Journal of 2013 Ultrasound in Medicine Official Proceedings AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE Annual Convention April 6–10 • New York, New York www.jultrasoundmed.org • www.aium.org frnt_mttr_Layout 1 3/5/13 10:42 AM Page 1 Official Proceedings 2013 Annual Convention April 6–10 • New York, New York frnt_mttr_Layout 1 3/5/13 10:42 AM Page 2 Leadership and Program Committee Executive Committee Board of Governors Liaisons President Rochelle F. Andreotti, MD Jude P. Crino, MD Mark A. Kliewer, MD Elisa Konofagou, PhD Mark Lockhart, MD, MPH Susan A. Lynch, RDMS, RVT, RDCS Joan Mastrobattista, MD Christopher L. Moore, MD, RDMS, RDCS Thomas R. Nelson, PhD James Pennington, RDMS Elizabeth Puscheck, MD, MS Leslie M. Scoutt, MD Rosy Silverman, RDMS Jay Smith, MD Joseph R. Wax, MD Jade Wong-You-Cheong, MD, RVT, FRCR American College of Obstetricians and Gynecologists American College of Radiology Medical Imaging and Technology Alliance Society of Diagnostic Medical Sonography Society for Maternal-Fetal Medicine Society of Radiologists in Ultrasound Society for Vascular Ultrasound Alfred Z. Abuhamad, MD First Vice President Brian D. Coley, MD Second Vice President Lisa M. Allen, BS, RDMS, RDCS, RVT President-Elect Steven R. Goldstein, MD Secretary J. Brian Fowlkes, PhD Treasurer Beryl R. Benacerraf, MD Immediate Past President Harvey L. Nisenbaum, MD Chief Executive Officer Carmine M. Valente, PhD, CAE 2013 Annual Convention Committee Rochelle Andreotti, MD, Chair Joan Mastrobattista, MD, Vice Chair Reem S. Abu-Rustum, MD David Bahner, MD, RDMS Harris L. Cohen, MD Arthur Fleischer, MD Phyllis Glanc, MDCM, BSC Luis Izquierdo, MD Elisa Konofagou, PhD Kenneth Lee, MD Anna Lev-Toaff, MD Janet O’Brien, RDMS, PA-C Manuel Porto, MD Khaled Sakhel, MD Chandra Sehgal, PhD Thomas Shipp, MD James Shwayder, MD, JD Rosy Silverman, RDMS, RVT, RT(S) Therese Weber, MD Beryl Benacerraf, MD Executive Committee liaison Rochelle Andreotti, MD, and Joan Mastrobattista, MD Board of Governors liaisons Jenny Clark Staff liaison Ex Officio Board Members Levon N. Nazarian, MD Journal of Ultrasound in Medicine Editor Marilyn K. Laughead, MD Delegate to the American Medical Association Michael Blaivas, MD Alternate Delegate to the American Medical Association 2013 Annual Convention Program Chairs Case-of-the-Day Cochairs Reem S. Abu-Rustum, MD Kenneth Lee, MD Therese Weber, MD E-Posters Cochairs Harris L. Cohen, MD Anna Lev-Toaff, MD Manny Porto, MD Continuing Medical Education Committee Representative Thomas Shipp, MD Scientific Session Cohairs Joan Mastrobattista, MD Deborah Rubens, MD Chandra Sehgal, PhD Hands-on Special Interest Session Cochairs Janet O’Brien, RDMS, PA-C James Shwayder, MD, JD Rosy Silverman Three- and Four-Dimensional Volume Data Set Manipulation Course Chair Khaled Sakhel, MD New Investigator Session Cochairs Arthur Fleischer, MD Phyllis Glanc, MDCM, BSC Elisa Konofagou, PhD Preconvention Program Cochairs Jacques Abramowicz, MD David Bahner, MD, RDMS Beryl Benacerraf, MD David Fessell, MD Luis Izquierdo, MD Beth Kline-Fath, MD Joan Mastrobattista, MD Bret Nelson, MD Mark Sklansky, MD Ilan Timor, MD frnt_mttr_Layout 1 3/5/13 10:42 AM Page i Table of Contents 2013 AIUM Award Winners William J. Fry Memorial Lecture Award........................................................................................................................................................................................................iii Joseph H. Holmes Basic Science Pioneer Award ........................................................................................................................................................................................iv Joseph H. Holmes Clinical Pioneer Award ....................................................................................................................................................................................................v Distinguished Sonographer Award ..............................................................................................................................................................................................................vi Honorary Fellow Award ................................................................................................................................................................................................................................vii Endowment for Education and Research Donors ....................................................................................................................................................................................viii 2013 Scientific Program SUNDAY, APRIL 7, 2013 Special Interest Sessions, 7:30 AM–11:30 AM Recent Innovations in Gynecologic Ultrasound, Including 3-Dimensional Imaging..........................................................................................................S1 Ultrasound-Guided Procedures for the Pediatric Patient: From the Perspective of Both Point-of-Care and Traditional Approaches ..........................S1 Special Interest Session, 8:00 AM–9:30 AM Hands-on Basic Obstetric Ultrasound and Simulation ..........................................................................................................................................................S1 Special Interest Session, 9:45 AM–11:15 AM Hands-on Advanced Obstetric Ultrasound and Simulation ..................................................................................................................................................S1 Special Interest Sessions, 3:15 PM–5:00 PM Advanced Point-of-Care Cardiac Ultrasound in the Emergency and Critical Care Patient ................................................................................................S2 Clinical Applications of Ultrasound Contrast, Part 1 ..............................................................................................................................................................S2 Hands-on Renal and Mesenteric Imaging ..............................................................................................................................................................................S2 How Does Ultrasound Compare in Safety and Radiation Dose to Other Imaging Modalities? ..........................................................................................S2 Interventional Musculoskeletal Ultrasound: Steroid Injections, Dry Needling, and Platelet-Rich Plasma Injections ................................................................................................................................S3 Point/Counterpoint: Ultrasound Versus Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta, Congenital Diaphragmatic Hernia, and Central Nervous System Anomalies ......................................................................................................................S3 Ultrasound in Global Health ....................................................................................................................................................................................................S3 MONDAY, APRIL 8, 2013 Special Interest Sessions, 8:15 AM–10:15 AM Advances in Clinical and Quantitative Pediatric Lung Ultrasound ......................................................................................................................................S5 Doppler Ultrasound: Basic and Advanced (Beyond the Umbilical Artery) ..........................................................................................................................S5 Gynecologic Imaging Using Multiple Imaging Modalities, Including Ultrasound, Computed Tomography, and Magnetic Resonance Imaging ........S5 Hemodialysis Vascular Access ..................................................................................................................................................................................................S6 New Horizons in Contrast Ultrasound ....................................................................................................................................................................................S6 Pediatric Hepatobiliary Disorders ............................................................................................................................................................................................S7 Taboos and Opportunities in Sonothrombolysis for Stroke: From Sonothrombolysis in Animals to Stroke Treatment in Patients ..............................S7 Special Interest Session, 11:00 AM–12:30 PM How to Be an Effective Manuscript Reviewer for the Journal of Ultrasound in Medicine ..................................................................................................S8 Scientific Sessions, 11:00 AM–12:30 PM Basic Science: Tissue Characterization, Part 1 ........................................................................................................................................................................S9 Breast Ultrasound and Elastography......................................................................................................................................................................................S12 Contrast-Enhanced Ultrasound..............................................................................................................................................................................................S16 Emergency Ultrasound, Part 1 ................................................................................................................................................................................................S18 Musculoskeletal and Interventional/Intraoperative Ultrasound ........................................................................................................................................S21 Obstetric Ultrasound: Uterus, Placenta, and Cervix ............................................................................................................................................................S24 Pediatrics and Fetal Echocardiography..................................................................................................................................................................................S28 Special Interest Sessions, 1:30 PM–3:30 PM Cellular Bioeffects and Applications ......................................................................................................................................................................................S31 Elastography 2013 ....................................................................................................................................................................................................................S31 Exploring the Interface of Ethics and Communication in Prenatal Care: A Video-Based Approach ..............................................................................S32 Hands-on Carotid and Transcranial Doppler Ultrasound....................................................................................................................................................S32 New Techniques and Methods in Ultrasound-Guided Interventions ................................................................................................................................S32 Vaginal Bleeding in the First Trimester ..................................................................................................................................................................................S32 Special Interest Sessions, 4:00 PM–5:30 PM Hands-on Elastography ..........................................................................................................................................................................................................S33 Interventional and Other Ultrasound Techniques: How I Do It ..........................................................................................................................................S33 Quantitative Ultrasound Biomarkers ....................................................................................................................................................................................S33 Ultrasound Incidentalomas ....................................................................................................................................................................................................S33 Scientific Sessions, 4:00 PM–5:30 PM Carotid/Cerebrovascular Ultrasound and Neurosonology ..................................................................................................................................................S34 TUESDAY, APRIL 9, 2013 Special Interest Sessions, 8:15 AM–10:15 AM Contrast-Enhanced Ultrasound in Pediatrics: What Have We Learned and How Can We Apply It? ................................................................................S37 Cutting-edge Musculoskeletal Ultrasound: Peripheral Nerves of the Upper Extremity....................................................................................................S37 Doppler Evaluation of the Abdomen......................................................................................................................................................................................S37 Hands-on How to Do Ultrasound-Guided Interventions ....................................................................................................................................................S38 Pearls From the Anatomic Survey (Skeletal Dysplasia and Central Nervous System, Renal, and Chest Abnormalities) ..............................................S38 i frnt_mttr_Layout 1 3/7/13 10:30 AM Page ii Small-Animal Preclinical High-Frequency Imaging..............................................................................................................................................................S38 Scientific Sessions, 11:00 AM–12:30 PM Applications of Therapeutic Ultrasound................................................................................................................................................................................S38 Basic Science: Instrumentation, Contrast Agents, and Bioeffects ......................................................................................................................................S41 Cardiovascular Ultrasound......................................................................................................................................................................................................S44 Gynecologic Ultrasound ..........................................................................................................................................................................................................S45 New Investigator Award Session ............................................................................................................................................................................................S49 Obstetric Ultrasound: Fetal Anomalies ..................................................................................................................................................................................S53 Special Interest Session, 11:00 AM–12:30 PM Hands-on How to Do the Biopsy ............................................................................................................................................................................................S57 Special Interest Sessions, 1:30 PM–3:30 PM Before and After: Case Presentations, Surgical Findings, and Clinical Outcomes ............................................................................................................S57 Hands-on Scanning: Peripheral Nerves of the Upper Extremity ........................................................................................................................................S57 Live Fetal Cardiac Scanning by the Experts ..........................................................................................................................................................................S57 Microbubbles and Drug/Gene Delivery ................................................................................................................................................................................S57 New Horizons in Critical Care Ultrasound ............................................................................................................................................................................S58 Perinatal Malformations of the Head, Face, and Neck ........................................................................................................................................................S58 Transplant Imaging ..................................................................................................................................................................................................................S59 Special Interest Sessions, 4:00 PM–5:30 PM Abdominal and Lower Extremity Arterial Imaging: Pitfalls and Misdiagnoses ..................................................................................................................S59 Hands-on Ultrasound-Guided Vascular Access ....................................................................................................................................................................S59 Scientific Sessions, 4:00 PM–5:30 PM Basic Science: Tissue Characterization, Part 2 ......................................................................................................................................................................S60 General and Abdominal Ultrasound ......................................................................................................................................................................................S65 Obstetric Ultrasound: General and Fetal Growth ................................................................................................................................................................S69 WEDNESDAY, APRIL 10, 2013 Special Interest Sessions, 8:15 AM–10:15 AM Breast Ultrasound ....................................................................................................................................................................................................................S73 Extracranial Ultrasound of the Head and Neck in Children ................................................................................................................................................S73 Gynecologic Ultrasound: The Basics Revisited......................................................................................................................................................................S73 Innovative Directions in Fetal Cardiac Imaging ....................................................................................................................................................................S73 Lumps, Bumps, and Extremity Pain in the Emergency Room: What Is the Role of Ultrasound? ....................................................................................S74 Peripheral Arterial Disease ......................................................................................................................................................................................................S74 Ultrasound-Guided Thrombolysis..........................................................................................................................................................................................S74 Special Interest Sessions, 10:45 AM–12:30 PM Acoustic Radiation Force Impulse Imaging: Benefits and Challenges With Increasing Acoustic Output Beyond Diagnostic Levels ..........................S75 Advanced Fetal Cardiac Evaluation and Comprehensive Overview....................................................................................................................................S76 Current Vascular Controversies ..............................................................................................................................................................................................S76 Musculoskeletal Ultrasound: Transition From Adults to Pediatrics ....................................................................................................................................S76 Ultrasound of the Head and Neck ..........................................................................................................................................................................................S76 Scientific Sessions, 10:45 AM–12:30 PM Emergency Ultrasound, Part 2 ................................................................................................................................................................................................S77 Obstetric Ultrasound: Multiple Gestations and New Techniques ......................................................................................................................................S79 Scientific E-Poster Sessions ........................................................................................................................................................................................................................S83 Continuing Medical Education Credit Information ..............................................................................................................................................................................S122 Faculty Disclosures ....................................................................................................................................................................................................................................S123 Disclosures From AIUM Officers, Board Members, Committee Members, and AIUM Staff ..........................................................................................................S129 Policy on Unlabeled/Off-Label Usage ....................................................................................................................................................................................................S130 Disclosure of Commerical Support for the 2013 AIUM Annual Convention ....................................................................................................................................S130 Index ............................................................................................................................................................................................................................................................S131 Manuscripts, Membership, and Business Matters Correspondence should be addressed to the American Institute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite 100, Laurel, MD 20707-5906 USA; phone: 301-498-4100. Information on membership can be found at www.aium.org. General Information Subscription Rates Journal of Ultrasound in Medicine (ISSN 0278–4297) is issued monthly in one indexed volume per year by the American Institute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite 100, Laurel, MD 20707-5906 USA. Subscription prices per year: institution $450 (online only) or $485 (print + online); individual $340 (print + online). Canada and Mexico please add $45.00. Outside the United States, Canada, and Mexico please add $60.00. Claims for missing issues, made within 6 months of the issue date, can be honored through contact with the AIUM Executive Office. The AIUM shall be responsible for the cost of resending the claimed issue(s) 1 time via USPS Priority Mail. Should the issue(s) be claimed a second time, the shipping and handling costs shall be the responsibility of the subscriber/member ($7.00 US/Canada/Mexico; $25.00 international). After 6 months, issues will be available at the back issue price. Duplicate copies will not be sent to replace ones undelivered through failure to notify the American Institute of Ultrasound in Medicine of a change of address. Single copy and back volume information available from the American Institute of Ultrasound in Medicine, upon request. Periodicals postage paid at Laurel, MD, and additional mailing offices. The Journal of Ultrasound in Medicine is indexed/abstracted in Index Medicus, Current Contents/Clinical Medicine, EMBASE/Excerpta Medica, Science Citation Index, Science Citation Index Expanded, ISI Alerting Service, Engineering Information, MEDLINE, Medical Documentation Service, and RSNA Index to Imaging Literature. Advertising Inquiries should be addressed to Advertising Sales, American Institute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite 100, Laurel, MD 20707-5906 USA; phone: 301-498-4100. Postmaster: Send address changes to Journal of Ultrasound in Medicine, American Institute of Ultrasound in Medicine, 14750 Sweitzer Ln, Suite 100, Laurel, MD 20707-5906 USA. The appearance of advertising in publications of the American Institute of Ultrasound in Medicine (and/or exhibits at meetings of the Institute) does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made for it by its manufacturer. The fact that a product, service, or company is advertised in a publication of the American Institute of Ultrasound in Medicine shall not be referred to by the manufacturer in collateral advertising. Printed in the USA. This journal is printed on acid-free paper. В© 2013 by the American Institute of Ultrasound in Medicine This journal has been registered with the Copyright Clearance Center, Inc. Consent is given for the copying of articles for personal or internal use, or for the personal or internal use of specific clients. This consent is given on the condition that the copier pay through the Center the per-copy fee listed online at www.copyright.com for copying beyond that permitted by the US Copyright Law. This consent does not extend to other kinds of copying, such as for general distribution, resale, advertising and promotional purposes, or for creating new collective works. ii frnt_mttr_Layout 1 3/5/13 10:42 AM Page iii 2013 AIUM Award Winners William J. Fry Memorial Lecture Award The William J. Fry Memorial Lecture Award was established by Joseph H. Holmes, MD, in 1969 and presented for the first time at the AIUM Annual Convention in Winnipeg that year. (William J. Fry was a physicist with a strong interest in ultrasound in medicine, whose innovative research efforts advanced the field of medical ultrasound.) One of Professor Fry’s most notable contributions was the successful design of an ultrasonic system used to pinpoint lesions in the brain without damaging adjacent tissues. This ultrasonic system was later used to treat various brain pathologies and, in particular, Parkinson disease. His impassioned interest in ultrasound led him to become president of the AIUM from 1966 until his death in 1968. The following year, the William J. Fry Memorial Lecture Award was established in his honor. It recognizes a current or retired AIUM member who has significantly contributed in his or her particular field to the scientific progress of medical ultrasound. Paul L. Carson, PhD This year, the AIUM has bestowed the honor of the William J. Fry Memorial Lecture Award on Paul L. Carson, PhD, but it is actually the AIUM that is honored to have a person of this caliber who is willing to share his considerable talents and extensive expertise with this organization. In a few paragraphs, it’s impossible to summarize a 108-page curriculum vitae, a full 2 pages of which is a list of the honors and awards Dr Carson has received during his exceptional career. Destined to be a leader from a young age (he was president of both his high school and college student bodies), Dr Carson graduated from Colorado College, followed by a fellowship at Harvard, and earned his MS and PhD in physics at the University of Arizona. His major scientific interest has been in medical physics with an emphasis in ultrasound, paying particular attention to the safety of diagnostic ultrasound equipment, as well as training and teaching. A professor of biomedical engineering at the University of Michigan, he also serves as associate director of basic radiological sciences at this same institution and is concurrent professor at Nanjing University in China and scientific coordinator at the Quantitative Imaging Biomarkers Alliance of the Radiological Society of North America. As if those academic appointments don’t keep him busy enough, he is currently the coinvestigator or principal investigator (PI) for 4 major grants from the National Institutes of Health, the National Science Foundation, and the Department of Defense Breast Cancer Research Program and has served as PI for dozens of funded research projects over the past 4 decades. Dr Carson’s love of both teaching and research is evidenced by the numerous dissertations and masters’ theses and projects he has supervised, plus the many postdoctoral fellows he has mentored and the visiting professors he has hosted. Due to his nurturing, many of these exceptional individuals have become active in the AIUM and the field of medical ultrasound. A prolific writer, with literally hundreds of journal articles, books and chapters, monographs, abstracts, and related communications to his credit, as well as the holder of 10 patents, Dr Carson does not limit the sharing of his expertise to academia or publishing. He has long recognized the value and importance of professional societies in promoting science and is an active member of a wide variety of associations, serving on committees and often in leadership positions. His commitment to the AIUM is legendary. He has served on the AIUM’s Board of Governors and the Editorial Board of the Journal of Ultrasound in Medicine and has been an active contributing member for dozens of AIUM committees and subcommittees, all with the aim of ensuring quality and safety in diagnostic ultrasound. With his intelligence and creativity, his exceptional leadership skills and drive, and his passion and willingness to share his time and knowledge with others, Dr Carson has carried on the tradition of Professor Fry and has set the perfect example for those who will follow in his footsteps. The title of Dr Carson’s William J. Fry Memorial Lecture is Ultrasonic Domination: Medical Imaging, Medicine, Daily Life. iii frnt_mttr_Layout 1 3/5/13 10:42 AM Page iv 2013 AIUM Award Winners Joseph H. Holmes Basic Science Pioneer Award The Pioneer Award, which honors an individual who has significantly contributed to the growth and development of medical ultrasound, was established in 1977. This special award was renamed in 1982 to honor Joseph H. Holmes, MD, who died that year. Dr Holmes, the first person named as an AIUM pioneer, was an important figure to both the field of diagnostic ultrasound and the AIUM. His early efforts in ultrasound research, which included tissue characterization and ultrasound’s diagnostic use in polycystic kidney disease and orthopedics, helped advance the field of ultrasound and encourage others to conduct new research. Serving the AIUM in many capacities, Dr Holmes was president from 1968 to 1970 and was editor of the AIUM’s official journal, which was then titled the Journal of Clinical Ultrasound, for nearly 10 years. Each year, the Joseph H. Holmes Pioneer Award honors 2 current or retired AIUM members, 1 in clinical science and 1 in basic science. Christy K. Holland, PhD You wouldn’t necessarily expect that a woman who spent her junior year abroad at the UniversitГ¤t Freiburg and Hochschule fГјr Musik Freiburg studying Beethoven and Schubert would be the recipient of the prestigious Joseph H. Holmes Basic Science Pioneer Award, but then you would be underestimating the talents and breadth of expertise of Christy K. Holland, PhD. Dr Holland earned her bachelor’s degree in physics and music from Wellesley College and her PhD in engineering and applied science from Yale University. She worked at Yale until 1994 when she joined the Department of Radiology at the University of Cincinnati College of Medicine. While at the University of Cincinnati, she has served in the Department of Aerospace Engineering and Engineering Mechanics and in the Department of Biomedical Engineering and Radiology in the College of Engineering and Medicine. She is currently a professor in internal medicine in the Division of Cardiovascular Diseases, Biomedical Engineering Program. Dr Holland has a long history of reviewing manuscripts for 9 peer-reviewed journals beginning immediately on graduation, as well as extensive experience reviewing for multiple national, state, and private funding agencies, including the National Institutes of Health (NIH) and the National Science Foundation. This is just one of the factors that led to her appointment as the editor-in-chief of Ultrasound in Medicine and Biology (UMB), the preeminent journal of the World Federation for Ultrasound in Medicine and Biology. A fellow of both the Acoustical Society of America (ASA) and the AIUM, Dr Holland has long been active in committees and in leadership positions for both organizations. She was elected to the Executive Council of the ASA and to the AIUM’s Board of Governors and to its Executive Committee, where she served as secretary. Her particular interest has focused on bioacoustics and bioeffects; a dedicated member of the ASA’s Biomedical Acoustics Committee, she cochaired the AIUM’s Mechanical Bioeffects Conference and was a guest editor for the resulting publication, Mechanical Bioeffects from Diagnostic Ultrasound: AIUM Consensus Statements. Currently engaged in 8 separate research projects with topics ranging from “Ultrasound-Assisted Thrombolysis for Stroke Therapy” to “Targeted Liposomes for Acoustic Cardiovascular Imaging,” Dr Holland has served as principal investigator or coinvestigator on dozens of research grants from the NIH and other organizations. With more than 85 publications to her credit, Dr Holland is best known for her exceptional teaching abilities and the large number of students, postdoctoral fellows, and clinical fellows whom she has advised. She may be musically gifted, but it is her ongoing scientific contributions to the growth and development of medical ultrasound for which she will be remembered. iv frnt_mttr_Layout 1 3/5/13 10:42 AM Page v 2013 AIUM Award Winners Joseph H. Holmes Clinical Pioneer Award The Pioneer Award, which honors an individual who has significantly contributed to the growth and development of medical ultrasound, was established in 1977. This special award was renamed in 1982 to honor Joseph H. Holmes, MD, who died that year. Dr Holmes, the first person named as an AIUM pioneer, was an important figure to both the field of diagnostic ultrasound and the AIUM. His early efforts in ultrasound research, which included tissue characterization and ultrasound’s diagnostic use in polycystic kidney disease and orthopedics, helped advance the field of ultrasound and encourage others to conduct new research. Serving the AIUM in many capacities, Dr Holmes was president from 1968 to 1970 and was editor of the AIUM’s official journal, which was then titled the Journal of Clinical Ultrasound, for nearly 10 years. Each year, the Joseph H. Holmes Pioneer Award honors 2 current or retired AIUM members, 1 in clinical science and 1 in basic science. Peter H. Arger, MD regarding the initiatives occurring under his leadership and doesn’t begin to address his contributions to the AIUM both before and after his tenure as president, through his hard work on almost every AIUM committee in existence. He undertook all these activities while serving as professor of radiology at the Hospital of the University of Pennsylvania, where he is now emeritus professor of radiology and concentrating on ultrasound research and ultrasound training for residents. A graduate of Washington University in St Louis and the University of Illinois Medical School, Dr Arger was a captain in the US Air Force before beginning his long history of awards for his research and his service to imaging associations, starting with a certificate of merit for “An Approach to Orbital Lesions” from the American Roentgen Ray Society more than 30 years ago to his most recent honor in 2011—the Gold Medallion Award—from the Pennsylvania Radiological Society. His many awards are a testament to his ongoing commitment to imaging. He has served as principal investigator on multiple major grants that addressed an enormously broad range of issues, such as mercury burden in dentists, staging of ovarian cancer, methods of giving contrast agents, evaluation of renal failure, and Doppler vascularity in breast cancer diagnosis. A well-published author with hundreds of original papers to his credit, as well as abstracts, books, reviews, and chapters, Dr Arger’s passion for education is further manifested by the countless presentations he has given and the outstanding courses he has directed. It’s not surprising that these incredible achievements were completed by an exceptional clinician, what is remarkable is that they were completed by such a kind, softspoken, self-effacing human being who has earned the highest respect and admiration from his colleagues, his students, his superiors, his subordinates, and association staff. He is truly the inveterate clinical pioneer. If we were to include only the contributions he made while president of the American Institute of Ultrasound in Medicine (AIUM), Peter H. Arger, MD, would still be the perfectly chosen recipient for this award. During his tenure as president of the AIUM (1995–1997), Dr Arger oversaw changes and improvements to this organization and to the field of medical ultrasound that resonate to this day. Recognizing the enormous potential for ultrasound in medicine but also aware that funding for research was limited, he spearheaded the establishment of what is now the AIUM’s Endowment for Education and Research, which has already allocated close to three-quarters of a million dollars to ultrasound research and educational endeavors. Dr Arger was also instrumental in the creation of the AIUM’s ultrasound practice accreditation program. The 2000+ practices that have subsequently received accreditation have demonstrated their commitment to the highest quality patient care—a tribute to Dr Arger’s foresight and vision. While he was president, the AIUM held an innovative leadership retreat to initiate a 5-year plan; built coalitions and established liaisons with 27 ultrasound-related associations to ensure the ability to take a proactive stance on legislation and to promote the best practices in diagnostic ultrasound, established the Distinguished Sonographer Award as well as the New Investigator Award, conducted a conference in which simultaneous Spanish translation was available, obtained a seat on the American Medical Association House of Delegates, and analyzed the entire operation of the Journal of Ultrasound in Medicine. That is just the tip of the iceberg v frnt_mttr_Layout 1 3/5/13 10:42 AM Page vi 2013 AIUM Award Winners Distinguished Sonographer Award Established in 1997, the Distinguished Sonographer Award is a means of recognizing and honoring current or retired AIUM members who have significantly contributed to the growth and development of medical ultrasound. This annual presentation honors an individual whose outstanding contributions to the development of medical ultrasound warrant special merit. Marsha Neumyer, BS, RVT The title “distinguished sonographer” does not do justice to the 2013 awardee, Marsha Neumyer, BS, RVT. Currently chief executive officer and international director of Vascular Diagnostic Educational Services, Ms Neumyer previously was an assistant professor of surgery at the Pennsylvania State University College of Medicine and director of the vascular laboratory section of the Pennsylvania State Vascular Institute. Ms Neumyer earned her bachelor’s degree in zoology from the Pennsylvania State University and spent the next 2 decades involved in research, starting with the Bovine Lymphosarcoma and Leukemia Research Team and Newcastle Virus Disease Research. She then founded and served as the director of the Diagnostic Laboratory and Tissue Culture Cell Bank, followed by a stint as the director of the Camp Hill Veterinary Laboratory and as a senior research technician at the Milton S. Hershey Medical Center. In 1985, her commitment to vascular imaging would firmly take hold with her certification as a registered vascular technologist. It comes as no surprise that this is a field in which she would excel and for which she has received multiple awards, including the Award for Excellence in Scientific Research (twice) from what is now the Society for Vascular Ultrasound (SVU), the Distinguished Service Award from the Society of Vascular Technology (SVT), the Burnham Editor’s Award for outstanding contributions to the field of vascular technology, the J. Baker Pioneer Award in Medical Sonography from the Society of Diagnostic Medical Sonography (SDMS), and the SVU Professional Achievement Award. A fellow of the AIUM, the SDMS, and the SVT, Ms Neumyer has served admirably in leadership roles for these 3 organizations, as a member of the Board of Governors, the Board of Directors, and president, respectively. In addition, she has demonstrated her belief in the importance of vascular imaging excellence by her active involvement in numerous committees addressing issues of education, training, bioeffects, risk management, and practice guidelines. A founding member of what is now the Intersocietal Accreditation Commission, Ms Neumyer has been the editor of the Journal of Color Flow Imaging and guest editor of the Journal for Vascular Technology multiple times. She serves on the editorial boards of the Journal of Vascular Ultrasound and the Journal of Diagnostic Medical Sonography and is a reviewer for the Journal of Ultrasound in Medicine, the Journal of Clinical Ultrasound, and the Journal of Diagnostic Medical Sonography. Her editorial responsibilities are a direct reflection of her prolific output as an author through publications, book chapters, books, abstracts, posters, and videos, CDs, and DVDs. But it is in lectures and presentations where her outstanding talents shine through. With her close to 900 presentations, Ms Neumyer has made Herculean efforts to educate users and promote exceptional and safe vascular imaging. She is truly a clinician who should be emulated. vi frnt_mttr_Layout 1 3/5/13 10:42 AM Page vii 2013 AIUM Award Winners Honorary Fellow Award The Honorary Fellow Award bestows an honorary membership to those individuals who have contributed significantly to the field of ultrasound. Paul A. Dubbins, MBBS, BSc, FRCR A graduate of Kings College Hospital Medical School, Paul A. Dubbins, MBBS, BSc, FRCR, is currently consultant radiologist at Derriford Hospital in Plymouth, England, where he led the ultrasound department for 30 years, and civilian consultant adviser in radiology to the Royal Navy. A member of numerous distinguished societies, he has been particularly active in the Royal College of Radiologists, where he has served on many committees and, most recently, as vice president. A reviewer for multiple peer-reviewed journals, Dr Dubbins has served on the editorial board of Clinical Radiology, the European Journal of Ultrasound, and the Journal of Ultrasound in Medicine and was the European editor of Ultrasound International. Dr Dubbins is a well-published author, with more than 60 articles and 30 book chapters. In addition, he is the editor, coeditor, or author of multiple books, some of which are now in second editions, including Urogenital Ultrasound: A Text Atlas and Clinical Doppler Ultrasound. A clinician with exceptional teaching skills, including 2 years as assistant professor in the Division of Diagnostic Ultrasound at Thomas Jefferson University Hospital and decades of experience as a course organizer, Dr Dubbins has lectured worldwide on ultrasound and has developed and led hands-on training courses in Nepal and India. Having made contributions to the field of medical ultrasound on multiple continents, it is not surprising that he would embrace and become a leader in e-learning. The Radiology Integrated Training Initiative, a concept proposed by Dr Dubbins, was initiated in 2005, long before most professionals in any field had begun to consider the advantages of online learning. This innovative new training program was based predominantly on an e-learning delivery strategy, supplemented by skills lab work and traditional apprenticeship-style learning; Dr Dubbins was the author and editor of the gynecologic imaging module until 2010. Dr Dubbins further developed the education program within health care by devising an introduction to imaging for the Foundation Year program (internship), for which he serves as lead editor. Not content to limit his e-learning ideas to the United Kingdom, Dr Dubbins has led work commissioned by the World Federation for Ultrasound in Medicine and Biology to develop an e-learning program for basic ultrasound. The first module, to be trialed in Uganda this year, consists of 10 interactive learning sessions covering technique, anatomy, and basic abnormalities. This is a program with worldwide potential to provide state-of-the-art affordable medical education to countries where it is most needed and where it might otherwise never be available. It is for his foresight, imagination, expertise, and pioneering efforts in the field of ultrasound education that the AIUM is proud to name Paul Dubbins as an honorary fellow. vii frnt_mttr_Layout 1 3/5/13 10:42 AM Page viii Endowment for Education and Research Donors The AIUM’s Endowment for Education and Research (EER) was created to provide much-needed funding for ultrasound research and educational initiatives. What makes this possible is the generous support of AIUM members, vendors, and individuals who provide gifts in honor or in memory of ultrasound professionals. It is with great appreciation that the AIUM thanks the individuals listed below who contributed to the EER in 2012. These individuals have a ribbon on their name badge acknowledging their generosity; please thank them for their support. Contributions of $1000 and Above Jacques Abramowicz, MD Alfred Abuhamad, MD Peter Arger, MD Carol Barnewolt, MD Beryl Benacerraf, MD Bryann Bromley, MD Frank Chervenak, MD Brian Coley, MD Joshua Copel, MD Jude Crino, MD Arthur C. Fleischer, MD Leonard Glassman, MD Steven R. Goldstein, MD Lennard Greenbaum, MD Luis Izquierdo, MD Samuel Maslak, DSc Levon Nazarian, MD Harvey L. Nisenbaum, MD William O’Brien Jr, PhD Kathryn Reed, MD Rudy Sabbagha, MD Thomas Shipp, MD, RDMS James Shwayder, MD, JD Carmine Valente, PhD, CAE Joseph Wax, MD Gary Whitman, MD Contributions of $250 and Above Lisa Allen, BS, RDMS, RDCS, RVT Rochelle Andreotti, MD David Bahner, MD, RDMS Carol Benson, MD John Benson, MD Michael Blaivas, MD William Brown III, MD Charles Church, PhD Harris L. Cohen, MD Deborah D’Agostini, RDMS Peter Doubilet, MD, PhD Diane Eberle J. Brian Fowlkes, PhD Barry Goldberg, MD H. Harcke Jr, MD Charlotte Henningsen, MS, RT, RDMS, RVT Frederick Kremkau, PhD Alfred Kurtz, MD Ernest Madsen, PhD Thomas Moore, MD Dolores Pretorius, MD Victor Reddick, RDMS, RDCS, RT Leslie Scoutt, MD Sachita Shah, MD Ronald Townsend, MD Isabelle Wilkins, MD James Zagzebski, PhD Contributions Up to $249 Samer Abdullah, MD Monzer Abu-Yousef, MB, BCh, ABR Susan Ackerman, MD Debra Acord, MD Juan Acosta, DO, MS Charles Adair, MD El-Zein Adam Jr, MBBS, MSC, PhD Annette Adams, BSN, RN, RDMS GermГЎn Adarme, MD Joseph Adashek, MD Arun Adhate, MPA, RDMS, BS Richard Aguilera, MD Khaled Ahmed, MD Zaheer Ahmed, BS, RDCS, RVS Robert Ahrens Jr, MD Anthony Akamaguna, MB, BS, DMRD Brigitte Ala, MD Sheikh Alam, PhD Vito Alamia, MD Joseph Albano, MD Juan Luis AlcГЎzar, MD John Alcini Jr, MD Archie Alexander, MD, JD, LLM Rustom Al-Khatib, MD Huda Al-Kouatly, MD John Allen, PhD Paul Allen, MD Mona Alqulali, MD, PhD Karen Alton, BS, RT, RDMS, RVT Muna Alzahrani Anthony Ambrose, MD David Amponsah, MD, RDCS Libby Anderson, MD Panagiotis Andrikopoulos, MD Anthony Annan Jackie Appleby, MS Jose Aquino, MD Hisham Arab, MD Irma Aragon, MD Edward Araujo JГєnior, PhD, MD viii Beckie Ard, RDMS, RVT Patricia Ardise, MD Ellen Arendt, MD Ignacio Armas, MD Albert Armstrong Jr, DPM Erin Arnold, MD William Arnold, MD Elsa Arribas, MD Belinda Artimovich Hilda Arzola Plascencia Yasuyuki Asakawa, MD, PhD Adam Ash, DO Graham Ashmead, MD Mohamed Ashour Fareeda Asif, MBBS Tamerou Asrat, MD Fiona Atkins Stephen Avery, MD Tin Tin Aye, MBBS Jean Ayoub, MD, PhD Daniel Azabache, MD Nami Azar, MD Kazunori Baba, MD, PhD Anthony Bacevice Jr, MD, MSE Norman Back, MD Jennifer Bagley, MPH, RDMS, RVT Emily Baker, MD Jeffrey Baker, MD Mary Baker Berzansky, MD Juanito Baladad, MD Adrian Balica, MD Bita Baligh, MD Natalie Ballweber, PA-C J. Oscar Barahona, BS, RDMS Antonio Barbera, MD Diego Barca Arlene Bardeguez, MD Donald Barford, MD Tudor Barglazan, RVT Darryl Barnes, MD Jolyn Barras, RT, RDMS, RVT frnt_mttr_Layout 1 3/5/13 10:42 AM Page ix Edgar Barros, RDMS Juan Barros, RVT, RDMS, RDCS Patricia Barry, MD Joan Bartello James Bartelsmeyer, MD Peter Barthe, PhD Edwin Bartlett, MD Bonnie Bartley, RDMS, RDCS Norman Barwin, MD, FRCOG, FSOGC Ahmet Baschat, MD Richard Basile, MD Naz Basit, MBBS, RDMS Jean-Philippe Bault, MD Tara Baum, MD John Baxter, MD Martine Beaudoin, RN, BSN Brian Beck, MSEE, MD Brent Becker, MD Theodore Bedard, MD Enrique Bedia, MD Rob Beekmans Kimberly Behling, RDMS, RVT, RRT Clifford Beinart, MD Gwendolynn Belle, RDMS William Benedetto, MD Richard Benoit, MD, MPH Eric Bentolila, MD Paul Bergh, MD Michele Bergmann, MD Nancy Berich, RDMS Daniel Berkowitz, MD Leslie Berlinsky, AAS, RDMS, RVT, RT Richard Bernardi, PhD James Bernasko, MD Lisa Bernhard, MD Vidor Bernstien, MD Richard Besinger, MD Pamela Besse, RT, RDMS Sherri Bethea, RDMS Maureen Beurskens, MD Gordon Beute, MD Connie Bevell, RDMS Daksha Bhansali, MD Barbara Biber, MD Benjamin Bieber, MD Teresa Bieker, MBA, RT, RDMS, RVT, RDCS Kenneth Bielak, MD Angela Biggs, MD Christine Bird, BS, RDMS, RVT Andrea Bishop, RDMS Mauricio Bitran, MD Debra Blackford, RDMS, RVT, RDCS J. Timothy Blackwelder, MD Marlene Blair, RT(R), RDMS Richard Blair, MD Christine Blake, MD, MPH Kristi Blanck, RDMS Ernesto Blanco, MD Alejandro Blando, MD Joseph Blankier, MD, FRCS(C) Alexander Blankstein, MD Jean Cadet, MD Alan Cadkin, MD Kenzie Caine, BA, RDMS Gail Calamari, MD Charles Camacho, MD Helio Sebastiao Camargo Jr, MD Angelo Campagna, MD, FRCS(C) Timothy Canavan, MD, MSc Mario Candal, MD Patricia Cantu, BS, RT(R), RDMS, RVT, RDCS Vito Cardone, MD Reynaldo Cardoso, MD, FRCSC Eric Carlson, DO, MPH Anselmo Carmo Francis Carmody, MBBS, FRCOG, FRANZCOG, DDU Stephen Carolan, MD Marshall Carpenter, MD Robert Carpenter Jr, MD, JD Stephen Carr, MD Elaine Carroll, MD Paul Carson, PhD Anthony Carter, MD Sarah Carter, MSEd, RDMS Mark Cartier, BS, RDMS, RT Carolyn Caruso, BS, RDMS Elba Cases, BS, RDMS, RDCS Alejandro Casillas, MD Meredith Cassidy, MD Mario Castillo, MD Augusto Castrillon Sr, MD Simon Castro, MD Diane Cervantez, RDMS, BS David Chaffin, MD Mark Chag, MD Laurence Chaise, MD Albert Chan, MD Ka Fai Chan, BS Lisa Charney, BS, RDMS Ming-Tak Chau, FRCR Rubila Chaudhry Meera Chaudhuri, MD, FRCOG Emiliano Chavira, MD, MPH Chou-Er Chen, BS Hee-Joo Cheon, MD Stephen Cherewaty, MD Melanie Cherry, MD Miranda Cheung Balwant Chhatwal, MD Suzin Cho Helgaas, MD Min Choi, PhD Tae-Sik Choi, MD Shaila Cholli, BS, RDMS Hajoon Chun, MD Marc Clachko, MD Craig Clark, MD, JD Linda Clark, RDMS, RT(R) William Clark, MD Daniel Clement, MD Marianne Clements, RDMS Phillip Clements, MD Suzanne Clemons, MD Rosemary Coffey Leeber Cohen, MD Veronica Cohen, RDMS Josef Blankstein, MD Anna Blask, MD Joseph Blazina III, BS, RDMS Andrew Blecher, MD David Blews, MD Adam Blickley, MD Donna Blodgett, RDMS Amy Blumenthal, MD Ronnie Bochner, MD Jean Bolan, MD J. Scott Bomann, DO Peter Bonadonna, EMT-P Gary Boss, RDMS, RDCS Radine Boss, RDMS Elton Bowen, MD Deanna Boyette, MD William Bracer, MD, RVT, RPVI Abigail Brackney, MD Terence Braden, DO E. Bradley, MD Kim Brady, MD Brittany Brasher, RDMS Amy Breakstone, MD Ashley Breaux Fred Brennan, DO Kim Brennan, MD Lesley Brennan, RDMS Steven Brenner, MD William Brewer, MD Marla Bridgford, BS, RDCS, RDMS Justin Briones, MD Steven Broadstone, PhD Marsha Brody, RDMS Fredrik Broekhuizen, MD Debra Brooks, BS, RTRM, RDMS, RVT Pamela Brower, RVT, RVS Christina Brown, MD Deborah Brown, BA, RDMS, RDCS Dina Brown, RDMS Douglas Brown, MD Elisa Brown, MD Carol Brown-Elliott, MD Hermann Bruhwiler, MD Stephen Bruny, MD Neal Buchalter Carmen Bucher Richard Budenz, MD, PhD Susan Bunch, MD Sherry Bunting, RDMS Holly Burge, MD M. Shannon Burke, MD Deland Burks, MD Kathleen Burnett, RDMS, RVT Leigh Burrell, RT, RDMS Michelle Bursese, RDMS Frances Buryk, RDMS Jacqueline Bush, MD Lawrence Busse, PhD Raydeen Busse, MD Jeffrey Butler, DO, RDMS Helia Buyck Paul Byrne, MD Michael Cabbad, MD James Cabell, MD, PhD ix Fred Coleman, MD Mark Collins, MD Robert Collins, MD Terry Collins, MD Pablo Colon, AAS, RDMS Lisa Comer, RTR, RDMS, RDCS Mary Comito, RT, RDMS Caroline Comparone, RDMS Frederick Conard III, MD Lori Conley, RDMS Mary Connell, MD Richard Cook, MD Brian Coolbaugh, MD Elizabeth Cooper, RDMS Penny Cooper Kristin Coppage, MD Andrea Corda, MD Raul Cordova, RDMS Laura Corio, MD Carla Corry, RDMS Erich Cosmi, MD, PhD Seid Cosovic, MD Carlos Costa Magda Costa, MD Tracey Cota Osterman Cotes, MD Carole Coughlin, RDMS Laura Coultrip, MD Jacqueline Cox, RDMS, RT Joseph Craig, MD, ChB William Craig IV, MD Blane Crandall, MD Tonie Crandall, MD Frank Craparo, MD Luther Creed, MD Vernon Croft, MD Kathleen Cross, RDMS, RT(R)(M)(CT) Dante Cubangbang, MD Gail Culbert Gabriel Culiat, RDMS Marianne Cullen, BS Mary Cunnane, MD Mark Curran, MD William Curtin, MD Maria Czerwinski, MD Diane Dalecki, PhD Stephen Dalton, MD Mary D’Alton, MD Suzanne Dambek, MD Paxton Daniel, MD Eugene Danko, MD Jerome Dansereau Byron Darby, MD Joseph Darby Jr, BS, RDMS Raymon Darling, MD Barry Davidson, MD, FRCP Jesse Dawkins Sr, MD Sue Ann Dayton, RDMS, RRT Maria De Elejalde, MS, RN M. Robert De Jong, RDCS, RDMS, RVT Marie De Lange, BS, RDMS, RDCS Jose De Sousa Pereira, MD, RDCS, RDMS frnt_mttr_Layout 1 3/5/13 10:42 AM Page x Rosa De Vermette, MD, RDCS, RDMS, ROUB Anthony Dean, MD Hollis Dean, RDCS Philippe Deblieck Mamta Deenadayal, MD Tony Deeths, MD Gary DeGuzman, MD Patricia Del Bondio, RDCS, RDMS, RVT Gerardo Del Valle, MD Brian Delahoussaye, MD Kimberly Delaney, RT, RDMS, FE Michael DeMass Michael Demishev, MD Fareed Denath, MB, FRCP(C) Linda DeOrio, RDMS Dail DeSouza, BA, BS, RDMS Stamatia Destounis, MD Karen DeTommaso Richard DeVeaux, MD Lawrence Devoe, MD Greggory DeVore, MD Daniel Dexeus, DO Gunwant Dhaliwal, MD Diane Di Girolamo, MD Michael Di Pietro, MD Lin Diacon, MD, RDMS Thiendella Diagne, MD David Dichiara, MD Jeffrey Dicke, MD Eitan Dickman, MD, RDMS William Dittman, MD Susan Dodd, MD Steven Domnitz, MD John Donlon Alan Donnenfeld, MD Leslie Donovan, MD Bernice Doring, RT, RDMS Jean Dormer, RT, RDMS N. Carol Dornbluth, MA, MD Mark Downey, RT, RDMS, RVT Margaret Drake, AA, RT(R), RDMS Kathryn Drennan, MD Dawn Driver, RDCS, RDMS, RVT Robert Dropkin, MD Julia Drose, BA, RT, RDMS, RVT, RDCS Terry DuBose, MS, RDMS Jerome Dubowy, MD Eva Duckett, MD Kelly Duncan, RDMS Lisa Dunn-Albanese, MD James Dunphy, MD Teresa Durbin, MD Olga Dynkin Gerald Dysert, MD Colette Eastman, DO Katherine Eastwood, MD Ian Ebesugawa, MD Steven Edell, DO Robert Eden, MD Rick Edmiston Peter Edmonds, PhD Christine Edwards, MD Robert Edwards III, MD Jonathan Foster, MD Lisa Foster, RDMS Arthur Fougner, MD Debra Fouts, RDMS, RDCS Grant Fowler, MD Lisa Fox, RDMS, RVT Parham Fox, BA, MD Pamela Foy, MS, RDMS Gerard Foye Jr, MD Terrell Frain, RDMS Gaetane Francis, MD Jennifer Franz, RT, RDMS Mahlon Freeman, MD, MedScD Atis Freimanis, MD Maija Freimanis, MD Dawn Frey, AA, RTR, RDMS Franklin Friedman, MD William Fry, MD Elizabeth Fuentes Teiichiro Fukushima, MD Pat Fulgham, MD Deena Fulton, RRT Maureen Galang, RDMS, RDCS, RVT Paul Gammell, BSEE, PhD Bryan Ganter, MD Jing Gao Rosa Garcia David Garfinkel, MD Brian Garra, MD David Garry, DO Frank Gaudier Jr, MD Michael Gebel, MD, PhD Gino Gennari, RDMS Herbert Gerstein, MD Tammy Gerstenfeld, DO Doreen Getty, RDMS Nabil Ghali, MD Goutam Ghoshal, PhD William Gilbert, MD Harlan Giles, MFM, MD, RDMS Cynthia Gill, PT, DScPT, MEd Jerry Gilles, MD Michael Ginn, RVT Anthony Giovine, MD Thomas Giudice, MD, MS Vincenzo Giuliano, MD, RPVI, RVT, RDMS, ARMRIT Phyllis Glanc, MDCM, BSC Angela Glaser, RDMS Mikhail Gleyzer, DO, MD John Goble Stephen Gocke, MD Ricardo Goes Chris Goeser, DC, MD Bradley Goldberg, MD James Goldberg, MD Nancy Goldenberg, MD Alan Goldman, MD Candace Goldstein, BS, RDMS Edwin Goldstein, MD Mercedes Gomez de Villasana, MD Jenice Gonyea, RDMS, RTR Mario Gonzalez Quiroz Eduardo Gonzalez-Jove, MD Antonio Gonzalez-Ruiz, MD William Edwards, MD Hugh Ehrenberg, MD Amy Eichfeld, MD Doug Eiland, MD Berit Eklund, RN, MS B. Rafael Elejalde, MD Paul Ellenbogen, MD Byron Elliott, BA, MD Sandra Emmons, MD Goodday Eng, RDMS Heywood Epstein, MD Christos Erinakes, MD Ernest Ertmoed, MD Frederick Eruo Sr, MD, MPH J. Fernando Escarzaga, RPA, RVT, RDMS, RT Sharon Eskam, MD Kristine Eule, MD Peter Evan, MUDR John Evans, MD Maggie Evans, MD Wayne Evans, MD Philippe Extermann, MD Steven Eyanson, MD Eric Fackler, MD Leonard Fagan, MD Gary Fait, MD Joseph Fakhry, MD Iman Fani, MD Harry Farb, MD Patricia Farias Darren Farley, MD Shahid Farooqi, MD Juan Fausti, MD Jean Fava Mark Favot, MD Beda Federici-Linehan, MS, RDMS Ding-Yu Fei, PhD Deborah Feldman, MD Damariz Feliz Terry Feng, MD Jonathan Fenton, DO Benedito Fernandes Hostos Fernandez-Caamano, MD Lauren Ferrara, MD Jacqueline Fielding, BS, RDMS Reinaldo Figueroa, MD Harris Finberg, MD Marcus Finch Janet Fiore, RT, RDMS Stuart Fischbein, MD Frank Fischer Jason Fischer, MD, MSc Colleen Fitzsimons Christi Flanagan, RDMS, RVT Meghan Flannery, MD Matthew Flannigan, DO Rodney Florek, MD Philip Florio, MD Katherine Foley, MD Jon Foran, MD Melissa Foreman, RDMS, RVT Flemming Forsberg, PhD Wilbert Fortson Jr, MD Stephen Fortunato, MD x Jean Goodman, MD Barbara Gordon, MD Alan Gorrell, MD, RDMS Kiyotoshi Gotoh, MD, PhD Daniel Gottschall, MD Gregory Goyert, MD Neville Graham, MD Sallye Granberry, MD Michael Granelli Vanessa Grano, MD Andrew Gray, MD, PhD Caron Gray, MD Cindy Gray, RDMS, CNMT, RT(R,M) Diana Gray, MD Robyn Gray, DO Michael Green, MD, FRCS Richard Green, MD, BS William Green, MD Mark Greenberg, MD, CCD Steven Greenberg, MD Vinette Greenland, MD Jill Ann Shu Gregg, RDMS Natalie Gregory, MD Kamal Greiss, MD, FRCP, FACE, ENCU Tim Grenemyer Basil Grieco, MD Kirby Gross, MD Yvette Groszmann, MD, MPH Emily Gubert, MD Alexandr Gudz, MD Gwen Guglielmi, MD Lesley Gumbs, MD Gowthaman Gunabushanam, MD, FRCR Shalesh Gupta, MD Joy Guthrie, PhD, RDCS, RDMS, RVT Glenford Guy, BSc, MD JoAnn Haberman, MD Shoshana Haberman, MD, PhD Wendy Hadden, MD Christine Haines, MD Lawrence Haines, MD, MPH, RDMS John Hale, MD Anne Hall, PhD Brian Hall, MD, RDMS, RDCS Mederic Hall, MD Michael Hall, MD Timothy Hall, PhD Thomas Halloin, MD Antoinette Ham, MD Caroline Hamel, MD Lee Ann Hammond, MD Lewis Hamner III, MD Ulrike Hamper, MD, MBA Magdi Hanafi, MD Susan Hancaviz, RDMS Glenn Haninger, MD Maryellen Hanley, MD, MPH Lara Hanlon, MD Kathleen Hanlon-Lundberg, MD Gina Hanna, MD Reid Hannon Jr frnt_mttr_Layout 1 3/5/13 10:42 AM Page xi Gail Hansen, MD Regina Hansen, RDMS James Harding, MD John Harding, MD Renee Harding, RDMS Seemanthini Hariharan, MD Gamal Haroun, MD, FRCP(C) Lorie Harper, MD, MSCI Jeffrey Harris, MD Herlof Harstad Sr Musarrat Hasan, MBBS Rebecca Haskett, RDMS, RVT Moustafa Hassan, MD Kathryn Hassinger, MD Jiro Hata, MD Toshiyuki Hata, MD Nawar Hatoum, MD Karen Havling, RDMS Clint Hayes, MD, RVT, RPVI Andrew Healey, MD, RDCS, RDMS, FRCPC Amie Healy Michael Heard, MD Stephanie Hedstrom, MD Frederick Hegge, MD Karen Hehnen, RDMS Timothy Heiser, RDMS Andrew Helfgott, MD Robert Helgans, MD Douglas Helm, MD Daryoush Hendessi IV Harold Henry, MD Cynthia Herbert, RDMS, RDCS, RVT Tomas Hernandez-Mejia, MD Oscar Herrera, MD Linda Herrmann, RN, CNP Barbara Hertzberg, MD L. Wayne Hess, MD Peter Heyl, MD Adam Hiett, MD, RDMS Kenneth Higby, MD Joseph Higgins Jr, MD, PhD Lyndon Hill, MD Meghan Hill, MBBS Kim Hillstrom Roger Hine, MD Neely Hines, MD Makiko Hirai, MD Calvin Hobel, MD Arthur Hodge, MD Eric Hodgson, MD Nicholas Hoff Jr, MD Douglas Hoffman, MD Francis Ho-Kang-You, MD Michael Hold, MD Lori Holden, RDMS, RVT, BSRT Christy Holland, PhD Mark Holland, PhD James Holman, MD Jay Holmes, MD Byron Holt, MD Todd Holt, MD Maryruth Hooper, RRT, RDMS Shari Hopp, RT, RDMS, RDCS Janet Horenstein, MD John Kamp, MD Mark Kandutsch, MD Leonard Kaplan, DO Teresa Karcnik-Mahoney, MD Ardeshir Karimi, MD Roberta Karlman, MD Barry Karpel, DO Namasivayam Karunanithy, MB, ChB, DRCOG, DMRD, FRCR Mitsunori Kasamo, MD Richard Kates, MD David Kauffman, MD Yoshio Kawamata Diane Kawamura, PhD, RT(R), RDMS Akihiro Kawauchi, MD, PhD, RDCS, RDMS, ROUB, RVT Angela Kay, RN, RDMS Alena Kazlouskaya, RDMS Aliaksandr Kazlouski, MS George Kazzi, MD, MBA Jeannette Keefe, RDMS, RVT, RT(R)(M) Alexandra Keegan, RDMS Christine Keer, RDMS, RT Ralph Kehl, MD Ian Kellman, MD Kevin Kelly, MD, RVT Randall Kelly, MD Anne Kennedy, MBBCh, MRCP, FRCR Bernadette Kennedy, BS, RDMS, RVT Karen Kennedy, MD Brian Keroack, MD Lacy Kessler, MD Lawrence Kessler, PhD William Ketcham, MD Maria Salud Kho, MD Aldo Khoury, MD Thomas Khoury, MD, RVT Butrus Khuri-Yakub, PhD Ania Kielar, MD, FRCPC Denise Kieso, RDMS, RVT Robert Kiltz, MD Min Kim, MD Sunny Kim, MD Young Kim, MD Andrew Kingzett Taylor Heidi Kinkade, RDMS, RVT Karen Kirker, RDMS Carolyn Kirkland, AS, RT Mary Kirves Michael Kirwin, MD Eugene Kissin, MD Debra Kitts, RDMS Harvey Klein, PhD Nicki Klein, RDMS, RDCS, RVT, RT Amy Knoeller, MD Debra Koenig, RDMS Alexander Kofinas, MD William Kohlhoff, BA Michael Kolios, PhD Shelley Kolton, MD Mary Komora, RDMS Eftichia Kontopoulos, MD, PhD Naoki Hotta Michael House, MD Bobby Howard, MD Thomas Howard Jr, MD Candace Howard-Claudio, MD, PhD Rodney Hoxsey, MD Sharlene Hsiao, RDMS Charles Hsieh, MD Tsang Tang Hsieh, MD William Huang, MD Judy Hudson, RDMS, RVT John Hughes, MD Shui Yee Hui, RDMS, RVT Roderick Hume Jr, MD Stephen Hunt, MD, PhD Timothy Hurley, MD Kristina Huster, RDMS Thomas Hutchens, MD Manly Hutchinson Jr, MD J. Hwang, PhD James Hwang, MD Kullervo Hynynen, PhD Eric Hyson, MD Debra Ilahi, RDMS Kenneth Iles, DC Sania Imtiaz, MBBS, MUSP Lorraine Iseman, RTR, RDMS Yoshihiko Iwasa, MD, PhD Christann Jackson, MD Jon Jacobson, MD Robert Jacobson, MD Daryoush Jadali, MD Kurt Jaenicke, MD Wieslaw Jakubowski, MD Roger Jammal, MD Warren Janowitz, MD Philippe Jeanty, MD, PhD Mussarat Jehan, MBBS Gary Jensen, MD Lisa Jervis, MD Jeng Jiang, MD Leticia Jimenez, BA, RDMS Gary Joffe, MD Lois Johanson-Maxwell, MD Lori Johansson, RDMS Christina Johnson, BS, AS, RDMS Tyronne Johnson, RDCS Doug Jones, BA, RVT, RDMS, RDCS, RCT Frederick Jones, MD Oliver Jones, MD Richard Jones, MD Teresa Jones William Jones, MD William M. Jones, MD Anthony Joseph, MD Mary Teresa Joseph, MD Nancy Judge, MD Svena Julien, MD Wagdy Kades, MD Ronny Kafiluddi, MD, PhD, FIPP, DABIPP Jeanne Kafoury, RVT, RDMS Costas Kaiafas, MD Krishna Kakani, MD xi Elizabeth Kopin, MD Asteris Korantzis, MD, PhD Jeffrey Korotkin, MD, MBA Karen Koscica, DO Helen Kosik-Westly, RDMS Dana Kottke, RDMS Bruce Kovacs, MD Kajoli Krishnan Mark Kristy, MD David Kroska, MD Robert Krugman, MD Reinhard Kubale, MD Kathleen Kuhlman, MD Koteswara Kunda, MD Gwen Kunken Sterns, MD Sui Ping Kwong, RDMS Marilyn LaBatte, RDMS Lane Laboda, RDMS Rene Lafreniere, MD, CM, FRCSC Rachel Lafser, BS, RDMS Sherelle Laifer-Narin, MD Faye Laing, MD Donna Lambers, MD Edward Lampton Jr, MD Barton Lane, MD Roberta Lange-Lifchez, RT, RDMS Orli Langer Most, MD Michael Lao, MD Janet Larson, MD Larry Larson, MD Timothy Larson, MD Elena Last Wendy Latshaw, MD Richard Latta, MD Jennie Lau Marilyn Laughead, MD Laura Lawrence, MD Sanford Lederman, MD Milton Lee, MD Yung Jae Lee, DO Thomas Leigh, MD Sher Leiman, MD Marlyn Leisy, MD Carol Lennon, MD Jack Lenox, MD Megan Leo, MD Tammy Leonard, MD Michael Leonardi, MD Armand Leone Jr, MD, Esq Jodi Lerner, MD Robert Lerner, MD, PhD Anna Leung, MD Wai Hang Leung David Levene, MD Roberto Levi-D’Ancona, MD Aaron Levine, MD Deborah Levine, MD Jonathan Levine, MD Michael Levine, MD Peter Lewin, MSc, PhD Dawnette Lewis, MD, MPH George Lewis, PhD Resa Lewiss, MD, RDMS Amy Lex, MS, RT(R), RDMS Melissa Liebling, MD frnt_mttr_Layout 1 3/5/13 10:42 AM Page xii Kee-Hak Lim, MD G. Sharat Lin, PhD Tonya Lindgren, RDMS Norman Lindley, MD Yael Lipschitz Michel Lirette, MD Kelly Liriano Karen Lissington, DMU Andrew Liteplo, MD, RDMS Christian Litton, MD Ji-Bin Liu, MD John Loewy, MD Salvatore Lombardi, MD Sherri Anne Longo, MD Luisa Lopez, RDMS JosГ© LГіpez-Zeno, MD Maureen Lorbert, RT(R), RDMS, CDT Seth Lotterman, MD Coreen Lowney, RDMS Jennifer Luckern Cristina Lundborg, RDMS, RVT Carmelina Luongo, MD David Luthy, MD Deborah Luthy, RT, RDMS Juarez Luz Susan Lynch, RDMS, RVT, RDCS Sadisu Maaji Deborah Mabin Lisa Maccarino, BS Marion MacInnis Laurence Mack, MD Karen Mackey, RVT, RDMS, RDC Charles Macri, MD Madhumala Madhavan, MD, ASPLS, MBBS Kazuo Maeda, MD, PhD Paul Maertens, MD David Magarik, MD Edward Magaziner, MD Rebecca Mahony, BAS Denise Main, MD Inder Makin, MD, PhD Patricia Ann Malek, RN, FRCN Srini Malini, MD Melinda Mann, MD S. Manohar IV, MD, DMRD Luis Mansilla, RDMS Darlene Mansueto, RDMS Giorgio Marchini, MD Joshua Markowitz, MD, RDMS Clifford Marshall, MD Chester Martin Jr, MD Clifford Martin, MD Felix Martin Jerry Martin, MD Joseph Martin, MD Kimberly Martin, MD Cecilia Martinez, MD Francis Martinez, DO Xavier Augusto Martinez Bejarano Carl Martino, MD Raymond Marty, MD Subha Maruvada, PhD Damon Masaki, MD Luleta Maslak, RDMS Subhash Mitra, MD, MPH Jennifer Mixdorf, RDMS Debra Mohr, RT, RDMS, BS Richard Molina, MD Steven Mollov, MD Kay Molt Anna Mongillo, RN, RDMS Ana Monteagudo, MD, RDMS Sandye Montes, RDMS Jules Moodley, MD Shanmugam Moopanar, MD, DMRD, DNB Casey Moore, RCS, RVT, RDMS Kathleen Moore, RDMS Nancy Moore, RDMS Azeema Moosa, MD Doreen Morales, RT, RDMS Michael Moretti, MD Richard Moretuzzo, MD Gail Morgan, MD Pablo Morikawa, MD, PhD Fuminori Moriyasu, MD Jeanine Morris-Rush, MD Gerhard Mostbeck, MD Elias Moukarzel, MD Mark Muilenburg, MD Ndaya Muleba, MD Jill Mulholland, AS Jean-Paul Muller, MD Joann Murano, BS, RDCS, RDMS Colleen Murphy, MD Deborah Murphy, RDMS James Murphy, MD Johanne Murphy, RDMS Joseph Muscat, MD Luc Nabet Michael Nabity, MD Samuel Nagle, MS Renuka Naidu, MBBS, RDMS Dean Nakamoto, MD Linda Nall, MD Rakhshanda Nasim, MBBS Doreen Nassimos, RDMS Howard Nathanson, MD Innocent Ndubuisi, BS, RT(R), RDMS, RDCS, RVT Gregory Neal, MD Donna Neale, MD Laurence Needleman, MD Kris Neenan, RTR, RDMS, RVT Joy Neimiller, RT, RDMS Lewis Nelson III, MD Thomas Nelson, PhD Amen Ness, MD Michael Nethers, MD, FICS Marsha Neumyer, BS, RVT Arnold Newman, MD Chris Nguyen, PhD Tuyen Nguyen, RDMS David Nichols, MD Terry Nicola, MD, MS Makoto Niizawa, MD Kurt Nilsson, MD, MS Takenori Nishi, MD Midori Nishio, MD John Nitsche, MD T. Douglas Mast, PhD Joan Mastrobattista, MD Dimitrios Mastrogiannis, MD, PhD Cherie Mathews, RDMS Sergey Matiashchuk Shoichi Matsutani, MD D. Matthews, MD Jason Matuszak, MD Dev Maulik, MD, PhD Alexander Maximovich, MD Lisa May, MD Kathleen Mayor-Lynn, MD W. Desmond McCallum, MD Kathleen McCarten, MD Michael McCoy, MD Stacy McCrosson, MD Deirdre McCullough, MD Darrick McDanald, MD Elinor McDermott, RDMS Kelly McGuire, MD Cindy McKay, RDMS Elizabeth McKinney, MD Monique McKnight, MD Kristen McLaughlin, RDMS David McLean, MD Michael McNamara, DO Thomas McNanley, MD Jakob McSparron, MD Joseph McWherter, MD Mary Meadows, RT(R), RDMS Jose Medina, MD Garo Megerian, MD Sofia Mehmoood Israel Meizner, MD Vlatka Mejaski-Bosnjak, MD, PhD Hugh Melnick, MD Paula Melone, DO K. Menon, MD, FRCOG Alexander Mentakis, MD John Mercer, MD Michelle Mercier, RTR Margret Mergelsberg, MD Daniel Merton, BS, RDMS Paul Meyer, MD Patrick Meyers, BS, RDMS, RDCS, RVT Lindsey Micek, RDMS Matthew Michaels, MD Joseph Milburn Jr, MD Ruben Millan Hugh Miller, MD James Miller, MS, PhD Nora Miller, MD Suzanne Miller, MD Thomas Miller, BSME Wayne Miller, MD Jeanna Miller-Borsini, RT(R), RDMS Claire Mills, RDMS, RVT Gerald Minkowitz, MD Maria Mintcheva, RDMS Paoletta Mirk, MD Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R) John Mitchell, MBBS, FRACR Maryann Mitchell, RDMS xii Jason Nomura, MD, RDMS Ron Norman, FRACR Schura Normand, RDMS, RTR Deborah Nucatola, MD Francis Nuthalapaty, MD Dawn Nutt, RT, RDMS Mitchell Nutt, MD, RDMS Chima Nwizu, MD Nkemdilim Nwosa Jake Ochoa Avice O’Connell, MD, MA Lawrence O’Connell, MD Mary O’Connor, REEGT/EPT, RNCST, RVT, BCIA Sean O’Connor, MBBS Mary O’Day, MD Svein Odegaard, MD, PhD Anthony Odibo, MD, MSCE Charles Odwin, BA, RDMS, PA-C Cherrie Ogin, RDMS, RVT Andrea Olanescu, MD August Olivar, MD Mark Oliver, RVT, MD Janine Oliveri, PhD, MSEd, BSRT, RDMS, RVT Chiou Li Ong, MBBS, FRCR Mehmet Onur Granger Osborne, MD Newton Osborne, PhD, MD, MS Kathleen O’Shea Bryan Oshiro, MD Steven Ostrow, MD Laurel Ott, RN, RDMS William Ott, MD Elizabeth Ottman, MD Robert Ozaki, MD Suha Ozbek Josephine Ozoemena, MBBS Kelly Pagidas, MDCM Lauren Painter, MD Sue Palmer, MD, PA Tracy Papa, DO Emmanuelle Pare, MD Luis Paredes Sr Yvon Parent, MD Barbara Parilla, MD Hoon Park, MD Billy Parkhill Jr, MD, PhD Julie Parrow, RDMS, RDCS, RTR Cornelia Partain, RNC, RDMS Richard Paschke, BS, MS Suean Pascoe Angela Pascual, PhD, MD Resad Pasic, MD Lee Paskar, MD Raj Mohan Paspulati, MD Bharatbhushan Patel, RDMS, RDCS Pravin Patel, MD Molly Paulson, RDMS Thea Paulson, RDMS Charles Paxson, MD Carlton Pearse, MD Harold Pedersen, BA, RDMS Peder Pedersen, PhD Ahmad Peeroo, MD, FRCP Linda Pendziwol, RDMS frnt_mttr_Layout 1 3/5/13 10:42 AM Page xiii Rebecca Pennell, MD James Pennington, RDMS Leif Penrose, MHSc, RDMS, RVT, RDCS, RT(R,CT) Sima Perelshteyn, RDMS Phillips Perera, MD Kalati Perese Richard Perkins, MD Anahi Perlas, MD, FRCPC Kenneth Perry Jr, MD Judith Peterson, MD Robert Petite, BS, RDMS, RDCS Albina Petrosian William Pfeffer, MD Pamela Phayre, RVT Marcia Phelps, RDMS Edward Phillips, MD J. Phillips, CCT Catherine Piccoli, MD Dana Piedmont, RDMS Cynthia Pierce Guy Pierno, RT Anne Pike, RDMS, RVT Paulette Pikey, RDMS James Pilcher, MBBS, MSc, MRCP, FRCR Emily Pineda, MD Jorge Pineda, MD Steven Pinheiro, MD Jon Pitman, MD Barbara Pittenger, RDMS Julie Platt, MD, MSPH Christopher Plummer, DO Ann Podrasky, MD Robin Poe-Zeigler, MD Gustavo Poggio, MD Monica Polacek, RDMS Betty Polanski, ALA, AAS, RDMS Donna Politi, RDMS Scott Pollock, MD Adrian Pop, MD Bruce Porter, MD John Postley, MD John Powell, MD Kelli Powell, RDMS Paul Prachun, MD, FRCP(C) Uma Prasad, MBBS, MD Ted Preston, PhD, MD Brent Price, MD Richard Price, MD David Principe, MD Sandra Pupa, MD Elizabeth Puscheck, MD, MS Sharyn Pussell, MBBS, FRACP, DDU Scott Puza, MD Pamela Queen, RDMS Kathy Quenneville, RDMS, RT(R) Fred Quenzer Jr, MD Valerie Quick, RDCS, RDMS Luis Ortiz Quintana, MD, PhD Yolanda Rabello Janet Radford, DMU Irina Radionova Monique Rose Rahmani, MBChB, DABR, FRCP James Ruiz, MD Gillian Rush, MBBS, FRANZCR Gilles Russ Shahnoz Rustamova, MD John Ryan, MD Constantine Saadeh, MD Alan Sacks, MD Jason Sagerman, MD Bal Sahay, MD, FRCP Christine Sahn, RDCS, RDMS, RVT David Sahn, MD Fumikazu Sakai, MD Sharon Salamat, MD, PhD Mustafa Salih Azen Salim, MD Caryl Salomon, MD Daniel Saltzman, MD Hera Sambaziotis, MD, MPH Timothy Sammon, RDMS, RVT Nadia Samo Karen Sanchez, BA, RDCS, AE, PE Norberto Sanchez, MD Carlos Sanchez Huerta Wanda Sanders, RDMS Anne Sandoval, BS, RDMS, RVT Aimee Sanfilippo Peter Sanfilippo, MD Thomas Sanford, MD Joaquin Santolaya, MD, PhD Lorena Santos Rigoberto Santos-Ramos, MD Albert Sarno Jr, MD, MPH Sergio Sartori, MD Andrew Satin, MD Michihiro Sato Satoshi Sato, MD Takahiro Sato Jeanette Satriano, RDMS Fouad Sattar, MD Lizabeth Sawyer, RDMS, RDCS Lois Scheffler, RDMS, RDCS, RVT Mark Schlimgen, MD Judith Schlissel James Schmidgall, MD Anita Schmidt, MD Mary Schmidt Ingrid Schneider, MD James Schneider Michael Schneider, MD Neil Schneider, MD Ronald Schneider, RDMS Thomas Schramm, MD Louis Schruff, MD Patrick Schuette, MD Harold Schulman, MD Heinz Schwab, BSc David Schwartz, MD, FRCOG Joyce Schwartz, RDMS, RVT, AS Mark Schwartz, RDMS, RPVI Ronda Schwartz, RDMS William Scruggs, MD Harish Sehdev, MD Chandra Sehgal, PhD Shyamashree Sengupta, MD Nelia Sering, RDMS Sharon Rais, MD Shankar Ramamurthy, MD, DMRD Carlos Ramirez Toledo Alberto Ramos Cruz, MD Jagpal Rana, MD Sheshagiri Rao, MD FRCP(C), DABR Cindy Rapp, RDMS Olga Rasmussen, RDMS John Reach Jr, MSc, MD Charles Read, MD Andrei Rebarber, MD Linda Rebolo, AS, RDMS, RVT, RCT Susan Rech, MD Raghurami Reddy Leslee Redfield, BA Victor Regenbogen, MD Jonathan Rehberg, MD Gregory Reid, MD Wendy Reiling, BS, RDMS Dale Reisner, MD Iseko Remilekun, MSc, RDMS Dana Resop, MD Janette Reynolds, RDMS Faranak Rezaie, MD Jennifer Rhodes Amy Richardson, MD Daniel Rightmire, MD, MS, RDMS, MBA Christopher Rigsby, MD Thomas Ripperda, MD Jennifer Risinger, MD Kristina Ritter, RRT Manuel Rivera-Alsina, MD, MBA Anne Rizzo, MD Michelle Robbin, MD, MS Donald Roberts, MD Dwain Roberts, MD Robert Robertson, MD, MBBS Kathryn Robinson, MD Hope Robinson-Beverly, RT(R), RDMS Kathleen Robischon, MD Thomas Rodenberg John Rodney, MD M. Hellen Rodriguez, MD Veronica Rodriguez, RT(R), RDMS Dennie Rogers, MD Ashley Roman, MD, MPH Nina Romanova, MD Audrey Romero, MD Ricardo Rosa Angel Rosas, MD Howard Rose, DO Gary Rosenberg, MD Emily Rosenbush, MD Marc Rosenn, MD Gary Rosensteel Brenda Ross-Shelton, MD Siegfried Rotmensch, MD Susan Rowling, MD Anna Rozenberg, RDMS Thomas Rubeo Jr, MD Tanya Rucker, RTR, RDMS Perry Rudich, MD xiii Edouard Servy, MD Donna Session, MD Roy Settergren, MSc, DC Bharat Shah, MD Leena Shah, MD Yogesh Shah, MD Shane Shapiro, MD Pradeep Sharma, MD Ralph Sharman, MD Candice Shea, MD Jessica Sheets, MD Claudette Shephard, MD Celeste Sheppard, MD Takashi Shimizu, MD, PhD Gregg Shimomura, MD Norio Shinozuka, MD, PhD Takako Shirakawa, MD, PhD Arnold Shkolnik, MD Janie Shunk, RDMS Jaye Shyken, MD Jeou-Jong Shyu Tariq Siddiqi, MD Salma Siddiqui, BS, RDMS Denise Sidisky, RDMS, RRT Neil Sikes Jr, RDMS, RDCS, RVT, RT(R) Natia Silagadze, RDMS Jessica Silliman, RDMS Rogerio Silva, MD Elizabeth Silverman, MD Neil Silverman, MD Ronald Silverman, PhD Julian Simmons, MD Mark Simonelli, MD Stephen Simons, MD Douglas Simpson, PhD Jerry Sims, MD Jorge Sinclair, MD Kathleen Singer, RDMS Shailini Singh, MD, FRCS(C) Elena Sinkovskaya, PhD, MD Casey Sinz, RDMS Daniel Sipple, DO Adam Sivitz, MD Daniel Skupski, MD Dan Skyba, PhD Povilas Sladkevicius, MD, PhD Michelle Slater, RDMS Jan Sloves, RVT, RCS Diana Smigaj, MD Jay Smith, MD Stephen Smith, MD Lynn Snyder, RDMS, RT Steven Soberman, MD Robert Sofferman, MD Julia Solomon, MD Kwang-Ho Son, MD Elie Soussan, MD Timothy Spaulding, MD Jean Spitz, MPH, RDMS Jacqueline Sposito, MD Melinda Staiger, MD, BS Camelia Stanciu, MD, RDMS Ioan Stanciu, MD, RDMS Jami Star, MD frnt_mttr_Layout 1 3/5/13 10:42 AM Page xiv David Stark, MD A. Thomas Stavros, MD Charles Stedman, MD Ralph Steiger, MD Janet Stein, MD Marjorie Stein, MD Michel-Patrick Steinmetz Craig Sternberg, MD John Stevens Jr, MD Virginia Stewart, MD Laurie Stolklane, RDMS, RDCS Kristine Stolt, RDMS Richard Strassberg, MD Mel Stratmeyer, PhD Heather Straub, MD Richard Striano Thomas Stubbs, MD Robert Stuntz, MD Hoda Sturman, AA, RT, RDMS Ian Suchet, MBBCh, FRCPC Cheryl Suiter, MD, PA Ronald Sultan, MD Yasukiyo Sumino, PhD Donna Summers, RDMS James Sutherland, MD M. Linda Sutherland, MD Robert Sutherland, MD Stephen Swanson, MD Manuel Sy, MD Humera Syeda, MD Thomas Szabo, PhD Celso Szmidt, MD Thomas Tabb, MD Evan Taber, MD Claudia Taboada, DO Filemon Tan, MD, PhD John Tassone, DPM Lucille Taverna, MD Barbara Taylor, MD Helen Taylor, MIR, DMU Jeff Taylor, BS, RVT Nathan Teismann, MD Shpetim Telegrafi, MD Deydre Teyhen, PT, PhD, OCS M. Jay Thomas, RDMS, RRT, RCT Dan Thomason, MD Kai Thomenius, PhD Michael Thompson, MPH, RDMS, RVT, RDCS, RCS, RVS Noel Thompson, BA, MS, MD Robert Thompson, MD Thomas Thompson, MD Stephen Thorn, MD Pietro Ticci, MD Cheryl Timblin, RDMS Mark Timken, MD Ilan Timor, MD Arkom Tivorsak, MD Ants Toi, MD, FRCP Lama Tolaymat, MD, MPH Tahisha Tolbert, MD Francis Tomasik, MD Charles Tomberlin, MD Jennifer Tomczak, MD Matthew Tompkins, MD Jan Weichert, MD James Weinstein, MD Judith Weiss, RDMS, BA Patricia Weiss, AAS, RDMS Heather Welch, RDMS Holly Wells, MD, FRCP(C), ABR Karen Wells, MD William Wells, MD Tony Wen, MD Katharine Wenstrom, MD Connie Wesley, RDMS Cathy Wesner, RDMS, RVT Emily West Ellen Wetter, MD Paul Wexler, MD Thomas Wheeler, MD Anita Whistler, RDMS, ROUB Katharine White, MD Sanford White, MD Amy Whitley, MD Gerrie Whitley, RDMS, RN Craig Whitmore, MD Rita Whitton, RDMS Janice Whitty, MD, RN Willyarto Wibisono, MD David Wicke, RDMS Marcin Wiechec Thomas Wigton, MD Martin Wilcox, BSEE Thomas Wilkins, MD Alisa Williams, MD John Williams III, MD Kristi Williams, BS, RT, RDMS, NT (R) Margaret Williams, RT, RDMS Suzanne Williams, RDMS Terri Williams-Weekes, MD Cielito Wills, BA, RVT, RDMS Donna Wilson Robert Wilson, MD, MSc Stephanie Wilson, MD Denise Winder, AS, RDMS Melissa Winstead, RDMS Michael Wise, DVM Kerri Wissmueller, RDMS, RVT, RDCS, CCT Dexter Witt, DPT, OCS Constance Witte, RTR, RDMS Diane Woelkers, BS, RT(R), RDMS Mark Wolf, MD Lynlee Wolfe, MD Michael Wolfe, MD Robert Wolfson, MD, PhD Wayne Wolfson, MD Cynthia Wong, RDMS, AB, BR, OB, NE, RVT Edward Wong, MD, FRCP Keet-Peng Wong, FRCS Roberta Wong, BS, RDMS, RDCS Steven Wong, MD Jade Wong-You-Cheong, MD, RVT, FRCR Aaron Wray, RDMS Andrew Wright, MD Jeffrey Wright, MD Tatyana Wright, RDMS Felicia Toreno, PhD, RDMS, RDCS, ROUB, RVT Eugene Toy, MD Fatma Trabulsi, ABR Donald Tradup, RDMS, RT Lan Tran, MD Michele Traves, RT(R), CBDT Dara Treadwell, BS, RT(R)(M), RDMS Jillian Trull Francis Tseng, MD Jed Turk, MD Elizabeth Turner, MS, MD Sandra Turner, RDMS John Turocy, MD, MS Carol Uher, RDMS, RT(R) R. Peter Ulland, MD Tonda Ulmer, RDMS, RDCS Richard Ulrich, BS, RDMS Edet Umana, MD, MBA Heidi Umphrey, MD, MS Evan Unger, MD William Unwin, MD Yoginder Vaid, MD Carmen Valderrabano, MD Antoine Van Straalen, MD Sue Van Zanten Elizabeth Vanderburgh, MD Jean-Louis Vanoverschelde, MD, PhD Tomy Varghese, PhD Ehrlich Varsovia, RDMS Sanjay Vasudeva, MD Jean-Claude Veille, MD Christina Veit, MD Danilda Veloz, RDMS Gwen Venegas, RDMS Priya Venkateswaran, RDMS Yvan Vial, MD Alex Vidaeff, MD, MPH S. Boopathy Vijayaraghavan, MD, DMRD Richard Viscarello Jr, MD Olaf Von Ramm, PhD Joni Voss, RT(R), RDMS, RVT Rolf Vrla, MD Gael Wager, MD, MPH, MBA Brent Wagner, MD Jason Wagner, MD Chu Wai Pong Lisa Wainright, RT(R), RDMS, RVT Camil Walker, MD Janine Wallin, BS, RDMS Cynthia Walsh, MD Rodolfo Walss, MD Barbara Walton, RDMS Eileen Wang, MD Shirley Wang, MD Alice Ward, BS, RDMS Damon Warhus, MD Steven Warsof, MD Antoinina Watkins, MD Peter Watson, MD Kevin Weary, MD Sandra Weber, RDMS Hassan Wehbeh, MD xiv Michael Yamazaki, MD Diana Yankowitz, BS, RDMS, RDCS Linxin Yao, PhD Amaryllis Yazon, MD Christopher Yenter, MD Duzgun Yildirim, MD William Yip, MBBS, MMED, MD, MRCP, DCH, FRCP Bruce Young, MD Donald Young, DO Warren Young, MD Mark Yuhasz, MD Michael Zaladonis Jr, BS, RVT Ivica Zalud, MD, PhD Jill Zavitsky, RT, RDMS Carolyn Zelop, MD J. Zetterberg, MD, MBBS Senait Zewde Xiaoming Zhang, PhD Ying Zhao, MD Marvin Ziskin, MD, PhD Lisa Zorn Smeglin, MD Patricia Zylman, MD 13proceedings_Layout 1 3/5/13 10:38 AM Page 1 2013 Scientific Program 13proceedings_Layout 1 3/5/13 10:38 AM Page 2 *Presenter of scientific paper with more than 1 author. 13proceedings_Layout 1 3/5/13 10:38 AM Page S1 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSIONS SUNDAY, APRIL 7, 2013, 7:30 AM–11:30 AM Recent Innovations in Gynecologic Ultrasound, Including 3-Dimensional Imaging Ultrasound-Guided Procedures for the Pediatric Patient: From the Perspective of Both Point-of-Care and Traditional Approaches Moderator: Beryl Benacerraf, MD Moderators: Alyssa Abo, MD, Beth Kline-Fath, MD In this session, advances in 3-dimensional sonography will be discussed, including practical applications for use in many aspects of gynecology practice and many conditions. The objective of this session is to describe the use of ultrasound to guide interventions and manage therapy in the pediatric patient by both point-of-care and traditional approaches. SPECIAL INTEREST SESSION SUNDAY, APRIL 7, 2013, 8:00 AM–9:30 AM Hands-on Basic Obstetric Ultrasound and Simulation Moderator: Jude Crino, MD Participants will scan second-trimester pregnant models with supervision by sonographer and physician experts. Skills taught in this basic-level session include image optimization, fetal biometry, and the basic fetal anatomic survey. Simulation stations for endovaginal scanning, amniocentesis, and fetal blood sampling will be available. SPECIAL INTEREST SESSION SUNDAY, APRIL 7, 2013, 9:45 AM–11:15 AM Hands-on Advanced Obstetric Ultrasound and Simulation Moderator: Jude Crino, MD This session is appropriate for those with experience in basiclevel obstetric ultrasound or who have attended the basic-level hands-on session. Participants will scan second-trimester pregnant models with supervision by sonographer and physician experts. Skills taught in this advanced-level session include detailed fetal anatomy, Doppler velocimetry, and basic 3- and 4-dimensional techniques. Simulation stations for endovaginal scanning, amniocentesis, and fetal blood sampling will be available. S1 13proceedings_Layout 1 3/5/13 10:38 AM Page S2 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSIONS SUNDAY, APRIL 7, 2013, 3:15 PM–5:00 PM Advanced Point-of-Care Cardiac Ultrasound in the Emergency and Critical Care Patient Hands-on Renal and Mesenteric Imaging Moderator: Jennifer McDowell, MM, RDMS, RT, RVT Moderator: Robert Arntfield, MD, RDMS Ultrasound Criteria for Renal Disease Margarita Revzin Diagnostic Radiology, Yale University Hospital, Wilton, Connecticut USA Efficient and Effective Point-of-Care Transesophageal Echocardiography: A Proposed Algorithm for Critical Care Scott Millington University of Ottawa, Ottawa, Ontario, Canada During this session, we will focus on the spectrum of renal diseases detected and diagnosed with Doppler ultrasound, with special emphasis on renal artery stenosis. The anatomy and principles of examination of the native renal vessels will be considered first, followed by a discussion on renal vascular disorders, including renal artery stenosis. In detail, we will review multiple Doppler-based criteria that are used in diagnosis of renal artery stenosis, including peak systolic velocity, renal to aortic ratio, waveform analysis, as well as secondary signs of renal artery stenosis. We will review current literature that validates the proposed criteria for renal artery stenosis and analyze potential pitfalls that may lead to misinterpretation of the findings affecting the number of false-positive or -negative diagnoses. Introduction—The use of transesophageal echocardiography (TEE) in the intensive care unit (ICU) is becoming more prevalent as point-of-care ultrasound applications expand in general and as specific providers seek more advanced training. Problem Identification—Point-of-care TEE differs significantly from comprehensive TEE in that it is goal directed and time sensitive and seeks to integrate ultrasound images with real-time physiology. As such, the traditional sequence of image acquisition applied to comprehensive TEE exams may not be ideal. Summary—A goal-directed algorithm for point-of-care TEE is proposed, comprising 4 core views applied to all patients and 4 additional views that are useful in specific clinical circumstances. The goals are: (1) to efficiently identify pathologies that are common in the ICU; and (2) to identify those pathologies that are less common but that mandate a major change in clinical management strategy. How Does Ultrasound Compare in Safety and Radiation Dose to Other Imaging Modalities? Moderators: George Lewis Jr, PhD, Thaddeus Wilson, PhD Clinical Applications of Ultrasound Contrast, Part 1 Food and Drug Administration Perspective on Diagnostic Ultrasound Safety Keith Wear, Gerald Harris Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland USA Moderator: Richard Barr, MD, PhD Contrast Imaging of Abdominal Transplants Paul Sidhu Radiology, King’s College London, London, England Diagnostic ultrasound does not produce ionizing radiation, and it has an excellent safety record over several decades of use. Potential bioeffects from diagnostic ultrasound are categorized into thermal and nonthermal mechanisms. Thermal mechanisms involve heating of tissue. The concept of the thermal dose, which involves both a temperature rise and the duration of exposure, is a useful tool in the study of thermal effects. Nonthermal mechanisms involve mechanical effects, which include streaming and cavitation. The likelihood of bioeffects is related to acoustic output. The 1976 Medical Device Amendments require new devices to be substantially equivalent in terms of safety and effectiveness to legally marketed devices. Consequently, recommended acoustic output levels are based on levels produced by devices on the market prior to the enactment of the 1976 Medical Device Amendments. The thermal index and mechanical index, which are indicators of the likelihood of bioeffects, are often displayed in real time next to the ultrasound image. However, the extent to which these indexes are used to guide examinations is unknown. Several studies indicate the occurrence of observable bioeffects at diagnostic output levels. Ultrasound examination of liver and renal transplants has revolutionized patient management with the addition of color Doppler ultrasound, establishing this technique as paramount in interpreting and investigating vascular abnormalities of any transplant organ. The early postoperative period is crucial for the establishment of good vascular perfusion to the transplant organ, a cornerstone of further medical management. In liver transplantations, the hepatic artery is crucial to the transplant and the long-term viability of the biliary system. Contrast-enhanced ultrasound (CEUS) will establish the patency of the hepatic artery, identify areas of stenosis, and identify any potential hepatic pseudoaneurysm. The integrity of the portal and hepatic veins may be ascertained. Focal areas of liver necrosis, abscess formation, and biliary duct dilatation are all clearly delineated on the CEUS examination. With renal transplantation, the CEUS examination will readily delineate areas of infarction, will depict vascular complications, and has the potential to assess regional and global perfusion. Similarly with pancreatic transplants, the addition of CEUS may be seen as an aid in the assessment of the vascular pedicle. Longterm follow-up is aided with the depiction of recurrence of disease, the development of hepatocellular carcinoma, and post-transplant lymphoproliferative disorder. This presentation will detail the use of CEUS in transplants and will adhere to the guidelines issued by the European Federation of Societies for Ultrasound in Medicine and Biology on liver and nonliver applications of CEUS. Radiation: The Two-Edged Sword Eric Hall Columbia University, New York, New York USA Modern medicine would be unimaginable without the use of x-rays for diagnosis, especially computed tomographic (CT) scans, which have revolutionized radiology. Radiation is often described as a two-edged S2 13proceedings_Layout 1 3/5/13 10:38 AM Page S3 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 dle tenotomy. This procedure, in which the diseased tendon is repeatedly punctured by a needle under ultrasound guidance, can induce a healing response and subsequent clinical improvement in a large proportion of patients. This presentation will review the technique for percutaneous needle tenotomy as well as show evidence from the literature regarding its effectiveness. sword because it offers great benefits to mankind but also has the potential to cause harm. Radiation was shown to be a mutagen in Drosophila by Muller in the 1930s, and for the next 30 years, radiation protection was based on the risk of genetic effects. That radiation could induce leukemia and cancer came from the study of the Japanese A-bomb survivors. Cancer risks from CT scans, based on the A-bomb data, were published more than a decade ago and were greeted with skepticism in many quarters but accepted by pediatric radiologists, who immediately began to reduce radiation doses. Within the past year, the first epidemiologic studies have appeared, in which 180,000 children who had received CT scans from 1980 to 2008 showed a small statistically significant excess of leukemia and brain cancers. The epidemiologic studies confirm the estimates from the A-bomb survivors and indicate that the risk to an individual is extremely small, so that if a CT examination is clinically justified, there is no doubt that the benefit will exceed the risk. The remaining concern is from a public health perspective, since some 70 million CT scans are performed each year in the United States. To my knowledge, comparable epidemiologic studies have never been performed on magnetic resonance imaging or ultrasound, and the expectation that these modalities are “safe” is based on other considerations. Point/Counterpoint: Ultrasound Versus Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta, Congenital Diaphragmatic Hernia, and Central Nervous System Anomalies Moderator: Sherelle Laifer-Narin, MD Placenta Accreta Magnetic Resonance Imaging Sherelle Laifer-Narin Radiology, Columbia University Medical Center, New York, New York USA Ultrasound has been the primary imaging modality for routine evaluation of the pregnant patient. A routine diagnostic scan involves detailed imaging of the fetus to detect fetal anomalies and evaluation of the placenta to determine mode of delivery and detect possible placental abnormalities. Over the past 20 years, the use of magnetic resonance imaging (MRI) has been steadily increasing and has been shown to be of value in detecting structural fetal abnormalities as well as placental abnormalities. In this session, we will present the role of diagnostic ultrasound and the complementary role of MRI in imaging 3 major categories: fetal neurologic abnormalities, congenital diaphragmatic hernia, and abnormal placentation. Advantages and disadvantages for each modality will be presented, with time for questions and answers from the panel at the end of the presentations. Interventional Musculoskeletal Ultrasound: Steroid Injections, Dry Needling, and Platelet-Rich Plasma Injections Moderator: Levon Nazarian, MD Steroid Injections Nathalie Bureau Diagnostic Radiology, University of Montreal Medical Center, Montreal, Quebec, Canada This presentation will provide an overview of the tendon structure and the mechanisms of tendon failure. We will discuss the potential adverse effects and the effectiveness of steroid injections in the treatment of tendon pathology and present different ultrasound-guided techniques of steroid injections. The tendon is a strong connective tissue band, which transmits muscular force to the skeleton. Tendons have a hyperechoic fibrillar appearance on ultrasound. The structural and functional properties of tendons enhance with appropriate exercise, deteriorate with disuse, and alter with age. Tendon injury may result from direct trauma, impingement, or friction and from overuse or overload, which may be acute or chronic and repetitive. Predisposing factors such as aging, chronic metabolic diseases, inflammatory diseases, and the use of steroids may weaken the tendon, thus reducing the threshold of tendon failure. Clinical management of tendinosis should initially include some form of conservative treatment, including relative rest, pain control, support, stretching exercises, and correction of provoking factors. There appears to be some evidence for the effectiveness of steroid injections in stenosing tenosynovitis such as De Quervain and trigger finger. Most studies agree that steroid injections are effective only in the short term in the treatment of insertional tendinosis. Although there are still no definite evidence-based guidelines for the use of steroid injections, suggestions include avoiding intratendinous injections, using caution with peritendinous injections, advising 2 weeks of rest after injection, allowing 6 weeks between injections to assess the effect, and limiting injections to 3 to any one site. Ultrasound in Global Health Moderator: Sachita Shah, MD, MPH Introduction to Ultrasound in Global Health: Strategies for Starting an Ultrasound Program in a Low-Resource Setting Sachita Shah Emergency Medicine, University of Washington School of Medicine, Seattle, Washington USA; Partners In Health, Boston, Massachusetts USA With improvements in portability, durability, and affordability, point-of care ultrasound has reached the bedsides of the most vulnerable populations in the developing world. Due to the lack of specialists in radiology and sonography in much of the developing world, a need for ultrasound training programs focused on clinicians exists. An ever-expanding body of literature has grown to support the use of bedside point-of-care ultrasound performed by nonradiologist physicians, nurses, and clinical officers in developing nations in clinical patient care. Creating a sustainable ultrasound program in a low-resource setting requires much more than ultrasound equipment and good will but is an important way to make a long-term impact on a low-resource community. In this session, we will discuss strategies for implementing a successful ultrasound service program in a low-resource setting, including opportunities for potential equipment donation and organizations of interest, host hospital leadership and infrastructure, features of ideal equipment, homemade coupling agents, how to conduct a needs assessment and plan a training course, pitfalls and barriers to ultrasound programs, and safety and machine maintenance in low-resource settings. Dry Needling of Tendons Levon Nazarian Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania USA Patients with chronic tendon conditions such as tennis elbow may reach a stage in which they have to either live with their pain or undergo surgery. Real-time ultrasound guidance has allowed development of a minimally invasive alternative to surgery, known as percutaneous neeS3 13proceedings_Layout 1 3/5/13 10:38 AM Page S4 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Point of Care Ultrasound in Resource-Limited Settings: Case Review Krithika Muruganandan Emergency Medicine, Brown University, Providence, Rhode Island USA Over the years, the portability and versatility of ultrasound have resulted in its extension from the hospital setting to disaster relief, military medicine, and the austere and resource-limited setting. It has moved from the hands of the specialist to the generalist physician. When developing a curriculum to train generalist physicians in resource-limited settings, ultrasound education must be tailored to their wide scope of practice while addressing local disease patterns and available resources. In addition to the common uses of ultrasound used by emergency physicians locally, point-of-care ultrasound in the resource-limited setting is valuable for a broader range of pathologies. Cardiopulmonary ultrasound should include assessment for rheumatic valvular disease, pericardial and pleural effusions related to tuberculosis and human immunodeficiency virus infection, cardiomyopathy, pulmonary edema, and parenchymal disease. Abdominal ultrasound education should include evaluation of amebic liver abscesses, echinococcal cystic disease, cirrhosis, hydronephrosis, nephropathy, and evaluation of abdominal free fluid (focused assessment with sonography for trauma exam). Soft tissue ultrasound should include evaluation for abscesses, pyomyositis, and cellulitis. Obstetric ultrasound performed by the generalist physician should include evaluation for intrauterine pregnancy, fetal heart rate, placenta positioning, presentation, and fetal dating. Ultrasound guidance for procedures such as thoracentesis, paracentesis, central and peripheral intravenous line placement, and suprapubic catheter placement may be useful in decreasing morbidity and mortality. This presentation will review interesting cases in which bedside ultrasound was instrumental in correctly identifying pathology unique to resource-limited settings, thus directing correct patient treatment. S4 13proceedings_Layout 1 3/5/13 10:38 AM Page S5 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSIONS MONDAY, APRIL 8, 2013, 8:15 AM–10:15 AM Risk Assessment Associated With Ultrasound Exposure of the Lung William O’Brien Jr Electrical and Computer Engineering, University of Illinois, Urbana, Illinois USA Advances in Clinical and Quantitative Pediatric Lung Ultrasound Moderators: Philip Levy, MD, Michael Oelze, PhD It is well documented that ultrasound-induced lung damage (hemorrhage) can occur in mice, rats, rabbits, pigs, and monkeys. Our own experimental studies have focused on mice, rats, rabbits, and pigs as animal models. The characteristics of the lung lesions were similar to those described in studies by our research group and others, suggesting a common pathogenesis for the initiation and propagation of the lesions at the macroscopic and microscopic levels. Six experimental in vivo studies have been conducted to evaluate whether cavitation is responsible for ultrasound-induced lung hemorrhage, namely, dependencies of hydrostatic pressure, frequency, pulse polarity, contrast agents, and lung inflation; the results of each study appeared inconsistent with the hypothesis that the mechanism for production of lung hemorrhage was inertial cavitation. Other dependencies evaluated included beam width, pulse repetition frequency, pulse duration, exposure duration, and animal species and age. The results of our studies using mice, rats, rabbits, and pigs have shown 2 important facts relative to the biological mechanisms of damage: (1) there are no differences in biological mechanisms of injury induced by ultrasound based on species and age; therefore, structural differences among mammalian species studied are independent of the biological mechanism that causes ultrasound-induced lung damage; and (2) lesions induced by ultrasound are similar in morphology in all species and age groups studied, and the character of the lesions is independent of frequency, pulse repetition frequency, and beam width but not necessarily age. The thresholds for producing ultrasound-induced lung hemorrhage, in general, were less than the US Food and Drug Administration’s regulatory limit of a mechanical index (MI) of 1.9. Furthermore, the MI does not appear to provide a risk-based index for lung hemorrhage. (Supported by National Institutes of Health grant R37EB02641.) Perspectives and History of Clinical Lung Ultrasonography Daniel Lichtenstein Medical Intensive Care Unit, HГґpital Ambroise-ParГ©, Boulogne, France Lung ultrasonography is one part of critical ultrasound, but its integration provides a new definition of priorities in diagnosis and management. This application requires a simple machine, the knowledge of basic techniques, and the mastery of no more than 10 signs. The best machine is the simplest; we use 1992 technology with simple gray scale without Doppler and a microconvex probe to acquire the images. The 10 signs that are found in children and neonates are the same as those assessed in adults. They include the bat sign (indicating the pleural line), lung sliding (yielding the seashore sign), the A-line (horizontal artifact), the quad sign and the sinusoid sign (indicating pleural effusion regardless of its echogenicity), the tissue-like sign and the shred sign (indicating lung consolidation), the B-line and the lung rockets (vertical comet tail artifacts indicating interstitial syndrome), abolished lung sliding with the stratosphere sign (suggesting pneumothorax), and the lung point (indicating pneumothorax). All these disorders were assessed using computed tomography (CT) as a gold standard, with sensitivity and specificity ranging from 90% to 100%, allowing us to consider ultrasound as a reasonable bedside gold standard in the critically ill. Major applications include the possibility to postpone referral to CT in critically ill patients, immediate diagnosis and cause of an acute respiratory failure (BLUE protocol), and a direct parameter of clinical volemia, of interest in the management of acute circulatory failure (FALLS protocol). In summary, clinical lung ultrasonography can be performed in trauma, the intensive care unit, as well as remote areas and has led to a major decrease in irradiation. Doppler Ultrasound: Basic and Advanced (Beyond the Umbilical Artery) Quantitative Acoustic Properties of the Lung: An Open Question Peder Pedersen Worcester Polytechnic Institute, Worcester, Massachusetts USA Moderator: Henry Galan, MD After attending this session, participants will be able to enumerate the various fetal vessels that can be interrogated. This presentation will give an overview of pulmonary ultrasound research over the last 50 years. Between 1960 and 1985, several studies were carried out, which showed that very high attenuation represents the main challenge of obtaining ultrasound diagnostic information about the adult lungs, even in their fully collapsed state and using frequencies of <1 MHz. An overview of these early investigations will be presented, covering measurement techniques, acoustic models, and results in the form of attenuation, phase and group velocities, and lung surface scattering characteristics. In the 1990s, a number of papers appeared in the clinical literature, which intriguingly indicated the possibility of imaging pulmonary nodules in the adult collapsed lung, often in connection with thoracoscopic surgery and using frequencies in the megahertz range. A summary of these clinical results will be given, along with some possible explanation of which mechanisms made the pulmonary imaging possible. Finally, some speculations as to the future role of pulmonary ultrasound will be presented. Gynecologic Imaging Using Multiple Imaging Modalities, Including Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Moderators: Sherelle Laifer-Narin, MD, Anna Lev-Toaff, MD Gynecologic Multimodality Imaging, Part 1 Sherelle Laifer-Narin Radiology, Columbia University Medical Center, New York, New York USA In the current medical environment, imaging of the female pelvis is often performed in the urgent care setting. The imager responsible for interpreting the images may have had little input into the choice of imaging modality for a given problem. Therefore, familiarity with the appearance of gynecologic abnormalities on multiple imaging modalities is required. In nonurgent cases, the imaging expert has important input into the decision regarding the need for and choice of complementary imaging. S5 13proceedings_Layout 1 3/5/13 10:38 AM Page S6 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 prompting the United States Food and Drug Administration to issue a “black box” for both of the commercially available perflutren-containing US contrast agents (Definity and Optison), warning of risks of serious cardiopulmonary reactions, and contraindicating their use in patients with critical cardiopulmonary conditions. Considerable debate about the safety, risks, and benefits of US contrast agents ensued and prompted the publication of numerous single- and multi-center retrospective and prospective analyses, all demonstrating a good safety profile, with a favorable balance of risks and benefits, comparable to, or better than, contrast agent use in other imaging modalities. Subsequently, although the black box remains, several revisions of product labeling have occurred, which have resulted in softening and/or removal of previous warnings and precautions, simplification of contraindications to the original concerns regarding intracardiac shunting and known hypersensitivity, and expansion of indications such that stress imaging was no longer an exclusion. In summary, US contrast agents have a favorable risk/benefit profile in patients requiring improved endocardial visualization for rest and stress echocardiographic imaging, and use for this purpose is currently required by US accreditation organizations. This session will discuss combining modalities for challenging clinical dilemmas in both urgent and nonurgent settings. The speakers will review a variety of topics that illustrate when ultrasound alone is sufficient for diagnosis and when obtaining additional clinically useful information from computed tomography and/or magnetic resonance imaging is optimal. These topics include the enlarged uterus, uterine anomalies, adnexal torsion, pelvic inflammation of gynecologic origin, pelvic lesions secondary to bowel disease, pelvic malignancy, evaluation of pelvic pain in pregnancy, and biopsy/aspiration of pelvic lesions. The lessons of this session will be reinforced by means of a series of “test” cases using audience participation. Hemodialysis Vascular Access Moderator: John Blebea, MD, MBA Flow Measurement to Predict Access Failure David Vilkomerson DVX, LLC, Princeton, New Jersey USA Blood flow is high when a graft is placed and goes to zero when it clots. Stenoses almost always cause this reduction in flow. It seems reasonable, then, to measure graft flow and, when it falls to a level indicating an impending clot, to treat the stenoses and prevent the graft failure. Ten years ago, 2 randomized clinical trials were undertaken to establish the validity of this approach; both showed that monthly flow surveillance led to more procedures but failed to reduce graft failures. Many suspected that more frequent flow measurements might be more effective. We developed, with National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases Small Business Innovation Research funding, a Doppler ultrasound system especially for weekly graft flow measurement. In an observation-only phase, the instrument was shown to be quick, inexpensive, and accurate in predicting graft failure. On the basis of these results, a clinical trial was begun. Dialysis volunteers were randomized to a surveillance group, who had their graft flow measured and recorded every week, and a control group, who continued to receive conventional treatment, including monthly flow measurements. After 21 months, in the surveillance group measured “per protocol,” only 8% had grafts that failed and a procedure rate similar to the control group. On an “intent-to-treat” basis, however, the clinical trial failed: skipped measurements, failure to notice graft flows showing impending clotting, and delays in treatment prevented the trial from meeting its goal of reduced graft failures. However, having a record of the graft flow after the missed signs allowed us to determine the important parameter of how fast grafts clot after reaching the impending failure criteria: about 70% of grafts clotted in less than a month after meeting the criteria. The most common interval between the signs of impending failure and thrombosis was 1 week. Lesson 1: Monthly flow surveillance can never, no matter the method, significantly reduce graft failures. Another result of having weekly flow data was being able to correlate postintervention graft flow with the succeeding graft history. Lesson 2: If postintervention flow is <950 mL/min, 50% of the grafts will fail in 8 months; if >950 mL/min, >70% will be patent after 21 months. Review of Molecular Imaging Joshua Rychak Targeson, Inc, San Diego, California USA Contrast ultrasound is an emerging technique for imaging tumor progression, both in clinical and research settings. In particular, targeted microbubbles are now being used as molecular contrast agents for molecular imaging of angiogenesis, thrombosis, and inflammatory disease. This presentation will review developments in the field over the past decade and attempt to trace the path from proof of concept to the introduction of commercial formulations for research and clinical use. Early incarnations of microbubbles for molecular imaging used antibody-targeting ligands conjugated using a biotin-avidin scheme. This system has proved to be remarkably robust and, with several modifications, has emerged into several widely used commercial products for small-animal imaging. Extending ultrasound molecular imaging to larger research species presents some challenges: antibodies are not always readily available to the desired molecular target for rabbits, canines, and swine, and the large volume of microbubble product required per dose makes cost a constraint. The use of small-molecule ligands that offer activity in a variety of species (and which can generally be made at low cost) can overcome this limitation. Replacement of biotin-avidin conjugation with covalent-coupling chemistries can further reduce the cost and improve the consistency of the microbubble product. Selection of conjugation chemistry, in addition to the ligand and shell components, proves to be an important aspect when translating to human use. In addition to their incarnation as reagents for biomedical research, the first generation of ultrasound molecular imaging agents are now entering clinical trials. Microvascular Mapping Paul Dayton,1* Ryan Gessner,1 Stephen Aylward 2 1 Biomedical Engineering, University of North Carolina, Chapel Hill, North Carolina USA; 2Kitware, Inc, Carrboro, North Carolina USA New Horizons in Contrast Ultrasound Microbubbles are unique as ultrasound contrast agents in that they are constrained to the microvascular space due to their large size, and they can be detected with high sensitivity due to their unique echo signatures. Through application of transducers and imaging strategies optimized to achieve high resolution and high signal to noise coupled with 3D approaches, it is possible to obtain maps of microvascular structures associated with healthy and pathologic tissue. It is well known that angiogenic processes involved in rapidly growing tumors promote increased vessel density, tortuosity, and other structural abnormalities. Using vessel segmentation methods, vessel patterns can be identified and characterized from contrast ultrasound data. We demonstrate that these “microvascular maps” can be used to characterize tissue volumes as tumor bearing or Moderator: Paul Dayton, PhD Safety Aspects of Contrast Ultrasound Sharon Mulvagh Medicine, Mayo Clinic, Rochester, Minnesota USA In the mid to late 2000s, several years after approval of ultrasound (US) contrast agents for enhancement of endocardial border definition and improved feasibility and quality of echocardiographic examinations, postmarketing surveillance suggested a “safety signal,” S6 13proceedings_Layout 1 3/5/13 10:38 AM Page S7 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 3-hour time window. Systemic tPA administration remains the fastest way to initiate treatment for acute ischemic stroke. Since tPA works by induction of partial recanalization of large thrombi, early augmentation of fibrinolysis to improve recanalization is desirable. This augmentation is feasible and can be safely achieved at the bedside with transcranial Doppler (TCD), or sonothrombolysis. In the CLOTBUST trial, all patients received systemic tPA as the standard of care, and 73% of patients achieved any recanalization (46% complete, 27% partial) with tPA + TCD vs 50% (17% complete, 33% partial) with tPA alone within 2 hours of treatment (P < .001). Sustained complete recanalization at 2 hours was 38% vs 13%, respectively (P = .03). A recent meta-analysis of 6 randomized and 3 nonrandomized clinical studies of sonothrombolysis showed that any diagnostic ultrasound monitoring can at least double the chance of early complete arterial recanalization at no increase in the risk of symptomatic intracerebral hemorrhage. Transcranial ultrasound delivery in an operator-independent and dose-controlled manner was successfully tested in phase I and II clinical studies in stroke-free volunteers and stroke patients treated with systemic tPA. A novel operator-independent device for sonolysis (Cerevast Therapeutics, Inc) is now being tested in a pivotal phase III clinical trial (CLOTBUSTER, NCT01098981). healthy, based on microvessel morphologic differences. Thus, contrastenhanced acoustic angiography presents a means to detect the presence of tumors based on observed microvascular abnormalities, without the need to evaluate the tumor mass itself. Pediatric Hepatobiliary Disorders Moderator: Rob Goodman, MD Sonographic Differential Diagnoses in Pediatric Focal Liver Lesions Rob Goodman Yale University, New Haven, Connecticut USA Sonographic analysis of the pediatric liver is often the first imaging used that detects a focal liver lesion. Assessment of the sonographic appearances of these lesions can sometimes be challenging if one is expected to determine a likely cause. The spectrum of conditions that give rise to focal liver lesions in a child is broad, and many lesions have similar sonographic appearances. In this session, congenital, inflammatory, traumatic, neoplastic (benign and malignant), vascular, and metabolic causes of focal liver lesions will be discussed, and specific clinico-sonographic features used to distinguish between these will be emphasized. With the help of these features, the practicing pediatric sonographer will be able to more accurately reach an appropriate diagnosis. Animal Models of Sonothrombolysis and Drug Delivery Christy Holland,1* Jonathan Sutton,1 Nikolas Ivancevich,2 Stephen Perrin,1 Deborah Vela3 1Internal Medicine, Division of Cardiovascular Diseases and Biomedical Engineering Program, University of Cincinnati, Cincinnati, Ohio USA; 2 Siemens Medical Solutions, Issaquah, Washington USA; 3Cardiovascular Pathology, Texas Heart Institute, Houston, Texas USA The Spectrum of Ultrasound Findings in the Pediatric Biliary Tree Valerie Ward Radiology, Boston Children’s Hospital, Boston, Massachusetts USA Ultrasound is the imaging modality of choice for the initial and noninvasive evaluation of biliary diseases in newborns, infants, young children, and adolescents. Initially in this presentation, patient preparation, sonographic technique, and common clinical indications for sonography of the biliary tract will be reviewed. Then both the common and infrequent etiologies for biliary disease in children, including cholestasis, cholelithiasis, choledochalithiasis, cholecystitis, cholangitis, choledochal cysts, and biliary atresia, will be discussed. Also, the correlation of prenatal and postnatal sonography will be presented for specific biliary tract diagnoses that can be diagnosed in the fetal period. Where applicable, the benefits of combining sonography with other biliary tract imaging modalities (such as hepatobiliary scintigraphy, cholangiography, and magnetic resonance cholangiopancreatography) will be also discussed as adjuncts in the evaluation of pediatric biliary tract abnormalities. Ultrasound-mediated thrombolysis, or sonothrombolysis, is an attractive adjuvant to conventional recombinant tissue-type plasminogen activator (rt-PA) therapy for acute ischemic stroke and other thromboocclusive diseases. Numerous in vitro and ex vivo porcine studies have demonstrated ultrasound-enhanced clot lysis, yet recent clinical trials have produced mixed results. Stable cavitation nucleated by an ultrasound contrast agent enhances the penetration of both rt-PA and plasminogen into clots. This enzymatic fibrinolysis is likely hastened due to an increased availability of plasminogen binding sites for rt-PA. However, the degree of clot retraction strongly affects the extent of thrombolytic efficacy. The lack of dense fibrin matrix formation throughout unretracted clots promotes susceptibility to ultrasound-enhanced thrombolysis. In contrast, the paucity of plasminogen present within retracted clots prevents ultrasound acceleration of lysis. Thus, the thrombus etiology and vascular origin may predispose the degree of sonothrombolytic susceptibility. Recent clinical, in vitro, and ex vivo data from a variety of clot models will be discussed. Taboos and Opportunities in Sonothrombolysis for Stroke: From Sonothrombolysis in Animals to Stroke Treatment in Patients Neurovascular Ultrasound in Stroke: What Sonographers Can Do Now Tatjana Rundek Neurology, University of Miami Miller School of Medicine, Miami, Florida USA Moderators: Tatjana Rundek, MD, PhD, Paul Sierzenski, MD, RDMS Neurovascular examination is widely used for assessment of patients in the acute, subacute, or chronic phases of cerebral ischemia. The availability of aggressive and effective treatments, which can be potentially harmful for acute ischemic stroke patients, requires fast and noninvasive examination of the intracranial and extracranial vasculature. Effective stroke therapy can be improved through real-time ultrasound monitoring of the neurologic and cardiovascular responses to treatments. This requires crucial knowledge on behalf of both the sonographer and stroke physician to make the best decisions for the patient, which would minimize the ischemic damage caused by stroke and reduce the risk of subsequent stroke. Current ultrasound techniques, transcranial Doppler and extracranial duplex or color Doppler, have the potential to provide crucial and reliable information about the status of the intracranial and extracranial arteries in a real time. Application of echo-enhancing agents promises to effectively extend current diagnostic techniques. Application Ups and Downs in Clinical Trials of Sonothrombolysis Andrei Alexandrov Comprehensive Stroke Center, University of Alabama, Birmingham, Alabama USA Intravenous tissue-type plasminogen activator (tPA) remains the only effective reperfusion therapy to reverse ischemic stroke. Its timely delivery to all eligible patients should be a priority in development of stroke treatment centers and ambulance delivery systems. Its augmentation with ultrasound will be discussed. Despite lower revascularization rates with respect to endovascular thrombectomy, patients treated with systemic thrombolysis achieve good functional outcomes likely due to earlier treatment initiation. Currently, no evidence exists that primary intraarterial revascularization could be any better than systemic tPA within the S7 13proceedings_Layout 1 3/5/13 10:38 AM Page S8 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 of action. Proper disclosure of the acoustic properties involved will aid in the further development of the field, guiding future research. The first part of this presentation will review the basics of proper reporting, which should be included with any presentation of sonothrombolysis results. Pressure, intensity, frequency, and acoustic field distribution information are the key elements, and other secondary metrics will also be discussed. The basic techniques for obtaining these acoustic data will also be presented. The presentation will conclude by discussing an operatorindependent ultrasound therapy device to treat ischemic stroke, which was specifically designed to incorporate full dosimetric data. The ultrasound delivery system includes a multiple-transducer transcranial head frame comprising broadband (1.0–2.5 MHz) transducers placed at the temporal windows (6 on each side) and the suboccipital window (6 additional transducers). A computer-controlled ultrasound generator receiver system could energize any transducer with sine bursts of varying frequency, amplitude, duty factor, and pulse repetition frequency. Prior to clinical deployment, ultrasonic dosimetry data were recorded for each transducer and saved in the system. During operation, the system logged all exposures in real time for later analysis. The system is now in clinical tests with stroke patients. This system exemplifies the utility of dosimetry/exposimetry in practice. of sonothrombolysis carries a promise to revolutionize the approach to treatment of acute stroke and improve stroke outcome. The clinical significance of neurovascular ultrasound, however, needs to be evaluated prospectively and preferably in an unbiased setting of clinical trials. This presentation will address the basics of neurovascular ultrasound in the examination of stroke patients, the interpretation of ultrasound studies, and the application of neurovascular ultrasound in the management and treatment of stroke. The role of sonographers will be emphasized, as neurovascular ultrasound is an important, user-friendly, noninvasive, and low-cost diagnostic and possibly therapeutic tool for patients with ischemic cerebrovascular disease. Therapeutic Ultrasound: Lessons Learned and What Should Be Reported Mark Schafer Sound Surgical Technologies, LLC, Louisville, Colorado USA While sonothrombolysis presents a tremendous clinical opportunity, the field has been hampered by a lack of proper dosimetry reporting. This has led to both confusion and controversy over not only the specifics of pressure, intensity, etc, but also of the underlying mechanisms SPECIAL INTEREST SESSION MONDAY, APRIL 8, 2013, 11:00 AM–12:30 PM How to Be an Effective Manuscript Reviewer for the Journal of Ultrasound in Medicine Moderator: Levon Nazarian, MD How to Be an Effective Manuscript Reviewer for the Journal of Ultrasound in Medicine Levon Nazarian Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania USA Peer review is the method used worldwide to determine whether manuscripts are suitable for publication, yet few physicians and sonographers are given formal instruction in how to review journal manuscripts. The purpose of this session is to describe the steps in the peerreview process at the Journal of Ultrasound in Medicine (JUM), to present the components that constitute a high-quality review, and to discuss ethical issues such as conflicts of interest, duplicate publication, and plagiarism. By demystifying the peer-review process and letting reviewers know what is expected of them, the ultimate goal is to improve the quality of manuscripts published in the JUM. S8 13proceedings_Layout 1 3/5/13 10:38 AM Page S9 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SCIENTIFIC SESSIONS MONDAY, APRIL 8, 2013, 11:00 AM–12:30 PM tography (EVE). It may be easier to distinguish stiffer tumors from healthy tissue from local shear moduli than inspecting B-mode images. This work proposes a statistically robust least squares fitting technique capable of detecting boundaries between materials with different shear wave velocities (SWVs). Methods—In an EVE tissue-mimicking phantom, an ablation electrode attached to an inclusion and vibrated by an actuator is used to generate shear waves. Ultrasound displacement estimators are used to track the shear wave pulse and record its arrival time at different locations. Assuming this plot is continuous and piece-wise linear, slopes and break points are detected using a least squares fit embellished with a Huber penalty. This penalty function switches from quadratic to linear for very large errors, thereby mitigating the effect of outliers. An Akaike information criterion is then used to trade off the error in the fit and the number of break points. The SWV estimates are compared with a commercial shear wave imaging system and mechanical testing. Results—SWV estimates are within 20% of those obtained using the commercial scanning system. Although the stiffness estimates are lower than those obtained from mechanical testing, the boundary delineation is quite good due to sharp transitions arising from the piece-wise linear fits. Conclusions—The use of statistically robust noise filtering techniques shows promise for improving results in the inverse problem of shear stiffness reconstruction from noisy ultrasound displacement data. (Supported by National Institutes of Health grants R01CA112192-05 and R01CA112192-S103.) Basic Science: Tissue Characterization, Part 1 Moderators: Keith Wear, PhD, Mark Holland, PhD 1539806 A Feasibility Study of Ultrasound Strain Imaging for Risk Assessment of Carotid Atherosclerotic Plaques Validated by Magnetic Resonance Imaging Xiaochang Pan,1 Shengzhen Tao,1 Lingyun Huang,2 Manwei Huang,3 Xihai Zhao,1 Le He,1 Chun Yuan,1,4 Jianwen Luo,1* Jing Bai1 1Biomedical Engineering, School of Medicine, Beijing, China; 2Philips Research Asia, Shanghai, China; 3 Ultrasonography, Meitan General Hospital, Beijing, China; 4 Radiology, University of Washington, Seattle, Washington USA Objectives—Conventional B-mode ultrasound images and Doppler/color flow measurement are mostly used to evaluate the degree of carotid atherosclerotic plaques, but they have a lack of histologic validation, while the correspondence between multicontrast magnetic resonance imaging (MRI) sequences and histology has been constructed. We propose a comprehensive MRI and ultrasound feasibility study to quantitatively measure morphologic and mechanic properties of carotid atherosclerotic plaques and develop a risk indicator for plaques. Methods—Sequences of raw ultrasound (radiofrequency) data were acquired from a 65-year-old male patient with carotid plaques on a Philips iU22 ultrasound system. The interframe strain of the plaques was estimated to indicate relative stiffness of different plaque compositions, using a coarse-to-fine 2D speckle-tracking algorithm based on cross-correlation and correlation filtering. The same patient underwent doubleblinded MRI scanning on a Philips Achieva 3T TX MR scanner using a multi–contrast imaging protocol. 