjectives—To show capsular erosion as an alert to bonemetastases.Methods—Eighty-one patients with capsular erosion evidenton 3D imaging were prospectively scanned with a GE Voluson E9 unitemploying an endorectal 18-MHz probe with conventional 3D/4D imagingusing 3D angio and glass body power Doppler image reconstructionand dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).Results—Sixty-seven of 81 patients had boney metastasesidentified on MRI and bone scans. Two hundred forty patients withoutcapsular erosion on 3D imaging showed bone metastases in 3 of 240cases. Capsular erosion was associated with perirectal adenopathy in 40of 81 patients.Conclusions—Patients with capsular erosion demonstrated a3× incidence of bone metastases and a 2× incidence of perirectal lymphadenopathy.Since bone metastases are difficult to image on some standardMRI protocols, DCE-MRI may be requested to highlight abnormalneovascularity.1507806 Evaluation of a Small Abdominal Circumference by Ultrasoundas a Predictor of Increased Doppler ResistancePedro Roca, 1 * Allen Kunselman, 2 Gabor Mezei, 1 Kari Whitley,1 Serdar Ural, 1 John Repke 1 1 Obstetrics and Gynecology,2Public Health Sciences, Penn State Hershey Medical Center,Hershey, Pennsylvania USAObjectives—Ultrasonographic fetal evaluation has been usedto diagnose intrauterine growth restriction (IUGR). A measurement thathas shown to be predictor of IUGR is the fetal abdominal circumference(AC). The use of Doppler of the umbilical arteries is helpful in followingfetuses previously diagnosed with IUGR. However, Doppler evaluation ofumbilical arteries has failed to be diagnostic for IUGR. To date, no studyhas specifically examined the relationship if any between AC measurementsby ultrasound and umbilical artery Doppler values. The objective ofthis study was to determine if findings of decreased AC during ultrasoundcan be used as an independent predictor of increased umbilical arteryDoppler resistance in fetuses.Methods—After Institutional Review Board approval, we conducteda retrospective cohort study of all ultrasound studies performed atthe maternal-fetal medicine Unit in our center from July to November2009. We obtained the fetal AC expressed as a percentile of gestational ageand measured the umbilical artery Doppler. The association between ACand elevated umbilical artery Doppler was evaluated.Results—A total of 299 patients were evaluated. We used theSAS 9.2 system to evaluate the 2 main variables, AC percentile and umbilicalartery Doppler. We found a linear association between AC percentilesand umbilical artery Doppler percentiles. The Pearsoncorrelation coefficient was –0.03 (95% confidence interval, –0.40, –0.19). The R2 value was only 0.09, which means that only 9% of theumbilical artery Doppler percentile variability is explained by the ACpercentile.S85

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Conclusions—The AC percentile is a weak predictor of abnormalumbilical artery Dopplers. Further research may help in determiningif ultrasound evaluations other than the AC percentile may stronglycorrelate with IUGR.1508173 Persistence of Placenta Previa in Twin Pregnancies Diagnosedin the Second Trimester by the Degree of CervicalOverlapSimi Gupta, 1 * Nathan Fox, 1,2,3 Andrei Rebarber, 1,2,3 DanielSaltzman, 1,2,3 Chad Klauser, 1,2,3 Ashley Roman 1,2,3 1 Obstetricsand Gynecology, New York University School of Medicine,New York, New York USA; 2 Maternal-Fetal Medicine, CarnegieImaging for Women, New York, New York USA; 3 Obstetrics andGynecology, Mount Sinai School of Medicine, New York, NewYork USAObjectives—Several studies in singleton gestations with completeprevia have determined that the degree of placental overlap correlateswith the likelihood of persistence of previa at the time of delivery. However,no studies have correlated these findings in twin gestations. The objectiveof this study was to determine if the measurement of placentaloverlap in twin pregnancies diagnosed with complete previa during thesecond trimester will predict persistence of placenta previa at the time ofdelivery.Methods—This was a retrospective cohort study of twin pregnancieswith complete placenta previa diagnosed at 15 to 19 and 20 to 23weeks’ gestation from 2005 to 2011. All patients underwent transvaginalultrasound using GE Voluson or Medison equipment. The degree ofplacental overlap was measured from the internal os to the edge of theplacenta and was correlated with the risk of persistence at the time of delivery.Groups were compared using the Mann-Whitney U test and Fisherexact test as appropriate with P < .05 as significance.Results—Of 532 twin gestations, 41 patients (7.7%) wereidentified as having complete previa at 15 to 19 weeks’ gestation, and 9of 41 patients (22%) had persistence of placenta previa at the time ofdelivery. At 15 to 19 weeks, there was no significant difference in medianoverlap between patients who had persistence of previa or resolutionof 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 medianoverlap between patients who had persistence of previa or resolution ofprevia 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 wasno significant difference in the risk of persistence at the time of delivery.Conclusions—In our population of twin gestations, the degreeof overlap of complete previa during the second trimester did not correlatewith the likelihood of resolution by the time of delivery.1509891 Sonographic Morphologic Score as a Predictor of the Outcomein Fetal Sacrococcygeal TeratomaMarjan Bolouri, 1 * Eveline Shue, 2 Douglas Miniati, 2 VickyFeldstein 1 1 Radiology and Biomedical Imaging, 2 Surgery,University of California San Francisco Medical Center, SanFrancisco, California USAS86Objectives—Sacrococcygeal teratoma (SCT) is the most commontumor of the neonate. Ultrasound (US) is critical in the prenatal evaluationof fetuses with SCT, for whom outcomes vary widely. The purposeof this study was to develop a morphologic scoring scheme to use as apredictor of the outcome in fetuses with SCT.Methods—The records of all patients carrying fetuses diagnosedwith SCT between 1986 and 2011 at our fetal treatment center werereviewed; those with available outcome data and US examinations wereincluded in the study (n = 40). Two radiologists, blinded to the outcome,retrospectively reviewed the obstetric sonograms performed at presentation.Tumor sonographic morphology was classified as predominantlycystic (>60%), predominantly solid (>60%), or mixed (40%–60% solidand cystic). Tumor volume measurements and volume/estimated fetalweight ratios were calculated. Good outcomes were defined as survival tohospital discharge, whereas poor outcomes were defined as intrauterinefetal demise, termination for hydrops or maternal mirror syndrome, perinataldeath, or need for fetal intervention. Sensitivity, specificity, and thepositive predictive value (PPV) of morphology as a predictor of outcomewas calculated.Results—A predominantly solid (>60%) sonographic appearancewas associated with a poor outcome. Of 40 cases in this series, 10SCTs were predominantly cystic, and 29 were predominantly solid on initialUS. One mass appeared 50% cystic and 50% solid. The mean gestationalage at presentation was 23 weeks. No significant difference in meantumor volume was seen between those with a poor outcome and those witha good outcome (347 versus 183 cm 3 ; P = .124). Mixed to predominantlysolid US morphology was associated with poor outcomes (sensitivity,100%; specificity, 67%; PPV, 83%). None of the SCT cases presenting withpredominantly cystic sonographic morphology had a poor outcome.Conclusions—A predominantly solid SCT appearance by USis a highly sensitive predictor of a poor outcome. Therefore, sonographicmorphologic assessment is a useful predictor of the postnatal outcome inthe prenatal evaluation of fetal SCT. This may be useful for prognosis andguiding obstetric management.1511819 Retrospective Review of Fetal Body LymphangiomaIncluding Postnatal OutcomeKari Thomas, Karen Oh, Roya Sohaey* Diagnostic Radiology,Oregon Health and Science University, Portland, Oregon USAObjectives—The purpose of this retrospective review is to studya series of 8 fetal body lymphangiomas (a type of lymphatic malformation)detected on prenatal ultrasound and to assess how findings on fetal magneticresonance imaging (MRI) and/or postnatal MRI or computed tomography(CT) differed from the prenatal ultrasound, primarily withregard to the overall anatomic extent of the malformation. Accuratedetermination of the overall extent of these malformations is critical indelivery and postnatal treatment planning.Methods—We reviewed each patient’s prenatal ultrasound andthen compared these findings with subsequent fetal MRI and/or postnatalimaging. Postnatal imaging included MRI and/or CT. Maternal and neonatalelectronic 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 deliveryplanning (with fetal MRI) and treatment options (with both fetal MRIand postnatal imaging). This information, regarding the size of the malformationand involvement of adjacent organs, was not fully disclosed byprenatal ultrasound findings alone.Conclusions—The extent of fetal body lymphangiomas is routinelyunderestimated by prenatal ultrasound. Fetal MRI and/or postnatalcross-sectional imaging provided additive diagnostic benefit in every case.These imaging modalities should be offered to patients when fetal lymphangiomais diagnosed on prenatal ultrasound.1513506 Effect of Targeted Ultrasound Contrast Agent Attachmenton Nonlinear Frequency EmissionsJohn Eisenbrey, 1 * Valgerdur Halldorsdottir, 1,2 Anush Sridharan,1,3 Joshua Rychak, 4 Flemming Forsberg 1 1 Radiology,Thomas Jefferson University, Philadelphia, Pennsylvania USA;2School of Biomedical Engineering and Health Systems, 3 Electricaland Computer Engineering, Drexel University, Philadelphia,Pennsylvania USA; 4 Targeson Inc, San Diego, California USAObjectives—Current strategies for differentiating attached fromunattached targeted ultrasound contrast agents (UCAs) rely on using motiontracking or signal changes after destructive pulses, both of which in-

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013herently introduce temporal artifacts. In this study, the effect of UCA attachmenton nonlinear frequency emissions was investigated as a potentialreal-time discriminatory attachment marker.Methods—Nonlinear UCA behavior was studied using singleelementtransducers and acoustically transparent Opticells (Nalge NuncInternational, Rochester, NY). Attachment Opticells were coated withstreptavidin (to provide a site for attachment) followed by incubation with5% 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 triplicateand attachment counting/confirmation via light microscopy. An Opticellcoated with BSA alone was used as a negative specificity control with anequivalent concentration of microbubbles (≈1 9 microbubbles/mL) added.Nonlinear bubble behavior was investigated by transmitting 4- and 5-MHz64-cycle pulses with a spherically focused single-element transducer(Panametrics, Waltham, MA) and receiving signals with a 3.5-MHz sphericallyfocused single-element transducer. Frequency spectra were thencompared after normalization to the fundamental peak.Results—Secondary harmonics (2f0) were evident in all caseswith no differences in relative amplitudes observed between attachedand unattached UCAs. Generating subharmonic signals (f0/2; 2.0/2.5MHz) proved difficult for both UCA groups. However, at 4 MHz, unattachedbubbles began to show subharmonic behavior at 470 kPa with aclear peak at 694 kPa. No definitive subharmonic peak was observedusing attached UCAs. Excitation at 5 MHz did generate some nonlinearbehavior in the subharmonic range, but differentiation of the subharmonicpeak was difficult, presumably due to reflections generated bythe Opticell surface.Conclusions—Targeted UCA attachment does not appear toaffect the second harmonic but may potentially inhibit the subharmonic.This criterion may be useful for real-time identification of microbubbleattachment.1513519 Correlation of Ultrasound Contrast Agent–Derived BloodFlow Parameters With Immunohistochemical Markers inMurine Xenografts: Influence of the Imaging Mode, TumorModel, and Subcutaneous LocationJohn Eisenbrey, 1 * Christian Wilson, 1,3 Raymond Ro, 1,4 TraciFox, 2 Ji-Bin Liu, 1 See-Ying Chiou, 1 Flemming Forsberg 11Radiology, 2 Radiological Sciences, Jefferson College of HealthProfessions, Thomas Jefferson University, Philadelphia, PennsylvaniaUSA; 3 College of Physicians and Surgeons, ColumbiaUniversity, New York, New York USA; 4 School of BiomedicalEngineering, Sciences, and Health Systems, Drexel University,Philadelphia, Pennsylvania USAS87Objectives—To compare ultrasound contrast agent (UCA)-derived blood flow parameters to immunohistochemical markers in gliomaand breast cancer murine xenograft models.Methods—Breast cancer (NMU) or glioma (C6) cells were implantedin either the abdomen or thigh of 144 Sprague Dawley rats andrandomly separated into groups of 6, 8, or 10 days post implantation (12rats per time point × 2 cell lines × 2 implant locations). Imaging was performedusing power Doppler imaging (PDI), harmonic imaging (HI), andmicroflow imaging (MFI) on with an Aplio scanner with a 7.5-MHz lineararray (Toshiba America Medical Systems, Tustin, CA) during bolus tailvein injection of the UCA Optison (GE Healthcare, Princeton, NJ; 0.4mL/kg). Contrast kinetic blood flow parameters consisting of maximumintensity, time to peak, perfusion, and time-integrated intensity (TII) werecalculated from time-intensity curves using parametric analysis on a pixelby-pixelbasis and averaged over the tumor area. These values were comparedto 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 inversecorrelation was only observed between TII and VEGF for all 3 imagingmodes (R = –0.35, –0.54, and –0.32 for PDI, HI, and MFI, respectively).When grouping data by tumor type, the NMU group correlationsbecame nonsignificant, while the correlation within the C6 group increased(R = –0.43, –0.54, and –0.52 for PDI, HI, and MFI, respectively). Whengrouping by tumor location, a significant correlation was not observed forthe thigh-implanted group, while the correlation within the abdominaltumor 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 theabove trends, the strongest correlation of TII to VEGF for all subgroupswas 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 angiogenicmarker VEGF. However, these correlations were found to depend on bothtumor type and location.1514789 Time From Nursing Request to Probe Placement DelaysUltrasound-Guided Peripheral Intravenous Catheter Placementin Emergency Department Difficult-Access PatientsGlenn Heimburger,* Leigh Patterson, Kori Brewer EmergencyMedicine, East Carolina University, Greenville, NorthCarolina USAObjectives—To assess the total time needed for ultrasound(US)-guided peripheral intravenous (IV) catheter placement by emergencymedicine (EM) physicians in difficult-access patients.Methods—Prospective convenience sample of patients presentingto an academic tertiary care center emergency department. Inclusioncriteria were the need for IV access and inability of any availablenurse to establish a peripheral IV catheter. Exclusion criteria were the needfor central venous access or unstable patients as defined by the treatingphysician. All physicians received introductory training prior to enrollingpatients. Outcomes measured were times from nursing request to probeplacement, probe placement to first skin puncture, first skin puncture tosuccessful cannulation or procedure abandonment, and total time fromnursing request to procedure completion. Number of failed nursing attempts,skin punctures, physician experience with US-guided peripheralIV catheter placements (0–4, 5–9, or ≥10 previously placed), and physiciantraining level were recorded.Results—Sixty-four patients were enrolled. The mean (±SD;range) times were: total time, 35.5 minutes (±21; 5–110 minutes); nursingrequest to probe placement, 20.9 minutes (±18; 1–100 minutes); probeplacement to first skin puncture, 5.8 minutes (±5; 1–34 minutes), and firstskin puncture to successful cannulation or procedure abandonment, 8.7minutes (±8; 1–36 minutes). Average number of failed nursing attemptswas 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 decreasedtotal procedure time (P = .04) and time from probe placement tofirst skin puncture (P = .04).Conclusions—The largest delay in placing a US-guided peripheralIV catheter by an EM physician after nursing failure occurs fromnursing request to probe placement. Future studies should examine if variablesexist during this period that could decrease total procedure time. Previousexperience with placing US-guided peripheral IV catheters decreasesoverall procedure time.1514851 A New Sonographic Sign for Perinatal Torsion: the “KiwiSign”Ashraf Goubran, 1,3 * Fern Karlicki, 1 Karen Letourneau, 1Ganesh Srinivasan 2 1 Ultrasound, 2 Neonatology, St BonifaceGeneral Hospital, University of Manitoba, Winnipeg, Manitoba,Canada; 3 Diagnostic Imaging, Ain Shams University,Cairo, EgyptObjectives—Perinatal torsion must be recognized in an urgentfashion if the testicle is to be salvaged. The purpose of this limited case se-

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013ries is to describe a new sonographic sign for perinatal torsion that has, toour knowledge, not been described previously.Methods—Five cases underwent grayscale, color, and pulsedDoppler evaluation for suspected torsion in the perinatal period during a26-month interval. The age of presentation ranged from birth to 30 days.The studies were performed using a Philips iU22 ultrasound machine. Alinear high-frequency transducer (17 MHz) was used for scanning. Thesecases were retrospectively analyzed with regard to clinical and sonographicfindings.Results—The grayscale appearance of the affected testicle wasquite abnormal in our cases (n = 5). We subdivided our cases into 2 groupsbased on the sonographic findings. The first group (n = 2) represented theearly phase of perinatal torsion, which we believe could have been potentiallysalvageable. The affected testicle in this group was markedly enlargedwith a heterogeneous echo texture. Linear hypoechoic striationswere seen, radially oriented from the mediastinum testicle, giving a characteristicappearance of a section in a kiwi fruit. The second group (n = 3)represented the nonsalvageable late phase of perinatal torsion, in which theaffected testicle was small and heterogeneous. Color Doppler assessmentin the affected testicle in both groups showed no flow.Conclusions—On the basis of the limited number of cases includedin our study and a review of the literature, we suggest that the “kiwisign” may become a useful finding representing the early phase of perinataltorsion. Future studies on a larger scale may prove that this sign canbe established as a reliable indicator to aid in surgical decision making.1515353 The Swollen Pediatric Scrotum: Ultrasound Technique andDifferential DiagnosisKelli Schmitz, 1 Kathryn Snyder, 1 David Geldermann, 2 RoyaSohaey 1 *1 Diagnostic Radiology, Oregon Health and ScienceUniversity, Portland, Oregon USA; 2 Colgate University, Hamilton,New York USAObjectives—Review the ultrasound protocol for performanceof scrotal ultrasound in pediatric patients and illustrate the ultrasound appearanceof conditions resulting in scrotal swelling. Provide a brief summaryof scrotal embryology.Methods—Retrospective review of an imaging database of pediatricpatients presenting with scrotal swelling who underwent diagnosticultrasound at a tertiary pediatric referral center. When available,surgical/pathologic correlation was obtained. Some cases were diagnosedin utero.Results—Causes for pediatric scrotal swelling include intravaginaland extravaginal torsion, epididymitis/orchitis, hydrocele (simple,inguinoscrotal, abdominoscrotal, iatrogenic, and spermatic cord), varicocele,inguinal hernia, trauma, adrenal rest, and testicular or paratesticularneoplasms.Conclusions—A variety of typical and atypical pathologicprocesses resulting in pediatric scrotal swelling will be presented in thispictorial review. Best-practice ultrasound technique will be reviewed.1515361 Suprarenal Masses in the FetusSarah Rogers, Karen Oh, Roya Sohaey* Diagnostic Radiology,Oregon Health and Science University, Portland, OregonUSAObjectives—Our objective is to review the imaging and differentialdiagnosis of fetal suprarenal masses.Methods—Prenatal ultrasound and magnetic resonance imagingof fetal suprarenal masses is presented, along with clinical informationand follow-up. Imaging pearls and differential considerations for each diagnosiswill be discussed.Results—Fetal suprarenal masses, diagnoses include congenitaladrenal hyperplasia (symmetric and asymmetric), extralobar pulmonarysequestration, neuroblastoma, partial multicystic dysplastic kidney, renalduplication, urinoma, gastric duplication cyst, and splenic cyst. Fetal adrenalmasses are often malignant, and every attempt should be made todifferentiate between them and other diagnoses. Recognizing the range ofmalignant and benign suprarenal fetal masses that can present on prenatalimaging can help guide patient counseling and management.Conclusions—The differential diagnosis of a suprarenal massis broad but can be narrowed by imaging characteristics. A pictorial reviewof suprarenal masses is presented along with technique and imaging pearlstoward accurate diagnosis.1518185 Extraovarian Adnexal Sonographic Findings in EctopicPregnancy: A ReappraisalMary Frates,* Peter Doubilet, Hope Peters, Carol BensonRadiology , Brigham and Women’s Hospital, Boston, MassachusettsUSAObjectives—To assess the frequency of extraovarian adnexalsonographic findings in patients with ectopic pregnancy using state-ofthe-artsonographic equipment.Methods—All patients with pathologic or sonographic confirmationof 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 retrospectivelyreviewed for the presence of an extraovarian adnexal massand for a moderate-to-large amount of free fluid. In cases with an adnexalmass, the presence of a tubal ring, yolk sac, or embryonic cardiac activitywas recorded.Results—Our study population comprised 231 patients. A positivefinding—adnexal mass and/or free fluid—was present in 220 of 231patients (95.2%): adnexal mass in 218 of 231 (94.4%) and a moderate-tolargeamount of free fluid in 56 of 231(24.2%). Among our 231 studycases, sonography demonstrated a tubal ring in 75 (32.5%), a yolk sac in19 (8.3%), and embryonic cardiac activity in 17 (7.4%). In 140 cases(60.6%), TVS demonstrated a nonspecific adnexal mass (without tubalring, yolk sac, or cardiac activity).Conclusions—TVS demonstrates an adnexal abnormality in>95% of patients with ectopic pregnancy. The most common finding is anonspecific adnexal mass. A tubal ring is found in fewer than half of casesand a yolk sac and cardiac activity in

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131518801 Ultrasound-Guided Fine-Needle Aspiration Biopsy ofThyroid Nodules Performed by Family Practitioners in aHealth Clinic SettingMaría Mata Castrillo, 1 * Jose Ignacio Jaen Diaz, 1 BlancaCordero Garcia, 1 Eugenio Cerezo Lopez, 2 Francisco Lopezde Castro, 1 Paolo Ciardo 1 1 Buenavista Health Care Center,Toledo, Spain; 2 Ultrasound Explorations, Madrid, SpainObjectives—Evaluate the impact of family practitioner interventionson 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 centerphysicians for their patients. These evaluations were previously performedin a reference hospital. All explorations were analyzed in writing, and thereports included a recommendation regarding patient follow-up and treatment.According to recommendations from the international literature, andfollowing informed consent, FNAB was performed on those nodules thatwere suitable for the procedure. Previously, the decision to perform theFNAB, its execution, and the treatment course were all left in the handsof the reference hospital.Results—A total of 392 ultrasonographic explorations wereperformed between July 2011 and July 2012. Of these, 336 (85.7%) ofthe subjects were female (mean age, 46.4 years), and 56 (14,3%) weremale (mean age, 45.2 years). The reasons for performing the explorationsincluded 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-upof other known thyroid problems (thyroiditis, postsurgical thyroids),12.2%. Seventy-five FNAB procedures were performed, 9 (12%) of whichyielded insufficient material for diagnosis. Four cases of cancer were detected,all of them of a papillary nature. There were no complications duringthe conduct of these procedures.Conclusions—Ultrasound-guided thyroid FNAB is a simpleand uncomplicated procedure that can be performed with a high degree ofsuccess by family practitioners in community health centers as part of thecomprehensive management of nodular thyroid pathology. In our study,this approach was time efficient for patients and provided a mechanism forrapid intervention in a rather frequent pathology. Future studies will be requiredto evaluate the overall cost-effectiveness of this approach.1522432 Small Retained Foreign Bodies: What Is the Limit of DetectionUsing Current Emergency Ultrasound Equipment?Daniel Jafari, 1 Kenneth Cody, 2 Nova Panebianco, 1 FrancesShofer, 1 Bon Ku, 3 Arthur Au, 3 Anthony Dean 1 *1 EmergencyMedicine, University of Pennsylvania, Philadelphia, PennsylvaniaUSA; 2 Emergency Medicine, Kaiser Oakland MedicalCenter, Oakland, California USA; 3 Emergency Medicine,Thomas Jefferson University, Philadelphia, Pennsylvania USAObjectives—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 ratesfor 4- to 5-mm FBs. This study aimed to determine the lower limit of sonographicdetection of FB using current emergency ultrasound equipment ina soft tissue model.Methods—FBs made of metal, glass, wood, and plastic (3 ofeach), 1 × 1 × 3 mm in size, were placed at a depth of 0.5 to 2.0 cm in 12pork feet. Eight feet were punctured without FB placement. Pork feet weresubmerged during this process to minimize air in tissue. Seven emergencydepartment (ED) sonologists with >2 years of experience were blinded tothe overall number, type, and depth of FBs but not to size. FB sites werescanned by each sonologist using either a hockey stick or traditional lineararray transducer in a randomized preassigned order. Sonologist confidencein the diagnosis was reported using a visual analog scale for eachsite. Sensitivity, specificity, and positive and negative predictive values(PPV and NPV) with 95% confidence intervals (CIs) were calculated. Todetermine if sonologist confidence differed by the perceived presence orabsence 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 2sites with 100% agreement). Sensitivity ranged from 25% to 75%, specificity37% 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 differencebetween detection rates of 4 types of FB did not reach statisticalsignificance.Conclusions—Current emergency ultrasound equipment usedby ED sonologists is unreliable in detection of 3-mm FBs in a human extremitysoft tissue model. Future studies may further delineate accuracyrates among different sizes and materials of FBs.1522516 Four Consecutive Recurrent Cesarean Scar Pregnancies ina Single PatientSimi Gupta, 1 * Christina Cordeiro, 2 Grace Pineda, 1 ShermanRubin, 3 Ilan Timor 1 1 Obstetrics and Gynecology, New YorkUniversity, New York, New York USA; 2 Weill Cornell MedicalCollege, New York, New York USA; 3 Sherman Rubin, JacksonHeights, New York USAObjectives—With the increase in conservative management ofcesarean scar pregnancies (CSP), there has been a growing interest in fertilityoutcomes for these patients. This is the first known report of 4 recurrentCSPs.Methods—This is a case report on a patient who was referredto 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 cesareansections, the first for breech presentation and the second an electiverepeat cesarean section. The patient’s first CSP was diagnosed 7 years laterwith an ultrasound finding of a pregnancy in the prior cesarean sectionscar at 7 6/7 weeks of gestation with positive fetal cardiac activity. Thispregnancy was initially treated with transcervical intra-amniotic injectionof methotrexate with complete resolution. Nine months later, the patientpresented with her second CSP at 6 0/7 weeks of gestation with positivefetal cardiac activity and was treated similarly with transcervical injectionof methotrexate with complete resolution. The patient’s third recurrencewas 9 months later when she presented at 5 4/7 weeks of gestation withpositive fetal cardiac activity and again was treated with transcervical injectionof methotrexate with complete resolution. Finally, the patient’sfourth recurrence occurred 8 months later. She was diagnosed at 6 1/7weeks of gestation with positive fetal cardiac activity and again was treatedwith transcervical injection of methotrexate. The patient is currently receivingfollow-up for this CSP.Conclusions—This is the first case report of 4 recurrent CSPsin single patient. Each of this patient’s CSPs was treated conservativelywith local methotrexate. In reviewing the literature, there have been 6cases of recurrent CSPs, with 1 report of 3 CSPs in the same patient. Thosecases were reportedly treated with methotrexate or surgery with or withoutresection of the scar. This information is important to help counsel patientswho desire future fertility after a CSP.S89

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131522877 Many Faces of Uterine Adenomyosis: Ultrasound andMagnetic Resonance ImagingVijayanadh Ojili Radiology, University of Texas HealthScience Center, San Antonio, Texas USAObjectives—To describe the sonographic findings in differenttypes of uterine adenomyosis and correlate these with magnetic resonanceimaging (MRI) findings where available.Methods—A brief review of different types of uterine adenomyosis(diffuse adenomyosis, focal adenomyosis/adenomyoma, and cysticadenomyosis) will be presented. The sonographic findings will bedescribed and correlated with MRI findings. The potential role of newerultrasound techniques (3D sonography and elastosonography) and pertinentmanagement issues will be briefly discussed.Results—Not applicable as this is a pictorial review.Conclusions—Uterine adenomyosis is often misdiagnosed oris not easily recognized, although it is responsible for disabling symptomssuch as menorrhagia, dysmenorrhea, and infertility. Therefore, it is importantfor the radiologist to accurately diagnose this condition in a timelyfashion. Although MRI is the imaging modality of choice for comprehensiveevaluation, ultrasound is often the initial imaging test performedin the diagnostic workup of these patients and will provide a diagnosis inmost cases.1527190 Determining the Accuracy of Ultrasound in IdentifyingAxillary Lymph Node Metastasis in Breast Cancer PatientsMadelene Lewis,* Abid Irshad, Susan Ackerman Radiology,Medical University of South Carolina, Charleston, SouthCarolina USAObjectives—Axillary lymph node staging is the most importantprognostic indicator of outcome in breast cancer patients. A positivepercutaneous biopsy eliminates the need for sentinel lymph node (SLN)biopsy, saving patients discomfort, time, and money. The purpose of thisstudy was to evaluate our ability to predict axillary nodal involvementusing ultrasound (US) in patients with invasive breast cancer.Methods—After Institutional Review Board approval, a retrospectivereview was performed of 116 patients diagnosed with invasivebreast cancer between January 2010 and June 2011. Sonographic evaluationof the axilla was performed as part of our standard protocol for patientsundergoing biopsy of a breast mass at our institution. Lymph nodeswere 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 werecorrelated with pathology results from fine-needle aspiration (FNA), coreneedle biopsy (CNB), SLN, and/or axillary lymph node dissection(ALND).Results—A total of 116 patients (all females) were diagnosedwith 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 otherraces. Axillary US was performed in all 116 patients. Sonographically, 41patients had positive axillary lymph nodes, and 39 (95.1%) of these 41were sampled by FNA, CNB, SLN, or ALND. Metastatic disease waspositive in 28 (72%) of 39 patients. Of the 75 patients with negative axillaryUS, 68 patients had final pathology. Of these, 51 (75%) remainednegative on SLN or ALND, while 17 (25%) of 68 had metastatic nodes.The sensitivity, specificity, positive predictive value, and negative predictivevalue of US for predicting axillary metastasis were 72% (95% confidenceinterval [CI], 55%–84%), 75% (95% CI, 63%–84%), 62% (95%CI, 47%–76%), and 82% (95% CI, 70%–90%). The overall accuracy ofUS was 74%.Conclusions—Preoperative US evaluation of the axilla inbreast cancer patients is effective for determining metastatic nodes. However,an SLN biopsy is still required in patients with negative preoperativeUS.1527866 Equivalence of 2- and 3-Dimensional Ultrasound inthe Evaluation of First-Trimester Nuchal Translucency byMaternal-Fetal Medicine FellowsSteffen Brown,* Michael Wolfe, Lesley de la Torre, MatthewBrennan, Rebecca Hall Obstetrics and Gynecology, Universityof New Mexico, Albuquerque, New Mexico USAObjectives—Conflicting data exist that 3D ultrasound producesequivalent images to 2D for nuchal translucency (NT) assessment. Weaimed to prospectively evaluate the equivalence of 2D and 3D techniquesfor obtaining the NT measurement as performed by maternal-fetal medicinefellows.Methods—Prospectively enrolled subjects had first-trimesterscreening performed per protocol at our institution by a fellow in maternal-fetalmedicine under the supervision of an NT-certified sonologist.This included transabdominal imaging first, followed by endovaginal imagingif necessary to obtain the proper image. A 3D image using the sameapproach was then obtained and manipulated for measurement of the NT.The 2D and 3D measurements were then compared using a Fisher exacttest and Bland-Altman plot, including root mean squared (RMS) to quantifypaired differences.Results—A total of 43 women were enrolled in the study.Acceptable transabdominal NT measurements were obtained in 34 of the43 subjects (79%), and the remaining 9 (21%) required endovaginal assessmentto complete the exam. The differences in the NT measurementsusing 2D vs 3D nuchal translucency values were normally distributed bythe 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 significantlyovermeasure or undermeasure the NT (P = .69). 2D and 3D modalitiescorrelated within 3.7 mm (RMS) of one another. 3D imaging required anaverage of 105 seconds more than 2D to complete (P < .001), though totaltime 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 assessmentmay provide an adjunct or confirmatory image.1528363 Comparative Effectiveness of Fetal Magnetic ResonanceImaging for Improvement of Diagnostic AccuracyChristina Herrera,* Amber Samuel, Sherelle Laifer-Narin,Lynn Simpson, Russell Miller Obstetrics and Gynecology,Columbia University Medical Center, New York, New York USAObjectives—Fetal magnetic resonance imaging (MRI) is performedas an adjunct to routine ultrasound with the intent of improving diagnosticaccuracy, yet data are limited to substantiate benefit to this costlyimaging modality. This study analyzed the billed cost of fetal MRI relativeto diagnostic information gained for patients with antenatal diagnosesof a fetal anomaly and known postnatal outcomes.Methods—This was a retrospective review of all fetal MRIsperformed between 2003 and 2011 at a tertiary care center. Potential caseswere identified if MRI was performed following sonographic concern fora fetal anomaly. Inclusion required documented neonatal outcomes orpostmortem assessments. Test performance characteristics were calculated,from which the number needed to secure an additional accurate diagnosisby MRI was determined. Applying the cost per MRI at the studycenter to this estimate, the cost per additional accurate diagnosis was calculated.Results—A total of 799 MRIs were performed, of which 406had documented neonatal or pathologic outcomes. One hundred thirtyonepostnatal diagnoses were secured, of which MRI identified 51 (12.6%)that ultrasound failed to correctly characterize. When the most common diagnosisgroups were considered, meningomyelocele had the lowest costper additional correct diagnosis by MRI and ventriculomegaly the highest(Table 1). The cost per additional accurate diagnosis for cases of congenitaldiaphragmatic hernia, omphalocele, vein of Galen malformation,S90

