American Institute of Ultrasound in Medicine <strong>Proceedings</strong> 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 <strong>Proceedings</strong> 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
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