3D MR images of this patient were reconstructed, and slices at the same position of the ultrasound incidence angle were selected and registered. Carotid plaque tissue compositions on MR images were characterized according to published criteria, while echogenicity and strain values in the ultrasound images were investigated and compared with MRI results. Results—The plaques with intraplaque hemorrhage (IPH) or a lipid-rich necrotic core (LRNC) on MR images were defined as high risk. In the ultrasound results, the calcified area of the plaque showed high echogenicity and low deformation (0.2%); IPH showed mid to high echogenicity and intermediate deformation (1.2%), and the LRNC showed the lowest echogenicity and large deformation (2.6%). The locations of the calcification, IPH, and LRNC were in good agreement with findings on MR images. Conclusions—We performed a quantitative measurement of the morphology and mechanical properties of high-risk plaques and showed that the combination of echogenicity and strain values obtained from raw ultrasound data is feasible to quantitatively evaluate the vulnerability of atherosclerotic plaques. Table 1 SWV, m/s Young Modulus, kPa Region Mechanical of Interest EVE SSI EVE SSI Testing Inclusion 3.4 В± 1.5 2.8 В± 1.1 42.2 В± 58 24.2 В± 5.8 54.4 В± 0.1 Partially ablated 2.0 В± 0.3 2.3 В± 0.8 12.1 В± 4.2 13.3 В± 3.5 21.6 В± 0.3 Background 1.4 В± 0.4 1.3 В± 0.4 6.5 В± 6.1 4.8 В± 0.5 3.7 В± 0.1 SSI indicates supersonic shear imaging. 1540416 A Comparison of Coherence of Radiofrequency Data From Ablated and Unablated Liver Tissue Using Multitaper Estimation Nicholas Rubert,* Tomy Varghese University of Wisconsin, Madison, Wisconsin USA Objectives—Thermally ablated liver tissue presents as a zone of mixed echogenicity on B-mode imaging, making it difficult to delineate the extent of treatment following thermal ablation. We demonstrate a novel contrast mechanism for ultrasonic imaging of thermal ablations based on the spatial distribution of acoustic scatterers. The portal triads and central vein of the liver are arranged in repeating subunits, which are hypothesized to correspond to quasi–periodically arranged acoustic scatterers. Estimates of the mean scatterer spacing (MSS) of these quasi–periodic scatterers have been hypothesized to be useful indicators of pathologic changes to the liver. Mathematically, the quasi–periodic scatterers gives rise to an ultrasound radiofrequency (RF) signal-possessing coherence. Methods—Coherence is a frequency domain quantity computed with tapered fast Fourier transforms of the ultrasound signal. Using simulation, we show that a coherence estimate using multiple orthogonal tapers outperforms coherence estimates computed with a single taper. We 1536174 A Huber-Penalized Akaike-Regularized Broken-Stick Least Squares Regression Algorithm for Shear Wave Velocity Reconstruction Atul Ingle,1* Tomy Varghese1,2 1Electrical and Computer Engineering, 2Medical Physics, University of Wisconsin, Madison, Wisconsin, USA Objectives—Tissue stiffness has been traditionally used as a qualitative metric for localizing cancerous tumors. The aim of this study is to obtain quantitative stiffness estimates using electrode vibration elasS9 13proceedings_Layout 1 3/5/13 10:38 AM Page S10 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 also perform receiver operating characteristic (ROC) analysis of 38 regions of interest (ROIs) from ex vivo bovine livers. Ultrasound imaging was performed using a 9L4 transducer on a Siemens S2000 system prior to and following RF thermal ablation in 19 independent samples cut from 4 bovine livers. Each ablation was approximately 1 to 2 cm in diameter. Results—In frequency domain Monte Carlo simulations, the multiple taper (MT) method was better able to estimate the MSS of gamma-distributed scatterers than any single taper (ST) calculations. In analyzing 2 different ROI sizes ex vivo, we found that for a gate length of 5 mm, we achieved an area under the ROC curve of 0.89, while at a gate length of 7 mm, we achieved an area under the ROC curve of 0.93 using MT coherence calculations. Conclusions—ROC analysis indicates that a tissue classifier using coherence is able to distinguish between ablated and unablated tissue and that an MT calculation of coherence is a better estimate than an ST calculation. (Supported by National Institutes of Health grants R01CA112192-05, R01CA112192-S103, and T32 CA09206-31). 1540510 Acoustic Radiation Force Impulse Delineation of Human Carotid Atherosclerotic Plaque Composition and Structure In Vivo Tomasz Czernuszewicz,1 Melissa Caughey,2 Peter Ford,3 Mark Farber,3 William Marston,3 Raghuveer Vallabhaneni,3 Jonathon Homeister,4 Matthew Mauro,5 Timothy Nichols,2,4 Caterina Gallippi1* 1Joint Department of Biomedical Engineering, 2Medicine, 3Surgery, 4Pathology and Laboratory Medicine, 5Radiology, University of North Carolina, Chapel Hill, North Carolina USA Objectives—Conventional atherosclerosis imaging methods rely on detecting luminal obstruction, which may not occur until late stages of disease progression and does not reflect plaque rupture potential. Plaque detection may be expedited and risk assessment improved by imaging methods that describe the plaque composition and structure. We have previously so demonstrated acoustic radiation force impulse (ARFI) ultrasound preclinically with immunohistochemical validation. The objective of this work was to similarly validate ARFI in human atherosclerosis. We hypothesize that ARFI delineates the fibrous cap, lipid/necrotic components, fibrous tissue, and calcium deposits in human atherosclerotic plaque in vivo. Methods—ARFI imaging was performed using a Siemens Acuson Antares imaging system with modifiable beam sequencing and a VF7-3 transducer in the carotid arteries of 2 patients undergoing clinically indicated carotid endarterectomy. Imaging was performed presurgically by focusing on the surgical plaque. After surgery, the extracted specimen was sectioned according to noted arterial geometry for spatial registration to the imaging plane. The sections were stained with hematoxylin-eosin, Verhoff van Gieson, Masson trichrome, and von Kossa. Parametric 2D ARFI images of peak displacement (PD) were rendered. Results—In a fibroatheromatic plaque, 3 times higher ARFI PD was measured in the position of a soft lipid/necrotic region than in the position of a thick fibrous cap above the region or fibrotic tissue below the region. ARFI PD was nearly zero in positions of small (<1 mm diameter) calcium deposits throughout the plaque. In a highly calcified plaque, ARFI PD was nearly zero throughout a large (15 mm laterally Г— 5 mm axially) calcium deposit but was >5 Вµm in the adjacent arterial tissue. Conclusions—These spatially matched ARFI and immunohistochemical data suggest that ARFI is relevant to describing the atherosclerotic plaque composition and structure in humans in vivo. The results also demonstrate the feasibility of collecting data to perform a larger-scale statistical reader study to evaluate human ARFI atherosclerosis imaging performance using spatially matched immunohistochemistry as the validating standard. 1539520 Echocardiography-Based Measurements of 3-Dimensional Myocardial Fiber Structure Michelle Milne,1 Kirk Wallace,4 Benjamin Johnson,1 Gautam Singh,2 Ravi Rasalingam,3 James Miller,1 Mark Holland1,2* 1 Physics, 2Pediatrics, 3Internal Medicine, Washington University, St Louis, Missouri USA; 4GE Global Research, Niskayuna, New York USA Objectives—Previous studies from our laboratory demonstrated that quantitative measurements of myocardial fiber structure for individual hearts can be derived from analyses of echocardiographic images. Echocardiography-based measurements of fiber structure at specific transverse planes agreed well with those obtained using diffusion tensor magnetic resonance imaging methods. The objective of this study was to extend the echocardiography-based measurements to produce 3D myocardial fiber structure images of the entire heart. Methods—A series of 2D apical echocardiographic images were acquired from each of 7 excised intact sheep hearts using a GE Vivid 7 clinical imaging system. Myocardial fiber orientations corresponding to specific distances from the apex of the heart were generated from analyses of radial line backscatter profiles within the ventricular walls of the heart in conjunction with a previously determined relationship between the backscatter level and the angle of insonification relative to myocardial fiber orientation. The fiber orientations at each measured distance from the apex were assembled to produce a 3D fiber orientation image of the entire heart. In addition, 3D volumetric apical echocardiographic images were acquired from a subset of the excised hearts for comparison. Results—3D images depicting myocardial fiber structure obtained from analyses of echocardiographic data appear consistent with the known fiber structure of the heart. Images demonstrate left ventricular mid-myocardial fibers oriented within the short-axis plane and gradually becoming more longitudinally oriented toward the epicardial and endocardial surfaces. Data from 3D volumetric apical echocardiographic images suggest similar results. Conclusions—These results demonstrate that measurements of 3D myocardial fiber structure of the entire heart can be successfully derived from analyses of echocardiographic images. Further development of this method may provide a method for mapping the myocardial fiber orientation in individual patients over the heart cycle and provide a means for assessing potentially altered fiber structure associated with congenital and acquired heart diseases. (Supported by National Institutes of Health grant R01 HL040302.) 1541124 Effects of Preprocessing on Reconstructed Shear Wave Speeds in Human Liver In Vivo Ned Rouze,1* Seung Yun Lee,1 Michael Wang,1 Mark Palmeri,1 Manal Abdelmalek,2 Kathryn Nightingale1 1 Biomedical Engineering, Duke University, Durham, North Carolina USA; 2Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina USA Objectives—Time-of-flight methods are often employed to provide quantitative measurement of shear wave speed (SWS) from ultrasonically tracked displacements following acoustic radiation force excitation in liver. These methods estimate overall group velocities of propagating shear waves and generally require filtering to reduce noise and motion artifacts. In addition, different systems employ different beam geometries in their push excitations, which also leads to differences in the shear wave frequency content. Differences in the shear wave frequency content can lead to differences in the estimated SWS due to the dispersive nature of hepatic tissue. In this study, we investigated the impact of these effects in a nonalcoholic steatohepatitis patient population from data obtained in an Institutional Review Board–approved protocol. Methods—Data from >170 patients with a range of fibrosis stages were processed using multiple filtering algorithms. Three types of motion filters were applied, including a quadratic motion filter, a high- S10 13proceedings_Layout 1 3/5/13 10:38 AM Page S11 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 pass filter (HPF) with an adjustable cutoff frequency, and differentiation of the displacement vs time data. The latter determines the axial velocity of the propagating pulse and allows the wave arrival time to be determined from the peak slope of the leading edge. This differentiation acts as a ramp filter in the frequency domain to reduce the effects of low-frequency motion. After filtering, SWSs were estimated using the arrival time as a function of position data and the radon sum algorithm. Results—Results obtained to date indicate that the application of motion filters does affect the reconstructed SWS. Both the HPF and differentiation filter bias the estimated group velocity to the higher phase velocity components; this effect is less significant for the quadratic filter. The differentiation filter leads to an ≈16% increase in SWS estimates over the range of 1.5 to 4.0 m/s compared to the quadratic filter. For the HPF, increasing the cutoff frequency from 25 to 150 Hz increases the SWS ≈13% over the same SWS range. Conclusions—Preprocessing algorithms used to remove lowfrequency noise and motion artifacts from in vivo data can skew group velocity SWS estimates toward the higher phase velocity components. 1540991 Evaluation of Shear Wave Elasticity Imaging for Characterizing the Contribution of Coronary Perfusion to Cardiac Diastolic Stiffness Maryam Vejdani-Jahromi,* Annette Kiplagat, Young Joong-Kim, Douglas Dumont, Gregg Trahey, Patrick Wolf Biomedical Engineering, Duke University, Durham, North Carolina USA Objectives—Heart failure is one of the leading causes of death in the world in which mechanical properties of the cardiac tissue are damaged. Diastolic heart failure occurs when the left ventricle loses its compliance to receive a sufficient volume of blood. Currently, there is no universally accepted technique to evaluate changes in mechanical properties of cardiac tissue. Shear wave elasticity imaging (SWEI) is an ultrasound-based technique used to evaluate the stiffness of the tissue by measuring the shear wave speed of propagation. To evaluate the capability of SWEI in determining the contribution of coronary perfusion to diastolic stiffness, normal and hypoperfused rabbit hearts were studied. Methods—Six rabbit hearts were isolated on a Langendorff preparation, perfused with Tyrode solution. Data were acquired using a VF10-5 linear transducer on a Sonoline Antares ultrasound system (Siemens Medical Solutions, Mountain View, CA) with a focal point of 1.6 cm, transmit frequency of 5.7 MHz and F-number of 1.5. The probe was fixed approximately 1 cm from the left ventricular free wall along the short axis and acquired data from the same location. Hypoperfusion was done in 3 isolated hearts by reducing the perfusion pressure until the flow rate was half of normal, and SWEI data were recorded before and 10 minutes after. Three rabbit hearts with a normal flow rate were studied as control subjects. Results—Initial results showed that reduction of 50% in perfusion pressure caused an average decrease of 27.7% in the shear wave velocity and 47.7% in the shear modulus, while normal hearts showed increases of 9.0% and 18.7% for the shear wave velocity and shear modulus, respectively. Conclusions—From these preliminary data, we conclude that the shear wave velocity and shear modulus recorded by SWEI can show the contribution of coronary perfusion pressure to diastolic stiffness. This new ultrasound-based imaging modality can be used to assess, characterize, and quantify the mechanical properties of the heart. Table 1 Hearts Hypoperfused before Hypoperfused after Normal before Normal after Shear Wave Velocity, m/s 1.69 1.22 1.23 1.34 Shear Modulus, kPa 2.84 1.49 1.50 1.79 1540671 Feasibility and Reproducibility of Right Ventricular Strain Measurement by Speckle-Tracking Echocardiography in Preterm Infants Philip Levy,1* Gautam Singh,1 Tim Sekarski,1 Aaron Hamvas,1 Mark Holland1,2 1Pediatrics, Washington University School of Medicine, St Louis, Missouri USA; 2Physics, Washington University, St Louis, Missouri USA Objectives—The right ventricle (RV) is the dominant ventricle in premature and term neonates, and its function is an important determinant of the clinical status and prognosis of congenital and acquired cardiopulmonary pathologies. Myocardial strain and the strain rate represent 2 sensitive measures of cardiac function. 2D speckle-tracking echocardiography (2DSE) is an angle-independent method for strain measurement but has not been applied in preterm infants for assessment of RV function. The aim of this study was to evaluate the feasibility and reproducibility of 2DSE-measured RV global longitudinal strain in preterm infants and establish standardized methods for acquiring and analyzing strain measurements. Methods—2DSE (GE EchoPac) was used to measure the peak global longitudinal strain (pGLS) and strain rate (pGLSR) in the apical 4chamber view of the RV in 50 preterm infants (27 В± 1 weeks at birth) at 32 weeks postmenstrual age. Images were acquired with frame rates between 60 and 100 Hz for 3 cardiac cycles and stored for offline analysis. Two observers measured the RV pGLS and pGLSR in 25 randomly selected images. Interobserver and Intraobserver reproducibility were assessed using Bland-Altman analysis (relative bias, 95% limits of agreement [LOA]), and the correlation was tested using linear regression. Results—Strain imaging was feasible from 85% of the acquisitions. Intraobserver 2DSE RV pGLS and pGLSR reliability demonstrated high reproducibility (bias, 4%; 95% LOA, –2.1 to +1.9; r = 0.98; P < .01; and bias, 6%; 95% LOA, –0.29 to +0.26; r = 0.94; P < .01, respectively). Interobserver 2DSE RV pGLS and pGLSR reliability also showed high reproducibility (bias, 7%; 95% LOA, –4.1 to +3.9; r = 0.92; P < .01; and bias, 7%; 95% LOA, –0.41 to +0.42; r = 0.94; P < .01, respectively). Conclusions—Our study demonstrates high feasibility and reproducibility of RV strain measurements by 2DSE in preterm infants and offers specific recommendations for image acquisition and data analysis that reduce measurement variability. Strain measurement by 2DSE offers a robust tool for the assessment of global RV function that is not achieved by conventional methods. (Supported by National Institutes of Health grants 1U01 HL101465 and R21 HL106417.) 1541514 Statistical Comparison of Backscatter Coefficients for MAT and 4T1 Tumors Across Multiple Ultrasound-Imaging Systems Douglas Simpson,1* Nathaniel Hirtz,1,2 William O’Brien Jr2 1 Statistics, 2Bioacoustics Research Laboratory, Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois USA Objectives—Quantitative ultrasound measurements such as the backscatter coefficient (BSC) have the potential to greatly enhance tissue characterization and identification of tumors. A balanced experiment was conducted to compare consistency across transducers and efficacy for distinguishing 2 well-characterized animal tumor types. Methods—The study included induced 4T1 and MAT tumors in mice and rats. Animals were scanned with 5 different transducers with a target of 5 scan lines per tumor region of interest. BSCs were computed for each scan. The resulting BSC data were analyzed across tumor types and transducers using spatially dependent linear mixed model analysis, where the spatial dependence was between neighboring frequencies within the same scan line. The model allowed comparison of BSC curves from transducers with varying frequency ranges. Results—For 4T1 tumors, transducer differences were not statistically significant. For MAT tumors, significant differences between S11 13proceedings_Layout 1 3/5/13 10:38 AM Page S12 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 transducers were found. All 5 transducers detected significant differences between tumor types either through a mean shift model or via changes in curve shape between tumor groups. Higher-frequency transducers produced significantly greater separation of mean BSC curves between MAT and 4T1 tumors. Mean differences between tumor types were smaller than the inherent variability in the BSC curves as measured by the residual standard error values, indicating a low signal to noise ratio for classification. Conclusions—All 5 ultrasound-imaging transducers were effective in detecting significant differences between MAT and 4T1 tumors, either through mean shift or through shape changes. Higher frequencies in the range above 8.5 MHz were more effective than lower frequencies in detecting tumor differences. 1540921 Automatic Detection of Keratoconus From HighFrequency Ultrasound Data Ronald Silverman,1,2* Raksha Urs,1 Arindam RoyChoudhury,1 Timothy Archer,3 Dan Reinstein3 1Ophthalmology, Columbia University Medical Center, New York, New York USA; 2Frederic L. Lizzi Center for Biomedical Engineering, Riverside Research, New York, New York USA; 3London Vision Clinic, London, England Objectives—Keratoconus (KC), a corneal dystrophy characterized by progressive corneal thinning and bulging, is currently detected by optically determined corneal topography and curvature. The corneal epithelium, however, tends to remodel to smooth out irregularities in the underlying stroma, potentially masking early KC topographic changes. In this report, we describe automated ultrasound detection of KC based on altered epithelial thickness patterns. Methods—Corneas of 128 normal and 68 KC subjects (1 randomly chosen eye per subject) were scanned using the Artemis-1 (Arcscan, Inc, Morrison, CO) high-frequency ultrasound system. Scans are performed with an optical fixation target and video monitoring of eye position while the 50-MHz transducer is scanned in an arc such that curvature in the focal plane approximately matches that of the corneal surface. Radiofrequency data are digitized at 500 MHz. Scans were acquired in 4 planes at 0В°, 45В°, 90В°, and 135В°. Postprocessing consisted of automatic detection of the corneal surfaces and the epithelial/stromal interface. Maps (100 Г— 100 at 0.1-mm intervals) of epithelial and stromal thickness were then automatically analyzed to extract 87 features that might potentially differentiate normal from KC eyes. Stepwise linear discriminant analysis (LDA) and neural network (NN) analysis using a radial basis kernel were then performed. NN analysis was repeated 10 times with different random test sets (30% of cases). Results—Stepwise LDA produced a model consisting of 11 features with sensitivity of 91.2%, specificity of 99.2%, and an area under the receiver operating characteristic (ROC) curve of 98.5%. A leave-oneout procedure gave identical sensitivity and specificity. The NN showed average sensitivity of 93.5% and specificity of 97.4% for the training set and 88.8% and 97.5%, respectively, for the test set. The area under the ROC curve was 97.8%. Conclusions—Our results show ultrasound-detected patterns in corneal layered topography to be very effective at distinguishing normal from KC corneas. Future studies will combine these methods with optical data for early detection, which would allow early treatment by collagen cross-linking and avoidance of potentially damaging corneal refractive surgical procedures. Breast Ultrasound and Elastography Moderator: Abid Irshad, MD 1538656 Correlation Between Parameters in Ultrasound-Guided Diffuse Optical Tomography and 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography for Breast Cancer Woo Jung Choi,* Hak Hee Kim, Joo Hee Cha, Hee Jung Shin, Hyunji Kim Radiology, Asan Medical Center, Seoul, Korea Objectives—The purpose of this study was to correlate parameters in ultrasound (US)-guided diffuse optical tomography and maximum standardized uptake value in 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). Methods—We retrospectively evaluated 228 patients (mean age, 46.9 years; range, 29–71 years) diagnosed with breast cancer between September 2009 and February 2012. Both US-guided diffuse optical tomography and 18F-FDG PET/CT were performed. For each lesion, the total hemoglobin concentration (HBT) level and oxygen saturation (SO2) level were calculated, and the synthesis diagnosis index (SDI) was designed using US-guided diffuse optical tomography. With 18F-FDG PET/CT, the maximum standardized uptake value (mSUV) was calculated. We compared the parameters in US-guided diffuse optical tomography with the mSUV of known malignant breast lesion on 18F-FDG PET-CT using the Spearman correlation coefficient. Results—All 228 malignant lesions were primary breast cancers, and the histologic types included invasive ductal carcinoma (n = 210), invasive lobular carcinoma (n = 4), invasive mammary carcinoma (n = 12), and metaplastic carcinoma (n = 2). Correlation between the SO2 level and mSUV was statistically significant (Spearman correlation coefficient = –0.280; P < .001). The HBT level and SDI showed a low correlation coefficient with the mSUV (spearman correlation coefficients = 0.049 and 0.072; P = .458 and .280, respectively). Conclusions—The SO2 level of US-guided diffuse optical tomography correlated well with the mSUV of 18F-FDG PET/CT. A low SO2 level in optical imaging may predict a high mSUV level on 18F-FDG PET/CT, and it may serve as a useful tool for predicting the response rate after neoadjuvant chemotherapy in breast cancer. 1540665 Comparison of Strain and Shear Wave Without or With a Quality Measure in Evaluation of Breast Masses Richard Barr Radiology Consultants, Inc, Youngstown, Ohio USA Objectives—Shear wave imaging (SVI) in the breast codes some cancers as soft. Coding a malignancy as soft can be due to poor shear wave propagation. The addition of a quality measure (QM) that determines if an adequate shear wave formed for accurate measurements. The aim of this paper was to compare the predictive value of strain (elasticity imaging [EI]) and SVI without and with a QM. Methods—Patients scheduled for an ultrasound breast biopsy had strain (EI) and SVI on a Siemens S2000 system modified to perform SVI with a QM. Lesions were evaluated for shear wave velocity (Vs ) and the QM. The highest Vs in the lesion or surrounding ring (if present) was used. The Vs was classified as benign (<4.5 m/s) or malignant (>4.5 m/s). For strain, an EI/B-mode ratio of <1 was considered benign, while ≥1 was considered malignant. Results were correlated with pathology. Receiver operating characteristic (ROC) curves were obtained. Results—A total of 144 patients with 166 lesions were enrolled. Patient age averaged 48.5 (range, 18–81) years. Lesion size averaged 10.6 (range, 5–43) mm. Pathology was benign in 110 (66.3%) and malignant in 56 (33.7%). Sixteen (14.6%) benign lesions had no SVI signal; 89 (80.9%) were benign on SVI; and 5 (4.5%) were malignant. In the malig- S12 13proceedings_Layout 1 3/5/13 10:38 AM Page S13 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 nant lesions, SVI had no Vs in 10 (18.1%); 25 (44.6%) were benign; and 21 (37.5%) were malignant. The QM was low in all cases where no SVI signal was obtained: in 19 of 25 (76.0%) soft malignant lesions, 2 of 5 (40%) hard benign lesions, and 6 of 89 (6.7%) soft benign lesions. The QM was high in 3 of 25 (12.0%) soft malignant lesions, which were lymphoma. Three false-negatives on EI were lymphomas. In cases were there is a low QM, if the lesion is solid, it is most likely a cancer. Conclusions—Strain imaging had the highest sensitivity, while SVI had the highest specificity (without or with the QM). There was a significant improvement in the sensitivity of SVI with the addition of the QM; however, an additional 16.9% of cases could not be evaluated. Table 1. Comparison of Techniques No. Sensitivity, Specificity, Evaluable % % AUROC 163 95 88 0.9595 166 41 95 0.6756 138 78 94 0.7988 166 93 87 0.9006 Technique Strain (EI) SVI – QM SVI + QM SVI + low QM and solid lesion = malignant AUROC indicates area under the ROC curve. 1536920 Differentiation of Benign and Malignant Breast Lesions: A Comparison Between Automatically Generated Breast Volume Scans and Handheld Ultrasound Examinations Hongyan Wang,1* Yuxin Jiang,1 Qingli Zhu,1 Jing Zhang,1 Qing Dai,1 He Liu,1 Xingjian Lai,1 Qiang Sun2 1Diagnostic Ultrasound, 2Breast Surgery, Peking Union Medical College Hospital, Beijing, China Objectives—To assess the diagnostic value of automated breast volume scanning (ABVS) and conventional handheld ultrasonography (HHUS) for the differentiation of benign and malignant breast lesions. Methods—The study prospectively evaluated 239 lesions in 213 women who were scheduled for open biopsy. The patients underwent ABVS and conventional HHUS. The sensitivity, specificity, accuracy, false-positive rate, false-negative rate, and positive and negative predictive values for HHUS and ABVS images were calculated using histopathologic examination as the gold standard. Additionally, diagnostic accuracy was further evaluated according to the size of the masses. Results—Among the 239 breast lesions studied, pathology revealed 85 (35.6%) malignant lesions and 154 (64.4%) benign lesions. ABVS was similar to HHUS in terms of sensitivity (95.3% vs 90.6%), specificity (80.5% vs 82.5%), accuracy (85.8% vs 85.3%), positive predictive value (73.0% vs 74.0%), and negative predictive value (93.3% vs 94.1%). The area under the receiver operating characteristic curve, which is used to estimate the accuracy of the methods, demonstrated only minor differences between HHUS and ABVS (0.928 and 0.948, respectively). Conclusions—The diagnostic accuracy of HHUS and ABVS in differentiating benign from malignant breast lesions is almost identical. However, ABVS can offer new diagnostic information. ABVS may help distinguish between real lesions and inhomogeneous areas, find small lesions, and demonstrate the presence of intraductal lesions. This technique is feasible for clinical applications and is a promising new technique in breast imaging. 1540513 Functional Images of Hemoglobin and Blood Oxygen Saturation Coregistered With Ultrasound Provide Accurate Differentiation of Breast Tumors Pamela Otto,1* Kenneth Kist,1 N. Carol Dornbluth,1 Thomas Stavros,2 Donald Herzog,2 Thomas Miller,2 Bryan Clingman,2 Jason Zalev,2 Michael Ulissey,3 Philip Lavin,4 Sergey Ermilov,5 Alexander Oraevsky2,5 1Radiology, University of Texas Health Science Center, San Antonio, Texas USA; 2Seno Medical Instruments, San Antonio, Texas USA; 3Radiology, University of Texas Southwestern Medical Center, Dallas, Texas USA; 4Aptiv Solutions, Southborough, Massachusetts USA; 5 TomoWave Laboratories, Inc, Houston, Texas USA Objectives—A novel system called Imagio combines ultrasound (US) and opto-acoustics (OA) to more accurately distinguish malignant from benign tumors. We analyzed the ability of blind readers to assess the probability of malignancy (POM) using coregistered functional and anatomic images vs conventional diagnostic ultrasound (DUS) alone. Methods—Seventy-three patients with breast masses were assessed with OA and DUS. All the masses were biopsied, and histology was the gold standard. OA employs near-infrared laser pulses at 2 different wavelengths (to provide contrast between oxygenated hemoglobin in benign lesions and deoxygenated hemoglobin in malignant lesions) to illuminate tissues through a fiber-optic bundle incorporated into a prototype handheld OA US probe. It detects the laser pulse–induced acoustic pressure waves that are then used for reconstruction of 2D functional and anatomic images. OA maps of total hemoglobin and blood oxygen saturation provide functional information that is coregistered with the morphological information from B-mode grayscale US images. Results—Five blinded readers independently assessed POM for OA and DUS. OA provided a >40% higher mean POM for all malignant lesions, a >30% higher mean POM for malignant Breast Imaging Reporting and Data System (BI-RADS) 4B lesions, and a >10% higher mean POM for malignant BI-RADS 5 lesions than did DUS. OA could potentially spare 23.7% more negative biopsies than DUS at the critical 2% POM level. Conclusions—The fused functional OA and grayscale anatomic information significantly improved distinction of benign from malignant breast masses compared with DUS alone, especially within the BI-RADS 4B category, where OA better distinguishes benign from malignant lesions and thereby prevents unnecessary biopsies. 1522001 Granulomatous Mastitis: Clinical and Sonographic Features With Image-Guided Biopsy Correlation Priyanka Handa,1* Derek Sun,1 Jill Leibman,1,2 Aryeh Goldberg,1 Maria Abadi1,2 1Jacobi Medical Center, Bronx, New York USA; 2Albert Einstein College of Medicine, Bronx, New York USA Objectives—Granulomatous mastitis (GM) is an unusual inflammatory lesion that can mimic breast cancer on clinical exam and imaging studies. The purpose of this study was to review the clinical presentation and imaging findings (including sonography) associated with GM and determine the adequacy of image-guided biopsy for diagnosis. Methods—A retrospective study was performed to identify patients with breast imaging studies and a pathologic diagnosis of GM. The clinical presentation, imaging findings, biopsy method, and pathology reports were reviewed. Results—Twenty-seven patients were included; average age was 35.3 years (range, 21–66 years). Twenty-four patients presented with pain, a palpable mass, and/or discharge. Three asymptomatic patients presented for screening mammograms. All patients were imaged with ultrasound (US), demonstrating a mass in 19 (70%), tubular lucencies without a mass in 6 (22%), and no findings in 2 (8%). In the 25 patients with positive sonographic findings, the mass was anechoic in 3 (12%), hypoechoic S13 13proceedings_Layout 1 3/5/13 10:38 AM Page S14 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 in 12 (48%), hyperechoic in 1 (4%), and mixed echogenicity in 9 (36%). Four of the 25 masses demonstrated posterior acoustic enhancement (16%), and 21 of the 25 masses did not demonstrate posterior acoustic enhancement (84%). Doppler vascularity was present in 11 patients (44%). A mass was demonstrated in 19 patients; 5 masses were well defined (26%), and 15 masses had irregular margins (74%). Twenty-six of the 27 patients had correlative mammographic findings. Pathologic diagnosis was made by US-guided biopsy in 11 of 27 (40%), US-guided fine-needle aspiration in 1 of 27 (4%), and mammotome biopsy in 1 of 27 (4%). Palpation-guided tissue sampling was performed in 12 of 27 (44%). Surgical excision was performed in 7 of 27 (26%). Conclusions—The sonographic features of GM are infrequently described. Our study demonstrated that the sonographic findings are indeterminate and may mimic malignancy. Although previously reported exclusively in young women with palpable findings, our study demonstrates that it can occur in postmenopausal as well as asymptomatic patients. The diagnosis of GM is optimally made by US-guided core biopsy. 1538026 Using a New Ultrasound Image-Processing Technique for Identification of Microcalcifications in Patients Prior to Biopsy Priscilla Machado,* John Eisenbrey, Barbara Cavanaugh, Flemming Forsberg Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA Objectives—To evaluate a new commercial image-processing technique (MicroPure; Toshiba America Medical Systems, Tustin, CA) for the identification of breast microcalcifications in patients undergoing stereotactic or ultrasound (US)-guided biopsies and to compare results to x-ray imaging of the tissue retrieved. Methods—Twelve women, scheduled for stereotactic biopsy or US-guided biopsy of an area with breast calcifications (identified on a prior mammogram), were enrolled in the study. The patients underwent a US examination consisting of real-time dual imaging of grayscale US and MicroPure using an Aplio XG scanner (Toshiba America Medical Systems) with a broad-bandwidth linear array. MicroPure combines nonlinear imaging and speckle suppression to mark suspected calcifications as white spots in a blue overlay image. Still images and digital clips of the target area were acquired. Independent and blinded readers (2 radiologists and 2 physicists) analyzed 26 digital clips to determine the number of calcifications seen with MicroPure and also to give a subjective view on the level of suspicion (LOS) of the findings. X-ray imaging of the specimen was analyzed by a radiologist who counted the exact number of microcalcifications. The number of microcalcifications was compared using the mean number from the 4 readers with the mean number on the x-ray image. The LOS was compared with the pathologic findings using receiver operating characteristic (ROC) analysis. Results—The mean number of microcalcifications seen on MicroPure was 6.96 (3.33–13.37). These values show excellent agreement with the mean number of microcalcifications seem on the x-ray image of the tissue retrieved (7.42; P = .39). ROC analysis of the readers’ LOS scores compared to the pathologic findings produced areas under the curve of 0.74–0.99. Conclusions—MicroPure imaging was able to identify microcalcifications at the target area as confirmed by x-ray imaging of the tissue specimen. These findings indicate that MicroPure may be used to guide breast biopsy procedures, but more studies are needed. 1540975 The Natural History of Thyroid Nodules With Peripheral Calcification Arash Anvari,* Anthony Samir Radiology, Abdominal Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts USA Objectives—Peripheral dystrophic calcification is a known pattern in thyroid nodules seen on ultrasound (US) and can be found in both benign and malignant nodules. The American Thyroid Association (ATA) guidelines for recommending biopsy in the setting of nodule follow-up are predicated on a change in nodule size exceeding 50%. It is unknown whether rim calcification in a thyroid nodule may prevent nodule enlargement, potentially rendering the ATA biopsy criteria ineffective. The objective of this study was to determine whether rim calcified nodules undergoing US follow-up are able to enlarge to an extent meeting ATA criteria for fine-needle aspiration biopsy (FNAB). Methods—We searched our institute’s radiology report database for thyroid nodules with rim calcification between 2002 and 2011. We then reviewed each subject to determine parameters like demographic data, nodule size, timing and number of follow-up sonograms, and FNAB and/or surgical pathologic results. We calculated nodule volumes using the formula for a rotational ellipsoid (volume = depth Г— width Г— length Г— ПЂ/6) to evaluate the growth rate between the first and last US reports. Results—We found 197 thyroid nodules with peripheral rim calcification in 192 subjects; 164 subjects (85.4%) were female (age range, 30–90 years; 60.35 В± 13.77 years; maximal dimension range, 3–36 mm; 11.95 В± 7.12 mm). We evaluated volume changes in 59 nodules that had a US follow-up interval of at least 1 year (range, 1–9.5 years; 3.58 В± 2.14 years). Thyroid nodule volumes ranged from 0.02 to 14.19 mL (1.04 В± 2.29 mL) at the initial follow-up and ranged from 0.02 to 10.75 mL (11 В± 2.06 mL) at the last follow-up. Over the period of follow-up, 17 of 59 rim calcified nodules (28.9%; 95% confidence interval, 17.3%–40.4%) changed in volume by >50%. The proportion of nodules with volume changes exceeding 50% increased with longer follow-up and when the maximal diameter was <10 mm. Of the 197 nodules, we had FNAB findings in 49 nodules (23 benign, 16 malignant/suspicious, and 10 nondiagnostic). We also had surgical pathologic findings in 28 nodules (16 malignant and 12 benign lesions). Conclusions—Rim calcification does not prevent changes in thyroid nodule volumes over time. 1541150 Value of Shear Wave Elastography to Differentiate Benign From Malignant Thyroid Nodules Lucy Kerr,* Uziel Nunes, Luana Cunha Sonimage dig Medico por US, SГЈo Paulo, Brazil Objectives—The purpose of this study was to evaluate the value of the shear wave elastography (E) to differentiate benign from malign thyroid nodules according 2 criteria: (1) nodule stiffness and (2) differences in size between B-mode sonography (US) and E. Methods—One hundred fifty thyroid nodules in 84 patients were prospectively evaluated from September 2010 to August 2012 with high-resolution US and shear wave E with the AS-2000 (Siemens). The nodules were grouped according the stiffness in 11 patterns: (1) ≥70% soft; (2) ≥70% intermediate; (3) ≥70% hard; (4) 51% to 69% soft; (5) 51% to 69% intermediate; (6) 51% to 69% hard; (7) no hardness dominance; (8) 50% soft and 50% intermediate; (9) 50% soft and 50% hard; (10) 50% intermediate and 50% hard; and (11) same stiffness of thyroid parenchyma. Patterns 1, 4, and 11 were considered benign, 3 and 6 malignant, and the others inconclusive. We also considered benign if the nodule was bigger on US than E, malignant if bigger on E than US, and inconclusive if had the same size in both. All E diagnosis was correlated with cytopathology and 55 nodules also with histopathology. Results—Among the 150 thyroid nodules, 21 were malignant. The sensibility, specificity, positive predictive value, and negative predic- S14 13proceedings_Layout 1 3/5/13 10:38 AM Page S15 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 tive value using the stiffness criterion were 90% (19/21), 93% (95/102), 73% (19/26), and 98% (95/97); and 88% (15/17), 91% (60/66), 71% (15/21), and 97% (60/62) using the size criterion. We had 2 false-negatives, both papillary cancer with cystic content giving the soft appearance, and 7 false-positives (3 lymphocytic thyroiditis and 4 colloid goiter). Of 150, 27 (18%) nodules were classified as inconclusive by the stiffness criterion and 62 (42%) by the size criterion. Conclusions—Shear wave E of suspicious thyroid nodules using the stiffness criterion is precise and helpful to differentiate between benign and malignant thyroid nodules, and we recommend it to be incorporated in clinical practice. The size criterion is less helpful due to many inconclusive cases, despite having good specificity and a good negative predictive value. 1506963 Ultrasound- and Ultrasound Elastography-Based Clinical Score for Screening of Thyroid Nodules Nami Azar, Edwin Vargas Velandia,* Ronald Novak, Dean Nakamoto Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio USA Objectives—In current clinical practice, most centers perform biopsies on all thyroid nodules with a size >1 cm independent of the sonographic findings. Our aim was to develop an imaging-based clinical score for better characterization of thyroid nodules with the aim of reducing nonindicated thyroid biopsies. Methods—In a retrospective review, data of patients who presented with suspicious thyroid nodules and underwent conventional (Doppler) ultrasound (US), US quantification elastography, and USguided fine-needle aspiration (FNA) were analyzed. The nodules were initially classified as benign or malignant according to the FNA result. The following imaging parameters (internal flow, irregular margins, hypoechogenicity, calcifications, size [volume and diameter], and quantification elastography) were analyzed under a direct logistic regression as accurate predictors of malignancy. Four clinical scores were designed based on these parameters and compared as diagnostic methods. Results—A convenience sample of 130 subjects was chosen for analysis. In this sample, thyroids of 24 subjects (18%) were proven by pathology to be malignant, and 106 (82%) were benign. Direct logistic regression was used to calculate areas under the curve (AUCs) for 4 clinical scoring indices (S1–S4), and regression parameters were used to compare the AUCs using the method of DeLong et al. Overall, 1 scoring index (S1), including irregular margins, hypoechogenicity, size, internal flow, and quantification elastography, was determined to be the best predictor of malignancy due to its larger AUC of 0.938. Choosing an index score of 5.0 maximized both sensitivity (95.8%) and specificity (87.7%) for predicting malignancy and would theoretically curtail the number of biopsies by 72.3%. Conclusions—Our clinical score based on imaging parameters evaluated during a conventional US examination exhibits high sensitivity and specificity for identifying malignant thyroid nodules. Application of this tool in daily clinical practice may reduce the number of nonindicated thyroid biopsies. Our study was limited by a small population size, and further analyses with larger patient samples are warranted. 1540472 Linear and Nonlinear Elastosonographic Data May Aid Differentiation of Thyroid Nodules Rafal Slapa,1* Bartosz Migda,1 Wieslaw S Jakubowski,1 Jacek Bierca,2 Jadwiga Slowinska-Srzednicka3 1Diagnostic Imaging, Medical University of Warsaw, Warsaw, Poland; 2 Surgery, Hospital at Solec, Warsaw, Poland; 3Endocrinology, Center for Postgraduate Medical Education, Warsaw, Poland Objectives—Although elastography can assist in the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at present. Further improvements in the technique and the diagnostic crite- ria are necessary for this examination to provide a useful contribution to diagnosis. The aim of the study was to evaluate a new linear/nonlinear approach for strain elastosonography of thyroid nodules, based on the analysis of time-strain curves, and to compare it with classic elasticity score and thyroid strain ratio methods. Methods—During 2009 to 2011, 67 patients scheduled for thyroidectomy (62 with myasthenia gravis) were evaluated with B-mode and power Doppler ultrasound of the whole thyroid. During ultrasound examination, 96 dominant nodules were examined with strain elastosonography with Aplio XG (Toshiba, Japan) with a linear 5–17-MHz transducer. The stiffness of each thyroid nodule was evaluated with classic features of strain elastosonography qualitatively (with elasticity scores) and semiquantitatively with thyroid tissue strain/nodule strain ratios with application of Elasto Q (Toshiba). Moreover, a novel original approach to elasticity data based on evaluation of time-strain curves was applied. Statistical analysis was performed with Statistica 10 (StatSoft, Inc). Results—There were 7 papillary carcinomas and 89 benign nodules. Classic elastosonographic analysis with the elasticity score and elasticity ratio on statistical analysis did not show a significant difference between cancer and benign nodules (P = .431 and .156). On linear/nonlinear analysis of time-strain curves, excellent differentiation (P = 5.6 Г— 10–9) was possible with a new parameter: the relative length of nonlinear relaxation. With a threshold of 0.5, sensitivity was 100% and specificity 85.4% (area under the receiver operating characteristic curve = 0.975). Conclusions—The analysis of linear and nonlinear elastosonographic data may greatly improve differential diagnosis of thyroid nodules. Further multicenter large-scale studies evaluating the usefulness of linear/nonlinear elastosonographic phenomena (involving evaluation of vioscoelasticity, eg, shear wave spectroscopy) in differential diagnosis of thyroid cancer are warranted. (Supported by Ministry of Science of Poland grant N402 476437.) 1540131 Noninvasive Determination of Corneal Elasticity Using Acoustic Radiation Force After Corneal Cross-Linking Raksha Urs,1* Harriet Lloyd,1 Ronald Silverman1,2 1 Ophthalmology, Columbia University Medical Center, New York, New York USA; 2Frederic L. Lizzi Center for Biomedical Engineering, Riverside Research Institute, New York, New York USA Objectives—There is immense interest in corneal cross-linking therapy (CXL) to strengthen the cornea for treatment of keratoconus. Currently, biomechanical tests to assess efficacy of CXL in vivo are limited. The objective of this project is to demonstrate the use of acoustic radiation force (ARF) to determine the stiffness of the rabbit cornea in vivo before and after CXL. Methods—The corneas of 2 live rabbits were exposed to ARF using a single-element transducer (25-MHz central frequency, 6-mm aperture, 18-mm focal length; Panametrics V324-SU). The beam sequence consisted of 20 pushing tone bursts of 400 microseconds duration (80% duty cycle), with imaging impulses interleaved in the dead time to allow radiofrequency (RF) data acquisition during the push mode. M-mode data were collected for another 200 milliseconds after the push sequence. The right eyes of the rabbits were then cross-linked with ultraviolet light and riboflavin. ARF measurements were performed once a week for 4 weeks following CXL. A spline-based algorithm was used to determine continuous displacement of the front and back surfaces of the cornea, using RF data sampled at 400 MHz (12 bits/sample), to determine the change in corneal thickness and strain. The acoustic output was characterized with a 40-Вµm-diameter needle hydrophone calibrated up to 60 MHz and measured to be 2.5 MPa. An absorption coefficient of 0.93 dB/cm-MHz was used to estimate the force in the cornea. ARF-induced strain was fit to the Voigt model to determine the elastic modulus. Results—The mean elastic modulus values during the 4 weeks of follow-up were 36 В± 8 and 32 В± 1 kPa for the untreated eyes and 49 В± S15 13proceedings_Layout 1 3/5/13 10:38 AM Page S16 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 5 and 45 В± 12 kPa for the cross-linked eyes. A paired t test revealed a statistically significant difference between untreated and cross-linked eyes in 1 rabbit (P = .04). While corneal stiffness increased with cross-linking in the other treated rabbit, the change was not statistically significant. Conclusions—Results show that changes in corneal stiffness after CXL can be measured in vivo using ARF. Future studies will be performed to evaluate the use of this method for detection of keratoconus, where the cornea’s biomechanical properties are believed to be altered. Contrast-Enhanced Ultrasound Moderators: Yuko Kono, MD, PhD, Theresa Tuthill, PhD 1541199 Volumetric Contrast-Enhanced Ultrasound Imaging of Renal Perfusion Marshall Mahoney, Anna Sorace, Kenneth Hoyt* University of Alabama at Birmingham, Birmingham, Alabama USA Objectives—The goal of this project was to evaluate wholeorgan ultrasound (US) imaging and microbubble (MB) contrast agents for characterizing perfusion in a phantom and an animal model and also to assess the impact of US scanning parameters on volumetric image quality. Methods—Real-time volumetric contrast-enhanced US (VCEUS) imaging was performed using the BioSONIC VIEW system (Bioscan Inc) equipped with a broadband 4DL14-5/38 probe. An MBsensitive harmonic imaging mode (transducer transmits at 5 MHz and receives at 10 MHz) was used to acquire VCEUS data. Following microbubble infusion, custom programs implemented in MATLAB (MathWorks) processed volumetric data sets and time-intensity curves to estimate perfusion parameters, namely, peak intensity, time to peak intensity, wash-in rate, and area under the curve. The VCEUS system was tested in vitro using a tissue-mimicking flow phantom at volume flow rates of 10, 20, 30, and 40 mL/min and MB concentrations of 0.005, 0.01, and 0.02 mL/L. The system was also tested using healthy Sprague Dawley rats to further analyze renal perfusion imaging results. All experiments used the Definity (Lantheus Medical Imaging) MB contrast agent. Results—All 3D reconstructions allowed visualization of in vitro and in vivo perfusion parameters. Volume summarizing statistics from in vitro experiments demonstrated that wash-in rate and time-to-peak measurements were proportional to volume flow rates, while the peak intensity and area under the curve measurements were proportional to the MB dose concentration. Results acquired in rat kidney demonstrated that parametric measurements were consistent for each animal. Importantly, rotation of the imaging transducer (up to 90В°) did not impact renal perfusion measurements at high-volume frame rates. Collectively, results indicate that MB destruction-replenishment and time-intensity curve parametric analysis with real-time volumetric ultrasound imaging is a promising modality for characterizing renal perfusion properties. Conclusions—VCEUS imaging was shown to be a promising modality for evaluating renal perfusion. Preliminary results are encouraging, and this imaging modality may prove feasible for evaluating acute and chronic kidney disease. 1540209 Parametric Contrast-Enhanced Ultrasound With Evaluation of Arrival Time Maps May Aid Differentiation Between Adrenal Nodular Hyperplasia and Adenomas: Initial Results Rafal Slapa,1* Anna Kasperlik-Zaluska,2 Bartosz Migda,1 Wieslaw S Jakubowski1 1Diagnostic Imaging, Medical University of Warsaw, Warsaw, Poland; 2Endocrinology, Center for Postgraduate Medical Education, Warsaw, Poland Objectives—Only some nonmalignant adrenal masses as some myelolipomas and cysts present pathognomonic features on computed tomography, the examination of choice for evaluation of adrenal gland pathology. Proper diagnosis in the cohort of nonmalignant adrenal masses may be important for further management. The aim of the study has been to evaluate possibilities of differentiation of nonmalignant masses of adrenals with application of a new technique for evaluation of enhancement after administration of an ultrasound contrast agent: parametric imaging. Methods—Seventeen nonmalignant adrenal masses in 14 patients were evaluated by dynamic examination after administration of 2.4 mL of the ultrasound contrast agent SonoVue with an Aplio XG convex 1–6-MHz transducer and parametric imaging. Patterns of parametric imaging of the arrival time and time to peak were evaluated. The final diagnosis was based on computed tomography, magnetic resonance imaging, biochemical studies, follow-up, and/or surgery. Results—There were 5 myelolipomas, 5 hyperplastic nodules, 4 adenomas, 2 hemangiomas with hemorrhage, and 1 cyst. Arrival time patterns of hyperplastic nodules (5/5) presented characteristic differential features of peripheral laminar inflow of SonoVue. Patterns for adenomas varied: nonenhancement (1/4), central enhancement (2/4), and peripheral/central inhomogeneous enhancement (1/4). Patterns for myelolipoma and hemangioma were different from those for adrenal hyperplastic nodules. Conclusions—Parametric imaging may differentiate adrenal adenomas from hyperplastic nodules and could be complementary to computed tomography. This could potentially influence the choice of treatment in patients with Conn syndrome and warrants further multicenter large-scale studies. (Supported by Ministry of Science of Poland grant N402 481239.) 1541233 Volumetric Molecular Ultrasound Imaging of Tumor Vascularity in a Preclinical Model of Prostate Cancer Anna Sorace, Marshall Mahoney, Kurt Zinn, Kenneth Hoyt* University of Alabama at Birmingham, Birmingham, Alabama USA Objectives—The goal of this project was to evaluate volumetric molecular ultrasound (US) imaging of tumor vascularity in a preclinical model or prostate cancer. Methods—Real-time volumetric molecular US imaging was performed using the BioSONIC VIEW system (Bioscan Inc) equipped with a broadband 4DL14-5/38 probe. An MB-sensitive harmonic imaging mode (transducer transmits at 5 MHz and receives at 10 MHz) was used to acquire molecular US images. Nude athymic mice (n = 10) were implanted with 2 million prostate cancer cells (PC3), and tumors were allowed to grow to approximately 1 cm in diameter. Microbubbles (Targestar-SA; Targeson) were conjugated with multiple antibodies targeting tumor vascularity (О±vОІ3, p-selectin, and vascular endothelial growth factor receptor 2) or with an immunoglobulin G isotype control antibody. Following tail vein injection of the MB contrast agent, a 5-minute delay allowed systemic circulation and target receptor binding. Molecular US images were captured to determine the amount of MBs bound and flowing. Then a high-intensity pulse via an external US transducer was administered to destroy all MBs, followed by an additional US scan to determine residual circulating MBs. Custom MATLAB software (MathWorks) was developed to determine overall intratumoral image intensity. Subtraction of US image data from before and after MB bursting yielded a measure of MBs bound to the targeted tumor receptors. All animals received both MB types following a 2-hour delay between injections. Results—Molecular US imaging of targeted MBs yielded a considerable increase in intratumoral image enhancement over that obtained using control MBs, as evident from volume reconstruction of segmented tumor data. More specifically, molecular US image enhancement using targeted MBs ranged from 30% to 160% when compared to control data from the same population of animals. Targeted MB image enhancement was consistent with fraction tumor vascularity measures. Conclusions—Whole-tumor molecular US imaging is a promising strategy for assessing biomarkers of prostate cancer vascularity, and further research is warranted. S16 13proceedings_Layout 1 3/5/13 10:38 AM Page S17 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1539659 Small Nodules Arising in Cirrhotic Liver During Surveillance: Possibility of Characterization Among Dysplastic Nodules, Early Hepatocellular Carcinoma, and Progressed Hepatocellular Carcinoma Using ContrastEnhanced Ultrasound Antonio Giorgio, Giorgio Calisti, Umberto Scognamiglio, Nunzia Farella, Giorgio de Stefano, Filomena Di Martino, Valentina Giorgio D. Cotugno Hospital, Naples, Italy Objectives—The evolution from low-grade dysplastic nodules (DNs) to hepatocellular carcinoma (HCC) is characterized by a gradual disappearance of intranodular portal tracts and a progressive development of neoangiogenic unpaired arteries. Contrast-enhanced ultrasound (CEUS) is able to depict intranodular vascularity. The aim of this study was to evaluate CEUS in the characterization of DNs and HCC in liver cirrhosis. Methods—Forty-six consecutive patients with liver cirrhosis and a single hepatic nodule ≤2 cm were enrolled from February to December 2009. The nodule was continuously observed for 4 to 6 minutes following contrast injected until the disappearing of the enhancement. We studied and recorded the arterial phase (15–30 seconds after contrast injection), the portal phase (30–60 seconds), and the sinusoidal phase (60– 240 seconds). Three patients needed a second injection of 2.4 mL of SonoVue because of inadequate visualization of the enhancement. We analyzed the pattern of the enhancement of the lesion after contrast injection, and we compared the features of nodule and surrounding liver parenchyma. All patients underwent CEUS and subsequent US-guided biopsy of the lesion. Histologic findings and imaging interpretation of DNs and HCC were compared. Results—Progressed HCC was identified by a homogeneous pattern of hypervascularization during the arterial phase with sensitivity of 90.9% and specificity of 100%. Early HCC showed an inhomogeneous and reticular pattern and was identified with sensitivity of 85.7% and specificity of 96.1%. Conclusions—CEUS is able to depict the vascularization pattern of hepatic nodules during the arterial phase and to differentiate DNs, early HCC, and progressed HCC. 1511998 Thyroscan: A Cost-Effective and Noninvasive Automated System for Thyroid Lesion Classification in 3-Dimensional Contrast-Enhanced Ultrasound Images U. Rajendra Acharya,1 Vinitha Sree,2 M. Mutu Rama Krishnan,1 Filippo Molinari,3 Roberto Garberoglio,4 Jasjit Suri*2,5 1 Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 2Global Biomedical Technologies, Roseville, California USA; 3Electronics and Telecommunications, Politecnico Torino, Torino, Italy; 4Scientific Foundation Mauriziana ONLUS, Torino, Italy; 5Biomedical Engineering, Idaho State University, Pocatello, Idaho USA Objectives—Ultrasound has great potential to aid in the differential diagnosis of malignant and benign thyroid lesions, but the accuracy is still poor. We developed and analyzed a range of knowledge representation techniques for characterizing the intranodular vascularization of thyroid lesions by using 3D contrast-enhanced ultrasound images. Methods—Twenty patients, 10 males (age, 53.5 В± 13.3 years; range, 22–71 years) and 10 females (age, 50.1 В± 10.8 years; range, 25–68 years) with a previously confirmed diagnosis of a solitary thyroid nodule were enrolled in this study. All subjects underwent a clinical examination, hormonal profile, and 3D contrast-enhanced ultrasound volume acquisition after 2.5 mL of SonoVue (Bracco, Italy) injection. The features of the 3D volumes were extracted by using the discrete wavelet transform (DWT), and the texture of the nodular vascularization was measured by using statistical and structural measurements. The 10 features were fed to 3 type of classifiers: K-nearest neighbor (K-NN), probabilistic neural networks (PNN), and decision tree (DT). Results—The performance of the classifiers was compared using receiver operating characteristic (ROC) curves. The combination of DWT and texture features coupled with K-NN resulted in good results, with an area under the ROC curve (AUC) of 0.987, a classification accuracy of 98.9%, sensitivity of 99.8%, and specificity of 98.1%. We proposed a novel integrated index called the thyroid malignancy index (TMI), made up of DWT and texture features, which was discriminant to diagnose benign or malignant nodules using just 1 index. Conclusions—This integrated TMI can be employed for the diagnosis of benign and malignant nodules effectively. The advantage is the fact that, to make a diagnosis, the physician needs to only look at the value of just 1 integrated index instead of checking the range of each individual feature. Table 1. Performance of the Classifiers Accuracy, Sensitivity, Specificity, Classifier TN FN TP FP % % % AUC K-NN 40 0 39 1 98.9 99.8 98.1 0.987 PNN 40 0 38 2 97.8 99.8 96.3 0.975 DT 40 0 38 2 97.8 99.8 96.3 0.975 FN indicates false-negative; FP, false-positive; TN, true-negative; and TP, true-positive. 1466379 Usefulness of Contrast-Enhanced Ultrasound in Clinical Practice: The Spanish Trial Carlos Nicolau,1* Teresa Fontanilla,2 Jose del Cura,3 Antonio Talegon,4 Xavier Serres5 1Radiology, Hospital Clinic, Barcelona, Spain; 2Radiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; 3Radiology, Hospital de Basurto, Bilbao, Spain; 4Radiology, Hospital Virgen del Rocio, Seville, Spain; 5Radiology, Hospital Vall Hebro, Barcelona, Spain Objectives—The aim of this multicenter study was to evaluate contrast-enhanced ultrasound (CEUS) diagnostic performance in clinical practice in Spain. Methods—A total of 1786 patients (mean age, 59.8 years) from 42 hospitals, with baseline US studies that were considered inconclusive, were included in this multicenter study. We evaluated 1516 (84.9%) abdominal cases (including 1272 livers [71.2%], 179 kidneys [10%], 35 spleens [2%], 17 pancreases [1%], and 38 in other abdominal locations [2.1%]), 77 breast studies (4.3%), 111 supra-aortic vessel studies (6.2%), and 82 in other locations (4.6%). All studies were performed using specific contrast software and intravenous injection of SonoVue (Bracco, Italy; mean dose, 3 mL). A low mechanical index (<0.2) was used in most cases. Results of CEUS studies were compared with the definite diagnosis by reference procedures. Results—Only 1 patient (0.001%) was excluded due to contraindications. Most studies (84.8%) were evaluated with a single dose of the contrast agent, and the mean time employed to perform the CEUS study was 7.8 minutes. CEUS use determined a significant improvement in the diagnostic confidence in 91.6% of the cases, allowing a conclusive diagnosis in 69.2% of the patients. The highest accuracy was obtained in supra-aortic vessel evaluation, with a conclusive diagnosis in 95.4% of the cases, followed by 72.6% of the abdominal cases. Conclusions—The use of CEUS provided a significant improvement in clinical practice with an accurate diagnosis in most of the inconclusive baseline US studies. S17 13proceedings_Layout 1 3/5/13 10:38 AM Page S18 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1517021 Four-Dimensional Subharmonic Breast Imaging: Initial Experiences John Eisenbrey,1* Anush Sridharan,1,2 Daniel Merton,1 Priscilla Machado,1 Kirk Wallace,3 Carl Chalek,3 Kai Thomenius,3 Flemming Forsberg1 1Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA; 2Electrical and Computer Engineering, Drexel University, Philadelphia, Pennsylvania USA; 3GE Global Research, Niskayuna, New York USA Objectives—To describe initial experiences of using 4D contrast-enhanced subharmonic ultrasound imaging (SHI) and harmonic ultrasound imaging (HI) for the characterization of mammographically identified breast lesions. Methods—4D SHI (transmitting 4 cycle pulses at 5.8 MHz, receiving at 2.4 MHz) was performed using a modified LOGIQ 9 ultrasound scanner with the 4D10L probe (GE Healthcare, Milwaukee, WI). After providing informed consent, 39 patients scheduled for an ultrasoundguided breast biopsy received 2 injections of the contrast agent Definity (Lantheus Medical Imaging, North Billerica, MA). Patients first received a 0.25-mL injection while being continuously scanned with 4D HI (transmitting 2 cycle pulses at 5 MHz, receiving at 10 MHz). After 30 minutes, patients received a 20-ВµL/kg injection while undergoing 4D SHI. Both the screen-captured, rendered images and raw slice data for the entire contrast wash-in/wash-out cycle were digitally stored for analysis and processing. Results—Volume acquisition rates varied based on the lesion size and depth of scanning ranged from 1.7 Hz (for a 3.7 Г— 1.3 Г— 2.0-cm lesion) to 6.1 Hz (for a 6 Г— 4 Г— 6-mm lesion) with volume angles of 9В° to 19В°. Contrast enhancement depended heavily on lesion vascularity (determined during initial physician exam using power Doppler). In 38 of 39 cases, SHI resulted in better tissue suppression relative to HI and improved contrast visualization in vascular lesions. In vascular cases, vessel connectivity was observed in 3D space with clear visualization of contrast wash-in and wash-out. Raw slice data were successfully processed to create 3D maximum intensity and perfusion parametric maps. These processed volumes further improved the ability to delineate blood vessels from the surrounding tissue and quantify flow parameters. Conclusions—In almost all cases, 4D SHI resulted in improved visualization of contrast relative to 4D HI. Access to raw slice data allows for the generation of 3D parametric maps of the vasculature. Future work will determine the value of 4D SHI for characterizing breast lesions. Emergency Ultrasound, Part 1 Moderators: Leslie Scoutt, MD, Gowthaman Gunabushanam, MD 1540915 Accuracy of Lung Ultrasound and Chest Radiography for Diagnosis of Cardiogenic Dyspnea Among Elderly Emergency Department Patients Emanuele Pivetta,1,2,3* Livia Ausiello,4 Elke Platz,1 Michael Stone,1 Maria Tizzani,5 Giulio Porrino,5 Enrico Ferreri,5 Giovanni Volpicelli,6 Paolo Balzaretti,4 Alessandra Banderali,7 Antonello Iacobucci,8 Enrico Lupia,2 Alberto Goffi,9 Giovanna Casoli,10 Gianalfonso Cibinel11 1Emergency Medicine, Division of Emergency Ultrasound, Brigham and Women’s Hospital, Boston, Massachusetts USA; 2Emergency Medicine, 3 Oncology and Hematology, Cancer Epidemiology Unit, San Giovanni Battista Hospital and University of Turin, Turin, Italy; 4 Emergency Medicine, Mauriziano Hospital, Turin, Italy; 5 Emergency Medicine, San Giovanni Battista Hospital, Turin, Italy; 6Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy; 7Emergency Medicine, Cardinal Massaia Hospital, Asti, Italy; 8Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy; 9Critical Care Medicine, St Michael’s Hospital, Toronto, Ontario, Canada; 10 Emergency Medicine, Martini Hospital, Turin, Italy; 11Emergency Medicine, Pinerolo Civil Hospital, Turin, Italy Objectives—This study aimed to evaluate the diagnostic accuracy of pleural and lung ultrasound (PLUS) vs chest radiography for the identification of interstitial syndrome and pleural effusions (indicators of acute decompensated heart failure) among elderly patients presenting to the emergency department (ED) with dyspnea. Methods—This was a prospective multicenter cohort study of patients presenting to an Italian ED with shortness of breath. After the initial assessment, emergency physicians categorized dyspnea as cardiogenic or noncardiogenic. Patients then underwent 8-zone PLUS with a curvilinear transducer assessing for sonographic artifacts (B-lines) and pleural effusions (mean scanning time, 3.47 minutes). Three or more B-lines were suggestive of interstitial syndrome. The same physician then recorded the new diagnostic category, incorporating both initial clinical assessment and PLUS findings. All patients also underwent standard chest radiography. After discharge, medical records were independently reviewed by 2 emergency physicians blinded to the PLUS results to determine the most likely cause of dyspnea. Results—Between October 2010 and August 2012, 674 elderly patients were enrolled. Median age was 79 years (range, 65–99 years); 54.7% were male; 22.4% had a history of heart failure; and 40.9% had chronic obstructive pulmonary disease. In 284 subjects (42.1%) the etiology of dyspnea was cardiogenic. PLUS had sensitivity (Se) of 97.7% (confidence interval [CI], 94.6%–99.2%) and specificity (Spe) of 96% (CI, 93.8%–99.3%) for the diagnosis of cardiogenic dyspnea, with a positive predictive value (PPV) of 98.1% (CI, 95.3%–99.5%) and a negative predictive value (NPV) of 97% (CI, 93%–99%). Chest radiography had Se of 70.3% (CI, 61.6%–78.1%), Spe of 80% (CI, 70.8%–87.3%), a PPV of 81.8% (CI, 73.3%–88.5%), and an NPV of 67.8% (CI, 58.6%–76.1%). PLUS improved the clinician’s diagnostic accuracy for cardiogenic dyspnea by 10% (CI, 7.7%–12.3%). Conclusions—In our study, PLUS had higher diagnostic accuracy than chest radiography for the diagnosis of cardiogenic dyspnea in elderly ED patients. PLUS may represent a more rapid and accurate tool in the bedside assessment of patients with suspected acute decompensated heart failure. 1540969 Bedside Cardiac Ultrasound Examination to Confirm Central Venous Catheter Placement Yiju Liu,1 Kathleen Calabrese,1* Kunal Ajmera,2 Mohammad Salimian,1 Thaison Tran,1 Hamid Shokoohi,1 Keith Boniface,1 Melissa McCarthy1 1Emergency Medicine, George Washington University Medical Center, Washington, DC USA; 2 School of Public Health and Human Services, George Washington University, Washington, DC USA Objectives—This study evaluated the use of bedside ultrasound examination (BUE) to confirm proper CVC insertion. More than 5 million central venous catheters (CVCs) are placed each year in the United States. Mechanical complications of CVC insertion range between 5% and 19%, and the malposition rate can be as high as 50%. Current practice of obtaining post-CVC chest radiography (CXR) to confirm placement may delay care and expose patients to repeated ionizing radiation. Methods—We prospectively enrolled patients requiring abovethe-diaphragm CVC placement from the emergency department (ED), intensive care unit (ICU), and operating room (OR) at a tertiary academic center. Within 24 hours of CVC placement, we pushed 10 mL of saline solution through a distal catheter port while simultaneously obtaining a single view of the heart using BUE and documented whether echo signals of the saline solution appeared in the right heart and the timing of their appearance. We hypothesized that the immediate presence of echogenic sig- S18 13proceedings_Layout 1 3/5/13 10:38 AM Page S19 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 nals from the saline flush signaled proper catheter tip placement. We compared the agreement between BUE results and those of CXR or computed tomography (CT) using a Оє statistic. Results—Twenty-seven patients were enrolled, and 26 were analyzed. One subject was excluded because his surgery was canceled, and he no longer required CVC. Eight patients were enrolled from the ED, 9 from the ICU, and 9 from the OR. On BUE, 1 patient had a technically limited study, and 25 demonstrated saline echoes in the right heart. One of the 25 demonstrated intracardiac catheter malposition, confirmed by CXR. All 26 patients had CXR, and 2 had additional CT; 25 had confirmed proper CVC placement, including the 1 patient for whom BUE was inconclusive. Timing for BUE was as follows: 20 cases done concurrently with CVC placement, 2 done within 1 hour, and 3 done within 24 hours. Of the 25 BUEs that were interpretable, there was 100% agreement between BUE and CXR in detecting CVC location (P = .000). Conclusions—Despite the small sample size, this study shows promise for the use of BUE to accurately confirm CVC placement more quickly than CXR. A larger study is needed before we can recommend using BUE routinely to replace post-CVC CXR. 1513191 Bedside Thoracic Ultrasound for Pulmonary Edema: Which Zones Are the Best? Zoe Howard,* Feras Khan, Anne-Sophie Beraud, Laleh Gharahbaghian, Raymond Balise, Ravi Pamnani, Michael Schaller, Joelle Barral, Sidhartha Sinha, Sarah Williams Emergency Medicine, Stanford University Medical Center, Stanford, California USA Objectives—Thoracic ultrasound (US) has been validated to predict pulmonary edema with high sensitivity and specificity in the presence of B-lines, a US reverberation artifact caused by interstitial fluid. Our study investigates whether there are specific anatomic zones with a greater positive predictive value for pulmonary edema. If so, we could perform this test more rapidly, an important consideration from both a resource utilization and patient care perspective. Methods—We performed a prospective observational study, scanning a convenience sample of adult emergency department (ED) patients with shortness of breath at a large tertiary care academic center. Following previously published protocols, the right anterior chest was divided into 4 zones with zones 1 and 2 representing an upper and lower midclavicular distribution, respectively, and 3 and 4 upper and lower midaxillary. The division was mirrored on the left with 5 and 6 anterior and 7 and 8 lateral. When there were at least 2 bilateral positive zones, the patient was enrolled. Compared to a gold standard of chest radiography combined with brain natriuretic peptide, echocardiography, and discharge diagnosis, patients were confirmed to have acute pulmonary edema. All images were reviewed by 2 US fellowship-trained ED physicians, and each zone was scored according to an a priori scale. Results—During the initial pilot, 24 patients were analyzed. There was no dominant pattern that emerged among the 8 zones. Thirteen percent (3/24) were positive in every zone. On the right, zones 2, 3, and 4 were positive in 79% (19/24), while on the left, zone 5 was positive in 71% (17/24) and zone 7 in 67% (16/24). When the right chest was noted to be positive, the contralateral zone noted to be positive in the greatest number of patients was zone 5. Conclusions—While the small number of patients limits this study, trends were noted in specific zones, particularly the right chest and zone 5. However, there is no dominant pattern or statistically significant results to suggest that any zone is more predictive for diagnosing acute pulmonary edema by B-lines on US. This suggests that it is necessary to scan all 8 zones and perform a thorough but expeditious thoracic US examination when rapid diagnosis of critically ill patients is crucial. 1538301 Central Venous Catheterization Location Changes and Complication Rates After the Institution of an Emergency Ultrasound Division Tahisha Tolbert,* Lawrence Haines, Lucas McArthur, Victoria Terentiev, Antonios Likourezos, Eitan Dickman Emergency Medicine, Maimonides Medical Center, Brooklyn, New York USA Objectives—To look at central venous catheter (CVC) placement patterns before and after the establishment of an emergency ultrasound division (EUSD). We hypothesized that the internal jugular vein (IJ) site would be used more often as familiarity with ultrasound (US) increased. A secondary objective was to compare the mechanical complication rates associated with CVC placement before and after the establishment of an EUSD. Methods—This was a retrospective chart review looking at all CVCs placed in an urban tertiary care medical center’s emergency department (ED) with an emergency medicine residency program and 115,000 ED visits per year. We queried our electronic medical record for all CVCs placed in the ED between the years 2004 and 2007 and the years 2007 and 2010, representing the 3 years before and after the establishment of the EUSD. The locations of these CVCs were compared to assess for any changes. This data set was then queried for patients who had a documented mechanical complication from the CVC placement. Results—In all, 1876 CVCs were placed between 2004 and 2007, and 1707 were placed between 2007 and 2010. Selection of the femoral vein CVC location changed from 50.8% to 42.5%, subclavian from 37.0% to 17.3%, and IJ from 12.2% to 40.2% (P = .0001 for all). The mechanical complication rate decreased from 9.1% to 5.4% (P = .0001). Conclusions—The establishment of an EUSD, with formal training in the use of US for CVC placement, is associated with a significant change in CVC site selection patterns, most notably a sharp increase in selection of the IJ site and a dramatic reduction in the selection of the subclavian site. In addition, there was a 41% decrease in the complication rates such as pneumothorax and arterial puncture. Table 1. Specific Complications Complication Pneumothorax Chest tube Arterial puncture 2004–2007 23 (1.2) 18 (1) 47 (2.5) n (%) 2007–2010 6 (0.4) 4 (0.2) 21 (1.2) P .004 .005 .005 1539748 Faster = Better? Pilot Sonographic Evaluation of Internal Jugular Vein Collapsibility Versus Inferior Vena Cava Collapsibility Indices in Critically Ill Patients David Evans,1* Daniel Eiferman,1 Alistair Kent,1 Creagh Boulger,2 Andrew Springer,3 Eric Adkins,2 Susan Yeager,1 Geoffrey Roelant,1 Stanislaw Stawicki,1 David Bahner2 1 Surgery, 2Emergency Medicine, 3Anesthesiology, Ohio State University, Columbus, Ohio USA Objectives—Intensivist-performed bedside sonographic assessment of volume status is a rapidly evolving area. Although the inferior vena cava collapsibility index (IVC-CI) has been shown to correlate with both clinical assessment and invasive monitoring of intravascular volume status, it is limited by difficult visualization of the IVC, interference by surgical dressings and tubes, and a relatively steep learning curve. Many physicians already have experience with internal jugular ultrasound for vascular access. Due to the ease of the technique and simpler anatomy, we hypothesized that the internal jugular vein collapsibility index (IJVCI) would be easier to perform than the IVC-CI. Methods—A prospective observational pilot study comparing IVC-CI and IJV-CI was performed in surgical intensive care unit patients. S19 13proceedings_Layout 1 3/5/13 10:38 AM Page S20 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 In addition to patient demographics and basic hemodynamic data, simultaneous M-mode measurements of the IVC-CI and IJV-CI were collected during each bedside sonographic session. IVC measurements were obtained using curvilinear probes. IJV measurements were obtained using high-frequency linear array probes. Statistical comparisons for paired data included linear regression with correlation coefficients and Bland-Altman analysis with construction of a mean difference plot for bias determination. Results—A total of 16 patients were enrolled (mean age, 52.8 years). There were 5 women and 11 men. Acquisition of adequate IJV-CI scans was faster than acquisition of IVC-CI scans (43 vs 105 seconds scanning time, respectively; P < .01). Thirty-five measurement pairs were obtained, with some correlation noted between paired IVC-CI and IJV-CI measurements (r = 0.54; r2 = 0.289). There was a 6% negative measurement bias between IJV-CI and IVC-CI measurements as determined by the Bland-Altman method. Conclusions—IJV-CI measurement can be performed significantly faster than IVC-CI measurement. In our pilot study, there was minimal mean measurement bias (6%) between the 2 techniques, indicating that the IJV-CI tends to overestimate collapsibility. More data are needed to better characterize the correlation between the IJV-CI and IVC-CI and define the role of the IJV-CI in clinical practice. 1540557 Point-of-Care Ultrasound Evaluation of Central Line Placement Eric Mervis,1* Elizabeth Turner,3 Alan Chiem,4 Robert Liou,2 Randy Hou,5 Craig Anderson,1 Arthur Youssefian,1 J. Christian Fox1 1Emergency Medicine, 2Pulmonary/Critical Care, University of California Irvine, Orange, California USA; 3Pulmonary/Critical Care, University of California Los Angeles, Los Angeles, California USA; 4Emergency Medicine, University of California Los Angeles, Olive View, Los Angeles, California USA; 5Pulmonary/Critical Care, Kaiser, Fontana, California USA Objectives—In our study we use point-of-care ultrasound (POC-US) to confirm proper central venous catheter (CVC) placement and compare the results of POC-US to chest x-ray (CXR), the current standard of evaluating CVC placement. Methods—This is an ongoing prospective single-center noninferiority study comparing the effectiveness of POC-US and CXR in confirming placement of CVCs. A convenience sample of critically ill patients that require emergent CVC placement in the intensive care unit (ICU) or the emergency department at the University of California Irvine Medical Center have been enrolled. Patients who are >18 years old and require placement of a subclavian (SC) or internal jugular (IJ) CVC are eligible for enrollment in this study. Qualified emergency medicine and ICU physicians place CVCs into IJ or SC veins. US is then performed to obtain multiple views for confirmation of CVC placement. These include views of the CVC within the central vein, the ipsilateral pleural line to rule out pneumothorax, and the contralateral IJ vein to rule out malposition. Last, a cardiac view is obtained to show the presence of the tip of the catheter in the right atrium or turbulence after a 10-mL saline flush, thus confirming placement of the catheter in the superior vena cava. The times of US and CXR completion and subsequent review of the CXR by the physician performing the procedure are recorded. Results—A total of 55 central lines with complete US imaging and comparable CXRs have been obtained to date with a goal of enrolling 140 subjects. The US method has identified 2 misplaced lines, and the CXR has shown 5 misplaced lines. Agreement between the 2 methods for confirming CVC placement is 91% (50/55). The US method thus far has a negative predictive value of 92.5% (confidence interval, 82%–98%). There is an average 17-minute difference between time to US and time to CXR. There have been no pneumothoraxes identified by either method. Conclusions—Preliminary data suggest that POC-US and CXR have similar agreement for identifying misplaced CVCs. There is a 17-minute time difference to POC-US vs CXR, which could translate to more expeditious use of central lines for intravenous fluids, antibiotics, or vasopressors in potentially unstable patients. 1541330 Three-Window Bedside Ultrasound Versus Chest Radiography for Confirmation of Endotracheal Tube Placement Arthur Youssefian,1* Elizabeth Turner,3 Shane Breazeale,2 Angelina Amian,2 Eric Mervis,1 J. Christian Fox,1 Negean Vandordaklou,4 Craig Anderson1 1Emergency Medicine, 2 Pulmonary and Critical Care, University of California Irvine, Orange, California USA; 3Pulmonary and Critical Care, University of California Los Angeles, Los Angeles, California USA; 4 Department of Emergency Medicine, Long Beach Memorial Hospital, Long Beach, California USA Objectives—In our study, we use 3-window bedside point-ofcare ultrasound (POC-US) to confirm proper endotracheal tube (ETT) placement and compare the results of POC-US to chest x-ray (CXR), the current standard of evaluation. The hypothesis is that POC-US will be noninferior to CXR for ETT placement and will be more expedient. Methods—This is an ongoing prospective noninferiority study comparing the effectiveness of 3-window bedside POC-US in confirming placement of ETTs. A convenience sample of critically ill patients who required emergent endotracheal intubation in the intensive care unit (ICU) or the emergency department (ED) at the University of California Irvine Medical Center have been enrolled. Patients who are >18 years old and require tracheal intubation are eligible for enrollment. Qualified ED and ICU physicians placed ETTs per the usual protocol. US is then performed to obtain multiple views for confirmation of ETT placement. These include views of the trachea, bilateral lungs, and diaphragms. The primary objective was to compare the sonographer’s ability to predict placement of ETTs based on a 3-window bedside US model compared to the formal interpretation of the postintubation CXR read by an attending radiologist. The secondary outcome objective was to measure and compare the time from the 3-window US exam to the time of the initial availability of postintubation CXR as well as to the time of availability of the radiologist’s formal interpretation of the film. Results—A total of 136 subjects with complete US imaging and CXRs have been enrolled to date, with a goal of 140 subjects. The 3window US method correctly identified 124 of 128 ETTs placed in the trachea (specificity, 94.7%). US correctly identified 1 of 5 ETTs found by CXR to be in a main stem bronchus (sensitivity, 20%), with a positive likelihood ratio (LR) of 3.74 and a negative LR of 0.845. Conclusions—Preliminary data suggest that 3-window POCUS and CXR have similar agreement for identifying correctly placed ETTs. Additional analysis of subjects with false-positive and false-negative US impressions will aim to determine factors contributing to these type I and II errors. 1541487 Transcricothyroid Ultrasound for Confirmation of Endotracheal Tube Placement by United States Military Emergency Medicine Providers Michael Rebener,* Chase Donaldson, Eric Chin Emergency Medicine, San Antonio Military Medical Center, San Antonio, Texas USA Objectives—The purpose of this study is to assess the accuracy of dynamic transcricothyroid ultrasound for confirming endotracheal tube (ET) placement by military emergency medicine (EM) providers, specifically physicians and physician assistants, and to examine the relationship between accuracy and prior ultrasound experience in this application. Methods—A prospective randomized double-blinded validation study to identify ET placement in a cadaver model using ultrasound was conducted. Twenty-six EM providers with variable ultrasound experience were given a brief presentation on how to identify airway land- S20 13proceedings_Layout 1 3/5/13 10:38 AM Page S21 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 marks using ultrasound and shown examples of esophageal and tracheal intubations. The cadavers were randomized to a tracheal or esophageal intubation, and the EM providers recorded their responses after performing dynamic transcricothyroid ultrasound (DTUS). Responses were timed, and the experience level of each provider with ultrasound was recorded. Results—The EM providers correctly identified the ET location in 266 of 329 scans, for accuracy of 80.1% for all providers. The difference in accuracy between experienced and inexperienced providers was not statistically significant (P = .433), but more experienced providers had shorter response times (P = .031). Physicians were not more accurate than physician assistants (P = .746), but physicians’ response times were shorter (P < .001). Conclusions—Our study suggests that EM providers with more ultrasound experience, defined as >250 scans, are not necessarily more accurate at identifying correct placement of ETs than those with less experience. Similarly, no statistically significant difference was seen in accuracy between provider types. This study suggests that DTUS can be easily learned by inexperienced sonographers, but given the relatively low accuracy rate of DTUS in this study, regardless of experience, DTUS should be used only as an adjunct to current ET confirmation methods. 1541012 Effect of the Prone Maximal Restraint (aka “Hog Tie”) Position on Cardiac Output and Other Hemodynamic Measurements Davut Savaser,* Colleen Campbell, Ted Chan, Virag Shah, Chris Sloane, Allan Hansen, Eddie Castillo, Gary Vilke Emergency Medicine, University of California San Diego, San Diego, California USA Objectives—To measure the impact of prone maximal restraint (PMR) with and without weight force on measures of cardiac function, including vital signs, oxygenation, stroke volume (SV), cardiac output (CO), and left ventricular outflow tract diameter (LVOTD). Methods—We conducted a randomized prospective crossover study of healthy volunteers (18–60 years of age) placed in 5 different body positions: supine, prone, PMR, PMR with 50 lb added to the subject’s back (PMR50), and PMR with 100 lb added to the subject’s back (PMR100) for 3 minutes. Data were collected on subject vital signs and echocardiographic measurement of SV, CO, and LVOTD, measured by credentialed emergency department faculty sonographers. Anthropomorphic measurements of height, weight, arm span, chest circumference, and body mass index were also collected. Data were analyzed using repeated measures analysis of variance to evaluate changes in each variable with respective positioning. Results—Twenty-five male subjects were enrolled in the study, ages ranging from 22 to 43 years. Cardiac output did change from the supine to prone position, decreasing on average by 0.61 L/min (P = .013; 95% confidence interval [CI], 0.142, 1.086 L/min). However, there was no significant change in CO when placing the patient in the PMR position (–0.11 L/min; P = .489; 95% CI, –0.43, 0.21 L/min), PMR50 position (0.19 L/min; P = .148; 95% CI, –0.07, 0.46 L/min), or the PMR100 position (0.14 L/min; P = .956; 95% CI, –0.29, 0.27 L/min) compared with the prone position. Systolic blood pressure never dropped below 100 mm Hg in any position; heart rate never increased above 100 beats per minute, and there were no incidents of syncope or other subjective complaints. Conclusions—CO is not significantly affected by the PMR position compared with the prone position, nor is it adversely affected with application of 50 or 100 lb of weight force to the back while in the PMR position. The PMR position and a weight force of up to 100 lb does not cause hemodynamic compromise of the restrained patient. 1541228 Ultrasound-Guided Peripheral Intravenous Insertion: Right Line at the Right Time James M. Joseph, Daniel Kagarise, Todd Henkaline, James White,* David Bahner Vascular Access, Ohio State University Medical Center, Columbus, Ohio USA Objectives—To increase the success rate of initial intravenous line (IV) attempts using ultrasound guidance and to use expert assessment and a triage process to choose the “right line at the right time.” Methods—We began in September 2005. Physician-initiated requests were placed in the electronic medical record and sent as consults to the vascular access team. Ninety-eight insertions occurred between September and December. The program has grown exponentially since its inception and to this date houses 47,153 requests for evaluation and insertion in a vascular access database. The vascular access team consists of 8 fulltime nurses covering approximately 850 beds. Additionally, we have trained super users in 3 areas with varying degrees of success and data collection. Results—The following data were queried from the vascular access database. Excluding the insertions completed by super users, requests for ultrasound-guided peripheral IV line insertion (USGPIV) totaled 47,153, 76.6% being attempted. Of the patients attempted, 32,366 were successful on the first attempt. Subsequent attempts were successful 92.4% of the time. The total success rate was 98.3%. Conclusions—USGPIV programs can be successful adjuncts to vascular access teams in serving patients with difficult access. Key concepts for branding success include using triage, assessment, ultrasound guidance, and insertion by experienced vascular access nurses. Musculoskeletal and Interventional/Intraoperative Ultrasound Moderator: Humberto Rosas, MD 1540764 Accuracy and Reliability of Direct Versus Indirect Peripheral Nerve Cross-sectional Area Mark Shoreman,1,2,3* Jeffrey Strakowski,1,2,3 Marcie Bockbrader,1,2 Mark Tornero,1,2 Darin Bradshaw1,2 1Physical Medicine and Rehabilitation, Ohio State University, Columbus, Ohio USA; 2Physical Medicine and Rehabilitation, Riverside Methodist Hospital, Columbus, Ohio USA; 3Musculoskeletal Department, McConnell Spine, Sport, and Joint Center, Columbus, Ohio USA Objectives—Standardizing the sonographic examination is essential to achieve diagnostic precision. Aspects of the examination, such as the cross-sectional area (CSA) measurement technique, can be controlled and ultimately standardized. We sought to determine if direct peripheral nerve CSA measurement increases accuracy and reliability in comparison to the indirect method. Methods—Five novice sonographers and 3 healthy models were recruited. One expert sonographer led the novices through 3 peripheral nerve ultrasound training sessions in addition to a final “test-out” session. The expert then obtained 1 ideal transverse image of each model’s radial, median, ulnar, and sciatic nerves. Each sonographer (expert and novice) then obtained 3 direct measurements of each nerve (3 models Г— 4 nerves Г— 3 = 36) and 3 indirect measurements of each nerve (36 + 36 = 72 measurements). The image order and method (direct/indirect) were randomized prior to obtainment, and sonographers were blinded to their results as well as their colleagues’. The expert’s measurements represented the accuracy gold standard. Accuracy was evaluated by calculating percent deviation from expert (%DE). Inter-rater reliability was evaluated using the intraclass correlation coefficient (ICC). Variance measurements were obtained using repeated measures analysis of variance (ANOVA). S21 13proceedings_Layout 1 3/5/13 10:38 AM Page S22 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Results—The %DE was decreased with direct measurement in comparison to indirect in every group of peripheral nerve measures (radial/median/ulnar/sciatic). The ICC was higher with direct measurement than indirect in every group of peripheral nerves measured. Repeated measures ANOVA did reveal significant differences between direct vs indirect measurements repeated on the same nerve/model (F(1,4) = 24.262; P < .008). There was no significant difference between expert and novice CSA measurements (P = .983), and no significant difference between multiple measurements (direct and indirect) of the same nerve by the same rater (P = .644). Conclusions—Direct CSA measurements produce more accurate results and greater inter-rater reliability than indirect measurements. There is a significant difference between direct and indirect CSA measurements repeated on the same nerve/model. 1540778 Developmental Plasticity of the Hip: Implications for Infant Hip Ultrasonography Azriel Benaroya,1,2* Arkady Voloshin,3 Bernard Karmel,2 Ha Phan2 1Orthopedics, Mount Sinai School of Medicine, New York, New York USA; 2Infant Development, New York State Institute for Basic Research in Developmental Disabilities, Staten Island, New York USA; 3Mechanical Engineering and Mechanics, Lehigh University, Bethlehem, Pennsylvania USA Objectives—A literature review of the combined method of infant hip ultrasonography (US) reveals persistent problems with overdiagnosis. Clues to these problems can be found in the wide range of morphologic variations reported in fetal and infant hips. The 2003 American College of Radiology–American Institute of Ultrasound in Medicine guidelines state that the femoral head is nearly spherical; thus, the position of the hip during US is unimportant. Authors agree, however, that the femoral head becomes less spherical during fetal development, that it reaches its greatest degree of asphericity at the time of birth, and that asphericity is further increased in borderline, immature, and dysplastic hips. We created a 3D mathematical model of an ellipsoidal infant femoral head to examine the impact of femoral head asphericity on current US methods. Methods—The femoral head was modeled as an oblate spheroid with asphericity of 25% (long axis = 20 mm; short axis = 15 mm). Four positions of the femoral head in space, replicating positions of diagnostic significance used in the combined and Graf methods, were computer simulated. Coronal or transverse sections through the center of the femoral head model, simulating infant femoral head US images, were produced and analyzed for cross-section diameter and inclination. Results—Femoral head cross-section diameters in the simulated coronal flexion stress view and transverse flexion stress view were 17.11 and 16.23 mm, respectively, compared to 14.37 mm for the femoral head cross-section diameter in the Graf coronal view and 13.93 mm for the coronal view with the hip in the “human” position. Conclusions—Our model demonstrated changes in the crosssection diameter of an irregularly shaped femoral head with rotation of the head in different positions. Femoral head asphericity would not affect the results in the Graf method, but it could affect the results in the combined method. Stress maneuvers of the infant hip in the presence of soft tissue subclinical morphologic variations, coupled with femoral head asymmetry, could produce “elastic whipping,” leading to erroneous interpretations of the US image. We recommend that the plasticity of the developing hip be reviewed with respect to its potential impact on the accuracy of current US methods. 1536958 Efficacy of Sonographically Guided Medial Plantar Nerve Perineural Space Injection at the Medial Longitudinal Arch Johnathan Childress,1 Oliver Joseph,2 Oleg Uryasev,2* John McNamara,1,2 Apostolos Dallas2 1Jefferson College of Health Sciences, Roanoke, Virginia USA; 2Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA Objectives—Medial plantar neuropraxia refers to entrapment of the medial plantar nerve (MPN) in the medial longitudinal arch by compression from the flexor hallucis longus (FHL) and flexor digitorum longus tendons. Like other nerve compression syndromes, corticosteroid injection could likely provide therapeutic relief to those with MPN compression. We hypothesize that sonographic guidance will allow for effective injection of the MPN perineural space distal to the flexor retinaculum and inferior to the navicular prominence (NP) of the foot. Methods—This study serves as a pilot study to investigate the efficacy of MPN perineural injections bilaterally on 4 cadaveric models. Cadaveric anatomy was unremarkable with the exception of 1 cadaver who had marked musculoskeletal deformity of the lower limbs, which precluded successful injection. A 10–5-MHz small linear array transducer was placed along the malleolar-calcaneal axis, rotated parallel to the tibia, and guided anteriorly along the medial longitudinal arch to visualize the NP. The MPN appeared spindle shaped with alternating hypoechoic and hyperechoic bands superficial to the FHL tendon. The MPN perineural space was injected inferior to the NP where it divides into its muscular branches. Using an anterior long-axis approach, 0.35 mL of 0.5% methylene blue was injected with anatomic dissection to provide confirmation. Injections were classified according to accuracy and precision. Accuracy referred to nerve staining; precision referred to no damage to adjacent structures. Results—Seven of 8 (88%) injections were accurate; 6 of 8 (75%) injections were precise. Conclusions—Research into sonographically guided MPN perineural injection is novel. Considering a limited sample size and marked musculoskeletal deformity of 1 cadaver, accuracy and precision (88% and 75%, respectively) provide an optimistic outlook for sonographically guided injections. The study supports the approach of sonographically guided perineural injections in the clinical address of medial plantar neuropathies. Future phases of this study will focus on expanding the initial data set and correlate the accuracy and precision of injection with improved patient outcomes. 1538067 Neuromusculoskeletal Ultrasound Courses: How Effective Are They in the Long Term? Sathish Rajasekaran,1* Rodney Shan,2 Mohan Radhakrishna3 1 Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 2Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; 3Physical Medicine and Rehabilitation, McGill University Health Center Pain Center and McGill University, Montreal, Quebec, Canada Objectives—To measure the short- and long-term effectiveness of a 2-day neuromusculoskeletal ultrasound course offered to Canadian physical medicine and rehabilitation (PM&R) residents. Methods—A 2-day course that included lectures, live scanning, and cadaver-based injection stations was attended by 22 PM&R residents from across Canada. Participants varied in training level from first- to final-year residents. Currently, ultrasound training is not a requirement for PM&R training programs in Canada. Prior to beginning the course, all attendees were asked to fill out a multiple-choice test based on the course curriculum objectives, which was readministered on completion and 6 months after completion of the course (electronically). Sixteen residents completed all 3 tests. The Wilcoxon signed rank test was used to compare scores from the 3 testing periods. S22 13proceedings_Layout 1 3/5/13 10:38 AM Page S23 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Results—The mean score (percentage) on the pretest was 50.6% (95% confidence interval [CI], 43.5%–57.6%), on the immediate posttest was 66.5% (95% CI, 60.6%–72.4%), and on the 6-month posttest was 53.5% (95% CI, 45.9%–60.6%). The 6-month posttest scores were not significantly higher than the pretest scores (P = .505). The immediate posttest scores were significantly higher than the pretest (P = .002) and 6month posttest (P = .003) scores. Conclusions—This pilot study found that the short-term effectiveness of attending an ultrasound course is supported by higher immediate posttest scores. However, the effectiveness of the course is diminished in the long term, as the 6-month posttest scores were lower than the immediate posttest scores. Although 6-month posttest scores still remained higher than pretest scores, this was not statistically significant. Our results suggest that the current trend of offering neuromusculoskeletal ultrasound courses as an early exposure may have suboptimal benefits to the learner on its own and may require reinforcement with continued structured longitudinal learning opportunities. Future studies done on a larger scale that also correlate testing performance to postcourse ultrasound use need to be undertaken to further investigate our conclusions. 1467503 Utility of Ultrasound for Detecting Anterior Compartment Thickness Changes in Chronic Exertional Compartment Syndrome: A Pilot Study Sathish Rajasekaran,1* Cole Beavis,2 Abdel-Rahman Aly,1 Dave Leswick3 1Physical Medicine and Rehabilitation, 2 Surgery, 3Diagnostic Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada Objectives—To test the hypotheses that patients with chronic exertional compartment syndrome (CECS) of the anterior leg compartment have an increased anterior compartment thickness (ACT) compared to controls after exertion using ultrasound. Methods—Four patients with CECS (3 males and 1 female) and 9 controls participated in the study. Our ultrasound technique was first validated with a precision phase (10 controls) prior to scanning study subjects. CECS patients ran on a treadmill until symptomatic (≥5 minutes) using a standardized protocol. ACT and anterior compartment pressures were measured prior to exercise and at scheduled intervals afterward. Controls underwent the same protocol without compartment pressure testing. Results—Anterior compartment pressures were diagnostic of CECS using the modified Pedowitz criteria in all 4 CECS patients. The mean percent change in ACT from rest in CECS vs controls at 0.5 minutes was 21.3% (95% confidence interval [CI], 6.92%, 35.6%) vs 6.32% (95% CI, 0.094%, 12.5%; P = .011); at 2.5 minutes, it was 24.6% (95% CI, 10.7%, 38.5%) vs 4.22% (95% CI, –1.85%, 10.3%; P = .003); and at 4.5 minutes, it was 24.9% (95% CI, 14.3%, 35.5%) vs 5.08% (95% CI, 0.813%, 11.0%; P = .003). The mean ACT in CECS patients vs controls was significantly increased after exertion at 0.5, 2.5, and 4.5 minutes (P = .003). Conclusions—Ultrasound reveals a significant increase in ACT in patients with CECS of the anterior leg compartment compared to controls. Our study shows a promising role for using ultrasound, a noninvasive, readily available, and cost-effective method, to diagnose CECS. Further studies are warranted to validate the findings of this study with a goal of developing anterior leg compartment CECS ultrasound diagnostic criteria and exploring the role of using ultrasound to diagnose CECS in other compartments. 1541063 Efficacy of Sonographically Guided Injections of the Common Peroneal Nerve Perineural Space at the Fibular Tunnel Matthew P Kona,1* Oliver Joseph,1 Oleg Uryasev,1 John McNamara,1,2 Apostolos Dallas1 1Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA; 2Jefferson College of Health Sciences, Roanoke, Virginia USA Objectives—The common peroneal nerve (CPN) originates as a branch of the sciatic nerve within the popliteal fossa. Continuing inferolaterally, the CPN crosses the fibular head and penetrates the posterior intermuscular septum, where it courses through the fibular tunnel (FT), defined by the fibula and peroneus longus tendon. CPN entrapment within the FT is associated with motor deficits, such as foot drop, as well as sensory deficits and pain in the distribution of its branches: the anterolateral third of the lower leg and dorsum of the foot. Treatment may involve steroid injections into the perineural space of the CPN or its distal branches. The CPN also serves as a valuable alternative when preoperative sciatic block is unsuccessful or when a faster time to complete block is desired. The CPN has been effectively imaged using sonography (US). We hypothesize that using sonography, one can effectively inject the CPN perineural space at the FT. Methods—To image the CPN in cross section, 4 cadaveric models were placed in a prone position, with the transducer over the fibular head, and rotated 20В° from a transverse position. A total of 8 injections with methylene blue were performed using an in-plane technique. FT dissection permitted classification of injections according to accuracy and precision. Accuracy referred to nerve staining with methylene blue; precision referred to nerve staining without damage to adjacent structures. Results—One hundred percent of injections were accurate, while 87.5% were precise. Conclusions—Limitations of this study stem primarily from operator dependence and the pronounced musculoskeletal abnormalities of 1 cadaver. In this case, the superficial branch of the CPN was misidentified as the CPN. All other injection attempts performed in this study were successful. This study, in conjunction with others designed to investigate the clinical applications of CPN perineural injections, collectively highlight the utility of sonography in these relevant patient populations. Future phases of this study will center on expanding the initial data set and correlate the accuracy and precision of sonographically guided CPN injections with improved patient outcomes. 1541082 Efficacy of Sonographically Guided Injections of the Ulnar Nerve Perineural Space at the Cubital Tunnel Daniel Plessl,1* Robert Summey,1 Oliver Joseph,1 Oleg Uryasev,1 John McNamara,1,2 Apostolos Dallas1 1Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA; 2 Jefferson College of Health Sciences, Roanoke, Virginia USA Objectives—Ulnar nerve (UN) entrapment is the second most common nerve entrapment of the upper limb. The most common entrapment site is at the cubital tunnel to produce cubital tunnel syndrome (CTS). At the elbow, the UN courses subcutaneously between the medial epicondyle and the olecranon in the condylar groove and then enters the cubital tunnel. CTS presents with medial elbow pain and varying symptoms from sensory complaints to weakness of intrinsic hand muscles. CTS may be caused by extrinsic compression of the UN, bone deformities, or soft tissue lesions. The cubital tunnel has been effectively imaged using sonography; however, clinical benefits of such imaging have yet to be confirmed. We hypothesize that, using sonography, one can effectively inject the UN perineural space at the cubital tunnel. Methods—In this pilot study, the UN was visualized bilaterally on 4 nonembalmed cadaveric models. The elbow was examined in external rotation, and the transducer was placed transverse to the condylar groove along the medial epicondyle-olecranon axis. Sonographically guided lateral-to-medial UN injections with 0.35 mL of methylene blue S23 13proceedings_Layout 1 3/5/13 10:38 AM Page S24 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 were performed. Incisions were made parallel to the condylar groove deep to the cubital tunnel retinaculum to expose the underlying UN. Injections were accurate if the UN perineural space was dyed, and they were precise if the injection did not damage adjacent anatomy. Results—Eight of 8 injections were both accurate and precise. Conclusions—UN perineural injection is significant as it can provide symptomatic relief for CTS with corticosteroid injections to reduce inflammation. Sonography is inexpensive, quick, and minimally invasive. Future phases of this study will investigate efficacy of sonographically guided UN perineural corticosteroid injections in patients with CTS. This study suggests that injections under sonographic guidance are accurate and precise, therefore serving as a potential adjunct to treatment that is worth further investigation. Future phases of this study will center on expanding the initial data set and correlate the accuracy and precision of injection with improved patient outcomes. 1539088 Translating Contrast-Enhanced Ultrasound Intraneural Vascularity From Bench to Bedside Kevin Evans,* Kevin Volz School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio USA Objectives—To describe contrast-enhanced ultrasound (CEUS) imaging of the human median nerve’s intraneural vascularity, with equipment settings and optimizations derived from experiments with a cohort of Macaca fascicularis. Methods—The equipment used was a GE LOGIQ 9, complete with contrast settings, and a GE LOGIQ i, which is considered a handcarried unit. A 9.0-MHz linear broadband transducer was used with the GE LOGIQ 9, and a 12.0-MHz linear broadband transducer was used with the GE LOGIQ i hand-carried unit. Definity was used for this study because it possesses the smallest microspheres, 1.1 to 1.3 Вµm, has stability of <10 minutes, and resonates at 4 MHz. Equipment settings that had been used with experiments conducted with 11 M fascicularis were repeated with 11 patients during a CEUS echocardiogram. PixelFlux Scientific software allowed for semiautomatic assessment of the intensity of the contrast pixels. Descriptive statistics are compared to pixel counts and intensities between humans and the monkeys, although contrast dosing amounts varied. The goal was to capture multi-incremental sampling of the images during CEUS, focused on the median nerve. Results—The GE LOGIQ equipment settings were applied to the human study based on previous experiments. A better visual yield was found with 4% output power and a mechanical index of 0.13; these translated settings provided optimum imaging of the median nerve. The 9.0MHz linear transducer was also downshifted to a transmit frequency of 6.0 MHz for the human studies. Trend graphs are provided for comparison purposes. Conclusions—It will be vital to replicate this pilot study to validate these results with a larger set of subjects and correlate the findings with nerve conduction studies. Higher levels of evidence will promote the use of CEUS to investigate intraneural vessels and allow for angle correction, thereby yielding increased accuracy. Table 1. Comparison of Semiautomatic Analysis of CEUS Data Within the Median Nerve in both Macacas and Humans (n = 11) Parameter Mean average intensity Mean maximum intensity Mean signal count Preclinical Dosing 0.39 1.89 3.85 Human Dosing 1.79 4.18 25.6 Obstetric Ultrasound: Uterus, Placenta, and Cervix Moderators: Harris Finberg, MD, Cyrethia McShane, RDMS, BS 1540994 Cervical Length Assessment by Transabdominal and Endovaginal Ultrasound Jennifer Thompson,* Michael Smrtka, Geeta Swamy, Chad Grotegut, Brita Boyd, Amy Murtha Duke University, Durham, North Carolina USA Objectives—Endovaginal (EV) cervical length identifies women at risk for preterm birth (PTB) and thus eligibility for vaginal progesterone. Our objective was to compare transabdominal (TA) with EV cervical lengths to determine the degree of correlation, the capability of TA ultrasound (US) to predict an EV-detected short cervix, and the rate of cervical change over time. Methods—Retrospective review of singleton pregnancies having TA and EV US for cervical length between 16 and 28 weeks’ gestation at Duke University from January to December 2011. TA measurements are routinely obtained on midtrimester exams with EV measurement for high PTB risk, TA <30 mm, assessment of placental location, and/or presence of cerclage. Serial US with TA and EV are performed when EV <25 mm. Pearson correlation and receiver operating characteristic -curves were used to compare TA and EV cervical lengths and determine optimal TA cutoffs for prediction of an EV cervical length <25 mm. Linear regression was used to compare the rate of cervical change by TA and EV by term vs PTBs. Results—A total of 142 subjects with 245 US observations met study inclusion criteria. TA and EV measurements were significantly correlated (r = 0.810; P < .0001). A TA cutoff of 30 mm accurately predicted an EV-detected short cervix (<25 mm): sensitivity, 90.4%; specificity, 80.2%; positive and negative predictive values, 70.1% and 94.2%. Using linear regression, women delivering preterm had a greater rate of cervical change by EV compared to women delivering at term (P = .014). TA failed to demonstrate such a difference (P = .592). Conclusions—TA and EV cervical lengths correlate well and TA <30 mm as an accurate predictor of shortened EV cervical length. Serial follow-up of a US-detected short cervix should be via EV measurements, given the better detection of the rate of cervical change than TA in patients who deliver preterm. Detecting a rapidly changing short cervix sooner may allow for earlier interventions. Prospective studies are required to confirm our findings. 1472715 Cervical Length in the Second and Early Third Trimesters as a Predictor of Cesarean Delivery in Singleton Gestations Ashley Roman,1,2,3* Terri-Ann Bennett,1 Nathan Fox,1,2,3 Daniel Saltzman,1,2,3 Chad Klauser,1,2,3 Andrei Rebarber1,2,3 1 Obstetrics and Gynecology, New York University School of Medicine, New York, New York USA; 2Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York USA; 3Maternal-Fetal Medicine, Carnegie Imaging for Women, New York, New York USA Objectives—A long cervical length (CL) at 22 to 24 weeks’ gestation has been shown to be associated with an increased risk of cesarean delivery. The objective of this study was to determine the association between CL at 28 to 32 weeks and the risk of cesarean delivery in singleton pregnancies and to evaluate whether it is more predictive of cesarean delivery than CL at 22 to 24 weeks. Methods—This was a retrospective cohort study of singleton gestations with a history of prior spontaneous singleton preterm birth managed in a single practice between 2005 and 2011. All patients were followed with serial CL measurements via transvaginal ultrasound. Patients met criteria for inclusion if they had a CL measurement between 28 and 32 weeks’ gestation. Patients were excluded if they underwent a planned S24 13proceedings_Layout 1 3/5/13 10:38 AM Page S25 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 cesarean delivery. The primary outcome was risk of cesarean delivery in labor. Groups were compared using Fisher exact and П‡2 tests with significance defined as P < .05. Results—A total of 216 patients met inclusion criteria. At 22 to 24 weeks, the mean CL was 35 mm (range, 4–60 mm); at 28 to 32 weeks, the mean CL was 29 mm (range, 3–54 mm). CL at 22 to 24 weeks was not significantly associated with the risk of cesarean delivery. However, CL at 28 to 32 weeks was significantly associated with the risk of cesarean delivery (Table 1). A CL ≥50 mm (95th percentile) had sensitivity of 20%, specificity of 99%, a positive predictive value of 71.4%, and a negative predictive value of 90.4% for cesarean delivery in labor (P < .001). Conclusions—CL at 28 to 32 weeks is significantly associated with the likelihood of cesarean delivery in labor; however, CL at 22 to 24 weeks did not correlate with the risk of cesarean delivery. A longer CL in the early third trimester may represent underdevelopment of the uterus, leading to a higher risk of cesarean delivery in labor. The lack of an association at 22 to 24 weeks suggests that the normal cervical ripening process is one that occurs after the second trimester. Table 1. Risk of Cesarean Delivery in Labor by CL Quartile at 28 to 32 Weeks’ Gestation Quartile 1st (3–23 mm) 2nd (24–29 mm) 3rd (30–36 mm) 4th (37–54 mm) P Cesarean Delivery, % (n) 5.6 (3/54) 10.9 (6/55) 9.1 (5/55) 21.2 (11/52) <.001 Vaginal Delivery, % (n) 94.4 (51/54) 89.1 (49/55) 90.9 (50.55) 78.8 (41/52) <.001 1524943 Intramuscular Progesterone Slows the Rate of Cervical Shortening Cara Pessel, Saila Moni,* Noelia Zork, Sara Brubaker, Samantha Do, Joy Vink, Karin Fuchs, Chia-Ling NhanChang, Cande Ananth, Cynthia Gyamfi Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA Objectives—To evaluate whether 17-alpha-hydroxyprogesterone caproate (17-OHPC) exposure is associated with the rate of cervical shortening. Methods—Women with a history of spontaneous preterm birth (PTB; <37 0/7 weeks) who had serial cervical length (CL) measurements in 2011 and 2012 were identified. 