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013and Dandy-Walker complex could not be calculated, as there were nopregnancies where MRI was accurate but ultrasound alone was not.Conclusions—There is a variable cost per additional diagnosiscorrectly secured that should be weighed when considering a pregnancyfor adjunct fetal MRI. Further study should be directed at assessing theglobal cost-benefit of fetal MRI, as well as considering the value of MRIfor prognostication and surgical planning purposes.1530478 Transcranial Sonography and 123 I-FP-CIT Single-PhotonEmssion Computed Tomography in Movement DisordersDavid Školoudík, 1,3 * Petra Bartova, 1 Tana Fadrna, 1 OtakarKraft, 2 Martin Havel 2 1 Neurology, 2 Nuclear Medicine,University Hospital Ostrava, Ostrava, Czech Republic;3Neurology, Palacký University Medical School and UniversityHospital Olomouc, Olomouc, Czech RepublicTable 1MRI StudiesNeeded for 1 Cost perAdditional Accurate AdditionalDiagnosis Diagnosis Accurate DiagnosisMeningomyelocele 3 $6,466.20Multiple anomalies 6 $12,932.40Brochopulmonary sequestration 9 $19,398.60Congenital cystic adenomatoid malformation 12 $25,864.80Ventriculomegaly 14 $31,175.601530454 Comparison of Brain Vessel Imaging From Transtemporaland Subcondylar Approaches Using Contrast-EnhancedTranscranial Color-Coded Duplex Sonography and a VirtualNavigatorDavid Školoudík, 1,3 * Martin Roubec, 1 Martin Kuliha, 1Jaroslav Havelka, 2 Katerina Langova, 4 Roman Herzig 31Neurology, 2 Radiology, University Hospital Ostrava, Ostrava,Czech Republic; 3 Neurology, Palacký University MedicalSchool and University Hospital Olomouc, Olomouc, Czech Republic;4 Biophysics, Faculty of Medicine and Dentistry, Instituteof Molecular and Translational Medicine, Palacký UniversityOlomouc, Olomouc, Czech RepublicObjectives—The transcondylar approach is a new approachused for detection of chronic cerebrospinal venous insufficiency and intracranialvenous reflux in patients with multiple sclerosis. The aim of thestudy was to assess the capability of native and contrast-enhanced (CE-)transcranial color-coded duplex sonography (TCCS) to detect flow andreflux in deep cerebral veins and intracranial venous sinuses fromtranscondylar and transtemporal approaches.Methods—Brain magnetic resonance imaging and TCCS fromtranstemporal and transcondylar approaches using the new technology,fusion imaging, were performed in 8 volunteers and 5 patients with multiplesclerosis.Results—Root mean square error .05) subjectsusing CE-TCCS, respectively. Intracranial venous reflux was not detectedin any subject. A bidirectional Doppler signal from the region of the cavernoussinus detected in 3 subjects was evaluated as a breathing artifact.Conclusions—The study results showed that the TCCStranscondylar approach has serious limitations for standard detection of intracranialvenous reflux.S91Objectives—Diagnosis of Parkinson’s disease (PD) and otherParkinsonian syndromes (PS) could be difficult in early stages of the disease.Transcranial sonography (TCS) is able to detect structural changes inthe substantia nigra and basal ganglia in PD and PS patients, and fluoropropyl-carbomethoxy-iodophenyl-tropane(FP-CIT) single-photon emissioncomputed tomography (SPECT) could detect presynaptic dysfunctionin several neurodegenerative diseases, including PD and PS. The aim ofour study was to assess correlation between TCS and SPECT findings anddiagnosis of PD, other PS, essential tremor (ET), and psychogenic movementdisorder (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 inthe study: 29 PD patients, 7 PS patients, 11 patients with ET, and 2 PMDpatients. Substantial nigra (SN) echogenicity and SN area were measuredusing TCS. SPECT evaluation of basal ganglia was performed using adopamine active transporter ligand ( 123 I-ioflupane). Both examinationswere performed within 2 months after clinical examination. The sensitivity,specificity, positive predictive value (PPV), and negative predictivevalue (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 diagnosisof 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 significantlywith 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 diagnosisof PD with high correlation. The sensitivity, specificity, PPV, and NPVwere similar for both methods. (Supported by a grant from the Moravian-Silesian Region).1535936 Cell-Free Fetal DNA Testing for Aneuploidy: Initial ExperienceKisti Fuller, 1,2 * Adam Borgida 2 1 Maternal-Fetal Medicine,University of Connecticut, West Hartford, Connecticut USA;2Maternal-Fetal Medicine, Hartford Hospital, Hartford, ConnecticutUSAObjectives—Cell-free fetal DNA (cffDNA) tesing is nowwidely available from commercial labs. We evaluated our initial experienceof patients choosing cffDNA testing for fetal aneuploidy.Methods—Since January 2012, we have been routinely offeringcffDNA 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, gestationalage at time of testing, type of cffDNA test, length of time for results, andout-of-pocket costs when known.Results—There were 106 patients who met with a geneticcounselor for possible cffDNA testing. Of these 14 of 106 (13%) declinedtesting, and 1 of 106 (1%) chose to undergo invasive testing. Of the 91 remainingpatients, 24 (26.4%) chose directed DNA (dDNA) testing, and 67(73.6%) chose massive parallel shotgun sequencing (MPSS). After theinitial 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. Theaverage time from serum sample until initial results were received was 10days. Testing indications were: advanced maternal age, 67%; abnormal

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013serum screen, 46.2%; ultrasound anomaly, 28.6%; and/or family history,4.4%. Patients that chose dDNA were not billed up front, and no informationon their out-of-pocket costs was available. Patients that choseMPSS testing required some prepayment. Of the 53 patients with a knownup-front charge, it was $235 for 26 and $475 for 27 patients.Conclusions—The most common indication for cffDNA testingwas advanced maternal age. The testing was most commonly done inthe 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-pocketcost prior to testing may affect the patient’s desire for testing.1536107 Hospital-Wide Survey of Bacterial Contamination of Pointof-CareUltrasound ProbesMatthew Lawrence, 1 * James Blanks, 2 Ruben Ayala, 2 JoelSchofer, 1 Diana Macian, 1 Douglas Talk, 3 Jessie Glasser 41Emergency Department, Naval Medical Center Portsmouth,Chesapeake, Virginia USA; 2 Laboratory Services, MicrobiologyDivision, 3 Obstetrics and Gynecology, 4 Internal Medicine,Infectious Disease Division, Naval Medical Center Portsmouth,Portsmouth, Virginia USAObjectives—With the increasing use of point-of-care ultrasoundin many areas of medicine, there is a concern that ultrasound equipmentcan facilitate transmission of infection to patients, especially methicillinresistantStaphylococcus aureus (MRSA). The primary objective of thisstudy is to determine the prevalence of bacterial colonization on hospitalwidepoint-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 sufficientto protect patients against such nosocomial spread of infection.Methods—The study was conducted at a single military hospitalon 43 point-of-care ultrasound machines (87 probes) located within 9 departmentsover an 8-week period. Every probe was cultured 4 times duringthe study period, at 2-week intervals. Intracavitary probes were excludedfrom 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 datacollection was complete (2 culture sets performed on each machine, 2 culturesets remaining). Of the 174 probe cultures, 13 resulted in positivegrowth (7.5%). Three cultures (1.7%) identified Micrococcus species, and8 cultures (4.6%) identified coagulase-negative Staphylococcus, both ofwhich are common human skin flora. Three cultures (1.7%) identifiedBacillus species, not B anthracis or B cereus. Finally, 3 cultures (1.7%)identified Pseudomonas species, which was not P aeruginosa. No culturesidentified MRSA.Conclusions—As hypothesized, bacterial contamination ofpoint-of-care ultrasound probes is low and primarily involves organismscommon to normal skin flora and the environment. MRSA contaminationwas not identified at our institution. Antibacterial wipes after each useseem to prevent significant bacterial growth on ultrasound probe surfaces.(The views expressed in this article are those of the authors and do notnecessarily reflect the official policy or position of the Department of theNavy, Department of Defense, or the United States Government.)1536431 A Novel Approach to Visualizing the Vasculature Architectureof the Placenta Using 3-Dimensional Slicer Software:A Pilot StudyRie Oyama, 1 * Chizuko Isurugi, 1 Tomonobu Kanasugi, 1 AkihikoKikuchi, 1 Toru Sugiyama, 1 Sonia Pujol, 2 Ron Kikinis 21Obstetrics and Gynecology, Iwate Medical University,Morioka, Japan; 2 Radiology, Brigham and Women’s Hospital,Boston, Massachusetts USAObjectives—The aim of this pilot study presents a novel approachto visualize the vasculature architecture of the placenta usinggrayscale to acquire volume data of the villous tree from the 3D ultrasoundmachine, and then these data restructure the placental vasculatureusing 3D Slicer software, which is an open-source medical visualizationand analysis software package for medical image computing.Methods—We used a Voluson E6 (GE Healthcare) system witha RAB4-8-D/OB 3D/4D 8-MHz transabdominal wideband convex volumetransducer. The 3D volume image was adjusted to include the entireplacenta. The volume data set was stored in the DICOM format for restructuringon the 3D Slicer software. This study included 2 women withsingleton pregnancies seen at 16 and 20 weeks at Iwate Medical UniversityHospital. Informed consent was obtained from each patient. The InstitutionalReview Board approved this study. The raw volume data wereimported into the Slicer software, which was loaded to display on the 2Dviewer (axial, sagittal, and coronal), and then the 3D image was displayedon the 3D viewer. The 3D volume image restructured the placental vasculatureusing volume rendering, and the manual segmentation moduleand label statistical analysis were used. (1) Volume-rendering module: Wedetermined region of interest of the placenta. Parameter set: The presetchosen was CT-AAA, and the rendering used VTK CPU casting. (2) Manualsegmentation module: Threshold Paint was used to create a region ofinterest of the placenta and an umbilical cord image, which was based onthe grayscale volume of original raw data. (3) Label statistical analysis:This module counted the number of voxels, which was the 3D volumeimage of the placenta displayed using the manual segmentation.Results—This study showed the placental vasculature of theultrasound 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 architectureof the placenta, which came from raw ultrasound data. Also, it willbe able to impact the filed of obstetric ultrasound and elucidation of theplacenta.1536710 Efficacy of Ultrasound-Guided Tibial Nerve PerineuralInjections at the Posterior Tarsal TunnelOliver Joseph,* Oleg Uryasev, John McNamara, ApostolosDallas Virginia Tech Carilion School of Medicine, Roanoke,Virginia USAObjectives—Compression of the tibial nerve (TN) within thetarsal tunnel results in posterior tarsal tunnel syndrome. Like other nervecompression syndromes, corticosteroid injections are a potential therapeuticmodality. We hypothesize that one can effectively inject the TNperineural space immediately proximal to the tarsal tunnel.Methods—This research is a pilot study to investigate the efficacyof TN perineural injections bilaterally on 4 cadaveric models.A 10–5-MHz small linear array transducer was placed along the medialmalleolus and Achilles tendon to visualize the neurovascular bundle. TheTN appeared spindle shaped with alternating hypoechoic and hyperechoicbands superficial and anterior to the flexor hallucis longus tendon. Anteriorlong-axis injections of 0.35 mL of 0.5% methylene blue with subsequentanatomic dissection were confirmatory. Injections were designatedaccurate (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 wereaccurate and precise. The most apparent source of error was from 1 cadaver’spronounced musculoskeletal deformity, which precluded successful injectionsbilaterally. 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 refractoryposterior tarsal tunnel syndrome, corticosteroid injections couldlikely provide symptomatic relief and postpone surgical intervention. Thisstudy suggests that ultrasound guidance can increase accuracy and precisionand is a potential adjunct to treatment. Future study will expand theinitial data set and allow for a consistent protocol, while later studies of patientoutcomes will demonstrate clinical relevance.S92

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131536801 Cloacal Exstrophy: When an Omphalocele Is Not Just anOmphaloceleReza Pakdaman, 1 * Anne Kennedy, 1,2 Mark Molitor, 3 JaniceByrne, 2 Paula Woodward 1,2 1 Radiology, 2 Obstetrics and Gynecology,3 Surgery, University of Utah, Salt Lake City, Utah USAObjectives—(1) Illustrate additional congenital abnormalitiesthat, when seen in a fetus with an omphalocele, should lead to the diagnosisof cloacal exstrophy. (2) Illustrate the role of fetal magnetic resonanceimaging (MRI) in making the diagnosis. (3) Correlate prenatalfindings with postnatal imaging and surgical findings in survivors. (4) Illustrateautopsy 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). FetalMRI was performed in 4. See Table 1 for US findings. Pregnancy outcomeswere 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 thesonologist to perform additional views and seek other anomalies in an effortto refine the diagnosis. In particular, inability to demonstrate a normalbladder and rectum and the presence of spine abnormalities shouldheighten suspicion for cloacal exstrophy. Cloacal exstrophy is a rare anomalynot associated with aneuploidy; however, the condition requires multiplesurgeries, and survivors require lifelong specialist care. Faced with thelong-term consequences of this condition, families may choose terminationof pregnancy. Therefore, correct prenatal diagnosis is of paramountimportance. In ongoing pregnancies, delivery should be planned at an appropriatefacility with the resources to manage children with complexmetabolic, surgical, and psychosocial needs.Table 1. US FindingsCase AWD Bladder Anus Spine Genitalia1 Y N NA Ab NA2 Y N N Ab Amb3 Y N N Ab Amb4 Y N NA NA Bifid5 Y N NA Ab Amb6 Y N NA Ab NA7 Y N NA Ab NAAb indicates abnormal; Amb, ambiguous; and AWD, abdominal wall defect.1536808 Imaging Spectrum of Fetal Autosomal Recessive PolycysticKidney DiseaseTony Trinh, 1 * Anne Kennedy, 2,3 Joe Sherbotie, 4 Janice Byrne 31School of Medicine, 2 Radiology, 3 Obstetrics and Gynecology,4Nephrology, University of Utah, Salt Lake City, Utah USAObjectives—(1) Illustrate the spectrum of findings of fetal autosomalrecessive polycystic kidney disease (ARPKD). (2) Correlate fetalstudies with postnatal imaging or autopsy results.Methods—Retrospective review of cases seen at a single referralcenter.Results—Renal enlargement was our most consistent finding.Most kidneys looked normal up to 20 weeks but abnormally echogenickidneys were seen as early as 16 weeks. Echogenicity varied from theclassic highly echogenic pattern with loss of normal architecture to increasedechogenicity with identifiable medullary pyramids to a pattern ofvery echogenic pyramids similar to that seen in medullary sponge kidneyin adults. Amniotic fluid volume was variable from severe oligohydramniosto normal. Not all cases had evidence of pulmonary hypoplasia.Conclusions—Not all cases of ARPKD present with the classicfindings of large, brightly echogenic kidneys and severe oligohydramnios.This reflects the variable phenotype with perinatal, neonatal,and infantile types described. It is very important that sonologists recognizethe full spectrum of findings to suggest ARPKD and differentiate itfrom other causes of renal enlargement or abnormal renal echogenicity.Fetuses with echogenic kidneys require postnatal follow-up. The prognosisis variable. Awareness of the possibility of ARPKD will result in appropriatetesting of the parents for recessive gene carrier status. Affectedcouples will have a 1:4 recurrence risk for future pregnancies.1536912 Abnormal Ultrasound Findings in Patients With ClinicalSuspicion of Chronic Liver Disease in Sokoto and ItsEnvironsSadisu Maaji,* Abdulmuminu Yakubu, Danielle OdunkoRadiology, Usmanu Danfodiyo University Teaching Hospital,Sokoto, Nigeria; Radiology, Federal Medical Center BirninKebbi, Birnin Kebbi, NigeriaObjectives—To describe the pattern of abnormal ultrasonographicfindings in patients with clinical suspicion of chronic liver diseasein Nigeria, especially from the northwestern region.Methods—A total of 61 consecutive patients with clinical signsand symptoms of chronic liver disease attending medical outpatient clinicsat the Department of Medicine, Usmanu Danfodiyo University TeachingHospital, and Federal Medical Center Birnin Kebbi were scanned atradiology departments for any abnormal intra- abdominal findings fromMay 2011 to April 2012. The exclusion criteria were patients with confirmedliver biopsy or diagnosis of chronic liver disease. Patients with cardiaccirrhosis and tropical splenomegaly syndrome were also excluded inthis study.Results—A total of 61 abdominal ultrasound examinationswere performed during this study period. All the cases met the inclusioncriteria. The mean age was 46 ± 12.6 years (range, 50 years). The meanliver 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 spleensize 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 indicationsfor abdominal ultrasound were hepatitis in 1 (1.61%), liver cirrhosisin 20 (50.82%), obstructive jaundice in 2 (3.28%), chronic liver disease in25 (40.98%), and chronic abdominal swelling in 2 (3.2%). Gallbladderwall 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 patientshad no ascites. Destroyed intrahepatic vascular architecture was demonstratedin 58 (95%), while 3 (4.9%) showed normal vascular architecture.Conclusions—Ultrasound is useful in the diagnosis of chronicliver disease in daily clinical practice. However, the sensitivity can be improvedif a high-frequency probe is used and done by experienced anddedicated operators. Liver biopsy remains the gold standard, especiallywhen patients are clinically asymptomatic.1536944 Carotid Ultrasound May Not Be Sufficient to PerformCarotid EndarterectomyRobert Colvin, 1 * Alvaro Magalhaes 2 1 Kansas City Universityof Medicine and Biosciences, Kansas City, Missouri USA;2Radiology, University of Missouri, Kansas City, Missouri USAObjectives—Evaluate the accuracy of ultrasound to determinetreatment of carotid artery stenosis when compared to advanced imagingmodalities.Methods—This study consisted of 47 patients who underwentimaging for carotid artery stenosis by magnetic resonance imaging withangiography or computed tomography with angiography at a Midwest regionalmedical center over a 27-month period. The results of the previouslyobtained duplex ultrasound studies were compared to results fromadvanced imaging studies.S93

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Results—Of the 47 patients, 12 (25.53%) had a carotid arterystenosis percentage diagnosed by ultrasound that agreed with the advancedimaging modality. Fifteen (31.91%) patients likely would have had alternatetreatment based on their advanced imaging studies. Based on the acceptedcurrent treatment, carotid endarterectomy for a symptomatic patientwith >70% stenosis by ultrasound, 3 patients would have undergone an unnecessarycarotid endarterectomy. Additionally, 12 patients would havemet criteria for carotid endarterectomy and not received one.Conclusions—Clinicians must consider that many patients mayreceive inappropriate treatment of carotid artery stenosis if ultrasound isthe sole modality used for diagnosis. Eighty percent of endarterectomiesare performed based on ultrasound alone in the United States, meaning alarge impact on American health care overall. While more research isneeded, alternate imaging and close monitoring may be required with atypicalor symptomatic patients before medical management or carotid endarterectomyis chosen as treatment.1536948 Efficacy of Ultrasound-Guided Injection of the SternoclavicularJoint SpaceYisrael Katz,* Oliver Joseph, Oleg Uryasev, John McNamara,Apostolos Dallas Virginia Tech Carilion School of Medicine,Roanoke, Virginia USAObjectives—The sternoclavicular joint (SCJ) space can be affectedby various osteoarthropathies, including degenerative, crystal deposition,and inflammatory. Like other osteoarthropathies, corticosteroidinjections could likely provide therapeutic relief to individuals with SCJosteoarthropathy. While the literature discusses the success of computedtomography (CT)-guided injection, we hypothesize that ultrasound (US)can be used to guide SCJ intra-articular injection without exposing patientsto unnecessary radiation.Methods—This study serves as a pilot study. The SCJ was injectedbilaterally on 4 nonembalmed cadaveric models. The anatomy forall cadavers was within normal limits, with the exception of 1, which hadmarked musculoskeletal deformity of the lower limbs; an identical procedurewas followed, and pathologic anatomy did not affect data collection.A 10–5-MHz small linear array transducer (L38n) was used. The SCJwas palpated, and the transducer was aligned parallel to the angle of theSCJ. Using a short-axis approach, US-guided injection was performed. A1.5-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 capsulewas dissected to visualize the dye as confirmation. Attempts wereclassified according to accuracy and precision. Accuracy measured if thejoint space was stained with dye; precision measured if the injection waslocalized without damage to adjacent anatomy.Results—Bilateral injections on all 4 cadavers were accurateand precise.Conclusions—US is inexpensive, quick, and minimally invasivecompared to CT. Given that CT-guided intra-articular SCJ injection with acorticosteroid and anesthetic has provided symptomatic relief to patientswith SCJ pain, the analogous procedure can be performed under US guidance.Future phases of this study will expand the current data set and investigatethe efficacy of US-guided SCJ injection in patients with SCJ arthralgia.1536971 Efficacy of Ultrasonographically Guided AnteriorInterosseus Nerve Perineural Injection at Its BifurcationFrom the Median NerveElizabeth Glazier,* Oleg Uryasev, Oliver Joseph, JohnMcNamara, Apostolos Dallas Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USAObjectives—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. Wehypothesize that one can effectively inject the AIN perineural space at itsbifurcation from the MN.Methods—This study serves as a pilot study. The AIN perineuralspace was injected bilaterally on 4 cadaveric models. Cadavericanatomy was unremarkable with the exception of 1, which had markedmusculoskeletal deformity that did not affect the upper extremities. Anidentical procedure was followed, and pathologic anatomy did not affectdata collection. A 10–5-MHz linear array transducer was used. The transducerwas placed transversely through the antecubital fossa. The MN wasidentified proximally as it coursed over the supracondylar eminence. Itappeared spindle shaped with alternating hyperechoic and hypoechoicbands. The MN was traced inferolateral to the origin of the pronator teresmuscle, where the AIN bifurcation was visualized. Ultrasonographically(US) guided injections were achieved with a long-axis, medial-to-lateralapproach 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. Accuracymeasured nerve staining; precision measured localized injection withoutdamage 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 fromthe MN is significant. Such ability can likely provide symptomatic reliefwith corticosteroid administration to patients with Kiloh-Nevin syndrome.US is inexpensive, quick, and minimally invasive. Future phases of thisstudy will expand on our current data set and, pending such results, investigateefficacy of US-guided AIN perineural corticosteroid injectionsin patients with Kiloh-Nevin syndrome.1536975 Efficacy of Ultrasonographically Guided Injection of theUlnar Nerve Perineural Space at the Guyon CanalJeffrey Heimiller,* Oliver Joseph, Oleg Uryasev, JohnMcNamara, Apostolos Dallas Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USAObjectives—The ulnar nerve (UN) can become compressed asit passes through the Guyon canal (GC). Like other nerve compressionsyndromes, corticosteroid injection is a therapeutic modality. We thereforehypothesize that ultrasonographic (US) guidance can aid in effectiveUN perineural injections in the GC at the level of the pisiform.Methods—This is a pilot study to explore the feasibility of USguidedinjections of the UN perineural space in the GC at the level of thepisiform. Injections were performed on 4 unembalmed cadavers, 1 ofwhich had marked musculoskeletal deformity that did not affect the upperextremities. The GC was imaged in the transverse plane at the level of thepisiform, and 0.25 mL of 0.5% methylene blue dye was injected into theUN perineural space using a long-axis approach from the medial end ofthe probe, just superficial to the pisiform. Anatomic dissection was performedsubsequently to evaluate injection accuracy and precision: accuracyrefers to nerve staining, while precision denotes that adjacentstructures were not damaged.Results—Six of 8 (75%) were accurate. All injections were precise.Conclusions—This study was able to demonstrate an effectivemeans of visualizing and injecting the UN perineural space at the GCunder US guidance. Inaccuracies were primarily operator dependent. Theoperator for most injections was a second-year medical student with noprior experience performing perineural injections. Initial attempts establishedan effective protocol. In the method described here, the operatordiscovered and consistently visualized a narrow window immediately superficialto the pisiform that allowed for repeatedly accurate and preciseinjections. Despite the initial learning curve, the operator was overall successfulwith accuracy of 75% and precision of 100%. US is a viable meansof increasing the accuracy and precision, and therefore effectiveness, ofUN perineural injections into the GC, but it must be combined with aworking knowledge of superficial landmarks and target anatomy.S94

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131537060 Comparative Analysis of Sonographic and Doppler Signsand Perinatal Outcomes in Patients With Twin-Twin TransfusionVariants and Selective Intrauterine Growth Restrictionof One of the Monozygote TwinsInessa Safonova, 1 * Irina Lukjanova, 2 Rizvan Abdullaev 11HMAPO, Kharkiv, Ukraine; 2 Pediatrics, Obstetrics, andGynecology Institute, Kiev, UkraineObjectives—Some complications of monochorionic (MH) multiplepregnancy, twin-twin transfusion syndrome (TTTS), twin anemiapolycythemiasequence (TAPS), acute intertwin transfusion, and selectiveintrauterine growth restriction (sIGR) of one of the twins, have differentperinatal prognoses and require differential tactics. Our objective was tocompare their sonographic and Doppler signs, sequences, and the perinatalresults.Methods—Nine cases of complicated diamniotic MH pregnancywere studied: with chronic progressive unimproved TTTS (4),TAPS (1), acute intertwin transfusion (2), and sIGR (2). Fetometry andfetal weight calculation were carried out. The amniotic fluid amount andDoppler of the umbilical artery, ductus venosus, and middle cerebral arterywere estimated.Results—The sequence of ultrasound signs and the perinatalresults in all cases have been described and compared. In 7 of 9 describedcases, the common sonographic feature turned out to be a discorded twin’sgrowth. In 8 of 9 cases, a volume asymmetry of the twin’s amniotic fluidwas observed. The worst perinatal outcomes and the most substantialweight differences were in women with natural flow of the TTTS, and all4 cases were accompanied by fetal bladder asymmetry and donor cardiomegaly.At birth, hematologic distinctions of the twins were the mostconsiderable with TAPS.Conclusions—Dynamic sonographic monitoring of an MHpregnancy should take into account several aspects, such as fetometric,amniometric, and Doppler as well as twin bladder symmetry and fetal cardiothoracicratio control.1537067 Transvaginal Sonographic Differential Diagnosis of theCauses of Postpartum Uterus Involution Slowdown:Clinical Experience of a Specialized Hospital DepartmentInessa Safonova, 1,2 * Yuri Paraschuk, 2,3 Roman Safonov 2,31HMAPO, Kharkiv, Ukraine; 2 Kharkiv Regional PerinatalCenter, Kharkiv, Ukraine; 3 Kharkov National Medical University,Kharkiv, UkraineObjectives—to compare the sonographic, clinical, and histopathologicresearch results in patients with slowing down of involution ofthe postpartum uterus.Methods—Transvaginal sonographic (TVS) examinationswere undertaken in 140 postpartum women receiving care in a specializedhospital department for treatment of postpartum complications. In 38of them, the uterine histopathology was studied.Results—The opportunities of TVS in the differential diagnosisof retained lochia, endometrial inflammation, and retained placentalfragments in the postpartum uterine cavity were defined. Some specificsonographic criteria of metritis after vaginal and operational births, as wellas retained unseparated placental fragments in the postpartum uterine cavitywere exposed.Conclusions—The diagnostic accuracy of most ultrasound criteriafor postpartum complications was not great. At the same time, TVShelped identify and differentiate the causes of uterine involution slowdownin some forms of endometritis and in women with unseparated placentalfragments in the uterine cavity.1537241 Unusual Anechoic Portal Vein Thrombosis and its Significancefor Predicting the Response to Anticoagulant TherapyShoichi Matsutani, 1,2 * Hideaki Muzumoto, 2 AkitoshiKobayshi, 2 Atsuyoshi Seki, 2 Takeshi Ando 2 1 Chiba PrefecturalUniversity of Health Science, Chiba, Japan; 2 Gastroenterology,Funabashi Municipal Medical Center, Funabashi,JapanObjectives—Acute portal vein thrombosis is still a challengingproblem in daily clinical practice. Ultrasonography usually contributes toan early diagnosis of portal vein thrombosis, which thus leads to appropriatetreatment. However, the response to anticoagulant therapy is somewhatunpredictable, and these situations trouble clinicians in themanagement of the disease. This report describes the unusual ultrasonographicappearance of acute portal vein thrombosis, which can predict apoor response to anticoagulant therapy.Methods—Sonographic changes in acute portal vein thrombiwere examined in 4 patients treated with anticoagulant therapy (heparinand vitamin K antagonist). The background diseases were acute colitis in2 patients, acute cholecystitis in 1 patient, and acute cholangitis in 1 patient.The thrombus was located in the right portal vein in 2 patients andin both the right and left portal veins in 2 patients. A Toshiba SSA 770Asystem 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 responseto anticoagulant therapy. However, 4 thrombi (group B) remained unrecanalizedwithout a response to the treatment. The group A thrombishowed echogenic material in the portal vein, which is a common sonographicappearance of thrombosis at the initiation of anticoagulant treatment.However, the group B thrombi were anechoic without any bloodflow signals at the initiation of the treatment, which was quite differentthan the sonographic appearance of group A. The thrombus in 2 patientsin group B, which had a 1-week interval before anticoagulation, showedechogenic material, which was similar to that seen in group A at the initialdiagnosis. However, these 2 thrombi became anechoic 1 week laterafter the initiation of the treatment. All portal veins with an anechoicthrombus became occluded and changed to a hyperechoic band.Conclusions—An unusual anechoic appearance of portal veinthrombosis may therefore indicate a poor response to anticoagulant therapy,although the mechanism of this kind of ultrasonographic appearanceof blood clots is undetermined.1537456 Sonographic Appearance of Cutaneous Basal Cell Carcinomasof the Head and NeckXimena Wortsman, 1 * Nelson Lobos 2 1 Radiology, Dermatology,Clinica Servet, Faculty of Medicine, 2 Health Sciences, Universityof Chile, Santiago, ChileObjectives—To assess the sonographic morphology of cutaneousbasal cell carcinomas of the head and neck.Methods—A retrospective review of cutaneous basal cell carcinomasof the head and neck sonographically diagnosed and confirmedby histology was performed (September 2009–July 2012). Postoperativecases and medically treated lesions were excluded from the analysis. Informationabout extension, location, blood flow, and deeper-layer involvementwas 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: 7.79mm 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 mm 2S95