17-OHPC administration and outcome data were collected. We excluded multiple gestations, patients lacking outcome data, medically indicated PTBs, and pregnancies with major fetal anomalies, vaginal progesterone use, and abdominal or vaginal cerclage. CL values from the second and third trimesters were recorded, and the rate of cervical change was modeled based on 17-OHPC status using methods for longitudinal analysis. Results—A total of 103 patients were included, with a total of 555 CL values. Eighty-five (82.5%) patients were exposed to 17-OHPC, and 18 (17.5%) were not. Gestational age (GA) and the number of previous PTBs, along with the timing of CL exams, were similar between these 2 groups, although women that did not receive 17-OHPC were more likely to have delivered multiples in their previous PTB (27.8% vs 4.8%). CL was plotted against GA for every patient starting at 16 weeks. Women were analyzed separately according to whether they delivered at term or preterm. The rate of CL change in women that delivered preterm was modeled using linear terms for GA at CL assessment, while the rate in women that delivered at term was modeled using second-degree polynomials. There was no difference in the risk of spontaneous PTB according to 17-OHPC exposure; however, among women who delivered preterm, the rate of CL shortening was slower in those exposed to 17-OHPC (1 vs 4 mm/wk). Conclusions—In women with previous PTB, cervical shortening occurs more gradually when exposed to 17-OHPC. Further studies may evaluate how 17-OHPC influences the cervical remodeling that leads to PTB. 1539329 Impaired Sonographic Cervical Assessment After Voiding: A Randomized Controlled Trial William Schnettler,1,2,3* Melissa March,1,2,3 Michele Hacker,2,3 Anna Merport Modest,2 Diana Rodriguez1,2,3 1MaternalFetal Medicine, 2Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts USA; 3 Harvard Medical School, Boston, Massachusetts USA Objectives—Sonographic cervical assessment is the leading tool for preterm birth prediction, and optimizing image quality is paramount. Focal myometrial contractions (FMCs) can impair imaging. We sought to determine if the timing of bladder emptying impacts FMC development and image adequacy. Methods—Women at 14.0 to 32.0 weeks’ gestation undergoing clinically indicated transvaginal ultrasound from January 1, 2012, to September 1, 2012, were eligible for this blinded randomized controlled trial. Participants were randomly assigned to undergo transvaginal imaging immediately after urination (within 5 minutes) or to defer the imaging by at least 15 minutes. The primary outcome was FMC development as determined by 2 independent blinded reviews of the images. Secondary outcomes included image adequacy and the diagnosis of placenta previa. Analysis was by intent to treat. Data are presented as proportions and medians (interquartile range). Relative risks (RRs) and 95% confidence intervals (CIs) were calculated using repeated measures log binomial regression. Results—A total of 222 women provided 336 randomized encounters; 1 was excluded due to poor image quality. In the immediate scan group, women voided a median of 3.0 (3.0–5.0) minutes before the scan and in the deferred scan group, and women voided a median of 28.0 (21.0– 38.0) minutes before. Women in the deferred group were 30% less likely to experience an FMC (RR, 0.70; 95% CI, 0.52–0.93) and 40% less likely to have inadequate images due to an FMC (RR, 0.60; 95% CI, 0.40–0.89). In the absence of an FMC, the 2 groups were equally likely to be diagnosed with placenta previa (P = .60). In the presence of an FMC, the deferred group was 76% less likely to be diagnosed with previa (RR, 0.24; 95% CI, 0.09–0.62) than women in the immediate scan group. Conclusions—A brief interval between voiding and transvaginal cervical evaluation is associated with a decrease in FMC incidence and improved imaging. Table 1 Immediate Scan (n = 168), n (%) FMC 68 (40.5) Inadequate imaging with FMC 49 (29.2) Previa without FMC 12 (7.1) Previa with FMC 21 (12.5) S25 Deferred Scan (n = 167), n (%) 47 (28.1) 29 (17.4) 17 (10.2) 5 (3.0) P .02 .01 .60 .003 13proceedings_Layout 1 3/5/13 10:38 AM Page S26 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1537208 Midtrimester Transabdominal Ultrasound for Detection of Placenta Previa Hayley Quant,* Alexander Friedman, Eileen Wang, Samuel Parry, Nadav Schwartz Maternal and Child Health Research Program, Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania USA Objectives—Transvaginal ultrasound (TVUS) is the gold standard for diagnosing placenta previa. Transabdominal ultrasound (TAUS) is often used as a screening test given the cost and invasiveness of TVUS. We sought to determine the ability of TAUS to diagnose previa. Methods—TAUS was performed prior to TVUS for all anatomic surveys at 18 to 23 6/7 weeks. Sonographers prospectively recorded the distance from the leading placental edge (if visible) to the internal os on both TA and TV scans. The primary outcome was a TV placental distance of 0 cm (complete previa). Secondary outcomes included TV distances of ≤1, ≤2, and ≤2.5 cm. ROC curves were generated using all cases with TA placental distance of ≤5cm. The TA placental distance cutoffs at 100% and 90% sensitivity were identified for each outcome and then applied to the entire cohort to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TAUS for detecting previa. Results—A total of 1214 patients underwent both TAUS and TVUS; 415 (34.2%) had a TA distance ≤5cm from placenta to os. The prevalence, optimal TA cutoffs by outcome and, test characteristics are presented Table 1. A TA measurement of ≤4.2 cm detected 93.3% of complete previas by TVUS with an NPV of 99.8% and a screen-positive rate (SPR) of 25%. A TA cutoff of 2.8 cm lowered the SPR to 11.4%, though the sensitivity decreased to 86.7% and the NPV to 88.6%. Conclusions—Despite a high NPV, the lack of a cutoff to exclude placenta previa makes TAUS an inadequate screen. Universal TVUS would improve midtrimester detection and allow for appropriate followup. Since most suspected previas resolve, further investigation is needed to assess whether TVUS can decrease morbidity later in gestation. Table 1 TV TA Placental Placental Distance Distance Cutoff, cm 0 (complete previa) 4.2 n = 30 (2.5%) 2.8 ≤1 cm 4.2 n = 45 (3.7%) 3.1 ≤2 cm 4.9 n = 100 (8.2%) 3.9 ≤2.5 cm 5.0 n = 146 (12.0%) 4.2 SPR, Sensitivity, Specificity, PPV, % % % % 25.0 93.3 76.7 9.2 11.4 86.7 90.5 18.7 25.0 93.3 77.6 13.8 13.5 84.4 89.2 23.2 32.9 89.0 72.2 22.3 21.0 81.0 84.4 31.8 34.2 82.9 72.5 29.2 25.0 76.7 82.0 36.8 NPV, % 99.8 88.6 99.7 99.3 98.7 98.0 96.9 96.3 1539742 Outcome of Pregnancies With a Low-Lying Placenta Diagnosed Between 16 and 24 Weeks’ Gestation Howard Heller,1 Katherine Mullen,1* Robert Gordon,1 Rosemary Reiss,2 Carol Benson1 1Radiology, 2Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts USA Objectives—To determine how often a low-lying placenta diagnosed between 16 and 24 weeks resolves prior to delivery. Methods—We assessed all cases of a low-lying placenta, defined as a placenta ending within 2 cm of the internal cervical os, diagnosed by sonography between 16 and 24 weeks’ gestation from July 1, 2007, to September 4, 2011. We reviewed medical records to determine the gestational age when a low-lying placenta was diagnosed, the gestational age at which the placenta was no longer low lying or previa, and, for those whose placentas never cleared sonographically, how many went on to cesarean section for placenta previa. Results—A total of 1416 pregnancies were diagnosed with a low-lying placenta between 16 and 24 weeks’ gestation. Of these, 174 were lost to follow-up. Of the remaining 1242 pregnancies, 1220 (98.2%) resolved to no previa prior to delivery. The mean age at resolution was 26.0 weeks. The age at resolution was similar in those diagnosed prior to 20 weeks’ gestation to those diagnosed after 20 weeks. Approximately 77% of placentas that eventually cleared did so before 29 weeks. Twentytwo patients had persistent placenta previa by sonography at or near term, all of which were confirmed at cesarean section. Conclusions—A low-lying placenta diagnosed between 16 and 24 weeks rarely (1.8% of the time) persists as placenta previa to term, necessitating cesarean section. Most cases resolve during the early third trimester. Thus, we suggest that reevaluation of the placental location in such cases be performed at approximately 28 to 30 weeks, not earlier. In addition, patients diagnosed with a low-lying placenta in the second trimester can be reassured that the likelihood of persistent placenta previa at the time of delivery is small. 1533371 Association Between Transvaginal Ultrasonographic Cervical Characteristics and Preterm Delivery After a History-Indicated Cerclage Emily Miller,* Susan Gerber Maternal-Fetal Medicine, Northwestern University, Chicago, Illinois USA Objectives—To assess the relationship between the transvaginal ultrasonographic characteristics of the cervix in the mid trimester and the risk of delivery prior to 34 weeks in women with a history-indicated cerclage. Methods—A retrospective case-control study of subjects with a singleton gestation and a history-indicated cerclage placed in the first trimester. Transvaginal ultrasound images of the cervix at the time of the anatomic survey in the second trimester were reviewed, and measurements of cervical length (CL) proximal and distal to the cervical suture as well as the presence or absence of funneling were recorded. П‡2 tests and logistic regression analysis were performed to evaluate the association between these cervical variables and preterm birth prior to 34 weeks. Results—One hundred three subjects met inclusion criteria. Sixteen (15.5%) delivered prior to 34 weeks’ gestation. CL proximal to the suture was lower in women who delivered prior to 34 weeks (1.6 vs 2.5 cm; P = .005), whereas distal CL was similar (1.5 vs 1.7 cm; P = .18). The frequency of cervical funneling was higher in women who delivered prior to 34 weeks (57% vs 9%; P < .001). In multivariable regression, only the presence of a cervical funnel remained significantly associated with an increased risk of preterm delivery before 34 weeks (Table 1). Conclusions—Cervical funneling is strongly associated with an increased risk of delivery before 34 weeks in women with a history-indicated cerclage. Midtrimester transvaginal cervical imaging can be used to augment risk assessment this patient population. Table 1. Odds Ratios for Birth Prior to 34 Weeks According to Ultrasonographic Cervical Appearance OR 95% CI aOR 95% CI Proximal CL 0.48 0.27–0.82 0.88 0.41–1.85 Distal CL 0.46 0.14–1.45 0.64 0.19–2.21 Cervical funnel present 13.5 3.74–48.74 9.96 1.62–61.03 aOR indicates adjusted odds ratio; CI, confidence interval; and OR, odds ratio. S26 13proceedings_Layout 1 3/5/13 10:38 AM Page S27 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1541264 The Natural History of Vasa Previa Across Gestation Andrei Rebarber,1,2,3* Cara Dolin,2 Nathan Fox,1,2,3 Chad Klauser,1,2,3 Daniel Saltzman,1,2,3 Ashley Roman1,2 1Carnegie Imaging for Women, New York, New York USA; 2Obstetrics and Gynecology, New York University School of Medicine, New York, New York USA; 3Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York USA Objectives—To estimate the prevalence and persistence of vasa previa in at-risk pregnancies using a standardized screening protocol. Methods—A descriptive study of patients from 1 ultrasound practice from June 2005 to May 2012. Cases were identified by ICD-9 code and content search analysis of the 2 ultrasound reporting systems, Sonultra and AS Ob/Gyn using the key words “vasa previa.” Vasa previa was defined as any velamentous fetal vessel (arterial or venous) noted to be within 2 cm of the internal cervical os. Screening for vasa previa using transvaginal ultrasound with color flow mapping was performed routinely in the following situations: resolved placenta previa, history of vasa previa in a prior pregnancy, velamentous insertion of the cord in the lower uterine segment, placenta succenturiata with implantation in the lower uterine segment, and twin gestations. Results—A total of 27,573 patients were referred to our unit for fetal anatomic surveys over the study period. Thirty-two cases of vasa previa were identified. Twenty-nine cases were available for analysis: 6 patients had migration and resolution of the vasa previa. When the initial diagnosis of vasa previa was made during the second trimester (<26 weeks), there was 28.6% resolution rate; if the diagnosis was made in the third trimester, none resolved (0/7 cases). Of the 23 cases (5 twin gestations and 18 singleton gestations) with persistent vasa previa, there was 100% survival with a median length of gestation of 35 weeks (range, 27 5/7–36 5/7 weeks). The median gestational age at diagnosis was 22 6/7 weeks (range, 16 1/7–36 5/7 weeks). The median gestational age at hospital admission was 33 weeks (range, 28–36 5/7 weeks). Conclusions—The incidence of vasa previa was 1.1 per 1000 pregnancies in our population. When vasa previa was diagnosed during the second trimester, there was a 28.6% resolution rate, but if diagnosed in the third trimester, none resolved. More than 90% of cases of vasa previa that were identified had either a history of a resolved placenta previa or a twin gestation. Effective prenatal diagnosis of vasa previa screening using transvaginal imaging with color flow mapping is attainable using focused criteria for evaluation. 1536702 Uterine Volume Between 11 and 14 Weeks’ Gestation in Singleton and Dichorionic Diamniotic Twins as Seen by Ultrasound Lindsay Kugler,* Joaquin Santolaya Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School, New Brunswick, New Jersey USA Objectives—We analyzed the changes in uterine volume in singleton and dichorionic diamniotic (DCDA) pregnancies between 11 and 14 weeks’ gestation. Methods—This was a nested case-control study performed in patients that were followed and delivered at our center. All patients had a <1 in 300 risk for Down syndrome after the first-trimester screening test and delivered vigorous newborns with a birth weight appropriate for gestational age. Pregnancies ending in stillbirth or with newborns with malformations or abnormal birth weight were excluded. The Student t test and regression analysis were used for group comparisons. P < .05 was considered significant. Results—At 11 weeks’ gestation, the mean uterine volume for singletons was 357 cm3 and for DCDA twins was 652 cm3 (P < .05). At 14 weeks’ gestation, the mean uterine volume in singleton pregnancies was 698 cm3 and in DCDA twins was 1026 cm3 (P < .05). Conclusions—Gaining insights into the normal and abnormal uterine changes early in gestation might have potential for predicting maternal maladaptations to pregnancy. This study provides a novel sonographic approach to the early physiologic uterine capacities. These preliminary data demonstrate the plasticity of the uterus early in pregnancy, becoming almost 50% larger in DCDA twins than singleton pregnancies by 11 weeks’ gestation. Interestingly, the difference in uterine volume decreases to 30% by 14 weeks’ gestation. This study paves the way to investigations aimed at determining if decreased uterine plasticity can be used for the early prediction of adverse perinatal outcomes in singleton and twin pregnancies. Table 1. Clinical Variables in Nested Case-Control Study With Singleton and Dichorionic Twins: Summary Statistics Mean Mean Mean Mean Fetal Nulli- GA at Newborn Median Median Newborn Maternal CRL, para, Delivery, Weight, 1-min 5-min Male, Cesarean Age, y mm % wk kg Apgar Apgar % Delivery, % Singleton 32 60 46 39.4 3.4 8 9 49 27 (n = 78) (5.4) (7.1) (1.0) (0.4) Twins 35 62.4 57 34.6 2.1 AB AB 36 95 (n = 23) (4.4) (10) (3.3) (0.6) 89 99 P .008 NS — < .001 < .001 NS NS — — CRL indicates crown-rump length; GA, gestational age; and NS, not significant. Patients’ ethnic background (%): singleton: Caucasian, 42; Asian, 20; African American, 7.5; unknown, 30; twins: Caucasian, 33; Asian, 20; African American, 10; other/unknown, 37. 1540615 Can 3-Dimensional Power Doppler Ultrasound of the Cervix Predict Preterm Labor in Women at Increased Risk? Ahmed Ahmed,* Shoshana Haberman, Howard Minkoff Maimonides Medical Center, Brooklyn, New York USA Objectives—To evaluate the diagnostic potential of 3D Doppler ultrasound measured by Virtual Organ Computer-Aided Analysis (VOCAL) for prediction of preterm labor (PTL) in asymptomatic women (singleton) at risk. Methods—A prospective ongoing cohort study (Institutional Review Board approved). Included: 300 -pregnant women at 18 to 24 weeks, singleton at high risk for PTL (prior spontaneous preterm delivery, history of cone biopsy, or >2 dilations and evacuations). Excluded: multiple gestation, preterm contractions, or fetal anomalies. Transvaginal sonographic (TVS) evaluation of the cervix using a GE Voluson E8 system (7.5 MHz) was performed. The stored volumes were processed using 4D View software for calculation of cervical volume in cubic centimeters and 3D Doppler indices (vascularization index [VI], flow index [FI], and vascularization flow index [VFI]) using VOCAL. The cervical length (CL) was measured using the tomographic ultrasound imaging (TUI) mode. All participants were observed until delivery. Using SPSS 11.5 software, the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and receiver operating characteristic curve were calculated. Regression analysis was done. Results—Only 105 women have delivered thus far. Eleven patients (group I) had PTL ≤34 weeks; 24 patients (group II) had PTL >34 to <37 weeks; and 70 patients (group III) delivered ≥37 weeks. Using analysis of variance, significant differences existed between the 3 groups with regard to CL by TUI, cervical volume, and FI (P = .019, .037, and .002, respectively). Unlike VI and VFI, a significant negative correlation was found between FI and gestational age at the time of delivery (R 2 = 0.176; P < .001). The highest sensitivity, specificity, and area under the curve (AUC) were for FI (Table 1). Conclusions—Women who delivered before 37 weeks had higher FI values when screened between 18 and 24 weeks, reflecting a more vascularized cervix during early ripening. 3D Doppler ultrasound S27 13proceedings_Layout 1 3/5/13 10:38 AM Page S28 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 of the cervix might be helpful for detection of the ripening process and possibly predicting PTL. Table 1. AUC, Sensitivity, Specificity, PPV, and NPV for 3D Ultrasound Parameters of the Cervix AUC CL by 2D TVS, mm 0.643 CL by TUI, mm 0.649 Cervical volume, cm3 0.501 FI 0.822 CI indicates confidence interval. Cutoff Point 29 32 44.6 46.2 Sensi- SpeciSignificant tivity, ficity, PPV, NPV, Level 95% % % % % AUC P CI 72 68 20 95 .055 0.54–0.73 73 63 19 95 .049 0.54–0.74 64 55 14 93 .987 0.40–0.60 82 82 36 98 .0002 0.73–0.89 Pediatrics and Fetal Echocardiography Moderator: Gary Satou, MD 1522495 Is Fetal Echocardiography Necessary in In Vitro Fertilization/Intracytoplasmic Sperm Injection Pregnancies After an Anatomic Survey? Oluyemi Aderibigbe,1* Angela Ranzini,1 Sumekala Nadaraj2 1 Obstetrics and Gynecology, Saint Peters University Hospital, New Brunswick, New Jersey USA; 2Pediatric Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA Objectives—In vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is one of the indications for fetal echocardiography (ECHO) due to a reported increased risk for cardiac anomalies. In this study, we evaluated the utility of ECHO after an anatomic survey (AS) in an experienced center. At the time of the AS, cardiac evaluation included views of the 4-chamber heart and attempts at outflow tracts and arch views. Methods—Records of patients seen in our hospital’s Antenatal Testing Unit with the indication of IVF/ICSI for an AS and ECHO between January 1996 and October 2010 and who delivered at our institution were evaluated. Results—Eighty-five patients carrying 110 fetuses were identified. Six cardiac anomalies (4 ventricular septal defects [VSDs], 1 pulmonary artery [PA]-aortic disproportion, and 1 postvalvular PA dilatation) were suspected on the AS. At ECHO, 2 VSDs were confirmed, 2 were not, and 2 additional VSDs were seen; 1 aberrant right subclavian artery (ARSA) and 1 right aortic arch (RAA) were found, and PA dilatation was confirmed. On neonatal ECHO, only 2 of the 7 VSDs seen at either the AS or ECHO were present; the postvalvular PA dilatation and RAA were confirmed. Second-trimester ECHO, however, identified only 2 additional anomalies confirmed at birth: an RAA in a fetus with a known VSD and an additional fetus with a VSD. Neonatally, 3 patients with a normal AS and ECHO were found to have VSDs. The most common cardiac abnormality in IVF/ICSI fetuses is a VSD, which is identified in 4.5% of all cases in the neonatal period. VSDs identified in the antenatal period resolved in 82% of cases. A RAA and an ARSA should be identified on the transtracheal view (3-vessel view [3VV]) of the heart. Conclusions—In IVF/ICSI pregnancies, VSDs are common but likely to resolve or be seen only at birth. In expert centers, fetal ECHO may not be necessary if the 3VV of the heart is evaluated and the heart is evaluated for VSDs. 1538566 Application of Acoustic Radiation Force Impulse Imaging in Quantitative Evaluation of Neonatal Brain Development Su Yijin,* Du Lianfang, Xia Jin, Wu Ying, Jia Xiao, Cai Yingyu, Li Yunhua, Zhao Jing, Liu Qian, Zhang Juan School of Medicine, Shanghai Jiaotong University, Shanghai, China Objectives—To quantitatively evaluate the effect of acoustic radiation force impulse imaging (ARFI) in neonatal brain development. Methods—we used ARFI on a Siemens S2000 system to quantitative evaluate white and gray matter of neonatal different tissues in brain with different gestational ages. We used a new technical index, Virtual Touch Tissue Quantification (VTQ) to evaluate elastic changes of brain tissues. Results—Different tissues in the brain had different elastic numerical values. Neonates with different gestational ages had different elastic numerical values. Elastic numerical values of full-term infants were higher than preterm infants. Conclusions—ARFI provides a new quantitative index to evaluate neonatal brain development. It increases objectivity and reliability of clinical analysis. Ultrasound is an examination method that is noninvasive, safe, simple, and convenient, so it has more usefulness with ARFI in quantitative evaluation of neonatal brain development. Table 1. Comparison of VTQ Values for Preterm and Full-Term Neonates Neonates Cases, n Mean, m/s SD, m/s Preterm 23 1.89 1.07 Full-term 35 2.35 1.24 Compared with full-term neonates, the VTQ value for preterm neonates was lower (P < .001). 1538283 Is Follow-up Sonography Necessary in Babies With Morphologically Normal but Unstable Hips? Christine Iseman, Bokyung Han, Henrietta Kotlus Rosenberg* Radiology, Mount Sinai Medical Center, New York, New York USA Objectives—To determine if follow-up (FU) hip ultrasound (US) is necessary in babies with an unstable hip when the hip morphology is normal (nl). Methods—This retrospective study included patients (pts) with at least 2 hip US examinations performed between January 1, 2008, and January 31, 2012. Pt population: 342 pts, 42 excluded as FU US performed in a Pavlik harness, 15 excluded as both hips nl aligned on first and FU US, and 10 excluded due to poor technique. A total of 515 hips were analyzed in 285 pts. Of those, 68 hips were excluded as they were normal on the first study. In total, 480 hips were analyzed. All sonograms and associated reports were reviewed by 1 attending and 1 resident radiologist. Degree of subluxation/dislocation assessed and graded: normal = 0; mild = 1; moderate = 2; severe = 3; and dislocation = 4. Results—A total of 447 hips were initially subluxed or dislocated and resolved on FU (93%; group 1). Thirty-three hips were initially subluxed or dislocated and did not resolve (7%). Of hips that did not resolve on FU, 4% were morphologically nl (group 2), and 2% were initially morphologically abnormal (abnl) but became morphologically nl on FU (group 3). Four hundred six of 447 hips (91%) demonstrated normal О± angles ≥ 60В° at first US and nl alignment during all maneuvers on FU. Forty-one of 447 hips had abnl О± angles ≤60В° initially and nl alignment during all maneuvers on FU. Age range at time of initial US: 1 to 136 days. Age range at time of FU US, which demonstrated resolution of subluxation/dislocation: 23 to 362 days for group 1, 35 to 174 days for group 2, and 23 to 174 days for group 3. One hundred fifty-one babies whose subluxation/dislocation resolved had US performed within the first 30 days of life; 21% resolved within 28 days; 52% in 29 to 56 days, 16% in 56 to 84 days, and 21% in >84 days. S28 13proceedings_Layout 1 3/5/13 10:38 AM Page S29 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Conclusions—The vast majority (94%) of unstable hips became stable on FU examination; 91% of these hips were morphologically nl at initial US, while 9% were morphologically abnl at the initial study but became morphologically nl on FU. Approximately 6% of total hips analyzed remained unstable on FU, 4% of these being morphologically nl hips. While these findings can be comforting to parents whose babies have hip instability, they also support the current practice of obtaining FU sonograms until stability is achieved. 1538513 Neonatal Ovarian Cysts: Can Sonography Predict Torsion? Dinesh Chinchure,1* Chiou Li Ong2 1Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore; 2Diagnostic Imaging, K. K. Women’s and Children’s Hospital, Singapore Objectives—The purpose of this study was to evaluate whether sonography can predict torsion in neonatal ovarian cysts. Methods—Seven surgically proven cases of neonatal ovarian cysts were included in this retrospective study. The patients were divided into 2 groups: torsion and nontorsion. These 7 patients were evaluated for clinical presentation, sonographic features, and surgical and pathologic findings. The findings on follow-up sonography after surgery were also noted. Results—The sonographic appearance was variable. Of the 4 cases with torsion, 2 lesions had internal echoes with a “fishnet appearance.” The other 2 lesions were predominantly cystic on sonography with internal echoes and echogenic nodules. A calcific focus was present in 1 of these echogenic nodules. One of the cysts had a fluid-fluid level. In the nontorsion group, only 1 of the lesions had a mixed echogenic appearance. The other 2 lesions were cystic with low-level internal echoes in 1 of the cysts. The surgical procedure performed in the torsion group was salpingo-oophorectomy in 2 patients and oophorectomy in 1 patient. In 1 patient, cystectomy was attempted without success. In the nontorsion group, only cystectomy was performed with preservation of normal ovaries, which was confirmed on follow-up sonography. Conclusions—The sonographic features of cysts with a fishnet appearance, a fluid-debris level, and echogenic nodules favor torsion. The former sign has so far not been described as a sonographic predictor for neonatal ovarian torsion. 1539741 Sonographic Evaluation of Pediatric Skeletal Lesions: Is It Worthwhile? Henrietta Kotlus Rosenberg,* Neil Lester Radiology, Mount Sinai Medical Center, New York, New York USA Objectives—To demonstrate how ultrasound (US) may serve as a readily available, cost-effective, noninvasive, nonionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. Methods—We reviewed the clinical and imaging findings in 31 patients in whom US demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or developmental dysplasia of the hip. Results—US proved useful in the following situations: evaluation of a hard superficial immobile mass (osteoma shin; 1), absent medial end clavicle on x-ray in the region of a neck mass (US showed an aneurysmal bone cyst in the medial end clavicle; 1), to determine if a soft tissue mass involves adjacent bone (nodular fasciitis surrounding the clavicular head; 1), diagnosis and follow-up of fracture (displaced/nondisplaced) in an infant (4), diagnosis of osteomyelitis in patients with cellulitis (4), question of fracture underlying cephalohematoma or subgaleal hematoma (4), rib mass (osteochondroma; 1; or a mass in costochondral junctions: contour deformities in the costochondral cartilage; 6), firm posterior knee mass (Baker’s cyst; 1), firm anterior knee mass (septated cystic mass in the suprapatella region due to rheumatoid disease; 1), immobile hard scalp mass due to an epidermoid cranial vault (1), painful mass in the occipital bone with soft tissue components extending through the skull externally and inter- nally due to Langerhan’s histiocytosis (1), indeterminate mass in the clavicle clinically thought to be posttraumatic sequelae, resolved on follow-up (1), assessment of craniosynostosis (3), ad differentiation of a pathologic entity from a normal anatomic structure (lump on the back of a slender baby proven to be a normal posterior spinous process; 1). Conclusions—US is worthwhile for evaluation of a wide range of pediatric skeletal abnormalities and helps determine if the a lesion is one that is “touch” or “don’t touch.” To maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, and laboratory and other imaging findings. In equivocal cases or in those patients in whom the field of view is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, US serves to triage those patients in whom further imaging is necessary. 1539575 Evaluation of Automated Multiplanar 3-/4-Dimensional Sonography in Prenatal Diagnosis of Conotruncal Cardiac Defects: Analysis of 150 Cases Elena Sinkovskaya,* Sharon Horton, Anna Klassen, Alfred Abuhamad Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, Virginia USA Objectives—The aim of this study was to assess potential clinical applicability of automated multiplanar imaging (AMI) in prenatal detection of conotruncal heart defects. Methods—Detailed 2D echocardiography was performed in 75 fetuses with normal cardiac anatomy and 75 fetuses with conotruncal heart anomalies between 18 and 23 weeks’ gestation by a trained sonographer. In addition, 3D/spatiotemporal image correlation volumes of the fetal chest were acquired at the level of the 4-chamber view. Two volume data sets per case (with and without color Doppler) were included in the study. The initial scan was interpreted and reported based on the 2D images. The volume data sets were independently reviewed offline using AMI software by a pediatric cardiologist with experience in fetal heart assessment. The diagnostic value, image quality, as well as time for acquisition and reading of AMI were evaluated and compared with the original 2D report. The prenatal diagnosis was confirmed in all cases by postnatal echocardiography, angiography, operative findings, or autopsy. Results—A summary of the results is provided in Table 1. Conclusions—The developed software demonstrates an excellent display of the diagnostic landmarks of conotruncal defects with appropriate image quality in most cases. This should help improve the detection of these heart anomalies in the future. Automated sonography also has the potential for improving the efficiency of ultrasound imaging by reducing the time needed to complete an ultrasound examination, thereby resulting in increased throughput of ultrasound laboratories. Table 1 Parameter Acquisition time, min Reading time, min Image quality, % Excellent Good Poor Sensitivity, % Specificity, % NS indicates not significant. S29 2D 16 В± 4 12 В± 2 AMI 0.3 В± 0.1 7В±2 P <.001 <.01 37 53 10 88 96 41 43 16 92 96 NS NS NS NS NS 13proceedings_Layout 1 3/5/13 10:38 AM Page S30 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1540606 Fetal Diagnosis of Hypoplastic Left Heart: Associations and Outcomes in the Current Era Roland Axt-Fliedner,1* Christian Enzensberger,1 Melanie Vogel,2 Jan Weichert,4 Ulrich Gembruch,5 Ute Germer,6 Thomas Kohl,3 Martin Krapp,7 Jan Degenhardt1 1Division of Prenatal Medicine, 2Division of Pediatric Cardiology, 3 German Center for Fetal Surgery and Minimally Invasive Therapy, University of Giessen & Marburg, Giessen, Germany; 4 Division of Prenatal Medicine, University of SchleswigHolstein, Campus Luebeck, Luebeck, Germany; 5Division of Prenatal Medicine, University of Bonn, Bonn, Germany; 6 Center for Prenatal Medicine, Caritas Krankenhaus St Josef, Regensburg, Germany; 7Center for Endocrinology and Reproductive and Prenatal Medicine, Amedes Hamburg, Hamburg, Germany Objectives—Hypoplastic left heart (HLH) is one of the most common forms of cardiac abnormality detectable during gestation by fetal echocardiography. Antenatal diagnosis allows for appropriate counseling and time to consider treatment options. We report the actual outcome data after fetal diagnosis of HLH. Methods—We conducted a retrospective analysis of the outcome in all cases with HLH from 1994 to 2011 presenting in fetal life at 2 tertiary referral centers for prenatal diagnosis and pediatric cardiology. Results—One hundred five cases were included, and the overall survival was 40.9% (43/105) after prenatal diagnosis. There was an 81.1% survival rate in infants undergoing surgery and a 64.1% survival rate from an intention-to-treat position. Two neonates died due to tamponade and cardiac arrest following balloon septostomy and 1 neonate from sepsis before surgery. Extracardiac anomalies occurred in 3 fetuses and karyotype anomalies in 7 fetuses (18.9%). In 4 of 5 babies born with additional extracradiac or karyotype anomalies, parents opted for compassionate care. The first had trisomy 13; the second had trisomy 18; the third neonate presented with spina bifida; and the fourth presented with hydronephrosis and pulmonary atresia. Termination of pregnancy took place in 17 cases (16.1%). Conclusions—Thorough antenatal evaluation should include karyotyping and detailed extracardiac and intracardiac assessment to accurately predict the risks of surgery. Prenatal counseling might be modified after the exclusion of additional anomalies. These data provide up-to-date information for parental counseling. 1539318 Fetal Pulmonary Venous Flow and a Restrictive Foramen Ovale in Hypoplastic Left Heart Roland Axt-Fliedner,1* Jan Degenhardt,1 Melanie Vogel,2 Jan Weichert,4 Ulrich Gembruch,5 Thomas Kohl,3 Christian Enzensberger1 1Division of Prenatal Medicine, 2Division of Pediatric Cardiology, 3German Center for Fetal Surgery and Minimally Invasive Therapy, University of Giessen & Marburg, Giessen, Germany; 4Division of Prenatal Medicine, University of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany; 5 Division of Prenatal Medicine, University of Bonn, Bonn, Germany Objectives—Hypoplastic left heart (HLH) with intact or restrictive interatrial communication (HLH- IAS/RAS) is associated with high mortality rates. The objective was to correlate pulmonary venous (PV) Doppler spectra and direct foramen ovale (FO) assessment with the neonatal need for early atrial septostomy (EAS) and neonatal outcome. Methods—We reviewed all prenatal echocardiograms and outcomes of 51 fetuses with HLH and information about the interatrial communication between 1994 and 2011. IAS/RAS was defined as a small/absent interatrial shunt on 2D imaging. Three PV Doppler spectra were observed: type A, continuous forward flow with a small a-wave reversal; type B, continuous forward flow with increased a-wave reversal; and type C, brief to-and-fro flow. Results—Three of 51 neonates with the type C PV flow pattern and suspicion of IAS/ RAS on 2D evaluation required EAS. In 1 fetus, PV flow changed from type B to type C spectra throughout gestation. Fetuses with type C spectra showed 71.4% survival after 30 days compared to 92.3% in fetuses with type A spectra. Short-term survival after EAS was 33%. Conclusions—The prenatal PV flow pattern and 2D evaluation of the FO size help in identifying the fetus at risk for neonatal EAS and patient selection for fetal cardiac intervention. Most late secondtrimester values will not change over time. 1538894 The Fetal-Maternal Vascular Impedance Index: A Potential New Tool for Characterization of Fetal Circulatory Health Debbra Soffer,* Margaret McCann, Xi Liu, Zhiyun Tian, Jack Rychik Fetal Heart Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA Objectives—Fetal circulatory health is often determined by characterization of (1) umbilical arterial blood flow, (2) cerebrovascular blood flow, or (3) the ratio between the two. However, these measures ignore the maternal contribution to placental perfusion. We sought to investigate the utility of the fetal-maternal vascular impedance index (FMVI), a new measure of vascular characterization that incorporates fetal cerebrovascular, umbilical, and maternal uterine circulations in assessing overall fetal well-being. Methods—Doppler interrogation of the fetal middle cerebral artery (MCA), umbilical artery (UA), and right maternal uterine artery (UTA) was performed and vascular impedance calculated for each through the pulsatility index (PI). Three groups of gestationally age-matched subjects were studied: (1) normal controls, (2) fetuses with maternal diabetes (MD), and (3) fetuses with a severe form of congenital heart disease (CHD), hypoplastic left heart syndrome (HLHS). The FMVI was calculated as the (MCA PI – UA PI)/UTA PI. Results—Mean and SD data are listed in Table 1. There was no difference in gestational age between the 3 groups. The MCA PI for the MD group was no different than for normal; however, HLHS was significantly lower (P < .05). There was no difference in the UA PI or UTA PI between the 3 groups. The FMVI for the MD group was significantly lower (P < .05) and for the HLHS group was markedly lower (P < .001), than normal. Conclusions—The FMVI is an index of relative vascular impedance between the fetal cerebrovasculature, UA, and maternal contribution to placental flow, which varies from normal in MD and complex CHD. Vascular impedance is naturally highest in the MCA, followed by the UA, and lowest in the UTA. The FMVI evaluates this natural trend, which may aid in detecting subtle circulatory alterations that are not evident by analysis of individual PI values alone. Table 1 n Normal 47 MD 54 HLHS 29 S30 Gestational Age, wk MCA PI UA PI 23.2 (3.7) 1.99 (0.38) 1.25 (0.19) 23.5 (4.8) 1.92 (0.39) 1.30 (0.29) 24 (3.4) 1.85 (0.31) 1.34 (0.26) UTA PI 0.92 (0.38) 0.91 (0.36) 0.89 (0.21) FMVI 0.97 (0.63) 0.73 (0.73) 0.62 (0.49) 13proceedings_Layout 1 3/5/13 10:38 AM Page S31 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSIONS MONDAY, APRIL 8, 2013, 1:30 PM–3:30 PM Directing Extracellular Matrix Protein Microstructure With Ultrasound Denise Hocking Pharmacology and Physiology, University of Rochester, Rochester, New York USA Cellular Bioeffects and Applications Moderator: Diane Dalecki, PhD Applications of Ultrasound Standing Wave Fields in Tissue Engineering Diane Dalecki University of Rochester, Rochester, New York USA The field of tissue engineering aims to develop technologies that enable the repair or replacement of diseased or injured tissues and organs. The spatial organization of cells within native and engineered tissues is essential for proper tissue assembly and organ function. Thus, successful engineering of complex tissues and organs requires methods to control cell organization in 3 dimensions. Acoustic radiation forces associated with ultrasound standing wave fields provide a rapid, noninvasive approach to spatially pattern cells in 3 dimensions without affecting cell viability. Results of several investigations will be presented that demonstrate the use of ultrasound standing wave fields to pattern cells or protein-bound microparticles in 3D hydrogels. Furthermore, patterning of endothelial cells with ultrasound standing wave fields leads to rapid and extensive vessel network formation in 3D collagen-based constructs. Thus, ultrasound standing wave fields provide new strategies to pattern cells and direct vascular network formation and morphology within engineered tissue constructs. Interactions of Microbubbles With Cells and Their Applications for Drug and Gene Delivery Cheri Deng University of Michigan, Ann Arbor, Michigan USA Sonoporation uses ultrasound application to generate microbubble activities to transiently disrupt the cell membrane for enhancing intracellular transport of exogenous agents for drug and gene delivery applications. However, success of sonoporation is hindered by low delivery efficiencies and variable outcomes. These difficulties are due to the lack of understanding of the detailed processes supporting ultrasound-induced transport into and within the cytoplasm of living cells. The dynamic microbubble activities driven by ultrasound application induce cellular bioeffects that can determine the delivery outcome, including delivery efficiency and cell viability. In this presentation, we provide an examination of these biophysical and biochemical effects resulting from interaction of ultrasound-driven microbubbles with cells and whether they play important roles in the sonoporation outcome. We developed novel techniques to control and investigate ultrasound-driven microbubble cavitation in reference to single cells and the resulting membrane disruptions. We used simultaneous whole-cell patch clamp recording and fluorescence microscopy to characterize the formation and resealing of ultrasound-induced membrane pores. We demonstrated spatiotemporally controlled subcellular delivery and calcium signaling in targeted cells. In addition, based on the ultrasound-driven microbubble activities, we implemented an ultrasound exposure strategy to improve gene transfection. These results may provide relevant information for further development of sonoporation. The extracellular matrix is a complex network of interconnected proteins and polysaccharides that provides structure to tissues and instructs cell behaviors. The microstructure and molecular conformation of extracellular matrix proteins provide signals that direct cell functions critical to tissue formation and regeneration, including proliferation, migration, and matrix remodeling. Thus, controlling extracellular matrix protein structure provides a means to regulate the mechanical properties of biomaterials and control cellular responses. Moreover, biomaterials with regionally defined extracellular matrix structure could provide local cues to instruct cell behavior and drive proper tissue function in 3 dimensions. Collagen is the primary fibrous component of the extracellular matrix. The tremendous diversity of the functional properties of type I collagen arises from variations in the micromolecular and macromolecular structure of polymerized collagen fibers. Results of our studies demonstrate the capability of ultrasound to spatially pattern various collagen microstructures within an engineered tissue noninvasively, thus enhancing the level of complexity of extracellular matrix microenvironments and cellular functions achievable within 3D engineered tissues. Elastography 2013 Moderator: Richard Barr, MD, PhD Elastography of Diffuse Liver Disease Giovanna Ferraioli,* Carlo Filice Infectious Diseases, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Policlinico San Matteo, Medical School, University of Pavia, Pavia, Italy The prognosis and management of patients with chronic liver diseases largely depend on the extent and progression of liver fibrosis. Liver biopsy is still considered the reference standard for assessing liver fibrosis. It is an invasive procedure that carries a risk of complications. Moreover, it is not an ideal method for repeated evaluation of disease progression. For these reasons, techniques that noninvasively assess liver fibrosis have been developed. Elastography is a technique that analyzes the mechanical and elastic properties of soft tissue that could be modified by pathologic conditions. Real-time elastography, which allows measurement of tissue’s stiffness while guided by the B-mode image, is either strain based or shear wave based. With strain-based elastography, the displacement of tissues due to an applied stress is detected. With all the shear wavebased techniques, there is a generation of shear waves determined by tissue’s displacement induced by the force of a focused ultrasound beam. Real-time elastographic methods are included in standard ultrasound systems. Based on our experience and that of other groups, we believe that shear wave–based methods are ready to be used in patients with chronic hepatitis C to assess liver fibrosis before therapy at a safe level of predictability. S31 13proceedings_Layout 1 3/5/13 10:38 AM Page S32 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Exploring the Interface of Ethics and Communication in Prenatal Care: A Video-Based Approach Moderator: Stephen Brown, MD Exploring the Interface of Ethics and Communication in Prenatal Counseling: A Video-Based Approach Stephen Brown,1* Bryann Bromley,3,4,5 Elaine Meyer2,6 1 Radiology, 2Institute for Professionalism and Ethical Practice, Boston Children’s Hospital, Boston, Massachusetts USA; 3 Diagnostic Ultrasound Associates, Boston, Massachusetts USA; 4Obstetrics and Gynecology, Massachusetts General Hospital and Brigham and Women’s Hospital, Boston, Massachusetts USA; 5Radiology, Brigham and Women’s Hospital, Boston, Massachusetts USA; 6Psychiatry, Harvard Medical School, Boston, Massachusetts USA Course objectives: (1) Evaluate strategies to communicate effectively when conveying difficult information to patients. (2) Explore how micro-ethical issues are embedded in patient-clinician communication. (3) Examine the clinical and ethical dimensions of prenatal counseling from the perspectives of upstream and downstream clinical providers. Course description: In this interactive workshop, faculty and audience will view and discuss videotaped counseling sessions between experienced clinicians and trained actors portraying expectant parents after diagnoses of miscarriage in the first trimester and spina bifida in the second trimester. When such conditions are diagnosed, practitioners who counsel patients must convey cognitively and ethically complex information under emotionally charged circumstances. Few educational opportunities exist to help practitioners acquire the skills necessary to approach these conversations effectively. Such skills are essential for obstetric and pediatric specialists who engage in prenatal diagnosis and counseling. In this workshop, participants will collectively explore and share their perspectives regarding: (1) the “art” of difficult communication; (2) how values may influence decision making; (3) how language usage, framing of choices, provision of information, and offers of resources may confound neutrality; (4) potential differences in attitudes and counseling practices between practitioners from different disciplines; and (5) strategies to teach this difficult communication process. Workshop faculty includes a pediatric and obstetric imaging specialist and bioethicist, a maternal-fetal medicine and obstetric imaging specialist, and a psychologist and pediatric critical care nursing specialist who is an expert in health care communication. Hands-on Carotid and Transcranial Doppler Ultrasound Moderator: Tatjana Rundek, MD In this session, participants will be provided with live demonstrations of carotid and transcranial Doppler scanning protocols and handson practice sessions at ultrasound stations. New Techniques and Methods in Ultrasound-Guided Interventions Moderator: Corinne Deurdulian, MD Utilization of Contrast-Enhanced Ultrasound in Interventional Radiology Dean Huang Clinical Radiology, King’s College Hospital, London, England The aim of this talk is to consider the applications of contrast-enhanced ultrasound (CEUS) in interventional radiology. One of the most es- tablished techniques in imaging-guided, minimally invasive procedures is with ultrasound, a tool that is safe, mobile, and cost-effective. CEUS provides better images than conventional B-mode images, improves the ability to differentiate between normal and abnormal tissue, and simplifies the precise navigation of needles during an intervention. CEUS therefore could play an important role in procedure planning, needle navigation, and postprocedure follow-up imaging, particularly when iodinated contrast or ionizing radiation is undesirable or in unstable patients where “bedside” procedures are advantageous. A number of interventional procedures in which CEUS has been integrated into the management, both in nonvascular and vascular intervention, are illustrated. Examples of nonvascular applications include urologic intervention with CEUS-guided nephrostomy and CEUS-guided nephrostography, CEUS-guided percutaneous biopsy and abscess drainage, CEUS-guided transhepatic T-tube cholangiography, and CEUS-guided oncologic intervention in thermal ablation of hepatic and renal tumors. Examples of vascular intervention with CEUS include management of endoleaks following endovascular aortic stent graft repair, pseudoaneurysms following arterial injury with CEUS-guided percutaneous thrombin injection, and CEUS-guided dialysis arteriovenous fistula angioplasty. Through a casebased approach, this talk aims to demonstrate that CEUS not only can be utilized safely and effectively in radiologic intervention but may also provide novel, tailor-made solutions to complex clinical problems. Vaginal Bleeding in the First Trimester Moderator: Leslie Scoutt, MD Ultrasound Evaluation for Retained Products of Conception Douglas Brown Radiology, Mayo Clinic, Rochester, Minnesota USA In this session, we will review sonographic features for identifying retained products of conception in patients with spontaneous miscarriage and after surgical intervention. Limitations of ultrasound for this purpose will be reviewed. Miscellaneous abnormalities occurring in women after spontaneous miscarriage will also be reviewed, including subinvolution of the placental bed, which can present a diagnostic dilemma. Diagnostic Criteria for Miscarriage and Nonviable Pregnancy in the Early First Trimester Peter Doubilet Radiology, Brigham and Women’s Hospital, Boston, Massachusetts USA; Radiology, Harvard Medical School, Boston, Massachusetts USA When a woman presents with symptoms of pain or bleeding in early pregnancy, the main diagnostic possibilities are currently viable intrauterine pregnancy, failed (or failing) intrauterine pregnancy, and ectopic pregnancy. Serum human chorionic gonadotropin (hCG) measurement and pelvic ultrasound are commonly performed to aid in the differential diagnosis. At that point, unless an emergently life-threatening situation dictates management, a key question is: “Is there a chance of a viable pregnancy?”. This question is central to management decision making in 2 main clinical settings: intrauterine pregnancy of uncertain viability and pregnancy of unknown location. Research over the past 2 to 3 years has called into question previously accepted dogma regarding criteria for ruling out the possibility of a viable pregnancy, which had been based on small study populations. We will consider 3 scenarios: (1) Ultrasound demonstrates an intrauterine gestational sac, with or without a visible embryo, with no cardiac activity: What are the criteria for definitive diagnosis of failed pregnancy (“miscarriage”)? (2) Ultrasound demonstrates a small saclike structure in the uterus, without a visible yolk sac or embryo: Is it a gestational sac or pseudogestational sac? (3) Ultrasound demonstrates no intrauterine fluid collection and no adnexal mass suspicious for ectopic pregnancy: What is the significance if the hCG value is above the “discriminatory level” or if it is below the “discriminatory level”? S32 13proceedings_Layout 1 3/5/13 10:38 AM Page S33 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Ectopic Pregnancy James Shwayder Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi USA This portion of the session will address new nomenclature related to ectopic pregnancies and pregnancies of unknown location. It will discuss the relative merit of various laboratory and ultrasound findings in diagnosing ectopic pregnancies, presented with clinical correlation. SPECIAL INTEREST SESSIONS MONDAY, APRIL 8, 2013, 4:00 PM–5:30 PM Hands-on Elastography Moderator: Richard Barr, MD, PhD This session is designed to provide a workshop with various vendors demonstrating how to perform and interpret elastography with their equipment and demonstrating the differences in techniques between vendors to obtain optimal images. Interventional and Other Ultrasound Techniques: How I Do It histopathologic methods. The QUS methods of particular interest in these applications are spectrum analysis and envelope statistics. QUS applied to detection of prostate cancer produces an area under the receiver operating characteristic curve of 0.84, while QUS applied to detection of lymph node colorectal and gastric cancer metastases produces an area exceeding 0.95; both results are markedly superior to the performance of current methods. The implications for prostate cancer management are improved biopsies, noninvasive disease monitoring, and accurate focal treatment targeting; the implications for lymph node histopathology are improved detection of metastases and more accurate cancer staging. Moderator: David Fessell, MD Ultrasound Incidentalomas After attending this session, participants will know when and how to use interventional musculoskeletal ultrasound techniques. Moderator: Franklin Tessler, MD, CM Incidental Findings in the Soft Tissue and Extremities Deborah Rubens Imaging Science, University of Rochester, Rochester, New York USA Quantitative Ultrasound Biomarkers Moderators: Paul Carson, PhD, Timothy Hall, PhD, ABR Quantitative Ultrasound Applied to Detection and Imaging of Prostate Cancer and Lymph Node Metastases Ernest Feleppa Frederic L. Lizzi Center for Biomedical Engineering, Riverside Research, New York, New York USA This session will cover incidental findings discovered during examination of the soft tissues and extremities. Topics will include solid masses, fluid collections, and vascular findings that are unexpected and not part of the original diagnostic question. Management and reporting issues will be addressed: which findings require immediate phone calls, which can be mentioned in the report but are not urgent, and which can be ignored altogether. Ultrasound is a popular clinical-imaging modality for displaying the macroscopic anatomy of soft tissue structures in medical and research applications. While conventional ultrasound methods (eg, Bmode, harmonic, and Doppler methods) are well established and continue to advance technically, quantitative ultrasound (QUS) technologies also are emerging that appear to offer exciting promise for significantly improving clinical imaging of disease. These emerging methods include spectrum analysis, envelope statistics analysis, strain and Young’s modulus estimation, contrast-based perfusion kinetics, and advanced flow detection and measurement techniques. Each QUS method provides independent information, and each offers powerful quantitative tissue-typing and imaging capabilities. However, a multifeature approach that combines estimates derived from different QUS methods may provide even more powerful capabilities, eg, by combining spectrum analysis and envelope statistic parameters. This presentation will review progress specifically in QUS applied to tissue-type imaging of prostate cancer and detection of lymph node metastases. Prostate cancer cannot be reliably imaged by conventional ultrasound, and small, but clinically significant, lymph node metastases easily can be overlooked by current S33 13proceedings_Layout 1 3/5/13 10:38 AM Page S34 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SCIENTIFIC SESSIONS MONDAY, APRIL 8, 2013, 4:00 PM–5:30 PM Carotid/Cerebrovascular Ultrasound and Neurosonology Moderator: David Vilkomerson, PhD 1538396 Monitoring the Formation of Aneurysms in Murine Aortas Using Pulse Wave Imaging Sacha Nandlall,* Monica Goldklang, Jeanine d’Armiento, Elisa Konofagou Columbia University, New York, New York USA Objectives—Abdominal Aortic Aneurysms (AAAs) are a common vascular disease. The leading cause of AAA-induced death is rapid internal bleeding following a sudden rupture of the vessel wall, typically within the sac of the aneurysm. This study aimed at showing that pulse wave imaging (PWI) can be used to differentiate normal murine aortas from AAAs, even for aneurysms that are not visible or easily detectable on a standard B-mode. PWI is a noninvasive technique for tracking the propagation of pulse waves along the wall of the aorta at high spatial and temporal resolutions. The velocity of these waves is a well-established marker of wall stiffness, which is closely related to the likelihood of rupture. Methods—An AAA model was generated by infusing 13 ApoE/TIMP-1 knockout mice with angiotensin II, delivered at a constant flow rate via subcutaneously implanted osmotic pumps. The suprarenal sections of the abdominal aortas were scanned every 2 to 3 days after implantation using a Vevo 770 imager (VisualSonics Inc) with axial and lateral resolutions of 55 and 115 Вµm, respectively. Pulse wave propagation was tracked at an effective frame rate of 8 kHz by using retrospective electrocardiographic gating. The displacements induced by the pulse waves were estimated by performing 1D cross-correlation on the pre–beamformed radiofrequency signals. Results—In normal aortas, the pulse waves propagated at constant velocities (r2 ≥ 0.9) between 2 and 4 m/s, indicating that the composition of these vessels was relatively homogeneous. However, in AAAs where the vessel diameter had increased by at least 50%, the wave speeds exhibited higher variances along the wall (r2 < 0.9). Moreover, the wall displacements induced by the pulse waves were at least 80% lower within the aneurysmal sacs, indicating that the AAAs had a higher relative stiffness. Conclusions—This study demonstrates that PWI can be used to distinguish normal murine aortas from AAAs based on the higher variance and lower wall displacements induced by the pulse wave in the latter case. Hence, PWI could potentially be used to monitor the growth and propensity for rupture of human aneurysms by providing complementary information to that provided by a standard B-mode. 1510020 Results of Evaluation of the Spectral Curve in Aortoiliac Disease Mireia CussГі Sorribas,* Xavier MartГ Mestre, Nicolo Rizza Siniscalchi, Sara Garcia PelegrГ, Antonio Romera Villegas, Ramon Vila Coll Vascular Surgery, Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain Objectives—To evaluate the morphology of the spectral curve of the supraceliac aorta as a complement of the diagnosis of aortoiliac occlusive disease. Methods—We studied 86 patients (70 men) with a mean age of 62 years (range, 16–90 years) recruited from August to February 2012. Arterial Doppler ultrasound of the aortoiliac and femoro-popliteal sector was used as a method of diagnosis of the stenotic-occlusive disease in these sectors. Stenosis was considered significant when it exceeded 70%, characterized by a ratio of peak systolic velocities in the stenosis compared to the previous stenosis ≥3. Occlusion was considered in the absence of flow. We determined the spectral wave morphology of the aortic flow at the visceral arteries level looking for the presence of a deceleration in the late systolic phase or a biphasic wave in the systolic waveform (notch). We studied the relationship of these signs of the spectral visceral aortic wave with the presence of disease of the aortoiliac sector in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), overall efficiency, and Оє correlation index. Data were treated using SPSS 15.0 for Windows. Results—Fifty-seven percent had aortoiliac disease, and 51.2% had femoro-popliteal disease. We detected the presence of alteration in the spectral visceral aorta wave in 46 patients (53.5%), of which 41 had aortoiliac disease. The sensitivity, specificity, PPV, and NPV for the morphologic alteration of the aortic spectral curve in the aortoiliac segment were 83.6%, 86.5%, 89.1%, and 80%, respectively, with overall efficiency of 84.9% and a Оє correlation index of 0.695 (good agreement). Conclusions—The existence of spectral wave disturbances in the visceral aortic territory might suggest the presence of stenotic-occlusive disease in the aortoiliac segment. 1530492 Comparison of Automatic and Manual Transcranial Sonographic Morphometric Measurement of the Substantia Nigra Monika Jelinkova,1 David Е koloudГk,2,3* Jiri Blahuta,4 Tomas Soukup,4 Petr Cermak,4 Petra Bartova,2 Katerina Langova,5 Roman Herzig3 1Neurology, Hospital Karvina-Raj, Karvina, Czech Republic; 2Neurology, University Hospital Ostrava, Ostrava, Czech Republic; 3Neurology, PalackГЅ University Medical School and University Hospital Olomouc, Olomouc, Czech Republic; Institute of Computer Science, Faculty of Philosophy and Science, Silesian University Opava, Opava, Czech Republic; Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, PalackГЅ University Olomouc, Olomouc, Czech Republic Objectives—Increased echogenicity of the substantia nigra (SN) is a typical transcranial sonographic (TCS) finding in Parkinson’s disease (PD). Experimental software for quantitative evaluation of the echogenic SN area was developed to overcome the main limitation of TCS, the dependency on the sonographer’s experience. The aim of the study was to compare the morphometric measurement of the SN using developed software with manual measurement and results achieved by 2 different ultrasound machines in PD patients and healthy volunteers. Methods—Totally, 113 healthy volunteers were enrolled in the derivation cohort and 50 healthy volunteers and 30 PD patients in the validation cohort. The SN was imaged from the right and left temporal bone windows in the mesencephalic plane using TCS. All subjects were examined twice using different sonographic machines (MyLab Twice, Esaote; and Vivid 7 Pro, GE). DICOM images of the SN were saved, encoded, and processed. Manual and automatic morphologic measurements of the SN were performed by an experienced sonographer. The 90th percentile of derivation cohort values was used as a cut point for the evaluation of a hyperechoic SN in the validation cohort. Spearman’s coefficient was used for the assessment of correlation between manual and automatic measurements. Cohen’s Оє coefficient was used for the assessment of correlation between automatic or manual measurement and PD diagnosis. S34 13proceedings_Layout 1 3/5/13 10:38 AM Page S35 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Results—Spearman’s coefficient between measurements using different machines was 0.686 for automatic and 0.721 for manual measurement (P < .0001 for both measurements). A hyperechoic SN was detected in the same 26 (86.7%) PD patients using both automatic and manual measurements. Cohen’s Оє coefficients for automatic and manual measurements were 0.787 and 0.762, respectively (P < .0001 for both measurements). Conclusions—The results of the presented study showed comparable findings for SN feature measurement using the designed application with manual measurement. (Supported by a grant from the Moravian-Silesian Region.) 1540954 Investigation of Asymmetries in Cerebral Collateral Flow for Patients With Carotid Stenosis Khalid Al Muhanna,1* Limin Zhao,2 Kirk Beach,3 Brajesh Lal,4,5 Gregory Kowalewski,5 Siddhartha Sikdar1 1Electrical and Computer Engineering and Bioengineering, George Mason University, Fairfax, Virginia USA; 2University of Maryland Medical Center, Baltimore, Maryland USA; 3Surgery and Bioengineering, University of Washington, Seattle, Washington USA; 4Vascular Surgery, University of Maryland Medical Center, Baltimore, Maryland USA; 5Baltimore Veterans Affairs Medical Center, Baltimore, Maryland USA Objectives— Stroke affects millions of people in the world each year. About 25% of ischemic strokes are caused by rupture of carotid artery plaque. Currently, stenosis severity is used as a surrogate for the risk of plaque rupture; however, other factors may play a larger role, such as the hemodynamics around the plaque, which may be affected both by extracranial hemodynamics and intracranial collateralization. In the present study, we investigated how an incomplete (noncollateralized) intracranial circle of Willis (COW) might affect intraluminal velocity around the carotid plaque and whether there are asymmetries of flow in the middle cerebral artery (MCA) in patients with extracranial carotid stenosis. Methods—We created a simple linear simulation model of the intracranial and extracranial circulation to investigate the relationship between MCA flow waveforms on the contralateral (normal) and ipsilateral (diseased) sides and carotid stenosis for a complete and incomplete COW. Then we compared the predictions of this model with bilateral MCA velocity measurements performed in patients with asymptomatic carotid stenosis using transcranial Doppler. Results—Simulation results showed no asymmetries in MCA flow waveforms for a complete (collateralized) COW, but for an incomplete COW, the systolic peak had a lower magnitude and was delayed by about 100 milliseconds on the ipsilateral side. In our clinical measurements on 32 patients, we found that 25 had waveforms consistent with those predicted for a collateralized COW, with minimal differences in delay, velocity magnitude, and resistivity index between the ipsilateral and contralateral sides. In 6 cases, some unexpected findings were noted, such as large delays for 2 patients who had ≤50% stenosis and a larger velocity difference with low delays for 5 patients with >50% stenosis. Conclusions—Our results indicate that intracranial flow is an important variable when interpreting intrastenotic velocities. The present study does not allow us to definitely interpret the reason for MCA flow asymmetries, since the COW was not directly imaged. We intend to enroll additional patients in our cohort with concomitant imaging of the COW to further strengthen our results. 1512012 Left-to-Right Image Registration of Longitudinal Carotid Images Improves Intima-Media Thickness and Atheroscerlsosis Disease Monitoring Filippo Molinari,1 Nobutaka Ikeda,2 U Rajendra Acharya,3 Luca Saba,4 Andrew Nicolaides,5 Jasjit Suri6,7* 1Electronics and Telecommunications, Politecnico Torino, Torino, Italy; 2 Division of Cardiovascular Medicine, Toho University Medical Center, Tokyo, Japan; 3Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 4Radiology, Azienda Ospedaliero, Universitaria di Cagliari, Cagliari, Italy; 5 Imperial College, London, England; 6Global Biomedical Technologies, Roseville, California USA; 7Biomedical Engineering, Idaho State University, Pocatello, Idaho USA Objectives—Automated systems for the measurement of the carotid intima-media thickness (CIMT) are useful in clinical practice if they ensure high measurement accuracy and high reproducibility. We developed a registration-based method to improve the carotid distal wall segmentation and CIMT measurement in noisy images. Methods—We tested 50 patients and acquired left and right common carotid arteries in 3 projections: anteroposterior, anterolateral, and lateroposterior. The total number of images was 300 (50 subjects, 2 arteries, 3 insonation angles), and we had all images manually segmented by 3 independent expert readers. We processed each image by a 3-stage system. Stage 1 is relative to automated carotid localization and far adventitia tracing. Stage 2 is relative to the definition of a guidance zone and registration of the left to the right distal wall. Registration was performed by relying on the profile of the far adventitia. The segmentation is carried out in stage 3 by using a edge snapper. We compared the CIMT measurement accuracy of the registered and unregistered image sets. Results—Stage 1 was successful in all 300 images. Left-toright registration was successful in 140 of 150 cases (93.3% success), whereas right-to-left registration was successful in 138 cases (92.0% success). The average CIMT measurement bias in the unregistered case was 0.012 В± 0.079 mm, which decreased to 0.006 В± 0.081 mm for the registered images. The figure of merit (FoM) increased from 98.19% for the unregistered to 99.09% for the registered image set. Conclusions—Registering the left to the right carotid artery images can increase CIMT measurement accuracy. We plan to extend this work by also including arteries with plaques in the registration framework. Table 1. Auto Edge Performance for the 3 Operators GT1 GT2 Original 0.020 В± 0.079 0.051 В± 0.083 CIMT bias, mm FoM, % 96.99 92.00 Registered 0.014 В± 0.085 0.045 В± 0.086 CIMT bias, mm FoM, % 97.90 92.96 GT3 –0.034 В± 0.090 Average GT 0.012 В± 0.079 95.24 –0.040 В± 0.090 98.19 0.006 В± 0.081 94.39 99.09 1540884 More Easily Deployable Long-term Transcranial Doppler Monitoring of the Middle Cerebral Artery Bill Beck PhysioSonics, Inc, Bellevue, Washington USA Objectives—Develop a system to facilitate long-term transcranial Doppler monitoring of the M1 segment of the middle cerebral artery (M1 MCA), allowing continuous data collection over a period of days without operator intervention after initial setup. Methods—Deployment of M1 MCA monitoring is facilitated by a structured procedure to guide the operator in: (1) positioning a 2D phased array transducer, mounted in a headset, over the temporal window, S35 13proceedings_Layout 1 3/5/13 10:38 AM Page S36 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 by measuring echo strength from the far side of the skull, then (2) articulating the transducer to point at the M1 MCA, through the use of flash color Doppler insonation of the 3D conical region of interest (ROI). The phased array is then electronically steered to gather data from the peak Doppler signal in the ROI; the Doppler spectrum is analyzed, and standard flow metrics are logged for future review. The peak Doppler signal is automatically relocated as required to maintain continuous monitoring without operator intervention. An alert is generated if the signal is lost or if flow metrics exceed user-specified limits. Results—The objective was achieved through development of appropriate acoustics, supported by refinements in signal processing and an enhanced user interface. Conclusions—A system has been developed to make transcranial Doppler monitoring of the M1 MCA more easily deployable and to support long-term monitoring over a period of days, without operator intervention. S36 13proceedings_Layout 1 3/5/13 10:38 AM Page S37 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSIONS TUESDAY, APRIL 9, 2013, 8:15 AM–10:15 AM Contrast-Enhanced Ultrasound in Pediatrics: What Have We Learned and How Can We Apply It? Cutting-edge Musculoskeletal Ultrasound: Peripheral Nerves of the Upper Extremity Moderator: Beth McCarville, MD Moderator: Corrie Yablon, MD Voiding Urosonography Kassa Darge Perelman School of Medicine, University of Pennsylvania, Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA After attending this session, participants should know how and when to perform ultrasound examinations of the peripheral nerves of the upper extremity, including interventional techniques. Currently, the most widespread application of ultrasound contrast agents (UCAs) in children is for the diagnosis of vesicoureteral reflux (VUR). This entails the intravesical administration of a UCA and is known as contrast-enhanced voiding urosonography (ceVUS). The procedure of ceVUS encompasses 5 steps: precontrast scan of the bladder and kidneys, intravesical UCA injection or infusion, postcontrast scan of the bladder and kidneys, during and postvoiding scans of the bladder and kidneys, and suprapubic and transperineal scans of the urethra during voiding. The use of harmonic imaging or contrast-specific ultrasound (US) modalities with low or high mechanical indices enables the conspicuous depiction of the echogenic microbubbles. The most widely used UCAs are the first- and second-generation ones, namely Levovist (Bayer-Schering, Berlin, Germany) and SonoVue (Bracco, Milan, Italy), respectively. The former one has been withdrawn from the market, and thus currently only the secondgeneration UCA is being used. There are many comparative studies of ceVUS with the conventional reflux diagnostic methods, voiding cystourethrography, and direct radionuclide cystography. Not only is ceVUS a radiation-free method, but these studies have also demonstrated that it is more sensitive in detection of VUR. The evaluations of the safety of intravesical UCA administration have found that no adverse events directly related to the UCA have been reported to date in children. This US method is widespread in Europe. There is currently a concerted effort by the Society of Pediatric Radiology Contrast-Enhanced Ultrasound Task Force to promote research and application of this method. Doppler Evaluation of the Abdomen Contrast-Enhanced Ultrasound in Pediatric Abdominal Trauma Annamaria Deganello Radiology, King’s College Hospital, London, England The objectives are to review the role of contrast-enhanced ultrasound (CEUS) in the setting of blunt abdominal trauma in the pediatric population and illustrate its applications in a major trauma center, describing the typical sonographic features of solid-organ injuries. CEUS has been proven to be a reliable and useful tool in the assessment of abdominal trauma in the adult population, as it provides detailed evaluation of parenchymal, capsular, and also vascular injuries. In addition to its established use in the liver, CEUS is applied, as an “off-label” use to the study of renal, splenic, intestinal, and testicular traumas. Equally, in the pediatric and young adult populations, CEUS has an increasingly important role, even though this area represents another off-label application of the technique. CEUS can depict active bleeding and posttraumatic pseudoaneurysm formation during the arterial phase, whereas in the late phase, it shows with accurate detail the extent of a parenchymal laceration, as the noninjured tissue enhances. Trauma patients often need to be reassessed to monitor progression or ensure resolution of the injuries, and CEUS becomes a valid, safe, and readily available alternative to repeated computed tomographic (CT) imaging; this is crucial in the pediatric population, where limitation of radiation exposure is of paramount importance. The typical CEUS features of hepatic, splenic, and renal injuries will be described, including examples with CEUS/CT correlation. Moderator: M. Robert De Jong, RDMS, RDCS, RVT Sonographic Evaluation of Portal Hypertension Monzer Abu-Yousef Radiology, University of Iowa, Iowa City, Iowa USA In this presentation, normal portal vein (PV) Doppler findings and variations will be discussed. Typically, this has biphasic pattern with mild undulations. All waves are above baseline: Vmax = 19 В± 3; Vmin = 13 В± 3, with Vmin /Vmax ≥0.5. With Valsalva, flow becomes nonphasic. Postprandially, flow velocity and volume and PV diameter increase. The Doppler ultrasound (US) findings in portal hypertension include increased PV diameter, splenomegaly, ascites, loss of PV flow phasicity, decreased PV flow velocity, reversed PV flow, and dilated portosystemic collaterals. The latter include a recanalized umbilical vein, flow reversal in the coronary vein, dilated gastric varices, splenorenal collaterals, a recanalized ductus venosus, gallbladder varices, and perihepatic collaterals. The portosystemic shunts will also be discussed, with emphasis on the transjugular intrahepatic portosystemic shunt (TIPS), including Doppler US signs of TIPS malfunction, direct and indirect. Direct signs include velocity in any stent segment of <60 or >200 cm/s, interval velocity change in the same area of >50 cm/s, velocity transition zone of >2 times, TIPS nonfilling or trickle flow, narrowing of the stent or the hepatic vein that drains it, and aliasing seen in any segment of the stent on color Doppler. Indirect signs include a decrease in PV velocity to <30 cm/s, a decrease in PV velocity of >33% of baseline, antegrade flow in PV branches, flow seen in the umbilical vein, loss of the triphasic flow pattern in the PV, worsening ascites, and splenomegaly. Pathologic Findings in Abdominal Vasculature Hanh Nghiem William Beaumont Hospital, Royal Oak, Michigan USA Color Doppler and spectral Doppler imaging have substantially enhanced the diagnostic capabilities of abdominal ultrasonography. When properly performed, Doppler ultrasonography provides rapid, comprehensive, and accurate evaluation of the hepatic vasculature and major abdominal vessels. In this session, we will discuss the Doppler imaging appearances of Budd-Chiari syndrome, a manifestation of hepatic venous outflow obstruction. Doppler imaging findings of hepatic artery abnormalities in native liver and abnormalities of the splenic vessels will also be reviewed, including vascular thrombosis and pseudoaneurysms. Participants should gain a greater understanding of the pathophysiology of hepatic vein and splenic vein thrombosis, causes of elevated and decreased hepatic arterial resistive indexes, and vascular thrombosis and pseudoaneurysms of the hepatic and splenic artery in non–liver transplant patients and recognize the sonographic images showing these conditions. S37 13proceedings_Layout 1 3/5/13 10:38 AM Page S38 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Hands-on How to Do Ultrasound-Guided Interventions Small-Animal Preclinical High-Frequency Imaging Moderator: Michael Kolios, PhD Moderator: Dean Nakamoto, MD After attending this session, participants will be able to describe prebiopsy preparations, use and have hands-on experience with the techniques of doing biopsies of soft tissue masses, thyroid nodules, breast masses, the liver, and kidneys, and recognize and manage complications. Pearls From the Anatomic Survey (Skeletal Dysplasia and Central Nervous System, Renal, and Chest Abnormalities) Moderator: Ana Monteagudo, MD, RDMS Fetal Central Nervous System Ana Monteagudo Obstetrics and Gynecology, New York University School of Medicine, New York, New York USA Advances in High-Frequency Transducers and Arrays K. Kirk Shung Biomedical Engineering, University of Southern California, Los Angeles, California USA High-frequency ultrasound (HFU) allows improved spatial resolution. Biomedical applications have been found for HFU in preclinical small-animal, intravascular, and eye imaging. Pediatric imaging is another area that holds great promise. As a result, high-frequency linear arrays, phased arrays, and curved linear arrays have been developed to satisfy these needs. More recently, miniature high-frequency arrays have been studied for intravascular and other clinical applications. In addition, ultra high-frequency high-performance single-element transducers have been investigated for cellular applications. Technical advances that have been made in these areas and potential biomedical applications will be reviewed in this talk. A significant number of sonographers and sonologists count the fetal central nervous system (CNS) as the most challenging organ to scan. This has resulted in an explosion in the number of fetal magnetic resonance imaging examinations of the CNS being ordered over the last few years. In this lecture, a systematic approach to the fetal CNS will be provided, as well as multiple imaging tips or pearls to improve the individual practitioner ability to diagnose common as well as relatively rare anomalies of the fetal CNS. SCIENTIFIC SESSIONS TUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PM Applications of Therapeutic Ultrasound Moderators: George Lewis Jr, PhD, Maggie Zhang, PhD 1541279 Antitumor Effects of Combining Docetaxel and Paclitaxel With the Antivascular Effects of Ultrasound-Stimulated Microbubbles Margarita Todorova,1,2 Vlad Agache,1 Raffi Karshafian,3 Kullervo Hynynen,1,2 David Goertz1,2* 1Sunnybrook Research Institute, Toronto, Ontario, Canada; 2Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; 3Ryerson University, Toronto, Ontario, Canada Objectives—Docetaxel (DTX) and paclitaxel (PTX) are used to treat a broad spectrum of cancers. We previously reported that the combination of DTX with ultrasound (US)-stimulated microbubble (MB) therapy resulted in enhanced antitumor effects in PC3 tumors. While the focus of US + MB therapy has been to promote drug uptake, these experiments were conducted with exposures that produced a vascular shutdown. As DTX and PTX can themselves induce antivascular effects, it was hypothesized that there may be an interaction between drug and MB antivascular effects. In this study, experiments were conducted on a cell line that is largely resistant to DTX and exhibits only mild sensitivity to PTX. Methods—EMT6 tumors were initiated in Balb/C mice and were exposed to pulsed 1-MHz US (1.6 MPa; n = 5–6/group) following the bolus injection of Definity MBs. The treatment scheme consisted of a sequence of 50 0.1-millisecond bursts sent at 1 KHz, repeated every 20 seconds for 3 minutes following MB injection. Growth delay experiments were performed when tumors reached a size of 100 to 120 mm3. The groups were control, drug + MBs, US + MBs, and combined drug + US + MBs. One set of experiments was performed with DTX at 5 mg/kg and a second set of experiments with PTX at 6 mg/kg, where drugs were injected 10 minutes prior to US treatment. The effects of treatment on blood flow were monitored with 7-MHz contrast imaging. Results—The exposure conditions were found to produce a pronounced acute vascular shutdown within the tumors and resulted in MB inertial cavitation. Neither the DTX-only or PTX-only groups produced significant growth inhibition relative to controls. The US + MB group induced significant growth delays relative to control tumors. Both the combined DTX + US + MB and the PTX + US + MB groups produced significant growth inhibition relative to the US + MB group. Conclusions—Given the low sensitivity of the tumor cell line to these drugs, and that they have the capacity at these low dose levels to act in an antivascular manner, the results suggest that there may be a synergistic antivascular action between these therapies in addition to a drug uptake mechanism. 1540384 Dynamic Positron Emission Tomographic Imaging of Drug Delivery and Hypoxia Using Acoustic Droplet Vaporization Mario Fabiilli, Morand Piert, Philip Sherman, Carole Quesada, Oliver D Kripfgans* Radiology, University of Michigan, Ann Arbor, Michigan USA Objectives—Perfluorocarbon (PFC) emulsions and acoustic droplet vaporization (ADV) have been used in therapeutic applications such as drug delivery and embolotherapy. The objective of this work was S38 13proceedings_Layout 1 3/5/13 10:38 AM Page S39 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 to use positron emission tomography (PET) to study (1) the biodistribution of an emulsion used in ADV and (2) the extent to which localized hypoxia can be induced by ADV. Methods—For the biodistribution study, a metabolic tracer, 18 F-fluorodeoxyglucose (FDG) was injected into Fisher 344 rats (n = 3) bearing vascular endothelial growth factor–positive glioma tumors (9L). The rats were imaged for 60 minutes after injection using dynamic PET imaging. After 24 hours, the same rats were injected with a PFC-FDG emulsion (2 Вµm mean size) and imaged again. In both cases, standardized uptake values (SUVs) were calculated using the tissue activity concentration, body weight, and injected dose. To confirm the imaging findings, a traditional ex vivo biodistribution was performed (n = 5 rats). For the hypoxia study, similar animal and tumor models were used. A PFC single emulsion was administered, followed by ADV in the feeder artery of the tumor using focused pulsed ultrasound (3.5 MHz). Dynamic PET imaging was performed before and after ADV using 18F-fluoroazomycin arabinoside (FAZA) as a tracer for hypoxia. Results—The area under the curve (AUC) for the SUVs was calculated for brain, tumor, and lungs as a measure of drug/FDG exposure for future drug encapsulation. A 39.1% В± 5.3% and 35.7% В± 15.6% AUC decrease was observed when compared to solution for brain and tumor, respectively. No significant difference in AUC was observed for lung. The biodistribution study showed a 67% and 70% decrease in the percent injected dose per gram for brain and tumor tissue, respectively, when comparing FDG emulsion versus solution. FAZA was retained in the tumor after ADV. Conclusions—The lower AUC values for the emulsion in highly metabolic tissues (brain and tumor) demonstrate that FDG is retained within the emulsion and is confirmed by alternative biodistribution. FAZA imaging confirms generation of localized hypoxia using ADV. Overall, PET imaging can provide critical feedback in developing stable drug-loaded PFC emulsions as well as tracking the effects of ADV-induced hypoxia. 1540880 Evaluation and Optimization of Nonfocused Sonothrombolysis Parameters in an In Vitro Chamber Model Shane Fleshman,* Adelaide de Guillebon, George Lewis Jr Zetroz, LLC, Ithaca, New York USA Objectives—Sonothrombolysis is emerging as a potential clinical tool to rapidly emulsify acute and chronic thrombi. The goal of this work was to study the effects of different therapeutics, frequency, thrombus diameter, and type of surrounding medium on the percent mass reduction of a thrombus after 1, 2, and 3 hours of sonothrombolysis treatment. Methods—Silicone tubing of 10 or 15 mm diameter was coated with or without 500 U of thrombin, filled with fresh porcine blood, allowed to clot for 1 hour, and stored at 4В°C for 8 to 10 days (Institutional Animal Care and Use Committee–approved protocol). Sonothrombolysis was evaluated in multiple-element custom ultrasonic chambers (75 Г— 55 Г— 55 cm) designed at both 85- and 191-kHz resonant frequencies. Blood clots of 2.0 В± 0.1 g were perforated with a guide wire, placed inside a chamber filled with either Dulbecco’s phosphate-buffered saline (DPBS) or freshly thawed human plasma, and injected with 0.5 mL of either 0.5mg/mL human tissue plasminogen activator (tPA), 1-mg/mL active plasmin, or 1Г— DPBS with a Uni-Fuse catheter 30 minutes after treatment commencement. Blood clot mass was recorded 1, 2, and 3 hours after treatment. Results—Thrombus treatment at 85 kHz with a peak pressure of 1.7 MPa was the only treatment that yielded significant results for thrombin and nonthrombin blood clots when compared to the control (P < .01) and was further used in the remaining experiments. Both thrombin and nonthrombin clots treated with ultrasound were statistically different from the control at all time points (P < .01). Comparisons of 15- or 10-mm-diameter clots and clots in DPBS or human plasma media treated with ultrasound yielded no significant results (P > .05). Comparisons of ultrasound-treated, tPA- or plasmin-injected clots with their respective controls yielded significant results at all time points (P < .0001) and at 1 hour (P < .01), respectively. Conclusions—We discovered that diameter, thrombin treatment, and medium do not play significant roles in thrombus dissolution. Using twelve 85-kHz transducers with mean peak pressures of 1.7 MPa and injecting the thrombus with tPA yielded the most significant results, with mean percent mass losses of >90% after 3 hours. 1540858 Hydrogel Materials as Ultrasound Coupling Media Matthew Langer,* Shane Fleshman, George Lewis Jr Zetroz, LLC, Ithaca, New York USA Objectives—The use of ultrasound in therapeutic medicine to promote healing and relieve pain has been thoroughly tested. Recent research has demonstrated that low-intensity therapeutic ultrasound applied on a daily basis is highly effective, and miniaturization technology has been developed, which will enable user-operated ultrasound systems. One significant challenge in developing a user-operated device is finding a coupling medium that is effective, easily used, and desirable for the patient. To facilitate the spread of user-operated ultrasound devices, novel coupling materials must be developed. Water is a perfect coupling medium for ultrasound, but its low viscosity makes it impractical to contain. Hydrogels are swollen polymer networks, which can be as much as 99% water by weight, but due to the size of the polymer, or its structure, they have properties of viscoelastic materials. High–water content hydrogels were evaluated for their ability to mediate transmission of ultrasound. Methods—Polyethylene oxide (PEO) hydrogels were tested and evaluated, along with polyethylene glycol (PEG) hydrogels and PEGbased copolymer hydrogels. The gels were tested as coupling media between a 3-MHz therapeutic 25-mm-diameter transducer and freshly harvested porcine skin. On the underside of the skin, ultrasound gel was used to couple the skin to a transducer hydrophone in a custom measurement apparatus. The electrical signal reported by the detector was read off a digital oscilloscope in millivolts. The signal measured with the hydrogel as a coupling medium was compared to that of the ultrasound gel as a coupling medium. The ultrasound transmission hydrogels was normalized to traditional ultrasound gel–based coupling. Results—The ultrasonic transmission of several hydrogels was measured. The PEG copolymer–based gel had a relative transmission of 0.70 В± 0.06. A PEO hydrogel with water content >90% had a relative transmission of 1.0 В± 0.07. Conclusions—PEO hydrogels with high water content possess similar sonic transmission properties to commercial ultrasound gel. These findings open the door to replacing commercial ultrasound gel with high– water content hydrogels. 1541006 Low-Intensity Pulsed Ultrasound Enhances Reactive Oxygen Species Production Following a Blunt Impact Injury in Articular Cartilage Kee Jang,1,2* Prem Ramakrishnan,1 Tae-Hong Lim,2 Joseph Buckwalter,3 James Martin1 1Orthopedics and Rehabilitation, 2Biomedical Engineering, University of Iowa, Iowa City, Iowa USA; 3Veterans Affairs Medical Center, Iowa City, Iowa USA Objectives—Elevated levels of reactive oxygen species (ROS) are associated with development of osteoarthritis. Previously we reported that mechanotransduction of mitochondrial ROS modulates cell survival and metabolism in a dose-dependent manner. Here, we hypothesized that low-intensity pulsed ultrasound (LIPUS) elicits its mechanotransductive effects by inducing ROS in cartilage, and we investigated the effect of LIPUS on ROS release in articular cartilage that underwent a blunt impact injury. Methods—Osteochondral explants (2.5 Г— 2.5 cm2) were prepared from mature bovine stifle joints and cultured in conditioned media at S39 13proceedings_Layout 1 3/5/13 10:38 AM Page S40 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 37В°C and 5% O2. After 48 hours, explants were subjected to a 7-J/cm2 impact with a customized drop tower device, and LIPUS (1 MHz, 54 mW/cm2, and durations of 30, 60, and 90 minutes) was immediately applied. A sham group was subjected to identical procedures except LIPUS stimulation. After LIPUS stimulation, cell viability (calcein AM/ethidium homodimer) and oxidative stress (dihydroethidine) were imaged with confocal microscopy and quantified. Results—Sixty-minute LIPUS after the 7-J/cm2 impact resulted in a significant increase in ROS production (≈2-fold) compared to the sham group. In contrast, no difference in ROS production was apparent in uninjured explants with or without LIPUS stimulation. After injury, the ROS response to the LIPUS duration showed a strong linear relationship (R2 = 0.75) with an increasing duration of stimulation inside the impacted area, whereas such a relationship was not observed in areas adjacent to the impact. No difference in post–24-hour chondrocyte viability was observed between LIPUS and sham groups. Conclusions—Our findings demonstrate that LIPUS stimulates ROS production in injured articular cartilage in a duration-dependent manner, and enhanced ROS production did not affect cell viability in cartilage. Although the exact role of enhanced ROS in response to LIPUS in injured cartilage remains unclear, we hypothesize that the increased oxidative stress may have implications in cartilage repair processes by modulating chondrocyte energy production, metabolism, and matrix synthesis. 1543362 Microbubble and Ultrasound Enhancement of RadiationInduced Tumor Cell Death In Vivo: ASMase Dependence Gregory Czarnota,1* Amr Hashim,1 Ahmed El Kaffas,1 Raffi Karshafian,2 Anoja Giles,1 Sara Iradji,1 Azza Al Mahrouki1 1 Radiation Oncology/Physical Sciences, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; 2Physics, Ryerson University, Toronto, Ontario, Canada Objectives—It is now appreciated that radiation not only damages the DNA inside tumor cells in vivo but also may act by damaging the endothelial cells of the vasculature. In this study, we tested the hypothesis that microbubble agents in vivo may be used a priori to cause endothelial cell perturbations, thus causing “radiosensitization” of tumors. Methods—Fibrosarcoma xenograft-bearing mice (n = 200+) were exposed to combinations of ultrasound, activated microbubbles, and radiation (8 animals per group). For ultrasound treatments, animals were exposed to a 500-kHz center frequency and 570-kPa peak negative pressure for treatment. For treatments involving bubbles, Definity bubbles (Bristol Myers-Squibb) were administered, and for radiation treatments 160-kVp x-rays were used at doses of 2 and 8 Gy. Representative tumor sections were examined using immunohistochemistry. Clonogenic assays and growth delay studies were also carried out. Experiments were carried out in ASMase +/+ and –/– mice to investigate endothelial cell apoptosis effects. Results—Analyses indicated a synergistic increase in tumor cell kill due to vascular disruption that was ASMase dependent, caused by the combined therapies that increased when microbubbles were used in conjunction with radiation, with increases of cell kill from 5% to >50% with combined single treatments. Immunohistochemistry indicated endothelial cell apoptosis and activation of the ceramide cell death pathway to be caused by microbubbles. Multiple treatments indicated a better therapeutic outcome with multiple treatments combining both modalities compared to single-modality treatments. Conclusions—Radiation effects were synergistically enhanced by using microbubbles to perturb tumor vasculature prior to the administration of radiotherapy. Analyses indicated activation of ceramide-mediated apoptotic cell death in endothelial cells leading to vascular disruption in tumors. This led to profoundly enhanced tumor cell death even after 1 combined treatment using a 2-Gy radiation dose. This work forms the basis for ultrasound-induced spatial targeting of radiotherapy enhancement. 1540684 On the Acceleration of Ultrasound Thermal Therapy by Patterned Acoustic Droplet Vaporization Oliver Kripfgans,1* Mario Fabiilli,1 Scott Swanson,1 Charles Mougenot,2 Paul Carson,1 Man Zhang,1 J. Brian Fowlkes1 1 Radiology, University of Michigan, Ann Arbor, Michigan USA; 2 Philips Healthcare, Toronto, Ontario, Canada Objectives—High-intensity focused ultrasound (HIFU), an established method for treating cancer and hyperplasia, often suffers from uneven heating and requires in general long treatment times for large target volumes. In situ gas bubbles have become more accepted as energy conversion agents for HIFU. If carefully controlled, these agents increase lesion sizes dramatically. Methods—Emulsions of perfluorocarbon droplets (lipid coated, C5F12, Г� 2.0 В± 0.1 Вµm, ≈99% < 8 Вµm Г�) were used to create thermal agents in polyacrylamide phantoms. The emulsion concentration in the gel was 3 Г— 105 droplets/mL. This corresponds to a volume fraction of 1 ppm (vol/vol). The samples were placed in thermal contact with a heating system to maintain 35В°C. Egg white was incorporated to allow for visual inspection of the phantoms after acoustic exposure from a Philips Sonalleve magnetic resonance–guided focused ultrasound system (1.5 T) using a 256-element phased array with a 120-mm focal length. At a transmit center frequency of 1.45 MHz, maximum electronic steering of 10 mm was achieved at a depth of 10 cm. In situ temperature monitoring limited focal heating to 75В°C. Lesion sizes were measured as a function of applied acoustic power. Acoustic trenches were created to accelerate thermal therapy, in which individual lesions were spaced 5.5 mm apart to create 25mm-diameter spiral patterns. Results—Single HIFU exposures in droplet-laden phantoms resulted in lesions of 2 to 5 mm in diameter. Rapid repetition of electronically steered therapy pulses (40 pulses/s) allowed for the generation of homogeneous and contiguous composite lesions at a rate >1 mL/s. For acoustic power levels ranging from 40 to 300 W (acoustic), lesion volumes increased by a factor of at least 15 when comparing lesion volumes in phantoms with droplets to without droplets. With the use of acoustic droplet vaporization (ADV) and the resulting trench, a uniform ablation volume of 15 mL was achieved in 15 seconds; without ADV, <15% of this volume was filled. Conclusions—Perfluorocarbon droplet emulsions have the potential to enhance clinically relevant HIFU performance by decreasing treatment time and increasing lesion homogeneity. 1540272 Potential Strong High-Intensity Focused Ultrasound Ablation-Induced Tissue Damage as Measured by Viscoelastic Characterization of Canine Liver Tissue After Ablation Danial Shahmirzadi,1* Gary Hou,1 Elisa Konofagou1,2 1 Biomedical Engineering, 2Radiology, Columbia University, New York, New York USA Objectives—High-intensity focused ultrasound (HIFU) has been shown capable of ablating soft tissues in vitro and in vivo. However, mainly due to the lack of knowledge of the exerted radiation force in tissue, mechanical characterization of ablated tissues, particularly at very high HIFU powers, remains largely understudied. This study aims at quantifying the canine liver tissue viscoelastic properties following a wide range of HIFU ablation powers. Methods—Fresh canine liver specimens (n = 6) were used. HIFU targeting and ablation were performed using a 7.5-MHz pulse-echo and 4.8-MHz therapeutic transducers, respectively. Mechanical testing using shear rheometry was performed on a set of unablated control samples (n = 13), as well as 4 sets of samples under increasing HIFU energies of 360 (n = 4), 750 (n = 8), 900 (n = 8), and 1080 (n = 8) J. The complex shear modulus and viscosity were measured. Results—The shear complex modulus and dynamic viscosity of all ablated samples were found to increase by approximately an order S40 13proceedings_Layout 1 3/5/13 10:38 AM Page S41 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 of magnitude higher compared to unablated samples. However, reduction in stiffening was obtained in samples ablated at higher energy levels relative to samples at lower energy levels (Table 1), which can be explained by the strong tissue thermo-mechanical effects occurring at very high temperatures that essentially alter the structure of the tissue. Conclusions—The monotonic increase in tissue stiffness and viscosity under increasing HIFU ablation power has been shown to hold up only up to a certain point, beyond which the tissue stiffening starts to decay due to structural changes mainly due to rapid boiling. Such quantitative understanding of tissue phenomenologic alterations during ablation is significant in the effective design and application of any HIFU-based therapeutic technique where a combination of tissue mechanical, thermal, and structural effects is expected. Table 1. Viscoelastic Properties of Canine Liver After Ablation Shear modulus, kPa Phase shift, В° Normalized shear modulus HIFU Energy, J 0 360 750 900 1080 4.4 В± 2.0 73.6 В± 19.0 85.7 В± 54.5 50.1 В± 38.7 53.9 В± 27.6 8.4 В± 1.9 1 12.3 В± 0.8 12.3 В± 0.4 12.2 В± 0.4 12.1 В± 0.6 15.8 В± 6.9 18.5 В± 13.9 10.4 В± 9.5 11.3 В± 7.4 1540029 Therapeutic Ultrasound as Treatment for Chronic Bacterial Prostatitis Mingde Li South China University of Technology, Richmond, British Columbia, Canada Objectives—Antibiotic therapy for chronic bacterial prostatitis often fails to eradicate pathogens due to poor antibiotic penetration into prostatic secretions where the infection occurs, caused by the bloodprostate barrier of the prostatic epithelium. It is our purpose to report antibiotic therapy enhanced by therapeutic ultrasound for a patient with chronic bacterial prostatitis with mixed pathogenic microorganisms of Staphylococcus aureus, coagulase-negative Staphylococcus and Ureaplasma urealyticum and with hardness of the prostate who was difficult to treat with methods in literature. Methods—After antibiotic medication, ultrasonic irradiation from the lower abdomen, perineum, and anus (not transrectally) on his prostate followed immediately. The working ultrasonic intensity was 3 W/cm2. Results—Without ultrasound, intravenous azithromycin and levofloxacin hydrochloride therapies could not eradicate the pathogens, and his symptoms recurred and became more severe. Under continuous ultrasonic irradiation at the intensity of 3 W/cm2, intravenous antibiotic therapies with azithromycin and imipenem eradicated S aureus and U urealyticum, but intravenous antibiotic therapies could not treat coagulasenegative Staphylococcus; interventional antibiotic therapies with imipenem and urethral perfusion treated coagulase-negative Staphylococcus successfully. The National Institutes of Health Chronic Prostatitis Symptom Index of the patient was reduced from 26 (pain, 16; urinary symptoms, 5; quality of life impact, 5) to 3 (pain, 0; urinary symptoms, 2; quality of life impact, 1). Conclusions—The eradication of S aureus and U urealyticum indicates the continuous therapeutic ultrasound can open the bloodprostate barrier. The blood-prostate barrier opening is explained by the hypothesis of ultrasonic emulsification of a secreted steroidogenic lipid in the basal layers of the prostatic epithelium caused by cavitations. Intravenous antibiotic therapies cannot treat coagulase-negative Staphylococcus due to the formation of biofilms adherent to the epithelium of the ductal system. The treatment for the patient was successful. 1540196 Ultrasound-Assisted Chronic Wound Management: Clinical Outcome Joshua Samuels,1* Michael Weingarten,2 Leonid Zubkov,1 Youhan Sunny,1 Christopher Bawiec,1 David Margolis,3 Peter Lewin1 1Biomedical Engineering, Drexel University, Philadelphia, Pennsylvania USA; 2Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania USA; 3Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania USA Objectives—The purpose of this research was to examine whether low-frequency (<100 kHz), low-intensity (<100 mW/cm2, spatialpeak temporal-peak [SPTP]) ultrasound applied to human patients can be used as an effective treatment of venous stasis ulcers; no similar study was reported to date. Venous ulcers affect >500,000 patients annually, costing $1 billion dollars, so in addition to helping patients, there is a strong financial motivation for reduction of the healing time. The frequency and ultrasound parameters were chosen based on the widely accepted safety of prolonged exposure at 100 mW/cm2 and previously published findings indicating that frequencies <100 kHz might be more effective than 1- to 3MHz frequencies. Methods—In a 20-human pilot study, patients were randomly assigned to 1 of 4 experimental groups: 15 minutes of 20-kHz ultrasound, 45 minutes of 20-kHz ultrasound, 15 minutes of 100-kHz ultrasound, or 15 minutes of sham (no treatment). All active treatments were at 100 mW/cm2 SPTP. All 4 groups received the standard of care, including moist wound dressings and compression therapy. Eligible patients were between the ages of 18 and 65 years, had wounds of at least 1 cm2, which were clinically documented for 8 weeks, and had no concomitant arterial disease. Progress was monitored through reduction in the wound area combined with an optical assessment using diffuse near-infrared spectroscopy. Results—Of the 20 patients who completed the study, 10 healed and 10 did not heal during the 4 treatments of the study. One particular treatment group, namely those receiving 20 kHz for 15 minutes, experienced complete healing in 100% (n = 5) of patients by the fourth treatment. Furthermore, this group showed a statistically (P < .03) faster rate of wound closure compared to the sham group. Overall, 8 of the 15 treated patients healed, versus 2 of the 5 control patients. Conclusions—Although statistically limited, this work is of importance as it represents the first systematic human study indicating that the use of low-intensity, low-frequency ultrasound holds promise as an effective tool for successful treatment of chronic venous ulcers. (Supported by National Institutes of Health grant 5 R01 EB009670.) Basic Science: Instrumentation, Contrast Agents, and Bioeffects Moderators: Chandra Sehgal, PhD, David Vilkomerson, PhD 1536946 Improved Accuracy in the Measurement of Acoustic Output Parameters via Complex Deconvolution of Hydrophone Sensitivity Keith Wear,1* Paul Gammell,2 Subha Maruvada,1 Yunbo Liu,1 Gerald Harris1 1Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland USA; 2Gammell Applied Technologies, Exmore, Virginia USA Objectives—Hydrophones are often used to measure acoustic pressure waveforms from diagnostic ultrasound transducers. The standard approach for estimation of acoustic pressure is to take the ratio of the hydrophone output voltage to the value of the hydrophone sensitivity at the acoustic working frequency. This approach assumes that hydrophone sensitivity is independent of frequency over the usable bandwidth of the source transducer. A more accurate approach entails performing a complex S41 13proceedings_Layout 1 3/5/13 10:38 AM Page S42 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 deconvolution between the hydrophone output voltage and the hydrophone frequency-dependent complex sensitivity. We have previously reported a method for measuring the magnitude and phase of hydrophone sensitivity using time delay spectrometry (TDS). The goal of this work is to assess the improvement in the accuracy of estimates of acoustic output parameters (pulse intensity integral and peak rarefactional pressure) using complex deconvolution. Methods—In the first set of experiments, a swept-frequency TDS system was used to measure magnitude and phase responses of several types of hydrophones used in medical ultrasound exposimetry. These included polyvinylidene difluoride spot-poled membrane, needle, and capsule designs. Measurements were performed using 4 broadband source transducers to measure hydrophone sensitivity over the band from 1 to 30 MHz. In the second set of experiments, 6 hydrophones were used to measure the acoustic pressure waveform generated by a 3-MHz single-element source transducer. The voltage waveforms acquired in the second set of experiments were deconvolved with sensitivities measured in the first set of experiments. The effect of deconvolution on measurements of the pulse intensity integral and peak rarefactional pressure was measured. Results—The effect of deconvolution on measurements of pulse the intensity integral and peak rarefactional pressure sometimes exceeded 10%. Conclusions—The frequency dependence of hydrophone sensitivity can have a substantial impact on measurements of the pulse intensity integral and peak rarefactional pressure. In these cases, complex deconvolution can be used to compensate for frequency-dependent hydrophone sensitivity. 1538679 Pulmonary Hemorrhage Induced by Diagnostic Ultrasound Revealed by Growth of Comet Tail Artifacts in the Image Douglas Miller Radiology, University of Michigan, Ann Arbor, Michigan USA Objectives—Ultrasound examination of the lung has become an important part of chest medicine, particularly for point-of-care diagnosis in emergency rooms and intensive care units. The objective of this study was to explore the potential for lung injury, which may arise from the interaction of ultrasound pulses with alveolar gas, using a rat model of pulmonary diagnostic ultrasound. Methods—Anesthetized rats were prepared by shaving the right thorax and then mounted in a 37В°C water bath. A linear array (CL157, HDI 5000; Philips Healthcare, Andover MA) was used for B-mode imaging of the right lung at ≈7.6 MHz. A low mechanical index (MI) of 0.21 was used to align the scan plane through an intercostal space. The MI then was raised for 5 minutes to higher settings in different groups of 5 rats. For a sham group, the rats were prepared but not scanned. The real-time image was recorded and evaluated for occurrence of comet tail artifacts (CTAs), which are indicative of alveolar fluid. The lungs were evaluated for the size of any pulmonary hemorrhages (PHs). Results—For the highest available MI (0.9), the image immediately displayed growing CTAs, which rapidly spread across the entire bright-line image of the lung surface. The CTAs appeared within seconds at MI = 0.7 or 0.9 but more slowly at lower MIs. Contusion-like PHs were found on the lungs, which appeared to have a one-to-one correspondence with the CTAs in the image. The proportion of positive results was statistically significant for MI = 0.52 (4 of 5 rats; P < .01) but not for MI = 0.37 (2 of 5, P > .1), relative to no PH in shams. Conclusions—PH was induced in a rat model of pulmonary diagnostic ultrasound at moderate MIs, and this bioeffect was indicated by the growth of CTAs in the image. The induction of PHs by pulsed ultrasound was discovered over 20 years ago but appeared to pose little risk to patients, because only incidental scanning of the lung was expected. However, direct scanning, which occurs for pulmonary applications, may carry a risk of pulmonary injury for some patients. More information will be needed to provide safety guidance consistent with optimal diagnostic imaging. 1528109 Evaluation of Definity Stability Over Time Using Double Passive Cavitation Detection Marianne Gauthier,1,2* Daniel King,1,3 William O’Brien Jr1,2 1 Bioacoustics Research Laboratory, 2Electrical and Computer Engineering, 3Mechanical Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois USA Objectives—Definity is the first ultrasound contrast agent (UCA) approved by the US Food and Drug Administration that offers flexible dosing and administration through intravenous bolus injection or continuous intravenous infusion. In a clinical context (for diagnosis, therapy, and bioeffect studies), temporal stability of the UCA can be critical using either infusion or bolus: infusion implies stability of the microbubbles during the time of the injection, while bolus may be repeated to acquire several images for the same patient, implying the microbubbles to exhibit the same properties over time. Methods—This study’s aim was to assess the stability of Definity over time. Experiments were performed using the double passive cavitation detection (DPCD) method, allowing the evaluation of the collapse thresholds of an isolated microbubble based on the detection of postexcitation signals occurring 1 to 5 microseconds after the principle excitation of the bubble. Five sets of DPCD experiments (3-cycle tone bursts at the central frequency of 2.8 MHz) were performed over 3 weeks. For each set of experiments, 5% and 50% collapse thresholds were determined with their 95% confidence interval (CI) based on the generalized linear model regression performed using MatLab. We also compared the size distribution of each tested microbubble set. Results—Statistical analysis exhibited no significant differences in the bubble size distributions and the 5% and 50% collapse thresholds measured using the DPCD method (Table 1). Conclusions—Definity microbubbles have been found to be stable over the 3 weeks of experiments from the size distribution and the 5% and 50% collapse thresholds points of view. Definity can be used without extra precaution concerning its temporal stability. (Supported by National Institutes of Health grant R37EB002641.) Table 1. Bubble Diameter, 5% and 50% Postexcitation Thresholds В± 95% CIs Evaluated Over 3 Weeks Group 1 2 3 4 5 Bubble Diameter В± 95% CI, Ојm 1.40 (1.28–1.52) 1.23 (1.12–1.34) 1.39 (1.26–1.52) 1.26 (1.13–1.39) 1.42 (1.31–1.53) 5% Postexcitation Threshold В± 95% CI, MPa 0.022 (0.001–0.191) 0.05 (0.001–0.277) 0.077 (0.003–0.226) 0.116 (0.015–0.269) 0.058 (0.001–0.235) 50% Postexcitation Threshold В± 95% CI, MPa 0.173 (0.001–0.559) 0.455 (0.005–0.944) 0.38 (0.075–0.671) 0.464 (0.162–0.72) 0.315 (0.01–0.663) 1541018 Arrival Time Estimation in a Sparsely Sampled Hemispheric Transducer Array Jason Tillett,1* Jeffrey Astheimer,1 Robert Waag1,2 1Electrical and Computer Engineering, 2Imaging Sciences, University of Rochester, Rochester, New York USA Objectives—Estimate waveform arrival time fluctuations caused by propagation through a breast model in a sparsely sampled faceted approximation of a hemispheric transducer array. Methods—A 3D pseudospectral k-space method was used to calculate acoustic propagation from a point source located near the center of an array of widely separated transducers. The point source, with a center frequency of 5 MHz and –6-dB bandwidth of 2.5 MHz, was situated near the chest wall of a numeric anthropomorphic breast model, and the transducer array surrounded the pendant boundary of the breast. The hemisphere was approximated using 40 triangular facets. The separation of elements averaged about 1.5 times the wavelength at 5 MHz, ie, about 3 S42 13proceedings_Layout 1 3/5/13 10:38 AM Page S43 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 times larger than the usual half-wavelength element separation. The sparse distribution of transducer elements and severe aberration caused by propagation through the breast model reduced correlation of waveforms in neighboring transducers that are typically used to estimate arrival time differences. Instead of cross-correlations, waveform 0 crossings in the neighborhood of the waveform arrival events were used to estimate arrival time differences at neighboring transducers. A least mean square estimate of arrival times was derived from the set of arrival time differences. Waveform similarity factors that equal 1 for identical waveforms were calculated and used to optimize parameters of the estimation method and evaluate the performance of the method. Results—A waveform similarity of 0.10 before compensation was increased to 0.94 after compensation using estimated arrival times. The 170-nanosecond SD of the arrival time distribution over the whole 40-facet array before compensation was decreased to 20 nanoseconds after compensation. For a single facet, the 154-nanosecond average SD of the arrival time distribution before compensation decreased to 15 nanoseconds after compensation. Conclusions—The developed method for arrival time estimation in a sparsely sampled hemispheric array for the described combination of source and transducer produces accurate estimates of arrival times for use in aberration correction methods. 1539831 The USAGES Study (Ultrasonographic Study of Alternative Gel Experimental Substances): A Trial of Alternative Substances for Use in Clinical Sonographic Imaging Davut Savaser,* Siobhan Gray, Anthony Medak, Virag Shah, Derrick Allen, Eddie Castillo, Mary Beth Johnson Emergency Medicine, University of California, San Diego, California USA Objectives—We sought to investigate image quality and the diagnostic utility of sonographic images obtained using household products as alternative conducting media. Tested alternatives included hand sanitizer (HS), hand lotion (HL), liquid detergent (LD), baby shampoo (BS), hairstyling gel (HG), and olive oil (OOi) and were compared to standard ultrasound gel (USG). Methods—We conducted a prospective reviewer-blinded crossover study of healthy volunteers (>18 years) obtaining 7 different sonographic images on each patient, including the right upper quadrant, subxiphoid, left upper quadrant, bladder, aorta, right lung, and right internal jugular vein views. Six alternative gel substances were tested in addition to standard USG. Images were obtained by a credentialed emergency sonographer and were reviewed and rated by 2 additional credentialed emergency sonographers and a credentialed radiologist. Image quality was rated on a visual analog scale (VAS) ranging from 0 to 10, and the diagnostic utility of each was assessed and compared to reviewer VAS thresholds. Data were analyzed by calculating image quality VAS means and using repeated measures analysis of variance to evaluate VAS mean differences for each substance. Results—A total of 189 images were obtained. Final VAS mean scores were: HS, 9.2; HL, 8.8; LD, 8.8; BS, 8.3; HG, 8.9; OOi, 8.9; and USG, 9.6. Compared to control (USG), HS was the only substance to not exhibit a statistically significant mean VAS difference: HS, 0.118 (P = .114); HL, 0.711 (P = .000); LD, 0.696 (P = .000); BS, 0.951 (P = .000); HG, 0.565 (P = .000); and OOi, 0.600 (P = .000). All VAS means for each substance scored above reviewer thresholds for diagnostic utility. Conclusions—Sonographic image quality and the diagnostic utility of HS are similar to those of standard USG. HL, LD, BS, HG, and OOi may still be used as alternatives for clinically useful diagnostic imaging but are comparatively inferior to images obtained using HS and standard USG as conducting media. 1540013 User-friendly System for Assessing Imaging Performance in the Clinic Ernest Madsen,* Chihwa Song, Gary Frank Medical Physics, University of Wisconsin, Madison, Wisconsin USA Objectives—One indicator of the effectiveness of a scanner/ transducer configuration to delineate the boundary of an abnormal mass is the level of detectability it affords for small low-echo cyst-like targets. (A scanner/transducer configuration includes the make and model of the scanner and transducer, foci, depth of field, time-gain compensation, sector angle, etc). Phantoms with spatially random distributions of 2-, 3.2-, or 4-mm-diameter low-echo spheres and scanning windows allowing use with any shape-emitting surface were reported at the 2012 AIUM meeting. Software allows quantification of sphere detectability as a function of depth. One objective is to complete refinements in data acquisition and reduction so that the phantoms and software are easily employed by clinical personnel for comparing scanner/transducer configurations. Another objective is to provide for minimal cost of production for commercial versions. Methods—Current MatLab software is being converted to a form executable on any personal computer with a user-friendly generalized user interface (GUI). The large laboratory data acquisition apparatus will be replaced with a small semiautomatic one to be part of the phantom. Also, minimal data acquisition will be determined for acceptable reproducibility. Results—The methods of data acquisition and reduction will be described. A transducer holder and stepper motor system provide for translation of the transducer in steps of one-fourth of the sphere diameter needed for determining the centers of the spheres. The procedure for using the GUI will be demonstrated. Also, reproducibility of detectability-versus-depth curves will be demonstrated. Imaging performance comparisons between scanner/transducer configurations will be shown; one interesting result using a pediatric transducer is that a 4-cm focus resulted in lesser detectability overall than a 3-cm focus. Conclusions—Comparisons will aid in choosing equipment for a given set of clinical applications, provide a new means of acceptance testing, and allow optimization of configurations of installed scanners for specific applications. The phantoms may also be useful for manufacturers to refine their systems. The cost of production may result in the need for multiple users to share one commercial form of the system. 1541363 Pulse-Echo–Based Sound Speed Estimations Using Speckle Statistics Ivan Rosado-Mendez, Kibo Nam, Timothy Hall, James Zagzebski* Medical Physics, University of Wisconsin, Madison, Wisconsin USA Objectives—Speed of sound estimates are required for optimal focusing and beam forming in medical ultrasound. Moreover, measurements of tissue sound speeds (ct ) have potential diagnostic value. We investigate a method for sound speed estimation using second-order speckle statistics to analyze ultrasound image clarity as a function of the assumed sound speed during beam forming (cbf ). The size of a region of interest (ROI) analyzed can be limited by tissue heterogeneities. This work focuses on defining a minimum ROI size required to obtain reliable ct estimates and on comparing estimates performed near the transmit focus with values obtained at other depths. Methods—Radiofrequency (RF) echo signals from a “nonfatty tissue” (N-F)- and a “fatty tissue” (F)-mimicking phantom were acquired with a Siemens S2000 system allowing control over cbf . Excitation frequencies were 6 and 9 MHz, and the nominal transmit focus was 5 cm. This process was repeated at 5 uncorrelated planes. RF echo signals were envelope detected and squared to obtain intensity data. 2D “correlation cell areas” (Sc ), based on the 2D autocovariance of the intensity data within the ROI, was tracked as the ROI size was reduced. Then, Sc was tracked S43 13proceedings_Layout 1 3/5/13 10:38 AM Page S44 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 as cbf varied from 1350 to 1550 m/s and from 1440 to 1640 m/s when scanning phantoms F and N-F, respectively, in steps of 10 m/s. The cbf at which Sc was minimized was chosen as the ct estimate. The ct estimate bias was computed as the interplane average of the percentage difference from substitution measurements (F phantom, 1452 m/s; N-F phantom, 1544 m/s). Results—The minimum required ROI size was 20 pulse lengths and 14 uncorrelated scan lines (7 Г— 9 mm2 in this experiment). In general, ct was underestimated by –1.0% В± 0.1% and by –1.3% В± 0.3% for the F and N-F phantoms, respectively. No significant differences were found among estimates from different excitation frequencies or among those at the physical location or the nominal location of the transmit focus. Conclusions—Results indicate that estimates can be performed within 1 cm2 at the location of the nominal transmit focus, which can be a fixed parameter during the in vivo application of this method. The method is being applied in the characterization of liver diseases and lesions. Cardiovascular Ultrasound Moderator: John Blebea, MD, MBA 1521708 Lagrangian Deformation Tracking of the Left Ventricle for Cardiac Ultrasound Strain Imaging Chi Ma,* Tomy Varghese Medical Physics, University of Wisconsin, Madison, Wisconsin USA Objectives—Lagrangian description of myocardial tissue structure deformation is key to accurate regional strain estimation of the left ventricular wall over time. Failure to couple the estimated displacement and strain information with the correct myocardial tissue structures will lead to erroneous result in the displacement and strain distribution over time. Methods—This study presents a method to obtain Lagrangianbased displacement tracking. Myocardial issue structures are divided into a fixed number of pixels whose deformation is tracked over the cardiac cycle. An algorithm that uses a polar grid generated between the estimated endocardial and epicardial contours for the left ventricle in cardiac shortaxis images is proposed to ensure Lagrangian description of the pixels. Displacement estimations from consecutive radiofrequency frames were then mapped onto the polar grid to obtain a distribution of the actual displacement that is mapped to the polar grid over time. Results—The method was validated against a finite-element– based canine heart model coupled with an ultrasound simulation program. Segmental analysis of the accumulated displacement and strain over a cardiac cycle demonstrated excellent agreement between the ideal result obtained directly from the finite-element model and our Lagrangian approach to strain estimation. Traditional Eulerian-based estimation results, on the other hand, showed a significant deviation from the ideal result. An in vivo comparison of the displacement and strain estimated using parasternal short-axis views is also presented. Conclusions—Lagrangian strain estimation using a polar grid demonstrates accurate results when validated in a finite-element cardiac model. In addition to the cardiac application, this approach can also be applied to transverse scans of arteries, where a polar grid can be generated between the contours delineating the outer and inner walls of the vessels from the blood flowing though the vessels. (Supported by National Institutes of Health grants 5R21EB010098 and R01CA112192-S103.) 1509371 Effects of Respiration on Estimation of Systolic Pulmonary Artery Pressure in Patients With Right Ventricle Systolic Dysfunction Xiao-Yong Zhang,* Tie-Sheng Cao, Li-Jun Yuan Ultrasound Diagnostics, Tangdu Hospital, Fourth Military Medical University, Xi’an, China Objectives—We investigated the effects of respiration on the peak velocity of tricuspid regurgitation (TR) and estimation of systolic pulmonary artery pressure (SPAP) in patients with right ventricle (RV) systolic dysfunction by Doppler echocardiography. Methods—Continuous wave Doppler spectra of TR were recorded in 32 patients with and 28 controls without RV systolic dysfunction. Electrocardiography and respiratory tracing were recorded simultaneously. The expiratory and inspiratory peak velocities of TR were acquired and averaged for 5 consecutive respiratory cycles. The SPAP during expiration and inspiration was calculated. Results—The velocity of TR and SPAP did not vary significantly between expiration and inspiration in controls (2.77 В± 0.23 and 2.82 В± 0.26 m/s; P = .776; 35.94 В± 4.96 and 36.18 В± 5.12 mm Hg; P = .747), whereas the velocity of TR and SPAP decreased significantly from expiration to inspiration in patients with RV systolic dysfunction (3.27 В± 0.35 and 2.59 В± 0.22 m/s; P < .001; 53.72 В± 7.39 and 38.45 В± 5.63 mm Hg; P < .001). Conclusions—Respiration has significant effects on the velocity of TR and SPAP in patients with RV systolic dysfunction, and the measurement should be carried out when patients are at the end of expiration. 1541517 High–Frame Rate Lateral Strain Estimation Using Virtual Beam Focusing in Canine and Human Hearts In Vivo Ethan Bunting,1* Jean Provost,1 Elisa Konofagou1,2 1 Biomedical Engineering, 2Radiology, Columbia University, New York, New York USA Objectives—Ultrasonic strain imaging is capable of providing clinicians with useful information regarding cardiac function in a fast, noninvasive manner. Lateral strain estimation is required to obtain the full 2D strain tensor of the heart and accurately represent the cardiac deformation within the image plane. Previous work has shown that 2 major parameters influencing the quality of lateral strain estimation are the motion estimation rate and beam density (Provost et al. Phys Med Biol 2011). Using element channel data, virtual beam focusing can be used to reconstruct a large number of beams from only a few acoustic interrogations. Furthermore, the rate of motion estimation can be increased by using temporally unequispaced acquisition sequences (TUAS), a technique developed previously by our group, which increases the motion estimation rate while reducing the motion sampling rate. Methods—Using a Verasonics scanner with a custom TUAS and virtual beam focusing, we have acquired short-axis views of human (n = 1) and open-chest canine (n = 3) hearts. Virtual beam focusing was used to reconstruct 156 radiofrequency (RF) lines from 12 focused acoustic transmits. Lateral displacement estimation was performed using RF cross-correlation, and strain was computed using a least squares strain estimator. The quality of strain estimation was evaluated by using the elastographic signal-to-noise ratio (SNRe). Results—We first show that lateral strain estimation can be achieved in vivo using virtual beam focusing and that the results are similar to conventional beam focusing. Also, we show that it is possible to use TUAS to estimate strain using a wide range of frame rates (57, 130, 447, 894, 1788, and 2682 Hz) while maintaining this high beam density. The SNRe for lateral strain was found to range from 2 to 10 and be optimal at a motion estimation rate of 894 Hz. Conclusions—In conventional scanners, there is a trade-off between the beam density and motion estimation rate, leading to a theoretical limit on the quality of strain estimation. The use of virtual beam focusing and TUAS techniques for lateral strain imaging was shown to eliminate this tradeoff and lead to good-quality lateral strain estimation at high frame rates. S44 13proceedings_Layout 1 3/5/13 10:38 AM Page S45 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1540358 Nurse-Based Use of Handheld Ultrasound Examination for Heart Failure Mikael Gustafsson,* Ulf DahlstrГ¶m, Urban Alehagen, Peter Johansson Cardiology, Medicine and Care, LinkГ¶ping, Sweden Objectives—Heart failure (HF) is a syndrome of high prevalence and poor prognosis. Structured nurse-based visits, where basic clinical data such as body weight, edemas, New York Heart Association (NYHA) functional class, respiratory symptoms, and biomarkers are assessed, is a strategy implemented in recent years to improve the quality of care. Ultrasound lung imaging can reveal lung water by the appearance of the so-called “comet tail artifact” (CTA), which is reported to be easily recognized after a short period of training. Pleural effusion (PE) and dilatation of liver veins and the inferior vena cava (IVC) are also common findings in decompensated HF that can be evaluated with ultrasound. Knowledge of these data may improve understanding of the current hemodynamic status of HF patients. We hypothesized that HF clinic nurses with 1 day of training would be able to record and correctly identify the CTA and PE using a handheld ultrasound scanner (HHUS). We also tested whether they would be able to correctly record the IVC diameter and liver veins. Methods—Using an HHUS (Vscan; GE Healthcare), 4 nurses recorded cine loops from all lung lobes, pleura IVCs, and liver veins in 58 consecutive HF outpatients. An experienced echocardiographer, blinded to the results, reviewed all recorded image sequences in parallel. Results—In this outpatient population of HF patients with median N-terminal pro-brain natriuretic peptide (NTproBNP) of 1670, nurses’ findings were CTA in 18, PE in 5, dilated IVC in 12, and dilated liver veins in 18 cases. These conditions, all associated with HF, were significantly (P < .05) found to covariate. CTA and a dilated IVC also correlated (both r = 0.4; P < .05) with the biomarker NTproBNP. CTAs were less abundant in NYHA I and II than in NYHA III (r = 0.10; P < .05). Agreement between nurse and echocardiographer findings was good for CTA (70%) and PE (90%), while IVC and liver vein assessments were less accurate. The HHUS examination time was on average 8 minutes. Conclusions—Nurse-performed HHUS examination directed to assess signs of increased lung water content and elevated central venous pressure can provide additional information with a potential impact on management of HF patients. 1520493 Performance Assessment of Cardiac Strain Imaging Using Radiofrequency and Envelope Signals Chi Ma,* Tomy Varghese Medical Physics, University of Wisconsin, Wisconsin USA Objectives—Clinical cardiac strain images are currently generated using B-mode signals. Accurate regional myocardial function analysis requires high spatial and temporal resolution in addition to fidelity to the underlying deformation. Performance analysis of radiofrequency (RF), envelope, and B-mode signals in the context of cardiac strain imaging will yield a better understanding of their respective properties. Methods—In this study, strain estimation performance is compared using a tissue-mimicking phantom, finite-element–based cardiac simulation, and clinical in vivo data to demonstrate the differences between the use of RF, envelope, and B-mode signals. Two performance metrics, ie, the regional mean value and the SD of the regional mean value, are studied. Results—In phantom studies, the signal-to-noise ratio improvements of the RF signal for linear array and phased array geometry are 5.80 and 9.48 dB, respectively, when compared with the envelope signal at the peak strain value. The cardiac simulation study shows that at the peak strain value, the SDs of the estimated strain of the envelope signal from anterior and anterolateral segments are 1.55 and 1.12 times larger than RF signal estimations, respectively. In vivo study results also show that the standard deviation of estimated strain is lower with RF signals. Conclusions—Results in phantom studies show that RF signals provide superior performance under cyclic compression for both linear array and phased array transducers when compared to the use of envelope signals. Cardiac simulation study and in vivo results also indicate performance advantages of strain estimation using RF signals over envelope signals. (Supported by National Institutes of Health grants 5R21EB010098 and R01CA112192-S103.) Gynecologic Ultrasound Moderator: Jodi Lerner, MD 1541483 Three-Dimensional Ultrasound Assessment of Uterine Cavity Remodeling After Surgical Correction of Subseptations Laura Detti Obstetrics and Gynecology University of Tennessee, Memphis, Tennessee USA Objectives—Arcuate and subseptate uteri taken together account for 53% of all mГјllerian anomalies. Their incidence is even higher in patients with infertility and recurrent pregnancy loss, and restoration of normal fertility/pregnancy outcomes is achieved with surgical correction. We sought to evaluate uterine cavity measurements in patients with arcuate or subseptate uteri in the pre- and post-resection periods. Methods—This was a prospective cohort study. Patients diagnosed with arcuate or subseptate uteri were evaluated with 3D ultrasound before and after undergoing surgical resection of the anomalies by hysteroscopic separation of the anterior from the posterior wall. Measurements of the subseptum’s length (measured from the base to the tip of the septum: <10 mm defined arcuate, and ≥10 mm defined subseptate uterus, respectively) and width (measured at the septum’s base as it comes off the fundus) and cavity width (measured between the tubal ostia, at the fundus) were obtained on a frozen coronal view of the uterus. A paired t test and simple t test were used for comparisons. P < .05 defined significance. Results—Ten patients were diagnosed with either an arcuate (n = 3) or subseptate (n = 7) uterus and underwent surgical correction. The overall uterine dimensions (length, width, and height) before and after resection were similar, as were the subseptum widths, despite the different lengths. However, cavity width was significantly decreased after resection (3.3 В± 0.4 cm preop vs 2.6 В± 0.4 cm postop, respectively; P < .001). The difference remained significant in the septate and arcuate uteri groups, when analyzed separately. Conclusions—It appears that the uterine fundus is only stretched by the septum, and the cavity is able to regain a normal shape and size after surgical correction. Postoperative measurements of the uterine cavity revealed a remarkable remodeling capacity of the uterus. 3D ultrasound was instrumental in characterizing this unique uterine elasticity outside the pregnant state. 1541423 Assessment of Levator Ani Muscle Deformation During the First and Third Trimesters of Pregnancy Using Tissue Doppler Imaging at Maximal Kegel: A Pilot Study Timothy Canavan Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Magee Women’s Hospital, Pittsburgh, Pennsylvania USA Objectives—To assess the feasibility of using tissue Doppler imaging (TDI) to evaluate levator ani muscle function by measuring the velocity, displacement, and strain of a levator ani contraction during a kegel in the first and third trimesters of primigravida pregnancies. Methods—This was a prospective pilot study of serial TDI of the levator ani muscle in 27 primigravid subjects in the first trimester and 7 who were also imaged in the third trimester. Measurements were obtained using TDI of the midsagittal plane of the pelvic floor at the level of the levator hiatus, recorded during maximal kegel. The mean velocities, S45 13proceedings_Layout 1 3/5/13 10:38 AM Page S46 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 displacements, strains, and strain rates were determined by postprocessing using QLab version 8.0 (Philips, Andover, MA). Results—The findings in the first and third trimesters are summarized in Table 1. There was no statistically significant effect of age, race, or body mass index (BMI) on any of the measurements; except for BMI (P = .03) on mean velocity in the third trimester. Gestational age at the time of the exam had a negative effect on mean velocity in the first (P <.001) and third (P = .04) trimesters. Wilcoxon signed rank testing was used to compare the first- and third-trimester means. There was no statistical difference in the mean velocities or strain testing between the trimesters; however, there was a statistical difference between the mean displacements, with a larger displacement in the third compared to the first trimester (P = .04). Conclusions—Tissue Doppler imaging has potential to be used to assess levator ani function. There may be a difference in the functional capacity of the levator ani between early and late pregnancy. Table 1. Mean velocity, Displacement, Strain, and Strain Rate by Gestational Age Mean Mean Gestational Velocity Age, wk В± 1 SD, cm/s 13.0 0.82 В± 0.65 31.0 1.13 В± 0.69 Mean Displacement В± 1 SD, mm 2.6 В± 2.0 4.0 В± 2.2 Mean Strain В± 1 SD, 1/s 6.89 В± 6.45 13.04 В± 9.37 Mean Strain Rate В± 1 SD, % 0.17 В± 0.14 0.27 В± 0.17 1523456 Biometric Ultrasound Findings of Trophoblastic Implantation on Cesarean Scars Elysia Moschos,1* C. Edward Wells,1 Diane Twickler1,2 1 Obstetrics and Gynecology, 2Radiology, University of Texas Southwestern Medical Center, Dallas, Texas USA Objectives—To review first-trimester transvaginal ultrasound (TVUS) of patients with cervicoisthmic implantations and a history of cesarean deliveries to determine whether biometry can distinguish between placenta accreta, cesarean scar pregnancy, and other outcomes. Methods—Our database was reviewed from October 2006 to December 2011 for patients with first-trimester US diagnoses of cervicoisthmic implantations and previous history of cesarean deliveries. Biometry was performed based on the location of the trophoblast on sagittal TVUS images of the uterus: (1) smallest distance from the anterior trophoblastic border to the uterine serosa; (2) anterior trophoblastic border distance from the endometrial center; and (3) posterior trophoblastic border distance from the endometrial center. Outcomes were classified into 5 categories: (1) cesarean scar pregnancy (n = 11); (2) placental invasion (accreta/increta/percreta) (n = 7); (3) previa without invasion (n = 1); (4) cervical ectopic pregnancy (n = 2); and (5) noninvaded pregnancy (spontaneous abortion, n = 31; or delivered intrauterine pregnancy, n = 4). Statistical methods included analysis of variance with the Tukey range test and Student t test. Results—Of 77 studies, outcome data were available for 56 patients. The average gestational age was 8.8 weeks (minimum, 2.0; maximum, 14.9). The anterior trophoblastic border distance from the uterine serosa was significantly smaller in cesarean scar and placental invasion pregnancies. Both trophoblastic borders of cesarean scar pregnancies were significantly different compared to placenta accretas. Conclusions—Smaller trophoblastic border distances from the uterine serosa are seen in cesarean scar pregnancies and placenta accretas; this distance distinguishes them from other pregnancy outcomes. Trophoblastic borders and their relative distances from the endometrial center at the hysterotomy implantation site are significantly different between cesarean scar pregnancies and placenta accretas. Table 1 Outcome (n) Mean distance Cesarean Placental Noninvaded (SD), mm Pregnancy (11) Invasion (7) Pregnancy (35) Anterior trophoblastic 1.6a (0.6) 2.2a (1.0) 7.9 (3.3) border to uterine serosa Anterior trophoblastic 32.0b (14.4) 16.3b (8.7) 10.7 (9.2) border Posterior trophoblastic 2.1c (4.7) 9.6c (3.8) 8.7 (6.7) border a Significantly different from the other pregnancy groups (P < .0001). b P = .02. c P = .003. 1537573 Diagnosis of Polycystic Ovaries (PCO) by Ovarian Appearance Only: A Prospective Study of Infertility Patients Comparing Those With Unilateral, Bilateral, and No PCO With Regard to Body Mass Index and Cycle Regularity Alex Hartman,* Rose Lee, Brian Hartman Imaging, True North Imaging, Thornhill, Ontario, Canada Objectives—Polycystic ovaries (PCO) is commonly diagnosed using the ovarian appearance and volume criteria. We hypothesized that using PCO appearance criteria alone, there would be a difference in cycle regularity and body mass index (BMI) between patients who do or do not have PCO and between patients with unilateral versus bilateral PCO. Methods—We studied 3871 consecutive infertility patients. Using the PCO syndrome Rotterdam Consensus Criteria for the appearance of ovaries (12 follicles in either/both ovaries), we determined whether the patient had unilateral, bilateral, or no PCO. BMI (height/weight) and cycle regularity were self-reported. П‡2 tests of independence and 1-way analysis of variance were performed. Results—Of 3871 consecutive patients, 363 (9.4%) had unilateral, 1045 (27%) had bilateral, and 2463 (63.6%) did not have PCO. There was a significant difference in cycle irregularity (present vs absent) based on PCO status (П‡2 = 1208.7; df = 2; P < .01). Woman with bilateral PCO had the highest frequency of menstrual cycle irregularity (71.9%) vs 34.8% in unilateral and 12.7% with no PCO. There was also a significant difference in mean BMI based on PCO status (F = 19.1; df = 2; P < .01). The mean BMI of woman with bilateral PCO was 26.0 (SD 6.2), while woman with unilateral or no PCO had a mean BMI of 25.2 (SD 5.7) and 24.5 (SD 6.5), respectively. Conclusions—This is the first study showing the PCO appearance alone to be significant when comparing unilateral vs bilateral PCO in infertility patients. While BMI was significantly different between patients with or without PCO, there was no significant difference in BMI between those with unilateral vs bilateral PCO. There was a significant difference in cycle regularity between those with and without PCO and between those with unilateral versus bilateral PCO using appearance criteria alone. Table 1 No. of patients BMI Irregular cycles, % S46 No PCO 2463 24.5 12.7 Unilateral 363 25.2 34.8 Bilateral 1045 26.0 71.9 P <.01 <.01 13proceedings_Layout 1 3/5/13 10:38 AM Page S47 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1538495 Evaluation of Cervical Cancer Detection With Acoustic Radiation Force Impulse Ultrasound Imaging: Preliminary Results Yijin Su,* Lianfang Du, Ying Wu, Juan Zhang, Xuemei Zhang, Xiao Jia, Yingyu Cai, Yunhua Li, Jing Zhao, Qian Liu School of Medicine, Shanghai Jiaotong University, Shanghai, China Objectives—To evaluate the application of acoustic radiation force impulse (ARFI) ultrasound imaging and its potential value for characterizing cervical cancer. Methods—ARFI of the uterine cervix was performed in 58 patients with cervical cancer before operation. Elastographic imaging (EI), Virtual Touch tissue imaging (VTI), and Virtual Touch tissue quantification (VTQ; Siemens Medical Solutions, Mountain View, CA) were used to qualitatively and quantitatively analyze the elasticity and hardness of lesions. Results—Compared to the surrounding cervix tissue, the EI, VTI, and VTQ images between malignant lesions and surrounding normal tissues showed a significant difference (P < .001). Conclusions—ARFI of the uterine cervix may be an objective method for assessment of softening of tissue. It has high sensitivity and specificity in evaluating cervical cancer and therefore has good diagnostic value in clinical applications. Table 1. Comparison of VTQ Between Cervical Cancer and Normal Tissue Tissue Cases, n Mean, m/s SD, m/s Cervical cancer 58 3.41 1.59 Normal tissue 58 2.12 1.27 Compared with normal tissue, VTQ of cervical cancer was higher (P < .001). 1512000 Texture-Based Ovarian Tumor Characterization Using 3-Dimensional Ultrasound U. Rajendra Acharya,1 Stefano Guerriero,2 Filippo Molinari,3 Luca Saba,4 Jasjit Suri5,6* 1Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 2Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 3Electronics and Telecommunications, Politecnico Torino, Torino, Italy; 4 Radiology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy; 5Global Biomedical Technologies, Roseville, California USA; 6Biomedical Engineering, Idaho State University, Pocatello, Idaho USA Objectives—Among gynecologic malignancies, ovarian cancer is the most frequent cause of death. Differential diagnosis is difficult, thus exposing patients to unneeded surgical treatment. We developed a computer-aided diagnostic technique that uses ultrasound images of the ovary to accurately classify benign and malignant ovarian tumors. Methods—Twenty women (age range, 29–74 years; mean В± SD, 49.5 В± 13.48 years), 11 premenopausal and 9 postmenopausal, were recruited for this study. The histologic specimens revealed 10 malignant and 10 benign lesions. Prior to surgery, each patient was associated with a 3D volume of 100 images. Feature extraction was made by using local binary pattern and laws texture energy. The data were used to train a classifier based on a support vector machine (SVM) with 5 different kernels. The data set was randomly split into 10 equal folds, each fold containing the same ratio of nonrepetitive samples from both classes (malignant and benign). At each iteration, 9 folds were used to train the SVM, and 1 fold was classified. We iterated the procedure 10 times to explore all the possible combinations. The averages of the performance metrics obtained in all the iterations are reported as the overall performance metrics. Results—The performance metrics obtained on training the SVM classifier of various kernel configurations using the 14 significant features are reported in Table 1. All the kernels demonstrated excellent ability in classifying the samples from both classes. The highest accuracy of 99.9% was registered by the radial basis function (RBF) kernel. Conclusions—The novelty of this study is the use of low-cost ultrasound images and a highly discriminating combination of simple texture features fed to an SVM classifier to obtain the highest accuracy of nearly 100% in ovarian tumor classification. Table 1. Classifier Performance SVM Accuracy, Sensitivity, Specificity, PPV, Kernel TP TN FP FN % % % % Linear 100 99 0 1 99.8 99.6 100 100 Poly 1 100 100 0 0 99.8 99.6 100 100 Poly 2 100 100 0 0 99.9 100 99.9 99.9 Poly 3 100 100 0 0 99.8 99.9 99.8 99.8 RBF 100 100 0 0 99.9 100 99.8 99.8 FN indicates false-negative; FP, false-positive; PPV, positive predictive value; TN, true-negative; and TP, true-positive. 1512001 Tumor Characterization From 3-Dimensional Gynecologic Ultrasound: A New Online Feature-Based Paradigm U. Rajendra Acharya,1 Luca Saba,2 Filippo Molinari,3 Stefano Guerriero,4 Jasjit Suri5,6* 1Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 2Radiology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy; 3Electronics and Telecommunications, Politecnico Torino, Torino, Italy; 4Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 5Global Biomedical Technologies, Roseville, California USA; 6Biomedical Engineering, Idaho State University, Pocatello, Idaho USA Objectives—Among gynecologic malignancies, ovarian cancer is the most frequent cause of death. Differential diagnosis is difficult, exposing patients to unneeded surgical treatment. The objective of this work was to develop a computer-aided diagnostic (CAD) technique that uses 3D acquired ultrasound images of the ovary and image-mining algorithms to characterize and classify benign and malignant ovarian tumors. Methods—Twenty women (age range, 29–74 years; mean В± SD, 49.5 В± 13.5 years), 11 premenopausal and 9 postmenopausal, were recruited for this study. The histologic specimens revealed 10 had malignant and 10 had benign lesions. Prior to surgery, each patient was associated with a 3D volume of 100 images. We extracted features based on the textural changes in the image and also features based on the higherorder spectra (HOS) information. The significant features were then selected and used to train and evaluate the decision tree (DT) classifier. The data set was randomly split into 10 equal folds, each fold containing the same ratio of nonrepetitive samples from both the classes (malignant and benign). At each iteration, 9 folds were used to train the DT, and 1 fold was classified. We iterated the procedure 10 times to explore all the possible combinations. The averages of the performance obtained in all the iterations are reported as the overall performance. Results—The simple DT classifier presented high accuracy of 95.1%, sensitivity of 92.5%, and specificity of 97.7%. Full performance is given in Table 1. Conclusions—A novel combination of 4 texture and HOS based features that adequately quantify the nonlinear changes in both benign and malignant ovarian ultrasound images was used to develop classifiers. The CAD tool would be a more objective alternative to manual analysis of ultrasound images, which might result in interobserver variations. The system can be installed as a stand-alone software application in the physician’s office at no extra cost. S47 13proceedings_Layout 1 3/5/13 10:38 AM Page S48 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Table 1. Classifier Performance Accuracy, Sensitivity, Specificity, PPV, TN FN TP FP % % % % DT 98 8 93 2 95.1 97.8 92.5 97.7 FN indicates false-negative; FP, false-positive; PPV, positive predictive value; TN, true-negative; and TP, true-positive. 1537972 Value of Transvaginal Ultrasonography in Diagnosing Adenomyosis Birsen Ogutcu,1,2* Kathryn Gunnison,2 Bakytbubu Arynova,1 Jack Garon,1,2 Josef Blankstein1,2 1Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, Illinois USA; 2Obstetrics and Gynecology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois USA Objectives—The purpose of this study was to look at ultrasonographic findings of uteri with adenomyosis confirmed by histopathology after hysterectomy. Methods—The ultrasound reports and images from 76 patients who underwent hysterectomy with a diagnosis of adenomyosis on pathologic reports were evaluated. Data collection included the myometrial echogenicity (focal or diffuse heterogeneous echo texture vs homogeneous echo texture), the presence or absence of myometrial cysts, the presence or absence of subendometrial linear striations, and the quality of the endometrial/myometrial border (ill defined vs well defined). Results—Of the 73 ultrasound images reviewed, 70 (96%) were shown to have a heterogeneous myometrial echo texture. Of these 70, 11 (26%) were described as focal heterogeneity. Myometrial cysts were found in 53 (72%) of the images. Forty-six (63%) images were shown to have an ill-defined endometrial/myometrial border. Thirty-two (44%) images were shown to have subendometrial linear striations. Of the images shown to have myometrial cysts, all 53 (100%) were shown to have a heterogeneous myometrial echo texture. Conclusions—In conclusion, based on our retrospective studies and others, transvaginal ultrasonography is a cost-effective, noninvasive, and widely available method to look for ultrasonographic findings that are common in uteri with pathologically confirmed adenomyosis. In this study, we identified a heterogeneous myometrial echo texture as the most common ultrasonographic finding in uteri with confirmed adenomyosis. Additional prospective studies to further determine the accuracy and reliability of transvaginal ultrasonography as a tool to diagnose adenomyosis are needed. 1509704 To Chaperone or Not to Chaperone Jenny Parkes,1,2* Michal Schneider-Kolsky,2 Paul Lombardo2 1 Australian School of Medical Imaging, Sydney, New South Wales, Australia; 2Medical Imaging and Radiation Science, Monash University, Melbourne, Victoria, Australia Objectives—Chaperone use during transvaginal (TV) ultrasound is variable. This paper discusses such use in regard to both the sonographer/sonologist and patient’s perspectives. Methods—A survey of sonographer members of the Australian Sonographers Association was performed online to audit current practice; in addition, a literature review of current international practices, protocols, and opinions was undertaken. Results—Three-hundred fifty of 2219 (15.8%) sonographers participated in this survey. Most sonographers surveyed used a chaperone occasionally (42.9%), with 70% preferring to never use a chaperone. Patient embarrassment and lack of privacy were key issues, findings that were supported by the literature. Female sonographers used chaperones occasionally or never (89%), while 60% of male sonographers used a chaperone always or most of the time to comply with departmental protocols and for medicolegal protection. Sonographers in private specialist obstetric and gynecologic centers where TV pelvic ultrasound is commonly a routine part of the examination never, or only occasionally, used a chaperone. Review of the current literature and protocols highlighted that the use of a chaperone should consider the patient’s privacy, embarrassment, and preference. In regard to the sonographer/sonologist, selection of an appropriate chaperone, availability, and the informed consent of the patient are important considerations. Conclusions—Chaperones for TV scanning are predominantly used by male sonographers in Australia. It is unclear if the patient preference for a chaperone to be present is taken into account. The appropriate protection for both sonographers/sonologists and patients needs to be considered, in particular, privacy issues. Protocols should be developed to take all of these factors into account. 1538726 What Causes Postmenopausal Bleeding (PMB)? A Prospective Study of 670 Consecutive Patients With PMB Examined With Regard to Body Mass Index and the Prevalence of Abnormalities on Sonohysterography Alex Hartman,* Rose Lee, Brian Hartman Imaging, True North Imaging, Thornhill, Ontario, Canada Objectives—The causes of postmenopausal bleeding (PMB) are myriad. This prospective study examines the causes of PMB and correlates these findings to patient body mass index (BMI). Methods—Sonohysterography was performed on 1108 consecutive postmenopausal women at an academically oriented private practice from October 2010 to August 2011. Six hundred seventy of the patients had PMB. The prevalence of uterine abnormalities and the patient’s BMI were obtained for each group. П‡2 tests of independence and 1-way analysis of variance were performed to determine significant differences. Results—Of the 670 with PMB, 262 (39.1%) had endometrial polyps; 273 (40.1%) had fibroids; 39 (6.8%) had submucosal fibroids; and 369 (55%) had a normal cavity, with no polyps, or submucosal fibroids. There was a statistically significant difference between the mean BMI of patients with endometrial polyps (28.34) and those with normal cavities (27.33) and only fibroids (27.64) (F = 2.95; df = 3; P = .03). Conclusions—More than half of patients with PMB have a normal uterine cavity, and almost 40% have endometrial polyps. Patients with endometrial polyps have a higher BMI than those without polyps. Table 1 No uterine abnormality Intramural fibroid Polyp Submucosal fibroid Polyp + intramural fibroid Polyp + submucosal fibroid Total Patients, n 233 136 164 39 91 7 670 Patients, % 34.8 20.3 24.5 5.8 13.6 1.0 100 BMI 27.33 27.64 28.34 27.60 28.80 28.76 27.93 1541040 Spatial Variability of Shear Wave Speed Estimation in the Normal Nonpregnant Cervix Lindsey Carlson,1* Mark Palmeri,2 Lisa Reusch,1 Helen Feltovich,1,3 Timothy Hall1 1Medical Physics, University of Wisconsin, Madison , Wisconsin USA; 2Biomedical Engineering, Duke University Pratt School of Engineering, Durham, North Carolina USA; 3Maternal-Fetal Medicine, Intermountain Healthcare, Park City, Utah USA Objectives—Throughout pregnancy, beginning soon after conception, the cervix remodels, resulting in softening, shortening, and dilation to allow for eventual delivery of a fetus. Premature remodeling may S48 13proceedings_Layout 1 3/5/13 10:38 AM Page S49 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 lead to premature birth, yet there is no clinically established method to objectively and quantitatively measure softening. Our objective is to develop a safe, reliable, noninvasive quantitative method to assess cervical softness. We have shown that shear wave speed estimation (SWS) is an effective method to measure cervical softness in hysterectomy specimens. A critical step toward transitioning to in vivo studies is to determine the spatial variability in cervical softness, and that is the aim of the current work. Methods—Five multiparous hysterectomy specimens from nonpregnant women were bivalved, placed in a saline bath, and scanned with a 9L4 linear array transducer aligned parallel with the endocervical canal using a Siemens Acuson S2000 system. SWS measurements were obtained in 5 positions along the canal (10–30 mm from the external os) and at 3 depths from the surface of the canal (0.25–8.25 mm deep) with 10 replicate measurements at each location. The shear wave speeds were estimated using an iterative random sample consensus (RANSAC) method. Results—In all specimens, the shear wave speed systematically increased along the canal from distal to proximal (closer to the uterus) on the anterior side (1.47 В± 0.08 vs 4.54 В± 0.22 m/s for distal and proximal, respectively). This represents an increase in SWS of 1.5 m/s/cm along the length of the cervix. The posterior side showed much greater, and less systematic, spatial variation (3.61 В± 0.98 vs 4.14 В± 0.58 m/s for distal and proximal, respectively). All estimates had a RANSAC inlier percentage of 99%, representing strong confidence in the SWS estimates. Conclusions—Normal cervical tissue has a significant stiffness gradient that can be characterized with acoustic radiation force-based shear elasticity imaging methods. With careful development and testing, SWS measurement will provide a means to noninvasively assess softening of the pregnant cervix and could be a useful research tool for exploring premature cervical remodeling. New Investigator Award Session Moderators: Arthur Fleischer, MD, Elisa Konofagou, PhD 1434714 Longitudinal Analysis of Grayscale Imaging and Electromyography in an Animal Model of Carpal Tunnel Syndrome Shawn Roll,1* Kevin Evans,2 Kevin Volz,2 Carolyn Sommerich2 1 Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, California USA; 2School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio USA Objectives—The objective of this research was to determine the ability of sonography to identify changes over time in median nerve morphology due to controlled exposure to a physical task related to the development of carpal tunnel syndrome. Methods—Fifteen Macaca fascicularis monkeys pinched a lever while in various amounts of wrist flexion to receive a treat. Subjects worked at a self-regulated pace up to 8 hours a day, 5 days a week, for 14 weeks. Nerve conduction velocity (NCV) and sonographic evaluation of the median nerve were completed every other week during 4 weeks of training (baseline), 16 weeks of working, and 6 weeks of recovery. A GE LOGIQ i with a 12-MHz linear transducer was used for sonographic evaluation. Cross-sectional area (CSA) was measured via a direct trace around the inner hyperechoic border of the nerve in the forearm and at the level of the pisiform. NCV and CSA measures were analyzed across the 3 phases using analysis of variance and trend graphs. Results—NCV slowed slightly from baseline to the working phase across all subjects (P = .03). CSA of the nerve at the level of the pisiform was noted to increase significantly from baseline and working phases as compared to the recovery phase (P = .03). At the same time, CSA of the median nerve in the distal forearm did not change across the phases (P = .20). Conclusions—Based on this controlled study, changes in CSA of the median nerve can be observed over time and may be directly associated with work exposure. Sonography may be a highly useful tool for periodic preventative screening for work-related musculoskeletal disorders. Early detection of these changes through longitudinal evaluations in workers at risk for carpal tunnel syndrome could trigger interventions meant to reverse the progression of tissue pathology. Table 1. Average (SD) Nerve Measurements Across the Study Phases Nerve conduction velocity, m/sec CSA in forearm, mm2 CSA at pisiform, mm2 CSA change (pisiform – forearm), mm2 Baseline Working Recovery P 35.96 (3.46) 34.33 (3.76) 34.81 (3.19) .03 0.61 (0.15) 0.82 (0.28) 0.20 (0.28) 0.59 (0.16) 0.81 (0.29) 0.22 (0.31) 0.64 (0.17) .20 0.96 (0.36) .03 0.30 (0.38) .27 1526604 Risk Reduction of Brain Infarction During Carotid Endarterectomy or Stenting Using Sonolysis: Prospective Randomized Study Pilot Data Martin Kuliha,1* David Е koloudГk,1,4 Eva HurtГkovГЎ,1 Martin Roubec,1 Andrea GoldГrovГЎ,1 Roman Herzig,4 VГЎclav ProchГЎzka,2 TomГЎЕЎ Jonszta,2 Dan CzernГЅ,2 Jan KrajДЌa,2 David OtГЎhal,3 TomГЎЕЎ HrbГЎДЌ3 1Neurology, 2Radiology, 3Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic; 4Neurology, University Hospital Olomouc, Olomouc, Czech Republic Objectives—Sonolysis is a new therapeutic option for acceleration of arterial recanalization. The aim of this study was to confirm risk reduction of brain infarction during carotid endarterectomy (CEA) and carotid stenting (CS) of the internal carotid artery (ICA) using sonolysis with continuous transcranial Doppler monitoring by a diagnostic 2-MHz probe. Methods—All patients with ICA stenosis >70%, an indication for CEA or CS, and signed informed consent were enrolled to the study during 18 months. Patients were randomized into 2 groups: group 1 with sonolysis during intervention and group 2 without sonolysis. Neurologic examination, cognitive tests, and brain magnetic resonance imaging were performed before and 24 hours after intervention in all patients. New brain infarctions, infarctions >0.5 cm3, a mini–mental state examination, a clock test, and a speech fluency test were statistically evaluated using a t test. Results—Totally, 127 patients were included in the study. Sixty-two (48 males; mean age, 65.6 В± 7.6 years) were randomized into group 1; 33 underwent CEA and 29 CS. Sixty-five patients (39 males; mean age, 65.6 В± 7.8 years) were randomized into group 2; 30 underwent CEA and 35 CS. New brain infarctions/infarctions >0.5 cm3 were found in 19 (30.6%)/4 (6.5%) patients in group 1 and in 26 (40.0%)/12 (18.5%) patients in group 2, respectively (P = .14/P = .02, respectively). No significant differences were found in cognitive tests (P > .05 in all tests). Conclusions—Sonolysis seems to be effective in prevention of large brain infarction during CEA and CS. (Supported by grants IGA MH CR NT/11386-5/2010, NT/11046-6/2010, and NT/13498-4/2012.) 1536178 Measured Single-Bubble Postexcitation Collapse Thresholds for Standard and Size-Altered Ultrasound Contrast Agents Daniel King,1,2* William O’Brien Jr2,3 1Mechanical Science and Engineering, 2Bioacoustics Research Laboratory, 3Electrical and Computer Engineering, University of Illinois at UrbanaChampaign, Urbana, Illinois USA Objectives—Experimentally measured responses of ultrasound contrast agents (UCAs) at high acoustic pressures are valuable for imaging and therapeutic ultrasound applications as well as for interpreting bio- S49 13proceedings_Layout 1 3/5/13 10:38 AM Page S50 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 effect mechanisms. Therefore, the goals for this research were to compare the size distribution and shell composition dependence for a characteristic type of collapse using 2 commercially available UCAs, lipid-shelled Definity and albumin-shelled Optison. Methods—Two Definity and 2 Optison populations of varying size distributions were tested. Experiments were conducted using a double passive cavitation detection setup at several frequencies (2.8–7.1 MHz) across a range of peak rarefactional pressures (0.1–6.0 MPa). Data were analyzed using a peak detection algorithm for the presence or absence of the postexcitation signal (PES), a rebound characteristic indicative of shell rupture, inertial cavitation, and symmetric collapse for single UCAs. Results—With standard preparations, Definity had lower postexcitation collapse thresholds than Optison at most frequencies (Table 1). Using alternate preparations to change the mean size of the bubble populations had little effect on these thresholds, except around 4.6 MHz. Furthermore, the predicted shift in PES thresholds using the Marmottant model followed similar trends to the experiments for Definity UCAs, showing greater variation around 4.6 MHz than at 2.8 or 7.1 MHz. Conclusions—Significant differences were found between the collapse thresholds of Definity and Optison. Moreover, the comparisons between varied size distributions showed that the different shell compositions had a significant impact on the measured PES thresholds at all frequencies, independent of mean size. (Supported by National Institutes of Health grant R37 EB002641.) Table 1. Mean Diameter В± SD and 50% Postexcitation Thresholds (95% Confidence Intervals) for Peak Rarefactional Pressure Amplitude 50% UCA Mean Threshold at Population Diameter, Вµm 2.8 MHz, MPa Definity 1.99 В± 0.54 0.81 (0.71–0.90) Altered Definity 2.50 В± 2.32 0.80 (0.75–0.85) Optison 4.24 В± 2.44 1.20 (0.99–1.39) Altered Optison 2.61 В± 2.04 1.17 (0.92–1.39) 50% Threshold at 4.6 MHz, MPa 2.26 (2.06–2.43) 1.65 (1.56–1.72) 1.76 (1.34–2.06) 2.62 (2.20–2.95) 50% Threshold at 7.1 MHz, MPa 3.90 (3.50–4.40) 3.61 (3.30–4.19) 4.24 (2.81–4.94) 4.04 (3.85–4.20) 1538841 Computer-Assisted Detection of Proximal Arterial Stenosis on Doppler Ultrasound John Millet,1* Gowthaman Gunabushanam,1 Erik Stilp,2 Forrest Crawford,3 Robert McNamara,2 Leslie Scoutt1 1 Diagnostic Radiology, 2Internal Medicine, Yale University School of Medicine, New Haven, Connecticut USA; 3Biostatistics, Yale University School of Public Health, New Haven, Connecticut USA Objectives—To determine if use of a novel computer-generated quantitative measure, effective acceleration time (effAT), can improve accuracy for detecting proximal arterial stenosis on Doppler ultrasound. Methods—This was a retrospective case-control study whereby aortic stenosis (AS) was used as a model to detect distal tardus parvus physiology. Patients with echocardiography-confirmed AS (n = 132; 60 mild, 44 moderate, 28 severe) and controls (n = 48) who underwent carotid ultrasound within 90 days were identified through a diagnostic imaging database at a single medical center. A custom-built computerized spectral analysis program generated effAT values for all carotid artery spectral Doppler waveforms, and a receiver operating characteristic (ROC) analysis was performed to determine the optimal median effAT cutoff value to detect AS. Two radiologists, blinded to subject disease status, reviewed all carotid sonograms for the presence of tardus parvus waveforms. Interobserver variability was measured, and the accuracy of the radiologists to detect AS with and without use of the effAT cutoff was calculated. Accuracy of the effAT cutoff to detect AS independent of radiologist waveform interpretation was also determined. Results—There were no significant differences between cases and controls with regard to age, sex, body mass index, or ejection fraction. Accuracy of radiologist detection of AS via waveform interpretation ranged from 43% to 61%. Observer agreement in the detection of tardus parvus waveforms was 76% (136/180 cases; Ољ = 0.44; P < .001). ROC analysis revealed an optimal effAT cutoff of ≥48 milliseconds to detect AS with a corresponding area under the curve of 0.77 (95% confidence interval, 0.74–0.84). Use of the effAT cutoff independent of radiologist waveform interpretation demonstrated accuracy of 72%. The combination of a tardus parvus pattern and a median effAT of ≥48 milliseconds demonstrated an accuracy range of 73% to 74%. Conclusions—Radiologist detection of proximal arterial stenosis though visual interpretation of spectral Doppler waveform morphology is limited by low accuracy and moderate interobserver variability. Use of a computer-generated median effAT cutoff markedly improves diagnostic accuracy and eliminates observer variability. 1536020 Contrast Ultrasound Imaging of the Aorta Does Not Affect Progression of Atherosclerosis in ApoE–/– Mice Brendon Smith,1,2* Douglas Simpson,3 Sandhya Sarwate,1,4 Rita Miller,1 Rami Abuhabsah,1 John Erdman,2,5 William O’Brien Jr1,2 1Bioacoustics Research Laboratory, Electrical and Computer Engineering, 2Division of Nutritional Sciences, 3 Statistics, 4Pathology, 5Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, Illinois USA Objectives—Ultrasound contrast agents (UCAs) are used clinically to enhance ultrasound imaging of the cardiovascular system. Adverse biological effects have been noted after administration of UCAs in human patients and animal models, and more research is needed for a comprehensive understanding of the biological effects of UCAs. We used the ApoE–/– mouse model of atherosclerosis to characterize these effects. Methods—Male ApoE–/– mice (8 weeks old; n = 38) were intravenously infused with the Definity UCA (2 Г— 1010 UCA/h) and either exposed to 2.8-MHz, 10-Hz pulse repetition frequency, 1.4-microsecond pulse duration, 2-minute exposure duration, 1.4-MPa peak rarefactional pressure amplitude ultrasound or sham exposed, and then consumed either a chow or Western diet for either 4 or 8 weeks after ultrasound exposure (n = 4–5 per group). The ultrasound exposure conditions, by design and independent measures, matched Definity’s 80% collapse threshold. Blood plasma samples were collected before ultrasound exposure and at 2, 4, 6, and 8 weeks after exposure. Animals were then euthanized, and tissues were collected for analysis. A pathologist measured atheroma thickness in formalin-fixed, hematoxylin-eosin–stained transverse sections of the aorta and scored them for severity of atherosclerosis. Results—Plasma total cholesterol initially averaged 302 mg/dL in the Western diet group, increased significantly to 742 mg/dL after 2 weeks on the diet (P < .0001), and remained significantly elevated after that. Total cholesterol increased significantly from 309 mg/dL at baseline to 420 mg/dL in the chow diet group after 4 weeks (P < .05) but was not significantly different from baseline at 6 or 8 weeks. Total cholesterol was significantly greater in the Western diet group than the chow group for all time points after baseline (P < .0001). Atheroma thickness was significantly greater in animals consuming the Western diet than in chow-fed animals (P < .001) and in animals euthanized after 8 weeks than after 4 weeks (P < .005). Ultrasound did not affect plasma total cholesterol levels or atheroma thickness. Conclusions—Contrast ultrasound did not increase the severity of atherosclerosis in the ApoE–/– mouse model. (Supported by National Institutes of Health grant R37EB002641.) S50 13proceedings_Layout 1 3/5/13 10:38 AM Page S51 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1540161 Heterogeneity Assessment of Tumor Perfusion Using Highresolution Dynamic Contrast-Enhanced Ultrasound and Dynamic Contrast-Enhanced Magnetic Resonance Imaging Song-Ee Baek,* Patrick Pan, Ergys Subashi, CГ¤cilia Reiner, Daniele Marin, Allan Johnson, Rendon Nelson Radiology, Duke University Hospital, Durham, North Carolina USA Objectives—To determine the reproducibility of measurements of tumor perfusion heterogeneity using high-resolution contrast-enhanced ultrasound compared to high-resolution dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) in murine colorectal cancer. We anticipate using this technique to predict and monitor treatment response to an antiangiogenesis agent. Methods—Experiments were approved by the local Animal Care Committee. Five CD-1 nu/nu athymic female mice with subcutaneous murine colorectal carcinomas (mean tumor height/width, 0.66/1.21 cm) were injected with SonoVue (Bracco Diagnostic, Inc) via a tail vein. At first, we determined reproducibility of tumor perfusion measurement with DCE-US using a GE LOGIQ E9 with an ML6-15-D transducer (4– 13 MHz). Three separate injections by 2 radiologists were performed, and maximum peak intensity (in video intensity) of all pixels within the regions of interest (ROIs) and coefficients of the enhancement for wash-in and wash-out (25%–75% of the peak enhancement) slopes were calculated. Quantitative measurements were performed by positioning of ROIs in the frame displaying maximum contrast enhancement of the tumor. A coefficient of variation was used to compare the variability for each parameter. Second, perfusion heterogeneity according to tumor region was performed with DCE-US and DCE-MRI, and the 2 results were compared (perfusion graph: wash-in and wash-out slopes) in 1 mouse. Results—The average coefficients of variation for repeated injections in the 5 mice were 3% (range, 1%–4%) for peak enhancement, 12% (range, 3%–25%) for slope of the wash-in phase, and 12% (range, 3%–19%) for slope of the wash-out phase. Perfusion measurement with DCE US showed reproducible results. Perfusion graphs showed a different pattern by regions presenting tumor heterogeneity. DCE-US and DCEMRI wash-in and wash-out slopes are well correlated. Conclusions—We obtained reproducible measurements of heterogeneity of tumor perfusion with DCE-US. These results also showed compatible perfusion patterns with DCE-MRI. As a result of this information, we will pursue a further experiment design to determine the ability of this technique to predict treatment response. 1541104 Subharmonic Imaging of Angiogenesis in a Murine Breast Cancer Model Andrew Marshall,1,3* Valgerdur Halldorsdottir,1,3 Jaydev Dave,1 Anya Forsberg,1,4 Manasi Dahibawkar,1,3 Traci Fox,2 Ji-Bin Liu,1 Xiangdong Hu,1,5 Yu He,1,6 Flemming Forsberg1 1 Radiology, 2Radiological Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania USA; 3School of Biomedical Engineering, Sciences, and Health Systems, Drexel University, Philadelphia, Pennsylvania USA; 4Plymouth Whitemarsh High School, Plymouth Meeting, Pennsylvania USA; 5Ultrasonography, Beijing Friendship Hospital, Beijing, China; 6Ultrasound, First Hospital of Jilin University, Jilin, China Objectives—To compare contrast-enhanced subharmonic ultrasound imaging (SHI) of breast tumor neovascularity to 3 immunohistochemical markers of angiogenesis in nude rats. Methods—Twenty-five athymic nude female rats were implanted with 5 Г— 106 breast cancer cells (MDA MB 231) in the mammary fat pad. The contrast agent Definity (Lantheus Medical Imaging, North Billerica, MA) was injected in a tail vein (dose, 200 ВµL/kg), and fundamental ultrasound imaging as well as pulse-inversion SHI were performed with a modified Sonix RP scanner (Ultrasonix Imaging, Richmond, British Columbia, Canada) using a L9-4 linear array (transmitting at 8 MHz and receiving at 4 MHz in SHI mode). After the experiments, specimens were stained for endothelial cells (CD31), vascular endothelial growth factor, and cyclooxygenase-2. Fractional tumor vascularity was calculated from digital images as contrast-enhanced pixels over tumor area (for SHI) and staining over tumor area (for specimens). Results were compared using a linear regression analysis. Results—Of the 25 rats implanted 16 (64 %) exhibited tumor growth, and 13 were successfully imaged. SHI depicted the tortuous morphology of tumor neovessels and delineated areas of necrosis better than fundamental ultrasound imaging, due to the marked suppression of tissue signals. The strongest correlation determined by linear regression in this breast cancer model was between SHI and percent area stained with CD31 (r = 0.42). Conclusions—Quantitative contrast-enhanced SHI measures of tumor neovascularity in a breast cancer xenograft model appear to provide a noninvasive marker for angiogenesis corresponding to the expression of CD31, albeit based on a limited sample size. (Supported by US Army Medical Research Material Command grant W81XWH-08-1-0503 and Lantheus Medical Imaging.) 1539281 A Sequential Stepwise Algorithm Helps Improve Detection of Fetal Venous Anomalies Elena Sinkovskaya,* Anna Klassen, Sharon Horton, Alfred Abuhamad Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, Virginia USA Objectives—The assessment of the fetal venous system is an essential component to fetal echocardiography as it adds significantly to the complete diagnosis of heart defects. The purpose of this study was to develop a method to standardize and simplify comprehensive examination of the fetal venous system. Methods—Eight hundred thirty-four fetal congenital cardiovascular anomalies (CVAs) were detected between January 2005 and December 2010 in the Division of Maternal-Fetal Medicine at Eastern Virginia Medical School. Fetal echocardiograms, which incorporated the assessment of anatomic components of the fetal venous system, were performed between 16 and 39 weeks’ gestation. Since 2008, the stepwise approach, which included evaluation of 5 transverse planes, was used: (1) view of the upper abdomen; (2) coronary sinus view; (3) 4-chamber view; (4) Three-vessel trachea view; and (5) view of the left brachiocephalic vein. Color and pulsed Doppler was used to detect blood flow patterns. Prenatal diagnosis was confirmed in most cases by postnatal echocardiography, angiography, operative findings, or autopsy. Results—Of 834 cases of CVAs, 333 (39.9%) were detected between years 2005 and 2007 and 501 (59.1%) between years 2008 and 2010. Since 2008, the detection of fetal isolated systemic and pulmonary vein anomalies significantly increased (Table 1), while the distribution of congenital heart defects (CHDs) with and without venous malformations stayed the same. This increased identification of fetal venous system abnormalities may be related to the adoption of the new stepwise approach. Conclusions—Our results demonstrated that the sequential analysis of 5 transverse views helps significantly improve the detection of isolated fetal anomalies of systemic and pulmonary veins. Table 1. Detection of Fetal Cardiovascular Anomalies Isolated Venous CHDs With Observation Anomalies, Venous System Period N n (%) Anomalies, n (%) 2005–2007 333 32/333 (9.6) 33/333 (10) 2008–2010 501 137/501 (27.3)a 40/501 (8) a Significant difference, P < .05. S51 CHDs With Normal Venous System, n (%) 268/333 (80.4) 324/501 (64.7) 13proceedings_Layout 1 3/5/13 10:38 AM Page S52 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1539534 Assessment of Longitudinal Myocardial Function of the Right Ventricle in Fetuses With Agenesis of the Ductus Venosus Using Tissue Doppler Imaging Anna Klassen,* Elena Sinkovskaya, Sharon Horton, Alfred Abuhamad Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, Virginia USA Objectives—Agenesis of the ductus venosus (DV) may lead to fetal congestive heart failure (CHF). Tissue Doppler imaging (TDI) is a relatively new method used for direct analysis of the myocardial function. The aim of this study was to analyze the systolic and diastolic myocardial function of the right ventricle (RV) in fetuses with an absent DV using TDI. Methods—Myocardial function of the RV was assessed in 42 normal fetuses and 27 fetuses with DV agenesis between 27 and 39 weeks’ gestation. Detailed echocardiography combined with pulsed and tissue Doppler was performed in all cases. To determine the degree of CHF, the cardiovascular score (CVS) was evaluated on each subject. TDI data were obtained at the level of the 4-chamber view by placing the sample volume at the lateral part of the tricuspid annulus. Pre-ejection (S1), systolic (S2), early diastolic (E′), and late diastolic (A′) myocardial velocities were assessed. The ratio of peak velocities in early and late diastole (E′/A′), ratio of peak velocities in early diastole measured by pulsed and tissue Doppler (E/E′), and index of global contractility (Tei index) were also calculated. Results—The CVS in fetuses with an absent DV ranged from 8 to 2 (mean, 6 В± 1.5), but none of these fetuses developed hydrops. The TDI Tei index was significantly higher in the group with an absent DV compared to normal (1.06 В± 0.11 vs 0.53 В± 0.8; P < .001). The ratio E/E′ was also greater in fetuses with agenesis of the DV (10.5 В± 2.3 vs 5.8 В± 1.1; P < .01). In fetuses with an absent DV, the following changes of myocardial velocities were noted: E′ was significantly decreased or absent (average Z score = –3.2); A′ was significantly increased (average Z score = 6.2); and S1 and S2 were elevated (average Z scores = 4.7 and 4.3, respectively). Conclusions—This represents the first study evaluating cardiac function in fetuses with agenesis of the DV. Agenesis of the DV results in systolic and diastolic myocardial dysfunction of the RV in the fetus. Our results validate the potential clinical applicability of the TDI technique in assessment of cardiac function in fetuses with an absent DV. 1541422 Does Early Second-Trimester Ultrasound Predict Obstetric and Neonatal Outcomes in Monochorionic Diamniotic Twin Pregnancies? M. Baraa Allaf,1* Sina Haeri,2 Ali Ozhand,3 Amir Shamshirsaz,4 Martin Chavez,1 Samadeh Ravangard,5 Adam Borgida,6 Glenn Markenson,7 Joseph Wax,8 Sarah Davis,9 Rebecca Habenicht,10 Manisha Gandhi,2 Jeff Johnson,10 Marjorie Meyer,9 Rodrigo Ruano,2 Paul Ogburn,1 Melissa Spiel,5 Winston Campbell,5 Anthony Vintzileos,1 Alireza Shamshirsaz2,5 1 Obstetrics and Gynecology, Stony Brook–Winthrop University Hospitals, Long Island, New York USA; 2Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas USA; 3Preventive Medicine, University of Southern California, Los Angeles, California USA; 4Obstetrics and Gynecology, George Washington University, Washington, DC USA; 5Obstetrics and Gynecology, University of Connecticut, Farmington, Connecticut USA; 6Obstetrics and Gynecology, Hartford Hospital, Hartford, Connecticut USA; 7Obstetrics and Gynecology, Baystate Medical Center, Springfield, Massachusetts USA; 8Obstetrics and Gynecology, Maine Medical Center, Portland, Maine USA; 9Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vermont USA; 10Obstetrics and Gynecology, DartmouthHitchcock Medical Center, Concord, New Hampshire USA Objectives—To determine the association of discordant abdominal circumference (AC), femoral length (FL), head circumference (HC), or estimated fetal weight (EFW) at time of early second-trimester ultrasound with adverse obstetric and neonatal outcomes. Methods—This was a multicenter retrospective cohort study in 9 perinatal centers in the United States from January 2006 to June 2011. All monochorionic diamniotic twin pregnancies with 2 live fetuses at early second-trimester (16–20 weeks) ultrasound and serial follow-up ultrasound until delivery were included. Pregnancies with known chromosomal abnormalities or major malformations were excluded. The composite obstetric outcome included intrauterine fetal demise (IUFD), twin-to-twin transfusion syndrome (TTTS), intrauterine fetal growth restriction (IUGR), and preterm birth ≤28 weeks. The composite neonatal outcome included Apgar score <7 at 5 minutes, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, early-onset sepsis, and neonatal demise. Receiver operating characteristic (ROC) curves of AC, FL, HC, and EFW discordance cutoffs were developed for the prediction of composite obstetric and neonatal outcomes. Results—A total of 180 twin pregnancies met inclusion criteria. Mean gestational age at delivery was 33 В± 3.4 weeks; 26.1% and 32% of pregnancies were found to have adverse composite obstetric and neonatal outcomes, respectively. Adverse obstetric outcomes included TTTS in 14 (7.7%), IUGR in 19 (10.5%), IUFD in 13 (7.2%), and preterm birth (≤28 weeks) in 14 (7.7%). Conclusions—In our population, AC and EFW discordances in monochorionic diamniotic twin pregnancies were fairly accurate in predicting an adverse composite obstetric outcome. Table 1. Early Second-Trimester Ultrasound Biometric Discordances for the Prediction of Adverse Composite Obstetric and Neonatal Outcomes AUC (95% CI) Composite Obstetric Composite Neonatal Outcome Outcome AC discordance 0.743 (0.66–0.81) 0.463 (0.34–0.58) HC discordance 0.651 (0.55–0.74) 0.556 (0.44–0.67) FL discordance 0.677 (0.58–0.76) 0.545 (0.42–0.66) EFW discordance 0.734 (0.65–0.81) 0.517 (0.40–0.63) AUC indicates area under the ROC curve; and CI, confidence interval. 1525459 Prenatal Visualization of the Pituitary Gland Using 2- and 3-Dimensional Ultrasound Imaging Eldad Katorza,1* Jean-Philippe Bault,2 Yinon Gilboa,1 Yoav Yinon,1 Reuven Achiron1 1Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel; 2Obstetrics and Gynecology, MaternitГ© Necker-Brune, Paris, France Objectives—The pituitary gland is critically important in the function of the endocrine axis. So far, antenatal demonstration of the pituitary gland was possible only by using magnetic resonance imaging. The objective of our study was to describe antenatal visualization of the pituitary gland using 2D and 3D ultrasound. Methods—Using a Voluson E8 ultrasound machine (GE Medical Systems, Zipf, Austria) equipped with a transabdominal multifrequency 4–8-MHz probe, during the third trimester of pregnancy, 2D images and 3D volume acquisitions were taken. Results—We identified the unique shape of the pituitary gland using 2D and 3D ultrasound imaging, on an axial plane of the skull, parallel to and slightly below the biparietal diameter plane, showing the circle of Willis. Four manipulated steps from the native volume were needed for 3D reconstruction of the gland using transabdominal ultrasound. The insertion of the stalk to the posterior part of the gland could be seen. The circle of Willis was found to be an excellent marker for the gland location. Conclusions—This is the first report to date indicating that prenatal visualization of the pituitary gland using ultrasound imaging is feasible. In cases with midline anomalies of the brain, face, or cranium, the demonstration of the pituitary gland, which is an essential endocrine gland, is recommended. S52 13proceedings_Layout 1 3/5/13 10:38 AM Page S53 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 MRI may not be indicated for diagnoses where it is unlikely to improve on the diagnostic accuracy of US alone. Notably, this study does consider potential cost, prognostic, and surgical-planning benefits of fetal MRI. Obstetric Ultrasound: Fetal Anomalies Moderators: Israel Meizner, MD, Heather Welch, MD 1525585 Late Diagnosis of Fetal Central Nervous System Anomalies Following a Normal Second-Trimester Anatomy Scan: Should a Third-Trimester Anatomy Scan Be Routinely Recommended? Eldad Katorza,1* Yoav Yinon,1 Chen Hoffmann,2 Shlomo Lipitz,1 Reuven Achiron,1 Boaz Weisz1 1Obstetrics and Gynecology, 2Radiology, Sheba Medical Center, Tel Hashomer, Israel Objectives—To determine the prevalence and nature of central nervous system (CNS) anomalies diagnosed during the third trimester following a normal anatomy scan at 21 to 24 weeks of gestation. Methods—This was a retrospective cohort study of all pregnant women referred to the fetal medicine unit at Sheba Medical Center due to fetal CNS anomalies detected at the late second and third trimesters following a normal anatomy scan at 21 to 24 weeks of gestation. All patients underwent a thorough workup, which consisted of a detailed anatomy scan, dedicated neurosonography, and amniocentesis as indicated. Fetal magnetic resonance imaging was performed in most patients to confirm the sonographic diagnosis. Maternal records and sonographic data of all patients with fetal CNS anomalies were reviewed. Results—During the study period, 47 patients were diagnosed with fetal CNS anomalies at a median gestational age of 31.1 weeks (range, 24–38 weeks) following a normal second-trimester anatomy scan. The 4 most common anomalies found included brain cysts (19%), mild ventriculomegaly (15%), absence or dysgenesis of the corpus callosum (10%), and intracerebral hemorrhage (10%). Other CNS anomalies detected in this group of patients included hydrocephalus, Dandy-Walker malformation, large cisterna magna, microcephalus with lissencephaly, craniosynestosis, periventricular pseudocysts, global brain ischemia, cerebellar hypoplasia, and a subependymal nodule. Conclusions—The fetal brain continues to evolve throughout gestation; therefore, some of the CNS anomalies can be diagnosed only during the late second and third trimesters of pregnancy. Consequently, a late anatomy scan at 30 to 32 weeks of gestation should be considered. 1531347 Fetal Magnetic Resonance Imaging as an Adjunct to Antenatal Ultrasound for Assessment of Fetal Anomalies Amber Samuel,* Sherelle Laifer-Narin, Christina Herrera, Lynn Simpson, Russell Miller Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA Objectives—Fetal magnetic resonance imaging (MRI) is used to enhance diagnosis of fetal anomalies without robust data to support benefit over ultrasound (US) alone. Our objective was to assess fetal MRI as an adjunct to conventional diagnostic US when compared to US alone in a cohort with known postnatal outcomes. Methods—In a retrospective review from 2003 to 2011 at a tertiary care center, potential cases were identified if MRI was performed following sonographic concern for a fetal anomaly. Inclusion required documented neonatal outcomes or postmortem assessments. Diagnostic accuracy of adjunct MRI was assessed with qualitative statistics. Results—Of 799 MRIs performed, 406 subjects possessed documented neonatal or pathologic outcomes. MRI agreed with US in 68% of cases. Overall, MRI confirmed the neonatal diagnosis in 56.4% of cases, improved the diagnosis in 12.8% of cases, detracted from the diagnosis in 5.9% of cases, and had no benefit in 24.9% of cases. Among individual anomalies, there were no cases of diaphragmatic hernia, omphalocele, vein of Galen malformation, or Dandy-Walker complex where MRI correctly changed the ultrasound diagnosis. Findings varied for all other diagnoses (Table 1). Conclusions—Fetal MRI generally agrees with US performed at a tertiary care center, which may limit its adjunct diagnostic benefit. Table 1 MRI MRI MRI Detracts MRI Confirms Improves From Has No Diagnosis, Diagnosis, Diagnosis, Benefit, n (%) n (%) n (%) n (%) n (%) 60 (15) 20 (33) 10 (17) 8 (13) 22 (37) 14 (4) 11 (79) 1 (7) 1 (7) 1 (7) 10 (3) 2 (20) 4 (40) 0 4 (40) 9 (2) 6 (67) 1 (11) 0 2 (22) Diagnosis Multiple anomalies Ventriculomegaly Meningomyelocele Bronchopulmonary sequestration Congenital cystic 24 (6) adenomatoid malformation Congenital diaphragmatic 69 (17) hernia Omphalocele 7 (2) Vein of Galen malformation 5 (1) Dandy-Walker complex 5 (1) 16 (67) 2 (8) 3 (13) 3 (13) 66 (96) 0 3 (4) 0 0 0 0 0 0 0 0 1 (20) 0 7 (100) 4 (80) 5(100) 1541099 Fetal Lymphatic Malformations: More Variable Than We Think? Beverly Coleman,1,2 Suzanne Iyoob,2 Edward Oliver,1,2* Teresa Victoria,2 Devon Looney,2 Steven Horii,1,2 Julie Moldenhauer,2 Lori Howell,2 N. Scott Adzick2 1Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA; 2Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA Objectives—To evaluate the ultrasound (US) characteristics of fetal lymphatic abnormalities referred to the Center for Fetal Diagnosis and Treatment at the Children’s Hospital of Philadelphia. The literature states that lymphangiomas can be reasonably differentiated from other masses by the predominance of cystic spaces with multiple septations and the lack of solid components. Methods—We performed a database search from September 1997 to August 2012 of all fetal imaging and medical records for cases where lymphatic malformations other than cystic hygroma were diagnosed or included in the differential. A detailed fetal anatomic survey was performed to determine mass location, volume, and US texture. Imaging findings were correlated with the final outcome. Results—The study population consisted of 73 patients, and 68 cases were correlated with fetal neurologic and/or body magnetic resonance imaging. The mean maternal age was 29 years, and the mean gestational age was 27 weeks 2 days. The location was classified as 46 head/neck/face, 9 axilla/upper extremity, 8 internal abdomen/pelvis, 5 chest/mediastinum, 3 superficial pelvis/back, and 2 lower extremity. The mean mass volume was 70 mL. The US texture was 40 (55%) multiseptate/cystic, 10 (14%) predominantly cystic with 1 or few septations, 11 (15%) purely cystic, and 12 (16%) mixed with cystic and solid components. Calcifications were reported in 4 cases of mixed masses. These anomalies are largely isolated and not associated with other structural defects. There were no findings of nonimmune hydrops. Conclusions—Fetal lymphatic malformations have a variable range of locations, sizes, and textures. In our series, 31% of masses were atypical, 4 with calcifications and confused as teratomas. A better understanding of the US features will result in improved diagnostic accuracy. This may allow for better parental counseling and overall pregnancy management. S53 13proceedings_Layout 1 3/5/13 10:39 AM Page S54 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1541459 Fetal Growth Restriction in Pregnancies Complicated by Isolated Cleft Lip or Palate Emily DeFranco,1,2* Jessica Smith,1 Paul DeFranco3 1 Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio USA; 2Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio USA; 3Neonatology, Springview Hospital, Lebanon, Kentucky USA Objectives—Children with isolated cleft lip and/or cleft palate havedelayedgrowthduringinfancyandchildhood.Theassociationbetween fetal growth delay and isolated orofacial clefts has not been definitively ascertained. Few prior studies have aimed to assess the association between cleftsandintrauterinegrowthrestriction(IUGR)butmayhavebeenlimited by unaccounted confounding factors and other methodologic constraints. Methods—In a population-based retrospective cohort study of 5 years (2001–2005) of US birth cohort–infant death data, we identified 913,707 birth records in which cleft lip and/or cleft palate was recorded on the birth certificate. A variable was created including any case of cleft lip, palate, or combination of both. There were minimal missing data on cleft lip/palate (n = 854 [0.6%]). Multivariate logistic regression assessed the association between IUGR and isolated cleft lip/palate after accounting for important coexisting risk factors. Results—There were 1086 cases of cleft lip/palate of 913,707 births reporting this anomaly. The frequency of cleft lip/palate was 0.12%, which is likely accurately reported given the previously reported frequency in the population of 1 in 700 (0.14%). Of the 1086 cases of cleft, 252 (23%) were associated with other congenital malformations, leaving 834 (77%) isolated cases of cleft lip/palate for analysis. The frequency of IUGR <10th percentile (Alexander) with isolated cleft was 24.8% vs 14% with no anomalies (P < .001; crude odds ratio [OR], 2.0 [1.7–2.3]), and the frequency of IUGR <5th percentile with isolated cleft was 14% vs 6.6% in pregnancies with no anomalies (P < .001; crude OR, 2.2 [1.8–2.7]). However, after adjustment for maternal age, race, marital status, tobacco, chronic hypertension, diabetes mellitus, and route of delivery, the relative risk (RR) of IUGR <10th percentile was not substantially increased (adjusted RR, 1.02; 95% confidence interval [CI], 1.01, 1.03), nor was it at <5th percentile (adjusted RR, 1.04; 95% CI, 1.03, 1.05). Conclusions—Pregnancies complicated by isolated cleft lip/palate have a 2-fold increase in the frequency of IUGR at <10th and <5th percentiles compared to pregnancies without anomalies; however, the risk does not remain significantly increased once adequate adjustment for confounding factors is considered. 1539040 Detection of Structural Anomalies in a Basic FirstTrimester Screening Program for Aneuploidy Bryann Bromley,1,2,3 Thomas Shipp,1,3 Jennifer Lyons,4 Reshama Navathe,5 Yvette Groszmann,1 Beryl Benacerraf1,2,3* 1 Obstetrics and Gynecology, Diagnostic Ultrasound Associates, Brookline, Massachusetts USA; 2Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA; 3 Obstetrics and Gynecology/Radiology, Brigham and Women’s Hospital, Boston, Massachusetts USA; 4Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA; 5Harvard Medical School, Boston, Massachusetts USA Objectives—To determine if a basic first-trimester screening program for aneuploidy is useful for the detection of anomalies between 11 and 14 weeks’ gestation. Methods—This is a retrospective medical record review of all patients referred to a private ultrasound facility for a nuchal translucency (NT) measurement between January 1, 2008, and June 30 2012. Transabdominal scans were performed to measure NT and crown-rump length (CRL). Nasal bone (NB) evaluation was performed if requested. Providers credentialed in NT/NB by the Nuchal Translucency Quality Review performed all scans. Patients were allotted 30 minutes for the scan, and trans- vaginal sonography (TV) was performed at the discretion of the sonologist. Patients were included in the study if the fetus was alive and had a CRL between 38 and 84 mm. Additional anatomic components evaluated if technically facile included the cranium, stomach, cord insertion, and extremities. Outcome was evaluated by review of the medical record and the results of a detailed anatomic survey done between 16 and 22 weeks. Fetal anomalies were categorized as lethal, major, and minor. The category of anomaly and gestational age at diagnosis (≤14 vs >14 weeks) were compared. Results—A total of 9698 NT scans were performed. The mean maternal age was 32.9 (SD, 4.4) years. Singletons made up 92.5% of the study group. The mean CRL was 59.6 (SD, 1.2) mm, and the mean NT was 1.6 (SD, 0.6) mm. An NT ≥3.0 mm was identified in 149 (1.5%), and TV evaluation was performed in 924 (9.5%). Anatomic surveys were performed on 9099 (93.8%) fetuses at 18 (SD, 1.2) weeks. Anomalies were detected in 49 (0.5%) fetuses at ≤14 weeks and in 131 fetuses (1.4%) at >14 weeks. Overall, 45 of 110 (41%) lethal or major anomalies were detected at the time of the NT scan. Two suspected minor abnormalities at the NT scan were not evident at the anatomic scan. Conclusions—A basic first-trimester risk assessment scan can pick up a significant portion of lethal and major anomalies. Table 1 Anomaly Lethal Major Minor Total ≤14 wk 12 33 4 49 >14 wk 6 59 66 131 Total 18 92 70 180 1508165 Maternal Serum О±-Fetoprotein Does Not Improve the Detection Rate for Neural Tube Defects in Patients Who Receive First- and Early Second-Trimester Ultrasound for a Fetal Anatomic Survey Ashley Roman,1,2,3* Simi Gupta,1 Nathan Fox,1,2,3 Daniel Saltzman,1,2,3 Chad Klauser,1,2,3 Andrei Rebarber1,2,3 1Obstetrics and Gynecology, New York University, New York, New York USA; 2Maternal-Fetal Medicine, Carnegie Imaging for Women, New York, New York USA; 3Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York USA Objectives—Maternal serum О±-fetoprotein (MSAFP) is used to identify patients at high risk for open neural tube defects (ONTDs). Many centers have started performing anatomic surveys during the first and early second trimesters in addition to the routine 18- to 20-week scan. This study evaluates whether MSAFP improves the detection rate for ONTDs in patients undergoing first- and early second-trimester anatomic surveys. Methods—A historical cohort of patients undergoing fetal ultrasound in a single ultrasound practice between May 2005 and August 2011 met criteria for inclusion. All patients were offered nuchal translucency ultrasound with evaluation of the fetal anatomy at 11 to 14 weeks and an early second-trimester fetal anatomic survey between 15 and 17 weeks. All cases of ONTDs diagnosed in our unit during this interval of time were identified using ICD-9 codes, and all MSAFP results over the same time frame were queried. Groups were compared using the Fisher exact test with P < .05 as significance. Results—Our unit performed 17,656 nuchal translucency ultrasound examinations and 21,436 early anatomic surveys and sent 11,809 specimens for MSAFP during the study period. Eleven ONTDs were diagnosed by our unit during this time frame (incidence of 0.56–0.67 per 1000). Eleven of 11 ONTDs (100%) were diagnosed by ultrasound; 0 of 11 (0%) were detected after MSAFP screening (P < .0001). The median gestational age at diagnosis was 12 weeks (range, 11–17 weeks). Seven of 11 cases (64%) were diagnosed during the first trimester; 4 of 11 (36%) S54 13proceedings_Layout 1 3/5/13 10:39 AM Page S55 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 were diagnosed at the early second-trimester anatomy scan. No cases of ONTD were diagnosed after 18 weeks’ gestation, and no cases of ONTD were missed by our unit (sensitivity, 100%). Conclusions—Ultrasound for a fetal anatomic survey during the first and early second trimesters detected 100% of ONTDs in our population, with the majority identified in the first trimester. MSAFP was not useful as a screening tool for ONTDs in the setting of this ultrasound screening protocol. Given the sensitivity of first- and early secondtrimester ultrasound in detecting ONTDs, physicians may choose not to offer MSAFP for this indication. 1541097 Novel Insights Into Early Embryonic Demise via 3Dimensional Surface-Rendered Imaging in 107 Cases David Hartge, Andreas Schroer, Jan Weichert* Division of Prenatal Medicine, University of Schleswig-Holstein, Luebeck, Schleswig-Holstein, Germany Objectives—Modern sonographic imaging techniques such as 3D volumetry will be evaluated for 107 cases of pregnant women with missed abortions in the first trimester. Special emphasis is put on the impact of additional information and improved visualization of embryonic and fetal anomalies due to application of newest imaging tools, eg, HD Live. Additionally, parental acceptance of a more realistic display of the embryo/fetus in missed abortion is analyzed. Methods—Between September 2009 and September 2012, 109 pregnancies with a missed abortion during the first trimester were included in this survey. Using a transvaginal approach, all studies were carried out with high-resolution 5–9- and 6–12-MHz probes. Postrendering processing of actual and stored volume sets included application of HD Live technology. 2D evaluation was also conducted during the same examination. Results—Two of 109 cases with a missed abortion were excluded from our study. In 1 case, the parents refused to participate in the survey. In another case, the 3D volume acquisition was not completed successfully. One hundred seven cases were included in the final evaluation. The mean gestational age was 70.4 days (range, 44–110 days). Mean crown-rump length (CRL) was 17.3 mm (2.9–49.9 mm). The difference between estimated gestational age and sonographic age at evaluation for missed abortion was 14.4 days (0–40 days). Sufficient sonographic evaluation was possible in 91 of 107 cases (85.0%). Additional information via 3D volume acquisition such as craniofacial deformities, clefts, neural tube defects, abdominal wall defects, and sirenomelia could be documented in 11 of 107 cases (10.3%), which were not detected by conventional 2D imaging. In 1 of 107 cases, the parents disapproved of the 3D visualization due to the more realistic presentation. Conclusions—3D ultrasound in cases of missed abortions can provide additional information regarding the presence of structural anomalies and may further give hints regarding the timing of embryonic/fetal demise in early pregnancy. Based on our data, sufficient informational value is regularly obtained in cases having a CRL >5 mm. In counseling parents, 3D ultrasound is a useful tool and is generally well accepted. 1536871 Prenatal Sonographic Predictors of Surgery-Treated Ureteropelvic Junction Obstruction: Which Is the Best Predictor? Hadar Mudrik-Zohar,1* Israel Meizner,1,2 Zvi Bar-Sever,1,3 David Ben-Meir,1,4 Miriam Davidovits1,5 1Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; 2Gynecologic Ultrasound Unit, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel; 3Nuclear Medicine Institute, 4Pediatric Urology Unit, 5Institute of Pediatric Nephrology, Schneider Children’s Medical Center, Petah Tikva, Israel Objectives—Prenatally detected hydronephrosis (HN) with no evidence of ureter dilatation or bladder anomalies might suggest ureteropelvic junction obstruction (UPJO), which requires postnatal pyeloplasty. Yet, in the majority of fetuses, the HN is transient and conservatively treated. Our study aimed to identify prenatal sonographic predictors of surgery-treated UPJO and their cutoff values. Methods—This case-control study compared the sonographic prenatal findings of HN-diagnosed fetuses that underwent pyeloplasty after birth and HN-diagnosed fetuses that needed conservative management only, all treated in Schneider Children’s Medical Center. We retrospectively evaluated 39 cases of patients who underwent pyeloplasty due to UPJO between 2001 and 2012 and 30 cases of patients that were diagnosed prenatally with HN and treated conservatively between 2005 and 2012. Prenatal sonographic data for both patient groups were taken from the Gynecologic Ultrasound unit at Rabin Medical Center. The main sonographic measures we tested were (1) anterior-posterior diameter (APD) of the affected kidney, (2) parenchymal thickness (PT), (3) calyces dilatation, and (4) renal length. A few patients had records of only some of the measures. Results—The prenatal APD dilatation of the surgery-treated UPJO group (mean, 22.9 mm; SD, 8.7 mm) was higher than the control group (mean, 14.3 mm; SD, 5.9 mm; P < .001). Furthermore, the PT in the surgery-treated UPJO group (mean, 5.9 mm; SD, 2.8 mm) was lower than the control group (mean, 8.1 mm; SD, 2.6 mm; P = .009). Logistic regression reveled that APD was the main parameter significantly associated with surgery-treated UPJO cases (receiver operating characteristic plot was 0.79). A possible threshold of 14 mm APD may be used as a cutoff value of the surgery-treated UPJO group with sensitivity of 77% and specificity of 69%. Conclusions—APD dilatation was the strongest predictor of surgery-treated UPJO. PT and renal length also significantly discriminate the two groups and correlate with APD, only with lower predictive power. Our findings expand the clinical knowledge in the field of prenatal consultation by highlighting a threshold of APD, which predicts the need for surgery in prenatally detected HN cases. 1540842 Prenatal Diagnosis and Neonatal Outcomes in Nonimmune Hydrops: A Comparison of 2 Decades at an Academic Center Padmalatha Gurram,1* Peter Benn,2 Naveed Hussain,3 Christine Crawford,1 Kisti Fuller,1 Ann Marie Prabulos,1 Winston Campbell1 1Obstetrics and Gynecology, 2Genetics and Developmental Biology, 3Pediatrics, University of Connecticut, Farmington, Connecticut USA Objectives—To evaluate the differences in the maternal characteristics, prenatal ultrasound (US) diagnosis and outcomes of nonimmune hydrops (NIH) delivered between 1990 and 2010. Methods—We performed a retrospective review of NIH cases diagnosed antenatally and delivered at our institution. The cases were divided into 2 groups: 1990 to 1999 and 2000 to 2010. Stillbirths and multiple gestations were excluded. Gestational age (GA) at diagnosis, prenatal US findings, GA at delivery, mode of delivery, birth weight (BW), postnatal diagnosis, length of neonatal intensive care unit (NICU) stay, survival >28 days, and mortality were compared. Results—In the 20-year period, there were 19 live-born cases of NIH (11 cases in the 1990 group vs 8 in the 2000 group). The mean GA at diagnosis was 2 weeks earlier in the 2000 group (Table 1). Ascites was the most common US feature in both groups, followed by pleural effusion. Amniocentesis was done in 50% of cases in the 2000 group vs 37.5% in 1990. The GA at delivery was similar in both groups, and BW was lower in the 1990 group (Table 1). In the 1990 group, 10 of 11 cases were delivered by cesarean delivery vs 8 of 8 in 2000. The etiologies were cardiac (27%), idiopathic (27%), genetic (18%), and infectious (9%) in 1990 vs idiopathic (50%), genetic (25%), and cardiac (12.5%) in 2000. The average length of the NICU stay for cases that were discharged home alive in the 1990 group (4 of 11) was 28.5 days and in the 2000 group (3 of 8) was 70 days. In the 2000 group, 3 of 8 cases were transferred to other facilities compared to 1 of 11 cases in the 1990 group S55 13proceedings_Layout 1 3/5/13 10:39 AM Page S56 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 for further care. There were 6 of 11 deaths in the 1990 group vs 2 of 8 deaths in 2000. Conclusions—The outcome of NIH cases improved in the later decade. The commonest etiology continues to be idiopathic. Table 1. Prenatal and Neonatal Characteristics Mean GA at diagnosis, wk Ascites on US, % GA at delivery, wk BW, g Idiopathic etiology, % Survival >28 d, % Mortality, % 1990–1999 (n = 11) 31 63 31 2018 27 46 54 2000–2010 (n = 8) 29 75 31 2560 50 75 25 1528272 Qualitative Performance of Fetal Magnetic Resonance Imaging Compared to Ultrasound in Cases of Multiple Fetal Anomalies Christina Herrera,* Amber Samuel, Sherelle Laifer-Narin, Lynn Simpson, Russell Miller Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA Objectives—Pregnancies complicated by multiple fetal anomalies are a common indication for fetal magnetic resonance imaging (MRI) as an adjunct to diagnostic ultrasound (US). This study investigated the diagnostic performance of fetal MRI when compared to US alone for the accurate characterization of fetuses with multiple anomalies. Methods—In a retrospective review from 2003 to 2011 at a single tertiary care center, potential cases were identified if MRI was performed following sonographic concern for multiple fetal anomalies. Inclusion required documented neonatal outcomes or postmortem assessments. Interstudy reliability between MRI and US was assessed by calculating Оє. Diagnostic accuracy of adjunct MRI compared to US alone was assessed using qualitative statistics. Results—A total of 121 MRIs were performed due to antenatal sonographic concern for multiple fetal anomalies, of which 60 cases possessed documented neonatal or pathologic outcomes. The Оє for MRI compared with US was 0.28. The correct diagnosis was secured in 47% of cases by US and 50% of cases by MRI (Table 1). Nearly all inaccurate sonographic diagnoses were due to additional postnatal findings (48%). While MRI was most commonly inaccurate due to additional postnatal findings (27%), discrepant postnatal findings (3%), discrepant and additional postnatal findings (13%), and false-positive imaging findings (5%) also contributed significantly to study inaccuracies. Conclusions—Agreement is poor between MRI and US for the characterization of fetuses with multiple anomalies. For either imaging modality, complete and accurate diagnosis of fetal anomalies occurs in approximately half of cases, with the majority of inaccuracies due to incomplete antenatal characterizations. Table 1 Accurate diagnosis Additional anomalies discovered postnatally Discrepant findings between imaging and postnatal assessment Discrepant and additional anomalies False-positive imaging findings Study inconclusive US, n (%) 28 (47) 29 (48) 2 (3) MRI, n (%) 30 (50) 16 (27) 2 (3) 0 1 (2) 0 8 (13) 3 (5) 1 (2) S56 13proceedings_Layout 1 3/5/13 10:39 AM Page S57 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSION TUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PM Hands-on How to Do the Biopsy Moderator: Dean Nakamoto, MD After attending this session, participants will be able to describe prebiopsy preparations, use and have hands-on experience with the techniques of doing biopsies of soft tissue masses, thyroid nodules, breast masses, the liver, and kidneys, and recognize and manage complications. SPECIAL INTEREST SESSIONS TUESDAY, APRIL 9, 2013, 1:30 PM–3:30 PM Before and After: Case Presentations, Surgical Findings, and Clinical Outcomes Moderator: James Shwayder, MD, JD Adnexal Masses James Shwayder Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi USA This portion of the session will present clinical cases addressing the options for diagnosing adnexal masses. Ultrasound findings comprising morphology, vascular studies, and 3D will be reviewed. The presentations will focus on clinical history and ultrasound findings correlated with surgical outcomes. recognition of normal outflow tracts in different orientations will increase the likelihood of identifying fetuses in which these connections are abnormal. Imaging the 3-vessel view can further help distinguish that the outflow tracts are normal. Vessel size, alignment, arrangement, number, direction of flow, and turbulent flow at the level of the 3-vessel view provide additional information about the normalcy of the outflow tracts. Given its high prevalence and significant infant morbidity and mortality, universal screening for congenital heart disease is warranted. Early detection allows for an assessment for associated chromosomal, syndromic, or extracardiac abnormalities as well as consideration of pregnancy options and planning for ongoing obstetric and neonatal care. A thorough evaluation of the outflow tracts can improve the overall prenatal diagnosis of major fetal heart malformations. Microbubbles and Drug/Gene Delivery Hands-on Scanning: Peripheral Nerves of the Upper Extremity Moderators: Christy Holland, PhD, and Kai Thomenius, PhD Moderator: Kenneth Lee, MD After attending this session, participants will have gained handson experience in scanning the peripheral nerves of the upper extremity. Live Fetal Cardiac Scanning by the Experts Moderator: Lami Yeo, MD Basics of Fetal Cardiac Screening: How to Confirm Normal Outflow Tracts Lynn Simpson Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA Although the majority of pregnant women undergo obstetric ultrasound, only a third to one-half of all major congenital heart defects are detected prior to birth. The 4-chamber view of the fetal heart can identify 40% to 50% of major cardiac anomalies. The prenatal detection of heart malformations can be increased to 60% to 80% when views of the right and left ventricular outflow tracts are also assessed. It is now recommended that in addition to the 4-chamber view, views of the outflow tracts be evaluated as part of the cardiac screening examination. This has the potential to increase the identification of conotruncal anomalies that frequently are associated with a normal-appearing 4-chamber view. The Improving Sonoporation Delivery and Gene Transfection by Controlling Ultrasound Excitation of Microbubbles Cheri Deng Biomedical Engineering, University of Michigan, Ann Arbor, Michigan USA Microbubble-facilitated disruption of the cell membrane, or sonoporation, has been exploited for nonviral intracellular delivery of therapeutic agents. However, ultrasound-mediated microbubble activities and their impact on cells are difficult to control and optimize due to the complex characteristics of ultrasound interaction with microbubbles. These often result in low delivery efficiency and variable delivery outcome. To develop sonoporation technique to achieve reproducible, robust delivery outcomes, we examined the detail characteristics of ultrasound interaction with microbubbles. The goal of our study is to improve ultrasoundmediated intracellular delivery and gene transfection by designing ultrasound exposure conditions based on the detailed dynamic processes of ultrasound interaction with microbubbles in the context of their impact to cells. We performed experiments using both free microbubbles and targeted microbubbles that were attached to a cell membrane via receptor-ligand binding. We identified 3 distinct regimes of ultrasound excitation of targeted microbubbles characterized by the rate of microbubble collapse and translational movement (displacement): stable cavitation with minimal displacement, coalescence and translation, and rapid collapse (inertial cavitation) with minimal displacement. We quantified and correlated the microbubble dynamics with the resulting membrane disruption, intracel- S57 13proceedings_Layout 1 3/5/13 10:39 AM Page S58 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 lular delivery, and cell viability. We found that rapid collapse of microbubbles with limited translational movement, typically generated by ultrasound excitations with high acoustic pressure and short duration, generated the highest delivery efficiency while maintaining high cell viability. Based on characterization of microbubble activities and membrane disruption, we implemented a 2-pulse ultrasound exposure scheme with ramped amplitude to improve gene transfection efficiency in mice (aortic) vascular smooth muscle cells for green fluorescence protein gene transfection. Our results show that rational design of ultrasound exposure parameters can be obtained from microbubble dynamics to improve delivery outcomes. Microbubbles and Gene/Drug Delivery: Future Therapeutic Applications of Contrast-Enhanced Ultrasound Imaging Steven Feinstein Cardiology/Medicine, Rush University Medical Center, Chicago, Illinois USA Today, the clinical applications of contrast-enhanced ultrasound imaging (CEUS) are solely based on diagnostic imaging. It is anticipated that the future applications of CEUS will provide a paradigm shift in the field of therapeutics. In fact, CUES as a therapy uses gas-filled microspheres as intravascular indicators and provides unprecedented microvascular access to tissues and organs. Hence, acoustic microspheres are ideal carrier vehicles for ultrasound-based, site-specific drug/gene delivery. The basis for devising newer therapeutic options is created by local in vivo microsphere disruption using externally applied acoustic energy. Based on data dating to at least to 1995, it appears that the application of therapeutic ultrasound delivery systems has a bright future. The advantages of using an acoustically medicated system derive from the value of using a nonviral, mediated system accompanied by low risk/benefit ratios. Leading scientists throughout the world have successfully demonstrated nonviral transduction in a variety of preclinical scenarios. The combined applications for diagnosis and therapy provide unique opportunities for clinicians and researchers to image, direct therapy, and monitor individuals during treatment. Targeted Thrombolysis With Ultrasound and Microbubbles Thomas Porter Section of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska USA Ultrasound-induced cavitation has been explored as a method of dissolving intravascular and microvascular thrombi in acute myocardial infarction (STEMI). Ongoing studies are being performed to determine the type of cavitation required for success and whether longer–pulse duration therapeutic impulses (which sustain the duration of cavitation) could restore both microvascular and epicardial flow with this technique. In 36 hyperlipidemic atherosclerotic pigs, thrombotic occlusions were induced in the mid left anterior descending artery. Pigs were then randomized to either (1) ВЅ dose of tissue plasminogen activator (TPA; 0.5 mg/kg) alone or the same dose of TPA and an intravenous microbubble infusion with either (2) guided high–mechanical index (MI) short-pulse (2.0 MI; 5microsecond) therapeutic ultrasound (TUS) impulses or (3) guided 1.0 MI long-pulse (20 microsecond) impulses. Passive cavitation detectors indicated that the high-MI impulses (both long and short pulse durations) induced inertial cavitation within the microvasculature. Epicardial recanalization rates at all time points following randomized treatments were highest in pigs treated with the long–pulse duration TUS impulses (83% vs 59% for short pulse and 49% for TPA alone; P < .05). Even without epicardial recanalization, however, early microvascular recovery (ST recovery) occurred with both short- and long-pulse TUS impulses (P < .005 compared to TPA alone), and wall thickening improved within the risk area only in pigs treated with ultrasound and microbubbles. These findings indicate that although short-pulse TUS impulses transiently improve microvascular flow, long-pulse TUS impulses are required to produce sustained epicardial and microvascular reflow in acute STEMI. New Horizons in Critical Care Ultrasound Moderator: Paul Mayo, MD New Horizons in Critical Care Ultrasound Michael Blaivas Northside Hospital Forsyth, Cumming, Georgia USA Point-of-care ultrasound has undergone tremendous growth in the last 5 years, and this has heralded multiple advancements in applications and techniques used on critically ill patients. In addition, new equipment available on the market has targeted ultrasound use in the emergency and critical care settings. Availability of multiple transducer types, highend imaging, and even transesophageal echocardiography has opened the door for previously unexplored levels of patient evaluation during the most critical presentations. One of the most exciting is the effect ultrasound has had on the evaluation, diagnosis, and management of the cardiac arrest and periarrest states. This presentation will focus on new applications in point-of-care ultrasound for the care and treatment of the cardiac arrest and periarrest patient. Current literature and applications including transesophageal echocardiography in point-of-care and intravascular volume determination for immediate clinical decision making in this critically ill patient population will be discussed. Perinatal Malformations of the Head, Face, and Neck Moderator: Eva Rubio, MD Perinatal Malformations of the Head, Face, and Neck: Head Beth Kline-Fath Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio USA Ultrasound is an integral part of prenatal care. With regard to the brain, sonographic imaging offers a rapid noninvasive window. Additional benefits of this technique are lack of radiation, portability, and low cost. The ability to use color and Doppler of intracranial vessels is also extremely valuable. Prenatal cranial ultrasound provides information regarding congenital anomalies, masses, and hydrocephalous. Destructive, vascular, hemorrhagic, infectious, and hypoxic ischemic pathologies are also demonstrated by this technique. In this lecture, the common prenatal abnormalities of the brain will be illustrated with ultrasound imaging. Correlation with fetal magnetic resonance imaging will also be provided to allow the sonographer to improve imaging technique and anatomy. The ability of prenatal sonography to promptly diagnose these central nervous system conditions is invaluable in directing fetal treatment and prenatal counseling. Perinatal Malformations of the Head, Face, and Neck Eva Rubio Children’s National Medical Center, Washington, DC USA This session will review common, rare, and urgent abnormalities of the head, face, and neck seen in the prenatal and early infant period. The timing of prenatal as well as postnatal imaging of these lesions, imaging parameters, and current recommendations will be discussed. What do the surgeons need to know, and what kind of team needs to be assembled for the most challenging cases? How should parents be counseled? This session will be both didactic and interactive. S58 13proceedings_Layout 1 3/5/13 10:39 AM Page S59 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Transplant Imaging Moderator: Susan Ackerman, MD Sonographic Evaluation of Liver Transplants Susan Ackerman Medical University of South Carolina, Charleston, South Carolina USA The purpose of this lecture is to discuss the use of ultrasound to evaluate liver transplants. In addition to normal or expected findings in the post-transplant patient, complications will also will be discussed. SPECIAL INTEREST SESSIONS TUESDAY, APRIL 9, 2013, 4:00 PM–5:30 PM Abdominal and Lower Extremity Arterial Imaging: Pitfalls and Misdiagnoses Hands-on Ultrasound-Guided Vascular Access Moderator: Jason Nomura, MD, RDMS Moderator: Jennifer McDowell, MM, RDMS, RT, RVT This session will review case studies in abdominal and lower extremity vascular imaging and demonstrate examples of technical pitfalls, artifacts, and misdiagnoses to learn how to prevent them. In this session, participants will be given a short didactic lecture on patient preparation, sterile technique, and basics of ultrasound-guided vascular access and fluid aspiration. This will be immediately followed by hands-on practice and interactions at various stations with expert faculty to learn and improve on techniques. S59 13proceedings_Layout 1 3/5/13 10:39 AM Page S60 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SCIENTIFIC SESSIONS TUESDAY, APRIL 9, 2013, 4:00 PM–5:30 PM Basic Science: Tissue Characterization, Part 2 Moderators: Michael Oleze, PhD, James Miller, PhD 1540933 Three-Dimensional In Vivo Prostate Shear Wave Elasticity Image Reconstruction Stephen Rosenzweig,1* Mark Palmeri,1 Samantha Lipman,1 Ned Rouze,2 Evan Kulbacki,2 John Madden,2 Thomas Polascik,2 Kathryn Nightingale1 1Biomedical Engineering, Duke University, Durham, North Carolina USA; 2Duke University Medical Center, Durham, North Carolina USA Objectives—Shear wave elasticity imaging (SWEI) and acoustic radiation force impulse (ARFI) imaging techniques have been reported to portray cancer and other pathologies as stiffer than the surrounding tissue.1,2 Previous work has shown artifacts in reconstructing SWEI images due to reflected waves.3,4 In this work, methods for reconstructing SWEI images designed to reduce these artifacts were validated in phantoms, applied to in vivo data, and compared to concurrently acquired ARFI data. Methods—Data were collected using a Siemens Acuson SC2000 and an ER7B transducer (Mountain View, CA) and a transducer rotation stage. The pulse sequence consisted of rapidly pushing at multiple foci (SSI-type push4) and tracking the resulting displacement using 16 parallel receive beams. The beam sequence was then translated laterally 0.7 mm and repeated across the field of view. The resulting SWEI data were spatially and temporally aligned to generate an image using high spatial sampling of the data. Separate left and right wave propagation images were generated along with combining the data via mean and maximum value approaches; these were compared to matched ARFI images in both calibrated CIRS (Norfolk, VA) phantoms and radical prostatectomy patients from an ongoing Institutional Review Board–approved study. Results—The contrast to noise ratios (CNRs) in the phantom data for the different combined SWEI methods were higher than those for the individual propagating waves. For example, a 10-mm cylindrical target with a 4:1 stiffness ratio had SWEI image CNR values of 1.65 (left), 1.47 (right), 2.59 (mean), and 3.74 (maximum). We will present data from all methods in various phantoms in addition to results from prostatectomy patients, after the whole-mount pathology is registered in 3D to the SWEI and ARFI volumes. Conclusions—The high spatial sampling of SWEI data obtained from concurrent acquisition with ARFI data affords opportunities for reducing SWEI image artifacts and improving the CNR. We are now applying the algorithms to data from an ongoing in vivo study to detect pathologies in the prostate. References 1. Zhai L, et al. Ultrasound Med Biol 2012; 38:50–61. 2. Barr RG, et al. Ultrasound Q 2012; 28:13–20. 3. Rouze N, et al. IEEE Trans Ultrason Ferroelectr Freq Control 2012; 59:1729–1740. 4. Deffieux T, et al. IEEE Trans Ultrason Ferroelectr Freq Control 2011; 58:2032–2035. 1511996 Hashimoto’s Thyroiditis Tissue Characterization and Pixel Classification Using Ultrasound Agnieszka Witkowska,1 U. Rajendra Acharya,2,3 Ratna Yantri,2 Filippo Molinari,4 Witold Zieleznik,5 Justyna Tumidajewicz,5 Beata Stepien,5 Ricardo Bardales,6 Jasjit Suri7, 8* 1 Internal Medicine, Diabetology, and Nephrology, Medical University of Silesia, Katowice, Poland; 2Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 3 Biomedical Engineering, University of Malaya, Kuala Lumpur, Malaysia; 4Electronics and Telecommunications, Politecnico Torino, Torino, Italy; 5Internal Medicine Practice, Silesia, Poland; 6Outpatient Pathology Associates, Sacramento, California USA; 7Global Biomedical Technologies, Roseville, California USA; 8Biomedical Engineering, Idaho State University, Pocatello, Idaho USA Objectives—Hashimoto’s thyroiditis (HT) is the most common type of inflammation of the thyroid gland, and accurate diagnosis of HT would be helpful to better manage the disease process and predict thyroid failure. This paper presents a computer-aided diagnostic (CAD) technique that uses grayscale features and classifiers to provide a more objective and reproducible classification of normal and HT-affected cases. Methods—Thyroid images were obtained from 68 normal and 82 patients affected by HT (a total of 150 patients). In this paradigm, we extracted grayscale features based on entropy, Gabor wavelet, moments, image texture, and higher-order spectra from the 100 normal and 100 HTaffected thyroid ultrasound images. Significant features were selected using the t test. The resulting feature vectors were used to build the following 3 classifiers using a 10-fold stratified cross-validation technique: support vector machine (SVM), K-nearest neighbor (KNN), and radial basis probabilistic neural network (RBPNN). Results—Our results show that a combination of 12 features coupled with the SVM classifier with the polynomial kernel of order 1 and linear kernel gives the highest accuracy of 80%, sensitivity of 76%, specificity of 84%, and positive predictive value (PPV) of 83.3% for the detection of HT. Conclusions—The proposed CAD system uses novel features that have not yet been explored for HT diagnosis. The technique is noninvasive, cost-effective, fast, and automatic and provides a more objective and reproducible classification of the thyroid in normal and HT-affected patients. Even though the accuracy is only 80%, the presented preliminary results are encouraging to warrant analysis of more such powerful features on larger databases. Table 1. Classifier Performance Measures Accuracy, PPV, Sensitivity, Specificity, TN FN TP FP % % % % 8 2 8 2 80 83.3 76 84 SVMlinear SVMpoly 1 8 2 8 2 80 83.3 76 84 8 3 7 2 78.5 82.3 74 83 SVMRBF KNN 7 2 8 3 75.5 75.6 77 74 RBPNN 8 4 6 2 74 80.3 64 84 FN indicates false-negative; FP, false-positive; RBF, radial basis function; TN, true-negative; and TP, true-positive. S60 13proceedings_Layout 1 3/5/13 10:39 AM Page S61 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1543325 Novel Quantitative Conventional-Frequency Detection of Cell Death In Vivo With Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer Gregory Czarnota,1* Ali Sadeghi-Naini,1 Omar Falou,1 Sara Iradji,1 William Tran,1 Michael Kolios2 1Radiation Oncology/ Physical Sciences, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; 2Physics, Ryerson University, Toronto, Ontario, Canada Objectives—We have previously demonstrated that highfrequency ultrasound and spectral analysis can detect cell death. Here we investigated whether quantitative conventional-frequency (7-MHz) ultrasound incorporating spectral analysis and textural parameters may be used for the same purpose in vivo in human patients receiving chemotherapy. Methods—A clinical study was undertaken investigating the efficacy of ultrasound to quantify cell death in tumor responses with cancer treatment. Patients (n = 60) with locally advanced breast cancer received anthracyline- and taxane-based chemotherapy treatments. Data collection consisted of acquiring tumor images and radiofrequency data prior to treatment onset and at 4 times during treatment (weeks 0, 1, 4, 8, and preoperatively). Digital low-frequency ultrasound data were collected and sampled with a 15-bit dynamic range using an Ultrasonix-RP device with a 7-MHz central frequency (3–10 MHz, –6-dB range). Whole-mount histology was obtained for all samples. Results—Data indicated that spectral ultrasound changes were significant at 4 weeks after the start of treatment. Increases of approximately 9 dBr (В±1.67) in ultrasound backscatter were observed in patients who responded to treatment. Patients assessed as responding poorly demonstrated significantly lower increases (2.3 В± 1.7 dBr). Increases in 0MHz intercept followed similar trends, while increases in spectral slope were observed from tumor regions demonstrating increases in tissue echogenicity. Textural analysis of parametric images indicated that features such as homogeneity and contrast could detect responses as early as 1 week after the start of treatment. Conclusions—This study demonstrates the potential of ultrasound to quantify changes in tumors in response to cancer treatment administration in a clinical setting. This approach may assist in the customization of cancer treatments facilitating switching from ineffective treatments to efficacious therapies. 1540914 Nonlinear Modeling of the Canine Liver With Increasing Hepatic Pressure Veronica Rotemberg,1* Brett Byram,1 Mark Palmeri,1,2 Michael Wang,1 Kathryn Nightingale1 1Biomedical Engineering, Duke University, Durham, North Carolina USA; 2 Anesthesiology, Duke Medical Center, Durham, North Carolina USA Objectives—Elevated hepatic venous pressure is associated with leading causes of death from advancing liver disease and is currently monitored using an invasive and expensive method. The mechanical behavior of the liver during pressurization is not well understood. In this work, liver strain during hepatic pressurization was characterized using successively acquired 3D B-mode volumes and was compared with concurrent shear wave speed (SWS) estimates. An experiment was designed to elucidate liver nonlinear material properties by using volumetric imaging in unconstrained ex vivo canine livers to estimate the change in liver strain with pressurization and compare this change in strain with simultaneous SWS estimates. The concurrent strain and SWS estimate information is actively being used to develop a nonlinear material model for hepatic behavior with increasing portal venous pressure. Methods—Hepatic pressure was increased stepwise from 0 to 20 mm Hg with 3D B-mode acquisition during each step at 3.2 volumes/s using a Siemens Acuson SC-2000 scanner and 4z1c matrix array transducer (Mountain View, CA). Displacements were calculated using 3D cross-correlation and a 2.88 Г— 0.60 Г— 0.68-mm tracking kernel.1 Strains were estimated in a 20 Г— 12 Г— 12-mm region of interest (ROI). Six acoustic radiation force impulse–based SWS estimates in the same ROI were generated at the end of each step. Results—Increases in SWS and axial strain as a function of hepatic pressure as well as the relationship between axial strain and SWS estimates were developed. During portal venous pressurization, 10% increases in axial strain corresponded to a 1.25-m/s increase in hepatic SWS estimates above baseline estimates at 0 to 5 mm Hg. Conclusions—Increases in axial strain and SWS estimates observed with increasing hepatic pressure support the development of a nonlinear mechanical material model for the pressurized liver. This material model may lead to noninvasive hepatic pressure characterization using stiffness metrics. References 1. Byram BC, et al. 3-D phantom and in vivo cardiac speckle tracking using a matrix array and raw echo data. IEEE Trans Ultrason Ferroelectr Freq Control 2010; 57:839–854. 1514461 UroImage: A Prostate Tissue Characterization/Classification System Using Grayscale Features Gyan Pareek,1 Rajendra Acharya,2,3 Swapna Goutham,4 Vinitha Sree,5 Ratna Yantri,2 Roshan Martis,2 Luca Saba,6 Ganapathy Krishnamurthi,7 Giorgio Mallarini,6 Ayman El-Baz,8 Shadi Al Ekish,1 Michael Beland,9 Jasjit Suri5,10* 1 Section of Minimally Invasive Urologic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island USA; 2Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; 3Biomedical Engineering, University of Malaya, Kuala Lumpur, Malaysia; 4Applied Electronics and Instrumentation, Government Engineering College, Kozhikode, Kerala, India; 5Global Biomedical Technologies, Roseville, California USA; 6Radiology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy; 7Mayo Clinic, Rochester, Minnesota USA; 8Bioengineering, Speed School of Engineering, University of Louisville, Louisville, Kentucky USA; 9Ultrasound, Rhode Island Hospital, Providence, Rhode Island USA; 10 Biomedical Engineering, Idaho State University, Pocatello, Idaho USA Objectives—Prostate transrectal ultrasound (TRUS) images can be easily acquired in real time at lower cost and hence are widely used for prostate cancer (CaP) diagnosis. However, the prostate regions in TRUS images are characterized by a weak texture, speckle, short grayscale ranges, and shadow regions. There is a need for image analysis frameworks that effectively quantify the subtle textural changes in cancerous and noncancerous TRUS prostate images to accurately detect CaP. In this work, we have proposed an online computer-aided diagnostic system called “UroImage” that classifies a TRUS image into cancerous or noncancerous with the help of nonlinear higher-order spectra (HOS) features and discrete wavelet transform (DWT) coefficients. Methods—The UroImage system consists of an online system where 5 significant features (1 DWT-based feature and 4 HOS-based features) are extracted from the test image. These online features are transformed by the classifier parameters obtained using the training data set to determine the class label of the test image. We trained and tested 6 classifiers. The data set used for evaluation had 144 TRUS images, which were split into training and testing sets, and cross-validation was adapted for training and estimating the accuracy of the classifiers. The ground truth used for training was obtained using the biopsy results. Results—Among the 6 classifiers, using 3- and 10-fold crossvalidation techniques, support vector machine and fuzzy Sugeno classifiers presented the best classification accuracy of 97.95% with equally high values for sensitivity, specificity, and positive predictive value. S61 13proceedings_Layout 1 3/5/13 10:39 AM Page S62 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Conclusions—Our proposed automated system uses a novel combination of DWT and HOS features to adequately characterize prostate TRUS images. On evaluation, the system presented high accuracy of 97.95% in detecting CaP. Thus, the preliminary results indicate that the UroImage system can be an adjunct tool to provide an initial diagnosis for the identification of patients with prostate cancer. 1540270 Quantitative Ultrasound as an Aid to Differentiate Benign From Malignant Breast Masses Haidy Nasief, Ivan Rosado-Mendez, James Zagzebski, Timothy Hall* Medical Physics, University of Wisconsin, Madison, Wisconsin USA Objectives—Ultrasound attenuation (Att), backscatter coefficients (BSC), effective scatterer diameter (ESD), and a scatterer size “heterogeneity index”(HI) give useful insight into the nature of a breast mass. The purpose of this study was to evaluate the potential of these quantitative features, both individually and in combination, to differentiate benign from malignant breast masses. Methods—Radiofrequency echo data from 26 patients scheduled for ultrasound-guided biopsy of suspicious breast masses were obtained, along with conventional grayscale and color flow images. Scans were done using a Siemens Acuson S2000 equipped with an 18L6 linear array transducer. Beam-steered acquisitions ranging between –20В° to 20В° were obtained in both radial and antiradial planes projecting through the mass. Att and BSC within masses were measured using the reference phantom method. ESDs were estimated using the BSC vs frequency data and a Gaussian form factor. HI was characterized using the SD among the ESD estimates (ignoring correlations among them). Isotropic features of the masses were studied by computing power law fits of Att vs frequency at each beam-steering angle. Combinations of quantitative ultrasound parameters were examined with a Bayesian classifier to estimate those with the strongest influence on characterization. Results—The mean Att in dB/cm-MHz was slightly higher for carcinomas (1.3 В± 0.7) than fibroadenomas (1.1 В± 0.5), the average value of the ESD was smaller for carcinomas (83.1 В± 9.8 Вµm) than for fibroadenomas (97.8 В± 13.1 Вµm), and carcinomas exhibited lower HI than fibroadenomas. Surprisingly, both tumor types exhibited a certain degree of anisotropic behavior. However, considerable overlap exists in backscatter and attenuation properties of benign and malignant masses. Using only pairs of parameters to classify the disease type performed relatively poorly, but the performance of a Bayesian classifier combining 3 parameters (Att, ESD, and HI) was cautiously encouraging (all classified correctly but on a very limited data set). Conclusions—Att, ESD, and HI show promise for characterizing breast masses. Very promising results are possible using combinations of these 3 parameters. 