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013(range, 0.01–2149 mm 2 ). 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 thicknessof vessels: 0.94 mm (range, 0.5–1.8 mm). Mean peak systolic velocity ofthe arterial vessels: 10 cm/s (range, 3.7–31 cm/s). One hundred percent ofarteries showed peak systolic velocity

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Fisher test was used to assess the significance of the morphologic changesbetween 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 theexposed 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 asignificant decrease (P < .05) of the volume (P = .033) and transverse axis (P= .033) of hemangiomas in comparison with the nonexposed group. The restof the P values were thickness, P = .057; longitudinal axis, P = .37; thicknessof vessels, P = 1; and peak systolic velocity, P = 1.Conclusions—Sonography can register the changes in the morphologyof cutaneous hemangiomas of infancy that are medically treated.Propanolol can significantly reduce the volume and transverse axis of hemangiomasof infancy in comparison with the nontreated group of patients.1537671 Natural History of Fetal Pyelectasis and Risk of InfantUropathyEmily Neri, 1 * Jean Goodman, 1,3 Jennifer Peck 2 1 Obstetricsand Gynecology, 2 School of Public Health, University of OklahomaHealth Sciences Center, Oklahoma City, Oklahoma USA;3Obstetrics and Gynecology, Loyola University Medical Center,Maywood, Illinois USAObjectives—The objectives of this study were to (1) determinethe rate of resolution of fetal pyelectasis identified in the second trimesterprior to delivery and (2) determine the predictive value of varied degreesof pyelectasis identified in the antenatal period and infant uropathy.Methods—A retrospective study was designed, with review ofall prenatal ultrasounds with a diagnosis of second-trimester pyelectasis inour established database between May 2010 and January 2011. Per ourroutine for this diagnosis, repeat ultrasounds in the third trimester wereperformed and also reviewed. Maternal and newborn records from ourelectronic 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 pyelectasisin the second trimester, persistence in the third trimester, and persistenceafter delivery were defined. Varied pyelectasis measure cut pointswere determined to assess the utility of pyelectasis as a screening test forpostnatal uropathy.Results—During the 9-month period, there were 119 secondtrimesterultrasounds with isolated pyelectasis identified with subsequentthird-trimester ultrasound and delivery at our facility. The incidence of pyelectasiswas 1%, with a mean anteroposterior renal pelvis diameter of 5.2mm in the second trimester and 6.0 mm in the third trimester (range, 4–10mm). Twelve percent of second-trimester pyelectasis resolved by the thirdtrimester, and 45% resolved by delivery. Of third-trimester follow-up scans,all those who resolved by delivery had measured diameters

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Table 1. Fluid Location in Relation to the Lateral Femoral Epicondyle at 0° and 30°of Knee Flexion (N = 40 Knees)Supine Supine 30° Standing Standing 30°Presence of Fluid Extended (%) Flexed (%) Extended (%) Flexed (%)No fluid 13 (32.5) 28 (70) 2 (5) 31 (77.5)Anterior only 3 (7.5) 4 (10) 0 (0) 6 (15)Anterior and deep 19 (47.5) 6 (15) 28 (70) 3 (7.5)Deep only 5 (12.5) 2 (5) 10 (25) 0 (0)Posterior 0 (0) 0 (0) 0 (0) 0 (0)1538060 Three-Dimensional Ultrasound of the Cumulus OophorusKyle Beiter, 1 * Thomas Hilgers, 2 Jeanine Johnson, 2 RachelStites 2 1 Saint Peter’s Healthcare System, New Brunswick,New Jersey USA; 2 Reproductive Ultrasound Center, Pope PaulVI Institute for the Study of Human Reproduction, Omaha, NebraskaUSAObjectives—The ability to observe the cumulus oophorus byultrasound has been controversial over the years. The Pope Paul VI Institutefor the Study of Human Reproduction’s Reproductive UltrasoundCenter has been very interested in this topic for a number of years and haspublished on it. This e-poster introduces the first published photos of thecumulus oophorus taken by 3D ultrasound.Methods—Examination was performed using a Medison AccuvixV20 Prestige ultrasound system. A 3D endovaginal 5–9-MHz transducerwas used. After 2D scanning of the cumulus oophorus wascompleted, a 3D acquisition with the region of interest set to encompassthe area of the dominant follicle and cumulus oophorus was acquired.SonoView Pro software was used to manipulate the 3D volumetric data byrotating the x-, y-, and z-axes to obtain a 3D rendering of the cumulusoophorus.Results—A 3D image of the mature follicle with the eccentricallylocated cumulus oophorus was obtained and is shown. This image isthen rotated on its axis, and it can be seen from different directions.Conclusions—This presentation shows that 3D ultrasound canprovide extraordinary pictures of the cumulus oophorus in a way thatleaves the determination of its presence inescapable. Further refinement ofthis technique should help in the ultrasound evaluation of normal ovulationpatterns and the various disorders of human ovulation.1538125 Design and Evaluation of a Point-of-Care UltrasoundCurriculum for Pediatricians Involved in Global HealthSachita Shah, 1,2 * Meera Muruganandan, 3 Sachin Shah, 4Randheer Shailam, 5 Sara Stulac, 2,6 Kim Wilson 6 1 EmergencyMedicine, Harborview Medical Center, University ofWashington School of Medicine, Seattle, Washington USA;2Partners in Health, Boston, Massachusetts USA; 3 EmergencyMedicine, Rhode Island Hospital, Brown University, Providence,Rhode Island USA; 4 Cardiology, Lahey Clinic, Burlington,Massachusetts USA; 5 Radiology, Massachusetts GeneralHospital, Harvard Medical School, Boston, MassachusettsUSA; 6 Pediatric Global Health, Boston Children’s Hospital,Boston, Massachusetts USAObjectives—As ultrasound becomes more portable, durable,and affordable, point-of-care ultrasound use by nonradiologists has beenrapidly increasing both in the United States and in resource-poor developingworld settings. However, training programs for ultrasound skillsspecific to global health work and pediatrics are lacking, leading to a dangerousknowledge gap for this operator-dependent technology. We describeour response to this knowledge and training gap with a novel curriculumin bedside ultrasound focused on pediatric clinical conditions common inresource-limited settings. Our primary objective is to describe this curriculumand response to the pilot training program.Methods—The 15-hour course was taught by a multidisciplinaryfaculty and focused on bedside clinician-performed ultrasound techniquesfor assessment of the pediatric global burden of disease. Lecturedidactics were complemented by practical skills sessions using live modelsand hand-carried ultrasound machines. An anonymous postcourse selfassessmentsurvey was conducted to assess confidence and attitudes.Results—The curriculum included training on ultrasound safetyand physics, uses in trauma, including the focused assessment with sonographyfor trauma exam, hemothorax and pneumothorax, procedural guidance,echocardiography (pericardial effusion, systolic dysfunction, andrheumatic valvular disease), liver lesions, splenomegaly, appendicitis, pyloricstenosis, and skin/soft tissue infections, including pyomyositis. Postcourseself-assessments of the participants were overwhelmingly positivewith high levels of confidence in the various ultrasound techniques exploredduring the course despite no prior experience. After the training, studentsfelt the most confident with trauma, pericardial effusion, skin/softtissue ultrasound, and procedural guidance and the least confident withidentification of specific liver lesions and use of the inferior vena cava asa proxy for dehydration. One hundred percent of the participants believedultrasound would be useful in low-resource settings.Conclusions—This clinical course of ultrasound skills for pediatriciansembarking on global health careers may serve as one modelfor more effectively preparing trainees to work in developing countries.1538182 Emergency Medicine Intern Ultrasound Proficiency:A Longitudinal StudyElizabeth Pontius, 1 * Kerri Layman, 1,2 Michael Antonis 1,21Emergency Department, MedStar Washington HospitalCenter, Washington, DC USA; 2 Emergency Department, Med-Star Georgetown University Hospital, Washington, DC USAObjectives—Our goal was to determine the level of proficiencythat interns had with emergency bedside ultrasound (US) over the courseof a year.Methods—Nineteen Georgetown School of Medicine 2010graduates entered emergency medicine residencies. An e-mail was sent toeach of the 19 graduates 3 times over the course of the 2010–2011 academicyear, in July 2010, February 2011, and July 2011. The e-mail containeda link to a 6-question Web-based survey. Graduates were askedwhether they had participated in an emergency bedside US elective and ifthey had other exposure to US during medical school. They were alsoasked to rate their proficiency with bedside US at the start of residency andat the time of the survey. Last, they were asked to rate themselves againsttheir peers in bedside US proficiency.Results—Of the 19 graduates, 15 responded to the survey inJuly 2010, 12 in February 2011, and 8 in July 2011. Half of respondentshad participated in an emergency bedside US elective, and approximately75% had exposure to US in another setting during medical school. In thefirst survey, respondents reported their level of comfort as 5.67 at the startof the year and 6.47 currently on a 10-point scale. By midyear, respondentsrated 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 ofthe year and 7.5 currently. The resident’s self-assessed level of proficiencywhen graded against their peers did not change appreciably, from 7.13 ona 10-point scale at the start of the year, 6.83 at the midyear mark, and 7.13at the end of the year.Conclusions—Emergency medicine interns became more proficientwith 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 yearlower than they had initially. Further study is needed to determine if theemergency bedside US elective in medical school provides any benefit.S98

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131538313 Case Presentations of “Cloudy Ascites” Associated WithFemale Pelvic MalignanciesRaydeen Busse, 1,2 Gail Hoshiko-Reed, 2 Chrystie Fujimoto 1,2 *1Obstetrics, Gynecology, and Women’s Health, University ofHawaii, Honolulu, Hawaii USA; 2 Hawaii Pacific Health, Honolulu,Hawaii USAObjectives—There is no effective early detection available forovarian cancer screening; therefore, vague symptoms of early satiety, abdominaldiscomfort, and abdominal bloating commonly result in pelvic ultrasoundimaging. Ascites in the gynecologic patient is easily identifiedusing high-resolution transvaginal pelvic ultrasound imaging even whenpresent in trace amounts. Although the presence of cul-de-sac free fluid inpatients of childbearing age is a routine finding due to ovulation and themenstrual cycle, the presence in postmenopausal women regardless ofamount warrants further investigation. We present 3 cases of echogenicpelvic fluid or “cloudy ascites” found in perimenopausal and postmenopausalwomen in whom pelvic malignancies were diagnosed.Methods—Transvaginal ultrasound that is performed in ourunit classifies and subjectively quantifies free pelvic fluid in all patients.We noted 3 cases in which the presence of free pelvic fluid in perimenopausaland postmenopausal women changed in character and quantityover a short period of time. There were no ovarian masses. Thepresence and change of the pelvic fluid was solely what led to the subsequentoperative diagnoses of 3 different pelvic malignancies in our 3 cases.Results—The presence of clear or anechoic cul-de-sac freefluid was present in each of the 3 cases, and short-term follow-up was recommended.In each case, the ascites changed from anechoic to complexon ultrasound imaging or increased in subjective amount. No ovarian abnormalitieswere seen in any of the 3 cases. Further evaluation was initiated,and subsequent operative pathology revealed a mucinous adenocarcinomaof the appendix, metastatic breast cancer after 15 years of remission, anda fallopian tube carcinoma.Conclusions—In perimenopausal, specifically, postmenopausalwomen, our premise is that ascites or pelvic free fluid should always beclassified as to its echogenicity and amount. If the fluid appears to representan exudate or contain echoes, some type of inflammatory processcould be present, or the fluid could represent malignant ascites. Althoughcomplex or cloudy ascites is not pathognomonic for malignancy, it certainlyis a cause for further evaluation.1538648 Predicting Prognostic Factors of Breast Cancer Using ShearWave ElastographyWoo Jung Choi,* Hak Hee Kim, Joo Hee Cha, Hee JungShin, Hyunji Kim, Min Ji Hong, Eun Suk Cha, Hyeon SookKim, Sung Hun Kim Radiology, Asan Medical Center, Seoul,KoreaObjectives—To investigate the correlation between histologicfactors, including immunohistochemical factors, of breast cancer relatedto the prognosis of tumors using shear wave elastography (SWE).Methods—One hundred twenty-two pathologically provenbreast cancers from 116 women (age range, 27–77 years; mean age, 48.1years) were included in this study. For each lesion, B-mode ultrasoundand SWE images were obtained. Of the SWE features, the mean elasticityvalue, maximum elasticity value, and SWE ratio were extracted. TheSWE ratio was calculated as the ratio of the stiffest portion of the lesionto the similar region of interest in fat tissue. Histologic findings frompathologic reports were used for comparison, namely, nuclear and histologicgrade, nodal status, vascular invasion, invasive size, and immunohistochemicalfactors such as estrogen receptor (ER), progesteronereceptor (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-Wallistest were used to compare the SWE values in the groups of histologicparameters. Subtypes based on the immunohistochemical profile werecompared with SWE values using the Kruskal-Wallis test.S99Results—The negative group of ER (P = .004), negative groupof PR (P = .016), positive group of p53 (P = .024), and positive group ofKi-67 (P = .008) showed statistically significant positive associations witha high SWE ratio. A high nuclear grade (P = .014), high histologic grade(P = .015), and large invasive size (P = .010) was associated with a significanthigh SWE ratio. The mean elasticity value and maximum elasticityvalue showed less statistical significance with the histologic factors.The Kruskal-Wallis analysis showed that the SWE ratio was significantlydifferent across the subtypes based on the immunohistochemical profile(P = .013).Conclusions—The SWE ratio may provide useful informationfor predicting prognostic factors of breast cancer.1538793 Understanding How Ultrasound Technology Promotes StudentAttention During Instruction of the Physical ExamCaridad Hernandez, 1 * Christine Bellew, 1 Alfredo Tirado, 1,2Andrew Payer, 1 Manette Monroe, 1 Juan Cendan 1 1 MedicalEducation, University of Central Florida College of Medicine,Orlando, Florida USA; 2 Emergency Medicine, Florida Hospital,Orlando, Florida USAObjectives—The use of point-of-care ultrasonography (US) isincreasing in medical practice. Accompanying this is an interest in incorporatingUS education in undergraduate medical education. Here we explorethe role of US technology as part of an instructional strategy toenhance students’ motivation to learn to perform the neck/thyroid exam.Methods—We used a qualitative research design usingprompted text responses. Second-year students in the physical diagnosiscourse participated. All students received traditional instruction onthe physical exam of the neck/thyroid with the addition of a student-runUS exam of the neck. Students worked in small groups with a facultyinstructor and a standardized patient. Following the sessions, they submittedresponses to 5 items aimed at assessing 4 categories of motivationalvariables: attention, relevance, confidence, and satisfaction. Datawere analyzed using a grounded theory approach. Two authors reviewedthe responses, devised a coding framework, and generatedthemes. NVivo, a qualitative data analysis platform, was used to evaluatethe data.Results—Sixty-five students completed the prompted-responseitems. We report analysis of students’ responses to the item, “Using USworked 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 identifyingstructures and getting to handle the probes was key to maintainingtheir attention; (3) clinical application of anatomy—application of theirknowledge of anatomy and anticipated applicability maintained their attention;(4) hands-on learning—actually doing the US themselves helpedthem learn the procedure/anatomic structures and relationships as opposedto looking at still images obtained by others.Conclusions—Incorporating the use of US with the physicalexam of the neck/thyroid helps maintain students’ attention because it promoteslearner engagement and provides clinical contextualization ofanatomy. Another theme that emerged was that hands-on real-time capturingof images by the students themselves improved their understandingof relevant anatomy.1538852 Value of Qualitative Sonoelastographic Evaluations in theDiagnosis of Solid Breast MassesHasan Yerli, 1 * Tugbahan Yilmaz, 2 Banu Ural 2 1 Radiology,2General Surgery, Baskent University Zubeyde Hanim, Practiceand Research Center, Izmir, TurkeyObjectives—To determine whether the use of a qualitative elasticityscoring method by sonoelastography (SE) is useful to differentiatebetween benign and malignant breast masses.Methods—One hundred seventy lesions in 145 consecutive pa-

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013tients with solid breast masses (139 benign, 31 malignant) were prospectivelyincluded in this study. For each lesion, B-mode ultrasound (US) andSE images were obtained. For each lesion, elasticity scores were determinedwith a 5-point scoring method by SE. The findings were comparedwith histopathology. The diagnostic performances for the elasticity scoringand B-mode US methods were determined.Results—The mean scores on SE were 2.58 ± 0.57 for benignlesions and 3.85 ± 0.69 for malignant lesions. Sensitivity, specificity, andaccuracy for the 5-point scoring method were 78%, 92%, and 88%, respectively;88%, 74%, and 84% for B-mode US when a cutoff point betweenscores 3 and 4 was used.Conclusions—After B-mode US analysis, qualitative evaluationwith the 5-point scoring method by SE is a complementary methodthat increases specificity when differentiating between benign and malignantbreast masses.1538946 Masses in Pregnancy: Blood Flow Provides Vascular Cluesto DiagnosisConstance Bitters,* Beth Kline-Fath Ultrasound, Radiology,Cincinnati Children’s Hospital Medical Center, Cincinnati,Ohio USAObjectives—Determining the etiology of an intrauterine masscan be difficult. The goal of this study was to determine if the origin ofthese masses can be established via color Doppler flow.Methods—An Institutional Review Board–approved retrospectivereview was performed by searching our fetal database from 2004to 2012. Twelve cases of intrauterine soft tissue masses without identifiablefetal parts were discovered. The lesions were evaluated with ultrasoundfor location and echo texture. Doppler was used to determine thevascular supply, site of supply, number of vessels (hypervascular ≥3 vessels),and waveforms.Results—The lesions were 8 proven chorioangiomas (CA), 2twin reversed arterial perfusion (TRAP), 1 fibroid, and 1 chronic intrauterinedemise (IUD). In the CA, the soft tissue mass was hypervascularand embedded in the placenta with the fetal placental cord insertionalong the margin. Six were heterogeneous and 2 homogeneous. Vascularityextended primarily from the placental cord insertion and superficialplacenta with less extending to the deep placenta. Five contained low-resistancearteries, and all had pulsatile veins. The 2 TRAP were heterogeneousand abutted the placenta contained in an encircling membrane. Bothhad 2 vessel feeders with a single artery and vein centralized in the mass.In 1 pregnancy, the arterial waveform was documented as reversed whencompared to the normal fetus. The fibroid was homogeneous and in themyometrium along the placental edge with a supplying artery and veinextending deep myometrium. The chronic IUD showed heterogeneoustissue with no color flow. A membrane was noted, supporting diamniotictwin gestation.Conclusions—The vascular supply can be helpful in evaluationof amorphous intrauterine masses. In CA, the lesion is hypervascularand embedded in the placenta, with vessels originating from the placentalsurface and fetal placental cord. In TRAP, the lesion demonstrates a centralizedvascular supply, with diagnosis supported by the presence of reversedarterial flow. Fibroids demonstrate vessels extending into the deepmyometrium. Chronic IUD should be considered in the absence of vascularflow, especially in the presence of a separating membrane.1539098 Ultrasound-Guided Vascular Access on a Phantom: ATraining Model for Medical Student Education—Trends inData, 2010–2012Lydia Sahlani, 1 * Eric Adkins, 1,2 David Bahner 1 1 EmergencyMedicine, 2 Internal Medicine, Ohio State University WexnerMedical Center, Columbus, Ohio USAObjectives—Patient safety and prevention of medical errorshave been emphasized as an integral part of medical education. Focusingon ultrasound-guided vascular access (USGVA) in the medical school curriculumcan improve patient safety and prevent errors. We reviewed a cohortof second-year medical students (MS2) to assess their proficiencywith USGVA access in 2010, 2011, and 2012.Methods—This study was an observational cohort study ofMS2s during their Introduction to Clinical Medicine program during 2010,2011, and 2012. Students reviewed an online training module from EM-SONO.com about USGVA, completed a quiz, and participated in a didacticsession using a Blue Phantom block gel model. Students were dividedinto groups and allowed to practice the skills. After the practice session,they were graded by a proctor using a standardized scoring sheet. The studentswere evaluated on their ability to visualize the simulated vessel indifferent planes, perform vascular cannulation in both the short and longaxes, the number of needle sticks attempted, and successful cannulation.Results—A total of 600 MS2s with complete data from 2010through 2012 were included. Students were able to cannulate the vessel inthe 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 shortaxis with a mean of 1.33 sticks (SD, 0.67; 95% CI, 1.27–1.38). A nonparametrictest, the Wilcoxon signed rank test, for paired data was used forfurther analysis. We tested the hypothesis that the median of differencebetween the number of sticks in long and short axes would equal 0. Combineddata show there was a significant difference (P = .0007) between thenumber of long- and short-axis sticks.Conclusions—A structured ultrasound curriculum can helpMS2s learn the psychomotor skills necessary to cannulate a vessel on aphantom using ultrasound guidance. Results indicate that there is a significantdifference between long- and short-axis sticks, with the short axisrequiring more sticks to cannulation. Future studies could focus on improvementof short-axis sticks to cannulation and retention of the skill astested at various intervals of training.1539608 Bayesian Methods for Streamlining and Enhancing theAnalysis and Presentation of Myocardial Strain and StrainRate DataOlga Neyman, 1 * Michelle Milne, 2 Gautam Singh, 3 RaviRasalingam, 4 James Miller, 2 Mark Holland 2,3 1 BiomedicalEngineering, 2 Physics, 3 Pediatrics, 4 Internal Medicine, WashingtonUniversity, St Louis, Missouri USAObjectives—Quantitative evaluation of global and regional myocardialstrain has been shown to be feasible in the echocardiographic laboratory.In spite of the potential for such strain-based evaluation, cliniciansfrequently find the time required to analyze the data to be prohibitive andthe amount of data to be far too large and unwieldy to permit routine clinicaluse. The goal of this work is to present to the physician a concise summaryof physiologically meaningful results (eg, values of the maximumstrain, strain rate, and time to maximum strain) as well as significantly improvedstrain rate vs time curves to facilitate meaningful interpretations.Methods—We introduce Bayesian methods for model selectionand parameter estimation that result in improved quality of automateddata reduction and reporting. Bayesian probability-based methods thatpermit 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 operatordependent than current manual interpretation approaches will be describedand illustrated.Results—Bayesian-based analysis methods were applied tomyocardial 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 constructedusing the Bayesian parameter estimation approach to be in good agreementwith the acquired strain data. The strain rate data derived from theS100

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013models for the strain data provided smoothly varying curves that are easilyinterpreted and compare favorably to results anticipated based on physiologicconsiderations.Conclusions—Bayesian probability-based methods appear toprovide an approach that shows promise for providing objective, operatorindependentanalysis of clinical myocardial strain and strain rate data alongwith significant reductions in the amount of time required of the cardiologistanalyzing the data. (Supported by National Institutes of Health grantR21 HL106417.)1539642 Sonographic Characterization of KeloidsXimena Wortsman, 1 * Nelson Lobos 2 1 Radiology, Dermatology,Clinica Servet, Faculty of Medicine, 2 Health Sciences, Universityof Chile, Santiago, ChileObjectives—To assess the sonographic morphology of keloids.Methods—A retrospective review of keloids that were sonographicallydiagnosed and confirmed by histology was performed (September2009–August 2012). Data on extension (millimeters), location,blood flow (activity), deeper layer involvement, and accompanying fistulaswere analyzed.Results—Twenty-five keloids in 20 patients (50% female [n =10], 50% male [n = 10]; total mean age, 26 years [22 years females and30 years old for males]; age range, 4–66 years) were found. Number of lesionsper patient: 1 lesion, 85% (n = 17); 2 lesions, 10% (n = 2); multiplelesions (≥3 lesions), 5% (n = 1). Body segment location of lesions: anteriorthorax, 24% (n = 6); upper extremity, 24% (n = 6); face, 20% (n = 5);lower extremity, 12% (n = 3); submandibular region, 12% (n = 3); dorsalregion, 4% (n = 1); epigastric region, 4% (n = 1). Layer location of lesions:dermis, 84% (n = 21); epidermis and dermis, 8% (n = 2); dermis andhypodermis, 4% (n = 1); epidermis, 4% (n = 1). Echo structure: hypo -echoic, 84% (n = 21); heterogeneous, 16% (n = 4). A linear pattern waspresent in 20% (n = 5) of keloids. Fistulas within the lesions were observedin 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 mm 2 (range,59.92–12922.07 mm 2 ). Vascularity was detected in 60% (n = 15) of lesions,and 100% of these lesions demonstrated a peak systolic velocityof arterial vessels

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131539668 A Committee Structure for Improved Efficacy of a StudentUltrasound Interest GroupKatherine Pollard,* Emily Hoover, David Bahner EmergencyMedicine, Ohio State University College of Medicine, Columbus,Ohio USAObjectives—To assess the impact of a new committee structureon the efficacy of a student ultrasound interest group.Methods—Our institution has a well-established student-runultrasound interest group. Since its founding, the interest group has servedas a central organizing body for all ultrasound educational activities. Theultrasound interest group has traditionally been led by a group of 4 secondandfourth-year medical student officers and a faculty advisor. During thisacademic year, a new committee structure was developed to provide moreopportunities for medical student involvement within ultrasound leadershipand to improve the ability of the interest group to support ultrasoundeducation initiatives. Six committees were formed focusing on medicalstudent education, resident/fellow/faculty education, outreach, research,grants/funding, and technology.Results—The initial development of the committee structureallowed the ultrasound interest group to better define its core goals andvalues. The committee structure has also provided opportunities for approximately30 medical students (currently 15 first-year, 5 second-year, 1third-year, and 7 fourth-year students) to take new leadership roles withinour ultrasound education program while decreasing the burden on the officersand advisor. The committee structure has improved ultrasound educationin numerous ways. Examples of this improvement include formingnew connections with ultrasound advocates within our institution, expandingthe ultrasound interest group’s online presence, and identifyingnew student research funding opportunities.Conclusions—The implementation of a new committee structurefor our student ultrasound interest group has greatly improved theability of our interest group to educate medical students, residents, andfaculty on the applications of and techniques involved in performing bedsideultrasonography.1539712 Sonographic Characterization of PilomatrixomasXimena Wortsman, 1 * Nelson Lobos 2 1 Radiology, Dermatology,Clinica Servet, Faculty of Medicine, 2 Health Sciences, Universityof Chile, Santiago, ChileObjectives—To assess the sonographic morphology of pilomatrixomas.Methods—A retrospective review of pilomatrixomas that weresonographically 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 wereanalyzed. Mean age: 17 years (age range, 5 months–82 years). Number oflesions per patient: 1 lesion, 93.4% (n = 100); 2 lesions, 4.6% (n = 5); 3lesions, 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 hyperechoiccenter, 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); longitudinalaxis, 6.22 mm (range, 0.5–19 mm). Mean volume: 187.32 cm 3(range, 0.07–2148.44 cm 3 ). Calcium deposits were present in 90% (n =106), and anechoic areas (cystic variant) were detected in 4% (n = 5) oflesions. 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 showedmaximum arterial peak systolic velocity

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013done. In 130 cases, ultrasound showed nodular lesions, and these patientshad a percutaneous biopsy performed under the control of ultrasound.Results—The authors have demonstrated that, in rare cases, ultrasoundexamination may be useful to illustrate nodular lesions located atthe chest wall. It is true that it is not possible to prepare an initial diagnosisof a lung tumor on this basis; to obtain such a diagnosis, a CT examinationwas used, but a precise collection of samples from a lesion locatedperipherally makes its display on real-time ultrasonography very easy.Conclusions—(1) It is possible to display 90.9% of lesions locatedperipherally in a traditional ultrasound examination. (2) In mostcases, as part of that procedure, it is necessary to establish the location ofthe tumor and the depth of the CT-guided biopsy. (3) Displaying lesionson ultrasonography makes it possible to collect material for histopathologicexamination accurately in 88.7%.Table 1. Number of Studies Carried out Under the Control of Ultrasound (out of2572 Cases)Inability of fiber-optic bronchoscopy 143Tumors located peripherally 130 (90.9%)Ultrasound-controlled biopsy 130 (90.9%)Histopathologic diagnosis 127 (88.8%)1539837 Sonoelastographic Qualitative Analysis in the Managementof Salivary Gland MassesHasan Yerli, 1 * Erkan Eski, 2 Ekrem Korucuk, 3 A. MuhtesemAgildere 4 1 Radiology, 2 Otolaryngology, Baskent UniversityZubeyde Hanim, Practice and Research Center, Izmir, Turkey;3Otolaryngology, Karsiyaka State Hospital, Izmir, Turkey;4Radiology, Baskent University Faculty of Medicine, Izmir, TurkeyObjectives—Our aim was to investigate whether the use of aqualitative elasticity scoring method by sonoelastography is useful for themanagement of salivary gland masses.Methods—Forty-six patients with salivary gland masses (38parotid and 8 submandibular) were prospectively included in this study.For each lesion, B-mode sonographic and sonoelastographic images wereobtained. Elasticity scores were determined with a 4-point scoring method.Differences among scores for benign and malignant salivary gland masseswere assessed using the Mann-Whitney U test. Qualitative variables werecompared using the Pearson χ 2 test. The findings were compared withhistopathology.Results—The score values of 37 benign masses ranged from 1to 4, while the score values of 9 malignant masses ranged from 2 to 4. Themean scores were 2.28 ± 0.94 for benign lesions and 3.1 ± 0.72 for malignantlesions (P < .05). When we considered scores 1 and 2 benign andscores 3 and 4 malignant, 12 false-positives were determined by the 4-point scoring method, and 62% of benign masses were diagnosed.Conclusions—Sonoelastography might be regarded as anotherultrasound parameter in the management of salivary gland masses in termsof detecting benign masses.1539862 Peripubertal Ovarian and Uterine Volumes: Are HistoricalValues Still Valid Today?Steven Kraus, 1,2 Sara O’Hara, 1,2 * Janet Adams, 1 Rachel Mistur 21Radiology, Cincinnati Children’s Hospital Medical Center,Cincinnati, Ohio USA; 2 Radiology, University of CincinnatiCollege of Medicine, Cincinnati, Ohio USAObjectives—With increasing reports of precocious puberty andconcerns of environmental exposures to young girls, we wondered if publishedreference values for normal peripubertal ovarian and uterine volumesdating back to the 1990s were still applicable today. Previous samplesizes were small, and accurate values are needed for diagnosis of peripubertaldisorders.Methods—We retrospectively reviewed pelvic ultrasoundexams performed on girls aged 7 to 12 years over a 29-month period, regardlessof indication for the scan. Ovarian and uterine dimensions wererecorded along with age at the time of the scan, menstrual status, and clinicalhistory. We excluded patients with precocious puberty and clear pelvicabnormalities 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 onlythe most recent exam. The volume of the ovary was calculated using theellipsoid formula: volume = (longitudinal × transverse × anteroposterior)× 0.5233.Results—Searching radiology records revealed 600 patients.After exclusions, 476 patients formed our data set. Three hundred thirtyeightpatients had not started their menses, while 138 had experienced atleast 1 menstrual cycle. Ovarian and uterine volumes with SD by age aretabulated below.Conclusions—The normative values obtained represent thecurrent peripubertal population and reflect changes in pubertal developmentthat have evolved over the past 20 years. Our study results highlightthe importance of age and menstrual status classification when assessingovarian volume; therefore, reference values for ovarian and uterine volumesshould be revised to include age and menstrual status categorization.These data provide reassurance when evaluating patients withpremature puberty.Table 1. Ovarian Volume by AgePremenarchalPostmenarchalMean Volume,Mean Volume,Age, y mL (SD) n mL (SD) n7 1.47 (1.14) 34 3.80 (0.00) 18 1.65 (0.84) 44 2.01 (0.83) 29 2.17 (1.66) 54 6.33 (3.23) 410 2.67 (1.78) 72 6.02 (3.59) 1311 3.32 (1.90) 74 4.65 (2.99) 2112 4.68 (2.54) 60 5.89 (2.71) 971539863 @EDUltrasoundQA: An Updated Twitter CurriculumDavid Bahner, 1 Saad Raginwala, 1,2 Nilesh Patel, 1 * CreaghBoulger, 1 Eric Adkins, 1 Eric Cortez 1 1 Emergency Medicine,Ohio State University, Columbus, Ohio USA; 2 Grand RapidsMedical Education Partners, Grand Rapids, Michigan USAObjectives—To demonstrate an updated Twitter-based ultrasoundcurriculum designed to provide educational pearls in a questionanswer–basedformat.Methods—A curriculum consisting of high-yield ultrasoundconcepts in a question-answer format was developed and posted to a Twitterpage every morning at 9 AM and evening at 5 PM beginning on July1, 2012. As with the previous curriculum, each post or “tweet” was limitedto 140 characters. Each month covers a separate ultrasound topic, includingfocused assessment with sonography for trauma, ultrasoundphysics, and cardiac scanning. The curriculum is supplemented by normaland pathologic images.Results—As of September 26, 2012, there were 106 followers;153 tweets have been published with an average length of 46 charactersper question and 94 characters per answer. Followers of @EDUltrasoundQAcome from a variety of backgrounds and levels of training, includingemergency medicine attendings and residents, sonographers,midlevel providers, medical students, and educators. Several followers arecontributors in various areas of social media, including podcasts, blogs,and medicine-related Twitter feeds. The feed has been mentioned 11 timesby other accounts and has been ranked in the FOAMed (Free Open AccessMeducation) top 25 Twitter feeds.S103

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Conclusions—Twitter provides an excellent means to delivereducational content to learners at all levels of training. This project hasdemonstrated another novel type of curriculum that has the potential to beused in many educational endeavors. Future goals include increasing interactivitybetween the curriculum designers and participants, further categorizingfollowers, and better characterizing its impact on education.Finally, given its broad applicability, additional efforts are being made toenable other educators to easily implement this technology.1539867 Ultrasound of Arteriovenous Malformations of the GenitourinarySystemVijayanadh Ojili, 1 * Gowthaman Gunabushanam, 2 RaviVassa, 1 Nagar Arpit, 3 Kedar Chintapalli, 1 Leslie Scoutt 21Radiology, University of Texas Health Science Center, SanAntonio, Texas USA; 2 Diagnostic Radiology, Yale UniversitySchool of Medicine, New Haven, Connecticut USA; 3 Radiology,Ohio State University Medical Center, Columbus, Ohio USAObjectives—To describe the sonographic findings of arteriovenousmalformations (AVMs) of the genitourinary system and correlatethese with computed tomographic (CT) and angiographic findings whereavailable.Methods—A brief review of the AVMs of the genitourinarysystem (including renal and uterine AVMs) will be presented. The sonographicfindings will be described and correlated with CT and angiographicfindings. Pertinent management issues, including angiographyand embolization procedures, will be briefly discussed.Results—Not applicable as this is a pictorial review.Conclusions—AVMs of the genitourinary tract are potentiallylife-threatening conditions that require aggressive image-guided or surgicalmanagement. Therefore, it is important for the radiologist to accuratelydiagnose these conditions in a timely fashion. Although multidetector CTand digital subtraction angiography are the imaging modalities of choicefor comprehensive evaluation, ultrasound is often the initial imaging testperformed in the diagnostic workup of these patients and will provide a diagnosisin most cases.1539898 Prenatal Diagnosis of Recurrent AtelosteogenesisJanice Byrne, 1,2 * Anne Kennedy, 3 Paula Woodward, 3 DeborahKrakow, 4 John Carey 2 1 Obstetrics and Gynecology, 2 Pediatrics,3 Radiology, University of Utah, Salt Lake City, UtahUSA; 4 Human Genetics, University of California, Los Angeles,California USAObjectives—Document the prenatal ultrasound and postnatalclinical findings in a rare condition.Methods—Prospective identification of recurrence of a veryrare lethal skeletal dysplasia by prenatal imaging and comparison withpostnatal findings from the previous affected pregnancy.Results—A 28-year-old G2P1001 married Caucasian womanwas referred at 35 weeks’ gestation for findings concerning for a skeletaldysplasia, possibly type 1 atelosteogenesis. Micromelia with severely affectedfibulae and humeri, mild long bone curvature, clubfeet, a smallchest, and polyhydramnios were noted. At 38 weeks, the patient deliveredvaginally a live-born infant with obvious skeletal dysplasia. In addition tothe findings noted by ultrasound, severely abducted (“hitchhiker”) thumbsand great toes were seen. Characteristic radiographic findings including taperedhypoplastic humeri confirmed the suspicion of type 2 atelosteogenesis.DTDST mutation analysis was sent, but prior to the results beingavailable, the patient again became pregnant. Ultrasound at 11 weeksshowed a cystic hygroma, and 2 weeks later, short curved long bones and“hitchhiker” thumbs and great toes could be seen. The patient terminatedthe pregnancy. Gross examination confirmed the ultrasound findings.Conclusions—These cases illustrate the critical importance ofpostnatal correlation of ultrasound findings in rare conditions, especiallywhen multiple types of a disorder are known. Types 1 (original proposeddiagnosis) and 3 atelosteogenesis are autosomal dominant and would confera negligible recurrence risk given the unaffected parents. Type 2, on theother hand, is autosomal recessive with a 25% recurrence risk. Identificationof a mutation in the DTDST sulfate transporter gene will allow preimplantationgenetic diagnosis in a future pregnancy.1539948 Association Between First-Trimester Ultrasonographic TwinCrown-Rump Length Discrepancies and Neonatal OutcomesPedro Roca, 1 * Allen Kunselman, 2 Gabor Mezei, 1 Kari Whitley, 1Dennis Mujsce, 3 Ian Paul, 3 Serdar Ural 1 1 Obstetrics andGynecology, 2 Public Health Sciences, 3 Pediatrics, Penn StateHershey, Hershey, Pennsylvania USAObjectives—Determine the association between increased fetalsize discrepancies in crown-rump length (CRL) during first-trimester ultrasoundand poor perinatal outcomes.Methods—Retrospective study, all twin pregnancies deliveredat our institution before December 2009. We excluded pregnancies thatcommenced with higher-order multiples as well as those with major fetalcongenital anomalies.Results—Forty-six pregnancies were included. The firsttrimesterultrasound was performed on average at 10 3/7 weeks (SD, 2weeks). The median percent discrepancy in CRL relative to the smaller twinin 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 associationof 4 predictors (ie, CRL during the first trimester [11–14 weeks’gestation] ultrasound of each twin, the deviation [ie, difference] from themean CRL for each twin set per delivery, the week of the first-trimester ultrasound,and the twin birth order) with each early neonatal outcome. Thisis an extension of logistic regression that accounts for the clustering of twinsper delivery. Similarly for continuous outcomes, mixed-effects models thataccount for twin clustering were fit using the same 4 predictors. Table 1 reportsthe adjusted odds ratios (AORs), 95% confidence intervals (CIs), andP values for 4 early neonatal outcomes. There was no evidence of an associationof CRL or the deviation from the mean CRL for twins with respiratorydistress syndrome (RDS), need for mechanical ventilation (MV), needfor total parenteral nutrition (TPN), or need for a nasogastric tube (NGT).Conclusions—The difference of CRL during first-trimester ultrasoundis a poor predictor for early neonatal complications. This studysuggests little relationship between the difference in size of twins as assessedby CRL during routine first-trimester ultrasound and early neonataloutcomes targeted above.Table 1. Predictor of OutcomesAOR (95% CI) [P]RDS MV TPN NGTCRL 0.94 1.18 0.97 0.95(0.85–1.03) (0.95–1.48) (0.90–1.05) (0.87–1.04)[.17] [.14] [.45] [.28]Deviation from 1.12 1.00 1.18 1.05mean CRL of twins (0.93–1.35) (0.73–1.38) (0.95–1.47) (0.90–1.23)[.23] [.99] [.14] [.53]S104

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131539989 The Work Flow Impact of Universal Transvaginal CervicalLength Screening With Anatomic Surveys in an UltrasoundUnitEileen Wang,* Alexander Friedman, Samuel Parry, NadavSchwartz Obstetrics and Gynecology, University of Pennsylvania,Philadelphia, Pennsylvania USAObjectives—Low-risk women with a short cervix transvaginallyat time of the second-trimester anatomic survey may have an increasedrisk of preterm birth. Vaginal progesterone may be offered toreduce this risk. Cost-effective analyses of universal transvaginal cervicalscreening (TVCL) have not included the impact of the extra time to performTVCLs on the work flow of an ultrasound (US) lab. We comparethe times for anatomic surveys and growth scans in periods before andafter universal TVCLs were instituted.Methods—This is a prospective observational study done in anurban tertiary care center. In our 4-room US unit, after sonographers (SGs)scan, the images are reviewed by the physician (MD), who then sees thepatient to either scan or discuss results. After implementation of TVCL, patientsvoid prior to TVCL after the anatomic survey. Durations of studieswere recorded for quality improvement. Studies by maternal-fetal medicinefellows or with missing times were excluded. The times for anatomicsurveys, for growth scans, and for patients to void were collected and categorizedper SG (n = 8) and per supervising MD (n = 9). Data from 5weeks before and from a convenience sample of 6 weeks after implementationwere compared. The data are presented as mean ± SD. The Studentt test and 1-way analysis of variance were used to evaluate pre-CL andpost-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 includedTVCLs with a mean duration of 61.0 ± 10.5 minutes. Mean voiding timewas 9.1 ± 6.2 minutes, ranging from 2 to 35 minutes. The mean time increaseper 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 surveyby almost 15 minutes, primarily due to the time to void. This must beaccounted for when exploring ways to optimize work flow. The potentialto impact the number of scans that can be accommodated should be consideredin future cost-benefit studies.1540030 Association of Ultrasonographic Twin Estimated FetalWeight Discrepancies With Early Neonatal OutcomesPedro Roca, 1 * Allen Kunselman, 2 Anthony Ambrose, 1Ian Paul, 3 Dennis Mujsce, 3 Serdar Ural, 1 Kari Whitley 11Obstetrics and Gynecology, 2 Public Health Science, 3 Pediatrics,Penn State Hershey, Hershey, Pennsylvania USAObjectives—Determine the association between increased fetalsize discrepancy during routine second-trimester ultrasound and poor perinataloutcomes.Methods—We designed a retrospective study including all twinpregnancies from our institution before December 2009. We excludedpregnancies with major fetal anomalies. A total of 98 pregnancies met theinclusion criteria. The second-trimester ultrasound was performed on averageat 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). Themedian percent discrepancy in EFW relative to the lighter twin in eachpregnancy 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 linkwere used to assess the association of 4 predictors. There was no associationof the deviation from the mean EFW for twins with gestationalage at delivery (P = .84) or for twins with admission to the neonatal intensivecare unit (adjusted odds ratio [AOR], 1.00; 95% confidence interval[CI], 0.99–1.01; P = .53) after adjusting for EFW, week ofsecond-trimester ultrasound, and birth order. The only significant effectwas the association of the deviation from the mean EFW of twins withnecrotizing enterocolitis.Conclusions—For every 1-g increase in the deviation from themean EFW of twins, the odds of NEC increase by 1.03 (or 3%), adjustingfor 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 deviationfrom the mean EFW of twins during second-trimester ultrasound is a poorpredictor for early neonatal complications.Table 1. Predictor of OutcomesAOR (95% CI) [P]IV CatheterRDS MV Days (≥1 vs 0) NEC TPN NGTEFW (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 1.00from (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 oftwins (g)Week of 1.36 1.14 1.81 5.32 1.76 1.552nd- (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] [

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Conclusions—There are few published cases, and almost allshow ultrasonographic findings similar to our cases. Until more evidencebecomes available regarding the echo pattern and blood flow mimickinga malignant ovarian tumor, surgical treatment cannot be avoided. In our experience,conservative surgery has had satisfactory results; all patientsgave birth without complications.Table 1Patient1 2 3 4 5 6Age, y 34 36 32 31 36 38Gestation, wk 21 8 23 16 8 12Laterality Right Bilateral Left Left Right LeftSize, mm 87 60/75 55 49 59 39Papillae Present Present Present Present Present PresentBlood flow Present Present Present Present Present PresentCA-125, IU/mL 43.71 22 40.20 26 — —Surgery During During During During No Nopreg- preg- preg- pregnancynancy nancy nancy1540162 Correcting for Acoustic Cavitation and Acoustic Streamingin Ultrasound CalibrationVictor Frenke, l * Thanh Nguyen, 2 Loan Bui, 1 Nghia HuuTran 2 1 Biomedical Engineering, 2 Electrical Engineering,Catholic University of America, Washington, DC USAObjectives—Commercial power meters for calibrating ultrasoundtransducers are used ubiquitously in clinical and laboratory settings.These devices are inherently inaccurate in that they do not compensate forthe effects of acoustic cavitation (AC) and acoustic streaming (AS). Bothphenomena can alter displacements generated on the meter’s target, introducingerrors in power measurement. The objectives of this study wereto investigate these phenomena and to propose a standardized procedureto marginalize their effects on power measurement.Methods—The experimental setup included a nonreflecting targetsuspended from an analytical balance, reproducing the procedure employedin commercial devices. Measurements were performed at 1 and 3.3MHz, where intensities employed precluded the onset of AC at the higherfrequency. The attenuating effect of AC bubbles in the ultrasound beamwas quantified by using a transmitting and receiving ultrasound transducerto determine the power loss within the beam. Evidence of the contributionof AS to erroneous measurements was demonstrated using an acousticallytransparent membrane positioned immediately above the target.Results—AS was found to significantly increase the powerbeing sensed, indicating its dependence on the attenuating effects of AC.The acoustically transparent membrane above the target effectively eliminatedthese effects. AC was found to significantly decrease the powerbeing measured where discrepancies with noncavitation measurementscorrelated positively with intensity. AC activity, itself, also correlated withintensity, as demonstrated using passive detection of harmonic emissions.Conclusions—This study demonstrated that AC and AS cansignificantly introduce errors in standard calibration measurements. Theseeffects were consistent with acoustic theory, including the dependence ofAS on the attenuation effects of AC bubbles. An acoustically transparentmembrane eliminated the effects of AS. The numerical relationship betweenthe attenuation of AC bubbles, and the manner by which they affectedthe measurements, was found to accurately correct for thesediscrepancies. The setup employed for the study can easily be assembledusing standard laboratory equipment.1540166 Usefulness of Uterine Tranverse Diameter Measurement inSuspicion of Congenital Uterine AnomaliesMeritxell Vila,* M. Angela Pascual, Betlem Graupera, LourdesHereter, Cristina Pedrero, Maria Fernandez-CidObstetrics, Gynecology, and Reproduction, Institut UniversitariDexeus, Barcelona, SpainObjectives—The purpose of this study was to evaluate the potentialrole of the transverse diameter, measured by conventional ultrasonography(2DUS), of the uterus in the diagnosis of suspected congenitaluterine anomalies.Methods—Between February 2011 and June 2012, womenaged 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 anomalieswere suspected when measured by 2DUS when the transverse diameter ofthe uterus was >45 mm. Women were categorized according to the sizerange of the transverse diameter: 45 to 54, 55 to 64, and ≥65 mm. To comparethe size range rate, Pearson’s χ 2 was used, and data were expressedas percentages according to its distribution.Results—Of all the patients that had a transverse diameter >45mm, 138 of them were diagnosed by 3DUS as having uterine anomalies.Among the women diagnosed with uterine anomalies, the minimum transversediameter measured was 45 mm, and the maximum was 88 mm.Table 1 shows the distribution of the uterine anomalies diagnosed and thesize range for each type. The results show that most arcuate septate andpartial septate anomalies have a transverse diameter of 45 to 54 mm, withstatistical significance (P < .001).Conclusions—Diameter measurements of the uterus throughtransverse diameter 2DUS provide indirect information on possible uterineanomalies. It seems a transverse diameter from 45 mm is a good indicatorto suspect possible uterine anomalies and thus complete the study by 3DUSfor the diagnosis and classification of congenital uterine anomaly types.Table 1Transverse Diameter, mmAnomaly Type 45–54 55–64 ≥65 TotalArcuate, n (%) 74 (76) 19 (19.8) 3 (3.1) 96Partial septate, n (%) 12 (70.6) 4 (23.5) 1 (5.9) 17Septate, n (%) 13 (59.1) 8 (36.4) 1 (4.5) 22Bicornuate, n (%) 1 (33.3) 0 (0) 2 (66.7) 3Total 100 31 7 1381540206 Ultrasonographic Diagnosis of Ovarian Ectopic PregnancyAfter In Vitro Fertilization With Salpingectomy and LiteratureReviewM. Angela Pascual, 1 * Lourdes Hereter, 1 Betlem Graupera, 1Francisco Tresserra, 2 Alicia Perez, 1 Buenaventura Coroleu, 1Pedro Barri 1 1 Obstetrics, Gynecology, and Reproduction,2Pathology, Institut Universitari Dexeus, Barcelona, SpainObjectives—Among ectopic pregnancies, ovarian ones are extremelyrare and much less frequent with previous history of salpingectomy.Diagnosis and treatment of this condition continue to be challenginggiven that no typical risk factors exist compared with other types of ectopicpregnancy, and signs and symptoms are similar to those observed in rupturedcorpus luteal cysts. Ultrasonographic diagnosis is feasible, althoughdifferential diagnosis from the corpus luteum is difficult. In this context,the goal is to diagnose as accurately as possible to apply the surgical treatmentto remove the ectopic pregnancy, preserving ovarian tissue.Methods—This is a case of a 31-year-old woman with rightsalpingectomy, 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-S106

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013view of the literature was performed to assess the frequency of this conditionand its association with in vitro fertilization procedures.Results—We identified >250 reported cases, most of them casereports and some series. Among the articles, 5 cases of OEP were foundin patients with a history of salpingectomy, and 4 papers reported OEPafter ICSI-ET.Conclusions—OEP may be an unexpected finding in patientswith salpingectomy; unfortunately, this condition cannot prevent OEP.Monitoring of β-human chorionic gonadotropin levels and the accuracy ofultrasonographic diagnosis allowed a conservative therapeutic strategyand proper postoperative course.1540300 Ultrasound Screening of the Dense Breast: An Analysis ofthe Costs and Benefits to Both the Patient and the PractitionerRen Tianbo, Sirisha Jasti,* Katherine Kaproth-Joslin, AviceO’Connell Radiology, University of Rochester, Rochester,New York USAObjectives—Approximately 40% of all women undergoingscreening mammography are found to have dense breasts. Unfortunately,the sensitivity and specificity of mammography are reduced in patients withdense breasts, and some research indicates that dense breasts have an increasedrisk of breast cancer development. Recent studies have suggestedthat mammography combined with screening breast ultrasound can help detectbreast cancers in patients with dense breasts. California and Connecticutare currently the only 2 states where screening ultrasound has beenapproved, and New York has recently passed a bill requiring the inclusionof breast density information sent to women after their mammogram. Thepurpose of this presentation is to review the advantages and disadvantagesof screening breast ultrasound and to analyze the feasibility of screening ultrasoundas a standard screening protocol in current radiology practice, includingboth the cost and time expenses to the patient and practitioner.Methods—In this presentation, we will review the sensitivityand specificity of screening ultrasound plus mammography. We will analyzeboth the monetary and time costs to the patient and to the practitionerassociated with screening ultrasound plus mammography vs standardmammography alone, with a close examination of what is occurring inConnecticut and California, including who is or will be paying for theseexams. Finally, we will discuss the general impact of additional ultrasoundscreening of dense breast tissue in light of the US Preventive ServicesTask Force 2009 recommendations, where even routine mammographicscreening for breast cancer is being questioned.Results—The results of our analysis as described above will bediscussed in the presentation.Conclusions—With the recent US Food and Drug Administrationapproval of an automated breast ultrasound system and the push forscreening ultrasound as a standard screening procedure in Connecticutand California, as well as the new legislation passed in New York State tonotify women of their breast density, it is necessary to understand the costsand benefits of screening ultrasound to both the patient and the practitioner,including efficacy of the procedure.1540301 Ultrasound Features of Follicular Neoplasms and UltrasoundFeatures of Follicular Neoplasms Proven to Be FollicularCarcinoma at SurgeryAnnette Ho,* Michael Davis, Annemarie Buadu MedicalImaging, University of Arizona, Tucson, Arizona USAfollicular neoplasms were reviewed to determine how often these lesionshad calcifications and/or were cystic. Thirty-three of the patients diagnosedwith follicular neoplasms subsequently underwent thyroidectomy.The surgical pathology reports were reviewed to determine how frequentthe follicular neoplasms were malignant.Results—The database included 62 patients with follicular neoplasmsafter ultrasound-guided thyroid biopsy. On ultrasound imaging, 21of 62 follicular neoplasms had cystic components, and 13 of 62 follicularneoplasms had calcifications. Four of the 33 FNB follicular neoplasmlesions were found to be malignant on surgical pathology. One was diagnosedas follicular carcinoma, 1 as papillary carcinoma, and 2 as the follicularvariant of papillary thyroid carcinoma.Conclusions—Follicular neoplasms did not often have calcificationsand were often solid. Follicular neoplasms were more often benignlesions than malignant.1540408 Advanced Ultrasound Evaluation of Carotid Plaque: Cana Combined 2-Dimensional and 3-Dimensonal UltrasoundAnalysis Provide Additional Information and Identify SignificantPlaque Characteristics Responsible for Strokes?Lysa Legault Kingstone, 1,2 * Carlos Torres, 1 Geoffrey Currie 21Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario,Canada; 2 School of Dentistry and Health Sciences, CharlesSturt University, Wagga Wagga, New South Wales, AustraliaObjectives—Using ultrasound (US) to image plaque morphologymay improve stroke prevention by identifying atherosclerotic plaquesat higher risk for cerebrovascular events and associating morphologic characteristicswith additional risk factors. This study evaluated how integratingan advanced US plaque imaging analysis adjunct to stenotic gradingidentifies vulnerable characteristics in carotid atheromatous structure.Methods—Patients with known high-grade carotid artery disease,confirmed on computed tomography (CT), and who were scheduledfor a future endarterectomy, were recruited for this study. Prior to surgery,these participants received advanced US plaque imaging to identifycombined high-risk morphologic features such as specific homogeneity,internal echo texture, ulceration, surface irregularities, intraplaquehemorrhage/lipid core, and calcification. These identified morphologicfeatures were further enhanced with the use of high-frequency and 3D reformattedimaging. We strengthened the study’s results by analyzing thecarotid US imaging findings and then correlating them with their postendartertectomyhistologic studies.Results—At the time of abstract submission, final data collectionwas not yet available; however, preliminary results indicate a highcorrelation rate, sensitivity, and specificity between the US findings andthe detailed surgical specimens.Conclusions—Applying advanced US plaque imaging to furtheridentify significant plaque characteristics responsible for strokes canprovide insight into early causative conditions of carotid atherosclerosis.This advanced imaging protocol could potentially shift the paradigm inearly carotid plaque imaging and possibly predict the onset in asymptomaticor mild to moderate plaques.1540482 Utility of 3-Dimensional Plaque Imaging in Carotid StenosisLysa Legault Kingstone, 1,2 * Carlos Torres, 1 Geoffrey Currie 21Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario,Canada; 2 School of Dentistry and Health Sciences, CharlesSturt University, Wagga Wagga, New South Wales, AustraliaObjectives—To determine how often follicular neoplasms diagnosedby ultrasound-guided fine-needle biopsy (FNB) had cystic componentsor calcifications. Also, to determine how often follicular neoplasmsdiagnosed with FNB are proven to be malignant after thyroidectomy.Methods—Two hundred thirty-one lesions in 202 patients whounderwent thyroid biopsy were reviewed. Of these, 62 were diagnosed asfollicular neoplasms by ultrasound-guided FNB. Ultrasound features ofS107Objectives—Emerging data suggest that carotid plaque morphologyand severity can significantly affect the cerebrovascular prognosis.Recent studies have reported that 3D ultrasound (3DUS) used as anadjuvant imaging technique may provide additional information in theevaluation and risk stratification of vulnerable carotid plaque. The aim ofthis study was to evaluate the utility of 3DUS in characterizing plaquefrom various degrees of stenosis.

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Methods—In a cohort of symptomatic patients referred fromneurosurgery, 3DUS of the carotid arteries was conducted using a vascularultrasound system (iU22; Philips Medical Systems) equipped with avolumetric mechanical high-resolution linear array transducer for 3D imaging.We employed a 3DUS imaging method to allow high-detail studiesin mild, moderate, and severe stenotic plaques. Constructed 3D plaqueimages were quantified using the internal plaque echo texture, volume,and surface morphology and evaluated by 2 independent observers usingour own classification protocol.Results—At the time of abstract submission, final data were notyet available; however, preliminary results indicate that 3DUS for plaquecharacterization was significantly better in mild to moderate imaging, possiblydue to the fluid-filled lumen acting as a substantial acoustic transmissionfor optimal plaque visualization. Higher-grade stenoses (>70%)were difficult to assess; however, proximal and edge surface imaging wasdiagnostic. These preliminary results indicate that our 3D approach may bea sensitive tool in the identification of early vulnerable markers in lowergradedstenoses, possibly identifying early prediction of stroke.Conclusions—Preliminary results show a high sensitivity andnegative predictive value of carotid plaque 3DUS in mild to moderatestenosis and can reliably characterize the surface, volume, and ulcerations.The sensitivity decreased with the severity of stenoses. 3DUS carotidplaque quantification may serve as an important clinical screening tool inearly onset of significant carotid disease, for high-risk patients, and forthose without known significant carotid disease.1540523 Practical Uniformity Evaluation of Ultrasound Systems:Tips and PitfallsDonald Tradup,* Nicholas Hangiandreou, Scott StekelRadiology, Mayo Clinic, Rochester, Minnesota USAObjectives—We have found uniformity evaluation (UE) to bethe single most effective imaging test to ensure proper function of medicalultrasound (US) imaging systems. In this presentation, we will describeour process for efficient and effective UE.Methods—Display quality assessment and mechanical inspectionof the imaging system should occur prior to UE. Begin the UE by annotatingthe image with the device identification and visually inspectingin-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 compensationare visually optimized. Next, acquire clips of a phantom. These clipsshould show a dynamic speckle pattern across the entire transducer face.We use a previously described custom, flexible, liquid phantom. Tips foroptimal use of this phantom will be described. Commercial phantoms maybe used, but multiple clips may be needed to test the complete face ofcurved arrays. Store 3 phantom clips (to guard against false-positive findingsdue to poor coupling) and 1 in-air clip. If possible, compute medianimages from each clip, and inspect these for artifacts. Review of medianimages acquired at acceptance (or use of subtracted median images) willreduce the incidence of false-positives. Any artifacts observed at any pointduring testing should be debugged to rule out poor coupling with the phantom,dirt/debris on the transducer face or connector, or scanner port, toidentify mechanical damage, cable-flex issues, and differentiate port vstransducer problems. The severity of reproducible artifacts should be determinedby assessing visibility of the artifact when scanning anatomy andthe size and location of the artifact.Results—This UE approach has allowed us to detect artifactsin our US practice with good sensitivity and specificity, and staff efficiency.For ≈10% to 15% of transducers, a potential artifact is noted duringinitial testing that is discounted during debugging.Conclusions—Artifacts and equipment problems can be effectivelyidentified using a standard UE protocol. The debugging step isessential for minimizing the incidence of false-positives.1540556 Utility of the Prefrontal Space Ratio to Screen for Trisomy21 in a Racially Diverse Population: A Pilot StudyBarrie Suskin Kaplan, 1,2 Anne Marie Roe, 2,3 Komal Bajaj 2,3 *1Obstetrics and Gynecology, Montefiore Medical Center, Bronx,New York USA; 2 Albert Einstein College of Medicine, Bronx,New York USA; 3 Obstetrics and Gynecology, North BronxHealthcare Network, Bronx, New York USAObjectives—The characteristic facial features of trisomy 21, includingthe dorsal displacement of the edge of the maxilla and thickeningof the prenasal skin, have been well described. The prefrontal space (PFS)ratio capitalizes on these changes and has been shown to be an effectivescreening marker for trisomy 21 when calculated from midsagittal 2Dsonographic 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 facialmorphology varies among different racial groups, it is plausible that thePFS ratio may differ in non-Caucasian fetuses. The objective of this studywas to evaluate the PFS ratio of euploid fetuses of African American decentto determine whether this difference may exist.Methods—The PFS ratio was calculated retrospectively fromstored 2D images of euploid African American fetuses in the second andthird trimesters. These prenatal sonograms were performed at an urbanacademic maternal-fetal testing unit under strict supervision by reproductivegenetics and maternal-fetal medicine specialists. The cases weredrawn from chronologic birth records from our institution. Images wereexcluded if the fetal profile was not truly midsagittal or if the anterioredges of the maxilla and skin were not clearly identifiable. Other data includingthe presence of the nasal bone, maternal age, gestational age, andethnicity were also collected.Results—Mean maternal age was 29.3 years. Median gestationalage at the time of ultrasound examination was 20 weeks 4 days (18weeks 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 meanPFS ratio was 0.51 (SD, 0.17).Conclusions—Though not statistically significant, the prefrontalspace ratio in African American euploid fetuses trended lower thanthat reported in euploid Caucasian fetuses in the literature. This pilot studysuggests that different racial groups may have different normal prefrontalspace ratios. We plan to expand this study as well as assess the prefrontalspace ratio of other groups to establish accurate normal values for a raciallydiverse population.1540570 An Objective Tool to Evaluate Ultrasound Image Quality:The Ultrasound Standardized Assessment ToolCreagh Boulger,* Katherine Pollard, David Bahner EmergencyMedicine, Ohio State University College of Medicine,Columbus, Ohio USAObjectives—Evaluation of the skill of a sonographer requiresobjective assessments of his or her ultrasound scans. However, little literatureexists to define a high-quality ultrasound image. The purpose of thisstudy is to develop a standardized tool (Ultrasound Standardized AssessmentTool [USAT]) to assess ultrasound image quality and perform a pilotreliability study of the tool.Methods—A specific USAT was developed for each core emergencyultrasound application: trauma, intrauterine pregnancy, abdominalaortic aneurysm, cardiac, biliary, urinary tract, deep venous thrombosis,soft tissue/musculoskeletal, thoracic, ocular, and procedural guidance. TheUSAT uses a series of objective yes-or-no questions in conjunction witha difficulty rating of each view to produce a score. Ten beginning sonographers(first-year medical students in our institution’s introductory ultrasoundtraining program), 10 experienced sonographers (fourth-yearmedical students in our institution’s honors ultrasound course), and 5 expertsonographers (ultrasound-credentialed faculty members at our institution)S108