1536102 Stochastic Hidden Markov Model–Based Filtering Algorithm for Tracking Shear Waves Through Disparate Media in Electrode Vibration Elastography Atul Ingle,1* Tomy Varghese1,2 1Electrical and Computer Engineering, 2Medical Physics, University of Wisconsin, Madison, Wisconsin USA Objectives—Much research effort in quantitative ultrasound elastography has been directed toward methods for setting up shear waves in tissue and modeling wave propagation characteristics. However, data processing has been mostly limited to using off-the-shelf function-fitting algorithms. The present work proposes a specialized noise-filtering algorithm to improve boundary delineation while reducing the risk of excessive smoothing. Methods—A shear wave pulse traveling through dissimilar media is assumed to have constant velocity while in the same medium, whereas its velocity changes abruptly when it crosses an interface. Ultra- sound displacement estimates are used to get the time of arrival (TOA) of the wave pulse at different locations. The noiseless TOA plot is assumed to be piece-wise linear with unknown transition points. The noisy data are described using a hidden Markov model whose hidden states are the noiseless TOA values and observed states corrupted by Gaussian noise. A particle filter is then used to unravel the hidden states. An electrode vibration elastography phantom is used, which consists of 3 different media. A needle bound to an inclusion in the phantom and attached to an actuator is used to set up shear waves. Results—Visual boundary delineation is improved because this algorithm uses probabilistic prior information of wave pulse propagation. Mean shear wave velocity estimates are within 1 m/s of those obtained using a commercial shear wave imaging system. Conclusions—Model-based algorithms have a potential to significantly improve results in shear wave elastography quantitatively in terms of estimates of mechanical properties and qualitatively in terms of the visualization of stiffness images. (Supported by National Institutes of Health grants R01CA112192-05 and R01CA112192-S103.) Table 1 Shear Wave Velocity, m/s Young’s Modulus, kPa Mechanical ROI EVE SSI EVE SSI Testing Inclusion 3.8 В± 2.2 2.8 В± 1.1 57.2 В± 70 24.2 В± 5.8 54.4 В± 0.1 Partially ablated 2.0 В± 0.2 2.3 В± 0.8 11.9 В± 2.6 13.3 В± 3.5 21.5 В± 0.3 Background 1.3 В± 0.2 1.3 В± 0.4 5.0 В± 1.9 4.8 В± 0.5 3.7 В± 0.1 EVE indicates electrode vibration elastography; ROI, region of interest; and SSI, supersonic shear imaging. 1540426 Viscoelastic Strain Response Ultrasound Assessment of Serial Changes in the Viscoelastic Property and Composition of Human Dystrophic Muscle In Vivo Mallory Scola,1 Melissa Caughey,2 Diane Meyer,3 Regina Emmitt,3 James Howard,2,4 Manisha Chopra,4 Caterina Gallippi1* 1Joint Department of Biomedical Engineering, 2 Medicine, 3Physical and Occupational Therapy, 4Neurology, University of North Carolina, Chapel Hill, North Carolina USA Objectives—In Duchenne muscular dystrophy (DMD), where muscle tissue undergoes necrosis and is replaced by fat and collagen, delineating the complex and poorly understood disease process and monitoring responses to novel therapies may be facilitated by imaging muscle viscoelasticity. Viscoelastic strain response (ViSR) ultrasound is a method for quantitatively evaluating the relaxation time constant, П„, in the Voigt model. The objective of this work is to demonstrate ViSR’s clinical relevance to monitoring dystrophic muscle degeneration over time. We hypothesize that ViSR ultrasound detects changes in percent fat/necrosis composition in DMD muscles that correspond to altered physical performance. Methods—ViSR ultrasound was performed on a 5-year-old boy with DMD at baseline and at 4-month follow-up using a Siemens Acuson Antares imaging system equipped for modifiable beam sequencing and a VF7-3 transducer. The acquired ViSR data were processed to calculate П„, and parametric 2D ViSR П„ images were rendered. Fat/necrosis composition was calculated as the percent muscle area with ViSR П„ values above an empirically determined threshold. Within 1 hour following each imaging episode, the boy underwent standardized timed function tests. ViSR outcome was compared to physical performance. Results—See Table 1. Conclusions—ViSR ultrasound detected a 39% increase from baseline to 4-month follow-up in fat/necrosis composition in the rectus femoris (RF), a 5% decrease in the sartorius (SART), and a 7% increase in the gastrocnemius (GAST), which is consistent with expected phenotypic variation in these muscles for a 5-year-old boy. The ViSR change S62 13proceedings_Layout 1 3/5/13 10:39 AM Page S63 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 was associated with a 39% increase in time to standing, a 13% decrease in distance walked in 6 minutes, and a 23% increase in time to walk 30 ft. These data suggest the relevance of ViSR ultrasound as a noninvasive biomarker for monitoring dystrophic muscle degeneration. Table 1. Serial ViSR and Physical Testing Outcomes ViSR % Fat/Necrosis Time Point Baseline RF SART GAST 29.2 7.1 19.8 4-mo follow-up 40.6 6.7 21.1 Physical Testing Time to Standing 6-min (5Г—) Walk 7.91 s 1488 ft, 0 falls, 0 rests 10.96 s 1300 ft, 1 fall, 0 rests 30-ft Walk 4.19 s 5.17 s 1506729 Prostate Cancer Ultrasound–Magnetic Resonance Imaging Fusion Cybernetic Biopsies Robert Bard Biofoundation, New York, New York USA Objectives—To show that 3D ultrasound computer fusion with magnetic resonance imaging (MRI) improves image cybernetic-guided biopsies of the prostate. Methods—Eleven patients with elevated prostate-specific antigen and abnormal sonographic and MRI findings were scanned with a cybernetic ultrasound system that fused the image of the MRI onto the sonogram, creating a template for biopsy. Targeted biopsies were performed based on image guidance. Twelve cores were obtained on each patient. Results—Gleason grade 3 (low grade): 72 of 87 cores were positive for cancer. Gleason grade 4 (medium): 41 of 45 cores were positive for cancer Conclusions—Ultrasound-MRI computer image-guided fusion biopsies improved cancer detection to 92% for Gleason 4 tumors and 81% for Gleason 3 cancers. Education and Training Moderator: James Pennington, RDMS 1540985 Enhancing Ultrasound Education Through Volunteer Participation in Cardiac Screening Mason Shieh,* Suzanne Klaus, Carter English, Stacy Hata, Bassil Aish, Uthara Mohan, J. Christian Fox University of California, Irvine, Yorba Linda, California USA Objectives—To develop medical student sonography skills through volunteer involvement in cardiac screening on local athletes for hypertrophic cardiomyopathy (HCM). Methods—University of California, Irvine, medical students were recruited and trained to obtain cardiac ultrasound images to detect HCM in local high school athletes. HCM ultrasound training involved watching an instructional video and up to 2 hours of supervised hands-on ultrasound use. Students had unlimited access to an ultrasound machine for nonsupervised practice. Ten Orange County, California, high schools and junior colleges hosted the ultrasound cardiac screening team of 5 to 12 medical students and 1 to 3 supervising physicians as part of student athlete physical events. An average of 150 student athletes were scanned during each 4hour screening. For each athlete, a medical student obtained 2-second video clips of parasternal long and parasternal short cardiac views. From the parasternal short view, apical to the mitral valve, the muscular ventricular septum and the left ventricular wall were monitored in motion mode (M-mode) and were measured in systole and diastole on a still Mmode image. The recorded ultrasound videos and images were reviewed by a pediatric cardiologist after the screening. Medical students were asked to complete a brief survey about their participation. Results—Twenty-five medical student volunteers and 5 physicians obtained cardiac ultrasound data for more than 1500 young athletes in Orange County over a 4-month period. The incidence of findings is pending final review by the research team pediatric cardiologist, who determined 67% to 74% of student-performed cardiac scans adequate for HCM assessment. Students reported increased confidence in obtaining specific cardiac views quickly, using extensive features of the ultrasound machine, and teaching the screening process to other students. Conclusions—Student participation in public ultrasound screening provides a public service and enhances student skills and confidence. 1536499 State of Ultrasound Education: A National Survey of Medical Schools David Bahner,1* Nelson Royall,2,3 David Way,1 Claudia Ranninger,4 Ellen Goldman,5 Yiju Liu4 1Emergency Medicine, Ohio State University College of Medicine, Columbus, Ohio USA; 2Surgery, Orlando Health, Orlando, Florida USA; 3College of Medicine, University of Central Florida, Orlando, Florida USA; 4Emergency Medicine, George Washington University Medical Center, Washington, DC USA; 5Human and Organizational Learning, George Washington University, Washington, DC USA Objectives—Ultrasound education is rapidly becoming a component of the curricula at medical schools across the United States. The teaching of focused ultrasound at earlier levels of training seems to be a byproduct of increased use of ultrasound in patient care. Early efforts to introduce ultrasound training in the undergraduate medical education (UGME) curricula have ranged from short workshops to full vertical integration. The purpose of this study was to profile the current landscape of ultrasound education in US medical schools. Methods—We developed a 9-item survey provided to the 135 Liaison Committee on Medical Education–accredited US medical schools. Curriculum deans were asked to report how, when, and for what purpose ultrasonography was taught to students. Additional items asked for opinions about how and when ultrasonography should be taught and about barriers to its inclusion in the UGME curriculum. Results—We received 82 surveys for a response rate of 61%. While a majority (62%) of respondents reported that ultrasound is taught at their medical school, only 16% reported it as a priority. More schools teach ultrasound at the clinical (56.1%) rather than preclinical (47.6%) level of training. More than half (52.4%) teach ultrasound at more than 1 level. The primary purpose for ultrasound at the preclinical level was as a tool for teaching science (57.3%). The primary purpose for ultrasound at the clinical level was to teach scan interpretation (45.1%). Seventy-nine percent of the respondents believe that ultrasound training should be integrated into existing UGME curricula. Conclusions—Focused ultrasound education is becoming more prevalent in US medical schools. We found that most schools have integrated ultrasound education into their UGME curricula. Despite general acceptance of the benefits of focused ultrasonography, further efforts to define the scope and sequence of teaching ultrasound at the UGME level are necessary. S63 13proceedings_Layout 1 3/5/13 10:39 AM Page S64 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1443469 Role of Spatial Ability as a Possible Ability Determinant in Skill Acquisition for Sonographic Scanning Douglas Clem,1* Brad Curs,2 Joe Donaldson,2 Sharlette Anderson,1 Moses Hdeib1 1Cardiopulmomnary and Diagnostic Sciences, 2Educational Leadership and Policy Analysis, University of Missouri, Columbia, Missouri USA Objectives—Spatial ability refers to an individual’s capacity to visualize and mentally manipulate 3D objects. Since sonographers manually manipulate 2D and 3D sonographic images to generate renderings of anatomic structures, it can be assumed that spatial ability is an ability determinant for understanding and producing these medical images. Using Ackerman’s theory of ability determinants of skilled performance as a conceptual framework, this study explored the relationship of spatial ability and learning sonographic scanning. Methods—Beginning sonography students from 3 different types of educational institutions were administered a spatial abilities test prior to their initial scanning lab coursework. The students’ spatial test scores were compared with their scanning competency performance scores after the first scanning competency test and then to the overall average of the competency scores for the 2 semesters. The spatial ability test was again administered after the 2-semester learning period to see if the students’ spatial ability had increased. Additionally, the role of spatial ability and student retention was explored. Results—A significant relationship between the students’ spatial ability test scores and their scanning performance scores was found after the first scanning competency (r = 9.46; P <.05) and slightly increased when averaging all competency scores throughout the learning period (r = 0.49; P < .05). A moderate increase in the spatial ability of the students was also found. Incoming grade point average was found to be more predictive of the students’ scanning scores than spatial or ACT test scores. No relationship was found for spatial ability as being predictive of student retention. Conclusions—Spatial ability is an important ability determinant for student achievement in sonographic scanning and may be an appropriate additional component of admissions data to be used in selecting candidates for admission to sonographic programs across the country. It is also appropriate for identifying low–spatial ability students who may require extra time for practice and/or additional instruction and remediation for success. 1539296 Daily Ultrasound Image Review Provides No Benefit Over Weekly Review for Physicians Learning Point-of-Care Ultrasound Romolo Gaspari Emergency Medicine, University of Massachusetts, Worcester, Massachusetts USA Objectives—Point-of-care ultrasound programs perform routine image review for educational purposes. At some academic centers, this review is used to improve both image quality and accuracy of image interpretation through feedback to the physician sonographers. Due to staff limitations, most programs review their images weekly. We hypothesize that more frequent quality assurance would produce more accurate interpretation and image quality. Methods—We conducted a prospective study comparing 1 year of weekly image review and 1 year of daily image review. During both time periods, ultrasound images were reviewed in a standardized fashion with data entered into an electronic database at the point of image review. Image quality was assessed using an 8-point scale from 1 (poor image quality) to 8 (excellent image quality). Interpretation was assessed as agreement with an expert reviewer for the presence of a primary finding. Physicians performing image review had a minimum of 3 years of experience following emergency ultrasound fellowship. All information from the review was e-mailed to the physician sonographer within a few hours of the review. Comparison between groups was performed using the Student t test or П‡2 where appropriate. Results—Ninety-six physicians participated in the first phase of the study (weekly review) and 104 in the second phase (daily review). A total of 21,078 ultrasound examinations were performed during both study periods with 9830 performed during the first phase and 11,248 performed during the second phase of the study. When comparing weekly vs daily, there was a statistical improvement in imaging quality for cardiac (5.3 vs 5.5; P = .02), gallbladder (5.9 vs 6.2; P = .0002), lower extremity duplex (5.6 vs 6.0; P = .0001), and renal (6.2 vs 6.5; P = .0002). There was no difference in imaging quality for aorta, focused assessment with sonography for trauma, soft tissue, or endovaginal uterus. There was an improvement in interpretation when comparing soft tissue (8% vs 4%; P = .009) but no improvement in other ultrasound types. Conclusions—Implementation of a daily quality assurance review improved image quality and interpretation when compared to weekly review, but the differences were not clinically significant. 1538080 Implementation and Assessment of a Formal Curriculum for Bedside Ultrasound Training Elizabeth Turner,1* Angela Allen,2 J. Christian Fox,3 Mark Rosen,4 Craig Anderson3 1Pulmonary and Critical Care, University of California, Los Angeles, California USA; 2 University of California, Irvine, Irvine, California USA; 3 Pulmonary and Critical Care, 4Emergency Medicine, University of California, Irvine, Orange, California USA Objectives—Training programs for bedside ultrasound (US) are widespread, but few have been evaluated for efficacy. This study assessed a curriculum for teaching bedside US to physicians (MDs). We hypothesized that a formal training program would lead to greater confidence, knowledge, and skills as compared to apprentice-based learning and similar to expert training paths. Methods—A program that incorporated e-learning paired with hands-on training by experts was administered to “simulation-based learners” (SBLs), MDs with no formal training in bedside US. The SBLs also completed a survey of attitudes and confidence before and after training. Confidence, knowledge, and skills in bedside US were measured. The survey and test results of the SBLs were compared to the scores of “expert” (EX) subjects, trained emergency MDs, and “traditional learners” (TL), critical care MDs trained via an apprentice model. Both comparison groups took the e-learning test and the survey but did not participate in the study curriculum. Results—There was a significant difference in the self-reported level of prior training between groups (SBL, 2.8; TL, 3.7; EX, 4.1; scale of 1–5; P = .02*), but there was no difference in interest level or perceived importance of bedside US. The study curriculum was successful in training subjects as demonstrated by scores that exceeded the comparison groups in the cardiac and pulmonary courses (cardiac SBL, 79%; TL, 73%; EX, 62%; P = .001*; pulmonary 84%, 75%, 72%; P = .02*). The SBLs gained confidence in overall skills, while both comparison groups lost confidence after taking the test (P < .00005*); however, the SBLs gained confidence in areas of US not presented during the curriculum (abdomen, P = .0002*; miscellaneous, P = .005*). Conclusions—The SBL curriculum produces comparable or higher knowledge scores and confidence in each area of US vs comparison groups. However, there is a risk of overgeneralization of confidence that highlights the importance of quality assurance and supervision in bedside US training programs. This method requires only 14 weeks to achieve scores equal to or superior to other paths that span 2 to 3 years, and this has implications for widespread dissemination of such a program. S64 13proceedings_Layout 1 3/5/13 10:39 AM Page S65 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1428470 Ultrasound Knowledge and Image Interpretation Gains by Students on Emergency Medicine Rotation Uche Blackstock,* Jaclyn Munson, Nina Yeboah, Demian Szyld Emergency Medicine, Bellevue Hospital/New York University Medical Center, New York, New York USA Objectives—Bedside ultrasound (BUS) competency is considered integral to emergency medicine (EM) practice, and EM residencies require BUS training. However, medical students are rarely formally taught BUS. We sought to develop and evaluate a BUS curriculum for medical students on their EM rotation. Methods—We prospectively enrolled a convenience sample of 26 medical students (second year, 8 [30.8%]; third year, 11 [42.3%]; and fourth year, 7 [26.9%]) on their EM rotation. Students completed a 33– multiple-choice question Web-based pretest assessing knowledge of physics (Ph; 17 items [51.5%]) and image interpretation (Im; 16 items [49.5%]). On pretest completion, participants viewed video tutorials covering (1) Ph, 2) focused assessment with sonography for trauma, and (3) ultrasound-guided vascular access. Next, participants attended a 3-hour hands-on BUS session covering the tutorial topics. Subsequently, participants completed a Web-based posttest, containing identical questions as the pretest. To validate results, a sample of 15 EM residents took the same Web-based posttest (5 postgraduate year 1 [PGY-1, 33.3%]; 3 PGY-2 [20%], 5 PGY-3 [33.3%], and 2 PGY-4 [13.3%]) We performed a withingroup analysis of participants’ pretest and posttest performance and between-group analysis as compared to the EM residents. Results—The students’ pretest mean score was 21.6/33 (65.6%; SD, 11.1%) made up of a Ph mean score of 11.5/17 (67.9%; SD, 14.1%) and an Im mean score of 10.1/16 (63.2%; SD, 15.6%). The students’ posttest mean score was 28.4/33 (86.3%; SD, 9.35%), with a Ph mean score of 15.0/17 (88.0%; SD, 10.8%) and an Im mean score of 13.4/16 (84.1%; SD, 12.8%), corresponding to an overall effect size of d = 1.7 (95% confidence interval [CI], 1.1, 2.3), Ph effect size of d = 1.5 (95% CI, 0.9, 2.0), and Im effect size of d = 1.2 (95% CI, 0.7, 1.7). There were no statistically significant differences between students’ and residents’ posttest scores (P = .47) or in any subcategory (Ph, P = .13; Im, P = .93). Conclusions—A standardized formal curriculum in BUS significantly improved medical students’ Ph knowledge and ability to interpret ultrasound images. Medical students performed as well as a sample of EM residents. 1540627 Enhancing Third-Year Medical Student Primary Care Clerkships With Handheld Ultrasound Mary Elizabeth Poston,1 Duncan Howe,2* Victor Rao,2 Richard Hoppmann,2 Chung Yoon1 1Internal Medicine, 2 Ultrasound Institute, University of South Carolina School of Medicine, Columbia, South Carolina USA Objectives—Future physicians may be better prepared to provide safer, higher-quality patient care if point-of-care ultrasound (US) is included in the medical school curricula. We piloted a handheld US curriculum for third-year medical students. The primary objective was to determine students’ ability to learn to perform and interpret point-of-care US images of the heart and assess global heart function. Secondary objectives included determining patterns of use (number/types of scans performed, indications for scans, and impact on patient management) and assessing impact on student learning. Methods—Fifty-four third-year medical students each received handheld US for 22 weeks during the M3 year (8 weeks each for internal medicine and pediatrics, 6 weeks for family medicine). During the M1 and M2 years, these students had previously been taught cardiac and abdominal scanning techniques with laptop US on live patient models. During each clerkship, students received didactic lectures on the use of the device and were instructed to view Web-based modules on global heart function assessment. Additional Web-based modules on other US-appro- priate scans were also available. Students received hands-on instruction at least once per clerkship using standardized patients. Students were instructed to save at least 1 cardiac and 2 other images and to record the type, indication, and impact of scans. Results—Students submitted information on patterns of use and pathology evaluated for 305 cardiovascular (heart/inferior vena cava [IVC]), 131 abdominal, 97 nonobstetric genitourinary, 9 lung, and 6 obstetric scans. In an end-of-the-year objective structured clinical examination, M3 students demonstrated the ability to obtain images of the heart (parasternal long-axis view) as well as IVC and comment on global heart function and volume status. In end-of-year surveys, students stated that their ability to recognize, understand, and manage patient problems improved with US, but lack of US-trained faculty to supervise was a major limitation. Conclusions—M3 students with some prior experience can learn to assess global heart function with handheld US. Students felt that understanding of patient pathology and management was improved. Lack of trained faculty is a barrier to this curriculum. 1541489 Cloud Documentation and iPad Telesonography From a Teaching Hospital in the Andes: A Culturally Competent Model for Obstetric Ultrasound Education, Quality Assurance, and Practice Improvement in Remote Ecuador John Rodney,1* Erin Dooley,2 John Simmons,1 Matthew Horning,3 Kelly Arnold,4 William Rodney2 1Family Medicine, Texas A&M Health Science Center, Bryan, Texas USA; 2 Surgical Family Medicine, Obstetrics, Medicos Para la Familia, Memphis, Tennessee USA; 3Family Medicine, St Luke’s Hospital, Ashland, Wisconsin USA; 4Family Medicine, University of Tennessee, Chattanooga, Tennessee USA Objectives—To create and implement a Spanish language– based obstetric ultrasound curriculum and record-keeping system by creating a cloud-enhanced iPad application as well as a textbook and lecture series translated into Spanish. Methods—Using AIUM guidelines for obstetric and gynecologic ultrasound, we developed a cloud-based iPad application to address the educational and data storage needs of a geographically isolated teaching hospital in the mountains of remote Ecuador. After a brief ultrasound seminar that included Spanish language–based lectures, texts, and demonstrations, the investigators used the iPad application to remotely monitor the performance and documentation of obstetric ultrasound examinations by family medicine trainees and physicians over a 6-week period. Results—We successfully addressed the educational and information management needs of family medicine trainees and physicians in an isolated Spanish-speaking teaching hospital in remote Ecuador. Conclusions—Cloud-enhanced tablet technology is a feasible means of overcoming geographic and cultural barriers for the purposes of ultrasound education, quality assurance, and practice improvement for family medicine trainees and physicians practicing in remote, resourcelimited locations. General and Abdominal Ultrasound Moderator: Abid Irshad, MD 1536712 European Federation of Societies for Ultrasound in Medicine and Biology Guidelines on the Clinical Use of Elastography David Cosgrove,1* Christoph Dietrich,2 Fabio Piscaglia3 1 Imaging Sciences, Imperial College, London, England; 2Gastroenterology, S. Orsola-Malpighi, Bologna, Italy; 3Medicine, Caritas Krankenhaus, Bad Mergentheim, Germany Objectives—Elastography has emerged as a clinically useful addition to conventional ultrasound in many diagnostic applications. How- S65 13proceedings_Layout 1 3/5/13 10:39 AM Page S66 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 ever, there is a need to improve standards of practice and interpretation as well as to standardize terminology. Methods—A steering committee commissioned experienced European users to submit sections of guidelines along the lines of those previously published for contrast-enhanced ultrasound.1,2 An introductory section on the basic principles was followed by sections covering parts of the body in which elastography is widely used, including the liver, the breast, endoscopic uses, the bowel, the prostate, the thyroid, and the musculoskeletal system. Results—The basic principles section aims to improve understanding of clinical elastography by synthesizing the underlying principles of the 2 most commonly used forms: strain and shear wave elastography. Each clinical section contains a survey of the literature, especially where there are meta-analyses, and practical advice on the performance and interpretation of elasticity examinations. The edited document is to be submitted to the European Journal of Ultrasound (Ultraschall in der Medizin) with a target date of January 2013. Conclusions—It is hoped that the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines on elastography will be as useful as the contrast-enhanced ultrasound guidelines in improving understanding and clinical practice. The contributions of the EFSUMB Elastography Guidelines Team are gratefully acknowledged. References 1. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinical practice recommendations for contrast-enhanced ultrasound (CEUS): update 2008. Ultraschall Med 2008; 29:28–44. 2. Piscaglia F, Nolsoe C, Dietrich CF, et al. The EFSUMB guidelines and recommendations on the clinical practice of contrast-enhanced ultrasound (CEUS): update 2011 on nonhepatic applications. Ultraschall Med 2012; 33:33–59. 1540689 Implementation of Bedside Ultrasonography Within an Internal Medicine Faculty and Residency: The IMBUS Program David Tierney,* Terry Rosborough Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota USA Objectives—Describe in detail and provide a rationale for a curriculum, structure, and successful implementation of an internal medicine bedside ultrasound (IMBUS) program in a residency program and its faculty. Methods—Design: Prospective cohort study in an internal medicine (IM) residency program at a private academic 700-bed tertiary care center. Participants: 33 residents and 13 full-time faculty members without significant prior ultrasound experience. Intervention: (1) Development of an IM ultrasound curriculum to maximize sensitivity/specificity of our routine physical exam as well as critical time sensitive diagnoses; (2) overlap training method using top-down and bottom-up methodologies; (3) 35-hour “boot camp” including didactic, hands-on model-based, and simulator-based training; (4) bedside hands-on training with faculty mentors until the trainee meets a prespecified exam count in each component and is deemed competent in that exam area; (5) ongoing mentored and remotely submitted/reviewed images until adequate technical and interpretive sensitivity/specificity are obtained; (6) final test-out using bedside and simulator-based summative evaluation prior to certification; and (7) a robust ongoing quality assurance system. Measurements: Comparative effectiveness of multiple implementation strategies; time to, variation in, and predictive factors of competence in each exam component; clinical impact of chosen components on patient outcomes; and effect of implementation on resident/faculty work flow, efficiency, and job satisfaction. Results—We describe in detail and rigorously critique a full ultrasound curriculum and implementation strategy for an IM residency. Thirty IM residents and 12 faculty members were trained using the IMBUS program. Learning curves for each ultrasound exam component have been established. We are analyzing multiple outcomes, including competency learning curves, skill decay, patient outcomes and experience, and physician impact of bedside ultrasound. Conclusions—We hope that by describing in detail our curriculum, methods, and learning, we can help other residency programs implement bedside ultrasound in an efficient, focused, evidence-based, politically aware, and impactful manner. 1506540 Prostate Cancer Responses to Testosterone and Growth Hormone Robert Bard Biofoundation, New York, New York USA Objectives—Hypogonadal patients with low-grade prostate cancer are now treated with testosterone +/– growth hormone. It has been established that high vascular density indicates a high-grade tumor. Our study was to observe Doppler sonographic vessel density imaging in known cancer sites to predict aggressive changes and arrest testosterone and or growth hormone supplementation. Methods—Sixty-three patients treated with testosterone having low-grade (Gleason 6) disease were followed over a 3-year period. The vessel index was assessed on sonography by 3D histogram analysis and by dynamic contrast-enhanced magnetic resonance imaging (DCEMRI). Follow-up biopsies were obtained shortly after imaging studies, which occurred at 6-month intervals for 3 years on patients with prostatespecific antigen (PSA) rises. Nineteen of 63 patients were concomitantly taking growth hormone formulations. Results—Forty-one of 63 testosterone patients had no increase in PSA or neovascularity at 6, 12, 24, and 36 months. Three of 63 patients had increased PSA and vessel density at 6 months. Biopsy confirmed Gleason 4+3 disease in 1 patient and Gleason 3+4 in 2 others. Testosterone was discontinued. One of 19 patients taking testosterone and growth hormone showed increased PSA at 6 months. Biopsy showed Gleason 3+4. Testosterone and growth hormone were discontinued. None of the studied group developed increased vessel densities after the initial 6-month period. Conclusions—Vessel density sonographic indexing and DCEMRI analysis correlated well with the biochemical response to testosterone/growth hormone therapies. There was high correlation with histologic findings. Vascular density increases may signal the need to discontinue hormone replacement therapies. Vascular density stability in the face of rising PSA most likely indicates progression of benign hyperplasia with increased prostate glandular volume. 1540891 Liver Sonography Is Predictive of Liver Steatosis; However, the Severity of Fatty Liver on Sonography Does Not Correlate With the Presence of Steatohepatitis Roberta diFlorio,* Robert Harris, David Kim, Eric Goodman, Alex Spinosa, Megan Murphy Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire USA Objectives—The spectrum of nonalcoholic fatty live disease (NAFLD) ranges from bland steatosis to cell injury and inflammation (steatohepatitis or nonalcoholic steatohepatitis [NASH]) to fibrosis/cirrhosis. End-stage disease is associated with increased risk of hepatocellular carcinoma (HCC). Patients with NASH are far more likely to progress to fibrosis than patients with simple steatosis. Currently, liver biopsy is considered the gold standard for diagnosis of NAFLD and for differentiating steatosis from NASH. However, there is significant variability in liver biopsy due to the error of a small sample size of a heterogeneous process. A noninvasive marker of NAFLD would allow detection of global disease status and allow stratification of risk for the development of fibrosis. This would permit early drug therapy and allow for surveillance of cirrhosis complications and HCC. Ultrasound findings that would differentiate simple steatosis from NASH would be helpful in diagnosing and monitoring the disease status of NAFLD. S66 13proceedings_Layout 1 3/5/13 10:39 AM Page S67 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Methods—We retrospectively reviewed the results of all abdominal ultrasound examinations in patients who also had liver biopsies from 2006 to 2010 to determine the positive predictive value of ultrasound for the detection of NAFLD in our department. We scored the severity of fatty liver on ultrasound from 0 to 3: 0, normal liver echo texture; 1, increased liver echogenicity relative to kidney; 2, increased liver echogenicity that obscures echogenic periportal fat; and 3, increased liver echogenicity that obscures visualization of deep liver parenchyma. We compared the ultrasound score to histology. Results—A total of 170 patients were included in the study. The sensitivity of ultrasound for detection of NAFLD in this patient population was 91% (86%–95%), specificity 75% (35%–97%), and positive predictive value 99% (95%–100%). There was, however, no correlation between the sonographic severity of NAFLD and the presence of NASH or fibrosis. Conclusions—Ultrasound has a high predictive value for the diagnosis of NAFLD in patients who undergo liver biopsy. However, the severity of fatty liver based on the sonographic appearance does not correlate with the histologic severity of fatty liver disease and does not differentiate between bland steatosis and NASH. 1537502 Shear Wave Velocity Discrimination of Inflamed Fibrotic Bowel Segments in a Crohn’s Disease Animal Model Jonathan Dillman, Ryan Stidham, Peter Higgins, David Moons, Laura Johnson, Jonathan Rubin* University of Michigan, Ann Arbor, Michigan USA Objectives—To determine if acoustic radiation force impulse (ARFI) elastography-derived bowel wall shear wave velocity (SWV) can distinguish inflamed from fibrotic intestine in a Crohn’s disease animal model. Methods—An acute inflammation Crohn’s disease model was produced by treating Lewis rats with a single trinitrobenzenesulfonic acid (TNBS) enema, with imaging performed 2 days later (n = 8). Colonic fibrosis in Lewis rats was achieved by administering repeated TNBS enemas over 4 weeks, with imaging performed 7 days later to allow resolution of acute inflammation (n = 8). Nine transcutaneous bowel wall SWV measurements (Virtual Touch IQ/Acuson S3000 ultrasound system; Siemens Medical Solutions USA) were obtained from the rectosigmoid colon region in all rats without and with applied strain. Mean bowel wall SWVs without and with applied strain were compared between animal cohorts. Receiver operating characteristic curves were created to assess diagnostic performance. Three rats were excluded from analysis due to demise. Results—Mean bowel wall SWVs were significantly higher for fibrotic vs acute inflammation cohort rats at 0% (3.42 В± 1.12 vs 2.30 В± 0.51 m/s; P = .047) and 30% (6.27 В± 2.20 vs 3.61 В± 0.87 m/s; P = .021) applied strain. Both acute inflammation and fibrotic cohort rats demonstrated linear increases in mean SWVs with increasing applied strain, with no overlap in the 95% confidence intervals. The mean slopes (0.054 В± 0.029 vs 0.114 В± 0.044; P = .016) and y-intercepts (2.07 В± 0.32 vs 3.33 В± 1.14; P = .023) were significantly different. The c-statistic of SWV for differentiating fibrotic from inflamed bowel was 0.764. Conclusions—Bowel wall SWV distinguishes fibrotic from inflamed intestine in a Crohn’s disease animal model. This finding could have a major impact in the diagnosis and treatment of strictures in Crohn’s disease where fibrotic strictures can only be treated surgically, while inflammatory strictures are treated medically. In addition, the linearity of the slopes in the shear wave vs applied strain model would remove preloading effects up to at least 30% applied strains, which could remove variations due to different operator preloads. 1540986 Volumetric Blood Flow Assessment in Transjugular Intrahepatic Portosystemic Shunt Revision Using 3-Dimensional Ultrasound Stephen Pinter,1* Jonathan Rubin,1 Oliver Kripfgans,1 Paula Novelli,1 Mario Vargas-Vila,2 Anne Hall,3 J. Brian Fowlkes1 1 Radiology, 2Medical School, University of Michigan, Ann Arbor, Michigan USA; 3GE Healthcare, Wauwatosa, Wisconsin USA Objectives—Transjugular intrahepatic portosystemic shunts (TIPS) are prone to thrombosis and stenosis over time and must be monitored to identify cases requiring flow restoration. The purpose of this study was to evaluate shunt patency using 3D ultrasound volumetric blood flow in patients undergoing shunt revision. Shunt volume flow is intended to provide a more sensitive and robust alternative to standard pulsed wave Doppler shunt velocity or invasive portosystemic pressure gradient measurements. Methods—Ten patients were recruited. A GE LOGIQ 9 ultrasound system (4D3CL, 2.0–5.0 MHz) was used to acquire multivolume respiratory-gated 3D color Doppler data sets for each patient to assess shunt volume flow before and after the revision procedure. Volume flow was computed offline by surface integration of Doppler-measured velocity vectors in a c-surface (lateral-elevational plane) positioned at the color flow focal depth, which ranged from 8.0 to 11.5 cm. Doppler power yielded pixel-by-pixel correction factors for partial volume integration. Volume flow was compared to routine measurements of pre and post pressure gradient across the shunt measured by catheterization. Results—Seven of the 10 patients recruited had their TIPS revised. Of these 7, the data from 2 were discarded because 1 had a deep shunt (14–15 cm due to ascites) and therefore insufficient signal power, while the other had a completely thrombosed shunt. Results from the remaining 5 patients show prerevision flows of 500 to 1200 mL/min and postrevision flows of 1300 to 2550 mL/min. A corresponding decrease in the prerevision and postrevision portosystemic pressure gradient was observed in each case. An important result was observed for patient 9, whose prerevision flow was 1910 mL/min, which suggests a revision may be unnecessary. Following shunt revision, the pressure gradient for patient 9 was unchanged, and postrevision flow was 1938 mL/min, effectively unchanged compared to prerevision flow. Conclusions—Results demonstrate that shunt volume flow has a negative correlation with the prerevision and postrevision portosystemic pressure gradient, illustrating that volume flow may be an effective indicator of shunt performance. 1541365 Implementation of a Competency-Based Online Curriculum to Train Medical Students and Primary Care Residents and Physicians in Point-of-Care Ultrasound Nicholas Cohen,1* Justin Lappen,1,2 Honor Wolfe,1 Kimberly Gecsi,2 Ashish Bhimani3 1Family Medicine and Community Health, 2Obstetrics and Gynecology, 3Cardiology, University Hospitals Case Medical Center, Cleveland, Ohio USA Objectives—The objective of our study was to design and integrate into the medical school curriculum at Case Western Reserve University School of Medicine and the family medicine residency curriculum at University Hospitals Case Medical Center a competency-based online curriculum to train medical students and residents in point-of-care ultrasound. Methods—We assembled a multidisciplinary team of physicians in obstetrics and gynecology, cardiology, and the Department of Family Medicine at our institution to design the curriculum. The modules consist of an introduction to ultrasound and modules focused on specific application of point-of-care ultrasound for obstetrics, cardiology, abdominal, vascular, and procedure guidance. Each module includes a didactic component featuring a Web-delivered screen capture PowerPoint video by an expert in the field, a demonstration of technique using a model and actual ultrasound, an online pretest and posttest to ensure competency, and a downloadable checklist for a hands-on evaluation by a credentialed sonographer. S67 13proceedings_Layout 1 3/5/13 10:39 AM Page S68 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Results—This curriculum has been adopted by the medical school as well as the residency program and is in its second year of implementation. One hundred fifty learners have participated in the curriculum. Eighty-five percent of learners rate the curriculum good or excellent. We demonstrate a 35% increase in knowledge from pretest to posttest. Ninety-eight percent of learners who achieve a score of ≥90% on the posttest are able to pass the hands-on skills test. Conclusions—We have demonstrated that our curriculum can be implemented in a medical school and primary care residency program, provides competency-based assessment, and results in knowledge and practical skills proficiency for learners with no prior training in ultrasound. This curriculum is available online and has the potential for adoption at medical schools and residency programs across the country. 1541515 Quantification of Renal Perfusion With Dynamic Power Doppler Ultrasonography in Allograft Kidneys Shuo-Meng Wang,1* Jeou-Jong Shyu,3 Nai-Kung Chou,2 Hao-Chih Tai,2 Sun-Hua Pao,4 Yio-Wha Shau4 1Urology, 2 Surgery, National Taiwan University Hospital, Taipei, Taiwan; 3 Veterinary Medicine, National Taiwan University, Taipei, Taiwan; 4 Industrial Technology Research Institute, Hsinchu, Taiwan Objectives—Kidney transplantation is the most effective method to save a patient’s life after renal failure. How to keep an allograft kidney in good condition is very important in clinics. The serum creatinine (Cre) assay is the most popular method used to diagnose renal function because of a single functioning kidney in the body. Dynamic power Doppler (PD) ultrasonography can examine the hemodynamic change of renal perfusion directly. To understand the application of the power Doppler vascular index (PDVI) for the diagnosis of renal function and the correlation with the serum Cre assay, allograft patients were used for study. Methods—Three groups of patients according to the result of Cre concentration (<1.0 vs <1.5 vs >1.5 mg/dL) were selected for PD ultrasonography. An HDI-5000 ultrasound system was applied, and serial renal vascular images were collected in the DICOM format. Lab-designed image-processing software was used for analysis. The PDVI was defined as the percentage of color pixels within a region of interest (ROI) among interlobular vessels of the cortex. Several PDVI indices, including (1) PDVImax/PDVImin during cardiac cycles, (2) mean of weighted PDVI (WPDVImean), (3) total vascular area (T) in the ROI, (4) small terminal pulsation area (S), and (5) S/T ratio, were applied for analysis. Results—The data for the PD indices in first group were: PDVImax/PDVImin, 1.19; WPDVImean, 21.81; T, 0.71 cm2; S/T ratio, 16.90%; resistive index (RI), 0.60 (0.55–0.65); and Cre, 1.07 (0.8–1.4) (n = 10). The data in the second group were: PDVImax/PDVImin, 1.75; WPDVImean, 14.23; T, 0.518 cm2; S/T ratio, 33.73%; RI, 0.66 (0.62–0.70); and Cre, 1.39 (1.2– 1.5) (n = 10). The data in the third group were: PDVImax/PDVImin, 3.81; WPDVImean, 10.81; T, 0.37 cm2; S/T ratio, 47.38%; RI, 0.78 (0.72–0.88); and Cre, 2.92 (1.9–5.3) (n = 20). Conclusions—The difference between each group and correlation with the Cre assay were significant. These novel PD indices used to evaluate the hemodynamic changes of renal perfusion in allograft kidneys have the potential to be applied in renal clinics in the near future. 1538512 Renal Perfusion Change of Dehydation Examined With Dynamic Power Doppler Ultrasonography in a Canine Model Jeou-Jong Shyu,1* Shuo-Meng Wang,2 Jiann-Gwu Lee,1 NaiKung Chou,3 Hao-Chih Tai,3 Sun-Hua Pao,4 Yio-Wha Shau4 1 Veterinary Medicine, National Taiwan University, Taipei, Taiwan; 2Urology, 3Surgery, National Taiwan University Hospital, Taipei, Taiwan; 4Industrial Technology Research Institute, Hsinchu, Taiwan How to make a precise diagnosis for effective treatment is very important to protect the allograft kidney. The renal perfusion is directly related to renal function. To identify the correlation between dehydration and renal perfusion, dynamic power Doppler (PD) ultrasonography was used to examine the hemodynamic change of renal perfusion in a canine model with a dehydration condition. Methods—Two groups of dogs aged 4 to 5 years (n = 4) and 10 to 12 years (n = 4) were used for study. The supplement of water was inhibited for 2 days to examine the renal perfusion change after dehydration. An HDI-5000 ultrasound system was applied, and serial renal vascular images were collected in the DICOM format. Lab-designed image-processing software was used for analysis. The power Doppler vascular index (PDVI) was defined as the percentage of color pixels within a region of interest (ROI) among interlobular vessels of the cortex. Several PDVI indices, including (1) PDVImax/PDVImin during cardiac cycles, (2) mean of weighted PDVI (WPDVImean), (3) total vascular area (T) in the ROI, (4) small terminal pulsation area (S), and (5) S/T ratio, were applied for analysis. The resistive index (RI) was also collected for comparison. Results—The data for the PD indices before water inhibition were: PDVImax/PDVImin, 1.215; WPDVImean, 17.25; T, 0.459 cm2; S/T ratio, 17.86%; and RI, 0.524 in the young group, and the data were 1.41, 16.03, 0.533 cm2, 25.98%, and 0.539, respectively, in the old group. After 1 day of water inhibition, renal perfusion changes were observed in 2 young dogs (1.533, 15.51, 0.438 cm2, 30.96%, and 0.547) and 3 old dogs (2.08, 12.49, 0.46 cm2, 43.91%, and 0.612). Renal perfusion changes occurred in 2 other young dogs after 2 days of water inhibition (1.515, 15.42, 0.403 cm2, 30.15%, and 0.626). Conclusions—The detailed change of renal perfusion during dehydration can be evaluated with dynamic PD ultrasonography, and these novel PD indices have the potential to be applied in renal clinics in the near future. 1516829 Upper Body Quadrant Pain in Sonographers Frank Claes,* Jan Berger, Gaetane Stassijns Physiotherapy, University Hospital Antwerp, Edegem, Belgium Objectives—The aims of this study were to evaluate the prevalence of upper body quadrant pain among sonographers and to evaluate the association between individual ergonomics, musculoskeletal disorders, and occurrence of neck pain. Methods—One hundred ten Belgian and Dutch male and female hospital sonographers were consecutively enrolled in the study. Data pertaining to work-related ergonomic and musculoskeletal disorders were collected with an electronic inquiry, including questions about ergonomics (position of the screen, high-low table, and ergonomic chair), symptoms (neck pain and upper limb pain) and work-related factors (consecutive working hours per day and average working hours per week). Results—Subjects with the screen on their left had significantly more neck pain (odds ratio [OR], 3.619; P = .0286). Depending on the work space, high-low tables increase the chance of developing neck-pain (OR, 12.90; P = .0246). A screen at eye level causes less neck pain (OR, 0.229; P = .0610). Employees with a fixed working space are less susceptible to arm pain (OR, 0.137; P 0.0058). The incidence of arm pain is significantly higher in the vascular department compared to the radiology, urology, and gynecology departments (OR, 9.273; P = 0.0278). Conclusions—In the prevention of upper limb pain in sonographers, attention should be paid to the work environment in general and to the more specific aspects of the ultrasound workstation layout. Primary ergonomic prevention can help sonographers work painlessly during their medical tasks. Objectives—Many allograft patients have dehydration problems due to diarrhea in clinics, which cause deterioration of renal function. S68 13proceedings_Layout 1 3/5/13 10:39 AM Page S69 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Obstetric Ultrasound: General and Fetal Growth Moderators: Wesley Lee, MD, Mani Montazemi, RDMS 1539437 Fetal Loss Rate and Associated Risk Factors After Amniocentesis, Chorionic Villus Sampling, and Fetal Blood Sampling Christian Enzensberger,1* Christina Pulvermacher,1 Jan Degenhardt,1 Andreaa Kawecki,1 Ute Germer,2 Ulrich Gembruch,3 Martin Krapp,4 Jan Weichert,5 Roland Axt-Fliedner1 1Division of Prenatal Medicine, University of Giessen & Marburg, Giessen, Germany; 2Center for Prenatal Medicine, Caritas Krankenhaus St Josef, Regensburg, Germany; 3Division of Prenatal Medicine, University of Bonn, Bonn, Germany; 4Center for Endocrinology and Reproductive and Prenatal Medicine, Amedes Hamburg, Hamburg, Germany; 5Division of Prenatal Medicine, University of SchleswigHolstein, Campus Luebeck, Luebeck, Germany relation coefficients and percent agreement (“excellent”: score difference, 0–1 points; “acceptable”: 2 points; “poor”: ≥3 points) were used to estimate inter-reviewer reproducibility. Bland-Altman plots were used to assess bias and compare the 95% limits of agreement between reviewers. Results—There was a significant correlation between the 2 reviewers’ overall scores (ПЃ = 0.73; P < .001). One hundred percent excellent agreement was observed in the individual categories of femur, outflow tracts, stomach/diaphragm, and spine. Poor agreement was rare (kidney, 2.5%; and face, 2.5%) Bland-Altman statistics demonstrated no evidence of systematic bias in the overall score (mean difference = 1.5; P = .761). The 95% limits of agreement were clinically acceptable for the overall score (–2.4 to 5.4) and all individual categories except fetal face views (Table 1). Conclusions—This image quality scoring tool demonstrated overall acceptable reproducibility without evidence of systematic bias. Careful evaluation of specific criteria comprising each individual scoring category is, however, warranted prior to implementation into practice. Table 1 Objectives—To assess the total and procedure-related fetal loss rates and associated risk factors following amniocentesis (AC), chorionic villus sampling (CVS), and fetal blood sampling (FBS). Methods—We performed a retrospective analysis of patients with invasive diagnostics from 1993 to 2011 in 2 tertiary referral centers. We aimed to classify pregnancy loss after an invasive procedure and included the time after the invasive procedure and the result of targeted ultrasound/karyotype analysis in the analysis. Fetal losses occurring within 2 weeks after an invasive procedure were classified as procedure related. Results—After excluding 1553 pregnancies with abnormal karyotypes, fetal malformations, and multiple insertions, 6256 cases were retrieved for final analysis. The total fetal loss rate was 1.5%. The procedure-related fetal loss rates were 0.4% for AC, 1.1% for CVS, and 0.4 % for FBS. Maternal vaginal bleeding in the first trimester was significantly associated with an increased procedure-related fetal loss rate (P = .008). The number of invasive procedures declined during the study period with increasing numbers of CVS in the first trimester. Conclusions—In our population, the procedure-related fetal loss rates were 0.4% after AC and 1.1% and 0.4% after CVS and FBS, respectively. Different gestational ages at the time of invasive procedures might account in part for those differences. Vaginal bleeding during the first trimester is associated with increased procedure-related fetal loss. Overall, declining numbers of invasive procedures are the result of changing attitudes toward invasive procedures and more sophisticated noninvasive prenatal screening programs over the last 20 years. 1537806 Quality Control in Obstetric Ultrasound: Evaluating the Reproducibility of an Image Scoring Tool for the SecondTrimester Anatomic Survey Katherine Goetzinger,* Methodius Tuuli, Alison Cahill, George Macones, Anthony Odibo Obstetrics and Gynecology, Washington University, St Louis, Missouri USA Objectives—To evaluate the reproducibility of an image scoring tool for quality control of second-trimester fetal anatomic surveys in a US academic center. Methods—This was a retrospective study of 40 randomly selected nonanomalous singleton gestations between 18 and 22 weeks who presented for an anatomic survey. Images from each ultrasound exam were evaluated by 2 independent reviewers and assigned a score based on a quality control tool, previously derived in a European ultrasound unit. This tool assigns an overall score (46 points possible), which is the sum of individual scores for each of the following anatomic views: head (6), abdomen (6), femur (4), 4-chamber heart (6), outflow tracts (5), kidneys (4), spine (5), stomach/diaphragm (6), and face (4). Individual scores are based on the number of specific criteria fulfilled for each view. Spearman cor- Category Head Abdomen Femur 4-Chamber heart Outflow tract Kidneys Stomach and diaphragm Spine Face Bias 0.2 0.2 –0.1 0.5 –0.1 0.4 –0.2 0.1 0.7 95% Limits of Agreement –1.0 to 1.5 –1.4 to 1.8 –1.2 to 1.1 –1.0 to 2.1 –1.4 to 2.2 –1.4 to 2.2 –1.7 to 1.2 –0.6 to 0.4 –1.3 to 2.7 1540992 Time Required for the Fetal Anatomic Survey in Obese and Morbidly Obese Women Robert Ehsanipoor,* Gofran Tarabulsi, Shannon Trebes, Erika Werner, Janice Henderson, Jude Crino Johns Hopkins University School of Medicine, Baltimore, Maryland USA Objectives—To determine if there is a difference in time required to perform the fetal anatomy survey in obese and morbidly obese women compared to women with a body mass index (BMI) of <30 m2/kg. Methods—Ultrasound examinations and reports were reviewed for women undergoing a fetal anatomic survey between 18 and 28 weeks’ gestation. The time required for the exam was determined by subtracting the time of the first image from the time of the last image. Examinations involving trainees and those that detected fetal anomalies were excluded. Maternal height and prepregnancy weight were self-reported and used to calculate BMI. Obese was defined as a BMI between 30.0 and 39.9, and morbid obesity was defined as a BMI of ≥40.0. П‡2, the Student t test, analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) were used to compare the groups. Results—A total of 306 women were included. Seventeen women (5.5%) were morbidly obese; 67 (21.8%) were obese; and 222 (72.5%) were not obese. The mean В± SD ultrasound times required for the fetal anatomy survey were as follows: morbidly obese, 61.2 В± 34.5 minutes; obese, 47.3 В± 23.1 minutes; and nonobese, 39.2 В± 19.3 minutes (P = .01). Women with a BMI of ≥30 m2/kg were less likely have a complete anatomic survey on 1 attempt (OR, 0.3; 95% CI, 0.16–0.47) and more likely to never obtain a complete evaluation of the fetal anatomy (OR, 8.2; 95% CI, 2.5–26.6). The groups were not significantly different in regard to maternal age, previous cesarean delivery, or gestational age at the initial examination. Conclusions—More time is required to evaluate the fetal anatomy in obese and morbidly obese women. Additionally, they are more likely to require more than 1 examination to evaluate the fetal anatomy and never have anatomy satisfactorily evaluated. S69 13proceedings_Layout 1 3/5/13 10:39 AM Page S70 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1539702 Association of Third-Trimester Abdominal Circumference With Provider-Initiated Preterm Delivery Leah Hawkins,1* William Schnettler,1,2 Anna Modest,2 Michele Hacker,1,2 Diana Rodriguez1,2 1Harvard Medical School, Boston, Massachusetts USA; 2Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts USA Objectives—To evaluate the association of a small abdominal circumference (AC, <10th percentile) at third-trimester ultrasound with gestational age (GA) at delivery, indication for delivery, and neonatal outcomes. Methods—All women seen at our institution from 2009 through 2011 for measurements from 28 to 34 weeks’ gestation with a singleton nonanomalous pregnancy were included in this retrospective cohort. We compared GA at delivery, indication for delivery, and neonatal outcomes between 2 groups: Normal AC (AC and estimate fetal weight [EFW] ≥10th percentile) and small AC (AC <10th percentile and EFW ≥10th percentile). Indications for delivery were categorized as spontaneous or provider initiated. Data are presented as medians, interquartile ranges (IQRs), and risk ratios (RRs) with 95% confidence intervals (CIs). Results—A total of 597 women met eligibility criteria. The median GA at ultrasound was 32.0 weeks (IQR, 30.6–33.0 weeks), and median maternal age at delivery was 32.9 years (IQR, 28.8–36.7 years). A small AC was found in 10.6% of the fetuses. The incidence of preterm delivery (PTD) in the cohort was 12.2%. Compared to fetuses in the normal-AC group, those with a small AC experienced a higher incidence of overall PTD, provider-initiated PTD, and provider-initiated PTD for a fetal indication (Table 1). No significant differences in immediate neonatal outcomes between the normal- and small-AC groups were witnessed aside from an expected difference in mean birth weight. Conclusions—A small AC, even in the setting of an EFW ≥10th percentile, is associated with a higher incidence of PTD, specifically, provider-initiated PTD. Fetal growth concerns appeared to drive the decision for delivery. Immediate neonatal outcomes were comparable between groups, challenging the need for provider-initiated PTD of fetuses with an isolated small AC. Further investigation into the rationale for PTD and long-term neonatal outcomes of such fetuses is warranted. Table 1. Pregnancy Outcomes Normal AC Small AC (n = 537 [90.7%]) (n = 55 [9.3%]) P Overall PTD 59 (11.0%) 13 (23.6%) .006 Iatrogenic PTD 24 (4.5%) 9 (16.4%) .003 Fetal indication for PTD 10 (1.86%) 7 (12.7%) < .001 RR (95% CI) 2.2 (1.3–3.7) 3.7 (1.8–7.5) 6.8 (2.7–17.2) 1508162 Incidence and Timing of Onset of Intrauterine Growth Restriction in Singleton Pregnancies With Low PregnancyAssociated Plasma Protein A, Elevated Maternal Serum О±-Fetoprotein, or Both Biochemical Abnormalities Simi Gupta,1* Nathan Fox,1,2,3 Andrei Rebarber,1,2,3 Daniel Saltzman,1,2,3 Chad Klauser,1,2,3 Ashley Roman1,2,3 1Obstetrics and Gynecology, New York University, New York, New York USA; 2Maternal-Fetal Medicine, Carnegie Imaging for Women, New York, New York USA; 3Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York USA Objectives—Low pregnancy-associated plasma protein A (PAPP-A) and elevated maternal serum О±-fetoprotein (MSAFP) are each individually associated with an increased risk of intrauterine growth restriction (IUGR). However, little is known about the incidence or timing of onset of IUGR in these pregnancies or in those affected by both biochemical abnormalities. The objective of this study was to compare the incidence and timing of IUGR in pregnancies affected by these abnormalities individually and in combination. Methods—This was a retrospective cohort study of singleton gestations with PAPP-A <5th percentile and/or MSAFP ≥2.0 multiples of the median at a single center from May 2005 through August 2011. Patients with low PAPP-A and/or elevated MSAFP were typically followed with ultrasound for fetal growth at least every 4 weeks from 20 weeks until delivery. Patients were excluded if the fetus was known to have an abnormal karyotype, an adverse obstetric event unrelated to IUGR, or no documented ultrasound examinations for growth. IUGR was defined as an estimated fetal weight on ultrasound <10th percentile for gestational age. The incidence of IUGR was compared using the Fisher exact test with P < .05 as significance. Results—The incidence of IUGR by biochemical abnormality is reported in Table 1. Patients with both low PAPP-A and elevated MSAFP were significantly more likely to be diagnosed with IUGR than patients with either biochemical abnormality alone. More than 70% of patients with IUGR in the setting of isolated elevated MSAFP or low PAPPA were diagnosed with IUGR after 28 weeks, whereas 100% of patients with IUGR in the setting of both biochemical abnormalities were diagnosed prior to 28 weeks (P = .03). Conclusions—The incidence and timing of onset of IUGR are similar in patients with isolated low PAPP-A and elevated MSAFP. When these biochemical abnormalities are seen in combination, the risk of IUGR is >3-fold greater than either abnormality alone, and the onset of IUGR is earlier. Patients with both low PAPP-A and elevated MSAFP represent a group at highest risk of IUGR in whom close fetal surveillance is merited. Table 1 IUGR No IUGR Low PAPP-A Only 24/421 (5.7%) 397/421 (94.3%) Elevated Low PAPP-A and MSAFP Only Elevated MSAFP 7/134 (5.2%) 2/11 (18%) 127/134 (94.8%) 9/11 (82%) P .02 1540608 Prenatal Ultrasound and Ethanol Biomarkers for Early Identification of Prenatal Alcohol Exposure Brennan Mathew,* Steffen Brown, Mahek Garg, Daniel Savage, William Rayburn, Ludmila Bakhireva Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico USA Objectives—A barrier in limiting effective treatment of fetal alcohol spectrum disorder is the lack of early and reliable diagnostic indices. Limited human studies suggest that selected fetal brain measures might be particularly affected by prenatal alcohol exposure (PAE). The objective of this study is to identify prenatal ultrasound indices associated with history and biomarker-proven PAE. Methods—This prospective study included 11 alcohol-exposed pregnant women (≥3 drinks/wk or binge drinking episodes during pregnancy and positivity for at least 1 ethanol biomarker) and 36 patients on opioid maintenance therapy (OMT) who abstained from alcohol during pregnancy (confirmed by 5 ethanol biomarkers) who were recruited at an early prenatal care visit and followed to term. The panel of ethanol biomarkers included serum Оі-glutamyltranspeptidase, urine ethyl glucuronide, urine ethyl sulfate, and whole-blood phosphatidylethanol (PEth). PEth was also measured in a dry blood spot card obtained from the newborn. Third-trimester sonograms were performed, and standard fetal biometry was obtained. The standard biparietal diameter (BPD) image was then reviewed to obtain the caval-calvarial distance (CCD) and fronto-thalamic distance (FTD). Fetal brain measures were compared among alcohol-exposed and OMT patients by analysis of covariance adjusting for gestational age at the exam. Results—The majority of patients were Hispanic (79%) and had a high school education or less (85%). The mean maternal age at recruitment was 26.1 В± 4.8 years. Fetuses of alcohol-exposed patients had a significantly shorter mean CCD and transcerebellar diameter (TCD) (P < S70 13proceedings_Layout 1 3/5/13 10:39 AM Page S71 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) compared to OMT patients. Conclusions—Prenatal ultrasound evaluation of the CCD and TCD correlate with biomarker-proven PAE. These results indicate that ultrasound parameters may be helpful in conjunction with other diagnostic indices in detecting PAE. Future studies need to examine the predictive utility of ultrasound indices on neurodevelopmental outcomes in children with PAE. 1521317 Effect of Maternal Body Mass Index on Fetal Growth: Use of Individualized Growth Assessment and 2-Level Modeling Timothy Canavan,1* Russell Deter2 1Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh– Magee Women’s Hospital, Pittsburgh, Pennsylvania USA; 2 Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas USA Objectives—To determine the effect of the maternal body mass index (BMI) on fetal biometry estimates of growth using individual growth assessment (IGA) and 2-level linear modeling. Methods—A retrospective review of serial biometry in the second and third trimesters from 246 normal term singleton fetuses was performed. Four to 8 biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FDL) measurements per fetus were available and used to determine second-trimester growth rates. Expected third-trimester size trajectories were generated from these data and percent deviations (%Dev = [{observed – expected}/ expected] Г— 100) were calculated. Two-level linear modeling was used to determine individual %Dev slopes and the effect of BMI on these slopes. Relationships between individual second- and third-trimester slopes and BMI values were also evaluated using regression analysis. Results—Linear regression analysis of second-trimester growth indicated no significant relationships between the fetal growth rate and the BMI (adjusted R2 = 0.0%–1.0% except for AC in 1 subgroup [5.6%]). With third-trimester %Dev slopes, there was a definite BMI effect for HC, but only a marginal effect was seen for AC (critical value = 1.98; t = 2.00). There was no BMI effect on BPD or FDL slopes. Regression analysis indicated no significant relationships (adjusted R 2 = 0%–0.2%) between BMI values and third-trimester %Dev slopes for any anatomic parameter. Conclusions—Our findings support the premise that the maternal BMI does not alter fetal growth in either the second or third trimester. It also demonstrates that IGA and 2-level linear modeling, used together, can assess the effect of an extrinsic factor on fetal growth. 1541336 Cerebral Autoregulation in Normal Pregnancy Teelkien van Veen,1* Sina Haeri,2 Rodrigo Ruano,2 Ronny Panerai,3 Gerda Zeeman,1,4 Michael Belfort2 1Obstetrics and Gynecology, University Medical Center Groningen, Groningen, the Netherlands; 2Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas USA; 3Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, England; 4Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands Objectives—Recent advances in transcranial Doppler (TCD) methodology now allow direct real-time estimation of the functional state of cerebral autoregulation. Since no normative data exist for pregnant patients, our aim was to establish baseline data for cerebral autoregulation in healthy pregnancy against which women with disease states can be compared. Methods—In this prospective cohort analysis, cerebral blood flow velocity (CBFV) in the middle cerebral artery (using TCD), blood pressure (using noninvasive continuous plethysmography), and end–tidal carbon dioxide (etCO2) were simultaneously evaluated at baseline and during voluntary breath holding (increased etCO2). The transfer function parameters (gain, phase, and coherence in the low-frequency range [<0.1 Hz]) were used to estimate the degree of autoregulation. Results—Nineteen normotensive pregnant women were enrolled, of whom 15 had good signal quality and were analyzed (maternal age, 28 В± 5 years; gestational age, 27 weeks [13в€’34 weeks]). Breath holding led to increases in etCO2 (34 В± 2 vs 38 В± 2 mm Hg; P < .001), mean arterial pressure (76 В± 8 vs 86 В± 11 mm Hg; P = .01), and CBFV (59 В± 15 vs 71 В± 15 cm/s; P = .04), along with increases in coherence and gain and a decrease in phase. Conclusions—The baseline data and the changes seen with breath holding in normal pregnancy are consistent with those seen in normal cerebral autoregulation as reported in nonpregnant individuals. These data now allow for further studies in pregnant women with disease states and drug exposures that may be expected to affect cerebral autoregulation. 1539866 Do Clinical Practitioners Seeking Credentialing for Nuchal Translucency Measurement Have an Understanding of Biosafety? The Experience of The Nuchal Translucency Quality Review Program Bryann Bromley,1,2* Karin Fuchs,3 Loralei Thornburg,4 Jean Spitz,5 Gregory Toland5 1Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA; 2 Obstetrics and Gynecology and Radiology, Brigham and Women’s Hospital, Boston, Massachusetts USA; 3MaternalFetal Medicine, Columbia University Medical Center, New York, New York USA; 4Maternal-Fetal Medicine, University of Rochester, Rochester, New York USA; 5Nuchal Translucency Quality Review, Perinatal Quality Foundation, Oklahoma City, Oklahoma USA Objectives—To evaluate compliance with the ALARA (as low as reasonably achievable) principle by practitioners seeking credentialing for nuchal translucency (NT) measurement between 11 and 14 weeks’ gestation. Methods—This was a retrospective evaluation of images submitted by 100 consecutive practitioners seeking NT credentialing prior to September 18, 2012. For each practitioner, the 5 required submitted images were r-evaluated for the presence or absence of the output display standard (ODS). In images with the ODS visible, the type of thermal index used (soft tissue [TIs] or bone [TIb]) was recorded as well as the numeric value of the index. Additional data collected included outcome of image submission (pass/fail), provider type (physician or sonographer), and, for sonographers, American Registry for Diagnostic Medical Sonography (ARDMS) status. A TIb <0.5 was considered the optimal setting for this gestational age window. The length of examination and dwell times were not available for review with a single static image. Results—Seventy-seven practitioners submitted at least 1 image demonstrating the ODS. Fifteen (19.5%) providers used TIb exclusively, while 37 (48.1%) used TIs exclusively; 25 providers (32.4%) submitted a batch using both TIb and TIs. The range for both TIb and TIs was 0.0 to 1.6. The mean, median, and mode were 0.7, 0.6, and 0.1 for TIb and 0.4, 0.2, and 0.1 for TIs. Of the 40 providers who used TIb for any image, 18 (45%) had a TIb between ≥0.5 and 1.0, and 11 (27.5%) had a TIb of >1.0. Although 44 of 77 (57%) providers maintained a TI (TIb or TIs) <0.5, only 4 of 77 (5.2%) used TIb exclusively at <0.5. Providers passing the image review process were twice as likely to be using TIb than those who failed (21.9% vs 9.1%), although this did not reach statistical significance (P = .33). No difference in TIb or TIs use was seen between sonographers (n = 59) and sonologists (n = 18; P = .78). Among sonographers, 41 held ARDMS credentials, but this did not influence the use of TI <.5 (66% vs 56%; P = .45). Conclusions—Clinicians seeking credentialing in NT measurement do not demonstrate compliance with the recommended use of TIb in monitoring acoustic output. S71 13proceedings_Layout 1 3/5/13 10:39 AM Page S72 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1537546 Early Second-Trimester Fetal Anatomy Scans Improve the Rate of Complete Anatomy Scans in Obese Patients Simi Gupta,* Judith Chervenak, Ilan Timor, Ana Monteagudo Obstetrics and Gynecology, New York University, New York, New York USA Objectives—Fetal anatomy scans are more difficult to perform on obese patients. However, there are little data available on methods to improve the rate of complete anatomy scans in these patients. The objective of this study was to determine if the addition of an early secondtrimester fetal anatomy scan improves the rate of complete anatomy ultrasound examinations in obese patients. Methods—This was a prospective cohort study at an inner-city public hospital of 100 obese patients who were scheduled for a fetal anatomy scan via transvaginal and transabdominal modalities at 14 to 16 weeks’ gestation (early fetal anatomy) and an anatomy scan at 18 to 22 weeks’ gestation (routine fetal anatomy). Inclusion criteria were body mass index (BMI) >30 kg/m2, singleton pregnancy, and presentation for prenatal care prior to 16 weeks’ gestation. Data for the routine anatomy scan alone versus the combination of early anatomy and routine anatomy scans was calculated using the McNemar П‡2 test for categorical outcomes and Wilcoxon signed ranks test for continuous variables. Results—The range of BMI in the study was 30–49.6 kg/m2 with an average BMI of 34.3 kg/m2. Table 1 shows the results for the routine anatomy scan alone and the combination of early anatomy and routine anatomy scans. Conclusions—The addition of an early second-trimester fetal anatomy ultrasound scan significantly improves the rate of complete anatomic scans and mean number of items seen in obese patients. The addition of this ultrasound scan may improve the detection of congenital anomalies in obese patients. Table 1 Routine Early and Routine Anatomy Anatomy Combination P % complete anatomy 42 51 < .01 Mean no. of items seen (1–21) 18.6 19.4 < .01 S72 13proceedings_Layout 1 3/5/13 10:39 AM Page S73 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SPECIAL INTEREST SESSIONS WEDNESDAY, APRIL 10, 2013, 8:15 AM–10:15 AM Breast Ultrasound Extracranial Ultrasound of the Head and Neck in Children Moderator: Abid Irshad, MD Moderator: Beth McCarville, MD Clinical Breast Ultrasound in an Outpatient Community Breast Center Stamatia Destounis Elizabeth Wende Breast Care, LLC, Rochester, New York USA This lecture will cover the clinical use of breast ultrasound in an outpatient community breast center. Topics to be covered will include evaluation of breast pain, palpable abnormalities, breast lesions in young patients, breast-feeding/lactating patients, and patients with dense breasts presenting for additional screening ultrasound. Particular discussion will be focused on screening breast ultrasound, in response to recent state legislation mandating that the patient be informed of her breast density. In addition, screening of the high-risk patient will be covered. Last, this lecture will discuss the role of diagnostic breast ultrasound. The role of new technologies, including elastography and automated breast ultrasound, will be briefly discussed. Significance and Implications of Various Sonographic Features in Breast Lesions Abid Irshad Radiology, Medical University of South Carolina, Charleston, South Carolina USA This lecture will encompass the diagnostic significance of various sonographic features seen in breast lesions from a clinical and pathologic perspective. The management issues regarding concordance after biopsy of these lesions will also be discussed. Additionally, various sonographic features seen in breast cancers will be individually discussed in light of literature to see how confidently the biological behavior such as the tumor grade and estrogen receptor/progesterone receptor/human epidermal growth factor receptor 2 status of these cancers can be predicted based on these individual sonographic features. Ultrasound as a Problem-Solving Tool in Breast Imaging Julie Mack Radiology, Penn State Hershey, Hershey, Pennsylvania USA Breast ultrasound is integral to the imaging evaluation of breast disease, and core biopsy under ultrasound guidance provides a mechanism for rapid diagnosis of breast pathology. This session will focus on the use of breast ultrasound as a problem-solving tool in patients presenting with mammographic or clinical evidence of breast disease. The sonographic findings in a variety of breast abnormalities of the female and male breast will be illustrated and correlated with the mammographic and magnetic resonance imaging (MRI) findings. The utility of breast ultrasound as a “second-look” exam after MRI will be discussed. Biopsy planning and radiologic-pathologic correlation will also be emphasized. Finally, a brief review of the data on breast ultrasound as a screening tool will be examined. This session is designed to educate the radiologist and sonographer about the value of ultrasound in assessing non-brain pathology in the head and neck of children, including the thyroid, superficial masses, and ocular disease. Gynecologic Ultrasound: The Basics Revisited Moderator: Ana Monteagudo, MD Getting to Know Your Ultrasound Machine: Essentials of Knobology Ana Monteagudo Obstetrics and Gynecology, New York University School of Medicine, New York, New York USA “Knobology” is defined as the functionality of controls on an instrument as relevant to their application. In the case of ultrasound (US), it is the function of the controls (knobs) on the US machine. All machines have essentially the same set of controls; however, in each brand, the controls (“knobs”) are arranged slightly differently. Therefore, it is imperative to become familiar with the location of the controls on the machine that you are using on a regular basis. Adjusting the controls is a way to improve the image quality, since a good image is an essential component of making a correct and reliable diagnosis. Controls that change the following parameters are indispensable: depth, gain, time-gain-compensation (TGC), focal zone, field of view, frame rate, “optimize” (this control changes several parameters as needed for a particular set of pictures), and zoom. Of course, there are many more of them; however, as you gain confidence with the scanning and working with the US machine, the utility of changing other parameters will become evident. Improving images not only requires knowing which control to use, but it also requires choosing the right transducer for the scanning approach; transducers commonly used in obstetrics and gynecology range from 3.5 to 7.5 MHZ (or higher). Low-frequency transducers achieve better penetration at the expense of a lower resolution; these are the ones employed when scanning transabdominally. Higher-frequency transducers have less penetration, but their real value is the increased resolution, and these are usually used transvaginally. Last, besides knowing what each control does and which transducer to use, we must know the indication for the scan and the age and last menstrual period of the patient. They all assist in making the diagnosis. Innovative Directions in Fetal Cardiac Imaging Moderator: Lami Yeo, MD The objective of this session is to review several new directions in the field of fetal cardiac imaging: imaging for fetal interventions, fetal magnetic resonance imaging, and automated screening for congenital heart disease. S73 13proceedings_Layout 1 3/5/13 10:39 AM Page S74 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Lumps, Bumps, and Extremity Pain in the Emergency Room: What Is the Role of Ultrasound? Ultrasound-Guided Thrombolysis Moderator: George Lewis Jr, PhD Moderator: Leslie Scoutt, MD Sonography of Abdominal Wall Hernias Levon Nazarian Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania USA Small abdominal wall hernias may be difficult to palpate on physical examination; therefore, hernias are an often-overlooked cause of pain or other complications. Because of its real-time nature, ultrasound has taken a central role in the evaluation of abdominal wall hernias, since many hernias are not present in the resting state. Since dynamic maneuvers may be necessary for diagnosis, many hernias go undetected by computed tomography or magnetic resonance imaging. This presentation will discuss the anatomy and technique pertinent to the diagnosis of abdominal wall hernias. Pathologic examples of the different hernia types will be presented using both static images and video clips. Lumps and Bumps Jason Wagner Radiological Sciences, University of Oklahoma, Edmond, Oklahoma USA This presentation will describe an algorithm-based approach to the ultrasound evaluation of a superficial mass, based on patient history, physical examination, lesion location, and sonographic findings. Specific topics will include identification of fluid collections, distinguishing nonneoplastic causes of a lump from neoplasms, and the differential diagnosis of superficial neoplasms. Peripheral Arterial Disease Medical Technology and Instrumentation for Sonothrombolysis: Current, Pipeline, and Future Platforms George Lewis Jr Zetroz, Ithaca, New York USA Ultrasound technologies to provide and monitor sonothrombolysis can currently be grouped into two broad categories: (1) catheterdirected and/or delivered ultrasound and (2) extracorporeal focused and/or applied ultrasound. The first class of technology is generally minimally invasive and carried out with a sterile field in an interventional radiology suite. The second class of device covers a much larger use case scenario relative to where it can be applied and used. In both categories of technology, sonothrombolysis effectiveness in thrombus dissolution is most regularly measured with precontrast and postcontrast fluoroscopy. More recently, however, ultrasound imaging including B-mode, Doppler flow, and intravascular ultrasound is making its way into fully integrated closedloop sonothrombolysis treatment and monitoring systems. This talk will review current sonothrombolysis ultrasound technologies, their performance characteristics, methods of use, and basic mechanisms of action in which they rely on. Catheter-directed ultrasound technologies include commercial systems such as Ekos and Omnisonics, as well as pipeline technologies still undergoing research in academia and the private sector. Extracorporeal noninvasive technologies, including power Doppler, lowintensity therapeutic ultrasound, plane-wave pulsed ultrasound, high-intensity focused ultrasound, and histotripsy, will be described along with their current use case scenarios, characteristics, and regulatory pathways. The catheter-directed sonothrombolysis approaches will be compared and contrasted to noninvasive sonothrombolysis. Additionally, recent innovations in closed-loop sonothrombolysis treatment monitoring and crossover sonothrombolysis platforms will be discussed as a gateway into clinical research presentations. Moderator: John Blebea, MD, MBA Ultrasound in the Preintervention Stage of Patient Evaluation Gowthaman Gunabushanam Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA; Radiology, VA Medical Center, West Haven, Connecticut USA This presentation will review the noninvasive evaluation of lower extremity peripheral arterial disease (PAD) in the vascular laboratory, including ankle-brachial index (ABI), toe-brachial index (TBI), pulse volume recording (PVR), segmental blood pressure measurement, and ultrasound of native arteries and bypass grafts. ABI is used to confirm vascular etiology and provide prognostic information in symptomatic patients. ABI is also used to screen high-risk asymptomatic patients for PAD and to monitor the efficacy of therapeutic interventions. ABI <0.9 is abnormal. Exercise ABI improves sensitivity for PAD detection in patients with normal rest ABI. TBI is especially useful when ABI is >1.3 as digital arteries are usually spared the medial calcinosis that affects the more proximal arteries. Segmental pressure measurements and PVR help determine the level of stenosis. A gradient >20 mm Hg between adjacent segments or between the two sides at the same level is significant. PVR provides an arterial pressure waveform profile by measuring limb volume changes with each cardiac cycle. A normal waveform has a rapid upstroke, a sharp peak, a dicrotic notch, and a downslope bowed toward the baseline. A slower rise time, flattened or rounded peaks, absence of a dicrotic notch, and a downslope bowed away from baseline suggest a proximal stenosis. Velocity criteria are used for grading stenosis on ultrasound. Peak systolic velocity (PSV) of 200 to 350 cm/s and PSV ratio of 2 to 3.5 are suggestive of moderate stenosis. PSV >350 cm/s and PSV ratio >3.5 are consistent with severe stenosis. Sonothrombolysis: Techniques, Mechanisms, and Safety Zhen Xu Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA Ultrasound has been shown to promote clot breakdown, as both a stand-alone procedure and in conjunction with thrombolytic drugs or contrast agents. In this talk, 3 sonothrombolysis approaches and their underlying mechanisms reported in the literature will be reviewed. First, lowintensity ultrasound is combined with fibrinolytic enzymes (such as plasminogen activator) to accelerate the clot dissolution. The mechanism underlying this approach includes the accelerated transport of drug molecules into the clot and alteration in fibrin structure to enhance enzyme binding. Both of these effects are caused by stable cavitation (ie, microstreaming and bubble translation) and inertial cavitation (ie, intense localized stresses and microjets). Microbubble contrast agents can be used in conjunction with fibrinolytic enzymes to enhance cavitation and further augment thrombolysis. Second, higher-intensity ultrasound and microbubble contrast agents are used together to cause clot fragmentation. The microbubbles that accumulate at the surface or within the clot serve as cavitation nuclei. For this approach, the primary mechanism is inertial cavitation, where energetic bubble growth and collapse induce high local stress and microjets, resulting in clot microfragmentation. Third, very high-intensity focused ultrasound pulses are used alone to produce rapid clot fragmentation. Similar to the second approach, the mechanism for this method is also inertial cavitation, where pre-exiting gas nuclei in clots are used to generate cavitation. No contrast agents or drugs are required. To conclude, safety studies of sonothrombolysis techniques will be discussed, including damage to vessel walls and surrounding tissue, changes in blood chemistry, and embolization. S74 13proceedings_Layout 1 3/5/13 10:39 AM Page S75 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Clinical Role and Potential of Ultrasound-Enhanced Thrombolysis in Peripheral Arterial Disease Richard Shlansky-Goldberg Radiology, University of Pennsylvania, Philadelphia, Pennsylvania USA Thrombosis from peripheral arterial disease (PAD) due to underlying atherosclerotic disease or thrombosis of a surgical bypass graft used to treat PAD can lead to limb loss. In addition, thrombosis of the deep venous system (DVT) can lead to chronic leg swelling due to postphlebitic syndrome. DVT can also lead to life-threatening pulmonary embolic disease (PE). Catheter-directed pharmacologic thrombolysis is a well-established technique to treat these arterial, venous, and graft occlusions. The utility of this approach continues to be limited by several factors, including the cost of the lytic dose, the duration of treatment required for effective clot lysis, costly intensive care monitoring, and the exposure of patients to the risk of intracranial hemorrhage and other life-threatening bleeding. Attempts to improve the efficacy of thrombolysis with different catheter configurations and mechanical devices have met with varied success. The addition of ultrasound by itself or with pharmacologic agents has been demonstrated to primarily induce or enhance thrombolysis. To date, the clinical applicability of these approaches has been limited. We will explore the current clinical data to determine the success of these approaches to improve lysis in DVT, PAD, and PE. Although the use of ultrasound appears promising, the question still remains whether the current iteration of techniques and devices will add enough efficiency to have a clinically significant impact on outcomes. We will evaluate what thresholds need to be crossed for ultrasound to dramatically improve on how these diseases will be treated in the future. SPECIAL INTEREST SESSIONS WEDNESDAY, APRIL 10, 2013, 10:45 AM–12:30 PM Acoustic Radiation Force Impulse Imaging: Benefits and Challenges With Increasing Acoustic Output Beyond Diagnostic Levels Moderators: Kathy Nightingale, PhD, Thomas Szabo, PhD The Historical Basis for the Food and Drug Administration’s Maximum Exposure Level Guidance for Diagnostic Ultrasound Gerald Harris US Food and Drug Administration, Silver Spring, Maryland USA US Food and Drug Administration (FDA) regulations designate most diagnostic imaging and Doppler ultrasound devices as class 2, which means that before a new device can be marketed in the United States, a “510(k)” (named for a section of the 1976 FDA Medical Device Amendments) premarket notification must be cleared by the FDA. In this notification, a device sponsor must demonstrate that the device is substantially equivalent (SE) in terms of safety and effectiveness to either a device legally marketed before May 28, 1976, the date of enactment of the FDA Medical Device Amendments, or to a device that has been legally marketed as a class 2 device since that date. To evaluate equivalent safety, the FDA has used several acoustic output quantities to compare maximum output levels, including the derated spatial-peak temporal-average intensity and the thermal index for thermal safety comparisons and the derated spatial-peak pulse-average intensity and the mechanical index for nonthermal considerations. In this presentation, the origin and use of these quantities in making SE determinations will be described. Also, their possible shortcomings for evaluating the safety of applications that employ long-duration, high-intensity pulse bursts, such as acoustic radiation force impulse imaging, will be discussed. An Analysis of the Mechanical Index as a Means for Ensuring Patient Safety During Acoustic Radiation Force Impulse Imaging Charles Church,* Cecille Labuda National Center for Physical Acoustics, University of Mississippi, University, Mississippi USA The mechanical index (MI) quantifies the likelihood that diagnostic ultrasound will produce an adverse biological effect by a nonthermal mechanism. The current formulation of the MI is based on inertial cavitation thresholds in water and blood as calculated for pulse durations of 1 period. However, tissue is not a liquid but a viscoelastic solid, and further, acoustic radiation force impulse imaging employs high-intensity pulses up to several hundred acoustic periods long. To quantify the importance of these differences, thresholds for inertial cavitation were determined in water, blood, and several representative tissues by performing numerical computations similar to the analytical work underlying the MI for pulse lengths of 1 to 1000 acoustic periods, equilibrium bubble radii (Ro) of 0.01 to 10.0 Вµm, a frequency range of 0.5 to 10 MHz, and 4 threshold criteria, including the criterion used for the MI (5000 K). Water and blood were modeled using the Gilmore equation, while tissues (smooth and skeletal muscle, kidney, liver, and skin) were modeled using a KellerMiksis–like equation assuming a linear Voigt solid. It is shown that the likelihood of an adverse biological effect due to cavitation is less in soft tissues, and much less in muscle, than in blood. More importantly, the literature suggests that the experimental threshold for cavitation in tissue is much higher than predicted here, casting doubt on the value of this simple theoretical approach in assessments of patient safety. By combining theoretical and experimental data, several options for transiently increasing output levels while ensuring patient safety become available. Investigation of the Use of Increased Acoustic Output Levels for Acoustic Radiation Force Impulse Imaging in the Research Setting Mark Palmeri Biomedical Engineering, Duke University, Durham, North Carolina USA Acoustic radiation force impulse (ARFI) imaging has experienced rapid development over the past decade, growing from a novel elasticity imaging method used in tissue-mimicking phantoms to clinical testing in a variety of target organs, including the liver, breast, prostate, vessels, and heart, to commercial implementation. While current commercial ARFI imaging implementation operates within current US Food and Drug Administration diagnostic ultrasound acoustic output guidelines, studies in the research environment have not been similarly restricted. For example, pilot clinical ARFI imaging research studies at Duke University involve a custom method for characterizing acoustic intensity, tissue heating, transducer heating, and the mechanical index to support in vivo safety of using increased output during acoustic radiation force excitations. Given the strong acoustic waveform nonlinearity that can occur when characterizing high pressures in water, acoustic radiation force pressure waveforms and intensity values are characterized using hydrophone measurements through attenuating fluids similar to that of the target organ. Thermocou- S75 13proceedings_Layout 1 3/5/13 10:39 AM Page S76 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 ple measurements are made at the transducer face to characterize lens heating. We are exploring the hypothesis that increases in tissue displacement amplitude associated with elevated acoustic output will lead to improvements in ARFI images and shear wave speed estimates. To that end, parametric clinical studies are in progress with ARFI shear wave liver imaging to quantify the correlations between displacement amplitude, jitter, shear wave speed reconstruction performance metrics, and increased acoustic output. A summary of the acoustic output characterization methods used in the research setting and preliminary results from the parametric clinical studies will be presented. The Role of Ultrasound in Screening for Vascular Disease Edward Bluth Radiology, Ochsner Medical Institutions, New Orleans, Louisiana USA Moderator: James Huhta, MD It has been suggested that it would be more useful to reallocate health care dollars to screening asymptomatic healthy patients compared to the large allocation of resources for end-of-life care. Ultrasound has an important role to play in screening for medical problems. As a noninvasive study that does not use ionizing radiation, ultrasound has an advantage over other imaging modalities. Included in the areas where screening studies can be useful with ultrasound are assessment of the carotid arteries for stenosis as well as evaluation of the aorta for the presence of aneurysms. Intima-media thickness is another study that has been described as valuable in assessing cardiovascular risk. A reemphasis on the value of screening the healthy would be advantageous to the ultrasound community as we enter into health care reform in the United States. Twin-Twin Transfusion Syndrome Jack Rychik Fetal Heart Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA Musculoskeletal Ultrasound: Transition From Adults to Pediatrics Advanced Fetal Cardiac Evaluation and Comprehensive Overview Twin-twin transfusion syndrome (TTTS) affects approximately 15% of monochorionic twin pregnancies. The condition is triggered by a placental vasculopathy, which then leads to a cascade of physiologic events. TTTS results in a donor twin who manifests hypovolemia and oligohydramnios and a recipient twin with polyhydramnios. The cardiovascular systems of both twins are affected in a unique and fascinating manner, which is observable through fetal echocardiography. The donor exhibits hyperdynamic ventricular function with increased placental resistance. The recipient develops a cardiomyopathy consisting of ventricular dilation, hypertrophy, decreased compliance, and systolic dysfunction with tricuspid and mitral regurgitation. Approximately 15% to 20% of recipients develop changes within the right ventricular outflow and pulmonary valve complex such as pulmonic stenosis or pulmonary atresia of a functional or anatomic nature. A scoring system for characterization of these changes, the Children’s Hospital of Philadelphia (CHOP) TTTS cardiovascular score, has been developed and is useful in assessing disease severity and response to therapy. Studies using fetal echocardiographyderived modalities such as ventricular strain and strain rate analysis have provided insight into the pathophysiology of this disease. Placental laser photocoagulation is an effective treatment therapy for TTTS. Laser results in regression of cardiovascular findings. Cardiovascular characterization through the CHOP score and other parameters can be performed after laser. Long-term outcomes and, in particular, cardiovascular outcomes after laser therapy are of great interest. TTTS may impact cardiovascular health and provide imprints for disease long into adulthood. Current Vascular Controversies Moderator: John Blebea, MD, MBA This session will examine the indications and follow-up duplex criteria for carotid stenting, review the indications, results, and imaging criteria for angioplasty and stenting of the renal arteries, and discuss the recommended protocols for deep vein thrombosis imaging in different clinical scenarios. Moderator: Michael Di Pietro, MD The objective of this session is to cover some of the anatomy and entities familiar to experienced adult musculoskeletal radiologists but not to pediatric radiologists, which pediatric radiologists are now being asked by their clinicians (pediatric orthopedics, pediatric sports medicine, and pediatric physical medicine and rehabilitation) to address. Ultrasound of the Head and Neck Moderator: Sharlene Teefey, MD Ultrasound of the Thyroid and Parathyroid Sharlene Teefey Mallinckrodt Institute of Radiology, Saint Louis, Missouri USA This lecture will focus on the thyroid and parathyroid glands. The different types of thyroid carcinoma will be discussed, including demographics, histopathology, presenting features, and recurrence and mortality. The sonographic features of papillary carcinoma, medullary carcinoma, primary thyroid lymphoma, and nodular hyperplasia will also be discussed, and examples will be shown. The American Thyroid Association guidelines for fine-needle aspiration and follow-up of benign nodules and the Bethesda system for reporting cytology will be presented. In the next part of the lecture, Graves’ disease and Hashimoto’s thyroiditis will be discussed, including clinical and pathologic features. Sonographic findings will be discussed and examples shown. There will also be a brief discussion of subacute thyroiditis. In the last part of the lecture, primary hyperparathyroidism will be presented, including etiology, symptoms, anatomy, sonographic technique, and appearance, and examples will be shown. S76 13proceedings_Layout 1 3/5/13 10:39 AM Page S77 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SCIENTIFIC SESSIONS WEDNESDAY, APRIL 10, 2013, 10:45 AM–12:30 PM Emergency Ultrasound, Part 2 Moderator: Leslie Scoutt, MD 1540052 A Systematic Review of the Diagnostic Accuracy of Bedside Ocular Ultrasound in the Diagnosis of Retinal Detachment Jonathan Kirschner,* Hal Minnigan, Michael Vrablik, Gregory Snead, Rawle Seupaul Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana USA Objectives—Systematically review the literature to determine the diagnostic accuracy of bedside ocular ultrasound (OUS) in the diagnosis of retinal detachment. Methods—The design of this review conformed to the recommendations from the Meta-analysis of Observational Studies in Epidemiology statement. An experienced medical librarian searched the following databases from their inception without language restrictions: Ovid MEDLINE, PubMed, EMBASE, the full Cochrane Library, Emergency Medical Abstracts, and Google Scholar. Content experts were contacted, and bibliographies of relevant studies were reviewed to identify additional references. Studies were included if they prospectively recruited adult patients with acute signs and symptoms suggestive of retinal detachment and provided enough detail on diagnostic test and criterion standard results to construct contingency tables. Evidence quality was independently assessed by 2 investigators using the revised Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Discrepancies were resolved by consensus or adjudication by a third reviewer. Diagnostic test characteristics were summarized for trials with a low risk of bias. Results—Of 7771 unique citations identified, 78 were selected for full text review, resulting in 4 trials assessed for quality. Agreement between authors’ QUADAS-2 scoring was good (Оє = 0.63). Overall trial quality was deemed to be excellent with a low risk of bias in 3 studies. All 3 trials enrolled emergency department–based patients (N = 199) and evaluated clinician-performed bedside OUS using either a 7.5- or 10-MHz linear array probe. The prevalence of retinal detachment ranged from 13% to 38%. Sensitivity and specificity ranged from 97% to 100% and 83% to 100%, respectively. Conclusions—Bedside OUS has a high degree of accuracy in identifying retinal detachment based on 3 small prospective investigations. A larger prospective validation of these findings would be valuable. 1540708 Accuracy and Interobserver Agreement of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children Joni Rabiner,1* Jeffrey Avner,1 Hnin Khine,1 Lana Friedman,2 James Tsung2 1Pediatrics, Division of Emergency Medicine, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York USA; 2Emergency Medicine, Division of Pediatric Emergency Medicine, Mount Sinai School of Medicine/Mount Sinai Medical Center, New York, New York USA Objectives—To determine the test performance characteristics and interobserver agreement for point-of-care ultrasound (US) performed by clinicians compared to computed tomography (CT) or x-ray diagnosis of skull fractures. Methods—This was a prospective study of a convenience sample of patients <21 years of age who presented to the emergency department with head injuries or suspected skull fractures requiring a CT scan or x-ray evaluation. After a 1-hour focused US training session, clinicians performed US examinations to evaluate patients for skull fractures. CT scan and x-ray interpretations by attending radiologists were the reference standards for this study. Point-of-care US scans were reviewed by an experienced sonologist to evaluate interobserver agreement. Results—Point-of-care US was performed on 72 subjects with suspected skull fractures by 17 clinicians. The mean age was 6.5 years (SD, 6.2 years), and 67% of patients were male. The prevalence of fracture was 11% (n = 8). Point-of-care US for skull fracture had sensitivity of 88% (95% confidence interval [CI], 53%–98%), specificity of 97% (95% CI, 89%–99%), a positive likelihood ratio of 28 (95% CI, 7–112), and a negative likelihood ratio of 0.13 (95% CI, 0.02–0.81). The only false-negative scan was due to a skull fracture not directly under a scalp hematoma, but rather adjacent to it. The Оє for interobserver agreement was 0.86 (95% CI, 0.67–1.0). Conclusions—Clinicians with focused US training were able to diagnose skull fractures in children with high specificity and interobserver agreement. 1540563 Bedside Ultrasonography as an Adjunct to Routine Workup in Evaluation of Suspected Acute Appendicitis in the Emergency Department Samuel Lam,1* Anthony Grippo,1 Christopher Kerwin,1 P. John Konicki,1 Diana Strasburger1,2 1Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois USA; 2 Emergency Medicine, MacNeal Hospital, Berwyn, Illinois USA Objectives—To evaluate the test characteristics of emergency physician–performed bedside ultrasound (BUS) for the diagnosis of appendicitis. To identify components of routine emergency department (ED) workup and BUS that are associated with the presence of appendicitis. Methods—Patients 4 years of age and older presenting to the ED with suspected appendicitis were eligible for enrollment. After informed consent was obtained, BUS was performed on the subjects by trained emergency physicians who had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose appendicitis. Elements of the clinical history and physical examination, white blood cell count (WBC) with polymorphonuclear percentage (PMN), and BUS findings were recorded on data forms. Recorded BUS images were reviewed weekly during quality assurance sessions. Subject outcomes were ascertained by a combination of medical record review and telephone follow-up. Results—A total of 125 subjects consented for the study, and 116 of them had adequate data for final analysis. The prevalence of appendicitis was 37%. The mean age of the subjects was 20.2 years, and 51% were male. BUS was 100% sensitive (95% confidence interval [CI], 87%–100%) for detection of appendicitis, with a positive predictive value of 72% (95% CI, 56%–84%). Specificity was not calculated because of the large number of nondiagnostic BUS studies. Subjects with appendicitis had a significantly higher occurrence of anorexia, nausea, and vomiting and higher WBC and PMN counts on presentation when compared to those without appendicitis. Their BUS studies were also significantly more likely to lead to visualization of the appendix, as well as findings of appendix diameter >6 mm, appendix wall thickness >2 mm, periappendiceal fluid, and sonographic McBurney’s sign (univariate analysis, P < .05). BUS success and accuracy were independent of operator, parenteral narcotic or antiemetic administration, subject body mass index, or scanning time. Conclusions—BUS was highly sensitive for appendicitis diagnosis in the ED in our study. The presence of several findings in the history, physical exam, and laboratory testing and on BUS increased the likelihood of the diagnosis. S77 13proceedings_Layout 1 3/5/13 10:39 AM Page S78 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1536633 Retrospective Review of Emergency Bedside Ultrasound for Diagnosis of Pediatric Intussusception Adam Wise,* P. John Konicki, Christopher Yenter, Samuel Lam Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois USA Objectives—To report the test characteristics of emergency physician–performed bedside ultrasound (BUS) for the diagnosis of pediatric intussusception at a single institution. Methods—The pediatric emergency department (ED) electronic medical record and BUS archive were first screened to retrospectively identify visits between January 1, 2909, and August 31, 2012, during which BUS was performed. These records were then reviewed to identify patients meeting the following inclusion criteria: (1) age 0 to 18 years seen in the ED with a clinical presentation concerning for intussusception, (2) BUS performed to identify intussusception and bedside impression documented in the medical record, and (3) a “formal” diagnostic study (computed tomography, ultrasound, or barium enema) was performed by the radiology department after BUS was completed. All emergency physicians who performed BUS had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose pediatric intussusception. Results—A total of 1607 charts were reviewed, with 46 meeting inclusion criteria. Four of those were later excluded for incomplete documentation or lack of saved BUS images. Of the 42 patients ultimately included, 28 were male (67%). The prevalence of intussusception was 21%. The mean age of the subjects was 32 months. There were a total of 11 positive and 31 negative BUS studies. BUS was 100% sensitive (95% confidence interval [CI], 62%–100%) and 94% specific (95% CI, 78%– 99%) for detection of intussusception compared to radiology study results. There were 2 false-positives (1 of which was determined to be transient intussusception after review of the bedside images with the radiologist) and no false-negative BUS studies. Specificity of BUS increased to 97% if only 1 false-positive was taken into account. Conclusions—BUS is an accurate means of diagnosing pediatric intussusception. Further study may be indicated to confirm such benefits. Table 1. Test Characteristics of BUS Against Radiology Study Results Radiology Results Intussusception Intussusception BUS Results Positive Negative 2 (1a) Intussusception positive 9 (10a) Intussusception negative 0 31 a Case of transient intussusception counted as true-positive. 1539106 Extension of the Thoracic Spine Sign as an Indicator of Pleural Effusion Eitan Dickman,* Suzanne Bialeck, Lawrence Haines, Catherine Baxtrom, Victoria Terentiev, Antonios Likourezos, Sergey Ayvazyan Emergency Department, Maimonides Medical Center, Brooklyn, New York USA Objectives—Shortness of breath is a frequent complaint for emergency department (ED) patients. Pleural effusion (PEf) is a common cause of dyspnea. While computed tomography (CT) is considered the criterion standard for the diagnosis of PEf, chest x-ray (CXR) is often employed. Ultrasonography can be rapidly performed at the bedside to identify many causes of dyspnea. PEf may appear as an anechoic collection superior to the diaphragm, but this finding is not always present. In a normal ultrasound, the thoracic spine is not detected superior to the diaphragm due to the high acoustic impedance of the lungs. If the thoracic spine is visualized extending superior to the diaphragm, this is likely due to the presence of fluid in the thorax. This study attempted to determine the utility of the extension of the thoracic spine as a sonographic sign for detecting PEf and to compare its diagnostic sensitivity to that of CXR. Methods—Emergency physicians enrolled ED patients who were undergoing a CXR and CT of the trunk. All participating physicians attended a lecture covering lung ultrasonography and performed supervised chest ultrasound examinations until deemed proficient. The sonographers were blinded to any other imaging results. Patients were placed supine with the head of the bed at approximately 45В°. A 6–2-MHz curved array transducer was placed in a coronal orientation in the midaxillary line in the right and left upper quadrants so that the diaphragm and the abdominal spine could be identified. Both hemithoraces were imaged, and the investigator documented whether the thoracic spine extended superior to the diaphragm, thus providing evidence of fluid in the hemithorax. These results were compared to radiologists’ interpretation of the CXR and CT. Results—A total of 149 patients were enrolled. Sensitivity of the extension of the thoracic spine sign for PEf was 72%; specificity was 89%. For CXR, sensitivity was 61%; specificity was 98%. Conclusions—The extension of the thoracic spine sign is helpful in determining the presence or absence of PEf. 1537918 Bedside Ultrasound Skills Acquisition by Medical Students on Emergency Medicine Rotation Uche Blackstock,* Jacqueline Munson, Christian Koziatek, Demian Szyld Emergency Medicine, Bellevue Hospital/New York University Medical Center, New York, New York USA Objectives—Few opportunities exist for medical students to receive formal instruction in bedside ultrasound (BUS). Therefore, we developed a BUS simulation-based curriculum for rotating emergency medicine (EM) students consisting of Web-based didactics and a handson skills session. We hypothesized that the curriculum would adequately prepare students to perform 2 common EM procedures: a focused assessment with sonography for trauma (FAST) exam and placement of ultrasound-guided internal jugular central venous access (IJ CVA). Methods—Forty-five medical students (16 second year, 21 third year, 8 fourth year) on an EM rotation were enrolled. Participants viewed 3 instructional Web-based videos about BUS physics, the FAST exam, and BUS-guided IJ CVA. Subsequently, participants attended a 3-hour handson BUS simulation-based training session led by a BUS expert, an EM attending physician with >7 years of BUS experience and >3000 completed BUS scans. After the initial training session, the BUS expert observed participants’ FAST exams on a live volunteer, while a trained research assistant evaluated participants’ IJ CVA skills on an instructional mannequin. Standardized checklists were used for both assessments. A passing score of 70% on each checklist was chosen prior to study initiation. Results—Eighty-nine percent (40/45) of participants passed the FAST and 96% (43/45) passed the IJ CVA skills assessments. Participants were successful in obtaining most required FAST views, yielding a right upper quadrant mean score of 90.6%, left upper quadrant score of 88.3%, bladder view score of 97.2%, and lung sliding score of 90.6%, but had the most difficulty with the cardiac view (72.2%). Eighty-four percent (38/45) of participants placed successful IJ CVA within 3 attempts, 64.4% (29/45) achieving success on the first attempt. Ninety-one percent (41/45) avoided inadvertent puncture of the carotid artery. Conclusions—A standardized curriculum consisting of Webbased didactics followed by a simulation-based hands-on session yields high passing rates by rotating EM medical students on BUS skills assessments. Further studies are required to investigate the impact of undergraduate BUS education on skills acquisition and retention once students reach residency. S78 13proceedings_Layout 1 3/5/13 10:39 AM Page S79 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1434950 Number of Proctored Pediatric Focused Assessment With Sonography for Trauma Exams Required for Proficiency Sharon Yellin,1,2* Jennifer Chao,2 Richard Sinert,2 John Gullett,2 Gerardo Chiricolo1 1Pediatric Emergency Medicine/Emergency Ultrasound, New York Methodist Hospital, Brooklyn, New York USA; 2Pediatric Emergency Medicine/ Emergency Medicine, Kings County Hospital/State University of New York Downstate Medical Center, Brooklyn, New York USA Objectives—To assess the number of proctored focused assessment with sonography for trauma (FAST) exams necessary for the novice sonographer to accurately acquire the 4 views of the exam. Methods—This was a prospective educational intervention study of FAST exam mastery by novice third- and fourth-year medical students (MS). Students were excluded if they had formal ultrasound training or prior experience. All students received a 2-hour online didactic course on basic ultrasound and FAST. Students were then randomized into 1 of 3 groups: group 1, students performed 5 proctored exams; group 2, 10 exams; and group 3, 15 exams. Proctored exams were designed to give the students hands-on practice under the guidance of trained sonographers. The proctored exams were administered monthly and limited to 10 minutes to standardize the training sessions. At the end of each month, students were tested on the FAST exam with the same 2 standardized patients, either a male 8 years old (body mass index [BMI] = 16.5 [66th percentile]) or a female 12 years old (BMI = 18.8 [60th percentile]). Students had 2 minutes to perform the test exam starting from the time they picked up the probe. The test exams were recorded using video and later reviewed and graded by examiners blinded (to groups) using a standardized data scoring sheet. To pass, the students were required to obtain the standard views of the organs and/or structures necessary to identify free fluid. Results—Forty-five students consisting of 23 MS3s and 22 MS4s, ages 24 to 43 years, were enrolled. Groups were evenly matched for MS year, age, and gender. Pass rates were lowest for group 1 (n = 15; 6.7%; 95% confidence interval [CI], 0.0%–31.8%) and significantly (P < .05) higher for group 2 (n = 15; 60%; 95% CI, 35.7%–80.2%) and group 3 (n = 15; 86.7%; 95% CI, 60.9%–97.5%). The majority of failures in group 1 were secondary to inability to complete the exam in the allotted time, followed by difficulty in identifying the splenorenal interface. Conclusions—An online course and proctored exams provides students with the skills to perform FAST accurately on children. Five proctored exams is insufficient training for novice sonographers to master FAST. Differentiating the added effect of increasing the number of proctored exams from 10 to 15 will depend on future enrollment. 1540999 Didactic and Hands-on Ultrasound Courses: Improving the Point-of-Care Ultrasound Knowledge Base and Confidence Levels in Emergency Medicine Providers Athena Mihailos,* Kevin O’Rourke, Timothy Mooney, Andrew Balk, Larissa Dudley, Lawrence Melniker, Sharon Yellin, Gerardo Chiricolo Ultrasound, New York Methodist Hospital, Brooklyn, New York USA Objectives—Point-of-care ultrasonography (POCUS) has proven to be a valuable, safe, and life-saving tool in the emergency department for ascertaining quick and often critical diagnoses. The goal of our study was to evaluate the effect of an ultrasound course on the knowledge base (KB) and overall confidence level (CL) of emergency medicine (EM) physicians in performing and interpreting ultrasounds. This course included didactics and hands-on training. Methods—On July 25, 2012, the Emergency Ultrasound Division at New York Methodist Hospital led a 9-hour didactic and hands-on ultrasound course. First, there were introductory lectures on the basics of POCUS: exam setup, knobology, reporting, and data management as well as the 5 life-saving competencies: procedural, echocardiography, focused assessment with sonography for trauma, first trimester, and aorta. A handson tutorial then followed. Two tests were administered to 30 providers assessing KB and CL in performing and interpreting the ultrasounds both prior to and at the conclusion of the course. The providers consisted of EM residents and attendings that were separated into 2 groups. Novice providers had not met the American College of Emergency Physicians ultrasound training guidelines, and more experienced providers had either met or exceeded the guidelines. The data were interpreted using the change in CL and KB of both groups prior to and on completion of the course. Results—There was a 75% increase in overall CL in the novice group on completion of the course vs a 35% increase in the more experienced providers. There was a 54% increase in the grades of the novice participants vs a 33% increase in the more experienced participants. There was no drop in CL or grades in either group. Conclusions—An Emergency Ultrasound Division course followed by hands-on training led to increased CL and KB in both performing and interpreting POCUS by all participating providers. The greatest percentage increase was appreciated in the novice providers. Obstetric Ultrasound: Multiple Gestations and New Techniques Moderators: Anthony Johnson, MD, Martha Kelly-Martinez, RDMS 1540640 Accuracy of Ultrasonographic Chorionicity Classification Yair Blumenfeld Eunice Kennedy Shriver National Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network, Bethesda, Maryland USA Objectives—Ultrasonographic (US) classification of chorionicity is important in managing multiple gestations, as some antepartum surveillance and delivery timing recommendations differ by chorionicity. Our objective was to estimate the accuracy of US chorionicity classification in a multicenter cohort of twins and investigate factors associated with accuracy. Methods—This was a secondary analysis of a randomized trial of preterm birth prevention of twins. Patients lacking data regarding US chorionicity classification or pathologic chorionicity determination were excluded. Maternal, obstetric, and US factors were assessed for possible effects on US accuracy. Results—A total of 545 twin sets whose chorionicity was classified by US prior to 20 weeks were included in this analysis (116 excluded). Of those, 455 were dichorionic and 90 were monochorionic by pathologic evaluation. US misclassified 35 of 545 twins (6.4% overall misclassification); 18 of 455 dichorionic twins were misclassified as monochorionic by US (4%), while 17 of 90 monochorionic twins were misclassified as dichorionic by US (19%). The sensitivity, specificity, and positive and negative predictive values of US chorionicity determination were 96%, 81%, 96%, and 80%. First-trimester US (<14 weeks’ gestation) was less likely to misclassify chorionicity than that performed from 15 to 20 weeks (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.23, 0.96). For each 1-day increase in gestational age, the odds of misclassification rose by 1% (OR. 1.01; 95% CI, 1.002, 1.03). None of the other factors, including maternal age, body mass index, parity, and prior cesarean, affected US accuracy. Conclusions—US performed prior to 20 weeks incorrectly identified chorionicity in 6.4% of twin gestations. Importantly, 1 in 5 monochorionic gestations were incorrectly classified as dichorionic and may not have been optimally managed. These data highlight the importance of evaluating chorionicity early in gestation and reconsidering the classification of dichorionicity in certain circumstances (eg, with features suggestive of twin-to-twin transfusion). S79 13proceedings_Layout 1 3/5/13 10:39 AM Page S80 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1539223 Outcome After Second-Trimester Amniocentesis and First-Trimester Chorionic Villus Sampling for Prenatal Diagnosis in Multiple Gestations Christian Enzensberger,1* Christina Pulvermacher,1 Jan Degenhardt,1 Andreaa Kawecki,1 Ute Germer,2 Jan Weichert,3 Martin Krapp,4 Ulrich Gembruch,5 Roland Axt-Fliedner1 1 Division of Prenatal Medicine, University of Giessen & Marburg, Giessen, Germany; 2Center for Prenatal Medicine, Caritas Krankenhaus St Josef, Regensburg, Germany; 3Division of Prenatal Medicine, University of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany; 4Center for Endocrinology, Reproductive and Prenatal Medicine, Amedes Hamburg, Hamburg, Germany; 5Division of Prenatal Medicine, University of Bonn, Bonn, Germany Objectives—The purpose of this study was to classify pregnancy loss and fetal loss as well as the influence of maternal risk factors in multiple pregnancies. Methods—Details of the procedure and pregnancy outcome of all patients were extracted from the clinical audit databases of 2 tertiary centers. The files were collected in the time from January 1993 to December 2010. The procedure-related pregnancy and fetal loss rates were classified as all unplanned abortions without important fetal abnormalities or obstetric complications within 14 days after amniocentesis (AC) and chorionic villus sampling (CVS). Results—We had a total of 288 multiple pregnancies with a total of 637 fetuses. After exclusion of 112 pregnancies with an abnormal karyotype or fetal abnormalities detected by ultrasound as well as cases of selective feticide, repeated invasive procedures, and monochorionic monoamniotic pregnancies, 176 pregnancies and 380 fetuses, respectively, were left for final analysis. Overall, 132 ACs and 44 CVSs were performed. The total pregnancy loss rate was 8.0% (14/176): 6.1% (n = 8) for AC and 13.6% (n = 6) for CVS. The procedure-related pregnancy loss rate was 3.4%: 2.3% after AC (3 cases) and 6.8% after CVS (3 cases). There was no statistical significance between the 2 procedures (P = .15). Conclusions—The procedure-related loss rate of 3.4% can be compared with those in literature. The higher loss rates in multiple pregnancies than in singleton pregnancies have to be discussed when counseling parents. 