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013will perform ultrasound scans on a group of standardized ultrasound patients.The ultrasound scans will be evaluated using the USAT by 3 ultrasound-credentialedfaculty evaluators from emergency medicine, criticalcare, and radiology, who will be blinded to the identity of the scanners. TheUSAT will then be evaluated for reliability.Results—A specific USAT has been developed for each coreemergency ultrasound application. Ultrasound scans for evaluation arebeing performed.Conclusions—The need for a standardized method to both objectivelyevaluate the quality of an ultrasound image and provide distinctdifferentiation between skill levels of ultrasound users is well documented.The USAT represents one of the first attempts to provide objective assessmentof ultrasound images. We anticipate that the USAT will be avaluable resource to assess the current skills of sonographers and followthe development of these skills over time.1540597 Mid or Late Second-Trimester Doppler Ultrasound of theUterine Artery: Is There a Difference?Koen Deurloo, 1 * John van Vugt, 2 Annemieke Bolte, 3 MartijnHeymans 4 1 Obstetrics and Gynecology, Diakonessenhuis,Utrecht, the Netherlands; 2 Obstetrics and Gynecology,Radboud University Medical Center, Nijmegen, the Netherlands;3 Obstetrics and Gynecology, 4 Clinical Epidemiology andBiostatics, VU University Medical Center, Amsterdam, theNetherlandsObjectives—Uterine artery (UA) Doppler measurements forscreening for hypertensive complications in pregnancy is usually performedat 22 to 24 weeks of gestation. However, most routine targetedultrasound examinations are performed at 19 to 21 weeks of gestation.It would be convenient to include the UA Doppler measurement in theroutine targeted ultrasound; therefore, we studied the correlation of UADoppler measurements at 19 to 21 and 22 to 24 weeks of gestation.Methods—Ninety-seven primigravidas with uncomplicatedsingleton pregnancies were analyzed. Combined UA velocity waveformswere assessed using transabdominal color Doppler ultrasound between 19and 24 weeks of gestation. The resistance index (RI) was calculated forleft and right UAs, and the results were averaged as a combined US RI.After log transformation of the US RI variable, the results were analyzedwith 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 RIsbetween 19 and 21 and 22 and 24 weeks of gestation.Results—Adequate UA velocity waveforms were assessed inall 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 at19 to 21 and 22 to 24 weeks of gestation are strongly correlated, and UADoppler measurements might be included in the routine targeted ultrasoundat 19 to 21 weeks of gestation. Further research is needed to assessits screening performance.1540605 Simulation Model as an Adjunct Method for EmergencyMedicine Transvaginal Ultrasound EducationOmar Corujo Vazquez,* Marie Romney, Penelope ChunLema, Cara Brown, Michael Radeos, Eric Tran, Anita DattaEmergency Medicine, New York Hospital Queens, Flushing,New York USAObjectives—This study assessed the importance of a mannequinsimulator model as an addition to a didactic lecture in point-ofcarepelvic ultrasound. We hypothesized an improvement in ultrasoundknowledge, technique, satisfaction, and confidence for residents exposedto the simulation model.S109Methods—First-year residents in emergency medicine wereenrolled 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 receiveddidactic education. Group B received additional hands-on ultrasoundsimulation training with the Combination IUP Ectopic PregnancyTransvaginal Ultrasound Training Model (Blue Phantom, Redmond, WA).Both groups were evaluated by a written test and an objective structuredclinical 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 writtenscore by 50% compared to group A (32% vs 21% median increase) but didnot reach statistical significance (P = .074). Group B increased their pretestto posttest OSCE score when compared to group A (31% vs 29.9% median),but this difference was not statistically significant (P = .92). Prior tothe 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 “extremelycomfortable” performing transvaginal ultrasound after the intervention.Conclusions—Simulation combined with didactic training maybe superior for resident satisfaction and confidence in point-of-care pelvicultrasound teaching. Although there was improvement in knowledge andtechnique, a larger study is needed on the use of simulation training in residenteducation to show significance.1540609 Analysis of Uniformity Artifacts Detected During ClinicalUltrasound Quality ControlScott Stekel,* Nicholas Hangiandreou, Donald TradupRadiology, Mayo Clinic, Rochester, Minnesota USAObjectives—Characterize trends in severity ratings of observedtransducer uniformity artifacts.Methods—We reviewed the results of quarterly quality control(QC) uniformity testing for the previous ≈2 years and characterized theevaluation history of all transducers exhibiting artifacts of any severity.Our evaluation protocol is able to reveal subtle transducer artifacts. All artifactswere scored by a single author (D.T.) using a subjective severityscale. Uniformity artifacts attributed to scanner defects were excludedfrom 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, withscore F), as well as those that did not fail but exhibited at least 2 successivesubcritical artifact scores (P1, P2, or P3).Thirty-one of these 58 probes failed (score F). Twenty-two ofthe 31 failing scores (71%) directly followed a prior QC assessment witha passing score (score P, no artifact seen). Only 9 failures (29%) were directlypreceded by ≥1 subcritical scores. The time between the first subcriticalscore and the failure ranged from 3 to 14 months, with a mean of9.1 months. No reliable trend of progressively worsening subcritical scoresending 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 notfailed. Two of these artifacts spontaneously resolved, returning to scoresof P. The remaining 25 artifacts were observed up to the last recorded QCsession. The time duration of these subcritical artifacts ranged from 0.5 to16.5 months, with a mean of 10.5 months. No reliable trend of progressivelyworsening subcritical scores was seen (the numbers of these probeswith improving, stable, and worsening subcritical scores were 5, 18, and3, respectively).Conclusions—These subjective artifact data are not consistentwith a model of initial minor defects progressively increasing in severityuntil failure occurs. We are working on methods to objectively score artifactseverity, which should allow a more sensitive analysis of artifact behavior.

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131540628 Carotid Plaque Classification System: A New StandardDiagnostic CriterionLysa Legault Kingstone, 1,2 * Carlos Torres, 1 Geoffrey Currie 21Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario,Canada; 2 School of Dentistry and Health Sciences, CharlesSturt University, Wagga Wagga, New South Wales, AustraliaObjectives—2D and 3D ultrasound (US) for carotid plaque imagingcan provide valuable information on the morphology. Particularsonographic features of the plaque have been recognized as the foundationfor stroke. Carotid plaque imaging is increasingly recognized as being asimportant as stenotic grading; however, various methods of echographicimage standardization have been described. Standard plaque analysis andcharacterization are lacking, and, to our knowledge, no global classificationsystem or form of image standardization exists. Our objective was todevelop a standard US characterization method and reporting system forcarotid atherosclerotic lesions.Methods—We created and implemented a quality assurancetool for plaque classification criteria in an effort to globalize image and reportingstandardization without the use of complex or expensive software.US images were subjectively graded using a standardized classification reportform that combines echographic image features. Three categoricalgroups were defined according to risk of vulnerability: type A (low risk),type B (moderate risk), and type C (high risk). Accuracy of the method wasdetermined by measuring the agreement of plaque characterization usingstandardized US images and comparing inter-observer agreement andinter-reader reliabilities. In addition, highly vulnerable plaques incorporatedRadpath correlation.Results—At the time of submission, final data analysis wasbeing completed. Preliminary results indicate that our plaque classificationsystem provided excellent sensitivity, specificity, positive predictive value,negative predictive value, and accuracy.Conclusions—Our standardized classification system has allowedus to improve the consistency and accuracy of plaque characterizationimaging and assessment without of the use of computed orautomated methodologies. This plaque analysis criterion may help promotethe use of a standard global US classification analysis and uniformreporting for carotid atherosclerotic lesions. Large-scale studies are requiredto fully assess the potential of this grading system.1540646 A Decade of Ultrasound Practice Accreditation at CaliforniaPrenatal Diagnosis Centers and Experience With FetalEchocardiography AccreditationSara Goldman Genetic Disease Screening Program, CaliforniaDepartment of Public Health, Richmond, California USAObjectives—Monitor the ultrasound practice accreditation andreaccreditation at prenatal diagnosis centers (PDCs) from 2001 to 2011and 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–approvedPDCs were required to apply for fetal echocardiography accreditationwith the AIUM or Intersocietal Commission for the Accreditationof Echocardiography Laboratories (ICAEL).Results—In 2001, 50 ultrasound practices (65 %) had achievedAIUM accreditation; 17 practices (22%) were in the process of achievingAIUM accreditation; and 10 practices (13%) had chosen American Collegeof Radiology (ACR) accreditation. In 2011, there were a total of 80ultrasound practices at 141 PDC sites. Seventy-five practices (94%) hadachieved AIUM accreditation, and 5 ultrasound practices had chosen ACRaccreditation. On average, 18 ultrasound practices achieve reaccreditationeach year. In March 2012, 34 ultrasound or pediatric cardiology practicessubmitted a fetal echocardiography accreditation application representing56 PDC sites, and 18 (53%) practices are currently accredited by either theAIUM or ICAEL representing 30 PDC sites.Conclusions—A requirement for OB ultrasound practice accreditationat PDCs and fetal echocardiography accreditation at fetal echo–approved PDCs is achievable through monitoring of the reaccreditationprogress.1540658 Medical Student Ultrasound Education as Part of theClinical Skills Immersion ExperienceZachary Robinson, 1 Colin Turney, 1 Creagh Boulger, 2 DavidBahner 2 *1 Ohio State University College of Medicine,Columbus, Ohio USA; 2 Emergency Medicine, Wexner MedicalCenter, Ohio State University, Columbus, Ohio USAObjectives—Focused ultrasound (US) allows physicians toquickly obtain high-quality, cost-effective images. While the technologyhas advanced, education in ultrasound has lagged at the graduate medicaleducation and medical student levels. Over the last several years, OhioState has emerged as a leader in ultrasound education by teaching focusedUS to medical students. US has been integrated into the Clinical SkillsImmersion Experience (CSIE), a unique 7-day course providing third-yearmedical students with experience in a variety of procedural and imagingtechniques.Methods—The CSIE curriculum consists of a series of lecturesand workshops over a variety of clinical skills. As part of this curriculum,we conducted a 3-hour session on focused ultrasound, which includedpelvic, aorta, and cardiac imaging, as well as evaluation of lung sliding andthe focused assessment with sonography for trauma scan. The session includeda brief lecture on basic US principles followed by extensive handsonexperience. After the session, students completed a survey evaluatingtheir skills with US using a 5-point Likert scale, where 1 = low skill leveland 5 = highly skilled. They were also asked how well the session improvedtheir understanding of ultrasound, where 1 = not at all and 5 =greatly improved.Results—Ten of 38 students responded to the survey for theAugust session (response rate, 26%). Nine of 10 respondents had performed

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013asis, abdominal pain, and hematuria was performed. Descriptive statisticswere used for all subjects. Normalcy for data was calculated, and all continuousdata were evaluated utilizing the Student t test or analysis of variance,when appropriate. All categorical data were calculated using theFisher exact test or χ 2 analysis.Results—We found 153 cases of kidney stones among the pediatricpopulation from January 2007 to 2011. The mean age was 19 years.Patients were evaluated by 24% ED physicians, 66% pediatric emergencyphysicians, and 10% midlevel providers (MLPs). Though there was anoverall 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 attendingvs pediatric attending vs MLP) had no significant effect on the use of computedtomography (CT) or US (P = .15; P = .15, respectively). The typeof provider or diagnostic modality did not affect the ED length of stay ofpatients (P = .08).Conclusions—There has been an overall increase in renal colicamong 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 USin patients suspected of having nephrolithiasis to further minimize the useof CT scans.1540672 Prenatal Stomach Size: Association With Cleft Lip and/orCleft PalateKristin Burhans, 1 * Lauren Mack, 1 Peter Koltz, 2 StephanieHenderson, 1 John Girotto, 2 Loralei Thornburg 1 1 Obstetricsand Gynecology, 2 Plastic Surgery, University of Rochester,Rochester, New York USAObjectives—Cleft lip/palate is listed as associated with an absentstomach due to poor fetal swallowing; however, it is unclear if a“small” stomach is also associated, especially without concurrent brainabnormalities.Methods—Records were reviewed for all nonanomalous infantsat Strong Memorial Hospital from 2003 to 2011 with cleft lip/cleftpalate with available second- or third-trimester images. In each abdominalcircumference, stomach width (W) and anterior-posterior (AP) measurementswere measured by a single author (L.M.), and polyhydramniosor “absent” stomach was recorded. Nondiabetic controls matched 2:1 forall but 9 patients (1:1) for the gestational age (GA) of measurement within1 week. As per prior nomograms, mean W and AP were compared in 3-to 5-week GA groups between infants with clefts and those without.Results—Of 32 infants with clefts, 108 measurements matched207 control measurements. The majority of infants received 2 or 3 prenatalultrasound examinations. There were only 3 infants with cleft with anabsent stomach at any point in gestation, 1 with polyhydramnios. Themean 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 and31 to 36 weeks.Conclusions—Few nonanomalous infants with clefts had anabsent stomach on ultrasound, suggesting this is an insensitive marker;however, mean W and AP stomach measurements were significantlysmaller in the mid trimester between 19 and 24 weeks when manyanatomic ultrasound examinations are performed. Abnormalities in prenatalstomach measurements, especially during this period, should promptevaluation for cleft lip/palate. Stomach size at 16 to 18 weeks did not differin either dimension, suggesting this is a poor marker prior to 19 weeks.Table 1. Stomach (mm), Mean ± SDInfants With Cleft Infants Without CleftGA, wk W AP W AP P, W P, AP16–18 5.0 ± 3.1 6.5 ± 5.3 6.8 ± 2.4 9.1 ± 4.5 .09 .1519–21 5.9 ± 2.8 6.4 ± 3.3 8.3 ± 2.4 9.3 ± 2.7 .01 .0122–24 4.9 ± 3.0 8.0 ± 4.9 9.4 ± 2.3 12.4 ± 4.3

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Fusion software was used had mean mA of 8574 and DLP of 1676 vs mAof 16,219 and DLP of 3342 in the group where solely CT-guided biopsieswere performed. Total reductions of 52% in mA and 50.1% in DLP wereachieved using Smart Fusion software.Conclusions—After examining the data gathered, we concludethat Smart Fusion software improves patients’ safety through radiationdose reduction as well as having a positive impact in interventional radiologyresource utilization. Multimodality imaging is a promising tool thatmight also decrease the cost of patient care. A larger sample will documentthe value of Smart Fusion software.1540683 Ultrasound of Musculoskeletal Conditions That ClinicallyMimic Lower Extremity Deep Venous ThrombosisGowthaman Gunabushanam, 1 * Vijayanadh Ojili, 2 LeslieScoutt 1 1 Diagnostic Radiology, Yale University School ofMedicine, New Haven, Connecticut USA; 2 Radiology, Universityof Texas Health Science Center, San Antonio, Texas USAObjectives—Venous Doppler examination is the first imagingstudy 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 ultrasounddiagnosis 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 conditionsthat mimic DVT are described, including: Baker’s cyst (ruptured, hemorrhagic,or infected); muscle tear, hematoma, or other injury; tendon inflammationand/or rupture; bursitis and infectious and inflammatoryarthritis; 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 vicinityof the symptomatic region enables an accurate alternate diagnosis ofmusculoskeletal pathologies.1540701 Implementation of Bedside Ultrasonography Within anInternal Medicine Faculty and Residency: The IMBUSProgramDavid Tierney,* Terry Rosborough Medical Education,Abbott Northwestern Hospital, Minneapolis, Minnesota USAObjectives—Describe in detail and provide a rationale for a curriculum,structure, and successful implementation of an internal medicine bedsideultrasound program (IMBUS) in a residency program and its faculty.Methods—Design: Prospective cohort study in an internalmedicine (IM) residency program at a private academic 700-bed tertiarycare center. Participants: Thirty-three residents and 13 full-time facultymembers 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-sensitivediagnoses; (2) overlap training method using top-down and bottom-upmethodologies; (3) 35-hour “boot camp” including didactic, hands-onmodel-based, and simulator-based training; (4) bedside hands-on trainingwith faculty mentors until trainee meets a prespecified exam count in eachcomponent and is deemed competent in that exam area; (5) ongoing mentoredand remotely submitted/reviewed images until adequate technicaland interpretive sensitivity/specificity obtained; (6) final test-out usingbedside 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) timeto, 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, andjob satisfaction.Results—We describe in detail and rigorously critique a full ultrasoundcurriculum 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 beenestablished. We are analyzing multiple outcomes, including competencylearning curves, skill decay, patient outcomes and experience, and physicianimpact of bedside ultrasound.Conclusions—We hope that by describing in detail our curriculum,methods, and learning, we can help other residency programsimplement bedside ultrasound in an efficient, focused, evidence-based,politically aware, and impactful manner.1540730 Utility of Point-of-care Ultrasound in the Management ofSnake BiteSrikar Adhikari,* Mazda Shirazi, Austin Gross EmergencyMedicine, University of Arizona Medical Center, Tucson,Arizona USAObjectives—To describe the use of point-of-care Ultrasound inthe management of a snake bite case in the emergency department (ED).Methods—We present a 67-year-old male who presented to theED with a rattlesnake bite to the right index finger approximately 4 hoursprior to arrival to the ED. The patient denied any history of diabetes, hypertension,or any other medical diseases. Physical examination revealednormal vital signs. Puncture wounds were noted on the second digit at themetacarpophalangeal joint with surrounding ecchymosis. There was significantedema of the right hand and forearm, with limitation of range ofmotion. He received 4 units of CroFab (antivenom) initially. A toxicologyconsult was obtained. Per toxicologist recommendations, the leading edgeof the swelling at the envenomation site was marked. Proximal progressionof swelling and induration were monitored to determine the need foradditional doses of CroFab. Two hours later, the treating emergency physicianwas asked to mark the leading edge of the swelling and induration inthe forearm to assess for any proximal progression. Based on clinical examinationfindings, it was determined that there was no significant proximalprogression of swelling and induration. Soft tissue ultrasound of theforearm was performed by another emergency physician who was not involvedin this patient’s care.Results—Bedside ultrasound revealed edema and subcutaneousfluid extending proximally into the elbow, beyond the leading edgemarked by the treating physician. The subcutaneous tissues were also hyperechoicin appearance. These ultrasound findings were highly suggestiveof proximal progression of local findings. Based on the sonographicfindings, additional doses of CroFab were given to the patient, who wasadmitted to the hospital.Conclusions—In this case, point-of-care ultrasound helpedclinicians make an accurate assessment of proximal progression of localfindings due to a snake bite. This case highlights the utility of bedside ultrasoundin the management of snake bite in ED patients. Point-of-careultrasound can expedite the consultation and appropriate treatment in patientswith snake bite.1540763 Scaled Signal Intensity of Uterine Fibroids on T2-weightedMagnetic Resonance Images: Objective Parameter toDetermine the Suitability for Magnetic Resonance–GuidedFocused Ultrasound Surgery of Uterine FibroidsSanghee Lee, 1 * Sang-Wook Yoon, 2 Mi Hee Lee, 3 Su MinKang 1 1 Radiology, Healthcare System, Gangnam Center,Seoul National University Hospital, Seoul, Korea; 2 Radiology,CHA Bundang Medical Center, CHA University, Seongnam,Korea; 3 Radiology, Seoul Metropolitan Government–SeoulNational University Boramae Medical Center, Seoul, KoreaObjectives—Magnetic resonance–guided focused ultrasoundS112

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013surgery (MRgFUS) is a noninvasive treatment for symptomatic uterinefibroids. Patient selection is the most important step to achieve good results.The purpose of this study was to assess the initial efficacy of scaledsignal intensity (SSI) of uterine fibroids on T2-weighted MR images as anew objective parameter to determine the suitability for MRgFUS.Methods—Twenty-four uterine fibroids in 20 premenopausalwomen were treated using MRgFUS. Treatments were performed fromOctober 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 standardizingits mean pixel intensity to a 0 to 100 scale, using reference intensitiesof muscle (0) and fat (100), respectively. SSI in each fibroid was retrospectivelyanalyzed according to the nonperfusion volume (NPV) ratio.Results—The mean NPV ratio in uterine fibroids with SSI 10 (n= 18), the mean NPV ratio was 51.8% ± 21.0%. Uterine fibroids with SSI10.Conclusions—SSI of uterine fibroids on T2-weighted MR imagescan be suggested as an objective parameter for patient selection inMRgFUS. Uterine fibroids with

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131540840 Spectrum of Ultrasound Findings in Patients With AnorectalMalformationSteven Kraus, 1,2 * Sara O’Hara, 1,2 Janet Adams 1 1 Radiology,Cincinnati Children’s Hospital Medical Center, Cincinnati,Ohio USA; 2 Radiology, University of Cincinnati College ofMedicine, Cincinnati, Ohio USAObjectives—There are many secondary and associated malformationsof multiple organ systems that can be discovered by ultrasound(US) and are important to detect in the clinical management of patientswith anorectal malformation (ARM). The objective of this poster is to reviewthe most common and important findings that can change the clinicalmanagement of these patients.Methods—Our radiology database was searched for patientswith ARM and US exams performed on these patients. The exams werereviewed, and both still images and US clips were collected and presentedpictorially, some with selective, radiographic, fluoroscopic, magnetic resonance(MR), and/or clinical images for correlation.Results—The most common associated malformations in patientswith 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 anomaliesdetected. Ectopic ureter insertion in the urethra with resultant hydroureterand hydronephrosis is also seen and must be detected early to avoid asignificant effect on long-term renal function. In females with cloaca, hydrocolposis seen in about 50% of patients at birth due to vaginal obstructionand is extremely important to detect since these patientsinvariably have urinary obstruction, which can cause permanent renal sequelae,vaginitis, and even vaginal perforation if not treated in the postnatalperiod. Other various anomalies of the female genital tract were seen, andexamples are shown. Males can present with multiple episodes of epidydymitisif they have high-pressure voiding due to a neurogenic bladder(bladder-sphincter incoordination), resulting in reflux of urine into the vasdeferens. Neonatal spine US is an excellent screening exam to detect spinalcord 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 ofthe GU tract and spine in patients with ARM are reviewed and presentedpictorially, some with radiographic, fluoroscopic, MR, and/or clinical correlation.1540916 Doppler Echocardiographic Estimates of Right VentricularPressure Are Inaccurate in Children With ElevatedRight Heart PressureGeorgeann Groh, 1 * Mark Holland, 2 Joshua Murphy, 1 TimothySekarski, 1 Philip Levy, 1 Craig Myers, 1 Diana Hartman, 1Gautam Singh 1 1 Pediatrics, 2 Physics, Washington UniversitySchool of Medicine, St Louis, Missouri USAObjectives—Doppler echocardiography (DE)-estimated rightventricular systolic pressure (RVp) is widely used as a surrogate for RVpmeasured by right heart catheterization (RHC), the gold standard. However,its accuracy has not been prospectively validated in children. Ourobjective was to prospectively validate the accuracy of DE-estimated RVpin children.Methods—Simultaneous pressure gradients between the rightventricle and right atrium were prospectively assessed by RHC and DEusing tricuspid valve regurgitation in 94 consecutive children (age 0–18years; median, 5.7 years) with 2-ventricle physiology. Subjects were classifiedinto 2 groups based on RHC-measured RVp: group 1 (n = 53) withnormal RVp (RVp 1/2 SBP). Correlation and agreementbetween the 2 methods were assessed using linear regression and Bland-Altman analysis, respectively. Accuracy was predefined as 95% limits ofagreement (LOA) ± 10 mm Hg for DE RVp estimates.Results—The correlation between DE- and RHC-measuredRVp 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 ingroup 1 (bias, 2.5 mm Hg; 95% LOA, +9.7 to –4.8 mm Hg) but poor ingroup 2 (bias, 0.89 mm Hg; 95% LOA, +25.1 to –25.1 mm Hg). DEestimatedRVp 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 inaccuratein children with elevated RVp. They should not be solely relied on in themanagement of children with elevated RVp.1540920 Cranial Ultrasound Findings in Preterm Infants WithGerminal Matrix and Periventricular LeukomalaciaArash Anvari, 1 * Anthony Samir, 1 Michael Gee 2 Radiology,1Abdominal Imaging and Intervention, 2 Pediatrics Division,Massachusetts General Hospital, Boston, Massachusetts USAObjectives—This educational poster will review germinal matrixand periventricular leukomalacia (PVL) in preterm infants and therole of cranial ultrasound in the diagnosis and characterization.Methods—Content Organization: (1) Introduction of germinalmatrix hemorrhage: epidemiology, pathophysiology, its complications likehydrocephalus and periventricular leukomalacia, and clinical outcomes.(2) Cranial ultrasound technique: transducer, standard views, supplementalacoustic windows, timing, advantages, and limitations. (3) Ultrasoundfindings in different classes (I–IV) of germinal matrix hemorrhage andPVL.Results—Not applicable because it is an educational e-poster.Conclusions—This e-poster emphasizes the clinical applicationof cranial ultrasound in early diagnosis of germinal matrix hemorrhageand PVL and its important role in clinical management.1540927 Focal Lesions in the Transplanted Liver: Differential DiagnosisRonald Wachsberg New Jersey Medical School , Newark,New Jersey USAObjectives—To illustrate the spectrum of focal lesions andpseudolesions that can be seen in liver transplant recipients.Methods—Cases are presented of various focal lesions andpseudolesions detected in liver transplant recipients at a busy transplantcenter.Results—A focal lesion in a liver graft can be an infarct, abscess,biloma, hematoma, steatosis, recurrent or de novo malignancy, preexistingincidental lesion in the donor liver, and arteriovenous fistula.Several pseudolesions, eg, loculated intrafissural fluid, thrombus withinthe donor inferior vena cava, and others, can mimic a liver lesion.Conclusions—Awareness of the spectrum and features of focallesions and pseudolesions that can be detected in a liver graft is essentialto arrive at the correct diagnosis.1540949 First-Trimester 3-Dimensional Placental Volume and ItsAssociation With Gestational DiabetesNwamaka Obi,* Karenrose Contreras, Andre Bieniarz, JeanGoodman, Paula Melone, Roberta Karlman Maternal-FetalMedicine, Loyola University Medical Center, Maywood, IllinoisUSAObjectives—Gestational diabetes mellitus (GDM) a commonmetabolic disorder in pregnancy and complicates about 3% to 10% ofpregnancies worldwide. The goal of predicting GDM has not beenreached, and its impact extends beyond just perinatal outcomes. The objectiveof the study was to determine if first-trimester 3D placental volumeis predictive of GDM.Methods—This was a prospective cohort study that included140 women aged ≥18 years with singleton pregnancies. At the time ofS114

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013nuchal translucency ultrasound, 3D images of the placenta were obtainedand volumes measured using the multiplanar volume method with PhilipsQLAB. The development of GDM and other pregnancy outcomes wererecorded. Continuous and categorical variables were compared using theStudent t test and χ 2 test. Logistic regression analysis was performed to determinethe association of first-trimester placental volume with gestationaldiabetes 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 ± 2.2vs 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 logisticregression analysis, first-trimester placental volume was not statisticallysignificant while controlling for age, race, and body mass index(BMI) between the groups. Women with a higher BMI were at significantlyincreased risk of GDM. 3D placental volume was predictive of birthweight regardless of the presence of gestational diabetes.Conclusions—First-trimester 3D placental volume was similarin women with and without gestational diabetes. A high BMI is a wellknownrisk factor for the development of GDM, which was also seen inthis study. Larger studies are needed to confirm our findings.Table 1. Logistic Regression AnalysisAdjusted ORPAge 1.127 .160Race 0.859 .85BMI 1.133 .021Placental volume 0.968 .228OR indicates odds ratio.1540968 Role of Bedside 3/4-Dimensional Ultrasonography in theDiagnosis of Acute AppendicitisTimothy Mooney,* Kevin O’Rourke, Gerardo ChiricoloEmergency, New York Methodist Hospital, Brooklyn, New YorkUSAObjectives—Abdominal ultrasonography (US) is commonlyused in diagnosing acute appendicitis (AA).Traditional 2D US is both safeand quickly performed. Diagnostic accuracy can be limited, and equivocalstudies are common. 3D/4D US technology could improve diagnosticaccuracy by enhancing visualization of anatomy and spatial relationships.Our objective was to evaluate the performance and accuracy of bedside3D/4D US in patients with suspected AA.Methods—All adult and pediatric patients with suspected AAwere eligible for enrollment. We excluded patients who underwent computedtomographic scanning prior to enrollment and those with a prearrivaldiagnosis of AA. Patients were enrolled when there was an emergencysonographer available. These emergency department physician sonographershad a 4-hour tutorial by an experienced application specialist on3D/4D image acquisition. The same sonographer scanned each patient’sright lower quadrant first using both 2D and 3D/4D multiplanar and surface-renderingUS. All clips and images were deindentified and interpretedby another sonographer who recorded an impression separately. The US interpretationswere then compared to surgical pathology or phone follow-up.Results—A total of 30 patients met inclusion criteria and wereenrolled. Twenty-one patients (70%) were ultimately diagnosed withAA. Of the 30 total patients, 13 (43%) were diagnosed with AA usingconventional 2D US, with the other 17 diagnosed with a nonvisualizedappendix, inconclusive US of the right lower quadrant. Two patients(6%) were diagnosed with AA from 3D/4D US images and clips (bothhad a diagnosis of AA from 2D US examination also). Sensitivity for2D US was 62% (95% confidence interval [CI], 48%–62%); specificitywas 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 sensitivityof 10% (95% CI, 2%–10%); specificity was 100% (95% CI, 82%–100%); positive predictive value was 100% (95% CI, 21%–100%); andnegative predictive value was 32% (95% CI, 27%–32%), with overallaccuracy of 36%.Conclusions—3D/4D US fails to increase the diagnostic accuracyof US in AA and has little utility in AA’s staged diagnostic workup.1540972 Reliability of Linear Measurements of the Thoracic ParaspinalMuscles Using Ultrasound ImagingNancy Talbott,* Dexter Witt Rehabilitation Sciences, Universityof Cincinnati, Cincinnati, Ohio USAObjectives—Ultrasound imaging (USI) has become more commonin the rehabilitation area. Muscles critical to the stabilization of thespine have been assessed to assist in guiding interventions. In the shoulder,function relies on scapular muscles, which work most effectivelywhen the thoracic spine is stabilized. To assist in understanding the role ofthe thoracic paraspinal muscles (TPSM) during arm elevation and in usingthat information in determining effective rehabilitation treatment, realtimemonitoring of the changes in the TPSM would be of benefit. The objectiveof this study was to determine if USI can reliably measure theTPSM during arm movements.Methods—USI of 18 healthy subjects was performed with subjectsprone and the arm elevated fully in the scapular plane. The spinousprocess and lamina of T7 were imaged as the subject rested the arm on astable surface, actively contracted, and held a weight. After resting, testingwas repeated twice on one arm and 3 times on the opposite arm. Ninesubjects returned to have the testing performed again by the original examiner.TPSM linear measurements were recorded in 2 locations: (1) betweenthe superior hyperechoic line of the laminae and the inferiorhyperechoic line of the lower trapezius muscle; and (2) between the superiorhyperechoic line of the transverse process and the inferior hyperechoicline of the lower trapezius.Results—Intrasession correlation values were strong. Within asession, intra-tester reliability ranged from 0.882 to 0.960. Inter-tester reliabilitywithin a session was also good, with intraclass correlation coefficients(ICCs) ranging from 0.706 to 0.906. Agreement between sessionswas also acceptable, with ICCs ranging from 0.733 to 0.885.Conclusions—The USI methodology used in this studyachieved TPSM measurements with high intra-rater reliability and goodinter-rater reliability at rest and during active contractions. Changes in theTPSM thickness occurring during active contraction of the shoulder andscapula can be reliably monitored by USI. As small but significant changesoccur during arm activities, USI of these muscles may be useful for guidinginterventions.1540981 Reliability of Ultrasound Measurements of the LowerTrapezius Muscle During Active and Resisted MovementsDexter Witt,* Nancy Talbott Rehabilitation Sciences, Universityof Cincinnati, Cincinnati, Ohio USAObjectives—Ultrasound imaging (USI) to assess patients withshoulder pain often emphasizes structural changes of the tendons. Pain,however, may be related to alterations in the scapular muscles, includingabnormal activation of the lower trapezius (LT). The ability to make reliablemeasurements of the LT during active contraction using USI wouldbe of benefit in determining firing patterns, identifying muscle atrophy,and designing interventions. While previous USI studies have establishedthe reliability of USI measurements of the LT at rest, the objective of thisstudy was to determine if USI could be used to reliably measure the thicknessof the LT muscle during LT contraction.S115