1540424 Breaking Bad News During Perinatal Sonography: Practical Aspects of a Novel Educational Pilot Using Highfidelity Hybrid Simulation David Jackson,1* Petar Planinic,1 James Pennington,1 Gigi Guizado de Nathan,2 Gwen Shonkwiler,3 Thomas Abdella1 1 Maternal-Fetal Medicine, 2Clinical Simulation Center of Las Vegas, University of Nevada School of Medicine, Las Vegas, Nevada USA; 3Medical Education and Evaluations, University of Nevada School of Medicine, Reno, Nevada USA Objectives—Few issues are as predictably inevitable as bad news occurring during fetal sonography. There are currently no standards on how to teach this essential communication skill. A pilot program using high-fidelity hybrid standardized patient (SP) encounters for the delivery of bad news in perinatal imaging is presented. Methods—The budget for the project was $7200. Four residents (25% of our program) experienced 2 simulations each. A live video feed allowed additional medical and sonography students to observe in a classroom setting. Transvaginal simulation of an anembryonic gestation and transabdominal simulation of severe fetal hydrocephalus were presented. Resident sonographers were unaware of the impending scenario outcome. The transvaginal exam used a MedaPhor virtual reality “realfeel” haptic simulator placed between the actor’s legs (covered by a sheet). The transabdominal exam used a linear video played on the screen of an ultrasound machine. Following the simulation, faculty gave immediate feedback on verbal and nonverbal mannerisms by sharing observations from the recorded video. SPs then provided additional insight on perceived communication skills. The exercise was completed with a classroom didactic on evidence-based techniques for breaking bad news followed by faculty and participant group discussion. Results—Residents and medical students enthusiastically reported that the simulation should be part of any future curricula. Postgraduate year 1 was designated as the year to begin. Despite varying levels of training, both residents and medical students rated the experience as level appropriate. The simulation was rated 5 overall (with 5 as excellent). Individual segments were rated as: didactic (5), faculty feedback (5), video review (4.9), SP feedback (4.75), and viewing in the classroom (4.7). Conclusions—High-fidelity hybrid simulation allows needed skill training in communicating bad news during perinatal sonography. Actor simulation, faculty video feedback, and a classroom didactic with group discussion are valued components. The use of simulation-based training for all sonographers in communicating bad news is an area for future study. 1525554 Coronal Measurement of Fetal Lateral Ventricles: A Crosssectional Ultrasonographic Study Eldad Katorza,1* Nir Duvdevani,1 Jeffrey-Michael Jacobson,2 Yinon Gilboa,1 Chen Hoffmann,2 Reuven Achiron1 1 Obstetrics and Gynecology, 2Radiology, Sheba Medical Center, Tel Hashomer, Israel Objectives—The aim of this study was to compare the diameter of the lateral cerebral ventricles measured on a traditional axial view with measurements obtained in an unconventional coronal plane. Methods—We conducted a prospective study of 144 fetuses in which 2D sonographic measurements of the lateral ventricles in both axial and coronal planes were performed at 19 to 38 weeks of gestation. Seventy-seven fetuses were evaluated as part of a routine fetal scan (routine group), and 67 were referred for a dedicated scan (referral group). For each fetus, only the distal lateral ventricle’s diameter was able to be measured by the “classic” transventricular axial plane, whereas both ventricles were visible in the posterior coronal plane at the level of the atria using a transcerebellar approach. Results—The mean gestational age was 27.7 В± 4.6 weeks. Good visualization of both ventricles was achieved in 91% of the cases using the coronal plane. For the entire study group, the mean width of the distal lateral ventricle on the axial plane was 7.9 В± 1.9 mm vs 8.2 В± 1.9 mm on the coronal plane (P < .001). The mean axial width was 6.6 В± 1.1 mm in the routine group vs 9.3 В± 1.6 mm in the referral group (P < .001). Coronal measurements yielded similar results. In addition, slight asymmetry of the ventricles was detected in the routine group (0.2 mm), and the asymmetry was even more significant in the referral group (1.6 mm; P < .001). Conclusions—Measurement of both proximal and distal ventricles is very important in the diagnosis of ventriculomegaly and essential in measuring ventricular asymmetry, both of which can be associated with a bad prognosis. Our study showed that coronal measurement of both proximal and distal ventricles is feasible, an advantage over the axial view in which only the distal ventricle is clearly visible and measurable. 1537200 Feasibility of an Automated Modified Myocardial Performance Index System: A Novel Technique for Automated Measurement of a Modified Fetal Myocardial Performance Index Mi-Young Lee,1* Hye-Sung Won,1 Eun-Jin Jeon,1 Jae-Yoon Shim,1 Hee-Chul Yoon,2 Jin-Young Choi,3 Soon-Jae Hong3 1 Maternal-Fetal Medicine, Asan Medical Center, Seoul, Korea; 2 Digital Media City Research and Development Center, 3 Reserch and Development Team, Health and Medical Equipment Business Team, Samsung Electronics Co, Ltd, Suwon, Korea Objectives—To evaluate the reliability and reproducibility of the fetal left modified myocardial performance index (Mod-MPI) meas- S80 13proceedings_Layout 1 3/5/13 10:39 AM Page S81 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 urements using an Auto Mod-MPI system as a novel technique for measuring the Mod-MPI. Methods—This was a prospective study of 117 cases from 110 normal singleton fetuses at 16.4 to 35.0 weeks of gestation. Two experienced operators each measured the left Mod-MPI twice manually and twice automatically using the Auto Mod-MPI system (Samsung Electronics Co, Ltd). This system operates as follows. At first, the clear image of the opening and closing clicks of mitral and aortic valves should be obtained. When the operator places the cursor on the aortic outflow in a single Doppler waveform and presses the Set key, the system automatically places the calipers at the beginning of each click and calculates the Mod-MPI within 0.1 second. We evaluated whether the automated system can successfully measure the left Mod-MPI. Intraoperator and interoperator reproducibility were also assessed using intraclass correlation coefficients (ICCs), and the manual and automated measurements obtained by a more experienced operator were compared using the Bland-Altman plot and ICCs. Results—Among 117 cases, both operators successfully measured the left Mod-MPI in 114 cases using the Auto Mod-MPI system (success rate, 97.4%). All values of automated measurements by both operators were perfectly matched (ICC = 1 for both intraoperator and interoperator reproducibility). Among the manual measurements, the intraoperator ICCs of both operators were 0.910 (95% confidence interval [CI], 0.872–0.937) and 0.826 (95% CI, 0.758–0.877), respectively. The interoperator ICC was 0.731 (95% CI, 0.678–0.785), and the mean difference between the operators was 0.017 (95% CI, 0.010–0.024). There was good agreement between the manual and automated values measured by the more experienced operator (ICC = 0.841). Conclusions—The Auto Mod-MPI system is a fast and reliable technique for measuring the Mod-MPI with excellent reproducibility. 1541081 First-Trimester Pregnancy Dating by Fetal Heart Rate: A Simple Formula Sarah Obican,1,2* Slava Khodak Gelman,2 John Larsen2 1 Maternal-Fetal Medicine, Obstetrics and Gynecology, Columbia University, New York, New York USA; 2Obstetrics and Gynecology, Maternal-Fetal Medicine, George Washington University, Washington, DC USA Objectives—Accurate dating is an essential tool in the management of pregnancies. Thus, we sought: (1) to develop a new formula that establishes an association between fetal heart rate (FHR) and gestational age in pregnancies <9 weeks; and (2) to compare the 2 methods of early pregnancy dating by crownrump length (CRL) measurement (established method) and FHR measurement (proposed method). Methods—We conducted a retrospective analysis of early ultrasound exams of 176 singleton pregnancies with care at George Washington University between January 2001 and May 2011. The FHR was obtained by standard Doppler techniques with low indices on pregnancies seen for dating ultrasound between 4.5 and 8.5 weeks. Three variables were subsequently retrieved for analysis from the selected cases: fetal heart motion (FHMO), CRL, and gestational age based on CRL measurement). A fourth variable, gestational age calculated from FHR measurement (GAFHRM), was created using a proposed formula: GAFHRM = FHR/20. The 2 methods of gestational age calculation were compared statistically using the Pearson correlation and the Student t test. Results—There was a very strong correlation between the established method and our proposed method (r = 0.95). The average difference between methods was 0.13 days with an SD of 2.5 days. There was no significant difference in gestational age (P = .48), suggesting that the methods did not differ significantly in pregnancy dating. It was found that 87.5% of the pairings of measurements were within the 2.5 days. Conclusions—We developed a novel formula to calculate gestational age early in pregnancy based on FHR: GAFHRM = FHR/20 В± 2.5 days, where 2.5 days is the SD derived from comparison to the estab- lished CRL method. Data analysis of this pilot study demonstrates that this method of pregnancy dating is highly consistent with the traditional approach of dating pregnancy by the CRL method during early pregnancy. Further study in an independent patient cohort is warranted to validate this approach. 1537085 Umbilical Cord Blood Volume Flow Evaluation Using 3-Dimensional Ultrasound Stephen Pinter,1* Jonathan Rubin,1 Oliver Kripfgans,1 Marjorie Treadwell,2 Vivian Romero,2 Michael Richards,1 Man Zhang,1 Anne Hall,3 J. Brian Fowlkes1 1Radiology, 2 Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA; 3GE Healthcare, Wauwatosa, Wisconsin USA Objectives—Umbilical cord blood volume flow measurement with the intention of providing a straightforward and accurate method that overcomes the limitations associated with traditional pulsed wave Doppler flow methods and provides a means to recognize and manage at-risk pregnancies. Methods—A GE LOGIQ 9 ultrasound system (4D16L [4.5– 16.0 MHz]; 4D3CL [2.0–5.0 MHz]) was used to acquire multivolume 3D color Doppler data sets to assess umbilical flow. Volume flow was computed offline by surface integration of Doppler-measured velocity vectors in a c-surface (lateral-elevational plane) positioned near the color flow focal depth. Partial volume effects were corrected using Doppler power. The proposed flow measurement technique overcomes the limitations of traditional pulsed wave Doppler flow methods. The first study involved volume flow measurements in 7 healthy ewes whose pregnancies ranged from 18 to 19 weeks’ gestation (7 singletons). Sonographic umbilical arterial and venous flow measurements (4D16L) from each fetus were compared to the corresponding average measured arterial/venous flow to assess measurement feasibility in a static vessel. A second complementary study involved flow measurements (4D3CL) in 7 healthy women whose pregnancies ranged from 17.9 to 36.3 weeks’ gestation (6 singletons, 1 twin). Umbilical venous flow measurements were compared to values reported in the literature to assess measurement feasibility in a dynamic vessel. Results—In the fetal sheep model, arterial/venous flow comparisons yielded errors of ≤10% for 8 of the 9 measurements. In the clinical study, venous flow measurements showed agreement with the literature over a gestational range of 24.6 to 36.3 weeks. Two of the 7 patients in the clinical study demonstrated lower flow than anticipated for gestational age; 1 was subsequently diagnosed with intrauterine growth restriction and the other with preeclampsia. Conclusions—Accurate measurements of umbilical cord blood volume flow can be performed with relative ease in both the sheep model and humans using the proposed 3D ultrasound flow measurement technique. Results encourage further development of the method as a clinical means for diagnosis and identification of at-risk pregnancies. 1536973 Defining the Spatial Relationships Between 8 Anatomic Planes in the 11 + 6- to 13 + 6-Week Fetus: A Pilot Study Reem Abu-Rustum,1* Sameer Abu-Rustum,2 M. Fouad Ziade3 1Center for Advanced Fetal Care, Tripoli, Lebanon; 2 Obstetrics and Gynecology, Nini Hospital, Tripoli, Lebanon; 3 Faculty of Public Health, Lebanese University, Tripoli, Lebanon Objectives—Our study aimed at investigating the spatial relationships between 8 anatomic planes in the 11 + 6- to 13 + 6-week fetus. Methods—This was a retrospective pilot study where 3D/4D stored data sets were manipulated to retrieve 8 anatomic planes starting from the midsagittal plane of the fetus. The initial volumes were manipulated in reference plane A using rotation along the x-, y-, and z-axes to de- S81 13proceedings_Layout 1 3/5/13 10:39 AM Page S82 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 pict the fetus in the same midsagittal plane required for nuchal translucency measurement. Subsequently, to ensure uniformity in the approach, standardization, a prerequisite for automation, had to be completed in 2 of the 3 orthogonal planes prior to navigating through the volume to commence the navigation from the plane of the transverse abdominal circumference. This was accomplished by placing the reference dot in the fetal spine at the level of the diaphragm in plane A, generating a transverse plane of the fetal abdomen with the fetal stomach visible in plane B. Plane B was then chosen as the designated reference plane 0 from which to navigate within the volume. We coined this standardized approach the midsagittal volume technique, and it was carried out on all the volume data sets prior to navigating through each volume. Parallel shift was used starting from plane 0, and the spatial relationships to 7 planes (5 cephalad and 2 caudad) were established. The median and range were calculated for each of the planes, and they were evaluated as a function of the fetal crown rump length. P < .05 was considered statistically significant. Results—A total of 63 volume data sets were analyzed. The 8 anatomic planes were found to adhere to normal distribution curves, and most of the planes were in a definable relationship to each other with statistically significant correlations. Conclusions—To our knowledge, this is the first study to describe the possible spatial relationships between eight 2D anatomic planes in the 11 + 6- to 13 + 6-week fetus, using a standardized approach. Defining these spatial relationships may serve as the first step for the potential future development of automation software for fetal anatomic assessment at 11 + 6 to 13 + 6 weeks. 1537670 Does Cervical Cerclage Placement Prolong Gestation in Twin Pregnancies With a Sonographically Short Cervix? Sara Brubaker,* Samantha Do, Noelia Zork, Cara Pessel, Joy Vink, Annette Perez-Delboy, Sreedhar Gaddipati Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA Objectives—There are limited data to support the use of cervical cerclage in twin pregnancies. The practice has become less common since the 2005 publication of a meta-analysis that revealed an increased risk of adverse pregnancy outcomes among twin pregnancies in which a cerclage was placed. The practice continues, however, likely driven in part by patient request. Our objective was to compare gestational age at delivery among patients with twins and a short cervix who underwent cerclage placement with those who did not. Methods—We created a retrospective database of twin gestations that were diagnosed with a short cervix (cervical length ≤2.5 cm) between 2004 and 2012 at our institution. Mean gestational age (GA) at delivery was compared in women who did and did not undergo cerclage placement using a 2-sample t test. The relative risk (RR) of delivery prior to 32 and 34 weeks’ gestation was compared using a 2-sided П‡2 test. Results—Of the 158 women that met the inclusion criteria, 25 underwent cerclage placement. The mean GA at delivery in the cerclage group was 32.6 weeks vs 33.8 weeks for the no-cerclage group (P = 0.77). The RRs of delivery at <32 and <34 weeks’ gestation in the cerclage vs nocerclage groups were 1.12 (confidence interval [CI], 0.81–1.58) and 0.99 (CI, 0.8–1.45), respectively. Conclusions—Studies evaluating the efficacy of cerclage in twin gestations are mixed and are limited by small sample sizes. This is among the largest single-center case series of cerclage in twin pregnancies with a short cervix. We found that cerclage placement in these patients is not associated with prolonged gestation. Larger prospective randomized trials are required to more definitively answer this question. S82 13proceedings_Layout 1 3/5/13 10:39 AM Page S83 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 SCIENTIFIC E-POSTERS 1426579 Process for Selection and Implementation of a New Ultrasound Imaging System Donald Tradup,1* Scott Stekel,1 Deirdre King,1,2 Nicholas Hangiandreou1 1Radiology, Mayo Clinic, Rochester, Minnesota USA; 2Trust Addenbrooke’s Hospital, Cambridge, England Objectives—Many factors come into play when selecting a new ultrasound (US) imaging system, including image quality, work flow efficiency, ergonomics and system usability, and system serviceability. This presentation will describe a comprehensive process for US equipment selection and implementation in the practice. Methods—(A) Assessment of practice requirements. (B) Key scanner features to consider: (1) available transducers; (2) imaging features; (3) work flow efficiency and ergonomic enhancements; (4) technical characteristics and features. (C) In-house prepurchase scanner evaluation: (1) performance testing; (2) volunteer imaging and image quality assessment; (3) patient imaging. Results—Clinical implementation after purchase: (1) acceptance testing; (2) configuration of image presets and exam protocols; (3) user training. Conclusions—This presentation will describe a comprehensive process for selection and implementation of new US imaging systems. Key elements of the selection process include a practice needs assessment, review of available scanner features and capabilities, and an in-house evaluation of all candidate systems prior to purchase. After purchase, acceptance testing, system configuration, and user training must all be addressed. 1427024 Usefulness of 4-Dimensional Ultrasonogaraphy to Evaluate Effects of Therapeutic Radiofrequency Ablation for Hepatocellular Carcinoma Naoki Hotta Gastroenterology, Masuko Memorial Hospital, Nagoya, Japan Objectives—Studies to evaluate the tumor vascularity in hepatocellular carcinoma (HCC) have been done extensively with various imaging modalities because the finding of the vascularity is helpful to evaluate the biological features of the tumor. In the present study, we investigated whether 4D real-time flow imaging is useful to display the accurate position of the radiofrequency ablation (RFA) needle in the tumor and evaluated the efficacy of RFA therapy in patients with HCC. Methods—Fifty-eight patients with 58 HCC lesions admitted to our Masuko Memorial Hospital between November 2007 and February 2011 were enrolled in the present study. Their diagnosis was confirmed by dynamic computed tomography and celiac angiography. All patients gave written informed consent, and this protocol had been approved by the Human Studies Committee at Masuko Memorial Hospital. For ultrasound (US) imaging, we used Voluson 730 (GE Medical Systems, Milwaukee, WI), Aplio XG (Toshiba Medical Systems, Tokyo, Japan), and iU22 (Philips Healthcare, Bothell, WA) systems for RFA therapy with a convex probe as US systems. The Aplio and Voluson machine probe is mechanical probe, and the iU22 probe is matrix array probe. 4D real-time refers here to the display of 3D moving images composed of 3 orthogonally intersecting scans in the transverse, longitudinal, and horizontal planes. RFA was carried out under real-time US guidance. We used an RF generator with 200 W of power connected to a 17-gauge perfusion needle (Radionics Inc, Burlington, MA); the circuit was closed through a dispersive electrode. Results—It was possible to obtain an accurate position of the cool-tip needle and to perform the RFA procedure in all 58 HCC patients with 58 nodules using 4D real-time US machines. We confirmed by various angles that the needle was inserted into the center of the tumor nodule. The simultaneous study before RFA therapy showed the inflow of arterial blood and tumor stain, and importantly, it appeared that 4D realtime US provided much perceptible information on the spatial relationship between the RFA needle and the target lesion. Conclusions—We experienced the treatment of 58 patient with HCC by RFA using 4D real-time US systems. Application of this method allowed more accurate cauterization of the tumor. 1463047 Using Lung Ultrasound in the Diagnosis of Transient Tachypnea of the Newborn and Hyaline Membrane Disease in Neonates at 28 Weeks’ Gestation and Later Claudia Cadet,* James Tsung, Ian Holzman Neonatology, Mount Sinai School of Medicine, New York, New York USA Objectives—Hyaline membrane disease (HMD) and transient tachypnea of the newborn (TTN) are common neonatal respiratory disorders with overlapping clinical presentations, gestational ages, and radiographic pictures. Ultrasonographic findings may distinguish these disorders; however, data comparing diagnoses and disease severity by lung ultrasound with those by chest radiography and clinical impression are lacking. This study aimed to determine if ultrasound (1) can predict the severity of the clinical course and (2) is diagnostically consistent with chest radiography and the clinical impression. Methods—We conducted a prospective study of infants ≥28 weeks’ gestation admitted from October 15, 2011, to June 15, 2012, with respiratory distress. A group of similar but well patients were enrolled as controls. Lung ultrasound was performed on each subject in the first 24 hours of life using a GE LOGIQ P5 ultrasound machine with a 10 linear probe in both sagittal and transverse planes on anterior, axillary, and posterior views of each lung. Demographic data, duration of respiratory support (DRS), surfactant administration, radiographic diagnosis, and clinical diagnosis were collected. An expert blinded to clinical data determined ultrasonic diagnoses and percentage of B-line confluence (PBC). The primary outcome was to correlate ultrasound PBC with DRS. Secondary outcomes were comparisons of ultrasound diagnoses with those by radiography and clinical impression. Results—Twenty-six neonates (1040–4430 g, 30–40 weeks) were enrolled. Sixteen had clinical diagnosis of TTN; 5, HMD; and 5, normal. DRS ranged from 0 to 797 hours. Linear regression gave a significant correlation of DRS with PBC (R = 0.693; P = .001), improved by gestational age in a multivariable model (R = 0.765, P = .024) but not by birth weight, age at ultrasound, maternal steroids, and mode of delivery. Ultrasound was 62.5% sensitive and 100% specific in diagnosing HMD. Conclusions—PBC on lung ultrasound in the first 24 hours of life in neonates with respiratory distress correlates well with the duration of respiratory support and thus may be a useful predictor of disease severity. Ultrasound was a moderately sensitive and extremely specific test to diagnose HMD. 1464510 Central Line Confirmation With Saline and Echocardiography Ershad Elahi,* Ninfa Mehta, Shahriar Zehtabchi Emergency Medicine, State University of New York Downstate, Brooklyn, New York USA Objectives—The purpose of this study is to determine the confirmation of central venous catheter (CVC) placement by using echocardiography and agitated saline flushed through the catheter port. S83 13proceedings_Layout 1 3/5/13 10:39 AM Page S84 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Methods—This study will be a prospective convenience sample of adults who received either subclavian of internal jugular CVCs as deemed necessary by the attending physician independent of the study. Enrolled patients will undergo CVC placement by a resident or attending physician with a study investigator present to perform echocardiography and interpret the study of the agitated saline flush in real time A chest xray will be performed to confirm CVC placement as the gold standard in confirmation. Outcome Measures: The primary outcome of the study is the correlation of positive interpretation of confirmation of CVC placement on echo with correct placement as seen on chest x-ray. The other outcome measure is time to confirmation with echo vs time to confirmation with chest x-ray. Methods of Data Analysis: Data will be presented as median and interquartiles (25%–75% quartiles) for continuous variables and percentages with 95% confidence intervals (CIs) for categorical variables. Operating characteristics of bedside ultrasound in confirmation of CVC will be reported by calculating sensitivity, specificity, and positive and negative likelihood ratios, with respective 95% CIs. The time from procedure completion to confirmation by bedside ultrasound and time from procedure completion to confirmation by chest x-ray will be presented as median minutes with interquartiles. The comparison of these 2 measurements will be performed by Mann-Whitney U test. Occurrence of adverse events will be reported as percentages with 95% CI. Sample size was calculated with projected sensitivity of 0.95 with a lower CI limit of 0.90; 91 patients will be enrolled in the study. Bedside ultrasounds for each enrolled subject will be saved and reviewed by a trained sonographer blinded to the chest x-ray results. The inter-rater agreement of the blinded sonographer with the real-time sonogram interpretations will be measured by Cohen’s weighted Оє. Results—This study is still undergoing Institutional Review Board approval. Conclusions—None yet. Results—3D-PDS and DCE-MRI showed the vascularity absent posttreatment in 8 of 9 rheumatoid patients with 80% symptomatic improvement and 4 of 6 psoriatic patients with 80% symptomatic improvement. Inflammatory neovascularity decreases occurred 1 to 2 months before 80% improvement attained in all responders. Conclusions—Vascular imaging combining DCE-MRI and Doppler ultrasound appears useful in follow-up of medical anti-inflammatory treatments. 1489583 Multimodality Imaging of Laser-Ablated Prostate Tumors Robert Bard,* Daniel Sperling Biofoundation, New York, New York USA Objectives—To follow thermal treatment progress of prostate cancers with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods—Fifty-nine patients with Gleason grade 3 or 4 focal prostate cancer were prospectively scanned with a GE Voluson E9 unit employing a linear 18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction. All patient images were imaged by DCE-MRI with a 3.0-T Siemens unit within 1 week of the sonogram. Patients were treated with a 980-wavelength diode laser with end-fire heat distribution. Safety thermal zones were outlined to protect the rectum and neurovascular bundles. Results—3D-PDS and DCE-MRI showed the tumor vascularity absent posttreatment in 59 of 59 patients. No posttreatment complications were noted. Conclusions—Vascular imaging combining DCE-MRI and Doppler ultrasound appears useful in preoperative planning and follow-up of laser ablative treatments. 1489649 Multimodality Vascular Imaging of Bladder Tumors Robert Bard,* Daniel Sperling Biofoundation, New York, New York USA 1489380 Vascular Imaging of Lymph Node Metastases Robert Bard Biofoundation, New York, New York USA Objectives—To demonstrate the appearance of benign and malignant lymphadenopathy with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods—One hundred twenty-five patients with invasive breast cancer and 221 patients with postoperative lumpectomy/mastectomy follow-up were prospectively scanned with a GE Voluson E9 unit employing a linear 12–18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction. All patient images were imaged by DCE-MRI with a 3T Siemens unit within 1 week of the sonogram. All lesions were later confirmed by surgery. Results—3D PDS and DCE-MRI showed the nodal neovascularity in both axillae in 56 of 346 and 80 of 346 in a unilateral axilla. The lesions were imaged well by both modalities and showed high correlation with surgical findings. Imaging showed 136 of 346 positive axillae as compared to 69 of 346 clinically detectable by palpation. Conclusions—3D power Doppler imaging appears to as sensitive as DCE-MRI in detecting axillary lymphadenopathy. Vascular mapping may be useful in preoperative lymphadenectomy planning. 3D mapping may permit image-guided treatment. 1489474 Ultrasonic Imaging of Treated Rheumatoid and Psoriatic Arthritis Robert Bard Biofoundation, New York, New York USA Objectives—To follow treatment progress of arthritis with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods—Nine patients with active rheumatoid arthritis of the wrist and digits and 6 patients with psoriatic arthritis of the phalanges were studied over a 1-year period. Objectives—To demonstrate the appearance of benign and malignant bladder masses with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods—Ninety-five patients with a Gleason grade 4 and/or 5 base of prostate cancer and 21 patients with bladder polyps and stones were prospectively scanned with a GE Voluson E9 unit employing a linear 12–18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction. Contrast-enhanced ultrasound was performed on 3 patients. All patient images were imaged by DCE-MRI with a 1.5-T Siemens unit within 1 week of the sonogram. All lesions were later confirmed by cystoscopy or surgery. Results—3D-PDS and DCE-MRI showed the tumor vascular connection from the prostate extending into the bladder base. The vascular framework of transitional cell carcinomas was generally separable from the previously noted base of prostate tumors. The lesions of a benign nature were imaged well by both modalities and included intravesical diseases such as polyps, stones, blood clots, and intraluminal prostate debris following postoperative procedures. Conclusions—3D power Doppler imaging appears to as sensitive as DCE-MRI in detecting bladder tumors. The role of a possible screening test for evaluating hematuria deserves further study. Imaging in patients with bladder base lesions may disclose unsuspected primary prostatic tumors. Vascular mapping may be useful in preoperative planning. 1505305 Multimodality Imaging of Microwave-Treated Prostate Tumors Robert Bard Biofoundation, New York, New York USA Objectives—To follow the thermal treatment progress of microwaved prostate cancers with 3D power Doppler sonography (3D-PDS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). S84 13proceedings_Layout 1 3/5/13 10:39 AM Page S85 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Methods—Twelve patients with Gleason grade 4 prostate cancer were prospectively scanned with a GE Voluson E9 unit employing a linear 18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction. All patients were imaged by DCE-MRI with a 1.5-T Siemens unit within 1 week of the sonogram. All lesions were followed by serial vascular imaging for 5 years. Six recurrences were found and biopsy proven. Three were retreated by microwave, remaining stable, and 3 were retreated with MRI-guided laser ablation in 2012. Results—3D-PDS and DCE-MRI showed the tumor vascular recurrence in 6 of 12 patients who were retreated and followed without recurrence measured either by a vascularity increase or prostate-specific antigen rise. Conclusions—Vascular imaging appears useful in preoperative planning and follow-up of microwave thermal treatments. 1505306 Multiplanar Mapping of Cellulite Robert Bard Biofoundation, New York, New York USA Objectives—To compare the accuracy of 3D sonographic mapping of cellulite with high-resolution small-field 3-T magnetic resonance imaging (MRI). Methods—Over a 2-year period, 99 consecutive patients with palpable lower extremity subcutaneous nodules were preoperatively scanned with a GE Voluson E9 unit employing a linear 18-MHz probe with 3D angio and glass body power Doppler image reconstruction and a 3.0-T MRI small field of view within 1 week. All images were compared with histologic sections. During the last year of the study, access to 22–70MHz linear probes permitted the concomitant study of 53 patients with cellulite. Cellulite was studied with A- and B-mode ultrasound, color, power, and angio Doppler, and 3D histogram analysis of the regional blood supply and small-field 3-T MRI. Treatment used laser and antioxidant therapies. Results—With the use of 22–70-MHz probes, areas of cellulite were imaged as part of a study using antioxidant therapies to reduce disfiguring areas. MRI had no diagnostic value in cellulite evaluation, although it accurately depicted fat compartments. Additionally, Doppler ultrasound blood flow analysis showed abnormal flows in the regions of greatest cellulite architectural distortion. The depth of the subcutaneous fat may be measured and the penetration of the cellulite may be assessed with 3D volumetric dermal/subdermal imaging. Conclusions—3D multiplanar ultrasound imaging appears to be significantly more accurate than MRI in diagnosing cellulite and may facilitate laser ultrasound-guided treatments. Previsual treatment improvement may be noted by a decrease in inflammatory neovascularity. 1506560 Prostate Cancer Neovascular Responses to Antioxidants Robert Bard Biofoundation, New York, New York USA Objectives—To show Doppler sonographic vessel density imaging responses to antioxidant therapies. Methods—One hundred eleven patients with prostate cancer treated with antioxidant supplement therapies composed of beta-sitosterol, resveratrol, and herbal antioxidants and followed over a 4-year period were prospectively scanned with a GE Voluson E9 unit employing an endorectal 18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction. Eighty-seven patients had Gleason 3, and 23 had Gleason 4. Follow-up at 6, 12, 18, 24, 30, and 36 months was obtained. The vessel index was assessed on sonography by 3D histogram analysis and by dynamic contrast enhanced magnetic resonance imaging (DCE-MRI). Follow-up biopsies were obtained shortly after imaging studies, which occurred on a 6-month basis. Results—Gleason grade 3 (low grade): 72 of 87 patients had decreased vascular indices, indicating a positive response to the protocol. Prostate-specific antigen (PSA) lowering was noted. Gleason grade 4 (high grade): 10 of 23 patients had decreased vascular indices, indicating a positive response to the protocol. PSA lowering was noted. Five patients were stable. Eight patients showed disease progression and a PSA rise, indicating a negative response to the protocol. DCE-MRI confirmed all sonographic tumor vascular findings. Biopsy correlation was good. Conclusions—Vessel density sonographic indexing and DCEMRI analysis correlated well with a positive biochemical response to antioxidant therapies. Twenty-one percent of patients with aggressive tumors who were nonresponders to this protocol were referred for alternative treatments in a timely manner. 1506561 Prostate Cancer 3-Dimensional Capsular Erosion Alert for Bone Metastases and Lymphadenopathy Evaluations Robert Bard Biofoundation, New York, New York USA Objectives—To show capsular erosion as an alert to bone metastases. Methods—Eighty-one patients with capsular erosion evident on 3D imaging were prospectively scanned with a GE Voluson E9 unit employing an endorectal 18-MHz probe with conventional 3D/4D imaging using 3D angio and glass body power Doppler image reconstruction and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Results—Sixty-seven of 81 patients had boney metastases identified on MRI and bone scans. Two hundred forty patients without capsular erosion on 3D imaging showed bone metastases in 3 of 240 cases. Capsular erosion was associated with perirectal adenopathy in 40 of 81 patients. Conclusions—Patients with capsular erosion demonstrated a 3Г— incidence of bone metastases and a 2Г— incidence of perirectal lymphadenopathy. Since bone metastases are difficult to image on some standard MRI protocols, DCE-MRI may be requested to highlight abnormal neovascularity. 1507806 Evaluation of a Small Abdominal Circumference by Ultrasound as a Predictor of Increased Doppler Resistance Pedro Roca,1* Allen Kunselman,2 Gabor Mezei,1 Kari Whitley,1 Serdar Ural,1 John Repke1 1Obstetrics and Gynecology, 2 Public Health Sciences, Penn State Hershey Medical Center, Hershey, Pennsylvania USA Objectives—Ultrasonographic fetal evaluation has been used to diagnose intrauterine growth restriction (IUGR). A measurement that has shown to be predictor of IUGR is the fetal abdominal circumference (AC). The use of Doppler of the umbilical arteries is helpful in following fetuses previously diagnosed with IUGR. However, Doppler evaluation of umbilical arteries has failed to be diagnostic for IUGR. To date, no study has specifically examined the relationship if any between AC measurements by ultrasound and umbilical artery Doppler values. The objective of this study was to determine if findings of decreased AC during ultrasound can be used as an independent predictor of increased umbilical artery Doppler resistance in fetuses. Methods—After Institutional Review Board approval, we conducted a retrospective cohort study of all ultrasound studies performed at the maternal-fetal medicine Unit in our center from July to November 2009. We obtained the fetal AC expressed as a percentile of gestational age and measured the umbilical artery Doppler. The association between AC and elevated umbilical artery Doppler was evaluated. Results—A total of 299 patients were evaluated. We used the SAS 9.2 system to evaluate the 2 main variables, AC percentile and umbilical artery Doppler. We found a linear association between AC percentiles and umbilical artery Doppler percentiles. The Pearson correlation coefficient was –0.03 (95% confidence interval, –0.40, – 0.19). The R2 value was only 0.09, which means that only 9% of the umbilical artery Doppler percentile variability is explained by the AC percentile. S85 13proceedings_Layout 1 3/5/13 10:39 AM Page S86 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Conclusions—The AC percentile is a weak predictor of abnormal umbilical artery Dopplers. Further research may help in determining if ultrasound evaluations other than the AC percentile may strongly correlate with IUGR. 1508173 Persistence of Placenta Previa in Twin Pregnancies Diagnosed in the Second Trimester by the Degree of Cervical Overlap Simi Gupta,1* Nathan Fox,1,2,3 Andrei Rebarber,1,2,3 Daniel Saltzman,1,2,3 Chad Klauser,1,2,3 Ashley Roman1,2,3 1Obstetrics and Gynecology, New York University School of Medicine, New York, New York USA; 2Maternal-Fetal Medicine, Carnegie Imaging for Women, New York, New York USA; 3Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York USA Objectives—Several studies in singleton gestations with complete previa have determined that the degree of placental overlap correlates with the likelihood of persistence of previa at the time of delivery. However, no studies have correlated these findings in twin gestations. The objective of this study was to determine if the measurement of placental overlap in twin pregnancies diagnosed with complete previa during the second trimester will predict persistence of placenta previa at the time of delivery. Methods—This was a retrospective cohort study of twin pregnancies with complete placenta previa diagnosed at 15 to 19 and 20 to 23 weeks’ gestation from 2005 to 2011. All patients underwent transvaginal ultrasound using GE Voluson or Medison equipment. The degree of placental overlap was measured from the internal os to the edge of the placenta and was correlated with the risk of persistence at the time of delivery. Groups were compared using the Mann-Whitney U test and Fisher exact test as appropriate with P < .05 as significance. Results—Of 532 twin gestations, 41 patients (7.7%) were identified as having complete previa at 15 to 19 weeks’ gestation, and 9 of 41 patients (22%) had persistence of placenta previa at the time of delivery. At 15 to 19 weeks, there was no significant difference in median overlap between patients who had persistence of previa or resolution of previa at delivery (17 vs 12 mm; P = .26) . A subset of 14 patients (2.6%) were identified as having complete previa at 20 to 23 weeks’ gestation, and 8 of 14 patients (57%) had persistence at the time of delivery. At 20 to 23 weeks, there was no significant difference in median overlap between patients who had persistence of previa or resolution of previa at delivery (12.5 vs 14 mm; P = .85). Using thresholds of 5, 10, 15, 20, and 25 mm overlap at either 15 to 19 or 20 to 23 weeks, there was no significant difference in the risk of persistence at the time of delivery. Conclusions—In our population of twin gestations, the degree of overlap of complete previa during the second trimester did not correlate with the likelihood of resolution by the time of delivery. 1509891 Sonographic Morphologic Score as a Predictor of the Outcome in Fetal Sacrococcygeal Teratoma Marjan Bolouri,1* Eveline Shue,2 Douglas Miniati,2 Vicky Feldstein1 1Radiology and Biomedical Imaging, 2Surgery, University of California San Francisco Medical Center, San Francisco, California USA Objectives—Sacrococcygeal teratoma (SCT) is the most common tumor of the neonate. Ultrasound (US) is critical in the prenatal evaluation of fetuses with SCT, for whom outcomes vary widely. The purpose of this study was to develop a morphologic scoring scheme to use as a predictor of the outcome in fetuses with SCT. Methods—The records of all patients carrying fetuses diagnosed with SCT between 1986 and 2011 at our fetal treatment center were reviewed; those with available outcome data and US examinations were included in the study (n = 40). Two radiologists, blinded to the outcome, retrospectively reviewed the obstetric sonograms performed at presenta- tion. Tumor sonographic morphology was classified as predominantly cystic (>60%), predominantly solid (>60%), or mixed (40%–60% solid and cystic). Tumor volume measurements and volume/estimated fetal weight ratios were calculated. Good outcomes were defined as survival to hospital discharge, whereas poor outcomes were defined as intrauterine fetal demise, termination for hydrops or maternal mirror syndrome, perinatal death, or need for fetal intervention. Sensitivity, specificity, and the positive predictive value (PPV) of morphology as a predictor of outcome was calculated. Results—A predominantly solid (>60%) sonographic appearance was associated with a poor outcome. Of 40 cases in this series, 10 SCTs were predominantly cystic, and 29 were predominantly solid on initial US. One mass appeared 50% cystic and 50% solid. The mean gestational age at presentation was 23 weeks. No significant difference in mean tumor volume was seen between those with a poor outcome and those with a good outcome (347 versus 183 cm3; P = .124). Mixed to predominantly solid US morphology was associated with poor outcomes (sensitivity, 100%; specificity, 67%; PPV, 83%). None of the SCT cases presenting with predominantly cystic sonographic morphology had a poor outcome. Conclusions—A predominantly solid SCT appearance by US is a highly sensitive predictor of a poor outcome. Therefore, sonographic morphologic assessment is a useful predictor of the postnatal outcome in the prenatal evaluation of fetal SCT. This may be useful for prognosis and guiding obstetric management. 1511819 Retrospective Review of Fetal Body Lymphangioma Including Postnatal Outcome Kari Thomas, Karen Oh, Roya Sohaey* Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon USA Objectives—The purpose of this retrospective review is to study a series of 8 fetal body lymphangiomas (a type of lymphatic malformation) detected on prenatal ultrasound and to assess how findings on fetal magnetic resonance imaging (MRI) and/or postnatal MRI or computed tomography (CT) differed from the prenatal ultrasound, primarily with regard to the overall anatomic extent of the malformation. Accurate determination of the overall extent of these malformations is critical in delivery and postnatal treatment planning. Methods—We reviewed each patient’s prenatal ultrasound and then compared these findings with subsequent fetal MRI and/or postnatal imaging. Postnatal imaging included MRI and/or CT. Maternal and neonatal electronic records were reviewed. Results—In each of the 8t cases in our series, fetal MRI (4/8) and postnatal imaging provided clinically relevant information for delivery planning (with fetal MRI) and treatment options (with both fetal MRI and postnatal imaging). This information, regarding the size of the malformation and involvement of adjacent organs, was not fully disclosed by prenatal ultrasound findings alone. Conclusions—The extent of fetal body lymphangiomas is routinely underestimated by prenatal ultrasound. Fetal MRI and/or postnatal cross-sectional imaging provided additive diagnostic benefit in every case. These imaging modalities should be offered to patients when fetal lymphangioma is diagnosed on prenatal ultrasound. 1513506 Effect of Targeted Ultrasound Contrast Agent Attachment on Nonlinear Frequency Emissions John Eisenbrey,1* Valgerdur Halldorsdottir,1,2 Anush Sridharan,1,3 Joshua Rychak,4 Flemming Forsberg1 1Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA; 2 School of Biomedical Engineering and Health Systems, 3Electrical and Computer Engineering, Drexel University, Philadelphia, Pennsylvania USA; 4Targeson Inc, San Diego, California USA Objectives—Current strategies for differentiating attached from unattached targeted ultrasound contrast agents (UCAs) rely on using motion tracking or signal changes after destructive pulses, both of which in- S86 13proceedings_Layout 1 3/5/13 10:39 AM Page S87 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 herently introduce temporal artifacts. In this study, the effect of UCA attachment on nonlinear frequency emissions was investigated as a potential real-time discriminatory attachment marker. Methods—Nonlinear UCA behavior was studied using singleelement transducers and acoustically transparent Opticells (Nalge Nunc International, Rochester, NY). Attachment Opticells were coated with streptavidin (to provide a site for attachment) followed by incubation with 5% bovine serum albumin (BSA) solution to reduce nonspecific binding. The coated Opticell was then incubated with Targestar-B microbubbles (Targeson Inc) followed by phosphate-buffered saline washing in triplicate and attachment counting/confirmation via light microscopy. An Opticell coated with BSA alone was used as a negative specificity control with an equivalent concentration of microbubbles (≈19 microbubbles/mL) added. Nonlinear bubble behavior was investigated by transmitting 4- and 5-MHz 64-cycle pulses with a spherically focused single-element transducer (Panametrics, Waltham, MA) and receiving signals with a 3.5-MHz spherically focused single-element transducer. Frequency spectra were then compared after normalization to the fundamental peak. Results—Secondary harmonics (2f0) were evident in all cases with no differences in relative amplitudes observed between attached and unattached UCAs. Generating subharmonic signals (f0/2; 2.0/2.5 MHz) proved difficult for both UCA groups. However, at 4 MHz, unattached bubbles began to show subharmonic behavior at 470 kPa with a clear peak at 694 kPa. No definitive subharmonic peak was observed using attached UCAs. Excitation at 5 MHz did generate some nonlinear behavior in the subharmonic range, but differentiation of the subharmonic peak was difficult, presumably due to reflections generated by the Opticell surface. Conclusions—Targeted UCA attachment does not appear to affect the second harmonic but may potentially inhibit the subharmonic. This criterion may be useful for real-time identification of microbubble attachment. 1513519 Correlation of Ultrasound Contrast Agent–Derived Blood Flow Parameters With Immunohistochemical Markers in Murine Xenografts: Influence of the Imaging Mode, Tumor Model, and Subcutaneous Location John Eisenbrey,1* Christian Wilson,1,3 Raymond Ro,1,4 Traci Fox,2 Ji-Bin Liu,1 See-Ying Chiou,1 Flemming Forsberg1 1 Radiology, 2Radiological Sciences, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, Pennsylvania USA; 3College of Physicians and Surgeons, Columbia University, New York, New York USA; 4School of Biomedical Engineering, Sciences, and Health Systems, Drexel University, Philadelphia, Pennsylvania USA Objectives—To compare ultrasound contrast agent (UCA)derived blood flow parameters to immunohistochemical markers in glioma and breast cancer murine xenograft models. Methods—Breast cancer (NMU) or glioma (C6) cells were implanted in either the abdomen or thigh of 144 Sprague Dawley rats and randomly separated into groups of 6, 8, or 10 days post implantation (12 rats per time point Г— 2 cell lines Г— 2 implant locations). Imaging was performed using power Doppler imaging (PDI), harmonic imaging (HI), and microflow imaging (MFI) on with an Aplio scanner with a 7.5-MHz linear array (Toshiba America Medical Systems, Tustin, CA) during bolus tail vein injection of the UCA Optison (GE Healthcare, Princeton, NJ; 0.4 mL/kg). Contrast kinetic blood flow parameters consisting of maximum intensity, time to peak, perfusion, and time-integrated intensity (TII) were calculated from time-intensity curves using parametric analysis on a pixelby-pixel basis and averaged over the tumor area. These values were compared to 4 immunohistochemical markers (basic fibroblast growth factor, CD31, cyclooxygenase 2, and vascular endothelial growth factor [VEGF]) determined after tumor excision. Results—When analyzing the entire data set, a significant inverse correlation was only observed between TII and VEGF for all 3 im- aging modes (R = –0.35, –0.54, and –0.32 for PDI, HI, and MFI, respectively). When grouping data by tumor type, the NMU group correlations became nonsignificant, while the correlation within the C6 group increased (R = –0.43, –0.54, and –0.52 for PDI, HI, and MFI, respectively). When grouping by tumor location, a significant correlation was not observed for the thigh-implanted group, while the correlation within the abdominal tumor group again strengthened relative to the entire data set (R = –0.41, –0.58, and –0.38 for PDI, HI, and MFI, respectively). Consistent with the above trends, the strongest correlation of TII to VEGF for all subgroups was found to be abdominally implanted C6 cells (R = –0.51, –0.55, and – 0.57 for PDI, HI, and MFI, respectively). Conclusions—TII appears to correlate best with the angiogenic marker VEGF. However, these correlations were found to depend on both tumor type and location. 1514789 Time From Nursing Request to Probe Placement Delays Ultrasound-Guided Peripheral Intravenous Catheter Placement in Emergency Department Difficult-Access Patients Glenn Heimburger,* Leigh Patterson, Kori Brewer Emergency Medicine, East Carolina University, Greenville, North Carolina USA Objectives—To assess the total time needed for ultrasound (US)-guided peripheral intravenous (IV) catheter placement by emergency medicine (EM) physicians in difficult-access patients. Methods—Prospective convenience sample of patients presenting to an academic tertiary care center emergency department. Inclusion criteria were the need for IV access and inability of any available nurse to establish a peripheral IV catheter. Exclusion criteria were the need for central venous access or unstable patients as defined by the treating physician. All physicians received introductory training prior to enrolling patients. Outcomes measured were times from nursing request to probe placement, probe placement to first skin puncture, first skin puncture to successful cannulation or procedure abandonment, and total time from nursing request to procedure completion. Number of failed nursing attempts, skin punctures, physician experience with US-guided peripheral IV catheter placements (0–4, 5–9, or ≥10 previously placed), and physician training level were recorded. Results—Sixty-four patients were enrolled. The mean (В±SD; range) times were: total time, 35.5 minutes (В±21; 5–110 minutes); nursing request to probe placement, 20.9 minutes (В±18; 1–100 minutes); probe placement to first skin puncture, 5.8 minutes (В±5; 1–34 minutes), and first skin puncture to successful cannulation or procedure abandonment, 8.7 minutes (В±8; 1–36 minutes). Average number of failed nursing attempts was 3.2 (range, 0–7). Average number of skin punctures was 1.5 (range, 1–5). Physician training level had no effect on time. Having performed ≥10 previous US-guided peripheral IV catheter placements vs 0 to 4 decreased total procedure time (P = .04) and time from probe placement to first skin puncture (P = .04). Conclusions—The largest delay in placing a US-guided peripheral IV catheter by an EM physician after nursing failure occurs from nursing request to probe placement. Future studies should examine if variables exist during this period that could decrease total procedure time. Previous experience with placing US-guided peripheral IV catheters decreases overall procedure time. 1514851 A New Sonographic Sign for Perinatal Torsion: the “Kiwi Sign” Ashraf Goubran,1,3* Fern Karlicki,1 Karen Letourneau,1 Ganesh Srinivasan2 1Ultrasound, 2Neonatology, St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; 3Diagnostic Imaging, Ain Shams University, Cairo, Egypt Objectives—Perinatal torsion must be recognized in an urgent fashion if the testicle is to be salvaged. The purpose of this limited case se- S87 13proceedings_Layout 1 3/5/13 10:39 AM Page S88 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 ries is to describe a new sonographic sign for perinatal torsion that has, to our knowledge, not been described previously. Methods—Five cases underwent grayscale, color, and pulsed Doppler evaluation for suspected torsion in the perinatal period during a 26-month interval. The age of presentation ranged from birth to 30 days. The studies were performed using a Philips iU22 ultrasound machine. A linear high-frequency transducer (17 MHz) was used for scanning. These cases were retrospectively analyzed with regard to clinical and sonographic findings. Results—The grayscale appearance of the affected testicle was quite abnormal in our cases (n = 5). We subdivided our cases into 2 groups based on the sonographic findings. The first group (n = 2) represented the early phase of perinatal torsion, which we believe could have been potentially salvageable. The affected testicle in this group was markedly enlarged with a heterogeneous echo texture. Linear hypoechoic striations were seen, radially oriented from the mediastinum testicle, giving a characteristic appearance of a section in a kiwi fruit. The second group (n = 3) represented the nonsalvageable late phase of perinatal torsion, in which the affected testicle was small and heterogeneous. Color Doppler assessment in the affected testicle in both groups showed no flow. Conclusions—On the basis of the limited number of cases included in our study and a review of the literature, we suggest that the “kiwi sign” may become a useful finding representing the early phase of perinatal torsion. Future studies on a larger scale may prove that this sign can be established as a reliable indicator to aid in surgical decision making. 1515353 The Swollen Pediatric Scrotum: Ultrasound Technique and Differential Diagnosis Kelli Schmitz,1 Kathryn Snyder,1 David Geldermann,2 Roya Sohaey1* 1Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon USA; 2Colgate University, Hamilton, New York USA Objectives—Review the ultrasound protocol for performance of scrotal ultrasound in pediatric patients and illustrate the ultrasound appearance of conditions resulting in scrotal swelling. Provide a brief summary of scrotal embryology. Methods—Retrospective review of an imaging database of pediatric patients presenting with scrotal swelling who underwent diagnostic ultrasound at a tertiary pediatric referral center. When available, surgical/pathologic correlation was obtained. Some cases were diagnosed in utero. Results—Causes for pediatric scrotal swelling include intravaginal and extravaginal torsion, epididymitis/orchitis, hydrocele (simple, inguinoscrotal, abdominoscrotal, iatrogenic, and spermatic cord), varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasms. Conclusions—A variety of typical and atypical pathologic processes resulting in pediatric scrotal swelling will be presented in this pictorial review. Best-practice ultrasound technique will be reviewed. 1515361 Suprarenal Masses in the Fetus Sarah Rogers, Karen Oh, Roya Sohaey* Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon USA Objectives—Our objective is to review the imaging and differential diagnosis of fetal suprarenal masses. Methods—Prenatal ultrasound and magnetic resonance imaging of fetal suprarenal masses is presented, along with clinical information and follow-up. Imaging pearls and differential considerations for each diagnosis will be discussed. Results—Fetal suprarenal masses, diagnoses include congenital adrenal hyperplasia (symmetric and asymmetric), extralobar pulmonary sequestration, neuroblastoma, partial multicystic dysplastic kidney, renal duplication, urinoma, gastric duplication cyst, and splenic cyst. Fetal adrenal masses are often malignant, and every attempt should be made to differentiate between them and other diagnoses. Recognizing the range of malignant and benign suprarenal fetal masses that can present on prenatal imaging can help guide patient counseling and management. Conclusions—The differential diagnosis of a suprarenal mass is broad but can be narrowed by imaging characteristics. A pictorial review of suprarenal masses is presented along with technique and imaging pearls toward accurate diagnosis. 1518185 Extraovarian Adnexal Sonographic Findings in Ectopic Pregnancy: A Reappraisal Mary Frates,* Peter Doubilet, Hope Peters, Carol Benson Radiology , Brigham and Women’s Hospital, Boston, Massachusetts USA Objectives—To assess the frequency of extraovarian adnexal sonographic findings in patients with ectopic pregnancy using state-ofthe-art sonographic equipment. Methods—All patients with pathologic or sonographic confirmation of ectopic pregnancy between July 1, 2008, and August 31, 2011, who underwent transvaginal sonography (TVS) prior to treatment were included. The sonogram performed closest to the point of treatment was retrospectively reviewed for the presence of an extraovarian adnexal mass and for a moderate-to-large amount of free fluid. In cases with an adnexal mass, the presence of a tubal ring, yolk sac, or embryonic cardiac activity was recorded. Results—Our study population comprised 231 patients. A positive finding—adnexal mass and/or free fluid—was present in 220 of 231 patients (95.2%): adnexal mass in 218 of 231 (94.4%) and a moderate-tolarge amount of free fluid in 56 of 231(24.2%). Among our 231 study cases, sonography demonstrated a tubal ring in 75 (32.5%), a yolk sac in 19 (8.3%), and embryonic cardiac activity in 17 (7.4%). In 140 cases (60.6%), TVS demonstrated a nonspecific adnexal mass (without tubal ring, yolk sac, or cardiac activity). Conclusions—TVS demonstrates an adnexal abnormality in >95% of patients with ectopic pregnancy. The most common finding is a nonspecific adnexal mass. A tubal ring is found in fewer than half of cases and a yolk sac and cardiac activity in <10%. 1518748 Axillary Lymph Nodes: Beyond Size and Shape Abdelmohsen Hussien,* Avice O’Connell Women’s Imaging, University of Rochester, Rochester, New York USA Objectives—Although ultrasound is helpful in detecting suspicious lymph nodes from breast cancer, many affected lymph nodes may be missed. It is known that size is a poor criterion for evaluation of metastasis. Also, lymph node shape has low sensitivity. In this presentation, we emphasize the role of ultrasound in detecting abnormal-appearing metastatic lymph nodes. Also, we will focus on the subtle sonographic signs of metastatic lymph nodes. Methods—We will demonstrate the value of the evaluation of subdermal lymphatics, the use of harmonics, Doppler, and sonoelastography in assessment of the metastatic axillary lymph nodes. Results—Some of the ultrasound techniques demonstrate better detection of the abnormal axillary lymph nodes. Conclusions—The use of advanced ultrasound techniques is helpful in evaluation of metastatic axillary lymph nodes and increases sensitivity. S88 13proceedings_Layout 1 3/5/13 10:39 AM Page S89 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1518801 Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules Performed by Family Practitioners in a Health Clinic Setting MarГa Mata Castrillo,1* Jose Ignacio Jaen Diaz,1 Blanca Cordero Garcia,1 Eugenio Cerezo Lopez,2 Francisco Lopez de Castro,1 Paolo Ciardo1 1Buenavista Health Care Center, Toledo, Spain; 2Ultrasound Explorations, Madrid, Spain Objectives—Evaluate the impact of family practitioner interventions on the development of nodular thyroid pathology: techniques diagnosis, fine-needle aspiration biopsy (FNAB), and surgical follow-up. Methods—Two family practitioners at a health clinic in Toledo, Spain, which is charged with overseeing the health of 16,800 individuals, performed all thyroid ultrasonography requested by the health center physicians for their patients. These evaluations were previously performed in a reference hospital. All explorations were analyzed in writing, and the reports included a recommendation regarding patient follow-up and treatment. According to recommendations from the international literature, and following informed consent, FNAB was performed on those nodules that were suitable for the procedure. Previously, the decision to perform the FNAB, its execution, and the treatment course were all left in the hands of the reference hospital. Results—A total of 392 ultrasonographic explorations were performed between July 2011 and July 2012. Of these, 336 (85.7%) of the subjects were female (mean age, 46.4 years), and 56 (14,3%) were male (mean age, 45.2 years). The reasons for performing the explorations included the following: clinical suspicion of thyroid pathology (goiter, nodules), 37.5%; suspicion of thyroid pathology based on clinical analyses, 15.9%; follow-up of known nodular pathology, 34.4%; and follow-up of other known thyroid problems (thyroiditis, postsurgical thyroids), 12.2%. Seventy-five FNAB procedures were performed, 9 (12%) of which yielded insufficient material for diagnosis. Four cases of cancer were detected, all of them of a papillary nature. There were no complications during the conduct of these procedures. Conclusions—Ultrasound-guided thyroid FNAB is a simple and uncomplicated procedure that can be performed with a high degree of success by family practitioners in community health centers as part of the comprehensive management of nodular thyroid pathology. In our study, this approach was time efficient for patients and provided a mechanism for rapid intervention in a rather frequent pathology. Future studies will be required to evaluate the overall cost-effectiveness of this approach. 1522432 Small Retained Foreign Bodies: What Is the Limit of Detection Using Current Emergency Ultrasound Equipment? Daniel Jafari,1 Kenneth Cody,2 Nova Panebianco,1 Frances Shofer,1 Bon Ku,3 Arthur Au,3 Anthony Dean1* 1Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA; 2Emergency Medicine, Kaiser Oakland Medical Center, Oakland, California USA; 3Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania USA Objectives—Previous studies of small foreign bodies (FBs) have shown a wide range of accuracies of FB detection using animal models, with high accuracy rates for FBs >10 mm and variable accuracy rates for 4- to 5-mm FBs. This study aimed to determine the lower limit of sonographic detection of FB using current emergency ultrasound equipment in a soft tissue model. Methods—FBs made of metal, glass, wood, and plastic (3 of each), 1 Г— 1 Г— 3 mm in size, were placed at a depth of 0.5 to 2.0 cm in 12 pork feet. Eight feet were punctured without FB placement. Pork feet were submerged during this process to minimize air in tissue. Seven emergency department (ED) sonologists with >2 years of experience were blinded to the overall number, type, and depth of FBs but not to size. FB sites were scanned by each sonologist using either a hockey stick or traditional lin- ear array transducer in a randomized preassigned order. Sonologist confidence in the diagnosis was reported using a visual analog scale for each site. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) with 95% confidence intervals (CIs) were calculated. To determine if sonologist confidence differed by the perceived presence or absence of a foreign body, a paired t test was used. Results—A total of 140 ultrasound scans were performed, which reported sensitivity, specificity, PPV, and NPV as 50% (95% CI, 39%–61%), 50% (37%–61%), 60% (48%–72%), and 40% (28%–52%), respectively. There was little agreement among the sonologists (only 2 sites with 100% agreement). Sensitivity ranged from 25% to 75%, specificity 37% to 62%, PPV 42% to 75%, and NPV 25% to 57% for each sonologist. Sonologists were more confident reporting a positive result (81% vs 51%; P < .0001), irrespective of the actual presence of FBs. The difference between detection rates of 4 types of FB did not reach statistical significance. Conclusions—Current emergency ultrasound equipment used by ED sonologists is unreliable in detection of 3-mm FBs in a human extremity soft tissue model. Future studies may further delineate accuracy rates among different sizes and materials of FBs. 1522516 Four Consecutive Recurrent Cesarean Scar Pregnancies in a Single Patient Simi Gupta,1* Christina Cordeiro,2 Grace Pineda,1 Sherman Rubin,3 Ilan Timor1 1Obstetrics and Gynecology, New York University, New York, New York USA; 2Weill Cornell Medical College, New York, New York USA; 3Sherman Rubin, Jackson Heights, New York USA Objectives—With the increase in conservative management of cesarean scar pregnancies (CSP), there has been a growing interest in fertility outcomes for these patients. This is the first known report of 4 recurrent CSPs. Methods—This is a case report on a patient who was referred to a single institution with 4 recurrent CSPs. Data on evaluation, treatment, and follow-up of each of the pregnancies were collected. Results—The patient had a pertinent obstetric history of 2 cesarean sections, the first for breech presentation and the second an elective repeat cesarean section. The patient’s first CSP was diagnosed 7 years later with an ultrasound finding of a pregnancy in the prior cesarean section scar at 7 6/7 weeks of gestation with positive fetal cardiac activity. This pregnancy was initially treated with transcervical intra-amniotic injection of methotrexate with complete resolution. Nine months later, the patient presented with her second CSP at 6 0/7 weeks of gestation with positive fetal cardiac activity and was treated similarly with transcervical injection of methotrexate with complete resolution. The patient’s third recurrence was 9 months later when she presented at 5 4/7 weeks of gestation with positive fetal cardiac activity and again was treated with transcervical injection of methotrexate with complete resolution. Finally, the patient’s fourth recurrence occurred 8 months later. She was diagnosed at 6 1/7 weeks of gestation with positive fetal cardiac activity and again was treated with transcervical injection of methotrexate. The patient is currently receiving follow-up for this CSP. Conclusions—This is the first case report of 4 recurrent CSPs in single patient. Each of this patient’s CSPs was treated conservatively with local methotrexate. In reviewing the literature, there have been 6 cases of recurrent CSPs, with 1 report of 3 CSPs in the same patient. Those cases were reportedly treated with methotrexate or surgery with or without resection of the scar. This information is important to help counsel patients who desire future fertility after a CSP. S89 13proceedings_Layout 1 3/5/13 10:39 AM Page S90 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1522877 Many Faces of Uterine Adenomyosis: Ultrasound and Magnetic Resonance Imaging Vijayanadh Ojili Radiology, University of Texas Health Science Center, San Antonio, Texas USA Objectives—To describe the sonographic findings in different types of uterine adenomyosis and correlate these with magnetic resonance imaging (MRI) findings where available. Methods—A brief review of different types of uterine adenomyosis (diffuse adenomyosis, focal adenomyosis/adenomyoma, and cystic adenomyosis) will be presented. The sonographic findings will be described and correlated with MRI findings. The potential role of newer ultrasound techniques (3D sonography and elastosonography) and pertinent management issues will be briefly discussed. Results—Not applicable as this is a pictorial review. Conclusions—Uterine adenomyosis is often misdiagnosed or is not easily recognized, although it is responsible for disabling symptoms such as menorrhagia, dysmenorrhea, and infertility. Therefore, it is important for the radiologist to accurately diagnose this condition in a timely fashion. Although MRI is the imaging modality of choice for comprehensive evaluation, ultrasound is often the initial imaging test performed in the diagnostic workup of these patients and will provide a diagnosis in most cases. 1527190 Determining the Accuracy of Ultrasound in Identifying Axillary Lymph Node Metastasis in Breast Cancer Patients Madelene Lewis,* Abid Irshad, Susan Ackerman Radiology, Medical University of South Carolina, Charleston, South Carolina USA Objectives—Axillary lymph node staging is the most important prognostic indicator of outcome in breast cancer patients. A positive percutaneous biopsy eliminates the need for sentinel lymph node (SLN) biopsy, saving patients discomfort, time, and money. The purpose of this study was to evaluate our ability to predict axillary nodal involvement using ultrasound (US) in patients with invasive breast cancer. Methods—After Institutional Review Board approval, a retrospective review was performed of 116 patients diagnosed with invasive breast cancer between January 2010 and June 2011. Sonographic evaluation of the axilla was performed as part of our standard protocol for patients undergoing biopsy of a breast mass at our institution. Lymph nodes were considered positive by US if any of the following criteria were present: cortical thickness ≥3 mm, eccentric cortical thickening, cortical lobulation, loss of fatty hilum, or nonhilar blood flow. US findings were correlated with pathology results from fine-needle aspiration (FNA), core needle biopsy (CNB), SLN, and/or axillary lymph node dissection (ALND). Results—A total of 116 patients (all females) were diagnosed with invasive breast cancer. Mean age was 58.6 В± 11.9 (SD) years (range, 33–84 years) and included 69 white, 42 black, and 4 females from other races. Axillary US was performed in all 116 patients. Sonographically, 41 patients had positive axillary lymph nodes, and 39 (95.1%) of these 41 were sampled by FNA, CNB, SLN, or ALND. Metastatic disease was positive in 28 (72%) of 39 patients. Of the 75 patients with negative axillary US, 68 patients had final pathology. Of these, 51 (75%) remained negative on SLN or ALND, while 17 (25%) of 68 had metastatic nodes. The sensitivity, specificity, positive predictive value, and negative predictive value of US for predicting axillary metastasis were 72% (95% confidence interval [CI], 55%–84%), 75% (95% CI, 63%–84%), 62% (95% CI, 47%–76%), and 82% (95% CI, 70%–90%). The overall accuracy of US was 74%. Conclusions—Preoperative US evaluation of the axilla in breast cancer patients is effective for determining metastatic nodes. However, an SLN biopsy is still required in patients with negative preoperative US. 1527866 Equivalence of 2- and 3-Dimensional Ultrasound in the Evaluation of First-Trimester Nuchal Translucency by Maternal-Fetal Medicine Fellows Steffen Brown,* Michael Wolfe, Lesley de la Torre, Matthew Brennan, Rebecca Hall Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico USA Objectives—Conflicting data exist that 3D ultrasound produces equivalent images to 2D for nuchal translucency (NT) assessment. We aimed to prospectively evaluate the equivalence of 2D and 3D techniques for obtaining the NT measurement as performed by maternal-fetal medicine fellows. Methods—Prospectively enrolled subjects had first-trimester screening performed per protocol at our institution by a fellow in maternal-fetal medicine under the supervision of an NT-certified sonologist. This included transabdominal imaging first, followed by endovaginal imaging if necessary to obtain the proper image. A 3D image using the same approach was then obtained and manipulated for measurement of the NT. The 2D and 3D measurements were then compared using a Fisher exact test and Bland-Altman plot, including root mean squared (RMS) to quantify paired differences. Results—A total of 43 women were enrolled in the study. Acceptable transabdominal NT measurements were obtained in 34 of the 43 subjects (79%), and the remaining 9 (21%) required endovaginal assessment to complete the exam. The differences in the NT measurements using 2D vs 3D nuchal translucency values were normally distributed by the Shapiro-Wilk test (P = .97). The 2D and 3D values averaged 1.40 В± 0.43 and 1.46 В± 0.49 mm, respectively. The 3D image did not significantly overmeasure or undermeasure the NT (P = .69). 2D and 3D modalities correlated within 3.7 mm (RMS) of one another. 3D imaging required an average of 105 seconds more than 2D to complete (P < .001), though total time for 3D averaged around 3 minutes (197 В± 179 seconds). Conclusions—2D and 3D NT measurements correlate closely. Performance and manipulation of a 3D volume sweep during NT assessment may provide an adjunct or confirmatory image. 1528363 Comparative Effectiveness of Fetal Magnetic Resonance Imaging for Improvement of Diagnostic Accuracy Christina Herrera,* Amber Samuel, Sherelle Laifer-Narin, Lynn Simpson, Russell Miller Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA Objectives—Fetal magnetic resonance imaging (MRI) is performed as an adjunct to routine ultrasound with the intent of improving diagnostic accuracy, yet data are limited to substantiate benefit to this costly imaging modality. This study analyzed the billed cost of fetal MRI relative to diagnostic information gained for patients with antenatal diagnoses of a fetal anomaly and known postnatal outcomes. Methods—This was a retrospective review of all fetal MRIs performed between 2003 and 2011 at a tertiary care center. Potential cases were identified if MRI was performed following sonographic concern for a fetal anomaly. Inclusion required documented neonatal outcomes or postmortem assessments. Test performance characteristics were calculated, from which the number needed to secure an additional accurate diagnosis by MRI was determined. Applying the cost per MRI at the study center to this estimate, the cost per additional accurate diagnosis was calculated. Results—A total of 799 MRIs were performed, of which 406 had documented neonatal or pathologic outcomes. One hundred thirtyone postnatal diagnoses were secured, of which MRI identified 51 (12.6%) that ultrasound failed to correctly characterize. When the most common diagnosis groups were considered, meningomyelocele had the lowest cost per additional correct diagnosis by MRI and ventriculomegaly the highest (Table 1). The cost per additional accurate diagnosis for cases of congenital diaphragmatic hernia, omphalocele, vein of Galen malformation, S90 13proceedings_Layout 1 3/5/13 10:39 AM Page S91 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 and Dandy-Walker complex could not be calculated, as there were no pregnancies where MRI was accurate but ultrasound alone was not. Conclusions—There is a variable cost per additional diagnosis correctly secured that should be weighed when considering a pregnancy for adjunct fetal MRI. Further study should be directed at assessing the global cost-benefit of fetal MRI, as well as considering the value of MRI for prognostication and surgical planning purposes. 1530478 Transcranial Sonography and 123I-FP-CIT Single-Photon Emssion Computed Tomography in Movement Disorders David Е koloudГk,1,3* Petra Bartova,1 Tana Fadrna,1 Otakar Kraft,2 Martin Havel2 1Neurology, 2Nuclear Medicine, University Hospital Ostrava, Ostrava, Czech Republic; 3 Neurology, PalackГЅ University Medical School and University Hospital Olomouc, Olomouc, Czech Republic Table 1 Objectives—Diagnosis of Parkinson’s disease (PD) and other Parkinsonian syndromes (PS) could be difficult in early stages of the disease. Transcranial sonography (TCS) is able to detect structural changes in the substantia nigra and basal ganglia in PD and PS patients, and fluoropropyl-carbomethoxy-iodophenyl-tropane (FP-CIT) single-photon emission computed tomography (SPECT) could detect presynaptic dysfunction in several neurodegenerative diseases, including PD and PS. The aim of our study was to assess correlation between TCS and SPECT findings and diagnosis of PD, other PS, essential tremor (ET), and psychogenic movement disorder (PMD). Methods—A total of 49 (32 male; age range, 26–73 years; mean age, 56.1 В± 9.1 years) out of 53 screened patients were enrolled in the study: 29 PD patients, 7 PS patients, 11 patients with ET, and 2 PMD patients. Substantial nigra (SN) echogenicity and SN area were measured using TCS. SPECT evaluation of basal ganglia was performed using a dopamine active transporter ligand (123I-ioflupane). Both examinations were performed within 2 months after clinical examination. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for TCS and SPECT were evaluated. Results—TCS and SPECT findings correlated in 84% patients (Оє = 0.62; 95% confidence interval [CI], 0.38–0.86; ACE1 = 0.61; P = .00002). TCS/SPECT sensitivity, specificity, PPV, and NPV for diagnosis of PD were 89.7%/96.6%, 60.0%/70.0%, 76.5%/82.4% and 80.0%/93.3%, respectively. Both positive TCS and SPECT findings correlated significantly with diagnosis of PD (Оє = 0.52; 95% CI, 0.27–0.76; ACE1 = 0.59; P = .0002; and Оє = 0.69; 95% CI, 0.49–0.90; ACE1 = 0.74; P = .000001, respectively). Conclusions—TCS and SPECT are helpful in early diagnosis of PD with high correlation. The sensitivity, specificity, PPV, and NPV were similar for both methods. (Supported by a grant from the MoravianSilesian Region). MRI Studies Needed for 1 Cost per Additional Accurate Additional Diagnosis Diagnosis Accurate Diagnosis Meningomyelocele 3 $6,466.20 Multiple anomalies 6 $12,932.40 Brochopulmonary sequestration 9 $19,398.60 Congenital cystic adenomatoid malformation 12 $25,864.80 Ventriculomegaly 14 $31,175.60 1530454 Comparison of Brain Vessel Imaging From Transtemporal and Subcondylar Approaches Using Contrast-Enhanced Transcranial Color-Coded Duplex Sonography and a Virtual Navigator David Е koloudГk,1,3* Martin Roubec,1 Martin Kuliha,1 Jaroslav Havelka,2 Katerina Langova,4 Roman Herzig3 1 Neurology, 2Radiology, University Hospital Ostrava, Ostrava, Czech Republic; 3Neurology, PalackГЅ University Medical School and University Hospital Olomouc, Olomouc, Czech Republic; 4Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, PalackГЅ University Olomouc, Olomouc, Czech Republic Objectives—The transcondylar approach is a new approach used for detection of chronic cerebrospinal venous insufficiency and intracranial venous reflux in patients with multiple sclerosis. The aim of the study was to assess the capability of native and contrast-enhanced (CE-) transcranial color-coded duplex sonography (TCCS) to detect flow and reflux in deep cerebral veins and intracranial venous sinuses from transcondylar and transtemporal approaches. Methods—Brain magnetic resonance imaging and TCCS from transtemporal and transcondylar approaches using the new technology, fusion imaging, were performed in 8 volunteers and 5 patients with multiple sclerosis. Results—Root mean square error <0.5 cm and accuracy of the system <1 mm, measured using a registration pen, were detected in all subjects. Using TCCS and CE-TCCS, arteries of the circle of Willis were detected from the transtemporal approach in 13 of 13 and 13 of 13 subjects and venous system in 8 of 13 and 10 of 13 subjects, respectively. However, arteries of the circle of Willis and venous system were detected from the transcondylar approach in only 5 of 13 (P < .01) and 1 of 13 (P = .03) subjects using TCCS and in 10 of 13 (P > .05) and 8 of 13 (P > .05) subjects using CE-TCCS, respectively. Intracranial venous reflux was not detected in any subject. A bidirectional Doppler signal from the region of the cavernous sinus detected in 3 subjects was evaluated as a breathing artifact. Conclusions—The study results showed that the TCCS transcondylar approach has serious limitations for standard detection of intracranial venous reflux. 1535936 Cell-Free Fetal DNA Testing for Aneuploidy: Initial Experience Kisti Fuller,1,2* Adam Borgida2 1Maternal-Fetal Medicine, University of Connecticut, West Hartford, Connecticut USA; 2 Maternal-Fetal Medicine, Hartford Hospital, Hartford, Connecticut USA Objectives—Cell-free fetal DNA (cffDNA) tesing is now widely available from commercial labs. We evaluated our initial experience of patients choosing cffDNA testing for fetal aneuploidy. Methods—Since January 2012, we have been routinely offering cffDNA testing as an alternative to invasive testing for fetal aneuploidy. We reviewed our database of patients undergoing cffDNA testing. Data collected included maternal age, indication for testing, gestational age at time of testing, type of cffDNA test, length of time for results, and out-of-pocket costs when known. Results—There were 106 patients who met with a genetic counselor for possible cffDNA testing. Of these 14 of 106 (13%) declined testing, and 1 of 106 (1%) chose to undergo invasive testing. Of the 91 remaining patients, 24 (26.4%) chose directed DNA (dDNA) testing, and 67 (73.6%) chose massive parallel shotgun sequencing (MPSS). After the initial draw, 3 of 24 (12.5%) samples for dDNA failed to produce a result, and a repeat sample was required. The average patient age was 36 years. The average gestational age at the time of testing was 16.5 weeks. The average time from serum sample until initial results were received was 10 days. Testing indications were: advanced maternal age, 67%; abnormal S91 13proceedings_Layout 1 3/5/13 10:39 AM Page S92 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 serum screen, 46.2%; ultrasound anomaly, 28.6%; and/or family history, 4.4%. Patients that chose dDNA were not billed up front, and no information on their out-of-pocket costs was available. Patients that chose MPSS testing required some prepayment. Of the 53 patients with a known up-front charge, it was $235 for 26 and $475 for 27 patients. Conclusions—The most common indication for cffDNA testing was advanced maternal age. The testing was most commonly done in the early second trimester, and it took an average of 10 days for results. There was a higher rate of test failure in the dDNA group (12%). The outof-pocket cost prior to testing may affect the patient’s desire for testing. 1536107 Hospital-Wide Survey of Bacterial Contamination of Pointof-Care Ultrasound Probes Matthew Lawrence,1* James Blanks,2 Ruben Ayala,2 Joel Schofer,1 Diana Macian,1 Douglas Talk,3 Jessie Glasser4 1 Emergency Department, Naval Medical Center Portsmouth, Chesapeake, Virginia USA; 2Laboratory Services, Microbiology Division, 3Obstetrics and Gynecology, 4Internal Medicine, Infectious Disease Division, Naval Medical Center Portsmouth, Portsmouth, Virginia USA Objectives—With the increasing use of point-of-care ultrasound in many areas of medicine, there is a concern that ultrasound equipment can facilitate transmission of infection to patients, especially methicillinresistant Staphylococcus aureus (MRSA). The primary objective of this study is to determine the prevalence of bacterial colonization on hospitalwide point-of-care ultrasound probes by performing cultures of the probes. Our hypothesis is that bacterial contamination is not a significant problem, and that our current ultrasound probe cleaning protocols are sufficient to protect patients against such nosocomial spread of infection. Methods—The study was conducted at a single military hospital on 43 point-of-care ultrasound machines (87 probes) located within 9 departments over an 8-week period. Every probe was cultured 4 times during the study period, at 2-week intervals. Intracavitary probes were excluded from the study due to high-level disinfection protocols at our institution. Positive cultures underwent species identification in the microbiology lab. Results—At the time of this submission, the first half of data collection was complete (2 culture sets performed on each machine, 2 culture sets remaining). Of the 174 probe cultures, 13 resulted in positive growth (7.5%). Three cultures (1.7%) identified Micrococcus species, and 8 cultures (4.6%) identified coagulase-negative Staphylococcus, both of which are common human skin flora. Three cultures (1.7%) identified Bacillus species, not B anthracis or B cereus. Finally, 3 cultures (1.7%) identified Pseudomonas species, which was not P aeruginosa. No cultures identified MRSA. Conclusions—As hypothesized, bacterial contamination of point-of-care ultrasound probes is low and primarily involves organisms common to normal skin flora and the environment. MRSA contamination was not identified at our institution. Antibacterial wipes after each use seem to prevent significant bacterial growth on ultrasound probe surfaces. (The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.) 1536431 A Novel Approach to Visualizing the Vasculature Architecture of the Placenta Using 3-Dimensional Slicer Software: A Pilot Study Rie Oyama,1* Chizuko Isurugi,1 Tomonobu Kanasugi,1 Akihiko Kikuchi,1 Toru Sugiyama,1 Sonia Pujol,2 Ron Kikinis2 1 Obstetrics and Gynecology, Iwate Medical University, Morioka, Japan; 2Radiology, Brigham and Women’s Hospital, Boston, Massachusetts USA Objectives—The aim of this pilot study presents a novel approach to visualize the vasculature architecture of the placenta using grayscale to acquire volume data of the villous tree from the 3D ultrasound machine, and then these data restructure the placental vasculature using 3D Slicer software, which is an open-source medical visualization and analysis software package for medical image computing. Methods—We used a Voluson E6 (GE Healthcare) system with a RAB4-8-D/OB 3D/4D 8-MHz transabdominal wideband convex volume transducer. The 3D volume image was adjusted to include the entire placenta. The volume data set was stored in the DICOM format for restructuring on the 3D Slicer software. This study included 2 women with singleton pregnancies seen at 16 and 20 weeks at Iwate Medical University Hospital. Informed consent was obtained from each patient. The Institutional Review Board approved this study. The raw volume data were imported into the Slicer software, which was loaded to display on the 2D viewer (axial, sagittal, and coronal), and then the 3D image was displayed on the 3D viewer. The 3D volume image restructured the placental vasculature using volume rendering, and the manual segmentation module and label statistical analysis were used. (1) Volume-rendering module: We determined region of interest of the placenta. Parameter set: The preset chosen was CT-AAA, and the rendering used VTK CPU casting. (2) Manual segmentation module: Threshold Paint was used to create a region of interest of the placenta and an umbilical cord image, which was based on the grayscale volume of original raw data. (3) Label statistical analysis: This module counted the number of voxels, which was the 3D volume image of the placenta displayed using the manual segmentation. Results—This study showed the placental vasculature of the ultrasound image using 2 module methods. The number of voxels (10 Г— 3) at 16 weeks was 60.519 and at 20 weeks was 193.934. Conclusions—The 3D Slicer visualized the vasculature architecture of the placenta, which came from raw ultrasound data. Also, it will be able to impact the filed of obstetric ultrasound and elucidation of the placenta. 1536710 Efficacy of Ultrasound-Guided Tibial Nerve Perineural Injections at the Posterior Tarsal Tunnel Oliver Joseph,* Oleg Uryasev, John McNamara, Apostolos Dallas Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA Objectives—Compression of the tibial nerve (TN) within the tarsal tunnel results in posterior tarsal tunnel syndrome. Like other nerve compression syndromes, corticosteroid injections are a potential therapeutic modality. We hypothesize that one can effectively inject the TN perineural space immediately proximal to the tarsal tunnel. Methods—This research is a pilot study to investigate the efficacy of TN perineural injections bilaterally on 4 cadaveric models. A 10–5-MHz small linear array transducer was placed along the medial malleolus and Achilles tendon to visualize the neurovascular bundle. The TN appeared spindle shaped with alternating hypoechoic and hyperechoic bands superficial and anterior to the flexor hallucis longus tendon. Anterior long-axis injections of 0.35 mL of 0.5% methylene blue with subsequent anatomic dissection were confirmatory. Injections were designated accurate (nerve stained) and precise (no damage to adjacent anatomy). Results—Five of 8 (63%) injections were accurate and 6 of 8 (75%) precise. Initial attempts were unsuccessful, while later injections were accurate and precise. The most apparent source of error was from 1 cadaver’s pronounced musculoskeletal deformity, which precluded successful injections bilaterally. Of the 3 cadavers unaffected by musculoskeletal deformity, accuracy was 5 of 6 (83%), and precision was 6 of 6 (100%). Conclusions—While surgery is the definitive treatment for refractory posterior tarsal tunnel syndrome, corticosteroid injections could likely provide symptomatic relief and postpone surgical intervention. This study suggests that ultrasound guidance can increase accuracy and precision and is a potential adjunct to treatment. Future study will expand the initial data set and allow for a consistent protocol, while later studies of patient outcomes will demonstrate clinical relevance. S92 13proceedings_Layout 1 3/5/13 10:39 AM Page S93 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1536801 Cloacal Exstrophy: When an Omphalocele Is Not Just an Omphalocele Reza Pakdaman,1* Anne Kennedy,1,2 Mark Molitor,3 Janice Byrne,2 Paula Woodward1,2 1Radiology, 2Obstetrics and Gynecology, 3Surgery, University of Utah, Salt Lake City, Utah USA Objectives—(1) Illustrate additional congenital abnormalities that, when seen in a fetus with an omphalocele, should lead to the diagnosis of cloacal exstrophy. (2) Illustrate the role of fetal magnetic resonance imaging (MRI) in making the diagnosis. (3) Correlate prenatal findings with postnatal imaging and surgical findings in survivors. (4) Illustrate autopsy findings. Methods—Retrospective review of 7 cases seen at 1 institution. Prenatal findings were correlated with postnatal multimodality imaging, surgical, or autopsy results. Results—7 cases were seen for prenatal ultrasound (US). Fetal MRI was performed in 4. See Table 1 for US findings. Pregnancy outcomes were live birth in 4, perinatal death in 1, intrauterine demise in 1, and termination of pregnancy in 1. Conclusions—The presence of an omphalocele should alert the sonologist to perform additional views and seek other anomalies in an effort to refine the diagnosis. In particular, inability to demonstrate a normal bladder and rectum and the presence of spine abnormalities should heighten suspicion for cloacal exstrophy. Cloacal exstrophy is a rare anomaly not associated with aneuploidy; however, the condition requires multiple surgeries, and survivors require lifelong specialist care. Faced with the long-term consequences of this condition, families may choose termination of pregnancy. Therefore, correct prenatal diagnosis is of paramount importance. In ongoing pregnancies, delivery should be planned at an appropriate facility with the resources to manage children with complex metabolic, surgical, and psychosocial needs. Table 1. US Findings Case AWD Bladder Anus Spine Genitalia 1 Y N NA Ab NA 2 Y N N Ab Amb 3 Y N N Ab Amb 4 Y N NA NA Bifid 5 Y N NA Ab Amb 6 Y N NA Ab NA 7 Y N NA Ab NA Ab indicates abnormal; Amb, ambiguous; and AWD, abdominal wall defect. 1536808 Imaging Spectrum of Fetal Autosomal Recessive Polycystic Kidney Disease Tony Trinh,1* Anne Kennedy,2,3 Joe Sherbotie,4 Janice Byrne3 1 School of Medicine, 2Radiology, 3Obstetrics and Gynecology, 4 Nephrology, University of Utah, Salt Lake City, Utah USA Objectives—(1) Illustrate the spectrum of findings of fetal autosomal recessive polycystic kidney disease (ARPKD). (2) Correlate fetal studies with postnatal imaging or autopsy results. Methods—Retrospective review of cases seen at a single referral center. Results—Renal enlargement was our most consistent finding. Most kidneys looked normal up to 20 weeks but abnormally echogenic kidneys were seen as early as 16 weeks. Echogenicity varied from the classic highly echogenic pattern with loss of normal architecture to increased echogenicity with identifiable medullary pyramids to a pattern of very echogenic pyramids similar to that seen in medullary sponge kidney in adults. Amniotic fluid volume was variable from severe oligohydramnios to normal. Not all cases had evidence of pulmonary hypoplasia. Conclusions—Not all cases of ARPKD present with the classic findings of large, brightly echogenic kidneys and severe oligohy- dramnios. This reflects the variable phenotype with perinatal, neonatal, and infantile types described. It is very important that sonologists recognize the full spectrum of findings to suggest ARPKD and differentiate it from other causes of renal enlargement or abnormal renal echogenicity. Fetuses with echogenic kidneys require postnatal follow-up. The prognosis is variable. Awareness of the possibility of ARPKD will result in appropriate testing of the parents for recessive gene carrier status. Affected couples will have a 1:4 recurrence risk for future pregnancies. 1536912 Abnormal Ultrasound Findings in Patients With Clinical Suspicion of Chronic Liver Disease in Sokoto and Its Environs Sadisu Maaji,* Abdulmuminu Yakubu, Danielle Odunko Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria; Radiology, Federal Medical Center Birnin Kebbi, Birnin Kebbi, Nigeria Objectives—To describe the pattern of abnormal ultrasonographic findings in patients with clinical suspicion of chronic liver disease in Nigeria, especially from the northwestern region. Methods—A total of 61 consecutive patients with clinical signs and symptoms of chronic liver disease attending medical outpatient clinics at the Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, and Federal Medical Center Birnin Kebbi were scanned at radiology departments for any abnormal intra- abdominal findings from May 2011 to April 2012. The exclusion criteria were patients with confirmed liver biopsy or diagnosis of chronic liver disease. Patients with cardiac cirrhosis and tropical splenomegaly syndrome were also excluded in this study. Results—A total of 61 abdominal ultrasound examinations were performed during this study period. All the cases met the inclusion criteria. The mean age was 46 В± 12.6 years (range, 50 years). The mean liver sizes were 13.25 В± 1.48 cm (range, 11 cm) and 14.00 В± 0.77 cm (range, 0.77 cm) for right and left lobes, respectively. The mean spleen size was 15.9 В± 1.22 cm (range, 6 cm). The sex distribution was 43 males (70.49%) and 18 females (29.5%). Of the 61 cases included, the indications for abdominal ultrasound were hepatitis in 1 (1.61%), liver cirrhosis in 20 (50.82%), obstructive jaundice in 2 (3.28%), chronic liver disease in 25 (40.98%), and chronic abdominal swelling in 2 (3.2%). Gallbladder wall thickening was demonstrated in 49 (80.33%) of the patients, while 12 (19.67) showed a normal gallbladder wall. Ascites was demonstrated in 45 (73.77%) of the patients, and the remaining 16 (26.23%) of the patients had no ascites. Destroyed intrahepatic vascular architecture was demonstrated in 58 (95%), while 3 (4.9%) showed normal vascular architecture. Conclusions—Ultrasound is useful in the diagnosis of chronic liver disease in daily clinical practice. However, the sensitivity can be improved if a high-frequency probe is used and done by experienced and dedicated operators. Liver biopsy remains the gold standard, especially when patients are clinically asymptomatic. 1536944 Carotid Ultrasound May Not Be Sufficient to Perform Carotid Endarterectomy Robert Colvin,1* Alvaro Magalhaes2 1Kansas City University of Medicine and Biosciences, Kansas City, Missouri USA; 2 Radiology, University of Missouri, Kansas City, Missouri USA Objectives—Evaluate the accuracy of ultrasound to determine treatment of carotid artery stenosis when compared to advanced imaging modalities. Methods—This study consisted of 47 patients who underwent imaging for carotid artery stenosis by magnetic resonance imaging with angiography or computed tomography with angiography at a Midwest regional medical center over a 27-month period. The results of the previously obtained duplex ultrasound studies were compared to results from advanced imaging studies. S93 13proceedings_Layout 1 3/5/13 10:39 AM Page S94 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Results—Of the 47 patients, 12 (25.53%) had a carotid artery stenosis percentage diagnosed by ultrasound that agreed with the advanced imaging modality. Fifteen (31.91%) patients likely would have had alternate treatment based on their advanced imaging studies. Based on the accepted current treatment, carotid endarterectomy for a symptomatic patient with >70% stenosis by ultrasound, 3 patients would have undergone an unnecessary carotid endarterectomy. Additionally, 12 patients would have met criteria for carotid endarterectomy and not received one. Conclusions—Clinicians must consider that many patients may receive inappropriate treatment of carotid artery stenosis if ultrasound is the sole modality used for diagnosis. Eighty percent of endarterectomies are performed based on ultrasound alone in the United States, meaning a large impact on American health care overall. While more research is needed, alternate imaging and close monitoring may be required with atypical or symptomatic patients before medical management or carotid endarterectomy is chosen as treatment. 1536948 Efficacy of Ultrasound-Guided Injection of the Sternoclavicular Joint Space Yisrael Katz,* Oliver Joseph, Oleg Uryasev, John McNamara, Apostolos Dallas Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA Objectives—The sternoclavicular joint (SCJ) space can be affected by various osteoarthropathies, including degenerative, crystal deposition, and inflammatory. Like other osteoarthropathies, corticosteroid injections could likely provide therapeutic relief to individuals with SCJ osteoarthropathy. While the literature discusses the success of computed tomography (CT)-guided injection, we hypothesize that ultrasound (US) can be used to guide SCJ intra-articular injection without exposing patients to unnecessary radiation. Methods—This study serves as a pilot study. The SCJ was injected bilaterally on 4 nonembalmed cadaveric models. The anatomy for all cadavers was within normal limits, with the exception of 1, which had marked musculoskeletal deformity of the lower limbs; an identical procedure was followed, and pathologic anatomy did not affect data collection. A 10–5-MHz small linear array transducer (L38n) was used. The SCJ was palpated, and the transducer was aligned parallel to the angle of the SCJ. Using a short-axis approach, US-guided injection was performed. A 1.5-in 22-gauge needle with 0.25 mL of 0.5% methylene blue was used. Incisions were made parallel and perpendicular to the SCJ. The joint capsule was dissected to visualize the dye as confirmation. Attempts were classified according to accuracy and precision. Accuracy measured if the joint space was stained with dye; precision measured if the injection was localized without damage to adjacent anatomy. Results—Bilateral injections on all 4 cadavers were accurate and precise. Conclusions—US is inexpensive, quick, and minimally invasive compared to CT. Given that CT-guided intra-articular SCJ injection with a corticosteroid and anesthetic has provided symptomatic relief to patients with SCJ pain, the analogous procedure can be performed under US guidance. Future phases of this study will expand the current data set and investigate the efficacy of US-guided SCJ injection in patients with SCJ arthralgia. 1536971 Efficacy of Ultrasonographically Guided Anterior Interosseus Nerve Perineural Injection at Its Bifurcation From the Median Nerve Elizabeth Glazier,* Oleg Uryasev, Oliver Joseph, John McNamara, Apostolos Dallas Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA Objectives—Compression of the anterior interosseus nerve (AIN) immediately distal to its bifurcation from the median nerve (MN) results in Kiloh-Nevin syndrome. Like other nerve compression syndromes, corticosteroid injections are a potential therapeutic modality. We hypothesize that one can effectively inject the AIN perineural space at its bifurcation from the MN. Methods—This study serves as a pilot study. The AIN perineural space was injected bilaterally on 4 cadaveric models. Cadaveric anatomy was unremarkable with the exception of 1, which had marked musculoskeletal deformity that did not affect the upper extremities. An identical procedure was followed, and pathologic anatomy did not affect data collection. A 10–5-MHz linear array transducer was used. The transducer was placed transversely through the antecubital fossa. The MN was identified proximally as it coursed over the supracondylar eminence. It appeared spindle shaped with alternating hyperechoic and hypoechoic bands. The MN was traced inferolateral to the origin of the pronator teres muscle, where the AIN bifurcation was visualized. Ultrasonographically (US) guided injections were achieved with a long-axis, medial-to-lateral approach with a 22-gauge syringe and 0.35 mL of 0.5% methylene blue. Anatomic dissection and dye visualization allowed for confirmation. Attempts were classified according to accuracy and precision. Accuracy measured nerve staining; precision measured localized injection without damage to adjacent structures. Results—Six of 8 (75%) injections were accurate, while 4 of 8 (50%) were precise. Conclusions—AIN perineural injection at its bifurcation from the MN is significant. Such ability can likely provide symptomatic relief with corticosteroid administration to patients with Kiloh-Nevin syndrome. US is inexpensive, quick, and minimally invasive. Future phases of this study will expand on our current data set and, pending such results, investigate efficacy of US-guided AIN perineural corticosteroid injections in patients with Kiloh-Nevin syndrome. 1536975 Efficacy of Ultrasonographically Guided Injection of the Ulnar Nerve Perineural Space at the Guyon Canal Jeffrey Heimiller,* Oliver Joseph, Oleg Uryasev, John McNamara, Apostolos Dallas Virginia Tech Carilion School of Medicine, Roanoke, Virginia USA Objectives—The ulnar nerve (UN) can become compressed as it passes through the Guyon canal (GC). Like other nerve compression syndromes, corticosteroid injection is a therapeutic modality. We therefore hypothesize that ultrasonographic (US) guidance can aid in effective UN perineural injections in the GC at the level of the pisiform. Methods—This is a pilot study to explore the feasibility of USguided injections of the UN perineural space in the GC at the level of the pisiform. Injections were performed on 4 unembalmed cadavers, 1 of which had marked musculoskeletal deformity that did not affect the upper extremities. The GC was imaged in the transverse plane at the level of the pisiform, and 0.25 mL of 0.5% methylene blue dye was injected into the UN perineural space using a long-axis approach from the medial end of the probe, just superficial to the pisiform. Anatomic dissection was performed subsequently to evaluate injection accuracy and precision: accuracy refers to nerve staining, while precision denotes that adjacent structures were not damaged. Results—Six of 8 (75%) were accurate. All injections were precise. Conclusions—This study was able to demonstrate an effective means of visualizing and injecting the UN perineural space at the GC under US guidance. Inaccuracies were primarily operator dependent. The operator for most injections was a second-year medical student with no prior experience performing perineural injections. Initial attempts established an effective protocol. In the method described here, the operator discovered and consistently visualized a narrow window immediately superficial to the pisiform that allowed for repeatedly accurate and precise injections. Despite the initial learning curve, the operator was overall successful with accuracy of 75% and precision of 100%. US is a viable means of increasing the accuracy and precision, and therefore effectiveness, of UN perineural injections into the GC, but it must be combined with a working knowledge of superficial landmarks and target anatomy. S94 13proceedings_Layout 1 3/5/13 10:39 AM Page S95 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1537060 Comparative Analysis of Sonographic and Doppler Signs and Perinatal Outcomes in Patients With Twin-Twin Transfusion Variants and Selective Intrauterine Growth Restriction of One of the Monozygote Twins Inessa Safonova,1* Irina Lukjanova,2 Rizvan Abdullaev1 1 HMAPO, Kharkiv, Ukraine; 2Pediatrics, Obstetrics, and Gynecology Institute, Kiev, Ukraine 1537241 Unusual Anechoic Portal Vein Thrombosis and its Significance for Predicting the Response to Anticoagulant Therapy Shoichi Matsutani,1,2* Hideaki Muzumoto,2 Akitoshi Kobayshi,2 Atsuyoshi Seki,2 Takeshi Ando2 1Chiba Prefectural University of Health Science, Chiba, Japan; 2Gastroenterology, Funabashi Municipal Medical Center, Funabashi, Japan Objectives—Some complications of monochorionic (MH) multiple pregnancy, twin-twin transfusion syndrome (TTTS), twin anemiapolycythemia sequence (TAPS), acute intertwin transfusion, and selective intrauterine growth restriction (sIGR) of one of the twins, have different perinatal prognoses and require differential tactics. Our objective was to compare their sonographic and Doppler signs, sequences, and the perinatal results. Methods—Nine cases of complicated diamniotic MH pregnancy were studied: with chronic progressive unimproved TTTS (4), TAPS (1), acute intertwin transfusion (2), and sIGR (2). Fetometry and fetal weight calculation were carried out. The amniotic fluid amount and Doppler of the umbilical artery, ductus venosus, and middle cerebral artery were estimated. Results—The sequence of ultrasound signs and the perinatal results in all cases have been described and compared. In 7 of 9 described cases, the common sonographic feature turned out to be a discorded twin’s growth. In 8 of 9 cases, a volume asymmetry of the twin’s amniotic fluid was observed. The worst perinatal outcomes and the most substantial weight differences were in women with natural flow of the TTTS, and all 4 cases were accompanied by fetal bladder asymmetry and donor cardiomegaly. At birth, hematologic distinctions of the twins were the most considerable with TAPS. Conclusions—Dynamic sonographic monitoring of an MH pregnancy should take into account several aspects, such as fetometric, amniometric, and Doppler as well as twin bladder symmetry and fetal cardiothoracic ratio control. Objectives—Acute portal vein thrombosis is still a challenging problem in daily clinical practice. Ultrasonography usually contributes to an early diagnosis of portal vein thrombosis, which thus leads to appropriate treatment. However, the response to anticoagulant therapy is somewhat unpredictable, and these situations trouble clinicians in the management of the disease. This report describes the unusual ultrasonographic appearance of acute portal vein thrombosis, which can predict a poor response to anticoagulant therapy. Methods—Sonographic changes in acute portal vein thrombi were examined in 4 patients treated with anticoagulant therapy (heparin and vitamin K antagonist). The background diseases were acute colitis in 2 patients, acute cholecystitis in 1 patient, and acute cholangitis in 1 patient. The thrombus was located in the right portal vein in 2 patients and in both the right and left portal veins in 2 patients. A Toshiba SSA 770A system with a 3.75-MHz convex probe was used for ultrasonography. Results—Two of the thrombi in the right portal vein (group A) completely recanalized with the disappearance of the thrombus in response to anticoagulant therapy. However, 4 thrombi (group B) remained unrecanalized without a response to the treatment. The group A thrombi showed echogenic material in the portal vein, which is a common sonographic appearance of thrombosis at the initiation of anticoagulant treatment. However, the group B thrombi were anechoic without any blood flow signals at the initiation of the treatment, which was quite different than the sonographic appearance of group A. The thrombus in 2 patients in group B, which had a 1-week interval before anticoagulation, showed echogenic material, which was similar to that seen in group A at the initial diagnosis. However, these 2 thrombi became anechoic 1 week later after the initiation of the treatment. All portal veins with an anechoic thrombus became occluded and changed to a hyperechoic band. Conclusions—An unusual anechoic appearance of portal vein thrombosis may therefore indicate a poor response to anticoagulant therapy, although the mechanism of this kind of ultrasonographic appearance of blood clots is undetermined. 1537067 Transvaginal Sonographic Differential Diagnosis of the Causes of Postpartum Uterus Involution Slowdown: Clinical Experience of a Specialized Hospital Department Inessa Safonova,1,2* Yuri Paraschuk,2,3 Roman Safonov2,3 1 HMAPO, Kharkiv, Ukraine; 2Kharkiv Regional Perinatal Center, Kharkiv, Ukraine; 3Kharkov National Medical University, Kharkiv, Ukraine Objectives—to compare the sonographic, clinical, and histopathologic research results in patients with slowing down of involution of the postpartum uterus. Methods—Transvaginal sonographic (TVS) examinations were undertaken in 140 postpartum women receiving care in a specialized hospital department for treatment of postpartum complications. In 38 of them, the uterine histopathology was studied. Results—The opportunities of TVS in the differential diagnosis of retained lochia, endometrial inflammation, and retained placental fragments in the postpartum uterine cavity were defined. Some specific sonographic criteria of metritis after vaginal and operational births, as well as retained unseparated placental fragments in the postpartum uterine cavity were exposed. Conclusions—The diagnostic accuracy of most ultrasound criteria for postpartum complications was not great. At the same time, TVS helped identify and differentiate the causes of uterine involution slowdown in some forms of endometritis and in women with unseparated placental fragments in the uterine cavity. 1537456 Sonographic Appearance of Cutaneous Basal Cell Carcinomas of the Head and Neck Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile Objectives—To assess the sonographic morphology of cutaneous basal cell carcinomas of the head and neck. Methods—A retrospective review of cutaneous basal cell carcinomas of the head and neck sonographically diagnosed and confirmed by histology was performed (September 2009–July 2012). Postoperative cases and medically treated lesions were excluded from the analysis. Information about extension, location, blood flow, and deeper-layer involvement was analyzed. Results—Forty-one lesions in 36 patients (55.6% female [n = 20], 44.4% male [n = 16]; mean age, 65 years [range, 38–92 years]). Number of lesions per patient: 1, 86.1% (n = 31); 2, 8.3% (n = 3); 3, 2.8% (n = 1); ≥4, 2.8% (n = 1). One hundred percent of cases were hypoechoic. Location: 52% nose, 15% lower eyelid, 8% inner canthus, 5% scalp, 5% supraciliary, 2.5% nasal fold line, 2.5% infraorbitary, 2.5% frontal region, 2.5% ear pinna, 2.5% other facial locations, 2.5% neck. Mean sizes: 7.79 mm transverse (range, 0.3–21.9 mm), 2.73 mm depth (range, 0.1–13 mm), 7.91 mm longitudinal (range, 0.5–31.1 mm). Mean area: 184.92 mm2 S95 13proceedings_Layout 1 3/5/13 10:39 AM Page S96 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 (range, 0.01–2149 mm2). Location of blood flow: 86.9% intralesional, 7.9% peripheral, 2.6% sublesional, 2.6% mixed,. Type of vessels: 74.3% arterial, 5.2% venous, 20.5% mixed arterial and venous. Mean thickness of vessels: 0.94 mm (range, 0.5–1.8 mm). Mean peak systolic velocity of the arterial vessels: 10 cm/s (range, 3.7–31 cm/s). One hundred percent of arteries showed peak systolic velocity <15 cm/s. Deeper involvement: 14% of lesions affected the nasal cartilage and 15.6% the orbicularis muscles in the face. Conclusions—Sonography can provide detailed anatomic data on cutaneous basal cell carcinomas of the face and neck. This information may support diagnosis and treatment. 1537466 Sonographic Staging in Hidradenitis Suppurativa With Clinical Correlation Ximena Wortsman,1* Claudia Moreno,2 Rosamary Soto,2 Javier Arellano,2 Carlo Pezo2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Dermatology, Faculty of Medicine, University of Chile, Santiago, Chile Objectives—To correlate the clinical (cutaneous) and ultrasound findings in hidradenitis suppurativa (HS) and assess the role of sonography in disease staging. Methods—A retrospective study of the ultrasound examinations of the HS cases was performed (January 2010–May 2012). The patients were clinically classified (Hurley) by 3 dermatologists through teledermatology. A radiologist performed the sonographic examinations and designed 2 sonographically based scorings, 1 based on Hurley parameters (HLS) and other based on sonographic parameters (SOS). A double-blind analysis of the clinical and sonographic stages was performed. The dermatologists and radiologist were blinded to each other’s report. The statistical analysis included the mode of the clinical classification using bivariate analysis of categorical variables. A Оє test was used to evaluate concordance (95% confidence interval). The study was approved by the Institutional Review Board. Results—Thirty-four HS patients (80% female; mean age, 26.7 В± 10 years) were evaluated. Combined locations were detected, and the most frequent sites were: axillae, 82.4%; groin, 26.5%; simultaneous axillae and groin 17.7%. Other locations included the inframammary, retroauricular, and thoracic regions: 3% for each, respectively. A significant correlation (bivariate analysis, P < .05) was observed between the clinicians. When comparing the clinical with the sonographic scoring (HLS and SOS), an underestimation of the severity (staging phase) by the clinical examinations was found. Concordance values were Оє = 0.343; P = .009 for clinical/HLS and Оє = 0.272; P = .023 for clinical/SOS scoring. Conclusions—Clinical examination can underestimate the severity (stage) of HS. Sonography may be a diagnostic tool to assess extension, types of lesions, and disease stage. It can provide noninvasive scoring of this dermatologic disease, which may support early and better management of these cases. 