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Methods—USI images of the LT were captured bilaterally in 20normal subjects at the T7 level. With the arm in 120° of abduction, imageswere taken in the prone position with the subject’s arm at rest, activelyholding the position and while holding a weight. This process was repeated3 times on both shoulders by a single examiner. Within 7 days, 10 of thesubjects returned. The same testing sequence was repeated on the dominantarm by the original examiner and by a second examiner. Images werestored electronically and analyzed offline. Reliability was assessed via intraclasscorrelation coefficients (ICCs).Results—Intersession intra-rater reliability agreement wasgood, with ICC values of 0.835, 0.871, and 0.909 at rest, during an activehold, and holding the weight, respectively. Same-session inter-rater reliabilitywas also good, with ICC values of 0.864, 0.881, and 0.891 in the respectivestates of rest, active hold, and holding the weight.Conclusions—The USI methodology used in this studyachieved LT measurements with high inter-rater and intra-rater reliabilityat rest and with the addition of active contraction and resistance. Benefitsfor having this reliability method include: (1) identification of percentchanges of thickness between rest and contraction; (2) an adjunct to electromyographyin the determination of muscle changes during activities; (3)a viable tool for clinical facilitation of LT activation; and (4) documentingatrophy of the LT.1540998 Evaluation of Acquisition and Interpretation of FocusedAssessment With Sonography for Trauma Scans in anUrban Level 1 Trauma CenterZachary Robinson, 1 * Lem Smith, 1 Eliza Beal, 1 Brian Abbott, 2Creagh Boulger, 2 Daniel Eiferman, 3 David Bahner 21College of Medicine, 2 Emergency Medicine, 3 Critical Care,Trauma, and Burn Surgery, Wexner Medical Center, Ohio StateUniversity, Columbus, Ohio USAObjectives—Focused assessment with sonography for trauma(FAST) has become the standard of care in the evaluation of traumapatients. A review of recent literature showed sensitivity of 84% to 94%,specificity of 96% to 98%, a positive predictive value of 61% to 87%, anda negative predictive value of 98% to 100%. A formalized ultrasound trainingprogram has been introduced at our institution for surgical residents toensure proper acquisition and interpretation of ultrasound images. A qualityreview process was initiated to evaluate accuracy in using FAST intrauma patients.Methods—Trauma FAST exams are wirelessly saved to a picturearchiving and communication system, and generated reports are savedto an electronic medical record. Patients who presented as a level 1 or level2 trauma between January and March 2012 and received a FAST scan aspart of their assessment were included in the quality review. The results ofthe FAST scan and any other imaging performed during the same encounterwere recorded and reviewed. The results of FAST were comparedto confirmatory testing of abdominal computed tomography (CT), chestCT, or operative reports. The results of FAST were then determined to betrue-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 bothsaved images and a generated report in the chart. Fifteen patients were excludedbecause the FAST scan results were not available; the FAST scanwas indeterminate; or the patient died prior to confirmatory imaging. Therewere 94 true-negatives, 2 false-negatives, 7 true-positives, and 3 falsepositivesin the remaining 106 patients reviewed, yielding sensitivity of78% and specificity of 97%. The positive predictive value was 70%; thenegative predictive value was 98%; and the accuracy was 95%.Conclusions—Our results confirm that FAST has a high negativepredictive value for abdominal injury in patients experiencingtrauma. These quality results, collected after a focused training program,show the training to be effective in educating surgical residents on theproper acquisition and interpretation of FAST in trauma patients.1541009 An Educational Model for Teaching Focused AssessmentWith Sonography for Trauma to Surgical ResidentsEliza Beal, 1 * Ashley Zielinski, 1 Creagh Boulger, 2 SereanaDresbach, 3 David Bahner, 2 Daniel Eiferman 4 1 College ofMedicine, 2 Emergency Medicine, 3 Pulmonary, Allergy, CriticalCare, and Sleep, 4 Critical Care, Burn, and Trauma Surgery, WexnerMedical Center, Ohio State University, Columbus, Ohio USAObjectives—Focused assessment with sonography for traumahas become indispensable in the evaluation of trauma patients. Few surgicaltraining programs have specific courses to teach the FAST exam.The Wexner Medical Center at Ohio State University has established apilot program with hands-on teaching sessions and self-directed learningto teach surgery residents the skills needed to accurately obtain and interpretFAST scan images.Methods—Thirteen postgraduate year 1 (PGY-1)-level residentsparticipated in an initial evaluation session, which included 10 confidencequestions, 12 ultrasound knowledge questions, and a practicalexam where they were asked to perform both the FAST exam and thelong-axis rescue cardiac view. Participants answered confidence questionson a spectrum from 1 to 8 with 1 being strongly disagree, 7 being stronglyagree, and 8 indicating that the individual had no experience with the skill.The practical exam was evaluated by 2 attending physicians with significantexperience with the FAST exam and ultrasound education. The imageswere graded on a 1 to 5 scale (1 = no image obtained and 5 = imageperfectly obtained with proper settings and labeling). The 13 PGY-1 residentswill undergo 2-hour hands-on training and will be reevaluated forknowledge 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 thecontinuum, but the means on the 9 confidence questions ranged fromslightly to strongly disagree (3.94–1.92). No resident answered “no experience”for any question. Skills assessed by the proctors showed a generaltendency 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 andknowledge are low, and practical scores show an inability to performFAST scans among PGY-1 level surgical residents. The initial results suggestthat training in the FAST exam is necessary for PGY-1 surgical residentsto adequately obtain images used for clinical decision making.1541032 Cervical Length Assessment by Transabdominal and Endo -vaginal UltrasoundJennifer Thompson,* Michael Smrtka, Geeta Swamy, ChadGrotegut, Brita Boyd, Amy Murtha Duke University,Durham, North Carolina USAObjectives—Endovaginal (EV) cervical length identifies womenat risk for preterm birth (PTB) and thus eligibility for vaginal progesterone.Our objective was to compare transabdominal (TA) with EV cervicallengths to determine the degree of correlation, the capability of TA to predictan EV-detected short cervix, and the rate of cervical change over time.Methods—Retrospective review of singleton pregnancies havingTA and EV ultrasound (US) for cervical length between 16 and 28 weeks’gestation at Duke University from January to December 2011. TA measurementsare routinely obtained on midtrimester exams with EV measurementfor high PTB risk, TA

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013study inclusion criteria. TA and EV measurements were significantly correlated(r = 0.810; P < .0001). A TA cutoff of 30 mm accurately predictedan EV-detected short cervix (

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131541066 Maximum Effort of the Multifidi Muscles in the PronePosition Using Musculoskeletal Ultrasound Imaging andElectromyographyRose Smith,* Dervarshi Patel, Susan Kotowski, Dexter Witt,Lauren Farwick, Erin Rathje, Ryan Steiner RehabilitationSciences, University of Cincinnati, Cincinnati, Ohio USAObjectives—The lumbar paraspinal muscles play a critical rolein supporting the trunk during functional activities. Rehabilitative ultrasoundimaging (RUSI) has been found to be a valid and noninvasivemethod to measure the activation of these muscles. RUSI of the multifidihas shown 19% to 43% of maximum effort on electromyography (EMG)while measuring muscle thickness. No study has compared EMG withRUSI using the trace method. The purpose of this study was to look at therelationship of EMG activity of the multifidi using RUSI by measuring thecross-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 criteriaincluded current or recent history (within 6 months) of shoulder, lumbar,or lower extremity pathology/surgery or pregnancy. Musculoskeletal ultrasoundimages of the multifidi were obtained using the Biosound Esaotemodel MyLab 25 Gold. The area was found using the trace method of theright and left multifidus during an arm raise, arm raise with weight, andleg raise activity while the subject lay prone. A simultaneous DataLINK(Biometrics, Ltd) EMG system was used to measure muscle activity. EMGsensors were placed over the belly of the muscle in the line of action. Maximumvoluntary contractions (MVCs) were taken at the start of data collectionby having the subject lie prone and raise the opposite arm and legagainst manual resistance. The measured trace area of each image wasnormalized against the measured area of the MVC trial.Results—Analysis showed that overall, RUSI trace-measuredCSA muscle activity ranged from ≈22% MVC (trial maximum) to ≈28%MVC (trial average), which corresponded to a measured area of the multifidusof 100% MVCs. Minimal nonsignificant differences were notedbetween the 3 activities with RUSI and EMG activity.Conclusions—The change in trace-measured CSA as comparedto EMG activity is consistent with measuring muscle thickness viaRUSI. This information can be helpful in guiding clinical practice but cannotbe applied without considering its limitations.1541115 Ocular Ultrasound Simulation Lab: Does It Translate tothe Bedside?Kevin O’Rourke,* Sharon Yellin, Adam Vytykac, TimothyMooney, Larry Melniker, Athena Mihailos, Andrew Balk,Gerardo Chiricolo Emergency Department, New YorkMethodist Hospital, Brooklyn, New York USAObjectives—Two percent of emergency department visits areeye-related complaints. Ocular ultrasound (US) gives the emergencyphysician the ability to noninvasively assess the eye for a variety of diseaseprocesses. The Council of Residency Directors Emergency UltrasoundConsensus Committee does not identify ocular US as a core UScompetency for emergency medicine resident graduation but recommendsthat it is incorporated into the resident curriculum. The accuracy of bedsideocular US has been studied, and published reports of models used forsimulation exist. The breadth of knowledge about the effectiveness ofusing simulation for ocular US is limited. The goal of this study was toevaluate if an ocular US lecture and simulation lab led to increased use atthe bedside and what diagnoses were found.Methods—In this retrospective review, we compiled data fromour US database for all ocular US examinations performed the 6 monthsbefore and after an ocular US lecture and simulation lab. We included allpatients who had US between September 21, 2011, and September 22,2012. Data collection included when the US was performed and what thediagnosis was based on US.Results—In the 6 months before the lecture and lab, 18 ocularUS examinations were performed. The findings included 9 normal USfindings, 2 vitreous hemorrhages (1 with posterior vitreous detachment),3 with an increased optic nerve sheath diameter, 2 retinal detachments, 1with postoperative changes, and 1 with a foreign body. In the 6 monthsafter the lab, 28 ocular US examinations were performed. The findingsincluded 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. Therewere 10 more US examinations performed in the emergency departmentafter the intervention, which equates to a 55% increase in US use.Conclusions—An ocular US lecture and simulation lab led toincreased use of bedside US for patients. In the future, we anticipate thisskill to decrease inappropriate transfers and increase appropriate andtimely evaluations by an ophthalmologist.1541203 Factors Influencing Intraoperator Variability When AssessingFibroid GrowthMalana Moshesh,* Shyamal Peddada, Donna BairdNational Institute of Environmental Health, Research TrianglePark, North Carolina USAObjectives—To assess factors associated with intraoperatorvariability (measured by the coefficient of variation [CV]) of fibroid measurementsand apply this to current practice.Methods—Study participants, recruited through communityoutreach and health care facilities were young African American women,aged 23 to 34 years, who had never been diagnosed with fibroids. All participantsunderwent transvaginal ultrasound to screen for the presence ofuterine fibroids (≥0.5 cm in diameter). The fibroid diameter was measuredin 3 perpendicular planes (longitudinal, sagittal, and transverse) at 3separate times during the examination. Volume was calculated using theellipsoid formula. Intraobserver variability as measured by the CV for fibroiddiameter and volume was calculated for each fibroid, and factorsassociated with the CV were assessed using regression models adjustingfor fibroid characteristics and individual participant characteristics.Results—Ninety-six women out of 300 women initiallyscreened were found to have at least 1 fibroid, yielding a total of 174fibroids for this analysis. The median CV for the 3 measurements of thefibroid maximum diameter was 4.9%, and the mean CV was 5.9%. Themedian 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 bothfibroid diameter (P = .04) and volume (P = .005). The CV was greater forsmaller fibroids. Individual participant factors and the fibroid type were notsignificantly associated with intraobserver measurement variability.Conclusions—When assessing fibroid growth, baseline fibroidsize should be considered. Small fibroids have greater measurement variabilitythan large fibroids. Thus, a small fibroid must have a proportionatelygreater increase in size compared to a large fibroid to conclude thatit is growing.1541265 Role of Transvaginal Ultrasound in the Diagnosis of CesareanSection and Its ComplicationsLourdes Hereter,* M. Angela Pascual, Betlem Graupera,Pere Barri-Soldevila, Cristina Pedrero, Maria Fernandez-CidObstetrics, Gynecology, and Reproduction, Institut UniversitariDexeus, Barcelona, SpainObjectives—To describe the findings of transvaginal ultrasound(TUS) in cesarean scar defects and their complications in nonpregnantwomen.Methods—Nonpregnant premenopausal women with a historyof a previous cesarean section, referred to TUS for an annual checkup,were included in this study. A cesarean scar defect was defined as a hypoechoicindentation at the anterior wall of the lower uterine segment,S118

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013measured in 3 dimensions. The number of previous cesarean sections andcomplications were reviewed. These included dehiscence (separation ofthe scar that does not disrupt the uterine serosa), uterine rupture (a completedisruption of the myometrium and serosa), and ectopic pregnancy inthe cesarean section scar.Results—Thirty-eight women were diagnosed with a cesareanscar defect at TUS. The number of previous cesarean sections in patientswith uterine dehiscence and ectopic pregnancy in the cesarean scar isshown 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 patientsrequired hysterectomy; 2 were treated with local methotrexateguided by TUS; and 1 was surgically sutured. Two patients (5%) had acomplete uterine rupture. One of them was diagnosed 6 months after thecesarean section and required hysterectomy. The other was diagnosed duringthe 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 1Previous Cesarean1 2 3 4Dehiscense 5 4 1 1Ectopic pregnancy 3 0 1 11541304 Ultrasound-Guided Dorsal Approach for Chemodenervationof the Psoas MuscleDavid Spinner Rehabilitation Medicine, Mount Sinai Schoolof Medicine, New York, New York USAObjectives—To directly treat the primary motor end plates ofthe psoas muscle for spasticity.Methods—Case report with description of procedure. Bilateralultrasound-guided psoas muscle injections were performed. An axial orshort-axis view was used for both the right- and left-sided injections. Theright psoas muscle was injected with an out-of-plane approach where onlythe needle tip was visualized. We then turned the probe 90° to visualize thelength of the needle in addition to using electromyography (EMG) forconfirmation. The left psoas muscle was injected using an in-plane techniquewith EMG confirmation.Results—The left and right psoas muscle injections were confirmedwith EMG. The patient gained 30° of extension from baseline tobilateral hip joints. The patient had overlying hip contractures that did notallow for further range of motion.Conclusions—The ultrasound-guided dorsal approach for performingpsoas muscle chemodenervation is a novel approach for treatinghip flexor spasticity while targeting the primary motor end plates.1541312 The BUILD Project: Bringing Ultrasound Internationallyfor Long-Term DevelopmentKeith Rosenberg, Fadi Kasyouhanan, David Bahner*Emergency Medicine, Ohio State University College of Medicine,Columbus, Ohio USAObjectives—With technological advances in imaging, ultrasound(US) equipment is increasingly affordable and portable. Studieshave shown that portable US can be an effective modality in low-resourceenvironments. Bringing Ultrasound Internationally for Long-term Development(BUILD), a global outreach project, is an attempt to collaboratewith Ohio State University’s (OSU’s) Office of Global Health to providethird- and fourth-year medical students from OSU’s College of Medicinethe opportunity to enroll in a longitudinal US program.Methods—BUILD creates a collaboration between the Collegeof Medicine and the Office of Global Health. The group combines existingmedical mission programs and promotes an effort to coordinate bothgroups. Current US resources were centralized, streamlined, and madeavailable to the program.Results—The Office of Global Health has funded 51 trips overthe past 5 years, while the medical school has sent 244 trips, to >25 developingcountries. BUILD’s team of 2 senior medical students and 1physician US expert acts to bridge these separate but similar programs.Approximately 6 of these trips have incorporated US. The program developeda needs assessment survey of current US resources for medicalmissions. BUILD has fostered interest among students traveling abroad tointegrate US into their trips.Conclusions—As trends in medicine shift toward more prudentuse of resources, US will become an integral part of medical training.It is increasingly common for students and residents to gain exposure toUS early in their schooling. Studies have shown that physicians and medicalstudents have successfully used portable US to determine medicalmanagement. BUILD intends to establish a protocol for students and facultyto bring US to underserved areas. The group will design didactics toteach travelers US skills and enable them to become teachers at their sites.BUILD will create partnerships leading to opportunities for travelers tobring donated equipment. The findings of this study will be used to showthat US can be successfully incorporated into global health programs.BUILD hopes to integrate this into the medical student curriculum as anoptional course.1541434 Trained Simulated Ultrasound Patients: Medical Studentsas Models, Learners, and TeachersMatt Blickendorf, 1 * Lindsay Mooney, 2 Krista Rath, 2 EricAdkins, 1,2 David Bahner 1,2 1 Emergency Medicine, WexnerMedical Center, Ohio State University, Columbus, Ohio USA;2Ohio State University College of Medicine, Columbus, OhioUSAObjectives—Despite the increased use of bedside ultrasound(US) by clinicians, US is not fully established in undergraduate and graduatemedical education. Medical schools and residency programs mustdevelop US education programs to ensure future physicians become competentwith this operator-dependent technology. Medical educators areoften challenged to find human models for hands-on scanning sessions.The goal is to outline the educational model of a university medical centerthat uses medical students to fulfill the need for human models whilealso offering these individuals a basic introduction to US education.Methods—Second-year medical students from the Ohio StateUniversity College of Medicine serve as trained simulated US patients(TSUPs) for hands-on scanning sessions held by the college and residencyprograms at the medical center. Students are offered a didactic and handsonUS education program as an added incentive for serving as a TSUP.Students were given a postcourse 5-point Likert survey to assess their perceivedbenefit from the TSUP program.Results—During the 2011–2012 academic year, 47 secondyearand 7 first-year students served as normal models for 71 hands-onscanning sessions, while only 28 sessions were left without TSUP participation.Counting each time a TSUP was used, a total of 173 models wereused for 160 hours of scanning. The college and 7 residency programsused the TSUP program. Student volunteers were split equally male andfemale with a diverse range of specialty interests. Approximately 75% ofTSUP participants served as US models for an average of 6 to 15 hours forthe year. Most attended a majority of the US educational events, and almostall TSUP participants endorsed increased US interest, knowledge,and skill as a result of the program.Conclusions—The TSUP program is a feasible and sustainablemethod of fulfilling the need for normal anatomy models in US educationwhile serving as a valuable extracurricular US educational program forTSUP participants. The program offers a model for the establishment ofUS education programs by educators at undergraduate and graduate levels.S119

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131541460 Developing and Evaluating an Ultrasound Curriculum fora Urology Residency Training ProgramJoseph Lopez, 1 * Daniel Box, 1 Geoffrey Box, 1 David Bahner 21Urology, 2 Emergency Medicine, Wexner Medical Center, OhioState University, Columbus, Ohio USAObjectives—In medicine, much has been written on ultrasound(US) use in focused settings looking for specific findings consistent withpathology and using this to make specific medical decisions. With the adventof other fields of discipline using US, some hospital infrastructureexists with US in critical care, emergency medicine, anesthesiology, andsurgery. In urology, program directors expressed a significant need for formalizedUS training. This project sought to provide an educational frameworkfrom which a urology program could incorporate US training andincrease proficiency and confidence in performing urologic US. The curriculumwas developed using the AIUM Practice Guideline for UltrasoundExaminations in the Practice of Urology developed in collaboration withthe American Urological Association.Methods—In our study, 13 urology residents were participantsin this pilot curriculum. Didactic and hands-on US training sessions onbasic US physics and techniques, kidney, bladder, scrotal, and prostate USwere undertaken, and a posttest was administered in addition to surveysevaluating their experience in the program. The implementation occurredover 1 year.Results—The results notably yielded a mean duration of approximately30 hours of hands-on, didactic, and clinic US experiences atthe bedside reported by each of the residents in the study. Approximately66% of the residents were confident in their ability to interpret their ownimages.Conclusions—We can conclude from the survey and posttestdata that the developed US curriculum for residents is beneficial for developingclinical acumen as well as confidence in making use of this imagingmodality. In the future, we hope to increase the participation in thiscurriculum and develop a more concrete timeline at which these traineesprogress through the curriculum as well as improve evaluation of the educationalefficacy of the course.1541471 Sonographic 2- and 3-Dimensional Aspects of IntrauterineDevice Evaluation: What Additional Information Can 3-Dimensional Images Provide?Claudia Maksoud Ultrasound, Colégio Estadual Padre EduardoMichelis, Rio de Janeiro, BrazilObjectives—Our goal is to show the role of identification of intrauterinedevice (IUD) positioning and integrity using 2D images and todemonstrate the possibilities 3D images can provide, by giving a betterview of the uterine cavity in the coronal plane, and also more details ofIUD location, especially with a levonorgestrel-releasing IUD.Methods—All ultrasound procedures were performed by radiologists,and the images were acquired using multifrequency transvaginaltransducers. 3D images were obtained from freehand scans. The 2Dimages included both longitudinal and transverse views and 3D images thecoronal view.Results—3D images can better localize the IUD position andgive a better identification of the arms of the IUD. In the case of a levonorgestrel-releasingIUD, we can see more details of the shaft with 3Dimages than with 2D images. Problems like an IUD embedded in the myometriumare better identified in the 3D coronal view.Conclusions—2D ultrasound evaluation can be the classictechnique 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 isavailable, it can be used as a helpful tool in the evaluation of IUDs.1541516 Point-of-Care Ultrasound in the Diagnosis of ComplexSubcutaneous Abscesses Requiring Surgical InterventionSrikar Adhikari, Austin Gross* Emergency Medicine, Universityof Arizona Medical Center, Tucson, Arizona USAObjectives—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 10days prior to the arrival to the ED while jogging. He subsequently notedredness and swelling in the thigh. Physical examination revealed lowgradefever and a warm, tender, and swollen thigh with induration. It wasdetermined that the patient had an abscess, and an incision and drainage(I&D) was planned by the treating emergency physician. Bedside US wasperformed by the emergency physician to assist with the procedure. TheUS examination revealed a large complex fluid collection extending >10cm deep into the subcutaneous tissues and facial planes and beneath themuscles. Based on the sonographic findings, a surgical consult was obtained.The patient was taken to the operating room (OR) where the abscesswas drained under general anesthesia. The initial surgical incisionhad to be extended to drain >200 mL of pus. We report another case, a 36-year-old male presenting to the ED with left arm swelling, pain, and rednessof 3 days’ duration. He gave a history of low-grade fever. Hepresented with similar symptoms to the ED twice within 2 months priorto this ED visit. An I&D was performed during both ED visits. Clinical examinationrevealed fluctuant, tender, erythematous swelling with an openarea spontaneously draining some purulent material. Because of repeatED visits, bedside US was performed by the emergency physician, whichrevealed a 6-cm hyperechoic foreign body embedded deep in the tissuesof the upper arm along with a complex fluid collection. A surgical consultwas obtained. The patient was taken to the OR for foreign body removalwith drainage of the abscess.Results—Point-of-care US allowed visualization of the extentof the abscess and occult foreign body in these cases. It helped prevent anunderestimation of the extent of the infection and determined the need foroperative intervention.Conclusions—Point-of-care ultrasound can help determine theneed for operative intervention in ED patients with complex subcutaneousabscesses.1541519 Impact of the Maternal Body Mass Index on the Durationand Completion of Fetal Anatomic UltrasoundDana Smith,* Carmen Beamon, Kacey Eichelberger, LisaCarroll, Neeta Vora Maternal Fetal Medicine, University ofNorth Carolina, Chapel Hill, North Carolina USAObjectives—Our objective was to examine the impact of theprepregnancy body mass index (BMI) on both the duration and completionof the fetal anatomic survey.Methods—A retrospective cohort study of singleton nonanomalousgestations presenting for fetal anatomic ultrasound between 16 and25 weeks’ gestation at our institution was performed over a 3-month period.Standard BMI categories were computed using self-reported prepregnancyweight and height. Outcomes of interest were the duration ofultrasound (defined as the difference in minutes between the first and lastabdominal image) and completion of ultrasound (“incomplete” defined asa provider recommending the subject return for reevaluation). Univariateand bivariate analyses as well as logistic regression modeling were usedto determine odds ratios for having an incomplete scan among subjectswith BMI ≥25.Results—Of the 551 women analyzed, 52.7% of the cohort wasoverweight or obese, with a mean BMI of 26.8 (range, 16.6–65.2). The averageduration of basic ultrasound was 28.8 minutes vs 35.2 minutes forS120

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013targeted ultrasound (P < .001). After controlling for gestational age, individualsonographer, race, and maternal age, we identified no statisticallysignificant 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 havingan 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 likelyto have an incomplete fetal anatomic survey when compared to normalweight referents, although we identified no impact of obesity on the durationof the scan.S121

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Continuing Medical Education (CME) Credit Information2013 AIUM Annual ConventionActivity DescriptionThe 2013 AIUM Annual Convention is the most comprehensive, cutting-edgemeeting for the entire medical ultrasound community. Our unique multidisciplinaryprogram provides a collaborative environment for all specialties and disciplines,from beginner to advanced.Accreditation StatementThe American Institute of Ultrasound in Medicine (AIUM) is accredited by the AccreditationCouncil for Continuing Medical Education (ACCME) to provide CMEactivities for physicians.Designation StatementThe AIUM designates the 2013 Annual Convention for a maximum of up to 30.5AMA PRA Category 1 CME Credits. Physicians should only claim credit commensuratewith the extent of their participation in the activity.Credit for SonographersSonographers participating in AIUM educational activities may earn credits towardmaintaining 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). Theseeducational activities are approved by the AIUM for ARRT Category A Credits.Target AudienceThis activity is designed to meet the needs of ultrasound professionals from variousmedical disciplines and specialty areas who perform and interpret ultrasoundexaminations.Course ObjectivesUpon completion of this learning activity, participants should be able to:• Demonstrate updated knowledge in: Basic Science and Instrumentation;Cardiovascular Ultrasound; Contrast-Enhanced Ultrasound; Emergency andCritical Care Ultrasound; Fetal Echocardiography; General and AbdominalUltrasound; Gynecologic Ultrasound; High-Frequency Clinical and PreclinicalImaging; Interventional-Intraoperative Ultrasound; MusculoskeletalUltrasound; 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• PerformanceDisclosure PolicyAs a provider accredited by the ACCME, the AIUM must ensure balance, independence,objectivity, and scientific rigor in all its activities. Anyone involved inplanning this CME activity is required to disclose to learners any relevant financialrelationship(s) that have occurred within the last 12 months with any commercialinterest(s) whose products or services are discussed in the CME content. Such relationshipsare defined by remuneration in any amount from the commercial interest(s)in the form of grants; research support; consulting fees; salary; ownershipinterest (eg, stocks, stock options, or ownership interest excluding diversified mutualfunds); honoraria or other payments for participation in speakers bureaus, advisoryboards, or boards of directors; and other financial benefits. Individualsinvolved in planning will be asked to recuse themselves from any portion of theplanning where a bias might exist.All faculty participating in an educational activity provided by the AIUM are requiredto disclose to the provider and to the learner any relevant financial relationshipswith any commercial interest. The AIUM must determine if the faculty’srelationships may influence the educational content with regard to exposition orconclusion and resolve any conflicts of interest prior to the commencement of theeducational activity. The intent of this disclosure is not to prevent faculty with relevantfinancial relationships from serving as faculty but rather to provide membersof the audience with information on which they can make their own judgments.The AIUM has reviewed all disclosures and resolved or managed all identified conflictsof interest, as applicable.Policy on Unlabeled/Off-Label UsageThe AIUM has determined that disclosure of unlabeled/off-label or investigationaluse of commercial products is informative for audiences and therefore requires thisinformation to be disclosed to the learners at the beginning of the presentation. Usesof specific therapeutic agents, devices, and other products discussed in this educationalactivity may not be the same as those indicated in product labeling approvedby the US Food and Drug Administration. The AIUM requires that any discussionsof such “off-label” use be based on scientific research that conforms to generallyaccepted standards of experimental design, data collection, and data analysis.Before recommending or prescribing any therapeutic agent or device, learnersshould review the complete prescribing information, including indications, contraindications,warnings, precautions, and adverse events.DisclaimerThe information presented in this activity represents the opinion of the faculty andis not necessarily the official position of the AIUM.Documenting CME CreditsThe AIUM provides CME certificates to those who have participated in an AIUMeducational activity. The AIUM does not submit credits to regulating bodies or certifyingorganizations on behalf of the participant. It is the participant’s responsibilityto submit proof of credits on his or her own behalf.Accreditation Council of Graduate Medical Education (ACGME)CompetenciesThese 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 LearningS122