1537472 Sonographic Characterization of Glomus Tumors of the Nail Unit Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile Objectives—To assess the sonographic morphology of glomus tumors of the nail unit. Methods—A retrospective review of glomus tumor cases in the ungual region that were sonographically diagnosed and histologically confirmed was performed (January 2010–August 2012). Results—Thirty-two glomus tumor cases (81% female/19% male; mean age, 47 years; range, 21–80 years) were studied. Ninety-seven percent of the cases involved the fingernails, 3% toenails; 71.9% affected the thumb, 9.3% index finger, 6.2% ring finger, 6.2% middle finger, 3.1% little finger, 3.3% big toe. Left side, 59%; right side, 41%. Morphology: 100% of tumors showed as a single oval hypoechoic nodule. Location in the nail bed: proximal, 69%; distal, 25%; middle third, 6%. Mean transverse axis, 4 mm (range, 1.4–7.4 mm); depth axis, 2.7 mm (range, 0.8–5.7 mm); longitudinal axis, 5.4 mm (range, 1.7–10 mm). Fifty-nine percent of the cases (n = 19) presented a depth axis <3 mm. Mean area of tumors: 41.2 mm2 (range, 1–220.8 mm2). Mean thickness of the tumor blood vessels: 1 mm (range, 0.6–2 mm); peak systolic arterial velocity: 10.5 cm/s (range, 3.3–18.2 cm/s). In 3% of cases, blood flow was not detected within the tumor. Eighty-one percent of tumors showed scalloping of the bony margin of the distal phalanx. Conclusions—Sonography provides detailed anatomic data on glomus tumors of the nail unit that can be used for surgical planning, including tumors that measure <3 mm. 1537544 Correlation of Central Obesity and Body Mass Index With the Number of Items Seen on Routine Anatomy Ultrasound in Obese Patients Simi Gupta,* Judith Chervenak, Ilan Timor, Ana Monteagudo Obstetrics and Gynecology, New York University, New York, New York USA Objectives—Fetal anatomy scans are more difficult to perform on obese patients. It has been suggested that central obesity may be a more accurate predictor of the difficulty of an anatomy scan than body mass index (BMI). The objective of this study was to determine if central obesity or BMI is correlated with the number of items seen on routine anatomy ultrasound in obese patients. Methods—This was a prospective cohort study at an inner city public hospital of 67 obese patients (BMI ≥30) who underwent routine anatomy ultrasound at 18 to 22 weeks’ gestation. Central obesity was measured by placing an ultrasound probe horizontally below the umbilicus and measuring the amount of subcutaneous fat between the skin and fascia. The number of items seen on ultrasound was based on the AIUM guidelines for second-trimester anatomy ultrasound. Data were calculated using Spearman’s ПЃ. Results—The range of subcutaneous fat was 1.69 to 8.00 cm. The range of BMI was 30 to 49.6 kg/m2. The correlation between central obesity and the number of items seen on ultrasound was –0.216 (P = .08). The correlation between BMI and the number of items seen on ultrasound was –0.198 (P < .05). The correlation between central obesity and BMI was 0.568 (P < .01). Conclusions—BMI but not central obesity is significantly correlated with the number of items seen on a routine anatomy scan in obese patients. This supports prior data that BMI is associated with the level of difficulty in fetal ultrasound. 1537561 Sonographic Assessment of the Efficacy of Propanolol in Cutaneous Hemangiomas of Infancy Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile Objectives—To assess the efficacy of propanolol in the treatment of cutaneous hemangiomas of infancy using sonography. Methods—A retrospective cohort study was performed that included ultrasound cases that were medically referred by dermatologists (September 2009–August 2012) with the diagnosis of hemangioma of infancy. Inclusion criteria were children ≤1 year old, 2 sonographic examinations with a minimum separation of 6 months, and a maximum separation of 12 months between baseline and follow-up. Exclusion criteria were patients presenting ≥3 lesions or exposed to other treatment (systemic or topical). The cases were separated in 2 groups: exposed to propanolol (2 mg/kg twice a day orally administered) and nonexposed to propanolol. Informed consent was obtained from the parents or guardians in all cases. The Institutional Review Board approved this study. Analysis of the location, size in all axes, and blood flow was performed. The S96 13proceedings_Layout 1 3/5/13 10:39 AM Page S97 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Fisher test was used to assess the significance of the morphologic changes between the exposed and nonexposed groups. Results—Twenty hemangiomas in 18 patients (66% female/ 34% male; age range, 1 month–1 year) were studied. Nine patients were in the exposed group and 9 in the nonexposed group. Single lesions: 89%; 2 lesions: 11%. Location: 75% head and neck (20% cheek, 20% lips, 13.6% nose, 13.3% scalp, 13.3% temple, 6.6% eyelid, 6.6% neck, 6.6% submandibular), 15% trunk, 5% upper extremity, 5%lower extremity. The exposed group showed a significant decrease (P < .05) of the volume (P = .033) and transverse axis (P = .033) of hemangiomas in comparison with the nonexposed group. The rest of the P values were thickness, P = .057; longitudinal axis, P = .37; thickness of vessels, P = 1; and peak systolic velocity, P = 1. Conclusions—Sonography can register the changes in the morphology of cutaneous hemangiomas of infancy that are medically treated. Propanolol can significantly reduce the volume and transverse axis of hemangiomas of infancy in comparison with the nontreated group of patients. 1537671 Natural History of Fetal Pyelectasis and Risk of Infant Uropathy Emily Neri,1* Jean Goodman,1,3 Jennifer Peck2 1Obstetrics and Gynecology, 2School of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA; 3 Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois USA Objectives—The objectives of this study were to (1) determine the rate of resolution of fetal pyelectasis identified in the second trimester prior to delivery and (2) determine the predictive value of varied degrees of pyelectasis identified in the antenatal period and infant uropathy. Methods—A retrospective study was designed, with review of all prenatal ultrasounds with a diagnosis of second-trimester pyelectasis in our established database between May 2010 and January 2011. Per our routine for this diagnosis, repeat ultrasounds in the third trimester were performed and also reviewed. Maternal and newborn records from our electronic medical record and infant renal ultrasound records were examined. Exclusion criteria were chromosome abnormalities, fetal anomalies, multiple pregnancies, and delivery not at our facility. The incidences of pyelectasis in the second trimester, persistence in the third trimester, and persistence after delivery were defined. Varied pyelectasis measure cut points were determined to assess the utility of pyelectasis as a screening test for postnatal uropathy. Results—During the 9-month period, there were 119 secondtrimester ultrasounds with isolated pyelectasis identified with subsequent third-trimester ultrasound and delivery at our facility. The incidence of pyelectasis was 1%, with a mean anteroposterior renal pelvis diameter of 5.2 mm in the second trimester and 6.0 mm in the third trimester (range, 4–10 mm). Twelve percent of second-trimester pyelectasis resolved by the third trimester, and 45% resolved by delivery. Of third-trimester follow-up scans, all those who resolved by delivery had measured diameters <9 mm. Thirtysix infants had postnatal ultrasound with 28 (78%) abnormal. Of those, 21 infants had voiding cystourethrograms with 4 abnormal (19%), and 4 required surgical intervention (1.9%). With a third-trimester cut point of 7 mm, all those requiring surgery were identified (sensitivity, 100%; specificity, 67%; positive predictive value, 11%; negative predictive value, 100%). Conclusions—Second-trimester pyelectasis of ≥4 mm warrants follow-up in the third trimester given the high likelihood of persistence. Follow-up at delivery is advised if pyelectasis is ≥7 mm on third-trimester assessment. 1537779 The Stripe Unraveled: From Dysfunctional Uterine Bleeding to Postmenopausal Bleeding Chitra Chandrasekhar,* Verghese George Diagnostic and Interventional Imaging, University of Texas Health Science Center, Houston, Texas USA Objectives—Transvaginal sonography (TVS) has become an acceptable and standard means of evaluation of the female patient with dysfunctional uterine bleeding or postmenopausal bleeding. TVS is a standard initial investigative tool easily performed in the office. The demonstration of a normal stripe by TVS is a reliable and easily performed noninvasive investigative procedure that obviates the necessity for endometrial biopsy. At least 70% of perimenopausal and postmenopausal visits and 20% of gynecologic office visits are for abnormal uterine bleeding, which call for sonographic evaluation of the endometrial stripe. Methods—(1) To comprehend the physiologic variations of the endometrial stripe (EMS) in the premenopausal, perimenopausal, and postmenopausal female. (2) To demonstrate normal and abnormal appearances of the EMS, including focal and diffuse processes within the endometrium and the effects of tamoxifen therapy. (3) To illustrate technical approaches for TVS and hysterosonography as methods to study the EMS and to prevent technical and interpretative pitfalls. Results—Review of this poster will enable the viewer to understand the following: (1) The standard of care in evaluation of the EMS is transvaginal sonography and should not be limited to the transabdominal approach only. A transabdominal scan alone is not considered sufficient to exclude endometrial pathology. (2) Technical pitfalls in imaging of the EMS will be illustrated. (3) Saline-infused hysterosonography is useful in delineating endometrial pathology to lead the clinician toward the next step such as a directed endometrial biopsy in the investigation of abnormal vaginal bleeding. Conclusions—Understanding the appearance of the EMS in premenopausal and postmenopausal females is critical to exclude or include underlying pathology. TVS is a standard, safe, and widely accepted first line of investigation in patients presenting with abnormal vaginal bleeding regardless of their reproductive status. Recognition of a normal stripe excludes or directs the clinician toward the next step in the investigation of vaginal bleeding. Demonstration of focal nodularity or thickening may direct the clinician to hysteroscopy and biopsy rather than a blind endometrial biopsy in the office. 1537941 Prevalence of Fluid Associated With the Iliotibial Band in Asymptomatic Recreational Runners: An Ultrasonographic Study Elena Jelsing,1,2* Jonathan Finnoff,3 Bruce Levy,1 Jay Smith1,2 1Sports Medicine, 2Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota USA; 3Sports Medicine, Tahoe Orthopedics and Sports Medicine, South Lake Tahoe, California USA Objectives—To evaluate the prevalence and distribution of fluid associated with the iliotibial band (ITB) in asymptomatic recreational runners. Methods—Five male and 15 female asymptomatic recreational runners (10–30 miles/wk), ages 18 to 40 years, were examined using ultrasonography to assess for the presence of fluid at the level of the lateral femoral epicondyle and determine its relationship to the ITB at 0В° and 30В° of knee flexion in both supine (non–weight-bearing) and standing (weightbearing) positions. Results—All subjects exhibited fluid associated with the ITB in at least 1 knee, and this finding was bilateral in 90% of subjects. When examined in full extension, fluid was seen in 67.5% of knees (n= 40) when supine, compared to 95% of the knees when standing. When examined in 30В° of flexion, the presence of fluid decreased to 30% when supine and 22.5% when standing. With the knee in full extension in a supine/standing position, fluid was located anterior and deep 70%/74% of the time and anterior only 11%/0% of the time. With the knee flexed to 30В° in a supine/standing position, fluid was located anterior and deep 50%/33% of the time and anterior only 33%/67% of the time. Conclusions—Fluid was associated with the ITB in at least 1 limb in 100% of asymptomatic recreational runners and was bilateral in 90%. Clinicians should use caution when interpreting the clinical significance of ITB-associated fluid in runners presenting with lateral knee pain syndromes. S97 13proceedings_Layout 1 3/5/13 10:39 AM Page S98 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Table 1. Fluid Location in Relation to the Lateral Femoral Epicondyle at 0В° and 30В° of Knee Flexion (N = 40 Knees) Presence of Fluid No fluid Anterior only Anterior and deep Deep only Posterior Supine Supine 30В° Standing Standing 30В° Extended (%) Flexed (%) Extended (%) Flexed (%) 13 (32.5) 28 (70) 2 (5) 31 (77.5) 3 (7.5) 4 (10) 0 (0) 6 (15) 19 (47.5) 6 (15) 28 (70) 3 (7.5) 5 (12.5) 2 (5) 10 (25) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1538060 Three-Dimensional Ultrasound of the Cumulus Oophorus Kyle Beiter,1* Thomas Hilgers,2 Jeanine Johnson,2 Rachel Stites2 1Saint Peter’s Healthcare System, New Brunswick, New Jersey USA; 2Reproductive Ultrasound Center, Pope Paul VI Institute for the Study of Human Reproduction, Omaha, Nebraska USA Objectives—The ability to observe the cumulus oophorus by ultrasound has been controversial over the years. The Pope Paul VI Institute for the Study of Human Reproduction’s Reproductive Ultrasound Center has been very interested in this topic for a number of years and has published on it. This e-poster introduces the first published photos of the cumulus oophorus taken by 3D ultrasound. Methods—Examination was performed using a Medison Accuvix V20 Prestige ultrasound system. A 3D endovaginal 5–9-MHz transducer was used. After 2D scanning of the cumulus oophorus was completed, a 3D acquisition with the region of interest set to encompass the area of the dominant follicle and cumulus oophorus was acquired. SonoView Pro software was used to manipulate the 3D volumetric data by rotating the x-, y-, and z-axes to obtain a 3D rendering of the cumulus oophorus. Results—A 3D image of the mature follicle with the eccentrically located cumulus oophorus was obtained and is shown. This image is then rotated on its axis, and it can be seen from different directions. Conclusions—This presentation shows that 3D ultrasound can provide extraordinary pictures of the cumulus oophorus in a way that leaves the determination of its presence inescapable. Further refinement of this technique should help in the ultrasound evaluation of normal ovulation patterns and the various disorders of human ovulation. 1538125 Design and Evaluation of a Point-of-Care Ultrasound Curriculum for Pediatricians Involved in Global Health Sachita Shah,1,2* Meera Muruganandan,3 Sachin Shah,4 Randheer Shailam,5 Sara Stulac,2,6 Kim Wilson6 1Emergency Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington USA; 2 Partners in Health, Boston, Massachusetts USA; 3Emergency Medicine, Rhode Island Hospital, Brown University, Providence, Rhode Island USA; 4Cardiology, Lahey Clinic, Burlington, Massachusetts USA; 5Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts USA; 6Pediatric Global Health, Boston Children’s Hospital, Boston, Massachusetts USA Objectives—As ultrasound becomes more portable, durable, and affordable, point-of-care ultrasound use by nonradiologists has been rapidly increasing both in the United States and in resource-poor developing world settings. However, training programs for ultrasound skills specific to global health work and pediatrics are lacking, leading to a dangerous knowledge gap for this operator-dependent technology. We describe our response to this knowledge and training gap with a novel curriculum in bedside ultrasound focused on pediatric clinical conditions common in resource-limited settings. Our primary objective is to describe this curriculum and response to the pilot training program. Methods—The 15-hour course was taught by a multidisciplinary faculty and focused on bedside clinician-performed ultrasound techniques for assessment of the pediatric global burden of disease. Lecture didactics were complemented by practical skills sessions using live models and hand-carried ultrasound machines. An anonymous postcourse selfassessment survey was conducted to assess confidence and attitudes. Results—The curriculum included training on ultrasound safety and physics, uses in trauma, including the focused assessment with sonography for trauma exam, hemothorax and pneumothorax, procedural guidance, echocardiography (pericardial effusion, systolic dysfunction, and rheumatic valvular disease), liver lesions, splenomegaly, appendicitis, pyloric stenosis, and skin/soft tissue infections, including pyomyositis. Postcourse self-assessments of the participants were overwhelmingly positive with high levels of confidence in the various ultrasound techniques explored during the course despite no prior experience. After the training, students felt the most confident with trauma, pericardial effusion, skin/soft tissue ultrasound, and procedural guidance and the least confident with identification of specific liver lesions and use of the inferior vena cava as a proxy for dehydration. One hundred percent of the participants believed ultrasound would be useful in low-resource settings. Conclusions—This clinical course of ultrasound skills for pediatricians embarking on global health careers may serve as one model for more effectively preparing trainees to work in developing countries. 1538182 Emergency Medicine Intern Ultrasound Proficiency: A Longitudinal Study Elizabeth Pontius,1* Kerri Layman,1,2 Michael Antonis1,2 1 Emergency Department, MedStar Washington Hospital Center, Washington, DC USA; 2Emergency Department, MedStar Georgetown University Hospital, Washington, DC USA Objectives—Our goal was to determine the level of proficiency that interns had with emergency bedside ultrasound (US) over the course of a year. Methods—Nineteen Georgetown School of Medicine 2010 graduates entered emergency medicine residencies. An e-mail was sent to each of the 19 graduates 3 times over the course of the 2010–2011 academic year, in July 2010, February 2011, and July 2011. The e-mail contained a link to a 6-question Web-based survey. Graduates were asked whether they had participated in an emergency bedside US elective and if they had other exposure to US during medical school. They were also asked to rate their proficiency with bedside US at the start of residency and at the time of the survey. Last, they were asked to rate themselves against their peers in bedside US proficiency. Results—Of the 19 graduates, 15 responded to the survey in July 2010, 12 in February 2011, and 8 in July 2011. Half of respondents had participated in an emergency bedside US elective, and approximately 75% had exposure to US in another setting during medical school. In the first survey, respondents reported their level of comfort as 5.67 at the start of the year and 6.47 currently on a 10-point scale. By midyear, respondents rated their level of comfort as 4 at the start of the year and 6.83 currently. In July 2011, respondents rated their comfort level as 4.13 at the start of the year and 7.5 currently. The resident’s self-assessed level of proficiency when graded against their peers did not change appreciably, from 7.13 on a 10-point scale at the start of the year, 6.83 at the midyear mark, and 7.13 at the end of the year. Conclusions—Emergency medicine interns became more proficient with bedside US over the course of their intern year. As the year progressed, however, they rated their level of comfort at the start of the year lower than they had initially. Further study is needed to determine if the emergency bedside US elective in medical school provides any benefit. S98 13proceedings_Layout 1 3/5/13 10:39 AM Page S99 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1538313 Case Presentations of “Cloudy Ascites” Associated With Female Pelvic Malignancies Raydeen Busse,1,2 Gail Hoshiko-Reed,2 Chrystie Fujimoto1,2* 1 Obstetrics, Gynecology, and Women’s Health, University of Hawaii, Honolulu, Hawaii USA; 2Hawaii Pacific Health, Honolulu, Hawaii USA Objectives—There is no effective early detection available for ovarian cancer screening; therefore, vague symptoms of early satiety, abdominal discomfort, and abdominal bloating commonly result in pelvic ultrasound imaging. Ascites in the gynecologic patient is easily identified using high-resolution transvaginal pelvic ultrasound imaging even when present in trace amounts. Although the presence of cul-de-sac free fluid in patients of childbearing age is a routine finding due to ovulation and the menstrual cycle, the presence in postmenopausal women regardless of amount warrants further investigation. We present 3 cases of echogenic pelvic fluid or “cloudy ascites” found in perimenopausal and postmenopausal women in whom pelvic malignancies were diagnosed. Methods—Transvaginal ultrasound that is performed in our unit classifies and subjectively quantifies free pelvic fluid in all patients. We noted 3 cases in which the presence of free pelvic fluid in perimenopausal and postmenopausal women changed in character and quantity over a short period of time. There were no ovarian masses. The presence and change of the pelvic fluid was solely what led to the subsequent operative diagnoses of 3 different pelvic malignancies in our 3 cases. Results—The presence of clear or anechoic cul-de-sac free fluid was present in each of the 3 cases, and short-term follow-up was recommended. In each case, the ascites changed from anechoic to complex on ultrasound imaging or increased in subjective amount. No ovarian abnormalities were seen in any of the 3 cases. Further evaluation was initiated, and subsequent operative pathology revealed a mucinous adenocarcinoma of the appendix, metastatic breast cancer after 15 years of remission, and a fallopian tube carcinoma. Conclusions—In perimenopausal, specifically, postmenopausal women, our premise is that ascites or pelvic free fluid should always be classified as to its echogenicity and amount. If the fluid appears to represent an exudate or contain echoes, some type of inflammatory process could be present, or the fluid could represent malignant ascites. Although complex or cloudy ascites is not pathognomonic for malignancy, it certainly is a cause for further evaluation. 1538648 Predicting Prognostic Factors of Breast Cancer Using Shear Wave Elastography Woo Jung Choi,* Hak Hee Kim, Joo Hee Cha, Hee Jung Shin, Hyunji Kim, Min Ji Hong, Eun Suk Cha, Hyeon Sook Kim, Sung Hun Kim Radiology, Asan Medical Center, Seoul, Korea Objectives—To investigate the correlation between histologic factors, including immunohistochemical factors, of breast cancer related to the prognosis of tumors using shear wave elastography (SWE). Methods—One hundred twenty-two pathologically proven breast cancers from 116 women (age range, 27–77 years; mean age, 48.1 years) were included in this study. For each lesion, B-mode ultrasound and SWE images were obtained. Of the SWE features, the mean elasticity value, maximum elasticity value, and SWE ratio were extracted. The SWE ratio was calculated as the ratio of the stiffest portion of the lesion to the similar region of interest in fat tissue. Histologic findings from pathologic reports were used for comparison, namely, nuclear and histologic grade, nodal status, vascular invasion, invasive size, and immunohistochemical factors such as estrogen receptor (ER), progesterone receptor (PR), Her-2 (c-erb B2), Her-1 (epidermal growth factor receptor), CK5/6, p53, and Ki-67. The Mann-Whitney U test and Kruskal-Wallis test were used to compare the SWE values in the groups of histologic parameters. Subtypes based on the immunohistochemical profile were compared with SWE values using the Kruskal-Wallis test. Results—The negative group of ER (P = .004), negative group of PR (P = .016), positive group of p53 (P = .024), and positive group of Ki-67 (P = .008) showed statistically significant positive associations with a high SWE ratio. A high nuclear grade (P = .014), high histologic grade (P = .015), and large invasive size (P = .010) was associated with a significant high SWE ratio. The mean elasticity value and maximum elasticity value showed less statistical significance with the histologic factors. The Kruskal-Wallis analysis showed that the SWE ratio was significantly different across the subtypes based on the immunohistochemical profile (P = .013). Conclusions—The SWE ratio may provide useful information for predicting prognostic factors of breast cancer. 1538793 Understanding How Ultrasound Technology Promotes Student Attention During Instruction of the Physical Exam Caridad Hernandez,1* Christine Bellew,1 Alfredo Tirado,1,2 Andrew Payer,1 Manette Monroe,1 Juan Cendan1 1Medical Education, University of Central Florida College of Medicine, Orlando, Florida USA; 2Emergency Medicine, Florida Hospital, Orlando, Florida USA Objectives—The use of point-of-care ultrasonography (US) is increasing in medical practice. Accompanying this is an interest in incorporating US education in undergraduate medical education. Here we explore the role of US technology as part of an instructional strategy to enhance students’ motivation to learn to perform the neck/thyroid exam. Methods—We used a qualitative research design using prompted text responses. Second-year students in the physical diagnosis course participated. All students received traditional instruction on the physical exam of the neck/thyroid with the addition of a student-run US exam of the neck. Students worked in small groups with a faculty instructor and a standardized patient. Following the sessions, they submitted responses to 5 items aimed at assessing 4 categories of motivational variables: attention, relevance, confidence, and satisfaction. Data were analyzed using a grounded theory approach. Two authors reviewed the responses, devised a coding framework, and generated themes. NVivo, a qualitative data analysis platform, was used to evaluate the data. Results—Sixty-five students completed the prompted-response items. We report analysis of students’ responses to the item, “Using US worked to maintain my attention by.” Four major themes emerged: (1) engagement—the session was “fun,” “engaging,” “extremely interesting,” and “interactive”; (2) active learning—being actively involved in identifying structures and getting to handle the probes was key to maintaining their attention; (3) clinical application of anatomy—application of their knowledge of anatomy and anticipated applicability maintained their attention; (4) hands-on learning—actually doing the US themselves helped them learn the procedure/anatomic structures and relationships as opposed to looking at still images obtained by others. Conclusions—Incorporating the use of US with the physical exam of the neck/thyroid helps maintain students’ attention because it promotes learner engagement and provides clinical contextualization of anatomy. Another theme that emerged was that hands-on real-time capturing of images by the students themselves improved their understanding of relevant anatomy. 1538852 Value of Qualitative Sonoelastographic Evaluations in the Diagnosis of Solid Breast Masses Hasan Yerli,1* Tugbahan Yilmaz,2 Banu Ural2 1Radiology, 2 General Surgery, Baskent University Zubeyde Hanim, Practice and Research Center, Izmir, Turkey Objectives—To determine whether the use of a qualitative elasticity scoring method by sonoelastography (SE) is useful to differentiate between benign and malignant breast masses. Methods—One hundred seventy lesions in 145 consecutive pa- S99 13proceedings_Layout 1 3/5/13 10:39 AM Page S100 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 tients with solid breast masses (139 benign, 31 malignant) were prospectively included in this study. For each lesion, B-mode ultrasound (US) and SE images were obtained. For each lesion, elasticity scores were determined with a 5-point scoring method by SE. The findings were compared with histopathology. The diagnostic performances for the elasticity scoring and B-mode US methods were determined. Results—The mean scores on SE were 2.58 В± 0.57 for benign lesions and 3.85 В± 0.69 for malignant lesions. Sensitivity, specificity, and accuracy for the 5-point scoring method were 78%, 92%, and 88%, respectively; 88%, 74%, and 84% for B-mode US when a cutoff point between scores 3 and 4 was used. Conclusions—After B-mode US analysis, qualitative evaluation with the 5-point scoring method by SE is a complementary method that increases specificity when differentiating between benign and malignant breast masses. 1538946 Masses in Pregnancy: Blood Flow Provides Vascular Clues to Diagnosis Constance Bitters,* Beth Kline-Fath Ultrasound, Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio USA Objectives—Determining the etiology of an intrauterine mass can be difficult. The goal of this study was to determine if the origin of these masses can be established via color Doppler flow. Methods—An Institutional Review Board–approved retrospective review was performed by searching our fetal database from 2004 to 2012. Twelve cases of intrauterine soft tissue masses without identifiable fetal parts were discovered. The lesions were evaluated with ultrasound for location and echo texture. Doppler was used to determine the vascular supply, site of supply, number of vessels (hypervascular ≥3 vessels), and waveforms. Results—The lesions were 8 proven chorioangiomas (CA), 2 twin reversed arterial perfusion (TRAP), 1 fibroid, and 1 chronic intrauterine demise (IUD). In the CA, the soft tissue mass was hypervascular and embedded in the placenta with the fetal placental cord insertion along the margin. Six were heterogeneous and 2 homogeneous. Vascularity extended primarily from the placental cord insertion and superficial placenta with less extending to the deep placenta. Five contained low-resistance arteries, and all had pulsatile veins. The 2 TRAP were heterogeneous and abutted the placenta contained in an encircling membrane. Both had 2 vessel feeders with a single artery and vein centralized in the mass. In 1 pregnancy, the arterial waveform was documented as reversed when compared to the normal fetus. The fibroid was homogeneous and in the myometrium along the placental edge with a supplying artery and vein extending deep myometrium. The chronic IUD showed heterogeneous tissue with no color flow. A membrane was noted, supporting diamniotic twin gestation. Conclusions—The vascular supply can be helpful in evaluation of amorphous intrauterine masses. In CA, the lesion is hypervascular and embedded in the placenta, with vessels originating from the placental surface and fetal placental cord. In TRAP, the lesion demonstrates a centralized vascular supply, with diagnosis supported by the presence of reversed arterial flow. Fibroids demonstrate vessels extending into the deep myometrium. Chronic IUD should be considered in the absence of vascular flow, especially in the presence of a separating membrane. 1539098 Ultrasound-Guided Vascular Access on a Phantom: A Training Model for Medical Student Education—Trends in Data, 2010–2012 Lydia Sahlani,1* Eric Adkins,1,2 David Bahner1 1Emergency Medicine, 2Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio USA Objectives—Patient safety and prevention of medical errors have been emphasized as an integral part of medical education. Focusing on ultrasound-guided vascular access (USGVA) in the medical school curriculum can improve patient safety and prevent errors. We reviewed a cohort of second-year medical students (MS2) to assess their proficiency with USGVA access in 2010, 2011, and 2012. Methods—This study was an observational cohort study of MS2s during their Introduction to Clinical Medicine program during 2010, 2011, and 2012. Students reviewed an online training module from EMSONO.com about USGVA, completed a quiz, and participated in a didactic session using a Blue Phantom block gel model. Students were divided into groups and allowed to practice the skills. After the practice session, they were graded by a proctor using a standardized scoring sheet. The students were evaluated on their ability to visualize the simulated vessel in different planes, perform vascular cannulation in both the short and long axes, the number of needle sticks attempted, and successful cannulation. Results—A total of 600 MS2s with complete data from 2010 through 2012 were included. Students were able to cannulate the vessel in the long axis with a mean of 1.25 sticks (SD, 0.60; 95% confidence interval [CI], 1.20–1.30). They were able to cannulate the vessel in the short axis with a mean of 1.33 sticks (SD, 0.67; 95% CI, 1.27–1.38). A nonparametric test, the Wilcoxon signed rank test, for paired data was used for further analysis. We tested the hypothesis that the median of difference between the number of sticks in long and short axes would equal 0. Combined data show there was a significant difference (P = .0007) between the number of long- and short-axis sticks. Conclusions—A structured ultrasound curriculum can help MS2s learn the psychomotor skills necessary to cannulate a vessel on a phantom using ultrasound guidance. Results indicate that there is a significant difference between long- and short-axis sticks, with the short axis requiring more sticks to cannulation. Future studies could focus on improvement of short-axis sticks to cannulation and retention of the skill as tested at various intervals of training. 1539608 Bayesian Methods for Streamlining and Enhancing the Analysis and Presentation of Myocardial Strain and Strain Rate Data Olga Neyman,1* Michelle Milne,2 Gautam Singh,3 Ravi Rasalingam,4 James Miller,2 Mark Holland2,3 1Biomedical Engineering, 2Physics, 3Pediatrics, 4Internal Medicine, Washington University, St Louis, Missouri USA Objectives—Quantitative evaluation of global and regional myocardial strain has been shown to be feasible in the echocardiographic laboratory. In spite of the potential for such strain-based evaluation, clinicians frequently find the time required to analyze the data to be prohibitive and the amount of data to be far too large and unwieldy to permit routine clinical use. The goal of this work is to present to the physician a concise summary of physiologically meaningful results (eg, values of the maximum strain, strain rate, and time to maximum strain) as well as significantly improved strain rate vs time curves to facilitate meaningful interpretations. Methods—We introduce Bayesian methods for model selection and parameter estimation that result in improved quality of automated data reduction and reporting. Bayesian probability-based methods that permit modeling strain and strain rate curves such that analysis, interpretation, and identification of specific features in these data are simplified, less time intensive, less affected by anomalous noise, and less operator dependent than current manual interpretation approaches will be described and illustrated. Results—Bayesian-based analysis methods were applied to myocardial strain data collected from the left ventricle of 49 adolescents. Echocardiographic data were acquired using a GE Vivid 7 imaging system, and the strain data were generated using the GE EchoPac system. Initial results show strain curves derived from model functions constructed using the Bayesian parameter estimation approach to be in good agreement with the acquired strain data. The strain rate data derived from the S100 13proceedings_Layout 1 3/5/13 10:39 AM Page S101 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 models for the strain data provided smoothly varying curves that are easily interpreted and compare favorably to results anticipated based on physiologic considerations. Conclusions—Bayesian probability-based methods appear to provide an approach that shows promise for providing objective, operatorindependent analysis of clinical myocardial strain and strain rate data along with significant reductions in the amount of time required of the cardiologist analyzing the data. (Supported by National Institutes of Health grant R21 HL106417.) 1539642 Sonographic Characterization of Keloids Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile Objectives—To assess the sonographic morphology of keloids. Methods—A retrospective review of keloids that were sonographically diagnosed and confirmed by histology was performed (September 2009–August 2012). Data on extension (millimeters), location, blood flow (activity), deeper layer involvement, and accompanying fistulas were analyzed. Results—Twenty-five keloids in 20 patients (50% female [n = 10], 50% male [n = 10]; total mean age, 26 years [22 years females and 30 years old for males]; age range, 4–66 years) were found. Number of lesions per patient: 1 lesion, 85% (n = 17); 2 lesions, 10% (n = 2); multiple lesions (≥3 lesions), 5% (n = 1). Body segment location of lesions: anterior thorax, 24% (n = 6); upper extremity, 24% (n = 6); face, 20% (n = 5); lower extremity, 12% (n = 3); submandibular region, 12% (n = 3); dorsal region, 4% (n = 1); epigastric region, 4% (n = 1). Layer location of lesions: dermis, 84% (n = 21); epidermis and dermis, 8% (n = 2); dermis and hypodermis, 4% (n = 1); epidermis, 4% (n = 1). Echo structure: hypoechoic, 84% (n = 21); heterogeneous, 16% (n = 4). A linear pattern was present in 20% (n = 5) of keloids. Fistulas within the lesions were observed in 8% (n = 2) of cases. Mean size: transverse axis, 22.58 mm (range, 7.1–69.1 mm); thickness, 5.79 mm (range, 2–17.5 mm); longitudinal, 24.77 mm (range, 6.2–66 mm). Mean area: 2596.65 mm2 (range, 59.92–12922.07 mm2). Vascularity was detected in 60% (n = 15) of lesions, and 100% of these lesions demonstrated a peak systolic velocity of arterial vessels <15 cm/s. Mean thickness of vessels was 0.8 mm (range, 0.5–1.1 mm). Mean maximum arterial peak systolic velocity: 5.45 cm/s (range, 4–9.5 cm/s). Location of vascularity: peripheral, 59.9%; intralesional, 33.5%; mixed type (peripheral and intralesional), 6.6%. Type of blood flow: arterial, 93.3%; arterial and venous, 6.7%. None the lesions showed deeper-layer involvement (tendon, muscle, or bone) or calcifications. Conclusions—Sonography can provide morphologic data on keloids, which can support diagnosis and/or treatment. 1539652 Contribution of Contrast-Enhanced Sonography to Transjugular Intrahepatic Portosystemic Shunt Follow-up Jean Ayoub,* Jean Marc Perarnau, FrГ©dГ©ric Patat University hospital, Chambray Les Tours, France Objectives—The objective of this study was to demonstrate the efficacy of a color Doppler velocity (CDV) profile combined with contrast-enhanced ultrasound (CEUS) in assessment of transjugular intrahepatic portosystemic shunt (TIPS) obstruction. Methods—Procedural data, including stent size and portal vein pressure (PVP) before and after TIPS placement, were obtained prospectively in 22 patients (14 males, 8 females; median age, 59 years; range, 44– 72 years). Patients were examined in a fasting condition. Patients had baseline CDV examinations 1 day before (D–1), and 1 day after (D+1) TIPS placement, with scheduled follow-up at 1, 3, 6, 9, and 12 months after the procedure. The following parameters (mean velocity [Vm], flow volume [Qv], hepatic resistance index, and PVP) of the portal vein, TIPS, and hepatic artery parameters were analyzed. Results—A total of 208 CDV examinations were performed on 22 patients with TIPS, for an average 9.5 studies per patient. At D+1, portal vein and hepatic artery Vm increased significantly by 407% and 199%. Qv increased by 501% in the portal vein and by 287% in the hepatic artery. The PVP decreased by 35%. There was a correlation between PVP and portal Vm (r = 0.54; P < .05) after the procedure. Most of these hemodynamic parameters decreased with time. One year after the TIPS procedure, portal vein Vm and hepatic artery Qv decreased respectively by 47% and 70%; within the TIPS, Vm decreased by 10% (P < .05). TIPS dilatation is decided in conjunction with modifications of these quantitative hemodynamic parameters. The TIPS is dilated in cases of reversed flow in portal branches or pronounced spectral curve dispersal on pulsed Doppler. CEUS was also used to confirm TIPS obstruction. CDV diagnosis was confirmed by angiography and portal vein pressure during dilatation. Thirty-six percent of these patients have TIPS dilatation 1 year after the procedure. Conclusions—Color Doppler ultrasonography combined with CEUS allowed quantitative and qualitative confirmation of the diagnosis of TIPS obstruction. 1539664 The Ultrasound Challenge: A Novel Approach to Ultrasound Education Eric Cortez,1* Creagh Boulger,1 Matthew Blickendorf,1 Emily Hoover,2 Adam Jasne,2 Stacy Boore,2 Anthony Mueller,2 Eric Adkins,1 David Bahner1 1Emergency Medicine, 2College of Medicine, Ohio State University, Columbus, Ohio USA Objectives—Our institution has a well-established extracurricular ultrasound program, which involves a sizable portion of the 4 medical school classes. The Ultrasound Challenge began in 2010 as a method of encouraging medical students to refine their skills in performing various focused ultrasound scans and demonstrate their abilities in a controlled setting. Now approaching its fourth year, the Ultrasound Challenge also encourages collegiality and interaction between the medical school classes. Methods—The Ultrasound Challenge comprises 6 events: focused assessment with sonography for trauma (FAST), aorta, cardiac, pelvic, musculoskeletal, and vascular access. Participants may choose to compete in 1 or all of these events. FAST, aorta, and cardiac scans were completed using medical student–trained simulated ultrasound patients. The musculoskeletal scan requires the participant to visualize his or her own anatomy. Pelvic and vascular access scans are completed using a phantom model. Time is limited for all scans. Images are reviewed and scored using a B-QUIET model with the exception of the procedural scan, which is scored in real time based on specific procedural technique. Awards were given to the top 3 students acquiring and labeling the best images in the allotted time. Results—Thirty-three medical students competed in the Ultrasound Challenge in 2012. This included 6 med 1, 15 med 2, 5 med 3, and 8 med 4 students. Event winners included individuals from each of the 4 classes (Table 1). Conclusions—The Ultrasound Challenge is a unique method of encouraging medical students to refine their learned skills in various focused ultrasound scans. Students participated in open scanning sessions to gain additional practice prior to the event. Medical students of all levels proficiently performed 6 focused ultrasound scans. Future competitions may involve residents or students from other institutions. Model criteria may also be instituted to further standardize the process. Table 1. Event Winners by Medical Student Year 1st place 2nd place 3rd place S101 FAST Cardiac Aorta Pelvic Vascular Musculoskeletal Overall 2nd 4th 4th 4th 4th 2nd 4th 1st 4th 3rd 3rd 4th 1st 4th 4th 3rd 2nd 2nd 3rd 4th 3rd 13proceedings_Layout 1 3/5/13 10:39 AM Page S102 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1539668 A Committee Structure for Improved Efficacy of a Student Ultrasound Interest Group Katherine Pollard,* Emily Hoover, David Bahner Emergency Medicine, Ohio State University College of Medicine, Columbus, Ohio USA Objectives—To assess the impact of a new committee structure on the efficacy of a student ultrasound interest group. Methods—Our institution has a well-established student-run ultrasound interest group. Since its founding, the interest group has served as a central organizing body for all ultrasound educational activities. The ultrasound interest group has traditionally been led by a group of 4 secondand fourth-year medical student officers and a faculty advisor. During this academic year, a new committee structure was developed to provide more opportunities for medical student involvement within ultrasound leadership and to improve the ability of the interest group to support ultrasound education initiatives. Six committees were formed focusing on medical student education, resident/fellow/faculty education, outreach, research, grants/funding, and technology. Results—The initial development of the committee structure allowed the ultrasound interest group to better define its core goals and values. The committee structure has also provided opportunities for approximately 30 medical students (currently 15 first-year, 5 second-year, 1 third-year, and 7 fourth-year students) to take new leadership roles within our ultrasound education program while decreasing the burden on the officers and advisor. The committee structure has improved ultrasound education in numerous ways. Examples of this improvement include forming new connections with ultrasound advocates within our institution, expanding the ultrasound interest group’s online presence, and identifying new student research funding opportunities. Conclusions—The implementation of a new committee structure for our student ultrasound interest group has greatly improved the ability of our interest group to educate medical students, residents, and faculty on the applications of and techniques involved in performing bedside ultrasonography. 1539712 Sonographic Characterization of Pilomatrixomas Ximena Wortsman,1* Nelson Lobos2 1Radiology, Dermatology, Clinica Servet, Faculty of Medicine, 2Health Sciences, University of Chile, Santiago, Chile Objectives—To assess the sonographic morphology of pilomatrixomas. Methods—A retrospective review of pilomatrixomas that were sonographically diagnosed and confirmed by histology (September 2009– July 2012) was performed. Extension in all axes, location, blood flow, deeper-layer involvement, and calcium deposits were analyzed. Results—A total of 118 pilomatrixomas in 107 patients were analyzed. Mean age: 17 years (age range, 5 months–82 years). Number of lesions per patient: 1 lesion, 93.4% (n = 100); 2 lesions, 4.6% (n = 5); 3 lesions, 0.9% (n = 1); 4 lesions, 0.9% (n = 1). Location of lesions: face, 55.1% (n = 65); upper extremity, 17.8% (n = 21); neck, 10.2% (n = 12); lower extremity, 9.3% (n = 11); trunk, 7.6% (n = 9). Layer location of lesions: dermis and hypodermis, 66% (n = 78); only hypodermis, 31% (n = 36); only dermis, 3% (n = 4). Echo structure: hypoechoic rim and hyperechoic center, 68,8% (n = 81); hyperechoic, 18.6% (n = 22); heterogeneous, 7.6% (n = 9); hypoechoic, 5% (n = 6). Mean size: transverse axis, 6.32 mm (range, 0.5–19 mm); depth, 3.81 mm (range, 0.3–12 mm); longitudinal axis, 6.22 mm (range, 0.5–19 mm). Mean volume: 187.32 cm3 (range, 0.07–2148.44 cm3). Calcium deposits were present in 90% (n = 106), and anechoic areas (cystic variant) were detected in 4% (n = 5) of lesions. A posterior acoustic shadowing artifact was present in 24.6% (n = 29) of lesions. Inner septa were observed in 1% (n = 1) of tumors. Blood flow was detected in 66% (n = 78), and 96% of these cases showed maximum arterial peak systolic velocity <15 cm/s. Blood flow location: peripheral, 79.4% (n = 62); mixed (peripheral and intralesional), 18% (n = 14); intralesional, 2.5% (n = 2). Type of vessels within lesions: arterial, 48.7% (n = 38); arterial and venous, 48.7% (n = 38); venous, 2.6% (n = 2). Mean thickness of the vessels: 0.95 mm (range, 0.5–1.7 mm). Mean maximum peak systolic velocity of arterial vessels: 10.14 cm/s (range, 5.3–23.1 cm/s). Extrinsic compression of muscles (orbicularis eyelid and epicranius frontal muscles): 5% (n = 6); extrinsic compression of cartilage (ear pinna): 1.6% (n = 2). Conclusions—Sonography can characterize pilomatrixomas, which may support diagnosis and surgical planning. 1539749 Accuracy of Sonographically Guided Deep Plantar Fascia (Intrafascial) Injections: Where Does the Injectate Go? Eugene Maida,* James Presley, Wojciech Pawlina, Jay Smith Physical Medicine and Rehabilitation, Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, Minnesota USA Objectives—To determine the accuracy and distribution of sonographically guided deep plantar fascia (intrafascial) injections using a cadaveric model. Methods—A single experienced operator completed sonographically guided intrafascial injections in 10 unembalmed cadaveric specimens (5 right and 5 left) obtained from 2 male and 4 female donors ages 49 to 95 years (mean, 77.5 years) with an average body mass index of 23.2 kg/m2. A 12–3-MHz linear array transducer was used to direct a 25-gauge, 38-mm stainless steel needle deep to the plantar fascia at the anterior aspect of the calcaneus using an in-plane, medial-to-lateral approach. In each case, 1.5 mL of 50% diluted colored latex was injected just deep to the plantar fascia. After a minimum of 72 hours, study coinvestigators dissected each specimen to assess injectate placement. Results—All 10 injections accurately placed latex adjacent to the deep side of the plantar fascia at the anterior calcaneus. No intrafascial latex was found in any specimen. In 9 of 10 (90%) specimens, small amounts of latex were found interdigitating within the flexor digitorum brevis at its origin from the deep plantar fascia. In all 10 specimens, latex also covered the traversing first branch of the lateral plantar nerve (ie, Baxter’s nerve). Conclusions—Within the methodological limitations of this cadaveric investigation, sonographically guided deep plantar fascia injections accurately deliver latex adjacent to the deep side of the plantar fascia while simultaneously covering the traversing first branch of the lateral plantar nerve (Baxter’s nerve). When clinically indicated, sonographically guided intrafascial injections may be used to deliver injectate to the deep portion of the plantar fascia and would probably anesthetize that traversing portion of Baxter’s nerve adjacent to the anterior calcaneus. Thus, intrafascial injections may have a role in the diagnosis and management of plantar fasciopathy, including chronic or atypical cases potentially involving Baxter’s nerve at the level of the anterior calcaneus. 1539819 Biopsy Diagnosis of Lung Tumors Situated Peripherally Marek Chorazy,1* Marta Majcher,1 Jedrzej Glasek,2 Katarzyna Urbanowicz,1 Robert Kwiatkowski3 1Clinical Oncology and Internal Medicine, 2Radiodiagnostics, 3Radiotherapy, St Leszczynski Hospital, Katowice, Poland Objectives—The most widely used test that could provide information as to the pattern of malignant tumors of the lung is fiber-optic bronchoscopy and its modifications. Another method that is also used is aspiration biopsy performed under the control of computed tomography (CT). In this study, the authors decided to present their own experiences in using traditional ultrasonography to diagnose peripherally situated lung tumors. Methods—Fiber-optic bronchoscopy was performed in the cases of 2429 patients out of 2572 CT examinations performed between January 2002 and September 2009. In 143 (5.55%) cases, out of 2572 patients, which could not be diagnosed by fiber-optic bronchoscopy because the tumor was located at the chest wall, an ultrasound examination was S102 13proceedings_Layout 1 3/5/13 10:39 AM Page S103 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 done. In 130 cases, ultrasound showed nodular lesions, and these patients had a percutaneous biopsy performed under the control of ultrasound. Results—The authors have demonstrated that, in rare cases, ultrasound examination may be useful to illustrate nodular lesions located at the chest wall. It is true that it is not possible to prepare an initial diagnosis of a lung tumor on this basis; to obtain such a diagnosis, a CT examination was used, but a precise collection of samples from a lesion located peripherally makes its display on real-time ultrasonography very easy. Conclusions—(1) It is possible to display 90.9% of lesions located peripherally in a traditional ultrasound examination. (2) In most cases, as part of that procedure, it is necessary to establish the location of the tumor and the depth of the CT-guided biopsy. (3) Displaying lesions on ultrasonography makes it possible to collect material for histopathologic examination accurately in 88.7%. Table 1. Number of Studies Carried out Under the Control of Ultrasound (out of 2572 Cases) Inability of fiber-optic bronchoscopy Tumors located peripherally Ultrasound-controlled biopsy Histopathologic diagnosis 143 130 (90.9%) 130 (90.9%) 127 (88.8%) 1539837 Sonoelastographic Qualitative Analysis in the Management of Salivary Gland Masses Hasan Yerli,1* Erkan Eski,2 Ekrem Korucuk,3 A. Muhtesem Agildere4 1Radiology, 2Otolaryngology, Baskent University Zubeyde Hanim, Practice and Research Center, Izmir, Turkey; 3 Otolaryngology, Karsiyaka State Hospital, Izmir, Turkey; 4 Radiology, Baskent University Faculty of Medicine, Izmir, Turkey Objectives—Our aim was to investigate whether the use of a qualitative elasticity scoring method by sonoelastography is useful for the management of salivary gland masses. Methods—Forty-six patients with salivary gland masses (38 parotid and 8 submandibular) were prospectively included in this study. For each lesion, B-mode sonographic and sonoelastographic images were obtained. Elasticity scores were determined with a 4-point scoring method. Differences among scores for benign and malignant salivary gland masses were assessed using the Mann-Whitney U test. Qualitative variables were compared using the Pearson П‡2 test. The findings were compared with histopathology. Results—The score values of 37 benign masses ranged from 1 to 4, while the score values of 9 malignant masses ranged from 2 to 4. The mean scores were 2.28 В± 0.94 for benign lesions and 3.1 В± 0.72 for malignant lesions (P < .05). When we considered scores 1 and 2 benign and scores 3 and 4 malignant, 12 false-positives were determined by the 4point scoring method, and 62% of benign masses were diagnosed. Conclusions—Sonoelastography might be regarded as another ultrasound parameter in the management of salivary gland masses in terms of detecting benign masses. 1539862 Peripubertal Ovarian and Uterine Volumes: Are Historical Values Still Valid Today? Steven Kraus,1,2 Sara O’Hara,1,2* Janet Adams,1 Rachel Mistur2 1 Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio USA; 2Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio USA Objectives—With increasing reports of precocious puberty and concerns of environmental exposures to young girls, we wondered if published reference values for normal peripubertal ovarian and uterine volumes dating back to the 1990s were still applicable today. Previous sample sizes were small, and accurate values are needed for diagnosis of peripubertal disorders. Methods—We retrospectively reviewed pelvic ultrasound exams performed on girls aged 7 to 12 years over a 29-month period, regardless of indication for the scan. Ovarian and uterine dimensions were recorded along with age at the time of the scan, menstrual status, and clinical history. We excluded patients with precocious puberty and clear pelvic abnormalities including: masses, cysts >2.5 cm in diameter, ovarian torsion, incomplete exams, postsurgical pelvis, polycystic ovarian syndrome, and nonvisualized organs. In patients with multiple exams, we used only the most recent exam. The volume of the ovary was calculated using the ellipsoid formula: volume = (longitudinal Г— transverse Г— anteroposterior) Г— 0.5233. Results—Searching radiology records revealed 600 patients. After exclusions, 476 patients formed our data set. Three hundred thirtyeight patients had not started their menses, while 138 had experienced at least 1 menstrual cycle. Ovarian and uterine volumes with SD by age are tabulated below. Conclusions—The normative values obtained represent the current peripubertal population and reflect changes in pubertal development that have evolved over the past 20 years. Our study results highlight the importance of age and menstrual status classification when assessing ovarian volume; therefore, reference values for ovarian and uterine volumes should be revised to include age and menstrual status categorization. These data provide reassurance when evaluating patients with premature puberty. Table 1. Ovarian Volume by Age Age, y 7 8 9 10 11 12 Premenarchal Mean Volume, mL (SD) 1.47 (1.14) 1.65 (0.84) 2.17 (1.66) 2.67 (1.78) 3.32 (1.90) 4.68 (2.54) n 34 44 54 72 74 60 Postmenarchal Mean Volume, mL (SD) 3.80 (0.00) 2.01 (0.83) 6.33 (3.23) 6.02 (3.59) 4.65 (2.99) 5.89 (2.71) n 1 2 4 13 21 97 1539863 @EDUltrasoundQA: An Updated Twitter Curriculum David Bahner,1 Saad Raginwala,1,2 Nilesh Patel,1* Creagh Boulger,1 Eric Adkins,1 Eric Cortez1 1Emergency Medicine, Ohio State University, Columbus, Ohio USA; 2Grand Rapids Medical Education Partners, Grand Rapids, Michigan USA Objectives—To demonstrate an updated Twitter-based ultrasound curriculum designed to provide educational pearls in a questionanswer–based format. Methods—A curriculum consisting of high-yield ultrasound concepts in a question-answer format was developed and posted to a Twitter page every morning at 9 AM and evening at 5 PM beginning on July 1, 2012. As with the previous curriculum, each post or “tweet” was limited to 140 characters. Each month covers a separate ultrasound topic, including focused assessment with sonography for trauma, ultrasound physics, and cardiac scanning. The curriculum is supplemented by normal and pathologic images. Results—As of September 26, 2012, there were 106 followers; 153 tweets have been published with an average length of 46 characters per question and 94 characters per answer. Followers of @EDUltrasoundQA come from a variety of backgrounds and levels of training, including emergency medicine attendings and residents, sonographers, midlevel providers, medical students, and educators. Several followers are contributors in various areas of social media, including podcasts, blogs, and medicine-related Twitter feeds. The feed has been mentioned 11 times by other accounts and has been ranked in the FOAMed (Free Open Access Meducation) top 25 Twitter feeds. S103 13proceedings_Layout 1 3/5/13 10:39 AM Page S104 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Conclusions—Twitter provides an excellent means to deliver educational content to learners at all levels of training. This project has demonstrated another novel type of curriculum that has the potential to be used in many educational endeavors. Future goals include increasing interactivity between the curriculum designers and participants, further categorizing followers, and better characterizing its impact on education. Finally, given its broad applicability, additional efforts are being made to enable other educators to easily implement this technology. Conclusions—These cases illustrate the critical importance of postnatal correlation of ultrasound findings in rare conditions, especially when multiple types of a disorder are known. Types 1 (original proposed diagnosis) and 3 atelosteogenesis are autosomal dominant and would confer a negligible recurrence risk given the unaffected parents. Type 2, on the other hand, is autosomal recessive with a 25% recurrence risk. Identification of a mutation in the DTDST sulfate transporter gene will allow preimplantation genetic diagnosis in a future pregnancy. 1539867 Ultrasound of Arteriovenous Malformations of the Genitourinary System Vijayanadh Ojili,1* Gowthaman Gunabushanam,2 Ravi Vassa,1 Nagar Arpit,3 Kedar Chintapalli,1 Leslie Scoutt2 1 Radiology, University of Texas Health Science Center, San Antonio, Texas USA; 2Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA; 3Radiology, Ohio State University Medical Center, Columbus, Ohio USA 1539948 Association Between First-Trimester Ultrasonographic Twin Crown-Rump Length Discrepancies and Neonatal Outcomes Pedro Roca,1* Allen Kunselman,2 Gabor Mezei,1 Kari Whitley,1 Dennis Mujsce,3 Ian Paul,3 Serdar Ural1 1Obstetrics and Gynecology, 2Public Health Sciences, 3Pediatrics, Penn State Hershey, Hershey, Pennsylvania USA Objectives—To describe the sonographic findings of arteriovenous malformations (AVMs) of the genitourinary system and correlate these with computed tomographic (CT) and angiographic findings where available. Methods—A brief review of the AVMs of the genitourinary system (including renal and uterine AVMs) will be presented. The sonographic findings will be described and correlated with CT and angiographic findings. Pertinent management issues, including angiography and embolization procedures, will be briefly discussed. Results—Not applicable as this is a pictorial review. Conclusions—AVMs of the genitourinary tract are potentially life-threatening conditions that require aggressive image-guided or surgical management. Therefore, it is important for the radiologist to accurately diagnose these conditions in a timely fashion. Although multidetector CT and digital subtraction angiography are the imaging modalities of choice for comprehensive evaluation, ultrasound is often the initial imaging test performed in the diagnostic workup of these patients and will provide a diagnosis in most cases. 1539898 Prenatal Diagnosis of Recurrent Atelosteogenesis Janice Byrne,1,2* Anne Kennedy,3 Paula Woodward,3 Deborah Krakow,4 John Carey2 1Obstetrics and Gynecology, 2Pediatrics, 3Radiology, University of Utah, Salt Lake City, Utah USA; 4Human Genetics, University of California, Los Angeles, California USA Objectives—Document the prenatal ultrasound and postnatal clinical findings in a rare condition. Methods—Prospective identification of recurrence of a very rare lethal skeletal dysplasia by prenatal imaging and comparison with postnatal findings from the previous affected pregnancy. Results—A 28-year-old G2P1001 married Caucasian woman was referred at 35 weeks’ gestation for findings concerning for a skeletal dysplasia, possibly type 1 atelosteogenesis. Micromelia with severely affected fibulae and humeri, mild long bone curvature, clubfeet, a small chest, and polyhydramnios were noted. At 38 weeks, the patient delivered vaginally a live-born infant with obvious skeletal dysplasia. In addition to the findings noted by ultrasound, severely abducted (“hitchhiker”) thumbs and great toes were seen. Characteristic radiographic findings including tapered hypoplastic humeri confirmed the suspicion of type 2 atelosteogenesis. DTDST mutation analysis was sent, but prior to the results being available, the patient again became pregnant. Ultrasound at 11 weeks showed a cystic hygroma, and 2 weeks later, short curved long bones and “hitchhiker” thumbs and great toes could be seen. The patient terminated the pregnancy. Gross examination confirmed the ultrasound findings. Objectives—Determine the association between increased fetal size discrepancies in crown-rump length (CRL) during first-trimester ultrasound and poor perinatal outcomes. Methods—Retrospective study, all twin pregnancies delivered at our institution before December 2009. We excluded pregnancies that commenced with higher-order multiples as well as those with major fetal congenital anomalies. Results—Forty-six pregnancies were included. The firsttrimester ultrasound was performed on average at 10 3/7 weeks (SD, 2 weeks). The median percent discrepancy in CRL relative to the smaller twin in each pregnancy was 7.2% (25th percentile, 2.8%; 75th percentile, 10.8%). Generalized estimating equations with a logit link were used to assess the association of 4 predictors (ie, CRL during the first trimester [11–14 weeks’ gestation] ultrasound of each twin, the deviation [ie, difference] from the mean CRL for each twin set per delivery, the week of the first-trimester ultrasound, and the twin birth order) with each early neonatal outcome. This is an extension of logistic regression that accounts for the clustering of twins per delivery. Similarly for continuous outcomes, mixed-effects models that account for twin clustering were fit using the same 4 predictors. Table 1 reports the adjusted odds ratios (AORs), 95% confidence intervals (CIs), and P values for 4 early neonatal outcomes. There was no evidence of an association of CRL or the deviation from the mean CRL for twins with respiratory distress syndrome (RDS), need for mechanical ventilation (MV), need for total parenteral nutrition (TPN), or need for a nasogastric tube (NGT). Conclusions—The difference of CRL during first-trimester ultrasound is a poor predictor for early neonatal complications. This study suggests little relationship between the difference in size of twins as assessed by CRL during routine first-trimester ultrasound and early neonatal outcomes targeted above. Table 1. Predictor of Outcomes CRL Deviation from mean CRL of twins S104 RDS 0.94 (0.85–1.03) [.17] 1.12 (0.93–1.35) [.23] AOR (95% CI) [P] MV TPN NGT 1.18 0.97 0.95 (0.95–1.48) (0.90–1.05) (0.87–1.04) [.14] [.45] [.28] 1.00 1.18 1.05 (0.73–1.38) (0.95–1.47) (0.90–1.23) [.99] [.14] [.53] 13proceedings_Layout 1 3/5/13 10:39 AM Page S105 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1539989 The Work Flow Impact of Universal Transvaginal Cervical Length Screening With Anatomic Surveys in an Ultrasound Unit Eileen Wang,* Alexander Friedman, Samuel Parry, Nadav Schwartz Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania USA Objectives—Low-risk women with a short cervix transvaginally at time of the second-trimester anatomic survey may have an increased risk of preterm birth. Vaginal progesterone may be offered to reduce this risk. Cost-effective analyses of universal transvaginal cervical screening (TVCL) have not included the impact of the extra time to perform TVCLs on the work flow of an ultrasound (US) lab. We compare the times for anatomic surveys and growth scans in periods before and after universal TVCLs were instituted. Methods—This is a prospective observational study done in an urban tertiary care center. In our 4-room US unit, after sonographers (SGs) scan, the images are reviewed by the physician (MD), who then sees the patient to either scan or discuss results. After implementation of TVCL, patients void prior to TVCL after the anatomic survey. Durations of studies were recorded for quality improvement. Studies by maternal-fetal medicine fellows or with missing times were excluded. The times for anatomic surveys, for growth scans, and for patients to void were collected and categorized per SG (n = 8) and per supervising MD (n = 9). Data from 5 weeks before and from a convenience sample of 6 weeks after implementation were compared. The data are presented as mean В± SD. The Student t test and 1-way analysis of variance were used to evaluate pre-CL and post-CL study times. Results—The time difference in anatomic surveys before (n = 275) vs after (n = 340) universal TVCL screening was statistically significant, 46.9 В± 11.6 vs 58.3 В± 11.9 minutes (P < .0001), regardless of MD. Seventy-three percent of postimplementation anatomic surveys included TVCLs with a mean duration of 61.0 В± 10.5 minutes. Mean voiding time was 9.1 В± 6.2 minutes, ranging from 2 to 35 minutes. The mean time increase per SG per scan with TVCL was 9.1 В± 3.8 minutes. As expected, there was no difference in the duration of growth scans in the 2 time periods (pre, 27.8 В± 11.2 vs post, 28.4 В± 9.6 minutes; P = .5). Conclusions—Universal TVCL lengthens each anatomic survey by almost 15 minutes, primarily due to the time to void. This must be accounted for when exploring ways to optimize work flow. The potential to impact the number of scans that can be accommodated should be considered in future cost-benefit studies. 1540030 Association of Ultrasonographic Twin Estimated Fetal Weight Discrepancies With Early Neonatal Outcomes Pedro Roca,1* Allen Kunselman,2 Anthony Ambrose,1 Ian Paul,3 Dennis Mujsce,3 Serdar Ural,1 Kari Whitley1 1 Obstetrics and Gynecology, 2Public Health Science, 3Pediatrics, Penn State Hershey, Hershey, Pennsylvania USA Objectives—Determine the association between increased fetal size discrepancy during routine second-trimester ultrasound and poor perinatal outcomes. Methods—We designed a retrospective study including all twin pregnancies from our institution before December 2009. We excluded pregnancies with major fetal anomalies. A total of 98 pregnancies met the inclusion criteria. The second-trimester ultrasound was performed on average at 20.0 weeks (SD, 2.5). The average estimated fetal weight (EFW) of twin A was 356 g (SD, 271) and for twin B was 351 g (SD, 247). The median percent discrepancy in EFW relative to the lighter twin in each pregnancy was 6.8% (25th percentile, 3.8%; 75th percentile, 25.0%). Thirteen (13.3%) of the pregnancies were at least 20% discordant. Results—Generalized estimating equations with a logit link were used to assess the association of 4 predictors. There was no association of the deviation from the mean EFW for twins with gestational age at delivery (P = .84) or for twins with admission to the neonatal intensive care unit (adjusted odds ratio [AOR], 1.00; 95% confidence interval [CI], 0.99–1.01; P = .53) after adjusting for EFW, week of second-trimester ultrasound, and birth order. The only significant effect was the association of the deviation from the mean EFW of twins with necrotizing enterocolitis. Conclusions—For every 1-g increase in the deviation from the mean EFW of twins, the odds of NEC increase by 1.03 (or 3%), adjusting for EFW, week of second-trimester ultrasound, and birth order (AOR, 1.03; 95% CI, 1.01–1.07; P = .02). This unique study shows that deviation from the mean EFW of twins during second-trimester ultrasound is a poor predictor for early neonatal complications. Table 1. Predictor of Outcomes AOR (95% CI) [P] IV Catheter RDS MV Days (≥1 vs 0) NEC TPN NGT EFW (g) 0.998 1.00 0.996 0.98 0.995 0.997 (0.994–1.002) (0.99–1.01) (0.991–1.001)(0.96–0.99) (0.991–1.000)(0.992–1.001) [.36] [.92] [.15] [.004] [.04] [.12] Deviation 1.00 1.01 1.00 1.03 1.01 1.00 from (0.99–1.01) (1.00–1.02) (0.99–1.01) (1.01–1.07) (1.00–1.02) (0.99–1.01) mean [.48] [.13] [.46] [.02] [.06] [.41] EFW of twins (g) Week of 1.36 1.14 1.81 5.32 1.76 1.55 2nd(0.86–2.16) (0.56–2.35) (0.98–3.35) (2.12–13.28) (1.07–2.88) (0.92–2.62) trimester [.18] [.71] [.06] [<.001] [.02] [.10] ultrasound Birth order 0.77 0.84 0.78 0.89 0.90 0.85 (twin A vs (0.55–1.09) (0.49–1.43) (0.56–1.09) (0.24–3.36) (0.63–1.29) (0.66–1.10) twin B) [.14] [.53] [.14] [.87] [.56] [.21] IV indicates intravenous; MV, mechanical ventilation, NEC, necrotizing enterocolitis; NGT, nasogastric tube; RDS, respiratory distress syndrome; and TPN, total parenteral nutrition. 1540075 Ultrasonographic Findings of Malignancy-Like Ovarian Deciduosis of Endometrioma During Pregnancy Marta Oliva,* M. Angela Pascual, Lourdes Hereter, Betlem Graupera, Cristina Pedrero, Maria Fernandez-Cid Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain Objectives—The aim of this study is to provide the description of ultrasound findings of a rare entity that occurs during pregnancy in patients with endometrioma, whose echo pattern changes by hormonal influences and mimics a malignant ovarian tumor. Methods—Six cases are described, in which an ovarian mass was discovered during pregnancy. We reported the patient’s age, weeks of gestation, tumor size, echo pattern, and blood flow observed by ultrasonography and the tumor marker cancer antigen 125 (CA-125). Results—The results are summarized in Table 1. The average age was 34.5 years. The tumor was bilateral in 1 case. In all cases, ultrasonographic findings showed the presence of papillae, and a color Doppler study showed intense vascularization with an intensity score of 4 according to the International Ovarian Tumor Analysis consensus. Patients 1 to 4 underwent a minimally invasive approach, with a histologic result of endometriosis with extensive decidualization. When this paper was written, patients 5 and 6 were pregnant, 1 of them pending surgery and the other 1 with doubts about the benefit of intervention during pregnancy. The tumor marker CA-125 showed a minimal elevation in some cases, as shown in Table 1, and 2 patients did not have information. S105 13proceedings_Layout 1 3/5/13 10:39 AM Page S106 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Conclusions—There are few published cases, and almost all show ultrasonographic findings similar to our cases. Until more evidence becomes available regarding the echo pattern and blood flow mimicking a malignant ovarian tumor, surgical treatment cannot be avoided. In our experience, conservative surgery has had satisfactory results; all patients gave birth without complications. 1540166 Usefulness of Uterine Tranverse Diameter Measurement in Suspicion of Congenital Uterine Anomalies Meritxell Vila,* M. Angela Pascual, Betlem Graupera, Lourdes Hereter, Cristina Pedrero, Maria Fernandez-Cid Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain Table 1 Objectives—The purpose of this study was to evaluate the potential role of the transverse diameter, measured by conventional ultrasonography (2DUS), of the uterus in the diagnosis of suspected congenital uterine anomalies. Methods—Between February 2011 and June 2012, women aged 15 to 45 years with suspected uterine anomalies such as arcuate, septate, and bicornuate with 2DUS were evaluated by 3D ultrasonography (3DUS) using multiplanar reformatted sections. The uterine anomalies were suspected when measured by 2DUS when the transverse diameter of the uterus was >45 mm. Women were categorized according to the size range of the transverse diameter: 45 to 54, 55 to 64, and ≥65 mm. To compare the size range rate, Pearson’s П‡2 was used, and data were expressed as percentages according to its distribution. Results—Of all the patients that had a transverse diameter >45 mm, 138 of them were diagnosed by 3DUS as having uterine anomalies. Among the women diagnosed with uterine anomalies, the minimum transverse diameter measured was 45 mm, and the maximum was 88 mm. Table 1 shows the distribution of the uterine anomalies diagnosed and the size range for each type. The results show that most arcuate septate and partial septate anomalies have a transverse diameter of 45 to 54 mm, with statistical significance (P < .001). Conclusions—Diameter measurements of the uterus through transverse diameter 2DUS provide indirect information on possible uterine anomalies. It seems a transverse diameter from 45 mm is a good indicator to suspect possible uterine anomalies and thus complete the study by 3DUS for the diagnosis and classification of congenital uterine anomaly types. 1 Age, y 34 Gestation, wk 21 Laterality Right Size, mm 87 Papillae Present Blood flow Present CA-125, IU/mL 43.71 Surgery During pregnancy 2 36 8 Bilateral 60/75 Present Present 22 During pregnancy Patient 3 32 23 Left 55 Present Present 40.20 During pregnancy 4 31 16 Left 49 Present Present 26 During pregnancy 5 36 8 Right 59 Present Present — No 6 38 12 Left 39 Present Present — No 1540162 Correcting for Acoustic Cavitation and Acoustic Streaming in Ultrasound Calibration Victor Frenke,l* Thanh Nguyen,2 Loan Bui,1 Nghia Huu Tran2 1Biomedical Engineering, 2Electrical Engineering, Catholic University of America, Washington, DC USA Objectives—Commercial power meters for calibrating ultrasound transducers are used ubiquitously in clinical and laboratory settings. These devices are inherently inaccurate in that they do not compensate for the effects of acoustic cavitation (AC) and acoustic streaming (AS). Both phenomena can alter displacements generated on the meter’s target, introducing errors in power measurement. The objectives of this study were to investigate these phenomena and to propose a standardized procedure to marginalize their effects on power measurement. Methods—The experimental setup included a nonreflecting target suspended from an analytical balance, reproducing the procedure employed in commercial devices. Measurements were performed at 1 and 3.3 MHz, where intensities employed precluded the onset of AC at the higher frequency. The attenuating effect of AC bubbles in the ultrasound beam was quantified by using a transmitting and receiving ultrasound transducer to determine the power loss within the beam. Evidence of the contribution of AS to erroneous measurements was demonstrated using an acoustically transparent membrane positioned immediately above the target. Results—AS was found to significantly increase the power being sensed, indicating its dependence on the attenuating effects of AC. The acoustically transparent membrane above the target effectively eliminated these effects. AC was found to significantly decrease the power being measured where discrepancies with noncavitation measurements correlated positively with intensity. AC activity, itself, also correlated with intensity, as demonstrated using passive detection of harmonic emissions. Conclusions—This study demonstrated that AC and AS can significantly introduce errors in standard calibration measurements. These effects were consistent with acoustic theory, including the dependence of AS on the attenuation effects of AC bubbles. An acoustically transparent membrane eliminated the effects of AS. The numerical relationship between the attenuation of AC bubbles, and the manner by which they affected the measurements, was found to accurately correct for these discrepancies. The setup employed for the study can easily be assembled using standard laboratory equipment. Table 1 Anomaly Type 45–54 Arcuate, n (%) 74 (76) Partial septate, n (%) 12 (70.6) Septate, n (%) 13 (59.1) Bicornuate, n (%) 1 (33.3) Total 100 Transverse Diameter, mm 55–64 ≥65 19 (19.8) 3 (3.1) 4 (23.5) 1 (5.9) 8 (36.4) 1 (4.5) 0 (0) 2 (66.7) 31 7 Total 96 17 22 3 138 1540206 Ultrasonographic Diagnosis of Ovarian Ectopic Pregnancy After In Vitro Fertilization With Salpingectomy and Literature Review M. Angela Pascual,1* Lourdes Hereter,1 Betlem Graupera,1 Francisco Tresserra,2 Alicia Perez,1 Buenaventura Coroleu,1 Pedro Barri1 1Obstetrics, Gynecology, and Reproduction, 2 Pathology, Institut Universitari Dexeus, Barcelona, Spain Objectives—Among ectopic pregnancies, ovarian ones are extremely rare and much less frequent with previous history of salpingectomy. Diagnosis and treatment of this condition continue to be challenging given that no typical risk factors exist compared with other types of ectopic pregnancy, and signs and symptoms are similar to those observed in ruptured corpus luteal cysts. Ultrasonographic diagnosis is feasible, although differential diagnosis from the corpus luteum is difficult. In this context, the goal is to diagnose as accurately as possible to apply the surgical treatment to remove the ectopic pregnancy, preserving ovarian tissue. Methods—This is a case of a 31-year-old woman with right salpingectomy, which presented a right ovarian ectopic pregnancy (OEP) after intracytoplasmic sperm injection–embryo transfer (ICSI-ET); laparoscopy was done to remove the OEP, preserving the ovary, and a re- S106 13proceedings_Layout 1 3/5/13 10:39 AM Page S107 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 view of the literature was performed to assess the frequency of this condition and its association with in vitro fertilization procedures. Results—We identified >250 reported cases, most of them case reports and some series. Among the articles, 5 cases of OEP were found in patients with a history of salpingectomy, and 4 papers reported OEP after ICSI-ET. Conclusions—OEP may be an unexpected finding in patients with salpingectomy; unfortunately, this condition cannot prevent OEP. Monitoring of ОІ-human chorionic gonadotropin levels and the accuracy of ultrasonographic diagnosis allowed a conservative therapeutic strategy and proper postoperative course. 1540300 Ultrasound Screening of the Dense Breast: An Analysis of the Costs and Benefits to Both the Patient and the Practitioner Ren Tianbo, Sirisha Jasti,* Katherine Kaproth-Joslin, Avice O’Connell Radiology, University of Rochester, Rochester, New York USA follicular neoplasms were reviewed to determine how often these lesions had calcifications and/or were cystic. Thirty-three of the patients diagnosed with follicular neoplasms subsequently underwent thyroidectomy. The surgical pathology reports were reviewed to determine how frequent the follicular neoplasms were malignant. Results—The database included 62 patients with follicular neoplasms after ultrasound-guided thyroid biopsy. On ultrasound imaging, 21 of 62 follicular neoplasms had cystic components, and 13 of 62 follicular neoplasms had calcifications. Four of the 33 FNB follicular neoplasm lesions were found to be malignant on surgical pathology. One was diagnosed as follicular carcinoma, 1 as papillary carcinoma, and 2 as the follicular variant of papillary thyroid carcinoma. Conclusions—Follicular neoplasms did not often have calcifications and were often solid. Follicular neoplasms were more often benign lesions than malignant. 1540408 Advanced Ultrasound Evaluation of Carotid Plaque: Can a Combined 2-Dimensional and 3-Dimensonal Ultrasound Analysis Provide Additional Information and Identify Significant Plaque Characteristics Responsible for Strokes? Lysa Legault Kingstone,1,2* Carlos Torres,1 Geoffrey Currie2 1 Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario, Canada; 2School of Dentistry and Health Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia Objectives—Approximately 40% of all women undergoing screening mammography are found to have dense breasts. Unfortunately, the sensitivity and specificity of mammography are reduced in patients with dense breasts, and some research indicates that dense breasts have an increased risk of breast cancer development. Recent studies have suggested that mammography combined with screening breast ultrasound can help detect breast cancers in patients with dense breasts. California and Connecticut are currently the only 2 states where screening ultrasound has been approved, and New York has recently passed a bill requiring the inclusion of breast density information sent to women after their mammogram. The purpose of this presentation is to review the advantages and disadvantages of screening breast ultrasound and to analyze the feasibility of screening ultrasound as a standard screening protocol in current radiology practice, including both the cost and time expenses to the patient and practitioner. Methods—In this presentation, we will review the sensitivity and specificity of screening ultrasound plus mammography. We will analyze both the monetary and time costs to the patient and to the practitioner associated with screening ultrasound plus mammography vs standard mammography alone, with a close examination of what is occurring in Connecticut and California, including who is or will be paying for these exams. Finally, we will discuss the general impact of additional ultrasound screening of dense breast tissue in light of the US Preventive Services Task Force 2009 recommendations, where even routine mammographic screening for breast cancer is being questioned. Results—The results of our analysis as described above will be discussed in the presentation. Conclusions—With the recent US Food and Drug Administration approval of an automated breast ultrasound system and the push for screening ultrasound as a standard screening procedure in Connecticut and California, as well as the new legislation passed in New York State to notify women of their breast density, it is necessary to understand the costs and benefits of screening ultrasound to both the patient and the practitioner, including efficacy of the procedure. Objectives—Using ultrasound (US) to image plaque morphology may improve stroke prevention by identifying atherosclerotic plaques at higher risk for cerebrovascular events and associating morphologic characteristics with additional risk factors. This study evaluated how integrating an advanced US plaque imaging analysis adjunct to stenotic grading identifies vulnerable characteristics in carotid atheromatous structure. Methods—Patients with known high-grade carotid artery disease, confirmed on computed tomography (CT), and who were scheduled for a future endarterectomy, were recruited for this study. Prior to surgery, these participants received advanced US plaque imaging to identify combined high-risk morphologic features such as specific homogeneity, internal echo texture, ulceration, surface irregularities, intraplaque hemorrhage/lipid core, and calcification. These identified morphologic features were further enhanced with the use of high-frequency and 3D reformatted imaging. We strengthened the study’s results by analyzing the carotid US imaging findings and then correlating them with their postendartertectomy histologic studies. Results—At the time of abstract submission, final data collection was not yet available; however, preliminary results indicate a high correlation rate, sensitivity, and specificity between the US findings and the detailed surgical specimens. Conclusions—Applying advanced US plaque imaging to further identify significant plaque characteristics responsible for strokes can provide insight into early causative conditions of carotid atherosclerosis. This advanced imaging protocol could potentially shift the paradigm in early carotid plaque imaging and possibly predict the onset in asymptomatic or mild to moderate plaques. 1540301 Ultrasound Features of Follicular Neoplasms and Ultrasound Features of Follicular Neoplasms Proven to Be Follicular Carcinoma at Surgery Annette Ho,* Michael Davis, Annemarie Buadu Medical Imaging, University of Arizona, Tucson, Arizona USA 1540482 Utility of 3-Dimensional Plaque Imaging in Carotid Stenosis Lysa Legault Kingstone,1,2* Carlos Torres,1 Geoffrey Currie2 1 Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario, Canada; 2School of Dentistry and Health Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia Objectives—To determine how often follicular neoplasms diagnosed by ultrasound-guided fine-needle biopsy (FNB) had cystic components or calcifications. Also, to determine how often follicular neoplasms diagnosed with FNB are proven to be malignant after thyroidectomy. Methods—Two hundred thirty-one lesions in 202 patients who underwent thyroid biopsy were reviewed. Of these, 62 were diagnosed as follicular neoplasms by ultrasound-guided FNB. Ultrasound features of Objectives—Emerging data suggest that carotid plaque morphology and severity can significantly affect the cerebrovascular prognosis. Recent studies have reported that 3D ultrasound (3DUS) used as an adjuvant imaging technique may provide additional information in the evaluation and risk stratification of vulnerable carotid plaque. The aim of this study was to evaluate the utility of 3DUS in characterizing plaque from various degrees of stenosis. S107 13proceedings_Layout 1 3/5/13 10:39 AM Page S108 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Methods—In a cohort of symptomatic patients referred from neurosurgery, 3DUS of the carotid arteries was conducted using a vascular ultrasound system (iU22; Philips Medical Systems) equipped with a volumetric mechanical high-resolution linear array transducer for 3D imaging. We employed a 3DUS imaging method to allow high-detail studies in mild, moderate, and severe stenotic plaques. Constructed 3D plaque images were quantified using the internal plaque echo texture, volume, and surface morphology and evaluated by 2 independent observers using our own classification protocol. Results—At the time of abstract submission, final data were not yet available; however, preliminary results indicate that 3DUS for plaque characterization was significantly better in mild to moderate imaging, possibly due to the fluid-filled lumen acting as a substantial acoustic transmission for optimal plaque visualization. Higher-grade stenoses (>70%) were difficult to assess; however, proximal and edge surface imaging was diagnostic. These preliminary results indicate that our 3D approach may be a sensitive tool in the identification of early vulnerable markers in lowergraded stenoses, possibly identifying early prediction of stroke. Conclusions—Preliminary results show a high sensitivity and negative predictive value of carotid plaque 3DUS in mild to moderate stenosis and can reliably characterize the surface, volume, and ulcerations. The sensitivity decreased with the severity of stenoses. 3DUS carotid plaque quantification may serve as an important clinical screening tool in early onset of significant carotid disease, for high-risk patients, and for those without known significant carotid disease. 1540523 Practical Uniformity Evaluation of Ultrasound Systems: Tips and Pitfalls Donald Tradup,* Nicholas Hangiandreou, Scott Stekel Radiology, Mayo Clinic, Rochester, Minnesota USA Objectives—We have found uniformity evaluation (UE) to be the single most effective imaging test to ensure proper function of medical ultrasound (US) imaging systems. In this presentation, we will describe our process for efficient and effective UE. Methods—Display quality assessment and mechanical inspection of the imaging system should occur prior to UE. Begin the UE by annotating the image with the device identification and visually inspecting in-air images. Some scan controls should be set to standard values (output, dynamic range, depth, compounding, transmit frequency, and focus) as will be described in the presentation. Gain and time-gain compensation are visually optimized. Next, acquire clips of a phantom. These clips should show a dynamic speckle pattern across the entire transducer face. We use a previously described custom, flexible, liquid phantom. Tips for optimal use of this phantom will be described. Commercial phantoms may be used, but multiple clips may be needed to test the complete face of curved arrays. Store 3 phantom clips (to guard against false-positive findings due to poor coupling) and 1 in-air clip. If possible, compute median images from each clip, and inspect these for artifacts. Review of median images acquired at acceptance (or use of subtracted median images) will reduce the incidence of false-positives. Any artifacts observed at any point during testing should be debugged to rule out poor coupling with the phantom, dirt/debris on the transducer face or connector, or scanner port, to identify mechanical damage, cable-flex issues, and differentiate port vs transducer problems. The severity of reproducible artifacts should be determined by assessing visibility of the artifact when scanning anatomy and the size and location of the artifact. Results—This UE approach has allowed us to detect artifacts in our US practice with good sensitivity and specificity, and staff efficiency. For ≈10% to 15% of transducers, a potential artifact is noted during initial testing that is discounted during debugging. Conclusions—Artifacts and equipment problems can be effectively identified using a standard UE protocol. The debugging step is essential for minimizing the incidence of false-positives. 1540556 Utility of the Prefrontal Space Ratio to Screen for Trisomy 21 in a Racially Diverse Population: A Pilot Study Barrie Suskin Kaplan,1,2 Anne Marie Roe,2,3 Komal Bajaj2,3* 1 Obstetrics and Gynecology, Montefiore Medical Center, Bronx, New York USA; 2Albert Einstein College of Medicine, Bronx, New York USA; 3Obstetrics and Gynecology, North Bronx Healthcare Network, Bronx, New York USA Objectives—The characteristic facial features of trisomy 21, including the dorsal displacement of the edge of the maxilla and thickening of the prenasal skin, have been well described. The prefrontal space (PFS) ratio capitalizes on these changes and has been shown to be an effective screening marker for trisomy 21 when calculated from midsagittal 2D sonographic images of the fetal profile in the second and third trimesters. These studies, which have been performed exclusively in Caucasian populations, reported a mean PFS ratio in euploid fetuses of 0.97. As facial morphology varies among different racial groups, it is plausible that the PFS ratio may differ in non-Caucasian fetuses. The objective of this study was to evaluate the PFS ratio of euploid fetuses of African American decent to determine whether this difference may exist. Methods—The PFS ratio was calculated retrospectively from stored 2D images of euploid African American fetuses in the second and third trimesters. These prenatal sonograms were performed at an urban academic maternal-fetal testing unit under strict supervision by reproductive genetics and maternal-fetal medicine specialists. The cases were drawn from chronologic birth records from our institution. Images were excluded if the fetal profile was not truly midsagittal or if the anterior edges of the maxilla and skin were not clearly identifiable. Other data including the presence of the nasal bone, maternal age, gestational age, and ethnicity were also collected. Results—Mean maternal age was 29.3 years. Median gestational age at the time of ultrasound examination was 20 weeks 4 days (18 weeks 3 days–25 weeks 4 days). The mean PFS ratio was 0.61 (SD, 0.21). In a subset of fetuses with a hypoplastic or absent nasal bone, the mean PFS ratio was 0.51 (SD, 0.17). Conclusions—Though not statistically significant, the prefrontal space ratio in African American euploid fetuses trended lower than that reported in euploid Caucasian fetuses in the literature. This pilot study suggests that different racial groups may have different normal prefrontal space ratios. We plan to expand this study as well as assess the prefrontal space ratio of other groups to establish accurate normal values for a racially diverse population. 1540570 An Objective Tool to Evaluate Ultrasound Image Quality: The Ultrasound Standardized Assessment Tool Creagh Boulger,* Katherine Pollard, David Bahner Emergency Medicine, Ohio State University College of Medicine, Columbus, Ohio USA Objectives—Evaluation of the skill of a sonographer requires objective assessments of his or her ultrasound scans. However, little literature exists to define a high-quality ultrasound image. The purpose of this study is to develop a standardized tool (Ultrasound Standardized Assessment Tool [USAT]) to assess ultrasound image quality and perform a pilot reliability study of the tool. Methods—A specific USAT was developed for each core emergency ultrasound application: trauma, intrauterine pregnancy, abdominal aortic aneurysm, cardiac, biliary, urinary tract, deep venous thrombosis, soft tissue/musculoskeletal, thoracic, ocular, and procedural guidance. The USAT uses a series of objective yes-or-no questions in conjunction with a difficulty rating of each view to produce a score. Ten beginning sonographers (first-year medical students in our institution’s introductory ultrasound training program), 10 experienced sonographers (fourth-year medical students in our institution’s honors ultrasound course), and 5 expert sonographers (ultrasound-credentialed faculty members at our institution) S108 13proceedings_Layout 1 3/5/13 10:39 AM Page S109 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 will perform ultrasound scans on a group of standardized ultrasound patients. The ultrasound scans will be evaluated using the USAT by 3 ultrasound-credentialed faculty evaluators from emergency medicine, critical care, and radiology, who will be blinded to the identity of the scanners. The USAT will then be evaluated for reliability. Results—A specific USAT has been developed for each core emergency ultrasound application. Ultrasound scans for evaluation are being performed. Conclusions—The need for a standardized method to both objectively evaluate the quality of an ultrasound image and provide distinct differentiation between skill levels of ultrasound users is well documented. The USAT represents one of the first attempts to provide objective assessment of ultrasound images. We anticipate that the USAT will be a valuable resource to assess the current skills of sonographers and follow the development of these skills over time. 1540597 Mid or Late Second-Trimester Doppler Ultrasound of the Uterine Artery: Is There a Difference? Koen Deurloo,1* John van Vugt,2 Annemieke Bolte,3 Martijn Heymans4 1Obstetrics and Gynecology, Diakonessenhuis, Utrecht, the Netherlands; 2Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands; 3Obstetrics and Gynecology, 4Clinical Epidemiology and Biostatics, VU University Medical Center, Amsterdam, the Netherlands Objectives—Uterine artery (UA) Doppler measurements for screening for hypertensive complications in pregnancy is usually performed at 22 to 24 weeks of gestation. However, most routine targeted ultrasound examinations are performed at 19 to 21 weeks of gestation. It would be convenient to include the UA Doppler measurement in the routine targeted ultrasound; therefore, we studied the correlation of UA Doppler measurements at 19 to 21 and 22 to 24 weeks of gestation. Methods—Ninety-seven primigravidas with uncomplicated singleton pregnancies were analyzed. Combined UA velocity waveforms were assessed using transabdominal color Doppler ultrasound between 19 and 24 weeks of gestation. The resistance index (RI) was calculated for left and right UAs, and the results were averaged as a combined US RI. After log transformation of the US RI variable, the results were analyzed with linear regression models and corrected for known confounders (ethnicity, assisted reproductive technology, age, body mass index, and smoking). Unpaired t testing was used to assess the correlation between UA RIs between 19 and 21 and 22 and 24 weeks of gestation. Results—Adequate UA velocity waveforms were assessed in all cases. There was no confounding demonstrated for the known confounders. Linear regression analysis showed a significant correlation (r = 0.79) between mid and late second-trimester UA Doppler measurements (P < .05). Conclusions—RIs of blood velocity waveforms of the UA at 19 to 21 and 22 to 24 weeks of gestation are strongly correlated, and UA Doppler measurements might be included in the routine targeted ultrasound at 19 to 21 weeks of gestation. Further research is needed to assess its screening performance. 1540605 Simulation Model as an Adjunct Method for Emergency Medicine Transvaginal Ultrasound Education Omar Corujo Vazquez,* Marie Romney, Penelope Chun Lema, Cara Brown, Michael Radeos, Eric Tran, Anita Datta Emergency Medicine, New York Hospital Queens, Flushing, New York USA Objectives—This study assessed the importance of a mannequin simulator model as an addition to a didactic lecture in point-ofcare pelvic ultrasound. We hypothesized an improvement in ultrasound knowledge, technique, satisfaction, and confidence for residents exposed to the simulation model. Methods—First-year residents in emergency medicine were enrolled in a prospective cohort study to assess an educational intervention. Subjects were randomly divided into a didactic-only group (group A) or didactic combined with simulation group (group B). Both groups received didactic education. Group B received additional hands-on ultrasound simulation training with the Combination IUP Ectopic Pregnancy Transvaginal Ultrasound Training Model (Blue Phantom, Redmond, WA). Both groups were evaluated by a written test and an objective structured clinical exam (OSCE) on pelvic ultrasound before and after the intervention. A survey was given to assess resident satisfaction and confidence. Results—Group B increased their pretest to posttest written score by 50% compared to group A (32% vs 21% median increase) but did not reach statistical significance (P = .074). Group B increased their pretest to posttest OSCE score when compared to group A (31% vs 29.9% median), but this difference was not statistically significant (P = .92). Prior to the course, 90% of the subjects reported feeling “not at all comfortable” with performing and interpreting normal pelvic ultrasound examinations. After the course, this number decreased to 30% and reached statistical significance (P = .002). When analysis was performed from group B independently, 80% of subjects were either “very comfortable” or “extremely comfortable” performing transvaginal ultrasound after the intervention. Conclusions—Simulation combined with didactic training may be superior for resident satisfaction and confidence in point-of-care pelvic ultrasound teaching. Although there was improvement in knowledge and technique, a larger study is needed on the use of simulation training in resident education to show significance. 1540609 Analysis of Uniformity Artifacts Detected During Clinical Ultrasound Quality Control Scott Stekel,* Nicholas Hangiandreou, Donald Tradup Radiology, Mayo Clinic, Rochester, Minnesota USA Objectives—Characterize trends in severity ratings of observed transducer uniformity artifacts. Methods—We reviewed the results of quarterly quality control (QC) uniformity testing for the previous ≈2 years and characterized the evaluation history of all transducers exhibiting artifacts of any severity. Our evaluation protocol is able to reveal subtle transducer artifacts. All artifacts were scored by a single author (D.T.) using a subjective severity scale. Uniformity artifacts attributed to scanner defects were excluded from this analysis. Results—A total of 58 probes with artifacts of varying severity, observed at QC between March 2010 and August 2012, were analyzed. These included probes that exhibited critical artifacts (failed, with score F), as well as those that did not fail but exhibited at least 2 successive subcritical artifact scores (P1, P2, or P3). Thirty-one of these 58 probes failed (score F). Twenty-two of the 31 failing scores (71%) directly followed a prior QC assessment with a passing score (score P, no artifact seen). Only 9 failures (29%) were directly preceded by ≥1 subcritical scores. The time between the first subcritical score and the failure ranged from 3 to 14 months, with a mean of 9.1 months. No reliable trend of progressively worsening subcritical scores ending in failure was seen (the numbers of probe failures with prior improving, stable, and worsening subcritical scores were 2, 7, and 0, respectively). Twenty-seven of the 58 probes with subcritical scores have not failed. Two of these artifacts spontaneously resolved, returning to scores of P. The remaining 25 artifacts were observed up to the last recorded QC session. The time duration of these subcritical artifacts ranged from 0.5 to 16.5 months, with a mean of 10.5 months. No reliable trend of progressively worsening subcritical scores was seen (the numbers of these probes with improving, stable, and worsening subcritical scores were 5, 18, and 3, respectively). Conclusions—These subjective artifact data are not consistent with a model of initial minor defects progressively increasing in severity until failure occurs. We are working on methods to objectively score artifact severity, which should allow a more sensitive analysis of artifact behavior. S109 13proceedings_Layout 1 3/5/13 10:39 AM Page S110 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1540628 Carotid Plaque Classification System: A New Standard Diagnostic Criterion Lysa Legault Kingstone,1,2* Carlos Torres,1 Geoffrey Currie2 1 Diagnostic Imaging, Ottawa Hospital, Ottawa, Ontario, Canada; 2School of Dentistry and Health Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia Objectives—2D and 3D ultrasound (US) for carotid plaque imaging can provide valuable information on the morphology. Particular sonographic features of the plaque have been recognized as the foundation for stroke. Carotid plaque imaging is increasingly recognized as being as important as stenotic grading; however, various methods of echographic image standardization have been described. Standard plaque analysis and characterization are lacking, and, to our knowledge, no global classification system or form of image standardization exists. Our objective was to develop a standard US characterization method and reporting system for carotid atherosclerotic lesions. Methods—We created and implemented a quality assurance tool for plaque classification criteria in an effort to globalize image and reporting standardization without the use of complex or expensive software. US images were subjectively graded using a standardized classification report form that combines echographic image features. Three categorical groups were defined according to risk of vulnerability: type A (low risk), type B (moderate risk), and type C (high risk). Accuracy of the method was determined by measuring the agreement of plaque characterization using standardized US images and comparing inter-observer agreement and inter-reader reliabilities. In addition, highly vulnerable plaques incorporated Radpath correlation. Results—At the time of submission, final data analysis was being completed. Preliminary results indicate that our plaque classification system provided excellent sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Conclusions—Our standardized classification system has allowed us to improve the consistency and accuracy of plaque characterization imaging and assessment without of the use of computed or automated methodologies. This plaque analysis criterion may help promote the use of a standard global US classification analysis and uniform reporting for carotid atherosclerotic lesions. Large-scale studies are required to fully assess the potential of this grading system. 1540646 A Decade of Ultrasound Practice Accreditation at California Prenatal Diagnosis Centers and Experience With Fetal Echocardiography Accreditation Sara Goldman Genetic Disease Screening Program, California Department of Public Health, Richmond, California USA Objectives—Monitor the ultrasound practice accreditation and reaccreditation at prenatal diagnosis centers (PDCs) from 2001 to 2011 and fetal echocardiography accreditation since April 2011. Methods—All PDCs were required to achieve obstetric (OB) ultrasound practice accreditation by 2000. By March 2012, Fetal echo–approved PDCs were required to apply for fetal echocardiography accreditation with the AIUM or Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). Results—In 2001, 50 ultrasound practices (65 %) had achieved AIUM accreditation; 17 practices (22%) were in the process of achieving AIUM accreditation; and 10 practices (13%) had chosen American College of Radiology (ACR) accreditation. In 2011, there were a total of 80 ultrasound practices at 141 PDC sites. Seventy-five practices (94%) had achieved AIUM accreditation, and 5 ultrasound practices had chosen ACR accreditation. On average, 18 ultrasound practices achieve reaccreditation each year. In March 2012, 34 ultrasound or pediatric cardiology practices submitted a fetal echocardiography accreditation application representing 56 PDC sites, and 18 (53%) practices are currently accredited by either the AIUM or ICAEL representing 30 PDC sites. Conclusions—A requirement for OB ultrasound practice accreditation at PDCs and fetal echocardiography accreditation at fetal echo– approved PDCs is achievable through monitoring of the reaccreditation progress. 1540658 Medical Student Ultrasound Education as Part of the Clinical Skills Immersion Experience Zachary Robinson,1 Colin Turney,1 Creagh Boulger,2 David Bahner2* 1Ohio State University College of Medicine, Columbus, Ohio USA; 2Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio USA Objectives—Focused ultrasound (US) allows physicians to quickly obtain high-quality, cost-effective images. While the technology has advanced, education in ultrasound has lagged at the graduate medical education and medical student levels. Over the last several years, Ohio State has emerged as a leader in ultrasound education by teaching focused US to medical students. US has been integrated into the Clinical Skills Immersion Experience (CSIE), a unique 7-day course providing third-year medical students with experience in a variety of procedural and imaging techniques. Methods—The CSIE curriculum consists of a series of lectures and workshops over a variety of clinical skills. As part of this curriculum, we conducted a 3-hour session on focused ultrasound, which included pelvic, aorta, and cardiac imaging, as well as evaluation of lung sliding and the focused assessment with sonography for trauma scan. The session included a brief lecture on basic US principles followed by extensive handson experience. After the session, students completed a survey evaluating their skills with US using a 5-point Likert scale, where 1 = low skill level and 5 = highly skilled. They were also asked how well the session improved their understanding of ultrasound, where 1 = not at all and 5 = greatly improved. Results—Ten of 38 students responded to the survey for the August session (response rate, 26%). Nine of 10 respondents had performed <10 ultrasound exams previously. On a scale of 1 to 5, students graded their ultrasound skills as 2.1 (В±0.62) before the session and 3.3 (В±0.42) after the session. When asked if the session improved their understanding of ultrasound, the mean score was 3.7 (В±0.3). Conclusions—Students felt the CSIE US session improved their understanding of and skill with US. These results are for the first of 6 sessions this academic year, each with a different group of students. We have asked the CSIE director to mandate participation in the educational survey to improve the response rate. Further evaluation of this curriculum will include elective standardized assessment tests to determine students’ acquisition of and long-term retention of the US material presented. 1540661 Increased Incidence of Renal Colic in the Pediatric Emergency Department Anita Datta, Omar Corujo Vazquez, William Apterbach,* Gregg Rusczyk, Sanjey Gupta, Marie Romney, Michael Radeos, Kruti Joshi, Penny Chun Lema Emergency Medicine, New York Hospital Queens, Flushing, New York USA Objectives—Multiple studies demonstrate an increasing incidence of urolithiasis. This increased incidence, combined with the trend toward reducing ionizing radiation use among children, makes ultrasonography (US) more desirable. The purpose of this study was to assess the incidence of renal colic among pediatric patients in an urban emergency department (ED) over a 5-year span. We reviewed the time to treatment, ED provider, patient demographics, and diagnostic modality used in patient workup. Methods—This was a retrospective analysis of medical records of patients seen in the Pediatric Emergency Department at New York Hospital Queens from January 2007 to September 2011. A search of key words such as renal colic, ureterolithiasis, flank pain, kidney stone, nephrolithi- S110 13proceedings_Layout 1 3/5/13 10:39 AM Page S111 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 asis, abdominal pain, and hematuria was performed. Descriptive statistics were used for all subjects. Normalcy for data was calculated, and all continuous data were evaluated utilizing the Student t test or analysis of variance, when appropriate. All categorical data were calculated using the Fisher exact test or П‡2 analysis. Results—We found 153 cases of kidney stones among the pediatric population from January 2007 to 2011. The mean age was 19 years. Patients were evaluated by 24% ED physicians, 66% pediatric emergency physicians, and 10% midlevel providers (MLPs). Though there was an overall increase in the incidence of renal colic in 2011 compared to 2007, it was not found to be statistically significant by the Fisher exact test (P = .11). The use of ultrasound increased with each progressive year (from 10% in 2007 to 27% in 2011). The type of provider (ED attending vs pediatric attending vs MLP) had no significant effect on the use of computed tomography (CT) or US (P = .15; P = .15, respectively). The type of provider or diagnostic modality did not affect the ED length of stay of patients (P = .08). Conclusions—There has been an overall increase in renal colic among the pediatric emergency patient population over the past 5 years. CT was more frequently used in the diagnostic workup compared to US. We plan to use these data to educate health care providers on the use of US in patients suspected of having nephrolithiasis to further minimize the use of CT scans. 1540672 Prenatal Stomach Size: Association With Cleft Lip and/or Cleft Palate Kristin Burhans,1* Lauren Mack,1 Peter Koltz,2 Stephanie Henderson,1 John Girotto,2 Loralei Thornburg1 1Obstetrics and Gynecology, 2Plastic Surgery, University of Rochester, Rochester, New York USA Objectives—Cleft lip/palate is listed as associated with an absent stomach due to poor fetal swallowing; however, it is unclear if a “small” stomach is also associated, especially without concurrent brain abnormalities. Methods—Records were reviewed for all nonanomalous infants at Strong Memorial Hospital from 2003 to 2011 with cleft lip/cleft palate with available second- or third-trimester images. In each abdominal circumference, stomach width (W) and anterior-posterior (AP) measurements were measured by a single author (L.M.), and polyhydramnios or “absent” stomach was recorded. Nondiabetic controls matched 2:1 for all but 9 patients (1:1) for the gestational age (GA) of measurement within 1 week. As per prior nomograms, mean W and AP were compared in 3to 5-week GA groups between infants with clefts and those without. Results—Of 32 infants with clefts, 108 measurements matched 207 control measurements. The majority of infants received 2 or 3 prenatal ultrasound examinations. There were only 3 infants with cleft with an absent stomach at any point in gestation, 1 with polyhydramnios. The mean W and AP were both significant at 19 to 21 and 22 to 24 weeks’ gestation, W only at 25 to 27 and 37 to 40 weeks, and AP only at 28 to 30 and 31 to 36 weeks. Conclusions—Few nonanomalous infants with clefts had an absent stomach on ultrasound, suggesting this is an insensitive marker; however, mean W and AP stomach measurements were significantly smaller in the mid trimester between 19 and 24 weeks when many anatomic ultrasound examinations are performed. Abnormalities in prenatal stomach measurements, especially during this period, should prompt evaluation for cleft lip/palate. Stomach size at 16 to 18 weeks did not differ in either dimension, suggesting this is a poor marker prior to 19 weeks. Table 1. Stomach (mm), Mean В± SD Infants With Cleft GA, wk W AP 16–18 5.0 В± 3.1 6.5 В± 5.3 19–21 5.9 В± 2.8 6.4 В± 3.3 22–24 4.9 В± 3.0 8.0 В± 4.9 25–27 8.7 В± 2.2 10.5 В± 3.1 28–30 9.8 В± 3.9 13.1 В± 1.7 31–36 12.4 В± 3.3 15.3 В± 4.8 37–40 12.5 В± 6.0 18.8 В± 11 Infants Without Cleft W AP 6.8 В± 2.4 9.1 В± 4.5 8.3 В± 2.4 9.3 В± 2.7 9.4 В± 2.3 12.4 В± 4.3 10.9 В± 4.2 12.5 В± 4.4 11.2 В± 3 17.2 В± 6.7 13.4 В± 3.6 19.3 В± 7.7 16.5 В± 6 25 В± 9.1 P, W .09 .01 <.001 .03 .4 .2 .04 P, AP .15 .01 .01 .09 .02 .005 .06 1540674 Emergency Ultrasound of Hemodialysis Arteriovenous Fistulas and Grafts Gowthaman Gunabushanam,1* John Millet,1 Vijayanadh Ojili,2 Leslie Scoutt1 1Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA; 2Radiology, University of Texas Health Science Center, San Antonio, Texas USA Objectives—Patients with hemodialysis arteriovenous fistulas and grafts (AVF/AVG) may emergently present with pain, swelling, and decreased or absent thrill. The purpose of this exhibit is to describe the spectrum of sonographic findings of acute complications of hemodialysis AVF/AVG and to correlate these with angiographic findings when available. Methods—A classification system for the acute complications of hemodialysis AVF/AVG will be provided by anatomic location and etiology. The sonographic appearances of these complications, including arterial inflow dissection, pseudoaneurysm, thrombosis, critical stenosis, graft disruption, hematoma, infection, and postoperative seroma, will be demonstrated. Grayscale, color, and pulsed Doppler imaging findings will be described. When available, sonographic findings will be correlated to other imaging modalities. Pertinent management issues, including endovascular and surgical therapy, will be briefly discussed. Results—Not applicable as this is a pictorial review. Conclusions—Ultrasound is the initial and often only diagnostic imaging modality used in the evaluation of hemodialysis AVF/AVG. Knowledge of the sonographic appearance of acute complications is essential for early detection and may enable a reduction in patient morbidity. 1540676 Radiation Dose Reduction Through the Use of Ultrasound Smart Fusion for Liver Nami Azar,* Edwin Vargas Velandia, Dean Nakamoto Radiology, Case Medical Center, Case Western Reserve University, Cleveland, Ohio USA Objectives—Radiation dose reduction without decreasing quality care delivery is one of the main priorities in the current interventional radiology practice. We seek to evaluate the value of using fused multimodality imaging (Smart Fusion software, ultrasound [US]-computed tomography [CT] fusion) in the reduction of the radiation dose in CT-guided liver biopsies. We present our current experience. Methods—In a retrospective review, data of patients who presented to the Interventional Radiology Department for liver biopsies during the months of January and February 2012 were analyzed. A statistical comparison of average radiation dose measured as milliamperes (mA) and dose length product (DLP) was performed between 2 groups. The first group underwent CT-guided guided biopsies only, and in the second group, Smart Fusion software (US-CT fusion) was used. Results—A convenience sample 12 subjects was chosen for analysis. In this sample, 5 cases had liver biopsies in which Smart Fusion software (US-CT fusion) was used vs 7 cases performed under CT guidance only. The mean age for this sample was 62.8 years, and the mean intervention time was 50.6 minutes. Patients in the group where Smart S111 13proceedings_Layout 1 3/5/13 10:39 AM Page S112 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Fusion software was used had mean mA of 8574 and DLP of 1676 vs mA of 16,219 and DLP of 3342 in the group where solely CT-guided biopsies were performed. Total reductions of 52% in mA and 50.1% in DLP were achieved using Smart Fusion software. Conclusions—After examining the data gathered, we conclude that Smart Fusion software improves patients’ safety through radiation dose reduction as well as having a positive impact in interventional radiology resource utilization. Multimodality imaging is a promising tool that might also decrease the cost of patient care. A larger sample will document the value of Smart Fusion software. 1540683 Ultrasound of Musculoskeletal Conditions That Clinically Mimic Lower Extremity Deep Venous Thrombosis Gowthaman Gunabushanam,1* Vijayanadh Ojili,2 Leslie Scoutt1 1Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA; 2Radiology, University of Texas Health Science Center, San Antonio, Texas USA Objectives—Venous Doppler examination is the first imaging study done to evaluate patients presenting with clinical symptoms (pain, swelling, tenderness, or erythema) of lower extremity deep venous thrombosis (DVT). This review presents a systematic approach to the ultrasound diagnosis of musculoskeletal conditions that can clinically present as DVT. Methods—The exact anatomic location (groin, thigh, knee, calf, or ankle) of the patient’s symptoms provides useful clues to the diagnosis. The sonographic findings of common musculoskeletal conditions that mimic DVT are described, including: Baker’s cyst (ruptured, hemorrhagic, or infected); muscle tear, hematoma, or other injury; tendon inflammation and/or rupture; bursitis and infectious and inflammatory arthritis; and primary and metastatic muscle and bone tumors. Results—Not applicable as this is a pictorial review. Conclusions—In patients with focal symptoms in the lower extremities, meticulous examination of all anatomic structures in the vicinity of the symptomatic region enables an accurate alternate diagnosis of musculoskeletal pathologies. 1540701 Implementation of Bedside Ultrasonography Within an Internal Medicine Faculty and Residency: The IMBUS Program David Tierney,* Terry Rosborough Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota USA Objectives—Describe in detail and provide a rationale for a curriculum, structure, and successful implementation of an internal medicine bedside ultrasound program (IMBUS) in a residency program and its faculty. Methods—Design: Prospective cohort study in an internal medicine (IM) residency program at a private academic 700-bed tertiary care center. Participants: Thirty-three residents and 13 full-time faculty members without significant prior ultrasound experience. Intervention: (1) Development of an IM ultrasound curriculum to maximize sensitivity/ specificity of our routine physical exam as well as critical time-sensitive diagnoses; (2) overlap training method using top-down and bottom-up methodologies; (3) 35-hour “boot camp” including didactic, hands-on model-based, and simulator-based training; (4) bedside hands-on training with faculty mentors until trainee meets a prespecified exam count in each component and is deemed competent in that exam area; (5) ongoing mentored and remotely submitted/reviewed images until adequate technical and interpretive sensitivity/specificity obtained; (6) final test-out using bedside and simulator-based summative evaluation prior to certification; and (7) a robust ongoing quality assurance system. Measurements: (1) Comparative effectiveness of multiple implementation strategies; (2) time to, variation in, and predictive factors of competence in each exam component; (3) clinical impact of chosen components on patient outcomes; (4) effect of implementation on resident/faculty work flow, efficiency, and job satisfaction. Results—We describe in detail and rigorously critique a full ultrasound curriculum and implementation strategy for an IM residency. Thirty IM residents and 12 faculty were trained using the IMBUS program. Learning curves for each ultrasound exam component have been established. We are analyzing multiple outcomes, including competency learning curves, skill decay, patient outcomes and experience, and physician impact of bedside ultrasound. Conclusions—We hope that by describing in detail our curriculum, methods, and learning, we can help other residency programs implement bedside ultrasound in an efficient, focused, evidence-based, politically aware, and impactful manner. 1540730 Utility of Point-of-care Ultrasound in the Management of Snake Bite Srikar Adhikari,* Mazda Shirazi, Austin Gross Emergency Medicine, University of Arizona Medical Center, Tucson, Arizona USA Objectives—To describe the use of point-of-care Ultrasound in the management of a snake bite case in the emergency department (ED). Methods—We present a 67-year-old male who presented to the ED with a rattlesnake bite to the right index finger approximately 4 hours prior to arrival to the ED. The patient denied any history of diabetes, hypertension, or any other medical diseases. Physical examination revealed normal vital signs. Puncture wounds were noted on the second digit at the metacarpophalangeal joint with surrounding ecchymosis. There was significant edema of the right hand and forearm, with limitation of range of motion. He received 4 units of CroFab (antivenom) initially. A toxicology consult was obtained. Per toxicologist recommendations, the leading edge of the swelling at the envenomation site was marked. Proximal progression of swelling and induration were monitored to determine the need for additional doses of CroFab. Two hours later, the treating emergency physician was asked to mark the leading edge of the swelling and induration in the forearm to assess for any proximal progression. Based on clinical examination findings, it was determined that there was no significant proximal progression of swelling and induration. Soft tissue ultrasound of the forearm was performed by another emergency physician who was not involved in this patient’s care. Results—Bedside ultrasound revealed edema and subcutaneous fluid extending proximally into the elbow, beyond the leading edge marked by the treating physician. The subcutaneous tissues were also hyperechoic in appearance. These ultrasound findings were highly suggestive of proximal progression of local findings. Based on the sonographic findings, additional doses of CroFab were given to the patient, who was admitted to the hospital. Conclusions—In this case, point-of-care ultrasound helped clinicians make an accurate assessment of proximal progression of local findings due to a snake bite. This case highlights the utility of bedside ultrasound in the management of snake bite in ED patients. Point-of-care ultrasound can expedite the consultation and appropriate treatment in patients with snake bite. 1540763 Scaled Signal Intensity of Uterine Fibroids on T2-weighted Magnetic Resonance Images: Objective Parameter to Determine the Suitability for Magnetic Resonance–Guided Focused Ultrasound Surgery of Uterine Fibroids Sanghee Lee,1* Sang-Wook Yoon,2 Mi Hee Lee,3 Su Min Kang1 1Radiology, Healthcare System, Gangnam Center, Seoul National University Hospital, Seoul, Korea; 2Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea; 3Radiology, Seoul Metropolitan Government–Seoul National University Boramae Medical Center, Seoul, Korea S112 Objectives—Magnetic resonance–guided focused ultrasound 13proceedings_Layout 1 3/5/13 10:39 AM Page S113 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 surgery (MRgFUS) is a noninvasive treatment for symptomatic uterine fibroids. Patient selection is the most important step to achieve good results. The purpose of this study was to assess the initial efficacy of scaled signal intensity (SSI) of uterine fibroids on T2-weighted MR images as a new objective parameter to determine the suitability for MRgFUS. Methods—Twenty-four uterine fibroids in 20 premenopausal women were treated using MRgFUS. Treatments were performed from October 2008 to January 2010, and the mean age of the patients was 37.9 В± 5.9 years. SSI was measured on T2-weighted MR images by standardizing its mean pixel intensity to a 0 to 100 scale, using reference intensities of muscle (0) and fat (100), respectively. SSI in each fibroid was retrospectively analyzed according to the nonperfusion volume (NPV) ratio. Results—The mean NPV ratio in uterine fibroids with SSI <10 (n = 28) was 65% В± 17.5%. In the case of uterine fibroids with SSI >10 (n = 18), the mean NPV ratio was 51.8% В± 21.0%. Uterine fibroids with SSI <10 on T2-weighted MR images showed a higher NPV ratio than uterine fibroids with SSI >10. Conclusions—SSI of uterine fibroids on T2-weighted MR images can be suggested as an objective parameter for patient selection in MRgFUS. Uterine fibroids with <10 are more eligible for MRgFUS. 1540772 Patient and Practitioner Perceptions of Ultrasound Screening in Pregnancy Susan Bradford,* Loralei Thornburg, J. Christopher Glantz Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York USA Objectives—To evaluate how patients and obstetric providers perceive ultrasound examinations in pregnancy, including safety and accuracy of screening. Methods—Anonymous surveys of pregnant patients undergoing first- or second-trimester ultrasound and obstetric providers who refer patients to ultrasound units were conducted. Results—Surveys were completed by 337 patients (42% firsttrimester screening [FTS], 47% anatomic screening [AS], and 12% unknown) as well as 142 practitioners (63% obstetrics and gynecology, 25% family practice, and 14% midlevel providers). The FTS patients were significantly more likely than AS to correctly identify the reason for ultrasound (67% vs 48%; P = .006), as were patients receiving care from a private office vs a hospital-based clinic regardless of the type of ultrasound (82% vs 46%; P < .0001). Among AS patients, 59% indicated that their doctor had sent them to determine the fetal sex; however, patients felt that determination of fetal growth (43%) and fetal sex (41%) were their personal primary reasons for the ultrasound. The majority of both patients and providers felt ultrasound to be safe (68%). Patients’ and providers’ understanding of the baseline anomaly risk was poor (29% providers and 5% patients; P < .0001). Providers’ understanding of the residual anomaly risk after normal anatomic ultrasound was better, but patients continued to have poor understanding (57% providers and 10% patients; P < .0001), and only 51% of patients knew that ultrasound cannot detect all problems. Despite these deficiencies, 86% of patients believed they had adequate information before their ultrasound. Only 25% of patients planned nonmedical ultrasound; this was significantly higher among FTS patients (30% FTS vs 20% AS; P = .03). Conclusions—Obstetric providers have significant gaps in their knowledge regarding ultrasound screening tests, and current counseling practices do not adequately provide patients with an understanding of these tests. Despite this, most patients feel adequately counseled. 1540777 Which Parameters Could Be Useful for Predicting Malignancy in Solid Adnexal Masses? Jesus Utrilla-Layna,* BegoГ±a Olartecoechea, MarГa AubГЎ, Daisy Diaz, Laura Pineda, Leyre Juez, Juan Luis Alcazar Obstetrics and Gynecology, Clinica Universidad de Navarra, Pamplona, Spain Objectives—To determine which clinical, biochemical, and other sonographic parameters could be useful to predict malignancy in sonographically purely solid adnexal masses. Methods—Clinical (age and menopausal status), biochemical (serum cancer antigen 125 [CA-125] level) and other sonographic features (tumor volume, ascites, bilaterality, signs of carcinomatosis, tumor contour [irregular or regular], presence of acoustic shadowing, and blood flow score) from women diagnosed as having a purely solid adnexal mass on B-mode grayscale sonography were reviewed for this retrospective study. In those women with bilateral masses, only the solid mass was included; if there were bilateral solid masses, the largest one was selected for the analysis. All patients had undergone surgery and mass removal. Definitive histologic diagnosis was available in all cases. All parameters were compared to final histologic diagnosis (benign or malignant) in univariate statistical analysis. Then a stepwise forward logistic regression analysis was performed to identify those features that independently predict malignancy and develop a model for prediction. Results—A total of 227 women were included. Patients’ mean age was 52.9 years (range, 15–84 years). One hundred fifty masses were malignant, and 77 were benign. All women with carcinomatosis (n = 52) on sonography had a malignant tumor; most of them had advanced stage primary ovarian cancer (84%). No case of a benign tumor had signs of carcinomatosis on sonography (specificity, 100%). In the remaining 175 cases, logistic regression analysis showed that log CA-125 (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.3–14.7), an irregular tumor contour (OR, 3.1; 95% CI, 1.1–10.46), absence of acoustic shadowing (OR, 6.0; 95% CI, 1.5–25.7), and moderate or abundant blood flow (OR, 27.3; 95% CI, 8.4–88.6) were independent predictors of malignancy. Using the proposed model, 94.4% of malignant tumors and 85.7% of benign tumors were correctly identified. Conclusions—In purely solid masses with the presence of carcinomatosis on sonography, malignancy is the rule. In cases without carcinomatosis, the CA-125 level, an irregular tumor contour, absence of acoustic shadowing, and moderate or abundant blood flow are predictors of malignancy. 1540783 Efficacy of Ultrasound-Guided Radiofrequency Ablation for Selective Feticide in Complicated Monochorionic Pregnancy Jae-Won Yoon,* Hye-Sung Won, Jae-Yoon Shim, Pil-Ryang Lee, Ahm Kim Asan Medical Center, Seoul, Korea Objectives—The purpose of this study was to evaluate the efficacy and safety of radiofrequency ablation (RFA) for selective feticide in complicated monochorionic multiple gestations. Methods—This was a retrospective review of patients who underwent selective feticide by RFA between December 2003 and June 2012 at Asan Medical Center. Results—Seventeen cases were included in the study (14 twins and 3 triplets). There were 3 intrauterine cotwin fetal deaths (17.6%), 1 within 24 hours and 2 by cord stricture regardless of procedure. There were 2 terminations of pregnancy because of preterm labor at 23.4 weeks and severe hydrops fetalis in a case of twin-twin transfusion syndrome at 23.5 weeks. The median gestational age at intervention was 21.4 weeks (range, 16.6–25.0 weeks) and at delivery was 37.1 weeks (range, 29.1– 39.0 weeks). The median operation time was 4 minutes (range, 2–13 minutes). Preterm prelabor rupture of membranes before 37 weeks occurred in 23.5% (4/17). The overall neonatal survival rate was 70.5% (12/17). All of the surviving infants are doing well without any complications. Conclusions—RFA is an effective method for selective feticide in monochorionic multiple pregnancies. S113 13proceedings_Layout 1 3/5/13 10:39 AM Page S114 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1540840 Spectrum of Ultrasound Findings in Patients With Anorectal Malformation Steven Kraus,1,2* Sara O’Hara,1,2 Janet Adams1 1Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio USA; 2Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio USA Objectives—There are many secondary and associated malformations of multiple organ systems that can be discovered by ultrasound (US) and are important to detect in the clinical management of patients with anorectal malformation (ARM). The objective of this poster is to review the most common and important findings that can change the clinical management of these patients. Methods—Our radiology database was searched for patients with ARM and US exams performed on these patients. The exams were reviewed, and both still images and US clips were collected and presented pictorially, some with selective, radiographic, fluoroscopic, magnetic resonance (MR), and/or clinical images for correlation. Results—The most common associated malformations in patients with ARM detected by US are genitourinary (GU) and spinal in etiology. Vesicoureteral reflux, absent kidney, multicystic dysplastic kidney, crossed fused ectopia, and horseshoe kidney are common renal anomalies detected. Ectopic ureter insertion in the urethra with resultant hydroureter and hydronephrosis is also seen and must be detected early to avoid a significant effect on long-term renal function. In females with cloaca, hydrocolpos is seen in about 50% of patients at birth due to vaginal obstruction and is extremely important to detect since these patients invariably have urinary obstruction, which can cause permanent renal sequelae, vaginitis, and even vaginal perforation if not treated in the postnatal period. Other various anomalies of the female genital tract were seen, and examples are shown. Males can present with multiple episodes of epidydymitis if they have high-pressure voiding due to a neurogenic bladder (bladder-sphincter incoordination), resulting in reflux of urine into the vas deferens. Neonatal spine US is an excellent screening exam to detect spinal cord tethering, filar thickening or a mass, evidence of caudal regression, and a presacral mass (important to detect prior to definitive repair). Conclusions—Examples of the most important US findings of the GU tract and spine in patients with ARM are reviewed and presented pictorially, some with radiographic, fluoroscopic, MR, and/or clinical correlation. 1540916 Doppler Echocardiographic Estimates of Right Ventricular Pressure Are Inaccurate in Children With Elevated Right Heart Pressure Georgeann Groh,1* Mark Holland,2 Joshua Murphy,1 Timothy Sekarski,1 Philip Levy,1 Craig Myers,1 Diana Hartman,1 Gautam Singh1 1Pediatrics, 2Physics, Washington University School of Medicine, St Louis, Missouri USA Objectives—Doppler echocardiography (DE)-estimated right ventricular systolic pressure (RVp) is widely used as a surrogate for RVp measured by right heart catheterization (RHC), the gold standard. However, its accuracy has not been prospectively validated in children. Our objective was to prospectively validate the accuracy of DE-estimated RVp in children. Methods—Simultaneous pressure gradients between the right ventricle and right atrium were prospectively assessed by RHC and DE using tricuspid valve regurgitation in 94 consecutive children (age 0–18 years; median, 5.7 years) with 2-ventricle physiology. Subjects were classified into 2 groups based on RHC-measured RVp: group 1 (n = 53) with normal RVp (RVp <1/2 systemic systolic blood pressure [SBP]) and group 2 (n = 41) with elevated RVp (RVp >1/2 SBP). Correlation and agreement between the 2 methods were assessed using linear regression and BlandAltman analysis, respectively. Accuracy was predefined as 95% limits of agreement (LOA) В± 10 mm Hg for DE RVp estimates. Results—The correlation between DE- and RHC-measured RVp was strong in both groups (group 1, r = 0.8; P < .001; group 2, r = 0.77; P < .001). The agreement between the 2 methods was good in group 1 (bias, 2.5 mm Hg; 95% LOA, +9.7 to –4.8 mm Hg) but poor in group 2 (bias, 0.89 mm Hg; 95% LOA, +25.1 to –25.1 mm Hg). DEestimated RVp was inaccurate, with both overestimation and underestimation, in 2% of subjects in group 1 vs 34% in group 2. Conclusions—DE estimates of RVp are frequently inaccurate in children with elevated RVp. They should not be solely relied on in the management of children with elevated RVp. 1540920 Cranial Ultrasound Findings in Preterm Infants With Germinal Matrix and Periventricular Leukomalacia Arash Anvari,1* Anthony Samir,1 Michael Gee2 Radiology, 1 Abdominal Imaging and Intervention, 2Pediatrics Division, Massachusetts General Hospital, Boston, Massachusetts USA Objectives—This educational poster will review germinal matrix and periventricular leukomalacia (PVL) in preterm infants and the role of cranial ultrasound in the diagnosis and characterization. Methods—Content Organization: (1) Introduction of germinal matrix hemorrhage: epidemiology, pathophysiology, its complications like hydrocephalus and periventricular leukomalacia, and clinical outcomes. (2) Cranial ultrasound technique: transducer, standard views, supplemental acoustic windows, timing, advantages, and limitations. (3) Ultrasound findings in different classes (I–IV) of germinal matrix hemorrhage and PVL. Results—Not applicable because it is an educational e-poster. Conclusions—This e-poster emphasizes the clinical application of cranial ultrasound in early diagnosis of germinal matrix hemorrhage and PVL and its important role in clinical management. 1540927 Focal Lesions in the Transplanted Liver: Differential Diagnosis Ronald Wachsberg New Jersey Medical School , Newark, New Jersey USA Objectives—To illustrate the spectrum of focal lesions and pseudolesions that can be seen in liver transplant recipients. Methods—Cases are presented of various focal lesions and pseudolesions detected in liver transplant recipients at a busy transplant center. Results—A focal lesion in a liver graft can be an infarct, abscess, biloma, hematoma, steatosis, recurrent or de novo malignancy, preexisting incidental lesion in the donor liver, and arteriovenous fistula. Several pseudolesions, eg, loculated intrafissural fluid, thrombus within the donor inferior vena cava, and others, can mimic a liver lesion. Conclusions—Awareness of the spectrum and features of focal lesions and pseudolesions that can be detected in a liver graft is essential to arrive at the correct diagnosis. 1540949 First-Trimester 3-Dimensional Placental Volume and Its Association With Gestational Diabetes Nwamaka Obi,* Karenrose Contreras, Andre Bieniarz, Jean Goodman, Paula Melone, Roberta Karlman Maternal-Fetal Medicine, Loyola University Medical Center, Maywood, Illinois USA Objectives—Gestational diabetes mellitus (GDM) a common metabolic disorder in pregnancy and complicates about 3% to 10% of pregnancies worldwide. The goal of predicting GDM has not been reached, and its impact extends beyond just perinatal outcomes. The objective of the study was to determine if first-trimester 3D placental volume is predictive of GDM. Methods—This was a prospective cohort study that included 140 women aged ≥18 years with singleton pregnancies. At the time of S114 13proceedings_Layout 1 3/5/13 10:39 AM Page S115 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 nuchal translucency ultrasound, 3D images of the placenta were obtained and volumes measured using the multiplanar volume method with Philips QLAB. The development of GDM and other pregnancy outcomes were recorded. Continuous and categorical variables were compared using the Student t test and П‡2 test. Logistic regression analysis was performed to determine the association of first-trimester placental volume with gestational diabetes while controlling for confounders. Results—A total of 140 women were included in the study. There were complete pregnancy outcomes recorded for 98 (70%), 8 (8%) of which had GDM. Mean first-trimester 3D placental volumes (57.6 В± 2.2 vs 51.6 В± 2.65 mL) and infant birth weights (3312.2 В± 61.2 vs 3629.6 В± 186.3g) were similar between the non GDM and GDM groups. In logistic regression analysis, first-trimester placental volume was not statistically significant while controlling for age, race, and body mass index (BMI) between the groups. Women with a higher BMI were at significantly increased risk of GDM. 3D placental volume was predictive of birth weight regardless of the presence of gestational diabetes. Conclusions—First-trimester 3D placental volume was similar in women with and without gestational diabetes. A high BMI is a wellknown risk factor for the development of GDM, which was also seen in this study. Larger studies are needed to confirm our findings. Table 1. Logistic Regression Analysis Age Race BMI Placental volume OR indicates odds ratio. Adjusted OR 1.127 0.859 1.133 0.968 P .160 .85 .021 .228 1540968 Role of Bedside 3/4-Dimensional Ultrasonography in the Diagnosis of Acute Appendicitis Timothy Mooney,* Kevin O’Rourke, Gerardo Chiricolo Emergency, New York Methodist Hospital, Brooklyn, New York USA Objectives—Abdominal ultrasonography (US) is commonly used in diagnosing acute appendicitis (AA).Traditional 2D US is both safe and quickly performed. Diagnostic accuracy can be limited, and equivocal studies are common. 3D/4D US technology could improve diagnostic accuracy by enhancing visualization of anatomy and spatial relationships. Our objective was to evaluate the performance and accuracy of bedside 3D/4D US in patients with suspected AA. Methods—All adult and pediatric patients with suspected AA were eligible for enrollment. We excluded patients who underwent computed tomographic scanning prior to enrollment and those with a prearrival diagnosis of AA. Patients were enrolled when there was an emergency sonographer available. These emergency department physician sonographers had a 4-hour tutorial by an experienced application specialist on 3D/4D image acquisition. The same sonographer scanned each patient’s right lower quadrant first using both 2D and 3D/4D multiplanar and surface-rendering US. All clips and images were deindentified and interpreted by another sonographer who recorded an impression separately. The US interpretations were then compared to surgical pathology or phone follow-up. Results—A total of 30 patients met inclusion criteria and were enrolled. Twenty-one patients (70%) were ultimately diagnosed with AA. Of the 30 total patients, 13 (43%) were diagnosed with AA using conventional 2D US, with the other 17 diagnosed with a nonvisualized appendix, inconclusive US of the right lower quadrant. Two patients (6%) were diagnosed with AA from 3D/4D US images and clips (both had a diagnosis of AA from 2D US examination also). Sensitivity for 2D US was 62% (95% confidence interval [CI], 48%–62%); specificity was 100% (95% CI, 65%–100%); positive predictive value was 100% (95% CI, 78%–100%); and negative predictive value was 53% (95% CI, 36%–53%), with overall accuracy of 72%. 3D/4D US had sensitivity of 10% (95% CI, 2%–10%); specificity was 100% (95% CI, 82%– 100%); positive predictive value was 100% (95% CI, 21%–100%); and negative predictive value was 32% (95% CI, 27%–32%), with overall accuracy of 36%. Conclusions—3D/4D US fails to increase the diagnostic accuracy of US in AA and has little utility in AA’s staged diagnostic workup. 1540972 Reliability of Linear Measurements of the Thoracic Paraspinal Muscles Using Ultrasound Imaging Nancy Talbott,* Dexter Witt Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio USA Objectives—Ultrasound imaging (USI) has become more common in the rehabilitation area. Muscles critical to the stabilization of the spine have been assessed to assist in guiding interventions. In the shoulder, function relies on scapular muscles, which work most effectively when the thoracic spine is stabilized. To assist in understanding the role of the thoracic paraspinal muscles (TPSM) during arm elevation and in using that information in determining effective rehabilitation treatment, realtime monitoring of the changes in the TPSM would be of benefit. The objective of this study was to determine if USI can reliably measure the TPSM during arm movements. Methods—USI of 18 healthy subjects was performed with subjects prone and the arm elevated fully in the scapular plane. The spinous process and lamina of T7 were imaged as the subject rested the arm on a stable surface, actively contracted, and held a weight. After resting, testing was repeated twice on one arm and 3 times on the opposite arm. Nine subjects returned to have the testing performed again by the original examiner. TPSM linear measurements were recorded in 2 locations: (1) between the superior hyperechoic line of the laminae and the inferior hyperechoic line of the lower trapezius muscle; and (2) between the superior hyperechoic line of the transverse process and the inferior hyperechoic line of the lower trapezius. Results—Intrasession correlation values were strong. Within a session, intra-tester reliability ranged from 0.882 to 0.960. Inter-tester reliability within a session was also good, with intraclass correlation coefficients (ICCs) ranging from 0.706 to 0.906. Agreement between sessions was also acceptable, with ICCs ranging from 0.733 to 0.885. Conclusions—The USI methodology used in this study achieved TPSM measurements with high intra-rater reliability and good inter-rater reliability at rest and during active contractions. Changes in the TPSM thickness occurring during active contraction of the shoulder and scapula can be reliably monitored by USI. As small but significant changes occur during arm activities, USI of these muscles may be useful for guiding interventions. 1540981 Reliability of Ultrasound Measurements of the Lower Trapezius Muscle During Active and Resisted Movements Dexter Witt,* Nancy Talbott Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio USA Objectives—Ultrasound imaging (USI) to assess patients with shoulder pain often emphasizes structural changes of the tendons. Pain, however, may be related to alterations in the scapular muscles, including abnormal activation of the lower trapezius (LT). The ability to make reliable measurements of the LT during active contraction using USI would be of benefit in determining firing patterns, identifying muscle atrophy, and designing interventions. While previous USI studies have established the reliability of USI measurements of the LT at rest, the objective of this study was to determine if USI could be used to reliably measure the thickness of the LT muscle during LT contraction. S115 13proceedings_Layout 1 3/5/13 10:39 AM Page S116 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Methods—USI images of the LT were captured bilaterally in 20 normal subjects at the T7 level. With the arm in 120В° of abduction, images were taken in the prone position with the subject’s arm at rest, actively holding the position and while holding a weight. This process was repeated 3 times on both shoulders by a single examiner. Within 7 days, 10 of the subjects returned. The same testing sequence was repeated on the dominant arm by the original examiner and by a second examiner. Images were stored electronically and analyzed offline. Reliability was assessed via intraclass correlation coefficients (ICCs). Results—Intersession intra-rater reliability agreement was good, with ICC values of 0.835, 0.871, and 0.909 at rest, during an active hold, and holding the weight, respectively. Same-session inter-rater reliability was also good, with ICC values of 0.864, 0.881, and 0.891 in the respective states of rest, active hold, and holding the weight. Conclusions—The USI methodology used in this study achieved LT measurements with high inter-rater and intra-rater reliability at rest and with the addition of active contraction and resistance. Benefits for having this reliability method include: (1) identification of percent changes of thickness between rest and contraction; (2) an adjunct to electromyography in the determination of muscle changes during activities; (3) a viable tool for clinical facilitation of LT activation; and (4) documenting atrophy of the LT. 1540998 Evaluation of Acquisition and Interpretation of Focused Assessment With Sonography for Trauma Scans in an Urban Level 1 Trauma Center Zachary Robinson,1* Lem Smith,1 Eliza Beal,1 Brian Abbott,2 Creagh Boulger,2 Daniel Eiferman,3 David Bahner2 1 College of Medicine, 2Emergency Medicine, 3Critical Care, Trauma, and Burn Surgery, Wexner Medical Center, Ohio State University, Columbus, Ohio USA Objectives—Focused assessment with sonography for trauma (FAST) has become the standard of care in the evaluation of trauma patients. A review of recent literature showed sensitivity of 84% to 94%, specificity of 96% to 98%, a positive predictive value of 61% to 87%, and a negative predictive value of 98% to 100%. A formalized ultrasound training program has been introduced at our institution for surgical residents to ensure proper acquisition and interpretation of ultrasound images. A quality review process was initiated to evaluate accuracy in using FAST in trauma patients. Methods—Trauma FAST exams are wirelessly saved to a picture archiving and communication system, and generated reports are saved to an electronic medical record. Patients who presented as a level 1 or level 2 trauma between January and March 2012 and received a FAST scan as part of their assessment were included in the quality review. The results of the FAST scan and any other imaging performed during the same encounter were recorded and reviewed. The results of FAST were compared to confirmatory testing of abdominal computed tomography (CT), chest CT, or operative reports. The results of FAST were then determined to be true-positive, true-negative, false-positive, or false-negative. Results—There were 200 trauma alerts during the study period. One hundred twenty-one patients were eligible for review with both saved images and a generated report in the chart. Fifteen patients were excluded because the FAST scan results were not available; the FAST scan was indeterminate; or the patient died prior to confirmatory imaging. There were 94 true-negatives, 2 false-negatives, 7 true-positives, and 3 falsepositives in the remaining 106 patients reviewed, yielding sensitivity of 78% and specificity of 97%. The positive predictive value was 70%; the negative predictive value was 98%; and the accuracy was 95%. Conclusions—Our results confirm that FAST has a high negative predictive value for abdominal injury in patients experiencing trauma. These quality results, collected after a focused training program, show the training to be effective in educating surgical residents on the proper acquisition and interpretation of FAST in trauma patients. 1541009 An Educational Model for Teaching Focused Assessment With Sonography for Trauma to Surgical Residents Eliza Beal,1* Ashley Zielinski,1 Creagh Boulger,2 Sereana Dresbach,3 David Bahner,2 Daniel Eiferman4 1College of Medicine, 2Emergency Medicine, 3Pulmonary, Allergy, Critical Care, and Sleep, 4Critical Care, Burn, and Trauma Surgery, Wexner Medical Center, Ohio State University, Columbus, Ohio USA Objectives—Focused assessment with sonography for trauma has become indispensable in the evaluation of trauma patients. Few surgical training programs have specific courses to teach the FAST exam. The Wexner Medical Center at Ohio State University has established a pilot program with hands-on teaching sessions and self-directed learning to teach surgery residents the skills needed to accurately obtain and interpret FAST scan images. Methods—Thirteen postgraduate year 1 (PGY-1)-level residents participated in an initial evaluation session, which included 10 confidence questions, 12 ultrasound knowledge questions, and a practical exam where they were asked to perform both the FAST exam and the long-axis rescue cardiac view. Participants answered confidence questions on a spectrum from 1 to 8 with 1 being strongly disagree, 7 being strongly agree, and 8 indicating that the individual had no experience with the skill. The practical exam was evaluated by 2 attending physicians with significant experience with the FAST exam and ultrasound education. The images were graded on a 1 to 5 scale (1 = no image obtained and 5 = image perfectly obtained with proper settings and labeling). The 13 PGY-1 residents will undergo 2-hour hands-on training and will be reevaluated for knowledge and skill acquisition. Results—With little formalized training in focused ultrasound, PGY-1 residents responded with fairly low overall confidence in skills (mean = 2.08). When asked about confidence in acquiring specific views, participants generally rated their views in the “disagree” portion of the continuum, but the means on the 9 confidence questions ranged from slightly to strongly disagree (3.94–1.92). No resident answered “no experience” for any question. Skills assessed by the proctors showed a general tendency of not being able to attain the image or missing relevant anatomy, with the means ranging from 1.38 to 2.46 for the 5 images obtained. Conclusions—Preliminary data show that confidence and knowledge are low, and practical scores show an inability to perform FAST scans among PGY-1 level surgical residents. The initial results suggest that training in the FAST exam is necessary for PGY-1 surgical residents to adequately obtain images used for clinical decision making. 1541032 Cervical Length Assessment by Transabdominal and Endovaginal Ultrasound Jennifer Thompson,* Michael Smrtka, Geeta Swamy, Chad Grotegut, Brita Boyd, Amy Murtha Duke University, Durham, North Carolina USA Objectives—Endovaginal (EV) cervical length identifies women at risk for preterm birth (PTB) and thus eligibility for vaginal progesterone. Our objective was to compare transabdominal (TA) with EV cervical lengths to determine the degree of correlation, the capability of TA to predict an EV-detected short cervix, and the rate of cervical change over time. Methods—Retrospective review of singleton pregnancies having TA and EV ultrasound (US) for cervical length between 16 and 28 weeks’ gestation at Duke University from January to December 2011. TA measurements are routinely obtained on midtrimester exams with EV measurement for high PTB risk, TA <30 mm, and assessment of placental location and/or presence of cerclage. Serial US with TA and EV are performed when EV <25 mm. Pearson correlation and receiver operating curves were used to compare TA and EV cervical lengths and determine optimal TA cutoffs for prediction of an EV cervical length <25 mm. Linear regression was used to compare the rate of cervical change by TA and EV by term vs PTB. Results—A total of 142 subjects with 245 US observations met S116 13proceedings_Layout 1 3/5/13 10:39 AM Page S117 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 study inclusion criteria. TA and EV measurements were significantly correlated (r = 0.810; P < .0001). A TA cutoff of 30 mm accurately predicted an EV-detected short cervix (<25 mm): sensitivity, 90.4%; specificity, 80.2%; positive and negative predictive values, 70.1% and 94.2%. Using linear regression, women delivering preterm had a greater rate of cervical change by EV compared to women delivering term (P = .014). TA failed to demonstrate such a difference (P = .592). Conclusions—TA and EV cervical lengths correlate well, and TA <30 mm is an accurate predictor of shortened EV cervical length. Serial follow-up of a US-detected short cervix should be via EV measurements, given the better detection of rate of cervical change than TA in patients who deliver preterm. Detecting a rapidly changing short cervix sooner may allow for earlier interventions. Prospective studies are required to confirm our findings. 1541037 Teaching Basic Obstetric Ultrasound Skills at Mulago Hospital, Kampala, Uganda Homa Ahmadzia,1* Urania Magriples,2 France Galerneau,2 Imelda Namagembe3 1Obstetrics and Gynecology, Duke University, Durham, North Carolina USA; 2Obstetrics and Gynecology, Yale University, New Haven, Connecticut USA; 3 Obstetrics and Gynecology, Makerere University, Kampala, Uganda Objectives—Basic ultrasound skills are useful in the assessment and management of obstetric patients. The purpose of the study is to assess the effectiveness of a teaching intervention (via pretest and posttest survey) implemented to teach basic obstetric ultrasound skills to residents, interns, and medical students at Mulago Hospital, Kampala, Uganda. Methods—Prior to the teaching intervention, participants completed a survey designed to assess their comfort level, knowledge, and skills via multiple-choice questions. The teaching intervention included a 1-hour didactic PowerPoint presentation coupled with a 1-hour hands-on skills training session. Topics reviewed include general principles of ultrasound, biometry, placental location, fetal position, amniotic fluid index, and biophysical profile. Following completion of the teaching intervention, participants completed the survey. Of the 40 total participants, there were 12 medical students, 23 interns. and 5 residents. Data were analyzed in Microsoft Excel and SAS software. Results—When pretest responses were compared to posttest responses, participants were more comfortable with any skill taught after the intervention (23% vs 73%; P < .0001). Further, when individual groups were compared separately, the mean survey score of medical students went from 34% to 76% correct (P < .0001); for interns, 33% to 71% correct (P < .0001); and for residents, 60% to 69% (P= .30). Conclusions—This original teaching intervention was an effective method to improve knowledge and skills for medical students and interns at Mulago Hospital in the area of basic obstetric ultrasound. 1541039 Improving Musculoskeletal Ultrasonography Through a Local Community Practice Inititative Brandon Price,1 David Bahner,2* Kendra McCamey,3 Nicole Bundy,4 Kimberly Fisher,5 Andrew Aten,1 Michael Roesch1 1 Ohio State University College of Medicine, Columbus, Ohio USA; 2Emergency Medicine, 3Family Medicine, 4Rheumatology and Immunology, 5Internal Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio USA Objectives—Communities of practice (COPs) involving groups of people from different backgrounds with similar interests commonly are encountered within medicine. Barriers often exist within the group because of variances like nomenclature, standards of care, and differences in charges for services. This project describes the creation of a COP for musculoskeletal (MSK) ultrasonography (US). The goals are to establish a multidisciplinary approach to MSK US education and standards of prac- tice at all levels of training to standardize MSK US within our institution. Methods—This group comprises attending physicians from emergency medicine, rheumatology, physical medicine, and rehabilitation and sports medicine, along with resident and medical student representatives. Regular meetings are held to establish credentialing guidelines, clinical protocols, and educational opportunities. Coordinated scanning sessions focused around MSK imaging have been implemented, allowing all levels of training to scan various joints while teaching MSK topics. This COP also is establishing an integrated MSK curriculum for medical students. Results—This group has convened administratively and during MSK scanning sessions to coordinate activities and standardize the MSK US educational framework. Commonalities such as proper probe orientation and standard labeling have been established and extend across all specialties involved. A multidisciplinary credentialing document with tiered privileging has been authorized, and 2 attendings have been granted these privileges. Standard billing practice for focused ultrasound has been discussed. The new MSK curriculum involving ultrasound is also being implemented thanks to aid from this COP. Conclusions—Local COPs are one way for focused US within specific specialties to coordinate goals and improve the training throughout all levels of expertise. Incorporating shared governance toward operationalizing an academic vision, this COP has helped focus these MSK US efforts at this medical center. The trajectory of this COP will continue to address the academic needs of the various departments and work toward improving the quality of US education and delivery of care. 1541050 Cervical Length Ultrasound Does Not Predict Preterm Birth in Patients With Cerclage Jennifer Thompson,* Michael Smrtka, Geeta Swamy, Chad Grotegut, Sarah Ellestad, Amy Murtha Obstetrics and Gynecology, Duke University, Durham, North Carolina USA Objectives—Cervical incompetence is an important contributor to preterm birth (PTB). Cerclage placement for cervical incompetence may reduce the risk of preterm birth in at-risk individuals. Once a cerclage is placed, endovaginal (EV) cervical lengths are used to monitor for cervical shortening. Our objective was to determine if cervical length and the rate of change of cervical length predict PTB (<34 weeks) in women with cerclage. Methods—We conducted a retrospective review of subjects with cerclage having both transabdominal and EV ultrasound for cervical length assessment between 16 and 28 weeks’ gestation at Duke University from January to December 2011. Serial EV measurements are routinely obtained on all patients with cerclage. EV ultrasound measurements were obtained following bladder emptying with application of fundal pressure. Measurements were divided into ≤25 mm (n = 73) and >25 mm (n = 98). Preterm birth rates were compared between groups by П‡2 analysis. Linear regression was used to compare the rate of cervical change in subjects who delivered preterm and term. Results—Twenty-nine subjects with 171 EV measurements met inclusion criteria. PTB rates were not significantly different when EV ≤25 mm compared to EV >25 mm (37% vs 26%; P = .1) Using linear regression, there was significant cervical shortening over time in subjects delivering term and preterm (preterm, P = .02; term, P < .0001). Importantly, the rate of cervical change in cerclage subjects delivering preterm was not significantly different from the rate of cervical change in cerclage subjects delivering at term (P = .868 for differences in slopes). Conclusions—In women with cerclage, a shortened cervical length does not appear to be related to PTB risk. Cervical length does significantly shorten over time in women with a cerclage; however, serial ultrasound for cervical length may not provide additional clinical guidance in women who deliver preterm. S117 13proceedings_Layout 1 3/5/13 10:39 AM Page S118 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1541066 Maximum Effort of the Multifidi Muscles in the Prone Position Using Musculoskeletal Ultrasound Imaging and Electromyography Rose Smith,* Dervarshi Patel, Susan Kotowski, Dexter Witt, Lauren Farwick, Erin Rathje, Ryan Steiner Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio USA Objectives—The lumbar paraspinal muscles play a critical role in supporting the trunk during functional activities. Rehabilitative ultrasound imaging (RUSI) has been found to be a valid and noninvasive method to measure the activation of these muscles. RUSI of the multifidi has shown 19% to 43% of maximum effort on electromyography (EMG) while measuring muscle thickness. No study has compared EMG with RUSI using the trace method. The purpose of this study was to look at the relationship of EMG activity of the multifidi using RUSI by measuring the cross-sectional area (CSA) using the trace method. Methods—A sample of convenience consisted of 22 volunteers (11 female and 11 male) with a mean age of 25 years. Exclusion criteria included current or recent history (within 6 months) of shoulder, lumbar, or lower extremity pathology/surgery or pregnancy. Musculoskeletal ultrasound images of the multifidi were obtained using the Biosound Esaote model MyLab 25 Gold. The area was found using the trace method of the right and left multifidus during an arm raise, arm raise with weight, and leg raise activity while the subject lay prone. A simultaneous DataLINK (Biometrics, Ltd) EMG system was used to measure muscle activity. EMG sensors were placed over the belly of the muscle in the line of action. Maximum voluntary contractions (MVCs) were taken at the start of data collection by having the subject lie prone and raise the opposite arm and leg against manual resistance. The measured trace area of each image was normalized against the measured area of the MVC trial. Results—Analysis showed that overall, RUSI trace-measured CSA muscle activity ranged from ≈22% MVC (trial maximum) to ≈28% MVC (trial average), which corresponded to a measured area of the multifidus of 100% MVCs. Minimal nonsignificant differences were noted between the 3 activities with RUSI and EMG activity. Conclusions—The change in trace-measured CSA as compared to EMG activity is consistent with measuring muscle thickness via RUSI. This information can be helpful in guiding clinical practice but cannot be applied without considering its limitations. 1541115 Ocular Ultrasound Simulation Lab: Does It Translate to the Bedside? Kevin O’Rourke,* Sharon Yellin, Adam Vytykac, Timothy Mooney, Larry Melniker, Athena Mihailos, Andrew Balk, Gerardo Chiricolo Emergency Department, New York Methodist Hospital, Brooklyn, New York USA Objectives—Two percent of emergency department visits are eye-related complaints. Ocular ultrasound (US) gives the emergency physician the ability to noninvasively assess the eye for a variety of disease processes. The Council of Residency Directors Emergency Ultrasound Consensus Committee does not identify ocular US as a core US competency for emergency medicine resident graduation but recommends that it is incorporated into the resident curriculum. The accuracy of bedside ocular US has been studied, and published reports of models used for simulation exist. The breadth of knowledge about the effectiveness of using simulation for ocular US is limited. The goal of this study was to evaluate if an ocular US lecture and simulation lab led to increased use at the bedside and what diagnoses were found. Methods—In this retrospective review, we compiled data from our US database for all ocular US examinations performed the 6 months before and after an ocular US lecture and simulation lab. We included all patients who had US between September 21, 2011, and September 22, 2012. Data collection included when the US was performed and what the diagnosis was based on US. Results—In the 6 months before the lecture and lab, 18 ocular US examinations were performed. The findings included 9 normal US findings, 2 vitreous hemorrhages (1 with posterior vitreous detachment), 3 with an increased optic nerve sheath diameter, 2 retinal detachments, 1 with postoperative changes, and 1 with a foreign body. In the 6 months after the lab, 28 ocular US examinations were performed. The findings included 11 normal US findings, 7 with an increased optic nerve sheath diameter, 5 with vitreous hemorrhage, 1 globe rupture, 1 with choroidal detachment, 1 with vitreous detachment, and 2 incomplete studies. There were 10 more US examinations performed in the emergency department after the intervention, which equates to a 55% increase in US use. Conclusions—An ocular US lecture and simulation lab led to increased use of bedside US for patients. In the future, we anticipate this skill to decrease inappropriate transfers and increase appropriate and timely evaluations by an ophthalmologist. 1541203 Factors Influencing Intraoperator Variability When Assessing Fibroid Growth Malana Moshesh,* Shyamal Peddada, Donna Baird National Institute of Environmental Health, Research Triangle Park, North Carolina USA Objectives—To assess factors associated with intraoperator variability (measured by the coefficient of variation [CV]) of fibroid measurements and apply this to current practice. Methods—Study participants, recruited through community outreach and health care facilities were young African American women, aged 23 to 34 years, who had never been diagnosed with fibroids. All participants underwent transvaginal ultrasound to screen for the presence of uterine fibroids (≥0.5 cm in diameter). The fibroid diameter was measured in 3 perpendicular planes (longitudinal, sagittal, and transverse) at 3 separate times during the examination. Volume was calculated using the ellipsoid formula. Intraobserver variability as measured by the CV for fibroid diameter and volume was calculated for each fibroid, and factors associated with the CV were assessed using regression models adjusting for fibroid characteristics and individual participant characteristics. Results—Ninety-six women out of 300 women initially screened were found to have at least 1 fibroid, yielding a total of 174 fibroids for this analysis. The median CV for the 3 measurements of the fibroid maximum diameter was 4.9%, and the mean CV was 5.9%. The median CV for fibroid volume was 10.5%, and the mean CV was 12.7 %. Fibroid size contributed significantly to the prediction of the CV for both fibroid diameter (P = .04) and volume (P = .005). The CV was greater for smaller fibroids. Individual participant factors and the fibroid type were not significantly associated with intraobserver measurement variability. Conclusions—When assessing fibroid growth, baseline fibroid size should be considered. Small fibroids have greater measurement variability than large fibroids. Thus, a small fibroid must have a proportionately greater increase in size compared to a large fibroid to conclude that it is growing. 1541265 Role of Transvaginal Ultrasound in the Diagnosis of Cesarean Section and Its Complications Lourdes Hereter,* M. Angela Pascual, Betlem Graupera, Pere Barri-Soldevila, Cristina Pedrero, Maria Fernandez-Cid Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain Objectives—To describe the findings of transvaginal ultrasound (TUS) in cesarean scar defects and their complications in nonpregnant women. Methods—Nonpregnant premenopausal women with a history of a previous cesarean section, referred to TUS for an annual checkup, were included in this study. A cesarean scar defect was defined as a hypoechoic indentation at the anterior wall of the lower uterine segment, S118 13proceedings_Layout 1 3/5/13 10:39 AM Page S119 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 measured in 3 dimensions. The number of previous cesarean sections and complications were reviewed. These included dehiscence (separation of the scar that does not disrupt the uterine serosa), uterine rupture (a complete disruption of the myometrium and serosa), and ectopic pregnancy in the cesarean section scar. Results—Thirty-eight women were diagnosed with a cesarean scar defect at TUS. The number of previous cesarean sections in patients with uterine dehiscence and ectopic pregnancy in the cesarean scar is shown in Table 1. Eleven patients (29%) showed uterine dehiscence. Seven cases were repaired by laparoscopy, and 4 cases required hysterectomy. Five ectopic pregnancies (13%) were diagnosed at TUS. Two patients required hysterectomy; 2 were treated with local methotrexate guided by TUS; and 1 was surgically sutured. Two patients (5%) had a complete uterine rupture. One of them was diagnosed 6 months after the cesarean section and required hysterectomy. The other was diagnosed during the puerperium period and was treated by surgical repair. Conclusions—TUS is useful for detecting cesarean scar defects, providing information for treatment in case of complications. Table 1 Dehiscense Ectopic pregnancy 1 5 3 Previous Cesarean 2 3 4 1 0 1 4 1 1 1541304 Ultrasound-Guided Dorsal Approach for Chemodenervation of the Psoas Muscle David Spinner Rehabilitation Medicine, Mount Sinai School of Medicine, New York, New York USA Objectives—To directly treat the primary motor end plates of the psoas muscle for spasticity. Methods—Case report with description of procedure. Bilateral ultrasound-guided psoas muscle injections were performed. An axial or short-axis view was used for both the right- and left-sided injections. The right psoas muscle was injected with an out-of-plane approach where only the needle tip was visualized. We then turned the probe 90В° to visualize the length of the needle in addition to using electromyography (EMG) for confirmation. The left psoas muscle was injected using an in-plane technique with EMG confirmation. Results—The left and right psoas muscle injections were confirmed with EMG. The patient gained 30В° of extension from baseline to bilateral hip joints. The patient had overlying hip contractures that did not allow for further range of motion. Conclusions—The ultrasound-guided dorsal approach for performing psoas muscle chemodenervation is a novel approach for treating hip flexor spasticity while targeting the primary motor end plates. 1541312 The BUILD Project: Bringing Ultrasound Internationally for Long-Term Development Keith Rosenberg, Fadi Kasyouhanan, David Bahner* Emergency Medicine, Ohio State University College of Medicine, Columbus, Ohio USA Objectives—With technological advances in imaging, ultrasound (US) equipment is increasingly affordable and portable. Studies have shown that portable US can be an effective modality in low-resource environments. Bringing Ultrasound Internationally for Long-term Development (BUILD), a global outreach project, is an attempt to collaborate with Ohio State University’s (OSU’s) Office of Global Health to provide third- and fourth-year medical students from OSU’s College of Medicine the opportunity to enroll in a longitudinal US program. Methods—BUILD creates a collaboration between the College of Medicine and the Office of Global Health. The group combines exist- ing medical mission programs and promotes an effort to coordinate both groups. Current US resources were centralized, streamlined, and made available to the program. Results—The Office of Global Health has funded 51 trips over the past 5 years, while the medical school has sent 244 trips, to >25 developing countries. BUILD’s team of 2 senior medical students and 1 physician US expert acts to bridge these separate but similar programs. Approximately 6 of these trips have incorporated US. The program developed a needs assessment survey of current US resources for medical missions. BUILD has fostered interest among students traveling abroad to integrate US into their trips. Conclusions—As trends in medicine shift toward more prudent use of resources, US will become an integral part of medical training. It is increasingly common for students and residents to gain exposure to US early in their schooling. Studies have shown that physicians and medical students have successfully used portable US to determine medical management. BUILD intends to establish a protocol for students and faculty to bring US to underserved areas. The group will design didactics to teach travelers US skills and enable them to become teachers at their sites. BUILD will create partnerships leading to opportunities for travelers to bring donated equipment. The findings of this study will be used to show that US can be successfully incorporated into global health programs. BUILD hopes to integrate this into the medical student curriculum as an optional course. 1541434 Trained Simulated Ultrasound Patients: Medical Students as Models, Learners, and Teachers Matt Blickendorf,1* Lindsay Mooney,2 Krista Rath,2 Eric Adkins,1,2 David Bahner1,2 1Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio USA; 2 Ohio State University College of Medicine, Columbus, Ohio USA Objectives—Despite the increased use of bedside ultrasound (US) by clinicians, US is not fully established in undergraduate and graduate medical education. Medical schools and residency programs must develop US education programs to ensure future physicians become competent with this operator-dependent technology. Medical educators are often challenged to find human models for hands-on scanning sessions. The goal is to outline the educational model of a university medical center that uses medical students to fulfill the need for human models while also offering these individuals a basic introduction to US education. Methods—Second-year medical students from the Ohio State University College of Medicine serve as trained simulated US patients (TSUPs) for hands-on scanning sessions held by the college and residency programs at the medical center. Students are offered a didactic and handson US education program as an added incentive for serving as a TSUP. Students were given a postcourse 5-point Likert survey to assess their perceived benefit from the TSUP program. Results—During the 2011–2012 academic year, 47 secondyear and 7 first-year students served as normal models for 71 hands-on scanning sessions, while only 28 sessions were left without TSUP participation. Counting each time a TSUP was used, a total of 173 models were used for 160 hours of scanning. The college and 7 residency programs used the TSUP program. Student volunteers were split equally male and female with a diverse range of specialty interests. Approximately 75% of TSUP participants served as US models for an average of 6 to 15 hours for the year. Most attended a majority of the US educational events, and almost all TSUP participants endorsed increased US interest, knowledge, and skill as a result of the program. Conclusions—The TSUP program is a feasible and sustainable method of fulfilling the need for normal anatomy models in US education while serving as a valuable extracurricular US educational program for TSUP participants. The program offers a model for the establishment of US education programs by educators at undergraduate and graduate levels. S119 13proceedings_Layout 1 3/5/13 10:39 AM Page S120 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 1541460 Developing and Evaluating an Ultrasound Curriculum for a Urology Residency Training Program Joseph Lopez,1* Daniel Box,1 Geoffrey Box,1 David Bahner2 1 Urology, 2Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio USA Objectives—In medicine, much has been written on ultrasound (US) use in focused settings looking for specific findings consistent with pathology and using this to make specific medical decisions. With the advent of other fields of discipline using US, some hospital infrastructure exists with US in critical care, emergency medicine, anesthesiology, and surgery. In urology, program directors expressed a significant need for formalized US training. This project sought to provide an educational framework from which a urology program could incorporate US training and increase proficiency and confidence in performing urologic US. The curriculum was developed using the AIUM Practice Guideline for Ultrasound Examinations in the Practice of Urology developed in collaboration with the American Urological Association. Methods—In our study, 13 urology residents were participants in this pilot curriculum. Didactic and hands-on US training sessions on basic US physics and techniques, kidney, bladder, scrotal, and prostate US were undertaken, and a posttest was administered in addition to surveys evaluating their experience in the program. The implementation occurred over 1 year. Results—The results notably yielded a mean duration of approximately 30 hours of hands-on, didactic, and clinic US experiences at the bedside reported by each of the residents in the study. Approximately 66% of the residents were confident in their ability to interpret their own images. Conclusions—We can conclude from the survey and posttest data that the developed US curriculum for residents is beneficial for developing clinical acumen as well as confidence in making use of this imaging modality. In the future, we hope to increase the participation in this curriculum and develop a more concrete timeline at which these trainees progress through the curriculum as well as improve evaluation of the educational efficacy of the course. 1541471 Sonographic 2- and 3-Dimensional Aspects of Intrauterine Device Evaluation: What Additional Information Can 3Dimensional Images Provide? Claudia Maksoud Ultrasound, ColГ©gio Estadual Padre Eduardo Michelis, Rio de Janeiro, Brazil Objectives—Our goal is to show the role of identification of intrauterine device (IUD) positioning and integrity using 2D images and to demonstrate the possibilities 3D images can provide, by giving a better view of the uterine cavity in the coronal plane, and also more details of IUD location, especially with a levonorgestrel-releasing IUD. Methods—All ultrasound procedures were performed by radiologists, and the images were acquired using multifrequency transvaginal transducers. 3D images were obtained from freehand scans. The 2D images included both longitudinal and transverse views and 3D images the coronal view. Results—3D images can better localize the IUD position and give a better identification of the arms of the IUD. In the case of a levonorgestrel-releasing IUD, we can see more details of the shaft with 3D images than with 2D images. Problems like an IUD embedded in the myometrium are better identified in the 3D coronal view. Conclusions—2D ultrasound evaluation can be the classic technique for IUD evaluation, but 3D images can improve the analysis, giving more spatial details of the uterine cavity, IUD integrity, and position. As freehand 3D acquisition is easy and quick to perform, once it is available, it can be used as a helpful tool in the evaluation of IUDs. 1541516 Point-of-Care Ultrasound in the Diagnosis of Complex Subcutaneous Abscesses Requiring Surgical Intervention Srikar Adhikari, Austin Gross* Emergency Medicine, University of Arizona Medical Center, Tucson, Arizona USA Objectives—We present the utility of point-of-care ultrasound (US) in the management of 2 cases of complex subcutaneous abscesses. Methods—A 45-year-old male presented to the emergency department (ED) with left thigh swelling and pain. He developed pain 10 days prior to the arrival to the ED while jogging. He subsequently noted redness and swelling in the thigh. Physical examination revealed lowgrade fever and a warm, tender, and swollen thigh with induration. It was determined that the patient had an abscess, and an incision and drainage (I&D) was planned by the treating emergency physician. Bedside US was performed by the emergency physician to assist with the procedure. The US examination revealed a large complex fluid collection extending >10 cm deep into the subcutaneous tissues and facial planes and beneath the muscles. Based on the sonographic findings, a surgical consult was obtained. The patient was taken to the operating room (OR) where the abscess was drained under general anesthesia. The initial surgical incision had to be extended to drain >200 mL of pus. We report another case, a 36year-old male presenting to the ED with left arm swelling, pain, and redness of 3 days’ duration. He gave a history of low-grade fever. He presented with similar symptoms to the ED twice within 2 months prior to this ED visit. An I&D was performed during both ED visits. Clinical examination revealed fluctuant, tender, erythematous swelling with an open area spontaneously draining some purulent material. Because of repeat ED visits, bedside US was performed by the emergency physician, which revealed a 6-cm hyperechoic foreign body embedded deep in the tissues of the upper arm along with a complex fluid collection. A surgical consult was obtained. The patient was taken to the OR for foreign body removal with drainage of the abscess. Results—Point-of-care US allowed visualization of the extent of the abscess and occult foreign body in these cases. It helped prevent an underestimation of the extent of the infection and determined the need for operative intervention. Conclusions—Point-of-care ultrasound can help determine the need for operative intervention in ED patients with complex subcutaneous abscesses. 1541519 Impact of the Maternal Body Mass Index on the Duration and Completion of Fetal Anatomic Ultrasound Dana Smith,* Carmen Beamon, Kacey Eichelberger, Lisa Carroll, Neeta Vora Maternal Fetal Medicine, University of North Carolina, Chapel Hill, North Carolina USA Objectives—Our objective was to examine the impact of the prepregnancy body mass index (BMI) on both the duration and completion of the fetal anatomic survey. Methods—A retrospective cohort study of singleton nonanomalous gestations presenting for fetal anatomic ultrasound between 16 and 25 weeks’ gestation at our institution was performed over a 3-month period. Standard BMI categories were computed using self-reported prepregnancy weight and height. Outcomes of interest were the duration of ultrasound (defined as the difference in minutes between the first and last abdominal image) and completion of ultrasound (“incomplete” defined as a provider recommending the subject return for reevaluation). Univariate and bivariate analyses as well as logistic regression modeling were used to determine odds ratios for having an incomplete scan among subjects with BMI ≥25. Results—Of the 551 women analyzed, 52.7% of the cohort was overweight or obese, with a mean BMI of 26.8 (range, 16.6–65.2). The average duration of basic ultrasound was 28.8 minutes vs 35.2 minutes for S120 13proceedings_Layout 1 3/5/13 10:39 AM Page S121 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 targeted ultrasound (P < .001). After controlling for gestational age, individual sonographer, race, and maternal age, we identified no statistically significant effect of BMI on the duration of either basic (P = .81) or targeted (P = .80) scans. An incomplete evaluation occurred in 13.4% of patients. Overweight and obese women had a higher likelihood of having an incomplete ultrasound evaluation compared to normal-weight women (adjusted odds ratio, 2.31; 95% confidence interval, 1.36–3.96). Conclusions—Overweight and obese women are more likely to have an incomplete fetal anatomic survey when compared to normal weight referents, although we identified no impact of obesity on the duration of the scan. S121 13proceedings_Layout 1 3/5/13 10:39 AM Page S122 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Continuing Medical Education (CME) Credit Information 2013 AIUM Annual Convention Activity Description The 2013 AIUM Annual Convention is the most comprehensive, cutting-edge meeting for the entire medical ultrasound community. Our unique multidisciplinary program provides a collaborative environment for all specialties and disciplines, from beginner to advanced. Accreditation Statement The American Institute of Ultrasound in Medicine (AIUM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME activities for physicians. Designation Statement The AIUM designates the 2013 Annual Convention for a maximum of up to 30.5 AMA PRA Category 1 CME Creditsв„ў. Physicians should only claim credit commensurate with the extent of their participation in the activity. Credit for Sonographers Sonographers participating in AIUM educational activities may earn credits toward maintaining their professional certification from the following organizations: American Registry for Diagnostic Medical Sonography (ARDMS) The ARDMS accepts AMA PRA Category 1 CME Creditsв„ў. American Registry of Radiologic Technologists (ARRT) The AIUM is a Recognized Continuing Education Evaluation Mechanism (RCEEM) for the American Registry of Radiologic Technologists (ARRT). These educational activities are approved by the AIUM for ARRT Category A Credits. Target Audience This activity is designed to meet the needs of ultrasound professionals from various medical disciplines and specialty areas who perform and interpret ultrasound examinations. Course Objectives Upon completion of this learning activity, participants should be able to: • Demonstrate updated knowledge in: Basic Science and Instrumentation; Cardiovascular Ultrasound; Contrast-Enhanced Ultrasound; Emergency and Critical Care Ultrasound; Fetal Echocardiography; General and Abdominal Ultrasound; Gynecologic Ultrasound; High-Frequency Clinical and Preclinical Imaging; Interventional-Intraoperative Ultrasound; Musculoskeletal Ultrasound; Neurosonology; Obstetric Ultrasound; Pediatric Ultrasound; Sonography; and Therapeutic Ultrasound. • Discuss state-of-the art ultrasound research. • Practice updated ultrasound skills for more effective diagnosis. • Apply updated knowledge and clinical skills in improving patient care. Activity Designed to Change • Competence • Performance Disclosure Policy As a provider accredited by the ACCME, the AIUM must ensure balance, independence, objectivity, and scientific rigor in all its activities. Anyone involved in planning this CME activity is required to disclose to learners any relevant financial relationship(s) that have occurred within the last 12 months with any commercial interest(s) whose products or services are discussed in the CME content. Such relationships are defined by remuneration in any amount from the commercial interest(s) in the form of grants; research support; consulting fees; salary; ownership interest (eg, stocks, stock options, or ownership interest excluding diversified mutual funds); honoraria or other payments for participation in speakers bureaus, advisory boards, or boards of directors; and other financial benefits. Individuals involved in planning will be asked to recuse themselves from any portion of the planning where a bias might exist. All faculty participating in an educational activity provided by the AIUM are required to disclose to the provider and to the learner any relevant financial relationships with any commercial interest. The AIUM must determine if the faculty’s relationships may influence the educational content with regard to exposition or conclusion and resolve any conflicts of interest prior to the commencement of the educational activity. The intent of this disclosure is not to prevent faculty with relevant financial relationships from serving as faculty but rather to provide members of the audience with information on which they can make their own judgments. The AIUM has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable. Policy on Unlabeled/Off-Label Usage The AIUM has determined that disclosure of unlabeled/off-label or investigational use of commercial products is informative for audiences and therefore requires this information to be disclosed to the learners at the beginning of the presentation. Uses of specific therapeutic agents, devices, and other products discussed in this educational activity may not be the same as those indicated in product labeling approved by the US Food and Drug Administration. The AIUM requires that any discussions of such “off-label” use be based on scientific research that conforms to generally accepted standards of experimental design, data collection, and data analysis. Before recommending or prescribing any therapeutic agent or device, learners should review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Disclaimer The information presented in this activity represents the opinion of the faculty and is not necessarily the official position of the AIUM. Documenting CME Credits The AIUM provides CME certificates to those who have participated in an AIUM educational activity. The AIUM does not submit credits to regulating bodies or certifying organizations on behalf of the participant. It is the participant’s responsibility to submit proof of credits on his or her own behalf. Accreditation Council of Graduate Medical Education (ACGME) Competencies These courses are designed to meet one or more of the following ACGME competencies: • Interpersonal and Communication Skills • Medical Knowledge • Patient Care and Procedural Skills • Practice-Based Learning and Improvement • Professionalism • Systems-Based Learning S122 13proceedings_Layout 1 3/5/13 10:39 AM Page S123 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Faculty Disclosures As of March 5, 2013, listed below are faculty members who disclosed that they have relevant relationship(s) with commercial interest(s) that may create a conflict of interest. Faculty members are instructed to advise the AIUM if new financial relationships with commercial interests arise since completing their disclosure forms. Described below each name are the commercial interest(s) and the nature of the financial relationship(s). Disclosures, if any, are listed under the speaker’s name. Otherwise, the speaker has indicated that he or she does not have any relevant financial relationships. All completed disclosure forms are on file and available for review at the AIUM office. Abadi, Maria Abbott, Brian Abdella, Thomas Abdelmalek, Manal Abdullaev, Rizvan Abo, Alyssa Abramowicz, Jacques Institute for Advanced Medical Education: honorarium; speaker Philips Healthcare: consultant; research machines Abuhabsah, Rami Abuhamad, Alfred Abu-Rustum, Reem Abu-Rustum, Sameer Abu-Yousef, Monzer Acharya, U. Rajendra Achiron, Reuven Ackerman, Susan Adams, Janet Aderibigbe, Oluyemi Adhikari, Srikar Adkins, Eric Adler, Ronald Adzick, N. Scott Agache, Vlad Agildere, A. Muhtesem Ahmadzia, Homa Ahmed, Ahmed Aish, Bassil Ajmera, Kunal AlcГЎzar, Juan Luis Alehagen, Urban Al Ekish, Shadi Alexandrov, Andrei Allaf, M. Baraa Allen, Angela Allen, Derrick Al Mahrouki, Azza Al Muhanna, Khalid Aly, Abdel-Rahman Amian, Angelina Amponsah, David Ananth, Cande Anderson, Craig Anderson, Sharlette Ando, Takeshi Andreotti, Rochelle Antonios, Likourezos Antonis, Michael Anvari, Arash Apterbach, William Archer, Timothy Arellano, Javier Arnold, Kelly Arntfield, Robert Arpit, Nagar Arroyo, Alex Arynova, Bakyytbubu Astheimer, Jeffrey Aten, Andrew Au, Arthur AubГЎ, Maria Ausiello, Livia Avner, Jeffrey Axt-Fliedner, Roland Ayala, Ruben Aylward, Stephen Ayoub, Jean Ayvazyan, Sergey Azar, Nami Aziz, Seerat Baek, Song-Ee Bahner, David Bai, Jing Baird, Donna Bajaj, Komal Bakhireva, Ludmila Balise, Raymond Balk, Andrew Balzaretti, Paolo Banderali, Alessandra Bantignies, Claire Barahona, J. Oscar Bard, Robert Bardales, Ricardo Barnewolt, Carol Barr, Richard Philips Healthcare: equipment and research grant; advisor, researcher, speaker Siemens Medical Solutions: equipment and research grant; advisor, researcher, speaker SuperSonic Imagine: equipment grant; researcher, speaker Toshiba America Medical Systems: honoraria; advisor Barral, Joelle Barri, Pedro Barri-Soldevila, Pere Bar-Sever, Zvi Bartels, Eva Bartova, Petra Baschat, Ahmet Bault, Jean-Philippe Bawiec, Christoper Baxtrom, Catherine Beach, Kirk Beal, Eliza Beamon, Carmen Beavis, Cole Beck, Bill PhysioSonics, Inc: independent contractor; consultant Beiter, Kyle Beland, Michael Belfort, Michael Bellew, Christine Benacerraf, Beryl Benaroya, Azriel Bendick, Philip Ben-Meir, David Benn, Peter Bennett, Terri-Ann Benson, Carol Beraud, Anne-Sophie Berdejo, George Berger, Jan Bhatt, Shweta Bhimani, Ashish Bialeck, Suzanne Bieniarz, Andre Bierca, Jacek Bird, Christine Bitters, Constance Blackstock, Uche Blahuta, Jiri Blaivas, Michael Blanchette Porter, Misty Blanks, James Blankstein, Josef Blebea, John Blews, David Blickendorf, Matthew Blumenfeld, Yair Bluth, Edward Bockbrader, Marcie Bolouri, Marjan Bolte, Annemieke Boniface, Keith Boore, Stacy Borgida, Adam Bouffard, J. Anthony Boulger, Creagh Box, Daniel Box, Geoffrey Boyd, Brita Bradford, Susan Bradley, Kathleen Bradshaw, Darin Breazeale, Shane Brennan, Matthew Brewer, Kori Bromley, Bryann Brown, Cara Brown, Douglas S123 Brown, James Brown, Steffen Brown, Stephen Brown III, William Brubaker, Sara Buadu, Annemarie Buckwalter, Joseph Bui, Loan Bulas, Dorothy Bundy, Nicole Bunting, Ethan Bureau, Nathalie Burhans, Kristin Burns, Peter Busse, Raydeen Byram, Brett Byrne, Janice Cabral, Digna Cadet, Claudia Cahill, Alison Calabrese, Kathleen Calisti, Giorgio Calvo-Garcia, Maria Campbell, Colleen Campbell, Winston Canavan, Timothy Cao, Tie-Sheng Carey, John Carlson, Lindsey Carroll, Lisa Carroll, Mary Carson, Paul GE Global Research: federal grants, research collaboration; principal investigator Light Age, Inc: modification of their commercial laser; help in specification and testing Sonetics Ultrasound, Inc: salary on their Small Business Innovation Research project; advised on transducer arrays and applications Casoli, Giovanna Cassady, Christopher Castillo, Eddie Caughey, Melissa Cavanaugh, Barbara Cendan, Juan Cermak, Petr Cha, Joo Hee Chalek, Carl Chan, Ted Chandrasekhar, Chitra Chao, Jennifer Chavez, Martin 13proceedings_Layout 1 3/5/13 10:39 AM Page S124 American Institute of Ultrasound in Medicine Proceedings Chervenak, Judith Childress, Johnathan Chin, Eric Chinchure, Dinesh Chintapalli, Kedar Chiou, See-Ying Chiricolo, Gerardo Choi, Woo Jung Chong, Wui Chopra, Manisha Chorazy, Marek Chou, Nai-Kung Chow, Kira Church, Charles Ciardo, Paolo Cibinel, GianAlfonso Claes, Frank Clem, Douglas Clingman, Bryan Cody, Kenneth Cohen, Harris L. Cohen, Leeber GE Healthcare: honoraria; speaker Philips Healthcare: honoraria; speaker Samsung Ultrasound: honoria; speaker Cohen, Nicholas Coleman, Beverly Coley, Brian Colvin, Robert Comerota, Anthony Contreras, Karenrose Cordeiro, Christina Coroleu, Buenaventura Correas, Jean-Michel Philips Healthcare: speaker’s fee; advisory board, speaker SuperSonic Imagine: speaker’s fee; speaker Toshiba Medical Systems: speaker’s fee; speaker Cortez, Eric Corujo, Omar Cosgrove, David Craig, Joseph Crawford, Christine Crawford, Forrest Crino, Jude Crites, Lori Cruz, Joshua Cunha, Luana Torres Currie, Geoffrey Curs, Brad CussГі Sorribas, Mireia Czarnota, Gregory Czernuszewicz, Tomasz CzernГЅ, Dan Dahibawkar, Manasi Dahiya, Nirvka DahlstrГ¶m, Ulf Dai, Qing Dalecki, Diane Dallas, Apostolos J Ultrasound Med 32(suppl):S1–S134, 2013 Darge, Kassa D’Armiento, Jeanine Datta, Anita Dave, Jaydev Davidovits, Miriam Davis, Michael Davis, Sarah Dayton, Paul Targeson, Inc: stock options; consultant, Scientific Advisory Board Dean, Anthony De Castro, Francisco De Franco, Emily De Franco, Paul Deganello, Annmaria Bracco SpA: lecture fees; speaker Degenhardt, Jan De Guillebon, Adelaide De Jong, M. Robert De la Torre, Lesley Del Cura, Jose Deng, Cheri Destounis, Stamatia Deter, Russell Detti, Laura Deurdulian, Corinne Deurloo, Koen Deutch, Todd GE Healthcare: consulting fee; speaker DeVore, Greggory GE Healthcare: honorarium; speaker Diaz, Daisy Dickman, Eitan Dietrich, Christoph Diffenderfer, Kristen DiFlorio, Roberta Dillman, Jonathan Di Matino, Filomena Di Pietro, Michael Do, Samantha Dogra, Vikram Dolin, Cara Donaldson, Chase Donaldson, Joe Doniger, Stephanie Donofrio, Mary Dooley, Erin Dornbluth, Carol Doubilet, Peter Dresbach, Sereana Dudley, Larissa Dumont, Douglas Duvdevani, Nir Ehsanipoor, Robert Eichelberger, Kacey Eiferman, Daniel Eisenbrey, John Elahi, Ershad El-Baz, Ayman El Kaffas, Ahmed Ellestad, Sarah Emmitt, Regina English, Carter Enzensberger, Christian Erdman, John Ermilov, Sergey Seno Medical Instruments: consultant; consulting fee Eski, Erkan Estroff, Judy Evans, David Evans, Kevin Fabiilli, Mario GE: other activities; other financial benefit Fadrna, Tana Falou, Omar Farber, Mark Farella, Nunzia Farwick, Lauren Feinstein, Steven GE Healthcare: consulting fees; consultant; research funds, research Feldstein, Vicky Feleppa, Ernest Feltovich, Helen Fenster, Aaron Eigen: royalties; research collaborator Fernandez-Cid, Maria Ferraioli, Giovanna Ferreri, Enrico Fessell, David Filice, Carlo Finnoff, Jonathan Fischer, Jason Fisher, Kimberley Fleischer, Arthur Fleshman, Shane ZetrOZ, LLC: employment; salary Fontanilla, Teresa Ford, Peter Fordham, Lynn Forsberg, Anya Forsberg, Flemming Foster, F. Stuart Fowlkes, J. Brian GE Healthcare: equipment support; other financial benefits; other activities; research Fox, J. Christian SonoSim, Inc: shares; consultant SonoSite, Inc: equipment loan; consultant Fox, Nathan Fox, Traci Francis, Charles Frank, Gary Frates, Mary Frenkel, Victor Friedman, Alexander Friedman, Lana Fuchs, Karin S124 Fujimoto, Chrystie Fujitani, Roy Fuller, Kisti Gadddipati, Sreedhar Galan, Henry Galerneau, France Gallippi, Caterina Gammell, Paul Gandhi, Manisha Gandikota, Girish Garami, Zsolt Edwards Lifesciences: honoraria; consultant Gore Medical: honoraria; consultant Garberoglio, Roberto Garcia, Blanca Garcia, Sara Garg, Mahek Garon, Jack Garra, Brian Gaspari, Romolo Gauthier, Marianne Gecsi, Kimberly Gee, Michael Geiger, Miwa Geldermann, David Gelman, Slava Gembruch, Ulrich George, Verghese Gerardo, Chiricolo Gerber, Susan Germer, Ute Geria, Rajesh Gessner, Ryan Gharahbaghian, Laleh Gilboa, Yinon Giles, Anoja Gindes, Liat Giorgio, Antonio Giorgio, Valentina Girish, Gandikota Girotto, John Glanc, Phyllis Glantz, J. Christopher Glasek, Jedrzej Glaser, Angela Glasser, Jessie Glazier, Elizabeth Goertz, David Goetzinger, Katherine Goffi, Alberto Goldberg, Aryeh GoldГrovГЎ, Andrea Goldklang, Monica Goldman, Ellen Goldman, Sara Goldstein, Ruth Goldstein, Steven Amgen: speakers bureau; honorarium Bayer: Gynecology Advisory Board; honorarium Cook Ob/Gyn: consultant, consulting fees 13proceedings_Layout 1 3/5/13 10:39 AM Page S125 American Institute of Ultrasound in Medicine Proceedings Philips Healthcare: consultant, equipment loan Warner Chilcott: speakers bureau; honorarium GonГ§alves, Luis GE Healthcare: honorarium, speaker Philips Healthcare: honorarium, speaker Goodman, Eric Goodman, Jean Ricci Goodman, Rob Goodman, Thomas Gordon, Robert Goubran, Ashraf Goutham, Swapna Graupera, Betlem Gray, Siobhan Grippo, Anthony Groh, Georgeann Gross, Austin Groszmann, Yvette Grotegut, Chad Guerriero, Stefano Guizado de Nathan, Gigi Gullett, John Gunabushanam, Gowthaman Gunnison, Kathryn Gupta, Sanjey Gupta, Simi Gurewitsch, Edith Gurram, Padmalatha Gustafsson, Mikael Gyamfi, Cynthia Haberman, Shoshana Habnenicht, Rebecca Hacker, Michele Haeir, Sina Haggerty, Patricia Haines, Lawrence Hall, Anne Hall, Eric Hall, Rebecca Hall, Timothy Halldorsdottir, Valgerdur Hamper, Ulrike Hamrick, M. Ann Hamvas, Aaron Han, Bokyung Handa, Priyanka Hangiandreou, Nicholas Hansen, Allan Harris, Gerald Harris, Robert Hartge, David Hartman, Alex Hartman, Brian Hartman, Diana Hashim, Amr Hata, Stacy Havel, Martin Havelka, Jaroslav Hawkins, Leah Hbeib, Moses He, Le He, Yu Heimburger, Glenn Heimiller, Jeffrey Heller, Howard Henderson, Janice Henderson, Stephanie Henkaline, Todd Hereter, Lourdes Hernandez, Caridad Herrera, Christina Herzig, Roman Herzog, Donald Heymans, Martijn Higgins, Peter Hilgers, Thomas Hingorani, Anil Hirtz, Nathaniel Ho, Annette Hobbs, Susan Hocking, Denise Hoffman, Chen Holland, Christy Holland, Mark Holzman, Ian Homeister, Jonathon Hong, Min Ji Hong, Soon Jae Hooley, Regina Hoover, Emily Hoppmann, Richard Horii, Steven Hornberger, Lisa Horning, Matthew Horrow, Mindy Horton, Sharon Hoshiko-Reed, Gail Hotta, Naoki Hou, Gary Hou, Randy Housman, Elise Howard James Howard, Zoe Howe, Duncan Howell Lori Hoyt, Kenneth HrbГЎДЌ, TomГЎЕЎ Hu, Xiangdong Huang, Dean Huang, Lingyun Huang, Manwei Huhta, James HurtГkovГЎ, Eva Hussain, Naveed Hussien, Abdelmohsen Hynynen, Kullervo Iacobucci, Antonello Ibrahim, Deena Ikeda, Nobutaka Ingle, Atul Iradji, Sara Irshad, Abid Iseman, Christine Ivancevich, Nikolas Izquierdo, Luis Jackson, David J Ultrasound Med 32(suppl):S1–S134, 2013 Jackson, Matt Jacobowitz, Glenn Jacobson, Jeffrey-Michael Jacobson, Jon Jaen Diaz, Jose Jafari, Daniel Jakubowski, Wieslaw Jang, Kee Jasne, Adam Jasti, Sirisha Jelinkova, Monika Jelsing, Elena Jeon, Eun-Jin Jiang, Yuxin Jing, Zhao Johansson, Peter Johnson, Allan Johnson, Benjamin Johnson, Jeanine Johnson, Jeff Johnson, Laura Johnson, Mary Beth Johnson, Neil Jon, Xia Jonszta, TomГЎЕЎ Joong-Kim, Young James, Joseph Joseph, Oliver Joshi, Kruti Ju, Hyeyoung Juan, Zhang Juez, Leyre Kagarise, Daniel Kang, Su Min Kaproth-Joslin, Katherine Karlicki, Fern Karlman, Roberta Karmel, Bernard Karshafian, Rarri Kasperlik-Zaluska, Anna Kasyouhanan, Fadi Katorza, Eldad Katz, Yisrael Kawecki, Andreaa Kelley-Martinez, Martha Kennedy, Anne Kent, Alistair Kerr, Lucy Kerwin, Christopher Ketterling, Jeff Khan, Feras Khine, Hnin Khorana, Alok Khoury, Viviane Khuri-Yakub, Butrus Kim, Ahm Kim, David Kim, Hak Hee Kim, Hyunji Kim, Laura King, Daniel King, Deirdre Kiplagat, Annette Kirschner, Jonathan Kist, Kenneth S125 Klassen, Anna Klaus, Suzanne Klauser, Chad Kliewer, Mark Kline-Fath, Beth Kobayshi, Akitoshi Kohl, Thomas Kolios, Michael Koltz, Peter Kona, Matthew Konicki, P. John Konofagou, Elisa Korucuk, Ekrem Kotowski, Susan Kowalewski, Gregory Koziatek, Christian Kraft, Otakar KrajДЌa, Jan Krakow, Deborah Krapp, Martin Kraus, Steven Kremkau, Fredrick Kripfgans, Oliver GE Healthcare: equipment support; other activities; other financial benefit Krishnamurthi, Ganapathy Krishnan, M. Muta Rama Kugler, Lindsay Kuhlmann, Randall Kulbacki, Evan Kuliha, Martin Kunselman, Allen Kunselman, Bon Kwiatkowski, Robert Labuda, Cecille LaFerriere, Janet Lai, Xingjian Laifer-Narin, Sherelle Lal, Brajesh Lam, Samuel Langer, Jill Langer, Matthew ZetrOZ, LLC: employment; salary Langova, Katerina Lappen, Justin Larsen, John LaRusso, Salvatore Lavin, Philip Lawrence, Matthew Layman, Kerri Lee, Jiann-Gwu Lee, Kenneth GE Healthcare: honorarium; course faculty Philips Healthcare: limited research support; principal investigator Siemens Medical Solutions: limited research support; principal investigator Lee, Mi Hee Lee, Mi-Young Lee, Pil-Ryang 13proceedings_Layout 1 3/5/13 10:39 AM Page S126 American Institute of Ultrasound in Medicine Proceedings Lee, Rose Lee, Sanghee Lee, Seung Yun Legault Kingstone, Lysa Leibman, Jill Lema, Penelope Lerner, Jodi Lester, Neil Leswick, Dave Lethiecq, Marc Letourneau, Karen Levine, Adam Levitov, Alexander Lev-Toaff, Anna Levy, Bruce Levy, Philip Lewin, Peter Lewis, George ZetrOZ, LLC: management position; salary Lewis, Madelene Lewiss, Resa Li, Mingde Lianfang, Du Lichtenstein, Daniel Likourezos, Antonios Lim, Tae-Hong Linam, Leann Liou, Robert Li Pi Shan, Rodney Lipitz, Shlomo Lipman, Samantha Liu, He Liu, Ji-Bin Liu, Teresa Liu, Yunbo Liu, Xi Lloyd, Harriet Lobos, Nelson Lockhart, Mark Lombardo, Paul Long, Suzanne Looney, Devon Lopez, Eugenio Lopez, Joseph Lopez, Robert Lowe, Lisa Ludomirsky, Achi Lukjanova, Irina Luo, Jianwen Lupia, Enrico Lyons, Jennifer Lyshchik, Andrej Philips Healthcare: research support; consultant Ma, Chi Maaji, Sadisu Machado, Priscilla Macian, Diana Mack, Julie Macones, George Madden, John Madsen, Ernest Madoff, David Magalhaes, Alvaro J Ultrasound Med 32(suppl):S1–S134, 2013 Magriples, Urania Mahoney, Marshall Maida, Eugene Majcher, Marta Maksoud, Claudia Mallarini, Giorgio Mamou, Jonathan March, Melissa Irene Margolis, David Marin, Daniele Markenson, Glenn Marks, William Marshall, Andrew Marshall, Randolph Marston, William MartГ Mestre, Xavier Martin, James Martis, Roshan Maruvada, Subha Mastrobattista, Joan Mata Castrillo, Maria Mathew, Brennan Matsutani, Shoichi Matthew Mauro Mayo, Paul Mazza, Rachel McArthur, Lucas McCamey, Kendra McCann, Margaret McCarthy, Melissa McCarville, Beth McDowell, Jennifer McNamara, John McNamara, Robert McShane, Cyrethia Medak, Anthony Medford, William SonoSite, Inc: salary; hands-on instructor Mehta, Ninfa Meizner, Israel Melniker, Lawrence Melone, Paula Merport Modest, Anna Merritt, Christopher Merton, Daniel Mervis, Eric Meyer, Diane Meyer, Elaine Meyer, Marjorie Mezei, Gabor Middleton, William Migda, Bartosz Mihailos, Athena Millard, Sarah Miller, Douglas Miller, Emily Miller, James Miller, Rita Miller, Russell Miller, Theodore Miller, Thomas Millet, John Millington, Scott Milne, Michelle Miniati, Douglas Minkoff, Howard Minnigan, Hal Mistur, Rachel Mohan, Uthara Mojibian, Hamid Moldenhauer, Julie Molinari, Filippo Molitor, Mark Moni, Saila Monroe, Manette Monteagudo, Ana Moon-Grady, Anita Mooney, Lindsay Mooney, Timothy Moons, David Moore, Christopher Philips Healthcare: consultant, consulting fee Sonosite, Inc: consultant, consulting fee Moreno, Claudia Moschos, Elysia Moshesh, Malana Mougenot, Charles Philips Healthcare: employment; salary Mueller, Anthony Mudrik-Zohar, Hadar Mujsce, Dennis Mullen, Katherine Mulvagh, Sharon GE Healthcare: consulting fee; consultant Lantheus Medical Imaging: research grant; research support Munden, Martha Munson, Jacqueline Murphy, Joshua Murphy, Megan Murtha, Amy Muruganandan, Krithika Muruganandan, Meera Muzumoto, Hideaki Myers, Craig Nadaraj, Sumekala Nakamoto, Dean Galil Medical: research support; research Toshiba America Medical Systems: honorarium; speaker Nakashima, Kazutaka GE Healthcare: salary; speaker Hitachi Aloka Medical, Ltd: salary; speaker Philips Healthcare: salary; speaker Nam, Kibo Namagembe, Imelda Nandlall, Sacha Nasief, Haidy Navathe, Reshama Nazarian, Levon Needleman, Laurence Nelson, Bret S126 Nelson, Rendon Neri, Emily Neyman, Olga Nghiem, Hahn Nguyen, Thanh Nhan-Chang, Chai-Ling Nichols, Timothy Nicolaides, Andrew Nicolau, Carlos Nightingale, Kathy Noble, Vicki Nomura, Jason Emergency Ultrasound Consultants, LLC: consulting fee; director of medical education Nomura Consulting, LLC: ownership; principle/owner Novak, Ronald Novelli, Paula Nunes, Uziel Obi, Nwamaka Obican, Sarah O’Brien, William Jr National Institutes of Health: funding for the work; other activities; other financial benefit O’Connell, Avice O’Connor, Rory O’Day, Mary Odibo, Anthony Odunko, Danielle Oelze, Michael Ogburn, Paul Ogutcu, Birsen Oh, Karen O’Hara, Sara Toshiba Medial Systems: equipment software; consulting Ojili, Vijayanadh Olartecoechea, BegoГ±a Olivia, Marta Oliver, Edward Ong, Chiou Li Oraevsky, Alexander Seno Medical Instruments: consulting; consulting fee O’Rourke, Kevin OtГЎhal, David Otto, Pamela Seno Medical Instruments: consulting; consulting fee Ozhand, Ali Pakdaman, Reza Palma, James Palmeri, Mark Paltiel, Harriet Pamnani, Ravi Pan, Patrick Pan, Xiaochang Panebianco, Nova Panerai, Ronny Pao, Sun-Hua Pareek, Gyan Parkes, Jenny Parry, Samuel 13proceedings_Layout 1 3/5/13 10:39 AM Page S127 American Institute of Ultrasound in Medicine Proceedings Pascual, M. Angela Paspulati, Raj Mohan Patat, FrГ©dГ©ric Patel, Dervarshi Patel, Nilesh Patterson, Leigh Paul, Ian Pawlina, Wojciech Payer, Andrew Peck, Jennifer Peddada, Shyamal Pedersen, Peder Pedrero, Cristina Pellerito, John Pennington, James Perarnau, Jean Marc Perez, Alicia Perez-Delboy, Annette Perrin, Stephen Pessel, Cara Peters, Hope Pezo, Carlo Phan, Ha Piert, Morand GE: other activities; other financial benefits Pineda, Grace Pineda, Laura Pinter, Stephen GE Healthcare: equipment support; other activities; other financial benefits Piscaglia, Fabio Pivetta, Emanuele Planinic, Petar Platt, Lawrence GE Healthcare: honorarium; consultant, speaker Platz, Elke Plessl, Daniel Polascik, Thomas Pollard, Katherine Pontius, Elizabeth Porrino, Giulio Porter, Thomas GE Healthcare: research support; principal investigator Lantheus Medical Imaging: research support; principal investigator Philips Healthcare North America: research support; principal investigator Posh, John Metrasens: consulting fee; employee trianing Poston, Mary Elizabeth Prabulos, Ann Marie Presley, James Pretorius, Dolores Price, Brandon ProchГЎzka, VГЎclav Provost, Jean Pruetz, Jay Pulvermacher, Christina J Ultrasound Med 32(suppl):S1–S134, 2013 Qian, Liu Quant, Hayley Quesada, Carole Rabener, Michael Rabiner, Joni Racadio, John Radeos, Michael Radhakrishna, Mohan Raginwala, Saad Raio, Christopher ZONARE Medical Systems: consulting fee; medical advisor Rajasekaran, Sathish Ramakrishnan, Prem Ranninger, Claudia Ranzini, Angela Rao, Victor Rasalingam, Ravi Rath, Krista Rathje, Erin Ravangard, Samadeh Rayburn, William Rebarber, Andrei Reeves, Shane Reiner, CГ¤cilia Reinstein, Dan Arcsan, Inc: other activities; ownership interest Reiss, Rosemary Repke, John Reusch, Lisa Revzin, Margarita Richards, Michael GE Healthcare: equipment support; other activities; other financial benefit Rizza Siniscalchi, Nicolo Ro, Raymond Roberts, Jessica Robinson, Kathryn Robinson, Zachary Roca, Pedro Rodney Rocco, John Rodney, William Rochon, Paul Rodriguez, Diana Roe, Anne Marie Roelant, Geoffrey Resch, Michael Rogers, Sarah Roll, Shawn Roman, Ashley Romera Villegas, Antonio Romero, Vivian Romney, Marie Rosado-Mendez, Ivan Rosas, Humberto Rosborough, Terry Rosen, Mark Rosenberg, Henrietta Kotlus Rosenberg, Keith Rosenzweig, Stephen Rotemberg, Veronica Roubec, Martin Rouze, Ned Royall, Nelson Andrew RoyChoudhury, Arindam Ruanno, Rodrigo Rubens, Deborah Rubert, Nicholas Rubin, Jonathan Rubin, Sherman Rubio, Eva Rundek, Tatjana Rutledge, Amy Rusczyk, Gregg Rychak, Joshua Siemens Medical Solutions: equipment support; collaborator/researcher Targeson, Inc: employment, stock ownership; employee, founder VisualSonics, Inc: consulting fee; technical consultant Saad, Nael Saba, Luca Sadeghi-Naini, Ali Safonova, Inessa Sahlani, Lydia Sahn, David Sakhel, Khaled Conceptus: speaker fee, speaker Hologic: consulting fee; consultant, speaker Salimian, Mohammad Saltzman, Daniel Samir, Anthony SuperSonic Imagine: speaker fee, speaker Samuel, Amber Samuels, Joshua Santolaya, Joaquin Sarwate, Sandhya Satou, Gary Savage, Daniel Savaser, Davut Schafer, Mark Schaller, Michael Scher, Lawrence Schmitz, Kelli Schneider, Darren Schneider-Kolsky, Michal Schnettler, William Schofer, Joel Schroer, Andreas Schwartz, Nadav Scissons, Robert Unetixs Vascular, Inc: independent contractor; royalty Scognamiglio, Umberto Scola, Mallory Scoutt, Leslie Philips Healthcare: honoraria; speaker Seed, Michael Sehgal, Chandra Sekarski, Timothy Seki, Atsuyoshi S127 Serres, Xavier Seupaul, Rawle Shah, Sachita Shah, Virag Shahmirzadi, Danial Shailam, Randheer Shamshirsaz, Amir Shau, Yio-Wha Sheets, Linda Philips Healthcare: employee; salary Sheppard, Celeste Sherbotie, Joe Sherman, Philip Shieh, Mason Shiels, William Sierzenski, Paul Emergency Ultrasound Consultants, LLC: partner; president and CEO Emergency Ultrasound Consultants, LLC: spouse/partner, COO, partner Sonosite, Inc: consulting fee, speaker Shim, Jae-Yoon Shin, Hee Jung Shipp, Thomas Shirazi, Mazda Shlansky-Goldberg, Richard Shofer, Frances Shokoohi, Hamid Shonkwiler, Gwen Shoreman, Mark Shue, Eveline Shung, K. Kirk Shwayder, James Cook Ob/Gyn: royaties; coinventor Philips Healthcare: consulting fees; consultant Shyu, Jeou-Jong Sidhu, Paul Hitachi, Inc: consulting fee; speaker Siemens AG: consulting fee; speaker Sierzenski, Paul Sikdar, Siddhartha Silas, Anne Silverman, Norman Silverman, Ronald Arcscan, Inc: interest other activities; ownership Simmons, John Simpson, Douglas Simpson, Lynn Sinert, Richard Singh, Gautam Sinha, Sidhartha Sinkovskaya, Elena Sivitz, Adam Sklansky, Mark Е koloudik, David Slapa, Rafal 13proceedings_Layout 1 3/5/13 10:39 AM Page S128 American Institute of Ultrasound in Medicine Proceedings Sloane, Chris Slowinska-Srzednicka, Jadwiga Smith, Brendon Smith Dana Smith, Jay Tenex Health: other financial benefit; other activities Smith, Jessica Smith, Lem Smith, Matthew Smith, Rose Smith, Susan Smrtka, Michael Snead, Gregory Snyder, Kathryn Soffer, Debbra Sohaey, Roya Solomon, Julia GE Healthcare: honorarium; preparation of educational materials Sommerich, Carolyn Song, Chihwa Sprace, Anna Soto, Rosamary Soukup, Tomas Sperling, Daniel Spiel, Melissa Spinner, David Spinosa, Al Spitz, Jean Springer, Andrew Sree, Vinitha Sridharan, Anush Srinivasan, Ganesh Stassijns, Gaetane Stavros, Thomas Seno Medical Instruments: consultant; consulting fee Stawicki, Stabuskaw Steiner, Ryan Stekel, Scott Stepien, Beata Stidham, Ryan Stilp, Erik Stites, Rachel Stone, Michael Philips Healthcare: consulting fee; consultant Strakowski, Jeffry Strasburger, Diana Strickland, Colin Amirsys: royalty for content; content author Elsevier: honorarium; book section editor iiCME: honorarium; speaker Stulac, Sara Subashi, Ergys Summey, Robert Sun, Derek Sun, Qiang Sunny, Youhan Suri, Jasjit Swamy, Geeta Swanson, Scott Szabo, Thomas Szyld, Demian Tai, Hao-Chih Talbott, Nancy Talegon, Antonio Talk, Douglas Tao, Shengzhen Tarabulsi, Gofran Tchelepi, Hisham Teefey, Sharlene Tegeler, Charles Terentiev, Victoria Tessler, Franklin Philips Healthcare: conulting fee; consultant Thomas, Kari Thomenius, Kai GE Healthcare: empoyment; salary Thompson, Jennifer Thornburg, Loralei Tian, Zhiyun Tierney, David Tillett, Jason Timor, Ilan Tirado, Alfredo Tizzani, Maria Todorova, Margarita Toland, Gregory Tolbert, Tahisha Tornero, Mark Torres, Carlos Tradup, Donald Trahey, Gregg Tran, Eric Tran, Nghia Tran, Thaison Tran, William Treadwell, Marjorie Trebes, Shannon Tresserra, Francisco Trinh, Tony Tsung, James Tumidajewicz, Justyna Tur-Kaspa, Ilan Turner, Elizabeth Turney, Colin Tuuli, Methodius Twickler, Diane Tworetsky, Wayne Ulissey, Michael Seno Medical Instruments: consultant; consulting fee Ural, Banu Ural, Serdar Urbanowicz, Katarzyna Urs, Raksha Uryasev, Oleg Utrilla-Layna, Jesus Vallabhaneni, Raghuveer Vance, Cheryl GE Healthcare: salary; WHS education Vandordaklou, Negean van Holsbeeck, Marnix van Veen, Teelkien J Ultrasound Med 32(suppl):S1–S134, 2013 Van Vugt, John Vargas Velandia, Edwin Vargas-Vila, Mario Varghese, Tomy Vassa, Ravi Vejdani-Jahromi, Maryam Vela, Deborah Victoria, Teresa Vila, Meritxell Vila Coll, Ramon Vilke, Gary Vilkomerson, David DVX, LLC: salary; management; ownership Vink, Joy Vintzileos, Anthony Vogel, Melanie Voloshin, Arkady Volpicelli, Giovanni Volz, Kevin Vora, Neeta Vrablik, Michael Vytkac, Adam Waag, Robert Wachsberg, Ronald Wagner, Jason Walker, Cynthia Wallace, Kirk GE Healthcare: employment; salary Wang, Eileen Wang, Hongyan Wang, Michael Wang, Shuo-Meng Ward, Valerie Wax, Joseph Way, David Wear, Keith Weichert, Jan Weingarten, Michael Weisz, Boaz Wells, C. Edward Werner, Erika White James White, Katherine Whitley, Kari Wildes, Douglas GE: dividends; salary; employee; stockholder Wilkens, Isabelle Williams, Sarah Wilson, Kim Wilson, Thaddeus Wise, Adam Wislon, Christian Witkowska, Agnieszka Witt, Dexter Wolf, Patrick Wolfe, Honor Wolfe, Michael Won, Hye-Sung Woodward, Paula Wortsman, Ximena Xiao, Jia Xu, Jonathan Xu, Zhen S128 Xuemei, Zhang Yablon, Corrie Yakubu, Abdulmuminu Yantri, Ratna Yeager, Susan Yeboah, Nina Yellin, Sharon Yenter, Christopher Yerli, Hasan Yeo, Lami Yijin, Su Master Yilma, Tugbahan Ying, Wu Yingyu, Cai Yinon, Yoav Yoob, Suzanne Yoon, Chung Yoon, Hee-Chul Yoon, Jae-Won Yoon, Sang-Wook Youssefian, Arthur Yuan, Chun Yuan, Li-Jun Yunhua, Li Zagzebski, James Zaharieva, Maria Zalel, Yaron Zalev, Jason Seno Medical Instruments: consultant; consulting fee Zeeman, Gerda Zehtabchi, Shahriar Zhang, Jing Zhang, Man Zhang, Xiao-Yong Zhao, Limin Zhao, Xihai Zhum, Qingli Ziade, M. Fouad Zieleznik, Witold Zielinski, Ashley Zinn, Kurt Zork, Noelia Zubkov, Leonid 13proceedings_Layout 1 3/5/13 10:39 AM Page S129 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Disclosures From AIUM Officers, Board Members, Committee Members, and AIUM Staff The faculty, committee members, and AIUM staff involved in planning this CME activity have completed a Disclosure of Financial Relationship. Disclosures are listed under the speaker’s name. All disclosures are printed in the 2013 Annual Convention Official Proceedings. All completed disclosure forms are on file and available for review at the AIUM office. Abo, Alyssa, MD Abuhamad, Alfred, MD Verinata Health: $10,000 (stock option/year) Abu-Rustum, Reem, MD Allen, Lisa, BS, RDMS, RDCS, RVT Andreotti, Rochelle, MD Bahner, David, MD, RDMS Benacerraf, Beryl, MD Bromley, Bryan, MD Clark, Jenny Cohen, Harris L., MD Coley, Brian, MD Cooper, Therese, BS, RDMS Costello, Jennifer Crino, Jude, MD Delanko, Danielle DiGiovanni, Laura, MD Eberle, Diane Fleischer, Arthur, MD Fowlkes, J. Brian, PhD Histosonics, Inc: ownership interest; researcher Glanc, Phyllis, MDCM, BSC Goldstein, Steven, MD Amgen: gynecology advisory board; honorarium Bayer: gynecology advisory board; honorarium Cook Ob/Gyn: consultant; consulting fees Philips Healthcare: consultant; equipment loan Shionogi: Gynecology Advisory Board; honorarium Warner Chilcott: honorarium Harvey, Glynis Hertzberg, Barbara, MD Izquierdo, Luis, MD Kinney, Brenda Kliewer, Mark, MD Konofagou, Elisa, PhD Kripfgans, Oliver, MD GE Healthcare: only equipment loaner Langer, Jill, MD LaRusso, Salvatore, MeD, RDMS, ARRT Lee, Kenneth, MD Lev-Toaff, Anna, MD Lewis, Michele Lockhart, Mark, MD, MPH Lynch, Susan, RDMS, RVT, RDCS Mastrobattista, Joan, MD Moore, Christopher, MD, RDMS, RDCS Philips Healthcare: consultant; consulting fee SonoSite, Inc: consultant; consulting fee Minton, Katherine, MA, RDMS, RDCS Muncey, Susan Nazarian, Levon, MD Nelson, Thomas, PhD Nisenbaum, Harvey L., MD O’Brien, Janet, RDMS, PA-C Pennington, James, RDMS Porto, Manuel, MD Robbin, Michele, MD Philips Healthcare: evaluate the utility of new transducer; new transducer/software upgrade Puscheck, Elizabeth, MD, MS Sakhel, Khaled, MD Hologic: consulting fee; speaker Scoutt, Leslie, MD Philips Healthcare: honoraria; teaching/speaking Sehgal, Chandra, PhD Shipp, Thomas, MD Shwayder, James, MD, JD Cook Ob/Gyn: coinventor royalties Silverman, Rosy, RDMS, RVT, RT(S) Smith, Jay, MD Andrews Institute: honoraria; teaching/speaking Gulf Coast Ultrasound Institute: honoraria; teaching/ speaking Tenex Health: consultant; consulting fee; royalties; stock; stock owner Toreno, Felicia, PhD, RDMS, RDCS, ROUB, RVT Valente, Carmine, PhD, CAE Wax, Joseph, MD Weber, Therese, MD Whitman, Gary, MD Woletz, Paula, MPH, RDMS, RDCS Wong-You-Cheong, Jade, MD Zanin, Linda, EdD, RDMS S129 13proceedings_Layout 1 3/7/13 3:05 PM Page S130 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Policy on Unlabeled/Off-Label Usage The AIUM has determined that disclosure of unlabeled/off-label or investigational use of commercial product(s) is informative for audiences and therefore requires this information to be disclosed to the learners at the beginning of the presentation. Uses of specific therapeutic agents, devices, and other products discussed in this educational activity may not be the same as those indicated in product labeling approved by the US Food and Drug Administration. The AIUM requires that any discussions of such “off-label” use be based on scientific research that conforms to generally accepted standards of experimental design, data collection, and data analysis. Before recommending or prescribing any therapeutic agent or device, learners should review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Alexandrov, Andrei Aylward, Stephen Barr, Richard Bulas, Dorothy Darge, Kassa Dayton, Paul Deganello, Annmaria Deng, Cheri Feinstein, Steven Feltovich, Helen Ferraioli, Giovanna Forsberg, Flemming Hata, Stacy Huang, Dean Hiang, Yuxin Jing, Zhao Johnson, Neil Kasperlik-Zaluska, Anna Klaus, Suzanne Lai, Xingjian Langer, Matthew Lewis, George Li, Mingde Liu, He Lyshchik, Andrej McCarville, Beth Sidhu, Paul Strickland, Colin Sun, Qiang Volz, Kevin Wang, Hongyan Xiao, Jia Xuemei, Zhang Ying, Wu Zhang, Jing Zhu, Qingli Migda, Bartosz Mohan, Uthara Mooney, Timothy Mulvagh, Sharon Nakamoto, Dean Nakashima, Kazutaka Novak, Ronald Palmeri, Mark Paltiel, Harriet Porter, Thomas Qian, Liu Reusch, Lisa Scissons, Robert Disclosure of Commercial Support for the 2013 AIUM Annual Convention Advertising In-kind Donations Support ADVANCE for Imaging and Radiation Oncology ALPINION Medical Systems Applied Radiology DiagnГіstico Journal Digisonics, Inc Health Imaging & IT Parker Laboratories, Inc Radiology Today Samsung Electronics America, Inc SuperSonic Imagine Texas Children’s Pavilion for Women Ultrasonix Medical Corporation Sidra Medical and Research Center ALPINION Medical Systems ATS Laboratories, Inc CIRS, Inc CIVCO Medical Solutions Esaote North America, Inc FUJIFILM SonoSite, Inc GE Healthcare Hitachi Aloka Medical, Ltd Nanosonics, Inc Parker Laboratories, Inc PCI Medical, Inc Philips Healthcare Samsung Electronics America, Inc Siemens Medical Solutions USA, Inc SIMULab Corporation Sound Ergonomics, LLC SuperSonic Imagine Terason Ultrasound Toshiba America Medical Solutions, Inc Ultrasonix Medical Corporation ZONARE Medical Systems, Inc Sidra Medical and Research Center Parker Laboratories, Inc Samsung Electronics America, Inc S130 Unrestricted Educational Grant AS Software, Inc 13proceedings_Layout 1 3/5/13 11:07 AM Page S131 American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013 Index A Abadi M S13 Abbott B S116 Abdella T S80 Abdelmalek M S10 Abdullaev R S95 Abo A S1 Abu-Rustum R S81 Abu-Rustum S S81 Abu-Yousef M S37 Abuhabsah R S50 Abuhamad A S29, S51, S52 Acharya R S61 Acharya UR S17, S35, S47, S60 Achiron R S52, S53, S80 Ackerman S S59, S90 Adams J S103, S114 Aderibigbe O S28 Adhikari S S112, S120 Adkins E S19, S100, S101, S103, S119 Adzick NS S53 Agache V S38 Agildere AM S103 Ahmadzia H S117 Ahmed A S27 Aish B S63 Ajmera K S18 Al Ekish S S61 Al Mahrouki A S40 Al Muhanna K S35 Alcazar JL S113 Alehagen U S45 Alexandrov A S7 Allaf MB S52 Allen A S64 Allen D S43 Aly A-R S23 Ambrose A S105 Amian A S20 Ananth C S25 Anderson C S20, S64 Anderson S S64 Ando T S95 Antonis M S98 Anvari A S14, S114 Apterbach W S110 Archer T S12 Arellano J S96 Arnold K S65 Arntfield R S2 Arpit N S104 Arynova B S48 Astheimer J S42 Aten A S117 Au A S89 AubГЎ M S113 Ausiello L S18 Avner J S77 Axt-Fliedner R S30, S69, S80 Ayala R S92 Aylward S S6 Ayoub J S101 Ayvazyan S S78 Azar N S15, S111 B Baek S-E S51 Bahner D S19, S21, S63, S100, S101, S102, S103, S108, S110, S116, S117, S119, S120 Bai J S9 Baird D S118 Bajaj K S108 BakhirevavL S70 Balise R S19 Balk A S79, S118 Balzaretti P S18 Banderali A S18 Bar-Sever Z S55 Bard R S63, S66, S84, S85 Bardales R S60 Barr R S2, S12, S31, S33 Barral J S19 Barri-Soldevila P S118 Bartova P S34, S91 Bault J-P S52 Bawiec C S41 Baxtrom C S78 Beach K S35 Beal E S116 Beamon C S120 Beavis C S23 Beck B S35 Beiter K S98 Beland M S61 Belfort M S71 Bellew C S99 Ben-Meir D S55 Benacerraf B S1, S54 Benaroya A S22 Benn P S55 Bennett TA S24 Benson C S26, S88 Beraud A-S S19 Berger J S68 Bhimani A S67 Bialeck S S78 Bieniarz A S114 Bierca J S15 Bitters C S100 Blackstock U S65, S78 Blahuta J S34 Blaivas M S58 Blanks J S92 Blankstein J S48 Blebea J S6, S44, S74, S76 Blickendorf M S101, S119 Blumenfeld Y S79 Bluth E S76 Bockbrader M S21 Bolouri M S86 Bolte A S109 Boniface K S18 Boore S S101 Borgida A S52, S91 Boulger C S19, S101, S103, S108, S110, S116 Box D S120 Box G S120 Boyd B S24, S116 Bradford S S113 Bradshaw D S21 Breazeale S S20 Brennan M S90 Brewer K S87 Bromley B S32, S54, S71 Brown C S109 Brown D S32 Brown S S32, S70, S90 Brubaker S S25, S82 Buadu A S107 Buckwalter J S39 Bui L S106 Bundy N S117 Bunting E S44 Bureau N S3 Burhans K S111 Busse R S99 Byram B S61 Byrne J S93, S104 C Cadet C S83 Cahill A S69 Cai Y S47 Calabrese K S18 Calisti G S17 Campbell C S21 Campbell W S52, S55 Canavan T S45, S71 Cao T-S S44 Carey J S104 Carlson L S48 Carroll L S120 Carson P S33, S40 Casoli G S18 Castillo E S21, S43 Caughey M S10, S62 Cavanaugh B S14 Cendan J S99 Cerezo Lopez E S89 Cermak P S34 Cha ES S99 Cha JH S12, S99 Chalek C S18 Chan T S21 Chandrasekhar C S97 Chao J S79 Chavez M S52 Chervenak J S72, S96 Chiem A S20 Childress J S22 Chin E S20 Chinchure D S29 Chintapalli K S104 Chiou S-Y S87 Chiricolo G S79, S115, S118 Choi J-Y S80 Choi WJ S12, S99 Chopra M S62 Chorazy M S102 Chou N-K S68 Chun Lema P S109, S110 Church C S75 Ciardo P S89 Cibinel G S18 Claes F S68 Clem D S64 Clingman B S13 Cody K S89 Cohen N S67 Coleman B S53 Coll RV S34 Colvin R S93 Contreras K S114 Cordeiro C S89 Cordero Garcia B S89 Coroleu B S106 Cortez E S101, S103 Corujo Vazquez O S109, S110 Cosgrove D S65 Crawford C S55 Crawford F S50 Crino J S1, S69 Cunha L S14 Currie G S107, S110 Curs B S64 Czarnota G S40, S61 Czernuszewicz T S10 CzernГЅ D S49 D d’Armiento J S34 Dahibawkar M S51 DahlstrГ¶m U S45 Dai Q S13 S131 Dalecki D S31 Dallas A S22, S23, S92, S94 Darge K S37 Datta A S109, S110 Dave J S51 Davidovits M S55 Davis M S107 Davis S S52 Dayton P S6 de Guillebon A S39 De Jong MR S37 de la Torre L S90 de Stefano G S17 Dean A S89 DeFranco E S54 DeFranco P S54 Deganello A S37 Degenhardt J S30, S69, S80 del Cura J S17 Deng C S31, S57 Destounis S S73 Deter R S71 Detti L S45 Deurdulian C S32 Deurloo K S109 Di Martino F S17 Di Pietro M S76 Diaz D S113 Dickman E S19, S78 Dietrich C S65 diFlorio R S66 Dillman J S67 Do S S25, S82 Dolin C S27 Donaldson C S20 Donaldson J S64 Dooley E S65 Dornbluth NC S13 Doubilet P S32, S88 Dresbach S S116 Du L S47 Dudley L S79 Dumont D S11 Duvdevani N S80 E Ehsanipoor R S69 Eichelberger K S120 Eiferman D S19, S116 Eisenbrey J S14, S18, S86, S87 El Kaffas A S40 El-Baz A S61 Elahi E S83 Ellestad S S117 Emmitt R S62 English C S63 Enzensberger C S30, S69, S80 Erdman J S50 Ermilov S S13 Eski E S103 Evans D S19 Evans K S24, S49 F Fabiilli M S38, S40 Fadrna T S91 Falou O S61 Farber M S10 Farella N S17 Farwick L S118 Feinstein S S58 Feldstein V S86 Feleppa E S33 Feltovich H S48 Fernandez-Cid M S105, S106, S118 13proceedings_Layout 1 3/5/13 11:07 AM Page S132 American Institute of Ultrasound in Medicine Proceedings Ferraioli G S31 Ferreri E S18 Fessell D S33 Filice C S31 Finberg H S24 Finnoff J S97 Fisher K S117 Fleischer A S49 Fleshman S S39 Fontanilla T S17 Ford P S10 Forsberg A S51 Forsberg F S14, S18, S51, S86, S87 Fowlkes JB S40, S67, S81 Fox JC S20, S63, S64 Fox N S24, S27, S54, S70, S86 Fox T S51, S87 Frank G S43 Frates M S88 Frenke V S106 Friedman A S26, S105 Friedman L S77 Fuchs K S25, S71 Fujimoto C S99 Fuller K S55, S91 G Gaddipati S S82 Galan H S5 Galerneau F S117 Gallippi C S10, S62 Gammell P S41 Gandhi M S52 Garberoglio R S17 Garg M S70 Garon J S48 Gaspari R S64 Gauthier M S42 Gecsi K S67 Gee M S114 Geldermann D S88 Gelman SK S81 Gembruch U S30, S69, S80 George V S97 Gerber S S26 Germer U S30, S69, S80 Gessner R S6 Gharahbaghian L S19 Gilboa Y S52, S80 Giles A S40 Giorgio A S17 Giorgio V S17 Girotto J S111 Glantz JC S113 Glasek J S102 Glasser J S92 Glazier E S94 Goertz D S38 Goetzinger K S69 Goffi A S18 Goldberg A S13 GoldГrovГЎ A S49 Goldklang M S34 Goldman E S63 Goldman S S110 Goodman E S66 Goodman J S97, S114 Goodman R S7 Gordon R S26 Goubran A S87 Goutham S S61 Graupera B S105, S106, S118 Gray S S43 Grippo A S77 Groh G S114 Gross A S112, S120 Groszmann Y S54 Grotegut C S24, S116, S117 Guerriero S S47 Guizado de Nathan G S80 Gullett J S79 Gunabushanam G S18, S50, S74, S104, J Ultrasound Med 32(suppl):S1–S134, 2013 S111, S112 Gunnison K S48 Gupta S S54, S70, S72, S86, S89, S96, S110 Gurram P S55 Gustafsson M S45 Gyamfi C S25 Huang M S9 Huhta J S76 HurtГkovГЎ E S49 Hussain N S55 Hussien A S88 Huu Tran N S106 Hynynen K S38 H Habenicht R S52 Haberman S S27 Hacker M S25, S70 Haeri S S52, S71 Haines L S19, S78 Hall A S67, S81 Hall E S2 Hall R S90 Hall T S33, S43, S48, S62 Halldorsdottir V S51, S86 Hamvas A S11 Han B S28 Handa P S13 Hangiandreou N S83, S108, S109 Hansen A S21 Harris G S2, S41, S75 Harris R S66 Hartge D S55 Hartman A S46, S48 Hartman B S46, S48 Hartman D S114 Hashim A S40 Hata S S63 Havel M S91 Havelka J S91 Hawkins L S70 Hdeib M S64 He L S9 He Y S51 Hee Lee M S112 Heimburger G S87 Heimiller J S94 Heller H S26 Henderson J S69 Henderson S S111 Henkaline T S21 Hereter L S105, S106, S118 Hernandez C S99 Herrera C S53, S56, S90 Herzig S91 Herzig R S34, S49 Herzog D S13 Heymans M S109 Higgins P S67 Hilgers T S98 Hirtz N S11 Ho A S107 Hocking D S31 Hoffmann C S53, S80 Holland C S7, S57 Holland M S9, S10, S11, S100, S114 Holzman I S83 Homeister J S10 Hong MJ S99 Hong S-J S80 Hoover E S101, S102 Hoppmann R S65 Horii S S53 Horning M S65 Horton S S29, S51, S52 Hoshiko-Reed G S99 Hotta N S83 Hou G S40 Hou R S20 Howard J S62 Howard Z S19 Howe D S65 Howell L S53 Hoyt K S16 HrbГЎДЌ T S49 Hu X S51 Huang D S32 Huang L S9 I Iacobucci A S18 Ikeda N S35 Ingle A S9, S62 Iradji S S40, S61 Irshad A S12, S65, S73, S90 Iseman C S28 Isurugi C S92 Ivancevich N S7 Iyoob S S53 J Jackson D S80 Jacobson J-M S80 Jaen Diaz JI S89 Jafari D S89 Jakubowski WS S15, S16 Jang K S39 Jasne A S101 Jasti S S107 Jelinkova M S34 Jelsing E S97 Jeon E-J S80 Jia X S47 Jiang Y S13 Jin X S28 Jing Z S28 Johansson P S45 Johnson A S51, S79 Johnson B S10 Johnson J S52, S98 Johnson L S67 Johnson MB S43 Jonszta T S49 Joong-Kim Y S11 Joseph JM S21 Joseph O S22, S23, S92, S94 Joshi K S110 Juan Z S28 Juez L S113 K Kagarise D S21 Kanasugi T S92 Kaplan BS S108 Kaproth-Joslin S107 Karlicki F S87 Karlman R S114 Karmel B S22 Karshafian R S38, S40 Kasperlik-Zaluska A S16 Kasyouhanan F S119 Katorza E S52, S53, S80 Katz Y S94 Kawecki A S69, S80 Kelly-Martinez M S79 Kennedy A S93, S104 Kent A S19 Kerr L S14 Kerwin C S77 Khan F S19 Khine H S77 Kikinis R S92 Kikuchi A S92 Kim A S113 Kim D S66 Kim H S12, S99 Kim HH S12, S99 Kim HS S99 Kim SH S99 King D S42, S49, S83 Kiplagat A S11 Kirschner J S77 Kist K S13 S132 Klassen A S29, S51, S52 Klaus S S63 Klauser C S24, S27, S54, S70, S86 Kline-Fath B S1, S58, S100 Kobayshi A S95 Kohl T S30 Kolios M S38, S61 Koltz P S111 Kona MP S23 Konicki PJ S77, S78 Kono Y S16 Konofagou E S34, S40, S44, S49 Korucuk E S103 Kotowski S S118 Kowalewski G S35 Koziatek C S78 Kraft O S91 KrajДЌa J S49 Krakow D S104 Krapp M S30, S69, S80 Kraus S S103, S114 Kripfgans O S40, S67, S81 Kripfgans OD S38 Krishnamurthi G S61 Krishnan MMR S17 Ku B S89 Kugler L S27 Kulbacki E S60 Kuliha M S49, S91 Kunselman A S85, S104, S105 Kwiatkowski R S102 L Labuda C S75 Lai X S13 Laifer-Narin S S3, S5, S53, S56, S90 Lal B S35 Lam S S77, S78 Langer M S39 Langova K S34, S91 Lappen J S67 Larsen J S81 Lavin P S13 Lawrence M S92 Layman K S98 Lee J-G S68 Lee K S57 Lee M-Y S80 Lee P-R S113 Lee R S46, S48 Lee S S112 Lee SY S10 Lee W S69 Legault Kingstone L S107, S110 Leibman J S13 Lerner J S45 Lester N S29 Leswick D S23 Letourneau K S87 Lev-Toaff A S5 Levy S114 Levy B S97 Levy L S11 Levy P S5 Lewin P S41 Lewis Jr G S2, S38, S39, S74 Lewis M S90 Li M S41 Li Y S47 Lianfang D S28 Lichtenstein S S5 Likourezos A S19, S78 Lim T-H S39 Liou R S20 Lipitz S S53 Lipman S S60 Liu H S13 Liu J-B S51, S87 Liu Q S47 Liu X S30 Liu Y S18, S41, S63 Lloyd H S15 13proceedings_Layout 1 3/5/13 11:07 AM Page S133 American Institute of Ultrasound in Medicine Proceedings Lobos N S95, S96, S101, S102 Lombardo P S48 Looney D S53 Lopez de Castro L S89 Lopez J S120 Lukjanova I S95 Luo J S9 Lupia E S18 Lyons J S54 M Ma C S44, S45 Maaji S S93 Machado P S14, S18 Macian D S92 Mack J S73 Mack L S111 Macones G S69 Madden J S60 Madsen E S43 Magalhaes A S93 Magriples U S117 Mahoney M S16 Maida E S102 Majcher M S102 Maksoud C S120 Mallarini G S61 Marc Perarnau J S101 March M S25 Margolis D S41 Marin D S51 Markenson G S52 Marshall A S51 Marston W S10 Martin J S39 Martis R S61 Maruvada S S41 Mata Castrillo M S89 Mathew B S70 Matsutani S S95 Mauro M S10 Mayo P S58 McArthur L S19 McCamey K S117 McCann M S30 McCarthy M S18 McCarville B S37, S73 McDowell J S2, S59 McNamara J S22, S23, S92, S94 McNamara R S50 McShane C S24 Medak A S43 Mehta N S83 Meizner I S53, S55 Melniker L S79, S118 Melone P S114 Merton D S18 Mervis E S20 Mestre XM S34 Meyer D S62 Meyer E S32 Meyer M S52 Mezei G S85, S104 Migda B S15, S16 Mihailos A S79, S118 Miller D S42 Miller E S26 Miller J S10, S60, S100 Miller R S50, S53, S56, S90 Miller T S13 Millet J S50, S111 Millington S S2 Milne M S10, S100 Min Kang S S112 Miniati D S86 Minkoff H S27 Minnigan H S77 Mistur R S103 Modest A S70 Modest AM S25 Mohan U S63 Moldenhauer J S53 Molinari S35 Molinari F S17, S47, S60 Molitor M S93 Moni S S25 Monroe M S99 Montazemi M S69 Monteagudo A S38, S72, S73, S96 Mooney L S119 Mooney T S79, S115, S118 Moons D S67 Moreno C S96 Moschos E S46 Moshesh M S118 Mougenot C S40 Mudrik-Zohar H S55 Mueller A S101 Mujsce D S104, S105 Mullen K S26 Mulvagh S S6 Munson J S65, S78 Murphy J S114 Murphy M S66 Murtha A S24, S116, S117 Muruganandan K S4 Muruganandan M S98 Muzumoto H S95 Myers C S114 N Nadaraj S S28 Nakamoto D S15, S38, S57, S111 Nam K S43 Namagembe I S117 Nandlall S S34 Nasief H S62 Navathe R S54 Nazarian L S3, S8, S74 Nelson R S51 Neri E S97 Neyman O S100 Nghiem H S37 Nguyen T S106 Nhan-Chang CL S25 Nichols T S10 Nicolaides A S35 Nicolau C S17 Nightingale K S10, S60, S61, S75 Nomura J S59 Novak R S15 Novelli P S67 Nunes U S14 O O’Brien Jr W S5, S11, S42, S49, S50 O’Connell A S88, S107 O’Hara S S103, S114 O’Rourke K S79, S115, S118 Obi N S114 Obican S S81 Odibo A S69 Odunko D S93 Oelze M S5 Ogburn P S52 Ogutcu B S48 Oh K S86, S88 Ojili V S90, S104, S111, S112 Olartecoechea B S113 Oleze M S60 Oliva M S105 Oliver E S53 Ong CL S29 Oraevsky A S13 OtГЎhal D S49 Otto P S13 Oyama R S92 Ozhand A S52 P Pakdaman R S93 Palmeri M S10, S48, S60, S61, S75 Pamnani R S19 Pan P S51 J Ultrasound Med 32(suppl):S1–S134, 2013 Pan X S9 Panebianco N S89 Panerai R S71 Pao S-H S68 Paraschuk Y S95 Pareek G S61 Parkes J S48 Parry S S26, S105 Pascual MA S105, S106, S118 Patat F S101 Patel D S118 Patel N S103 Patterson L S87 Paul I S104, S105 Pawlina W S102 Payer A S99 Peck J S97 Peddada S S118 Pedersen P S5 Pedrero C S105, S106, S118 PelegrГ SG S34 Pennington J S63, S80 Perez A S106 Perez-Delboy A S82 Perrin S S7 Pessel C S25, S82 Peters H S88 Pezo C S96 Phan H S22 Piert M S38 Pineda G S89 Pineda L S113 Pinter S S67, S81 Piscaglia F S65 Pivetta E S18 Planinic P S80 Platz E S18 Plessl D S23 Polascik T S60 Pollard K S102, S108 Pontius E S98 Porrino S18 Porter T S58 Poston ME S65 Prabulos AM S55 Presley J S102 Price B S117 ProchГЎzka V S49 Provost J S44 Pujol S S92 Pulvermacher C S69, S80 Q Qian L S28 Quant H S26 Quesada C S38 R Rabiner J S77 Radeos M S109, S110 Radhakrishna M S22 Raginwala S S103 Rajasekaran S S22, S23 Ramakrishnan P S39 Ranninger C S63 Ranzini A S28 Rao V S65 Rasalingam R S10, S100 Rath K S119 Rathje E S118 Ravangard S S52 Rayburn W S70 Rebarber A S24, S27, S54, S70, S86 Rebener M S20 Reiner C S51 Reinstein D S12 Reiss R S26 Repke J S85 Reusch L S48 Revzin M S2 Richards M S81 Ro R S87 S133 Robinson Z S110, S116 Roca P S85, S104, S105 Rodney J S65 Rodney W S65 Rodriguez D S25, S70 Roe AM S108 Roelant G S19 Roesch M S117 Rogers S S88 Roll S S49 Roman A S24, S27, S54, S70, S86 Romero V S81 Romney M S109, S110 Rosado-Mendez I S43, S62 Rosas H S21 Rosborough T S66, S112 Rosen M S64 Rosenberg HK S28, S29 Rosenberg K S119 Rosenzweig S S60 Rotemberg V S61 Roubec M S49, S91 Rouze N S10, S60 Royall N S63 RoyChoudhury A S12 Ruano R S52, S71 Rubens D S33 Rubert N S9 Rubin J S67, S81 Rubin S S89 Rubio E S58 Rundek R S7 Rundek T S7, S32 Rusczyk G S110 Rychak J S6, S86 Rychik J S30, S76 S Saba L S35, S47, S61 Sadeghi-Naini A S61 Safonov R S95 Safonova I S95 Sahlani L S100 Salimian M S18 Saltzman D S24, S27, S54, S70, S86 Samir A S14, S114 Samuel A S53, S56, S90 Samuels J S41 Santolaya J S27 Sarwate S S50 Satou G S28 Savage D S70 Savaser D S21, S43 Schafer M S8 Schaller M S19 Schmitz K S88 Schneider-Kolsky M S48 Schnettler W S25, S70 Schofer J S92 Schroer A S55 Schwartz N S26, S105 Scognamiglio U S17 Scola M S62 Scoutt L S18, S32, S50, S74, S77, S104, S111, S112 Sehgal S41 Sekarski T S11, S114 Seki A S95 Serres X S17 Seupaul R S77 Shah S S3, S98 Shah V S21, S43 Shahmirzadi D S40 Shailam R S98 Shamshirsaz A S52 Shan R S22 Shau Y-W S68 Sherbotie J S93 Sherman P S38 Shieh M S63 Shim J-Y S80, S113 Shin HJ S12, S99 13proceedings_Layout 1 3/5/13 11:08 AM Page S134 American Institute of Ultrasound in Medicine Proceedings Shipp T S54 Shirazi M S112 Shlansky-Goldberg R S75 Shofer F S89 Shokoohi H S18 Shonkwiler G S80 Shoreman M S21 Shue E S86 Shung KK S38 Shwayder J S33, S57 Shyu J-J S68 Sidhu P S2 Sierzenski P S7 Sikdar S S35 Silverman R S12, S15 Simmons J S65 Simpson D S11, S50 Simpson L S53, S56, S57, S90 Sinert R S79 Singh G S10, S11, S100, S114 Sinha S S19 Siniscalchi NR S34 Sinkovskaya E S29, S51, S52 Е koloudГk D S34, S49, S91 Slapa R S15, S16 Sloane C S21 Slowinska-Srzednicka S15 Smith B S50 Smith D S120 Smith J S54, S97, S102 Smith L S116 Smith R S118 Smrtka M S24, S116, S117 Snead G S77 Snyder K S88 Soffer D S30 Sohaey R S86, S88 Sommerich C S49 Song C S43 Sorace A S16 Sorribas MC S34 Soto R S96 Soukup T S34 Sperling D S84 Spiel M S52 Spinner D S119 Spinosa A S66 Spitz J S71 Springer A S19 Sree V S17, S61 Sridharan A S18, S86 Srinivasan G S87 Stassijns G S68 Stavros T S13 Stawicki S S19 Steiner R S118 Stekel S S83, S108, S109 Stepien B S60 Stidham R S67 Stilp E S50 Stites R S98 Stone M S18 Strakowski J S21 Strasburger D S77 Stulac S S98 Su Y S47 Subashi E S51 Sugiyama T S92 Summey R S23 Sun D S13 Sun Q S13 Sunny Y S41 Suri J S17, S35, S47, S60, S61 Sutton J S7 Swamy G S24, S116, S117 Swanson S S40 Szabo T S75 Szyld D S65, S78 T Tai H-C S68 Talbott N S115 Talegon A S17 Talk D S92 Tao S S9 Tarabulsi G S69 Teefey S S76 Terentiev V S19, S78 Tessler F S33 Thomas K S86 Thomenius K S18, S57 Thompson J S24, S116, S117 Thornburg L S71, S111, S113 Tian Z S30 Tianbo R S107 Tierney D S66, S112 Tillett J S42 Timor I S72, S89, S96 Tirado A S99 Tizzani M S18 Todorova M S38 Toland G S71 Tolbert T S19 Tornero M S21 Torres C S107, S110 Tradup D S83, S108, S109 Trahey G S11 Tran E S109 Tran T S18 Tran W S61 Treadwell M S81 Trebes S S69 Tresserra F S106 Trinh T S93 Tsung J S77, S83 Tumidajewicz J S60 Turner E S20, S64 Turney C S110 Tuthill T S16 Tuuli M S69 Twickler D S46 U Ulissey M S13 Ural B S99 Ural S S85, S104, S105 Urbanowicz K S102 Urs R S12, S15 Uryasev O S22, S23, S92, S94 Utrilla-Layna J S113 V Vallabhaneni R S10 van Veen T S71 van Vugt J S109 Vandordaklou N S20 Vargas Velandia E S15, S111 Vargas-Vila M S67 Varghese S45 Varghese T S9, S44, S62 Varghese Y S9 Vassa R S104 Vejdani-Jahromi M S11 Vela D S7 Victoria T S53 Vila M S106 Vilke G S21 Vilkomerson D S6, S34, S41 Villegas AM S34 Vink J S25, S82 Vintzileos A S52 Vogel M S30 Voloshin A S22 Volpicelli G S18 Volz K S24, S49 Vora N S120 Vrablik M S77 Vytykac A S118 W Waag R S42 Wachsberg R S114 Wagner J S74 Wallace K S10, S18 J Ultrasound Med 32(suppl):S1–S134, 2013 Wang E S26, S105 Wang H S13 Wang M S10, S61 Wang S-M S68 Ward V S7 Wax J S52 Way D S63 Wear K S2, S9, S41 Weichert J S30, S55, S69, S80 Weingarten M S41 Weisz B S53 Welch H S53 Wells CE S46 Werner E S69 White J S21 Whitley K S85, S104, S105 Williams S S19 Wilson C S87 Wilson K S98 Wilson T S2 Wise A S78 Witkowska A S60 Witt D S115, S118 Wolf P S11 Wolfe H S67 Wolfe M S90 Won H-S S80, S113 Woodward P S104 WoodwardcP S93 Wortsman X S95, S96, S101, S102 Wu Y S47 X Xiao J S28 Xu Z S74 Y Yablon C S37 Yakubu A S93 Yantri R S60, S61 Yeager S S19 Yeboah N S65 Yellin S S79, S118 Yenter C S78 Yeo L S57, S73 Yerli H S99, S103 Yijin S S28 Yilmaz T S99 Ying W S28 Yingyu C S28 Yinon Y S52, S53 Yoon C S65 Yoon H-C S80 Yoon J-W S113 Yoon S-W S112 Youssefian A S20 Yuan C S9 Yuan L-J S44 Yunhua L S28 Z Zagzebski J S43, S62 Zalev J S13 Zeeman G S71 Zehtabchi S S83 Zhang J S13, S47 Zhang M S38, S40, S81 Zhang X S47 Zhang X-Y S44 Zhao L S35 Zhao X S9 ZhaocJ S47 Zhu Q S13 Ziade MF S81 Zieleznik W S60 Zielinski A S116 Zinn K S16 Zork N S25, S82 Zubkov L S41 S134 В© Greater Phoenix CVB
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