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Faculty DisclosuresAs of March 5, 2013, listed below are faculty members who disclosed that they have relevant relationship(s) with commercial interest(s) thatmay create a conflict of interest. Faculty members are instructed to advise the AIUM if new financial relationships with commercial interestsarise 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 relevantfinancial relationships. All completed disclosure forms are on file and available for review at the AIUM office.Abadi, MariaAbbott, BrianAbdella, ThomasAbdelmalek, ManalAbdullaev, RizvanAbo, AlyssaAbramowicz, JacquesInstitute for Advanced MedicalEducation: honorarium;speakerPhilips Healthcare: consultant;research machinesAbuhabsah, RamiAbuhamad, AlfredAbu-Rustum, ReemAbu-Rustum, SameerAbu-Yousef, MonzerAcharya, U. RajendraAchiron, ReuvenAckerman, SusanAdams, JanetAderibigbe, OluyemiAdhikari, SrikarAdkins, EricAdler, RonaldAdzick, N. ScottAgache, VladAgildere, A. MuhtesemAhmadzia, HomaAhmed, AhmedAish, BassilAjmera, KunalAlcázar, Juan LuisAlehagen, UrbanAl Ekish, ShadiAlexandrov, AndreiAllaf, M. BaraaAllen, AngelaAllen, DerrickAl Mahrouki, AzzaAl Muhanna, KhalidAly, Abdel-RahmanAmian, AngelinaAmponsah, DavidAnanth, CandeAnderson, CraigAnderson, SharletteAndo, TakeshiAndreotti, RochelleAntonios, LikourezosAntonis, MichaelAnvari, ArashApterbach, WilliamArcher, TimothyArellano, JavierArnold, KellyArntfield, RobertArpit, NagarArroyo, AlexArynova, BakyytbubuAstheimer, JeffreyAten, AndrewAu, ArthurAubá, MariaAusiello, LiviaAvner, JeffreyAxt-Fliedner, RolandAyala, RubenAylward, StephenAyoub, JeanAyvazyan, SergeyAzar, NamiAziz, SeeratBaek, Song-EeBahner, DavidBai, JingBaird, DonnaBajaj, KomalBakhireva, LudmilaBalise, RaymondBalk, AndrewBalzaretti, PaoloBanderali, AlessandraBantignies, ClaireBarahona, J. OscarBard, RobertBardales, RicardoBarnewolt, CarolBarr, RichardPhilips Healthcare: equipmentand research grant; advisor,researcher, speakerSiemens Medical Solutions:equipment and research grant;advisor, researcher, speakerSuperSonic Imagine: equipmentgrant; researcher, speakerToshiba America MedicalSystems: honoraria; advisorBarral, JoelleBarri, PedroBarri-Soldevila, PereBar-Sever, ZviBartels, EvaBartova, PetraBaschat, AhmetBault, Jean-PhilippeBawiec, ChristoperBaxtrom, CatherineBeach, KirkBeal, ElizaBeamon, CarmenBeavis, ColeBeck, BillPhysioSonics, Inc: independentcontractor; consultantBeiter, KyleBeland, MichaelBelfort, MichaelBellew, ChristineBenacerraf, BerylBenaroya, AzrielBendick, PhilipBen-Meir, DavidBenn, PeterBennett, Terri-AnnBenson, CarolBeraud, Anne-SophieBerdejo, GeorgeBerger, JanBhatt, ShwetaBhimani, AshishBialeck, SuzanneBieniarz, AndreBierca, JacekBird, ChristineBitters, ConstanceBlackstock, UcheBlahuta, JiriBlaivas, MichaelBlanchette Porter, MistyBlanks, JamesBlankstein, JosefBlebea, JohnBlews, DavidBlickendorf, MatthewBlumenfeld, YairBluth, EdwardBockbrader, MarcieBolouri, MarjanBolte, AnnemiekeBoniface, KeithBoore, StacyBorgida, AdamBouffard, J. AnthonyBoulger, CreaghBox, DanielBox, GeoffreyBoyd, BritaBradford, SusanBradley, KathleenBradshaw, DarinBreazeale, ShaneBrennan, MatthewBrewer, KoriBromley, BryannBrown, CaraBrown, DouglasBrown, JamesBrown, SteffenBrown, StephenBrown III, WilliamBrubaker, SaraBuadu, AnnemarieBuckwalter, JosephBui, LoanBulas, DorothyBundy, NicoleBunting, EthanBureau, NathalieBurhans, KristinBurns, PeterBusse, RaydeenByram, BrettByrne, JaniceCabral, DignaCadet, ClaudiaCahill, AlisonCalabrese, KathleenCalisti, GiorgioCalvo-Garcia, MariaCampbell, ColleenCampbell, WinstonCanavan, TimothyCao, Tie-ShengCarey, JohnCarlson, LindseyCarroll, LisaCarroll, MaryCarson, PaulGE Global Research: federalgrants, research collaboration;principal investigatorLight Age, Inc: modification oftheir commercial laser; help inspecification and testingSonetics Ultrasound, Inc:salary on their Small BusinessInnovation Research project;advised on transducer arraysand applicationsCasoli, GiovannaCassady, ChristopherCastillo, EddieCaughey, MelissaCavanaugh, BarbaraCendan, JuanCermak, PetrCha, Joo HeeChalek, CarlChan, TedChandrasekhar, ChitraChao, JenniferChavez, MartinS123

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Chervenak, JudithChildress, JohnathanChin, EricChinchure, DineshChintapalli, KedarChiou, See-YingChiricolo, GerardoChoi, Woo JungChong, WuiChopra, ManishaChorazy, MarekChou, Nai-KungChow, KiraChurch, CharlesCiardo, PaoloCibinel, GianAlfonsoClaes, FrankClem, DouglasClingman, BryanCody, KennethCohen, Harris L.Cohen, LeeberGE Healthcare: honoraria;speakerPhilips Healthcare: honoraria;speakerSamsung Ultrasound: honoria;speakerCohen, NicholasColeman, BeverlyColey, BrianColvin, RobertComerota, AnthonyContreras, KarenroseCordeiro, ChristinaCoroleu, BuenaventuraCorreas, Jean-MichelPhilips Healthcare: speaker’sfee; advisory board, speakerSuperSonic Imagine: speaker’sfee; speakerToshiba Medical Systems:speaker’s fee; speakerCortez, EricCorujo, OmarCosgrove, DavidCraig, JosephCrawford, ChristineCrawford, ForrestCrino, JudeCrites, LoriCruz, JoshuaCunha, Luana TorresCurrie, GeoffreyCurs, BradCussó Sorribas, MireiaCzarnota, GregoryCzernuszewicz, TomaszCzerný, DanDahibawkar, ManasiDahiya, NirvkaDahlström, UlfDai, QingDalecki, DianeDallas, ApostolosDarge, KassaD’Armiento, JeanineDatta, AnitaDave, JaydevDavidovits, MiriamDavis, MichaelDavis, SarahDayton, PaulTargeson, Inc: stock options;consultant, Scientific AdvisoryBoardDean, AnthonyDe Castro, FranciscoDe Franco, EmilyDe Franco, PaulDeganello, AnnmariaBracco SpA: lecture fees;speakerDegenhardt, JanDe Guillebon, AdelaideDe Jong, M. RobertDe la Torre, LesleyDel Cura, JoseDeng, CheriDestounis, StamatiaDeter, RussellDetti, LauraDeurdulian, CorinneDeurloo, KoenDeutch, ToddGE Healthcare: consulting fee;speakerDeVore, GreggoryGE Healthcare: honorarium;speakerDiaz, DaisyDickman, EitanDietrich, ChristophDiffenderfer, KristenDiFlorio, RobertaDillman, JonathanDi Matino, FilomenaDi Pietro, MichaelDo, SamanthaDogra, VikramDolin, CaraDonaldson, ChaseDonaldson, JoeDoniger, StephanieDonofrio, MaryDooley, ErinDornbluth, CarolDoubilet, PeterDresbach, SereanaDudley, LarissaDumont, DouglasDuvdevani, NirEhsanipoor, RobertEichelberger, KaceyEiferman, DanielEisenbrey, JohnElahi, ErshadEl-Baz, AymanEl Kaffas, AhmedEllestad, SarahEmmitt, ReginaEnglish, CarterEnzensberger, ChristianErdman, JohnErmilov, SergeySeno Medical Instruments:consultant; consulting feeEski, ErkanEstroff, JudyEvans, DavidEvans, KevinFabiilli, MarioGE: other activities; otherfinancial benefitFadrna, TanaFalou, OmarFarber, MarkFarella, NunziaFarwick, LaurenFeinstein, StevenGE Healthcare: consultingfees; consultant; researchfunds, researchFeldstein, VickyFeleppa, ErnestFeltovich, HelenFenster, AaronEigen: royalties; research collaboratorFernandez-Cid, MariaFerraioli, GiovannaFerreri, EnricoFessell, DavidFilice, CarloFinnoff, JonathanFischer, JasonFisher, KimberleyFleischer, ArthurFleshman, ShaneZetrOZ, LLC: employment;salaryFontanilla, TeresaFord, PeterFordham, LynnForsberg, AnyaForsberg, FlemmingFoster, F. StuartFowlkes, J. BrianGE Healthcare: equipmentsupport; other financial benefits;other activities; researchFox, J. ChristianSonoSim, Inc: shares; consultantSonoSite, Inc: equipment loan;consultantFox, NathanFox, TraciFrancis, CharlesFrank, GaryFrates, MaryFrenkel, VictorFriedman, AlexanderFriedman, LanaFuchs, KarinFujimoto, ChrystieFujitani, RoyFuller, KistiGadddipati, SreedharGalan, HenryGalerneau, FranceGallippi, CaterinaGammell, PaulGandhi, ManishaGandikota, GirishGarami, ZsoltEdwards Lifesciences:honoraria; consultantGore Medical: honoraria;consultantGarberoglio, RobertoGarcia, BlancaGarcia, SaraGarg, MahekGaron, JackGarra, BrianGaspari, RomoloGauthier, MarianneGecsi, KimberlyGee, MichaelGeiger, MiwaGeldermann, DavidGelman, SlavaGembruch, UlrichGeorge, VergheseGerardo, ChiricoloGerber, SusanGermer, UteGeria, RajeshGessner, RyanGharahbaghian, LalehGilboa, YinonGiles, AnojaGindes, LiatGiorgio, AntonioGiorgio, ValentinaGirish, GandikotaGirotto, JohnGlanc, PhyllisGlantz, J. ChristopherGlasek, JedrzejGlaser, AngelaGlasser, JessieGlazier, ElizabethGoertz, DavidGoetzinger, KatherineGoffi, AlbertoGoldberg, AryehGoldírová, AndreaGoldklang, MonicaGoldman, EllenGoldman, SaraGoldstein, RuthGoldstein, StevenAmgen: speakers bureau;honorariumBayer: Gynecology AdvisoryBoard; honorariumCook Ob/Gyn: consultant,consulting feesS124

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Philips Healthcare: consultant,equipment loanWarner Chilcott: speakers bureau;honorariumGonçalves, LuisGE Healthcare: honorarium,speakerPhilips Healthcare: honorarium,speakerGoodman, EricGoodman, Jean RicciGoodman, RobGoodman, ThomasGordon, RobertGoubran, AshrafGoutham, SwapnaGraupera, BetlemGray, SiobhanGrippo, AnthonyGroh, GeorgeannGross, AustinGroszmann, YvetteGrotegut, ChadGuerriero, StefanoGuizado de Nathan, GigiGullett, JohnGunabushanam, GowthamanGunnison, KathrynGupta, SanjeyGupta, SimiGurewitsch, EdithGurram, PadmalathaGustafsson, MikaelGyamfi, CynthiaHaberman, ShoshanaHabnenicht, RebeccaHacker, MicheleHaeir, SinaHaggerty, PatriciaHaines, LawrenceHall, AnneHall, EricHall, RebeccaHall, TimothyHalldorsdottir, ValgerdurHamper, UlrikeHamrick, M. AnnHamvas, AaronHan, BokyungHanda, PriyankaHangiandreou, NicholasHansen, AllanHarris, GeraldHarris, RobertHartge, DavidHartman, AlexHartman, BrianHartman, DianaHashim, AmrHata, StacyHavel, MartinHavelka, JaroslavHawkins, LeahHbeib, MosesHe, LeHe, YuHeimburger, GlennHeimiller, JeffreyHeller, HowardHenderson, JaniceHenderson, StephanieHenkaline, ToddHereter, LourdesHernandez, CaridadHerrera, ChristinaHerzig, RomanHerzog, DonaldHeymans, MartijnHiggins, PeterHilgers, ThomasHingorani, AnilHirtz, NathanielHo, AnnetteHobbs, SusanHocking, DeniseHoffman, ChenHolland, ChristyHolland, MarkHolzman, IanHomeister, JonathonHong, Min JiHong, Soon JaeHooley, ReginaHoover, EmilyHoppmann, RichardHorii, StevenHornberger, LisaHorning, MatthewHorrow, MindyHorton, SharonHoshiko-Reed, GailHotta, NaokiHou, GaryHou, RandyHousman, EliseHoward JamesHoward, ZoeHowe, DuncanHowell LoriHoyt, KennethHrbáč, TomášHu, XiangdongHuang, DeanHuang, LingyunHuang, ManweiHuhta, JamesHurtíková, EvaHussain, NaveedHussien, AbdelmohsenHynynen, KullervoIacobucci, AntonelloIbrahim, DeenaIkeda, NobutakaIngle, AtulIradji, SaraIrshad, AbidIseman, ChristineIvancevich, NikolasIzquierdo, LuisJackson, DavidJackson, MattJacobowitz, GlennJacobson, Jeffrey-MichaelJacobson, JonJaen Diaz, JoseJafari, DanielJakubowski, WieslawJang, KeeJasne, AdamJasti, SirishaJelinkova, MonikaJelsing, ElenaJeon, Eun-JinJiang, YuxinJing, ZhaoJohansson, PeterJohnson, AllanJohnson, BenjaminJohnson, JeanineJohnson, JeffJohnson, LauraJohnson, Mary BethJohnson, NeilJon, XiaJonszta, TomášJoong-Kim, YoungJames, JosephJoseph, OliverJoshi, KrutiJu, HyeyoungJuan, ZhangJuez, LeyreKagarise, DanielKang, Su MinKaproth-Joslin, KatherineKarlicki, FernKarlman, RobertaKarmel, BernardKarshafian, RarriKasperlik-Zaluska, AnnaKasyouhanan, FadiKatorza, EldadKatz, YisraelKawecki, AndreaaKelley-Martinez, MarthaKennedy, AnneKent, AlistairKerr, LucyKerwin, ChristopherKetterling, JeffKhan, FerasKhine, HninKhorana, AlokKhoury, VivianeKhuri-Yakub, ButrusKim, AhmKim, DavidKim, Hak HeeKim, HyunjiKim, LauraKing, DanielKing, DeirdreKiplagat, AnnetteKirschner, JonathanKist, KennethKlassen, AnnaKlaus, SuzanneKlauser, ChadKliewer, MarkKline-Fath, BethKobayshi, AkitoshiKohl, ThomasKolios, MichaelKoltz, PeterKona, MatthewKonicki, P. JohnKonofagou, ElisaKorucuk, EkremKotowski, SusanKowalewski, GregoryKoziatek, ChristianKraft, OtakarKrajča, JanKrakow, DeborahKrapp, MartinKraus, StevenKremkau, FredrickKripfgans, OliverGE Healthcare: equipmentsupport; other activities; otherfinancial benefitKrishnamurthi, GanapathyKrishnan, M. Muta RamaKugler, LindsayKuhlmann, RandallKulbacki, EvanKuliha, MartinKunselman, AllenKunselman, BonKwiatkowski, RobertLabuda, CecilleLaFerriere, JanetLai, XingjianLaifer-Narin, SherelleLal, BrajeshLam, SamuelLanger, JillLanger, MatthewZetrOZ, LLC: employment;salaryLangova, KaterinaLappen, JustinLarsen, JohnLaRusso, SalvatoreLavin, PhilipLawrence, MatthewLayman, KerriLee, Jiann-GwuLee, KennethGE Healthcare: honorarium;course facultyPhilips Healthcare: limitedresearch support; principalinvestigatorSiemens Medical Solutions:limited research support;principal investigatorLee, Mi HeeLee, Mi-YoungLee, Pil-RyangS125

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Lee, RoseLee, SangheeLee, Seung YunLegault Kingstone, LysaLeibman, JillLema, PenelopeLerner, JodiLester, NeilLeswick, DaveLethiecq, MarcLetourneau, KarenLevine, AdamLevitov, AlexanderLev-Toaff, AnnaLevy, BruceLevy, PhilipLewin, PeterLewis, GeorgeZetrOZ, LLC: managementposition; salaryLewis, MadeleneLewiss, ResaLi, MingdeLianfang, DuLichtenstein, DanielLikourezos, AntoniosLim, Tae-HongLinam, LeannLiou, RobertLi Pi Shan, RodneyLipitz, ShlomoLipman, SamanthaLiu, HeLiu, Ji-BinLiu, TeresaLiu, YunboLiu, XiLloyd, HarrietLobos, NelsonLockhart, MarkLombardo, PaulLong, SuzanneLooney, DevonLopez, EugenioLopez, JosephLopez, RobertLowe, LisaLudomirsky, AchiLukjanova, IrinaLuo, JianwenLupia, EnricoLyons, JenniferLyshchik, AndrejPhilips Healthcare: research support;consultantMa, ChiMaaji, SadisuMachado, PriscillaMacian, DianaMack, JulieMacones, GeorgeMadden, JohnMadsen, ErnestMadoff, DavidMagalhaes, AlvaroMagriples, UraniaMahoney, MarshallMaida, EugeneMajcher, MartaMaksoud, ClaudiaMallarini, GiorgioMamou, JonathanMarch, Melissa IreneMargolis, DavidMarin, DanieleMarkenson, GlennMarks, WilliamMarshall, AndrewMarshall, RandolphMarston, WilliamMartí Mestre, XavierMartin, JamesMartis, RoshanMaruvada, SubhaMastrobattista, JoanMata Castrillo, MariaMathew, BrennanMatsutani, ShoichiMatthew MauroMayo, PaulMazza, RachelMcArthur, LucasMcCamey, KendraMcCann, MargaretMcCarthy, MelissaMcCarville, BethMcDowell, JenniferMcNamara, JohnMcNamara, RobertMcShane, CyrethiaMedak, AnthonyMedford, WilliamSonoSite, Inc: salary; hands-oninstructorMehta, NinfaMeizner, IsraelMelniker, LawrenceMelone, PaulaMerport Modest, AnnaMerritt, ChristopherMerton, DanielMervis, EricMeyer, DianeMeyer, ElaineMeyer, MarjorieMezei, GaborMiddleton, WilliamMigda, BartoszMihailos, AthenaMillard, SarahMiller, DouglasMiller, EmilyMiller, JamesMiller, RitaMiller, RussellMiller, TheodoreMiller, ThomasMillet, JohnMillington, ScottMilne, MichelleMiniati, DouglasMinkoff, HowardMinnigan, HalMistur, RachelMohan, UtharaMojibian, HamidMoldenhauer, JulieMolinari, FilippoMolitor, MarkMoni, SailaMonroe, ManetteMonteagudo, AnaMoon-Grady, AnitaMooney, LindsayMooney, TimothyMoons, DavidMoore, ChristopherPhilips Healthcare: consultant,consulting feeSonosite, Inc: consultant,consulting feeMoreno, ClaudiaMoschos, ElysiaMoshesh, MalanaMougenot, CharlesPhilips Healthcare: employment;salaryMueller, AnthonyMudrik-Zohar, HadarMujsce, DennisMullen, KatherineMulvagh, SharonGE Healthcare: consulting fee;consultantLantheus Medical Imaging:research grant; research supportMunden, MarthaMunson, JacquelineMurphy, JoshuaMurphy, MeganMurtha, AmyMuruganandan, KrithikaMuruganandan, MeeraMuzumoto, HideakiMyers, CraigNadaraj, SumekalaNakamoto, DeanGalil Medical: research support;researchToshiba America MedicalSystems: honorarium; speakerNakashima, KazutakaGE Healthcare: salary; speakerHitachi Aloka Medical, Ltd:salary; speakerPhilips Healthcare: salary;speakerNam, KiboNamagembe, ImeldaNandlall, SachaNasief, HaidyNavathe, ReshamaNazarian, LevonNeedleman, LaurenceNelson, BretNelson, RendonNeri, EmilyNeyman, OlgaNghiem, HahnNguyen, ThanhNhan-Chang, Chai-LingNichols, TimothyNicolaides, AndrewNicolau, CarlosNightingale, KathyNoble, VickiNomura, JasonEmergency Ultrasound Consultants,LLC: consulting fee;director of medical educationNomura Consulting, LLC:ownership; principle/ownerNovak, RonaldNovelli, PaulaNunes, UzielObi, NwamakaObican, SarahO’Brien, William JrNational Institutes of Health:funding for the work; other activities;other financial benefitO’Connell, AviceO’Connor, RoryO’Day, MaryOdibo, AnthonyOdunko, DanielleOelze, MichaelOgburn, PaulOgutcu, BirsenOh, KarenO’Hara, SaraToshiba Medial Systems:equipment software; consultingOjili, VijayanadhOlartecoechea, BegoñaOlivia, MartaOliver, EdwardOng, Chiou LiOraevsky, AlexanderSeno Medical Instruments:consulting; consulting feeO’Rourke, KevinOtáhal, DavidOtto, PamelaSeno Medical Instruments:consulting; consulting feeOzhand, AliPakdaman, RezaPalma, JamesPalmeri, MarkPaltiel, HarrietPamnani, RaviPan, PatrickPan, XiaochangPanebianco, NovaPanerai, RonnyPao, Sun-HuaPareek, GyanParkes, JennyParry, SamuelS126

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Pascual, M. AngelaPaspulati, Raj MohanPatat, FrédéricPatel, DervarshiPatel, NileshPatterson, LeighPaul, IanPawlina, WojciechPayer, AndrewPeck, JenniferPeddada, ShyamalPedersen, PederPedrero, CristinaPellerito, JohnPennington, JamesPerarnau, Jean MarcPerez, AliciaPerez-Delboy, AnnettePerrin, StephenPessel, CaraPeters, HopePezo, CarloPhan, HaPiert, MorandGE: other activities; otherfinancial benefitsPineda, GracePineda, LauraPinter, StephenGE Healthcare: equipmentsupport; other activities; otherfinancial benefitsPiscaglia, FabioPivetta, EmanuelePlaninic, PetarPlatt, LawrenceGE Healthcare: honorarium;consultant, speakerPlatz, ElkePlessl, DanielPolascik, ThomasPollard, KatherinePontius, ElizabethPorrino, GiulioPorter, ThomasGE Healthcare: research support;principal investigatorLantheus Medical Imaging:research support; principalinvestigatorPhilips Healthcare NorthAmerica: research support;principal investigatorPosh, JohnMetrasens: consulting fee;employee trianingPoston, Mary ElizabethPrabulos, Ann MariePresley, JamesPretorius, DoloresPrice, BrandonProcházka, VáclavProvost, JeanPruetz, JayPulvermacher, ChristinaQian, LiuQuant, HayleyQuesada, CaroleRabener, MichaelRabiner, JoniRacadio, JohnRadeos, MichaelRadhakrishna, MohanRaginwala, SaadRaio, ChristopherZONARE Medical Systems:consulting fee; medical advisorRajasekaran, SathishRamakrishnan, PremRanninger, ClaudiaRanzini, AngelaRao, VictorRasalingam, RaviRath, KristaRathje, ErinRavangard, SamadehRayburn, WilliamRebarber, AndreiReeves, ShaneReiner, CäciliaReinstein, DanArcsan, Inc: other activities;ownership interestReiss, RosemaryRepke, JohnReusch, LisaRevzin, MargaritaRichards, MichaelGE Healthcare: equipmentsupport; other activities; otherfinancial benefitRizza Siniscalchi, NicoloRo, RaymondRoberts, JessicaRobinson, KathrynRobinson, ZacharyRoca, PedroRodney Rocco, JohnRodney, WilliamRochon, PaulRodriguez, DianaRoe, Anne MarieRoelant, GeoffreyResch, MichaelRogers, SarahRoll, ShawnRoman, AshleyRomera Villegas, AntonioRomero, VivianRomney, MarieRosado-Mendez, IvanRosas, HumbertoRosborough, TerryRosen, MarkRosenberg, Henrietta KotlusRosenberg, KeithRosenzweig, StephenRotemberg, VeronicaRoubec, MartinRouze, NedRoyall, Nelson AndrewRoyChoudhury, ArindamRuanno, RodrigoRubens, DeborahRubert, NicholasRubin, JonathanRubin, ShermanRubio, EvaRundek, TatjanaRutledge, AmyRusczyk, GreggRychak, JoshuaSiemens Medical Solutions:equipment support; collaborator/researcherTargeson, Inc: employment,stock ownership; employee,founderVisualSonics, Inc: consultingfee; technical consultantSaad, NaelSaba, LucaSadeghi-Naini, AliSafonova, InessaSahlani, LydiaSahn, DavidSakhel, KhaledConceptus: speaker fee,speakerHologic: consulting fee;consultant, speakerSalimian, MohammadSaltzman, DanielSamir, AnthonySuperSonic Imagine: speakerfee, speakerSamuel, AmberSamuels, JoshuaSantolaya, JoaquinSarwate, SandhyaSatou, GarySavage, DanielSavaser, DavutSchafer, MarkSchaller, MichaelScher, LawrenceSchmitz, KelliSchneider, DarrenSchneider-Kolsky, MichalSchnettler, WilliamSchofer, JoelSchroer, AndreasSchwartz, NadavScissons, RobertUnetixs Vascular, Inc: independentcontractor; royaltyScognamiglio, UmbertoScola, MalloryScoutt, LesliePhilips Healthcare: honoraria;speakerSeed, MichaelSehgal, ChandraSekarski, TimothySeki, AtsuyoshiSerres, XavierSeupaul, RawleShah, SachitaShah, ViragShahmirzadi, DanialShailam, RandheerShamshirsaz, AmirShau, Yio-WhaSheets, LindaPhilips Healthcare: employee;salarySheppard, CelesteSherbotie, JoeSherman, PhilipShieh, MasonShiels, WilliamSierzenski, PaulEmergency Ultrasound Consultants,LLC: partner; presidentand CEOEmergency Ultrasound Consultants,LLC: spouse/partner,COO, partnerSonosite, Inc: consulting fee,speakerShim, Jae-YoonShin, Hee JungShipp, ThomasShirazi, MazdaShlansky-Goldberg, RichardShofer, FrancesShokoohi, HamidShonkwiler, GwenShoreman, MarkShue, EvelineShung, K. KirkShwayder, JamesCook Ob/Gyn: royaties;coinventorPhilips Healthcare: consultingfees; consultantShyu, Jeou-JongSidhu, PaulHitachi, Inc: consulting fee;speakerSiemens AG: consulting fee;speakerSierzenski, PaulSikdar, SiddharthaSilas, AnneSilverman, NormanSilverman, RonaldArcscan, Inc: interest otheractivities; ownershipSimmons, JohnSimpson, DouglasSimpson, LynnSinert, RichardSingh, GautamSinha, SidharthaSinkovskaya, ElenaSivitz, AdamSklansky, MarkŠkoloudik, DavidSlapa, RafalS127

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Sloane, ChrisSlowinska-Srzednicka, JadwigaSmith, BrendonSmith DanaSmith, JayTenex Health: other financialbenefit; other activitiesSmith, JessicaSmith, LemSmith, MatthewSmith, RoseSmith, SusanSmrtka, MichaelSnead, GregorySnyder, KathrynSoffer, DebbraSohaey, RoyaSolomon, JuliaGE Healthcare: honorarium;preparation of educational materialsSommerich, CarolynSong, ChihwaSprace, AnnaSoto, RosamarySoukup, TomasSperling, DanielSpiel, MelissaSpinner, DavidSpinosa, AlSpitz, JeanSpringer, AndrewSree, VinithaSridharan, AnushSrinivasan, GaneshStassijns, GaetaneStavros, ThomasSeno Medical Instruments:consultant; consulting feeStawicki, StabuskawSteiner, RyanStekel, ScottStepien, BeataStidham, RyanStilp, ErikStites, RachelStone, MichaelPhilips Healthcare: consultingfee; consultantStrakowski, JeffryStrasburger, DianaStrickland, ColinAmirsys: royalty for content;content authorElsevier: honorarium; booksection editoriiCME: honorarium; speakerStulac, SaraSubashi, ErgysSummey, RobertSun, DerekSun, QiangSunny, YouhanSuri, JasjitSwamy, GeetaSwanson, ScottSzabo, ThomasSzyld, DemianTai, Hao-ChihTalbott, NancyTalegon, AntonioTalk, DouglasTao, ShengzhenTarabulsi, GofranTchelepi, HishamTeefey, SharleneTegeler, CharlesTerentiev, VictoriaTessler, FranklinPhilips Healthcare: conultingfee; consultantThomas, KariThomenius, KaiGE Healthcare: empoyment;salaryThompson, JenniferThornburg, LoraleiTian, ZhiyunTierney, DavidTillett, JasonTimor, IlanTirado, AlfredoTizzani, MariaTodorova, MargaritaToland, GregoryTolbert, TahishaTornero, MarkTorres, CarlosTradup, DonaldTrahey, GreggTran, EricTran, NghiaTran, ThaisonTran, WilliamTreadwell, MarjorieTrebes, ShannonTresserra, FranciscoTrinh, TonyTsung, JamesTumidajewicz, JustynaTur-Kaspa, IlanTurner, ElizabethTurney, ColinTuuli, MethodiusTwickler, DianeTworetsky, WayneUlissey, MichaelSeno Medical Instruments:consultant; consulting feeUral, BanuUral, SerdarUrbanowicz, KatarzynaUrs, RakshaUryasev, OlegUtrilla-Layna, JesusVallabhaneni, RaghuveerVance, CherylGE Healthcare: salary; WHSeducationVandordaklou, Negeanvan Holsbeeck, Marnixvan Veen, TeelkienS128Van Vugt, JohnVargas Velandia, EdwinVargas-Vila, MarioVarghese, TomyVassa, RaviVejdani-Jahromi, MaryamVela, DeborahVictoria, TeresaVila, MeritxellVila Coll, RamonVilke, GaryVilkomerson, DavidDVX, LLC: salary; management;ownershipVink, JoyVintzileos, AnthonyVogel, MelanieVoloshin, ArkadyVolpicelli, GiovanniVolz, KevinVora, NeetaVrablik, MichaelVytkac, AdamWaag, RobertWachsberg, RonaldWagner, JasonWalker, CynthiaWallace, KirkGE Healthcare: employment;salaryWang, EileenWang, HongyanWang, MichaelWang, Shuo-MengWard, ValerieWax, JosephWay, DavidWear, KeithWeichert, JanWeingarten, MichaelWeisz, BoazWells, C. EdwardWerner, ErikaWhite JamesWhite, KatherineWhitley, KariWildes, DouglasGE: dividends; salary;employee; stockholderWilkens, IsabelleWilliams, SarahWilson, KimWilson, ThaddeusWise, AdamWislon, ChristianWitkowska, AgnieszkaWitt, DexterWolf, PatrickWolfe, HonorWolfe, MichaelWon, Hye-SungWoodward, PaulaWortsman, XimenaXiao, JiaXu, JonathanXu, ZhenXuemei, ZhangYablon, CorrieYakubu, AbdulmuminuYantri, RatnaYeager, SusanYeboah, NinaYellin, SharonYenter, ChristopherYerli, HasanYeo, LamiYijin, Su MasterYilma, TugbahanYing, WuYingyu, CaiYinon, YoavYoob, SuzanneYoon, ChungYoon, Hee-ChulYoon, Jae-WonYoon, Sang-WookYoussefian, ArthurYuan, ChunYuan, Li-JunYunhua, LiZagzebski, JamesZaharieva, MariaZalel, YaronZalev, JasonSeno Medical Instruments:consultant; consulting feeZeeman, GerdaZehtabchi, ShahriarZhang, JingZhang, ManZhang, Xiao-YongZhao, LiminZhao, XihaiZhum, QingliZiade, M. FouadZieleznik, WitoldZielinski, AshleyZinn, KurtZork, NoeliaZubkov, Leonid

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Disclosures From AIUM Officers, Board Members,Committee Members, and AIUM StaffThe 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 disclosureforms are on file and available for review at the AIUM office.Abo, Alyssa, MDAbuhamad, Alfred, MDVerinata Health: $10,000(stock option/year)Abu-Rustum, Reem, MDAllen, Lisa, BS, RDMS, RDCS,RVTAndreotti, Rochelle, MDBahner, David, MD, RDMSBenacerraf, Beryl, MDBromley, Bryan, MDClark, JennyCohen, Harris L., MDColey, Brian, MDCooper, Therese, BS, RDMSCostello, JenniferCrino, Jude, MDDelanko, DanielleDiGiovanni, Laura, MDEberle, DianeFleischer, Arthur, MDFowlkes, J. Brian, PhDHistosonics, Inc: ownershipinterest; researcherGlanc, Phyllis, MDCM, BSCGoldstein, Steven, MDAmgen: gynecology advisoryboard; honorariumBayer: gynecology advisoryboard; honorariumCook Ob/Gyn: consultant; consultingfeesPhilips Healthcare: consultant;equipment loanShionogi: Gynecology AdvisoryBoard; honorariumWarner Chilcott: honorariumHarvey, GlynisHertzberg, Barbara, MDIzquierdo, Luis, MDKinney, BrendaKliewer, Mark, MDKonofagou, Elisa, PhDKripfgans, Oliver, MDGE Healthcare: only equipmentloanerLanger, Jill, MDLaRusso, Salvatore, MeD,RDMS, ARRTLee, Kenneth, MDLev-Toaff, Anna, MDLewis, MicheleLockhart, Mark, MD, MPHLynch, Susan, RDMS, RVT,RDCSMastrobattista, Joan, MDMoore, Christopher, MD, RDMS,RDCSPhilips Healthcare: consultant;consulting feeSonoSite, Inc: consultant; consultingfeeMinton, Katherine, MA, RDMS,RDCSMuncey, SusanNazarian, Levon, MDNelson, Thomas, PhDNisenbaum, Harvey L., MDO’Brien, Janet, RDMS, PA-CPennington, James, RDMSPorto, Manuel, MDRobbin, Michele, MDPhilips Healthcare: evaluatethe utility of new transducer;new transducer/softwareupgradePuscheck, Elizabeth, MD, MSSakhel, Khaled, MDHologic: consulting fee; speakerScoutt, Leslie, MDPhilips Healthcare: honoraria;teaching/speakingSehgal, Chandra, PhDShipp, Thomas, MDShwayder, James, MD, JDCook Ob/Gyn: coinventorroyaltiesSilverman, Rosy, RDMS, RVT,RT(S)Smith, Jay, MDAndrews Institute: honoraria;teaching/speakingGulf Coast Ultrasound Institute:honoraria; teaching/speakingTenex Health: consultant;consulting fee; royalties; stock;stock ownerToreno, Felicia, PhD, RDMS,RDCS, ROUB, RVTValente, Carmine, PhD, CAEWax, Joseph, MDWeber, Therese, MDWhitman, Gary, MDWoletz, Paula, MPH, RDMS,RDCSWong-You-Cheong, Jade, MDZanin, Linda, EdD, RDMSS129

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Policy on Unlabeled/Off-Label UsageThe AIUM has determined that disclosure of unlabeled/off-label or investigational use of commercial product(s) is informative for audiencesand 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 theUS Food and Drug Administration. The AIUM requires that any discussions of such “off-label” use be based on scientific research that conformsto generally accepted standards of experimental design, data collection, and data analysis. Before recommending or prescribing any therapeuticagent or device, learners should review the complete prescribing information, including indications, contraindications, warnings,precautions, and adverse events.Alexandrov, AndreiAylward, StephenBarr, RichardBulas, DorothyDarge, KassaDayton, PaulDeganello, AnnmariaDeng, CheriFeinstein, StevenFeltovich, HelenFerraioli, GiovannaForsberg, FlemmingHata, StacyHuang, DeanHiang, YuxinJing, ZhaoJohnson, NeilKasperlik-Zaluska, AnnaKlaus, SuzanneLai, XingjianLanger, MatthewLewis, GeorgeLi, MingdeLiu, HeLyshchik, AndrejMcCarville, BethMigda, BartoszMohan, UtharaMooney, TimothyMulvagh, SharonNakamoto, DeanNakashima, KazutakaNovak, RonaldPalmeri, MarkPaltiel, HarrietPorter, ThomasQian, LiuReusch, LisaScissons, RobertSidhu, PaulStrickland, ColinSun, QiangVolz, KevinWang, HongyanXiao, JiaXuemei, ZhangYing, WuZhang, JingZhu, QingliDisclosure of Commercial Support for the2013 AIUM Annual ConventionAdvertisingADVANCE for Imaging and RadiationOncologyALPINION Medical SystemsApplied RadiologyDiagnóstico JournalDigisonics, IncHealth Imaging & ITParker Laboratories, IncRadiology TodaySamsung Electronics America, IncSuperSonic ImagineTexas Children’s Pavilion for WomenUltrasonix Medical CorporationSidra Medical and Research CenterIn-kind DonationsALPINION Medical SystemsATS Laboratories, IncCIRS, IncCIVCO Medical SolutionsEsaote North America, IncFUJIFILM SonoSite, IncGE HealthcareHitachi Aloka Medical, LtdNanosonics, IncParker Laboratories, IncPCI Medical, IncPhilips HealthcareSamsung Electronics America, IncSiemens Medical Solutions USA, IncSIMULab CorporationSound Ergonomics, LLCSuperSonic ImagineTerason UltrasoundToshiba America Medical Solutions, IncUltrasonix Medical CorporationZONARE Medical Systems, IncSupportSidra Medical and Research CenterParker Laboratories, IncSamsung Electronics America, IncUnrestricted Educational GrantAS Software, IncS130

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013IndexAAbadi M S13Abbott B S116Abdella T S80Abdelmalek M S10Abdullaev R S95Abo A S1Abu-Rustum R S81Abu-Rustum S S81Abu-Yousef M S37Abuhabsah R S50Abuhamad A S29, S51, S52Acharya R S61Acharya UR S17, S35, S47, S60Achiron R S52, S53, S80Ackerman S S59, S90Adams J S103, S114Aderibigbe O S28Adhikari S S112, S120Adkins E S19, S100, S101, S103, S119Adzick NS S53Agache V S38Agildere AM S103Ahmadzia H S117Ahmed A S27Aish B S63Ajmera K S18Al Ekish S S61Al Mahrouki A S40Al Muhanna K S35Alcazar JL S113Alehagen U S45Alexandrov A S7Allaf MB S52Allen A S64Allen D S43Aly A-R S23Ambrose A S105Amian A S20Ananth C S25Anderson C S20, S64Anderson S S64Ando T S95Antonis M S98Anvari A S14, S114Apterbach W S110Archer T S12Arellano J S96Arnold K S65Arntfield R S2Arpit N S104Arynova B S48Astheimer J S42Aten A S117Au A S89Aubá M S113Ausiello L S18Avner J S77Axt-Fliedner R S30, S69, S80Ayala R S92Aylward S S6Ayoub J S101Ayvazyan S S78Azar N S15, S111BBaek S-E S51Bahner D S19, S21, S63, S100, S101,S102, S103, S108, S110, S116, S117,S119, S120Bai J S9Baird D S118Bajaj K S108BakhirevavL S70Balise R S19Balk A S79, S118Balzaretti P S18Banderali A S18Bar-Sever Z S55Bard R S63, S66, S84, S85Bardales R S60Barr R S2, S12, S31, S33Barral J S19Barri-Soldevila P S118Bartova P S34, S91Bault J-P S52Bawiec C S41Baxtrom C S78Beach K S35Beal E S116Beamon C S120Beavis C S23Beck B S35Beiter K S98Beland M S61Belfort M S71Bellew C S99Ben-Meir D S55Benacerraf B S1, S54Benaroya A S22Benn P S55Bennett TA S24Benson C S26, S88Beraud A-S S19Berger J S68Bhimani A S67Bialeck S S78Bieniarz A S114Bierca J S15Bitters C S100Blackstock U S65, S78Blahuta J S34Blaivas M S58Blanks J S92Blankstein J S48Blebea J S6, S44, S74, S76Blickendorf M S101, S119Blumenfeld Y S79Bluth E S76Bockbrader M S21Bolouri M S86Bolte A S109Boniface K S18Boore S S101Borgida A S52, S91Boulger C S19, S101, S103, S108, S110,S116Box D S120Box G S120Boyd B S24, S116Bradford S S113Bradshaw D S21Breazeale S S20Brennan M S90Brewer K S87Bromley B S32, S54, S71Brown C S109Brown D S32Brown S S32, S70, S90Brubaker S S25, S82Buadu A S107Buckwalter J S39Bui L S106Bundy N S117Bunting E S44Bureau N S3Burhans K S111Busse R S99Byram B S61Byrne J S93, S104CCadet C S83Cahill A S69Cai Y S47Calabrese K S18Calisti G S17Campbell C S21Campbell W S52, S55Canavan T S45, S71Cao T-S S44Carey J S104Carlson L S48Carroll L S120Carson P S33, S40Casoli G S18Castillo E S21, S43Caughey M S10, S62Cavanaugh B S14Cendan J S99Cerezo Lopez E S89Cermak P S34Cha ES S99Cha JH S12, S99Chalek C S18Chan T S21Chandrasekhar C S97Chao J S79Chavez M S52Chervenak J S72, S96Chiem A S20Childress J S22Chin E S20Chinchure D S29Chintapalli K S104Chiou S-Y S87Chiricolo G S79, S115, S118Choi J-Y S80Choi WJ S12, S99Chopra M S62Chorazy M S102Chou N-K S68Chun Lema P S109, S110Church C S75Ciardo P S89Cibinel G S18Claes F S68Clem D S64Clingman B S13Cody K S89Cohen N S67Coleman B S53Coll RV S34Colvin R S93Contreras K S114Cordeiro C S89Cordero Garcia B S89Coroleu B S106Cortez E S101, S103Corujo Vazquez O S109, S110Cosgrove D S65Crawford C S55Crawford F S50Crino J S1, S69Cunha L S14Currie G S107, S110Curs B S64Czarnota G S40, S61Czernuszewicz T S10Czerný D S49Dd’Armiento J S34Dahibawkar M S51Dahlström U S45Dai Q S13Dalecki D S31Dallas A S22, S23, S92, S94Darge K S37Datta A S109, S110Dave J S51Davidovits M S55Davis M S107Davis S S52Dayton P S6de Guillebon A S39De Jong MR S37de la Torre L S90de Stefano G S17Dean A S89DeFranco E S54DeFranco P S54Deganello A S37Degenhardt J S30, S69, S80del Cura J S17Deng C S31, S57Destounis S S73Deter R S71Detti L S45Deurdulian C S32Deurloo K S109Di Martino F S17Di Pietro M S76Diaz D S113Dickman E S19, S78Dietrich C S65diFlorio R S66Dillman J S67Do S S25, S82Dolin C S27Donaldson C S20Donaldson J S64Dooley E S65Dornbluth NC S13Doubilet P S32, S88Dresbach S S116Du L S47Dudley L S79Dumont D S11Duvdevani N S80EEhsanipoor R S69Eichelberger K S120Eiferman D S19, S116Eisenbrey J S14, S18, S86, S87El Kaffas A S40El-Baz A S61Elahi E S83Ellestad S S117Emmitt R S62English C S63Enzensberger C S30, S69, S80Erdman J S50Ermilov S S13Eski E S103Evans D S19Evans K S24, S49FFabiilli M S38, S40Fadrna T S91Falou O S61Farber M S10Farella N S17Farwick L S118Feinstein S S58Feldstein V S86Feleppa E S33Feltovich H S48Fernandez-Cid M S105, S106, S118S131

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Ferraioli G S31Ferreri E S18Fessell D S33Filice C S31Finberg H S24Finnoff J S97Fisher K S117Fleischer A S49Fleshman S S39Fontanilla T S17Ford P S10Forsberg A S51Forsberg F S14, S18, S51, S86, S87Fowlkes JB S40, S67, S81Fox JC S20, S63, S64Fox N S24, S27, S54, S70, S86Fox T S51, S87Frank G S43Frates M S88Frenke V S106Friedman A S26, S105Friedman L S77Fuchs K S25, S71Fujimoto C S99Fuller K S55, S91GGaddipati S S82Galan H S5Galerneau F S117Gallippi C S10, S62Gammell P S41Gandhi M S52Garberoglio R S17Garg M S70Garon J S48Gaspari R S64Gauthier M S42Gecsi K S67Gee M S114Geldermann D S88Gelman SK S81Gembruch U S30, S69, S80George V S97Gerber S S26Germer U S30, S69, S80Gessner R S6Gharahbaghian L S19Gilboa Y S52, S80Giles A S40Giorgio A S17Giorgio V S17Girotto J S111Glantz JC S113Glasek J S102Glasser J S92Glazier E S94Goertz D S38Goetzinger K S69Goffi A S18Goldberg A S13Goldírová A S49Goldklang M S34Goldman E S63Goldman S S110Goodman E S66Goodman J S97, S114Goodman R S7Gordon R S26Goubran A S87Goutham S S61Graupera B S105, S106, S118Gray S S43Grippo A S77Groh G S114Gross A S112, S120Groszmann Y S54Grotegut C S24, S116, S117Guerriero S S47Guizado de Nathan G S80Gullett J S79Gunabushanam G S18, S50, S74, S104,S111, S112Gunnison K S48Gupta S S54, S70, S72, S86, S89, S96,S110Gurram P S55Gustafsson M S45Gyamfi C S25HHabenicht R S52Haberman S S27Hacker M S25, S70Haeri S S52, S71Haines L S19, S78Hall A S67, S81Hall E S2Hall R S90Hall T S33, S43, S48, S62Halldorsdottir V S51, S86Hamvas A S11Han B S28Handa P S13Hangiandreou N S83, S108, S109Hansen A S21Harris G S2, S41, S75Harris R S66Hartge D S55Hartman A S46, S48Hartman B S46, S48Hartman D S114Hashim A S40Hata S S63Havel M S91Havelka J S91Hawkins L S70Hdeib M S64He L S9He Y S51Hee Lee M S112Heimburger G S87Heimiller J S94Heller H S26Henderson J S69Henderson S S111Henkaline T S21Hereter L S105, S106, S118Hernandez C S99Herrera C S53, S56, S90Herzig S91Herzig R S34, S49Herzog D S13Heymans M S109Higgins P S67Hilgers T S98Hirtz N S11Ho A S107Hocking D S31Hoffmann C S53, S80Holland C S7, S57Holland M S9, S10, S11, S100, S114Holzman I S83Homeister J S10Hong MJ S99Hong S-J S80Hoover E S101, S102Hoppmann R S65Horii S S53Horning M S65Horton S S29, S51, S52Hoshiko-Reed G S99Hotta N S83Hou G S40Hou R S20Howard J S62Howard Z S19Howe D S65Howell L S53Hoyt K S16Hrbáč T S49Hu X S51Huang D S32Huang L S9Huang M S9Huhta J S76Hurtíková E S49Hussain N S55Hussien A S88Huu Tran N S106Hynynen K S38IIacobucci A S18Ikeda N S35Ingle A S9, S62Iradji S S40, S61Irshad A S12, S65, S73, S90Iseman C S28Isurugi C S92Ivancevich N S7Iyoob S S53JJackson D S80Jacobson J-M S80Jaen Diaz JI S89Jafari D S89Jakubowski WS S15, S16Jang K S39Jasne A S101Jasti S S107Jelinkova M S34Jelsing E S97Jeon E-J S80Jia X S47Jiang Y S13Jin X S28Jing Z S28Johansson P S45Johnson A S51, S79Johnson B S10Johnson J S52, S98Johnson L S67Johnson MB S43Jonszta T S49Joong-Kim Y S11Joseph JM S21Joseph O S22, S23, S92, S94Joshi K S110Juan Z S28Juez L S113KKagarise D S21Kanasugi T S92Kaplan BS S108Kaproth-Joslin S107Karlicki F S87Karlman R S114Karmel B S22Karshafian R S38, S40Kasperlik-Zaluska A S16Kasyouhanan F S119Katorza E S52, S53, S80Katz Y S94Kawecki A S69, S80Kelly-Martinez M S79Kennedy A S93, S104Kent A S19Kerr L S14Kerwin C S77Khan F S19Khine H S77Kikinis R S92Kikuchi A S92Kim A S113Kim D S66Kim H S12, S99Kim HH S12, S99Kim HS S99Kim SH S99King D S42, S49, S83Kiplagat A S11Kirschner J S77Kist K S13Klassen A S29, S51, S52Klaus S S63Klauser C S24, S27, S54, S70, S86Kline-Fath B S1, S58, S100Kobayshi A S95Kohl T S30Kolios M S38, S61Koltz P S111Kona MP S23Konicki PJ S77, S78Kono Y S16Konofagou E S34, S40, S44, S49Korucuk E S103Kotowski S S118Kowalewski G S35Koziatek C S78Kraft O S91Krajča J S49Krakow D S104Krapp M S30, S69, S80Kraus S S103, S114Kripfgans O S40, S67, S81Kripfgans OD S38Krishnamurthi G S61Krishnan MMR S17Ku B S89Kugler L S27Kulbacki E S60Kuliha M S49, S91Kunselman A S85, S104, S105Kwiatkowski R S102LLabuda C S75Lai X S13Laifer-Narin S S3, S5, S53, S56, S90Lal B S35Lam S S77, S78Langer M S39Langova K S34, S91Lappen J S67Larsen J S81Lavin P S13Lawrence M S92Layman K S98Lee J-G S68Lee K S57Lee M-Y S80Lee P-R S113Lee R S46, S48Lee S S112Lee SY S10Lee W S69Legault Kingstone L S107, S110Leibman J S13Lerner J S45Lester N S29Leswick D S23Letourneau K S87Lev-Toaff A S5Levy S114Levy B S97Levy L S11Levy P S5Lewin P S41Lewis Jr G S2, S38, S39, S74Lewis M S90Li M S41Li Y S47Lianfang D S28Lichtenstein S S5Likourezos A S19, S78Lim T-H S39Liou R S20Lipitz S S53Lipman S S60Liu H S13Liu J-B S51, S87Liu Q S47Liu X S30Liu Y S18, S41, S63Lloyd H S15S132

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Lobos N S95, S96, S101, S102Lombardo P S48Looney D S53Lopez de Castro L S89Lopez J S120Lukjanova I S95Luo J S9Lupia E S18Lyons J S54MMa C S44, S45Maaji S S93Machado P S14, S18Macian D S92Mack J S73Mack L S111Macones G S69Madden J S60Madsen E S43Magalhaes A S93Magriples U S117Mahoney M S16Maida E S102Majcher M S102Maksoud C S120Mallarini G S61Marc Perarnau J S101March M S25Margolis D S41Marin D S51Markenson G S52Marshall A S51Marston W S10Martin J S39Martis R S61Maruvada S S41Mata Castrillo M S89Mathew B S70Matsutani S S95Mauro M S10Mayo P S58McArthur L S19McCamey K S117McCann M S30McCarthy M S18McCarville B S37, S73McDowell J S2, S59McNamara J S22, S23, S92, S94McNamara R S50McShane C S24Medak A S43Mehta N S83Meizner I S53, S55Melniker L S79, S118Melone P S114Merton D S18Mervis E S20Mestre XM S34Meyer D S62Meyer E S32Meyer M S52Mezei G S85, S104Migda B S15, S16Mihailos A S79, S118Miller D S42Miller E S26Miller J S10, S60, S100Miller R S50, S53, S56, S90Miller T S13Millet J S50, S111Millington S S2Milne M S10, S100Min Kang S S112Miniati D S86Minkoff H S27Minnigan H S77Mistur R S103Modest A S70Modest AM S25Mohan U S63Moldenhauer J S53Molinari S35Molinari F S17, S47, S60Molitor M S93Moni S S25Monroe M S99Montazemi M S69Monteagudo A S38, S72, S73, S96Mooney L S119Mooney T S79, S115, S118Moons D S67Moreno C S96Moschos E S46Moshesh M S118Mougenot C S40Mudrik-Zohar H S55Mueller A S101Mujsce D S104, S105Mullen K S26Mulvagh S S6Munson J S65, S78Murphy J S114Murphy M S66Murtha A S24, S116, S117Muruganandan K S4Muruganandan M S98Muzumoto H S95Myers C S114NNadaraj S S28Nakamoto D S15, S38, S57, S111Nam K S43Namagembe I S117Nandlall S S34Nasief H S62Navathe R S54Nazarian L S3, S8, S74Nelson R S51Neri E S97Neyman O S100Nghiem H S37Nguyen T S106Nhan-Chang CL S25Nichols T S10Nicolaides A S35Nicolau C S17Nightingale K S10, S60, S61, S75Nomura J S59Novak R S15Novelli P S67Nunes U S14OO’Brien Jr W S5, S11, S42, S49, S50O’Connell A S88, S107O’Hara S S103, S114O’Rourke K S79, S115, S118Obi N S114Obican S S81Odibo A S69Odunko D S93Oelze M S5Ogburn P S52Ogutcu B S48Oh K S86, S88Ojili V S90, S104, S111, S112Olartecoechea B S113Oleze M S60Oliva M S105Oliver E S53Ong CL S29Oraevsky A S13Otáhal D S49Otto P S13Oyama R S92Ozhand A S52PPakdaman R S93Palmeri M S10, S48, S60, S61, S75Pamnani R S19Pan P S51Pan X S9Panebianco N S89Panerai R S71Pao S-H S68Paraschuk Y S95Pareek G S61Parkes J S48Parry S S26, S105Pascual MA S105, S106, S118Patat F S101Patel D S118Patel N S103Patterson L S87Paul I S104, S105Pawlina W S102Payer A S99Peck J S97Peddada S S118Pedersen P S5Pedrero C S105, S106, S118Pelegrí SG S34Pennington J S63, S80Perez A S106Perez-Delboy A S82Perrin S S7Pessel C S25, S82Peters H S88Pezo C S96Phan H S22Piert M S38Pineda G S89Pineda L S113Pinter S S67, S81Piscaglia F S65Pivetta E S18Planinic P S80Platz E S18Plessl D S23Polascik T S60Pollard K S102, S108Pontius E S98Porrino S18Porter T S58Poston ME S65Prabulos AM S55Presley J S102Price B S117Procházka V S49Provost J S44Pujol S S92Pulvermacher C S69, S80QQian L S28Quant H S26Quesada C S38RRabiner J S77Radeos M S109, S110Radhakrishna M S22Raginwala S S103Rajasekaran S S22, S23Ramakrishnan P S39Ranninger C S63Ranzini A S28Rao V S65Rasalingam R S10, S100Rath K S119Rathje E S118Ravangard S S52Rayburn W S70Rebarber A S24, S27, S54, S70, S86Rebener M S20Reiner C S51Reinstein D S12Reiss R S26Repke J S85Reusch L S48Revzin M S2Richards M S81Ro R S87Robinson Z S110, S116Roca P S85, S104, S105Rodney J S65Rodney W S65Rodriguez D S25, S70Roe AM S108Roelant G S19Roesch M S117Rogers S S88Roll S S49Roman A S24, S27, S54, S70, S86Romero V S81Romney M S109, S110Rosado-Mendez I S43, S62Rosas H S21Rosborough T S66, S112Rosen M S64Rosenberg HK S28, S29Rosenberg K S119Rosenzweig S S60Rotemberg V S61Roubec M S49, S91Rouze N S10, S60Royall N S63RoyChoudhury A S12Ruano R S52, S71Rubens D S33Rubert N S9Rubin J S67, S81Rubin S S89Rubio E S58Rundek R S7Rundek T S7, S32Rusczyk G S110Rychak J S6, S86Rychik J S30, S76SSaba L S35, S47, S61Sadeghi-Naini A S61Safonov R S95Safonova I S95Sahlani L S100Salimian M S18Saltzman D S24, S27, S54, S70, S86Samir A S14, S114Samuel A S53, S56, S90Samuels J S41Santolaya J S27Sarwate S S50Satou G S28Savage D S70Savaser D S21, S43Schafer M S8Schaller M S19Schmitz K S88Schneider-Kolsky M S48Schnettler W S25, S70Schofer J S92Schroer A S55Schwartz N S26, S105Scognamiglio U S17Scola M S62Scoutt L S18, S32, S50, S74, S77, S104,S111, S112Sehgal S41Sekarski T S11, S114Seki A S95Serres X S17Seupaul R S77Shah S S3, S98Shah V S21, S43Shahmirzadi D S40Shailam R S98Shamshirsaz A S52Shan R S22Shau Y-W S68Sherbotie J S93Sherman P S38Shieh M S63Shim J-Y S80, S113Shin HJ S12, S99S133

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Shipp T S54Shirazi M S112Shlansky-Goldberg R S75Shofer F S89Shokoohi H S18Shonkwiler G S80Shoreman M S21Shue E S86Shung KK S38Shwayder J S33, S57Shyu J-J S68Sidhu P S2Sierzenski P S7Sikdar S S35Silverman R S12, S15Simmons J S65Simpson D S11, S50Simpson L S53, S56, S57, S90Sinert R S79Singh G S10, S11, S100, S114Sinha S S19Siniscalchi NR S34Sinkovskaya E S29, S51, S52Školoudík D S34, S49, S91Slapa R S15, S16Sloane C S21Slowinska-Srzednicka S15Smith B S50Smith D S120Smith J S54, S97, S102Smith L S116Smith R S118Smrtka M S24, S116, S117Snead G S77Snyder K S88Soffer D S30Sohaey R S86, S88Sommerich C S49Song C S43Sorace A S16Sorribas MC S34Soto R S96Soukup T S34Sperling D S84Spiel M S52Spinner D S119Spinosa A S66Spitz J S71Springer A S19Sree V S17, S61Sridharan A S18, S86Srinivasan G S87Stassijns G S68Stavros T S13Stawicki S S19Steiner R S118Stekel S S83, S108, S109Stepien B S60Stidham R S67Stilp E S50Stites R S98Stone M S18Strakowski J S21Strasburger D S77Stulac S S98Su Y S47Subashi E S51Sugiyama T S92Summey R S23Sun D S13Sun Q S13Sunny Y S41Suri J S17, S35, S47, S60, S61Sutton J S7Swamy G S24, S116, S117Swanson S S40Szabo T S75Szyld D S65, S78TTai H-C S68Talbott N S115Talegon A S17Talk D S92Tao S S9Tarabulsi G S69Teefey S S76Terentiev V S19, S78Tessler F S33Thomas K S86Thomenius K S18, S57Thompson J S24, S116, S117Thornburg L S71, S111, S113Tian Z S30Tianbo R S107Tierney D S66, S112Tillett J S42Timor I S72, S89, S96Tirado A S99Tizzani M S18Todorova M S38Toland G S71Tolbert T S19Tornero M S21Torres C S107, S110Tradup D S83, S108, S109Trahey G S11Tran E S109Tran T S18Tran W S61Treadwell M S81Trebes S S69Tresserra F S106Trinh T S93Tsung J S77, S83Tumidajewicz J S60Turner E S20, S64Turney C S110Tuthill T S16Tuuli M S69Twickler D S46UUlissey M S13Ural B S99Ural S S85, S104, S105Urbanowicz K S102Urs R S12, S15Uryasev O S22, S23, S92, S94Utrilla-Layna J S113VVallabhaneni R S10van Veen T S71van Vugt J S109Vandordaklou N S20Vargas Velandia E S15, S111Vargas-Vila M S67Varghese S45Varghese T S9, S44, S62Varghese Y S9Vassa R S104Vejdani-Jahromi M S11Vela D S7Victoria T S53Vila M S106Vilke G S21Vilkomerson D S6, S34, S41Villegas AM S34Vink J S25, S82Vintzileos A S52Vogel M S30Voloshin A S22Volpicelli G S18Volz K S24, S49Vora N S120Vrablik M S77Vytykac A S118WWaag R S42Wachsberg R S114Wagner J S74Wallace K S10, S18S134Wang E S26, S105Wang H S13Wang M S10, S61Wang S-M S68Ward V S7Wax J S52Way D S63Wear K S2, S9, S41Weichert J S30, S55, S69, S80Weingarten M S41Weisz B S53Welch H S53Wells CE S46Werner E S69White J S21Whitley K S85, S104, S105Williams S S19Wilson C S87Wilson K S98Wilson T S2Wise A S78Witkowska A S60Witt D S115, S118Wolf P S11Wolfe H S67Wolfe M S90Won H-S S80, S113Woodward P S104WoodwardcP S93Wortsman X S95, S96, S101, S102Wu Y S47XXiao J S28Xu Z S74YYablon C S37Yakubu A S93Yantri R S60, S61Yeager S S19Yeboah N S65Yellin S S79, S118Yenter C S78Yeo L S57, S73Yerli H S99, S103Yijin S S28Yilmaz T S99Ying W S28Yingyu C S28Yinon Y S52, S53Yoon C S65Yoon H-C S80Yoon J-W S113Yoon S-W S112Youssefian A S20Yuan C S9Yuan L-J S44Yunhua L S28ZZagzebski J S43, S62Zalev J S13Zeeman G S71Zehtabchi S S83Zhang J S13, S47Zhang M S38, S40, S81Zhang X S47Zhang X-Y S44Zhao L S35Zhao X S9ZhaocJ S47Zhu Q S13Ziade MF S81Zieleznik W S60Zielinski A S116Zinn K S16Zork N S25, S82Zubkov L S41

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